Interrelationship Between Periapical Lesion and Systemic Metabolic Disorders

Leveraging Pre-Trained Transformers for Efficient Segmentation and Lesion Detection in Cone-Beam CT Scans

INTRODUCTION

Cone-beam computed tomography (CBCT) is widely used to detect jaw lesions, although CBCT interpretation is time-consuming and challenging. Artificial intelligence (AI) for CBCT segmentation may improve lesion detection accuracy. However, consistent automated lesion detection remains difficult, especially with limited training data. This study aimed to assess the applicability of pre-trained transformer-based architectures for semantic segmentation of CBCT volumes when applied to periapical lesion detection.

METHODS

CBCT volumes (n=138) were collected and annotated by expert clinicians using five labels - "lesion", "restorative material", "bone", "tooth structure", and "background". U-Net (convolutional neural network (CNN)-based) and Swin-UNETR (transformer-based) models, pre-trained (Swin-UNETR-PRETRAIN) and from scratch (Swin-UNETR-SCRATCH), were trained with subsets of the annotated CBCTs. These models were then evaluated for semantic segmentation performance using the Sørensen-Dice coefficient (DICE), lesion detection performance using sensitivity and specificity, and training sample size requirements by comparing models trained with 20, 40, 60, or 103 samples.

RESULTS

Trained with 103 samples, Swin-UNETR-PRETRAIN achieved a DICE of 0.8512 for "lesion", 0.8282 for "restorative materials", 0.9178 for "bone", 0.9029 for "tooth structure", and 0.9901 for "background". "Lesion" DICE was statistically similar between Swin-UNETR-PRETRAIN trained with 103 and 60 images (P>.05), with the latter achieving 1.00 sensitivity and 0.94 specificity in lesion detection. With small training sets, Swin-UNETR-PRETRAIN outperformed Swin-UNETR-SCRATCH in DICE over all labels (P<.001 [n=20], P<.001 [n=40]), and U-Net in lesion detection specificity (P=.006 [n=20], P=.031 [n=40]).

CONCLUSIONS

Transformer-based Swin-UNETR architectures allowed for excellent semantic segmentation and periapical lesion detection. Pre-trained, it may provide an alternative with smaller training datasets compared to classic U-Net architectures.

Gut microbiota dysbiosis links chronic apical periodontitis to liver fibrosis in nonalcoholic fatty liver disease: Insights from a mouse model

AIM

In this study, we investigated the systemic implications of chronic apical periodontitis (CAP). CAP may contribute to the nonalcoholic fatty liver disease (NAFLD) progression through the gut microbiota and its metabolites, which are related to the degree of fibrosis.

METHODOLOGY

Sixteen 7-week-old male apolipoprotein E knockout (apoE-/-) mice were randomly divided into two groups: the CAP and Con groups. A CAP model was established by sealing the first- and second-maxillary molars with bacterium-containing cotton balls. Apical lesions were evaluated by micro-CT. Histological evaluations of NAFLD were performed using second harmonic generation/two-photon excitation fluorescence (SHG/TPEF) assays. Additionally, we comprehensively analyzed the gut microbiota using 16S rRNA gene sequencing and explored metabolic profiles by liquid chromatography-mass spectrometry (LC-MS). Immunofluorescence analysis was used to examine the impact of CAP on tight junction proteins and mucin expression. Transcriptome assays have elucidated gene expression alterations in liver tissues.

RESULTS

Micro-CT scans revealed an evident periapical bone loss in the CAP group, and the total collagen percentage was increased (Con, 0.0361 ± 0.00510%, CAP, 0.0589 ± 0.00731%, p < .05). 16S rRNA sequencing revealed reduced diversity and distinct taxonomic enrichment in the CAP group. Metabolomic assessments revealed that differentially enriched metabolites, including D-galactosamine, were enriched and that 16-hydroxyhexadecanoic acid and 3-methylindole were depleted in the CAP group. Immunofluorescence analyses revealed disruptions in tight junction proteins and mucin production, indicating intestinal barrier integrity disruption. Liver transcriptome analysis revealed upregulation of Lpin-1 expression in the CAP group.

CONCLUSION

This study provides comprehensive evidence of the systemic effects of CAP on liver fibrosis in NAFLD patients by elucidating alterations in the gut microbiota composition and metabolism.

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.

Effect of apical foraminal enlargement on postoperative pain and inflammatory markers in asymtomatic single-rooted mandibular teeth with apical periodontitis - An in vivo randomized controlled trial

Aim of the Study

This study aims to assess the effect of apical foraminal enlargement on inflammatory markers and pain in patients with asymptomatic single-rooted mandibular teeth with apical periodontitis.

