GERIATRIC ENDODONTICS

2. Introduction
Chief Complaint
Dental History
Subjective Symptoms
Objective Signs
Medi. Compromised
Individuals
Radiographs

3. Diagnosis
Treatment plan
Prognosis
Isolation
Access Opening
Preparation
Obturation
Endodontic surgery
Conclusion

4. Geriatric Dentistry Or Gerodontics is 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.
Geriatric Endodontics is Endodontic Consideration for the
Older Adults.

5.  The World Health Organization Categorizes Aging
Population into four classes:
 Aging individuals 45-60 years old
 Older individuals 61-75 years old
 Old individuals 76-90 years old
 Very Old individuals 91-100 years old

6. Endodontic considerations in geriatric patients are
not without challenges.
Challenges include.
Biological
Medical
Psychological and
Treatment Complications.

7. Pulp response
Nature of pulp response to injury
Periradicular response
Healing

8. Changes with age:
Structural (histologic) changes as a
function of time
Tissue changes – response of irritation from injury.
Injury prematurely can age a pulp
Chronological and physiologic aging
Injured or irritated pulp, which has aged, is considered to
react less favorably than an aged pulp in an old individual.

9. 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.

10. Dimensional change
 in the pulp size – due to dentin deposition.
Dentin formation - not necessarily continuous throughout
life & not uniform deposition
 with Irritation
Restoration or
Periodontal disease.

11.  Molars: More on the roof and floor of the pulp chamber
than on walls leading to flattened disc like chamber.
 In maxillary anterior teeth secondary dentin formation:
occurs at lingual wall of pulp chamber

12. Older patients pulp has more adverse pulpal reactions than
in similar conditions in younger patients.
The reasons cited are
Iatrogenic
Tooth experienced severe injuries in the past.
Injury due to crown preparation, crown placement and
final restorations.

13. Age
Few cells or blood vessels
no more different than young persons teeth with a
completed root apex.
Systemic conditions
Atherosclerosis, though not much effect is seen in pulpal
vessels is seen as a reason.

14.  Little information is available but is considered to be not
much different from the young.
 Reason: There is relatively little change in periradicular
cellularity, vascularity, or nerve supply with aging.

15. A slight delay in healing may be present but with similar
patterns of repair of oral tissues.
No difference in radiological healing after endodontic
treatment
Mucosal vascularity is no different in healthy olds than
young, this healing of soft tissue also shows minimal
difference.

16.  In general geriatric patient suffers from either
cardiovascular, respiratory or central nervous system
diseases and as a result of this they are on drug therapy.
 Blood Pressure: For geriatric patient normal blood
pressure is 140/90 mm Hg. It is said that no treatment
should be done when blood pressure i.e. diastolic BP is
over 100 mm of Hg.

17.  Pulse Rate : Normal pulse rate is about 60-100 beats/min.
Respiration is 16-18 breaths per minute.
 Temperature: Normal body temperature is 37o
C as 98.6o
F.
Temperature above 98.6o
F and less than 100o
F indicate
localized disease. This localized disease can be treated by
removing the cause (e.g. cleaning the root canal) and or
incision and drainage.

18. Do not complaint readily about signs & symptoms of
pulpal & periapical disease
Consider them as minor compared with other health
concerns & discomfort
Disease process – assumes more chronic / less dramatic
form

19. Pain assoc. with vital pulps - ↓ with age & severity seems
to diminish overtime.
Heat sensitivity – only symptom suggests a reduced
pulpal volume.
↓ Pulpal healing capacity & necroses quickly after
microbial invasion ( ↓ symptoms).

20. Recent pulp exposure & restoration
Multiple restorations on the same tooth are common

21. DENTAL HISTORY :DENTAL HISTORY :
Subjective symptoms objectiveSubjective symptoms objective
symptomssymptoms
 pt. complaintpt. complaint
 Stimulus / irritant thatStimulus / irritant that
causes pain.causes pain.
 Nature of painNature of pain
 Relation to stimulus/irritant.Relation to stimulus/irritant.

