“He, who is born, has to go through childhood, youth and old

age. If aging is inevitable, let’s be graceful and serene about it

and lead a disciplined quality life.” – Bhagvad Gita.
GERIATRIC ENDODONTICS
CONTENTS
•INTRODUCTION
•DEFINITION
•CHIEF COMPLAINT
•DENTAL HISTORY
•DIAGNOSIS AND TREATMENT PLANNING
•TREATMENT
•RESTORATION
•CONCLUSION
•REFERENCES
 I N T R O D U C T I O N 
Geriatric Endodontics is Endodontic
Consideration for the Older Adults.
Currently the old age population in India - 8%-80 million .
In 2025-reach 12%-830 million ,India alone will contribute
to 110 million and One out of every 7 aged persons in the
world will be an India.
Unfortunately, geriatric dental care in India is still in its
infancy, dental treatment is considered the last priority
owing to lack of awareness and poor socioeconomic
status.
Geriatric restorative care - the need, the demand and the challenges
Journal of Conservative Dentistry | Jul-Sept 2011 | Vol 14 | Issue 3
 DEFINITION

“Geriatric dentistry is the delivery of dental care to older adults involving

diagnosis, prevention and treatment of problems associated with normal
aging and age related diseases as part of an inter - disciplinary team with
other health care professionals”.

Holm-Pedersen P, Walls AW, Ship JA. Textbook of geriatric dentistry: John Wiley & Sons; 2015.
Three groups of older subjects are
identified

YOUNG OLD OLDER OLD OLDEST OLD

(65-74) (75-84) (>85)

. Journals of Gerontology, 64A(4), 481-486. doi:10.1093/gerona/gln045

Endodontic considerations in elderly patients include biologic,
medical, and some psychologic differences from younger
patients, as well as treatment complications.

Geriatric Endodontics ▲ Richard E. Walton

Age changes in the pulpo-dentinal
complex
Tertiary dentine, ( reactionary or reparative dentine) deposited in
response to insult to the pulp, including caries, attrition, cavity
preparations and trauma.

The dentine of older patients less water content than younger teeth, and
more likely to have cracks present within its structure.

Physiologic ageing results in occlusion of the dentinal tubules by

deposition of peritubular dentine.

Older patients commonly show evidence of occlusal attrition from a

lifetime of function, which also contributes to the deposition of tertiary
dentine.

Degeneration of pulpal neurons, especially in the subodontoblastic layer

and the pulp horns, occurs with age.
 PULP RESPONSE
Changes with Age
There are two considerations:
(1) structural (histologic) changes that take place as a function of time and
(2) tissue changes that occur in response to irritation from injury. These tend to
have similar appearances in the pulp

Therefore an “old” pulp may be found in a tooth of a younger person (a tooth that
has experienced caries, restorations, and so on). Whatever the etiology, these older
(or injured) pulps react somewhat differently than do younger (or noninjured) pulps.
Calcifications
Calcifications include denticles (pulp stones) and those that are
diffuse (linear). These increase in the aged pulp , as well as in the
irritated pulp. Pulp stones tend to be found in the coronal pulp,
and diffuse calcifications are found in the radicular pulp.
Dimensional
Generally, pulp spaces progressively decrease in size and often
become very small. Dentin formation with time or irritation is
not uniform.
PU LP C HAN G E S WITH AG
E

