Geriatric endodontics Contents

Introduction Definitions Biological aspects of ageing and theories of ageing o Genetic theories o Non genetic theories Manifestations of ageing Factors which determine ageing o Genetic factors o Environmental factors Changes in the stomatognathic system o Macroscopic changes o Microscopic changes Treatment plan in elderly o Ideal and rational treatment plan o Staged treatment plan Endodontic considerations in elderly o Patient considerations o Medical considerations o How important is the tooth? o Barriers to a successful endodontic therapy o Can the tooth be saved? o Diagnostics in the elderly o Preparing for the treatment o Clinical tips for successful endodontics in the elderly ! Entering the canal system ! Orientation during entry ! Negotiating the root canal ! Completion of the treatment Retreatment Endodontic surgery Coronal seal Conclusion References

INTRODUCTION Nationally representative population surveys indicate that increasing numbers of adults are retaining teeth into old age. In many cases, teeth in older adults would be affected by dental diseases such as caries and periodontal disease, and pathological or physiological tooth wear. The vitality of teeth may have been compromised by these processes, and pulp necrosis may be the consequence. Treatment options to manage this situation involve either extraction of the tooth or endodontic procedures. Endodontic procedures in the elderly have been considered challenging because of the likelihood of the root canal system being sclerosed. The purpose of this seminar is to outline the role of endodontics in helping older adults to retain healthy teeth and satisfactory oral function into old age. DEFINITIONS: The term Geriatric comes from the Greek "geron" meaning "old man" and "iatros" meaning "healer", and was proposed in 1909 by Dr. Ignatz Leo Nascher. Geriatrics: Is the branch of medicine that focuses on health promotion and the prevention and treatment of disease and disability in later life. Geriatric Dentistry (Gerodontics or Gerodontology): Geriatric dentistry or gerodontics is the delivery of dental care to older adults involving the diagnosis, prevention, and treatment of problems associated with normal aging and age-related diseases as part of an interdisciplinary team with other health care professionals. BIOLOGY OF AGEING (Biological aspects of Ageing) Some changes that occur with age and with time are natural. Other changes that occur with age are a consequence of the imposition of diseases, effects of drugs and effect of society and culture on the ageing individual.

BIOLOGICAL THEORIES OF AGEING A number of theories have been proposed to explain the biology of ageing. Most of these theories focus only on the derangement that occurs at some target molecule in the body. - GENETIC THEORIES OF AGEING - NON-GENETIC THEORIES OF AGEING - GENETIC THEORIES OF AGEING (i) Error theories (ii) Disposal theory (i) Error theories. Senescence is related to the progressive accumulation of metabolic errors in macromolecules. Accumulation of errors in the production of macromolecules would eventually become great enough to impair function and is particularly serious for cells that do not divide after they have been differentiate [e.g. brain and muscle cells.] and less serious for dividing cells. Error theories includes: Somatic mutation theory: somatic mutations causes some changes in cell and tissue function. A sufficient number of cells carrying such mutations could affect a tissue or organ function. Genetically programmed senescence: According to this theory, ageing is considered as an extension of development. One of the most basic prediction of this theory is genetic specification of life span. ii) Disposal soma theory According to this theory, soma (Greek = body) is a vehicle for germ line for assuring reproduction. Exhaustion of resources available to soma results in ageing and death. It is applicable to the species which produce off springs repeatedly. NON GENETIC THEORIES OF AGEING i) Immunologic theory: with ageing, immune system tends to be less able to distinguish normal molecules from abnormal ones and so abnormal cells may proliferate and autoimmune reaction takes place.

ii) Free radical theory: Free radicals are ubiquitous, short lived, highly reactive chemicals produced during normal metabolic reactions. These free radicals combine with essential molecules causing damage to DNA or other cellular structures which contributes to ageing and age associated diseases.

