รศ ปทมา ชัยเลิศวณิชกุลรศ ปทมา ชัยเลิศวณิชกุล

ENDODONTIC ENDODONTIC TREATMENT IN TREATMENT IN THE ELDERLYTHE ELDERLY

Geriatrics is the branch of medicine thatfocuses on health promotion, prevention & treatment of disease & disability in later life.

The term itself can be distinguished fromgerontology, which is the study of the agingprocess itself. The term comes from theGreek geron meaning “old man” & iatrosmeaning “healer” & was proposed in 1909 byDr. Ignatz Leo Nascher.

ObjectivesObjectives

To discuss the effect of aging on the diagnosis of pulpal & periapical diseases & successful RCT

Medical historyMedical historyElders use more drugs than youngersConsider the interaction of drugs (decline in renal & liver function)Some may not understand the implications of their medical conditionSome may be reluctant to let the clinician into their confidence

Chief complaintChief complaint

Allow the patient to explain the problem in his/her own wayOpportunity to observe the ability to communicate, interest, etcPain associated with vital pulps (caused by heat, cold, sweets or referred pain) seems to be reduced with age

Dental historyDental historyDental histories are rarely completedHistory of pain may establish the degenerative processSubclinical injuries caused by repeated episodes of tx ex: multiple restorations may accumulate & approach a significant threshold

Subjective symptomsSubjective symptoms

Patient’s complaintStimulus that causes painNature of pain

“Determining types of tests are necessary to confirm findings”

Objective signsObjective signsMissing teeth – loss of chewing efficiency: more cariogenic foods, xerostomia

– loss VD: limit mouth opening, TMJ dysfunction

Gingival recession (sensitivity, less resistant to decay)

Objective signsObjective signs

Root caries, attrition, abrasion & erosion

Objective signsObjective signs

Pulpal calcificationsMultiple restorations Marginal leakage

Reparative dentine formn, canal & chamber decreases in size

Objective signsObjective signs

Cracks/craze linesPeriodontal diseases

PulpalPulpal calcificationscalcifications

Common occurrencePathologic process related to injury2 types of calcifications– Pulp stones (denticles) found in coronal– Diffuse (linear calcifications) found in radicular

Pulp stonesPulp stones

Organic matrix composed of collagen fibrils in which hydroxyapatite crystals are embedded2 types: free & attached

CDJ moves farther from radiographic apex (0.5-2.5 mm)2-3 times increase thickness of cementum (100-200µ in youngers)

Pulp calcificationsPulp calcifications

Age changesAge changesContinued formation of 2nd dentine– Maxillary anterior: lingual wall– Molar: floor of pulp chamberReduce size of pulp chamber & canalsReduce number of nerves & blood vessels

Age changesAge changes

Increase number & thickness of collagen fibersIncrease peritubular dentine, dentinal sclerosisDecrease dentinal permeability (reduce diameter of dentinal tubules)

TestTestTransilluminating & staining to detect cracksNo correlation between degree of response to EPT & degree of inflammationWeaker response to EPT (fewer nerve branches)

TestTestReferred pain should be consideredTest cavity is less useful (reduce dentin innervation)Presence of tori, exostoses & denser bone may require increased exposure times for contrast for x-ray film

TestTest

Periapical area must be included in the radipgraphLamina dura should be examined (incidence of cysts & tumour increase with age)

Diagnosis & Treatment planDiagnosis & Treatment plan

One-appointment RCT is considered Consultation & ConsentLife expectancy should not alter tx plans & is no excuse for extractions or poor RCT

TreatmentTreatmentMorning appointments are preferableIsolation (GI when need mechanical retention, multiple-tooth isolation)Access (canal position, root curvature & inclination should be considered)Magnification (2.5 to 4.5)

Access & Endo Access & Endo surgerysurgeryMicroscope

ProblemProblem--solving in tooth solving in tooth isolationisolation

LeakagePatched or blocked with Cavit, OraSeal, Rubber base adhesive or periodontal packingReplace with a new one

TreatmentTreatmentDG 16 explorer Very few canals have adequate diameter to allow the safe & effective use of broachesFlaring should be performed to provide for a reservoir of irrigation

TreatmentTreatment

CDJ vary from 0.5-2.5 mm from the apexDo not require great tapersCoronal seal is important

Success & FailureSuccess & FailureRate of bone formation & normal resorption decreases with age & aging of bone results in greater porosity & decreased mineralisation of the formed bone6-month recall period to evaluate repair radiographically may not be adequate

Further ReadingFurther Reading

Pathways of the Pulp 9th ednProblem Solving in Endodontics 4th ednWalton RE (1997). EndodonticConsiderations in the Geriatric Patient. The Dental Clinic of North America 41 (4): 795-816