Teeth in Geriatric Patients: To Restore or Extract?

The retention of one's dentition is essential to maintaining form and function, has a profound impact on chewing, swallowing, and nutrition, and aids in preserving speech and esthetics-all of which are paramount to quality of life. With most healthy elderly patients, dental care is straightforward, and all treatment options to preserve the dentition should be considered. Growing evidence is showing that oral health has broad implications and is synergistically linked to general health, namely for cardiovascular disease, diabetes, chronic respiratory disease, and cancer.^1,2 But as older adults become frail and care-dependent, the risk for oral disease increases and the negative effects on general health and well-being accelerate. Patient management, treatment planning, informed consent, and the provision of dental care become more complex.

The blueprint for developing a successful treatment plan, including restorative care and extractions if needed, depends on a comprehensive evaluation and strategic approach that considers many factors, including natural age-related changes, both physical and oral; the cumulative effects of a lifetime of restorations; the progressive nature of dental disease; the prevalence and incremental likelihood of comorbid conditions; medications; drug interactions; saliva; diet; oral hygiene; sensory, motor, and cognitive impairments; and socio-economic and behavioral determinants. Patient expectations and desires need to be considered and the patient's needs prioritized. Clinicians must weigh the risks, benefits, and prognoses of alternative treatment options and ascertain the patient's ability to both tolerate the stress of treatment and maintain the restorations or treatment/extractions provided. A thorough assessment of these mitigating factors will ultimately determine which approach to take: restoration or extraction, or a combination of both. Best practice is to provide care along a continuum with prevention and tooth retention at the forefront. With the advancement of new and alternative caries management strategies, such as glass ionomers, silver diamine fluoride, fluoride varnishes, and antimicrobial therapy, etc, dentists have a vast arsenal at their disposal to prevent, maintain, and arrest decay with minimally invasive procedures.

Today, the proportion of edentulism in older adults is declining,³ and they no longer live with the expectation of losing their teeth. More than ever, these patients are motivated to maintain their natural dentition and, as a result, generally prefer restorative treatment over extractions. However, when warranted, extraction may be necessary due to irreversible infection, mobility, gross decay, fracture, malposition, or nonfunctioning teeth.

As healthcare providers, dentists should consider the whole patient and address their ever-changing dental needs from a holistic interdisciplinary standpoint, always considering how patients function in their daily environment. Age is not something dental providers should be afraid of. With good communication, flexibility, and careful evaluation, dentists can address a patient's needs while embracing the opportunity to apply the advancements and gifts that today's dentistry has to offer to promote improved oral health and the retention of teeth.

An extensively carious tooth has multiple treatment options. Elderly patients may be inclined to consider a treatment option that might not have the best prognosis but is cost-effective and may enable them to keep their natural tooth longer. A direct restoration to replace function and esthetics might not be a viable choice, and complexity increases when options such as endodontic therapy, crown lengthening, fixed or removable partial dentures, and implants are considered. The decision of restoration versus extraction hinges on a number of contributing factors.

Esthetics: Social interactions, particularly at shared meal times, are vital for elderly patients to stay active. Dental esthetics can play an important role in social life, and the patient may or may not place a high emphasis on this.

Nutrition: The ability to chew adequately will impact food choices and necessarily affect diet and nutrition, both of which are important aspects to maintaining health and appropriately managing chronic diseases such as diabetes.

Finances: Collectively, endodontic therapy, a core build-up, and a crown can be expensive. Irrespective of prognosis, total cost may overwhelm a patient, who in turn may choose extraction. This may be a reasonable decision depending on the position of the tooth in the arch and the remaining natural teeth. First molar occlusion is functional and does not negatively affect esthetics; an extracted premolar, however, may affect both function and esthetics.

Perception of longevity: The patient's beliefs may impact the decision to treat or extract. As people age, they may not value the expense of keeping a natural tooth if they perceive that they will not receive adequate benefit from the costly dental treatment in their remaining lifespan.

Existing removable prostheses: If there are missing teeth in the arch replaced by a removable partial denture, it may be possible to extract the tooth in question and add a tooth to the existing partial framework. This may be an affordable, esthetic, and functional option. The framework of the existing partial denture and the position of the tooth in the arch both must be optimal to utilize this alternative.