MANIFESTATIONS OF AGEING Individuals vary considerably in both rate and magnitude of age related changes in cells, tissues and organs. CHANGES IN ELDERLY PATIENT i) Physical ii) Psychological iii) Physiological iv) Pathological. i) Physical - Reduced visual acuity. - Reduced manual dexterity. - Hearing loss. - Other disability. - Forgetfulness. ii) Psychological Feeling of being unwanted. Helpless Dont care attitude.

iii) Physiological - Tooth wear which is a physiologic process, irreversible and progressive. - Alterations in the periodontal tissue. - Edentulous state which is a patho-physiologic condition.

iv) Pathological Structural changes (such as in bone) Increased mineralization (such as in dentin) Decreased vascularity (which results in slower healing) Thinning of oral epithelium.

FACTORS WHICH DETERMINE AGEING i) Genetic factor ii) Environmental factors i) Genetic factor Genetic factors play a substantial role in ageing. Mutations: Several mutations reduces the lifespan of an individual. Species specific life span: The longevity in mammals ranges from about 120 years in humans to that of about 2 years in rodents. Increased longevity seen in hybrids (Hybrid vigor). Sex: Males are short lived than females. If genes carried on sex chromosomes indicate life span then genes on the X chromosome may decrease vulnerability to degenerative diseases. Genes on Y chromosomes may exert life shortening effects. Premature aging syndromes: such as progeria, werners syndrome, cockaynes syndrome. ii) Environmental factors It has been suggested that four types of environmental factors influence the rate of ageing. - Physical and chemical components. Environmental pollutants such as radiation affect ageing. - Biological factors. Nutrition may be the probable cause of differential ageing in humans.

- Pathogens and parasites have been implicated in influencing the rate of human development and ageing - Socio-economic factors. Bad housing, poor working conditions or stresses of life is commonly believed to accelerate ageing process. CHANGES IN STOMATOGNATHIC SYSTEM Stomatognathic system consists of teeth (with enamel, dentin and pulp), periodontium, oral mucosa, tongue and salivary glands. In examination of Stomatognathic system of elderly, observations should be directed towards changes in morphology and functional ability. History should have special emphasis on reduction and impairment in function.

Macroscopic age changes: 1. Tooth wear is seen in old age: Attrition: Definition: It is defined as loss of tooth structure resulting from direct functional forces between contacting teeth. Abrasion: Definition: Abrasion is the pathologic wearing away of teeth due to abnormal processes, habits or abrasive substances Erosion: Definition: Loss of tooth structure resulting from chemico-mechanical acts in the absence of specific micro-organisms. 2. Tooth color changes: Yellowing and general loss of translucency are common age changes. Pigmentation of anatomical defects, corrosion products and inadequate oral hygiene may also change tooth color.

Age changes in enamel: Loss of rod ends and perikymata Deceased permeability to oral fluids Increase in nitrogen and fluorine content Darkening of organic portion of enamel is seen. It increases the resistance to decay. Enamel exhibits attrition, abrasion and erosion. Clinical significance: Loss of function and esthetics due to wear and staining.

Age changes in dentin: Reparative dentin is formed and dentin becomes thicker Gradual obliteration of dentinal tubules by increased deposition of peritubular dentin Dentinal sclerosis is seen Transparent dentin is formed by the deposition of apatite crystals in the dentinal tubules Clinical significance: Exposure of dentin results in hypersensitivity Transparent and sclerotic dentin has low resiliency so fracture potential increases Age changes in pulp: Reduction in the size and volume of pulp. Complete pulpal obliteration is also seen. Dystrophic calcification in the form of pulp stones is seen Increased fibrosis of pulp and decreased cellularity Blood supply to the tooth decreases with age

Clinical significance: As pulp chamber size reduces, there is difficulty in locating canal orifices Calcification of pulp can result in false vitality response to testing.

