Geriatric Endodontics : A Seminar

Introduction :

Endodontic considerations in the elderly patient are similar in many ways to those in the younger patients with some differences. This seminar discusses the similarities as well as the differences. Most of the elderly wil accept extraction only when there are no alternatives. Their expectations for dental health parallels their demand for quality medical care. A large chunk of our population consists of the old or the aged  and it is seen that there is a substantial increase in the longevity of their dentition, this is because of the increased awareness towards dental health and advanced restorative procedures. Treatment of geriatric patients require special care as the treatment procedure is more complex. Thus geriatric dentistry as a new speciality is slowly sprouting out. Endodontic considerations in the elderly age are not without challenges. These include biological, medical, and psychological differences from the younger patients as well as treatment complications. These considerations are further discussed in this seminar.

 

Biological considerations :

-          They are both systemic and local

-          In older patients there are no systemic or local changes particularly unique to endodontics that are different from those for other dental procedures. Similarly pulp and pulp and peri radicular tissues do not respond markedly differently than do other tissues.

Pulp response :

Changes with age :

2 considerations

i)        Structural (histologic) changes that take place as a function of time.

ii)      Tissue changes that occur in response to irritation from injury.

Both tend to have similar appearance in the pulp. In other words, injury may prematurely “age” a pulp. Therefore an old pulp may be found in a tooth of a younger person. I.e. a tooth that has experienced caries, restorations etc., whatever the etiology these older (injured) pulps react somewhat differently than do younger (or non injured) pulps.

Chronologic versus physiologic :

There is a debate as to which is more important, chronic or physiologic change, as to how a pulp responds to additional injury. The interpretation of what information is available is that a previously injured pulp probably has a less resistance to injury than the pulp in  an older individual. In any case pulp is tough and can withstand damage but only to a point.

Structural changes :

            The pulp is a dynamic connective tissue. with age there are changes in cellular, extracellular and supportive elements. There is gradual decrease in cells including both odontoblasts and fibroblasts and a concomitant increase in the number of thickness of collage fibres particularly in the radicular pulp. The thick collagen fibres may serve as foci for Pulpal calcification. The odontoblasts decreases in size and number and they may disappear altogether in certain areas of the pulp. Particularly on the Pulpal floor over the bifurcation and trifurcation areas of multirooted teeth.

            There is also decrease in the supportive elements i.e. blood vessels and nerves. Evidence suggests that aging results in an increase in the resistance of pulp tissue to the action of proteolytic enzymes, hyaluronidase and sialidase suggesting an alteration in both collagen and proteoglycans in the pulp of older teeth.

Calcifications :

            These include denticles (pulp stones) and diffuse (linear) calcifications. Pulp stones are found in coronal pulp and diffuse calcifications in radicular pulp. These increase is the with age  as well as in the irritated pulp.

            Other changes taking place are :

-          Increase in peritubular dentin

-          Increase in dentinal sclerosis – produces gradual decrease in dentinal permeability as the tubules reduce in diameter

-          Increases in number of dead tracts.

Dimensional changes :

            Continued formation of secondary dentin throughout age gradually decreases the size of the pulp chamber and root canals although the width of the cementodentinal junction appears to stay relatively the same. Dentin formation is not necessarily continuous through out life but it often does occur and may be accelerated by irritation from caries, restorations and periodontal disease.

NATURE OF RESPONSE TO INJURY

           

            The older patient does tend to have more adverse pulpal reactions to irritation than those that occur in the younger patient. The reason for these differences is debatable and not fully understood, but they are probably the result of a lifetime of cumulative injuries.

 

Iatrogenic Reasons :

There are reasons for pulp pathosis after restorative procedures. First, the tooth may have experienced several injuries in the past. Second, there are likely to be more extensive procedures that involve considerable tooth structure, such as crown preparation. There are multiple potential injuries associated with a full crown: foundation placement, bur preparation, impressions, temporary crown placement (often these leak), cementation, and unsealed crown margins. The final insult to a pulp that is already compromised may be that final restoration.

 

Age :

            Although it would seem that a pulp with fewer cells, blood vessels, and nerves would be less resistant to injury, this has not been proven. Pulp responses to various procedures in different age groups have not shown differences, although the large number of variables In these types of clinical studies make it difficult to isolate age as a factor. This is not necessarily the case with the immature tooth (open apex), in which pulps have indeed been shown to be more resistant to injury. There are some who theorize that pulps in older teeth may, in fact, be more resistant because of decreased permeability of dentin. Again this resistance to injury in old teeth has not been proven. The bottom line is that older pulps in older patients do require more care in preparation and restoration; this is probably due to a history of previous insults rather than age per se.

