Root Canal Treatment and Apical Periodontitis in a Brazilian Population with Type 1 Diabetes Mellitus: A Cross-sectional Paired Study

Interplay between diabetes mellitus and periodontal/pulpal-periapical diseases

This longevity of life expectancy has indirectly led to an increase in the number of chronic diseases such as periodontitis, apical periodontitis (AP), and diabetes mellitus (DM) in the aging society, thus affecting people's quality of life. There is an interaction between periodontitis/AP and DM with a two-way relationship. Although type 1 and 2 diabetes (T1DM, T2DM) have different etiologies, glycemic control may affect the infection, inflammation and tissue healing of periodontitis and AP. Non-surgical periodontal treatment may influence the glycemic control as shown by decrease of HbA1c level in T2DM patient. However, the effect of periodontal treatment on glycemic control in T1DM and root canal treatment/apical surgery on T1DM and T2DM patients awaits investigation. DM may affect the periodontal and periapical tissues possibly via altered oral microbiota, impairment of neutrophils' activity and host immune responses and cytokine production, induction of oxidative stress etc. While periodontitis associated systemic inflammation and hyperlipidemia is suggested to contribute to the control of T2DM, more intricate studies are necessary to clarify the detailed mechanisms. The interactions between DM (T1DM and T2DM) and periodontitis and AP are therefore reviewed to provide a basis for the treatment of subsequent patients with pulpal/periodontal disease and diabetes. A two-pronged approach of medical and dental treatment is needed for the management of these patients, with emphasis on blood glucose control and improving oral hygiene and periodontal maintenance care, to ensure the best treatment outcome.

Prevalence of Apical Periodontitis in Patients with Autoimmune Liver Diseases on Immune Suppressants and Immune Modulators: A Cross-sectional Study

INTRODUCTION

Autoimmune liver diseases (ALDs) are chronic conditions generated by an immune-mediated autoaggressive inflammatory reaction in genetically susceptible individuals. The purpose of this study was to evaluate the prevalence of apical periodontitis (AP) in patients suffering from ALDs undergoing treatment with the immune suppressants glucocorticoids, azathioprine, and/or ursodeoxycholic acid.

METHODS

The ALD group included 46 patients (11 men and 35 women, average age = 57.9 ± 11.8 years) and 1186 teeth. The control group included 50 healthy patients not taking any medications (15 men and 35 women, average age = 58.6 ± 10.4 years) and 1251 teeth. Demographic data and medical, pharmacologic, and dental history were recorded. Dental and radiographic examinations were performed. The presence of AP; the periapical index score; decayed, missing, and filled teeth; quality of restoration, and root canal treatment were evaluated. The influence of the medications the patients were taking on the prevalence of AP was also tested.

RESULTS

The prevalence of AP was significantly lower in ALDs than in the control group at the patient (P = .019) and tooth level (P = .014). Smoking and age were associated with a significant increase in AP in cases and controls (P = .045 and P = .001, respectively). In both groups, endodontically treated teeth showed a higher prevalence of AP.

CONCLUSIONS

Considering the limitations because of the observational nature of the study, the patients affected by ALDs liver diseases and undergoing treatment with immune suppressors (often associated with immune modulators) were found to exhibit a lower prevalence of AP.

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.

Diabetes Mellitus Increases the Risk of Apical Periodontitis in Endodontically-Treated Teeth: A Meta-Analysis from 15 Studies

INTRODUCTION

At present, the incidence of diabetes mellitus (DM) is gradually increasing globally. In clinical practice, many patients with diabetes with apical periodontitis (AP) have poor and slow healing of periapical lesions. However, the potential relationship between the 2 is still unclear and controversial. The consensus is that DM can be deemed a risk factor for AP in endodontically-treated teeth. Therefore, we pooled existing studies and carried out a meta-analysis to explore the potential association between the 2.

METHODS

Studies that met the inclusion criteria were selected from the database, and relevant data were extracted. Stata SE 17.0 software was used to analyze the relevant data, and the Newcastle-Ottawa Scale was used to assess the literature's quality. The pooled odds ratio (OR) with a 95% confidence interval (CI) was used to determine the strength of the association between DM and the prevalence of AP after root canal treatment (RCT).

RESULTS

After searching, 262 relevant studies were retrieved, fifteen of which met the inclusion criteria. A total of 1087 patients with 2226 teeth were included in this meta-analysis. According to the findings, diabetics showed a higher prevalence of AP after RCT than controls at the tooth level (OR = 1.51, 95% CI = 1.22-1.87, P < .01). At the patient level, DM increased the probability of developing AP in RCT teeth more than 3 times (OR = 3.38, 95% CI = 1.65-6.93, P < .01). Additionally, subgroup analysis was performed by blood glucose status, preoperative AP, and study design. Except for the status of blood glucose, the results were significant in the other 2 groups (P < .05).

CONCLUSIONS

Available scientific evidence suggests that DM may increase the risk of AP in endodontically-treated teeth. In teeth with preoperative AP, DM might promote the development of AP.

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.

Periapical and endodontic status of patients with inflammatory bowel disease: Age- and sex-matched case-control study

AIM

Crohn's disease (CD) and ulcerative colitis (UC) are two chronic recurrent inflammatory processes of the gastrointestinal tract, grouped under the name inflammatory bowel disease (IBD), causing clinical episodes of intestinal inflammation. The aim of this study was to investigate the possible association between IBD and the prevalence of apical periodontitis (AP) and root canal treatment.

