GERIATRIC ENDODONTICS in Endodontics dentistry

endodontics

1. GERIATRIC ENDODONTICS SREE VARSHINI S MDS - III

2. INTRODUCTION Number of elderly patients has risen in the last decade In India, citizens over 60 are estimated to increase from 100 million to 170 million by 2026. Contribute of 28% of dental expenditure in 2018 Cognitive status, presence of chronic diseases and medications – more prevalent Physical, emotional and psychological status should be considered – practical evidence-based endodontic treatment approach is needed.

3. PHYSIOLOGICAL CHANGES

4. ENAMEL Reduction in the inter-prismatic organic matrix Decrease in the hardness of the outer surface by 12% BRITTLE

5. DENTIN Secondary dentin formation Lingual wall of the pulp chamber Floor of the pulp chamber Sclerotic dentin Hypermineralised Less permeable DENTIN Less water cracks Reduction in fracture resistance Decreased sensation

6. CALCIFICATIONS Removal of pulp stones Necrotic and degenerated pulp tissue and microorganisms – harboured in the crevices SYSTEMIC CONDITIONS High blood cholesterol – statins Raynaud’s syndrome – prostacyclin (PGI2) Free Attached Embedded denticles Diffuse calcifications

7. CEMENTUM 100 to 200 microns 400 to 500 microns 3 fold increase Thickest layer – at the apex Distance increases Radiographic apex and apical constriction Electronic apex locator POE Apical foramen Accessory foramina Less permeable due to calcification

8. PULP Volume of pulp decreases – reduction in the neurovascular components Decreased cell density – fewer fibroblasts, odontoblasts and antigen-presenting cells Fibrosis of pulp tissue Increased dentin thickness – reduction in the lumen of pulp chamber and root canal system. Reduces the reparative capacity of pulp Pulp protection Decrease in pulp cell density Increase in dentin thickness Consideration while performing pulp capping

9. Neurovascular elements of pulp Decrease in capillaries in the sub-odontoblastic layer Thinning of pulp tissue endothelium Reduction in number of pulpal neurons A-beta fibres – remain constant A- delta fibres decrease with age – reduced sensitivity to pain perception Marked decrease in pulpal Calcitonin Gene Related Protein (CGRP) and Substance P (SP) Pulpal breakdown in the elderly often occurs without the classic symptoms of irreversible pulpitis Pulpal necrosis – commonly encountered 90% teeth Will have calcifications – in patients older than 40 years

10. PERIRADICULAR BONE PERIODONTAL LIGAMENT Bone formation steadily declines with age Might be due to a decrease in osteoblast proliferation or decreased secretion of bone matrix proteins Osteoporosis – metabolic disorder – reduction in number of bony trabeculae and thinning of cortical region (anterior – maxilla; posterior – mandible) Fibre and cellular content of PDL decrease with age Lower rates of proliferation and chemotaxis Progressive changes – gingival recession, PDL disease, PDL treatment – expose the lateral and accessory canals and act as POE for microorganisms to dental pulp

11. SALIVARY GLANDS Reduction in volume of acini Increase in ductal volume – fatty and fibrous tissue Reduced salivary IgA, mucins, immunologic system More susceptible to caries and oral lesions XEROSTOMIA Radiation therapy, Sjogren’s syndrome, Certain medications Xerostomia-related side effects – root caries, hypersensitivity – increased demand for endodontic treatment

12. TEMPOROMANDIBULAR JOINT Elderly – multiple missing teeth, drifted teeth, bruxism, loss of vertical dimension Leads to compromised occlusion – temporomandibular joint dysfunction (TMJD) Cause acute or chronic pain – affects the inter-incisal opening and the duration for which the patient can keep the mouth open during endodontic treatment. Atypical facial neuralgia – referred pain from the muscles of mastication Accumulation of inflammatory mediators – cytokines, eicosanoids and neuropeptides in muscles evoke chronic pain Mimics endodontic pain Diagnosis – palpating the muscle

13. PATHOLOGICAL CHANGES

14. DIABETES Higher prevalence of apical periodontitis – lower success rate Large lesions Incidence of flare-ups Diminished reparative response

15. HYPERTENSION HOW TO DECIDE?? Severe uncontrolled hypertension Elective dental treatment should be delayed – until BP is under control Emergency dental treatment needed 1 to 2 cartridges of LA with vasoconstrictor can be used Adrenergic blockers (propranolol) Marked peripheral vasoconstriction Medicament induced inhibition of compensatory skeletal muscle vasodilatation Cardio-selective beta blockers (Lopressor)

16. MEDICATIONS Thorough medical history METHOTREXATE BISPHOSPHONATE Rheumatoid arthritis, Crohn’s disease, ulcerative colitis Multiple myeloma, Paget’s disease, metastatic cancer, osteoporosis Non-surgical root canal therapy – treatment of choice

17. TRAUMA FALLS Frailness Postural imbalance Exhaustion Referred to endodontic treatment Rule out cranial injury Trauma management Same as that of young patients Routine follow-ups and RCT before the tooth undergoes calcification Diminished capacity for pulpal healing –pulp capping not recommended Silent trauma Careful medical history – general anesthesia and intubation Teeth heal by laying down secondary dentin with pulp canal obliteration or pulp necrosis with inflammatory resorption

18. CLINICAL CONSIDERATIONS

19. ENDODONTIC TREATMENT OUTCOME No correlation with age Healing pattern of oral tissues Young Old Healing response Delayed response in elderly NO MEDICAL CONTRAINDICATIONS Treatment outcome affected by: Pre-operative apical periodontitis Quality and extent of root filling CONDITIONS: Diabetes Immunosuppression Medications 90% SURVIVAL OF TEETH AFTER NS - RCT- good alternative