22. Objective symptoms :
 Missing teeth
 Gingival recession
 Removal of root caries
 Interproximal root caries
 Attrition , abrasion, erosion
 Canal & chamber vol.
 CDJ
 Calcification process
 Dentinal tubules
 Tubular permeability
 Lateral & accessory canals

23.  Compensating bite – TMJ dysfunction
 Diminished eruptive forces
 Multiple restorations
 Cracks or craze lines
 Periodontal disease & treatment
 Sinus tracts.
 Pulp testing
 Transillumination & staining
 Test cavity
 Non Odontogenic sources
 Discoloration of single teeth
 Radiographs
 RVG

25. Missing teeth
◦ ↓ functional ability
◦ Loss of chewing efficiency – higher CHO diet of
softer, cariogenic foods
◦ ↑ sugar intake to compensate for loss of taste
◦ Xerostomia – suscep. to decay
Gingival recession
Creates sensitivity
Exposes cementum & dentin – less resistant to decay
A clinical study of 600 patients older than age 60 years
showed that 70% had root caries and 100% had some
degree of gingival recession.

26. Microbiology Of The Disease
• Not substantially different in different age groups,
• The altered host response during aging may modify the
progression of these diseases

27. Attrition, Abrasion, Erosion
Expose dentin through slow process
Allows pulp to respond with dentinal sclerosis &
reparative dentin
Secondary dentin formation throughout the life
Pulp obliteration
Maxi. Antr – Sec. dentin on the lingual wall of the pulp
chamber
Molar - on the floor of the chamber
Pulp may appear to recede, small pulpal remnants can
remain.

28. Canal and pulp chamber volume
Inversely proportional to age
Reparative dentin- from restorative procedures, trauma,
attrition, recurrent caries- diminution of chamber
CDJ moves farther away from radiographic apex with
continued cementum deposition
Thickness of apical cementum – 3 times more than
young ( 100- 200µm)

29. Calcification process
More linear type
DT – more occluded
↓ dentin permeability
Lat. / acc. Canals calcify

30. TMJ dysfunction
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.
Any limitation in opening reduces available working
time and the space needed for instrumentation.

31. Cracks / Craze lines
Pulp exposures by cracks – less likely to present acute
probs. in old pts
Penetrate the sulcus to create perio. defects / periapical
Incomplete cracks – not detected early – prognosis
questionable
Violating the principles of cavity design with loss of
resiliency from a ↓ org. component of dentin - ↑ susecp.
of cracks and cuspal fractures

32. Periodontal disease – principal problem
The relationship between pulpal and periodontal disease
can be expected to be more significant with age.
The periodontal tissues must be considered a pathway for
sinus tracts.
Narrow, bony-walled pockets associated with nonvital
pulps are usually sinus tracts,
Patients with diabetes have increased periodontal disease
in endodontically treated teeth- success

33. 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.

34. 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.

35. 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

36. Neural & vascular components – ↓
Pulp volume - ↓
Nerve branches - ↓
Response to stimuli is weaker in older adults
Extensive restorations
Calcification
Limitations in electric & thermal pulp testing
Discoloration – common
Dentin thickness greater & tubules are less permeable to
blood / breakdown products
Dentin deposition – yellow opaque color – progressive

37.  The electric pulp tester, CO2 snow, and
difluorodichloromethane were found to be 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.

38.  Use of even this small electric stimulus in patients with
pacemakers is not recommended. The same caution holds
true for electrosurgical units.
 A test cavity is generally 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.

39. Canals examined for – number, size, shape & curvature
Calcifications – throughout their length
Lamina Dura & Anatomic Landmarks – distinguished
from periapical radiolucencies & radiopacities
Resorption with chronic apical periodontitis – alter shape
& anatomy of foramen ( thro’ infam. osteoclastic activity)

40. Based on
Pt’s complaint
History
Signs & symptoms
Testing and radiographs
Vitality of the pulp
Peraiapical pathology
Pulpitis tends to be less acute due to:
Less volume of pulp and
less nerve supply
Pulp capping not recommended – reduced blood supply

41.  Single Sitting:
 One appointment procedures offers more advantages to
older patients.
 The length of procedure does not cause any inconvenience
as more and more appointments will cause more
inconvenience especially if patient rely on another person
for transportation.

42.  Because of reduced blood supply direct pulp capping is not
much successful in older individuals so that is not
recommended in older individuals.
 Endodontic surgery at later time is not as viable as for a
younger patient so one should also avoid endodontic surgery
on older people.

43. Consultation and consent of the patient :
 Good communication should be established.
 In consultation relatives and 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.

44.  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.

45. The procedures are generally more technically complex due
to:
1. Extensive restoration.
2. History of multiple carious insults.
3. Periodontal involvement.
4. Decreased pulp space.
5. Tipping
6. Rotation.