Materials and Methods

The study included 60 patients based on inclusion and exclusion criteria. Before beginning root canal treatment (RCT), a blood sample was obtained from the antecubital fossa to evaluate the inflammatory markers, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Access opening was done and initial irrigation was done. Working length (WL) was determined with an electronic apex locator and verified with a radiograph. In the control group, the determined WL was maintained, while in the experimental group, the WL was set till the apical foramen. Biomechanical preparation was done in both groups till F2 or F3 based on the initial apical file, followed by final irrigation and obturation based on the master apical file size. Patients were given a Visual Analog Scale to record pain sensations at 24, 48, and 72 h postoperative. After 72 h, patients were recalled for follow-up appointments, and blood was taken from the antecubital fossa again to evaluate inflammatory markers.

Statistical Analysis

The resultant findings for the reduction in inflammatory markers before and after RCT with or without foraminal enlargement were statistically analyzed using the Student's t-test. The pain was statistically examined with one-way "analysis of variance" and Tukey's post hoc test for inter-group comparison of pain. The level of significance was set at P < 0.05. The statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) Version 23 for Windows (SPSS Inc., Chicago, IL, USA). As pain in the control groups is zero before and after RCT, statistical analysis is not required as the overall pain score is zero.

Results

The P values of the CRP and ESR of the control group were 0.02 and 0.03, respectively, which indicates it is significant whereas the P values of the ESR and CRP of the experimental group were 0.0002 and 0.0008 which indicates it is highly significant. Results indicate that the experimental group is more effective compared to the control group in reducing inflammatory markers. Pain in the control group after RCT was zero at the end of 24, 48, and 72 h. In the experimental group, where RCT was done with apical foraminal enlargement, mild pain was present at the end of 24 h which gradually decreased at the end of 48 h and no pain was reported at the end of 72 h.

Conclusion

Reduction in inflammatory markers was more effective in RCT with apical enlargement than without apical enlargement. RCT with apical enlargement caused mild pain in the patients immediately after treatment which gradually decreased over time.

The importance of mechanosensitive cell mediated prostaglandin and nitric oxide synthesis in the pathogenesis of apical periodontitis: comparative with chronic periodontitis

OBJECTIVES

Mechano-sensitive odontoblast cells, which sense mechanical loading and various stresses in the tooth structure, synthesize early signaling molecules such as prostaglandin E2 (PGE2) and nitric oxide (NO) as an adaptive response. It is thought that these synthesized molecules can be used for the diagnosis and treatment of periodontal and periapical diseases. The aim of this study was to investigate the relationship between the severity of apical periodontitis (AP) and chronic periodontitis (CP) and serum (s) TNF-α, IL-10, PGE2 and NO levels, as well as PGE2 and NO levels in gingival crevicular fluid (GCF) samples.

MATERIALS & METHODS

A total of 185 subjects were divided into three categories: AP group (n = 85), CP group (n = 50) and healthy control group (n = 50). The AP group was divided into 3 subgroups according to abscess scoring (AS-PAI 1, 2 and 3) based on the periapical index. The CP group was divided into 4 subgroups according to the periodontitis staging system (PSS1, 2,3 and 4). After recording the demographic and clinical characteristics of all participants, serum (s) and gingival crevicular fluid (GCF) samples were taken. TNF-α, IL-10, PGE2 and NO levels were measured in these samples.

RESULTS

Unlike serum measurements (sTNF-α, sIL-10, sNO and sPGE2), GCF-NO and GCF-PGE levels of the AP group were significantly higher than the control group in relation to abscess formation (54.4 ± 56.3 vs. 22.5 ± 12.6 µmol/mL, p < 0.001 and 100 ± 98 vs. 41 ± 28 ng/L, p < 0.001, respectively). Confirming this, the GCF-NO and GCF-PGE levels of the AS-PAI 1 group, in which abscesses have not yet formed, were found to be lower than those in AS-PAI 2 and 3, which are characterized by abscess formation [(16.7(3.7-117.8), 32.9(11.8-212.8) and 36.9(4.3-251.6) µmol/mL, p = 0,0131; 46.0(31.4-120.0), 69.6(40.3-424.2) and 74.4(32.1-471.0) ng/L, p = 0,0020, respectively]. Consistent with the increase in PSS, the levels of sTNF [29.8 (8.2-105.5) vs. 16.7(6.3-37.9) pg/mL, p < 0.001], sIL-10 [542(106-1326) vs. 190(69-411) pg/mL, p < 0.001], sNO [182.1(36.3-437) vs. 57.0(15.9-196) µmol/mL, p < 0.001], sPGE2 [344(82-1298) vs. 100(35-1178) ng/L, p < 0.001], GCF-NO [58.9 ± 33.6 vs. 22.5 ± 12.6 ng/L, p < 0.001] and GCF-PGE2 [ 99(37-365) vs. 30(13-119), p < 0.001] in the CP group were higher than the control group. Comparison ROC analysis revealed that the GCF-PGE2 test had the best diagnostic value for both AP and CP (sensitivity: 94.1 and 88.0; specificity: 64.0 and 78.0, respectively; p < 0.001).

