Download high risk in root canal negociation in elderly patients

Endodontics
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Senior lecturer, PhD, Faculty of Dental Medicine, “Carol Davila” University of Bucharest
Univ.Assist., PhD student, Faculty of Dental Medicine, “Carol Davila” University of Bucharest
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DMD, PhD student, Faculty of Dental Medicine, “Carol Davila” University of Bucharest
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Senior lecturer, PhD, DDS, Faculty of Dental Medicine, University of Craiova
Corresponding author: [email protected]
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access to the cavity [4].
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Traversing the pulp chamber without noticing
canal treatment, due to the morphological changes of the
endodontic space in elderly patients. The changes in the
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shape of pulp chamber and root canal make the treatment
cavity without perforating the pulp chamber
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The obliterated canals lead to a challenging negotiation of
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the root canals. To avoid errors in the appreciation of the
Sometimes, in anterior teeth, there is no soft
general health condition of the patient, the specialists
tissue left in the coronal part [5].
should have an accurate preoperative radiograph or cone
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(dental operative microscope), safe-ended burs, consider
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carefully any morphological changes, and apply the most
inconclusive. The thermal test gives more reliable
proper techniques.
results than the electrical one. Even test cavities
.H\ZRUGV endodontic morphology, elderly patients, root
canal treatment
can be made into dentin without edifying
conclusion [6-9].
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The root canal is becoming narrow especially
in the coronal third, because of dentin deposition.
Most of the middle and apical third of the root
Endodontic therapy in older adults is
canal is still patent, even in very old patients [10],
nowadays a rather challenging procedure. The
which has a special clinical importance, because
percentage of elderly people in the population is
it directs the clinicians to approaching the root
rising. Patients require preservation of teeth for
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coronal third, the apical portion can remain
of retaining teeth are obvious [1-3].
patent throughout the years. Because of the
Teeth morphology in elderly patients is
concentric deposition of dentin, the root canal is
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maintaining its position in the middle of the axial
reparative dentin. This phenomenon occurs due
section of root dentin.
to minor trauma and wear, or as a result of caries
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or dental treatments. The pulp chamber
higher rigidity may be useful, along with
diminishes its volume, the pulp horns are
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as reamer or Golden Medium (Maillefer,
approaching each other and the shape can
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HIGH RISK IN ROOT CANAL NEGOCIATION IN ELDERLY PATIENTS: CLINICAL CASE SERIES
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5 - may be useful. Establishing the glide path is
the most important step in the cleaning and
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Copious irrigation should be done. Once the
correct working length is established, the root
canal treatment follows the general rules. One
should also consider that the distance between
the cemento-dentinal junction and the radiological
apex is increasing in older adults [11].
Also, tipping and rotation of teeth makes the
root canal treatment in elderly patients more
challenging. Sometimes, the access to the cavity
is often made through large restorations or
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procedure [12].
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A 91 year-old patient attended our clinic for
evaluation and treatment of 22. The two x-ray
radiographies provided by the patient revealed
an obliterated canal, due both to age and to
dental attrition (Fig. 1). The dentist could not
identify the canal and the attempt of accessing
the cavity led to 2 consecutive, large perforations
of the root (Fig. 2). Because of the unsuitable
approach of this clinical case, the tooth had to be
extracted.
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A 72 year-old patient visited our clinic for
evaluation of 41. The 2 conventional periapical
radiographs presented by the patient revealed a
perforation caused by the missing pulp chamber
and the obliterated canal (Figs. 3, 4).
These two clinical cases demonstrate the
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in elderly patients, because of the deposition of
secondary dentin.
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International Journal of Medical Dentistry
53
Paula PERLEA, Cristina Coralia NISTOR, Mihaela Georgiana ILIESCU, Andrei ILIESCU, Liana AMINOV,
Maria VATAMAN, Alexandru Andrei ILIESCU
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Although 47 had a large coronal destruction,
and narrow root canals, a complete endodontic
WUHDWPHQW ZDV VXFFHVVIXOO\ UHDOL]HG LQ WKLV year-old patient, to avoid a free end saddle.
Because of the diminished pulp space and
missing distal pulp horn, the endodontic
treatment became challenging (Fig. 5). Finally,
correct preoperative radiographs, dental
operative microscopy and the use of safe end
burs made the treatment successful (Fig. 6).
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In this 85 year-old man, 35 was considered as
a strategic abutment. The second premolar had
a particular morphology, with 2 roots. The root
FDQDO V\VWHP FRXOG QRW EH YLVXDOL]HG )LJ Both canals could be negotiated by means of Ni
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(Fig. 8). The root pulp was vital, although the
vital tests were inconclusive, a quite frequent
situation in elderly patients, caused by pulp
sclerosis.
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HIGH RISK IN ROOT CANAL NEGOCIATION IN ELDERLY PATIENTS: CLINICAL CASE SERIES
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Increased sugar consumption for compensating
the loss of taste and xerostomia in elderly patients
is an important factor, increasing susceptibility
to decay. Because of gingival recession, cementum
is exposed and root caries are very often found.
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because of the deposition of reparative dentin.
In a 78 year-old patient, 42 revealed a root
decay favored by marginal periodontitis (Fig. 9).
The tooth showed multiple root defects,
endodontic and periodontal lesions, typical for
elderly people. The endodontic treatment raised
many problems due to the missing pulp chamber,
calcified canals and modified endodontic
morphology caused by root decay (Fig. 10).
