I’m happy to share my video tutorial of tips to help you with the MTA Pulpotomy, or you can read more in the transcription below:
I’d like to share with you some tricks regarding the MTA Pulpotomy since I often get requests to learn that procedure. I’m going to focus on how to do that when you have a pulp exposure, and hopefully this is a better way to illustrate how to do the direct pulp cap:
Determining When an MTA Pulpotomy is Needed
There are two instances when I encourage my referring dentists to do an MTA Vital Pulp Therapy in their office, and they don’t necessarily need me to do this treatment. MTA is a great option when you have a pulp exposure on an adult tooth, or for a child who has adult tooth that still has an immature apex. You can have that with a carious pulp exposure or with trauma — maybe they had a crown fracture that exposed the pulp.
Even if the pulp has been exposed for a few days, you can do a Cvek Pulpotomy. You just have to remove 2mm of that pulp so that you can get out the bacteria that has infiltrated into the pulp, and then you patch it with MTA. The MTA is super biocompatible. It also loves to promote dentin bridge formation. It just provides that great seal so there’s no more bacterial penetration, and you get a pulp that can continue to form the root. It really works well in a very young pulp, but I’ve also seen it work well with an adult tooth.
Buying Some Time
So let’s say you’re working on a tooth with deep decay and you have some pretty small pulp exposure. As long as this patient is not symptomatic, this could work pretty well. You will need to prep your patient that you may need to do a root canal in the future, but you can buy them some time. Perhaps you can do the MTA pulpotomy and a resin restoration to relieve their symptoms. Then, they won’t have to make that investment of a larger procedure and a crown right now.
I’ve actually seen patients who have had the MTA Pulpotomy with a composite, and they’ve had no need for any further treatment on that tooth. That’s completely possible, but you always want to make sure they understand that there’s still a risk of needing root canal therapy.
How do you do an MTA Pulpotomy
First, if you have a cavity in the tooth, make sure you clean out the cavity, prep it and get squeaky clean walls. Then, where you still have some decay over the pulp, you want to remove that decay area. (It’s ok if you remove some of the pulpal tissue. The idea is to get the bacteria out – that is really the issue!)
Once you get the bacteria out, even if you have a little bit of bleeding in the area, you want to soak a cotton pellet in hypochlorite (just enough to get it damp) and then put pressure on that pulp exposure directly. Don’t be concerned that the hypochlorite will damage the pulp, because it’s really the bacteria that will damage the pulp. Just keep that pressure on the pulp until the bleeding stops. You do want a little bit of moisture because that is what sets the MTA – it should be in a moist environment for at least 24 hours for an appropriate set.
Put the MTA right up against the pulp — you want a thickness of about 2-3mm. Now, cover that MTA to prevent washout of your material when you etch, bond and restore. You’re going to use something like Vitrebond. I will carry that Vitrebond over the MTA, plus extend it to do an indirect pulp cap of the remaining pulpal roof, and that way other parts of the tooth won’t get sensitive from the etching process. Once that’s all set you will etch, bond and restore to a normal resin restoration.
You do want to follow up with your patients at 1 month, 3 months and 6 months. Especially for a young tooth, you want to make sure that it’s still vital, so do a cold test at those appointments. Then, for every recall thereafter, check that tooth when they come in for their cleanings.
What You Should Use
Something I’ve been using forever is the ProRoot MTA by Dentsply – this was really the only product that was out 9 years ago when I started, but now there are a lot of other options on the market. Each box costs around $212 and comes with 5 packets. They do last you forever, but once it’s open make sure you store it in an airtight container.
The ProRoot comes in white and grey – I use grey on posterior teeth and white on anterior teeth. There are some reports that this material can stain teeth, so you’ll want to prep you patient that there could be some discoloration as a result. However, the idea is to keep that pulp vital so there is continue root formation and no pain.
More on ProRoot
This product is the typical MTA, but there a few downsides with it. I would say ease of use is probably its biggest drawback. With this, there is a little bit of a learning curve when it comes to mixing — you and a team member have to be very capable of mixing it. Once you have it mixed, how do you carry it into the tooth? I use the MAP System. This is a pretty big investment, so I don’t see that most general dentists would want to use it. However, if you do a lot of these procedures, it may be a really good investment.
This system gives you a micro amalgam carrier. We mix the MTA on a glass slab, then we pack it in the tool. After that, we carry it to the tooth and then pop it into the spot you want it the MTA to go in. The pieces are fully autoclavable. The tips can get clogged when the MTA sets, so the rule in my office is that, as soon as you are done getting the material into the tooth, you stop what you’re doing and get the tips clean to give you longer lifetime on your equipment.
The other material option is Biodentine by Septodont, which comes in little amalgam-like capsules. You have to triturate them, and you get about 15 capsules in a box for about $204. This form makes the handling a little bit easier. The good news is that you’re not banking on someone knowing how to mix it well – the triturator will do it for you. However, you will still need something to carry it into the tooth, so you would still need to invest in the MAP system.
A small amalgam carrier could also work. The other product that could be everyone’s favorite is the EndoSequence BC Sealer putty. You get one syringe (in a pouch) for $108. The shelf life is pretty good, about 18 months. It’s a material just like cavit temporary material – there’s no mixing because it’s already done for you. You can put it on a plastic instrument and place it in the tooth. It’s very easy to use and you don’t need a special carrier for it. I really like this a lot, and it’s not a big investment.
I hope these tips help you! In E-School there will be a bonus section where I talk further about MTA Vital Pulp Therapy, so sign up on the form below to be the first on the list!