Endothelial Dysfunction Marker Variation in Young Adults with Chronic Apical Periodontitis before and after Endodontic Treatment

Association between severity of dental caries and the risk of stroke

OBJECTIVE

The relationship between dental caries and stroke remains inconclusive. The aim of this study is to investigate whether different severities of dental caries affect the risk of stroke.

METHODS

This retrospective cohort study was conducted using the 2000-2013 Taiwan National Health Insurance Database. We selected 23,662 patients with advanced/severe dental caries and 23,662 patients with incipient/moderate dental caries between 2000 and 2006. These patients were followed to the occurrence of stroke or to the end of the study in 2013. Hazard ratios (HRs) and 95% confidence intervals (CIs) derived from the Cox proportional hazards models were calculated to assess the association between severity of dental caries and the risk of stroke.

RESULTS

The advanced/severe dental caries group had a significantly higher risk of stroke compared with incipient/moderate dental caries group (adjusted HR, 1.16; 95% CI, 1.03-1.31). Stratified analyses showed that advanced/severe dental caries was positively associated with the risk of ischemic stroke in patients aged ≥40 years and with the risk of hemorrhagic stroke in patients aged <40 years.

CONCLUSION

There is a severity-dependent association between dental caries and stroke in an Asian population.

Endodontic Treatment of Chronic Apical Periodontitis Ameliorates Systemic Inflammation and Restores Impaired Cellular Responses to Insulin in an In Vitro Model

INTRODUCTION

A growing body of research supports an association between periapical inflammation and an increased risk of developing systemic diseases. There is currently no scientific evidence to support a causal effect of inflammation on the onset of insulin resistance (IR) in patients with apical periodontitis (AP). The aim of this in vitro study was to evaluate any association between AP and levels of serum inflammatory factors potentially associated with the onset of IR, and to investigate the effect of root canal treatment (RCT) on these systemic inflammation markers and on the response in vitro to insulin.

METHODS

A total of 27 control subjects and 27 patients with AP were enrolled. Patients with AP underwent RCT and were followed-up 6 and 12 months post-treatment. Enzyme-linked immunosorbent assays were used to evaluate serum levels of proinflammatory cytokines interleukin (IL)-1, IL-6, IL-8, and tumor necrosis factor (TNF)-α. The response in vitro to insulin was assessed by measuring glucose consumption in a human pancreatic epithelioid carcinoma cell line treated with sera from healthy and AP subjects.

RESULTS

At baseline AP was associated with significant higher levels of IL-1, IL-6, and IL-8 in the serum of untreated (AP) patients vs controls (P < .001). Glucose consumption decreased in pancreatic cells incubated with baseline serum from patients with AP, in a manner proportional to total cytokines amount. Notably, endodontic treatment was associated with reduced levels of cytokines (P < .001) and improved response to insulin in AP group (P < .001).

CONCLUSIONS

Our findings suggest that AP may promote inflammatory-driven IR in an in vitro model, and that RCT may ameliorate inflammatory mediators in vivo and the cellular response to insulin in vitro.

Is there any association between the presence of biomarkers and apical periodontitis? A systematic review

This systematic review aimed to verify whether there is evidence of an association between apical periodontitis and the presence of systemic biomarkers. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA. For this, the acronym PECO was used; population (P) of adult humans exposed (E) to the presence of apical periodontitis, compared (C) to adult humans without apical periodontitis, and the outcome (O) of the presence of biomarkers was observed. The articles were searched in PubMed, Scopus, Web of Science, LILACS, Cochrane Library, OpenGray, and Google Scholar grey databases. Subsequently, studies were excluded based on title, abstract, and full article reading, following the eligibility criteria. The methodological quality of the selected studies was evaluated using the Newcastle-Ottawa qualifier. After exclusion, 656 studies were identified, resulting in 17 final articles that were divided into case-control, cross-sectional, and cohort studies. Eight studies were considered to have a low risk of bias, one had a medium risk of bias, and eight had a high risk of bias. In addition, 12 articles evaluated biomarkers in blood plasma, four evaluated them in saliva, and only one evaluated them in gingival crevicular fluid. The results of these studies indicated an association between apical periodontitis and the systemic presence of biomarkers. These markers are mainly related to inflammation, such as interleukins IL-1, IL-2, and IL-6, oxidative markers, such as nitric oxide and superoxide anions, and immunoglobulins IgG and IgM.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier (CRD42023493959).

