Socio‐economic and health status as a predictor of apical periodontitis in adult patients in Croatia

Assessment of Systemic Condition and Smoking Impact Over Incidence of Apical Periodontitis

This study aimed to assess the prevalence of apical periodontitis in a subset of the population of south-eastern Romania and to analyze the overall health status of the group of patients with apical periodontitis. The medical and dental history, including age, gender, background, presence of smoking, level of education, the total number of teeth present and with apical periodontitis, and the general health status were recorded from a total of 200 patients. The periapical status was analyzed using an orthopantomogram and periapical radiographs of teeth that were diagnosed with periapical lesions by the same dental professional. The periapical status was classified according to the periapical index (PAI), with apical periodontitis being present if the PAI score ≥3. The majority of patients were female (58.5%), with secondary or higher education from urban areas and the mean number of teeth with apical periodontitis was 2.29 ± 1.26, with a median of 2 teeth. A total of 17.1% of patients were smokers, these patients had two more teeth with periapical pathology, and 16% of all patients had general diseases, the most common of which was cardiovascular disease (8.2%). Compared with those without the disease, these patients had a higher number of teeth with apical periodontitis (median = 2.5, IQR = 2-4 vs. median = 2, IQR = 1-3). As a result, this scientific research suggests an association between smoking, cardiovascular disease, and gastritis with apical periodontitis, but no association could be demonstrated between apical periodontitis and other systemic diseases.

Prevalence of apical periodontitis in patients with autoimmune diseases: A case-control study

AIM

The purpose of this case-control study was to compare the prevalence of apical periodontitis (AP) in patients affected by autoimmune disorders (AD) (inflammatory bowel disease [IBD], rheumatoid arthritis [RA] and psoriasis [Ps]) with the prevalence of AP in subjects without AD. The prevalences of AP in patients taking biologic medications, conventional medications and no medication were also compared.

METHODOLOGY

Eighty-nine patients (2145 teeth) with AD were investigated and the control group included 89 patients (2329 teeth) with no systemic diseases. Full dental panoramic tomograms were used to determine the periapical status of the teeth. Additional variables investigated included patient's socio-demographic characteristics, medications taken by AD patients, the decayed, missing and filled teeth (DMFT) index. The chi-square test and logistic regression analysis were used to evaluate the correlation between AD and AP. p-Values lower than .05 were considered to be statistically significant.

RESULTS

The prevalence of AP was 89.9% in AD patients and 74.2% in control subjects (odds ratio [OR] = 3.75, p = .015). The DMFT score was found to be significantly higher in the AD group (p = .004). Patients with RA had the highest risk of being affected by AP, whereas those with IBD had the lowest risk. Multiple binary logistic regression analysis indicated that the teeth of AD patients who were not taking any medication or were being treated with biologic disease-modifying anti-rheumatic drugs (bDMARDs) had a higher risk of being affected by AP than did the teeth of the control subjects (OR = 1.42 and OR = 2.03, respectively; p = .010). The teeth of patients taking conventional DMARDs (cDMARDs) were less affected by AP compared with those of patients taking bDMARDs.

CONCLUSIONS

Patients with AD, whether treated or not with biologic medications, showed a higher prevalence of AP than did those in the control group. The DMFT index score, which was higher in AD patients compared with controls was identified as a significant predictor of AP prevalence.

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.

Apical periodontitis and associated factors in a rural population of southern Brazil: a multilevel analysis

OBJECTIVES

This study aims to evaluate the association between apical periodontitis (AP) and sociodemographic/clinical factors in a probability sample of individuals living in a rural area of southern Brazilian.

MATERIALS AND METHODS

A cross-sectional study was conducted involving 584 non-edentulous adult individuals who had undergone a full-mouth radiographic survey. Periapical status was analysed using the periapical index (PAI). Endodontic status was evaluated considering the occurrence of voids in the filling material and the root filling length. Crown status was classified based on the presence of caries, restorations, and prosthetic crowns. Sociodemographic variables, frequency of dental care, and periodontal disease were also registered. The data were analysed using hierarchical multilevel Poisson regression analysis. The multilevel structure was composed of three models: sociodemographic variables, clinical variables, and clinical variables adjusted by sociodemographic variables (α = 5%).

RESULTS

The prevalence of AP in the sample was 60.45%. AP was significantly associated with age, skin colour, schooling, periodontal disease, and frequency of dental care (P < 0.005). Among the 10,396 teeth evaluated, 868 (8.35%) had AP, which was significantly associated with tooth group, dental arch, crown status, and endodontic treatment (P < 0.005).

CONCLUSIONS

The prevalence of AP was high in the population studied. An older age, black/brown skin colour, low level of schooling, infrequent dental care, severe periodontal disease, mandibular teeth, posterior teeth, inadequate crown status, and having undergone endodontic treatment were significantly associated with the outcome. Clinical relevance This study about a rural probability sample reinforces that AP is still a recurrent oral health problem.

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.