Continue dentin formation Calcification increase

 Canal and pulp space decreases in Pulpal calcification
Reparative dentin formation
size
 PERIRADICULAR RESPONSE
•Little information is available on changes of bone and soft tissues with age
and how these might affect the response to irritants or to subsequent
healing after removal of those irritants.
•The indicators are that there is relatively little change in periradicular
cellularity, vascularity, or nerve supply with aging.
• Therefore it is unlikely that there are significantly different periapical
responses in older compared with younger individuals.
 HEALING
•A popular concept is that healing in older individuals is impaired, compromised,
or delayed when compared with healing in younger patients.
• Not necessarily true. Studies in animals have shown remarkably similar patterns
of repair of oral tissues in young versus old but with a slight delay in healing
response.
• Radiographic evidence of healing of younger versus older patients after root
canal treatment demonstrated no apparent difference in success and failure.
• No evidence exists that vascular or connective tissue changes in older
individuals result in significantly slower or impaired healing.
 Effects of aging in oral soft tissues.
•Oral mucosa, becomes thinner, smoother, and exhibits an edematous appearance.
•The tongue becomes smoother and loses filiform papillae.
•Periodontal support is affected by age: in general, less than 3 mm gingival recession has been
observed on the buccal surfaces of elderly patients
• The flow rates of submandibular and sublingual salivary glands are reduced with aging, whereas
the flow rates of the parotid and minor glands do not appear to significantly change with aging.
• Xerostomia is not considered a normal aspect of aging. It is estimated that between 25% and 50%
of older adults exhibit xerostomia. This may occur as a result of various biological reasons, such as: a
history of radiotherapy to the head and neck area, salivary gland diseases, diabetes, alcoholic
cirrhosis, cystic fibrosis, hormonal imbalance, autoimmune diseases (such as Sjögren syndrome,
rheumatoid arthritis, or systemic lupus erythematosus), AIDS, or Parkinson’s disease
 BLEEDING
DISORDERS

CANCER ALLERGY

CVS AND COMMON OSTEOARTHRITIS

CEREBRAL MEDICAL
OSTEOPOROSIS
DISEASE PROBLEMS

DRUG
RHEUMATOLOG
ABUSE AND ICAL DISEASE
ADDICTION
NEOROLOGICAL
DISEASE
•Bisphosphonates are one therapeutic agent that is of concern. This drug counteracts conditions
or diseases that are associated with bone resorption. Oral bisphosphonates are extensively
prescribed to postmenopausal females (and also to males) who are osteoporotic.
• Potent intravenous (IV) bisphosphonates are used to treat the effects of metastatic breast and
prostate cancers on bone, as well as bone resorption defects from multiple myeloma and acute
hypercalcemia.
• A rare side effect of this family of drugs is osteonecrosis of the jaw, particularly with IV
administration. Patients on bisphosphonates should be carefully monitored to attempt to
minimize the occurrence of pathosis.
•Dental treatment should be noninvasive.
•Rubber dam placement should be used with care to avoid hard and soft tissue
trauma.
• Root canal treatment should be performed without injuring apical tissues with
instruments, irrigants, and materials. In addition, surgical procedures, including
extractions, root-end surgery, and periodontal surgery, should be avoided if
possible.
• Evidence does not suggest that bisphosphonate therapy should be altered or
interrupted during dental procedures
Saudi Med J 2019; Vol. 40
 MILD COGNITIVE IMPAIRMENT
•Mild cognitive impairment (MCI) has been observed in
approximately 15-20% of people aged 65 or older.
• People with MCI, especially MCI involving memory
problems, are more susceptible to the development of
Alzheimer’s or other dementias than people without MCI.
•Senile dementia is a common phenomenon among the
elderly that can result in memory loss, confusion, inability
to perform decision-making tasks, comprehension
difficulties, and inability to learn new tasks required for
appropriate treatment.
DRUG INTERACTIONS

Pharmacotherapy in the geriatric population

Pharmacotherapy in the geriatric population
 ATTRITION
ABRASION
GINGIVAL
RECESSION
LONG COMMUNICATION
STANDING PROBLEMS AND
PERIODONTAL COMPLEX
DISEASE MEDICAL HISTORY

CHALLENGES

PULPAL
CALCIFICATION POSTURAL
AND HEAVLY
RESTORED PROBLEMS
TEETH

PROBLEMS
WITH
RUBBERDAM

ENDODONTOLOGY Volume: 26 Issue 1 June 2014 ENDODONTIC CONSIDERATIONS IN THE ELDERLY - CASE SERIES
 C H I E F C O M P LA I N T
•The clinician should, without leading, allow the patient to explain the
problem in his or her own way.
•Most geriatric patients do not complain readily about signs or
symptoms of pulpal and periapical disease and may consider them to
be minor compared with other health concerns and discomfort.
•Patiently encouraging the patient to talk about problems may lead
into areas of only peripheral interest to the clinician, but it
establishes a needed rapport and demonstrates sincere interest.
 D E N TAL H I S T O RY