Reduced C-reactive protein levels after root canal treatment in clinically healthy young apical periodontitis individuals at cardiovascular risk. A prospective study

AIM

To determine the systemic inflammatory burden, including hsCRP and its monomeric forms, in patients with apical lesions of endodontic origin treated with root canal treatment (RCT).

METHODOLOGY

Prospective pre-/post-study. Apical periodontitis (AP) individuals aged 16-40 were included (N = 29). Individuals received RCT and were followed at 1 and 6 months. Fasting blood samples were obtained. Apical lesions of endodontic origin (ALEO) diameter (mm), and periapical index (PAI), were recorded. The serum concentrations of total hsCRP were determined by turbidimetry. Tumour necrosis factor (TNF)-α, interleukin (IL)-6, IL-10, IL-1β, and soluble (s) E-selectin were assessed by Multiplex assay. Additionally, mCRP forms were determined in the serum of AP patients with a baseline moderate to high cardiovascular risk based on hsCRP stratification (hsCRP ≥1 mg/L) by immunowestern blot (n = 15). Also, CRP isoforms were explored in ALEOs from AP individuals (n = 4). Data were analysed with StataV16.

RESULTS

Periapical index and ALEO sizes were reduced at both follow-up visits after RCT (p < .05). Serum levels of TNF-α, IL-6, IL-10, IL-1β, and sE-selectin did not show significant differences. CRP was borderline reduced at 1 month (p = .04); however, in AP individuals at cardiovascular risk (hsCRP ≥ 1 mg/L), hsCRP and its monomeric isoform significantly decreased at 1 and 6 months (p < .05).

CONCLUSIONS

High-sensitivity CRP and mCRP are reduced after RCT in AP individuals at cardiovascular risk.

Asymptomatic Apical Periodontitis Lesions and Their Association With Systemic Inflammatory Burden: A Preliminary Prospective Clinical Study

Background: Apical periodontitis (AP) is an inflammatory disorder of the periapical tissues caused by the persistence of a microbial infection within the root canal system of the affected tooth. Clinically, it is symptomatic or asymptomatic depending on several factors such as the type of microorganisms, bacterial load, immunological reaction, and local tissue mediators. Chronic or asymptomatic infections may initiate and modulate intravascular accumulation of inflammatory cells resulting in endothelial dysfunction which subsequently represents a possible systemic inflammatory burden. Aim: The present study aimed to evaluate the relationship between asymptomatic AP and systemic inflammatory burden by assessing the levels of chronic inflammatory cells. Methodology: A total of 25 patients diagnosed with asymptomatic AP who showed a negative response to the pulp sensitivity test with no history of any systemic diseases were included in this preliminary prospective observational study. Blood samples were collected at each phase of the study, and a complete hemogram was carried out. All hematological parameters were recorded before and after root canal therapy and they were analyzed for statistical significance at p <.05 using IBM SPSS Statistics for Windows, Version 21 (Released 2012; IBM Corp., Armonk, New York, United States). Results: Evaluation of the mean total leukocyte count (TLC), lymphocyte, and eosinophil cell count showed a significant reduction in the number of cells before and after root canal therapy treatment respectively (p<.05). One-way analysis of variance also revealed statistical significance at p < .05 with a weak positive correlation between the TLC, lymphocyte, and eosinophil count before and after treatment. Conclusion: The present study showed that systemically healthy individuals with asymptomatic AP had increased inflammatory burden in the circulation, and thus, it is essential to identify and quantify the risk associated. It was evident that complete healing of the asymptomatic AP lesions results in an overall reduction of systemic inflammatory cells ultimately reducing the burden and risk of associated systemic inflammatory diseases.

Effect of endodontic treatment on endothelial dysfunction and subclinical atherosclerosis-a prospective intervention study

OBJECTIVE

The objective of this study is to investigate the effect of endodontic treatment on flow-mediated dilatation (FMD) and carotid intima-media thickness (c-IMT) in patients with apical periodontitis (AP).

