GERIATRIC -recent pulp exposure and restoretion

GERIATRIC -recent pulp exposure and restoretion

1. Geriatric
endodontics
-Diagnosis and
treatment
DR . P. DINESH KUMAR
POST-GRADUATE STUDENT

2. CONTENTS
Chief complaint
Dental history
Subjective symptoms
Diagnostic procedures
.objective signs
.pulp testing
Transillumination & staining
Electric pulp test
Test cavity
.Radiographs

3. Treatment plan
Consultation & consent
Treatment
.Isolation
.Access
.Preparation
.obturation

4. Chief complaint
Dental pain
Diagnostic process
vitality of pulp
pulpal/ periapical disease
source
Should be in Own words

5. Pain associated with vital pulp
. referred pain
. pain caused by heat, cold and sweets
Heat sensitivity only  reduced pulp volume

6. Dental history
Recent pulp exposure and restoration or
crown preparation 15-20 years ago
History of pain before or after treatments may
establish the beginning of the degenerative
process.

7. Subjective symptoms
patient’s complaint,
Stimulus / irritant that causes the pain
Nature of the pain
It’s relation to the stimulus or irritant
useful in determining
Whether the source of pain is pulpal
Reversible
Inflammation has extended to the apical tissues

8. Diagnostic procedures
Pulpal symptoms are usually chronic in older
patients.
Other sources of orofacial pain should be ruled
out when pain is not soon localized.
Much information obtained from
. The complaint
. History
.subjective symptoms

9. Objective signs
Intra oral and extra oral clinical examination
Over all oral condition
Exposure to factors that contribute to oral
cancers
Systemic diseases
Missing teeth
xerostomia

11. Gingival recession
Asymptomatic pulp exposures on one root
surface of a multi rooted tooth
Inter proximal root caries
Attrition
Abrasion
Erosion

15. Secondary dentin formation
maxillary anteriors  lingual wall of pulp chamber
molars floor of the chamber

Canal and chamber volume ∞ 1/Age

17. 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 µm and increases with age to two or three
times that thickness.

19. 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.

20. 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 presence of multiple restorations indicates a
history of repeated insults and an accumulation
of irritants.
Marginal leakage and microbial contamination of
cavity walls are a major cause of pulpal injury.

22. Many cracks or craze lines may be evident as a
result of staining, but they do not indicate dentin
penetration or pulp exposure.
Periodontal disease may be the principal problem
for dentate seniors
Sinus tracts may have long clinical histories and
usually indicate the presence of chronic
periapical inflammation.

24. Pulp Testing
 Slow and gentle testing should be done to
determine pulp and periapical status .
  Must correlate with clinical and radiographic
findings and be interpreted as a supplement in
developing clinical judgment.

25. Transillumination and staining have been
advocated as means to detect cracks,
presence of cracks is of little significance in the
older teeth,.
 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 on radiographs.
The high magnification available with
microscopes during access opening and canal
exploration permits visualization of the extent of
cracks in determining prognosis.

26. Cracks in teeth with vital pulp reasonable
prognosis .
In chronic periapical pathologic condition
prognosis is questionable (even when pocket
depths appear normal).
Periodontal pockets associated with cracks 
poor prognosis

28. 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

29. No correlation exists between the degree of
response to electric pulp testing and the degree
of inflammation. 
 Extensive restorations, pulp recession, and
excessive calcifications are limitations in both
performing and interpreting results of electric and
thermal pulp testing.

30. An alternative to the electric pulp test is
assessment of pulp vitality by applying a thermal
stimulus to the tooth surface.
The electric pulp tester, CO
2
 snow, and
difluorodichloromethane were found to be more
reliable than ethyl chloride or ice in producing a
positive response.

31. Use of even small electric stimulus in patients with
pacemakers

is not recommended
A test cavity is generally less useful as the test of
last resort because of reduced dentin innervation

32. Diffuse pain of vague origin is also uncommon in
older pulps and limits the need for selective
anesthesia
Discoloration of single teeth may indicate pulp
death, but this is a less likely cause of discoloration
with advanced age.

33. Radiographs
Indications for and techniques of taking
radiographs do not differ much among adult age
groups. 
 Older patients may be less capable of assisting in
film placement, and holders that secure the
position should be considered.
 Angled radiographs should be ordered only after
the original diagnostic radiograph suggests that
more information is needed for diagnosis .

