(a, b) Male patient, 70 years old, no systemic problem, strong attrition, secondary dentine formation and calcifications in pulp chamber, and vertical dimensional loss. This sort of clinical situations may restrict access cavity preparations even it seems easy at the first moment. Because of heavy calcifications in the pulp chamber and in the root canal, pulpal recessions of root canal recapitulation might be challenging
As age increases, canal size decreases. Reparative dentine resulting from restorative procedures, trauma, and tooth wear in the form of attrition, abrasion, erosion, and recurrent caries also contributes to diminution of canal and chamber size. There is also decreased vertical dimension and temporomandibular joint dysfunction due to compensation bite related to loss of teeth. This may lead to limited mouth opening and increased muscular fatigue thus posing a challenge during instrumentation.
11.12 Pulp Testing
The reduced neural and vascular component of aged pulps, the overall reduced pulp volume, and the change in character of the ground substance create an environment that responds with difficulty to both stimuli and irritants. Therefore thermal electrical pulp tests are mostly deceptive in elderly patients and not very much reliable. The response to stimuli may be weaker than in the more highly innervated younger one. Extensive restorations, pulp recession, and excessive calcifications are limitations in both performing and interpreting results of electrical and thermal pulp testing.
Such tests must be avoided in patients with pacemakers. A test cavity and selective anesthesia test is not valuable in elderly patients. Discoloration of single tooth may indicate pulp death, or it may be a sign of aging in elderly patients (generally this is normal).
11.14 Treatment Considerations
Short appointments and if possible single visit are better for the elderly patients. Practitioners’ ability to perform the treatment is important (competency and experience). Endodontic surgery is not the first option, and re-treatment alternatives must be given priority.
Good communication should be established and maintained with all the patients. Relatives or patient’s trusted friends should be included in consultations if their judgment is valued by the patient or needed for consent. Procedures should be explained in detail. Obtaining signed consent to the outlined treatment is encouraged and may be useful if the patient is forgetful. The patient’s 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 kept well informed of risks and alternatives at all stages. Treatment for the medically compromised patients must be done after consulting with the physician.
11.15 Patient Comfort
The ideal time of day for scheduling appointments must take into consideration patients’ daily personal, eating, and resting habits as well as any medication schedule. Morning appointments are preferable for most older patients. Chair positioning and comfort may be of greater importance for the elderly than younger. If necessary patient should be offered assistance in the operatory. When it comes to the number of sittings, functionally independent patients who can tolerate stress can be treated in a single sitting. For patients who cannot tolerate prolonged mouth opening, shorter multiple appointments would be required. As much work as possible should be performed at each visit, and a restroom break should be offered at intervals as the patient’s needs indicate. Jaw fatigue should be prevented by using bite blocks.
The need for anesthesia depends on pulp vitality status and cervical positioning of rubber dam clamp. During anesthesia in geriatric patients, the anatomic landmarks are more prominent; hence, anesthetic should be deposited more slowly. Teeth with necrotic pulp should be treated without anesthesia (optional) or minimal anesthesia. Where possible, it is best to allow the patient’s response to instrumentation through apical foramen to determine/confirm the working length or need for adjustment and reduce risk of over instrumentation and inoculation of canal contents into the periapical tissue. Electronic apex locator is best for the elderly patients.
The reduced width of PDL makes needle placement for supplementary intraligamentary injections more difficult. Avoid intraosseous anesthesia as much as possible. But if required, smaller amounts of solution (3% mepivacaine instead of 2% lidocaine) should be used during intraosseous anesthesia. Intra-pulpal anesthesia is difficult to achieve due to the reduced volume of the pulp chamber, thus making the diffusion into the canals much more difficult.
11.17 Orthostatic Hypotension
At the completion of the appointment, the patient should not be brought to a different position abruptly. Orthostatic hypotension is a frequent occurrence in the older adult with quick positional changes. Allowing the patient to sit for a minute or two before escorting the patient to the reception area helps them regain their balance.