MATERIAL AND METHOD

The study includes 32 young men having AP with a mean age of 25.78 years free from cardiovascular disease (CVD) and its risk factors, including periodontitis. All subjects underwent complete physical and dental examination, echocardiography, and ultrasound assessment of FMD on the brachial artery and c-IMT on the carotid artery at baseline and 12 months after the endodontic treatment. Data were analyzed using paired Student's t-test and Pearson's correlation coefficient (r) test using SPSS 26 version.

RESULTS

Endodontic treatment leads to the improvement of FMD significantly from a pooled baseline value of 4.84 ± 1.55% to 7.68 ± 2.08% (p < 0.05). The study also depicts a statistically significant difference between c-IMT (mean = 0.62 ± 0.11 mm) before treatment as compared to 12 months after treatment (mean = 0.59 ± 0.11 mm) (p < 0.05).

CONCLUSION

Endodontic treatment leads to improved FMD and decreased c-IMT suggesting that treating AP can be help revert the early stages of CVD.

CLINICAL RELEVANCE

AP could be a potential etiological factor of future CVD and should be treated as soon as diagnosed.

Association of severely damaged endodontically infected tooth with carotid plaque and abnormal carotid intima-media thickness: a retrospective analysis

OBJECTIVE

We investigated the association of severely damaged endodontically infected tooth with carotid artery plaque and abnormal mean carotid intima-media thickness (CIMT) ≥ 1.0 mm.

METHODS

A retrospective analysis of 1502 control participants and 1552 participants with severely damaged endodontically infected tooth who received routine medical and dental checkup in Health Management Center, Xiangya Hospital was performed. Carotid plaque and CIMT were measured with B-mode tomographic ultrasound. Data were analyzed using logistic and linear regression.

RESULTS

Severely damaged endodontically infected tooth group had a significantly higher prevalence of carotid plaque (41.62%) compared to 32.22% of carotid plaque in control group. Participants with severely damaged endodontically infected tooth had a significantly higher prevalence of abnormal CIMT (16.17%) and a significantly increased level of CIMT (0.79 ± 0.16 mm) in comparison to 10.79% of abnormal CIMT and 0.77 ± 0.14 mm CIMT in control participants. Severely damaged endodontically infected tooth was significantly related with formation of carotid plaque [1.37(1.18-1.60), P < 0.001], top quartile length [1.21(1.02-1.44), P = 0.029] and top quartile thickness [1.27(1.08-1.51), P = 0.005] of carotid plaque and abnormal CIMT [1.47(1.18-1.83), P < 0.001]. Severely damaged endodontically infected tooth was significantly associated with both single [1.277(1.056-1.546), P = 0.012] and multiple carotid plaques [1.488(1.214-1.825), P < 0.001] and instable carotid plaques [1.380(1.167-1.632), P < 0.001]. Presence of severely damaged endodontically infected tooth increased 0.588 mm of carotid plaque length (P = 0.001), 0.157 mm of carotid plaque thickness (P < 0.001) and 0.015 mm of CIMT (P = 0.005).

CONCLUSION

Severely damaged endodontically infected tooth was associated with carotid plaque and abnormal CIMT.

CLINICAL RELEVANCE

Early treatment of endodontically infected tooth is warranted.

Evaluation of the correlation between oral infections and systemic complications in kidney transplant patients: a retrospective pilot study

BACKGROUND

Data regarding the efficacy of the dental clearance required prior to kidney transplantation (KT) for preventing post-transplant complications is controversial. The aim of this retrospective study was to investigate a possible correlation between any untreated oral infectious foci and the onset of systemic complications in KT patients.

METHODS

Patients scheduled for regular check-ups during the post-transplant period were visited at the C.I.R. Dental School in Turin, Italy. Patients were asked to bring orthopantomography (OPT) acquired prior to transplantation to compare the possible presence of untreated infectious foci at the time of transplantation with the time of their post-transplant visit. Patients were then divided, according to the evaluation of the OPT obtained prior to the transplantation, into two groups according to their dental status prior to the transplant. "Group Infected" was comprised of patients with no dental clearance, and "Group Clear" included patients with dental clearance. The medical records were then retrospectively reviewed for the evaluation of any systemic complications that occurred after transplantation. The following medical complications were considered: fever, pneumonia, urinary tract infections, systemic infections, kidney rejection, and death. Complications were divided in two groups: early complications, which occurred within 100 days of transplantation, and late complications, which occurred more than 100 days after transplantation.