 

Systemic Conditions

            There is no conclusive evidence that systemic or medical conditions directly affect (decrease) pulp resistance to injury. One proposed condition is atherosclerosis, which has been presumed to directly affect pulp vessels; however the phenomenon of pulpal atherosclerosis could not be demonstrated.

 

Periradicular Response

            Little information is available on changes of bone and soft tissues with age, and how these might affect the response to irritants or to subsequent healing after removal of those irritants. The indicators are that there is relatively little change in periradicular cellularity, vascularity, or nerve supply with aging. Therefore it is unlikely that there are significantly different periapical responses in older compared with younger individuals.

 

Healing

            There is a popular concept that healing in older individuals is impaired, compromised, or delayed compared with that in younger patients. This is not necessarily true. Studies in animals have shown remarkably similar patterns of repair of oral tissues in young versus old, but with a slight delay in healing of response. Radiographic evidence of healing of younger versus older patients after root canal treatment demonstrated no apparent difference in success and failure. There is no evidence that vascular or connective tissue changes in older individuals result in significantly slower or  impaired healing. Overall, there is little difference in the speed or nature of healing between the different age groups; this includes both bone and soft tissue. Critical to healing is vascularity. Current research indicates that in healthy individuals, mucosal blood flow is not impaired with age (Effect of ageing in oral mucosa and skin. Boca Raton, FL., CRC Press, 1994, p 99).

 

Medically Compromised Patients

            Certainly, systemic problems in the older patient tend to occur more often and with greater severity. In general, medical conditions are no more significant for endodontic procedures in the older patient than for other types of dental treatment. In fact, there is little information on the relationship of medical conditions or medically compromised patients as to adverse reactions during or after endodontic procedures.

            It has been presumed that systemic conditions such as diabetes or immunosuppressant therapy would predispose an endodontic patient to infection or to delayed healing. There is no evidence that this presumption is true nor that these conditions will have more of an adverse effect in elderly patients. There is concern, however, about the person with severe, uncontrolled diabetes, who may require additional precautions and careful monitoring.

            Of interest is osteoporosis, a rather common condition of older women. There is evidence that osteoporosis is associated with a decrease in trabecular bone density in the jaws, particularly in the anterior maxilla and the posterior mandible., However it is not known whether patients with fact, it has been demonstrated that there is always a pulp space, even when it is not visible radiographically. Apical root and canal anatomy tends to be somewhat different in elderly patients because of continued cementum formation. This may be further complicated by apical root resorption from pathosis.

Diagnosis:

The same basic principles of diagnosis apply with older as with younger patients. As previously indicated the biologic differences are minimal but do occur. There are  some considerations to keep in mind.

Diagnostic Procedure:

It is important that a routine sequence be applied to diagnosis, particularly with the elderly.the most important findings are from the subjective examination to determine symptoms and history. Careful questioning then allowing sufficient time for the patient to recall and answer, often yields valuable information.

 

Chief Complaint

            Most patients who are experiencing pain have a pulpal or periapical problem that requires root canal treatment or extraction. Dental needs are often manifested initially in the form of a complaint which usually contains the information necessary to make a diagnosis.

            Allow the patient to express the problem in his / her own words. Not only will this divulge symptoms but it also provides an opportunity to determine the patients dental knowledge and ability to communicate and a rapport is set. This ability may be impaired because of problems with sight, hearing and mental status. Consultation with family, friends or physician is then done.

            Most geriatric patients do not complain about signs and symptoms of Pulpal and periapical diseases and may consider them minor when compared to their other health problems.

            Pain associated with vital pulps (i.e. referred pain, pain caused by heat, cold or sweets) seem to reduce with age and severity diminishes over time. Heat sensitivity that occur as the only symptom suggests a reduced pulp volume such as that occurring in older pulps.

            Pulp healing capacity is also reduced and necrosis may occur quickly after microbial invasion, again with reduced symptoms.

            The best patients are those who have had a successful root canal treatment.

  

MEDICAL HISTORY

            It is important to focus on those factors that will truly indicate the risks undertaken in treating the older patient. Clinicians must recognize that the biologic or functional age of an individual is far more important than chronologic age. A medical history should be taken before the patient is brought into the treatment room, and a standardized form should be used to identify any disease or therapy that would alter treatment or its outcome. In general, aging causes dramatic changes to the cardiovascular, respiratory, and central nervous system (CNS) that results in most drug therapy needs. However, the decline in renal and liver function in older patients should also be considered when predicting behavior and interaction of drugs (e.g. anesthetics, analgesics, antibiotics) that may be used in dental treatment.