SUBJECTIVE
OBJECTIVE SIGNS
SYMPTOMS

 Missing teeth , Gingival recession

Stimulus that causes pain. Root caries , Attrition , abrasion,
Nature of pain erosion ,Canal & chamber
Relation to vol.,Calcification process ,Dentinal
stimulus/irritant. tubules ,Tubular permeability ,
Lateral & accessory canals
Many older patients are stoic, do not readily express adverse
symptoms, and may consider them to be minor relative to other
systemic problems or pains. A careful, concerned discussion about
these seemingly minor problems also helps establish rapport and
confidence
•Missing teeth contribute to reduced functional
ability . 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.
•Periodontal disease may be the principal problem for
dentate seniors.
• The relationship between pulpal and periodontal
disease can be expected to be more significant with
age ,retention of teeth alone demonstrates some
resistance to periodontal disease
•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.
•Gingival recession, which creates sensitivity and is
hard to control, exposes cementum and dentin that
are less resistant to decay than enamel.

•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
•Many cracks or craze lines may be evident as
a result of staining, but they do not indicate
dentin penetration or pulp exposure.
•Pulp exposures caused by cracks are less likely
to present acute problems in older patients
and often penetrate the sulcus to create a
periodontal defect as well as a periapical one.
•If incomplete cracks are not detected early,
the prognosis for cracked teeth in older
patients is questionable.
Vertical root fracture
 O C C LU S I O N
During opening and closing of the mouth, deviations and deflections associated
with maxillary and mandibular midlines should be checked.
The maximum opening can be measured with a Boley gauge or a plastic
prosthodontic ruler(40–60mmisthenormalrange).
Dysfunctional occlusion can be identified by (1) tooth mobility and migration; (2)
pain in the temporomandibular joint, periodontium or tooth; (3) alterations in the
lamina dura; (4) widening of the periodontal membrane space; and (5) atypical
occlusal wear
D IAG N O STI C PR O C E D U R
ES
 Pulp Testing
•Slow and gentle testing should be done to determine pulp and periapical
status and whether palliative or definitive therapy is indicated. Vitality
responses must correlate with clinical and radiographic findings and be
interpreted as a supplement in developing clinical judgment.

• The reduced neural and vascular components of aged pulps , the overall
reduced pulp volume, and the change in character of the ground
substance create an environment that responds differently to both stimuli
and irritants than that of younger pulp.
•.This may be due to retrogressive changes resulting from mineralization of the nerve
and nerve sheath .Consequently, the response to stimuli may be weaker than in the
more highly innervated younger pulp younger pulps. Arteriosclerosis, a common
condition in older people, has not been shown to occur in the pulp.
•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.
• An alternative to the electric pulp test is assessment of pulp vitality by applying a
thermal stimulus to the tooth surface. The electric pulp tester, CO2 snow, and
difluorodichloromethane were found to be more reliable than ethyl chloride or ice in
producing a positive response.
Increased bulk of dentin 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
 RAD I O G RAPH S
•Film placement may be adversely affected by tori but can be assisted by the apical position of
muscle attachments that increase the depth of the vestibule.

•The subjective nature of interpretation can be reduced with correct processing, proper
illumination, and magnification. The periapical area must be included in the diagnostic
radiograph, which should be studied from the crown toward the apex.

•Digital radiography may be more useful than conventional radiography in detecting early bone
changes
•The depth of the chamber should be measured from the occlusal surface and its mesiodistal
position noted. receding pulp horns that are apparent on a radiograph may remain
microscopically much higher.
•Canals should be examined for their number, size, shape, and curvature. Pulp has been
demonstrated histologically even when not visible on radiographs, but in general, the two
measurements did not differ even when pulp calcifications were present.
•Comparisons with adjacent teeth should be made. Small canals are the rule in older patients
•The lamina dura should be examined in its entirety and anatomic landmarks distinguished
from periapical radiolucencies and radiopacities.
• The incidence of some odontogenic and nonodontogenic cysts and tumors characteristically
increases with age, and this should be considered when vitality tests do not correlate with
radiographic findings.
•Resorption associated with chronic apical periodontitis may significantly alter the shape of the
apex and the anatomy of the foramen through inflammatory osteoclastic activity.
•The narrowest point in the canal may be difficult to determine; it is positioned farther from the
radiographic apex because of continued cementum deposition.
 R E S PO N S E O F PE R IAPI CAL TI S S U E S