RESULTS

A total of 77 patients were enrolled in the study. Group Infected was composed of 19 subjects (25%), while Group Clear was composed of 58 patients (75%). In Group Infected, 13 (68%) patients developed complications within 100 days of transplantation, and 11 (58%) did so after 100 days. In Group Clear, 31 (53%) patients had complications within 100 days of the transplant, and 23 (40%) did after 100 days. Patients in Group Infected had a statistically significant increase in episodes of fever (p = 0.03), compared to Group Clear, with a higher relative risk (RR) of 3.66 in the first 100 days after transplantation.

CONCLUSION

Within the limitations of the present retrospective pilot study, and based on the results, a correlation between the absence of dental clearance prior to KT and a higher RR of developing a fever within the first 100 days post transplantation was highlighted. The present results encourage doctors to continue research on the topic, which remains controversial. Further prospective studies are required to confirm the results of the present study.

The Link between Stroke Risk and Orodental Status-A Comprehensive Review

One of the primary causes of disability and mortality in the adult population worldwide is stroke. A person's general health is significantly impacted by their oral and dental health. People who have poor oral health are more susceptible to conditions such as stroke. Stroke risk has long been linked to oral and dental conditions. The risk of stroke and its cost impact on the healthcare systems appear to be significantly reduced as a result of the decline in the incidence and prevalence of oral and dental illnesses. Hypothetically, better management of oral hygiene and dental health lead to reduced stroke risk. To the authors' best knowledge, for the first time, the potential link between dental health and stroke were cross-examined. The most typical stroke symptoms, oral and dental illnesses linked to stroke, and the role of oral healthcare professionals in stroke prevention are revealed. The potential mediating processes and subsequent long-term cognitive and functional neurological outcomes are based on the available literature. It must be noted that periodontal diseases and tooth loss are two common oral health measures. Lack of knowledge on the effects of poor oral health on systemic health together with limited access to primary medical or dental care are considered to be partially responsible for the elevated risk of stroke. Concrete evidence confirming the associations between oral inflammatory conditions and stroke in large cohort prospective studies, stratifying association between oral disease severity and stroke risk and disease effects on stroke survival will be desirable. In terms of clinical pathology, a predictive model of stroke as a function of oral health status, and biomarkers of systemic inflammation could be useful for both cardiologists and dentists.

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.

The impact of apical periodontitis, non-surgical root canal retreatment and periapical surgery on serum inflammatory biomarkers

AIM

The aim of the study was to measure serum levels of molecular markers of inflammation in patients undergoing non-surgical root canal retreatment (Re-RCT) and periapical surgery (PS) for the treatment of apical periodontitis and to establish if such levels are influenced by the size of apical radiolucencies at baseline and by the treatment outcome.

METHODOLOGY

A total of 115 participants were recruited (n = 50 Controls, n = 35 Re-RCT, n = 30 PS). Preoperative periapical radiographs and cone beam CT (CBCT) scans of teeth were taken. Blood was collected from treatment groups at baseline, 3-, 6-, and 12-month post-treatment and from controls at baseline and 12 months. Serum levels of IL-1β, IL-6, IL-8, TNF-α, Pentraxin 3, ICAM-1, VCAM-1, hs-CRP, FGF-23, MMP-2, MMP-8, MMP-9, C3 and ADMA were analysed using multiplex immunoassay and enzyme-linked immunosorbent assay. Different time points within the same group were compared using Wilcoxon signed-rank test, and differences between groups were analysed using the Mann-Whitney test. Non-linear association between different factors was assessed using Spearman's correlation.

