Navigating Endodontic Care: Perspectives Among Dentists Managing Older Adults—A Qualitative Study

ABSTRACT

Using a qualitative approach, this study explored the perspectives and practices among New Zealand general dental practitioners (GDPs) providing endodontic care to older adults. Semi‐structured questions guided focus group discussions with 18 GDPs who had varied practice experience and characteristics. Transcribed data were analysed and using reflexivity, six primary themes emerged to provide context: philosophies towards managing older adults; confidence; pulpal diagnosis; treatment planning; informed consent; and referral to an endodontist. GDPs were philosophically positive towards older people with endodontic problems although pulp diagnosis could be difficult. Age‐related changes in the pulp‐dentine complex, medical conditions, mobility difficulties, and finances frequently complicated treatment decisions. Confidence, consent processes, and specialist referral were mostly managed on an individual basis. Ongoing professional development to update practice is essential for GDPs to holistically manage a growing and heterogeneous older population when they present with signs and symptoms of pulp and periapical disease.

1. Introduction

Globally, there is an increasing population of older adults (aged over 65 years), and many are retaining their teeth well into old age. In Australia and New Zealand (NZ), around 16%–17% of the population are defined as older adults, and over the next few years, this cohort is projected to rise further [1, 2]. This group is diverse and when they present for dental care, they have different medical and dental health statuses, a spectrum of life experiences, and priorities towards oral health and bring a range of socioeconomic backgrounds and lifestyles [3].

Apical periodontitis (AP) is defined as ‘inflammation and destruction of the apical periodontium’ and most commonly occurs in response to pulpitis and infection within the root canal system. It may be classified as symptomatic or asymptomatic [4]. The global prevalence of AP is 52% at an individual level and 5% at a tooth level [5], and the prevalence increases with age, peaking between 60 and 69 years [6]. AP frequently presents as asymptomatic chronic disease identified as an incidental clinical finding or on radiographs in older adults. Many teeth were traditionally managed by extraction. Increasingly, GDPs play an essential role in problem‐solving to maintain function, aesthetics, prostheses, or patients' overall health and quality of life. They are more often performing endodontic procedures to increase tooth survival. Notably, the proportion of teeth that are root‐filled increases with age and is highest in those aged over 70 years, and so unsurprisingly, the proportion of root‐filled teeth with AP also increases with age and peaks between 60 and 69 years [6].

Gerodontology teaching typically only contributes a small component of most undergraduate dental curricula [7], and endodontics is often described as an advanced area of practice which GDPs find difficult [8]. Dental students and employers have reported that clinical experience in endodontics during dental training is more limited and older patients are most commonly managed in integrated general practice clinics [9, 10]. Performing root canal treatment (RCT) to manage pulp and periapical disease is generally considered a complex procedure and when assessing and managing, the endodontic needs of older adults RCT can be further complicated by the physiological changes that occur within the pulp‐dentine complex throughout life. Individual patient factors also need to be considered when planning and discussing care.

With increasing age and in response to irritants, the deposition of secondary and tertiary dentine reduces the size of the coronal pulp space, and pulp calcifications are more common [11]. Further, the pulp tissue becomes less cellular and vascular with aging and there is a diminished neural response to painful stimuli [12]. Notably, the interaction of functional forces with the residual tooth structure means that cracks and fractures are more common in older teeth which are often heavily restored. In turn, anatomical landmarks used for coronal and radicular access may be indistinct or lost, increasing the risk of missed canals or procedural errors such as perforations or canal transportation.

There is an increased burden of oral disease with increasing age and chronic health conditions, while prescribed medications and mobility issues associated with frailty become more common. While associations between systemic health and endodontic disease have been highlighted, there are no absolute medical contraindications to performing RCT for patients aged over 65 years [13]. A recent survey of older community dwelling adults in the Netherlands found that around two thirds attending the dentist had a medical condition and three quarters used medication [14]. Establishing how comfortable dentists feel managing patients' co‐morbidities alongside their endodontic needs is unclear. There is a need to improve clinical protocols and outcomes for patients and to focus on areas for professional development.

