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Geriatric Endodontics

The document discusses geriatric endodontics, emphasizing the importance of preserving teeth in older adults to enhance their quality of life. It covers various age-related changes in oral health, challenges faced in diagnosis and treatment, and the significance of tailored dental care for elderly patients. Additionally, it highlights the necessity for detailed medical and dental histories, effective communication with patients, and considerations for successful endodontic procedures in geriatric populations.

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G E R I AT R I C E N D O D O N T I C S D R . S U R A B H I S O U M YA
CONTENTS • Oral aspects of aging • Age changes in the teeth • Endodontics in Geriatric patients • Diagnosis and treatment planning • References History Chief complaint Symptoms Vitality tests Radiographs
• Currently the old age population in India is 8% of its population (80 million) • In 2025 we will reach 12% ( 830 million) • Out of every 7 aged person in the world , one will be an According to the WHO, the global population is increasing at the annual rate of 1.7%, while the population of those over 65 years is increasing at a rate of 2.5%. Both the developed, as well as the lesser-developed countries, are expected to experience significant shifts in the age distribution of the population by 2050.
AGING IS INEVITABLE… • “He, who is born, has to go through childhood, youth and old age. If aging is inevitable, let’s be graceful and serene about it and lead a disciplined quality of life.”- Bhagvad Gita • The need, expectations, desires and demands of older patients may exceed of any age group, and the gratitude shown by older patients is among the most satisfying professional experiences • The QUALITY OF LIFE for older patients can be significantly improved by saving teeth through Endodontic treatment which can have a large and impressive value to the overall DENTAL, PHYSICAL AND MENTAL HEALTH – ( Cohen Pathways of Pulp 11th edition)
 Expectations, desire, demands are least from any other groups  The basic expectation in Geriatric population is just FUNCTIONAL  Geriatrics are not interested in long term solutions MISCONCEPTIONS
GERIATRICS- Derived from “ GERON” meaning old man and “IATROS” means healer. 3 groups of older subjects: Young (65-74yrs) Older old (75-84 yrs) Oldest old ( >85 yrs) (Nadig et al, JCD 2011)
G E R I AT R I C E N D O D O N T I C S I S T H E E N D O D O N T I C C O N S I D E R AT I O N F O R O L D E R A D U LT S . Geriatric dentistry : DCNA 1989 defined geriatric dentistry as the provision of care for adults with one or more chronic, debilitating, physical or mental illness with associated medication and psychosocial problems
INDIAN SCENARIO • Unfortunately, geriatric dental care in India is still in its INFANCY • Dental treatment is considered the LAST PRIORITY owing to lack of awareness and poor socio- economic status
Age changes are at various levels: Teeth Bone Periodont al Tissue Oral Mucos a Salivar y glands
AGE CHANGES IN TEETH Enamel Dentin Pulp Cementum ENAMEL • Darker and brittle • Mineral content increases & organic content decreases • Exhibits physiological wear ( chipping, wearing, craze lines, staining of chipped areas)
Old toothNew tooth Secondary den Secondary den  DENTIN • Exposed dentin Secondary dentin • Gradual obliteration of tubules- decreased sensitivity • Reduced dentin sensitivity – ingress of toxic products prevented • Decrease in size
 PULP • Recession in the size of pulp chamber • More fibers and less cells • Blood supply decreases • More incidences of calcification
AGE CHANGES IN BONE AND PERIODONTIUM PERIODONTAL TISSUES o Decrease in fibroblasts and fiber content o Increase in size of interstitial compartments containing B.Vs o Calcification b/w collagen fibers BONE • Cortical thinning • Loss of trabeculae • Cellular atrophy • Sclerosis of bone ( Mothanna K. et al)< 3 mm gingival recession on buccal surface
• Bothhistologiclayers,theepithelium,andconnectivetissuehave importantdefensivefunctions • Changesinepithelium: Oral mucosa becomes increasingly smooth, thin, dry, and have edematous appearance with loss of elasticity and stippling and thus becomes more susceptible to injury. CHANGES IN ORAL MUCOSA
• Diminished functional of salivary glands leading to xerostomia. • The main consequences of xerostomia are: • Dry mouth and generalized soreness • Burning and painful tongue • Taste changes • Difficulty in chewing, swallowing talking and denture retention AGE CHANGES IN SALIVARY GLANDS
Drugs causing hyposalivation: • Anticholinergic • Antidepressants • Antipsychotic • Diuretic • And NSAIDS Hyposalivation can lead to in adequate bi carbonate and urea buffering, remineralization, and sugar and acid clearance, which may cause an increase rate of caries
E N D O D O N T I C S I N G E R I A T R I C P A T I E N T S G O A L : T O I M P R O V E T H E Q U A L I T Y O F L I F E B Y P R E V E N T I N G T H E L O S S O F T E E T H W H I C H C A N A D D A L A R G E I M P R E S S I O N O N T H E P A T I E N T ’ S P H Y S I C A L , M E N T A L A N D D E N T A L H E A L T H .
Before starting the patient • A detailed medical history • Chief complaint in the patient’s own words • Past Dental history • Patient symptoms (subjective/ objective)
MEDICAL & DENTAL HISTORY • Medical History : • Recognizing the biological or functional age more imp than chronological age • A standardized form should be used to identify any disease or therapy that would alter the treatment plan or its outcome • The Physicians’ Desk Reference (PDR) should be consulted, and any precaution or side effect of a medication noted. The PDR is available online (www.pdr.net/). Several other websites (e.g., Epocrates [www.epocrates.com]) have been developed specifically to be consulted about drug interactions and dental treatment. th
FEWSYSTEMICCONDITIONS • Diabetes: less predictable healing Graber SE. JOE 2004 , found less dentin bridge formation in exposed pulps of rats with induced diabetes compared with rats without diabetes • Hypertension Contrary to popular belief, using epinephrine in Local Anesthetics carries a low risk of adverse effects. ( Brown RS et al OOOE 2005) • Osteoporosis Osteonecrosis of the jaw (ONJ) is a painful condition secondary to bisphosphonate therapy. occurs at a much higher rate in older patients (>65 yrs), patients receiving i.v treatment for bone diseases than it does in older patients receiving the oral treatment common for osteoporosis. Also patients with a h/o smoking, diabetes and obesity are at a higher risk  Tooth retention are recommended alternatives to the risk of extraction as osteoporosis occurs spontaneously with dental procedures that involve bone trauma AAE position paper on the endodontic implications of ONJ is available online (www.aae.org/guidelines) –COHEN 11th Edition
Dental History: search the patients records and explore their memories to determine the history of the involved teeth history can be as obvious as a recent pulp exposure and restoration or it may be as subtle as a routine crown preparation 15 to 20 years ago In conclusion – Root canal treatment is certainly far less traumatic in the extremes of age or health than extraction and implant placement.
