Review article

Endodontic considerations in the elderly

P. Finbarr Allen1 and John M. Whitworth2

1
Department of Restorative Dentistry, University Dental School and Hospital, Wilton, Cork, Ireland; 2School of Dental Sciences, Framlington
Place, Newcastle-upon-Tyne NE2 4BW, UK

Gerodontology 2004; 21; 185–194

Endodontic considerations in the elderly
1 Tooth retention has increased significantly in older adults, and dentists are now challenged by the need to
preserve critical teeth. There will be a need to consider endodontic therapy, and this paper describes how
successful endodontics can be provided for elderly patients. Strategic treatment planning is essential, and
preservation of key teeth will facilitate satisfactory oral function for elderly patients. These teeth may be
important in achieving and maintaining an intact anterior dental arch, for removable partial denture
retention or preservation of alveolar bone. In some cases, this can only be achieved if endodontic proce-
dures are undertaken. When infection of a root canal is present, there is no reason why good quality
endodontic therapy should not work in a healthy elderly patient. Elimination of infection can be chal-
lenging in narrow root canals, and a systematic approach for improving access into and negotiating these
canals is outlined.

Keywords: elderly, partially dentate, endodontics.

Accepted 29 August 2004

However, outcomes reported in studies of pros-

Introduction
thodontic procedures indicate that:
Nationally representative population surveys indi- 1 Patients rendered edentulous in old age are
cate that increasing numbers of adults are retaining unlikely to adapt successfully to complete dentures3.
teeth into old age1,2. In many cases, teeth in older 2 There is a high non-compliance rate (20–40%)
adults will have been challenged by dental diseases with bilateral free-end saddle partial dentures4.
such as caries and periodontal disease, and tooth 3 Older adults may reject implant therapy for rea-
wear with pathological or physiological aetiology. sons of fear or cost5.
The vitality of teeth may have been compromised In the light of these research findings, the con-
by these processes, and pulp necrosis may be the cept of long-term planning for the older partially
consequence. This may present as an opportunistic dentate adult has become more critical. Manage-
finding on a radiograph or when the patient pre- ment strategies such as the shortened dental arch
sents in pain. Treatment options to manage this (SDA) concept are now widely employed in the
situation involve either extraction of the tooth or elderly, and it is accepted that becoming edentu-
endodontic procedures. lous in old age with no denture wearing experience
Endodontic procedures in the elderly have been is undesirable.
considered challenging from a technical perspective The purpose of this paper is to outline the role of
in view of the likelihood of the root canal system endodontics in helping older adults achieve the
being ‘sclerosed’. A more insidious reason for not goal of retaining healthy teeth and satisfactory oral
undertaking these procedures is the feeling that function into old age.
endodontics, particularly in posterior teeth, is not
worthwhile for elderly patients. In the past,
Patient considerations
extraction of teeth was by far the more commonly
used treatment option for teeth with compromised At the outset, old age must not be confused with ill-
vitality in older adults. health. The response of teeth in older healthy

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186 P.F. Allen, J.M. Whitworth