All oral health practitioners are legally required to gain valid informed consent from patients prior to treatment; however, it is not always well understood or recorded. The most current Dental Council of New Zealand (DC(NZ)) Practice Standard for Informed Consent requires that all treatment is delivered in the best interests of the patient, and patients or their legal guardians need to be provided with treatment options, risks and benefits, time, and cost of treatment. There must also be an opportunity to ask questions to enable patients to make informed choices about their care [15]. An online questionnaire of 452 dentists from Saudi Arabia found that while informed consent was mostly adopted for endodontic treatment, improvements in informed consent processes were needed [16]. The importance of engaging geriatric patients in the informed consent process has been highlighted [17]; however, little is known about this in endodontics. Given the complexity of RCT and the higher likelihood of auditory or cognitive impairment with the increased age, it is important to understand the processes GDPs use for obtaining informed consent from older adults prior to treatment and to identify any potential risks.

GDPs commonly refer patients to endodontists for the diagnosis and treatment of more difficult cases. A recent survey study of 152 Australian GDPs reported that endodontic specialist referrals are more common if dentists perceive their knowledge, skills, understanding, or confidence as weak, or if they do not have the necessary armamentarium [8]. In NZ, there are a limited number of specialists mostly located in the main centres. There is very limited publicly funded dental care for older adults, and this does not extend to specialist endodontic care. It is therefore important to identify the context of endodontic referral patterns from GDPs, including any barriers older adults may experience accessing this care.

A challenge for the profession is that GDPs need to have sufficient knowledge, skills, and confidence to holistically address the endodontic needs of a growing older population, and which accommodates patients' general health and social circumstances, with a process for specialist referral where necessary. Students and new graduates are reported to find endodontics difficult, and they have low self‐efficacy in managing complex cases [18, 19, 20]. Furthermore, a survey and problem‐solving activity of graduating students found that a perceived ‘difficulty’ in performing RCT is related to self‐reported anxiety and reduced confidence in endodontics [21]. Anecdotally, and in informal settings, GDPs commonly share with colleagues their difficulties performing RCT for older adults, but it is important to understand the context, and to date, it appears that no studies have explored this. Given that GDPs are at the coalface of providing primary care to older adults, they are also uniquely positioned to reflect on their own practice to inform and share a deeper understanding of their perspectives when assessing and managing the endodontic needs of older adults. Therefore, the aim of this study was to use a qualitative approach to explore the perspectives of a range of NZ GDPs including their overall philosophy, approach to endodontic practise, and how they integrate patient and tooth factors into clinical decision‐making and informed consent processes when managing older adults.

2. Methods

2.1. Study Design

A qualitative approach using semi‐structured interviews was used to provide context and rich insights into the collective experiences and perspectives of NZ GDPs managing the endodontic needs of older adults. Three focus groups, guided by semi‐structured interviews, were conducted by experienced endodontists (LF and NC) and an endodontic postgraduate student (PH) who had extensive experience as a GDP. The other researcher (BD) was an educational academic with expertise in qualitative health research. Given the limited research in this area, the questions were guided by a relativist approach which enabled the exploration of the various perspectives of the enquiry, particularly the interrelationship between the researchers and the participants. This methodology allowed for reflexivity using the Alvesson and Sköldberg [22] framework as the researchers analysed the data and interpreted the collective responses to understand the context in which the GDPs managed the endodontic needs of older adults and the challenges and enablers to their care.

2.2. Ethical Approval

Ethical approval was obtained from the University of Otago Ethics Committee (H18/104), and Māori research consultation was undertaken with the Ngāi Tahu Research Committee. All participants provided informed written consent.

2.3. Participant Recruitment

The project was completed at the University of Otago, Faculty of Dentistry, and GDPs were recruited using a purposeful sampling technique. This approach enhanced the variation within the individuals and enabled the collection of views from male and female GDPs who had a range of clinical experience and were geographically spread throughout the country in main centres and provincial areas. Potential participants were contacted by the research team through emails and provided with information about the study. They were advised that the researchers included endodontists and an endodontic postgraduate student, and what they would be asked to do. As part of the informed consent process they were told that their contributions were voluntary and that there would be no identifying personal information. A total of 18 GDPs who worked more than 25 h per week and provided endodontic treatment to all types of teeth were recruited. Participants were allocated to one of the three focus groups (FG).