            The review of the patients’ medical history is the first opportunity for the dentist to talk with the patient. The time and consideration taken at the outset will set the tone for the entire treatment process. This first impression should reflect a warm, caring practitioner, who is highly trained and able to help patients with complex treatments. Some older patients may need assistance in filling out the forms and may not be fully aware of their conditions or history. Some patients may withhold their date of birth to conceal their age for reasons of vanity or even fear of ageism. Vision deficits caused by outdated glassed or cataracts can adversely affect a patient’s ability to read the small print on many history forms. Consultation with the patient’s family, guardian, or physician may be necessary to complete the history; however, the dentist is ultimately responsible for the treatment.

            An updated history, including information on compliance with any prescribed treatment and sensitivity to medications, must be obtained at each visit and reviewed. In general, older adults use more drugs than younger patients, and most of these medications are potentially important to the dentist. The physicians’ Desk Reference should be consulted and any precaution or side effect of medication noted.

            Although geriatric patients are usually knowledgeable about their medical history, some may not understand the implications of their medical conditions in relation to dentistry or may be reluctant to let the clinician into their confidence. Their perceptions of their illnesses may not be accurate, so any clue to a patient’s conditions should be investigated.

            Symptoms of undiagnosed illnesses may present the dentist with a screening opportunity that can disclose a condition that might otherwise go untreated or lead to an emergency. Management of medical emergencies in the dental office is best directed toward prevention rather than treatment.

            Few families are there with at least one member whose life has been extended as a result of medical progress. A great number have had diseases or disabilities controlled with therapies that may alter the clinician’s case selection. Root canal treatment is certainly far less traumatic in the extremes of age or health than is extraction.

 

DENTAL HISTORY

            The clinician should search patients’ records and explore their memories to determine the history of involved teeth or surrounding areas. The history may be as obvious as a recent pulp exposure and restoration, or it may be as subtle as a routine crown preparation 15 or 20 years ago. Any history of pain before or after treatments may establish the beginning of a degenerative process. Subclinical injuries caused by repeated episodes of decay and its treatment may accumulate and approach a clinically significant threshold that can be later exceeded after additional routine procedures. Multiple restorations on the same tooth are common.

            Recording information at the time of treatment may seem to be unnecessary “busy work,” but it could prove to be helpful in identifying the source of a complaint or disease many years later. A patient’s recall of dental treatments is usually limited to a few years, but the presence of certain materials or appliances, such as silver points, can sometimes date a procedure. Aging patients’ dental histories are rarely complete and may indicate treatment by several dentists at different locations. They likely have outlived at least one dentist and been forced to establish a relationship with a new, younger dentist. This new dentist may find dental needs that require an updated treatment plan.

Subjective symptoms :

            The examiner can pursue responses to questions about the patient’s compliant, the stimulus or irritant that causes pain, the nature of the pain, and its relationship to the stimulus or irritant. This information is most useful in determining whether the source is pulpal disease, whether inflammation or infection has extended to the apical tissues, and whether these problems are reversible. Thus the dentist can determine what types of tests are necessary to confirm findings or suspicions.

Diagnostic procedures :

            It is important to remember that pulpal symptoms are usually chronic in older patients, and other sources of orofacial pain should be ruled out when pain is not soon localized. Much of the information to be obtained from the complaint, history, and description of subjective symptoms can be gathered in a screening interview by the clinician’s assistant or over the phone by the receptionist. The need for treatment can be established and can provide a focus for the examination.

Objective signs :

            The intraoral and extraoral clinical examination provides valuable first-hand information about disease and previous treatment. The overall oral condition should not be overlooked while centering on the patient’s complaint, and all abnormal conditions should be recorded and investigated. Exposure to factors that contribute to oral cancers accumulate with age, and many systemic diseases may initially manifest prodromal oral signs or symptoms.

            Missing teeth contribute to reduced functional ability. The resultant loss of chewing efficiency leads to a higher carbohydrate diet of softer, more cariogenic foods. Increased sugar intake to compensate for loss of taste and xerostomia (often induced by medication) are also factors in the renewed susceptibility to decay.

            Gingival recession, which creates sensitivity and is hard to control, exposes cementum and dentin that are less resistant to decay. A clinical study of 600 patients older than age 60 showed that 70% had root caries and 100% had some degree of gingival recession. The removal of root caries is irritating to the pulp and often results in pulp exposures or reparative dentin formation that affect the negotiation of the canal, should root canal treatment later be needed. Asymptomatic pulp exposures on one root surface of a multirooted tooth can result in the uncommon clinical situation of the presence of both vital and nonvital pulp tissue in the same tooth.   