Both older and younger patients have similar patterns of healing, but with a
slight delay in older.
 C O N S U LTAT I O N & C O N S E
NT
•Good communication should be established and maintained
with all patients, regardless of whether they are physically
impaired or unable to make treatment decisions for
themselves.
• Relatives or trusted friends should be included in
consultations if their judgment is valued by the patient or
needed for consent, but the clinician should direct the
discussion toward the patient.
•Determining the patient’s desires is as important as
determining his or her needs, and it is required in obtaining
informed consent
• When a physician told one patient that the problem with his knee was
due to age, he said, “The other knee is the same age and nothing is wrong
with it
•Neuropsychiatric impairment may result in gross manifestations and
indicate a reduced level of competency.
•Physicians or mental health experts should be consulted as needed, and
no elective procedures should be performed until valid consent is
established.
 Number of Appointments
•Always been a subject of debate and conjecture. Studies have shown that there are no
advantages overall to multiple appointments relating to posttreatment pain or prognosis.
• However, with pulp necrosis, treatment in multiple appointments and the use of calcium
hydroxide as an intracanal medicament may speed healing and possibly promote better
long-term outcomes.
•Single appointment procedures are beneficial in elderly patients. Longer appointments may
be less of a problem than several shorter appointments if the patient must rely on others
for transportation or requires assistance to reach the office or to get in and out of the chair.
• At times, the elderly patient may require special positioning of the chair, support of the
back or neck or limbs, or other such considerations
 tReat
ment
plan
ning
foR
elde
Rly
the
deCi
sion
maK
ing
dile
mm
a

“Adding life to years” rather than “years to

life”, expresses the state of geriatric care model
– Philip. J. Clark
 T R E AT M E N T P LA N
Stage I – Emergency care
Stage II – Maintenance and monitoring: Includes management of chronic
infection, Root canal therapy, Root planing and curettage, restoration of carious
lesions, work related to dentures, Patient education to improve oral health. A
further period of evaluation is required before one proceeds further
Stage III – Rehabilitation phase: Includes Implants, Surgical endodontics,
Surgical periodontics, esthetic rehabilitation, reconstruction of occlusal plane
and restoration of vertical dimension
•A clinical judgment can be made based on the patient’s complaint, history, signs, symptoms,
testing, and radiographs as to the vitality of the pulp and the presence or absence of periapical
pathologic conditions.

•Predicting the need for future root canal treatment and a clinician’s ability to perform treatment
later is even more important because the risk of losing the restoration during later access
preparation increases with the thickness of the restoration and the reduction in canal size .

•Because of a reduced blood supply, pulp capping is not as successful in older teeth as in younger
ones, so it is not recommended.
 T R EAT M E N T
•The vast majority of geriatric patients who need and demand endodontic therapy are
ambulatory and not institutionalized. Institutionalized and nonambulatory patients require
clinicians trained in those environments and facilities designed for access to dental health care.
• The dental office building, including both the interior design and the exterior approach, must be
able to accommodate people with special needs.
•Access for those who use ambulation aids (e.g., canes, walkers, wheelchairs) should include
comfort and safety in the parking lot, reception room, operatory, and rest room.
• Dental units can be designed to accommodate patients while in their own wheelchairs so that
they do not require any transfer
•Older patients are more likely to tolerate long appointments, although chair positioning
and comfort may be more important for older adults than for younger patients
•Pillows should be offered, as well as assistance in positioning them comfortably The
patient’s eyes should be shielded from the intensity of the clinician’s light.
• 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 is readily recognizable and may be the most limiting factor in a long
procedure, requiring periods of rest; however, once such fatigue is evident, the
procedure should be terminated as soon as possible. Bite blocks are useful in
comfortably maintaining freeway space and reducing jaw fatigue.
•Retired persons may rely on rides from friends or relatives or public transportation to get to the
dental office
• Enough time should be scheduled to allow some social exchange, and a sincere personal
interest should be demonstrated before proceeding.
• Endodontic specialists need to consider separate consultations for making this initial social
contact and evaluating the degree of difficulty that will determine the chair time needed to
perform treatment.
• Staff should allow patients to initiate handshakes, which may be very uncomfortable to people
with arthritic joints. From a behavioral and management standpoint, geriatric patients are
among the most cooperative, available, and appreciative.
A.Compensating for vision problems:
1) Use bold, large print for written text.
2) Use contrasting colours for written messages
3) When speaking in person, face the patient directly and maintain eye contact.
4) Stand closer to older patients.
5) Use touch as a way to reduce the distance.

