Dental service requirements are determined by four demographic and epidemiologic factors:
The population at risk
The incidence and prevalence of dental diseases
The accepted standards of care
The perceived need and expectations toward dental health by the public
These factors are changing as a result of the aging of the population.
An Aging Society
According to the U.S. Census Bureau, America’s population aged 65 years or older grew by 82% between 1965 and 1995. Between 1980 and 1995 this same population grew by 28%, and according to the most current demographic information, the number was 40.4 million in 2010, an increase of 15.3% since 2000. That represents 13.1% of the total U.S., population. The oldest old are defined as those who are at least 85 years of age. This group is the fastest growing segment of America’s senior citizen population. The number of people 85 years or older has more than doubled since 1965 and has grown by 40% since 1980.
The 75 million people born in the United States between 1946 and 1964 constitute the baby boom generation. In 1994, baby boomers represented nearly one third of the U.S. population. These people began to enter the 65 years or older category in 2011. As the baby boomers continue to age, the United States will see an unparalleled increase in the absolute number of older people. One in eight Americans was age 65 or older in 1994; in a little more than 30 years, about one in five is expected to be in this group ( Fig. 26-1 ).
Information from the U.S. Census Bureau and the National Institute on Aging indicates that America’s older population is unevenly distributed among geographic locations. The most populous states have the largest number of older adults; Florida and the Midwestern states currently have the highest proportions of older adults. In 1993, Florida was the only state where older adults accounted for greater than 16% of the population; however, it is predicted that 32 states will fall into this category by 2020.
The increased longevity of the dentition, made possible by expanding fields of advanced restorative procedures and periodontology, implies that dentistry will see a substantial growth in the number of older patients. Until 1983, individuals aged 65 years or older made an average of 1.5 dental visits annually, a lower utilization rate than for any other age group. Between 1983 and 1986, a 29% increase in visits by those age 65 or older was noted by the National Health Survey. According to this survey, older adults currently make more visits per year, on average, than those in the “all ages combined” category. The percentage of office visits, services provided, and patient expenditures attributed to patients age 65 or older exceeded the percentage of the population in that age group. In the future, clinicians will routinely serve a growing number of older people, who will account for one third to two thirds of their workload.
The growth of the population age 65 or older has affected every aspect of U.S. society, presenting both challenges and opportunities to policymakers, families, businesses, and health care providers. Age, ability to cooperate with dental treatment, and type of residence are important considerations in identifying preventive and treatment strategies. Future dental services for older patients (including root canal procedures) are expected to be of two general types:
Services for relatively healthy older adults who are functionally independent
Services for older patients with complex conditions and problems who are functionally dependent
The second group will require care from clinicians who have advanced training in geriatric dentistry. This age group is being targeted in dental education programs and advanced training through improved curriculums, research, and publications on aging. The National Institute on Aging has stated that all dental professionals should receive education in the treatment of older adults as part of their basic professional education.
This chapter discusses the effect of aging on the diagnosis of pulpal and periapical disease and on successful root canal treatment. The quality of life for older patients can be significantly improved by saving teeth through endodontic treatment and can have significant value for overall dental, physical, and mental health.
With age, the simple pleasure of being able to eat what one wishes often becomes an issue, as does the increased need for proper diet and nourishment. Every tooth may be strategic, and old age is no time to be forced to replace sound teeth with removable appliances or dentures. Age is a factor in reduced stability and retention of removable partial dentures. Consultation with older patients should help them overcome what may be a very limited knowledge of root canal treatment and lack of appreciation for regular dental care. Well-meaning friends and spouses who contend that their dentures are as good or better than their natural teeth may have had a lifetime of poor dental experiences or may have forgotten what it is like to enjoy natural dentition.
Negative social attitudes toward older adults tend to carry over into their care. Older patients are in danger of being dismissed as hopeless or not worth the effort. At times, clinicians shy away from providing care for seniors because of the perceived difficulty or cost of certain treatment procedures or because of complicated medical conditions. Clinicians sometimes consider older patients less able to pay for treatment because of their age and appearance. However, most older adults engage in normal activities and can recognize and afford the value of good dentistry.
