S 7 geriatric endodontic

GERIATRIC
ENDODONTICS
Neha Verma
2nd Year Pg
Department of
Conesrvative Dentistry and
Endodontics

CONTENTS
 Introduction
 Age Changes in the Teeth
 Diagnosis
 Common Challanges in Geriatric Patients
 Treatment Planning
 Endodontic Considerations
 Restorative considerations
 Preventive Measures for Dental Diseases
 Conclusion

INTRODUCTION
Dental service requirements are determined by four demographic and epidemiologic factors:
1. The population at risk
2. The incidence and prevalence of dental diseases
3. The accepted standards of care
4. The perceived need and expectations toward dental health by the public
 These factors are changing as a result of the aging of the population.
 The study of the physical and psychological changes which is incident to old age is called
gerontology or geriatrics.
 The term geriatric - Dr. Ignatz Leo Nasher (1909)
• Cohen- pathways’s of pulp- ed 10th
• Nadig RR, Usha G, Kumar V, Rao R, Bugalia A. Geriatric restorative care - the need, the demand and the challenges. J Conserv Dent 2011;14:208-14

GERIATRIC DENTISTRY or GERODONTICS
Definition:
The delivery of dental care to older adults involving the diagnosis, prevention and treatment of
problems associated with normal aging and age-related diseases as part of an interdisciplinary
team with other health care professionals.
 Government of India classified, the people who are 60 years of age and above as elderly
 Developed countries the age is 65 years
 AGE CHANGES IN THE TEETH
 Macroscopic Changes
 Age Changes in Enamel
 Age Changes in Cementum
 Age Changes in Dentin
 Age Changes in Pulp
Pardhan MS, Sonarkar SS, Shenoi PR, Uttarwar V, Mokhade V. Geriatric Dentistry-an Overview. International Journal of Oral Health Dentistry. 2016;2(1):26-8.

Macroscopic Changes
• Changes in form and color
• Causes for change in color of teeth:
– Decrease in thickness of dentin
– General loss of translucency
– Corrosion products
– Inadequate oral hygiene.
• Wear and attrition of teeth
AlRahabi MK. Root canal treatment in elderly patients: A review and clinical considerations. Saudi Med J. 2019 Mar;40(3):217-223.
.Pardhan MS, Sonarkar SS, Shenoi PR, Uttarwar V, Mokhade V. Geriatric Dentistry-an Overview. International Journal of Oral Health Dentistry. 2016;2(1):26-8.
AGE CHANGES IN THE TEETH

Age Changes in Enamel
• All changes in enamel are based on ionic exchange mechanism
• Decrease in permeability of enamel
• Enamel becomes more brittle with age
• Enamel exhibits attrition, abrasion and erosion
Age Changes in Cementum
• Increases gradually in thickness with age
• More susceptible to resorption
• Increased fluoride and magnesium content of cementum with age

Age Changes in Dentin
• Physiologic secondary dentin formation
• Gradual obliteration of dentinal tubules
• Dentin sclerosis
• Size of the pulp chamber reduces with age
• Occlusion of dentinal tubules by a gradual deposition of the peritubular dentin.
Clinical Implications of Age Changes in Dentin
• Obliteration of the tubules leads to reduction in sensitivity of the tissue
• Reduction in dentin permeability prevents the ingress of toxic agents
• Addition of more bulk to the dentin reduces pulpal reactions and chances of pulp
exposures.
AlRahabi MK. Root canal treatment in elderly patients: A review and clinical considerations. Saudi Med J. 2019 Mar;40(3):217-223.

Dentin formation
• Dentin formation continues throughout the entire life as long as the pulp remains vital.
Continued dentin formation occurs with the deposition of
a. Secondary dentin
b. Tertiary dentin - irritation dentin and reparative dentin.
• Secondary dentin formation is greatest in the -
- Incisal pulp in the anterior teeth
- On the floor in the posterior teeth.
• This makes location of the pulp chamber and/ or root canals difficult.
• The pulp chamber of the posterior teeth becomes flattened and disc- like making it easier
to pass a bur through the chamber into the furcation.
US DN, Roma M, Sureshchandra B, Majumdar A. Endodontic considerations in the elderly-case series. Endodontology. 2014 Jun;26(1).

• Tertiary dentin forms under the stimulation of function and irritation.
• An aged tooth may represent a premature response to the
- Abuses of caries
- Extensive restorative procedures
- Inflicted trauma
• Regressive alterations result in increased amounts of hard tissue in the underlying pulp.
• Irritation dentin may be extensive enough to fill the entire pulp space.