Age changes in cementum: There is hypercementosis or abnormal thickening of cementum. The CDJ moves farther away from radiographic apex because of hypercementosis. Increase in thickness and hardness of cellular which leads to gradual constriction of apical foramen. Decrease in cellular content of cementum with age

Age changes in PDL: Greater no. of elastic fibers Decrease in vascularity and mitotic activity Fibroplasia increase in collagen fibers is seen Increase in arteriosclerotic changes in PDL with age Cementicles or calcification may be seen

Age changes in alveolar bone: When Teeth are lost, gradually alveolar process undergoes resorption creating facial profile of edentulous person Osteoporosis - Increased chances of fracture Reduction in metabolic rate and wound healing capacity. Blood supply to the bone reduces with age

Age changes in gingiva: Diminished keratinization and reduction in amount of stippling

Increased width of attached gingiva Decreased C.T cellularity A greater amount of intercellular substances Reduced oxygen consumption

Age changes in oral mucosa: Atrophy and thinning of the oral epithelium An increased keratinization of lip and cheek mucosa Atrophy of C.T with loss of elasticity A decrease in the no. of protein-bound hexoses and mucoproteins Increase in no. of mast cells

Masticatory efficiency: M.E reduces with aging, o due to the unreplaced missing teeth o loose teeth o poorly fitting dentures o an unwillingness to wear dentures Reduced M.E leads to poor chewing habits and possibility of dev. digestive disturbances. Avitaminosis is relatively common in aged person.

Temporomandibular joint: The temporomandibular joint in the healthy elderly shows some structural differences compared to the young adult but these may be mainly an adaptation to functional stress than simply a result of aging. Reduction in synovial fluid accumulation and synthesis of proteoglycans. Degeneration of the fibrous tissue covering over the articulating surfaces and disc.

Loss of elasticity in the articular cartilage.

Functional changes: Recently it has been suggested that the only age-related difference was a limitation of jaw opening i.e., reduced maximal interincisal distance in the older subjects.

TREATMENT PLAN The dilemma, ideal or rational treatment planning Ideal treatment is treatment that leads to the best dental prognosis without taking modifying factors into account. Brash, suggested that when conditions prevent the achievement of an ideal treatment plan, the dentist should collect more data, focus on each problems and then develop a rational treatment plan.

Kamen divided the care provided to the elderly into 4 broad categories: Class I: Class II: Comprehensive treatment. Intermediate care (maintenance of dentition and prevention of disease). Class III: Class IV: Emergency care (alleviation of pain & infection) No treatment.

One of the difficulties encountered in treatment planning is that dental treatment options are continuously evolving and new information and techniques becomes available to clinicians. Before formulating the treatment plan, following, global patient related factors must be assessed by answering following questions: Patients attitude: "To what degree does the patient desire dental treatment and will they give informed consent to institute the treatment"

Quality of life: treatment"

"How much is the patient affected either physically or

emotionally by dental problem and how will they respond to different levels of

Limitations of treatment: "How much do existing medical, psychological or social problems limit patients ability to benefit from treatment?

Iatrogenic potential:

"How much possibility is there of creating iatrogenic

problems, a medical emergency, a drug reaction or a dental problem associated with the treatment plan?" Prognosis: "What are the consequences of not treating the dental problem and how long should the treatment continue (risk per benefit)" Dentist limitations: "Does dentist have equipments, skill and experience to provide the appropriate therapy at appropriate site?"

Bennet & Creamer suggested the concept of staged treatment planning: Staged treatment plan When all requisite information has been gathered, including medical consultation, a staged dental treatment plan can be evolved. Stage I - Emergency care Stage II - Maintenance and Monitoring Stage III - Rehabilitative Phase

Stage I - Emergency care Life threatening emergency - immediate referral to the hospital for care.

Oral emergency-alleviation of pain and infection. -Perform biopsy of the lesion.

-Extract high risk teeth -Perform pulpectomy of symptomatic tooth. -Deride periodontal tissues and follow-up with chemotherapy. -Control caries with temporary dressing or stainless steel crowns for symptomatic teeth.

At this point the dentist should evaluate the long term needs of the patient and undertake the following: -Consider the potential life span of the patient. -Undertake special investigations, such as blood tests. -Consult with specialist -Evaluate mounted study casts. -Evaluate need for stress reduction.