adults to high quality endodontic procedures is as stability, avoid the need for a removable partial
good as it would be in younger adults6. In older denture altogether, or at least avoid the need for it
adults, as with younger adults, successful outcome to have a free-end saddle.
of endodontic procedures depends on elimination 5 A means of preserving bone when planning a
of pathogenic bacteria from the pulp space and partial or complete tooth supported overdenture.
prevention of re-infection7. Teeth, which are periodontally compromised may
There are, nonetheless, some general considera- serve well as overdenture abutments after root
tions which are pertinent to the elderly. The patient canal treatment and decoronation. Even short-
should be able to sit comfortably in the dental chair term retention of a tooth may facilitate the
and tolerate a lengthy course of treatment. This progressive transition into edentulousness by pro-
may not be possible in patients with, for example, viding natural occlusal stops and facilitating the
chronic back conditions or transient cerebral isch- development of motor skills in controlling partial
aemia. dentures.
There are few medical contraindications to root In each of these scenarios, the clinician needs to
canal treatment. Situations, which may contra- deal with the immediate problem of management
indicate endodontic intervention include: of a non-vital, possibly infected, tooth and also plan
1 Patients requiring radiotherapy to the head and the long-term care for this patient. Retention of
neck region. A 30 year retrospective review of strategic teeth may be extremely helpful in
head and neck cancer patients who received achieving a successful outcome for prosthodontic
radiotherapy found tooth extraction to be procedures.
responsible for 50% of all cases of osteoradio- In other situations, preservation of a tooth may
necrosis8. To reduce the risk of periapical disease be unhelpful. It may be possible to successfully
necessitating extraction, all potential foci of complete endodontic procedures; however, teeth
infection should be removed prior to commence- judged after clinical and radiographic examination
ment of radiotherapy. to be unrestorable should be extracted (Fig. 1). This
2 Poor compliance, for example, patients with includes teeth, which have no functional capacity,
Parkinson’s disease, tremors, or dementia. have fractured unfavourably or become grossly
Some concern has been expressed regarding carious and teeth, which have unmanageable per-
endodontic procedures in patients at risk of infec- iodontal disease. Occasionally, a tooth may be
tive endocarditis. However, antibiotic prophylaxis grossly over-erupted and may create difficulties for
is not usually required for endodontic treatment achieving an acceptable occlusal scheme for an
confined to the pulp space as this carries a very low opposing denture or bridge, and extraction is a
risk of significant bacteraemia9. preferable course of action.

How important is the tooth?

Prior to considering the technicalities of achieving a
successful endodontic procedure, the appropriate-
ness of preserving the tooth should be considered.
The ‘end-point’ for the patient’s dentition must be
planned well before urgent extraction of teeth is
required. The decision-making process regarding
endodontic treatment should be guided by the
strategic importance of the tooth. Preservation of a
tooth may be useful as:
1 A means of preserving an intact dental arch,
particularly in an aesthetically important part of
the mouth.
2 A means of enhancing the retention of a
removable prosthesis, particularly when loss of the
tooth will result in a free-end saddle.
3 A retainer for a fixed prosthesis. Figure 1 Restorability should be carefully assessed
4 A means of maintaining an important occlusal before making any promises. This may involve removing
contact in a reduced dentition. Retention of a final all questionable restorations and certainly all caries to
standing molar may help to preserve occlusal determine just what remains.

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 Endodontics and the elderly 187

Factors such as financial cost and ability to attend

for treatment must also be considered. There may
be occasions when patients will not consent or
subject themselves to complex treatment plans,
ruling out the preservation of a tooth, which could
be saved by root canal treatment. Ideal treatment
plans may be beyond the financial means of
patients. Simpler treatment is often dictated, and
once again, a tooth, which could be preserved
should be sacrificed within a simpler plan of care.