• The difference between dental pulp of old individuals and young teeth is due to more fibers
and less cells
• Blood supply to the tooth decreases with age
• The prevalence of pulp stones increases with age.
 Pulpal changes due to aging
• Number and size of pulpal cells decrease
• Number of pulpal collagen fibres increase
• Constant recession of the pulp due to secondary and tertiary dentin formation
• The number of blood vessels and nerve fibres decreases
AGE CHANGES IN PULP

 Pulpal cellular changes due to aging
• Number of odontoblasts and fibroblasts decrease
• Remaining odontoblasts and fibroblasts are more likely to appear less active
 Pulpal fibrotic changes due to aging
• Decrease in the number and size of fibroblast.
• Apparent increased fibrosis with time may not be from continued formation of collagen but
may be due to the persistence of connective tissue sheaths in an increasingly narrow space.
 Pulpal vascular changes in the pulp
• Decrease in the number of blood vessels.
• Many pulpal arteries may demonstrate arteriosclerotic changes.
• Arteriosclerosis results in the decrease of the lumen size with intimal thickening and
hyperplasia of elastic fibres.
• Calcification of precapillaries and arterioles is also common.

DIAGNOSIS
 Chief complaint : Patient’s dental knowledge and ability to communicate
 Medical history ( systemic condition and drugs)
 Dental history
• Subjective tests (absence of significant signs and symptoms are common)
• Objective tests : Pulp vitality testing
a. EPT , Routine pulp testing done, cold testing is said to be more reliable
b. Periapical testing
 Pulps with a high degree of pulpal calcifications may give false negative responses to
pulp testing procedures including heat, cold and electric pulp testing.
 • Radiographic Findings

 Most common reason for pain in old age patients is pulpal or periapical problem that
requires either root canal treatment or extraction.
 Older patients are more likely to have already had root canal treatment and have a more
realistic perception about treatment comfort.
 Usually the pain associated with vital pulps seems to be reduced with aging, and
severity seems to diminish overtime suggesting a reduced pulp volume.
 The desire for root canal treatment is increasing considerably amongst aging patients.
Root canal treatment can be offered as a favorable alternative to the terms of extraction
and cost of replacement.
CHIEF COMPLAINT OF GERIATRIC PATIENTS

 Dentists should recognize that the biologic or functional age of an individual is far more
important than chronological age.
 As most of the old aged people suffer from one or the other medical problems, a medical
history should be taken prior to starting any treatment for geriatric patients.
Systemic Diseases and its dental relation :
Most common diseases seen in elderly patients which have relation with dental manifestations
are-
• Cardiovascular Diseases
• Diabetes
• Respiratory Diseases
• Blood Dyscrasias
MEDICAL HISTORY

WHO 1982 : Oral health is a standard of the oral and related tissues which an individual to
eat, speak and socialize without active disease, discomfort or embarrassment and which
contributes to general well-being.
 Oral health status of elderly people was found to be poor with higher incidence of tooth
loss - at risk of root caries, which follows as a consequence of periodontitis.
 Cardiovascular diseases (CVD) and periodontitis has interrelationship because of
common bacteria associated with its pathogenesis.
 Periodontal inflammation leads to bacteremia caused by common oral pathogens like
Porphyromonas Gingivalis, isolated from CVD like coronary and carotid atheromas.
 Therefore, CVD and Periodontitis are interrelated and commonly seen in geriatric
patients.

 Infective endocarditis, other common disease found in elderly patients has association
with periodontitis.
 The bacteria like viridians streptococci normally found in oral cavity, whereas the bacteria
found in dental plaque like Actinobacillus actinomyce-temcomitans, Eiknella
Corrodens, Fusobacterium Nucleatum and Bacteriodes Forsythus have been isolated from
the blood sample of Infective endocarditis patients.
 Respiratory infections are usually caused by oropharyngeal and periodontal
microorganism and bacteria.
 The main cause of respiratory infections and bacterial pneumonia in adults is aspiration of
oropharyngeal bacteria.
 This micro flora habitats in inadequate oral hygiene resulting in formation of dental plaque
further surving as a reservoir for respiratory pathogens

 Rheumatoid arthritis (RA) is seen in elderly patients.
 RA has similar characteristic of periodontitis as there is destruction of hard and soft
tissues as a result of inflammatory response.
 However, the interrelationship as well as association between RA and periodontitis has
not been proved.
 Diabetes Mellitus (DM) the other most common disease seen adult and elderly
individuals in 21st century.
 Patients suffering from DM have distinguished dental manifestations such as
- Loss of Periodontal Attachment
- Gingival And Periodontal Abscess
- Early loss of teeth.

PAST DENTAL HISTORY
Patient explains regarding
their complaint, stimulus
or irritant that causes pain,
nature of pain, its
relationship to the stimulus
or irritant. This
information is useful in
determining whether the
source is pulpal or
periapical and if these
problems are reversible or
not.
Subjective
tests
Objective symptoms are the
one diagnosed by the
dentist by clinical
examination. Extraoral and
intraoral clinical
examination provides
dentist useful information
regarding the disease and
previous treatment done
Objective
tests
 To access the patient’s dental status and plan future treatment accordingly.
 Patient’s knowledge about dental treatment and his psychological attitude, expectations
from dental treatment, assessed.

