C.E. Credit. Aging and Endodontics: A Narrative Review to Guide Case Selection and Treatment

ABSTRACT

Background

Understanding the implications of aging on endodontic treatment is important to appropriately care for patients with increasingly complex and diverse health needs in conjunction with increasingly intact and complex dentition.

Types of Studies Reviewed

Content from existing studies and literature on aging, oral health and endodontics was reviewed and integrated to present a holistic approach to endodontics for older adults. The full spectrum of need and ability of older adults, from well to frail elders, was taken into consideration.

Results

Age-related changes in the dentition present challenges to endodontic diagnosis and treatment that are compounded by physical or cognitive impairments that alter presentation of disease and response to treatment. Communication may need to extend beyond the patient and the referring provider to establish a diagnosis, clear expectations and goals of treatment.

Practical Implications

It is important to understand the complexities unique to aging and aging’s potential impact on clinical outcomes to ensure the appropriate inclusion and delivery of endodontic care to older adults.

Continuing Education Credit Available

The practice worksheet is available online in the supplementary material tab for this article. A CDA Continuing Education quiz is online for this article: https://www.cdapresents360.com/learn/catalog/view/20.

KEYWORDS:

• Endodontics
• geriatrics
• aging
• treatment planning

Introduction

Projections show that the population aged 60 and older in California will grow more than three times as fast as the total population from 2010–2060. More than 50% of the state’s counties will experience more than a 100% increase, over 40% of the counties will increase by more than 150%, and four counties, Merced, Riverside, San Bernardino, San Joaquin, and Santa Clara, are expected to increase their population of adults aged 60 and older by more than 200%. The fastest increases, however, are occurring in the population that is 85 and older, with more than 40% of counties at more than 400% increase during this time period.¹ This significant shift toward an aging population will invariably result in an increase in older patients seeking dental care.

The current generation of those over 60 has benefited from improved oral health care. As a result, they have maintained more of their dentition than any generation before. They have different expectations and values around oral health as they age, with a greater focus on maintenance, prevention, minimally invasive care and restoration of their existing dentition instead of opting for extractions and replacement of teeth with prostheses.² Root canal therapy will be essential for many older adults to retain their natural dentition into old age.

Despite the significant decrease in edentulism, significant risks to oral health remain for aging older adults. Many of the chronic diseases and medications common to older adults also place oral health at risk. For example, caries can result from many medications that cause diminished salivary flow and physical and cognitive disabilities that may impair daily oral hygiene or routine access to care. Lack of money or insurance for routine care (which is a reality for many older adults, particularly those in retirement) can also place patients at risk, with diagnosis delayed until some acute event occurs.³ Delayed treatment of caries can result in the need for endodontics. Some older adults may have increased risk of falls due to systemic conditions,⁴ and unfortunately, some may experience abuse or neglect. Both of these situations could potentially result in maxillofacial trauma with pulpal involvement.⁵

While we have constructs to assign someone as being older or old, such as landmark birthdays (50 years), retirement age (65 years) and advanced age (85-plus years), the number itself often has less relevance to oral health needs and ability to receive and tolerate dental care than health status and the presence of any level of dependence.⁶ There is no typical older person, as there is great variability in physical and cognitive ability among older adults. So-called well-elders may benefit from and tolerate root canal therapy, as well as young people, but someone with multiple co-morbidities and/or moderate-to-high dependency may be less able to tolerate and respond to dental care including endodontic treatment, regardless of age.⁶ Chronological age alone should not be the basis for treatment planning. Considering age and life expectancy alone, root canal therapy and restoration for an 80-year-old patient could be perceived by some as superfluous. However, if the patient reaches 90 years old and the tooth remains functional and disease free, then the previously considered extraneous treatment would be demonstrably valuable. By the same token, a frail individual who was able to receive treatment may derive a great deal of value, benefit to overall health and quality of life from the opportunity to retain their own dentition and be pain- and disease-free.⁷ The value of oral health care cannot be viewed solely from the lens of expected or even actual longevity.⁸ All older adults deserve the most appropriate care to achieve ideal treatment outcomes that meet their oral health needs and values. This article will review the implications for endodontics that result from or in tandem with normal age-related changes and commonly occurring diseases and conditions as well as strategies to overcome challenges in diagnosis, treatment planning and patient care.