CHIEFCOMPLAINT • For a geriatric patient, a lifetime of experiencing pain puts a different perspective on interpreting dental pain. • Pain associated with vital pulps (i.e., referred pain; pain caused by heat, cold, or sweets) seems to be reduced with age, and its severity seems to diminish over time. • Heat sensitivity that occurs as the only symptom suggests a reduced pulp volume, such as that occurring in older pulps. • Pulpal healing capacity is also reduced, and necrosis may occur quickly after microbial invasion, again with reduced symptoms. • The diagnostic process is directed toward determining the vitality of the pulp, whether pulpal or periapical disease is present, and which tooth is the source
SYMPTOMS SUBJECTIVE • Patients explain about their complaint, stimulus or irritant that causes pain, nature of pain and its relationship with the stimulus or irritant • From this the dentist can determine the type of diagnostic tests to be done to confirm the findings
• Important to remember that pulpal symptoms are usually chronic in older patients, and other sources of orofacial pain should be ruled out when pain is not soon localized. • One example is herpes zoster, which commonly has a prodromal period of 2 to 4 days, when shooting pain, paresthesia, burning, and tenderness appear along the course of the affected nerve possibly leading to pulpitis, necrosis, or internal resorption and apical periodontitis.
• clinical examination done by the dentists • Common observations: I. Missing teeth II. Hyposalivation III. Gingival recession & root caries( interproximal) IV. Attrition, abrasion and erosion V. Compensating bites – T.M.J dysfunction VI. Multiple restorations– further care while restoring VII. Periodontal problems like deep pockets OBJECTIVE
PULPVITALITYTESTS • Often very difficult to quantify the response to a stimulus applied to a tooth. • Extensive restoration, pulp recession and excessive calcification are the limitation both with thermal and electric pulp testing • Discoloration of single teeth may indicate pulp death, but this is a less likely cause of discoloration with advanced age. • Electric stimulus in patients with pacemakers is not recommended
• Transilluminating and staining have been advocated as means to detect cracks, but most older teeth, especially molars demonstrate some cracks. • Abbot showed that 60% of all teeth requiring endodontic treatment demonstrated cracks after the complete removal of all restorations. • Vertically cracked teeth could be a pathway for bacteria when pulpal or periapical disease is observed • Pockets associated with cracks indicate a poor prognosis
RADIOGRAPHS • Film placement may be adversely affected by tori and older patients may be less capable of assisting the film placement • Presence of exostoses, and denser bone may require increased exposure time for proper diagnostic contrast. • In older patients, pulp recession is accelerated by reparative dentin and complicated by pulp stones and dystrophic calcification. Deep proximal or root decay and restorations may cause calcification between the observable chamber and root canal. – ( P. Allen & Whiteworth, Gerodontology 2004)
DIAGNOSIS&TREATMENTPLAN • One- appointment procedures offer obvious advantages to older patients • Root canal treatment as a restorative treatment should be considered when cusps have fractured, supraerupted or maligned teeth, intra coronal attachments, guide planes for partial abutments, rest seats or over denture require significant tooth reduction • Because of reduced blood supply, pulp capping is not as successful as in young teeth, hence not recommended
CONSULTATION&CONSENT • Good communication should be established and maintained with geriatric patients. • They should be explained about the procedures’ risk and benefits irrespective of the patients life expectancy as they aren’t an excuse for poor RCTs and extractions • Determining the patients desires is as important as obtaining informed consent • Priorities in treating pain and infection to properly and esthetically restore teeth to health and function should be unaffected by age Pathways of the Pulp, Cohen 11th Edition
TREATMENTCONSIDERATIONS • Morning appointments are preferred • Older patients are more likely to tolerate longer appointments although chair position and comfort are more important than for younger patients • Patients should be offered assistance into the operatories and into and out of the chair, and chair adjustments should be made slowly • Every effort should be made to accommodate the ideal position even at some expense to clinician’s comfort
• Patient’s eyes should be shielded from the intensity of the clinicians light • Jaw fatigue is readily recognizable, hence bite blocks are indicated to reduce the jaw fatigue • Older, medically compromised patients are at more risk than their younger counterparts, so clinicians to take necessary precautions • Clinicians should recognize that root canal therapy is far less traumatic than extraction • Geriatric patients are usually amongst the most cooperative, available and appreciative -P. Allen & whiteworth, Gerontology
ROOTCANALTREATMENT CONSIDERATIONS
CLINICALCONSIDERATIONSFORELDERLY PATIENTSUNDERGOINGRCT • Preservation of teeth in elderly patients provides several benefits like - maintenance of intact dental arch - increased retention of removable dentures - provision of abutments for FPD - preservation of occlusion and alveolar bone • RCTs in elderly patients could be a challenge due to calcified and limited pulp chamber • However, Root Canal Treatment is contraindicated in some medical conditions like patients undergoing radiotherapy to head & neck region, poor compliance ( eg- pt with Parkinson’s disease, tremors, dementia) Mothanna K. et al, Saudi Medical Journal 2019
ISOLATION • Rubber dam isolation can be done Involving a single tooth or multiple teeth • Multiple teeth isolation can be done if adjacent teeth can be clamped and if saliva output is low or well placed saliva ejector can be tolerated • In patients with hyposalivation artificial saliva can be used to facilitate easy insertion of the dam
ACCESSCAVITY • The effects of access on existing restorations and the possible need for actual removal of restoration should be discussed with the patients before initiating the treatment • Adequate access and identification of canal orifices • Although the effects of aging and multiple restorations may reduce the volume and coronal extent of the chamber or canal orifices, its bucco- lingual and mesio-distal positions remain the same and can be predicted from radiographs and clinical examinations • In roots, the deposition of dentin is always concentric toward the center of the mass of dentin. Hence, deposition is most marked in the coronal Abbot. Aust Dent J. 2004
Clark & Khademi. (Dent Clin N America 2010 )
PROCEDURE • Location and penetration of the canal orifices can be difficult and time consuming in calcified canals for which Ultrasonic tips can be used. • Use of DG-16 Endodontic explorer which will not stick in solid dentin, but it will resist dislodgment in the canal • After canal location, negotiation with SS No. 8, 10 or 15 K files • No 6 K file lacks stiffness in its shaft and easily bends and curls under gentle apical pressure • Ni-Ti Files lack strength in the long axis and are contra indicated for initial negotiation • Canal negotiated using watch winding action with the help of chelating agents
C+ FILES (DENTSPLY) • Strong buckling resistance compared with K files, which allows easier location of the canal orifices • Pyramid shaped tip facilitates insertion during negotiation of canal, and the square cross section provides better resistance to distortion • Polished surface allows smoother insertion into the canal
BIOMECHANICALPREPARATION • The calcified appearance of canals resulting from aging process presents a much different clinical situation than that in a younger pulp in which trauma, pulpotomy, caries or restorative procedures have induced canal obliteration • The calcification appears to be much more concentric and linear, thus allows easier penetration of canals once they are found • AN OLDER TOOTH IS MORE LIKELY TO HAVE A HISTORY OF EARLIER TREATMENTS, WITH A COMBINATION OF CALCIFICATIONS PRESENT • Due to hyper cementosis, the apical constriction is even farther from the apex, which makes the penetration into the cemental canal almost impossible
• Achieving and maintaining apical patency is more difficult. Apical root resorption associated with peri apical pathosis further changes the shape, size and position of the constriction. • Increased pulp FIBROSIS may present challenges for canal negotiation, with potential to compact fibrous pulp tissue and cause obstructions which may be as difficult to overcome as the most troublesome hard tissue ledges or blockages P. Allen & Whiteworth, Gerodontology 2004
• Flaring of the canal should be performed early in the procedure to provide for a reservoir of irrigating solution and reduce the stress on instruments that occurs when they bind with the canal walls • Thorough and frequent irrigation to remove the debris that could block access • A single- file NiTi system is considered appropriate for elderly patients who require short times for canal preparation • Instrumentation techniques used for the preparation of calcified canals require an understanding of the variations in taper, tip geometrics, rake angle, pitch, and metallurgy. Instruments with little or no rake angle and a crown-down technique are recommended.