Stage II - Maintenance and Monitoring -Management of chronic infections. -Root canal therapy. -Root planning and curettage. -Patient education to improve oral health (such as changes in dietary habits, plaque control and use of topical fluorides) -Restoration of caries lesions.

A further period of evaluation is required before one proceeds further. Stage III - Rehabilitative Phase -Orthognathic surgery or implants. -Surgical endodontics. -Surgical periodontics. -Esthetic dentistry.

-Reconstruction of the occlusal plane and restoration of vertical dimension with fixed and removable prostheses. If the practitioner carefully stages the provision of dental care, the patient can receive the requisite treatment in increments that are appropriate to the resolution of the immediate problem.

ENDODONTIC CONSIDERATIONS IN THE ELDERLY Patient considerations: The response of teeth in older healthy adults to high quality endodontic procedures is as good as it would be in younger adults. In older adults, as with younger adults, successful outcome of endodontic procedures depends on elimination of pathogenic bacteria from the pulp space and prevention of re-infection. There are, however, some general considerations which are specific to the elderly. The patient should be able to sit comfortably in the dental chair and tolerate a lengthy course of treatment. This may not be possible in patients with chronic back conditions or transient cerebral ischaemia. There are few medical contraindications to root canal treatment. Situations, which may contraindicate endodontic intervention include: 1. Patients requiring radiotherapy to the head and neck region. To reduce the risk of periapical disease necessitating extraction or endodontic therapy, all potential foci of infection should be removed prior to commencement of radiotherapy. 2. Poor compliance, for example, patients with Parkinsons disease, tremors, or dementia.

Medical considerations: A medical history should be taken before the patient is brought into the treatment room, to identify any disease or therapy that would alter treatment or its outcome. Questions to ask: ! Drug allergies ! Cardiac condition ! Renal condition ! Hypertension ! Diabetes ! Immuno suppressant therapy Although geriatric patients are usually knowledgeable about their medical history, some may not understand the implications of their medical conditions in relation to dentistry. Their perceptions of their illnesses may not be accurate, so any clue to a patient's conditions should be investigated. There has been some concerns regarding endodontic procedures in patients at high risk of infective endocarditis.

Antibiotic prophylaxis is not usually required for endodontic treatment con!ned to the pulp space as this carries a very low risk of signi!cant bacteraemia. How important is the tooth? Prior to considering an endodontic procedure, the appropriateness of preserving the tooth should be considered. The decision-making process regarding endodontic treatment should be guided by the strategic importance of the tooth. Preservation of a tooth may be useful as: 1. A means of preserving an intact dental arch. 2. A means of enhancing the retention of a removable prosthesis. 3. A retainer for a !xed prosthesis. 4. A means of maintaining occlusal contact in a reduced dentition. 5 A means of preserving bone when planning a partial or complete tooth supported overdenture. In some situations, preservation of a tooth may be unhelpful. Teeth judged after clinical and radiographic examination to be unrestorable should be extracted. This includes teeth, which have no functional capacity, severely fractured or grossly carious teeth, and periodontally compromised teeth. Factors such as !nancial cost and ability to attend for treatment must also be considered. Barriers to successful endodontics in the elderly: Age changes in the dentine-pulp complex: Old pulps are frequently described as being sclerosed or calci!ed. This term often denotes the dif!cult task of entering the pulp space in older teeth.

Pulp space diminishes throughout life by the deposition of regular secondary dentine. This occurs most commonly in pulp horns and on the "oor and roof of the pulp chamber. The clinician may !nd themselves deep into the "oor of the pulp chamber during access cavity preparation having traversed the small chamber without realising.

In roots, deposition is always concentric towards the centre of the mass of dentine. Deposition is most marked in the coronal portion of the canal system, with deeper areas of root canals remaining widely patent. These points are important to remember during the search for root canals. The clinician must not assume that because a canal is narrow coronally, it will not open into a manageable system at a deeper level.