Interproximal root caries is difficult to restore, and restoration failure as a result of continued decay is common. Although the microbiology of diseases is not substantially different in different age groups, the altered host response during aging may modify the progression of these diseases.

Attrition. Abrasion, and erosion also expose dentin through a slower process that allows the pulp to respond with dentinal sclerosis and reparative dentin. Secondary dentin formation occurs throughout life and may eventually result in almost complete pulp obliteration. In maxillary anterior teeth, the secondary dentin is formed on the lingual wall of the pulp chamber ; in molar teeth the greatest deposition occurs on the floor of the chamber. Although this pulp may appear to recede, small pulpal remnants can remain or leave a less calcific tract that may lead to a pulp exposure.   

In general, canal and chamber volume is inversely proportional to age: as age increases, canal size decreases. Reparative dentin resulting from restorative procedures, trauma, attrition, and recurrent caries also contributes to diminution of canal and chamber size. In addition, the cementodentinal junction (CDJ) moves farther from the radiographic apex with continued cementum deposition. The thickness of young apical cementum is 100 to 200 mm and increases with age to two or three times that thickness.   

The calcification process associated with aging appears clinically to be of a more linear type than that which occurs in a younger tooth in response to caries, pulpotomy, or trauma. Dentinal tubules become more occluded with advancing age, decreasing tubular permeability. Lateral and accessory canals can calcify, thus decreasing their clinical significance.

            The compensating bite produced by missing and tilted teeth (or attrition) can cause temporomandibular joint (TMJ) dysfunction (less common in older adults) or loss of vertical dimension. The authors have observed diminished eruptive forces with age, reducing the amount of mesial drift and supra eruption. Any limitation on opening reduces available working time and the space needed for instrumentation.

            The presence of multiple restorations indicates a history of repeated insults and an accumulation of irritants. Marginal leakage and microbial contamination of cavity walls is a major cause of pulpal injury. Violating principles of cavity a reduced organic component to the dentin to increase susceptibility to cracks and cuspal fractures. In any further restorative procedures on such teeth, the clinician should consider the effect on the pulp and the effect on accessing and negotiating canals through such restorations if root canal therapy is indicated later.

            Many cracks or craze lines may be evident as a result of staining, but they do not indicate dentin penetration or pulp exposure. 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.

Periodontal disease may be the principal problem for dentate seniors. The relationship between pulpal and periodontal disease can be expected to be more significant with age. Retention of teeth alone demonstrates some resistance to periodontal disease. The increase in disease prevalence is largely attributable to an increase in the proportional size of the population who have retained their teeth. The periodontal tissues must be considered a pathway for sinus tracts. Narrow, bony-walled pockets associated with nonvital pulps are usually sinus tracts, but they can be resistant to root canal therapy alone when, with time, they become chronic periodontal pockets.

Periodontal treatment can produce root sensitivity, disease, and pulp death. In developing a successful treatment plan it is important to determine the effects of periodontal disease and its treatment on the pulp. The mere increase in incidence and severity of periodontal disease with age increases the need for combined therapy. The chronic nature of pulp disease demonstrated with sinus tracts can often be manifested in a periodontal pocket. Root canal treatment is commonly indicated before root amputations are performed. With age, the size and number of apical and accessory foramen are actually reduced as pathways of communication, as is the permeability of dentinal tubules.

Examination of sinus tracts should include tracing with gutta – percha cones to establish the tracts’ origin. Sinus tracts may have long clinical histories and usually indicate the presence of chronic periapical inflammation. Their disappearance after treatment is an excellent indicator of healing. The presence of a sinus tract reduces the risk of interappointment or postoperative pain, although drainage’ may follow canal debridement or filling.

Pulp testing :

            Information collected from the patient’s complaint, history, and examination may be adequate to establish pulp vitality and to direct the clinician toward the techniques that are most useful in determining which tooth or teeth are the object of the complaint. Slow and gentle testing should be done to detemine pulp and periapical status and whether palliative or definitive therapy is indicated. Vitality responses must correlate with clinical and radiographic findings and be interpreted as a supplement in developing clinical judgment.