Barriers to successful endodontics in the

elderly

Age changes in the dentine-pulp complex

Old pulps are frequently described as being ‘scle-
rosed’ or ‘calcified’. This term denotes the often
difficult task of entering the pulp space in older
teeth, and is explained by a range of reactive and
degenerative changes, which may result from a Figure 2 An obliterated canal in the coronal reaches
lifetime of minor insult and wear and tear. These expands into a manageable system at a deeper level.
changes are not necessarily because of aging and
can be encountered in the teeth of young patients
after episodes of dental disease, accidental, and treatment, or to heal frank pulpal exposures.
iatrogenic trauma10,11. Reactionary dentine represents material laid down
Pulp space diminishes throughout life by the in such circumstances by original, surviving odon-
deposition of regular secondary dentine12. This toblasts. Reparative dentine on the other hand
occurs most commonly in pulp horns and on the comes from new odontoblast-like cells which dif-
floor and roof of the pulp chamber in molars, ferentiate and migrate to injured sites following the
which may be converted from a large rectangular death of primary odontoblasts12. These changes are
cavern in the young, to a flat disc in the elderly. again mostly confined to the coronal reaches of the
The unwary may find themselves deep into the canal system where external irritants have greatest
floor of the pulp chamber during access cavity impact.
preparation for endodontics, having traversed the Not only does the pulp space diminish, but it
small chamber without realising. In anterior teeth, becomes filled with less dentist-friendly material14.
the pulp retreats progressively in a cervical direc- Cumulative insults reduce the vascularity and cell
tion, becoming narrower and often leaving no soft content of the pulp, with a concomitant increase in
tissue within the crown at all. fibrosis. This, added to the relatively thicker over-
In roots, deposition is always concentric towards lying dentine means that old pulps may be less
the centre of the mass of dentine. Deposition is sensitive to thermal changes and less easy to sti-
often most marked in the coronal reaches of the mulate for the purpose of diagnosis. Most pulp
canal system, with deeper areas of root canals breakdown in the elderly is in fact without the
remaining widely patent even into very old age13. classic symptoms of reversible and irreversible
These points are important to remember during the pulpitis15.
search for root canals. Increased pulp fibrosis may present challenges
The clinician should always look in the middle of for canal negotiation, with the potential to compact
masses of dentine, and must not assume that fibrous pulp tissue and cause obstructions which
because a canal is narrow coronally that it will not may be as difficult to overcome as the most
open into a manageable system at a deeper level troublesome hard tissue ledge or blockage.
(Fig. 2). Pulp space is further reduced by reaction- Degenerating pulp tissue also finds itself the
ary and reparative dentine (formerly classified nidus for growth of calcified inclusions. Coronally,
together as tertiary or irritation dentine), which is these are usually encountered as pulp stones; not
laid down to reduce the porosity of dentinal tubules strictly dentine, but concentric spheroidal masses of
opened to the mouth by caries, trauma or dental calcified material which may become incorporated

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188 P.F. Allen, J.M. Whitworth

which have gained entry to the pulp space17,18.

Rarely do microbes spread in large numbers from
the canal system to invade the peri-radicular tis-
sues, rather, the drip-feed of microbial toxin
through apical and lateral portals of exit provokes a
host response to contain disease, one of the con-
sequences of which is bony rarefaction19. Treat-
ment is therefore aimed at eliminating microbial
infection from the canal space and preventing its
recurrence. In cases where this is done before api-
cal periodontitis has developed, it is predicted that a
lesion will not develop. In the case of established
apical periodontitis, elimination of root canal
infection creates the conditions needed for the
periapical tissues to restore themselves to health6.
Expectations of root canal treatment are high,
and many quote success rates in excess of 90%,
although 70% or lower may be realistic for general
practice20. An important question to ask is whether
host defences play a key role in outcome and
whether the elderly may expect less favourable
Figure 3 Pulp stones, spheroidal masses of calcified outcomes than the young. Limited epidemiology to
material (a), some becoming incorporated into canal date has made no such age-related observa-
walls (b) and others lying free. Fronds of soft tissue tions6,20–25, and it is widely accepted that root canal
separate them and allow cleavage for removal. treatment is as predictable in the young as the old,
provided that pulp canal infection can be properly
managed. However, technical challenges to proper
with the pulp chamber walls, or lie freely with- infection control may be encountered in damaged,
in14,16 (Fig. 3). Rarely are these masses complete, biologically old teeth.
containing interspersed leaves of soft tissue, which
provide cleavage planes for their disruption and
Diagnostics in the elderly
removal. Pulp stones are rarely encountered deeper
into root canals, where degenerating blood vessels The diagnosis of pathological conditions is based
and nerve cells act as foci for linear calcified as always on clinical history, examination and
deposits14,16. From a clinical standpoint, these special tests. While classic acute symptoms of
accumulations are often described in terms of a wet pulpal and periapical pathosis are commonly
cocktail stick, providing a hard barrier, but with reported by elderly patients, much endodontic
opportunities to penetrate along the ‘grain’. disease arises without the patient being aware.
Pulp breakdown is often discovered without the
patient recalling episodes of painful symptoms15,
Can the tooth be saved?
and patients may sometimes have been living for
Predictable treatment demands access to the long periods of time with painlessly discharging
infected pulp space. If this is complicated by limited sinuses, or periodic episodes of low grade swelling
mouth opening, unfavourable tooth alignment or or discomfort.
over-eruption, intolerance of lengthy operative There are no singular tests for assessing pulp
procedures or calcification of the pulp space, it may condition. Thermal and electrical pulp sensitivity
not be possible to save the tooth, and treatment tests are commonly applied, with better qualitative
should be planned accordingly. information on the status of symptomatic pulps
The fundamental aim of root canal treatment is coming from thermal. Increased bulk of dentine
to prevent or heal apical periodontitis. Whether and increased pulpal fibrosis may diminish
assessing a tooth with a large and patent pulp responses. This is certainly not licence to assume
space, or a canal system barely visible radiogra- pulpal breakdown and justify treatment without
phically, the biological aims of treatment are the other supporting evidence. Finding sites to apply
same. Pulp breakdown and the development of provocation tests can also present challenges for
apical periodontitis is mediated by microorganisms heavily restored teeth, and some electronic pulp

Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
 Endodontics and the elderly 189

testers are supplied with small tips to engage the

narrow band of tooth tissue which often presents
supragingivally beneath restoration margins.
Test cavities into the dentine of un-anaesthetised
teeth may be a justified method of confirming pulp
diagnosis in young teeth, but there should be no
surprises if an old tooth with a diminished but vital
pulp is entered deeply without major symptoms.
Radiographs also have an important part to
play, both in diagnosing endodontic status and in
evaluating the restorability and technical chal-
lenges to treatment. Good quality, paralleling views
should be secured wherever possible, and two
views at different horizontal angles may be useful
in building a three-dimensional picture of complex
and multirooted teeth. Figure 4 Mesial canals of a first molar which appeared
Disease associated with pulpal breakdown, such to be obliterated coronally. Entry was relatively simple by
as caries, defective restoration margins, tooth wear patient picking into cocktail stick-like linear deposits with
in close proximity with the pulp should be readily a size 10 file and lubricant after developing an entry
identified. Cracks will rarely be well imaged point with a sharp probe.
radiographically unless the line of the crack is for-
tuitously in the direct line of the exposure.
Assessment of restorability should also include and not required in search for pulp horns. The pulp is in
evaluation of periodontal bony support. the centre.
Radiographic appearances of apical periodontitis Special challenges may arise when there is really
are little different in the young and old. Care no sign of pulp space throughout the length of the
should be exercised in the interpretation of loose tooth. If the tooth has apical periodontitis, there
bony trabeculation, and a careful watch should as must be microorganisms within it, and a canal
ever be made for non-dental pathosis which may space for them to occupy. While the radiograph
arise at any age26,27,28. Unusual radiographic justifiably leads to realistic discussion with the
appearances should be interpreted with the view patient that entry may not be possible to heal their
that common lesions are common, but always lesion, the presence of linear calcific deposits can
mindful of previous medical history. give a worse impression than direct inspection
The physiological, reparative and degenerative reveals (Fig. 4). It is usually worth a careful search,
hard tissue changes, which may have taken place taking visual and tactile clues of tissue colour and
in the pulp space should be carefully assessed texture, often with a rewarding outcome.
radiographically. An accurately projected radio- The final diagnostic process should involve
graphic image should allow the clinician to assess stringent removal of all caries, defective, leaking
the depth at which the pulp might be expected restorations, and undermined tooth tissue to allow
during initial access and safeguard against cata- a proper evaluation of what remains.
strophic overcutting. Pulp stones are readily iden-
tified as irregular masses of calcification within the
Preparing for treatment
chamber. Armed with this knowledge, access
should not proceed until the bur drops into a
Local anaesthesia
seemingly hollow space. The chamber is not empty,
and its identification will require careful explora- Most patients are more confident about invasive
tion at the anticipated depth, often with additional dental treatment after the administration of local
light and magnification. Sometimes there is no anaesthetic. Elderly patients may be stoic, and
radiographic sign of pulp space within the crown. have endured substantial dental intervention
As the eye travels apically, it is usual to find a without anaesthesia, but pain control is always
narrow radiolucent line emerging at a deeper level, advised, even for teeth with established apical
centred within the mass of root dentine (Figs 2 and periodontitis. Better to proceed in comfort than to
4). This information guides the clinician to keep chance upon tags of vital pulp tissue or to cause
their access opening narrow and absolutely centred discomfort and be compromised during rubber
in the tooth, as wide expansion within the crown is dam isolation.