RESULTS

Preoperative serum levels of FGF-23, IL-1β, hs-CRP and ADMA were significantly higher in the diseased groups compared with controls (p < .001; p = .008; p < .001; p = .013, respectively). The preoperative size of the radiolucency was associated with increased levels of FGF-23, IL-1β and IL-6. At 3-months following treatment, IL-1β, IL-8, hs-CRP, C3, MMP-2 and MMP-9 levels increased compared with baseline in treatment groups. IL-1β and IL-8 further increased at 6 months, whereas FGF-23, hs-CRP, C3, MMP2 and MMP-9 decreased. One-year post-treatment, FGF-23, pentraxin-3 and ADMA were significantly reduced below baseline levels. At the 1-year review, CBCT revealed that 25.9% of treated cases completely healed, while 63% were healing, and 11.1% failed. Treatment outcome was found to be influenced by preoperative levels of ADMA and IL-8 levels at 6 months.

CONCLUSIONS

Both symptomatic and asymptomatic apical periodontitis (AP) can contribute to increased levels of molecular markers of inflammation. A further transient inflammatory markers rise after root canal retreatment and apical surgery were demonstrated. Successful endodontic treatment and periapical surgery result in a long-term reduction in inflammatory marker levels.

Chronic Endodontic Infections and Cardiovascular Diseases: Does the Evidence Support an Independent Association?

Previous studies have shown that endodontic infections might increase the risk of cardiovascular diseases. However, there is no conclusive evidence that endodontic infections are associated with cardiovascular diseases among individuals with cardiac conditions. This systematic review aimed to collect and evaluate the current evidence on the relationship between chronic endodontic infections and cardiovascular diseases.

The PubMed, Scopus, and Web of Science databases were searched, and Google Scholar was used to retrieve relevant clinical studies within the past 10 years (2011-2021). Observational studies (prospective cohort, retrospective cohort, cross-sectional, and case-control studies), which investigated the impact of endodontic infections and apical periodontitis in individuals with cardiac conditions at risk of cardiovascular disease, in English were considered. Review papers, duplicates, animal studies, and other irrelevant studies were excluded. Four investigators independently carried out the study selection and data collection processes. Quality assessment was performed in this review. Fourteen studies with 960,652 human subjects were included in this review. No association between endodontic infections and cardiovascular diseases among individuals with cardiac conditions was noted. Most of the studies showed a moderate overall risk of bias by 57.14% (n=8).

There is weak evidence regarding the association between cardiovascular diseases and chronic endodontic infections. Further longitudinal clinical studies are required to determine the association between cardiovascular diseases and endodontic infections.

Cardiovascular Disease and Chronic Endodontic Infection. Is There an Association? A Systematic Review and Meta-Analysis

The aim of the present study was to systematically assess existing evidence on the possible association between chronic endodontic infections and cardiovascular disease (CVD). An electronic database search was implemented until 2 October 2020. The main outcome was risk of CVD diagnosis. Risk of bias was assessed through the ROBINS-I tool, while random effects meta-analyses were conducted. The quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation. Twenty-one studies were eligible for inclusion, while 10 were included in the quantitative synthesis. Risk for CVD diagnosis in patients with chronic endodontic infection was 1.38 times those without infection (RR = 1.38; 95% CIs: 1.06, 1.80; p = 0.008). Risk of bias ranged from moderate to serious, while the quality of the evidence was graded as very low. Indications for an identified association between chronic endodontic infection and CVDs do exist; however, they are not grounded on high-quality evidence at present. Further research for an establishment of an association based on temporal sequence of the two entities and on unbiased well-conducted cohort studies would be highly valued.

Impact of endodontic and periodontal diseases and treatments on the aorta and liver of obese and non-obese rats

AIM

To evaluate the impact of the presence and treatment of periodontal disease (PD) and apical periodontitis (AP) on the aorta and liver of obese and non-obese rats.

METHODOLOGY

One hundred and forty Wistar rats were divided into two groups, according to the diet administered: normal diet (-n), without obesity; and cafeteria diet (-c), with induced obesity. These groups were divided into seven subgroups according to the specific experimental protocols: naïve control (NC); AP; AP with treatment (APt); PD; PE with treatment (PDt); AP and PD (APPD); and AP and PD with treatment (APPDt). AP and PD lesions were induced for four weeks. Four weeks after treatments, the animals were euthanatized, and the aorta and liver were dissected for histological evaluation. For the comparison of the thickness of the aorta between groups, the Kruskal-Wallis test was used, followed by the Mann-Whitney test. For the analysis of other variables related to the aorta and liver outcomes, logistic regression was carried out.