CONCLUSIONS

GCF-PE2 and GCF-NO have high diagnostic value in the determination of AP and CP, and can be selected as targets to guide treatment. In addition, the measurements of PGE2 and NO in GCF can be used as an important predictor of pulpal necrosis leading to abscess in patients with AP.

CLINICAL RELEVANCE

In this article, it is reported that syntheses of early signaling molecules such as PGE2 and NO can be used for the diagnosis and treatment target of periapical and periodontal infections.

Unveiling the oral-gut connection: chronic apical periodontitis accelerates atherosclerosis via gut microbiota dysbiosis and altered metabolites in apoE-/- Mice on a high-fat diet

The aim of this study was to explore the impact of chronic apical periodontitis (CAP) on atherosclerosis in apoE-/- mice fed high-fat diet (HFD). This investigation focused on the gut microbiota, metabolites, and intestinal barrier function to uncover potential links between oral health and cardiovascular disease (CVD). In this study, CAP was shown to exacerbate atherosclerosis in HFD-fed apoE-/- mice, as evidenced by the increase in plaque size and volume in the aortic walls observed via Oil Red O staining. 16S rRNA sequencing revealed significant alterations in the gut microbiota, with harmful bacterial species thriving while beneficial species declining. Metabolomic profiling indicated disruptions in lipid metabolism and primary bile acid synthesis, leading to elevated levels of taurochenodeoxycholic acid (TCDCA), taurocholic acid (TCA), and tauroursodeoxycholic acid (TDCA). These metabolic shifts may contribute to atherosclerosis development. Furthermore, impaired intestinal barrier function, characterized by reduced mucin expression and disrupted tight junction proteins, was observed. The increased intestinal permeability observed was positively correlated with the severity of atherosclerotic lesions, highlighting the importance of the intestinal barrier in cardiovascular health. In conclusion, this research underscores the intricate interplay among oral health, gut microbiota composition, metabolite profiles, and CVD incidence. These findings emphasize the importance of maintaining good oral hygiene as a potential preventive measure against cardiovascular issues, as well as the need for further investigations into the intricate mechanisms linking oral health, gut microbiota, and metabolic pathways in CVD development.

Correlation Between Proinflammatory Cytokine Expression and Clinical Data in Apical Granuloma

INTRODUCTION

This study was intended to evaluate the expression of inflammatory cytokines commonly secreted by CD4+ T cells (IL-2, IL-5, IL-17, TGF-β, TNF-α, and IFN-γ) in apical granulomas and correlate with the clinical conditions and time elapsed since root canal treatment.

METHODS

Eighteen biopsy specimens obtained by periradicular surgery of teeth with post-treatment apical periodontitis and diagnosed as apical granuloma were available from the oral pathology laboratory. Silanized slides containing paraffin sections were used for immunohistochemical reactions. Images were analyzed by using an optical microscopy and each slide was subdivided into 5 fields at high magnification.

RESULTS

IFN-γ and TGF-β were the cytokines with the highest expression levels. There were statistically significant differences when comparing IL-2 and IFN-γ (P < .05), and IL-2 and TGF-β (P < .05). Comparison between the detected cytokines and clinical data and time of treatment demonstrated significant correlation (P < .05) between lower expression of IL-2 and the presence of painful symptoms, absence of sinus tract, and treatments performed more than 4 years before. It was also possible to observe a significant correlation between lower expression of IL-5 and treatments performed less than 4 years before (P < .05).

CONCLUSION

IFN-γ and TGF-β were highly expressed in apical granulomas. However, only IL-2 and IL-5 levels were associated with clinical data and time since previous root canal treatment.

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.

Experimental apical periodontitis alters salivary biochemical composition and induces local redox state disturbances in the salivary glands of male rats

OBJECTIVES

The objective was to evaluate the effects of experimental apical periodontitis on the inflammatory, functional, biochemical, and redox parameters of the parotid and submandibular glands in rats.