• CDJ 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 may 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. • Use of electronic apex-finding devices is avoided in heavily restored teeth
OBTURATION • For the older patient, gutta-percha filling techniques are usually selected that do not require unusually large mid-root tapers and do not generate pressure in this area, which could result in root fracture • Use of single-cone with bio ceramic sealers is a viable option for obturation • THE CORONAL SEAL PLAYS AN IMPORTANT ROLE in maintaining an apically healthy environment. Even a root-filled tooth should not have its canals exposed to the oral environment. • 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 -Cohen 11th Edition -Mothanna K. et al, Saudi Medical Journal 2019
• Use of Resilon as an obturation material may significantly reduce coronal leakage that can result from root caries after root canal treatment, as well as increase resistance to root fractures • When mechanical retention is not ensured with preparation, GICs are recommended • Cold lateral and Warm Vertical gutta percha obturations are the most commonly used and best documented Walton and Torabinejad, Endodontic Priciples & Practicle 4th Ed
POSTENDODONTICRESTORATIONS • Root canal treatment saves roots, and restorative procedures save crowns. Combined, these procedures are returning more teeth to form and function than were thought possible a few decades ago • Successful restorative outcomes have been shown to be related to full coverage restorations on molars and older patient age. • Post is an extension of the foundation into the root canal of structurally damaged teeth, needed for the core and the coronal restoration stability and retention. • Post performs both mechanical and biological function by protecting the apical seal from bacterial contamination in case of coronal leakage This fracture of a cast post presents a very difficult challenge for removal.
• Post space preparation should be kept as conservative as possible to avoid any risk of root fracture • Fiber post preferred in the aged tooth as it occupies one-third to one-half of the length of the canal and also the radicular extension is about the coronal length of the core • Root fracture (vertical) is common in older adults when much taper is used, hence excessive taper should be avoided • Posts are not usually needed when root canal treatment is performed through an existing crown that will continue to be used Pathways of the pulp. 10th Edition - Cohen
• In 1980, Nayyar and Walton described the amal-core or the coronal-radicular restoration. Rather than placing a post, the coronal restoration is extended 2 to 3 mm into the pulp chamber of each canal which is used for retention of the build up material • Advantage: Predictable & cost effective modality for posterior endodontically treated teeth -Grossman’s Endodontic Practice -12 th Ed
REFERRALS: The factors that determine the situations that must be referred to the appropriate specialist for Root Canal Treatment (AAE)
SUCCESS&FAILURES • Repair of peri apical tissues after endodontic treatment in older patients is determined by same local and systemic factors that govern the process in all the patients • With Vital pulps, peri apical tissues are normal and can be maintained with an aseptic technique, confining preparation and filling procedures to the canal space • With infected non vital pulps with peri apical pathosis must have the process altered in favor of the host tissue, and repair is determined by the ability of the tissue to respond • Factors that influence repair have their greatest effect on the prognosis of endodontic therapy when periapical abnormality are present
• Aging causes arteriosclerotic changes of the blood vessels which alters the viscosity of the connective tissue, making repair more difficult • Rate of bone formation and normal resorption decreases with age, and the aging of bone results in greater porosity and decreased mineralization of the formed bone Cohen 11th Edition
ENDODONTICSURGERY • Generally, considerations and indications for endodontic surgery are not affected by age. • Anatomic complications of the root canal systems, such as small or completely calcified canals, non negotiable root curvature, extensive apical root resorption, or pulp stones occur with greater frequency in older patients • PERFORATION DURING ACCESS, LOSING WORKING LENGTH DURING INSTRUMENTATION, LEDGING AND INSTRUMENT SEPARATION are some iatrogenic treatment complications associated with treatment of calcified canals
HEALINGAFTERSURGERY • Both hard and soft tissues will heal predictably, although the healing is somewhat slow • Even elderly patient will have a good healing, provided they follow post treatment protocols • Post surgical instructions should be given verbally as well as in writing to avoid complications
MEDICALCONSIDERATIONS • Ecchymosis is a more common post operative finding in older patients and may appear to be extreme • Patient should be re assured that this condition is normal and may take as long as two weeks to return to normal color. • Blue discoloration will change into brown and yellow before it disappears • Immediate application of an ice pack after surgery reduces bleeding and initiate coagulation to reduce the extent of ecchymosis • Later, the application of heat helps to dissipate the discoloration Pathways of Pulp, 10th Ed – Cohen Endodontics – Principles & Practice; 4th Ed – Torabinejad
MEDICALCONSIDERATIONS: • A thorough medical history and evaluation reveal the need of any special considerations such as prophylactic antibiotics, pre medications , sedation, hospitalization • Many old patients receive low-dose aspirin therapy to prevent blood clot formation and may subject to embolic formation if the treatment is interrupted, hence aspirin should be continued throughout the dental procedures, even during extraction or surgery. Local methods are sufficient to control bleeding Pathways of Pulp, 10th Edition Cohen
• Smaller amounts of anesthesia and vasoconstrictor needed for profound anesthesia • Tissue is less resilient and resistance to reflection appears to be diminished. • The oral cavity is usually more accessible with the teeth closed together, because the lips can be more easily stretched • The apex can actually become more surgically accessible in older patients. • Mepivacaine 3% can be used as a safe choice for elderly patients with medical conditions MEDICALCONSIDERATIONS:
ANATOMICFACTORS • The position of anatomic features - The sinus, Floor of the nose and neurovascular bundles REMAIN SAME , but their RELATIONSHIP to the surrounding structures may CHANGE when teeth have been lost • The need may arise to combine endodontic and periodontal flap procedures and complete them in one sitting • When root–end surgery is to be performed, the surgeon must consider whether the root that will be left is long enough and thick enough to continue to remain functional and stable . This factor is especially important when the tooth is to be used as an abutment
RESTORATION • The restorability of older teeth can be affected when ROOT DECAY has limited access to sound margins or reduced the integrity of remaining tooth structure • Esthetic rehabilitative dentistry has come from average American “ Baby Boomer” now between 44 to 62 years of age, who take their health and beauty more seriously than their ancestors • Patients in this age category often have dated restorations and other dental esthetic compromises from a long and a varied history of dental treatments • provides patients with an opportunity to “ TURN THE CLOCK BACK” by restoring their dentitions to a healthier, more youthful state Jacinthe Paquette, Inside Dentistry Jan 2009
RESTORATIVECONSIDERATIONS ROOT CARIES • Mostly present subgingivally, or gingival to the proximal surface, making visibility, accessibility and isolation extremely difficult. • GIC - choice of restorative material • Holmes demonstrated the reversal of leathery root caries on exposure to ozone • Exposure to ozone for 10-40 sec is antimicrobial, eliminates the ecological niche and removes acidity, hence CORONAL CARIES • Direct plastic restorations preferred as they can be readily or inexpensively repaired or replaced • Caries activity is quite high and therefore requires frequent maintenance which might not be done easily in an indirect restoration - Nadig R.R. et al JCD Sept 2011
Topical Fluorides, Remineralizati on agents, Frequent recall Excavation of lesion, reshaping of margins, fluoride application Restoration with GIC Endodontics or Extracti on Classificationofrootcaries
MANAGEMENTOFWORNOUTTEETH Principles and guidelines for managing tooth wear: a review – Azouzi et al Jan 2018
DAHLCONCEPT • Dahl et al introduced a concept to create space to restore worn anterior teeth where such space was absent. • Involved the use of a cobalt-chrome removable anterior bite plane that caused separation of the posterior teeth • Mechanism: a combination of eruption of posterior teeth, intrusion of anterior teeth and possibly mandibular repositioning, the posterior occlusion was re-established. • The anterior space could then be utilized to place indirect restorations without the need for occlusal surface reduction. • This technique has proved successful, in 94−100% of
Turner and Missirilian Active restorative management of generalized TW: Principles and guidelines for managing tooth wear: a review – Azouzi et al Jan 2018
CATEGORY1:EXCESSIVETOOTHWEAR, TOGETHERWITHALOSSINTHEOVD • At first, removable splint or partial denture is placed and observed periodically for 6-8 weeks • The splint will provide not only an increase in the OVD but also offers a mutually protective occlusal scheme
• Fixed provisional restorations are placed for another 2-3 months before planning permanent restorations. ( A removable trial restoration cannot be solely relied because the patient may have removed the prosthesis during the periods of stress, soreness, etc) • Heat polymerized acrylic resin is satisfactory for provisional restorations
CATEGORY2:EXCESSIVETOOTHWEAR, WITHOUTALOSSINTHEOVD,BUTWITH LIMITEDSPACE
• Patients in this category have a long history of gradual wear caused by – Bruxism Moderate oral habits, or Environmental factors • In these patients, OVD is maintained by continuous tooth eruption • However, the amount of space available would still be less for restoration, hence; Gingivoplasty- gain the crown length Enameloplasty- of the opposing tooth, provide some space for the restorative material Disadvantages- • irreversible as some level of tooth reduction may be involved accommodating the adequate thickness of composite resin • time consuming and skill demanding
CATEGORY3:NOLOSSOFTHEOVDWITH INSUFFICIENTSPACEFORRESTORATIVEMATERIAL, THETWMANAGEMENTVARIES. • These are the most complex cases to manage where no adequate space for restoration is available while compensatory tooth repositioning is observed. • The challenge faced in this situation is to provide space without increasing the OVD which is not evident.
• A variety of strategies have been presented in literature:- 1. surgical procedure: it consists of crown lengthening with an osseous re-contouring increasing, thus, the height of coronal tooth tissue. This improves retention and resistance of the future conventional restoration. 2. orthodontic treatment : It consists of intruding over erupted teeth or extruding short crowns associated with later restorative treatment • However, this option is complicated regarding time, costs and patient availability.Unless such methods fail to provide enough space, an increase in the OVD would be promoted. It would be assessed through occlusal splints
STAGEDPLANNINGFORELDERLY • STAGE 1 : EMERGENCY CARE • STAGE II : MAINTENANCE AND MONITORING ; includes management of chronic infections, Root Canal Therapy, Root Planing and curettage, restoration of carious lesions, work related to dentures, patient education to improve oral health. Further evaluation • STAGE III : REHABILITATION PHASE ; includes implants, surgical Endodontics, surgical periodontics, esthetic rehabilitations, reconstruction of occlusion plane, and restoration of vertical dimension. - Nadig R.R. et al JCD Sept 2011
W H I L E W R I N K L E S A N D G R A Y I N G A R E I N E V I T A B L E W I T H A G E , T O O T H L O S S I N N O T . S O , L E T ’ S G E A R U P T O C A T E R T H E N E E D , T H E D E M A N D A N D C H A L L E N G E S O F G E R I A T R I C C A R E . CONCLUSION
REFERENCES Pathways of Pulp 11th Ed – Cohen Endodontics: Principles and Practice, 4th Ed Grossman's Endodontic Practice 12 Th. Ed The Dental Pulp – Seltzer and Bender Textbook of Endodontics 2nd Ed- Nisha Garg Oral Histology – Tencate The Aging Skeleton – Clifford J Rosen Journal of Conservative Dentistry Journal of Endodontics Gerodontology Dental Clinics of North America Journal of International and Clinical Medicine Journal of Dental Education Journal of Dental Research Journal of American Dental Association Inside Dentistry
Geriatric Endodontics

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Geriatric Endodontics

  • 1.
    G E RI AT R I C E N D O D O N T I C S D R . S U R A B H I S O U M YA
  • 2.
    CONTENTS • Oral aspectsof aging • Age changes in the teeth • Endodontics in Geriatric patients • Diagnosis and treatment planning • References History Chief complaint Symptoms Vitality tests Radiographs
  • 3.