2.4. Focus Groups—Data Collection

All interviews were conducted in person at the same venue on the same day, and concurrently, researchers recorded field notes containing descriptive and reflections to enhance analysis. Interview questions arose from the researchers' experience in endodontics and their reflection on practice. Areas of questioning covered demographic characteristics (of the participants and the patient cohorts they manage), GDPs’ philosophies towards endodontic treatment for older adults, and their perspectives and approach to practice. In addition, questions explored participants confidence in managing older adults including those with medical conditions, clinical decision‐making, informed consent, and specialist referral patterns. Focus group discussions were audio‐recorded and transcribed verbatim.

2.5. Data Analysis

Written transcripts were reviewed for familiarity and accuracy to the audio‐recording prior to being imported into NVivo 14 (Lumivero Denver, Colorado, USA) to assist in the organisation and reflexive thematic analysis of the data [23]. PH, LF, and BD read the transcripts and independently coded the first FG to identify preliminary patterns, themes, and sub‐themes from the collected data. Using an iterative approach, coding was checked for consistency, refined, organised and any contradictory views were discussed to reach consensus agreement. Remaining transcripts were then coded by PH following the agreed protocol and reviewed by the other researchers prior to analysis. To provide context to the analysis and enhance the rigour of the research, authors maintained a reflexive journal in NVivo [24].

3. Results

Each FG (n = −3) consisted of six individuals and a range of demographic characteristics (Table 1). A third of participants and mainly those who had practiced more than 20 years reported that older adults comprised the greatest proportion of their patient cohort. The participants all performed RCT for older adults and were interested in endodontics, enabling a strong dialogue between participants and the researchers. All viewed RCT as a viable treatment option for older patients; however, pulp diagnosis was challenging, and treatment planning could be complex particularly when there were contributing tooth or patient factors. The importance of updating knowledge and endodontic skills for an aging population was highlighted. Six primary themes and sub‐themes emerged from the data which provided context and perspectives of GDPs approach to older adults with pulp and periapical disease: (1) philosophies towards managing older adults, (2) confidence providing RCT, (3) pulpal diagnosis, (4) treatment planning, (5) informed consent, and (6) referral to an endodontist. Saturation was reached by the end of the third focus group discussion when no new themes were identified across the data. Key themes and sub‐themes are summarised in Table 2, and participants' quotations are presented to explain the findings.

TABLE 1.

Focus group characteristics.

Focus group	N	Sex		Experience in practice (years)			Practice location		Age range of patient base		Patient base characteristics
		Male	Female	< 10	11–19	> 20	Main centre	Provincial	All ages	Mainly older patients	Low income	High income	Mixed income
1	6	4	2	1	3	2	4	2	3	3	1	2	3
2	6	3	3	2	1	3	5	1	5	1	2	1	3
3	6	3	3	2	2	2	4	2	4	2	1	1	4
Total	18	10	8	5	6	7	13	5	12	6	4	4	10

Note: Data are presented as n.

TABLE 2.

Themes and sub‐themes.

Theme	Sub‐themes
Philosophy towards RCT for older adults	Holistic approach
	Individual risk assessment
	Planning for the future
	Practitioner age
Confidence providing RCT to older adults	Practitioner factors
	Armamentarium
	Tooth factors
	Patient health and mobility
Pulpal diagnosis	Challenges
	Techniques
Treatment planning	Decision‐making
	Transitional treatments
	Case selection
	Patient factors
Informed consent	Methods
	Challenges
Referral to an endodontist	Indications
	Enablers
	Barriers

3.1. Philosophy Towards RCT for Older Adults

Overall, the participants shared very positive and respectful philosophies towards managing the endodontic needs of older adults and highlighted the importance of a holistic approach and maintaining ‘good quality of life aligned to their (patients) values’ (FG3). Most of them expressed that their approach to managing older patients was consistent with patients of all ages; for example,

My philosophy for older patients would be the same for any of my patients, there would be no difference. Oral health is an integral part of general health and everyone has the right to good oral health. (FG2)

For me the philosophy is would I want this done to myself or would I want this treatment presented to me? (FG1)

