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By: Sarah Kahil

Course: ENDO511

19/12/2015

MANAGING GERIATRIC
PATIENTS
PATIENTS MAY BE:
1. Tempered
2. Uncooperative
3. Low dental IQ
2 Types of Patients:
- Relatively healthy older adults: functionally independent
- Unhealthy older patients: have complex conditions and need
assistance
1. Find out the patients daily eating and resting habits to determine
the ideal time for the appointment. Early morning is usually
preferable.
2. Provide pillows for comfortable positioning in the chair.
3. Special needs may require rest room breaks.
4. Eye shades maybe needed to shield patient from intense light.
DIAGNOSIS AND TREATMENT PLAN
-

Clinical judgement should be made based on:


Patients complaint
History
Signs
Symptoms
Testing
Radiographs

MEDICAL HISTORY

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By: Sarah Kahil

Course: ENDO511

19/12/2015

Dramatic changes to C.V.S, Respiratory System, CNS.


Decline in liver and renal function. When predicting behavior and
interaction of drugs (anesthesia, analgesics, antibiotics)
UPDATE THE MEDICAL HISTORY
- Updating the medical history at each visit is very important.
- It may help to use a standard form listing various diseases
because many diseases of elderly are chronic and these patients
may under estimate the importance of informing you about a 30
years old chronic problem for example.
- Obtain information about drug therapy.
- Sensitivity to medications at every visit.
- Consult the physician for side effects and precautions
- Old patients with vision problems may need help filling out the
form, and you may need consult a family member or physician to
obtain further information.
- Because elder patients rarely present with an acute problem.
Treatment can be postponed until consultations are completed.
- Management of medical emergencies in the dental office is best
directed toward prevention rather than treatment.
CHIEF COMPLAINT
- First step in evaluating the patients condition is encouraging the
patient to talk about the problem.
- This consultation with the patient serves several purposes, not
only you can learn about the complaint but you can evaluate any
handy capping, ability to communicate and dental IQ.
- Most geriatric patients do not complain readily about signs or
symptoms of pulpal and periapical disease and may consider
them to be minor compared with other health concerns and
discomfort.
- A disease process usually arises as an acute problem in children
but assumes a more chronic or less dramatic form in the older
adult.

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By: Sarah Kahil

Course: ENDO511

19/12/2015

- Pain associated with vital pulps (referred pain; or pain caused by


heat, cold, or sweets) seems to be reduced with age, and severity
seems to diminish over time.
- Pulpal healing capacity is also reduced, and necrosis may occur
quickly after microbial invasion, again with reduced symptoms.
DENTAL HISTORY
Search patients records
Explore their memories to determine the history of involved teeth or
surrounding area
Subjective symptoms:
Examiner should pursue responses to questions about the chief
complaint, the stimulus or irritant that causes pain, nature of pain and
its relationship to the stimulus or irritant.
Diagnostic procedures:
It is important to remember that pulpal symptoms are usually chronic
in older patients and other sources of oro-facial pain should be ruled
out when pain is not soon localized.
Objective Signs:
- Intraoral and extra oral examination
- Exposures to factors that contribute to oral cancers accumulate
with age
- Many systemic diseases may initially manifest oral signs or
symptoms
- Missing teeth, tilt, rotation, supra eruption of adjacent and
opposing teeth contribute to reduced functional ability.
- Resultant loss of chewing efficiency leads to a higher
carbohydrate diet of softer, more cariogenic foods increasing
susceptibility to caries and periodontal disease.
- Increased sugar intake to compensate for loss of taste and
xerostomia are also factors in the renewed susceptibility to decay.
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By: Sarah Kahil

Course: ENDO511

19/12/2015

- Saliva has a significant role in the maintenance of oral and


general health
- Aging has no significant clinical impact on salivary secretion.
- Most common cause of salivary hypofunction in the elderly is
medication use and is most commonly associated with dental
caries and oral fungal infections.
Gingival recession: creates sensitivity which is hard to control,
exposes cementum and dentin that are less resistant to decay
causing root caries
Removal of root caries irritating to the pulp and often results in pulp
exposures or reparative dentin formation that affects the negotiation
of the canal if root canal later is needed.
- Interproximal caries is difficult to restore.
- Restoration failure as a result of continued decay is common.
Attrition, Abrasion and Erosion also exposes dentin through a slower
process that allows the pulp to respond with dentinal sclerosis and
reparative dentin.
Secondary dentin formation may eventually result in complete pulp
obliteration.
In anterior teeth secondary dentin is deposited on the lingual surface
while in molar teeth its deposition occurs on the floor of the pulp
chamber.
PULPAL CHANGES DUE TO AGING
- Decrease in size and number of pulpal cells
- Increase in number of collagen fibers
- Decrease in size of pulpal space due to continued dentin
formation
- Decrease in number of pulpal blood vessels
- Decrease in number of pulpal nerve fibers