    • Currently theold age population in India is 8% of its population (80 million) • In 2025 we will reach 12% ( 830 million) • Out of every 7 aged person in the world , one will be an According to the WHO, the global population is increasing at the annual rate of 1.7%, while the population of those over 65 years is increasing at a rate of 2.5%. Both the developed, as well as the lesser-developed countries, are expected to experience significant shifts in the age distribution of the population by 2050.
  • 4.
    AGING IS INEVITABLE… •“He, who is born, has to go through childhood, youth and old age. If aging is inevitable, let’s be graceful and serene about it and lead a disciplined quality of life.”- Bhagvad Gita • The need, expectations, desires and demands of older patients may exceed of any age group, and the gratitude shown by older patients is among the most satisfying professional experiences • The QUALITY OF LIFE for older patients can be significantly improved by saving teeth through Endodontic treatment which can have a large and impressive value to the overall DENTAL, PHYSICAL AND MENTAL HEALTH – ( Cohen Pathways of Pulp 11th edition)
  • 5.
     Expectations, desire,demands are least from any other groups  The basic expectation in Geriatric population is just FUNCTIONAL  Geriatrics are not interested in long term solutions MISCONCEPTIONS
  • 6.
    GERIATRICS- Derived from “GERON” meaning old man and “IATROS” means healer. 3 groups of older subjects: Young (65-74yrs) Older old (75-84 yrs) Oldest old ( >85 yrs) (Nadig et al, JCD 2011)
  • 7.
    G E RI AT R I C E N D O D O N T I C S I S T H E E N D O D O N T I C C O N S I D E R AT I O N F O R O L D E R A D U LT S . Geriatric dentistry : DCNA 1989 defined geriatric dentistry as the provision of care for adults with one or more chronic, debilitating, physical or mental illness with associated medication and psychosocial problems
  • 8.
    INDIAN SCENARIO • Unfortunately,geriatric dental care in India is still in its INFANCY • Dental treatment is considered the LAST PRIORITY owing to lack of awareness and poor socio- economic status
  • 9.
    Age changes areat various levels: Teeth Bone Periodont al Tissue Oral Mucos a Salivar y glands
  • 10.
    AGE CHANGES INTEETH Enamel Dentin Pulp Cementum ENAMEL • Darker and brittle • Mineral content increases & organic content decreases • Exhibits physiological wear ( chipping, wearing, craze lines, staining of chipped areas)
  • 11.
    Old toothNew tooth Secondaryden Secondary den  DENTIN • Exposed dentin Secondary dentin • Gradual obliteration of tubules- decreased sensitivity • Reduced dentin sensitivity – ingress of toxic products prevented • Decrease in size
  • 12.
     PULP • Recessionin the size of pulp chamber • More fibers and less cells • Blood supply decreases • More incidences of calcification
  • 13.
    AGE CHANGES INBONE AND PERIODONTIUM PERIODONTAL TISSUES o Decrease in fibroblasts and fiber content o Increase in size of interstitial compartments containing B.Vs o Calcification b/w collagen fibers BONE • Cortical thinning • Loss of trabeculae • Cellular atrophy • Sclerosis of bone ( Mothanna K. et al)< 3 mm gingival recession on buccal surface
  • 14.
    • Bothhistologiclayers,theepithelium,andconnectivetissuehave importantdefensivefunctions • Changesinepithelium: Oralmucosa becomes increasingly smooth, thin, dry, and have edematous appearance with loss of elasticity and stippling and thus becomes more susceptible to injury. CHANGES IN ORAL MUCOSA
  • 15.
    • Diminished functionalof salivary glands leading to xerostomia. • The main consequences of xerostomia are: • Dry mouth and generalized soreness • Burning and painful tongue • Taste changes • Difficulty in chewing, swallowing talking and denture retention AGE CHANGES IN SALIVARY GLANDS
  • 16.
    Drugs causing hyposalivation: •Anticholinergic • Antidepressants • Antipsychotic • Diuretic • And NSAIDS Hyposalivation can lead to in adequate bi carbonate and urea buffering, remineralization, and sugar and acid clearance, which may cause an increase rate of caries
  • 17.
    E N DO D O N T I C S I N G E R I A T R I C P A T I E N T S G O A L : T O I M P R O V E T H E Q U A L I T Y O F L I F E B Y P R E V E N T I N G T H E L O S S O F T E E T H W H I C H C A N A D D A L A R G E I M P R E S S I O N O N T H E P A T I E N T ’ S P H Y S I C A L , M E N T A L A N D D E N T A L H E A L T H .
  • 18.
    Before starting thepatient • A detailed medical history • Chief complaint in the patient’s own words • Past Dental history • Patient symptoms (subjective/ objective)
  • 19.
    MEDICAL & DENTALHISTORY • Medical History : • Recognizing the biological or functional age more imp than chronological age • A standardized form should be used to identify any disease or therapy that would alter the treatment plan or its outcome • The Physicians’ Desk Reference (PDR) should be consulted, and any precaution or side effect of a medication noted. The PDR is available online (www.pdr.net/). Several other websites (e.g., Epocrates [www.epocrates.com]) have been developed specifically to be consulted about drug interactions and dental treatment. th
  • 20.
    FEWSYSTEMICCONDITIONS • Diabetes: lesspredictable healing Graber SE. JOE 2004 , found less dentin bridge formation in exposed pulps of rats with induced diabetes compared with rats without diabetes • Hypertension Contrary to popular belief, using epinephrine in Local Anesthetics carries a low risk of adverse effects. ( Brown RS et al OOOE 2005) • Osteoporosis Osteonecrosis of the jaw (ONJ) is a painful condition secondary to bisphosphonate therapy. occurs at a much higher rate in older patients (>65 yrs), patients receiving i.v treatment for bone diseases than it does in older patients receiving the oral treatment common for osteoporosis. Also patients with a h/o smoking, diabetes and obesity are at a higher risk  Tooth retention are recommended alternatives to the risk of extraction as osteoporosis occurs spontaneously with dental procedures that involve bone trauma AAE position paper on the endodontic implications of ONJ is available online (www.aae.org/guidelines) –COHEN 11th Edition
  • 21.
    Dental History: search thepatients records and explore their memories to determine the history of the involved teeth history can be as obvious as a recent pulp exposure and restoration or it may be as subtle as a routine crown preparation 15 to 20 years ago In conclusion – Root canal treatment is certainly far less traumatic in the extremes of age or health than extraction and implant placement.
  • 22.