Benefits of Root Canal Therapy Across the Spectrum: Well-To-Frail Older Adults

Retaining teeth with root canal therapy allows for the restoration of oral function and maintenance of proprioception for optimal oral motor function.^9,10 Tooth extraction and removable prostheses is often a default treatment plan for older adults, especially those who are viewed as elderly or frail. However, tooth loss significantly impairs masticatory performance, and proprioception may be lost.⁷ Maintenance of proprioception and functional dentition is especially beneficial to those with oral motor dysfunction that may arise from a history of stroke or the presence of progressive diseases such as multiple sclerosis or Parkinson’s Disease.¹¹ Furthermore, the long-term success of both fixed and removable prostheses relies on sound and adequate numbers of abutment teeth that may also be dependent on the receipt of appropriate endodontic treatment. In some cases, teeth that may otherwise be extracted in a younger patient may be functionally important and essential to retain. For example, endodontic treatment of a third molar may not normally be considered. However, if it is essential for the retention of a prosthesis, saving it with root canal therapy would be of great functional importance. The option for endodontics to maintain over-denture abutments or to maintain a shortened dental arch should not be overlooked, especially for individuals who cannot, do not want or cannot afford to have implants.¹² Root canal therapy may also be necessary for patients with endodontically involved teeth that cannot be extracted due to a high risk of osteoradionecrosis or medication-related osteonecrosis of the jaws (MRONJ).

Natural dentition allows for the maintenance of chewing function and the ability to eat nutritious food such as fresh fruits and vegetables. With diminished chewing function, food choices often become less healthy as individuals choose more highly processed foods that are easier to chew but also pose a systemic and oral health risk.¹³ The maintenance of a patient’s natural dentition is also beneficial for psychosocial well-being. Loss of self-confidence and the stigma of aging as a consequence of tooth loss can affect older adults, potentially contributing to social isolation and withdrawal.^14,15 Maintenance of the dentition with endodontics can improve health, emotional well-being and quality of life for many older adults.^16,17

Goals of Endodontic Treatment

The goal of root canal therapy for older and younger patients is to retain the natural tooth by eliminating the source of infection, preventing reinfection and creating an environment that will allow healing of the peri-radicular tissue.¹⁸ The success rate of root canal therapy for older patients is the same as for younger patients. Two systematic reviews found that age had no effect on the outcome of root canal therapy.^19,20

Considerations in Root Canal Therapy for Older Adults

Although the steps and goals of root canal therapy are similar between young and old, dependency or advanced age may result in treatment challenges unique to these populations. The stress and anxiety associated with dental treatment, especially root canal therapy, should be minimized for every patient, but this consideration is of particular importance in frail elderly patients and patients with medical problems who have a decreased capacity to cope with stress.²¹ A critical factor in providing an anxiety-free situation is the relationship established among the dentist, the office staff, and the patient. Good communication establishes trust and tends to reduce patient anxiety. This often leads to better patient experiences and fewer misunderstandings, complaints, and potential legal issues.^22,23 Age-related changes in hearing and vision are normal and can result in older adults needing more time to process information. An estimated one-third of those between 65 and 74 years have some degree of hearing loss.²⁴ For those patients who read lips, making eye contact, removing the face mask (if possible), and facing the patient when speaking improves communication. (Figure 1). For patients with hearing and vision impairment, be aware of issues such as excessive noise, distractions, glare, or poor lighting that may hamper communication.²³

Figure 1. Take the time to communicate with the patient speak directly to patients and maintain eye contact. Remove mask if possible as patients may read lips. Picture courtesy of Jon Draper, Dugoni School of Dentistry.