Pulp space is further reduced by reactionary and reparative dentine (formerly classi!ed together as tertiary or irritation dentine) deposition. Reduced vascularity and cell content of the pulp, with a concomitant increase in !brosis and the relatively thicker overlying dentine means that old pulps may be less sensitive to thermal changes and less easy to stimulate for the purpose of diagnosis.

Increased pulp !brosis may present challenges for canal negotiation, with the potential to compact !brous pulp tissue and cause obstructions which may be dif!cult to overcome.

Degenerating pulp tissue also acts as a nidus for growth of calci!ed inclusions such as pulp stones. Pulp stones are concentric spheroidal masses of calci!ed material which may become incorporated with the pulp chamber walls, or lie freely within. Pulp stones are rarely encountered deeper into root canals, where degenerating blood vessels and nerve cells act as foci for linear calci!ed deposits. These accumulations are often described in terms of a wet cocktail stick appearance.

Can the tooth be saved? Predictable treatment demands access to the infected pulp space. If this is complicated by limited mouth opening, unfavourable tooth alignment or overeruption, intolerance of lengthy operative procedures or calci!cation of the pulp space, it may not be possible to save the tooth, and treatment should be planned accordingly. Whether assessing a tooth with a large and patent pulp space, or a canal system barely visible radiographically, the biological aims of treatment are the same i.e. complete disinfection of the root canal system. Root canal treatment is as predictable in the young as the old, provided that pulp canal infection can be properly managed.

Diagnostics in the elderly: The diagnosis of pathological conditions is based as always on clinical history, examination and special tests. History: While classic acute symptoms of pulpal and periapical pathosis are commonly reported by elderly patients, much endodontic disease arises without the patient being aware. Pulp breakdown is often discovered without the patient recalling episodes of painful symptoms, and patients may sometimes have been living for long periods of time with painlessly discharging sinuses, or periodic episodes of low grade swelling or discomfort.

Pulp vitality tests: Thermal and electrical pulp tests are commonly applied, with better information on the status of symptomatic pulps coming from thermal. Increased bulk of dentine and increased pulpal !brosis may diminish responses. Finding sites to apply provocation tests can also present challenges for heavily restored teeth, and some electronic pulp testers are supplied with small tips to engage the narrow band of tooth tissue which often presents supragingivally beneath restoration margins. Test cavities may be a justi!ed method of con!rming pulp diagnosis, but there should be no surprises if an old tooth with a diminished but vital pulp is entered deeply without major symptoms. Radiographs: Radiographs also have an important part to play, both in diagnosing endodontic status and in evaluating the restorability and technical challenges to treatment. Disease associated with pulpal breakdown, such as caries, defective restoration margins, tooth wear in close proximity with the pulp should be readily identi!ed in a radiograph. Assessment of restorability and evaluation of periodontal bony support should be done carefully before initiating endodontic precedures. The physiological, reparative and degenerative hard tissue changes, which may have taken place in the pulp space should be carefully assessed radiographically. An accurately projected radiographic image should allow the clinician to assess the depth at which the pulp might be expected during initial access and safeguard

against catastrophic overcutting. Pulp stones are readily identi!ed as irregular masses of calci!cation within the chamber. In such cases, access should not proceed until the bur drop is felt. The chamber is not empty, and its identi!cation will require careful exploration at the anticipated depth, often with additional light and magni!cation. Sometimes there is no radiographic sign of pulp space within the crown. As the eye travels apically, it is usual to !nd a narrow radiolucent line emerging at a deeper level, centred within the mass of root dentine. This information guides the clinician to keep their access opening narrow and absolutely centred in the tooth. The pulp is in the centre in such cases. Special challenges may arise when there is really no sign of pulp space throughout the length of the tooth.