COMMON CHALLANGES IN GERIATRIC PATIENTS

Missing teeth and the subsequent tilt,
rotation, and supraeruption of adjacent and
opposing teeth contribute to reduced
functional ability and increased
susceptibility to caries and periodontal
disease.
Gingival recession exposes cementum and dentin, which are
less resistant to caries. A-B, Root caries often results in pulp
exposures (C-D) that require endodontic treatment.

• Pulp exposures caused by cracks are less likely to present acute
problems in older patients and often penetrate the sulcus to create
a periodontal defect as well as a periapical one. If incomplete
cracks are not detected early, the prognosis for cracked teeth in
older patients is questionable
• A split tooth should always be considered when a nonvital pulp
and chronic apical periodontitis are evident on a nonrestored
tooth. The crack usually extends into the periodontium, and the
prognosis is generally poor.
Multiple restorations on this 74-year-old patient suggest repeated
episodes of caries and restorative procedures with pulpal effects that
accumulated in the form of subclinical inflammation and
calcification.

(A) Attrition exposes dentin through a slow
process that allows the pulp to respond with
reparative dentin, but pulp exposure
eventually becomes clinically evident (B).
Gingival recession also exposes cementum and dentin that are less resistant to abrasion and erosion, which
can expose pulp or require restorative procedures that could result in pulp irritation.

A) Deep root caries that appears to involve the pulp
B) Mesial abutment for long fixed bridge
C) Canals negotiated through the buccal access cavity
D) Buccal canal access
E) Treatment is completed and access cavity permanently
restored

A, In general, canal chamber volume is inversely proportional to age. As age increases, canal size decreases.
The upper right central incisor exhibits a reduced canal and chamber volume. B, Negotiation using small hand
files. C, Treatment completed for this calcified canal
This radiograph illustrates pulp volume changes in
mandibular premolars. Left to right: a normal pulp,
reparative dentin adjacent to a shallow restoration, more
extensive reparative dentin adjacent to a more extensive
restoration, and the overall reduced volume that occurs
during aging.

 Pulp vitality tests are not very accurate because of extensive calcification and reduced size
of pulp cavity.
 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.
 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
 Neural & vascular components – ↓ Pulp volume - ↓ Nerve branches - ↓ Response to
stimuli is weaker in older adults.
PULP VITALITY TESTS

 Extensive restorations, pulp recession, and excessive calcifications - limitations - electric
and thermal pulp testing.
 The electric pulp tester, CO2 snow, and difluorodichloromethane - more reliable than ethyl
chloride or ice in producing a positive response.
 Attachments that reduce the amount of surface contact necessary to conduct the electric
stimulus are available (SybronEndo, Orange, CA), and bridging the tip to a small area of
tooth structure with an explorer has been suggested.
 A test cavity - less useful as the test of last resort because of reduced dentin innervation.
 Test cavities should be used only when other findings are suggestive but not conclusive
 Dentin thickness is greater, and the tubules are less permeable to blood or breakdown
products from the pulp. Dentin deposition produces a yellow, opaque color that would
indicate progressive calcification in a younger pulp, but this is common in older teeth.

Radiographs help the dentist in identifying the tooth condition/status and the treatment to be
advised-
 Canals examined for – number, size, shape & curvature
 Lamina Dura & Anatomic Landmarks – distinguished from periapical radiolucencies &
radiopacities
 Receded pulp cavity which is accelerated by reparative dentin
 Calcifications – throughout their length
 Presence of pulp stones and dystrophic calcification
 Receding pulp horns can be noted in the radiograph
COMMON RADIOGRAPHIC OBSERVATIONS IN GERIATRIC PATIENTS
Radiograph showing reduced size of pulp cavity
of geriatric patients

PULP ITALITY TESTS
RADIOGRAPHS
advised.
radiopacities
 Resorption with chronic apical periodontitis – alter shape & anatomy of foramen ( thro’
infam. osteoclastic activity)
 Resorption associated with chronic apical periodontitis may significantly alter the
shape of the apex and the anatomy of the foramen through inflammatory osteoclastic
activity
A, Resorption associated with chronic apical periodontitis may alter the shape and position of the
foramen through osteoclastic activity.
B, The narrowest point in the canal is now positioned farther from the radiographic apex.

PULP ITALITY TESTS
RADIOGRAPHS
advised.
radiopacities
(A) Hypercementosis may completely obscure the apical anatomy
(B) Result in a constriction farther from the radiographic apex
 The narrowest point in the canal may be difficult to determine; it is positioned farther
from the radiographic apex because of continued cementum deposition.

