GERIATRIC

ENDODONTICS

Dr Harshita Lath
CONTENTS
• Introduction
• Age changes
• Endodontic challenges
• Diagnosis and treatment planning
• Treatment procedure
• Post endo restoration & challenges
• Retreatment
• Endodontic surgery
INTRODUCTION
• Geriatric is a Greek word where “geras” means old and “iatro” means doctor.
• Geriatric dentistry is providing dental care to older adults involving diagnosis, prevention,
management and treatment of problems associated with older age.
• In general, geriatric dental treatment starts at the age of 65 years.
• By this age, teeth have experienced decades of dental disease, restorative and periodontal
procedures. These all have an adverse effect on the pulp, periradicular and surrounding tissues.

DCNA 1989 defined geriatric dentistry as the provision of care for adults with one or more chronic,
debilitating, physical or mental illness with associated medication and psychosocial problems.
 The World Health Organization categorizes aging population into four classes:
1. Aging individuals: 45-60 years old
2. Older individuals: 61-75 years old
3. Old individuals: 76-90 years old
4. Very Old individuals: 91-100 years old

According to the WHO, the global population is increasing

at the annual rate of 1.7%, while the population of those
over 65 years is increasing at a rate of 2.5%.

• Currently the old age population in India is 8% of its

population (80 million)
• In 2025 we will reach 12% ( 830 million)
• Out of every 7 aged person in the world , one will be an
Indian
 Age Changes in the Teeth
ENAMEL DENTIN CEMENTUM PULP

Darker and brittle Physiologic secondary Thickness of Recession in the size of pulp
Mineral content dentin formation cementum increases
chamber
increases & organic Dentin sclerosis with age
More fibers and less cells
content decreases Gradual obliteration of Becomes more Blood supply
Exhibits physiological tubules- decreased susceptible to
decreases
wear ( chipping, sensitivity resorption
More incidences of
wearing, craze lines, Reduced dentin Increased fluoride and calcification
staining of chipped sensitivity – ingress of magnesium content of
areas) toxic products cementum with age
prevented

In older patients, pulp recession is accelerated by reparative dentin and complicated by pulp stones and
dystrophic calcification. Deep proximal or root decay and restorations may cause calcification between the
observable chamber and root canal.

P. Allen & Whiteworth, Gerodontology 2004

Age Changes in Oral Mucosa
• With age, oral mucosa becomes increasingly thin, smooth and dry with loss of
elasticity and stippling and thus becomes more susceptible to injury.
• Tongue exhibits loss of filiform papillae and deteriorating taste sensation and
 Drugs causing hyposalivation:
occasional burning sensation.
Anticholinergic
Age Changes in Salivary Glands
Antidepressants
• Diminished function resulting in: xerostomia, mouth soreness, burning or painful
tongue, taste changes, chewing difficulty, problems with swallowing and talking.
Antipsychotic
Diuretic
Age Changes in Periodontal Connective Tissue
• Gingival connective tissueNSAIDS
becomes denser and coarsely textured upon aging
• Decrease in the number of fibroblasts and
 Hyposalivation canfiber
leadcontent
to inadequate bicarbonate and
• Evidence of calcification on and between the collagen fibers
buffering, remineralization, and sugar and acid
clearance, which may cause an increase rate of caries
Age Changes in Bone Tissue
• Cortical thinning
• Loss of trabeculae
• Cellular atrophy
• Sclerosis of bone
DIAGNOSTIC PROCEDURE
Diagnosis and Treatment Plan
• Chief Complaint of Geriatric Patients
• Medical History
• Past Dental History
• Examination of the Patient
• Pulp Vitality Tests
• Radiographs
• Treatment Plan
Medical History

• Recognizing the biological or functional age is more imp than chronological age
• In general geriatric patient suffers from either cardiovascular, respiratory or central
nervous system diseases and as a result of this they are on drug therapy.
• A standardized form should be used to identify any disease or therapy that would alter the
treatment plan or its outcome.
• The Physicians’ Desk Reference (PDR) should be consulted, and any precaution or side effect of a
medication noted. The PDR is available online (www.pdr.net/).
• Several other websites (e.g., Epocrates [www.epocrates.com]) have been developed specifically to
be consulted about drug interactions and dental treatment.