Coronal Restoration as a Predictor of Periapical Disease in Non-Endodontically Treated Teeth

Objectives

To compare the frequency of apical periodontitis (AP) in non-endodontically treated teeth restored with full coverage crowns, amalgam and resin composite fillings, and to disclose the association of type and quality of coronal restoration with periapical disease.

Material and Methods

The cross-sectional study involved 597 subjects who attended the Dental Clinic of the Clinical Hospital Centre, Rijeka, Croatia for the first time. Data were collected by means of a clinical and radiological survey. The following data were recorded for all permanently restored non-endodontically treated teeth: the type, the quality of coronal restoration according to clinical and radiographic criteria for marginal integrity as well as the recurrent caries presence, periapical status and marginal bone loss. Chi-square tests were used to analyze the difference in periapical status regarding the type and the quality of restoration. The multivariate logistic regression analysis was used to assess the effect of explanatory tooth-specific variables on periapical status.

Results

There was no significant difference in the proportion of AP with regards to the type and material of adequate quality coronal restorations (χ²=5.000, P=0.082). The regression analysis revealed significant positive associations with outcome variable (AP) for crowns (OR=3.39; P<0.001), recurrent caries (OR=4.67; P<0.001) and premolar teeth (OR=1.73; P=0.002).

Conclusion

If the quality of restorations is adequate, there is no difference in the periapical status of non-endodontically treated teeth regarding the type and material of coronal restoration.

The global prevalence of apical periodontitis: a systematic review and meta-analysis

BACKGROUND

Apical periodontitis (AP) frequently presents as a chronic asymptomatic disease. To arrive at a true diagnosis, in addition to the clinical examination, it is mandatory to undertake radiographic examinations such as periapical or panoramic radiographs, or cone-beam computed tomography (CBCT). Thus, the worldwide burden of AP is probably underestimated or unknown. Previous systematic reviews attempted to estimate the prevalence of AP, but none have investigated which factors may influence its prevalence worldwide.

OBJECTIVES

To assess: (i) the prevalence of AP in the population worldwide, as well as the frequency of AP in all teeth, nontreated teeth and root filled teeth; (ii) which factors can modify the prevalence of AP.

METHODS

A search was conducted in the PubMed-MEDLINE, EMBASE, Cochrane-CENTRAL, LILACS, Google scholar and OpenGrey databases, followed by hand searches, until September 2019. Cross-sectional, case-control and cohort studies reporting the prevalence of AP in humans, using panoramic or periapical radiograph or CBCT as image methods were included. No language restriction was applied. An adaptation of the Newcastle-Ottawa Scale was used to evaluate the quality of the studies. A meta-analysis was performed to determine the pooled prevalence of AP at the individual level. Secondary outcomes were the frequency of AP in all teeth, nontreated teeth and rootfilled teeth. Subgroup analyses using random-effect models were carried out to analyse the influence of explanatory covariables on the outcome.

RESULTS

The search strategy identified 6670 articles, and 114 studies were included in the meta-analysis, providing data from 34 668 individuals and 639 357 teeth. The prevalence of AP was 52% at the individual level (95% CI 42%-56%, I²  = 97.8%) and 5% at the tooth level (95% CI 4%-6%; I²  = 99.5%). The frequency of AP in root-filled teeth and nontreated teeth was 39% (95% CI 36%-43%; I²  = 98.5%) and 3% (95% CI 2%-3%; I²  = 99.3%), respectively. The prevalence of AP was greater in samples from dental care services (DCS; 57%; 95% CI 52%-62%; I²  = 97.8%) and hospitals (51%; 95% CI 40%-63%; I²  = 95.9%) than in those from the general population (GP; 40%; 95% CI 33%-46%; I²  = 96.5%); it was also greater in people with a systemic condition (63%; 95% CI 56%-69%, I²  = 89.7%) compared to healthy individuals (48%; 95% CI 43%-53%; I²  = 98.3%).

DISCUSSION

The subgroup analyses identified explanatory factors related to the variability in the prevalence of AP. However, the high clinical heterogeneity and high risk of bias across the primary studies indicate that the findings must be interpreted with caution.

CONCLUSIONS

Half of the adult population worldwide have at least one tooth with apical periodontitis. The prevalence of AP is greater in samples from the dental care services, but it is also high amongst community representative samples from the general population. The present findings should bring the attention of health policymakers, medical and dental communities to the hidden burden of endodontic disease in the population worldwide.

Does tobacco smoking predispose to apical periodontitis and endodontic treatment need? A systematic review and meta-analysis

BACKGROUND

Controversial findings exist in the literature regarding the association between tobacco smoking and development of apical periodontitis or need for root canal treatment, with some studies reporting an increase in the prevalence of these outcomes in smokers, whilst others reporting no association.

AIM

To evaluate if there is scientific evidence to support an association between tobacco smoking and a greater prevalence of apical periodontitis and/or root canal treatments.