Some 16–20% of older adults experience mild cognitive impairment.²⁵ Those with short-term memory issues will benefit from written materials to review in between visits. They may also benefit from someone accompanying them who can act as an advocate and reservoir of information. As with any patient, confirm with them a mutual understanding of the procedure to be performed. Whether an older adult has full physical and cognitive capacity, mild cognitive or physical impairments or are highly dependent, they should be spoken to directly.²⁶ Do not speak over them to a family member, friend, caregiver or even surrogate decision-maker who may accompany them to their appointment. If it is not clear to you if the patient has capacity to consent and/or who may give consent, consult with their primary care provider.¹¹

Older patients with some kinds of physical of cognitive impairments such as altered speech from a stroke or Parkinson’s disease may require more time to listen and respond to your questions. Do not attempt to finish sentences or try to guess what they will say.²³ While these kinds of actions may seemingly save time in the moment, they undermine establishing a connection and sense of trust. Extra time spent establishing clear communication and conveying understanding, empathy and compassion is critical, so schedule accordingly.

Diagnosis

The first step of any treatment is to arrive at a diagnosis. Challenges with the diagnostic process are due to communication challenges, the presence of heavily restored teeth, and age-related changes in the pulp. Cognitive deficits can further complicate diagnosis. Someone with dementia may not be able to articulate their symptoms and may not understand how to respond to the objective tests performed by the dentist.¹¹

Clinicians use the results of pulp sensibility tests (thermal and electric tests) to determine whether the pulp is normal, inflamed, or necrotic.²⁷ The results are based on feedback received from the patient. The results are therefore only as good as the patient’s cooperation and accurate reporting of sensation or lack of sensation. In addition to communication challenges, sensibility tests have been shown to be less accurate for patients who are over age 50.²⁸ Normal age-related changes in the pulp tissue resulting in more fibrous and less cellular composition may diminish sensation in the dentition and contribute to the diagnostic challenge. Using a combination of tests, clinicians need to combine the subjective and all objective data and integrate this with their clinical expertise and experience to arrive at an accurate diagnosis. A study by Weisleder et al. concluded that the use of both the cold test and EPT resulted in a more accurate pulpal diagnosis.²⁹ Unfortunately, the use of EPT may be unsuitable in many cases as teeth may be restored with full coverage restorations and tooth structure may be unavailable for placement of the probe directly on tooth structure.

Diagnosis can further be complicated by age-prevalent diseases or conditions. For example, someone who had a stroke and lost sensation in some part of their mouth would not have the usual sensation to pathosis of endodontic origin or to pulp testing.¹¹ Individuals with chronic pain who regularly take pain medications may be at risk for covering their symptoms. The pain medication may also interfere with the diagnostic testing.³⁰ Additionally, the incidence of orofacial pain is higher in the elderly. When the symptoms and objective tests are inconclusive, orofacial pain should be on the list of differential diagnosis and the patient may need referral to an orofacial pain specialist.³¹

Treatment Planning

Once a diagnosis is established, there are several considerations in treatment planning. Issues of dependency should be considered along with any complications or treatment modifications that will be needed as a result of any diseases or treatment the patient may be receiving. The AAE Endodontic Case Difficulty Assessment Form and Guidelines³² serves as a valuable resource for assessing preoperative cases and identifying the likelihood of complication during endodontic treatment. Conditions listed on this form, such as a complex medical history, limited ability to open the mouth, and canal visibility, are potential risk factors that may complicate treatment and lead to a diminished prognosis or adverse outcome.