11.18 Endodontic Considerations in the Elderly
As already mentioned, there are many technical challenges encountered during the root canal treatment of the elderly starting from diagnosis to various stages in the therapy. Increased bulk of dentine and increased pulpal fibrosis may diminish the response to traditional vitality testing. Hence, it will be wrong to assume that the pulp is non-vital and carry out the treatment without other supporting evidences . Certain systemic conditions may preclude the use of epinephrine, reducing the duration of anesthesia warranting reinjections .
11.18.1 During Access and Orientation
Access and canal negotiation probably present the greatest challenge in geriatric endodontics . The physiological changes in the pulp space should be analyzed in the preoperative radiograph in order to prevent any complications . If antibiotic is necessary, prescribe minimum doses. Rubber dam must be used (tilted teeth may be excluded during the access preparation until you locate the pulp chamber because of the misorientation problems). Reduction in salivary flow and gag reflex reduces the need for saliva ejector. Isolation should be carried out for single tooth preferably.
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 as well as the removal of the artificial crown prior to access preparation. If patient has multiple restorations, removal of them and coronal disassembling are necessary.
In anterior teeth, the pulp retreats progressively in a cervical direction, becoming narrower. In roots, deposition is always concentric toward the center of the mass of dentine. Deposition is often pronounced more in the coronal parts of the canal, with deeper areas of root canals remaining widely patent even in old age . These points are important to remember during the search for root canals. The clinician should always look in the middle of masses of dentine and must not assume that because a canal is narrow coronally it will not open into a manageable system at a deeper level.
Safe-ended, slow-speed burs have to be used in order to not damage the pulp chamber floor. Use of magnification (operating microscope gives the best result or magnifying glasses, 2.5X–3.5X) is an advantage during the identification of canal orifices. Another aid in the treatment of geriatric patients is the use of transillumination. The pulp stones can be visualized often with additional light and magnification [37, 38]. Ultrasonic troughing tips are especially useful in cutting through the calcifications that cover the canal orifices. Proper planning is required for over-erupted, tilted teeth with reduced clinical crown height .
Entry to a calcified canal system should be carefully planned, and care should be taken to identify features of the pulp space from an accurate preoperative radiograph, with attention to the expected depth of patent pulp space and long axis orientation. In most cases, a high-speed medium tapered diamond bur will be sufficient to outline the cavity and gain initial penetration. Define a classic cavity outline, with a narrower and more cervically placed starting point in the case of calcified anterior teeth.
Orientation should be constantly checked and rechecked and the cavity inspected periodically for extent and alignment. Special care should be taken to inspect the cavity at a depth at which it is anticipated the pulp will be entered. If the initial access bur has not entered the canal, it is time to reconsider alignment. In such a situation, it is possible that the clinician may be at the correct level, but needs to bypass it on any side. Exposure of radiographs is important to confirm the progress and realignment. Under no circumstances should the clinician progress beyond the expected entry depth without careful consideration, else the bur could enter the periodontal ligament.
Once the clinician has reached the extent of a medium tapered diamond bur in good orientation, but without entry, it is advisable to change to less aggressive, slow-speed burs to continue the procedure. Ideal are instruments with narrow necks to allow the active head to be observed at all times. Working with magnification, there are often visual clues to give an idea about penetration, owing to the altered color, texture, and translucency of the mineralized deposits in the former pulp space, in comparison to the surrounding primary dentine. Some researchers suggest the use of fine ultrasonic cutting tips to gently advance apically. These instruments may, however, cause drying and burning of dentine, which can distract the natural features of the tooth, alter color and translucency, and lead to misdirected preparation.
At intervals, probing should be attempted firmly with a DG16 canal probe to help locate a small puncture spot into the pulp space. If no such luck, carefully attempt to align burring and probing and continue until a stick is found or until a decision is made that entry will not be secured.
In the case of multirooted teeth, the chamber should be fully unroofed. Safe-ended, high-speed burs (Endo Z or Diamendo, Maillefer) are ideal and avoid injury to the chamber floor. Pulp stones should be removed. Most often heavy probing with a DG16 is sufficient to fragment/remove stones. Ultrasonic scalers are also useful tools for fragmentation and elimination. Again, care should be exercised to avoid damage to the pulp chamber floor.