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

Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194 185
186 P.F. Allen, J.M. Whitworth
adults to high quality endodontic procedures is as
good as it would be in younger adults6. In older
adults, as with younger adults, successful outcome
of endodontic procedures depends on elimination
of pathogenic bacteria from the pulp space and
prevention of re-infection7.
There are, nonetheless, some general considera-
tions which are pertinent to the elderly. The patient
should be able to sit comfortably in the dental chair
and tolerate a lengthy course of treatment. This
may not be possible in patients with, for example,
chronic back conditions or transient cerebral isch-
aemia.
There are few medical contraindications to root
canal treatment. Situations, which may contra-
indicate endodontic intervention include:
1 Patients requiring radiotherapy to the head and
neck region. A 30 year retrospective review of
head and neck cancer patients who received
radiotherapy found tooth extraction to be
responsible for 50% of all cases of osteoradio-
necrosis8. To reduce the risk of periapical disease
necessitating extraction, all potential foci of
infection should be removed prior to commence-
ment of radiotherapy.
2 Poor compliance, for example, patients with
Parkinson’s disease, tremors, or dementia.
Some concern has been expressed regarding
endodontic procedures in patients at risk of infec-
tive endocarditis. However, antibiotic prophylaxis
is not usually required for endodontic treatment
confined to the pulp space as this carries a very low
risk of significant bacteraemia9.
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.
4 A means of maintaining an important occlusal
contact in a reduced dentition. Retention of a final
standing molar may help to preserve occlusal
Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
stability, avoid the need for a removable partial
denture altogether, or at least avoid the need for it
to have a free-end saddle.
5 A means of preserving bone when planning a
partial or complete tooth supported overdenture.
Teeth, which are periodontally compromised may
serve well as overdenture abutments after root
canal treatment and decoronation. Even short-
term retention of a tooth may facilitate the
progressive transition into edentulousness by pro-
viding natural occlusal stops and facilitating the
development of motor skills in controlling partial
dentures.
In each of these scenarios, the clinician needs to
deal with the immediate problem of management
of a non-vital, possibly infected, tooth and also plan
the long-term care for this patient. Retention of
strategic teeth may be extremely helpful in
achieving a successful outcome for prosthodontic
procedures.
In other situations, preservation of a tooth may
be unhelpful. It may be possible to successfully
complete endodontic procedures; however, teeth
judged after clinical and radiographic examination
to be unrestorable should be extracted (Fig. 1). This
includes teeth, which have no functional capacity,
have fractured unfavourably or become grossly
carious and teeth, which have unmanageable per-
iodontal disease. Occasionally, a tooth may be
grossly over-erupted and may create difficulties for
achieving an acceptable occlusal scheme for an
opposing denture or bridge, and extraction is a
preferable course of action.
Figure 1 Restorability should be carefully assessed
before making any promises. This may involve removing
all questionable restorations and certainly all caries to
determine just what remains.

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
lifetime of minor insult and wear and tear. These
changes are not necessarily because of aging and
can be encountered in the teeth of young patients
after episodes of dental disease, accidental, and
iatrogenic trauma10,11.
Pulp space diminishes throughout life by the
deposition of regular secondary dentine12. This
occurs most commonly in pulp horns and on the
floor and roof of the pulp chamber in molars,
which may be converted from a large rectangular
cavern in the young, to a flat disc in the elderly.
The unwary may find themselves deep into the
floor of the pulp chamber during access cavity
preparation for endodontics, having traversed the
small chamber without realising. In anterior teeth,
the pulp retreats progressively in a cervical direc-
tion, becoming narrower and often leaving no soft
tissue within the crown at all.
In roots, deposition is always concentric towards
the centre of the mass of dentine. Deposition is
often most marked in the coronal reaches of the
canal system, with deeper areas of root canals
remaining widely patent even into very old age13.
These points are important to remember during the
search for root canals.