PULP ITALITY TESTS
RADIOGRAPHS
advised.
radiopacities
 Good communication should be established.
 All the procedures should be properly explained to the patients.
 Proper consent of the patient is taken, as older patients are at greater risk as compared to
younger patient.
 All patients should be properly informed about the risks and alternatives.
 If the patient is medically compromised, in these cases physician or mental health experts
are consulted and so procedures are performed until consent is given by the patient.
 Fortunately, acute pulpal and periapical episodes in which immediate treatment is indicated
are less common in older individuals.
CONSULTATION AND CONSENT

TREATMENT PLANNING
 Bannet and Cramer : staged treatment planning for the maintenance of the oral health of
the elderly patients.
Stage I :
• EMERGENCY CARE : Life threating emergency, oral emergency alleviation of pain
and infection.
Stage II :
• MAINTENANCE AND MONITORING : Management of chronic infection, root
canal therapy, root planning and curettage, restorations of carious lesions, work related
to dentures, patient education to improve oral health.
Stage III :
• REHABILITATION PHASE : Implants, surgical endodontics, surgical periodontics,
esthetic rehabilitation, reconstruction of occlusal plane and restoration of vertical
dimension.
Nadig RR, Usha G, Kumar V, Rao R, Bugalia A. Geriatric restorative care - the need, the demand and the challenges. J Conserv Dent 2011;14:208-14

ENDODONTIC CONSIDERATIONS
© 2015 Australian Dental Association
When to consider Endodontic Referral ??
PATIENT FACTORS
• Spinal conditions limit patient mobility
• Inability to tolerate long appointments
• Limited mouth opening
• Significantly medically compromised
TOOTH FACTORS
• Calcified root canal systems
• Broken down teeth
• Heavily restored teeth
• Access through cast restorations
• Difficult isolation
• Retreatment of posterior teeth

GUIDELINES FOR MANAGING THE ELDERLY ENDODONTIC
PATIENT :
 Short appointments (Treatment appointments should be scheduled according to the
physical and mental condition of elderly patients)
 The emotional needs of elderly patients should be considered.
 Dental practitioners should make every effort to satisfy their patients.
 Prescribe prophylactic antibiotics when indicated.
 Blankets should be available if the office temperature is too cool for elderly patients.
 The use of bite blocks is recommended to ensure comfortable jaw opening during
long procedures. However, practitioners should avoid jaw fatigue-the session should
be terminated as rapidly as possible

 Pillows for back/neck comfort
 Mouth props/bite blocks
 Magnification and transillumination
 Identify calcified canals
 Rotary NiTi instrumentation to reduce treatment time
 For patients that cannot firmly stabilize mid-treatment radiographs, such as using the rubber
dam to support the film holders- Snap-A-Ray (Dentsply International, Tulsa Dental, Tulsa,
OK, USA) gives a broader surface area for the patient to grip, which may be easier to
support during mid-treatment films, especially in the anterior region
‘Snap-A-Ray’ intraoral radiograph support.

• Older patients are often less anxious about dental treatment - low threshold and
conduction velocity of nerves, limited extension of nerves into the dentin, the
dentinal tubules are more calcified so painful response may not be encountered until
there is actual pulp exposure.
• In older patients, the width of the periodontal ligament is reduced, makes the needle
placement for 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
ANESTHESIA :

• Intrapulpal anesthesia is difficult in older patients as the volume of pulp chamber is
reduced.
• Epinephrine should be used with caution in hyperthyroid patients, because hypertensive
crisis and cardiac arrhythmias are possible; likewise, care should be taken with diabetic
patients because of their increased risk for hyperglycemia.
• 2% lidocaine with 1:100,000 epinephrine (correct ratio) solution experience a transient
increase in heart rate.
• Patient with medical condition, drug therapies, or epinephrine sensitivity suggests caution-
3% mepivacaine - alternative for intraosseous injections.

• Rubber dam is the best method of isolation.
• If the tooth to be treated is badly mutilated making the placement of rubber dam clamp
difficult then an alternative mode of isolation should be considered which can be multiple
tooth isolation with saliva ejector.
• The dentist should not attempt isolation and access preparation in a tooth with
questionable marginal integrity of its restoration.
• Petroleum based lubricant for lips & gingiva.
• Reduction in salivary flow and gag reflex reduces the need for a saliva ejector
• Fluid tight isolation cannot be compromised when sodium hypo chlorite is used as an
irrigant
ISOLATION :

• Single-tooth isolation is the best choice for root canal treatment.
• However, severely deteriorated teeth may require multitooth rubber dam isolation.
• Single-visit root canal treatment, if possible, has several advantages for elderly patients,
especially for those patients who depend on others for transportation or who require
physical assistance to visit the dental office.
ACCESS TO CANAL ORIFICE :
One of the most difficult parts in the treatment of older patients is the identification of the
canal orifices.
• Obtaining access to the root canal and making the patients to keep their mouth open for a
longer period of time is a real problem in older patients.
• Radiographs/RVG should be used to determine canal position, root curvature, axial
inclinations of roots and crowns and involvement of caries and periapical extent of lesion.