Preparing for the treatment: Local anaesthesia: Most elderly patients are more confident about invasive dental treatment after the administration of local anaesthetic. Primary injections: it includes the nerve blocks, field blocks and infiltrations. The need for anaesthesia is somewhat less in the older patients as: Older patients tend to be less sensitive Older patients tend to be less anxious and therefore have a higher threshold of pain. Although there are no differences in effectiveness of anaesthetic solutions, various

systemic problems or medications may preclude the use of vasoconstrictors. Duration of anaesthesia is considerably decreased without vasoconstrictors; reinjection during the procedure may be required. Supplemental injections: intraosseous, PDL and intrapulpal injections are effective adjuncts if the primary injection does not give adequate anaesthesia.

Isolation: If the message of microbial infection and endodontic disease is taken seriously, there is no alternative to rubber dam isolation. For most situations, a single hole is punched in a sheet of rubber, and the dam applied with a clamp which makes stable, four point contact on the tooth. In the case of decoronated teeth, a slit dam method may be applied if there are adjacent teeth. In this technique, two overlapping holes are punched on the dam. The dam is stretched over the tooth to be treated and one adjacent tooth on each side. For lone-standing decoronated teeth, it may sometimes be necessary to impinge on the gingival tissues, or remove some gingival tissue before the procedure to allow a clamp to engage the root. If the tooth cannot be isolated, the question must again be asked if it is restorable.

Clinical tips for successful endodontics in the elderly: Entering the canal system: Access and canal negotiation probably present the greatest technical challenges in root canal treatment of the old tooth. Useful aids include: an accurate preoperative radiograph, light, front silvered mirror, magni!cation, medium length tapered diamond bur, safeended endodontic access burs, ultrasonics, long-necked round burs (pin bur, Goose-neck bur), DG16 canal probe and lubrication. Orientation during entry: Entry to a calcified canal system is difficult. Care should be taken to identify features of the pulp space from an accurate preoperative radiograph, with particular attention to the expected depth of patent pulp space, and long axis orientation. In most circumstances, a high-speed medium length tapered diamond bur will suf!ce to outline the cavity and gain initial penetration. Long burs should only be used when needed, avoiding the risk of overcutting. Access should commence by de!ning a classic cavity outline. Orientation should be constantly checked, and the cavity inspected periodically for extent and alignment with a clean front-silvered mirror under good lighting and magni!cation. Special care should be taken to inspect the cavity at a depth at which it is anticipated the pulp will be entered. Exposure of radiographs is desirable to con!rm progress and inform realignment. Sometimes placing a radiopaque marker, such as a ball of compacted warm gutta percha in the depth of the excavations helps in radiographic orientation and reveals the path to follow. When working with magni!cation, there are often visual clues to the altered

colour, texture and translucency of the mineralised deposits in the former pulp space, in comparison with the surrounding dentin. Some clinicians advocate the use of !ne ultrasonic cutting tips to gently advance apically. These instruments may, however, cause drying and burning of dentine, which can alter colour and translucency, and lead to misdirected preparation. At intervals, areas of discoloured tissue are probed !rmly with a DG16 canal probe in an effort to !nd a sticky spot which may represent a small puncture into the pulp space, or the entry into linear calci!cations within the canal system. If no sticky spot is felt, there is no justi!cation to pick up !les, which will simply bend on the hard barrier at the base of the preparation. Pulp stones are usually identi!ed as glassy translucent inclusions in the chamber. These should be removed to reveal the dark, dome shaped structure of the pulp chamber "oor with its helpful roadmap of !ssures, which will guide the observer to canal entrances. Often heavy probing with a DG16 is able to fragment stones and allow removal. Ultrasonic scalers are also powerful tools for fragmentation and elimination. Care is exercised to avoid damage to the chamber "oor, which may convert a domed structure with funnelled entry points to the root canals into a flat surface with frustrating dots. Negotiating the root canal: Having established a sticking spot, !les can now be brought into play. Lubricants are always helpful to ease the glide path during entry. Small !les, typically 21 mm size 10, or dedicated entry !les (Path!nder !les C+ !les) with increased rigidity are gently advanced into the canal in a watchwinding motion. If watch winding motion of the instrument becomes tight, the instrument should be withdrawn to free it from the canal walls and lubricant is used and the process is repeated, progressing the instrument apically.

