Opinion
Volume 7 Issue 1 - 2016
Geriatric Endodontics, Clinical Changes and Challenges
Mehmet Omer Gorduysus*
Department of Preventive and Restorative Dentistry, University of Sharjah, College of Dental Medicine, Sharjah, UAE
*Corresponding Author: Mehmet Omer Gorduysus, Department of Preventive and Restorative Dentistry, University of Sharjah, College of Dental Medicine, Sharjah, UAE.
Received: December 29, 2016; Published: December 30, 2016
Citation: Mehmet Omer Gorduysus. “Geriatric Endodontics, Clinical Changes and Challenges”. EC Dental Science 7.1 (2016): 38-40.
Geriatric Dentistry (gerodontology) is the dental field that studies dental problems, their diagnosis and solutions in the old. As a key member of health deliver team, also in the field of dentistry the geriatric dentistry and geriatric endodontics gaining more importance because of increasing number of the elder population over 65 years, also over 80 years are becoming a new group and target as a second category in geriatrics and beyond that the centenarians. More geriatric patients are seeking endodontic therapy in the clinics. This is good news for the profession but that means we will be faced more calcified canals, more challenging cases, we need more competency, skills, special training, we need more patience, tolerance, empathy and we will be facing more stress in the clinics. Some geriatric patients are with heavy systemic disorders, communication problems, Alzheimer and Parkinson disease, dementia, anxiety, cooperation problems, and handicapped besides the technical problems in the root canals which we might have being involved during our daily practice. The purpose of this short opinion paper aims focusing the technical details in the clinics during the endodontic therapy more than the other general geriatric problems.
In our daily routine as endodontists we are facing more calcified canals and challenges to overcome at the dental chair with the geriatric patients.
Major difference (contrast) in teeth of geriatric patients from the point of endodontics (geriatric patients versus young age) are aging related pulpal tissue calcifications, delayed electrical pulp testing results and delaying pulpal reactions to cold and heat tests, complicating factors administering interligamentery injections (more damaging),rubber-dam isolation techniques because of badly broken-down (or weared) coronal structures in old patients, location and/or locating the canal orifice in calcified teeth (in olders we see very often).Repair of periapical tissues following endo treatment seems late in geriatric patients. We can see many previously done multiple restorations in one tooth by many dentists during the years. Also, the dosage of anesthetics and medicaments which we might prescribed must be considered.
There is no conclusive evidence that systemic or medical conditions directly decrease the pulpal resistance to injury, but may decrease the healing capacity (theoretically atherosclerosis may effect vessels but pulpal atherosclerosis could not be demonstrated). Indirect effects of systemic diseases to pulpal resistance to injury is a reality (i.e. diabetes, rheumatoid arthritis, multiple sclerosis, other auto immune diseases and immune deficiency problems). Relatively little change in periradicular cellularity, vascularity, or nerve supply by age (healing slower than youngers but even later, the healing is a reality with a proper treatment). Pulpal and periapical reactions (problems) seem ongoing more chronically in elderly patients.
Endodontics has been successively performed on patients ranging from age 2 years to 96 years. In other saying since first day the teeth appear in the oral cavity till the last day of human life. Endodontics is less traumatic than extraction in older patients. Elder patients (also babies) are not fragile to touch. They just need more care and competency to work with. Pain associated with vital pulps (that which is caused by heat, cold, sweets or referred pain) seems to be reduced by age and the severity of symptoms diminished because of biological changes. Asymptomatic pulp exposures on the root of a multi-rooted tooth can result in the surface uncommon clinical situation of the presence of both vital and non-vital pulp tissue in the same tooth. Abrasion, attrition, erosion (common teeth wearing) are pulp responses which those are effects of dentinal sclerosis and reparative dentin. Secondary dentine formation occurs throughout life-time and may eventually result in almost complete pulp obliteration. In maxillary anterior teeth, the dentin is formed on the lingual wall of the pulp chamber, in molar teeth the greatest deposition occurs on the floor of the pulp chamber. Apical foramen becomes more constricted, cement-dentinal junction moves farther from the radiographic apex with continued cementum deposition and also dentinal tubules become more occluded, besides that the tubular permeability decrease is a reality.
Lateral and accessory canals can be calcified (maybe this is good for us) thus decreasing their clinical significance. Because of missing and tilted teeth TMJ functions are limited and loss of vertical dimension, limited mouth opening, muscular fatigue, less space for accessing the instruments are clinical challenges during the root canal treatments. Cracks and cuspal foundation cracks and craze lines of former multiple restorations, and previous dental procedures can be seen and may become problem during the clinical applications and may cause big fractures in the tooth structure and this may be ended up with serious restorability problems. Periodontal disease may be the principal problem for dentate senior and increased incidence of perio-endo cases, sinus tracts because of perio problems or chronic pulpal infections, deep periodontal pockets, chronic food accumulations, halitosis, root and dentinal sensitivity and all those require periodontal therapy. The reduced neural and vascular component of aged pulps, the overall reduced pulp volume and the change in character of the ground substance in the pulp and structural and histological changes in the pulp create an environment that pulp may responds with difficulty to both stimuli and irritants than the youngsters. Therefore, cold and electrical pulp test is mostly deceptive in elderly patients and not very reliable. The response to stimuli may be weaker than in the more highly innervated younger ones. Extensive restorations, pulp recession and excessive calcifications are limitations in both performing and interpreting results of electrical and thermal pulp tests. If they use cardiac pacemakers do not use electric pulp test and other electrosurgical units. A test cavity and selective anesthesia test is not valuable and necessary in elderly patients. Discoloration of single tooth may indicate pulp death but this is a less likely cause of discoloration in the old. This is a result of aging in elderly patients and generally this is normal. Radiographically pulp stones, dystrophic calcifications, reparative dentine, deep proximal caries or root caries can be seen. Also, pulp recession and diminished depth of pulp chamber and lessen MD length and narrowed canals can be seen radiographically. Receding pulp horns, deep and extensive restorations, tilted teeth, mid-root disappearance of a detectable canal may indicate bifurcation rather than calcification, the incidence of some odontogenic and nonodontogenic cysts and tumors characteristically increases with age besides the risk of osteosclerosis and condensing osteitis might be the other radiographic findings in geriatric patients during the endodontic therapy. Tight and calcified canals are almost the rule in older patients in radiographs. Resorptions associated with chronic apical periodontitis significantly alter the shape of apex and the anatomy of the foramen through inflammatory osteoclastic activity, usually hypercementosis at the apex and sometimes silent and old root fractures can be detected radiographically. As treatment plan, single visit appointment procedures offer obvious advantages to elderly patients. Length of dental appointment is important and if possible shorter appointments are better. Practitioners ability to perform the treatment is important. Competency and experience is crucial. Endodontic surgery is not the first option or an alternative as for a young patient (be reluctant for endo-surgery). Retreatment alternatives must be given the priority.