(Cohen 11th Edition)

 Cardiovascular Disease
• Medications that treat cardiovascular disease often: • Patients taking digoxin may experience arrhythmias when
• reduce salivary flow or cause xerostomia, epinephrine is used.
• cause an overgrowth of gingival tissues (calcium • Because stress can induce arrhythmias and raise blood
channel blockers), pressure, anxiolytics also may be considered.
• altered taste (ACE inhibitors) • Prophylactic antibiotics are considered only for those at
• risk for bleeding gingiva or excessive postoperative highest risk of infective endocarditis.
bleeding (anticoagulants)
• When cardiovascular disease is uncontrolled, options are
• Discontinuation of anticoagulants is not typically required. often limited to palliative care only.
• prone to orthostatic hypotension, • Elective treatment should be deferred for patients with
pressures higher than 180/110.
• epinephrine-impregnated packing cords should be avoided
• Elective dental care can be resumed 1 month post
• Contrary to popular belief, using epinephrine in Local
myocardial infarction without symptoms and with
Anesthetics carries a low risk of adverse effects. ( Brown RS
appropriate precautions; however, the physician should be
et al OOOE 2005)
consulted to confirm the severity of the event and stability
• However, epinephrine at 1:100,000 solutions should be of the patient’s condition.
limited to 2 or fewer cartridges.
 Cancer
• The oral mucosa and salivary system are especially • Routine dentistry can be resumed after cancer therapy
susceptible to the effects of chemotherapy and has ended and the patient’s condition has stabilized.
radiation treatment.
• Indicators of stability may include neutrophils returning
• Mucositis, xerostomia, dysgeusia, trismus, pain, to more than 2000/mm3, and platelet levels to a
dysphagia, rampant caries, dehydration, and threshold of more than 60K and approaching normal
malnutrition. low range of 150K.
• Osteoradionecrosis (ORN): Bone remodeling becomes • Restorative dentistry, reconstructive dentistry, and
impaired, and following surgery or trauma or dental extractions can be considered when platelet
sometimes spontaneously, the bone becomes necrotic. number, function, and neutrophil numbers have
stabilized.
• Precancer treatment: stabilize or eliminate/minimize
oral disease before the initiation of cancer treatment.
• Intracancer treatment: palliative treatment (not
including dental extractions); frequent recall visits to
manage pain, mucositis, trismus, dysgeusia, xerostomia,
and fungal infections.
 Chronic Obstructive Pulmonary Diseases

• Chronic bronchitis and emphysema severe COPD and use with caution in mildly
• Providing proper anesthesia affected individuals

• Using pulse oximetry to monitor oxygen • Avoiding several drug classes, including
narcotics, antihistamines, and anticholinergics,
saturation if the patient has severe COPD
which have the potential for producing
• Providing low-flow oxygen, 2 to 3 L/min respiratory depression and/or thickened
• Avoiding elective dentistry if the patient has an mucus.
upper respiratory infection • Because these diseases are associated with a
• Avoiding a reclined chair position to ease the history of smoking, patients should have
burden of breathing regular screenings for oral cancer.
• Avoiding rubber dams in the severely affected
patient
• Avoiding nitrous/oxygen in the patient with
 Cerebro-Vascular
• Decrease or occlusion of blood flow to the brain. • The patient’s physician should be consulted if
altering the medication is thought to be necessary.
• Atherosclerosis may lead to a transient ischemic
attack (TIA) or if completely blocked by a clot or an • The use of topical hemostatic agents.
air bubble, may result in an ischemic stroke.
• It is important to consider that risk for another stoke
• Hemorrhagic strokes occur when a vessel ruptures. is higher in the first 6 months, so elective care and
definitive treatment planning should be delayed
• Treatment for prevention of strokes is primarily with
during this recovery period.
platelet inhibitors, such as aspirin, ticlopidine,
clopidogrel, or anticoagulants such as Warfarin.
• INR (normal range is 1–2, and takes into account the
variation in PT results from laboratory to laboratory).
• If the patient is having extensive oral surgery, it may
be best to treat at an INR of 3.0 or less.
 Dementia
• Disease progressively destroys cognitive skills.

