AUDIENCE: Dentists; Dental Hygienists; Dental Assistants; Specialists; Office Staff; Endodontists
ABSTRACT: Geriatric endodontics will gain a more significant role in complete dental care as an aging population recognizes that a complete dentition, and not complete dentures, is a part of its destiny. This course focuses on the differences and challenges in diagnosing and treating pulpal and periradicular disease in older patients by reviewing the signs, symptoms and treatment of root canal procedures. The growing population’s needs are different than those of the general population, and this course touches on how to observe various factors that can affect older adults.
- Describe the epidemiology of the elderly population, the prevalence of their dental disease, and the needs and expectations unique to the elderly.
- Recognize the degree of difficulty that is a factor in successful endodontic care of the elderly.
- Assist the elderly in the clinical decision-making process when endodontic treatment is an option.
CLINICAL CATEGORY: Geriatric Endodontics
CE ACTIVITY: Self-Instructional
NUMBER OF CREDITS: 2 CE Credits
PUBLISH DATE: January 2014
EXPIRATION DATE: December 2017
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Geriatric Endodontics: Field to expand as elderly population increases
An Aging Society
The 75 million people born in the United States between 1946 and 1964 constitute the baby boom generation. These people have now entered the 65-years-and-older category. The oldest old are defined as those who are at least 85 years of age. This group is the fastest-growing segment of America’s senior citizen population.1
The growth of the population aged 65 years and older has affected every aspect of U.S. society, presenting challenges as well as opportunities to policymakers, families, businesses and health care providers.
Attitudes about saving teeth have also changed, and the demand for dental treatment will reflect a population of older people who are more likely already regular visitors to the dental office. Records from Carl Newton’s office, Indianapolis Endodontics, PC, confirm the national trend (Figure 1) that these are the same middle-aged patients that were treated there 10 years ago.2
The desire for root canal treatment among aging patients has increased considerably in recent years. Older patients are aware that treatment can be performed comfortably and that age is not a factor in predicting success.3-6
Age, ability to cooperate with dental treatment and type of residence are important considerations in identifying preventative and treatment strategies.7 Today’s dental office can be a confusing environment of required paperwork. Consultation with the patient’s family, guardian or physician may be necessary to complete the history; however, dentists function as primary caregivers in today’s healthcare environment and are ultimately responsible for involving the patient in decision-making and the treatment.8
More older people will mean more older teeth that will need root canal treatment. The quality of life for older Americans may well depend upon retaining teeth. That means more teeth with root decay, secondary decay, restoration failure, gingival recession, abrasion and attrition in a dentition with missing teeth, malocclusion, periodontal disease9 and narrow root canal spaces.
Accommodating the special needs of geriatric patients created by their medical history or physical and mental limitations certainly affects all dental procedures and would need an extensive discussion of its own.10 The intent of this article is to focus on the differences and challenges in diagnosing and treating pulpal and periradicular disease in older patients.
Chief Complaint and Subjective Symptoms
Dental needs are often manifested initially in the form of a complaint, which usually contains the information necessary to make a diagnosis. The diagnostic process is then directed toward determining whether pulpal or periapical disease is present, whether or not root canal therapy is indicated, the vitality of the pulp and which tooth is the source.
The clinician should, without leading, allow the patient to explain the problem in his or her own way. This gives the examiner an opportunity to observe the patient’s level of dental knowledge and ability to communicate. Visual and auditory handicaps may become evident at this time.
Patiently encouraging the patient to talk about problems may lead into areas of only peripheral interest to the dentist, but it establishes a needed rapport and demonstrates sincere interest. Older patients are more likely to have already had a root canal treatment and have a more realistic perception about treatment comfort. The best patients are those who have already had successful endodontic treatment.
Most geriatric patients do not readily complain about signs or symptoms of pulpal and periapical disease and may consider them to be minor compared with other health concerns and discomfort. A lifetime of experiencing pains can put a different perspective on interpreting dental pain. Pulp disease usually arises as an acute problem in young patients, but assumes a more chronic or less dramatic form in the older adult. The mere presence of teeth likely indicates proper maintenance or even resistance to disease.
Information collected from the patient’s complaint, history and examination may be adequate to establish pulp vitality and direct the clinician toward the techniques that are most useful in determining which tooth or teeth are the object of the complaint. Vitality responses must correlate with clinical and radiographic findings and be interpreted as a supplement in developing clinical judgment.