However, co‐morbidities and cognitive and physical decline as part of aging were raised by most GDPs as significant patient factors which necessitate dentists to modify how they plan and provide care. For example, it was consistently recognised that a patient who experiences barriers accessing care due to their geographic location or transport difficulties needs more time and a practical approach,

I find a lot of the older people are a lot slower so I'm making longer appointments … or they have to come in by taxi ‘cause they might not be driving or are being brought in and even getting from the waiting room to the chair takes a lot longer and getting out takes time’. So, we'll just make a longer appointment with plenty of time … that's just a more practical way of approaching things (FG1)

Conversely, younger GDPs philosophies were more focused on teeth and the difficulties associated with the aging dentition. Specifically, these participants raised the challenges that come with managing heavily restored teeth and patients who have had a lifetime of dentistry.

I would say more challenging because they've had more dentistry done so obviously there are lots of big amalgams on teeth and they don't respond to vitality testing and they might have crowns and all kinds of things going on … so it's, yeah a lot harder to narrow down on older patients. (FG1)

the canals seem to be somewhat smaller and more difficult, but you know, what's life without a challenge. But I would present the issues the same as for any other patient. (FG3)

Almost all practitioners said that it is often hard to predict how a patient's general health may change, and decline can happen quickly which can influence planning and treatment decisions around RCT or extraction. They emphasised the importance of spending time with older patients talking about their future needs because while they ‘can retain teeth through RCT, knowing how their dexterity and mobility will enable them to maintain their dentitions in years to come is less certain’ (FG1).

The GDPs described a pragmatic and holistic approach towards older adults needing RCT, and particularly, those who had managed patients for many years. A proportion explained how they frequently and informally used an individual risk assessment for this cohort of patients to evaluate, communicate, and prioritise their immediate and future needs.

If I'm worried, I'll get them back more frequently as a risk assessment” and “in discussions try to introduce problems that can arise from endodontic disease … in terms of do we keep this tooth? Is this tooth going to be a good strong tooth long term?… and not just the tooth but the tooth in the whole mouth (FG2)

Practitioners age was somewhat reflected in their philosophy towards providing RCT for their patients. Younger GDPs felt that they ‘hadn't had sufficient experience to develop a philosophy’ (FG1). Comparatively, those who had graduated for more than 30 years provided insights into their changing perspective of patients' needs as they have aged, and many GDPs had grown older with their patients and provided care over many years, which shaped their dentist: patient relationships.

it taught me a lesson of somebody that age, I thought she's elderly, does she really need these RCTs and crowns, how long is she going to live for, but it taught me a really good lesson and I'm getting more elderly, and you start to look at things a lot differently

3.2. Confidence Providing RCT for Older Adults

Participants shared a spectrum of confidence levels when performing RCT for older patients which was related to growing competence and having a good armamentarium, particularly access to cone beam computed tomography (CBCT), ultrasonics, good lighting, and loupes, and two GDPs had a microscope. Some recent graduate GDPs said that they would never say they were 100% confident performing endodontic treatment … no matter how old the patient was (FG1). Comparatively, others who had graduated more than 10 years said that they were “more competent now than I was a few years ago so I guess, ideally that will carry on” (FG1). Discussion prompted the groups to highlight that their confidence levels were often different for each patient. They commented that their confidence was not so much related to knowledge and understanding of endodontic theory and perceived hand‐skills but was commonly related to the anatomy of the tooth being treated or the patient's mobility and cognitive health status. All groups described how even with good endodontic equipment and magnification, older patients who had teeth with sclerosed pulp chambers and canals or needed RCT on multirooted teeth made them feel uneasy and cautious, compared to single rooted teeth with visible pulp spaces. GDPs in all groups said patients' mobility and their ability to recline in the dental chair significantly affected their confidence performing RCT; for example,

Good patient mobility is probably one of the biggest factors in my confidence because many of them don't like to recline all the way back and so it doesn't matter which tooth I'm doing my confidence plummets… (FG2)

All participants treated older adults who had a range of medical conditions, but hypertension, diabetes, arthritis, and asthma were most common. The GDPs generally felt confident providing RCT for these patients, but most described being uncomfortable when a medical condition was unstable or a patient's safety in the chair may be at risk, for example, due to neurological conditions or cognitive decline.

