Impact of diabetes mellitus, hypertension, and coronary artery disease on tooth extraction after nonsurgical endodontic treatment

Endodontic Microsurgery Outcomes over 10 Years and Associated Prognostic Factors: A Retrospective Cohort Study

INTRODUCTION

This retrospective cohort study aimed to evaluate long-term healing outcomes (10-17.5 years) after contemporary endodontic microsurgery (EMS) and identify the associated prognostic factors.

METHODS

Clinical and radiographic data of an EMS cohort (2006-2013) from the electronic database of the dental hospital were reviewed retrospectively by 2 independent examiners to determine their survival and healing outcomes, and potential prognostic factors were analyzed by Cox proportional hazards regression and logistic regression (α = 0.05).

RESULTS

Through strict inclusion and exclusion criteria and 721 EMS-treated teeth in the cohort, 309 (42.9%) were included (male = 35.0%; female = 65.0%; age = 45.83 ± 15.53 years) with a mean final follow-up of 152.26 ± 26.37 months (range, 120-211 months; median = 148 months). Clinical and radiographic assessments found an 80.5% 10-year survival rate with 63.4% of success. Collectively, tooth type, tooth mobility, preoperative lesion size, clinical crown-to-root ratio, and crown restorations at follow-up were significantly associated with long-term success and survival over 10 years.

CONCLUSIONS

The preoperative status and condition of the tooth including its alveolar bone support and adequate full-crown restorations may be relevant prognostic determinants of success and survival after EMS over time.

Healing of apical periodontitis in type II diabetes mellitus patients: A prospective study

OBJECTIVE

This study aimed to compare the healing of periapical bone between type II diabetes patients and healthy patients after root canal treatment.

SUBJECTS AND METHODS

This study included 26 diabetic patients and the control group with healthy patients matching the diabetic group in age and sex. The study included only teeth with satisfactory coronal restoration. The periapical index system was used to evaluate the periapical status of treated teeth at follow-ups after 6 and 12 months.

RESULTS

Analysis of the results revealed a significantly higher healing rate in the control group compared to the diabetic group only at the 6-month follow-up (66.6 vs. 33.3%; Χ2 = 4.857; p = 0.0275). Analysis of the full-scale PAI index disclosed significantly higher PAI values in the diabetic subjects at 6- and 12-month follow-up. The regression analysis showed that the risk of apical periodontitis persistence increased significantly with female gender (OR = 3.92; 95% CI = 1.04-14.79; p = 0.043), diabetes mellitus (OR = 4.27; 95% CI: 1.18-15.50; p = 0.027) and higher household income (OR = 5.39; 95% CI = 1.33-21.89; p = 0.018).

CONCLUSION

Root canal treatment remains an effective means of conservative treatment in diabetic patients. While the healing is not compromised, regular follow-ups are necessary to monitor the healing process.

Expert consensus on endodontic therapy for patients with systemic conditions

The overall health condition of patients significantly affects the diagnosis, treatment, and prognosis of endodontic diseases. A systemic consideration of the patient's overall health along with oral conditions holds the utmost importance in determining the necessity and feasibility of endodontic therapy, as well as selecting appropriate therapeutic approaches. This expert consensus is a collaborative effort by specialists from endodontics and clinical physicians across the nation based on the current clinical evidence, aiming to provide general guidance on clinical procedures, improve patient safety and enhance clinical outcomes of endodontic therapy in patients with compromised overall health.

Prevalence of apical periodontitis and non-retention of root-filled teeth in hypertensive patients: Systematic review and meta-analysis

BACKGROUND

Several studies have suggested a relationship between AP, as well as the loss of root-filled teeth (RFT), and hypertension (HTN).

OBJECTIVES

The aims of this systematic review and meta-analysis were to investigate the prevalence of AP, and non-retention of RFT, in hypertensive patients.

METHODS

A search was performed in PubMed/MEDLINE, Web of Science, Scopus and EMBASE. The inclusion criteria established were studies published until February 2023, comparing hypertensive subjects with controls, assessing the prevalence of AP and/or providing data on the prevalence of non-retained RFT. Meta-analysis was performed using the RevMan (analyst) tool to determine the pooled prevalence of AP and loss of RFT. Risk of bias was assessed using the Cochrane Risk-of-Bias tool. The quality of evidence was assessed by GRADE.

RESULTS

The search strategy identified 454 articles, and only eight met the inclusion criteria. Six studies had analysed the association between AP and HTN and two studies had analysed the association between non-retention of RFT and HTN. Meta-analysis showed and overall OR = 1.71 (95% CI = 0.92-3.16; p = .09) for the prevalence of AP among patients with HTN. The prevalence of non-retention of RFT among patients with HTN has an overall OR = 1.78 (95% CI = 1.60-1.98; p = .000001). The risk of bias in the individual studies was low or moderate, and the quality of the overall evidence has shown a level of certainty very low.