Pain associated with vital pulps (i.e., referred pain, and pain caused by heat, cold or sweets) seems to be reduced with age, and 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 following microbial invasion, again with reduced symptoms. The examiner should pursue responses to questions about the patient’s complaint, the stimulus or irritant that causes pain, the nature of the pain, and its relationship to the stimulus or irritant.
The clinician should search patients’ records and explore their memories to determine the history of involved teeth or surrounding areas. The history may be as obvious as a recent pulp exposure and restoration, or it may be as subtle as a routine crown preparation 15 or 20 years ago. Any history of pain before or after treatments may establish the beginning of a degenerative process. Subclinical injuries caused by repeated episodes of decay and treatment, or root planning, may accumulate and approach a clinically significant threshold that can later be exceeded following additional routine procedures. Multiple restorations on the same tooth are common.
Aging patients’ dental histories are rarely complete and may indicate treatment by several dentists at different locations. They have likely outlived at least one dentist and are forced to establish a relationship with a new, younger dentist. This new dentist may find previously undetected dental needs that require an updated treatment plan.
Intraoral and extraoral clinical examinations provide valuable firsthand information about disease and previous treatment. The overall oral condition should not be overlooked while centering on the patient’s complaint, and all abnormal conditions should be recorded and investigated. Exposure to factors that contribute to oral cancers accumulate with age, and many systemic diseases may initially manifest prodromal oral signs or symptoms.11
Missing teeth contribute to reduced functional ability (Figure 2). The resultant loss of chewing efficiency leads to a higher carbohydrate diet of softer, more cariogenic foods. Increased sugar intake to compensate for loss of taste and xerostomia are also factors in the renewed susceptibility to decay. Saliva plays a significant role in the maintenance of oral and general health. Aging, per se, has no significant clinical impact on salivary secretion. The most common cause of salivary hypofunction in the elderly is medication use and is most commonly associated with dental caries and oral fungal infections.12
Gingival recession, which creates sensitivity and is hard to control, exposes cementum and dentin that are less resistant to decay. The removal of root caries is irritating to the pulp and often results in pulp exposures or reparative dentin formation that affects the negotiation of the canal if root canal treatment is later needed (Figure 3). Asymptomatic pulp exposures on one root surface of a multirooted tooth can result in the uncommon clinical situation of the presence of both vital and nonvital pulp tissue in the same tooth. Interproximal root caries are difficult to restore, and restoration failure as a result of continued decay is common.
Attrition (Figure 4), abrasion and erosion also expose dentin through a slower process that allows the pulp to respond with dentinal sclerosis and reparative dentin. Secondary dentin formation occurs throughout life and may eventually result in almost complete pulp obliteration. Although this pulp may appear to recede, small pulpal remnants can remain and leave a less calcified tract that may lead to pulp exposure.
In general, canal and chamber volume is inversely proportional to age: as age increases, canal diameter decreases (Figure 5). 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.13 The thickness of young apical cementum14 is 100 to 200 µm and increases with age to two or three times that thickness.15 This continued normal rate of cementum formation may be demonstrated by a canal or foramen that appears to end or exit short of the radiographic apex, and hypercementosis may completely obscure the apical anatomy. Dentinal tubules become more occluded with advancing age, thus decreasing tubular permeability.16 Lateral and accessory canals can calcify, thus decreasing their clinical significance.
The compensating bite produced by missing, worn and tilted teeth can cause loss of vertical dimension or temporomandibular joint (TMJ) dysfunction, which is less common in older adults. Diminished eruptive forces occur with age, reducing the amount of mesial drift and supraeruption.17 Any limitation in opening the mouth reduces the space needed for instrumentation and affects available working time.
The presence of multiple restorations indicates a history of repeated insults and an accumulation of irritants (Figure 3). Marginal leakage and microbial contamination of cavity walls are a major cause of pulpal injury. Violating principles of cavity design combined with the loss of resiliency resulting from a reduced organic component to the dentin can increase susceptibility to cracks and cuspal fractures. In any further restorative procedures on such teeth, the clinician should consider the effect on the pulp and the effect on accessing and negotiating canals through such restorations if root canal therapy is indicated later.
Periodontal treatment can produce root sensitivity, disease and pulp death.18 The chronic nature of pulp disease demonstrated with sinus tracts can often be manifested in a periodontal pocket (Figure 6). Root canal treatment is commonly indicated before root amputations are performed. With age, the size and number of apical and accessory foramina are actually reduced as pathways of communication, as is the permeability of dentinal tubules.