20. ACCESSIBILITY TO CARE APPOINTMENT TIME AND DURATION Use accessories – cane, wheel chair or motorized cart Office requires – ramp or a elevator Equipped with waiting rooms and rest rooms Morning appointments Synchronized with patients’ medications and meals Short duration Reduction in the number of visits

21. MEDICAL HISTORY DENTAL HISTORY Visual, auditory and cognitive impairment – family, friend or caregiver assistant Thorough medical history – need for medical consultation, premedication or drug interactions Number of restorations H/O falls H/O surgery under GA Exposure to factors – contributing to oral cancer Systemic diseases – initially manifest prodromal oral signs and symptoms

22. DIAGNOSTIC TESTS Decrease in muscle tonicity Limited mouth opening Exostoses Difficult to position the IOPA films and inflexible digital sensors Pediatric sensors Soft foam padding Axial inclination of the crown does not coincide with the long axis of the root Multiple-angled x rays Bitewing radiographs Contralateral tooth x ray

23. DIFFERENTIAL DIAGNOSIS TMJD Atypical facial pain Neuritis Neuralgia Maxillary sinusitis Osteonecrosis of jaw Tumours Mask or mimic odontogenic pain in the elderly

24. CASE SELECTION No contraindications for endo TREATMENT OF CHOICE MEDICALLY COMPROMISED PATIENTS Oseoradionecrosis – due to radiation therapy BRONJ - bisphosphonates PROPHYLACTIC ROOT CANAL TREATMENT Overdenture abutments – asymptomatic healthy pulp Root amputation – localized periodontitis

25. PATIENT POSITIONING AND COMFORT Minimally reclined position Dental chair – equipped with an adjustable headrest and pillows Osteoarthritis and back and neck problems - Difficulty reclining to an extreme supine position To avoid orthostatic hypotension – bring back the patient gradually from supine position Parkinson’s disease – affects muscle tonicity – bit blocks to stabilise the jaws

26. ANESTHESIA Less anxious High pain threshold Prefer less anaesthetic – especially if tooth is asymptomatic No contraindications to use vasoconstrictors Supplemental anesthesia Last option Educated about – the anticipated heart rate increase 3% mepivacaine – without vasoconstrictor

27. Tooth isolation CHALLENGES Placing a clamp – decreased muscle tonicity, limited mouth opening Frequent breaks – facilitate breathing and use of restroom RECOMMENDED Dam placement – after access opening and location of orifices Avoid clasping teeth – with extensive caries or restorations

28. ACCESS CAVITY Enhanced illumination and magnification – for enhanced visibility Consider the modification in patient positioning – as it may alter the orientation of the crown and root “Walking” the periodontal probe – along the CEJ Initial access without dam – to aid in the pulp chamber visualization and avoid procedural errors Traditional “drop into the pulp chamber” may not be felt Endodontic explorer – for careful exploration Pre-op measurements

29. Access cavity – often modified and enlarged to locate the orifices Dam placement – as soon as locating the canals Canals may appear calcified on a radiograph …..but HISTOLOGICALLY A ROOT CANAL IS ALWAYS PRESENT!!!!!

30. CANAL LENGTH DETERMINATION Age-related cementum thickening Alteration in apical foramen location Electronic apex locators Good radiographs Paper point test Tactile sensation Patency may not achievable in all cases

31. CLEANING AND SHAPING Small root canal lumen Dentin sclerosis STANDARD PROTOCOLS CAN BE USED Copious chelating agents Specific files Special rotary systems Frequent NaOCl use EDTA STIFF FILES, CFILES, C-PLUS FILES PROGLIDERS PATHFILES Soften and dissolve fibrous pulp tissue

32. Shaft provides 300% increased resistance to buckling while penetration

33. OBTURATION CHALLENGE ALTERNATIVE Inadequate intra-oral opening Movement of the patient during the procedure Especially during down-packing and backfilling for warm vertical obturation Carrier - based Single cone technique

34. TOOTH RESTORATION Multiple carious lesions or restorations Full-coverage restoration Onlays Previous cervical caries or root caries GIC and RMGIC – recommended Ease of application Fluoride releasing property

35. RETREATMENT INCIDENCE OF RETREATMENTS Coronal leakage Recurrent caries Fracture of teeth Fracture of restorations Missed canals Isolated symptom Heat sensitivity

36. APICAL SURGERY Change in position of anatomic structures Due to multiple missing teeth and the consequent residual ridge resorption These entities should be carefully observed and considered before treatment planning

37. Patients on anti-coagulant therapy Medications preferably not to be stopped control haemorrhage using local haemostatic agents Informed about possibility of ecchymosis Self – limiting and resolves within few weeks

38. CONCLUSION Older patients should be treated the same as younger patients, with the expectation of the same degree of success. The biology of older patients’ pulp tissue and surrounding dentin undergoes changes that, if not recognized, will lead to mistreatment and loss of teeth.

39. Benzer s. The development and morphology of physiological secondary dentin. J dent res. 1948;27(5):640-646. Doi:10.1177/00220345480270051401 Rotstein I, ingle JI, editors. Ingle's endodontics. PMPH USA; 2019 jun 1. Goodis he, kinaia bm. Endodontic management of the aging patient. Caring for our aging population. 2014:116. Johnstone m, parashos p. Endodontics and the ageing patient. Australian dental journal. 2015 mar;60:20-7. Allen pf, whitworth jm. Endodontic considerations in the elderly. Gerodontology . 2004 dec;21(4):185-94. REFERENCES

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