34. Digital radiography 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.

35. 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
 The axial inclinations of crowns may not correlate
with the clinical observation when tilted teeth
have been crowned or become abutments for
fixed or removable appliances.
 Access to the root canals is the most limiting
condition in root canal treatment of older
patients.

36. Canals should be examined for their number, size,
shape, and curvature.
 Pulp has been demonstrated histologically even
when not visible on radiographs, but in general,
the two measurements did not differ even when
pulp calcifications are present.

37.  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., caries, restoration, cervical
abrasion) has separated the chamber from the
root canal.
Root-end fillings during root-end resection (more
common during retreatment of older patients)
indicate missed canals and roots as a common
cause of failure.

40. 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.

41. Resorption associated with chronic apical
periodontitis may significantly alter the shape of
the apex and the anatomy of the foramen
through inflammatory osteoclastic activity

43. Diagnosis and Treatment
Plan
One-appointment procedures offer obvious
advantages to older patients
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

44.  Because of a reduced blood supply, pulp
capping is not as successful in older teeth as in
younger ones, so it is not recommended

45. Consultation and Consent
 Relatives or trusted friends should be included in
consultations if their judgment is valued by the
patient or needed for consent.
 clinicians should explain procedures in a
comprehensive manner.

46. Obtaining signed consent to outlined treatment is
encouraged and may be especially useful if the
patient is forgetful.
Determining the patient's desires is as important as
determining his or her needs, and it is required in
obtaining informed consent

47.  A patient's limited life expectancy should not
appreciably alter treatment plans and is no
excuse for extractions or root canal treatment.
The capability of the clinician and the availability
of endodontic specialists should also be
considered

48. Clinician should provide the endodontist with as
much information about the patient as possible
medically compromised or cognitively impaired
patients may make it difficult to acquire valid
informed consent.
Neuropsychiatric impairment may result in gross
manifestations and indicate a reduced level of
competency.

49. Physicians or mental health experts should be
consulted as needed, and no elective
procedures should be performed until valid
consent is established.

50. Treatment
Access for those who use ambulation aids (e.g.,
canes, walkers, wheelchairs) should include
comfort and safety in the parking lot, reception
room, operatory, and rest room
A physical and mental evaluation of the patient
should determine the ideal time of day and
length of time necessary to schedule treatment. 

51. Morning appointments are preferable for some
older patients.
Some patients prefer late morning or early
afternoon visits to allow “morning stiffness” to
dissipate.
Older patients are more likely to tolerate long
appointments, although chair positioning and
comfort may be more important for older adults
than for younger patients. 

52. The patient's eyes should be shielded from the
intensity of the clinician's light.
 Jaw fatigue is readily recognizable and may be
the most limiting factor in a long procedure,
requiring periods of rest;
 Bite blocks are useful in comfortably maintaining
freeway space and reducing jaw fatigue

53. The pulp vitality status and the cervical positioning
of the rubber dam clamp determine the need for
anesthesia.
Older patients more readily accept treatment
without anesthesia, and sometimes they must be
persuaded that anesthesia is necessary for root
canal treatment if their routine operative
procedures have been performed without it. 

54. Anatomic landmarks that are used as guides to
needle placement during block and infiltration
injections are usually more distinguishable in older
patients
The reduced width of the periodontal ligament

makes needle placement for supplementary
intraligamentary injections more difficult.

55. Intraosseous injections can significantly increase
the success of pulpal anesthesia but can be
associated with a transient increase in heart rate
when anesthetics contain epinephrine. 
Smaller amounts of anesthetic should be
deposited during intraosseous injections, and the
depth of anesthesia should be checked before
repeating the procedure.

56. The majority of patients receiving an intraosseous
injection of 2% lidocaine with 1:100,000
epinephrine (correct ratio) solution experience a
transient increase in heart rate.
 This would not be clinically significant in most
healthy patients, but in the older patient whose
medical condition, drug therapies, or epinephrine
sensitivity suggests caution, 3% mepivacaine is a
good alternative for intraosseous injections.

58. The reduced volume of the pulp chamber makes
intrapulpal anesthesia difficult in single-rooted
teeth and almost impossible in multirooted teeth.
Initial pulp exposures are also hard to identify. 
 Wedging a small needle into each canal to
produce the necessary pressure for anesthesia is
the method of last resort.

59. Isolation
Either single-tooth or multitooth rubber dam
isolation can be used. 
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
Canals should be identified and their access
maintained if restorative procedures are
indicated for isolation.  