Most older patients have led active, productive lives; they are very interested in maintaining their dignity and do not consider themselves a bad investment. Tooth loss is often associated with the prospect of aging and loss of vitality. As with any age group, older patients must be considered as individuals. This may prove difficult in the face of the tendency of many health care professionals to assign any person older than 65 years to the classification geriatric and to stereotype patients (e.g., confusion, dementia, poor treatment response). Each older adult patient comes with a unique psychological and social life history and a set of values, needs, and resources unlike those of any other patient the provider will see. Most seniors are more concerned with maintaining control of their lives than they are about being old. Clinicians’ perception of the effects of aging on the diagnosis and treatment of pulp and periradicular disease is also improving, along with the rate at which older patients need and seek specialty care.
Because the primary function of teeth is mastication, it is presumed that loss of teeth leads to detrimental food changes and reduction in health. However, this may not be the driving force when seniors are seeking treatment. Many times, social issues are the motivation for a senior to visit a clinician. After suggesting a mandibular anterior tooth extraction to an 89-year-old man, one clinician was told by the patient, “I can’t, Doctor. I’m taking a cruise next week with my older brother and our girlfriends, I can’t look like that.” Most people older than age 60 who still have their own natural anterior teeth would not wish for a change in appearance if they needed prosthodontic reconstruction.
Clinicians should not presume that they know what is best for senior patients or what they can afford without talking with the patient. The needs, expectations, desires, and demands of older people may exceed those of any age group, and the gratitude shown by older patients is among the most satisfying of professional experiences.
The desire for root canal treatment among aging patients has increased considerably in recent years. Older patients are aware that treatment can be performed comfortably and that age is not a factor in predicting success. *
* References .
In addition, obtaining informed consent requires that root canal treatment be offered as a favorable alternative to the trauma of extraction and the cost of prosthetic replacement. The distribution of specialists, the many technologic advances, and the improved endodontic training of all clinicians have broadened the availability of most endodontic procedures to everyone, regardless of age. Expanded dental insurance benefits for retirees and a heightened awareness of the benefits of saving teeth have encouraged many older patients to seek endodontia rather than extraction. People with private dental insurance are more likely to visit a clinician. There is a trend toward less insurance in most demographic groups except the elderly, who also enjoyed benefits during their working years. Most dental coverage in the United States is obtained through plans offered by employers; however, basic Medicare does not include such benefits, so seniors’ spending on dental care is more sensitive to income than spending by younger age groups. Unfortunately, oral health provisions in recent U.S health care reform does not benefit older patients.
This chapter compares the typical geriatric patient’s endodontic needs with those of the general population. (Pulp changes attributable to age are discussed in Chapters 12 and 13 ; their effects on clinical treatment are also discussed in this chapter.)
It is important to focus on the factors that truly indicate the risks undertaken in treating the older patient. Clinicians must recognize that the biologic or functional age of an individual is far more important than his or her chronologic age. A medical history should be taken before the patient is brought into the treatment room, and a standardized form (see Chapter 1 , Fig. 1-2 ) should be used to identify any disease or therapy that would alter treatment or its outcome. In general, the dramatic changes to the cardiovascular, respiratory, and central nervous systems caused by aging result in most of the older patient’s drug therapy needs. However, the clinician also should consider the decline in renal and liver function in older patients when predicting the behavior and interaction of drugs that may be used in dental treatment (e.g., anesthetics, analgesics, antibiotics).