DISCUSSION

There is no association between the prevalence of AP and HTN. In addition, hypertensive patients have significantly increased odds of losing RFT. Given the high prevalence of hypertension, it is very common to perform root canal treatments on hypertensive patients. It is imperative to communicate this heightened risk to patients and recommend periodic monitoring of oral health and hypertension, paying special attention to this subset of patients.

REGISTRATION

PROSPERO CRD42022302385.

Impact of chronic diseases on the periapical health of endodontically treated teeth: A systematic review and meta-analysis

Systemic diseases affecting the immune system can influence the body's response time to endodontic treatment, potentially necessitating a longer duration for the complete resolution of existing infections when compared to healthy controls. This systematic review aims to evaluate the association between the presence of chronic diseases and periapical status after endodontic treatment through a systematic and comprehensive assessment of existing literature on this topic. The search strategy covered seven electronic databases and grey literature, encompassing articles published until October 2023. Two reviewers independently assessed potentially eligible studies based on the following criteria: Included were studies involving populations exposed to pre-existing chronic diseases who underwent endodontic treatment in permanent teeth. These studies evaluated periapical health status, making comparisons with healthy individuals. There were no language or publication date restrictions. Additionally, two reviewers independently extracted data regarding the characteristics of the included studies. The risk of bias was assessed using the Joanna Briggs Institute Critical Assessment Checklist. Meta-analysis was conducted using random effects models. The certainty of evidence was assessed using the GRADE tool. Twenty-three studies were included in the synthesis. Patients with diabetes were found to have about half the odds of having periapical health compared to non-diabetic patients (OR = 0.46; 95% CI = 0.30-0.70%; I2 = 58%) in teeth that underwent endodontic treatment. On the other hand, other systemic diseases like HIV, cardiovascular disease, and rheumatoid arthritis did not demonstrate significant differences concerning the outcome. In conclusion, diabetic patients showed a lower likelihood of maintaining periapical health. Conversely, patients with HIV, cardiovascular disease, and rheumatoid arthritis did not exhibit significant differences, although the existing evidence is still considered limited. It is crucial to manage these patients in a multidisciplinary manner to provide appropriate care for this population.

A literature review of local and systemic considerations for endodontic treatments in older adults

OBJECTIVES

The aim of this literature review was to summarise the clinical important findings on the endodontic treatment outcome in older patients (≥60 years old) with pulpal/periapical disease considering local and systemic factors from a body of knowledge that is heterogeneous in methods or disciplines.

BACKGROUND

Due to the increasing number of older patients in the endodontic practice, and the current trend for tooth preservation, the need for clinicians to have a better understanding of age-related implications that may influence the required endodontic treatment in older adults to retain their natural dentition is indispensable.

METHODS

PubMed/Medline and Embase was searched by a medical librarian using specific terms based on inclusion/exclusion criteria. The reference list was hand-seached for additional relevant publications between 2005-2020. A combination of these terms was performed uing Boolean operators and MeSH terms.

RESULTS

Of the 1577 publications identified manually and electronically, 25 were included to be fully reviewed by the examiners. The data was derived from three systematic reviews, one systematic and meta-analysis, three case series, four prospective and 14 retrospective cohorts. Overall, there was heterogeneity in reporting as well as limitations in most studies.

CONCLUSIONS

The outcome of endodontic treatment (ET) either nonsurgical or surgical or combination of these is not affected by older age. ET can be the treatment of choice in older patients wiht pulpal/periapical disease. There is no evidence that older age per se affects the outcome of any type of endodontic treatment.

Periapical Lesions Associated with Demographic Variables, Dental Conditions, Systemic Diseases, and Habits

AIM AND BACKGROUND

The aim of this study was to analyze the prevalence of periapical lesions and possible associations with demographic, dental conditions, systemic diseases, and habit variables in patients from a private Brazilian university.

MATERIALS AND METHODS

Data from 452 patients of both sexes, aged 18-78 years, from a Brazilian university were evaluated. Panoramic radiographs were analyzed, and the presence of periapical lesions was recorded. In these cases, the dental condition was assessed for the presence or absence of endodontic treatment. Medical records provide information related to general health (diabetes, cardiovascular diseases, altered cholesterol, autoimmune diseases, gallstones, or kidney stones) and habits (smoking or alcoholism). The data were descriptively analyzed, and then logistic regression and the Wald test were performed in Stata/SE v.14.1.