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190 P.F. Allen, J.M. Whitworth

Isolation
Having secured a clean and caries-free tooth with a
realistic prospect of restoration, it must now be
isolated from the oral flora. If the message of
microbial infection and endodontic disease is taken
seriously, there is no alternative to rubber dam
isolation. Methods should not be over complicated.
For most situations, a single hole is punched
somewhere near the middle of a sheet of rubber,
and the dam applied with a clamp which makes
stable, four point contact on the tooth beneath its
maximum bulbosity.
In the case of decoronated teeth, a slit dam
method may be applied if there are adjacent teeth,
plugging leaking gaps in the dam with a proprietary Figure 5 Lack of depth orientation combines with loss of
caulking agent. For lone-standing decoronated alignment to create a disaster. Short or medium tapered
burs are preferred which will usually be long enough to
teeth, it may sometimes be necessary to impinge on
puncture the chamber roof and which will fail safe if they
the gingival tissues, or remove some gingival tissue
are not.
before the procedure to allow a clamp to engage the
root. If the tooth cannot be isolated, the question
must again be asked if it is restorable. needed, avoiding the risk of damaging overcutting
The dam should be applied from the outset un- where internal landmarks are unclear (Fig. 5).
less there is serious concern that disorientation may Access should commence by defining a classic
lead to misdirected cutting, failure to find the pulp cavity outline, noting a somewhat narrower and
or even perforation. more cervically placed starting point in the case of
calcified anterior teeth. Orientation should be
constantly checked, and the cavity inspected
Clinical tips for successful endodontics periodically for extent and alignment with a clean
in the elderly front-silvered mirror under good lighting and
magnification. While the use of an operating
Entering the canal system microscope cannot currently be regarded as the
universal standard of care, anyone who has
Access and canal negotiation probably present the enjoyed the vision, understanding and fine control
greatest technical challenges in root canal treat- that this offers will never willingly return to con-
ment of the old tooth. Useful aids include: an ventional methods. Even the simplest of magnify-
accurate preoperative radiograph, light, front- ing loupes will provide a helpful advantage.
silvered mirror, magnification, medium length Special care should be taken to inspect the cavity
tapered diamond bur, safe-ended endodontic access at a depth at which it is anticipated the pulp will be
burs, ultrasonics, long-necked round burs (pin bur, entered. If the initial access bur has not entered the
Goose-neck bur), DG16 canal probe and lubri- canal, it is time to reconsider alignment; you may
cation. be at the correct level, but bypassing it on any side.
Exposure of radiographs is legitimate to confirm
progress and inform realignment. Sometimes pla-
Orientation
cing a radiopaque marker, such as a ball of com-
Entry to a calcified canal system cannot be an pacted warm gutta percha in the depth of the
unthinking procedure. Care should be taken to excavations helps radiographic orientation and
identify features of the pulp space from an accurate reveals the path to follow (Fig. 6a–c). Under no
preoperative radiograph, with particular attention circumstances should the clinician progress beyond
to the expected depth of patent pulp space, and the expected entry depth without careful consid-
long axis orientation. Access cavities may be con- eration, otherwise the bur could enter the perio-
sidered deep preparations, but in most circum- dontal ligament.
stances, a high-speed medium tapered diamond bur Having reached the extent of a medium tapered
will suffice to outline the cavity and gain initial diamond bur in good orientation, but without
penetration. Long burs should only be used when entry, it is time to move to less aggressive, slow

Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
 Endodontics and the elderly 191

Figure 6 (a) Careful progress with magnification still yields no entry point. (b) Warm gutta percha compacted with a
fluid sealer (AHPlus, Dentsply) reveals a pathway. (c) Progress along the easily identified sealer-track allows easy access
to a wide apical canal.

find a sticky spot which may represent a small

puncture into the pulp space, or the entry into
linear calcifications within the canal system. If no
stick is felt, there is no justification to pick up files,
which will simply bend on the hard barrier at the
base of the preparation, and quickly form a grow-
ing pile of casualties. In these circumstances, care-
fully aligned burring and probing should continue
until a stick is found, or until a decision is made
that entry will not be secured.
In the case of multirooted teeth, the chamber
should be fully unroofed to expose its contents.
Safe-ended high speed burs (Endo Z or Diamendo,
Maillefer) are ideal, guided around the walls of the
Figure 7 Long, narrow-necked burs for chasing canals. preparation with light touch, and avoiding injury
The narrow shank allows the tip of the bur to be viewed to the chamber floor.
during excavation and minimises the risk of misalign- In the case of pulp stones, they are usually
ment. identified as glassy translucent inclusions in the
chamber. These should be removed to reveal the
speed burs to continue the procedure. Ideal are burs dark, domed structure of the pulp chamber floor
such as the Meissenger goose neck bur and the with its helpful roadmap of fissures, which will
Maillefer LN pin bur (Fig. 7), instruments with guide the observer to canal entrances. Often heavy
narrow necks to allow the active rose head to be probing with a DG16 is able to fragment stones
illuminated and observed at all times. Working with along soft-tissue cleavage planes and allow
magnification, there are often visual clues owing to removal. Ultrasonic scalers are also powerful tools
the altered colour, texture and translucency of the for fragmentation and elimination. Again, care is
mineralised deposits in the former pulp space, in exercised to avoid damage to the chamber floor,
comparison with the primary dentine, which sur- which may convert a domed structure with fun-
rounds. Some advocate the use of fine ultrasonic nelled entry points to the root canals into an irre-
cutting tips to gently advance apically. These gular or flat surface with pinprick canal orifices
instruments may, however, cause drying and (Fig. 8).
burning of dentine, which can distract from the As in single-rooted teeth, all suspected canal
natural features of the tooth, alter colour and entrances should first be probed and chased with
translucency, and lead to misdirected preparation. long-necked burs if needed to develop a sticking
At intervals, areas of discoloured tissue are pro- spot before picking up files (Fig. 9). Any puncture
bed firmly with a DG16 canal probe in an effort to holes, which look doubtful should be explored with

Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
192 P.F. Allen, J.M. Whitworth

