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Endodontics +,*+5,6.,15227&$1$/1(*2&,$7,21,1(/'(5/<3$7,(176 &/,1,&$/&$6(6(5,(6 Paula PERLEA1&ULVWLQD&RUDOLD1,672520LKDHOD*HRUJLDQD,/,(6&8$QGUHL ,/,(6&8/LDQD$0,12950DULD9$7$0$1$OH[DQGUX$QGUHL,/,(6&8 Senior lecturer, PhD, Faculty of Dental Medicine, “Carol Davila” University of Bucharest Univ.Assist., PhD student, Faculty of Dental Medicine, “Carol Davila” University of Bucharest 3 DMD, PhD student, Faculty of Dental Medicine, “Carol Davila” University of Bucharest 4 3URIHVVRU3K')DFXOW\RI'HQWDO0HGLFLQH´$SROORQLDµ8QLYHUVLW\RI,DüL 5 8QLY$VVLVW3K')DFXOW\RI'HQWDO0HGLFLQH´*U73RSDµ8QLYHUVLW\RI,DüL 6 3URIHVVRU3K')DFXOW\RI'HQWDO0HGLFLQH´*U73RSDµ8QLYHUVLW\RI,DüL 7 Senior lecturer, PhD, DDS, Faculty of Dental Medicine, University of Craiova Corresponding author: [email protected] 1 2 $EVWUDFW GHYHORSLQWRDÁDWGLVFZKLFKPDNHVGLIÀFXOWWKH access to the cavity [4]. 6HYHUDO FOLQLFDO FDVHV RXWOLQH WKH GLIÀFXOWLHV RI URRW Traversing the pulp chamber without noticing canal treatment, due to the morphological changes of the endodontic space in elderly patients. The changes in the LVDPDMRUSUREOHPIRUUHDOL]LQJDFRUUHFWDFFHVV shape of pulp chamber and root canal make the treatment cavity without perforating the pulp chamber PRUH GLIÀFXOW ,W LV DOVR VKRZQ WKDW WKH SXOS FKDPEHU GLPLQLVKHV GXH WR UHSDUDWLYH GHQWLQ &DOFLÀFDWLRQ RI WKH ÁRRU 3XOS VFDOH FDQ DOVR UHVWULFW WKH SDWK IRU SXOS VSDFH PDNHV PRUH GLIÀFXOW WKH DFFHVV WR WKH FDYLW\ LGHQWLI\LQJWKHURRWFDQDORULÀFHV The obliterated canals lead to a challenging negotiation of 3XOS LV FRQVLGHUHG VFOHURVHG RU FDOFLÀHG 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 3XOS ÀEURVLV DQG D WKLFN GHQWLQ OD\HU PDNH EHDPFRPSXWLQJWRPRJUDSK\&%&7XVHPDJQLÀFDWLRQ (dental operative microscope), safe-ended burs, consider GLIÀFXOWWKHGLDJQRVLVZKLOHWKHYLWDOLW\WHVWVDUH 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]. ,1752'8&7,21 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 FDQDO(YHQWKRXJKLWLVGLIÀFXOWWRQHJRWLDWHWKH DHVWKHWLF DQG IXQFWLRQDO SXUSRVHV 7KH EHQHÀWV 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 PRGLÀHGGXHWRWKHDSSRVLWLRQRIVHFRQGDU\DQG 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 'HGLFDWHG HQWU\ ÀOHV ZLWK FXWWLQJ WLS DQG or dental treatments. The pulp chamber higher rigidity may be useful, along with diminishes its volume, the pulp horns are OXEULFDQWVOLNH('7$(YHQKDOIVL]HGÀOHVXVHG GLVDSSHDULQJ WKH SXOS ÁRRU DQG WKH URRI DUH as reamer or Golden Medium (Maillefer, approaching each other and the shape can 52 9ROXPH,VVXH-DQXDU\0DUFK HIGH RISK IN ROOT CANAL NEGOCIATION IN ELDERLY PATIENTS: CLINICAL CASE SERIES 'HQWVSO\6ZLW]HUODQGÀOHVVXFKDVDQG 5 - may be useful. Establishing the glide path is the most important step in the cleaning and VKDSLQJSURFHGXUHLQFDOFLÀHGFDQDOV 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 FURZQV ZKLFK DGGV WR WKH GLIÀFXOW\ RI WKH procedure [12]. &$6(5(32576 &DVHUHSRUW 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. )LJ6HFRQGDWWHPSWWRQHJRWLDWH &DVHUHSRUW 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 GLIÀFXOWLHVLQQHJRWLDWLQJWKHURRWFDQDOV\VWHP in elderly patients, because of the deposition of secondary dentin. )LJ0RGLÀHGPRUSKRORJ\RIWKHHQGRGRQWLF V\VWHPRILQDQHOGHUO\SDWLHQW )LJ&DOFLÀHGFDQDODQGÀUVWDWWHPSWWRQHJRWLDWH International Journal of Medical Dentistry 53 Paula PERLEA, Cristina Coralia NISTOR, Mihaela Georgiana ILIESCU, Andrei