• In case of compromised access for preparation, coronal tooth structure or restorations need
to be sacrificed.
• Endodontic microscopes can be of greater help in identifying and treating narrow geriatric
canals
 Creation of the access cavity prior to dam placement can be helpful if a prosthetic crown
is present.
 Reference to the pre-operative radiograph will help determine the depth of the pulp
chamber.
 If the pulp chamber cannot be located, then a location radiograph is useful to give
information about the angulation and depth of the access.
• Location & penetration difficult – calcified canals DG 16 explorer for initial penetration.
• Initial negotiation with stainless steel (SS) #8, #10, or #15 K-file is done.
• The #6 file lacks stiffness in its shaft and easily bends and curls under gentle apical
pressure. Nickel titanium (NiTi) files lack strength in the long axis and are contraindicated
for initial negotiation

• Safe-ended access burs Endo Z Bur:
• The Endo Z bur is a tapered and safe-ended carbide
bur.
• Its noncutting end can be safely placed directly on
the pulpal floor without a risk of perforation.
• The Endo Z bur’s lateral cutting edges are used to
flare, flatten, and refine the internal axial walls.
 Ultrasonic tips
- To eliminate pulp stones, through along grooves to uncover hidden orifices, and chase
calcified canals.
- To refine and finish the access preparation.
- Combination with ultrasonic instruments are driving an increasing number of
“microsonic” techniques.
 To facilitate removal of the pulp chamber roof and canal location.

 Observation of the floor of the cavity for features such as -
altered colour and translucency in the form of a white spot indicate
 Use of long shank, narrow neck burs
Eg : (Maillefer) LN pin –and (Meissenger) Goose neck Burs or Pulp Chamber Burs –
Muller Burs allow light to fall on the cutting end of the bur at all times.
 The Mueller bur and the LN bur have similar shaft diameters, but their respective design
features limit their usefulness for deep radicular access procedures. The Mueller is too flexible
and lacks small enough tip diameters, and the LN bur, available in 1/2-round tip size only, has
an inadequate overall length of only 28 mm.

 https://www.dentistrytoday.com/endodontics/1020-sleuthing-out-hard-to-find-canals
 https://www.dentalmartsales.com/product/mueller-burs-191r-assorted-5pk/
 LN bur (Dentsply) : 1/2-round bur with a shaft
diameter similar to that of the smallest Mueller burs
(~0.55 mm).
 Because the narrowed portion of the LN bur shaft is
only 8 mm long as compared to the narrowed portion of
the Mueller bur, which is 15 mm long, the LN shaft is
considerably stiffer.
 The overall length of the LN bur, however, is only 28
mm and that renders it far less useful for troughing and
deep exploration because of decreased reach and
decreased visual vector beyond the head of the
handpiece.

 Electronic apex locators (EALs) are considered
accurate devices for determination working length.
Electronic apex locators can be used safely in
patients with cardiovascular implantable electronic
devices, when general precautions are to be followed.
 The use of an apex locator enables the patient to
remain in one position, rather than having to move to
have diagnostic radiographs taken.
 Cementum deposition continues for a lifetime, this will lead to cementum thickness
increasing.
 This morphological change will increase the distance between apical foramen and
radiographic apex.
 All these changes will reduce the reliability of working length determination by X-Ray.

• Use of broaches avoided in older patients, due to inadequate diameter to allow safe and
effective uses of broaches.
• Flaring of root canals .
• Files with a triangular or square cross-section may penetrate into the walls with greater force
than the fracture resistance of small files (when used with a reaming action) and result in
instrument fatigue and fracture.
• The benefits of instruments with no rake angle and a crown-down technique are
recommended - helps in reduced binding of instrument and provides space for irrigating
solutions in narrow, sclerotic canals.
• It is difficult to locate apical constriction in these patients because of reduced periapical
sensitivity in older patients, reduced tactile sense of the clinician and limited use of apex
locator in heavily restored teeth.
CLEANING AND SHAPING

• Rotary NiTi instrumentation reduces treatment time and procedural accidents during cleaning
and shaping.
• However, because the canals are much narrower, this approach requires additional time, effort,
and care to prepare the root canal and reduce the risk of binding and separation.
• A single-file NiTi system is considered appropriate for elderly patients who require short times
for canal preparation.
• the use of the single-file reciprocating motion system is not influenced by the operator’s
experience.
• After preparing adequate glide path the canal instrumentation completed with a single-file
NiTi system.