46. Appointments preferable morning time
Patients eye- shielded from intensity of
light
Jaw fatigue – bite block for long
procedures
Need for anesthesia

47. Painful response – not encountered actual pulp exposure
has occurred
Number of low threshold high conduction velocity
nerve endings in dentin- reduced or absent
Cutting of dentin does not produce same level of
response in an older patient
Dentinal tubules more calcified
Reduced width of PDL makes needle placement for
supplementary intraligamentary injection more difficult

48. 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

49. Periradicular tissue heals as readily as in a young
person.
But many factors can decrease the rate of success.
Every case should have post treatment prognosis.

50. Petroleum based lubricant for lips & gingiva
Artificial saliva –used just before isolation
Canals should identified & their access maintained –
restorative procedures are indicated for isolation
Fluid tight isolation cannot be compromised when
sodium hypo chlorite is used as an irrigant
Difficult to isolate defects produced by root decay

51. 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
Coronal tooth structure or restoration – compromised for
access preparation
Magnification range 2.5x to 4.5x

52. Location & penetration difficult – calcified canals
DG 16 explorer for initial penetration
Negotiation with K files – no 8,10,15
NiTi – contraindicated for initial negotiation
Watch – winding action with apical pressure – ideal
Chelating – seldom value
Dyes distinguish orifice from dentin
Supra erupted tooth – easily perforate

53.  A lengthy, unproductive search for canals is fatiguing and
frustrating to both the clinician and the patient. Scheduling
a second attempt at this procedure is often productive.
 Modifications to enhance access vary from
widening the axial walls to increase visibility
Alterations may be indicated after canal penetration to the
apex if tooth structure interferes with instrumentation or
filling procedures.

54. Flaring of canal – perform as early in procedure
Thorough & frequent irrigation / Crown – down technique
Files penetrate in to walls than reamers – calcified canals
CDJ (narrow constriction) identifying by tactile sense –
difficult
Reduced periapical sensitivity reduces patient response
– penetration of foramen
Achieving & maintaining apical patency – more
difficult

55. 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

56. Restoration :
 Generally it is said that larger and deeper the
restorations more complicated the root canal treatment.
 The porcelain fused to metal crown is more common
than full metal crown and has greater problems.
 Porcelain may fracture of large but this problem can be
minimized by using burs specially designed to prepare
through porcelain.

57.  Metal should be removed earlier and not alter because after
the chamber is open the metal shavings can enter and block
the canals.
 The access opening through metal and gold is best retained
by amalgam and anterior non metallic crowns should be
restored by composites.
 Special consideration must be given to post design,
especially when small posts are used. Root fracture also
occurs when greater taper is used. Most commonly
fractures are related to small diameter parallel posts.

58. 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.
 In geriatric patients 6 months recall visit may not be
adequate and it may take as long as 2 years to produce
healing that would occur at 6 months in an adolescent.

59. ENDODONTIC SURGERY :
 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

60. Calcified canal
External root
resoprtion
Periradicular periodontitis & distal
root caries

61. In Geriatric Patients(endodontic surgery) :
 Smaller amount of anaesthesia is needed. Tissue is more
resilient.
 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.
 Therefore sometimes need may arise to combine endo and
perio procedures and every effort should be made to
complete the procedures in one setting.

62.  Ecchymosis is more common post-operative finding. In
older patients and may appear to extreme.
 In such cases patient should be reassured that this condition
is normal and that normal color can take as long as 2 weeks
to return.
 The blue discoloration will change to brown and yellow
before it disappear.
 Immediate application of cold or ice pack after surgery
reduces bleeding and initiates coagulation to reduce
ecchymosis.
 Later application of heat helps to dissipate the
discoloration.

63. BLEACHING:
 Both internal and external tooth discoloration occurs in
older individuals.
 Internal discoloration is related to either dental
restorative or endodontic procedures or due to increased
dentin formation with loss of translucency.
 External discolouration occurs from stains.
 Both internal and external procedures are successful in
these patients.

64. The needs expectations, desires, and demands of older
people may exceed those of any group, and the gratitude
shown by older adult patients is among the most satisfying
of professional experience.
The incidence and complexity of endodontic procedures
increases with age but these procedures are equally
successful when performed properly including endodontic
surgery and bleaching.

65.  Principles & practice of endodontics – Walton &
Torabinejad
 Pathways of pulp- Cohen 10th
ed
 Ingle’s endodontics – 6th
edition
 Endodontic therapy – Weine 6th
edition
 A preliminary evaluation of effects of electric pulp tester on
dogs with artificial pacemaker.
(JADA1974,vol89,1099-1101)
 Endodontic considerations in geriatric patients
(DCNA 1997, 795)

66. Thank u