Transilluminating and staining have been advocated as means to detect cracks, but the presence of cracks is of little significance in the absence of complaints because most older teeth, especially molars, demonstrate some cracks. Vertically cracked teeth should always be considered when pulpal or periapical disease is observed and little or no cause for pulpal irritation can be observed clinically or radiographically. The high magnification available with microscopes during access opening and canal exploration permits visualization of the extent of cracks in determining prognosis. Cracks that are detected while the pulp is still vital can offer a reasonable prognosis if immediately restored with full cuspal coverage. The chronic nature of any periapical pathologic condition caused by vertically cracked teeth indicates that it is long-standing, and the prognosis is questionable (even when pocket depths appear normal). Periodontal pockets associated with cracks indicate a hopeless prognosis. 

The reduced neural and vascular components of aged pulps, the overall reduced pulp volume, and the change in character of the ground substance create an environment that responds differently to both stimuli and irritants than that of younger pulps.

There are fewer nerve branches in older pulps. This may be due to retrogressive changes resulting from mineralization of the nerve and nerve sheath. Consequently, the response to stimuli may be weaker than in the more highly innervated younger pulp.          

No correlation exists between the degree of response to electric pulp testing and the degree of inflammation. The presence or absence of response is of limited value and must be correlated with other tests, examination findings, and radiographs. Extensive restorations, pulp recession, and excessive calcifications are limitations in both performing and interpreting results of electric and thermal pulp testing. Attachments that reduce the amount of surface contact necessary to conduct the electric stimulus are available (Analytic Technology, Orange County, Calif.) and bridging the tip to a small area of tooth structure with an explorer has been suggested. Use of even this small electric stimulus in patients with pacemakers is not recommended; any such risk would outweigh the benefit. The same caution holds true for electrosurgical units.

            A test cavity is generally less useful and used as the test of last resort because of reduced dentin innervation. Vital pulps can produce pain; then the root canal treatment becomes part of the diagnostic procedure. Test cavities should be used only when other findings are suggestive but not conclusive.

            Diffuse pain of vague origin is also uncommon in older pulps and limits the need for selective anesthesia. Pulpal disease is progressive and produces signs or symptoms in a relatively short time. Nonodontogenic sources should be considered when factors associated with pulpal disease are not readily identified or when acute pain does not localize within a short time.

            Discoloration of single teeth may indicate pulp death, but this is a less likely cause of discoloration with advanced age. Dentin thickness is greater and the tubules are les 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 ; however, this is common in older teeth.

Radiographs :

Indications for and techniques of taking radiographs do not differ much among adult age groups. However, several physiologic, anatomic changes can significantly affect their interpretation. Film placement may be adversely affected by tori but can be assisted by the depth of the vestibule. Older patients may be less capable of assisting in film placement, and holders that secure the position should be considered. The presence of tori, exostoses, and denser bone may require increased exposure times for proper diagnostic contrast. The subjective nature of interpretation can be reduced with correct processing, proper illumination, and magnification.

            The periapical area must be included in the diagnostic radiograph, which should be studied from the crown toward the apex. Angled radiographs should be ordered only after the original diagnostic radiograph suggests that more information is needed for diagnosis or to determine the degree of difficulty of treatment. Radio VisioGraphy (RVG) may be more useful than conventional radiography in detecting early bone changes.

            In older patients, pulp recession is accelerated by reparative dentin and complicated by pulp stones and dystrophic calcification. Deep proximal or root decay and restorations may cause calcification between the observable chamber and root canal.

            The depth of the chamber should be measured from the occlusal surface and its mesiodistal position noted. receding pulp horns that are apparent on a radiograph may remain microscopically much higher. Deep restorations or extensive occlusal crown reduction may produce pulp exposures that were not expected. The axial inclinations of crowns may not correlate with the clinical observation when fixed or removable appliances are present. Access to the root canals is the most limiting condition in root canal treatment of older patients.

            Canals should be examined for their number, size, shape, and curvature. Comparisons to adjacent teeth should be made. Small canals are the rule in older patients. A midroot disappearance of a detectable canal may indicate bifurcation rather than calcification. Canals calcify evenly throughout their length unless an irritant (e.g., decay, restoration, cervical abrasion) has separated the chamber from the root canal. The lamina dura should be examined in its entirety and anatomic landmarks distinguished from periapical radiolucencies and radiopacities. The incidence of some odontogenic and nonodontogenic cysts and tumors characteristically increases with age, and this should be considered when vitality tests do not correlate with radiographic findings. However, the incidence of osteosclerosis and condensing osteitis decreases with age.

            Resorption associated with chronic apical periodontitis may significantly alter the shape of the apex and the anatomy of the foramen through inflammatory osteoclastic activity. The narrowest point in the canal may be difficult to determine; it is positioned farther from the radiographic apex because of continued cementum deposition.