B. Compensating for auditory decline:

1) Speak more slowly and clearly, but without exaggerating each syllable.
2) Raise voice slightly but without shouting.
3) Speak with older patients and their caregivers in a quiet, relaxed setting.
4) Avoid physical barriers between the patient and dentist
Sensory changes and communication in the practitioner– aged patient relationship,GERIATRIC
C. Compensating for cognitive decline:
1) Structure the message.
2) Take more time with older patients.
3) Do not present too much information at once
D. Compensating for sensory and cognitive decline
Use multiple channels of communication and multiple modes of presentation.
 AN E STH E S IA
•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. A painful response may not be encountered until actual pulp exposure
has occurred.
•Anatomic landmarks that are used as guides to 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 (and skeletal muscle
avoided) if epinephrine is the vasoconstrictor.
• 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.
•Like intrapulpal anesthesia, intraosseous anesthesia is not prolonged. The majority
of patients receiving an intraosseous injection of 2% lidocaine with 1:100,000
epinephrine (correct ratio) solution experience a transient increase in heart rate.
• This would not be clinically significant in most healthy patients, but in the older
patient whose medical condition, drug therapies, or epinephrine sensitivity
suggests caution, 3% mepivacaine is a good alternative for intraosseous injections.
I S O LAT I O N
Badly broken-down teeth may not provide an adequate purchase point for the
rubber dam clamp, so alternate rubber dam isolation methods should be
considered
 CAR D IAC D EV I C E S
•Pacemakers and implantable cardioverter defibrillators (ICDs) are devices that
regulate cardiac rate and rhythm. Both are susceptible to electromagnetic
interference.

•Electronic apex locators (EALs) rely on an electric current to determine canal

length. Several case reports have been published outlining the successful use of
electronic apex locators in patients with implanted cardiac devices with no
harm coming to the patient.
•A petroleum-based lubricant for the lips and gingiva reduces chafing from saliva
or perspiration beneath the rubber dam.
•Reduction in salivary flow and gag reflex reduces the need for a saliva ejector.
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 in a tooth with
questionable marginal integrity of its restorations. Fluid-tight isolation cannot be
compromised when sodium hypochlorite is used as an irrigant.
 ACC E SS
•Although the effects of aging and multiple restorations may reduce
the volume and coronal extent of the chamber or canal orifice, its
buccolingual and mesiodistal positions remain the same and can be
predicted from radiographs and clinical examination.
•Location and penetration of the canal orifice are often difficult and
time consuming in calcified canals. The most important instrument
for initial penetration is the DG-16 explorer.
•Modifications to enhance access vary from widening the axial walls
to increasing visibility or light to complete removal of the crown.
Alterations may be indicated after canal penetration to the apex if
tooth structure interferes with instrumentation or filling procedures.
•The effects of access on existing restorations and the possible need for actual removal
of the restoration should be discussed with the patient before initiating treatment.
• Coronal tooth structure or restorations should be sacrificed when they compromise
access for preparation or filling
 Characteristics of canal morphology and
dentinal structure in different age groups
20 years old or 21 to 40 years old 41 years old or
less more

Canal -
-
Simple anatomy
Mostly wide-oval canal
- Oval and round canals
- Auxiliary canals
- Rounder canals with a
small diameter
morphology -
-
No isthmuses
No auxiliary canals
- Prominent isthmuses - Decreasing volume of
isthmuses, more partial
isthmuses up to
disappearance
- -Fewer auxiliary canals

Dentin Large number of tubules with Dentinal sclerosis at apical

large diameter region
Massive obliteration of
dentinal tubules
structure Thin dentinal walls Reduction in the dentin
water content and more
modifications of collagen

Restor Dent Endod. 2020 May

 The algorithm for root canal
instrumentation in different age groups

20 years old or 21 to 40 years old 41 years old or more

less
Instrumentation Scraping instruments Regular NiTi systems with Manual stainless steel K-file
  subsequent agitation of (#06, #08, and #10) >> NiTi
sodium hypochlorite. system for glide path >> NiTi
Scraping instruments are instruments with a smaller
considered in oval canals. core, with smaller taper (0.02,
0.04), and with flexible NiTi
(control memory wire).