ease the glide path during entry; whether the

ethylenediaminetetraacetic acid (EDTA) many
contain contributes significantly to the process is
questionable. Small files, typically 21 mm size 10,
or dedicated entry files (Pathfinder files C+ files)
with increased rigidity are gently advanced into the
canal in a watch-winding motion, twiddling the
instrument lightly between forefinger tip and
thumb. If progress and rotation of the instrument
as it is twiddled becomes tight, resist the temptation
to drive on. The instrument should be withdrawn
(picking motion) to free it from the canal walls and
allow entry of irrigant/lubricant. Progress contin-
ues in a twiddling and picking motion as the
instrument progresses apically.
It should be recalled that canals are often nar-
rower coronally than they are apically, and that a
false mental picture may be carried during entry of
an instrument binding at its tip in a canal becoming
ever narrower. So often the reality is that the
instrument is hanging up on a coronal narrowing
Figure 8 Damage to the chamber floor converts help- which, once cleared, allows the instrument to fall
fully funnelled canal entrances into frustrating dots on a simply into the deeper parts of the canal.
flattened surface.
Progress is not always smooth despite careful
instrumentation and copious irrigation/lubrication.
If the negotiating instrument ceases to advance
well, the clinician should determine how the
instrument feels in the canal. If the instrument is
advanced with a watch winding motion, engages
with the canal, and demonstrates a tugging or
sticky sensation on removal, this is tight resistance.
The instrument is engaging a fine canal orifice, and
there is every anticipation that with persistence it
will nibble its way into the deeper parts of the
canal, often with a gratifying drop to reward the
operator as the canal opens up.
If, on the contrary, the instrument sails loosely
through the canal and hits an obstruction with no
sticky sensation, this is loose resistance. This is
Figure 9 Work underway to uncover the dark, domed often rationalised as ‘apical calcification’, a rare
pulp chamber floor with its network of fissures which event deep in a canal system. The reality is usually
guide the eye to canal entrances. A possible canal that the canal is curving, and the response is to
entrance is probed with a DG16 explorer to identify a apply a smooth curve to the apical 2–3 mm of the
sticking spot. file before re-inserting and manipulating around
the walls to find a sticking spot.
an electronic apex locator before they are opened Despite best efforts, canals are not always
or entered deeply. The apex locator will provide an negotiated to definitive length, and decision
‘apex’ reading if the orifice is in fact a perforation. making should balance the risks of attempting to
The perforation should be repaired immediately, cut further, perhaps in an iatrogenic path, or to
and the search continued elsewhere. accept the outcome. This in turn will be influ-
enced by the pathological state (whether there is
apical periodontitis or not) and the restorative
Entering the canal
plan for the tooth, and decisions should always
Having established a sticking spot, files can now be be made with proper patient information and
brought into play. Lubricants are always helpful to consent.

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 Endodontics and the elderly 193

Figure 10 (a) A challenging case. (b) Patient negotiation lays the foundation for NiTi enlargement, dense obturation
and restoration.

It should also be borne in mind that after some Finally, prolonged mouth opening may also
coronal opening of the canal and soaking with bring its challenges, in terms of fatigue and the
sodium hypochlorite, canal systems which development of tremor. Considerable improvement
appeared initially to be non-negotiable become is usually achieved with a simple rubber bite block,
manageable with routine methods. If one canal of placed on the least interfering side of the mouth
a multirooted tooth is difficult to enter, work and allowing the patient to close and rest into a
should continue in the other canals through a comfortable position, rather than strive to maintain
pulp chamber flooded with sodium hypochlorite, themselves ‘wide open’.
and a further attempt made to negotiate later in Preparing to leave at the end of the session may
the appointment. Heavy handed efforts to gain also take time and care, with a gradual return of the
access are seldom rewarded. patient to the sitting position, and the opportunity
On occasions difficulty can be encountered in to loosen up and ‘find their feet’ before departure.
initial development of the canal for instrumenta- In short, sessions cannot be unduly hurried, and
tion. Problems are especially common in moving the dental team must be sensitive to the basic
from the negotiating size 10 instrument to the size physical needs of elderly patients, which will
15 file, which is 50% wider. The use of half-sized enhance their comfort and compliance.
files such as Golden Mediums (Maillefer/Dentsply), In conclusion, successful endodontics can be
which include instruments in sizes 12.5, 17.5, and achieved in the elderly with special attention to
22.5 help to overcome the issues of early enlarge- diagnosis, good quality radiographs and technique
ment to form a ready flight path for the enlarging oriented to overcoming the challenges posed by
tools to follow. calcification of the root canal system. As long as a
tooth has a strategically important role to play,
then endodontic procedures are indicated and jus-
Ongoing treatment
tified in healthy, elderly patients.
Once the canal is negotiated, all that remains is
to finalise canal preparation and obturation
(Fig. 10a,b). There are few special issues of rele- References
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tenance to ensure that caries and periodontal oral prostheses. J Prosthet Dent 1982; 47: 472–476.
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