The routine customary stable health conditions are not a barrier” (FG1) and “Basic medical problems are not the big thing … it's just the physical inability to be able to get in there or they're unsafe like Parkinson's, epilepsy and full‐blown dementia … particularly if they live alone (FG3)

The more experienced participants described feeling more confident when they could step back and think about the patient holistically, and if there were multiple confounding factors, they could refer to an endodontist.

It's kind of thinking about them on the whole and if there are any medical things that are going to make it a little bit trickier … how much they can tolerate and … the tooth, is it going to be difficult and whether they're going to be happy to sit there while I take my time to try and figure out what's going on … I have a low threshold and can refer (FG2)

3.3. Pulpal Diagnosis

All participants highlighted the difficulties and frustrations associated with making a pulpal diagnosis in older teeth. They explained that challenges frequently arise from communication difficulties, incomplete or conflicting pain histories, lack of objective findings to sensibility and percussion tests, heavily filled dentitions, cracks, the presence of extra‐coronal restorations, and referred pain and that non‐odontogenic problems are more common in older adults.

Use of technology and specific endodontic equipment, including modern imaging, CBCT, and sensibility tests, were helpful and considered important for providing additional information to aid pulp diagnosis. All participants took digital intraoral radiographs and while most did not have access to CBCT, they sometimes referred patients for a scan as they found “it helped them see things that were not visible on plain films” (FG2). Most of them considered electric pulp testing more accurate than cold testing, but only a small number of the GDPs had access to an electric tester. Thermal testing using a dental dam and hot water was commonly used, and two participants cut test cavities without local anaesthetic to aid diagnosis in older patients. While these investigations helped build a diagnostic picture, some typical responses highlighted the shortcomings of tests in older patients which can influence treatment decisions.

One day you can be bang on the money and another day, phew, it's really difficult. Sometimes you just cannot get a reaction for anything on any of those teeth. It's really frustrating and if you rush or get pushed, you can end up treating the wrong tooth. (FG1)

If patients are cognitively impaired, they become like children. Signs and symptoms are not as accurate as a person who is cognitively aware so it can be challenging to diagnose a problem (FG3)

Previous dentistry makes it very difficult. Sclerosed pulps make pulp testing almost a waste of time … PFM crowns create problems because you just can't see anything radiographically. You have no idea what the coronal portion of the tooth is like and sometimes if you take one off, it's just a big mush of caries … you have to be patient because some of my patients need time to think about their answers before they do tell you if that tooth is more tender than the other. (FG1)

3.4. Treatment Planning for Endodontics in Older Adults

The participants unanimously said that additional patient and tooth factors may need to be considered alongside endodontic treatment needs of older patients, and this could be more complex for those who are frail. Those who were ‘fit and old’ were managed no differently than younger patients, but those who were ‘frail and old’ needed careful planning, often in collaboration with the patient's medical practitioner, family, or caregiver. Sometimes referral to an endodontist was needed for RCT, and transitional treatment was more common.

Only a small number of participants performed vital pulp treatment (VPT) in older patients, and this was usually as a transitional treatment to ‘bide time’ rather than be related to diagnosis and the continued health of the pulp. Almost all GDPs described being ‘hesitant about the ability of the pulp to heal with a pulp cap’ (FG2, FG3). Because pulp chamber sclerosis was common in older adults, a healthy bleeding pulp was not expected.

often when you are burrowing down and you come across the pulp chamber, there's hardly anything there at all and if anything red comes, you're thinking of a perforation. (FG2)

Younger GDPs and new graduate dentists reported a more contemporary approach. They were aware of the healing potential of the pulp in older patients, and in selected situations, they were comfortable performing VPT using a bioceramic material; for example, “If you can get good bleeding, I think the success rate of VPT with mineral trioxide aggregate (MTA) is actually much better for older patients than what we initially used to think, but each case is dependent” (FG1).