RESULTS

A rate of 58.4% of participants were women, and the mean age was 36.4 (±14.6) years. Periapical lesions prevailed in 193 (42.7%) patients, and 281 (72.4%) teeth were not previously endodontically treated. Mandibular first molars (19%) and men (48.9%) were the most affected. The adjusted model showed that the age group of 26-45 years was 5 times more likely [odds ratio (OR) = 5.01; 95% confidence interval (CI): 2.85-8.82] to have lesions than those aged ≤25 years. Participants aged above 46 years were 19.1 times more prone (OR = 19.1; 95% CI: 10.2-36.0) to morbidity than younger ones (≤25 years).

CONCLUSION

The studied sample showed that periapical lesions were more prevalent in males, in mandibular molars, and without prior endodontic treatment. There was no observed association between periapical lesions and comorbidities or habits; however, a significant correlation occurred with advancing age.

CLINICAL SIGNIFICANCE

Comorbidities and habits were not associated with the presence of periapical lesions. However, aging has been identified as a significant risk factor for the development of periapical lesions. This finding is clinically relevant as it highlights the importance of monitoring and maintaining oral health in patients with advanced age. How to cite this article: dos Santos VC, de Oliveira Kublitski PM, Marques da Silva B, et al. Periapical Lesions Associated with Demographic Variables, Dental Conditions, Systemic Diseases, and Habits. J Contemp Dent Pract 2023;24(11):864-870.

Tooth survival after endodontic treatment

BACKGROUND

There are several measures that are, or could be, in use in relation to estimating the outcome of endodontic treatments. It is important to reflect on when and why a certain outcome measure is used; when caring for an individual patient it is obvious that the goal always should be a tooth in a healthy state, that is striving to remove any infection and aim for the tooth to have healthy periapical tissues. For patients in general and for society, it is also interesting to know if endodontic treatments will lead to retention of teeth in a functioning state. From epidemiological studies, with high prevalence of root filled teeth with periapical radiolucencies, it is implied that dentists and/or patients accept the retention of a root filled tooth with persistent apical periodontitis. In conjunction with an endodontic treatment the prognosis is considered and since the prognostic factors seem to be somewhat different depending on whether one is considering for example the outcome 'healthy periapical tissues' or 'tooth survival' they are equally important to know. Factors affecting the outcome 'healthy periapical tissues' probably has to do with removal of infection and reconstituting the barrier to prevent leakage whilst 'tooth survival' is more likely associated with factors outside of the classical endodontic field such as restorability and avoidance of further destruction of tooth substance. Objective This narrative review will focus on tooth survival after endodontic treatment and root canal treatment will be the focus. Method The search was performed in PubMed. Results As a crude estimation, there is to be an annual loss of 2% of teeth which have received a root canal treatment. Conclusion Of the pre-, peri- and postoperative factors that have been studied in conjunction with root canal treatments the restoration of the tooth is the factor that has been most extensively studied. Many studies imply that root filled teeth restored with indirect restorations have a better survival than teeth restored with direct restorations, it is not possible to determine whether this indeed is a prognostic factor. Registration None.

Impact of systemic health on treatment outcomes in endodontics

BACKGROUND

The healing of periapical lesions after root canal treatment (RCT) is not the result of the curative action of the treatment. The process of healing begins with inflammation, and is resolved by the clearance of the immunogen that induces the immune response. Then, the periapical tissue itself carries out the healing of the periapical lesion, by repair or by a combination of repair and regeneration, depending on the host's reparative response working properly. The ultimate objective of RCT is to achieve wound healing by removing the source of bacterial antigens and toxins, allowing chronic inflammatory tissue to become reparative tissue. Some systemic conditions increase the susceptibility of the host to infection or impair the tissue reparative response, maintaining the inflammatory process and periapical bone resorption after RCT. This can cause the failure of RCT and even the need for extraction of the affected tooth.

OBJECTIVE

To analyse the scientific literature on the possible influence of systemic conditions on the treatment outcomes in endodontics, as well as to discuss the biological mechanisms that may be involved.

METHODS

The search was carried out in PubMed, SCOPUS and EMBASE. The inclusion criteria established were original scientific articles reporting data about some systemic condition in relation to treatment outcomes in endodontics, including clinical studies and studies carried out in animal models.

RESULTS

Systemic factors (age, nutrition, stress, hormones, smoking habits), and systemic diseases, such as diabetes, cardiovascular diseases, osteoporosis, HIV infection, inflammatory bowel disease, and others, can influence or interfere in the repair of periapical tissues after RCT.