            A continued normal rate of cementum formation may be demonstrated by a canal or foramen that appears to end or exit short of the radiographic apex, and hypercementosis may completely obscure the apical anatomy.

DIAGNOSIS AND TREATMENT PLAN :

            A clinical classification that accurately reflects the histologic status of the pulp and periapical tissues is not possible and not necessary beyond determining whether root canal treatment is indicated. A clinical judgment can be made, based on the patients’s complaint, history, signs, symptoms, testing, and radiographs, as to the vitality of the pulp and the presence or absence of periapical pathologic conditions. this classification has not been shown to be a factor in predicting success, interappointment or postoperative pain, or the number of visits necessary to complete treatment when the objectives of cleansing, shaping, and filling are clearly understood and consistently met. Of great clinical significance in treatment procedures is the assessment of pulp status to determine the depth of anesthesia necessary to perform the treatment comfortably.

            One appointment procedures offer obvious advantages to older patients. The length of a dental appointment does not usually cause inconvenience, as may more numerous appointments, especially if a patient must rely on another person for transportation or needs physical assistance to get into the office or operatory.

            Root canal treatment as a restorative expediency on teeth with normal pulps must be considered when cusps have fractured or when supraerupted or malaligned teeth, intracoronal attachments, guide planes for partial abutments, rest seats, or overdentures require significant tooth reduction. Predicting the need for future root canal treatment and a clinician’s ability to perform treatment later is even more important, because the risk of losing the restoration during later access preparation increases with the thickness of the restoration and the reduction in canal size. because of a reduced blood supply, pulp capping is not as successful in older teeth as in younger ones; therefore it is not recommended. Any risk to the patient’s future health and the effect that health may have on his or her ability to withstand future procedures should also be considered. Endodontic surgery at a later time is not as viable an alternative as for a younger patient.       

  

CONSULTATION AND CONSENT OF THE PATIENT :

            Good communication should be established and maintained with all the patients, regardless they are physically impaired.

§  In consultation relatives and friends are friends are included whose judgement is valued by the patient, however, the clinician should direct the discussion towards the patient.

§  All the procedures should be properly explained to the patients. “Patient Friendly” pamphlets are also available which should be given to the patients before the treatment.

§  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.

TREATMENT :

            The majority of geriatric patients who need endodontic therapy are ambulatory and not institutionalized. For ambulatory patients clinicians trained in those environments are required.

            The dental office building, should includes both interior and exterior design that can accommodate people with special needs.

            Needs such as wheelchairs, walker should be present in dental office.

            Proper packing space, reception room, operatory and rest room should be present.

            Proper Physical and Mental evaluation of the patient should be done. Patient’s daily personal, eating and resting habits should be considered.

            Morning appointments are preferable for some older patients, but some patients late morning or early afternoon visits to allow ‘morning stiffness’ to decrease.

Chair Position :

            Older patients are likely to tolerate longer appointments so chair positioning should be very much comfortable for the patients. Patients should be assisted into and out of the chair. Chair adjustments are made slowly. Sometime pillows are also offered to make patient more comfortable.

            Patient’s eyes should be protected or shredded to protect them from light. In cold environment blanket should be offered to the patients after performing the procedure ‘REST ROOM BREAK’ should be given to the patient and jaw fatigue can occur so rest to be given.

            From behavioural and management point of view, geriatric patients are most co-operative, and appreciate.

LOCAL ANESTHESIA :

1. While performing root canal therapy sometimes they have to be convinced to take local anaesthesia as at times they can do without it.
2. Cutting of dentin does not perform same level of response in older patient because of less number of low threshold, high conduction velocity nerve endings and do not extend for into dentin. In some cases these nerve endings are even absent. A painful response in some cases may occur when there is actual pulpal exposure.
3. Anatomic landmarks for needle placement are more pronounced in older patients LA should be deposited very slowly.
4. Reduced width of periodontal ligament makes needle placement for intraligamentary injection is more difficult.

While given intraossoeus injection one thing should be kept in mind that intraosseous anesthesia is not prolonged.

Because of this reason pulp tissue should be removed within 20 minutes. In older individual intraosseous anesthesia with 2% Lidocaine with 100,000 epinephrine solution leads to increase heart rate, therefore in these cases 3% Mepivacaine can be administered.

Because of reduced volume of pulp chamber, intra pulpal anesthesia is difficult in single rooted teeth and almost impossible in multirooted teeth.

In such cases wedging the needle in the canal to produce pressure for anaesthesia is last resort.

In geriatric patients every effort should be made to produce profound anaesthesia.