Pre-dependent Advanced
stages stages

• Prevention and the

• Restorative and prosthodontic
preservation of comfort and
treatment should be completed
dignity
• Medication or rinses to relieve
pain or discomfort
 Diabetes Mellitus
Symptoms: Consider:
• Frequent dental evaluations
• Candida • Caries risk assessment
• Dysphagia • Avoid dry or acidic foods
• Taste disorders
Rx
• Burning mouth • oral antibacterial
• Poor wound healing • Fluoride
• Increased risk of infection • Xylitol
• Calcium/phosphate and
• Periodontal disease caries
• pH neutralizing products
• Diminished salivary flow
Renal Diseases Liver Diseases
• Xerostomia • Hyposalivation
• pigmented oral mucosa • Xerostomia
• dysgeusia; candida • Gastric reflux Erosion
• Petechiae • Poor wound healing
• uremic stomatitis • prolonged bleeding
• lichen planus
• periodontitis
• hairy tongue
• Increased oral infections
• increased risk of pyogenic granulomas
• Radiolucent jaw lesions (hyperparathyroidism)
 Poly-Pharmacy
• Refers to taking multiple medications at once
or taking 1 or more medications incorrectly
• Some patients will have prescriptions that are
needed during an emergency; that is,
nitroglycerin for angina or inhalers for
shortness of breath, due to COPD.
• These patients must bring these medications
to their appointments and they should be
readily available in an emergency drug kit.
• Possibility of some adverse event
• Potential for side effects on the oral cavity
• Adverse drug interactions
 Dental History

• To assess patients dental status and plan future treatment plan

• Also helps to know patients dental knowledge and psychological attitude ,expectation from dental
treatment.
• History can be as obvious as a recent pulp exposure and restoration or it may be as subtle as a
routine crown preparation 15 to 20 years ago
• For a geriatric patient, a lifetime of experiencing pain puts a different perspective on
interpreting dental pain.
• The diagnostic process is directed toward determining the vitality of the pulp, whether pulpal or
periapical disease is present, and which tooth is the source
Subjective Symptoms
• Many older patients are stoic, do not readily express adverse symptoms, and may consider them to be minor
relative to other systemic problems or pains.
• Pain associated with vital pulps (i.e., referred pain; pain caused by heat, cold, or sweets) seems to be
reduced with age, and its severity seems to diminish over time.
• Heat sensitivity that occurs as the only symptom suggests a reduced pulp volume, such as that
occurring in older pulps.
• Overall, symptoms of pulpitis do not seem to be as acute in the older patient. One reason may be that
there is a reduced pulp volume and a decrease in sensory nerves, particularly in dentin.
• The absence of significant signs and symptoms is also very common, more so than the presence.
• Most irreversible pulpal and apical pathosis are asymptomatic at any age.
• Thus when pathosis is suspected, objective tests are required regardless of whether significant signs
and symptoms are present.
Objective Findings
• Common observations:
I. Missing teeth
II. Hyposalivation
III. Gingival recession & root caries( interproximal)
IV. Attrition, abrasion and erosion
V. Compensating bites – T.M.J dysfunction
VI. Multiple restorations– further care while restoring
VII. Periodontal problems like deep pockets
Pulp Vitality
• Often very difficult to quantify the response to a stimulus applied to a tooth.
• The pulp becomes less responsive to stimuli with age .
• Electric stimulus in patients with pacemakers is not recommended.
• Percussion (biting and tapping) and palpation tests indicate periapical inflammation but are not
particularly useful unless the patient reports significant pain.
• Transilluminating and staining have been advocated as means to detect cracks, but most older teeth,
especially molars demonstrate some cracks.
• Abbot showed that 60% of all teeth requiring endodontic treatment demonstrated cracks after the
complete removal of all restorations.
• Vertically cracked teeth could be a pathway for bacteria when pulpal or periapical disease is
observed
• Pockets associated with cracks indicate a poor prognosis
Radiographs
• Bony growths, such as tori and muscle attachments (frena), may affect film positioning.
• Also, the older patient may have difficulty in placing the film, thus holders should be used.
• Common Radiographic Observations in Geriatric Patients
• Receded pulp cavity which is accelerated by reparative dentin
• Presence of pulp stones and dystrophic calcification
• Receding pulp horns can be noted in the radiograph
• Deep proximal or root decay may cause calcification of pulp cavity
• A midroot disappearance of a detectable canal may indicate bifurcation rather than calcification
• In cases where the vitality tests do not correlate with the radiographic findings, one should consider
the presence of odontogenic and nonodontogenic cysts and tumors
• In teeth with root resorption along with apical periodontitis, shape of apex and anatomy of foramen
may change due to inflammatory osteoclastic activity
• In teeth with hypercementosis, the apical anatomy may become unclear
Differential Diagnosis
• Non-endodontic symptomatic disorders that may mimic endodontic pathosis
include sinus infection, muscle spasm, headache, temporomandibular joint
dysfunction, and neuritis and neuralgia.
• The incidence of these tends to increase somewhat with age, particularly in
patients who have specific disorders, such as arthritis, that may affect the joints
 Treatment Planning and Case Selection
Prior to any clinical treatment planning, the following determinants to be considered.
• Patient desires and expectations.
• Type and severity of patients dental problems after evaluating the four domains of need such
• as function, symptoms, pathology, and esthetics.
• Impact on patient’s quality of life in terms of ability to eat, comfort level, and esthetics that
• could affect self- image.
• Probability of positive treatment outcome.
• Availability of reasonable and less extensive alternatives.
• Ability to tolerate treatment stress.
• Patient’s capability to maintain oral health, whether he or she is well motivated and can
• carry out independently or require assistance.
• Patient’s financial resources. Life span.
• Family support - physical, psychological or financial.
 Bannet and Cramer have suggested staged treatment planning for the
maintenance of the oral health of the elderly patients.