The patients limited life expectancy should not appreciably alter treatment plans and surely is no excuse for extractions or poor root canal treatment. It is important that each geriatric patient be well informed of risks and alternatives. Medically compromised patients must be consulted with the physician. The ideal time of day must be asked to patient for scheduling depending patients’ daily personal, eating, and resting habits should be considered as well as any medication schedule. Morning appointments are preferable for most older patients because of timing of the medications and generally elder patients are more fresh during the morning hours also they wake up earlier. Chair positioning and comfort may be of greater importance for the elderly than younger. Against a jaw fatigue and TMJ problems bite-blocks are useful.
Teeth with necrotic pulp should be treated without anesthesia (optional). That may allow the patients response to instrumentation through apical foramen to determine file length or need for adjustment and reduce risk of over instrumentation and inoculation of canal contents into the periapical tissue, if patient has no cardiac pacemaker electronic apex locator is best for the elderly patients. The reduced width of PDL makes needle placement for supplementary intraligamentary injections more difficult and avoid intraosseous anesthesia as much as possible. If antibiotic is necessary to prescribe minimum doses are better for the beginning. The effects of access preparation on existing restoration and the possible need for the actual removal of the restoration should be discussed with the patient before the procedure and always remove the artificial crown prior to access preparation. Avoid making small holes for accessing into the canals from the artificial crowns, this may lead perforations, bleeding, difficulty of decay removal and many other technical problems, overall may jeopardize success. If the tooth is tilted the initial access must be done with high speed and can be performed without rubber-dam to maintain correct axial direction and avoid perforations and later RD should be applied. If there is a thick restoration or recessed pulp the length of the bur may not be adequate, use long shank burs or if necessary do proper occlusal reduction. To locate the orifices sometimes magnification is necessary (operating microscope gives the best result, or magnifying glasses, 2.5X to 3.5X better for start). Especially in geriatric patients magnification is essential. Be careful against furca perforations while looking for the canal orifices. Use fiberoptic light for more illumination and use smaller size k-files for canal negotiation (#8 or 10). Using lubricants and chelating agents (i.e. RC-prep, EDTA, etc.) for easy insertion to the canal and for canal preparation is necessary always.
If you feel you are hopeless to locate the canal and if you feel fatiguing and frustrating as the operator, and also your patient re-schedule the patient and give yourself and to the patient one more chance. In such a case second appointment will be more productive.
Is geriatric endodontic a hope or a challenge? In conclusion, geriatric endodontics will gain a more significant role in complete dental care because of the “aging society”. Dental services including root canal procedures, for the elderly population of the future are anticipated to be of two general types (I)services for the relatively healthy elderly who are functionally independent and (II) services for elderly patients with complex conditions and problems who are functionally dependent the second group will require care from practitioners who have specialized and advanced training in geriatric dentistry. This age group being targeted in dental education programs and advanced training through improved curriculum, research, and publication on aging.
Copyright: © 2016 Mehmet Omer Gorduysus. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PubMed Indexed Article


EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005


EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777


EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347


EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478


EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253


EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033


EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992


EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505


EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793


EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211


EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047


EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560


EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318


EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819


EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840


EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344


EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476


EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658


EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489


EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278


EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108


EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571


EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333


EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883


EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001


EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937


EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723


EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726


EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603


EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646


EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616


EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290


EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226


EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812


EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268


News and Events


August Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the August issue of respective journals and can be viewed in the current issue pages.

Submission Deadline for September Issue

Ecronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the September issue of respective journals. Submissions are accepted on/before August 15, 2020.

Certificate of Publication

Ecronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

Ecronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.

Immediate Assistance

The prime motto of this team is to clarify all the queries without any delay or hesitation to avoid the inconvenience. For immediate assistance on your queries please don't hesitate to drop an email to editor@ecronicon.uk