Endodontic Considerations

Elderly patient are similar in many ways to those in the younger patient, but with differences. This chapter will discuss those similarities as well as concentrating on the differences. The topics will include the biologic aspects of pulpal and periradicular tissues, healing patterns, diagnosis, and treatment aspects in the geriatric patient.

The number of persons aged 65 and over in the United States exceeds 35 million. Not only is this age group expanding in numbers, but their dental needs continue to increase.More elderly patients will not accept tooth extraction unless there are no alternatives.³'⁴ Their expectations for dental health parallel their demands for quality medical care An even more important consideration is that their dentitions will have experienced decades of dental disease as well as restorative^s and periodontal procedures These all have compound adverse effects on the pulp, periradicular, and surrounding tissues. In other words, the more injuries that are inflicted, the greater the likelihood of irreversible disease and thus the greater the need for treatment.

The combination of an increase in pathosis and dental needs, coupled with greater expecta­tions, has resulted in more endodontic procedures among these aging patients Furthermore, expanded dental insurance benefits for retirees as well as more disposable income has made complex treatment more affordable.²

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

Biologic Considerations

Biologic Considerations are both systemic and local. The wide variety of systemic changes related to the patient's medical status are covered in other textbooks. In the older patient, there are no sys­temic or local changes particularly unique to endodontics that are different from those for other dental procedures. Similarly, pulp and periradicu­lar tissues do not respond markedly differendy.

Pulp Response

CHANCES WITH AGE

There are two Considerations: (1) structural (histologic) changes that take place as a function time; and (2) tissue changes that occur in response to irritation from injury. These tend to have similar appearances in the pulp. In other words, injury may prematurely "age" a pulp. Therefore an “old” pulp may be found in a tooth of a younger person, a tooth that has experienced caries, restora­tions, etc. Whatever the etiology, these older (or injured) pulps react somewhat differently than do younger (or noninjured) pulps.

Structural

The pulp is a dynamic connective tissue. It has been well documented that, with age, there are changes in both cellular, extracellular, and supportive elements. There is a decrease in cells, including both odontoblasts and fibroblasts. There is also a decrease in the supportive elements, blood vessels and nerves.There is presumably an increase in the percentage of space occupied by collagen, but less ground substance; these changes in proportions have not been measured, but only have been observed histologically.

Calcífications

These include denticles (pulp stones) and diffuse (linear) calcifications. These increase in the aged pulp as well as in the irritated pulp.¹⁰ Pulp stones tend to be found in the coronal pulp, and diffuse calcifications are in the radicular pulp. It has been speculated that the indices of calcification arise from degenerated nerves or blood vessels, but this has not been proven. Another common specula-tion is that pulp stones may cause odontogenic pain; this is not true.

Dimensional

Pulp spaces generally progressively decrease in size and often become very small. Dentin formation is not necessarily continuous throughout life, but it often does occur and may be accelerated by irritation from caries, restorations, and periodontal disease. Dentin formation with time or irritation is not uniform. For example, in molar pulp chambers there is more dentin formation on the roof and floor than on the walls. The result is a. flattened (disc-like) chamber

NATURE OF RESPONSE TO INJURY

The older patient does tend to have more adverse pulpal reactions to irritation than those that occur in the younger patient. The reason for these differences is debatable and not fully understood, but They are probably the result of a lifetime of  cumulative injuries..

Age

Although it would seem that a pulp with fewer cells, blood vessels, and nerves would be less resistant co injury, this has not been proven. Pulp responses to various procedures in different age groups have not shown differences, although the large number of variables in these types of clinical studies make it difficult to isolate age as a factor. This is not necessarily the case with the immature tooth (open apex), in which pulps have indeed been shown co be more resistant to injury. There are some who theorize that pulps in older teeth may, in face, be more resistant because of decreased permeability of dentin. Again this resistance to injury in old teeth has not been proven. The bottom line is that older pulps in older patients do require more care in preparation and restoration; this is probably due to a history of previous insults rather than age per se.

Systemic Conditions

There is no conclusive evidence that systemic or medical conditions directly affect (decrease) pulp resistance to injury. One proposed condition is atherosclerosis, which has been presumed to directly affect pulp vessels; however the phenomenon of pulpal atherosclerosis could not be demonstrated

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 sup-ply with aging. Therefore it is unlikely that there are significantly different periapical responses in older compared with younger individuals.

Healing

There is a popular concept that healing in older individuals is impaired, compromised, or delayed compared with that in younger patients. This is 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.¹⁸ Radiographic evi­dence of healing of younger versus older patients after root canal treatment demonstrated no apparent difference in success and failure.¹⁹ There is no evidence that vascular or connective tissue changes in older individuals result in significantly slower or in impaired healing. Overall, there is lit­tle difference in the speed or nature of healing between the different age groups; this includes both bone and soft tissue. Critical to healing is vascu­larity. In healthy individuals, blood flow is not im­paired with age.