Geriatric endodontics

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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.

  • Geriatric endodontics

    1. 1. GERIATRIC ENDODONTICS GERIATRIC ENDODONTICS DR. ABHISHEK JOHN SAMUEL Dept. of Conservative Dentistry and Endodontics 1
    2. 2. 2
    3. 3. 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 3
    4. 4. CONTENTS Introduction Chief Complaint Dental History Subjective Symptoms Objective Signs Medi. Compromised Individuals Radiographs Diagnosis Treatment plan Prognosis Isolation Access Opening Preparation Obturation Conclusion 4
    5. 5. • Expectations, Desire, Demands are least from any other group. • The basic expectation of geriatrics are Functional • Geriatrics are not interested in long-term solutions 5
    6. 6. 6
    7. 7. 7
    8. 8. Attrition Erosion Abrasion 8
    9. 9. 9
    10. 10. Diagnosis Based on Pt’s complaint History Signs & symptoms Testing and radiographs Vitality of the pulp Peraiapical pathology 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 10
    11. 11. 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
    12. 12. Objective Testing 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 response. 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. 12
    13. 13. Pulp Testing Determine pulp & periapical status Vitality responses must correlate with clinical & radiographic findings 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 prognosis 13
    14. 14. Radiographic Findings 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. 14
    15. 15. TREATMENT PLAN The procedures are generally more technically complex due to: 1. Extensive restoration. 2. History of multiple carious insults. 3. Periodontal involvement. 4. Decreased pulp space. 5. Tipping 6. Rotation. 15
    16. 16. Treatment 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 16
    17. 17. Painful response – not encountered till actual pulp exposure has occurred 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
    18. 18. PROGNOSIS 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. 18
    19. 19. Isolation Single tooth rubber dam isolation Multiple-tooth isolation – adjacent teeth can be clamped and saliva output is low or well-placed ejector can be tolerated 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
    20. 20. 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 – considered Coronal tooth structure or restoration – compromised for access preparation Magnification range 2.5x to 4.5x 20
    21. 21. 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
    22. 22. Preparation 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 with age 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 22
    23. 23. Obturation 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 Endodontic surgery Medical consideration Local consideration Position of anatomic features Apicoectomy 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. 23
    24. 24. Structural changes cells (both odontoblasts and fibroblasts) also the supportive elements (blood vessels and nerves).  of collagen and  ground substance. Calcifications 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 24
    25. 25. Dimensional change  in the pulp size – due to dentin deposition. Dentin formation - not necessarily continuous thro’ out life & not uniform deposition  with Irritation Restoration or Periodontal disease. 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 25
    26. 26. 26
    27. 27. Comparison among the ages 27
    28. 28. Attrition, Abrasion, Erosion Expose dentin thro’ slow process Allows pulp to respond with dentinal sclerosis & reparative dentin Secondary dentin formn. thro’ out the life Pulp obliteration Maxi. Antr – Sec. dentin on the lingual wall of the pulp chamber 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, 1996 28
    29. 29. • 100- 200 μm in youth  Thickness of apical cementum 29
    30. 30. 30
    31. 31. 31
    32. 32. Feski J, Davies DM, Frances C, Gelbier S: The emotional effects of tooth loss in edentulous people. Br Dent J 184:90, 1998. 32
    33. 33. 33
    34. 34. 34
    35. 35. 35

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