Restor Dent Endod. 2020 May

 Working Length

•There are some differences in working length in the older patient. Because the
apical foramen varies more widely than in the younger tooth and because of
decreased diameter of the canal apically, it is more difficult to determine the
preferred length.
•In teeth of any age, materials and instruments are best confined to the canal
space.
•One to 2 mm short of the radiographic apex is the preferred working and
obturation length, this should be decreased if an apical stop is not detected.
• Electronic apex locators are also useful, particularly when there is difficulty
obtaining adequate working length radiographs.
Location and penetration of the canal orifice are often difficult and time consuming in calcified
canals. The most important instrument for initial penetration is the DG-16 explorer.
 O B T U RAT I O N
•For the older patient, the prudent clinician selects gutta-percha filling techniques that do not require
unusually large midroot tapers and do not generate pressure in this area, which could result in root
fracture.
•The coronal seal plays an important role in maintaining an apically healthy environment, and it has a
significant impact on long-term success.
•Even a root-filled tooth should not have its canals exposed to the oral environment.
•A thermoplastic synthetic polymer-based root-filling material (resilon) may significantly reduce the coronal
leakage that can result from root caries after root canal treatment, as well as increase resistance to root
fracture.
• 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.
•When mechanical retention is not ensured with the preparation, glass ionomer cements are recommended.
 ENDODONTIC SURGERY
•Generally, considerations and indications for endodontic surgery
are not affected by age. The need for establishing drainage and
relieving pain are not common indications for surgery.

• Anatomic complications of the root canal system, such as small

or completely calcified canals, nonnegotiable root curvatures,
extensive apical root resorption, or pulp stones, occur with
greater frequency in older patients.

• Perforation during access, losing length during instrumentation,

ledging, and instrument separation are iatrogenic treatment
complications associated with treatment of calcified canals.
•Medical considerations may require consultation but do
not contraindicate surgical treatment when extraction is
the alternative.
• Many older patients receive low-dose aspirin therapy to
prevent blood clot formation and may be subject to
embolic formation if the treatment is interrupted.
•Aspirin therapy should be continued throughout dental
procedures, even during extraction or surgery. local
measures are sufficient to control bleeding.
• Interrupting therapeutic levels of continuous
anticoagulation therapy for dental surgery is not based on
scientific fact but seems to be based on its own mythology
•Local considerations in treatment of older patients include an increase in the incidence of
fenestrated or dehisced roots and exostoses. The thickness of overlying soft and bony tissue is
usually reduced, and apically positioned muscle attachments extend the depth of the vestibule.
•Tissue is less resilient, and resistance to reflection appears to be diminished. The oral cavity is
usually more accessible with the teeth closed together, because the lips can more easily be
stretched. The apex can actually be more surgically accessible in older patients.
 Biologic and Anatomic
Factors
•Bony and soft tissues are similar and respond the
same in older and younger patients. There may be
somewhat less thickness of overlying soft tissue;
however, alveolar mucosa and gingiva seem to be
structurally similar.
• Anatomic structures, such as the sinuses, floor of the
nose, and location of neurovascular bundles, are
essentially unchanged. Often, periodontal and
endodontic surgery must be combined.
•Also, crown-to-root ratios may be compromised
because of periodontal disease or root resorption.
 Healing After Surgery
•Hard and soft tissues will heal as predictably, although somewhat more slowly.
•Ice and pressure (in particular) applied over the surgical area reduces bleeding and edema
and minimizes swelling. Overall, older patients experience no more signifcant adverse affects
from surgery than do younger patients. Outcomes depend more on oral hygiene than on age,
as has been shown in periodontal surgery patients.
•One problem that seems to be more prevalent in older patients is ecchymosis after surgery.
• This is hemorrhage that often spreads widely through underlying tissue and commonly
presents as discoloration. Patients are informed that this may occur and should not be a
concern.
•Normal color may take 1 to 2 weeks or longer to return. In addition, the discoloration may go
through different color phases (purple, red, yellow, green) before disappearing.
 R E S T O RAT I O N
• Special consideration must be given to post design, especially
when small posts are used in abutment teeth; root fracture is
common in older adults when much taper is used.
• Post failure or fracture occurs when small-diameter parallel
posts are used.
•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 reduced the
integrity of remaining tooth structure
 Billings’ classification for root caries
Grade Description Management

