Systemic Health

Considerations in the
Endodontic Patient and
Geriatric Endodontics
Dr. Javeria Ali Khan
Assistant Professor
Department of Operative Dentistry
Learning Objectives
Final year students will be able to:
• Recognize the various ways in which endodontic pathosis and
systemic disease interact and some of the mechanisms of such
interactions
• Identification of disease for the safety of the patient during
endodontic treatment
• Effect of different diseases on the treatment outcome
• Recognize the possibility of acute and chronic endodontic infections
to cause or contribute towards systemic disease
Learning objectives
• Identify age changes in the anatomy and physiology of the older
dental pulp and periapical tissues, as well as differences in
pathogenesis of disease and response to treatment.
• Identify factors that complicate case selection and discuss the
differences in treatment between older and younger patients.
• Identify those elderly patients who should be considered for referral
Health and medical history
• Thorough evaluation of the patient and on determining the diagnosis
and treatment plan that takes risks and benefits into consideration
• Determine and identify modifications to the dental treatment for a
medically complex patient.
The systemic health assessment
of the
endodontic Patient
• Previous experiences that patients have may render them especially
anxious about procedure
• Patients have severe apprehension about having endodontic
treatment, and their care may need premedication, sedation, or other
auxiliary methods.
• Patients pain perception after endodontic treatment should be noted
as it may guide whether patients are at an increased risk of
postoperative and/or of persistent pain.
Detailed history of:
• Local anesthesia
• Analgesics
• Antibiotics and medications
• Previous hospitalization
• Cardiovascular
• Endocrine
• Respiratory
• Hepatic
• Renal system
Vitals
• Temperature
• Blood pressure
• Pulse
• Respiratory rate
Pre-operative assessment and
labs
• Glycemix index (HbA1c, random and fasting blood sugar)
• INR (prothrombin time test)
• Complete blood picture
• Hepatitis
• COVID-19
Systemic diseases that may influence
endodontic
pathosis or its treatment
• moderate risk for and/or association of cardiovascular disease and
diabetes with endodontic pathosis
• interaction of systemic disease with endodontic healing and reported
that certain systematic diseases are associated with endodontic
healing
Endodontic disease may initiate or contribute
to
systemic diseases
• The dental pulp is protected from bacteria by intact enamel and
dentin, whereas the periodontium is protected by periodontal
attachment and sulcular epithelium.
• With marginal periodontitis or pulpal pathosis, these barriers are
absent, and the oral microflora may have free access to the
periodontium or periapical tissues; in this way, microorganisms that
are normally commensals become pathogenic.
Acute endodontic infections
• Obtain adequate diagnostic data for patients with acute endodontic
infections and to evaluate their progress carefully, in case they need
referral for management in a hospital setting
• Patients with abscesses should have their temperature measured, and
they must be evaluated for lymphadenopathy, malaise, and facial space
infection
• These patients should receive prompt and complete elimination of local
irritants, including drainage of the swelling. Those with a facial space
infection (cellulitis) also should be treated with adjunctive antibiotics
and, most important, should be monitored carefully until their
condition improves
Chronic endodontic infections
• Number of bacteria in persistent periapical lesions after unsuccessful
treatment may be much higher
• Teeth with chronic apical abscesses and sinus tracts have been
reported to have very complex bacteriologic conditions with biofilm
attached
• report showed association of periapical lesion-years and incident
coronary heart disease in men younger than age 40.
• Another study of patients with myocardial infarction (MI) reported a
significantly higher number of patients with missing teeth and teeth
with periapical lesions in the MI group compared with controls
Diabetes mellitus
• Diabetics have a higher prevalence of teeth with periapical lesions
• People with diabetes may have compromised healing, particularly
those with higher glycemic rates and with preoperative endodontic
infection, for several reasons
Risk for osteoradionecrosis or
osteonecrosis
of the jaw
• Patients who have undergone radiation therapy for the treatment of
malignancies in the craniofacial area are at risk of osteoradionecrosis
• Teeth that would ordinarily not be amenable to treatment but that
are retained with endodontic treatment to avoid the risk of
osteoradionecrosis
• Although rare, BRONJ may occur after endodontic treatment or
endodontic surgery
• Care should be taken not to injure the soft tissue
• The clamps should be carefully placed to avoid injury to the soft
tissues and alveolar bone
Hypertension
• Hypertension is a sign of cardiovascular disease that may indicate a
variety of underlying conditions and comorbidities, including diabetes
• Patients who had diabetes and/or hypertension had a significantly
reduced chance of retention of endodontically treated teeth
Viral infections
• Patients with acquired immune deficiency syndrome (AIDS) who had
received oral health procedures did not appear to suffer any undue
pain or infection with endodontic treatment
• Herpes zoster infection may also induce spontaneous pulpal pathosis
• Periapical lesions in patients infected with HCMV and/or EBV, but not
herpes simplex viruses, may be larger and more painful. In addition,
irreversible pulpitis or acute endodontic infections may be associated
with a higher incidence of EBV or the HHV pathogens
Sickel cell anemia
• Oral findings of sickle cell anemia include the radiographic
“stepladder” trabecular pattern of bone, enamel hypomineralization,
calcified canals, increased overbite, and overjet.