Existing fixed prosthesis: If there is an existing fixed partial denture (FPD) involving the tooth in question, the options must be evaluated in the context of this FPD. The most involved and expensive option is to remove the FPD and evaluate the natural tooth retainers. Extraction and use of the next natural tooth to support a longer FPD may be the optimal choice. However, if there is no "next" natural tooth or if the span of the longer bridge is not mechanically reasonable, endodontic therapy through the retainer crown may be considered in order to prolong the life of the existing FPD. There are less expensive "bonded bridges" that can be used to replace a single tooth with minimal intervention on adjacent teeth, however these have shorter lifespans than traditional FPDs.

If extracted, the options to replace a single tooth include a FPD, an implant-supported crown, or possibly a removable partial denture when there are other missing teeth. However, cost is a factor, and it generally increases from removable to fixed to implant solutions. Additionally, existing oral or systemic health characteristics may preclude the surgical options.

For cases that involve teeth with guarded restorative prognosis, this is a complex question with no single right answer. The geriatric tooth is attached to a geriatric person. Older people have more time to develop medical, cognitive, or functional conditions that can compromise oral health. Dentists need to consider these confounders, in addition to the patient's socio-economic status, when making recommendations about whether to extract, restore, or "do nothing for" a questionable tooth.

Social economics is the practical variable. Does the patient have transportation to come in for multiple appointments for restorative treatment, if required? Does the patient have the funds to pursue more complex dental treatment? Will extracting the tooth compromise function, such that the patient will need to restore with a prosthesis? The costs, in time and money, of different restorative options must be weighed.

A clinician may be asked to "clear" a patient for a joint prosthesis or organ transplant, or before the start of antiresorptive therapy. Symptomatic or infected teeth can affect blood pressure and diabetes control or cause headaches.^4-6If extracting a tooth with a guarded restorative prognosis will more assuredly improve medical health, the argument for extraction wins. However, medical conditions may influence a clinician to restore a tooth as the first option. For extractions, patients who had prolonged antiresorptive therapy as part of cancer chemotherapy treatment may have healing complications, and those who are on dual antiplatelet therapy, often prescribed after a coronary event, may have higher immediate postoperative bleeding risk.^7,8

Cognitive factors include the capacity to give informed consent. If the patient does not have this capacity, a power-of-attorney or legal guardian is needed. Then, it must be determined whether the patient's behavior will allow treatment. Temporary restorations, such as glass ionomer or the use of silver diamine fluoride, may be considered if local anesthesia cannot be given. For a patient with dementia, the benefits of limited dental care may not outweigh the risks associated with intravenous or general anesthesia. The clinician will need to coordinate with the patient's medical provider about the appropriateness of using "oral pharmacological restraints."

Patients who develop arthritis, become blind, cannot ambulate, or have paralysis or other functional limiting conditions are more susceptible to oral diseases. Teeth with guarded prognosis turn into teeth with poor prognosis, potentially becoming sources of infection. The specific location in the arch, such as in the very posterior, which may be harder to reach to clean, can affect the likelihood or rate that a specific tooth will fail. Yet, extracting that tooth might compromise masticatory function. Silver diamine fluoride usage and/or a restoration may be considered to prolong the life of the tooth until extraction becomes the healthier option.

There is a lot to consider when treatment planning for any patient. For a geriatric patient, more factors are involved and the answers are not always clear-cut. Clinicians must respect these patients' values and goals while educating them and formulating the treatment plan together.

Karin Arsenault, DMD, MPH
Assistant Professor, Clinical Director, Geriatric Center Program, Department of Public Health and Community Service,
Tufts University School of Dental Medicine, Boston, Massachusetts

Domenica G. Sweier, DDS, PhD
Clinical Associate Professor, Department of Cariology, Restorative Sciences, and Endodontics, University of Michigan School of Dentistry, Ann Arbor, Michigan

Tam Van, DDS
Clinical Associate Professor, Department of Comprehensive Dentistry, and Director, Senior Care Dental Clinic, University of Texas Health Science Center, San Antonio, Texas