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“Geroendodontology” & Its Clinical Challenges Drs. Kenneth Koch and Dennis Brave

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by Drs. Kenneth Koch and Dennis Brave

2012 is an election year and we have already heard heated debate about both Social Security and Medicare. The common denominator for each of these issues is elderly or retired individuals. The simple truth is that we are living longer than ever before. This is a good thing. In fact, we hear "The Graying of America" all the time. It certainly applies to dentistry as we are seeing increasingly more geriatric patients. Although it is surely wonderful that more geriatric patients are actively seeking dental treatment, it is also true that endodontic treatment for these patients is far more challenging. Let's look at some of the difficulties we face in performing root canal therapy for these patients.

First and foremost, geriatric patients require a thorough medical history to confirm that they can safely handle anesthetic requirements and other medications given during the course of dental treatment. Once we are assured that they can indeed handle the procedure, and after establishing an endodontic diagnosis, the next step is access and instrumentation. But how difficult are these to accomplish in the geriatric patient?

The most challenging aspect in performing clinical root canal therapy on geriatric patients is finding the canals. Access is important for all endodontic cases, but this can be an especially huge challenge with the elderly. Many geriatric patients have pulp chambers that no longer contain any pulp tissue. The pulp tissue in these cases has receded into the root as a result of previous restorative materials or hyper-occlusion. The challenge in these cases is to create access (and locate the canal orifices) without perforating the floor of the chamber. A good way to avoid perforating the floor is prior to treatment, place a bur alongside an X-ray to determine the depth of the chamber. The determination of depth will act as a governor when making the access. Therefore, if you find yourself getting close to the critical depth, yet you are not exactly certain where you are, stop and take an X-ray.

As previously mentioned, quite often with geriatric patients, there is little or no pulp in the chamber and regardless of how careful we are, perforations can and will occur. But how are they best handled? Three things are crucial to perforation repair: time, size and location.

It is absolutely critical (for the long-term success of the tooth) to repair a perforation as soon as it happens. This applies to both large and small perforations. Do not reappoint the patient to further evaluate the situation. Simply seal the perforation at the time of its occurrence.

The second key element is size; the smaller the perforation, the better its long-term prognosis. There is a big difference between a perforation with a #10 hand file and a #4 round bur.

The third factor is location; the more apical the perforation, the better the prognosis. Where did the perforation occur? A perforation in the apical third with a small hand file can be considered somewhat like an accessory canal. Make certain the canal has been cleaned and irrigated properly and then obturate like normal. This is where a bioceramic sealer can be a huge help.

The most common perforations we see with our geriatric patients are floor perforations and perforations in the coronal area. Although a perforation in the coronal third of the root has a reduced prognosis, it is still quite good. However, a perforation that occurs directly at the CEJ has a reduced prognosis due to the percolation of oral fluids from the gingival sulcus. Nonetheless, the overall prognosis, if handled correctly, is also quite good.

Therefore, the next question should be "What is the best way to repair a perforation?"

Historically, all kinds of materials have been utilized in perforation repair. Granted, when MTA was introduced it was a significant advance in perforation repair. However, the challenge to some has been its lack of handling ability. It does not come premixed and therefore must be mixed by hand, can be difficult to use and has such a large particle size that it cannot be extruded through a small syringe. Nonetheless, it's a good material and has a number of favorable characteristics including a pH of 12.5 which is quite anti-bacterial. The science of repair materials has continued to evolve to a higher level through nanotechnology. This is why you should be using a true bioceramic material for perforation repair.

As mentioned in previous articles, EndoSequence Root Repair Material (Brasseler USA) is a true bioceramic which comes premixed in a syringe, or as a putty form. This is a tremendous help not just in terms of assuring a proper mix but also in terms of ease of use. Consequently, for the first time, we have a root repair material with an easy and efficient delivery system that can deliver excellent results.

When using the putty, simply remove a small amount from the room temperature jar and knead it for a few seconds with a spatula or in your gloved hands. Then start to roll it into a hotdog shape. This is very similar to creating similar shapes with desiccated ZOE or SuperEBA (Bosworth). Once you have created an oblong shape, you can pick up a section of it with a sterile instrument and use this to deliver it where needed. This is an easy technique for perf repairs, resorption defects and even for apico retro fills. After placing the putty into the apical preparation (or defect) simply wipe with a moist cotton ball and finish the procedure.