    CHIEFCOMPLAINT • For ageriatric patient, a lifetime of experiencing pain puts a different perspective on interpreting dental pain. • Pain associated with vital pulps (i.e., referred pain; pain caused by heat, cold, or sweets) seems to be reduced with age, and its severity seems to diminish over time. • Heat sensitivity that occurs as the only symptom suggests a reduced pulp volume, such as that occurring in older pulps. • Pulpal healing capacity is also reduced, and necrosis may occur quickly after microbial invasion, again with reduced symptoms. • The diagnostic process is directed toward determining the vitality of the pulp, whether pulpal or periapical disease is present, and which tooth is the source
  • 23.
    SYMPTOMS SUBJECTIVE • Patientsexplain about their complaint, stimulus or irritant that causes pain, nature of pain and its relationship with the stimulus or irritant • From this the dentist can determine the type of diagnostic tests to be done to confirm the findings
  • 24.
    • Important toremember that pulpal symptoms are usually chronic in older patients, and other sources of orofacial pain should be ruled out when pain is not soon localized. • One example is herpes zoster, which commonly has a prodromal period of 2 to 4 days, when shooting pain, paresthesia, burning, and tenderness appear along the course of the affected nerve possibly leading to pulpitis, necrosis, or internal resorption and apical periodontitis.
  • 25.
    • clinical examinationdone by the dentists • Common observations: I. Missing teeth II. Hyposalivation III. Gingival recession & root caries( interproximal) IV. Attrition, abrasion and erosion V. Compensating bites – T.M.J dysfunction VI. Multiple restorations– further care while restoring VII. Periodontal problems like deep pockets OBJECTIVE
  • 26.
    PULPVITALITYTESTS • Often verydifficult to quantify the response to a stimulus applied to a tooth. • Extensive restoration, pulp recession and excessive calcification are the limitation both with thermal and electric pulp testing • Discoloration of single teeth may indicate pulp death, but this is a less likely cause of discoloration with advanced age. • Electric stimulus in patients with pacemakers is not recommended
  • 27.
    • Transilluminating andstaining have been advocated as means to detect cracks, but most older teeth, especially molars demonstrate some cracks. • Abbot showed that 60% of all teeth requiring endodontic treatment demonstrated cracks after the complete removal of all restorations. • Vertically cracked teeth could be a pathway for bacteria when pulpal or periapical disease is observed • Pockets associated with cracks indicate a poor prognosis
  • 28.
    RADIOGRAPHS • Film placementmay be adversely affected by tori and older patients may be less capable of assisting the film placement • Presence of exostoses, and denser bone may require increased exposure time for proper diagnostic contrast. • In older patients, pulp recession is accelerated by reparative dentin and complicated by pulp stones and dystrophic calcification. Deep proximal or root decay and restorations may cause calcification between the observable chamber and root canal. – ( P. Allen & Whiteworth, Gerodontology 2004)
  • 29.
    DIAGNOSIS&TREATMENTPLAN • One- appointmentprocedures offer obvious advantages to older patients • Root canal treatment as a restorative treatment should be considered when cusps have fractured, supraerupted or maligned teeth, intra coronal attachments, guide planes for partial abutments, rest seats or over denture require significant tooth reduction • Because of reduced blood supply, pulp capping is not as successful as in young teeth, hence not recommended
  • 30.
    CONSULTATION&CONSENT • Good communicationshould be established and maintained with geriatric patients. • They should be explained about the procedures’ risk and benefits irrespective of the patients life expectancy as they aren’t an excuse for poor RCTs and extractions • Determining the patients desires is as important as obtaining informed consent • Priorities in treating pain and infection to properly and esthetically restore teeth to health and function should be unaffected by age Pathways of the Pulp, Cohen 11th Edition
  • 31.
    TREATMENTCONSIDERATIONS • Morning appointmentsare preferred • Older patients are more likely to tolerate longer appointments although chair position and comfort are more important than for younger patients • Patients should be offered assistance into the operatories and into and out of the chair, and chair adjustments should be made slowly • Every effort should be made to accommodate the ideal position even at some expense to clinician’s comfort
  • 32.
    • Patient’s eyesshould be shielded from the intensity of the clinicians light • Jaw fatigue is readily recognizable, hence bite blocks are indicated to reduce the jaw fatigue • Older, medically compromised patients are at more risk than their younger counterparts, so clinicians to take necessary precautions • Clinicians should recognize that root canal therapy is far less traumatic than extraction • Geriatric patients are usually amongst the most cooperative, available and appreciative -P. Allen & whiteworth, Gerontology
  • 33.
  • 34.
    CLINICALCONSIDERATIONSFORELDERLY PATIENTSUNDERGOINGRCT • Preservation ofteeth in elderly patients provides several benefits like - maintenance of intact dental arch - increased retention of removable dentures - provision of abutments for FPD - preservation of occlusion and alveolar bone • RCTs in elderly patients could be a challenge due to calcified and limited pulp chamber • However, Root Canal Treatment is contraindicated in some medical conditions like patients undergoing radiotherapy to head & neck region, poor compliance ( eg- pt with Parkinson’s disease, tremors, dementia) Mothanna K. et al, Saudi Medical Journal 2019
  • 35.
    ISOLATION • Rubber damisolation can be done Involving a single tooth or multiple teeth • Multiple teeth isolation can be done if adjacent teeth can be clamped and if saliva output is low or well placed saliva ejector can be tolerated • In patients with hyposalivation artificial saliva can be used to facilitate easy insertion of the dam
  • 36.
    ACCESSCAVITY • Theeffects of access on existing restorations and the possible need for actual removal of restoration should be discussed with the patients before initiating the treatment • Adequate access and identification of canal orifices • Although the effects of aging and multiple restorations may reduce the volume and coronal extent of the chamber or canal orifices, its bucco- lingual and mesio-distal positions remain the same and can be predicted from radiographs and clinical examinations • In roots, the deposition of dentin is always concentric toward the center of the mass of dentin. Hence, deposition is most marked in the coronal Abbot. Aust Dent J. 2004
  • 37.
    Clark & Khademi.(Dent Clin N America 2010 )
  • 38.
    PROCEDURE • Location andpenetration of the canal orifices can be difficult and time consuming in calcified canals for which Ultrasonic tips can be used. • Use of DG-16 Endodontic explorer which will not stick in solid dentin, but it will resist dislodgment in the canal • After canal location, negotiation with SS No. 8, 10 or 15 K files • No 6 K file lacks stiffness in its shaft and easily bends and curls under gentle apical pressure • Ni-Ti Files lack strength in the long axis and are contra indicated for initial negotiation • Canal negotiated using watch winding action with the help of chelating agents
  • 39.
    C+ FILES (DENTSPLY) •Strong buckling resistance compared with K files, which allows easier location of the canal orifices • Pyramid shaped tip facilitates insertion during negotiation of canal, and the square cross section provides better resistance to distortion • Polished surface allows smoother insertion into the canal
  • 40.