The clinician should always look in the middle of
masses of dentine, and must not assume that
because a canal is narrow coronally that it will not
open into a manageable system at a deeper level
(Fig. 2). Pulp space is further reduced by reaction-
ary and reparative dentine (formerly classified
together as tertiary or irritation dentine), which is
laid down to reduce the porosity of dentinal tubules
opened to the mouth by caries, trauma or dental
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Endodontics and the elderly 187
Figure 2 An obliterated canal in the coronal reaches
expands into a manageable system at a deeper level.
treatment, or to heal frank pulpal exposures.
Reactionary dentine represents material laid down
in such circumstances by original, surviving odon-
toblasts. Reparative dentine on the other hand
comes from new odontoblast-like cells which dif-
ferentiate and migrate to injured sites following the
death of primary odontoblasts12. These changes are
again mostly confined to the coronal reaches of the
canal system where external irritants have greatest
impact.
Not only does the pulp space diminish, but it
becomes filled with less dentist-friendly material14.
Cumulative insults reduce the vascularity and cell
content of the pulp, with a concomitant increase in
fibrosis. This, added to the relatively thicker over-
lying dentine means that old pulps may be less
sensitive to thermal changes and less easy to sti-
mulate for the purpose of diagnosis. Most pulp
breakdown in the elderly is in fact without the
classic symptoms of reversible and irreversible
pulpitis15.
Increased pulp fibrosis may present challenges
for canal negotiation, with the potential to compact
fibrous pulp tissue and cause obstructions which
may be as difficult to overcome as the most
troublesome hard tissue ledge or blockage.
Degenerating pulp tissue also finds itself the
nidus for growth of calcified inclusions. Coronally,
these are usually encountered as pulp stones; not
strictly dentine, but concentric spheroidal masses of
calcified material which may become incorporated
188 P.F. Allen, J.M. Whitworth
Figure 3 Pulp stones, spheroidal masses of calcified
material (a), some becoming incorporated into canal
walls (b) and others lying free. Fronds of soft tissue
separate them and allow cleavage for removal.
with the pulp chamber walls, or lie freely with-
in14,16 (Fig. 3). Rarely are these masses complete,
containing interspersed leaves of soft tissue, which
provide cleavage planes for their disruption and
removal. Pulp stones are rarely encountered deeper
into root canals, where degenerating blood vessels
and nerve cells act as foci for linear calcified
deposits14,16. From a clinical standpoint, these
accumulations are often described in terms of a wet
cocktail stick, providing a hard barrier, but with
opportunities to penetrate along the ‘grain’.
Can the tooth be saved?
Predictable treatment demands access to the
infected pulp space. If this is complicated by limited
mouth opening, unfavourable tooth alignment or
over-eruption, intolerance of lengthy operative
procedures or calcification of the pulp space, it may
not be possible to save the tooth, and treatment
should be planned accordingly.
The fundamental aim of root canal treatment is
to prevent or heal apical periodontitis. Whether
assessing a tooth with a large and patent pulp
space, or a canal system barely visible radiogra-
phically, the biological aims of treatment are the
same. Pulp breakdown and the development of
apical periodontitis is mediated by microorganisms
Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
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
outcomes than the young. Limited epidemiology to
date has made no such age-related observa-
tions6,20–25, and it is widely accepted that root canal
treatment is as predictable in the young as the old,
provided that pulp canal infection can be properly
managed. However, technical challenges to proper
infection control may be encountered in damaged,
biologically old teeth.
Diagnostics in the elderly
The diagnosis of pathological conditions is based
as always on clinical history, examination and
special tests. While classic acute symptoms of
pulpal and periapical pathosis are commonly
reported by elderly patients, much endodontic
disease arises without the patient being aware.
Pulp breakdown is often discovered without the
patient recalling episodes of painful symptoms15,
and patients may sometimes have been living for
long periods of time with painlessly discharging
sinuses, or periodic episodes of low grade swelling
or discomfort.