 For obturation of root canals in older patients, those obturation techniques are employed
which do not require large mid root taper.
 Coronal seal – important role in maintaining the apically sealed environment &
significant impact in long term success
 The use of a single-cone with bioceramic sealers is a viable option for obturation,
which has achieved a high success rate.
 Full coverage restorations on molars in elderly patients exhibit a high success rate
 If a post is used in restoration of endodontically treated teeth, the taper of the post should
be particularly careful, as excessive taper can cause vertical root fracture.
 A post is not necessary when performing root canal treatment through the full crown;
the decision can be made to continue using this crown.
OBTURATION :

 In case of vital pulp the prognosis of treatment depends on many local and systemic
factors.
 In case of nonvital pulp, the repair is slow because of:
• Arteriosclerostic changes in blood vessels
• Decreased rate of bone formation and resorption
• Increased mineralization of bone
• Altered viscosity of connective tissue.
PROGNOSIS OF ENDODONTIC TREATMENT :

Indications of surgery are not affected by age.
• Small or completely calcified canals.
• Root curvatures
• Extensive apical root resorption
• Pulp stones
• Perforation during access
• Ledging, loosing length drug instrumentation.
• Instrument breakage
• Calcified canal External root resoprtion Periradicular periodontitis & distal rootcaries
 In Geriatric Patients (endodontic surgery) :
• Smaller amount of anaesthesia is needed.
• Tissue is more resilient.
ENDODONTIC SURGERY :

• Teeth are more accessible as lip and cheeks can be more easily stretched.
• The position of sinus, floor of nose and neurovascular bundles remains same but their
relationship to surrounding may change as teeth are lost.
 Ecchymosis :
• more common postoperative finding in older patients and may appear to be extreme.
• The patient should be reassured that this condition is normal and that normal color may
take as long as 2 weeks to return.
• The blue discoloration will change to brown and yellow before it disappears.
• Immediate application of an ice pack after surgery reduces bleeding and initiates
coagulation to reduce the extent of ecchymosis.
• Later, application of heat helps to dissipate the discoloration.

RESTORATIVE MANAGEMENT IN ELDERLY
DENTAL CARIES –
• The prevalence of dental caries in older adults is said to be > 50-60%.
• While the incidence of coronal caries in the old is more or less similar to the young, root
caries incidence is much higher (40-70%).
• In the elderly, proportion of secondary caries predominates over primary caries and repairs
and replacements make the major operative work in today's practice.
• 93% of recurrent caries are associated with silver amalgam occurs at gingivo-proximal
locations of class II restorations or crowns.
• As a first step it is imperative to evaluate the risk factors involved as it plays a major role in
treatment planning.

• A thorough history of medical conditions and medication has to be analyzed.
• Diet history with specific information on sucking candies etc. has to be elicited.
• Salivary volume and buffering capacity tests can also help make decisions.
• Taking into consideration the various determinants, treatment can be instituted in two phases
- Restorative phase
- Maintenance phase
RESTORATIVE PHASE :
CORONAL CARIES-
 The selection of restorative techniques in older adults is more or less similar to that in
younger population.
 However, permissible direct plastic restorative materials are preferred in the former as these
restorations can be readily and inexpensively repaired or replaced.
 Owing to the presence of several risk factors, caries activity is quite high and therefore
requires frequent maintenance which might not be easily done in an indirect restoration.

ROOT CARIES
 Root carious lesions are mostly situated subgingivally or gingival to the proximal surface
making visibility, accessibility and isolation extremely difficult.
 The process of mineral loss in root caries can be twice as fast as that on enamel.
RESTORATIVE OPTIONS :
• Amalgam
• Composites
• Anterior, Posterior, Hybrid, Nanofill, etc.
• Compomers (Dyract)
• Modified Glass Ionomer (Fugi II LC)
• Glass Ionomer Cements
• Glass Ionomer Sealant
ada.org/en/member-center/oral-health-topics/aging-and-dental-health

Glass Ionomer Cement (GIC) is the choice of restorative material due to the it's adhesive
property allowing minimum preparation, fluoride release, reasonable esthetics, biocompatibility
and less technique sensitivity as compared to composites.
MAJOR ADVANTAGES OF GLASS IONOMERS :
• Chemical adhesion – not bonded
• Stronger bond to dentin
• Closer adaption to underlying structure - dentin (unaffected, affected, or infected)
– cementum
• Ability to re-mineralize affected and infected dentin due to high fluoride release • Easy
placement for interim restorations (faster set/bonded)

 Holmes demonstrated reversal of leathery root caries (non
cavitated sites) on exposure to ozone.
 Exposure of the lesion to ozone (a) for 10-40 seconds is said to
be anti-microbial, eliminates the ecological niche, and removes
acidity allowing remineralization.
 Use of carisolv (b) and lasers (c) for caries excavation has also
been suggested especially for those who don’t tolerate local
anesthetics.
(a)
(b)
(c)

MAINTENANCE PHASE :
 In the elderly, not only are the risk factors are many and co - exist; many of them cannot
be eliminated.
 Therefore caries activity will continue to remain high and unpredictable which might
even increase with advancing age.
 So maintaining low caries activity amidst increasing risk factors for the rest of their life
is challenging and many a times frustrating.
 With the mechanism of caries being the same in the young and the old, preventive
strategy also remains the same with minor modifications to suit the elderly.
 Daily use of fluoride dentifrices and fluoride rinses along with periodic topical fluoride
application regime is advisable.