RESULTS

Both PD and AP were associated with the development of histological alterations in the aortic arch, with no significant difference between obese and non-obese animals (p = .17). The aorta thickness was increased significantly (p < .05) with the combination of PD and AP in obese rats (APPDt-c group) compared with the other groups (NC-n, APt-n, APt-c and AP-c). The logistic regression models revealed that the untreated (OR = 7.78; 95%CI = 2.4-25) and treated (OR = 2.9; 95%CI = 1.0-8.4) groups were significantly more likely to have endothelial alterations compared with the control groups (p = .002). Obesity (OR = 16.5; 95%CI = 3.4-81.3) was the only predictor variable of liver steatosis (p < .001).

CONCLUSION

Histological alterations in the aortic arch of obese and non-obese rats were observed in the presence of periodontal disease and apical periodontitis. The combination of PD and AP increased the aorta thickness in obese rats. A reduction of vascular endothelial lesions was observed with the treatments of PD and AP.

Cardiac, biochemical and histopathological analysis reveals impaired heart function in hypertensive rats with apical periodontitis

AIM

To investigate the association between experimentally induced apical periodontitis (AP) and heart function in hypertensive rats.

METHODOLOGY

Forty-eight normotensive Wistar albino and spontaneously hypertensive (SHR) rats were divided into four equal groups: control (C), normotensive with AP (AP), SHR and SHR with AP (SHR + AP). AP was induced on the first right mandibular molars by exposing the pulp chambers to the oral environment for four weeks and confirmed radiographically. Thereafter, the animals were sacrificed by cervical dislocation, whilst hearts were isolated and perfused according to the Langendorff technique gradually increasing coronary perfusion pressures 40-120 cmH₂ O. The hemimandibles were analysed radiographically (mm² and pixels) to verify the presence of AP. Biomarkers of cardiac oxidative stress (OS) were determined in coronary venous effluent and cardiac tissue homogenate. Cardiac tissue was analysed histopathologically for signs of heart damage (oedema, fibrosis and necrosis). All data were analysed by Kruskal-Wallis and one-way anova tests (p < .05).

RESULTS

The levels of the maximum left ventricular pressure development rate of the SHR + AP group were significantly increased compared to the AP and C groups, and of the SHR group compared with the C group (p < .05). The levels of the minimum left ventricular pressure development rate of the SHR + AP group were significantly decreased compared to the AP, SHR and C groups, and of the SHR group compared to the C group (p < .05). The radiographic AP area was significantly larger in the SHR + AP group than in the AP group (p < .01). The levels of superoxide anion were significantly higher in the SHR + AP group than in the AP, SHR and C groups (p < .05). The activities of superoxide dismutase in cardiac tissue homogenate were significantly lower in the SHR + AP and AP groups compared with the SHR and C groups (p < .05).

CONCLUSIONS

In rats, AP was associated with impaired cardiodynamics, disturbed cardiac OS, antioxidant defence and cardiac pathologic changes in hypertensive conditions. Hypertension was associated with an increase in the AP radiographic area. Further studies should confirm whether root canal treatment can have a cardioprotective effect and reduce cardiac OS in hypertensive conditions.

Can Probiotics Emerge as Effective Therapeutic Agents in Apical Periodontitis? A Review

Apical periodontitis (AP) is a biofilm-associated disease initiated by the invasion of dental pulp by microorganisms from the oral cavity. Eradication of intracanal microbial infection is an important goal of endodontic treatment, and this is typically accomplished by mechanical instrumentation and application of sodium hypochlorite and chlorhexidine. However, these agents are tissue-irritating at higher concentrations and cytotoxic. Certain probiotics have been found effective in controlling marginal periodontitis, as evidenced by reduction of pathogenic bacterial loads, gains in clinical attachment levels, and reduced bleeding on probing. In vitro studies have shown inhibitory activity of some probiotics against endodontic pathogens. Similarly, in vivo studies in rats have demonstrated a positive immuno-modulatory role of probiotics in AP, as manifested by decreased levels of proinflammatory markers and increased levels of anti-inflammatory markers. A role for probiotics in effecting a reduction of bone resorption has also been reported. This review provides an outline of current research into the probiotic management of AP, with a focus on understanding the mechanisms of their direct antagonistic activity against target pathogens and of their beneficial modulation of the immune system.