• Stage I : Emergency care

• Stage II: Maintenance and monitoring- includes management of chronic infection, root canal
therapy, root planing and curettage, restorations of carious lesions, work related to dentures,
patient education to improve oral health. A further period of evaluation is required before
proceeds further.
• Stage III: Rehabilitation phase – includes implants, surgical endodontics, surgical periodontics,
esthetic rehabilitation, reconstruction of occlusal plane and restoration of vertical dimension

- Nadig R.R. et al JCD Sept 2011

Appointments
• Studies have shown that there are no advantages of single appointments overall to multiple
appointments relating to post treatment pain or prognosis.
• Single appointment procedures are beneficial in elderly patients because:
• Longer appointments may be less of a problem than several shorter appointments if the patient must
rely on others for transportation or requires assistance.
• At times, the elderly patient may require special positioning of the chair, support of the back or
neck or limbs, or other such considerations
• Conversely, these problems may require shorter, multiple appointments.
• Morning appointments are preferred
• Patient’s eyes should be shielded from the intensity of the clinicians light
• Jaw fatigue is readily recognizable, hence bite blocks are indicated to reduce the jaw fatigue.

-P. Allen & whiteworth, Gerondontology

Impact of Restoration
• Generally the larger and deeper the restoration, the more complicated the root
canal treatment.
• The old tooth is more likely to have a full crown.
• There are two concerns when there is a crown:
(1) potential damage to retention or components of the crown
(2) blockage of access and poor internal visibility
• Preservation of teeth in elderly patients provides several benefits like
- maintenance of intact dental arch
- increased retention of removable dentures
- provision of abutments for FPD
- preservation of occlusion and alveolar bone
•Root canal treatment as a restorative treatment should be considered when cusps have fractured,
supra-erupted or maligned teeth, for partial abutments, rest seats or over denture require
significant tooth reduction
•Because of reduced blood supply, pulp capping is not as successful as in young teeth, hence not
recommended

Mothanna K. et al, Saudi Medical Journal 2019

PROCEDURE
• Anaesthesia
• Less anxious: low conduction velocity of nerves, limited extension of nerves into dentin and
dentinal tubules are more calcified
• The width of periodontal ligament is reduced which makes the needle placement for intra-
ligamentary injection more difficult.
• Only smaller amounts of anesthetic should be deposited and the depth of anesthesia should
be checked before repeating the procedure
• Intra pulpal anesthesia is difficult in older patients as the volume of pulp chamber is reduced

