endodontic treatment in the elderly - … tx in... · endodontic treatment in the elderly. ......
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รศ ปทมา ชัยเลิศวณิชกุลรศ ปทมา ชัยเลิศวณิชกุล
ENDODONTIC ENDODONTIC TREATMENT IN TREATMENT IN THE ELDERLYTHE ELDERLY
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Geriatrics is the branch of medicine thatfocuses on health promotion, prevention & treatment of disease & disability in later life.
The term itself can be distinguished fromgerontology, which is the study of the agingprocess itself. The term comes from theGreek geron meaning “old man” & iatrosmeaning “healer” & was proposed in 1909 byDr. Ignatz Leo Nascher.
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ObjectivesObjectives
To discuss the effect of aging on the diagnosis of pulpal & periapical diseases & successful RCT
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Medical historyMedical historyElders use more drugs than youngersConsider the interaction of drugs (decline in renal & liver function)Some may not understand the implications of their medical conditionSome may be reluctant to let the clinician into their confidence
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Chief complaintChief complaint
Allow the patient to explain the problem in his/her own wayOpportunity to observe the ability to communicate, interest, etcPain associated with vital pulps (caused by heat, cold, sweets or referred pain) seems to be reduced with age
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Dental historyDental historyDental histories are rarely completedHistory of pain may establish the degenerative processSubclinical injuries caused by repeated episodes of tx ex: multiple restorations may accumulate & approach a significant threshold
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Subjective symptomsSubjective symptoms
Patient’s complaintStimulus that causes painNature of pain
“Determining types of tests are necessary to confirm findings”
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Objective signsObjective signsMissing teeth – loss of chewing efficiency: more cariogenic foods, xerostomia
– loss VD: limit mouth opening, TMJ dysfunction
Gingival recession (sensitivity, less resistant to decay)
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Objective signsObjective signs
Root caries, attrition, abrasion & erosion
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Objective signsObjective signs
Pulpal calcificationsMultiple restorations Marginal leakage
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Reparative dentine formn, canal & chamber decreases in size
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Objective signsObjective signs
Cracks/craze linesPeriodontal diseases
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PulpalPulpal calcificationscalcifications
Common occurrencePathologic process related to injury2 types of calcifications– Pulp stones (denticles) found in coronal– Diffuse (linear calcifications) found in radicular
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Pulp stonesPulp stones
Organic matrix composed of collagen fibrils in which hydroxyapatite crystals are embedded2 types: free & attached
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CDJ moves farther from radiographic apex (0.5-2.5 mm)2-3 times increase thickness of cementum (100-200µ in youngers)
Pulp calcificationsPulp calcifications
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Age changesAge changesContinued formation of 2nd dentine– Maxillary anterior: lingual wall– Molar: floor of pulp chamberReduce size of pulp chamber & canalsReduce number of nerves & blood vessels
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Age changesAge changes
Increase number & thickness of collagen fibersIncrease peritubular dentine, dentinal sclerosisDecrease dentinal permeability (reduce diameter of dentinal tubules)
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TestTestTransilluminating & staining to detect cracksNo correlation between degree of response to EPT & degree of inflammationWeaker response to EPT (fewer nerve branches)
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TestTestReferred pain should be consideredTest cavity is less useful (reduce dentin innervation)Presence of tori, exostoses & denser bone may require increased exposure times for contrast for x-ray film
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TestTest
Periapical area must be included in the radipgraphLamina dura should be examined (incidence of cysts & tumour increase with age)
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Diagnosis & Treatment planDiagnosis & Treatment plan
One-appointment RCT is considered Consultation & ConsentLife expectancy should not alter tx plans & is no excuse for extractions or poor RCT
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TreatmentTreatmentMorning appointments are preferableIsolation (GI when need mechanical retention, multiple-tooth isolation)Access (canal position, root curvature & inclination should be considered)Magnification (2.5 to 4.5)
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Access & Endo Access & Endo surgerysurgeryMicroscope
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ProblemProblem--solving in tooth solving in tooth isolationisolation
LeakagePatched or blocked with Cavit, OraSeal, Rubber base adhesive or periodontal packingReplace with a new one
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TreatmentTreatmentDG 16 explorer Very few canals have adequate diameter to allow the safe & effective use of broachesFlaring should be performed to provide for a reservoir of irrigation
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TreatmentTreatment
CDJ vary from 0.5-2.5 mm from the apexDo not require great tapersCoronal seal is important
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Success & FailureSuccess & FailureRate of bone formation & normal resorption decreases with age & aging of bone results in greater porosity & decreased mineralisation of the formed bone6-month recall period to evaluate repair radiographically may not be adequate
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Further ReadingFurther Reading
Pathways of the Pulp 9th ednProblem Solving in Endodontics 4th ednWalton RE (1997). EndodonticConsiderations in the Geriatric Patient. The Dental Clinic of North America 41 (4): 795-816