Once proper straight-line access is created, finding all the canals can also be a chore. A good help (in fact, we believe a necessity) is the use of a piezo electric ultrasonic to remove secondary dentin and coronal sclerosis. We particularly like the Varios 350 (Brasseler USA) to remove these obstructions.

While the size alone distinguishes this unit from all others, there is another feature that makes it outstanding. The Varios 350 comes with a fiber-optic light source that is actually built into the handpiece. The brilliance of this design is that the fiber optic is protected and its arc of light is precisely directed to the field of treatment. This is unlike any other fiber optic in that the light is completely circumferential and surrounds the tip. The primary benefit of having a fiber optic built into an ultrasonic is enhanced vision. In addition to length control, the biggest challenge facing the general practitioner (in all patients) is finding the canals. Endodontic cases with elderly patients are becoming increasingly difficult, particularly, those cases where the orifice has become occluded by secondary dentin. You cannot perform root canal therapy unless you find the orifice and can then enter the canal. Piezo electric ultrasonics are excellent for removing the secondary dentin that often slopes off the mesial wall. This is what blocks the MB-2 canal in maxillary molars. It is particularly in these maxillary molar cases, when looking for the MB-2, that the Varios 350 becomes invaluable. Another tip to remember when searching for hidden canals, is that secondary dentin is generally whitish or opaque, while the floor of the chamber is darker and more gray in composition. The fiber optic can really help the clinician in these cases by making this an obvious distinction.

The Varios 350 is especially helpful at breaking through the calcification that covers the canal orifice. A troughing tip is a good choice for this task. We prefer the E-14D, E-9D and E-15D Brasseler diamond-coated tips for gaining access. Since we are seeing more coronal calcification with these patients, the solution is obvious. You need to have a piezo electric ultrasonic.

Another aid in the treatment of geriatric patients is the use of transillumination. The technique is quite simple. Turn off all the lights in the treatment room and turn off the light on the dental unit. Proceed to shine the fiber optic light (whether on a handpiece or ultrasonic) through the tooth at the CEJ level. The tooth will appear like a "Jack O' Lantern." Calcified canals will appear as dark dots, not as wide canals. Transillumination is also a good way to diagnose cracked and fractured teeth.

The root canals themselves associated with the elderly can be sufficiently cleaned and shaped if you can take the preparation to a fully tapered .04 taper. This generally can be achieved, although quite often we have to employ a hybrid technique utilizing both hand files and rotaries. Additionally, Dr Ali Nasseh discussed in a previous Dentaltown Magazine column the use of the new Scout Race files. To quote Dr. Nasseh:

The Scout Race Files offer the same predictability in efficient cutting of dentin that I've come to expect from their sister files, the EndoSequence File Series. These files have the additional benefit of being very useful in thinner, more curved roots found in most molars. With these small sizes, the clinician can bypass the tedious work of hand instrumentation in smaller sizes and can benefit from the super elasticity of the NiTi metal with the efficiency of rotary instrumentation vs. hand filing.

Following the use of a size 6 or 8 hand file, and some coronal enlargement (as recommended in all crown down techniques), the size 10-20 (or merely 10 and 15) Scout Race files can rapidly enlarge the canals and create a patent canal that can then be instrumented predictably and safely with the EndoSequence Files or your rotary instruments of choice.

I've used these files now for several months and have been extremely happy with their performance in the more difficult and more curved molars. They have made my more difficult cases easier to manage than when I used mere hand instrumentation to scout the canal prior to the use of rotary files.
One other thing that needs to be mentioned is that we believe the use of .02 taper rotary files (whatever system) should be limited to those dentists with considerable experience with rotary files. If one's endodontic clinical experience is somewhat limited, the clinician is best served using hand files (which are also .02 taper) in these challenging narrow canals.

Once the canals have been adequately prepared, the majority of these canals can accommodate a simplified obturation technique. This is where a synchronized hydraulic condensation technique (utilizing a bioceramic sealer and coated cones) should be used. Not only is this an excellent technique but it is also quick and reduces the time in the chair for the patient.

In fact, "time in the chair" is a serious consideration with the elderly patient. With our regular patients, we try to do as many cases as possible in one visit, but a word of caution is necessary for geriatric patients. Don't make the appointments too long and remember, many of these individuals do not do well placed way back in the dental chair. Try to keep the appointments to 45 minutes and certainly no longer than 60. This of course depends upon the individual.