Grade i White or Light brown, surface Topical fluorides Remineralization

cannot be penetrated agents, frequent recall

Grade ii Light brown, 0.5-1 mm Excavation of lesion, reshaping of

penetration margins, fluoride application

Grade iii Dark brown Penetration > 1 mm Restoration with Glass Ionomer
Not extending to pulp Cement

Grade iv Brown black Penetration into Endodontics or extraction

dental pulp

Journal of Conservative Dentistry | Jul-Sept 2011 | Vol 14 | Issue 3

 Maintenance phase
•With the mechanism of caries being the same in the young and the old, preventive strategy also
remains the same with minor modifications to suit the elderly.
•Daily use of fluoride dentifrices and fluoride rinses along with periodic topical fluoride application
regime is advisable. Fluoride varnishes may be preferred over other forms.
• Automated toothbrushes may be of some value in people with reduced dexterity.
• Chlorhexidine gel/mouth rinses/varnishes are advised. 10 % varnish is preferred over rinse/gel once
a week for four weeks.
•[ New remineralization products containing casein phosphopeptide-amorphous calcium phosphate
(CPP-ACP), casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-ACPF) , may also be
of some benefit.
• Xylitol containing candies help not only in getting over the dryness but also prevents caries
• Osteoarthritis or rheumatoid arthritis in the hand, fingers, elbow, shoulder, and/or neck can
affect a person’s ability to maintain good quality home oral care.
•Modification of manual toothbrush handles (e.g., with Velcro® straps or attaching a bicycle
handlebar grip) or use of an electronic toothbrush with a wide, grippable handle can help
accommodate for lost mobility.
• Floss holders or interdental cleaners/brushes can aid in cleaning between teeth. Increasing
the frequency of dental cleanings and examinations can help promote optimal maintenance of
oral hygiene
 CONCLUSION
‘Old people are sick because they are sick ,not

because they are old.’

Sir Ferguson Anderson ,
famous Scottish Geriatrician
•Successful endodontics can be achieved for the elderly, if proper attention is given to the
diagnosis, good quality radiographs and adapting techniques that overcome the challenges
posed by calcification of the root canal system.
•As long as the tooth has a strategically important role to play, endodontic therapy is indicated
and justified in any patient Clinicians should not presume that they know what is best for
senior patients or what they can afford without the patient’s full awareness.
•The needs, expectations, desires, and demands of older people may exceed those of any age
group, and the gratitude shown by older patients is among the most satisfying of professional
experiences
•Expanded dental insurance benefits for retirees and a heightened awareness of the benefits of
saving teeth have encouraged many older patients to seek endodontia rather than extraction
 REFERENCES
COHEN’S PATHWAYS OF THE PULP, Tenth Edition
Pharmacotherapy in the geriatric population, Special Care in Dentistly, Vol12 No 3 1992
Endodontics and the ageing patient,2015 Australian Dental Association
Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key indicators of well-being. Accessed
February 22, 2019.
The rise of dentine hypersensitivity and tooth wear in an ageing population,BRITISH DENTAL JOURNAL | VOLUME 223 NO. 4
| AUGUST 25 2017
Influence and safety of electronic apex locators in patients with cardiovascular implantable electronic devices: a systematic
review ,Mothanna K. AlRahabi & Hani M. Ghabbani
Geriatric restorative care - the need, the demand and the challenges
Textbook of Geriatric Dentistry,3RD EDITION