There are no singular tests for assessing pulp
condition. Thermal and electrical pulp sensitivity
tests are commonly applied, with better qualitative
information on the status of symptomatic pulps
coming from thermal. Increased bulk of dentine
and increased pulpal fibrosis may diminish
responses. This is certainly not licence to assume
pulpal breakdown and justify treatment without
other supporting evidence. Finding sites to apply
provocation tests can also present challenges for
heavily restored teeth, and some electronic pulp

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.
Disease associated with pulpal breakdown, such
as caries, defective restoration margins, tooth wear
in close proximity with the pulp should be readily
identified. Cracks will rarely be well imaged
radiographically unless the line of the crack is for-
tuitously in the direct line of the exposure.
Assessment of restorability should also include and
evaluation of periodontal bony support.
Radiographic appearances of apical periodontitis
are little different in the young and old. Care
should be exercised in the interpretation of loose
bony trabeculation, and a careful watch should as
ever be made for non-dental pathosis which may
arise at any age26,27,28. Unusual radiographic
appearances should be interpreted with the view
that common lesions are common, but always
mindful of previous medical history.
The physiological, reparative and degenerative
hard tissue changes, which may have taken place
in the pulp space should be carefully assessed
radiographically. An accurately projected radio-
graphic image should allow the clinician to assess
the depth at which the pulp might be expected
during initial access and safeguard against cata-
strophic overcutting. Pulp stones are readily iden-
tified as irregular masses of calcification within the
chamber. Armed with this knowledge, access
should not proceed until the bur drops into a
seemingly hollow space. The chamber is not empty,
and its identification will require careful explora-
tion at the anticipated depth, often with additional
light and magnification. Sometimes there is no
radiographic sign of pulp space within the crown.
As the eye travels apically, it is usual to find a
narrow radiolucent line emerging at a deeper level,
centred within the mass of root dentine (Figs 2 and
4). This information guides the clinician to keep
their access opening narrow and absolutely centred
in the tooth, as wide expansion within the crown is
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Endodontics and the elderly 189
Figure 4 Mesial canals of a first molar which appeared
to be obliterated coronally. Entry was relatively simple by
patient picking into cocktail stick-like linear deposits with
a size 10 file and lubricant after developing an entry
point with a sharp probe.
not required in search for pulp horns. The pulp is in
the centre.
Special challenges may arise when there is really
no sign of pulp space throughout the length of the
tooth. If the tooth has apical periodontitis, there
must be microorganisms within it, and a canal
space for them to occupy. While the radiograph
justifiably leads to realistic discussion with the
patient that entry may not be possible to heal their
lesion, the presence of linear calcific deposits can
give a worse impression than direct inspection
reveals (Fig. 4). It is usually worth a careful search,
taking visual and tactile clues of tissue colour and
texture, often with a rewarding outcome.
The final diagnostic process should involve
stringent removal of all caries, defective, leaking
restorations, and undermined tooth tissue to allow
a proper evaluation of what remains.
Preparing for treatment
Local anaesthesia
Most patients are more confident about invasive
dental treatment after the administration of local
anaesthetic. Elderly patients may be stoic, and
have endured substantial dental intervention
without anaesthesia, but pain control is always
advised, even for teeth with established apical
periodontitis. Better to proceed in comfort than to
chance upon tags of vital pulp tissue or to cause
discomfort and be compromised during rubber
dam isolation.
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
caulking agent. For lone-standing decoronated
teeth, it may sometimes be necessary to impinge on
the gingival tissues, or remove some gingival tissue
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.
The dam should be applied from the outset un-
less there is serious concern that disorientation may
lead to misdirected cutting, failure to find the pulp
or even perforation.
Clinical tips for successful endodontics
in the elderly
Entering the canal system
Access and canal negotiation probably present the
greatest technical challenges in root canal treat-
ment of the old tooth. Useful aids include: an
accurate preoperative radiograph, light, front-
silvered mirror, magnification, medium length
tapered diamond bur, safe-ended endodontic access
burs, ultrasonics, long-necked round burs (pin bur,
Goose-neck bur), DG16 canal probe and lubri-
cation.