• Isolation
• Rubber dam is the best method of isolation. If the tooth is badly mutilated making the rubber
dam placement difficult, then consider multiple tooth isolation with saliva ejector.
• In patients with hyposalivation artificial saliva can be used to facilitate easy insertion of the
dam
Access to Canal Orifice
• One of the most difficult parts: identification of the canal orifices
• Obtaining access making the patients to keep their mouth open for a longer period of time is a real problem
in older patients
• Radiograph should be taken to determine canal position, root curvature, axial inclinations of root and crown
and extent of the lesion.
• Endodontic microscopes can be of greater help in identifying and treating narrow geriatric canals.
• Location and penetration of the canal orifices can be difficult and time consuming in calcified canals for
which Ultrasonic tips can be used.
• Use of DG-16 Endodontic explorer which will not stick in solid dentin, but it will resist dislodgment in
the canal
• After canal location, negotiation with SS No. 8, 10 or 15 K files
• Ni-Ti Files lack strength in the long axis and are contra indicated for initial negotiation
 • C+ FILES (DENTSPLY)
• Strong buckling resistance compared with
K files, which allows easier location of the
canal orifices
• Pyramid shaped tip facilitates insertion
during negotiation of canal, and the square
cross section provides better resistance to
distortion
• Polished surface allows smoother
insertion into the canal
Working Length
• CDJ is the ideal place to terminate the canal preparation.
• This point may vary from 0.5 to 2.5 mm from the radiographic apex and may be difficult to determine
clinically.
• Calcified canals reduce the clinician’s tactile sense in identifying the constriction clinically and reduced
periapical sensitivity in older patients reduces the patient’s response that would indicate penetration
of the foramen.
• Use of electronic apex-finding devices is avoided in heavily restored teeth
Cleaning and Shaping

• Use of broaches for pulp tissue extirpation is avoided in older patients, because very few canals of older teeth
have adequate diameter to allow safe and effective uses of broaches
• Achieving and maintaining apical patency is more difficult. Apical root resorption associated with peri apical
pathosis further changes the shape, size and position of the constriction.
• Increased pulp fibrosis may present challenges for canal negotiation
• Flaring of the canal should be performed early in the procedure to provide for a reservoir of irrigating
solution and reduce the stress on instruments that occurs when they bind with the canal walls.
• NiTi instruments are used for cleaning and shaping in crown down technique rather than stainless steel
hand files. This saves time, provides flexibility of NiTi and avoids tiredness of hand while working in
sclerosed canals
• Thorough and frequent irrigation.
Obturation
• For obturation, those obturation techniques are employed which do not require large midroot
taper and do not generate pressure in this area, which could result in root fracture.
• Use of single-cone with bio ceramic sealers, cold lateral technique are advocated.
• CORONAL SEAL PLAYS AN IMPORTANT ROLE in maintaining an apically healthy
environment. When mechanical retention is not ensured with preparation, GICs are
recommended
• Permanent restorative procedures should be scheduled as soon as possible, and
intermediate restorative materials should be selected and properly placed to maintain
a seal until that time
Post endo restoration
• Permanent restorative procedures should be scheduled as soon as possible.
• Posts are not usually needed when root canal treatment is performed through an
existing crown that will continue to be used
• Post space preparation should be kept as conservative as possible to avoid any risk of
root fracture
• Fiber post preferred in the aged tooth as it occupies one-third to one-half
of the length of the canal and also the radicular extension is about the
coronal length of the core
• In 1980, Nayyar and Walton described the amal-core or the coronal-radicular
restoration. Rather than placing a post, the coronal restoration is extended
2 to 3 mm into the pulp chamber of each canal which is used for retention of the
build up material
• Advantage: Predictable & cost effective modality for posterior endodontically
treated teeth
 Geriatric Endodontics

Endo-Perio Endo-Prostho

root caries, furcation Loss of vertical dimension

involvement, mobility Full mouth rehab
Principles and
guidelines
for
managing
tooth
wear: a
review –
Azouzi et
al Jan 2018
 Restorative decision-making chart. FPD, fixed partial denture;
RPD, removable partial denture; MOD, mesio-occlusal-distal

14th ed
Grossman
Root Caries
• Root caries is a major cause of tooth loss in older adults, and
tooth loss is the most significant negative impact on oral
health-related quality of life for the elderly.
• Causative org: S. mutans, lactobacilli,  Actinomyces ,
Atopobium, Olsenella, Pseudoramibacter, Propionibacterium,
and Selenomonas.
• Cariogenic species involved in root caries are less dependent
on carbohydrates since collagen degradation inside the
dentinal tubules can provide nutrients and microcavities for
the invading microorganisms.
• Furthermore, the root surface has fewer minerals in
comparison with enamel, which may accelerate the onset of
demineralisation.
 Classification of root caries