Participants also explained the importance of case selection when planning RCT in older patients and highlighted the patient's ability to tolerate treatment and the practitioner's competence to perform treatment to a high standard. Where there was concern about a patient's ability to cope, GDPs who had easy access to an endodontist reported that they had a low threshold for referral. In addition, participants described the financial barriers associated with the high cost of RCT and the significance and uncertainty associated with unstable medical conditions. Self‐directed agism from older adult patients towards their oral health was commonly reported by GDPs including that teeth and periodontal health were not always perceived as a priority ‘because they were old’. For example,

it's more technically difficult … I tend to find that older patients put up more barriers for root canal treatment … they might say I'm on the pension now, I can't afford to do something like that, or I've only got a few years left to live … Well, my tooth lasted long enough, take it out. (FG1)

Comparatively, some participants explained patients who pragmatically engaged with aging and financial decision‐making “well, no point being richest person in the graveyard, go ahead and do it”. (FG3).

The GDPs recognised that it was common in older adults to diagnose asymptomatic periapical disease and pathology as an incidental finding on radiographs and this could create a treatment planning dilemma. Patients were often resistant to embark on invasive treatment when there was no pain. Recall appointments or placement of biomaterials into the pulp chamber to monitor or delay the need for invasive treatment until signs or symptoms develop was common.

a dressing is often their long‐term solution so long as they understand that it's not what we recommend, that their priorities are probably comfort and finances and so that may work for them for let's say two years. (FG2)

Those participants who mainly treated older adults estimated that about a third of older patients were moderately unwell. While they usually came with carers or family, their medical condition influenced treatment planning decisions which tended to be more conservative or involve referral to an endodontist. Older adults prescribed excessive polypharmacy or intravenous bisphosphonate therapy or experiencing acute odontogenic pain while undergoing chemotherapy were highlighted as high risk in treatment plans and needed careful multidisciplinary management.

Older people who develop acute endodontic pain and in the middle of chemotherapy … there has to be a judgement call about whether the chemo is stopped so you can safely do the endodontic treatment or whether you manage the symptoms because it's more important to be managing the patient's medical problem. (FG3)

3.5. Informed Consent Processes

All groups agreed that a comprehensive and effective informed consent process was essential prior to RCT in older adults. This prompted discussion and agreement that this should cover treatment options, risks and complications, what they could expect, time required, cost and information about seeing specialist if needed. Some participants described additional consent items which were more specific to RCT in older dentitions and the aging process in general. For example, “complications such as calcifications, blockages, broken files, re‐infection, and missed canals compromised restorability of the tooth and the time that's needed to carry out the treatment” (FG2).

Most of them justified using the same process for patients of all ages, and a typical response was “there are some people who are 100 years old who are sharper than people who are 20 years old, so I don't think the chronological age has a significant bearing on the consent process” (FG1).

Obtained verbal consent was typical, but this was frequently supplemented with the dentist drawing pictures to reinforce the explanation of treatment and providing generic educational material about RCT to take away. A small number of GDPs altered their approach for older patients and used verbal and written consent.

Our consent is a little bit different for elderly but mostly it's verbal and we use the New Zealand Dental Association information form for RCT as well. I like to give the opportunity for patients to ask any questions I'll exclusively say what questions do you have? One of the challenges that we have with older people is whether they can hear well what's being said. They often smile and nod, but I am not sure they understand. That's where the written consent's really important (FG1)

Involving family and caregivers in the consent process was considered important for older adults who are cognitively impaired or who may not have the capacity to provide consent. While this can positively enhance the patient experience, obtaining consent from family members can also create challenges around expectations and acting in the patient's best interests. For example,

one older lady who has dementia is brought into my practice by her daughter and she is fully involved in the process to get the best outcome for her mother, and I also discuss it with the patient (FG1)

a certain proportion of people who want their parents to have the very very best care but sometimes RCT is unrealistic because of the difficulties with patient access, oral hygiene, and the overall decline of their dentition. (FG2)

3.6. Referral to an Endodontist

The participants described referring older patients to an endodontist when they had multiple or unstable medical problems, failed RCT or persistent disease, sclerosed canals, limited mouth opening, obvious root resorption, and fractured instruments or when they suspected non‐odontogenic pain. Several mentioned having a “low threshold for referral” (FG1), “delegating responsibility” (FG1), and “passing the buck” (FG3) when they felt out of their comfort zone.