METHODOLOGY

A case-control study design matched to age and sex was used. The study group (SG) included 28 patients with IBD (13 with CD, 15 with UC). Another 28 healthy subjects, without IBD and age- and sex-matched, were included in the control group (CG). Radiographic records were analysed and AP was diagnosed as radiolucent periapical lesions (RPLs), using the periapical index score. Student's t-test, χ2 test and multivariate logistic regression were used in the statistical analysis.

RESULTS

In the CG, only 17 subjects (61%) had at least one tooth with AP, whilst in the SG group they were 23 patients (82%; OR = 2.98; 95% CI = 0.87-10.87; p = .08). The number of subjects with one or more root filled teeth (RFT) in the CG was 14 (50%), whilst in the SG they were 22 (79%; OR = 3.67; 95% CI = 1.14-11.79; p = .026). At least one RFT with AP was evident in three subjects (10.7%) in the CG, whilst in the SG 15 patients (53.6%) showed RFT with AP (OR = 9.60; 95% CI = 2.35-39.35; p = .001). In the multivariate logistic regression analysis, only endodontic status was found to be associated with IBD (OR = 1.86; 95% CI = 1.24-2.80; p = .003).

CONCLUSION

IBD, UC and Crohn's disease are associated with higher prevalence of RFT and higher percentage of RFT with periapical lesions. Dentists should consider these findings when caring for IBD patients by monitoring the evolution of periapical lesions of endodontically treated teeth.

The Complex Interrelationship between Diabetes Mellitus, Oral Diseases and General Health

There is emerging evidence that several oral diseases and conditions can be associated with DM. Dental caries, hyposalivation, fungal diseases and endodontics lesions may represent potential oral complications that can be aggravated by chronic hyperglycemia. Individuals with DM have a low perception of oral diseases which can lead to clinically important oral and systemic complications. This review aims to provide data on the most common oral signs and symptoms related to DM and to explore the mechanisms that might explain associations between DM and oral diseases in order to clarify the risks posed by poor oral health in DM. Since the linkage between oral diseases and DM is part of multifactorial aspects related to chronic hyperglycemic status and several common conditions affecting the whole body, both require rigorous self-control from patients and attention from medical and dental professionals.

Association between Pulpal-Periapical Pathology and Autoimmune Diseases: A Systematic Review

Several studies have linked apical periodontitis and systemic diseases. The aim of this study is to present a systematic review of the available literature investigating whether there is an association between pulpal-periapical pathology and autoimmune disease. The review was conducted following the PRISMA statement. A literature search was performed in five databases. Studies involving patients with pulpal-periapical pathology and autoimmune diseases were included in the review. Based on the PICO model, the research question aimed to assess whether there is an increased risk of developing pulpal-periapical pathology in patients with autoimmune disease. Article selection, data extraction, and quality assessment were performed using an adapted version of the STROBE guidelines. A total of seven studies were included in our review. The types of articles were five case-control and two cross-sectional studies. Periapical pathologies were associated to three autoimmune diseases (diabetes mellitus I, rheumatoid arthritis, and inflammatory bowel disease). Among the included studies, four show a low risk of bias, while three present a moderate risk. There could be an association between apical periodontitis and autoimmune diseases, although most studies report statistically non-significant associations.

Evolution of endodontic medicine: a critical narrative review of the interrelationship between endodontics and systemic pathological conditions

Endodontics has gained emphasis in the scientific community in recent years due to the increase in clinical and in animal models studies focused on endodontic medicine, which aims to evaluate the interrelationship between systemic and periapical tissues pathological conditions. These studies have shown that systemic changes can boost the pathogenesis of endodontic infection, favoring its development and progression. A contrary relationship is reported in numerous studies that affirm the potential of endodontic infection to trigger systemic damage and may lead to the worsening of pre-existing pathologies. Recently, the potential of filling materials to develop systemic changes such as neurological alterations had been evaluated, also showing that systemic diseases can negatively influence tissue responses to filling materials after endodontic treatment. Despite advances in endodontic medicine studies, there are still gaps in knowledge on the mechanisms of interactions between apical periodontitis (AP) and systemic diseases and much research to be done. In this sense, this critical narrative literature review aimed to show the evolution of studies in endodontic medicine to help the endodontist to know the role of systemic diseases in the pathogenesis of AP and the possible interference in the repair of periapical tissues after endodontic treatment, as well as to evidence the systemic complications that can be triggered or aggravated in the presence of endodontic infection.

Comparative analysis of different periapical index systems used in cone-beam computed tomography

This study aimed to compare the three index systems designed for cone-beam computed tomography (CBCT) in terms of intra- and inter-observer agreement. 117 root-filled teeth with or without periapical radiolucency from 77 of already existing CBCT images were chosen randomly. Two observers evaluated the periapical status of the selected teeth and graded the scores twice using CBCT periapical index (CBCTPAI), endodontic radiolucency index (ERI) and complex periapical index (COPI) part of the periapical and endodontic status scale (PESS), respectively. The researchers' self-agreement kappa values ranged from substantial to almost perfect. A moderate inter-observer agreement was present for the COPI and ERI, whereas a fair agreement was present for CBCTPAI. The researchers' ICC for the inter-observer reliability of CBCTPAI, ERI and COPI was 0.75, 0.77 and 0.80, respectively. COPI had the highest self-agreement and inter-observer reliability. ERI showed the highest intra-observer variation, whereas CBCTPAI showed the highest inter-observer variation.