In the aging person, a number of changes occur normally in the root canal system that have the potential to further compromise the response of the pulp to injury. These changes include the nearly complete or partial occlusion of the pulpal space by secondary and tertiary dentin formation,^1–6 the buildup of dense connective tissue within the pulp (a condition called pulpal fibrosis)^7,8 and a marked reduction in both nerve^9–13 and blood vascular supply.^14–17 Not only do the latter changes likely have a significant effect on the response of the pulp to injury, they also may both delay the patient from seeking dental care (owing to the loss of tooth sensitivity to pain) and limit the treatment options needed to retain an intact, functioning dentition.

Given the changing demographics in the United States, these alterations in tooth structure and function could have a profound impact on dental care. Studies have demonstrated that the number of older people in the United States is steadily increasing¹⁸ and have shown the improving tooth retention rate among these people.^19,20 Indeed, Meskin and Berg²⁰ recently reported that among experienced dentists, in the decade between 1988 and 1998, there was a 30 to 51 percent increase in the number of patient visits by people aged 65 years and older, with a corresponding increase in the level of service provided. How many of these patients encountered endodontic problems associated with having occluded root canals is unknown, but an approximate calculation made from data presented in the Meskin and colleagues’²⁰ article suggests that about 17 percent of patient expenditures in the 65-years-and-older age group were for endodontic care.

To better understand the dental practitioner’s perspective on the status of the root canal related to the clinical management of the older patient (older than 65 years), we mailed a questionnaire focused on these issues to diplomates of the American Board of Endodontics, or ABE. We chose diplomates for this survey because they have been certified by the ABE for their experience and expertise in treating root canal problems. It is hoped that the information collected from this survey will form the basis for a more comprehensive analysis of the clinical consequences of age-related changes in the root canal and help resolve some important but as yet unresolved questions about the need for endodontic care in an aging population.

	SUBJECTS, MATERIALS AND METHODS

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Using a mailing list provided by the ABE, we mailed surveys to the diplomate members of the ABE in November and December 1999. This survey (Figure 1) included questions on the respondent’s length of time in endodontic practice, the current age distribution of his or her patients and whether he or she was seeing more patients aged 65 years and older than he or she had in the past. The questionnaire also included a series of "agree/disagree" questions intended to provide information on the diplomate’s perception of root canal closure in the older patient and the clinical circumstances under which occlusion was observed. It also asked whether canal closure contributed to tooth loss or to difficulty in providing care. Finally, space was provided at the bottom of the questionnaire for comments concerning the diplomate’s experience as well as his or her reactions to the survey.

View larger version (62K): [in this window] [in a new window]   Figure 1. A portion of the questionnaire sent to diplomates of the American Board of Endodontics.

	RESULTS

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Not surprisingly, the responses indicated that diplomates are very experienced practitioners, with a substantial majority being in practice 16 or more years (Figure 2, page 1528). Indeed, more than 30 percent of this group had been seeing patients for more than 25 years. Responding diplomates typically saw patients over a wide range of ages, with most in the 45-to-64-years age category. Furthermore, an estimated 26 percent of responding diplomate practices included patients aged 65 years and older (Figure 3, page 1528). Moreover, according to 59 percent of the respondents, and in keeping with overall demographic change, this number is increasing (Figure 4, page 1529).

View larger version (37K): [in this window] [in a new window]   Figure 2. Years in practice: diplomates of the American Board of Endodontics (n = 353). Note that most diplomates have been treating patients for more than 16 years.

View larger version (43K): [in this window] [in a new window]   Figure 3. Age range of patients in practices of diplomates of the American Board of Endodontics. To prepare this graph, a number was assigned to the age-range categories used in the survey: 1 corresponded to < 10 percent, 2 to 10–25 percent, 3 to 26–50 percent, 4 to 51–75 percent and 5 to > 75 percent (the latter two categories not shown here). These assigned numbers then were totaled from the responses given in the questionnaires and a mean was calculated. These means are presented on the y-axis along with representative percentage age-range equivalents. The data show that diplomates see patients covering a wide spectrum of ages, but that most fall into the age range of 45 to 64 years. The results also show that 26 percent of patients are aged 65 years and older.

View larger version (51K): [in this window] [in a new window]   Figure 4. A substantial majority—59 percent—of responding practitioners (n = 334) indicated that the number of patients 65 years and older is increasing in their practices.

View larger version (47K): [in this window] [in a new window]   Figure 5. Most diplomates (62 percent; n = 373) did not consider age-associated canal occlusion a major reason for unsuccessfully treated and, subsequently, lost teeth.