DISCUSSION

Some of these systemic diseases can alter bone turnover and fibroblast function, preventing or delaying periapical wound healing. Others can alter the microvasculature, reducing nutrients and oxygen supply to periapical tissues. As a result, these systemic conditions can decrease the success rate of RCT and provoke incomplete wound healing (typically granulomatous tissue formation) in the periapical region.

CONCLUSIONS

The results of this narrative review show worse success rate of RCT, with higher percentage of postoperative radiolucent periapical lesions and higher proportion of non-retained teeth (RFT), associated with several systemic conditions, such as smoking habits and diabetes.

Association between Endodontic Infection, Its Treatment and Systemic Health: A Narrative Review

The ‘Focal Infection Era in Dentistry’ in the late 19th and early 20th century resulted in widespread implementation of tooth extraction and limited the progress of endodontics. The theory proposed that bacteria and toxins entrapped in dentinal tubules could disseminate systemically to remote body parts, resulting in many types of degenerative systemic diseases. This theory was eventually refuted due to anecdotal evidence. However, lately there has been increased interest in investigating whether endodontic disease could have an impact on general health. There are reviews that have previously been carried out on this subject, but as new data have emerged since then, this review aims to appraise the available literature investigating the dynamic associations between apical periodontitis, endodontic treatment, and systemic health. The available evidence regarding focal infection theory, bacteraemia and inflammatory markers was appraised. The review also collated the available research arguing the associations of apical periodontitis with cardiovascular diseases, diabetes mellitus, adverse pregnancy outcome and autoimmune disorders, along with the effect of statins and immunomodulators on apical periodontitis prevalence and endodontic treatment prognosis. There is emerging evidence that bacteraemia and low-grade systemic inflammation associated with apical periodontitis may negatively impact systemic health, e.g., development of cardiovascular diseases, adverse pregnancy outcomes, and diabetic metabolic dyscontrol. However, there is limited information supporting the effect of diabetes mellitus or autoimmune disorders on the prevalence and prognosis post endodontic treatment. Furthermore, convincing evidence supports that successful root canal treatment has a beneficial impact on systemic health by reducing the inflammatory burden, thereby dismissing the misconceptions of focal infection theory. Although compelling evidence regarding the association between apical periodontitis and systemic health is present, further high-quality research is required to support and establish the benefits of endodontic treatment on systemic health.

Akt-GSK3β-mPTP pathway regulates the mitochondrial dysfunction contributing to odontoblasts apoptosis induced by glucose oxidative stress

Diabetes Mellitus can cause dental pulp cells apoptosis by oxidative stress, and affect the integrity and function of dental pulp tissue. Mitochondria are the main attack targets of oxidative stress and have a critical role in apoptosis. However, whether mitochondria are involved in dental pulp damage caused by diabetes mellitus remains unclear. This study aimed to investigate the role of mitochondria in the apoptosis of odontoblast-like cell line (mDPC6T) induced by glucose oxidative stress, and to explore its possible mechanism. We established an oxidative stress model in vitro using glucose oxidase/glucose to simulate the pathological state under diabetic conditions. We found that the opening of mitochondrial permeability transition pore (mPTP) contributed to the apoptosis of mDPC6T treated with glucose oxidase, as evidenced by enhanced mitochondrial reactive oxygen species (mtROS) and intracellular Ca²⁺ disorder, significantly reduced mitochondrial membrane potential (MMP) and ATP production. Antioxidant N-acetylcysteine (NAC) or Cyclosporine A (mPTP inhibitor) blocked the mPTP opening, which significantly attenuated mitochondrial dysfunction and apoptosis induced by glucose oxidative stress. In addition, we found that glucose oxidative stress stimulated mPTP opening may through inhibition of Akt-GSK3β pathway. This study provides a new insight into the mitochondrial mechanism underlying diabetes-associated odontoblast-like cell apoptosis, laying a foundation for the prevention and treatment of diabetes-associated pulp injury.

Association between General Anesthesia and Root Canal Treatment Outcomes in Patients with Mental Disability: A Retrospective Cohort Study

In the population of individuals with a disability, mental illness patients can be uncooperative during dental treatment; thus, general anesthesia has been widely applied during dental procedures. This study aims to investigate the association between general anesthesia and the outcomes of root canal treatment in patients with disability. Teeth treatment records of patients with disability from Kaohsiung Medical University Hospital Research Database and electronic database from January 2005 to December 2018 were used in this retrospective cohort study. The authors conducted analysis comparing root canal treatment outcomes under general anesthesia and non-general anesthesia, indicated by endodontic re-treatment or post-treatment teeth extraction. Over the 9-year follow-up period, root canal treatment outcomes representing a cumulative survival rate of 87.68% and 74.51% in the general anesthesia group and non-general anesthesia group, respectively, were found. After adjustment for potential confounders, the teeth with general anesthesia showed a substantially and significantly reduced HR of root canal treatment failure at 0.24 (95% confidence interval, 0.12 to 0.49). Our study supported the notion that root canal treatment with general anesthesia may entail substantial reduction of treatment failure in patients with disability.

