Endodontic therapy and the elderly patient

Mark Allen explores the current state of play for treating older adults with root canal treatment, including the considerations, risk factors and benefits.

The challenge that the UK’s ageing population will present to health and social care provision is a pertinent topic.

In 1948, when the NHS was founded, just over half of the population lived beyond the age of 65. The King’s Fund states this figure now to be around 14%. Although there is new evidence that life expectancy is stalling. According to projections from the Office for National Statistics, more than 20% of the UK will be aged 65 or over by 2027.

Advances in research, science and technology have given us wonderful things. But a longer life isn’t always a healthier one.

Dentists, like healthcare professionals in every discipline, will be treating more patients who are physically and mentally frail and find it hard to communicate.

Older patients may:

• Lack the dexterity to clean their teeth properly
• Have difficulty shopping for and preparing healthy meals from scratch, meaning diet is often poor
• Miss routine appointments
• Be susceptible to xerostomia; impaired salivary flow can cause a range of oral health problems, such as a propensity to dental caries
• Wear dentures, or the teeth may be heavily restored following decades of wear and tear
• Have gingival recession, which is more common in the elderly too.

On a positive note, tooth retention has increased.

In the last Adult Dental Health Survey 2009, the majority of adults in every age group – including the over 85s – were dentate; the first time this has been the case in the series.

This also reflects the increasing trend to want to avoid extraction (if possible) and preserve the natural teeth.

This will apply to your older patients too, and is another challenge that dentists will be facing.

Endodontics and the elderly

The modern dental landscape has shifted towards prevention, but practitioners will be treating elderly patients who may have been subject to years of dental disease and invasive procedures – even if they do present with a generally good level of oral health.

Some patients will require endodontic therapy to maintain their level of oral wellbeing that, in turn, will support general good health.

Practitioners may deem it necessary to perform endodontics to save a tooth from extraction if the tooth is needed in order to help support surrounding prostheses in place. Other strategic reasons to treat a patient endodontically include if extraction would affect function, speech and eating and/or aesthetics.

Practitioners should not underestimate the impact that poor aesthetics can have on the confidence and self-esteem of elderly patients.

Feeling too embarrassed to speak or smile can exacerbate any feelings of social isolation, loneliness and ultimately depression. These feelings are common for this vulnerable demographic.

Treatment planning

During treatment planning for elderly endodontic patients, many risk factors stand out that practitioners must take into consideration before proceeding.

Consent to dental treatment means they understand the alternatives, limitations and consequences as well as what the process entails, including rehabilitation and aftercare.

The aim is to motivate the elderly patient to maintain their oral health following endodontic therapy.

A full and thorough assessment of medical as well as dental history is important. Pre-tests, as well as the usual radiographs, will need to determine if and how old age has affected the pulp and surrounding tissue.

There is the possibility of various pulpal changes due to ageing. This includes a decrease in the number and size of pulpal cells, vascular changes and arteriosclerotic changes – as well as issues due to dentine formation. Once the patient consents to treatment and goes through all of the relevant checks, efficient and ethical preparation is key.

Proper irrigation of the root canal system will increase the chances of the treatment being a success. The consequences of reinfection for an elderly patient is potentially devastating. Practitioners must assiduously remove all debris and microorganisms. Along with scrupulous cleansing, the impact of any injury to this delicate area for elderly, vulnerable patients would be tremendous.

In order to achieve endodontic success for these individuals, the practitioner must not only have the required level of skill, but selecting the right products and tools is also fundamental.

Practitioners can use irrigation solutions for the irrigation/debridement of root canals during and after instrumentation. Multiple solutions are available to achieve a variety of goals, such as dissolving vital and necrotic tissue and lubricating the canal system.

In order to cleanse well, the canals must be enlarged and shaped properly. 

Treatment considerations

When it comes to treating older patients, remember they may:

• Lack the dexterity to clean their teeth properly
• Have difficulty shopping for and preparing healthy meals from scratch, meaning diet is often poor
• Miss routine appointments
• Be susceptible to xerostomia; impaired salivary flow can cause a range of oral health problems, such as a propensity to dental caries
• Wear dentures, or the teeth may be heavily restored following decades of wear and tear
• Have gingival recession, which is more common in the elderly too.

Successful outcomes

Dental professionals will not just be treating more elderly patients in the future, but more edentate elderly patients. Those who want to avoid extraction just as much as younger ones do.

It is important to get endodontics right for this age group. You can dramatically improve both their general as well as their oral health related quality of life.

Successful endodontic therapy for elderly adults requires skill, excellent planning and the very best tools for consistently successful outcomes.

This article first appeared in Irish Dentistry magazine. You can read the latest issue here.