 Fluoride varnishes may be preferred over other forms.
 Automated toothbrushes may be of some value in people with reduced dexterity.
Chlorhexidine gel/mouth rinses/varnishes are advised.
 10 % varnish is preferred over rinse/gel once a week for four weeks.
 New remineralization products containing casein phosphopeptide-amorphous calcium
phosphate (CPP-ACP), casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-
ACPF) , may also be of some benefit.
 Xylitol containing candies help not only in getting over the dryness but also prevents caries.
 3 FDAAPPROVED AGENTS
- All 3 are approved for tooth sensitivity
- All 3 are used off-label for caries prevention/reduction
• Fluoride Varnish
• Chlorhexidine Varnish
• Silver Nitrate(SN) / Silver Diamine Fluoride(SDF)
.

Dental update
 FLUORIDE VARNISH
- Are all Fluoride varnishes equal
- All are 25,000 ppm (5%)
 CHLORHEXIDINE VARNISH
- Cervitec Plus – 1% CHX and 1% Thymol
- Colorless transparent liquid - once dried its therapeutic level of CHX is 10% -
- Decreases dentin permeability up to 6 months - reduces antibacterial activity –
- CHX destroys cell membranes
- Thymol is an essential oil that is bacteriostatic and fungistatic - significant reduction in S
Mutans, S Sobrinus, Actin naeslundii and candida - many studies showing significant
caries reduction

• Silver acts as a -
- Strong antimicrobial,
- Fluoride promotes remineraliztion and ammonia stabilizes - 25% silver,
- • The treated lesion in mineral density and hardness while the lesion depth
• When SDF was applied to carious lesions , impressive prevention was seen for other surfaces
• Annual application prevented caries more than 4x/year flouride varnish
• Suggested application: every 6 months for 2 years (if a restoration is not placed).
• No adverse pulpal effects.

NON CARIOUS TOOTH TISSUE LOSS
• The mechanisms by which teeth wear include attrition, abrasion and erosion, that are rarely
ever seen isolated.
• It is for this reason that the more general term “tooth wear” was introduced by Smith and
Knight in 1984.
• In addition to long term wear and tear, several factors contribute to this phenomenon.
• Xerostomia results in the loss of buffering action of saliva making the teeth more
susceptible to acid erosion of teeth.
• Exposed cementum is susceptible to abrasion and erosion. Lack of proper posterior support
is another factor that gives rise to attrition.
• Consequences of tooth wear in the elderly include unsightly appearance, possible
development of caries in the exposed cemental / dentinal surfaces, sensitivity and
reduction in clinical crown height.

 Reduction in the height of the crowns of teeth is usually accompanied by progressive
eruption so that teeth continue to migrate incisally or occlusally together with the
alveolar bone, resulting in long bulky alveolar processes that helps to maintain the
occlusal vertical dimension.
 For problems concerning tooth wear, the need for treatment is decided on the degree
relative to the age of the patient, symptoms, patient's perceived needs and motivation.
 Generally, the treatment is directed towards eliminating etiological factors and
strengthening the modifying factors.
 Davies - treatment may be either passive or active.

PASSIVE TREATMENT
 Monitoring
 Prevention.
 Monitoring:
 Knowing whether tooth surface loss is progressive or static.
 Periodic checkup, study casts, photographs etc. made at different time intervals help in
assessing the progress.
 Preventive treatment is to ensure that there is no further tooth tissue loss and depends on
predominant etiological factors.
 If erosion is on account of excessive citrus fluid consumption, dietary modifications along
with fluoride regimen can be suggested.
 Most patients can be successfully managed only by passive treatment.
• Nadig RR, Usha G, Kumar V, Rao R, Bugalia A. Geriatric restorative care - the need, the demand and the challenges. J Conserv Dent
2011;14:208-14

ACTIVE TREATMENT
 Required for the following reasons such as sensitivity, aesthetics, functional difficulty
space loss in vertical dimension.
 Localized defects - attrition, abrasion or erosion can be restored by using composite
resin materials or glass ionomers depending on the location, occlusal load and esthetic
needs.
 Very few patients need advanced rehabilitative therapy.
 Careful selection of cases is essential after taking into consideration tolerability to stress
and the time involved in the treatment process as well as the motivation and the financial
status of the patient.