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By: Sarah Kahil

Course: ENDO511

19/12/2015

- Cellularity of older pulp tissue gradually decreases in size and


number and may disappear at certain areas.
- Canal and chamber volume is inversely proportional to age
- Reparative dentin resulting from restorative procedures, trauma,
attrition and recurrent caries also contribute to diminution of
canal and chamber size
- CDJ moves farther from the radiograph apex with continued
cementum deposition
- Thickness of young apical cementum is 100to 200 micro m and
increases with age to 2-3 times that thickness
- Calcification process associated with aging appears clinically to be
more of linear type than that which occurs in a young tooth in
response to caries, pulpotomy or trauma.
- Dentinal tubules becomes more occluded with advancing age,
decreasing tubular permeability
- Lateral and accessory canals can calcify by age, thus decreasing
their clinical significance.
- Violating principles of cavity design combined with the loss of
resiliency that results from a reduced organic component to the
dentin can increase susceptibility to cracks and cuspal fractures.
- Pulp exposures caused by cracks are less likely to present acute
problems in older patients and often penetrate the sulcus to
create a periodontal defect or even a periapical one.
- High
magnification
available
with
microscopes
and
transillumination during access opening and canal exploration
permits visualization of the extent of cracks in determining
prognosis
- Cracks is of little significance in the absence of complaints.
- Cracks detected while pulp is still vital can offer good prognosis
- Vertically cracked teeth should always be considered when pulpal
or periapical disease is observed and little or no cause for pulpal
irritation can be observed clinically or radiographically.
- Narrow, boney wall defects associated with non-vital pulps are
usually sinus tracts, but they can be resistant to root canal
therapy alone when with time they become chronic periodontal
pockets.
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By: Sarah Kahil

Course: ENDO511

19/12/2015

- Patients with diabetes have increased periodontal disease in


endodontic treated teeth and have a reduced likelihood of success
of endodontic treatment in cases with preoperative periradicular
lesions.
PULP TESTING
- Vitality response must correlate with clinical and radiographical
findings and be a supplement in developing clinical judgement
- Slow and gentle testing should be done to determine pulpal
and periapical status and whether palliative or definitive
therapy is indicated.
- Fewer nerve branches are present in older pulps, due to
retrogressive changes resulting from mineralization of the
nerve and nerve sheath.
- Due to reduced neural and vascular response, response to
stimuli and irritants may be lowered. Presence or absence of
response is of limited value and must be correlated with other
tests.
- Extensive restorations, pulp recession and excessive
calcifications are limitations in both performing and interpreting
results of electric and thermal tests. Pulp testers are of little
value.
- Test cavity is generally less useful,
- Viral pulps can sometimes be exposed and even negotiated
with a file with minimal pain; then the root canal becomes part
of the diagnostic procedures.
- So test cavity should be used only when other findings are
suggestive but not conclusive.
- Diffuse pain of vague origin is also uncommon in older pulps
and limits the need for selective anesthesia
- Non-odontogenic sources should be considered when factors
associated with pulpal disease are not readily identified or
when acute pain does not localize within a short time.
- Discoloration of single teeth may indicate pulp death, but this
is uncommon with advanced age, when it occurs discoloration
is usually a result of restorative material following RCT because
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By: Sarah Kahil

Course: ENDO511

19/12/2015

dentin is generally thicker in older patients, it is not an


indicator of pulp necrosis.
- Dentin deposition produces a yellow, opaque color that would
indicate progressive calcification in a younger pulp; however
this is common in older teeth.
RADIOGRAPHS
- Digital radiography may be more useful than conventional
radiography in detecting early bone changes.
- Older patient may find difficulty in film placement, holders should
be used.
- Pulp recession by reparative dentin and complicated by pup
stones and dystrophic calcification
- Depth of the chamber should be measured from the occlusal
surface and its mesiodistal position noted.
- Receding pulp horns that are apparent on radiograph may remain
microscopically much higher.
Canals should be examined for:
-

Numbers
Size
Shape
Curvature

Resorption associated with chronic apical periodontitis may


significantly alter the shape of the apex and the anatomy of the
foramen through inflammatory osteoclastic activity.
Hyper cementosis completely obscure the apical anatomy and result in
constriction far from radiographic apex due to continued cementum
deposition.

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By: Sarah Kahil

Course: ENDO511

19/12/2015

Lamina dura should be examined in its entirely and anatomic


landmarks distinguished from periapical radiolucencies and radioopacities,
The incidence of some odontogenic and non-odontogenic cysts and
tumors increases with age and should be considered when vitality does
not correlate with radiographic findings.
Dense bone indicate the need for increased exposures times to
improve contrast needed to see the canal and root anatomy.

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