Examination of sinus tracts should include tracing with gutta-percha cones whenever possible to establish the tracts’ origin. Sinus tracts may have long clinical histories and usually indicate the presence of chronic periapical infection. Their disappearance after treatment is an excellent indicator of healing. The presence of a sinus tract reduces the risk of interappointment or postoperative pain, although drainage may follow a canal debridement or filling.
Transilluminating and staining have been advocated as means to detect cracks, but the presence of cracks is of little significance in the absence of complaints because most older teeth, especially molars, demonstrate some cracks. Vertically cracked teeth should always be considered when pulpal or periapical disease is observed, and little or no restorative cause for pulpal irritation can be observed clinically or on radiographs. In determining prognosis, the high magnification available with microscopes during access opening and canal exploration permits visualization of the extent of cracks. Cracks that are detected while the pulp is still vital can offer a reasonable prognosis if immediately restored with full cuspal coverage.19 If incomplete cracks are not detected early, the prognosis for cracked teeth with necrosis20 is questionable. Periodontal pockets associated with cracks are usually narrow and indicate a very poor prognosis.
The reduced neural and vascular components of aged pulps,21 the overall reduced pulp volume and the change in character of the ground substance22 create an environment that responds differently to both stimuli and irritants than that of younger pulps. Fewer sensory nerve branches are present in older pulps. This may be due to retrogressive changes resulting from mineralization of the nerve and nerve sheath.21 Consequently, the response to stimuli may be weaker than in the more highly innervated younger pulp.
Information collected from the patient’s complaint, history and examination may be adequate to establish pulp vitality and direct the clinician toward the techniques that are most useful in determining which tooth or teeth are the object of the complaint. It is very difficult to quantify the response to a stimulus applied to a tooth for a pulpal diagnosis, and age is a factor in sensitivity testing.23
No correlation exists between the degree of response to electric pulp testing and the degree of inflammation. The presence or absence of response is of limited value and must be correlated with other tests, examination findings and radiographs. Extensive restorations, pulp recession and excessive calcifications are limitations in both performing and interpreting results of electric and thermal pulp testing. An alternative to the electric pulp test is the assessment of pulp vitality by applying a thermal stimulus to the tooth surface. The electric pulp tester, CO2 snow and difluordichlormethane were found to be more reliable than ethyl chloride or ice in producing a positive response.24 Attachments that reduce the amount of surface contact necessary to conduct the electric stimulus are available (Analytic Technology, Orange, CA). Use of even this small electric stimulus in patients with pacemakers25 is not recommended; any such risk would outweigh the benefit. The same caution holds true for electrosurgical units.
Discoloration of single teeth may indicate pulp death, but this is a less likely cause of discoloration with advanced age. Dentin thickness is greater, and the tubules are less permeable to blood or breakdown products from the pulp. Dentin deposition produces a yellow, opaque color that would indicate progressive calcification in a younger pulp; however, this is common in older teeth.
Symptoms of undiagnosed illnesses may present the clinician with a screening opportunity that can disclose a condition that might otherwise go untreated. Squamous cell carcinoma and salivary gland tumors increased with age, especially past 80 years old, and the prognosis is less favorable.26
Osteonecrosis of the jaw (ONJ) is a painful condition secondary to bisphosphonate therapy. Although it occurs at a much higher rate in patients receiving intravenous treatment for bone diseases versus oral treatment common for older patients with osteoporosis, forced eruption and tooth or root retention are recommended alternatives to the risk of extraction.27 The American Association of Endodontists has developed a position paper on the endodontic implications of ONJ.28
It is 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 two to four days, when shooting pain, paresthesia, burning and tenderness appear along the course of the affected nerve. Although it rarely occurs in the maxillary or mandibular divisions of the trigeminal nerve, the viral eruptions may include peripheral nerve endings in the pulp and PDL possibly leading to pulpitis, necrosis, or internal resorption and apical periodontitis. 29-33
Radiograph indicators and techniques do not differ much among adult age groups. However, several physiologic and anatomic changes can significantly affect their interpretation.
The periapical area must be included in the diagnostic radiograph, which should be studied from the crown toward the apex. Angled radiographs should be ordered only after the original diagnostic radiograph suggests that more information is needed for diagnosis or to determine the degree of difficulty for treatment. Digital radiography may be more useful than conventional radiography in detecting early bone changes.34 Cone beam computed tomography (CBCT) seems to be a very promising tool for more accurate diagnosis of changes in the root supporting structures.35-37
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 (is there a word missing, “or” should be removed?) may cause calcification between the observable chamber and root canal.
