C H A P T E R 23 Vital Pulp Therapy

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A B

C D
FIG. 23-18 Radiographic sequence of treatment of a maxillary right second molar in a 14-year-old patient,
previously recommended for extraction because of advanced caries. A, Preoperative radiograph showing extensive
caries at the occlusal level of the erupting third molar. The patient was asymptomatic but had pain on cold testing.
B, Postoperative radiograph after complete exposure of axial wall during caries excavation, mineral trioxide
aggregate (MTA) pulpotomy, and placement of flowable resin-modified glass ionomer cement over wet MTA with
bonded composite placement. C, One-year radiographic recall. D, Two-year radiographic control showing absence
of apical disease. The molar was functioning normally and without symptoms. ( Dr. George Bogen.)

illumination are strongly recommended to guide the opera-
tor. A bonded composite restoration is placed, following the
manufacturers recommendations, after the MTA has been
checked to ensure proper curing.
9. After completion of the permanent bonded restoration, the
occlusion is checked and adjusted as required. Subjective
symptomatology and cold testing should be evaluated at 6
weeks. Radiographic follow-up, cold testing, and subjective
symptomatology can be reevaluated at 6 and 12 months if
the initial follow-up appears favorable. Yearly or biannual
recalls are recommended.
One-Step Pulp Capping
The manufacturer of MTA (ProRoot MTA, DENTSPLY Tulsa
Dental Specialties) recommends that pulp capping be com-
pleted in one visit. In some instances, treatment of the imma-
ture permanent tooth can be difficult, particularly in young
patients with challenging medical or behavioral problems that
require treatment under sedation. The manufacturer of MTA
recommends the following protocol when one-step treatment
is indicated.
1. With dental dam isolation, complete a cavity prepara-
tion outline using high-speed burs under constant
water cooling.
2. If caries is present, excavate using a round bur in a
handpiece at low speed or use hand instruments.
3. Rinse the cavity and exposure site (or sites) with 2.6%
to 5% NaOCl. Heavy bleeding may be controlled with
a cotton pellet moistened with NaOCl.
4. Prepare ProRoot MTA according to mixing instructions.
5. Using a small ball applicator or similar device, apply a
small amount of ProRoot MTA over the exposure.
6. Remove excess moisture at the site with a dry cotton
pellet.
7. Apply a small amount of Dyract flow flowable com-
pomer (Dentsply International, York, Pennsylvania) (or
an equivalent light-cured resinglass ionomer liner) to
cover the ProRoot MTA and light cure according to the
materials instructions.
8. Etch the remaining cavity walls with 34% to 37% phos-
phoric acid gel for 15 seconds. Rinse thoroughly.
9. Dry the cavity gently, leaving the dentin moist but
not wet. Apply Prime and Bond NT material or an
equivalent bonding material. Cure according to its
instructions.
10. Place TPH Spectrum (Dentsply Caulk, Milford, Dela-
ware) composite material or an equivalent composite
resin to complete the restoration. Cure according to its
instructions.
11. At the next appointment, assess the pulp vitality. Pulp
vitality and status should be assessed radiographically
every 3 to 6 months or as needed.
The authors recommend the following modifications: Caries
removal can be completed under magnification and illumina-
tion with the aid of a caries detector dye (step 2). During MTA
placement against the exposure site (step 5), a larger bulk of
MTA be placed that includes most of the surrounding dentin
at a thickness of at least 1.5mm. One-step pulp capping and
pulpotomy procedures can also be completed with the faster-
setting hydraulic tricalcium silicate materials.