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From: Mark Dreyer
Sent: Wednesday, May 21, 2008 7:49 PM
Subject: [roots] MTA pulpotomy
Cutest little 7 yr old girl in the entire world. She was a super star patient also.
Kids like this keep me from giving up tx'ing kids. I now have 2 pedo docs referring to me.
I think I'll cap it there. :-)) At least the pedo docs don't mind be restoring the
teeth of their patients.
The pulp was nice and healthy looking after I removed the caries which resulted in a
frank exposure. I'm hoping this bodes well for continued vitality.- Mark
Mark, would you mind giving us a description of your procedure for this young lady?
I treat a ton of kids in my office and feel like pulpotomy treatment is about the least
scientific procedure I do... Thanks, Craig
I excavate caries under rubber dam isolation. I try to excavate circumferentially and irrigate with
bleach prior to exposure of the chamber so as to minimize any bacterial innoculation of the chamber.
When the chamber is exposed, I'll irrigate with bleach and if there is remaining vital pulp,
I work to control the bleeding (usually with anolyte soaked cotton pellets-don't like to use too much
bleach in the interests of avoiding pulp digestion). Once the pulp is not bleeding I'll apply a layer
of MTA over it then go through my normal bonding sequence to place the permanent filling.
I've had pretty good success with the few cases I've done over the years. Rarely does a kid come back
with problems, and the ones I've been lucky enough to see on recall usually have continued root
development and vitality.
Obviously if there is no pulpal vitality noted once you breach the chamber, you'd go in a different
direction-ie traditional root canal therapy with MTA barrier at the apex of undeveloped roots, or
perhaps apexification with caoh tx. - Mark
Ok. I need to jump in here. So you are placing a layer of mta under optimum conditions and then on
the same day "bonding" over the top of the wet mta. How much of a bond do you really think you are
getting under those circumstances. For that matter, it is even possible to bond to Portland cement?
I'm not bonding to the MTA, but it is possible to go through the normal bonding process (etch, rinse dry)
without disturbing the MTA. This is a trick Joey D taught me. Historically I had always placed a liner
of GI over the MTA before going to bonding, but thanks to Joey's tip, I'm now saving a step.
As for the setting of the MTA, perhaps it is ideal to leave a moist cotton in there and bring the kid back
another day, but my theory is that the vital pulp will supply enough moisture to let the MTA set and even
if it doesn't set so what? It's contained and seems to have a beneficial effect on the remaining vital
pulp judged by the cases I've seen in my own practice and the practices of other dentists who have
reported on this technique.
Although I'm in general not a two stepper, I'm REALLY not a two stepper on 7 yr olds if
I can avoid it. :-)) - Mark
Ok, I give, what is joey's tip that allows you to do it without disturbing the mta. - gary
Gary, Just do your normal bonding process-etch rinse, dry. If you've ultrasonically densified your MTA
it won't wash away. It stays perfectly. - Mark
Hi Mark, Isn't it better to wait for the MTA to harden before bonding? - Siju
Siju, I can't give you an answer to that question based on any lit that I'm aware of. All I can say is that
from my clinical experience these teeth do pretty well with this approach. I "think" the MTA probably
sets from the moisture in the underlying vital pulp, but I don't know for sure, neither do I know if it
really matters. As I mentioned in the other email, if I can avoid multi-visits on most of these rug rats
I'm way ahead of the game. - Mark
Hello MArk. What do you think of doing pulpotomy in a 15 year old? - Marilinda Guerrero Valenzuela
Marilinda, On a kid that age, the roots on most any tooth in their mouth (other than 3rd molars) should
be mature, and thus I would tend to go more for traditional root canal therapy rather than pulpotomy
in that situation - Mark
Mark, is this to allow apical growth/closure ?
I see kids from the pedodontist like this , but the anesthesiologist usually IV Sedates. - Danny
Yes , Danny - Mark