The depth of the chamber should be measured from the occlusal surface, and its mesiodistal position should be noted. Receding pulp horns that are apparent on a radiograph may remain microscopically much higher. Deep restorations or extensive occlusal crown reduction may produce pulp exposures that were not expected. 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.
Canals should be examined for their number, size, shape and curvature. Pulp has been identified clinically even when not visible on radiographs. Comparisons with adjacent teeth should be made. Small-diameter root canal spaces are the rule in older patients. A mid-root 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.
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 convinced that anesthesia is necessary for root canal treatment if their routine operative procedures have been performed without it. Generally, older patients demonstrate less anxiety about dental treatment.
The cutting of dentin does not produce the same level of response in an older patient for the same reason that a test cavity is not as revealing during examination. The number of low-threshold, high-conduction velocity nerve endings in dentin is reduced or absent, and they do not extend as far into the dentin. In addition, the dentinal tubules are more calcified.38 A painful response may not be encountered until actual pulp is exposed.
Anatomic landmarks that are used as guides for needle placement during block and infiltration injections are usually more distinguishable in older patients. The effects of epinephrine should be considered when selecting anesthetics for routine endodontic procedures. Anesthetics should be deposited very slowly (avoiding skeletal muscle) if epinephrine is the vasoconstrictor.
The reduced width of the periodontal ligament makes needle placement for supplementary intraligamentary injections more difficult. Placing an anesthetic under pressure produces an intraosseous anesthesia that extends to the apex and to adjacent teeth, but it also distributes small amounts of solution systemically.39 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. Like intrapulpal anesthesia, intraosseous anesthesia is not prolonged; therefore, the pulp tissue must be removed within about 20 minutes. The majority of patients receiving an intraosseous injection of 2% lidocaine with 1:100,000 epinephrine solution experience a transient increase in heart rate.40 This would not be clinically significant in most healthy patients. However, in the older patient whose medical condition, drug therapies or epinephrine sensitivity suggest caution, 3% mepivacaine is a good alternative for intraosseous injections.
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 a method of last resort. Every effort should be made to produce profound anesthesia. Patients should be encouraged to report any unpleasant sensation, and a prompt response should be made to any complaint. Patients should never be expected to tolerate pulpal pain.
Rubber dam isolation is mandatory, and single-tooth rubber dam isolation should be used whenever possible. Badly broken-down teeth may not provide an adequate purchase point for the rubber dam clamp, and alternate rubber dam isolation methods or banding should be considered. Multiple-tooth isolation may be used if adjacent teeth can be clamped (Figure 7) and saliva output is low, or a well-placed saliva ejector can be tolerated. A petroleum-based lubricant for the lips and gingiva reduces chafing from saliva or perspiration beneath the rubber dam. A reduction in salivary flow or an exaggerated gag reflex reduces the need for a saliva ejector. Tissue can be aspirated into the perforated tip of the saliva ejector and torn upon removal. Artificial saliva is available and should be used just before isolation because it is difficult to apply after the dam is in place.
The clinician should not attempt isolation and access of a tooth with questionable marginal integrity of its restorations. Fluid-tight isolation cannot be compromised when sodium hypochlorite is used as an irrigant.
One-appointment procedures offer obvious advantages to older patients. No detectable difference was found in the effectiveness of root canal treatment in terms of radiologic success between single and multiple visits.41 The length of a dental appointment is less inconvenient than multiple appointments, especially if a patient must rely on another person for transportation or needs physical assistance to get into the office or operatory. The benefits of multiple-visit treatment are reduced if an interappointment seal is lost due to postponed or cancelled appointments.
Adequate access and identification of canal orifices are probably the most difficult parts of providing root canal treatment for older patients. Canal position, root curvature, and axial inclinations of roots and crowns should be considered during the examination. The effects of access on existing restorations and the possible need for actual removal of the restoration should be discussed with the patient before proceeding. Coronal tooth structure or restorations should be sacrificed when they compromise access for preparation or filling. Perhaps 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. One study found that almost all teeth (93%) had these factors; only 56% were detectable clinically or on radiographs.42
The growing acceptance and availability of endodontic microscopes offer clear magnification of up to 25 times or greater and have obvious advantages in treating smaller geriatric canals.