ILIESCU, Liana AMINOV, Maria VATAMAN, Alexandru Andrei ILIESCU )LJ3HUIRUDWLRQGXHWRFDOFLÀHGFDQDOV RILQDQHOGHUO\SDWLHQW &DVHUHSRUW 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). )LJ3UHRSHUDWLYHUDGLRJUDSK\RI 54 )LJ3RVWRSHUDWLYHUDGLRJUDSK\RI &DVHUHSRUW 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 7,URWDU\ÀOHVDQGGHQWDORSHUDWLYHPLFURVFRS\ (Fig. 8). The root pulp was vital, although the vital tests were inconclusive, a quite frequent situation in elderly patients, caused by pulp sclerosis. )LJ3UHRSHUDWLYHUDGLRJUDSK\RI 9ROXPH,VVXH-DQXDU\0DUFK HIGH RISK IN ROOT CANAL NEGOCIATION IN ELDERLY PATIENTS: CLINICAL CASE SERIES )LJ3RVWRSHUDWLYHUDGLRJUDSK\RI &DVHUHSRUW 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. $OVRWKHURRWFDQDOV\VWHPLVGLIÀFXOWWRQHJRWLDWH because of the deposition of reparative dentin. In a 78 year-old patient, 42 revealed a root decay favored by marginal periodontitis (Fig. 9). The tooth showed multiple root defects, endodontic and periodontal lesions, typical for elderly people. The endodontic treatment raised many problems due to the missing pulp chamber, calcified canals and modified endodontic morphology caused by root decay (Fig. 10). )LJ3RVWRSHUDWLYHUDGLRJUDSK\ &DVHUHSRUW The main complain of an 88 year-old patient was acute pain at 28 (Fig. 11). The periapical UDGLRJUDSK\ UHYHDOHG H[WUHPHO\ FDOFLÀHG URRW canals, which could be negotiated using very VPDOO KDQG ÀOHV DQG OXEULFDQWV ('7$ The tooth was preserved because of the occlusal contact with 38 (Fig. 12). )LJ3UHRSHUDWLYHUDGLRJUDSK\RI )LJ3UHRSHUDWLYHUDGLRJUDSK\ International Journal of Medical Dentistry 55 Paula PERLEA, Cristina Coralia NISTOR, Mihaela Georgiana ILIESCU, Andrei ILIESCU, Liana AMINOV, Maria VATAMAN, Alexandru Andrei ILIESCU &DVHUHSRUW 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 FDOFLÀHGPHUJLQJFDQDOVLQWKHPHVLDOURRW7KHVH morphological particularities favoured a correct HVWLPDWLRQ RI WKH GLIÀFXOW\ RI WKH HQGRGRQWLF procedures. )LJ3RVWRSHUDWLYHUDGLRJUDSK\RI )LJ&%&7LPDJHRI 56 9ROXPH,VVXH-DQXDU\0DUFK HIGH RISK IN ROOT CANAL NEGOCIATION IN ELDERLY PATIENTS: CLINICAL CASE SERIES )LJ&%&7LPDJHRI ',6&866,21 According to the above-illustrated clinical FDVHVWKHSUHVHQWVWXG\RXWOLQHVWKHGLIÀFXOWLHV 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 GLIÀFXOW The clinical cases show that the pulp chamber GLPLQLVKHVGXHWRUHSDUDWLYHGHQWLQ&DOFLÀFDWLRQ RIWKHSXOSVSDFHPDNHVPRUHGLIÀFXOWWKHDFFHVV 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 SXOSFKDPEHUÁRRU>@ The obliterated canals lead to a challenging negotiation of the root canals. The patients were referred to our clinic because their general GHQWLVWV IDLOHG WR ÀQG WKH URRW FDQDOV RU WR negotiate the entire canal path. The root canals ZHUHWUHDWHGZLWKURWDU\3UR7DSHUÀOHVDQGÀOOHG 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 YLVXDOL]DWLRQXVLQJGHQWDORSHUDWLYHPLFURVFRSH 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, PDJQLÀFDWLRQ GHQWDO RSHUDWLYH PLFURVFRSH 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]. 57 Paula PERLEA, Cristina Coralia NISTOR, Mihaela Georgiana ILIESCU, Andrei ILIESCU, Liana AMINOV, Maria VATAMAN, Alexandru Andrei ILIESCU &21&/86,216 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, MHRSDUGL]HV D SURSHU DFFHVV DQG QHJRWLDWLRQ RI 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. 5HIHUHQFHV 1. 2. 3. 58 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. 9ROXPH,VVXH-DQXDU\0DUFK