Orientation
Entry to a calcified canal system cannot be an
unthinking procedure. Care should be taken to
identify features of the pulp space from an accurate
preoperative radiograph, with particular attention
to the expected depth of patent pulp space, and
long axis orientation. Access cavities may be con-
sidered deep preparations, but in most circum-
stances, a high-speed medium tapered diamond bur
will suffice to outline the cavity and gain initial
penetration. Long burs should only be used when
Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
Figure 5 Lack of depth orientation combines with loss of
alignment to create a disaster. Short or medium tapered
burs are preferred which will usually be long enough to
puncture the chamber roof and which will fail safe if they
are not.
needed, avoiding the risk of damaging overcutting
where internal landmarks are unclear (Fig. 5).
Access should commence by defining a classic
cavity outline, noting a somewhat narrower and
more cervically placed starting point in the case of
calcified anterior teeth. Orientation should be
constantly checked, and the cavity inspected
periodically for extent and alignment with a clean
front-silvered mirror under good lighting and
magnification. While the use of an operating
microscope cannot currently be regarded as the
universal standard of care, anyone who has
enjoyed the vision, understanding and fine control
that this offers will never willingly return to con-
ventional methods. Even the simplest of magnify-
ing loupes will provide a helpful advantage.
Special care should be taken to inspect the cavity
at a depth at which it is anticipated the pulp will be
entered. If the initial access bur has not entered the
canal, it is time to reconsider alignment; you may
be at the correct level, but bypassing it on any side.
Exposure of radiographs is legitimate to confirm
progress and inform realignment. Sometimes pla-
cing a radiopaque marker, such as a ball of com-
pacted warm gutta percha in the depth of the
excavations helps radiographic orientation and
reveals the path to follow (Fig. 6a–c). Under no
circumstances should the clinician progress beyond
the expected entry depth without careful consid-
eration, otherwise the bur could enter the perio-
dontal ligament.
Having reached the extent of a medium tapered
diamond bur in good orientation, but without
entry, it is time to move to less aggressive, slow

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.
Figure 7 Long, narrow-necked burs for chasing canals.
The narrow shank allows the tip of the bur to be viewed
during excavation and minimises the risk of misalign-
ment.
speed burs to continue the procedure. Ideal are burs
such as the Meissenger goose neck bur and the
Maillefer LN pin bur (Fig. 7), instruments with
narrow necks to allow the active rose head to be
illuminated and observed at all times. Working with
magnification, there are often visual clues owing to
the altered colour, texture and translucency of the
mineralised deposits in the former pulp space, in
comparison with the primary dentine, which sur-
rounds. Some advocate the use of fine ultrasonic
cutting tips to gently advance apically. These
instruments may, however, cause drying and
burning of dentine, which can distract from the
natural features of the tooth, alter colour and
translucency, and lead to misdirected preparation.
At intervals, areas of discoloured tissue are pro-
bed firmly with a DG16 canal probe in an effort to
Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
Endodontics and the elderly 191
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
preparation with light touch, and avoiding injury
to the chamber floor.
In the case of pulp stones, they are usually
identified as glassy translucent inclusions in the
chamber. These should be removed to reveal the
dark, domed structure of the pulp chamber floor
with its helpful roadmap of fissures, which will
guide the observer to canal entrances. Often heavy
probing with a DG16 is able to fragment stones
along soft-tissue cleavage planes and allow
removal. Ultrasonic scalers are also powerful tools
for fragmentation and elimination. Again, care is
exercised to avoid damage to the chamber floor,
which may convert a domed structure with fun-
nelled entry points to the root canals into an irre-
gular or flat surface with pinprick canal orifices
(Fig. 8).