Location and penetration of the canal orifice are often difficult and time-consuming in a calcified canal. Once the canal has been distinguished, negotiation is attempted with a stainless steel (SS) 21 mm, #8 or, perferrably, #10 K-file since it is stiffer and more easily detected on a radiograph. The #6 file lacks stiffness in its shaft and easily bends and curls under gentle apical pressure. 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. A lengthy, unproductive search for canals is fatiguing and frustrating to both the clinician and the patient. Scheduling a second attempt at this procedure is often productive. Personal clinical experiences and judgment determine when the search for the canals must be terminated and referral or alternatives to nonsurgical root canal treatment considered.
Teeth with apical periodontitis will usually have patent canals (Figure 5). 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 (Figure 8).
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 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. This 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.
The length of the canal from the actual anatomic foramen to the CDJ increases with the deposition of cementum throughout life. This “cemental canal” will contain necrotic, infected debris when periapical pathosis is already present. The actual CDJ width or most apical extent of the dentin remains constant with age.43
Because this CDJ is the narrowest constriction of the canal, it is the ideal place to terminate the canal preparation. This point may vary by 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. Achieving and maintaining apical patency are more difficult. Apical root resorption associated with periapical pathosis further changes the shape, size and position of the constriction. The use of electronic, apex-finding devices is sometimes limited in heavily restored teeth when contact with metal can bleed off the current.
Flaring of the canal should be performed as early in the procedure as possible to provide for a reservoir of irrigation solution and to reduce the stress on metal instruments that occurs when they bind within the canal walls. Thorough and frequent irrigation should be performed to remove the debris that could block access. State-of-the-art nickel-titanium rotary instruments are designed for crown-down preparation and create a geometric shape ideal for filling. Indeed, file shape is virtually imposed on the canal. Instrumentation techniques utilized for the preparation of calcified canals requires an advanced understanding of the variations in taper, tip geometrics, rake angle, pitch and metallurgy. The benefits of instruments with little or no rake angle and a crown-down technique are recommended.
For the older patient, the experienced clinician selects filling techniques that do not require unusually large mid-root tapers and do not generate pressure in this area, which could result in root fracture (Figure 9).
The coronal seal plays an important role in maintaining the apically sealed environment, and it has a significant impact on long-term success. Even a well 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. Glass-ionomer cements are of value when mechanical retention is not ensured with the preparation.
Outcomes studies have shown that success is affected by the preoperative presence of apical periodontits, the quality and extent of the root canal filling, and quality and type of restoration following root canal treatment.44 Patients with diabetes have increased periodontal disease in teeth involved endodontically and have a reduced likelihood of success of endodontic treatment in cases with preoperative periradicular lesions.45
Repair of periapical tissues after endodontic treatment in older patients is determined by most of the same local and systemic factors that govern the process in all patients. With vital pulps, periapical tissues are normal and can be maintained with an aseptic technique, confining preparation and filling procedures to the canal space. Infected, nonvital pulps with periapical pathologic abnormalities must have this process altered in favor of the host tissue, and repair is determined by the ability of this tissue to respond. Factors that influence repair have their greatest effect on the prognosis of endodontic therapy when periapical disease is present.
Although older patients prefer to save their natural teeth, the retention rate of restored implants compares favorably to restored root canal-filled teeth.46,47 The implant-retained mandibular overdenture is the first-choice standard of care for an edentulous mandible.48
Overlooked canals are a more common cause of failure in older patients, which explains the increased clinical indications for retrograde fillings when surgical treatment is attempted.49 As an isolated symptom, heat sensitivity usually indicates a missed canal.
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 just a few decades ago. Special consideration must be given to post design, especially when small posts are used in abutment teeth, as root fracture is common in older adults when much taper is used. Post failure or fracture occurs when small-diameter parallel posts are used. Posts are not usually needed when root canal treatment is performed through an existing crown that will continue to be used.
Successful restorative outcomes have been shown to be related to full-coverage restorations on molars and older patient age.50
The value of the tooth, its restorability, its periodontal health and the patient’s wishes should be part of the evaluation preceding endodontic therapy. The restorability of older teeth can be affected when root decay has limited access to sound margins or has reduced the integrity of the remaining tooth structure. There can also be insufficient vertical and horizontal space when opposing or adjacent teeth are missing. Patient desires to save appliances can sometimes be fulfilled with creative attempts that may outlive them.
