GERIATRIC ENDODONTICS

GERIATRIC ENDODONTICS

DR. ABHISHEK JOHN SAMUEL

Dept. of Conservative Dentistry and Endodontics

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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

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CONTENTS IntroductionChief ComplaintDental HistorySubjective SymptomsObjective SignsMedi. Compromised IndividualsRadiographs

DiagnosisTreatment planPrognosisIsolation Access Opening Preparation ObturationConclusion

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• Expectations, Desire, Demands are least from any other group.

• The basic expectation of geriatrics are Functional• Geriatrics are not interested in long-term solutions

MISCONCEPTIONS

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Attrition

Erosion

Abrasion 8

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DiagnosisBased on

Pt’s complaintHistorySigns & symptomsTesting and radiographsVitality of the pulpPeraiapical 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

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

Objective TestingAs 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.

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Pulp TestingDetermine pulp & periapical statusVitality 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 prognosisChronic nature (periapical pathologic condition) vertically cracked teeth -prognosis - questionablePeriodontal pockets associated with cracks - a hopeless prognosis

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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 depositionThere is change in apical root anatomy.Sometimes there is apical root resorption.

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TREATMENT PLANThe 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. Tipping6. Rotation.

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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 lightJaw fatigue – bite block for long procedures Medically compromised patients- recognize that RCT is less traumatic than extractionNeed for anesthesia

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Painful response – not encountered till actual pulp exposure has occurred

Number of low threshold fibres are lessHigh conduction velocity nerve endings in dentin- reduced or absentCutting of dentin does not produce same level of response in an older patientDentinal 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

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.

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IsolationSingle 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 & gingivaArtificial saliva –used just before isolation –difficult-to-apply after dam placed

Canals should identified & their access maintained – restorative procedures are indicated for isolationFluid 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 – considered

Coronal tooth structure or restoration – compromised for access preparation Magnification range 2.5x to 4.5x

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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 – idealChelating – seldom value Dyes distinguish orifice from dentin Supra erupted tooth – easily perforate

Modification to enhance accessWidening the axial wall - visibility Complete removal of crown 21

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 procedureThorough & 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

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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 surgeryMedical consideration Local considerationPosition 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.

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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

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Dimensional change in the pulp size – due to dentin deposition.

Dentin formation - not necessarily continuous thro’ out life & not uniform deposition

with IrritationRestoration 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

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Comparison among the ages

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Attrition, Abrasion, Erosion

Expose dentin thro’ slow processAllows pulp to respond with dentinal sclerosis & reparative dentinSecondary dentin formn. thro’ out the life

Pulp obliteration

Maxi. Antr – Sec. dentin on the lingual wall of the pulp chamberMolar - on the floor of the chamberPulp 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

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• 100- 200 μm in youth Thickness of apical cementum 29

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32Feski J, Davies DM, Frances C, Gelbier S: The emotional effects of tooth loss in edentulous

people. Br Dent J 184:90, 1998.

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