    BIOMECHANICALPREPARATION • The calcifiedappearance of canals resulting from aging process presents a much different clinical situation than that in a younger pulp in which trauma, pulpotomy, caries or restorative procedures have induced canal obliteration • The calcification appears to be much more concentric and linear, thus allows easier penetration of canals once they are found • AN OLDER TOOTH IS MORE LIKELY TO HAVE A HISTORY OF EARLIER TREATMENTS, WITH A COMBINATION OF CALCIFICATIONS PRESENT • Due to hyper cementosis, the apical constriction is even farther from the apex, which makes the penetration into the cemental canal almost impossible
  • 41.
    • Achieving andmaintaining apical patency is more difficult. Apical root resorption associated with peri apical pathosis further changes the shape, size and position of the constriction. • Increased pulp FIBROSIS may present challenges for canal negotiation, with potential to compact fibrous pulp tissue and cause obstructions which may be as difficult to overcome as the most troublesome hard tissue ledges or blockages P. Allen & Whiteworth, Gerodontology 2004
  • 42.
    • Flaring ofthe canal should be performed early in the procedure to provide for a reservoir of irrigating solution and reduce the stress on instruments that occurs when they bind with the canal walls • Thorough and frequent irrigation to remove the debris that could block access • A single- file NiTi system is considered appropriate for elderly patients who require short times for canal preparation • Instrumentation techniques used for the preparation of calcified canals require an understanding of the variations in taper, tip geometrics, rake angle, pitch, and metallurgy. Instruments with little or no rake angle and a crown-down technique are recommended.
  • 43.
    • CDJ isthe ideal place to terminate the canal preparation. • This point may vary from 0.5 to 2.5 mm from the radiographic apex and may 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. • Use of electronic apex-finding devices is avoided in heavily restored teeth
  • 44.
    OBTURATION • For theolder patient, gutta-percha filling techniques are usually selected that do not require unusually large mid-root tapers and do not generate pressure in this area, which could result in root fracture • Use of single-cone with bio ceramic sealers is a viable option for obturation • THE CORONAL SEAL PLAYS AN IMPORTANT ROLE in maintaining an apically healthy environment. Even a root-filled tooth should not have its canals exposed to the oral environment. • 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 -Cohen 11th Edition -Mothanna K. et al, Saudi Medical Journal 2019
  • 45.
    • Use ofResilon as an obturation material may significantly reduce coronal leakage that can result from root caries after root canal treatment, as well as increase resistance to root fractures • When mechanical retention is not ensured with preparation, GICs are recommended • Cold lateral and Warm Vertical gutta percha obturations are the most commonly used and best documented Walton and Torabinejad, Endodontic Priciples & Practicle 4th Ed
  • 46.
    POSTENDODONTICRESTORATIONS • Root canaltreatment saves roots, and restorative procedures save crowns. Combined, these procedures are returning more teeth to form and function than were thought possible a few decades ago • Successful restorative outcomes have been shown to be related to full coverage restorations on molars and older patient age. • Post is an extension of the foundation into the root canal of structurally damaged teeth, needed for the core and the coronal restoration stability and retention. • Post performs both mechanical and biological function by protecting the apical seal from bacterial contamination in case of coronal leakage This fracture of a cast post presents a very difficult challenge for removal.
  • 47.
    • Post spacepreparation should be kept as conservative as possible to avoid any risk of root fracture • Fiber post preferred in the aged tooth as it occupies one-third to one-half of the length of the canal and also the radicular extension is about the coronal length of the core • Root fracture (vertical) is common in older adults when much taper is used, hence excessive taper should be avoided • Posts are not usually needed when root canal treatment is performed through an existing crown that will continue to be used Pathways of the pulp. 10th Edition - Cohen
  • 48.
    • In 1980,Nayyar and Walton described the amal-core or the coronal-radicular restoration. Rather than placing a post, the coronal restoration is extended 2 to 3 mm into the pulp chamber of each canal which is used for retention of the build up material • Advantage: Predictable & cost effective modality for posterior endodontically treated teeth -Grossman’s Endodontic Practice -12 th Ed
  • 49.
    REFERRALS: The factorsthat determine the situations that must be referred to the appropriate specialist for Root Canal Treatment (AAE)
  • 50.
    SUCCESS&FAILURES • Repair ofperi apical tissues after endodontic treatment in older patients is determined by same local and systemic factors that govern the process in all the patients • With Vital pulps, peri apical tissues are normal and can be maintained with an aseptic technique, confining preparation and filling procedures to the canal space • With infected non vital pulps with peri apical pathosis must have the process altered in favor of the host tissue, and repair is determined by the ability of the tissue to respond • Factors that influence repair have their greatest effect on the prognosis of endodontic therapy when periapical abnormality are present
  • 51.
    • Aging causesarteriosclerotic changes of the blood vessels which alters the viscosity of the connective tissue, making repair more difficult • Rate of bone formation and normal resorption decreases with age, and the aging of bone results in greater porosity and decreased mineralization of the formed bone Cohen 11th Edition
  • 52.
    ENDODONTICSURGERY • Generally, considerationsand indications for endodontic surgery are not affected by age. • Anatomic complications of the root canal systems, such as small or completely calcified canals, non negotiable root curvature, extensive apical root resorption, or pulp stones occur with greater frequency in older patients • PERFORATION DURING ACCESS, LOSING WORKING LENGTH DURING INSTRUMENTATION, LEDGING AND INSTRUMENT SEPARATION are some iatrogenic treatment complications associated with treatment of calcified canals
  • 53.
    HEALINGAFTERSURGERY • Both hardand soft tissues will heal predictably, although the healing is somewhat slow • Even elderly patient will have a good healing, provided they follow post treatment protocols • Post surgical instructions should be given verbally as well as in writing to avoid complications
  • 54.
    MEDICALCONSIDERATIONS • Ecchymosisis a more common post operative finding in older patients and may appear to be extreme • Patient should be re assured that this condition is normal and may take as long as two weeks to return to normal color. • Blue discoloration will change into brown and yellow before it disappears • Immediate application of an ice pack after surgery reduces bleeding and initiate coagulation to reduce the extent of ecchymosis • Later, the application of heat helps to dissipate the discoloration Pathways of Pulp, 10th Ed – Cohen Endodontics – Principles & Practice; 4th Ed – Torabinejad
  • 55.
    MEDICALCONSIDERATIONS: • A thoroughmedical history and evaluation reveal the need of any special considerations such as prophylactic antibiotics, pre medications , sedation, hospitalization • Many old patients receive low-dose aspirin therapy to prevent blood clot formation and may subject to embolic formation if the treatment is interrupted, hence aspirin should be continued throughout the dental procedures, even during extraction or surgery. Local methods are sufficient to control bleeding Pathways of Pulp, 10th Edition Cohen
  • 56.