Restorability of the tooth and proper isolation with a rubber dam are required for successful and safe root canal therapy. If the ability to achieve this is questionable, then root canal therapy may not be a feasible option. If the patient was referred to a specialist, this needs to be discussed with the referring dentist, as the goals of treatment and the final restoration are critical components of the treatment following root canal therapy.³³ A holistic approach to patient care is essential.³⁴

Other factors that impact a patient’s ability to tolerate or benefit from endodontic treatment may be less definitive or obvious and can present a challenge when determining an appropriate course of treatment. The Seattle Care Pathway (SCP) is an evidence-based approach to treatment planning for older adults.⁶ This approach is based not just on medical complexity, but also on dependency. The elements of risk assessment, prevention, treatment considerations and communication are considered in detail and can be applied to endodontic treatment planning, case selection and delivery of care. Integrating the level of difficulty from the AAE Case Difficulty Form with the considerations addressed in SCP can enhance a clinician’s ability to consider the patient’s total needs. As an example, endodontic cases that are determined to be of low complexity in a patient assessed to be in no dependency or pre-dependent status would likely qualify for all endodontic and restorative treatment options; those patients with a high complexity endodontic case who are also highly dependent are likely be managed by palliative measures⁶ (See Table 1 for applications).

Table 1. Endodontic considerations using the Seattle Care Pathway (SCP) as a Framework^{.(Petty et al, Robbins, Innes, deBaat, Murphy, Baumgartner, Rajeswari)}

	None	Pre	Low	Med	High
	Healthiest for their age group No diseases or medications with a potential impact on oral health or the provision of dental care	Has a disease and or medication with the potential to impact oral health, but no evidence of such yet e.g., well controlled diabetes, mild arthritis managed with light to moderate NSAID use	There is now evidence that the disease and or medication to treat is having some impact on oral health or the ability for patient to receive dental care e.g., xerostomic medications, moderate arthritis limiting chair time and increased NSAID use	The disease or medications are limiting or preventing receipt of dental care, evidently impacting oral health and they have a high risk for oral diseases. e.g, advancing Parkinson’s Disease, poorly controlled diabetes, angina, history of stroke with some moderate impact on physical and/or cognitive ability	The disease or medications are preventing individuals from receiving care, evidently impacting oral health and they have a high risk for oral diseases. e.g., Advanced Dementia, significant disability post CVA or MI, advance MS, individuals with high need for assistance with basic activities of daily living, dressing, bathing, toileting, hygiene, eating
Risk Assessment	No specific risks likely to increase risk of caries and need for endo	No specific risks likely to increase need for endo however if patient is taking potentially xerostomic medications, discuss the risk for caries if this occurs and importance to discuss with GP	Pt ability to tolerate procedures and positioning, possible need for consultation. Consideration of Polypharmacy If dry mouth is observed, inform patient of extreme caries risk and refer back to GP for CRA and preventive plan	Possible need for consultation with PCP re: uncontrolled disease, potential for recovery to a lower level of disability, potential impact on planned medical treatment such as starting bisphosphonates, impending chemotherapy or head and neck radiation.	Consultation with PCP if doubt as to pt ability to tolerate treatment planned. Discuss benefit of endo to maintain dentition in question. Assess barriers to access and success of care, confirm there is a daily care plan to maintain dentition.
Prevention of disease	Routine	Routine	Routine	Consider perio-operative course of antibiotics for individuals with high risk of infection	Be alert to potential abuse if endo needed as a result of trauma. Mandated reporters should contact Adult Protective Services or Ombudsman (for those in long-term care) if suspected.* Consider possible atypical presentation of some other systemic disease if endo indicated due to trauma such from falls resulting from orthostatic hypertension, poor vision, orthopedic or neuropathic issues.
Treatment considerations	routine	Routine	Treatment of disease in early stages. Goal is to maintain dentition with endo to restore and maintain function	Consider if interim palliative care possible and then definitive tx later if pt’s condition may improve Extraction may be a more viable alternative, depending on pt ability to tolerate tx and likelihood to benefit from endo and maintenance of the tooth/teeth later. Consider benefit of maintaining natural dentition to support oral motor function and diet.	palliative care, can include: Rx ABX and pain medication for those unable to tolerate endodontics or extraction Consider indications and contraindications for care on a case by case basis for endodontic tx. Although frail, patients with a high risk for osteonecrosis may still be candidates for endodontic treatment upon review of RBA. Some individuals in long term care may be able to tolerate tx with appropriate supportive structures in place. Consider benefit of maintaining natural dentition to support oral motor function and diet.
Communication considerations	Direct to the patient, routine discussion of RBAs, pre-operative and post-operative care	Direct to the patient Routine discussion of RBAs, pre-operative and post-operative care	Direct to the patient May need to consider consultation if adverse drug reaction, interaction or potential contraindicate are likely	Increasing communication with providers and caregivers and possibly surrogate decision makers.	all caregivers and providers involved, surrogate decision makers as indicated