Impact of root canal treatment on high-sensitivity C-reactive protein levels in systemically healthy adults with apical periodontitis - a preliminary prospective, longitudinal interventional study

AIM

To assess the influence of root canal treatment on serum high-sensitivity C-reactive protein (hsCRP) levels in systemically healthy human adults.

METHODOLOGY

Fifteen individuals aged 20-40 years diagnosed with apical periodontitis [Periapical Index (PAI) score ≥3] who were otherwise healthy took part in this prospective interventional study. Patients with moderate to severe periodontitis, systemic diseases and traditional cardiac risk factors (hypertension, diabetes, dyslipidemia and smoking) were excluded. Root canal treatment was completed in two visits with an inter-appointment calcium hydroxide intracanal medicament. After 6 months, healing of apical periodontitis was evaluated clinically and radiographically, and serum hsCRP levels were recorded. A paired sample T-test was used to compare the mean hsCRP values between the pre- and post-treatment groups. The Mann-Whitney U test was used to compare hsCRP values between patients with PAI scores of 3 and 4, and the Wilcoxon signed-rank test was used to compare pre- and postoperative PAI scores.

RESULTS

The mean preoperative baseline serum hsCRP level was 2.88 ± 1.06 mg L^-1 which can be associated with a moderate risk for cardiovascular disease (CVD). Based on the preoperative hsCRP levels, eight of the 15 patients were categorized as high risk (hsCRP > 3 mg L^-1 ) and the other seven as medium risk (hsCRP 1-3 mg L^-1 ) for CVD. The mean preoperative hsCRP value of patients with a PAI score of 3 was 2.88 ± 1.19 mg L^-1 , and the mean preoperative hsCRP of patients with a PAI score of 4 was 2.87 ± 0.15 mg L^-1 , which was not significantly different (P = 0.942). Six months after root canal treatment, the mean PAI score had significantly reduced from 3.2 ± 0.42 to 1.4 ± 0.69 (P = 0.003). The PAI score had reduced to ≤2 in 87% of the patients, and the mean serum hsCRP levels had significantly reduced to 1.34 ± 0.52 mg L^-1 (P < 0.001). Ten of the 15 patients had a reduction in their CVD risk status.

CONCLUSIONS

This study suggests that root canal treatment can reduce serum hsCRP levels in systemically healthy individuals with apical periodontitis.

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.

Relationship between Apical Periodontitis and Metabolic Syndrome and Cardiovascular Events: A Cross-Sectional Study

Aim: Both apical periodontitis (AP) and metabolic syndrome (MetS) are associated with atherosclerotic cardiovascular disease (ACVD), the main cause of cardiovascular events. The aim of this study was to investigate the prevalence of AP and the oral inflammatory burden in control subjects and patients suffering cardiovascular events, analyzing the possible association between AP and the oral inflammatory burden with MetS. Materials and Methods: Using a cross-sectional design, 83 patients suffering a cardiovascular event were recruited in the study group (SG), and 48 patients without cardiovascular events were included in the control group (CG). Periapical index (PAI) was used to diagnose AP, and total dental index (TDI) was used to assess the total oral inflammatory burden. Diagnosis of MetS was made by meeting three or more American Heart Association Scientific Statement components. Results: In the multivariate logistic regression analysis, the number of teeth with AP (OR = 2.3; 95% C.I. = 1.3–4.3; p = 0.006) and TDI scores (OR = 1.5; 95% C.I. = 1.2–1.9; p = 0.001), significantly correlated with cardiovascular events. MetS was strongly associated (OR = 18.0; 95% C.I. = 6.5–49.7; p = 0000) with cardiovascular events. Higher TDI scores were significantly associated with MetS (OR = 1.3; 95% C.I. = 1.1–1.6; p = 0.003. Neither the number of root-filled teeth (RFT) (OR = 0.9; 95% C.I. = 0.6–1.3; p = 0.61) nor the number of teeth with apical periodontitis (OR = 1.1; 95% C.I. = 0.8–1.7; p = 0.49) were associated with MetS. Conclusions: Apical periodontitis is significantly associated with cardiovascular events. Total oral inflammatory burden assessed by TDI, but not AP alone, is associated with MetS.