• Spontaneous development of pulpal pathosis in some noncarious
teeth in patients with sickle cell anemia
• Patients with sickle cell anemia have a significantly higher incidence of
orofacial pain than controls and have pulp necrosis in 6% of their
teeth
Smoking
• There is association between smoking with with pulpal and periapical
diseases. Smoking is also associated with a high prevalence of
periapical lesions
• Smoking was also shown to increase the incidence of pain and/or
swelling after endodontic surgery.
• Smoking has been reported to change the immune-regulatory
function of the cytokines and chemokines in dental pulps
Presentation of Endodontic
Disease in the
Older Adults
• These dentitions will continue to experience caries and decades of
dental disease, in addition to restorative and periodontal procedures
• Endodontic considerations in older patients include physical, biologic,
medical, and some psychologic differences from young patients, in
addition to treatment complications.
• Physical Limitations: If a patient cannot be suitably reclined or if the
mouth opening is limited, referral should be considered
• Restorative Considerations: Severe caries or fractures from trauma
may render the tooth difficult to isolate or restore
• Biologic Considerations: In the older patient, systemic or local
changes unique to endodontics are not different from those for other
dental procedures.
Anatomy
• Pulp Chamber: tooth ages, pulp chamber space decreases. Chamber
size and pulp stones and more chances of calcifications in the canal
• Canal Calcification (Calcific Metamorphosis): Secondary and perhaps
tertiary dentin formation leads to narrowing of the canals.
Calcifications include denticles (pulp stones) and diffuse (linear)
calcifications. Pulp stones tend to be found in the coronal pulp, and
diffuse calcifications are found in the radicular pulp. Pulp stones were
shown to increase in patients with cardiovascular disease and those
on statins
Pulp response
• Changes with age: (1) structural (histologic) changes that take place
as a function of time and (2) tissue changes that occur in response to
irritation from injury. injury may prematurely “age” a pulp.
• Chronologic vs physiologic: younger person probably has less
resistance to injury than an undamaged pulp in an older individual.
• Structural: With age, there are changes in cellular, extracellular, and
supportive elements. There is a decrease in cells, including both
odontoblasts and fibroblasts. There are also fewer supportive
elements (i.e., blood vessels and nerves).Capillaries show somewhat
degenerative changes in the endothelium with age.
• Dimensional: In general, pulp spaces progressively decrease in size
and often become very small, a phenomenon known as calcific
metamorphosis or pulp canal obliteration. molar pulp chambers there
is more dentin formation on the roof and floor than on the walls,
flattened (disk-like) chamber
• Nature of response to injury: The older patient does tend to have
more severe pulpal reactions to irritation than the reactions that
occur in the younger patient.
• Irritation: There are reasons for pulp pathosis after restorative
procedures. First, the tooth may have experienced several injuries in
the past. Second, the tooth is likely to have undergone more
extensive procedures that involve considerable tooth structure, such
as crown preparation
• 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 direct affect to
pulp vessel
• Periapical response: little change occurs in periapical cellularity,
vascularity, or nerve supply with aging. It is unlikely that there are
significantly different periapical responses in older patients compared
with younger individuals
• Additional considerations: Systemic health should be kept in mind.
Esthetic and functional concerns may not differ.
Root canal treatment
considerations
• Time required: longer appointments are necessary to accomplish the
same procedures in older adult patients
• Anesthesia: The need for anesthesia is somewhat less in older
patients with pulp necrosis and an increased risk to local anesthetic
toxicity. Certain cardiac conditions may preclude the use of
epinephrine, particularly with the intraosseous and PDL techniques.
The duration of anesthesia is considerably decreased without a
vasoconstrictor, and reinjection during the procedure may be required
Procedures
• Isolation: Isolation is often difficult because of subgingival caries or
defective restorations
• Access preparation: locate and then negotiate canal orifices is
challenging in older teeth because of the internal anatomy.
Radiographs (PA and CBCT) and magnification is mandatory. larger,
rather than a small, access opening is preferable, particularly through
large restorations such as crowns. A supererupted tooth, as a result of
caries or restoration, has a short clinical crown, requiring a less deep
access preparation. The distance from the reference cusp to the
chamber roof should be measured on the bur radiographically
• Working length: the apical foramen varies more widely than in the
younger tooth and because of the decreased diameter of the canal
apically, it is more difficult to determine the preferred length
• Cleaning and shaping: a much smaller canal that requires more time
and effort to enlarge. Chelators, Glide path 0.02 taper instruments
such as PathFiles or ProGlider (Sirona/Dentsply) maybe helpful.
• Intracanal medicaments: CaOH is used in case of necrosis and in
between visits.
• Obturation: cold lateral and warm-vertical gutta-percha obturations
• Effect of restoration: the larger and deeper the restoration, the more
complicated the root canal treatment would be. concerns when there
is a crown: (1) potential damage to retention or components of the
crown and (2) blockage of access and poor internal visibility. For PFM
specific burs, slow cutting with copious water. Occlusal access should
be wide
• Retreatment: Factors that lead to failure tend to increase with age;
thus retreatment is more common in older patients
• Endodontic surgery: Indications for surgery are similar in older adult
and younger patients
• Medical considerations: Excessive hemorrhage during or after surgery
is a concern; many older adult patients are receiving anticoagulant
therapy
Healing after surgery
• Slow healing
• Post surgical or post procedure instructions given verbally and written
• more prevalent in older patients is ecchymosis after surgery