The above are a limited set of examples to demonstrate application of SCP to the care of older adults requiring endodontic care. These are not exhaustive examples. Determining level of disability can be subjective with many factors to be considered for final treatment planning and patient management that may differ from the examples and recommendations provided in this framework.

*Link to California Adult Protective Services page https://www.cdss.ca.gov/inforesources/adult-protective-services.

Patient Comfort

If a decision is made to proceed with treatment, consider that cognitive decline is often associated with apprehension and anxiety when patients are subjected to unfamiliar treatment, which could result in the patients becoming resistant to care and difficult to treat.³⁵

Benzodiazepines are often used to achieve anxiolysis to allow the provision of necessary care. In the elderly, triazolam, lorazepam, and oxazepam have properties that are most desirable. They are all short acting and have no active metabolites.³⁶ Inhalation sedation has been shown to also be very effective in reducing anxiety and stress in the elderly patient.³⁷

Many older patients require a semi-supine position and cannot be placed in a supine position.^34,38 This may be due to systemic issues, such as COPD or congestive heart failure, or arthritis and joint pain. Providing patients with pillows or a bite block for support and comfort, shorter appointments and frequent breaks may allow root canal therapy to proceed comfortably. A dental office may be too cold for some older individuals. Offering blankets or other coverings to keep help keep the patient warm is a simple measure to ensure comfort and reduce disruptions in treatment. Some patients taking diuretics or with prostate issues may require frequent bathrooms breaks. Communicating with the patient during the procedure to assure they are comfortable and able to continue will reduce the patient’s emotional and physical stress.

Intra-Operative Pain Management

Pain control during and after an endodontic procedure is a vital aspect of patient care. The anticipation of pain and the actual experience of pain and discomfort during treatment can be detrimental in the elderly patient population as their capacity to cope with stress can be diminished. Notably, patients with significant cardiovascular disease (hypertension, dysrhythmias, heart failure, valvular insufficiency, or congestive heart disease) require excellent pain control to avoid the release of endogenous epinephrine in response to stress from pain or anxiety.³⁹

Profound local anesthesia is essential in dental treatment. However, for elderly patients, this should be achieved with consideration of lower doses than for otherwise healthy adult patients. Older patients may be at increased risk for excessive, and thereby toxic, local anesthetic blood levels due to decreased liver function, lowered plasma protein binding, and other age-related changes that affect drug distribution and biotransformation of the local anesthetic.³⁸ As the elimination half-life of amide local anesthetics is usually significantly increased in the presence of decreased liver function, it is advisable to stay well below the FDA-published maximum dosing recommendation.⁴⁰ This is especially important for elderly patients weighing less than a normal adult patient or less than 100 pounds. The “rule of 25” from pediatric dentistry is easy to remember for determining a safe dose of anesthetics intended for the older patient population who may present with a body weight below ideal: 1 cartridge (1.7 ml) of any anesthetic formulation can be administered safely for every 25 pounds of a child’s body weight.⁴¹ The maximum recommended dose by weight should always be calculated for pediatric patients, medically compromised patients, and elderly patients.⁴²