Topical Fluorides, Remineralizati

on agents, Frequent recall Endodontics or Extraction
Restoration with GIC
Excavation of lesion, reshaping
of margins, fluoride
application
• Root caries could be prevented by patient education, modification of risk factors, and the use of
in-office and home remineralization tools.
• The use of non-invasive approaches to control root caries is recommended, as the survival rate of
root caries restorations is poor.
• When plaque control is impossible and a deep/large cavity is present, glass ionomer or resin-
based restorations can be placed.
• Active decay may be inactivated using professional application of fluoride varnishes/solutions or
self-applied high-fluoride toothpaste.
PROGNOSIS
• In case of vital pulp, the prognosis depends on many local and systemic factors.
• In case of nonvital pulp, the repair is slow because of arteriosclerotic changes in blood vessels
• Decreased rate of bone formation and resorption
• Increased mineralization of bone
• Altered viscosity of connective tissue
• An extensively restored tooth is more prone to coronal leakage.
• Canals that cannot be negotiated to length may contain persistent irritants.
• Tipped or rotated teeth restored with castings that are misaligned are more difficult to access and therefore
more difficult to clean, shape, and obturate.
• Aging causes arteriosclerotic changes of the blood vessels which alters the viscosity of the connective
tissue, making repair more difficult
• Rate of bone formation and normal resorption decreases with age, and the aging of bone results in greater
porosity and decreased mineralization of the formed bone
RETREATMENT
• Factors that lead to failure tend to increase with age; thus retreatment is more
common in older patients.
• Retreatment at any age is often complicated and should be approached with
caution; these patients should be considered for referral.
• Retreatment procedures and outcomes are similar in both older and younger
teeth
ENDODONTIC SURGERY
• Considerations and indications for surgery are similar in elderly and younger patients.
• Overall, the incidence of these increase with age. Small nonnegotiable canals, resorptions, and
canal blockages occur more often with age.
• Perforation during access or preparation, ledging, and instrument separation are related to
restorative and anatomic problems.
• Medical history is important in older patients
• Following local anatomic considerations should be considered in elderly patients:
• Increased incidence of dehiscence of roots and exostoses
• Apically positioned muscle attachment
• Less resilient tissue
• Decreased resistance to reflection
• Ecchymosis and delayed healing are common postoperative findings
• The position of anatomic features -the sinus, floor of the nose and neurovascular bundles
remain same , but their relationship to the surrounding structures may change when teeth
have been lost
• The need may arise to combine endodontic and periodontal flap procedures and complete
them in one sitting
• When root–end surgery is to be performed, the surgeon must consider whether the root that
will be left is long enough and thick enough to continue to remain functional and stable . This
factor is especially important when the tooth is to be used as an abutment.
HEALING AFTER SURGERY
• Hard and soft tissues will heal as predictably, although somewhat more slowly.
• Postsurgical instructions should be given both verbally and in writing to minimize complications. If the
patient has cognitive problems, instructions are repeated to the person accompanying the patient.
• Ice and pressure packs (in particular) applied over the surgical area reduces bleeding and edema and
minimizes swelling.
• Overall, older patients experience no more significant adverse affects from surgery than do younger
patients. Outcomes depend more on oral hygiene than on age, as has been shown in periodontal
surgery patients
• One problem that seems to be more prevalent in older patients is ecchymosis after surgery.
• This is hemorrhage that often spreads widely through underlying tissue and commonly presents as
discoloration .
• Patients are informed that this may occur and should not be a concern. Normal color may take 1 to 2
weeks or longer to return.
• In addition, the discoloration may go through different color phases (purple, red, yellow, green) before
disappearing.
References
•Pathways of Pulp 11th Ed – Cohen Endodontics: Principles and Practice, 4th Ed Grossman's Endodontic Practice
12 Th. Ed The Dental Pulp – Seltzer and Bender Textbook of Endodontics 2nd Ed- Nisha Garg Oral Histology –
Tencate
•The Aging Skeleton – Clifford J Rosen Journal of Conservative Dentistry Journal of Endodontics
•Gerodontology
•Dental Clinics of North America
•Journal of International and Clinical Medicine Journal of Dental Education
•Journal of Dental Research
•Journal of American Dental Association Inside Dentistry
Thank You