MATERIALS AND METHODS

Twenty 12-week-old male Wistar rats were randomly divided into two groups (n = 10): a control group and apical periodontitis group. After 28 days, the saliva was collected for salivary flow rate and biochemistry composition. Both glands were sampled for quantification of the tumor necrosis factor-alpha (TNF-α) and biochemical analyses of redox state.

RESULTS

TNF-α concentrations were higher in both salivary glands adjacent to the periapical lesions in animals with apical periodontitis and also compared to the control group. The apical periodontitis group increased the salivary amylase, chloride, potassium, calcium, and phosphate. The total oxidant capacity increased in the parotid gland adjacent to the periapical lesions in the same rat and compared to the control group. Conversely, the total antioxidant capacity of the parotid glands on both sides in the apical periodontitis group was lower than that in the control group. Furthermore, glutathione peroxidase activity increased in the submandibular gland adjacent to the apical periodontitis group compared to the control group.

CONCLUSIONS

Experimental apical periodontitis alters salivary biochemical composition, in addition to increasing inflammatory marker and inducing local disturbances in the redox state in the parotid and submandibular glands of male rats.

CLINICAL RELEVANCE

Apical periodontitis could exacerbate the decline in oral health by triggering dysfunction in the salivary glands.

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.

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.

Adjuvant therapy with a 980-nm diode laser in root canal retreatment: randomized clinical trial with 1-year follow-up

The purpose of this study is to assess the laser effect in root canal disinfection and periapical healing of endodontically treated teeth from patients with asymptomatic apical periodontitis. This study was performed as a randomized clinical trial. Thirty patients were selected according to the inclusion/exclusion criteria. Fifteen patients received the root canal retreatment (RCR) combined with 980-nm diode laser irradiation (LI). The canals were irrigated with saline solution and gently dried with paper points, keeping the dentin partially moist. The irradiation was performed using a 320-µm-diameter fiber in helicoidal movements (pulsed mode, power output of 1.5 W, 100 Hz for 20 s). The other 15 patients received the RCR with placebo irradiation (PI). Microbiological samples were taken in three periods: S1, after the filling material removal (baseline); S2, after laser or placebo irradiation (LI or PI); and S3, after the RCR followed by laser or placebo. The samples were submitted to the total microbial and E. faecalis counting. The periapical radiographic healing was analyzed after 3, 6, 9, and 12 months. Microbiological data (CFU/mg) were analyzed by ANOVA and Tukey's test (P < 0.05), and the repair by Mann-Whitney test (P < 0.05). In S2, the laser provided 42.44% microbial reduction and 53.14% of E. faecalis, different from the placebo that had no reduction, and 4.85% for Enterococcus (P < 0.05). In S3, the bacterial counts decreased without differences between groups. No differences in healing were found at 3 months. However, diode laser facilitated the repair from 3- to 12-month follow-up (P < 0.05) and had 45% more healed cases than placebo. Diode laser provided an antimicrobial effect before the biomechanical preparation but was not synergistic in RCR. It improved the periapical healing during follow-up.

Proinflammatory Cytokine Expression in Apical Periodontitis from Diabetic Patients

Diabetes mellitus has been regarded as a condition capable of influencing the evolution of periapical lesions. Therefore, this study evaluated the immunoexpression of IL-1β, TNF-α, and IL-17 in apical periodontitis from type 2 diabetic patients through immunohistochemistry. Twenty-six periapical lesions were selected, and the images obtained through immunohistochemistry reactions were analyzed. The statistical significance was set at p < 0.05. IL-1β expression was considered focal (54%), weak to moderate (38%), and strong (8%) in diabetics, and focal (46%), weak to moderate (31%), and strong (23%), in controls. TNF-α was focal (85%) and weak to moderate (15%) in diabetics, and focal (92%) and weak to moderate (8%), in controls. IL-17 was focal (8%), weak to moderate (46%), and strong (46%) in diabetics, and focal (62%), weak to moderate (8%), and strong (30%), in controls. The quantitative analysis revealed greater expression of IL-17, with a significant difference between IL-17 × IL-1β × TNF-α(p=0.0009) in the diabetic group. The cytokines IL-1β and TNF-α did not express statistical differences between the tested groups. The IL-17 showed higher immunoexpression in the diabetic group (p=0.047), which may suggest higher bone resorption activity in chronic apical periodontitis in this group of patients.