The vasoconstrictor epinephrine is added to local anesthetics to increase the duration and depth of anesthesia. It also reduces the blood level of the anesthetic by slowing the rate of absorption from the area of injection into the surrounding vasculature from adrenergic-mediated vasoconstriction. However, the safe use of epinephrine for patients with cardiovascular disease due to the vasoconstrictor’s transient effect on increasing arterial pressure and heart rate must be considered for patients unable to tolerate these stressors. Balancing the risk of epinephrine with the importance of profound anesthesia is essential. Malamed recommends the use of epinephrine up to 0.040 mg as generally safe for elderly patients and those with cardiovascular disease, although specific patient considerations may preclude the use altogether of local anesthetics formulated with epinephrine.^43,44 In most instances, the enhanced clinical effect of local anesthesia with the addition of epinephrine will help prevent increased stress and the release of endogenous catecholamines in amounts that exceed those in the local anesthetic. Frequently, angina, arrhythmias, and acute stress reactions (tremor, nausea and vomiting, and shortness of breath) have a higher incidence in the stressed, poorly anesthetized patient with cardiovascular disease. These events are less likely to occur in relaxed well-anesthetized patients with cardiovascular disease.⁴⁵

In situations where the dental provider is concerned about the use of epinephrine in local anesthetics, a consultation with the patient’s physician is warranted to gather information on formulating an appropriate clinical treatment plan. Providing relevant and sufficient therapeutic information to the consultant physician, such as the amount of epinephrine to be administered and reason for use, are critical. For example, a dentist may send a consultation to inquire if an elderly patient’s condition is stable enough to tolerate transient increases in heart rate and blood pressure for 5–10 minutes with anywhere from 0.017 mg to 0.040 mg of epinephrine used in dentistry. The consultant may also be able to recommend strategies for peri-operative stress reduction as well as postoperative pain control recommendations.

Access

Coronal access represents the most challenging treatment aspect of a calcified tooth. Access into the pulp chamber of teeth of older patients is challenging due to the receded pulps and presence of full coverage restorations (Figures 2 and 3) Reviewing a cone beam computed tomography image (CBCT) prior to treatment can assist in finding the location of calcified canals or a calcified pulp chamber. The three-dimensional CBCT information guides the operator in the approach, depth, and direction of the access.⁴⁶

Figure 2. Note calcified chamber of #19. Difficult case to access.

Figure 3. Teeth #24 and #25 are necrotic. Canal is visible toward apical third. Consider guided access.

Although a rubber dam must be used during root canal therapy, in cases where access will be difficult, it is beneficial to place the rubber dam after access has been achieved. The orientation of adjacent teeth may help guide the access, and the absence of a clamp will make any radiographs necessary for guidance with access easier to evaluate and to direct the access. In certain instances, an intra-appointment CBCT may also be necessary to assess the approach of the access.⁴⁷

A few tips on locating calcified canals are listed below. All of these techniques require magnification and illumination, and most will require the use of various burs and ultrasonic tips that are designed for performing the deep troughing required to locate and enter calcified pulp chambers and canals.

1. Use a sharp DG16 Endo Explorer to detect small canal orifices. The canal orifice is often softer to the probing than the surrounding dentin.⁴⁸

2. Place NaOCl in the chamber to detect bubbles emerging from a calcified canal.⁴⁷ The bubbles are due to the oxygenation of the pulp tissue when it reacts with NaOCl.^48,49

3. Use a fiberoptic light at the level of the CEJ to transilluminate the tooth from the buccal or lingual, which can help discriminate between the dentinal color of the orifice and the floor of the pulp chamber and help in locating the canal.⁴⁷ It is beneficial to turn off any overhead light source during transillumination.

4. Use methylene blue dye to identify canals.⁴⁹

5. For an efficacious approach in a multi-canal tooth, enlarge the orifice of any canal found before searching for the other canals. The enlarged orifice helps with the orientation, and the now discernable dentinal map (the dark developmental lines connecting canal orifices) helps guide the operator to the other canals.⁴⁸

To assure a canal was located while searching as opposed to the creation of a perforation, a small file can be attached to the apex locator and placed a few millimeters inside the canal. A reading of “apex” would indicate a perforation.^50,51 A smaller perforation that can be quickly repaired improves the prognosis for the tooth.⁴⁷ However, before any files are used, the rubber dam must be placed if it was not placed prior to access.