The review of the patient’s medical history is the clinician’s first opportunity to talk with the patient. The time and consideration taken at the outset set the tone for the entire treatment process. This first impression should reflect a warm, caring clinician who is highly trained and able to help patients with complex treatments. Some older patients may need assistance filling out forms, and they may not be fully aware of their conditions or history. Some patients may withhold their date of birth to conceal their age for reasons of vanity or even fear of ageism. Some may not list current medications because they think it would be unnecessary information for the clinician to know. Vision deficits caused by outdated glasses or cataracts can adversely affect a patient’s ability to read the small print on many history forms. Consultation with the patient’s family, guardian, or physician may be necessary to complete the history; however, oral health care professionals function as primary caregivers in today’s health care environment, and they are ultimately responsible for involving the patient in decision making and treatment choices.
Today’s dental office can be a confusing environment of required paperwork. An updated history, including information on compliance with any prescribed treatment and sensitivity to medications, must be obtained at each visit and reviewed. The elderly usually take more drugs, prescription and nonprescription, than the general adult population, and drug interactions and adverse drug reactions are more likely to result from polypharmacy. As polypharmacy continues to increase, the likelihood of adverse drug interactions in older dental patients also will increase. It is very important that the clinician take a careful history and update it at every visit. 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.
Although geriatric patients are usually knowledgeable about their medical history, some may not understand the implications of their medical conditions in relation to dentistry or may be reluctant to let the clinician into their confidence. Their perceptions of their illnesses may not be accurate, so any clue to a patient’s condition should be investigated.
Symptoms of undiagnosed illnesses may present the clinician with a screening opportunity that can disclose a condition that might otherwise go untreated or may lead to an emergency. Management of medical emergencies in the dental office is best directed toward prevention rather than treatment. Squamous cell carcinoma and salivary gland tumors increase with age, especially past age 80, and the prognosis is less favorable.
Osteonecrosis of the jaw (ONJ) is a painful condition secondary to bisphosphonate therapy. Although it occurs at a much higher rate in patients receiving intravenous treatment for bone diseases than it does in older patients receiving the oral treatment common for osteoporosis, forced eruption and tooth or root retention are recommended alternatives to the risk of extraction ( Fig. 26-2 ). In addition, when discussing treatment options of endodontic retreatment versus endodontic surgery, the clinician should steer patients at risk for developing ONJ away from the surgical option ( Fig. 26-3 ). The American Association of Endodontists’ position paper on the endodontic implications of ONJ is available online ( www.aae.org/guidelines ) .
Few families are without at least one member whose life has been extended as a result of medical progress. A great number have had diseases or disabilities controlled with therapies that may alter the clinician’s case selection. Root canal treatment is certainly far less traumatic in the extremes of age or health than is extraction and implant placement.
Most patients experiencing dental pain have a pulpal or periapical problem that requires root canal treatment or extraction. Dental needs are often manifested initially in the form of a complaint, which usually contains the information necessary to make a diagnosis. 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 (see Chapter 1 ).
Without leading, the clinician should allow the patient to explain the problem in his or her own way. This gives the examiner an opportunity to observe the patient’s level of dental knowledge and ability to communicate. Visual and auditory impairments may become evident at this time. An effort should be made to maintain privacy if the clinician is required to speak louder because of a patient’s hearing impairment.
Patiently encouraging the patient to talk about problems may lead into areas of only peripheral interest to the clinician, but it establishes a needed rapport and demonstrates sincere interest. A patient may show some feelings of distrust if there is a history of failed treatments or if well-meaning, denture-wearing friends or relatives have claimed normal function and extolled their freedom from the need for dental treatment. The effect of the “focal infection” theory is still evident when other aches and pains cannot be adequately explained and loss of teeth is accepted as inevitable. The best patients are those who have already had successful endodontic treatment. Older patients are more likely to have already had root canal treatment and have a more realistic perception about treatment comfort.
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. The mere presence of teeth indicates proper maintenance or resistance to disease. A lifetime of experiencing pain puts a different perspective on interpreting dental pain.
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. Pulpal healing capacity is also reduced, and necrosis may occur quickly after microbial invasion, again with reduced symptoms.
Although complaints are fewer, they are usually more conclusive evidence of disease. The complaint should isolate the problem sufficiently to allow the clinician to take a periapical radiograph before proceeding. Studying radiographs before an examination can prejudice rather than focus attention; accordingly, they should be reviewed after the clinical examination has been completed.