The impact of cardiovascular disease and endodontic outcome: a systematic review of longitudinal studies

OBJECTIVES

To date, the relationship between cardiovascular disease (CVD) and endodontic treatment outcomes remains elusive with mixed reports. Thus, the purpose of this systematic review of longitudinal cohort studies was to evaluate whether CVD was a risk factor for endodontic outcome.

MATERIALS AND METHODS

Two reviewers independently conducted a comprehensive electronic database search to July 2020. The bibliographies of all relevant articles, textbooks, and gray literature were manually searched. The methodological quality of evidence was appraised by the Newcastle-Ottawa Scale and GRADE. The authors considered any publication on CVD and endodontic outcome. Endodontic outcome referred to either healing or survival of endodontically treated tooth. Risk ratio (RR) with 95% confidence interval (CI) was used.

RESULTS

Three articles met the inclusion criteria with a low risk of bias. Patients with CVD demonstrated a 67% higher risk for negative endodontic outcomes compared with patients who were healthy (RR = 1.67, P = 0.001, 95% confidence interval 1.53-1.81).

CONCLUSION

With the limitations of this systematic review, the overall confidence by GRADE was moderate suggesting that CVD might be a risk factor for endodontic outcomes.

CLINICAL RELEVANCE

The results support an association between CVD and endodontic outcomes.

Knowledge, attitude, and practice of general dental practitioners toward following proper standards of endodontic practice and use of latest technology in Dehradun: A cross-sectional study

BACKGROUND

Choosing latest technology for the treatment improves the chances of favorable prognosis and saves the time of the clinician; hence, the aim of the study was to explore their knowledge, attitude, and practice (KAP) toward following proper standards of endodontic practice and use of latest technology.

MATERIALS AND METHODS

The present study was a cross-sectional, descriptive questionnaire study conducted among general dental practitioners (GDPs). The survey was conducted among 156 GDPs. In the present study, a close-ended interview schedule was prepared to test the KAP of GDPs.

RESULTS

For diagnosis, most of the study participants (58 [37.08%]) relied on case history and radiograph. Apex locator was used by 71 (45.51%) of the study subjects. Among all the study participants, 58 (37.17%) dental practitioners used rotary nickel-titanium (NiTi) files with normal saline and preheated disinfectants for cleaning and shaping of root canal. It was observed that the knowledge of majority of the dental practitioners was fair (58 [37.17%]). However, the attitude and practice toward following proper standards of endodontic practice and use of latest technology were poor.

CONCLUSION

It was concluded that very few general practitioners used the latest technology in endodontics. Knowledge was fair while attitude and practice regarding following proper standards of endodontic practice and use of latest technology were poor among study participants.

Impact of systemic diseases and tooth-based factors on outcome of root canal treatment

AIM

To investigate the impact of systemic health and tooth-based factors on the outcome of root canal treatment (RCT).

METHODOLOGY

The target population consisted of all patients receiving RCT at the Helsinki University Clinic in 2008-2011. The inclusion criteria were diagnosable pre- and postoperative (minimum 6 months after root filling) radiographs and adequate patient records of RCT available. Teeth extracted for nonendodontic reasons were excluded. Patient documents including digital radiographs of 640 permanent teeth in 504 patients were scrutinized. The radiographs were assessed by two examiners under standardized conditions. The Periapical Index was used to define radiographically 'healthy' and 'healing' cases as successful. Data included systemic health, technical quality of root fillings, type of restoration and level of alveolar bone loss. Statistical evaluation of differences between groups included chi-squared tests and Fisher's exact tests. Logistic regression modelling utilizing robust standard errors to allow for clustering within patients was applied to analyse factors related to the outcome of RCT.

RESULTS

The mean age of patients was 51.5 years (standard deviation (SD) 15.0; range 10-83), and 49% were female. In 41 cases (6%), the patient had diabetes mellitus (DM), in 132 (21%) cardiovascular disease and in 284 (44%) no systemic disease. The follow-up period was 6-71 months (mean 22.7). In the primary analyses, the success rate of RCT was 73.2% in DM patients and 85.6% in patients with no systemic disease (P = 0.043); other systemic diseases had no impact on success. In the multifactorial analysis, the impact of DM became nonsignificant and RCTs were more likely to succeed in the absence of apical periodontitis (AP; odds ratio (OR) = 4.4; P < 0.001), in teeth with optimal root filling quality (OR = 2.5; P < 0.001), in teeth restored with indirect restorations (OR = 3.7; P = 0.002) and in teeth with none/mild alveolar bone loss (OR = 2.4; P = 0.003).