If the negotiating instrument ceases to advance well, the clinician should determine how the instrument feels in the canal. If the instrument is advanced with a watch winding motion, engages with the canal, and demonstrates a tugging or sticky sensation on removal, this is tight resistance. The instrument is engaging a !ne canal ori!ce and careful instrumentation should be continued, with the use of lubricants, till the entire canal is negotiated.

If, on the contrary, the instrument sails loosely through the canal and hits an obstruction with no sticky sensation, this is loose resistance. This is often rationalised and wrongly interpreted as apical calci!cation, a rare event deep in a canal system. The reality is usually that the canal is curving, and the response is to apply a smooth curve to the apical 23 mm of the !le before re-inserting and manipulating around the walls to !nd a sticking spot.

It should also be borne in mind that after some coronal opening of the canal and soaking with sodium hypochlorite, canal systems which appeared initially to be non-negotiable become manageable with routine methods. If one canal of a multirooted tooth is dif!cult to enter, work should continue in the other canals through a pulp chamber "ooded with sodium hypochlorite, and a further attempt should be made to negotiate the canal later in the appointment.

Dif!culty can be encountered in initial instrumentation of the canal. Problems are especially common in moving from the negotiating size 10 instrument to the size 15 !le, which is 50% wider. The use of half-sized !les such as Golden Mediums (Maillefer/Dentsply), which include instruments in sizes 12.5, 17.5, and 22.5 helps to overcome the issues of early enlargement.

Completion of the treatment: Once the canal is negotiated, all that remains is to finalize canal preparation and obturation. Contemporary methods of canal preparation delivers predictable cleaning and shaping, and lays the foundation for simple obturation. Prolonged mouth opening may also result in fatigue and the development of tremor. Considerable improvement is usually achieved with the help of a simple rubber bite block, allowing the patient to bite and rest on it, rather than asking the patients to keep their mouth wide open. Preparing to leave at the end of the session may also take time and care, with a gradual return of the patient to the sitting position.

Retreatment: Factors that lead to failure tend to increase with age. Thus, retreatment is more common in older patients. Retreatment at any age is often complicated and should be approached with caution. Retreatment procedures and outcomes are similar in both older and younger teeth.

Endodontic Surgery: Considerations and indications for surgery are similar in elderly and younger patients. These include incision for drainage, periradicular procedures, corrective surgeries, root removal and intentional replantation. Overall the incidence of most of these will increase with age.

Medical Considerations before surgery: Medically compromised patients may require physicians consultation and are of concern but generally a surgical approach is not contraindicated.

It should be kept in mind that when extraction is an alternative to surgery, surgery is often less traumatic, when compared to extractions. Coronal Seal after root canal therapy: Coronal surfaces must be sealed from oral fluids forever to prevent failure. As older patients are more susceptible to recurrent caries or abrasion particularly on cervical root surfaces, these lesions do not have to penetrate deeply to expose obturation materials. Obturation materials will be contaminated with saliva and bacteria with resultant periapical pathosis. This is most common cause of treatment failure and reason for retreatment in elderly.

Conclusion: Successful endodontics can be achieved in the elderly with special attention to diagnosis, good quality radiographs and techniques oriented to overcome the challenges posed by calci!cation of the root canal system. As long as a tooth has a strategically important role to play, then endodontic procedures are indicated and justi!ed in healthy, elderly patients.

References: Gerodontology 2004; 21:185194 Endodontic Considerations In The Geriatric Patient, DCNA, Oct1997;41(4):795818 Principles and Practise of Endodontics, 3rd Edition, Richard.E.Walton et al, W.B.Saunders Company Endontic Therapy, 6th Edition, Franklin.S.Weine, 2004, Mosby Dental clinics of north america January 2004, Pages 159-182 Pathways Of The Pulp- Stephen Cohen et al, 9th Edition