View larger version (47K): [in this window] [in a new window]   Figure 6. Is the need for endodontic treatment of generally more healthy teeth more common in the older patient? While a majority (55 percent) of the 370 practitioners who responded to this question thought this not to be the case, a substantial minority (40 percent) agreed with this proposition.

No statistically significant differences in answers emerged when we stratified the data on the basis of number of years in practice. However, some trends were apparent, notably among practitioners with less than 10 years of experience. In contrast to more experienced diplomates, those who had been in practice less than 10 years tended to believe that pulpal disease is associated with periodontal disease (48 percent vs. 31 percent) and that the poorer condition of teeth is related to lowered sensitivity to pain (57 percent vs. 37 percent). The less experienced diplomates also were more inclined to view the need for endodontic treatment in generally healthy teeth as more common in the older patient (52 percent vs. 36 percent). This same group also believed that fewer teeth are lost because of canal occlusion than are successfully treated in older patients (20 percent vs. 37 percent).

	DISCUSSION

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Data from the U.S. Census Bureau¹⁸ make it abundantly clear that there is a rapid growth in the United States of people aged 65 years and older. These people are maintaining more of their natural teeth as they age and, therefore, are seeking dental care appropriate to being dentate—whereas their predecessors had fewer teeth and sought care appropriate to being edentulous. However, teeth commonly undergo a number of changes with age, and some of these changes might be expected to significantly affect the need and complexity of dental care. One site where such change occurs is the dental pulp in the root canal—which with age, on average, becomes smaller because of occlusion or calcification, and also becomes more fibrotic and less well-vascularized and less well-innervated. The purpose of our study was to determine the effect, if any, of these age-related changes on endodontic treatment as viewed by endodontic practitioners.

Consistent with our expectations and the ABE’s certification criteria, ABE diplomates are a highly experienced group of practitioners, the great majority having practiced endodontics for more than 16 years. Although these dentists see patients covering a wide range of ages—in fact, these data suggest that age, as an adult, is not a strong determinant of need for endodontic therapy—a substantial proportion of their patients are aged 65 years and older. Moreover, most respondents saw this percentage as increasing in their practices, an observation consistent with changing demographics.

The majority of responding diplomates did not feel there was a great need to provide endodontic treatment for teeth that are otherwise healthy in older patients. However, there was a substantial minority who felt otherwise, a finding that seems to parallel anecdotal reports by endodontists suggesting that elderly patients are more likely to require treatment of teeth that are not carious and have no history of restoration or trauma (H. Goodis, D.D.S., and colleagues, unpublished data, 1999 and 2000). The latter view would seem to follow the well-documented, naturally occurring occlusion of the root canal that is part of the aging process in many teeth.

Although the vast majority of diplomates agreed that the size of the root canal is smaller in the older patient, this anatomical change did not appear to present a hindrance to successful treatment, at least in the view of about two-thirds of the respondents. These successes probably can be attributed to the introduction of the surgical microscope and advanced rotary instrumentation in endodontic practice, as well as to the participation of practitioners in advanced education courses. The impact of new technology on clinical outcome is borne out, at least indirectly, by the apparent difference in success rates between relatively new graduates (those with less than 10 years in practice) and those who had been diplomates for a longer time.

Most diplomates indicated that the teeth of the older patient generally are in poorer condition than those of younger patients. This is not surprising, given the longer exposure of teeth to oral pathogens, mechanical wear and tear, and underlying anatomical age-related change, such as secondary dentin formation. A majority of respondents did not believe that the poorer dental status of elderly people is related to a diminished sensitivity to pain that can lead to delays in seeking treatment. However, from our perspective, it seems likely that the well-documented loss of nerve supply to the aging tooth must affect the urgency in seeking dental care, a subject that needs further analysis. Indeed, anecdotal evidence suggests that general dentists who treat large numbers of elderly patients rarely have to use local anesthetics for routine tooth preparations and restorative procedures (H. Goodis, D.D.S., and colleagues, unpublished data, 1999 and 2000).

One of the more controversial issues in endodontics is whether pulpal disease is related to periodontal disease. Overall, most respondents (65 percent) indicated that no such association exists. This result is in agreement with studies of pulpitis and periodontitis on animal models.^21,22 However, such studies were not conducted using age as a major variable, nor have there been human studies that have considered age as a factor in a possible link between periodontal and pulpal disease.

	CONCLUSION

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It is apparent from the results of this survey that more work needs to be done to define the impact of aging on pulp biology, disease and treatment, particularly in human subjects. Other areas of interaction between dental health, dental care and aging have been explored in the past—for example, the relationship between prosthodontics and aging²³—but have not been examined or reexamined in many years. As our population ages, it will become increasingly important to understand these relationships to provide proper care for those dental conditions that are more common in, or even peculiar to, older patients.