In conclusion, geriatric endodontics will gain a more significant role in complete dental care as an aging population recognizes that a complete dentition, and not complete dentures, is a part of its destiny.
1. A Profile of Older Americans: 2011, Administration on Aging, U.S. Department of Health and Human Services.
2. 2002 Survey of Dental Practice: Endodontists in Private Practice, ADA Survey Center p. 90.
3. Friedman, S. Prognosis of initial therapy. Endodontic Topics. 2002; 2:59-88.
4. Keredes and Tronstad. Long-term results of endodontic treatment performed with a standardized technique. J Endod 1979; 5:83-90.
5. Sjogren, et al. Factors affecting the long-term results of endodontic treatment. J Endodon 1990; 14:498-504.
6. Stravik and Hordsted-Bindslev. A comparison of endodontic treatment results at two dental schools. Int Endod J 1993; 26;348-354.
7. Morgan, J.P., et al. The oral health status of 4,731 adults with intellectual and developmental disabilities. JADA 2012; 143(8):838-846.
8. Gary, C.J., and Glick, M. Medical clearance: An issue of professional autonomy, not a crutch. JADA 2012; 143(11):1180-81.
9. Evans, C.A., Kleinman, D.V. The surgeon general’s report on America’s oral health: Opportunities for the dental profession. JADA 2000; 13:1721-28.
10. Ettinger, R. Oral health and the aging population, JADA Supplement on Oral Longevity 2007; 138:4-5.
11. Crispin S., and Ettinger, R. The influence of systemic diseases on oral health care in older adults. JADA Supplement on Oral Longevity 2007; 138:7-14.
12. Navazesh, M.: How can oral health care providers determine if patients have a dry mouth. JADA 2003; 134:613.
13. Kuttler, Y.: Microscopic investigation of root apexes, JADA 1955; 50:544.
14. Selvig, K.F.: The fine structure of human cementum. Acta Odontol Scand 1965; 23:423.
15. Zander, H., Hurzeler, B.: Continuous cementum apposition. J Dent Res 1958; 37:1035.
16. Miller, W.A., Massler, M.: Permeability and staining of active and arrested lesions in dentine. Br Dent J 1962; 112:187.
17. Shugars, D.A., Bader, J.D., Phillips, S.W. Jr., White, B.A., Brantley, C.F.: The consequences of not replacing a missing posterior tooth. JADA 2000; 131:1317.
18. Lowman, J.V., Burke, R.S., Pelleu, G.B.: Patent accessory canals: Incidence in molar furcation region. Oral Surg 1972; 36:580.
19. Krell, K.V. and Rivera, E.M. A six-year evaluation of cracked teeth diagnosed with reversible pulpitis: Treatment and prognosis. J Endodon 2007; 33:1405-1407.
20. Berman and Kuttler: Fratrure necrosis: Diagnosis, prognosis sassessment, and treatment recommendations. J Endod 2010; 36: 442-452.
21. Bernick, S.: Effect of aging on the nerve supply to human teeth. J Dent Res 1967; 46:694.
22. Stanley, H.R., Ranney, R.R.: Age changes in the human dental pulp. I. The quantity of collagen. Oral Surg 1962; 15:1396.
23. Newton, C.W., Hoen, M.M., Goodis, H.E., Johnson, B.R., and McClanahan, S.B.: Identify and determine the metrics, hierarchy, and predicticve value of all the parameters and/or methods during endodontic diagnosis. J Endod 2009; 35(12):1635-1644.
24. Fuss, Z., Trowbridge, H., Bender, I.B., Rickoff, B., Sorin, S.: Assessment of reliability of electrical and thermal pulp testing agents. J Endod 1986; 12:301.
25. Woodly, L., Woodworth, J., Dobbs, J.L.: A preliminary evaluation of the effect of electric pulp testers on dogs with artificial pacemakers. JADA 1974; 89:1099.
26. Correa, et al. Oral lesions in elderly population: A biopsy survey using 2,250 histopathological records. Gerontology 2006; 23:48-54.
27. Smidt, A., Lipovetsky, M., and Sharon, E. Forced eruption as an alternative to tooth extraction in long-term use of oral bisphosphonates. JADA 2012; 143(12):1303-1312.
28. The American Association of Endodontics: http://www.aae.org/guidelines/
29. Gregory, W.B. et al. Herpes zoster associated with pulpless teeth. J Endodon 1975; 1:32-38.
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