CONCLUSIONS

DM diminished the success of RCT, especially in teeth with apical periodontitis. However, tooth-based factors had a more profound impact on the outcome of RCT. This should be considered in clinical decision-making and in assessment of RCT prognosis.

Endodontics in Systemically Compromised Patients

A substantial number of people in today’s world are elderly and as the incidence of a number of pathologies increases with age, it is predicted to produce millions of individuals with systemic medical conditions that can affect oral health and subsequent dental treatment. The dental management of these medically compromised patients can be sometimes problematic in terms of oral complications, dental therapy, and emergency care. One of the challenges faced by dental specialists today is the assessment and management of these patients. As mentioned in detail in Chap. 12, geriatric patients are much more likely to be at least partially dentulous having a complex medical history and the use of multiple medications.

Investigations of the prevalence and virulence of Candida albicans in periodontal and endodontic lesions in diabetic and normoglycemic patients

Pulpal and periodontal tissues have similar microbiota that allows cross-contamination between the pulp and periodontal tissues.

Oral manifestations of Diabetes Mellitus. A systematic review

BACKGROUND

Diabetes Mellitus has become a global epidemic and presents many complications, usually proportional to the degree and duration of hyperglycemia. The aim of this systematic review was to investigate the different oral manifestations associated with Diabetes Mellitus.

MATERIAL AND METHODS

A MEDLINE search for "Diabetes Mellitus and oral manifestations" was performed. A further search was conducted for "diabetes" and its individual oral manifestation. Inclusion criteria were as follows: human clinical studies with a minimum of 30 patients; studies published in relevant scientific journals between January 1998 and January 2016. Nineteen studies fulfilled the inclusion criteria and were analyzed, assessing the strength of scientific evidence according to recommendations made by the Centre for Evidence-Based Medicine, Oxford (OCEBM), which permits adequate assessment of prevalence studies.

RESULTS

A total 3,712 patients (2,084 diabetics) were included in the studies reviewed. Of the 19 studies analyzed, 4 were longitudinal studies and 15 cross-sectional studies. Periodontal disease, periapical lesions, xerostomia and taste disturbance were more prevalent among diabetic patients. An association between diabetes and caries and mucosal lesions proved positive in 5 out of 10 studies.

CONCLUSIONS

Despite multiple oral manifestations associated with DM, awareness of the associations between diabetes, oral health, and general health is inadequate. It is necessary for doctors and dentists to be aware of the various oral manifestations of diabetes in order to make an early diagnosis.

Association between Systemic Diseases and Endodontic Outcome: A Systematic Review

INTRODUCTION

To date, the relationships between systemic diseases and endodontic treatment outcomes remain poorly studied. Thus, the purpose of this systematic review was to evaluate the relationship between host-modifying factors and their association with endodontic outcomes.

METHODS

Two reviewers independently conducted a comprehensive literature search. The MEDLINE, Embase, Cochrane, and PubMed databases were searched. In addition, the bibliographies and gray literature of all relevant articles and textbooks were manually searched. There was no disagreement between the 2 reviewers.

RESULTS

Sixteen articles met the inclusion criteria with moderate to high risk of bias. There was no article with low risk of bias. Available scientific evidence remains inconclusive as to whether diabetes and/or cardiovascular disease(s) may be associated with endodontic outcomes. Human immunodeficiency virus and oral bisphosphonate did not appear to be associated with endodontic outcomes.

CONCLUSIONS

Although additional well-designed longitudinal clinical studies are needed, the results of this systematic review suggest that some systemic diseases may be correlated with endodontic outcomes.

Interrelationship Between Periapical Lesion and Systemic Metabolic Disorders

BACKGROUND

Periapical periodontitis, also known as periapical lesion, is a common dental disease, along with periodontitis (gum disease). Periapical periodontitis is a chronic inflammatory disease, caused by endodontic infection, and its development is regulated by the host immune/inflammatory response. Metabolic disorders, which are largely dependent on life style such as eating habits, have been interpreted as a "metabolically-triggered" low-grade systemic inflammation and may interact with periapical periodontitis by triggering immune modulation. The host immune system is therefore considered the common fundamental mechanism of both disease conditions.

