Endodontics for the aged and Geriateric. What should one look for, and what changes do we need to deal with in our clinics. A comprehensive review presentation- Dr. Abhishek John Samuel, MDS (Endodontics).
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dead tracts—Dentinal tubules seen in histologic sections to be devoid of cellular processes indicating odontoblastic destruction; may contain debris and microorganisms. dystrophic calcification —Diffuse foci of calcification frequently found in the aging pulp; usually described as being perivascular or perineural.
DR. ABHISHEK JOHN SAMUEL
Dept. of Conservative Dentistry
THE AGEING PROCESS IS INEVITABLE
“The provision of Dental care for adult persons with one or more chronic
debilitating, physical or mental illness with associated medication and
psychosocial problems” - DCNA 1989
Signs & symptoms
Testing and radiographs
Vitality of the pulp
Pulpitis tends to be less acute due to:
Less volume of pulp and
less nerve supply
Pulp capping not recommended – reduced blood supply
Heithersay GS, Morile AJ. Aust Dent J 1982
MEDICALLY COMPROMISED OLD
PATIENTS.They are a special category who present with more problems
and increased severity.
Diabetes Mellitus or Immuno-suppresssion may present with
delayed healing but has not been proved in endodontics.
Osteoporosis in females, the oral bone is least affected and
so no problem of healing as with endodontics.
• The decreased radio-opacity of osteoporosis is of less
magnitude to be confused with an endo diagnosis.
For any medically compromised, RCT procedure or other
endodontic procedure are better than extraction.
Fouad AF, Burleson J: The effects of diabetes mellitus in endodontic treatment outcome: data
from electronic patient record. J Am Dent Assoc 134:43, 2003. 11
As the pulp is less innervated and the volume of
dentin is more, the pulp is generally less responsive
to stimuli in older individuals.
There is no evidence that pacemaker can be affected
by the electric pulp test but is best avoided.
Even the time tested test cavity can give false
Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S: Assessment of reliability of
electrical and thermal pulp testing agents. J Endod 12:301, 1986.
Determine pulp & periapical status
Vitality responses must correlate with clinical &
Vertically cracked teeth should always be considered
when pulpal or periapical disease is observed
Cracks detected – pulp vital- reasonable prognosis
Chronic nature (periapical pathologic condition) vertically
cracked teeth -prognosis - questionable
Periodontal pockets associated with cracks - a hopeless
Some difference is present periapically.
There is increase in incidence of non-endodontic pathosis.
Pulp space is diminished or absent radio-graphically.
But the pulp is present.
Due to continuous cementum deposition
There is change in apical root anatomy.
Sometimes there is apical root resorption.
The procedures are generally more technically complex due
1. Extensive restoration.
2. History of multiple carious insults.
3. Periodontal involvement.
4. Decreased pulp space.
Access for those who use ambulation aids should
include comfort and safety
Appointments preferable time & comfort
Positioning & comfort
Patients eye- shielded from intensity of light
Jaw fatigue – bite block for long procedures
Medically compromised patients- recognize that
RCT is less traumatic than extraction
Need for anesthesia
Painful response – not encountered till actual pulp exposure has
Number of low threshold fibres are less
High conduction velocity nerve endings in dentin- reduced or absent
Cutting of dentin does not produce same level of response in an older patient
Dentinal tubules more calcified
Reduced width of PDL makes needle placement for supplementary
intraligamentary injection more difficult
Intrapulpal anesthesia, intraosseous anesthesia – not
prolonged –pulp tissue must be removed within 20 minutes
reduced volume of pulp chamber makes intrapulpal anesthesia
difficult in single rooted teeth – almost impossible in multirooted teeth
Initial pulp exposure – hard to identify
Walton RE: Endodontic considerations in the Geriateric Patient. Dent Cl. North Am. 41,
795, 1997 17
Periradicular tissue heals as readily as in a young person.
But many factors can decrease the rate of success.
Every case should have pre and post treatment prognosis.