The clinician should search patients’ records and explore their memories to determine the history of involved teeth or surrounding areas. The history may be as obvious as a recent pulp exposure ( Fig. 26-4 ) and restoration, or it may be as subtle as a routine crown preparation 15 or 20 years earlier ( Fig. 26-5 ). Any history of pain before or after treatments may establish the beginning of a degenerative process. Subclinical injuries caused by repeated episodes of decay and its treatment may accumulate and approach a clinically significant threshold that can be later exceeded after additional routine procedures. Multiple restorations on the same tooth are common ( Fig. 26-6 ).
Recording information at the time of treatment may seem to be unnecessary “busy work,” but it could prove to be helpful in identifying the source of a complaint or disease many years later. A patient’s recall of dental treatments is usually limited to a few years, but the presence of certain materials or appliances, such as silver points, can sometimes date a procedure. Aging patients’ dental histories are rarely complete and may indicate treatment by several clinicians at different locations. These patients are likely to have outlived at least one clinician and been forced to establish a relationship with a new, younger clinician. This new clinician may find dental needs that require an updated treatment plan.
The examiner can pursue responses to questions about the patient’s complaint, the stimulus or irritant that causes pain, the nature of the pain, and its relationship to the stimulus or irritant. This information is most useful in determining whether the source of the pain is pulpal in origin, if the problem is reversible, and whether inflammation or infection has extended to the apical tissues. Thus the clinician can determine what types of tests are necessary to confirm findings or suspicions (see Chapter 1 for further information).
It is important to remember that pulpal symptoms are usually chronic in older patients, and other sources of orofacial pain should be ruled out when pain is not soon localized. One example is herpes zoster, which commonly has a prodromal period of 2 to 4 days, when shooting pain, paresthesia, burning, and tenderness appear along the course of the affected nerve ( Fig. 26-7 ). Although it rarely occurs in the maxillary or mandibular divisions of the trigeminal nerve, the viral eruptions may include peripheral nerve endings in the pulp and periodontal ligament (PDL), possibly leading to pulpitis, necrosis, or internal resorption and apical periodontitis.
Much information obtained from the complaint, history, and description of subjective symptoms can be gathered in a screening interview by the clinician’s assistant or over the phone by the receptionist. The potential need for treatment can be established, and the information obtained can provide a focus for the examination and for the determination of how much chair time will be required.
The intraoral and extraoral clinical examination provides valuable firsthand information about disease and previous treatment. The overall oral condition should not be overlooked while the patient’s chief complaint is evaluated, and all abnormal conditions should be recorded and investigated. Exposures to factors that contribute to oral cancers accumulate with age. Oral premalignant and malignant mucosal lesions require state-of-the-art diagnostic tools to ensure early diagnosis of these lesions. Furthermore, many systemic diseases may initially manifest with prodromal oral signs or symptoms.
Missing teeth contribute to reduced functional ability. The resultant loss of chewing efficiency leads to a higher carbohydrate diet of softer, more cariogenic foods. Increased sugar intake to compensate for loss of taste and xerostomia are also factors in the renewed susceptibility to decay. Saliva plays a significant role in the maintenance of oral and general health and may be of diagnostic value in evaluating overall health. Aging per se has no significant clinical impact on salivary secretion. The most common cause of salivary hypofunction in the elderly is medication use, and it is most commonly associated with dental caries and oral fungal infections.
Gingival recession, which creates sensitivity and is difficult to control, exposes cementum and dentin, which are less resistant to decay than enamel ( Fig. 26-8 ). A clinical study of 600 patients over age 60 showed that 70% had root caries and 100% had some degree of gingival recession. Caries and the use of removable prostheses can synergistically compromise tooth survival in older patients. Patients who wore prostheses and had multiple active carious teeth had the highest risk of losing teeth soon after the decay was treated. The removal of root caries is irritating to the pulp and often results in pulp exposures, reparative dentin formation, or a deep restoration that could affect negotiation of the canal if root canal treatment is later needed ( Fig. 26-9 ). Asymptomatic pulp exposures on one root surface of a multirooted tooth can result in the uncommon clinical situation of the presence of both vital and nonvital pulp tissue in the same tooth ( Fig. 26-10 ).
