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Introduction
Chief Complaint
Dental History
Subjective Symptoms
Objective Signs
Medi. Compromised
Individuals
Radiographs
Diagnosis
Treatment plan
Prognosis
Isolation
Access Opening
Preparation
Obturation
Endodontic surgery
Conclusion
Geriatric Dentistry Or Gerodontics is the delivery of
dental care to older adults involving the diagnosis,
prevention, and...
 The World Health Organization Categorizes Aging
Population into four classes:
 Aging individuals 45-60 years old
 Olde...
Endodontic considerations in geriatric patients are
not without challenges.
Challenges include.
Biological
Medical
Psychol...
Pulp response
Nature of pulp response to injury
Periradicular response
Healing
Changes with age:
Structural (histologic) changes as a
function of time
Tissue changes – response of irritation from injur...
Structural changes
cells (both odontoblasts and fibroblasts)
also the supportive elements (blood vessels and
nerves).
 ...
Dimensional change
 in the pulp size – due to dentin deposition.
Dentin formation - not necessarily continuous throughout...
 Molars: More on the roof and floor of the pulp chamber
than on walls leading to flattened disc like chamber.
 In maxill...
Older patients pulp has more adverse pulpal reactions than
in similar conditions in younger patients.
The reasons cited ar...
Age
Few cells or blood vessels
no more different than young persons teeth with a
completed root apex.
Systemic conditions
...
 Little information is available but is considered to be not
much different from the young.
 Reason: There is relatively...
A slight delay in healing may be present but with similar
patterns of repair of oral tissues.
No difference in radiologica...
 In general geriatric patient suffers from either
cardiovascular, respiratory or central nervous system
diseases and as a...
 Pulse Rate : Normal pulse rate is about 60-100 beats/min.
Respiration is 16-18 breaths per minute.
 Temperature: Normal...
Do not complaint readily about signs & symptoms of
pulpal & periapical disease
Consider them as minor compared with other ...
Pain assoc. with vital pulps - ↓ with age & severity seems
to diminish overtime.
Heat sensitivity – only symptom suggests ...
Recent pulp exposure & restoration
Multiple restorations on the same tooth are common
DENTAL HISTORY :DENTAL HISTORY :
Subjective symptoms objectiveSubjective symptoms objective
symptomssymptoms
 pt. complai...
Objective symptoms :
 Missing teeth
 Gingival recession
 Removal of root caries
 Interproximal root caries
 Attrition...
 Compensating bite – TMJ dysfunction
 Diminished eruptive forces
 Multiple restorations
 Cracks or craze lines
 Perio...
Missing teeth
◦ ↓ functional ability
◦ Loss of chewing efficiency – higher CHO diet of
softer, cariogenic foods
◦ ↑ sugar ...
Microbiology Of The Disease
• Not substantially different in different age groups,
• The altered host response during agin...
Attrition, Abrasion, Erosion
Expose dentin through slow process
Allows pulp to respond with dentinal sclerosis &
reparativ...
Canal and pulp chamber volume
Inversely proportional to age
Reparative dentin- from restorative procedures, trauma,
attrit...
Calcification process
More linear type
DT – more occluded
↓ dentin permeability
Lat. / acc. Canals calcify
TMJ dysfunction
The compensating bite produced by missing and tilted
teeth (or attrition) can cause temporomandibular join...
Cracks / Craze lines
Pulp exposures by cracks – less likely to present acute
probs. in old pts
Penetrate the sulcus to cre...
Periodontal disease – principal problem
The relationship between pulpal and periodontal disease
can be expected to be more...
They are a special category who present with more problems
and increased severity.
Diabetes Mellitus or Immuno-suppresssio...
As the pulp is less innervated and the volume of dentin is
more, the pulp is generally less responsive to stimuli in
older...
Vertically cracked teeth should always be considered
when pulpal or periapical disease is observed
Cracks detected – pulp ...
Neural & vascular components – ↓
Pulp volume - ↓
Nerve branches - ↓
Response to stimuli is weaker in older adults
Extensiv...
 The electric pulp tester, CO2 snow, and
difluorodichloromethane were found to be more reliable
than ethyl chloride or ic...
 Use of even this small electric stimulus in patients with
pacemakers is not recommended. The same caution holds
true for...
Canals examined for – number, size, shape & curvature
Calcifications – throughout their length
Lamina Dura & Anatomic Land...
Based on
Pt’s complaint
History
Signs & symptoms
Testing and radiographs
Vitality of the pulp
Peraiapical pathology
Pulpit...
 Single Sitting:
 One appointment procedures offers more advantages to
older patients.
 The length of procedure does no...
 Because of reduced blood supply direct pulp capping is not
much successful in older individuals so that is not
recommend...
Consultation and consent of the patient :
 Good communication should be established.
 In consultation relatives and frie...
 Proper consent of the patient is taken, as older patients are
at greater risk as compared to younger patient. All patien...
The procedures are generally more technically complex due
to:
1. Extensive restoration.
2. History of multiple carious ins...
Appointments preferable morning time
Patients eye- shielded from intensity of
light
Jaw fatigue – bite block for long
proc...
Painful response – not encountered actual pulp exposure
has occurred
Number of low threshold high conduction velocity
nerv...
Intrapulpal anesthesia, intraosseous anesthesia –
not prolonged –pulp tissue must be removed within
20 minutes
reduced vol...
Periradicular tissue heals as readily as in a young
person.
But many factors can decrease the rate of success.
Every case ...
Petroleum based lubricant for lips & gingiva
Artificial saliva –used just before isolation
Canals should identified & thei...
Adequate access & identification of canal orifices - most
difficult parts of providing RCT for older patients
The effect o...
Location & penetration difficult – calcified canals
DG 16 explorer for initial penetration
Negotiation with K files – no 8...
 A lengthy, unproductive search for canals is fatiguing and
frustrating to both the clinician and the patient. Scheduling...
Flaring of canal – perform as early in procedure
Thorough & frequent irrigation / Crown – down technique
Files penetrate i...
Generate pressure in large mid root area – result in root
fracture
Coronal seal – important role in maintaining the apical...
Restoration :
 Generally it is said that larger and deeper the
restorations more complicated the root canal treatment.
 ...
 Metal should be removed earlier and not alter because after
the chamber is open the metal shavings can enter and block
t...
SUCCESS AND FAILURES
 Factors leading to failures increases with age as a
result of this retreatment is more common in ol...
ENDODONTIC SURGERY :
 Indications of surgery are not affected by age.
 Small or completely calcified canals.
 Root curv...
Calcified canal
External root
resoprtion
Periradicular periodontitis & distal
root caries
In Geriatric Patients(endodontic surgery) :
 Smaller amount of anaesthesia is needed. Tissue is more
resilient.
 Teeth a...
 Ecchymosis is more common post-operative finding. In
older patients and may appear to extreme.
 In such cases patient s...
BLEACHING:
 Both internal and external tooth discoloration occurs in
older individuals.
 Internal discoloration is relat...
The needs expectations, desires, and demands of older
people may exceed those of any group, and the gratitude
shown by old...
 Principles & practice of endodontics – Walton &
Torabinejad
 Pathways of pulp- Cohen 10th
ed
 Ingle’s endodontics – 6t...
Thank u
Geriatric endodontics by Dr. JAGADEESH KODITYALA
Geriatric endodontics by Dr. JAGADEESH KODITYALA
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Geriatric endodontics by Dr. JAGADEESH KODITYALA