DATA SOURCES

A systematic search was performed using MeSH terms and free terms in the PubMed, Scopus, Virtual Health Library (VHL), Cochrane library and Open Gray databases.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Observational studies that evaluated the association between smoking and the development or healing of periapical lesion and/or the prevalence of root canal treatment in humans were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

A quality assessment of included studies was performed, and the relevant information and findings were evaluated. A meta-analysis using nine included studies was performed through RevMan software, and the certainty of evidence was evaluated through GRADE.

RESULTS

Fifteen studies were included, of which 10 were classified as low risk of bias, 4 were considered as moderate risk of bias and 1 as high risk of bias. Ten studies reported that smoking was associated with a greater prevalence of periapical periodontitis and/or root canal treatment. Five studies reported no association. Nine studies were included in the pooled meta-analysis, comprising two subgroups: apical periodontitis and root canal treatment. From these nine studies, eight studies were included in the apical periodontitis subgroup meta-analysis and demonstrated that this condition was significantly more prevalent in smokers when compared to the nonsmokers (odds ratio = 2.78[CI: 1.60, 4.85], P < 0.001; I²  = 79%; no adjusted odds ratio). Three studies were included in the root canal treatment subgroup meta-analysis and demonstrated an increased prevalence in smokers when compared to the nonsmokers (odds ratio = 2.73 [CI: 1.06, 2.83], P < 0.001; I²  = 72%; no adjusted odds ratio). The pooled meta-analysis demonstrated that smokers had twice the chance of having apical periodontitis and/or root canal treatment when compared to nonsmokers (odds ratio of 2.42 [CI: 1.59, 3.68], P < 0.01; I²  = 85%). The GRADE analysis demonstrated moderate certainty of evidence.

LIMITATIONS

Several confounding factors were identified such as misinformation regarding the period of time subjects had smoked, as well as the frequency of smoking and the number of cigarettes consumed. No adjustment in odds ratio data for confounding was performed.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

This systematic review and meta-analysis indicate that tobacco smokers have an increased prevalence of periapical periodontitis and root canal treatments with moderate certainty of evidence.

Prevalence of Apical Periodontitis in patients with Multiple Myeloma

BACKGROUND

Aim Previous reports have been analyzed the prevalence/association of apical periodontitis (AP) with systemic diseases. The present study aims to analyze the prevalence of healthy/diseased periapex and endodontic treatments in patients with Multiple Myeloma (MM) and compare the results with those of control subjects.

MATERIAL AND METHODS

Methodology Panoramic radiographs of 50 individuals with MM were evaluated and compared with 50 controls that were sex and age matched exactly with the diseased group. Radiographic analysis was performed by 2 two experienced endodontists under standardized conditions. The periapical status (presence or not of AP) was assessed using the periapical index (PAI). Data included systemic health, technical quality of root fillings, total number of teeth, quality of restoration, and periapical status. Statistical evaluation of differences between groups included used chi-squared tests and Fisher's exact tests.

RESULTS

The prevalence of root canal-treated teeth was 10.11% in the MM group and 12.05% in the control group (p=0.90). The average root canal-treated teeth in the test group was 2,34 and 2.48 in the control group, where the difference was statistically significant (p=0.05). AP in 1 or more teeth was found in 86 % and in 78% of the patients in the MM and the control groups, respectively. When analyzed by subject, there was no statistically significant difference in the prevalence of AP (p>0.72). Similarly there was also no statistically significant difference in the prevalence of PA (p=0.85), when analyzed by tooth, AP was found in 63.2% and 62.9% in MM and control groups.

CONCLUSIONS

The presence of AP and endodontic treatment was not significantly different in individuals with MM compared with control subjects. Future studies are needed to elucidate and confirm the association between MM and AP.

The association between smoking and periapical periodontitis: a systematic review

OBJECTIVES

The purpose of this systematic review was to examine if, in adult patients, the absence or presence of smoking influenced the prevalence of periapical periodontitis (PP).

MATERIALS AND METHODS

Databases were searched, and original research manuscripts up to June 2019 were identified by two reviewers. The Newcastle-Ottawa Scale (NOS) was used for risk of bias. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used for certainty in the evidence. A meta-analysis was performed using RevMan 5 software. Risk ratio (RR) was used for the cohort studies, and odds ratio (OR) was used for the case-control studies with 95% confidence interval (CI).

RESULTS

All the studies had many covariates and confounding variables. Three longitudinal cohort articles discussed radiographic findings as they related to the prevalence of PP in root-filled teeth. The RR of smoking and the prevalence of PP was 2.11 (95% CI 0.88-5.05, p = 0.09). Nine case-control studies focused on the prevalence of PP and smoking. There was a positive association between smoking and the prevalence of PP with an OR of 2.78 and a 95% confidence interval of 2.23-3.48, with p value < 0.05. The quality of the studies was fair per NOS, and the certainty of the literature assessment was moderate per GRADE.

CONCLUSIONS

The current best available evidence suggests that smoking was associated with the prevalence of PP but more studies are needed to report this association in the longitudinal cohort studies.

CLINICAL RELEVANCE

Smoking has a positive association with the prevalence of PP.