The graying of endodontics

May 1, 2003
We hear it all the time. "The Graying of America." It also applies to dentistry, as we increasingly are seeing more geriatric patients.

Dennis Brave, DDS & Kenneth Koch, DMD

We hear it all the time. "The Graying of America." It also applies to dentistry, as we increasingly are seeing more geriatric patients. Although it is certainly wonderful that more geriatric patients are actively seeking dental treatment, it is also true that endodontics for these patients is more challenging. Let's look at some of the difficulties we face in performing root canal therapy for these patients.

Of course, 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. But what about the basic aspects of endodontics, such as access, cleaning, and shaping? How difficult are these to accomplish in the geriatric patient?

The first and most serious difficulty in performing root canal therapy on geriatric patients is access. Access is important for all endodontics cases, but can be particularly challenging 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 without perforating the floor of the chamber. The following tip is a good way to avoid perforating the floor. Prior to treatment, place a bur alongside an X-ray to determine the depth of the chamber. Determining depth will act as a governor when making the access. Perforations are most commonly seen in two types of patients: Geriatric patients and difficult individuals. We easily can prevent floor perforations in the former with a little pre-treatment consideration.

Once proper, straight-line access is created, finding all the canals also can be a chore. A good help is the use of a piezo electric ultrasonic to remove secondary dentin and coronal sclerosis. We particularly like the CT-4 tip (SybronEndo) to remove these obstructions. Another aid 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. Shine the fiberoptic light through the tooth at the CEJ level. The tooth will look 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.

Geriatric canals will be sufficiently cleaned and shaped if you can take the preparation to a fully tapered .04 taper. Subsequently, the majority of these canals can accommodate a simplified obturation technique. The Galaxy .04 taper cones (Real World Endo) will work well with either a Profile or K3 .04 taper preparation.

Another consideration with the elderly patient is time. 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. Remember, many of these individuals do not do well placed way back in the dental chair. Try to keep the appointments to around 45 minutes and certainly no longer than 60 to 70 minutes. This of course depends upon the individual.

Geriatric patients can and should be an integral part of your practice. Hopefully, we have given you some tips on how to make endodontics easier for both you and your patients. As usual, we will continue to give you, "Just the Facts, Nothing but the Facts."

Dr. Dennis Brave is a diplomate of the American Board of Endodontics and was the senior managing partner of a group specialty practice for 27 years. Dr. Kenneth Koch is the founder and past director of the new program in postdoctoral endodontics at the Harvard School of Dental Medicine. Drs. Koch and Brave together are Real World Endo, an endodontic education company. They can be reached at (866) RWE-ENDO, or visit their Web site at

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