Single tooth rubber dam isolation
Multiple-tooth isolation – adjacent teeth can be clamped
and saliva output is low or well-placed ejector can be
Petroleum based lubricant for lips & gingiva
Artificial saliva –used just before isolation –difficult-to-
apply after dam placed
Canals should identified & their access maintained – restorative
procedures are indicated for isolation
Fluid tight isolation cannot be compromised when sodium hypo
chlorite is used as an irrigant
Difficult to isolate defects produced by root decay 19
Access• LA + Vasoconstrictor use: Joint National Committee on Prevention,
Detection, Evaluation, and Rx of High Blood Pressure (JNC 7)
• 0.036 to 0.054 mg of epinephrine (approximately two to three
cartridges of local anesthetic with 1:100,000 epinephrine) should be
safe for all patients except those with severe cardiovascular issues
Adequate access & identification of canal orifices - most difficult
parts of providing RCT for older patients
The effect of aging & multiple restoration reduces volume & coronal
extent of – chamber or canal orifice- but Buccolingual & mesiodistal
positions remains same
Canal position, curvature & axial inclination of roots and crowns –
Coronal tooth structure or restoration – compromised for access
Magnification range 2.5x to 4.5x 20
Location & penetration difficult – calcified canals
DG 16 explorer for initial penetration
Not stick in solid dentin
Will resist dislodgement in the canal
Negotiation with K files – no 8
NiTi – contraindicated for initial negotiation
Watch – winding action with apical pressure – ideal
Chelating – seldom value
Dyes distinguish orifice from dentin
Supra erupted tooth – easily perforate
Modification to enhance access
Widening the axial wall - visibility
Complete removal of crown 21
Calcified canals – more concentric & linear
Length of the canal from actual anatomic foramen to CDJ - with
deposition of cementum through out life
The actual CDJ width or most apical extend of dentin remains constant
Flaring of canal – perform as early in procedure
Thorough & frequent irrigation / Crown – down technique
Files penetrate in to walls than reamers – calcified canals CDJ (narrow
construction) identifying by tactile sense – difficult
Reduced periapical sensitivity reduces patient response – indicate
penetration of foramen
Hypercementosis – CDJ constriction farther from apex – penetration in
to cemental canal impossible
Achieving & maintaining apical patency – more difficult
Sperber Gh, Yu DC. Patient age is no contraindication to endodontic treatment. J. Can.
Dent. Assoc 69, 2003
Generate pressure in large mid root area – result in root fracture
Coronal seal – important role in maintaining the apically sealed
environment & significant impact in long term success
Success & failure
vital pulp/ nonvital pulp
Position of anatomic features
Teixeira FB, Teixeira EC, Thompson JY, Trope M: Fracture resistance of roots endodontically treated
with a new resin filling material. J Am Dent Assoc 135:646, 2004.
cells (both odontoblasts and fibroblasts)
also the supportive elements (blood vessels
of collagen and ground substance.
as isolated mass called Denticles
(mostly in crown) and / or as a diffuse linear
calcification in the root pulp (Pulp stones).
Key Changes in Pulp in the Elderly
in the pulp size – due to dentin deposition.
Dentin formation - not necessarily continuous thro’ out life & not
More on the roof and floor of the pulp chamber than on walls
leading to flattened disc like chamber.
Effect of Ageing on Human Pulp: Bernick S and Dedalman C. J Endod 3, 88, 1973
Attrition, Abrasion, Erosion
Expose dentin thro’ slow process
Allows pulp to respond with dentinal sclerosis &
Secondary dentin formn. thro’ out the life
Maxi. Antr – Sec. dentin on the lingual wall of the
Molar - on the floor of the chamber
Pulp may appear to recede, small pulpal
remnants can remain / leave a less calcific tract-
lead to pulp exposure.
Berkey D, Berg RG. The Age-old patient: Challaenges in Decision Making. JADA 127,
• 100- 200 μm in youth Thickness of apical cementum 29