METHOD

We have reviewed >200 articles to discuss the interrelationship between periapical lesions and metabolic disorders including type 2 diabetes mellitus, hypertension, and non-alcoholic fatty liver diseases (NAFLD), and their common pathological background in immunology/osteoimmunology and cytokine biology.

RESULTS

An elevated inflammatory state caused by metabolic disorders can impact the clinical outcome of periapical lesions and interfere with wound healing after endodontic treatment. Although additional well-designed clinical studies are needed, periapical lesions appear to affect insulin sensitivity and exacerbate non-alcoholic steatohepatitis.

CONCLUSION

Immune regulatory cytokines produced by various cell types, including immune cells and adipose tissue, play an important role in this interrelationship.

Viruses in pulp and periapical inflammation: a review

The presence of viruses in endodontic disease has been studied in the last decade. Their presence is associated with periapical radiolucency and with clinical findings, such as pain. The aim of this review is to analyze the scientific evidence currently published about viruses in pulp and periapical inflammation, and its possible clinical implications. A literature review was carried out using the Medline/Pubmed database. The search was performed, in English and Spanish, using the following keyword combinations: virus AND endodontic; virus AND periapical; virus AND pulpitis; herpesvirus AND periapical; papillomavirus AND periapical. We subsequently selected the most relevant studies, which complied with the search criterion. A total of 21 articles were included, of which 18 detected the present of viruses in the samples. In 3 of the studies, viral presence was not found in the samples studied. The Epstein-Barr virus was found in about 41 % of cases compared to controls, in which it was present in about 2 %. The main association between viruses and endodontic pathosis is between Cytomegalovirus and Epstein-Barr virus; these are found in 114 of the 406 samples of different endodontic pathosis. Some evidence supports that the Epstein-Barr virus is present in a significant number of endodontic diseases, without exact knowledge of their action in these diseases.

Diabetes mellitus and inflammatory pulpal and periapical disease: a review

Diabetes mellitus (DM) is one of the most common metabolic disorders. DM is characterized by hyperglycaemia, resulting in wound healing difficulties and systemic and oral manifestations, which have a direct effect on dental pulp integrity. Experimental and clinical studies have demonstrated a higher prevalence of periapical lesions in patients with uncontrolled diabetes. The influence of DM on periapical bone resorption and its impact on dental intervention of such patients are reviewed, and its aetiology and pathogenesis are analysed at molecular level. Pulps from patients with diabetes have the tendency to present limited dental collateral circulation, impaired immune response, increased risk of acquiring pulp infection (especially anaerobic ones) or necrosis, besides toothache and occasional tendency towards pulp necrosis caused by ischaemia. In regard to molecular pathology, hyperglycaemia is a stimulus for bone resorption, inhibiting osteoblastic differentiation and reducing bone recovery. The relationship between poorly controlled diabetes and bone metabolism is not clearly understood. Molecular knowledge about pulp alterations in patients with diabetes could offer new therapeutic directions. Knowledge about how diabetes affects systemic and oral health has an enduring importance, because it may imply not only systemic complications but also a higher risk of oral diseases with a significant effect on pulp and periapical tissue.

Outcome of periapical lesions in a rat model of type 2 diabetes: refractoriness to systemic antioxidant therapy

INTRODUCTION

This study evaluated the development of periapical lesions in a rat model of type 2 diabetes and assessed the potential actions of the antioxidant agent tempol in this model.

METHODS

Male Wistar rats were used; they received tap water (N = 5) or a 20% glucose solution (N = 15) during a period of 9 weeks. At the sixth week, periapical lesions were induced on the first mandibular molars, and the animals were subdivided into 4 groups. The subgroup 1 was composed of nondiabetic rats orally receiving saline solution (10 mL/kg). Chronically glucose-fed rats were divided into the following subgroups: (2) saline-treated animals (10 mL/kg by oral route), and animals treated with tempol by gavage at doses of (3) 50 mg/kg or (4) 100 mg/kg. The body weight was monitored thoroughly. After 21 days of apical periodontitis induction, the animals were killed, and the mandibles were collected and submitted to radiographic and histologic analysis. The livers were collected to determine free radicals, and the blood plasma was used to measure insulin levels.

RESULTS

Type 2 diabetic rats displayed a significant decrease of body weight gain and a slight increase of insulin levels, which were allied to reduced levels of the antioxidant components catalase and reduced glutathione; these alterations were reversed by tempol. Concerning the periapical lesions, neither radiographic nor histologic analysis revealed any significant difference between control and type 2 diabetic rats. In diabetic rats, the apical periodontitis was refractory to tempol treatment.

CONCLUSIONS

The extent and cellularity of periapical lesions in glucose-fed type 2 diabetic rats were similar to those seen in control rats. Despite affecting other parameters related to diabetes, tempol failed to improve the outcome of endodontic lesions in type 2 diabetic animals.