Interproximal root caries is difficult to restore, and restoration failure as a result of continued decay is common ( Fig. 26-11 ). Although the microbiology of diseases is not substantially different in different age groups, the altered host response during aging may modify the progression of these diseases.
Attrition (see Fig. 26-11 ), abrasion, and erosion ( Fig. 26-12 ) also expose dentin through a slower process that allows the pulp to respond with dentinal sclerosis and reparative dentin. Secondary dentin formation occurs throughout life and may eventually result in almost complete pulp obliteration. In maxillary anterior teeth, the secondary dentin is formed on the lingual wall of the pulp chamber ; in molar teeth, the greatest deposition occurs on the floor of the chamber. Although this pulp may appear to recede, small pulpal remnants may remain or leave a less calcific, more permeable, tract that may lead to pulp exposure.
In general, canal and chamber volume is inversely proportional to age: as age increases, canal size decreases ( Fig. 26-13 ). Reparative dentin resulting from restorative procedures, trauma, attrition, and recurrent caries also contributes to diminution of canal and chamber size. In addition, the cementodentinal junction (CDJ) moves farther from the radiographic apex with continued cementum deposition ( Fig. 26-14 ). The thickness of young apical cementum is 100 to 200 µm, and it increases with age to two or three times that thickness.
The calcification process associated with aging appears clinically to be of a more linear type than that which occurs in a younger tooth in response to caries, pulpotomy, or trauma ( Fig. 26-15 ). Dentinal tubules become more occluded with advancing age, reducing tubular permeability. Lateral and accessory canals can calcify, thus decreasing their clinical significance.
The compensating bite produced by missing and tilted teeth (or attrition) can cause temporomandibular joint (TMJ) dysfunction (less common in older adults) or loss of vertical dimension. Diminished eruptive forces occur with age, reducing the amount of mesial drift and supraeruption. Any limitation in opening reduces available working time and the space needed for instrumentation.
The presence of multiple restorations indicates a history of repeated insults and an accumulation of irritants. Marginal leakage and microbial contamination of cavity walls are a major cause of pulpal injury. 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. In any further restorative procedures on such teeth, the clinician should consider the effect on the pulp and the effect on gaining access to and negotiating canals through such restorations if root canal therapy is indicated later.
Many cracks or craze lines (see Fig. 26-12 ) may be evident as a result of staining, but they do not indicate dentin penetration or pulp exposure. 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 in addition to a periapical one. If incomplete cracks are not detected early, the prognosis for cracked teeth with necrosis is questionable ( Fig. 26-16 ).
Periodontal disease may be the principal problem for dentate seniors. The relationship between pulpal and periodontal disease can be expected to be more significant with age. Retention of teeth alone demonstrates some resistance to periodontal disease. The increase in disease prevalence is largely attributable to an increase in the proportional size of the population who have retained their teeth. The periodontal tissues must be considered a pathway for sinus tracts ( Fig. 26-17 ). Narrow, bony-walled pockets associated with nonvital pulps are usually sinus tracts, but they can be resistant to root canal therapy alone when, with time, they become chronic periodontal pockets. Patients with diabetes have increased periodontal disease in endodontically treated teeth and have a reduced likelihood of success of endodontic treatment in cases with preoperative periradicular lesions.