Cardiovascular diseases and apical periodontitis: association not always implies causality

Background

Several studies published in the last two decades have found an association between the prevalence of apical periodontitis (AP) or root canal treatment (RCT) and cardiovascular diseases (CVDs). However, the demonstration of association does not prove by itself the existence of a cause–effect relationship. Two diseases can appear as statistically related without any of them directly affecting the values of the other, resulting in a non-causal relationship. The aim of this narrative review is to summarize the current state of knowledge regarding the association between AP and CVDs, analysing it according to the Hill's causality criteria.

Material and Methods

Epidemiological studies carried out on the association between CVDs and AP or RCT published in English until 8 December 2019 were identified. Forty-four articles were selected and its results were analysed.

Results

Numerous cross-sectional epidemiological studies have found significant relationship between CVDs and AP. The odds ratio values range 1.6 - 5.4. However, other studies have not found significant association. Respect to RCT, some studies found correlation, but others found no association or even found that RCT is a protective factor against CVDs.

Conclusions

The results are inconsistent and a causal relationship between CVDS and endodontic disease cannot be stablished. The risk factors common to both diseases can act as confounding factors, biasing the results. To reach definitive conclusions about the type of association (causal or non-causal) between both diseases, longitudinal epidemiological studies must be carried out to establish the temporal relationship and the dose-response gradient.

Key words:Apical periodontitis, atherosclerosis, cardiovascular disease, coronary heart disease, endodontic medicine, root canal treatment.

Relationship between apical periodontitis and atherosclerosis in rats: lipid profile and histological study

AIM

To investigate the relationship between apical periodontitis and atherosclerosis in rats by lipid profile and carotid artery intima tunic measurement, and histological and histometric evaluation of periapical lesions.

METHODOLOGY

Forty male Wistar rats were allocated into four groups: control (C), with apical periodontitis (AP), with atherosclerosis (AT) and with AP and AT (AP + AT). Atherosclerosis was induced using a high-lipid diet associated with a surgical ligature in the carotid artery and a super dosage of vitamin D₃ . AP was induced via pulp exposure to the oral environment. At 45 and 75 days, serum levels of total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) were measured. The maxillary and mandibular jaws and carotid artery were collected and processed for histological analysis. The Kruskal-Wallis or Mann-Whitney test was performed for nonparametric data, and the Tukey's or Student's t-test was performed for parametric data (P < 0.05).

RESULTS

In nonatherosclerotic animals, the induction of apical periodontitis increased TG levels significantly, from 63.1 ± 11.4 mg dL^-1 in group C to 88.2 ± 7.9 mg dL^-1 in the AP group (P < 0.05). The induction of AP was associated with a trend for higher TC and LDL-C levels in atherosclerotic animals (P > 0.05); however, it only significantly increased TG levels, from 93.2 ± 18.0 mg dL^-1 in AT group to 121.9 ± 14.5 mg dL^-1 in the AP + AT group (P < 0.05). Animals in the AP + AT group had a 36.5% increase in the thickness of the carotid intima tunic when compared with the AT group (P < 0.05). The intensity of the inflammatory infiltrate was significantly larger in the AP + AT group when compared with AP group (P < 0.05). The AP + AT group exhibited significantly greater alveolar bone loss, with a periapical lesion size of 206.4 ± 56.3 × 10⁴ μm² , compared with 151.4 ± 49.1 × 10⁴ μm² in the AP group (P < 0.05).

CONCLUSION

Apical periodontitis influenced triglyceride levels, increasing them even in the absence of atherosclerosis, and influenced the increase in the thickness of the carotid artery intima tunic in the presence of atherosclerosis. Atherosclerosis intensified the inflammatory reaction and increased bone resorption in periapical lesions.