The most important enabler for specialist referral was having an endodontist in their area and preparing patients for possible referral as part of the informed consent process. Almost all described having an endodontist to refer to (even those in provincial areas), but distance, wait times to be seen, and cost of treatment were barriers. Participants from larger group practices highlighted the value of GDP colleagues with a special interest in endodontics when specialist referral was not viable for patients or beyond their perceived level of competency.

4. Discussion

This study explored the perspectives and experiences of GDPs managing the endodontic needs of older adults. Findings identified that while age‐related changes in teeth, patients' medical and mobility problems, and financial constraints could complicate treatment and access to specialist care, dentists generally had a positive philosophy towards their older patients and used a similar approach for endodontic decision making and consent processes for patients of all ages. Diagnosing the inflammatory status of pulp in older patients was typically perceived as difficult and unreliable, even with the use of specialised armamentarium and contemporary clinical techniques. In most instances, GDPs perceived that challenges performing RCT were due to age‐related changes in the dentine‐pulp complex and patient factors. However, the wide spectrum of ‘wellness’ in older patients meant that dentists' confidence and potential complications performing treatment and obtaining informed consent were judged on a case‐by‐case basis.

In considering the strengths and limitations of this study, the findings contribute to the limited evidence around dentists' perspectives when managing independent older adults needing endodontic treatment and provides significant context about their approach to practice, including barriers and enablers of RCT. The use of a qualitative approach was helpful for providing meaningful insights and context to participant experiences and perspectives which can be lost or unexplained in quantitative survey data. Although the purposeful sampling strategy for recruitment may have a perceived level of potential bias due to it being a group of GDPs who already manage older patients and regularly perform RCT, this was deliberately chosen and effective for positively influencing discussion. Purposeful sampling is widely used in qualitative research to identify and recruit participants who represent a range of characteristics and can provide information‐rich contexts [25], and the characteristics of the focus groups were varied including the GDP geographic distribution, practice type, and clinical experience. Moreover, data saturation was reached after three FGs and as such, the findings are likely to be recognisable and translatable to dentists internationally who provide endodontic care as well as in other advanced areas of practice. For example, where there is cognitive or physical decline due to aging, GDPs performing fixed or removable prosthodontics procedures are likely to experience similar challenges in treatment planning and informed consent processes. Using questions to derive the themes may have been considered a limitation as the data were potentially influenced by the lens of the endodontists and an endodontic postgraduate student who facilitated the FGs. However, this approach is usual in qualitative research and use of reflexivity provided a transparent process for the analysis [24]. The discussions, comments, and reflexivity notes of the researchers did not indicate any bias.

The GDPs appeared to hold patient‐centric and positive views and philosophies towards treating older adults with pulp and periapical disease. They all recognised the heterogeneity which exists within older adult demographics. Where there were challenges with patients' mobility, communication, or medical problems, the GDPs accommodated their management using a practical approach including allowing additional time for appointments, involvement of family or caregivers, and communication with medical practitioners and where needed referrals were made to endodontists. The focus group discussions and comments are consistent with recent findings from a survey of NZ GDPs who reported that they enjoy managing older patients for their general care [10]. However, notably, these responses are in contrast to a survey study of Singaporean dentists and specialists that reported that over a third of practitioners were unwilling to manage patients who had mobility problems and almost half were uncomfortable managing patients who were unable to communicate [26].

It was interesting (although not surprising) that in the current study, the more experienced dentists had grown older with their patients, and this positively influenced their dentist: patient relationship, ability to consider patients holistically, and confidence managing endodontic problems and providing RCT. The importance of a good dentist: patient relationship for enhancing communication, consent processes, and patient outcomes is well established [17, 27], and a recent cohort study from Norway has shown that older patients who maintained the same dentist had a lower likelihood of oral health impacts and improved oral health quality of life [28].