 Small increase in vertical dimension not more than 1-2 mm can be achieved by
reconstruction using direct composite build-up.
 More than 1-2 mm:
• involves more than one or two surfaces
• Extensive crown and bridge work
• Establishing centric relation with stabilization splint, prior to restoring the existing facial
height.
ESTHETIC REHABILITATION OF THE ELDERLY
• Simple recontouring procedures to bleaching, laminates and crowns.
• Any major esthetic rehabilitation should be undertaken only after proper occlusal and
esthetic analysis to achieve predictable results.

A) An older patient with tooth surface loss affecting the maxillary and mandibular anterior dentitions as a result of
long-term acid reflux and tooth grinding.
B) Selective crown lengthening and provision of full coverage porcelain crowns.
A)
B)

PREVENTIVE MEASURES FOR DENTAL DISEASES
The five golden rules for preventive dental diseases in geriatric patients are given below:-
 A well balanced diet - overall development, growth and maintenance of tooth structure,
connective tissue, alveolar bone and oral mucosa
 Don’t eat sweet or sticky foods between meals because high sugar diet have often been
associated with caries so such intake should be restricted.
 Regular brushing after every meals or at least every meal at night which helps to keep
teeth free of plaque and fight decay.
 Choose right toothbrush that fits comfortably in hand and is easy to control. Massage
your gums with your fingers after brushing and gently brush your tongue too.
 Visit your dentist regularly.

CONCLUSION
 The management of the elderly population differs from that of the general population
because of age-related physiological changes, the presence of age-related
conditions/diseases, increased incidence of physical and mental disabilities, and also
social and economic concerns.
 Geriatric dentistry is a specialized multidisciplinary branch of general dentistry
designed to provide dental services to elderly patients. Dental care should be integrated
into overall health management of all geriatric patients.

Clinical Changes in Epithelium
With age, oral mucosa has been reported to become
increasingly thin, smooth, and dry to have a stain like,
edematous appearance with loss of elasticity and stippling
and thus becomes more susceptible to injury.
Tongue exhibits loss of filliform papillae, and deteriorating
taste sensation with occasional burning sensation.
Histological Changes in Oral Mucosa
• Epithelial changes
• Connective tissue changes.
Epithelial Changes
These are:
• Decreased thickness of epithelial cell layer
• Reduced keratinization
• Alteration in the morphology of epithelial-connective
tissue interface
• Decrease in the length of retepegs of oral epithelium have
been reported with age
• Rate of cell renewal in human oral epithelia decreases with
aging.

Connective Tissue Change
• There is increase in number and density of elastin fibers.
Cellular changes are also reported, which include:
– Cells becoming shrunken
– Cells becoming inactive
– Reduction in number of cells.
Age Changes in Periodontal Connective Tissue
Structural Changes
• Gingival connective tissue becomes denser and coarsely
textured upon aging
• Decrease in the number of fibroblasts
• Decrease in the fiber content
• Increase in the size of interstitial compartments containing
blood vessels
• Evidence of calcification on and between the collagen
fibers. Connective Tissue Change
• There is increase in number and density of elastin fibers.
Cellular changes are also reported, which include:
– Cells becoming shrunken
– Cells becoming inactive
– Reduction in number of cells.

Age Changes in Salivary Glands
A common generalized association with aging
oral cavity
is the diminished function of salivary glands
which further
results in reduced salivation or xerostomia. The
main
consequences of xerostomia include dry
mouth, generalized
mouth soreness, burning or painful tongue,
taste changes,
chewing difficulty, problems with swallowing,
talking, and
reduced denture retention.
Age Changes in Bone Tissue
• Cortical thinning: The cortex thins and
porosity increases
from about an age of 40 to 80
• Loss of trabeculae
• Cellular atrophy
• Sclerosis of bone

Continued cementum deposition is seen with increasing
age thus moving cementodentinal junction (CDJ) farther
from the radiographic apex (Figs 35.9A to C).
• Calcifications are observed in the pulp cavity which can be
due to caries, pulpotomy or trauma and is more of linear
type. The lateral and accessory canals can be calcified,
thus decreasing their clinical significance.
• Reduced tubular permeability is seen as the dentinal
tubules become occluded with advancing age.
 The missing and titled teeth in older patients result in
change in the molar relationship, biting pattern in older
patients which can cause TMJ disorders.
• Reduced mouth opening in older patients increases
working time and decreases the space needed for
instrumentation.

Preventive regimen for elderly with dry
mouth
If it is drug induced and is causing major
discomfort, modifying the medication can be
considered in consultation with the attending
physician (substituting the drug with one
having lesser anti-cholinergic effect or altering
the time of medication). Symptomatic relief
could be obtained by asking the patient to sip
water frequently throughout the day and reduce
caffeine containing beverages. Instruct the
patient not to use sugar containing lozenges and
candies; instead replace them with Xylitol
containing gums and candies. In patients with
severe salivary gland dysfunction artificial
saliva can be prescribed that is available in the
form of gels, sprays and liquids.[24]

S 7 geriatric endodontic

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