Isolation

            Single tooth rubber dam isolation should be use whenever possible. Badly broken-down teeth may not provide an adequate purchase point for the rubber dam clamp, and alternate rubber dam isolation methods should be considered. Multiple-tooth isolation may be used if adjacent teeth can be clamped and saliva output is low or a well-placed saliva ejector can be tolerated. A petroleum-based lubricant for the lips and gingiva reduces chafing from saliva or perspiration beneath the rubber dam. Reduction in salivary flow and gag reflex reduces the need for a saliva ejector. Artificial saliva is available and should be used just before isolation because it is difficult to apply after the dam is in place.

            Canals should be identified and their access maintained if restorative procedures are indicated for isolation. The clinician should not attempt isolation and access in a tooth with questionable marginal integrity of its restorations. Fluid-tight isolation cannot be compromised when sodium hypo-chlorite is used as an irrigant. Difficult-to-isolate defects produced by root decay present a good indication, in initial preparation, for the use of sonic hand pieces that use flow-through water as an irrigant.

            The many merits of single visit root canal procedures should again be considered when isolation is compromised. The few minor benefits of multiple visit treatment are further reduced if an interappointment seal is difficult to obtain.

Access :

Adequate access and identification of canal orifice is most difficult part of providing root canal treatment.

Although multiple restorations and physiological changes may reduce the volume of pulp but buccolingual and mesiodistal positions remains the same.

Coronal tooth structure and restorations may be sacrificed when they compromise access cavity preparation.

While using surgical microscopes, magnifications in the range of 2.5x to 4.5 x are most comfortable. And these microscopes offer clear magnification of up to 25x or greater.

Locating calcified canal is most difficult and time consuming. In such cases most important tool is DG16 explorer. Now once the orifice is located and stainless steel 21 mm No.8 or No.10 K-files are used.

Initially NiTi files are not recommended and are contraindicated as they lack strength in long axis.

Canals negotiated with watch winding motion with slight apical pressure.

Chelating agents are also used for negotiating canals and lead to perforation. In such cases repair should be done immediately.

Pain, bleeding or unfamiliar feel can lead to perforation. In such cases repair should be done immediately.

Sometimes it will take long time for searching a canal which is irritating to both clinician and the patient in such cases we should always opt for second appointment.

Preparation :

            The calcified appearance of the canals resulting from the aging process presents a much different clinical situation than that of a younger pulp in which trauma, pulpotomy, decay, or restorative procedures have induced premature canal obliteration. Unless further complicated by reparative dentin formation, this calcification appears to be much more concentric and linear. This allows easier penetration of canals once they are found. An older tooth is more likely to have a history of earlier treatments, with a combination of calcifications present. 

            The length of the canal from the actual anatomic foramen to the CDJ increases with the deposition of cementum throughout life. The advantage of this situation in the treatment of teeth with vital pulps is countered by the presence of necrotic, infected debris in this longer canal when periapical pathosis is already present. The actual CDJ width or most apical extent of the dentin remains constant with age.

            Flaring of the canal should be performed as early in the procedure as possible to provide for a reservoir of irrigation solution and to reduce the stress on metal instruments that occurs when they bind with the canal walls. Thorough and frequent irrigation should be performed to remove the debris that could block access. 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 should be considered.

            Because this CDJ is the narrowest constriction of the canal, it is the ideal place to terminate the canal preparation. This point may vary from 0.5 to 2.5 mm from the radiographic apex and be difficult to determine clinically. Calcified canals reduce the clinician’s tactile sense in identifying the constriction clinically, and reduced periapical sensitivity in older patients reduces the patient’s response that would indicate penetration of the foramen. Increased incidence of hypercementosis, in which the constriction is even farther from the apex, makes penetration into the cemental canal almost impossible. Achieving and maintaining apical patency is more difficult. Apical root resorption associated with periapical pathosis further changes the shape, size, and position of the constriction. The use of electronic, apex finding devices is sometimes limited in heavily restored teeth when contact with metal can bleed off the cement.

            The frequency and intensity of discomfort after instrumentation has not been shown to be related to the amount of preparation, the type of interappointment medication or temporary filling, the pulp or periapical status, the tooth number or age, or whether the root canal filling is completed at the same appointment. The more constricted dentin and cementum junction (DCJ) permits a much smaller pulp wound and resists penetration, even with the initial small files. Patency is difficult to establish and maintain. Dentin debris creates a matrix early in the preparations and further reduces the risk of overinstrumentation or the forcing of debris into the periapical tissues, which could cause an acute apical periodontitis or abscess. Further access to periapical tissues through the canal is likewise limited. 