60. Difficult-to-isolate defects produced by root
decay present a good indication, in initial
preparation, for the use of sonic handpieces that
use flow-through water as an irrigant.
The many merits of single-visit root canal
procedures is generally recommended when
isolation is compromised

61. Access
Adequate access and identification of canal
orifices are likely the most challenging aspects of
providing root canal treatment for older patients. 
Coronal tooth structure or restorations should be
sacrificed when they compromise access for
preparation or filling 

62. Canal position, root curvature, and axial
inclinations of roots and crowns should be
considered during the examination 
All restorations should be removed before
endodontic treatment in order to remove the
common factors (caries, marginal breakdown,
cracks) that may have caused the pulp and
periradicular disease and to assess the tooth's
prognosis and future treatment needs

63. Magnification in the range of 2.5× to 4.5× (e.g.,
Designs for Vision, Ronkonkoma, NY) has become
a common tool and can be designed to fit the
clinician's most comfortable working distance.
The growing acceptance and availability of
endodontic microscopes

offer clear
magnification ranging up to 25× or greater and
have obvious advantages in treating smaller and
narrower geriatric canals

64. Location and penetration of the canal orifice are
often difficult and time consuming in calcified
canals.
The most important instrument for initial
penetration is the DG-16 explorer. 
 Once the canal has been distinguished,
negotiation is attempted with a stainless steel (SS)
#8, #10, or #15 K-file.

65. The #6 file lacks stiffness in its shaft and easily
bends and curls under gentle apical pressure
Nickel-titanium (NiTi) files lack strength in the long
axis and are contraindicated for initial
negotiation.
The canal can be negotiated using a watch-
winding action with slight apical pressure.
Chelating agents are seldom of value in locating
the orifice but can be useful during canal
negotiation.

66.  Dyes may distinguish an orifice from the
surrounding dentin.
Pain, bleeding, disorientation of the probing
instruments, or an unfamiliar feel to the canal may
indicate a perforation
 Supraerupted teeth can be easily perforated if
the reduced distance to the furcation is not
noted.

68. Modifications to enhance access vary from
widening the axial walls to increasing visibility or
light to complete removal of the crown
Teeth with chronic apical periodontitis will usually
have patent canals .
 Surgical access may be preferred if the risk of
deviation from the long axis exists when canals
are calcified and the tooth is heavily restored 

69. Very few canals of older teeth, even maxillary
anterior teeth, have adequate diameter to allow
the safe and effective use of broaches

70. 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/caries, 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. 

71. 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. 

72. 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 reduce the stress
on metal instruments that occurs when they bind
with the canal walls

73.  Thorough and frequent irrigation should be
performed to remove the debris that could block
access
The benefits of instruments with no rake angle and
a crown-down technique are recommended

74. 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

75. Increased incidence of hypercementosis, in
which the constriction is even farther from the
apex, makes penetration into the cemental canal
almost impossible. 
Apical root resorption associated with periapical
pathosis further changes the shape, size, and
position of the constriction

77. The use of electronic apex-finding devices is
sometimes limited in heavily restored teeth.
The frequency and intensity of discomfort after
cleaning and shaping have 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.

78. 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

79. Obturation
For the older patient, the prudent clinician selects
gutta-percha filling techniques that do not require
unusually large midroot tapers and do not
generate pressure in this area, which could result
in root fracture
The coronal seal plays an important role in
maintaining an apically healthy environment, and
it has a significant impact on long-term success.

80. Even a root-filled tooth should not have its canals
exposed to the oral environment.
 A thermoplastic synthetic polymer-based root-
filling material (Resilon) may significantly reduce
the coronal leakage that can result from root
caries after root canal treatment, as well as
increase resistance to root fracture.

82.  Permanent restorative procedures should be
scheduled as soon as possible, and intermediate
restorative materials should be selected and
properly placed to maintain a seal until that time
When mechanical retention is not ensured with
the preparation, glass ionomer cements are
recommended.

83. References
Cohen’s pathways of the pulp-10
th
edition
Ingles Endodontics-6
th
edition
A review of Geriatric Dentistry - The Dental Clinics
of North America (Volume 33, Number I, January
1989
Journal of Conservative Dentistry | Jul-Sept 2011 |
Vol 14 | Issue 3
Endodontic principles and practice Walton and
Torabinejad

84. Thermally induced pulpalgia in endodontically
treated teeth J Endod 17-38;1991
Geriatric pharmacology. Dent Clin North Am
88:73,2002
The dental Pulp ;Seltzer and Bender
Missed anatomy: frequency and clinical impact
Endodontic Topics 2009, 15, 3–31

85. Thank you