Diabetes mellitus, periapical inflammation and endodontic treatment outcome

The possible connection between chronic oral inflammatory processes, such as apical periodontitis and periodontal disease (PD), and systemic health is one of the most interesting aspects faced by the medical and dental scientific community. Chronic apical periodontitis shares important characteristics with PD: 1) both are chronic infections of the oral cavity, 2) the Gram-negative anaerobic microbiota found in both diseases is comparable, and 3) in both infectious processes increased local levels of inflammatory mediators may have an impact on systemic levels. One of the systemic disorders linked to PD is diabetes mellitus (DM); is therefore plausible to assume that chronic apical periodontitis and endodontic treatment are also associated with DM. The status of knowledge regarding the relationship between DM and endodontics is reviewed. Upon review, we conclude that there are data in the literature that associate DM with a higher prevalence of periapical lesions, greater size of the osteolityc lesions, greater likelihood of asymptomatic infections and worse prognosis for root filled teeth. The results of some studies suggest that periapical disease may contribute to diabetic metabolic dyscontrol.

Key words: Apical periodontitis, diabetes mellitus, endodontics, root canal treatment.

Type 2 diabetes mellitus and the prevalence of apical periodontitis and endodontic treatment in an adult Brazilian population

INTRODUCTION

This cross-sectional study evaluated the prevalence of apical periodontitis (AP) and endodontic treatment in type 2 diabetic individuals as compared with nondiabetics from an adult Brazilian population.

METHODS

Full-mouth radiographs from 30 type 2 diabetic and 60 age- and sex-matched nondiabetic individuals were examined, and the presence of AP lesions in untreated and root canal-treated teeth was recorded. The number of teeth and the prevalence of root canal treatment were also evaluated.

RESULTS

AP was significantly more present in teeth from diabetic individuals (98/652, 15%) than in nondiabetic controls (162/1,368, 12%) (P = .05). A separate analysis of untreated and treated teeth revealed that significance was mostly because of the prevalence of AP in untreated teeth, which was 10% in diabetics and 7% in nondiabetics (P = .03). No significant difference between diabetics and nondiabetics was observed for the other parameters under study, including the prevalence of AP in root canal-treated teeth, the number of teeth in the oral cavity, the number of treated teeth per individual, the number of individuals with at least 1 AP lesion or 1 root canal treatment, and the number of teeth with AP per individual (P > .05).

CONCLUSIONS

AP was significantly more prevalent in untreated teeth from type 2 diabetics. This suggests that diabetes may serve as a disease modifier of AP in the sense that individuals with diabetes can be more prone to develop primary disease. However, findings do not confirm that diabetes may influence the response to root canal treatment because treated teeth had no increased prevalence of AP when compared with controls.

Effects of the antioxidant agent tempol on periapical lesions in rats with doxorubicin-induced cardiomyopathy

INTRODUCTION

Cardiovascular diseases have been associated with increased risk of endodontic complications. This study evaluated the effects of the antioxidant agent tempol on periapical lesions in rats with doxorubicin-induced cardiomyopathy in comparison with control animals.

METHODS

Forty male Wistar rats were divided into 4 groups: (1) naïve rats orally treated with saline solution (10 mL/kg, during 21 days after periapical lesion induction); (2) naïve rats treated with tempol (30 and 50 mg/kg, during 21 days after periapical lesion induction) by oral pathway; (3) rats with doxorubicin-induced cardiomyopathy treated with saline solution by oral route (10 mL/kg, from day 3 to day 10 after initiating treatment with doxorubicin); and (4) rats with doxorubicin-induced cardiomyopathy orally treated with tempol (30 and 50 mg/kg, from day 3 to day 10 after initiating treatment with doxorubicin). Periapical lesions were induced on the first right mandibular molar tooth. After 21 days of apical periodontitis induction, the animals were killed, and the mandibles were collected for radiographic and histologic analysis.

RESULTS

The oral administration of tempol (50 mg/kg) was able to significantly prevent the establishment of periapical lesions in either control animals or rats submitted to the model of doxorubicin-induced cardiomyopathy, according to radiographic and histologic evaluation. Nevertheless, the protective effects of tempol were virtually greater in control animals in comparison with doxorubicin-treated rats, as indicated by histologic inflammatory assessment, which might be related to the increased production of free radicals under cardiomyopathy.

CONCLUSIONS

We provide novel evidence on the beneficial systemic effects of the antioxidant tempol on apical periodontitis in both control animals and rats with doxorubicin-elicited cardiomyopathy.