Working Length :

            Because of this working length of 1-2 mm short of radiographic apex is preferred.

Intracanal Medicaments :

            These are contraindicated with exception of calcium hydroxide. This is antimicrobial agent and inhibits growth between appointments and also may release periapical inflammation.

            It is indicated if pulp is necrotic and canal preparation is essentially complete.

Obturation :

            In geriatric patients gutta percha filling techniques are preferred with cold lateral and warm vertical obturation techniques. Hence coronal seal plays very important role and also permanent restorative procedures should be finished as soon as possible.

ENDODONTIC SURGERY

            Generally considerations and indications for endodontic surgery are not affected by age. The need for establishment of drainage and relief of pain are not common indications for surgery. Anatomic complications of the root canal system, such as small or completely calcified canals, nonnegotiable root curvatures, extensive apical root resorption, or pulp stones, occur with greater frequency in older patients. Perforation during access, losing length during instrumentation, ledging, and instrument separation are iatrogenic treatment complications associated with treatment of calcified canals.

            Medical considerations may require consultation but do not contraindicate surgical treatment when extraction is the alternative. In most instances surgical treatment may be performed less traumatically than an extraction, which may also result in the need for surgical access to complete root removal. A thorough medical history and evaluation should reveal the need for any special considerations, such as prophylactic antibiotic premedication, sedation, hospitalization, or more detailed evaluation.

            Local considerations in treatment of older patients include an increase in the incidence of fenestrated or dehisced roots and exostoses. The thickness of overlying soft and bony tissue is usually reduced, and apically positioned muscle attachments extend the depth of the vestibule. Smaller amounts of anesthetic and vasoconstrictor are needed for profound anesthesia. Tissue is less resilient, and resistance to reflection appears to be diminished. The oral cavity is usually more accessible with the teeth closed together because the lips can more easily be stretched. The apex can actually be more surgically accessible in older patients. Agility to gain such access varies with skill of the surgeon; however, some areas are unreachable by even the most experienced clinicians.

            The position of anatomic feat prophylactic antibiotic premedication, sedation, hospitalization,ures, such as the sinus, floor of the nose, and neurovascular bundles, remains the same, but their relationship to surrounding structures may change when teeth have been lost. The need may arise to combine endodontic and peridontic flap procedures, and every effort should be made to complete these procedures in one sitting.

            When apicoectomy is to be performed, the surgeon must consider whether the root that will be left is long enough and thick enough for the tooth to continue remain functional and stable. This factor is especially important when the tooth will be used as an abutment.

            Ecchymosis is a 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.

RESTORATION :

            Root canal treatment saves roots, and restorative procedures save crowns. Combined, these procedures are returning more teeth to form and function than was thought possible just a few decades ago. Special consideration must be given to post design, especially when small posts are used in abutment teeth; root fracture is common in older adults when much taper is used. Post failure or fracture occurs when small diameter parallel posts are used. Posts are not usually needed when root canal treatment is performed through an existing crown that will continue to be used.

            The value of the tooth, its restorability, its periodontal health, and the patients wishes should be part of the evaluation preceding endodontic therapy. The restorability of older teeth can be affected when root decay has limited access to sound margins or reduced the integrity of remaining tooth structure. There can also be insufficient vertical and horizontal space when opposing or adjacent teeth are missing. Patient desires to save appliances can sometimes be fulfilled with creative attempts that may outlive them.

            In conclusion, it can be seen that geriatric endodontics will gain a more significant role in complete dental care as our aging population recognizes that a complete dentition, and not complete dentures, is a part of their destiny. 

SUCCESS AND FAILURES :

            Factors leading to failures increases with age as a result of this retreatment is more common in older individuals.

            Rate of bone formation and normal resorption decreases with age and also ageing results in greater porosity.

            In geriatric patients 6 moths recall visit may not be adequate and it may take as long as 2 years to produce healing that would occur at 6 minutes in an adolescent.

•         In conclusion, it can be seen that geriatric endodontics will gain a more significant role in complete dental care as our aging population recognizes that a complete dentition, and not complete dentures, is a part of their destiny.

REFERENCES:

•         DCNA: Walton RE; Endodontic considerations in the geriatric patients, Volume 41; Number 4; October 1997 p. 795-816

•         Stephen Cohen; Cohen’s Pathways of the Pulp 10^th Ed.

•         Charles H. Rankin; Tufts Open Course Ware, Geriatric Dentistry 2005.

•         Dr. Mithra N. Hegde; Textbook of Endodontics 1^st Ed.

•         Vimal K. Sikri; Essentials of endodontics.