As in single-rooted teeth, all suspected canal
entrances should first be probed and chased with
long-necked burs if needed to develop a sticking
spot before picking up files (Fig. 9). Any puncture
holes, which look doubtful should be explored with
192 P.F. Allen, J.M. Whitworth
Figure 8 Damage to the chamber floor converts help-
fully funnelled canal entrances into frustrating dots on a
flattened surface.
Figure 9 Work underway to uncover the dark, domed
pulp chamber floor with its network of fissures which
guide the eye to canal entrances. A possible canal
entrance is probed with a DG16 explorer to identify a
sticking spot.
an electronic apex locator before they are opened
or entered deeply. The apex locator will provide an
‘apex’ reading if the orifice is in fact a perforation.
The perforation should be repaired immediately,
and the search continued elsewhere.
Entering the canal
Having established a sticking spot, files can now be
brought into play. Lubricants are always helpful to
Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
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
which, once cleared, allows the instrument to fall
simply into the deeper parts of the canal.
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
often rationalised as ‘apical calcification’, a rare
event deep in a canal system. The reality is usually
that the canal is curving, and the response is to
apply a smooth curve to the apical 2–3 mm of the
file before re-inserting and manipulating around
the walls to find a sticking spot.
Despite best efforts, canals are not always
negotiated to definitive length, and decision
making should balance the risks of attempting to
cut further, perhaps in an iatrogenic path, or to
accept the outcome. This in turn will be influ-
enced by the pathological state (whether there is
apical periodontitis or not) and the restorative
plan for the tooth, and decisions should always
be made with proper patient information and
consent.

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
coronal opening of the canal and soaking with
sodium hypochlorite, canal systems which
appeared initially to be non-negotiable become
manageable with routine methods. If one canal of
a multirooted tooth is difficult to enter, work
should continue in the other canals through a
pulp chamber flooded with sodium hypochlorite,
and a further attempt made to negotiate later in
the appointment. Heavy handed efforts to gain
access are seldom rewarded.
On occasions difficulty can be encountered in
initial development of the canal for instrumenta-
tion. Problems are especially common in moving
from the negotiating size 10 instrument to the size
15 file, which is 50% wider. The use of half-sized
files such as Golden Mediums (Maillefer/Dentsply),
which include instruments in sizes 12.5, 17.5, and
22.5 help to overcome the issues of early enlarge-
ment to form a ready flight path for the enlarging
tools to follow.
Ongoing treatment
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-
vance to the old tooth, and contemporary crown to
apex methods of canal preparation with nickel
titanium instruments should deliver predictable
cleaning and shaping, and lay the foundations for
simple obturation. As in all circumstances, root
filled teeth should receive the necessary protection
against unplanned tissue loss, and coronal micro-
leakage, and should be subjected to regular main-
tenance to ensure that caries and periodontal
disease do not seriously compromise.
Ó 2004 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2004; 21: 185–194
Endodontics and the elderly 193
Finally, prolonged mouth opening may also
bring its challenges, in terms of fatigue and the
development of tremor. Considerable improvement
is usually achieved with a simple rubber bite block,
placed on the least interfering side of the mouth
and allowing the patient to close and rest into a
comfortable position, rather than strive to maintain
themselves ‘wide open’.
Preparing to leave at the end of the session may
also take time and care, with a gradual return of the
patient to the sitting position, and the opportunity
to loosen up and ‘find their feet’ before departure.
In short, sessions cannot be unduly hurried, and
the dental team must be sensitive to the basic
physical needs of elderly patients, which will
enhance their comfort and compliance.
In conclusion, successful endodontics can be
achieved in the elderly with special attention to
diagnosis, good quality radiographs and technique
oriented to overcoming the challenges posed by
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-
tified in healthy, elderly patients.
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Correspondence to:
Dr Finbarr Allen,
University Dental School and Hospital,
Wilton, Cork, Ireland.
Tel.: 353 21 490 1186
Fax: 353 21 434 5737
E-mail: f.allen@ucc.ie