Guided Access

Guided endodontics is a relatively new approach to access calcified teeth. There are currently two methods for guided access, both utilizing CBCT images.⁵² The static guided approach uses a 3D printed guide that covers the tooth to be accessed and is designed with a drill hole that allows direct access to the calcified canal. (Figure 4) The dynamic navigation system provides real time visualization and guidance during endodontic access preparation utilizing the CBCT and spatial positioning technology. (Figure 5) Once the canal is accessed with the aid of either technique, conventional root canal treatment can continue.

Figure 4. Splint for guided access. Arrow points to guide for bur. Picture courtesy of Dr. David Kelliny.

Figure 5. Real time orientation of bur drill path with a dynamic navigation system. Picture courtesy of Dr. Sameer Jain.

Rubber Dam Placement

The rubber dam is the standard of care when performing root canal therapy.⁵³ The placement of the rubber dam may be challenging on some teeth, but below are some tips to simplify the process.

1. Place the rubber dam as one unit, together with the clamp and frame, to minimize the risk of the clamp falling into the patient’s mouth. In addition to safety, this approach is also easier because the dam remains taut and is thus easier to place.

2. For teeth that are prepped for crowns or badly broken down, use a butterfly clamp with the beaks close together to easily secure the tooth.

3. Add composite or GI to the buccal and lingual of teeth to help secure the clamp when there is no height of contour (undercut) on the crown.

4. Use cyanoacrylate to secure the rubber dam when it is not possible to place a clamp on a tooth.⁵⁴

Establishing Working Length

Cementum continues to be formed throughout life, especially in the apical half of the root, resulting in a gradual increase in thickness. The increased thickness of cementum results in increased distance between the foramen and the radiographic apex. This alteration in the apical anatomy associated with aging affects the radiographic perception of the working length. In advanced age, there may be a discrepancy between the location of the apical constriction as determined by the electronic apex locator (EAL) and the radiographic appearance. Although the working length may appear to be short of the apical constriction, the EAL should be trusted to avoid over instrumentation and extrusion of material due to the known anatomical changes in the apical area.⁵⁵

A CBCT may also eliminate the need for intraoperative radiographs, expediting the treatment, decreasing radiation exposure and alleviating challenges posed by intra-appointment radiographs, especially with the elderly.^56,57,58

Restoring the Endodontically Treated Tooth

The type of final restoration of the endodontically treated tooth is at the discretion of the restorative dentist. The endodontic referral should be as clear and informative as possible to minimize any misunderstanding regarding the proposed treatment plan. If new information affecting outcome is elucidated during treatment, a recommendation for the final restoration can be made by the endodontist upon consultation with the referring dentist. Both the endodontic treatment and restorative treatment are necessary to maintain the tooth, and this requires coordination and good communication between both providers.

Postoperative Pain Management

Postoperative pain management should be carefully evaluated relative to potential drug-drug interactions and the physiological effect of aging on drug pharmacokinetics. Hepatic and renal function can be significantly decreased with age and may affect the ability to metabolize and eliminate medications. Some drug interactions may hinder or augment enzymatic activity of the liver too. NSAIDs are commonly prescribed to treat acute pain associated with inflammation. However, NSAIDS should be used with caution in the elderly and for limited duration (<5 days). Common adverse effects in the elderly associated with NSAIDs include gastrointestinal bleeding, renal impairment, and even heart failure with the reduction in circulating prostaglandins.⁵⁸