The findings suggest that GDPs confidence providing RCT to older adults was somewhat distinct from their perceived endodontic knowledge and mostly dependent on navigating the age‐related changes within the dentine‐pulp complex, particularly pulp canal calcification and challenges associated with older, frail patients with mobility problems or cognitive decline. This highlights the importance of a careful assessment of the difficulty level of each case and any associated patient or tooth‐related risk factors prior to treatment. The outcome of this assessment is an essential component of the informed consent process to assist patients making a choice about their care and can be used to inform indications of referral to an endodontist [29]. More recently, web‐based assessment tools and technological innovations have become available to help dentists identify and manage endodontic complexities [30]. Recent graduates tended to more hesitant and less confident managing older adults for RCT; however, these findings may be less related to the age of patients and are possibly associated with their limited clinical experience in RCT during dental training. Competence in advanced areas of practice take time to develop [10]. Younger dentists were often less confident managing older patients with cognitive or physical decline, which is consistent with a study from the Netherlands that reported that those who were uncomfortable providing care to older cognitively impaired patients tended to see fewer older adults [31].

A key finding of this study was the frequent difficulty establishing a pulpal diagnosis for older teeth. This is consistent with other studies that have shown poor correlation between clinical findings and the histological status of the pulp, and the outcome of the FG discussions reinforces the international call and need for an improved endodontic classification for pulp diagnosis [32, 33]. Age‐related changes in the dentine‐pulp complex mean that a patient's pain history may be vague and auditory and cognitive decline can be associated with communication difficulties. Many current diagnostic tests are crude, subjective, and often unreliable [32].

Encouragingly, while recent graduates had less clinical experience, most had adopted the use of newer techniques aimed at preserving the vitality of the pulp, including for older adults, and they reported using an evidence‐based approach for case selection. Latest research evidence, international clinical guidelines, and undergraduate endodontic curricula advocates the use of VPT as a valid option for patients of all ages where the pulp has the capacity to heal [34, 35]. In contrast, older dentists were more likely to perform dental pulp capping procedures to prolong ‘tooth survival’ and as a transitional treatment rather than it being a biological answer for continued pulp health. Further, while dentists reported a process for obtaining consent, treatment decisions were frequently patient driven and these findings highlight the importance of ongoing updates on best practice and the value of written as well as verbal consent where treatment is more complex or when prognosis or capacity to consent may be uncertain [17].

As part of a holistic and patient‐centric approach to care, careful consideration needs to be given to a patients' general health and physical status alongside endodontic treatment planning. In common with other studies, the GDPs frequently managed older patients who were unwell and they were not always confident considering the adverse effects of multiple medications [14]. Although GDPs were mostly comfortable managing patients with chronic health conditions, medical problems were a common reason for specialist referral. Ensuring dentists are updated and competent to manage older adults ‘well’ in general practice is therefore essential to meet the needs of an increasing older population.

Proximity to a specialist for referral of complex tooth or patient problems positively impacted on dentists' management of older adults. However, the identified barriers to referral in this study were similar to others which have highlighted financial burden, waiting‐time, transport, and self‐reflected agism as impediments to older patients accessing dental specialists [31]. Finally, while the GDPs responses frequently included sharing feedback from patients, understanding patients' viewpoints directly would be valuable and enable the findings to be triangulated.

5. Conclusions

GDPs frequently managed older people with pulp and periapical disease who have a range of general health and physical statuses. A proportion of the group had treated patients for a long time and aged with their patients, which positively influenced communication and their dentist: patient relationship. Pulpal diagnosis was consistently described as difficult, and additional tests were often unreliable. While performing RCT using contemporary techniques was the norm, the less experienced dentists recognised the benefits of VPT as a valid treatment option for selected cases. Overall, the GDPs shared a positive, practical, and patient‐centric approach to endodontic care. Obtaining informed consent, confidence performing RCT and reasons for referral to a specialist tended to be influenced by individual age‐related tooth and patient factors including pulp canal sclerosis, mobility problems, cognitive decline, and complex medical conditions. This highlights the need to continually update practice to manage a growing and aging demographic.

Author Contributions

Payman Hamadani: investigation, data analysis and interpretation. Nicholas P. Chandler: conceptualisation, methodology, supervision, critical revision of the article. Ben K. Daniel: methodology, supervision, data analysis, interpretation and presentation. Lara T. Friedlander: corresponding author, conceptualisation, methodology, ethics, data analysis and interpretation, supervision, project administration, writing – original draft, writing – review and editing. All authors are supportive of the submission of this manuscript for publication.

Ethics Statement

All research involving human participants has abided by the principles of the Declaration of Helsinki (revised 2013).

Conflicts of Interest

The authors declare no conflicts of interest.