An appropriate way to complete this article is to have an experienced endodontist share his opinions on treating our elderly patients. Here is what Dr John Gatti, a noted endodontist in Lee's Summit, Missouri, has to say. In his own words…



The 80-year-old patient today is the new 60. Although, medical history at any age is an important aspect in the diagnosis and the treatment of a patient, age alone should not deter endodontically treating our senior patients. In the capacity of endodontics, an 80-year-old tooth is just that, an 80-year-old tooth. One thing for sure will be the diminished canal space. The progression in endodontics from hand filing to the use of nickel-titanium rotary instrumentation was not only a tremendous advantage in the way in which teeth were endodontically treated, but a true advancement for treating our seniors because it allows thorough cleaning and shaping with predictable results in an efficient manner.

Many senior patients enjoy going to the dentist. Often, it is a planned event which takes precedent over everything else for them. It is important to take note of this, as a mere "thank you for coming in today" can be the precursor to a successful appointment. In particular, following six principles in treating seniors will allow for a very successful appointment. 1) Sense. Use the 'sixth' sense, by being aware of a patient's faculties. This is important as to how they will be communicating. 2) Engage. It might be a smile, a pause (slowing down the pace) or even an initial handshake. 3) Nice. Sometimes our seniors don't feel well and often for good reason. Being extremely pleasant can often change a patient's attitude for the better, than might otherwise be construed as defiant. 4) Include. Include these patients in treatment. Patients might not grasp everything being explained, but they do understand when they are included, and that is a very good feeling. 5) Observe. Most of the time, the endodontic treatment is the lesser of the difficulties in the treatment of our seniors. Make sure to observe their movements and watch their body language, especially when the patient is prepped and ready for root canal access. 6) Respect. Respect is a very easy task, but commonly ignored. Many seniors feel unimportant. A patient can feel respect by the way we as practitioners communicate. There is no better feeling than a senior patient being able to leave an appointment feeling respected.

Case: 81-year-old woman presents as an active senior. Generally good health and active lifestyle, yet very small stature. She prides herself in walking one mile each day.

Initial considerations of this case are a thorough medical history and diagnosis of the patient's pain. Medical history was non-contributory and it was concluded that due to the recent FPD placement, an irreversible pulpitis ensued. Clinical and radiographic evaluation revealed a very thin mandible, small mouth, with limited opening. The pre-operative radiograph exhibits a large FPD restoration with an angulated root system. This type of configuration requires special attention during access. A greater portion of porcelain and metal will be thicker toward the mesial as required for proper occlusion, thus access should be done incrementally (initial removal of the porcelain with a diamond burr, small pilot hole with a #4 round burr, followed by using a trans-metal burr to make conservative ovoid access in the first 2mm of the crown. Once this has been initiated, the round bur is then used to penetrate closer to the chamber, while also using ultrasonic instrumentation for removal of calcifications). Natural tooth support can always be taken away, but not put back. If the access is properly performed, location of the canals becomes exponentially easier. Remember, tooth anatomy will not change even when clinical perception can cast doubt on the root system. In other words, what appears in the mouth might not conform with the root system.

This case also presents with two other concerns: the coronally calcified mesial root, as well as the S curved distal root. As shown in the microscopic photo, the mesial canals are very close together and the distal root required hand file patency prior to using rotary instrumentation. This along with synchronized hydraulic condensation made this difficult case very manageable allowing for a successful result.
Geriatric patients can and should be an integral part of your practice. Hopefully, we have given you some tips on how to make "geroendodontology" easier for both you and the patients.
Author Bios
Dr. Dennis Brave is a diplomate of the American Board of Endodontics, and a member of the College of Diplomates. Dr. Brave received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in endodontics from the University of Pennsylvania. He is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas Odontologic Honor Society Member. In endodontic practice for more than 25 years, he has lectured extensively throughout the world and holds multiple patents, including the VisiFrame. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Dr. Brave is a co-founder of Real World Endo.

Dr. Kenneth Koch received both his DMD and certificate in endodontics from the University of Pennsylvania School of Dental Medicine. He is the founder and past director of the new program in postdoctoral endodontics at the Harvard School of Dental Medicine. Prior to his endodontic career, Dr. Koch spent 10 years in the Air Force and held, among various positions, that of Chief of Prosthodontics at Osan AFB and Chief of Prosthodontics at McGuire AFB. In addition to having maintained a private practice, limited to endodontics, Dr. Koch has lectured extensively in both the United States and abroad. He is also the author of numerous articles on endodontics. Dr. Koch is a co-founder of Real World Endo.
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