    • Smaller amountsof anesthesia and vasoconstrictor needed for profound anesthesia • Tissue is less resilient and resistance to reflection appears to be diminished. • The oral cavity is usually more accessible with the teeth closed together, because the lips can be more easily stretched • The apex can actually become more surgically accessible in older patients. • Mepivacaine 3% can be used as a safe choice for elderly patients with medical conditions MEDICALCONSIDERATIONS:
  • 57.
    ANATOMICFACTORS • The positionof anatomic features - The sinus, Floor of the nose and neurovascular bundles REMAIN SAME , but their RELATIONSHIP to the surrounding structures may CHANGE when teeth have been lost • The need may arise to combine endodontic and periodontal flap procedures and complete them in one sitting • When root–end surgery is to be performed, the surgeon must consider whether the root that will be left is long enough and thick enough to continue to remain functional and stable . This factor is especially important when the tooth is to be used as an abutment
  • 58.
    RESTORATION • The restorabilityof older teeth can be affected when ROOT DECAY has limited access to sound margins or reduced the integrity of remaining tooth structure • Esthetic rehabilitative dentistry has come from average American “ Baby Boomer” now between 44 to 62 years of age, who take their health and beauty more seriously than their ancestors • Patients in this age category often have dated restorations and other dental esthetic compromises from a long and a varied history of dental treatments • provides patients with an opportunity to “ TURN THE CLOCK BACK” by restoring their dentitions to a healthier, more youthful state Jacinthe Paquette, Inside Dentistry Jan 2009
  • 59.
    RESTORATIVECONSIDERATIONS ROOT CARIES • Mostlypresent subgingivally, or gingival to the proximal surface, making visibility, accessibility and isolation extremely difficult. • GIC - choice of restorative material • Holmes demonstrated the reversal of leathery root caries on exposure to ozone • Exposure to ozone for 10-40 sec is antimicrobial, eliminates the ecological niche and removes acidity, hence CORONAL CARIES • Direct plastic restorations preferred as they can be readily or inexpensively repaired or replaced • Caries activity is quite high and therefore requires frequent maintenance which might not be done easily in an indirect restoration - Nadig R.R. et al JCD Sept 2011
  • 60.
    Topical Fluorides, Remineralizati onagents, Frequent recall Excavation of lesion, reshaping of margins, fluoride application Restoration with GIC Endodontics or Extracti on Classificationofrootcaries
  • 61.
    MANAGEMENTOFWORNOUTTEETH Principles and guidelinesfor managing tooth wear: a review – Azouzi et al Jan 2018
  • 62.
    DAHLCONCEPT • Dahl etal introduced a concept to create space to restore worn anterior teeth where such space was absent. • Involved the use of a cobalt-chrome removable anterior bite plane that caused separation of the posterior teeth • Mechanism: a combination of eruption of posterior teeth, intrusion of anterior teeth and possibly mandibular repositioning, the posterior occlusion was re-established. • The anterior space could then be utilized to place indirect restorations without the need for occlusal surface reduction. • This technique has proved successful, in 94−100% of
  • 63.
    Turner and Missirilian Activerestorative management of generalized TW: Principles and guidelines for managing tooth wear: a review – Azouzi et al Jan 2018
  • 64.
    CATEGORY1:EXCESSIVETOOTHWEAR, TOGETHERWITHALOSSINTHEOVD • At first,removable splint or partial denture is placed and observed periodically for 6-8 weeks • The splint will provide not only an increase in the OVD but also offers a mutually protective occlusal scheme
  • 65.
    • Fixed provisionalrestorations are placed for another 2-3 months before planning permanent restorations. ( A removable trial restoration cannot be solely relied because the patient may have removed the prosthesis during the periods of stress, soreness, etc) • Heat polymerized acrylic resin is satisfactory for provisional restorations
  • 66.
  • 67.
    • Patients inthis category have a long history of gradual wear caused by – Bruxism Moderate oral habits, or Environmental factors • In these patients, OVD is maintained by continuous tooth eruption • However, the amount of space available would still be less for restoration, hence; Gingivoplasty- gain the crown length Enameloplasty- of the opposing tooth, provide some space for the restorative material Disadvantages- • irreversible as some level of tooth reduction may be involved accommodating the adequate thickness of composite resin • time consuming and skill demanding
  • 68.
    CATEGORY3:NOLOSSOFTHEOVDWITH INSUFFICIENTSPACEFORRESTORATIVEMATERIAL, THETWMANAGEMENTVARIES. • These arethe most complex cases to manage where no adequate space for restoration is available while compensatory tooth repositioning is observed. • The challenge faced in this situation is to provide space without increasing the OVD which is not evident.
  • 69.
    • A varietyof strategies have been presented in literature:- 1. surgical procedure: it consists of crown lengthening with an osseous re-contouring increasing, thus, the height of coronal tooth tissue. This improves retention and resistance of the future conventional restoration. 2. orthodontic treatment : It consists of intruding over erupted teeth or extruding short crowns associated with later restorative treatment • However, this option is complicated regarding time, costs and patient availability.Unless such methods fail to provide enough space, an increase in the OVD would be promoted. It would be assessed through occlusal splints
  • 70.
    STAGEDPLANNINGFORELDERLY • STAGE 1: EMERGENCY CARE • STAGE II : MAINTENANCE AND MONITORING ; includes management of chronic infections, Root Canal Therapy, Root Planing and curettage, restoration of carious lesions, work related to dentures, patient education to improve oral health. Further evaluation • STAGE III : REHABILITATION PHASE ; includes implants, surgical Endodontics, surgical periodontics, esthetic rehabilitations, reconstruction of occlusion plane, and restoration of vertical dimension. - Nadig R.R. et al JCD Sept 2011
  • 71.
    W H IL E W R I N K L E S A N D G R A Y I N G A R E I N E V I T A B L E W I T H A G E , T O O T H L O S S I N N O T . S O , L E T ’ S G E A R U P T O C A T E R T H E N E E D , T H E D E M A N D A N D C H A L L E N G E S O F G E R I A T R I C C A R E . CONCLUSION
  • 72.
    REFERENCES Pathways ofPulp 11th Ed – Cohen Endodontics: Principles and Practice, 4th Ed Grossman's Endodontic Practice 12 Th. Ed The Dental Pulp – Seltzer and Bender Textbook of Endodontics 2nd Ed- Nisha Garg Oral Histology – Tencate The Aging Skeleton – Clifford J Rosen Journal of Conservative Dentistry Journal of Endodontics Gerodontology Dental Clinics of North America Journal of International and Clinical Medicine Journal of Dental Education Journal of Dental Research Journal of American Dental Association Inside Dentistry