Acetaminophen is considered the drug of choice for mild to moderate dental pain in the elderly.⁵⁹ Generally considered to have minimal side effects with low to usual dosing, acetaminophen is associated with few drug interactions. However, patients with significant hepatic compromise should be carefully evaluated before acetaminophen administration as even normal adult dosing can cause liver damage. Opioid analgesics should be used sparingly for dental pain management in elderly patients. Opioid analgesics are associated with common side effects such as sedation, nausea, constipation, and most significantly, respiratory depression. These side effects are often exaggerated in the geriatric patient.⁵⁹

Antibiotics

When antibiotics are indicated, comorbidities and potential drug interactions must be considered. Beta-lactam-based antibiotics (primarily 500 mg amoxicillin three times per day) are the first choice for adjunct treatment of endodontic infections. For patients with a penicillin allergy, the primary alternative is now azithromycin.⁶⁰ Clindamycin is only indicated if there is a contraindication to azithromycin. Fortunately, azithromycin has less drug interactions than other macrolides such as clarithromycin or erythromycin.³⁸ However, caution should be used when prescribing azithromycin to patients on statins as azithromycin may increase the plasma level of the statin drugs.⁶¹ There is also a potential for an increase in digoxin levels when a macrolide is prescribed. The anti-coagulant effect of warfarin may be increased by several antibiotic classes, but cephalosporins, macrolide antibiotics, and metronidazole have the most effect. Penicillin combined with a beta lactamase inhibitor such as Augmentin has a much higher incidence of increasing the risk of bleeding than penicillin with a narrower spectrum.⁶¹

Conclusion

With increasing retention of teeth and greater expectations for oral health among baby boomers and the generations that follow, endodontic treatment is increasingly necessary and valuable for older adults and even some frail older adults. Dental prognoses must be considered in terms of both the prognosis for the tooth to be treated as well as the patient’s ability to tolerate, and the likelihood of benefitting from, the treatment provided. Rather than considering age alone, the patient’s general health, the presence or absence of physical or cognitive disability, and the potential impact on their ability to receive treatment should be the principle determinants for treatment planning. Effective communication, high level of clinical skills, and patient-centric treatment planning are critical for successful outcomes of endodontic treatment for patients with increasing dental and medical complexity at any age.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19424396.2023.2263937.

Additional information

Notes on contributors

Yaara Berdan

Yaara Berdan, DDS, MBA, is an associate professor of clinical dentistry and Co-Chair of the Department of Endodontics and Periodontics at the Herman Ostrow School of Dentistry of USC. Following graduation from the University of California, San Francisco (UCSF), she completed a Pediatric Residency Program at Children’s Hospital Boston and practiced pediatric dentistry in the Boston area for a couple of years. She earned her certificate in endodontics from the University of Illinois at Chicago and returned to Los Angeles where she practiced endodontics until 2008 when she began teaching at Ostrow. She is active in the American Dental Education Association (ADEA) where she represents the Endodontics Section on the Council of Sections and is the Chair of the Sustainability in Dentistry Special Interest Group. She has lectured locally and nationally in the field of endodontics. She is a fellow of the American College of Dentists and the International College of Dentists. She received her MBA from the USC Marshall School of Business.

Elisa M. Chávez

Elisa M. Chávez, DDS, is a Professor in the Department of Diagnostic Sciences at the Arthur A. Dugoni School of Dentistry, San Francisco. She graduated from The University of California San Francisco, School of Dentistry and earned her certificate in Geriatric Dentistry from The University of Michigan, Ann Arbor. Dr. Chávez has practiced in private, community health, long-term care and hospital settings including Centro de Salud Familiar La Fe in her hometown of El Paso Texas, The Veteran’s Administration in Ann Arbor, Michigan, The Jewish Home for the Aged in San Francisco and On Lok PACE in the Bay Area. She has served on the California Dental Association Medicare Task Force and as a member of The Santa Fe Group she is an advocate for the oral health needs of older adults nationwide. She currently serves as the Director of the Pacific Center for Equity in Oral Health Care. (https://dental.pacific.edu/dental/faculty-and-research/research-facilities/pc)