How Is Mineral Trioxide Aggregate Used in Pediatric Dentistry?
Mineral trioxide aggregate (MTA) is an endodontic filling material or cement that is highly biocompatible and hydrophilic and holds the potency to stimulate tissue healing. It is an aggregate of tricalcium silicate and tricalcium aluminate that forms a colloidal gel with a potential hydrogen (pH) of 12.5 formed when this composition powder is hydrated.
It has excellent physical properties in terms of covering and sealing cavities. The material can be used economically by the pediatric dentist to seal the pulp and allow effective crown or coronary closure.
In addition, the applications associated typically with glass ionomer resins can increase the efficacy of endodontic sealing or covering properties and long-term durability in the child.
It also allows proper root growth in immature permanent teeth that have been impacted by traumatic dental injuries or accidental falls. The MTA should ideally be placed at least one to two millimeters thick below the cementoenamel junction (CEJ).
When Is Mineral Trioxide Aggregate Obturation Recommended in Children or Young Adults?
In children and young adults, often the root canal anatomy is quite fragile and complex because of the thin, breakable dentinal walls. Furthermore, a traumatic infection of the tooth after an accident, fall, or injury can lead to the possibility of the oral cavity immunity being completely breached by the entry of infectious microorganisms. The additional challenge in young permanent teeth would be that root formation is only complete at the age of 12 to 13 years. If there is damage to the vascularity of the pulp or at the tooth root apex, there is a high chance of root canal failure, along with the following complications:
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Material leakage at the apex (tip of the root).
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Short crown root ratio of the primary or permanent tooth.
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Difficulty in cleaning, shaping, or disinfecting the root canal anatomy or space.
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Fragile dentin walls because of which mechanical obturation of the root canal can be a Failure
These complications and challenges commonly faced by the pediatric dentist or the endodontist can result in MTA for its excellent sealing properties, and being the obturating material of choice in these age groups.
What Are the Steps Involved in Endodontic Filling With Mineral Trioxide Aggregate?
The pediatric dentist or the endodontist, who is ideally preferred for root canal therapy or obturation of permanent teeth, should try placing the mineral trioxide aggregate (MTA) material on the formed clot in the case of children and young adolescents. Though this can be a technically difficult procedure, care is to be taken by the dental surgeon during the process of condensation. This is necessary because the material can be easily moved from the cementoenamel junction (CEJ) to the apical point of the root. The steps are as follows:
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The dentist or an endodontist administers a local anesthetic and isolates the tooth to be treated by rubber dam isolation.
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An access cavity is first prepared to allow endodontists to access, explore, or analyze the root canal opening in the tooth for treatment.
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Each root canal opening is then expanded subsequently, which can facilitate the placement of MTA medicament.
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The remaining root canals, where the roots have not yet completely formed, as in the case of immature permanent teeth, are not instrumented. Instrumentation is usually avoided in these sensitive areas.
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The next step involves copious and passive irrigation using the solution of sodium hypochlorite (NaOCl 20 milliliters of 1.5 percent) for approximately five minutes for each root canal.
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Then, further irrigation and disinfection are done using a sterile saline solution or, ideally, ethylenediaminetetraacetic acid (EDTA), which is an important irrigant used for absolute disinfection (20 milliliters for each canal for approximately five minutes). EDTA, or a sterile irrigant solution, is ideally important at this step to maintain the stem cell vitality within the apical tissue of the tooth
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It is an irrigation system that comprises a needle with a closed end that would be used by the dentist and also has side vents inside. This is mainly to minimize the odds of possible extrusion that might occur of the irrigant agents into the in and around periapical areas of the tooth. The irrigation needle is angled or positioned by the dental surgeon at an approximation of one millimeter away from the tooth root end while doing this step. The rationale is to minimize the cytotoxicity of the potent stem cells present in the apical tissues.
In the first appointment itself, a triple antibiotic paste that is an antibiotic mix prepared from Ciprofloxacin, Metronidazole, and Minocycline is used in a ratio of 1:1:1 ideally. Proper care is taken to deliver the paste-like consistency into the root canals via a syringe, and then a sterile cotton pellet is placed into the canal just below the CEJ of the tooth.
If the patients have a good prognosis for the endodontic treatment, then closure is done by permanent obturation and filling of the access cavity. Patients are then recalled for a second sitting again if there is a chance of high infection risk.
In this case, at the end of the first appointment, the cavity is sealed completely with a temporary filling to prevent any microleakage.
What Happens in the Second Appointment After Filling With Mineral Trioxide Aggregate?
The second appointment usually ranges from one to four weeks after the first appointment. Based on the dentist's judgment, the endodontic response of the tooth would be thoroughly evaluated, and the clinical symptoms that may be persisting are elicited from the patient.
If the first appointment has been a success, then the tooth would have become asymptomatic, and the second session would be ideally started through local anesthesia again. In the second visit, the access cavity of the root canal needs to be permanently sealed with a restorative material, the dentist may opt for alternative materials to MTA, such as modern bioceramics, and tricalcium silicate cement. It can also be restored with MTA itself based on the dental operator's mode of convenience. The access cavity is then finally restored with a suitable permanent restorative material.
Conclusion
Mineral trioxide aggregate (MTA) is, hence, an effective endodontic material that has been extensively used in conservative pediatric and endodontic treatments in modern dentistry. The material ensures the preservation of pulp vitality and the complete formation of immature permanent teeth. Early endodontic intervention by the dentist would be most beneficial to the patient or child affected by dental fractures or trauma.