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Geriatric endodontics by Dr. JAGADEESH KODITYALA

  1. 1. Introduction Chief Complaint Dental History Subjective Symptoms Objective Signs Medi. Compromised Individuals Radiographs
  2. 2. Diagnosis Treatment plan Prognosis Isolation Access Opening Preparation Obturation Endodontic surgery Conclusion
  3. 3. 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.
  4. 4.  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
  5. 5. Endodontic considerations in geriatric patients are not without challenges. Challenges include. Biological Medical Psychological and Treatment Complications.
  6. 6. Pulp response Nature of pulp response to injury Periradicular response Healing
  7. 7. 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.
  8. 8. 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.
  9. 9. 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.
  10. 10.  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
  11. 11. 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.
  12. 12. 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.
  13. 13.  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.
  14. 14. 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.
  15. 15.  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.
  16. 16.  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.
  17. 17. 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
  18. 18. 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).
  19. 19. Recent pulp exposure & restoration Multiple restorations on the same tooth are common
  20. 20. 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.
  21. 21. 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
  22. 22.  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
  23. 23. 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.
  24. 24. Microbiology Of The Disease • Not substantially different in different age groups, • The altered host response during aging may modify the progression of these diseases
  25. 25. 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.
  26. 26. 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)
  27. 27. Calcification process More linear type DT – more occluded ↓ dentin permeability Lat. / acc. Canals calcify
  28. 28. 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.
  29. 29. 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
  30. 30. 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
  31. 31. 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.
  32. 32. 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.
  33. 33. 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
  34. 34. 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
  35. 35.  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.
  36. 36.  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.
  37. 37. 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)
  38. 38. 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
  39. 39.  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.
  40. 40.  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.
  41. 41. 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.
  42. 42.  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.
  43. 43. 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.
  44. 44. Appointments preferable morning time Patients eye- shielded from intensity of light Jaw fatigue – bite block for long procedures Need for anesthesia
  45. 45. 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
  46. 46. 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
  47. 47. 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.
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51.  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.
  52. 52. 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
  53. 53. 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
  54. 54. 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.
  55. 55.  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.
  56. 56. 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.
  57. 57. 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
  58. 58. Calcified canal External root resoprtion Periradicular periodontitis & distal root caries
  59. 59. 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.
  60. 60.  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.
  61. 61. 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.
  62. 62. 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.
  63. 63.  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)
  64. 64. Thank u

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