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The main complain of an 88 year-old patient
was acute pain at 28 (Fig. 11). The periapical
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canals, which could be negotiated using very
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The tooth was preserved because of the occlusal
contact with 38 (Fig. 12).
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International Journal of Medical Dentistry
55
Paula PERLEA, Cristina Coralia NISTOR, Mihaela Georgiana ILIESCU, Andrei ILIESCU, Liana AMINOV,
Maria VATAMAN, Alexandru Andrei ILIESCU
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A 71 year-old patient was referred to our
endodontic department for root canal treatment
of 32 and 36. CBCT provided information on the
missing pulp chamber and presence of two
narrow canals which are dividing in the middle
third of the root of 32 (Fig. 13).
According to the CBCT image (Fig. 14), 36
showed a retracted pulp chamber and two
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morphological particularities favoured a correct
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procedures.
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HIGH RISK IN ROOT CANAL NEGOCIATION IN ELDERLY PATIENTS: CLINICAL CASE SERIES
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According to the above-illustrated clinical
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of root canal treatment due to the morphological
changes of the endodontic space in elderly
patients [1]. Changes in the shape of the pulp
chamber and root canal make the treatment more
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The clinical cases show that the pulp chamber
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cavity. In elderly patients, the access cavity of the
teeth is placed more cervically. Safe-ended, slowspeed burs have to be used for not damaging the
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The obliterated canals lead to a challenging
negotiation of the root canals. The patients were
referred to our clinic because their general
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negotiate the entire canal path. The root canals
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with warm guttapercha, continuous wave of the
condensation technique. In some clinical cases,
International Journal of Medical Dentistry
the teeth were extracted due to severe iatrogenic
damages.
In cases of periapical periodontitis, even if the
radiography evidences no sign of pulpal space,
the specialist can attempt at negotiating the
canal, with the written consent of the patient [6,
7]. There are obviously microorganisms in the
remaining root canal space, and the direct
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can contribute to a successful treatment.
To avoid errors in the geriatric endodontic
treatment, the general health condition of the
patient should be known, based on an accurate
preoperative periapical radiography or CBCT,
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good light, ultrasonic, safe-ended burs,
knowledge of the morphological changes and
application of proper cleaning and shaping
techniques [4].
The parallel and additional ex-centric views
of the radiographs must guide the clinician for a
correct appreciation of root canal morphology.
CBCT is even more accurate, providing 3D
images in any plan and at any level [8, 9].
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Paula PERLEA, Cristina Coralia NISTOR, Mihaela Georgiana ILIESCU, Andrei ILIESCU, Liana AMINOV,
Maria VATAMAN, Alexandru Andrei ILIESCU
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The aging process is leading to progressive
morphological changes in both pulp chamber
and root canals. Pulp tissue calcification,
frequently associated to chronic marginal
periodontal disease and irreversible pulpits,
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the root canals. Operative microscopy and the
written consent of the patient are highly
recommended. Sometimes, an additional conebeam computed tomography (CBCT) is extremely
helpful for a safe management of the root canal
treatment.
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1.
2.
3.
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Qualtrough, A.J., Mannocci, F. (2011) Endodontics
and the older patient. Dent Update, 38(8):559-566.
Ng.Y.L., Mann, V., Gulabivala, K. (2010) Tooth
survival following non-surgical root canal treatment: a
systematic review of the literature. Int Endod J 43:171189.
Liu, P., McGrath, C., Cheung, G. (2014) What are the
NH\HQGRGRQWLFIDFWRUVDVVRFLDWHGZLWKRUDOKHDOWKUHODWHG
quality of life? Int Endod J 47:238-245.
4.
Petka, K. (2001) The 14 warning signs. Endod Practice
4:18-26.
5. Allen, P.F., Whitworth, J.M. (2004) Endodontic
considerations in elderly. Gerodontology 21:185-194.
6. Shukla, P., Poonia, N., Chadha M., Dahiya, V. (2010)
The periodontal endodontic controversies: a review. J
Indian Dent Assoc 12: 593-594.
7. Wan, L., Lu, H.B., Xuan, D.Y., Yan, Y.X., Zhang, J.C.
(2015) Histological changes within dental pulps in teeth
with moderate-to-severe chronic periodontitis. Int Endod
J 48:95-102.
8. Abella, F., Patel, S., Duran-Sindreu, F., Mercad, M.,
Bueno, R., Roig M. (2012) Evaluating the periapical
status of teeth with irreversible pulpitis by using conebeam computed tomography scanning and periapical
radiographs. J Endod 38:1588-1591.
9. Patel, S., Durack, C., Abella, F., Shemesh, H., Roig,
M., Lemberg, K. (2015) Cone beam computed
tomography in endodontics – a review. Int Endod J 48:315.
10. Gani, O., Visvisian, C. (1999) Apical canal diameter in
WKHÀUVWXSSHUPRODUDWYDULRXVDJHV J Endod 25: 689691.
11. Newton, C. W., Jeffrey, M. C.(2011) Effects of age and
systemic health in endodontics. In Cohen’s Pathway of
the pulp, 10th edition, Mosby Elsevier; 858-889.
12. Walton, R.E. (2009) Geriatric Endodontics. In
Torabinejad, M., Walton, R.E. Endodontics Principles
and Practice, 4th edition, Saunders Elsevier; 405-418.
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