Periodontal treatment can produce root sensitivity, disease, and pulp death. In developing a successful treatment plan, it is important that the clinician determine the effects of periodontal disease and its treatment on the pulp ( Fig. 26-18 ). Age was not a factor in response to periodontal therapy for advanced periodontal tissue breakdown. The mere increase in incidence and severity of periodontal disease with age increases the need for combined therapy. The chronic nature of pulp disease demonstrated with sinus tracts can often be manifested in a periodontal pocket. Root canal treatment is commonly indicated before root amputations are performed. With age, the size and number of apical and accessory foramina are actually reduced, which reduces these foramina’s function as pathways of communication. The permeability of dentinal tubules also is reduced.
Examination of sinus tracts should include tracing with gutta-percha cones to establish the tracts’ origins ( Fig. 26-19 ). Sinus tracts may have long clinical histories and usually indicate the presence of chronic periapical inflammation. Their disappearance after treatment is an excellent indicator of healing. The presence of a sinus tract reduces the risk of interappointment or postoperative pain, although drainage may follow canal debridement or filling.
Information collected from the patient’s complaint, history, and examination may be adequate to establish pulp vitality and direct the clinician toward the techniques that are most useful in determining which tooth or teeth are the object of the complaint. During pulp testing, it is often very difficult to quantify the response to a stimulus applied to a tooth; age can also be a factor in sensitivity testing. Slow and gentle testing should be done to determine pulp and periapical status and whether palliative or definitive therapy is indicated. Vitality responses must correlate with clinical and radiographic findings and must be interpreted as a supplement in developing clinical judgment. (Techniques for clinical pulp testing procedures are discussed in Chapter 1 .)
Transilluminating and staining have been advocated as means to detect cracks, but the presence of cracks is of little significance in the absence of complaints because most older teeth, especially molars, demonstrate some cracks. Vertically cracked teeth should always be considered a pathway for bacteria when pulpal or periapical disease is observed, especially where there is little or no cause for pulpal irritation observed clinically or radiographically. The high magnification available with microscopes during access opening and canal exploration permits visualization of the extent of cracks in determining the prognosis. Abbot showed that 60% of all teeth requiring endodontic treatment demonstrated cracks after the complete removal of all restorations.
Cracks that are detected while the pulp is still vital can offer a reasonable prognosis if immediately restored with full cuspal coverage. The chronic nature of any periapical pathologic condition caused by vertically cracked teeth indicates that it is longstanding, and the prognosis is questionable (even when pocket depths appear normal). Periodontal pockets associated with cracks indicate a poor prognosis.
The reduced neural and vascular components of aged pulps, the overall reduced pulp volume, and the change in character of the ground substance create an environment that responds differently to both stimuli and irritants than does that of younger pulps ( Fig. 26-20 ). Arteriosclerosis, a common condition in older people, has not been shown to occur in the pulp.
Fewer nerve branches are present in older pulps. This may be due to retrogressive changes resulting from mineralization of the nerve and nerve sheath ( Fig. 26-21 ). Consequently, the response to stimuli may be weaker than in the more highly innervated younger pulp.
No correlation exists between the degree of response to electric pulp testing and the degree of inflammation. The presence or absence of response is of limited value and must be correlated with other tests, examination findings, and radiographs. Extensive restorations, pulp recession, and excessive calcifications are limitations in both performing and interpreting results of electric and thermal pulp testing. An alternative to the electric pulp test is assessment of pulp vitality by applying a thermal stimulus to the tooth surface. The electric pulp tester, CO 2 snow, and difluorodichloromethane were found to be more reliable than ethyl chloride or ice in producing a positive response. Attachments that reduce the amount of surface contact necessary to conduct the electric stimulus are available (SybronEndo, Orange, California), and bridging the tip to a small area of tooth structure with an explorer has been suggested. Use of even this small electric stimulus in patients with pacemakers is not recommended; any such risk would outweigh the benefit. The same caution holds true for electrosurgical units.
A test cavity is generally less useful as the test of last resort because of reduced dentin innervation. Vital pulps can sometimes be exposed and even negotiated with a file with minimal pain ( Fig. 26-22 ); then the root canal treatment becomes part of the diagnostic procedure. Test cavities should be used only when other findings are suggestive but not conclusive.