Dental caries and risk of newly-onset systemic lupus erythematosus: a nationwide population-based cohort study

OBJECTIVE

This study investigated whether patients with history of dental caries are associated with an increased risk of newly-onset systemic lupus erythematosus (SLE).

METHODS

A total of 501,461 carious patients and 258,918 controls without carious teeth were enrolled between 1997 and 2013 from the National Health Insurance Research Database. Subgroup analyses were conducted based on restorative materials including amalgam, composite resins, or both. The cumulative incidence and hazard ratios (HRs) of SLE development were derived after adjusting for age, sex, socioeconomic status, income, insured classification, comorbidities, and frequency of dental visit in a multivariable model.

RESULTS

The risk of SLE was significantly higher in carious patients (HR = 1.98, 95% confidence interval [CI] = 1.65-2.38) compared to controls. Dose-dependent relationship between caries and risk of SLE was identified. The risk of SLE was higher among those who had dental visits ≧11 (HR = 2.53, 95% CI = 1.86-3.43), followed by those with 3-10 dental visits (HR = 1.86, 95% CI = 1.36-2.54), when compared to those with 1-2 visits, and was higher among those who had carious teeth extractions ≧5 (HR = 1.88, 95% CI = 1.19-2.97), followed by those with 1-4 carious teeth extractions (HR = 1.36, 95% CI = 1.17-1.59) than those without extraction. The risk of SLE for dental caries management among different restorative materials, including amalgam, composite resins, or both, was not statistically different.

CONCLUSIONS

Patients with dental caries were associated with higher SLE risks. The relationship between dental caries and risk of SLE was dose-dependent, regardless of the material used for the restoration.

Gut microbiota may mediate the impact of chronic apical periodontitis on atherosclerosis in apolipoprotein E-deficient mice

AIM

There are growing evidences linking chronic apical periodontitis (CAP) to atherosclerosis. Gut microbiota is found to be involved in the development of atherosclerosis. Recent studies have shown that CAP could change the diversity and composition of the gut microbiota. It was therefore, we hypothesized that gut microbiota and its metabolites could mediate the impact of CAP on atherosclerosis.

METHODOLOGY

Twenty-four 5-week-old lipoprotein E knockout (apoE^-/- ) mice were randomly divided into four groups: the CAP group, Con group, Co-CAP (cohoused with CAP) and Co-Con (cohoused with Con) group. In the CAP group, sterile cotton wool containing P. gingivalis was placed into the exposed pulp chamber, followed by coronal resin-based composite restoration of the bilateral maxillary first and second molars. In the Con group, a sham operation was performed. Biweekly, mice in the CAP group were anaesthetised to check the sealing of coronal access. Meanwhile, the animals in the Con group were anaesthetised. The cohousing approach was used to introduce gut microbiota from the CAP and Con groups into the Co-CAP and Co-Con groups, respectively. Alterations in the abundance and diversity of the gut microbiota were detected using 16S rRNA sequencing, Oil-red O staining was used to demonstrate the extent of lesions, and serum levels of trimethylamine N-oxide (TMAO), and immunohistochemistry of flavin-containing monooxygenase 3 (FMO3) in liver were used to assess TMAO-related metabolic alterations.

RESULTS

Alterations of alpha and beta diversity were shown both in the CAP and the Co-CAP groups. Moreover, the percentage of atherosclerotic lesion area increased in the CAP and Co-CAP groups (p < .05). Linear discriminant analysis effect size (LEfSe) at the family level found the increases of Lachnospiraceae and Ruminococcaceae (p < .05), which were positively correlated with serum TMAO levels (p < .05). In the redundancy analysis technique (RDA), serum levels of TMAO were positively associated with the atherosclerotic lesions. Co-occurrence analysis revealed that the relative abundances of Lachnospiraceae and Porphyromonadacae were positively correlated with both the percentage of lesion area and TMAO level (p < .05).

CONCLUSION

Thus, within the limitations of this study, the data suggest that the gut microbiota can mediate the effects of CAP on atherosclerosis.

Melatonin decreases IRF-3 protein expression in the gastrocnemius muscle, reduces IL-1β and LPS plasma concentrations, and improves the lipid profile in rats with apical periodontitis fed on a high-fat diet

To evaluate the effects of melatonin (MEL) on the expression of toll-like receptor-4 (TLR4); myeloid differentiation primary response protein-88 (MyD88); TIR-domain-containing adapter-inducing interferon-β (TRIF); IFN regulatory-factor-3 (IRF-3); nuclear factor kappa-B (NF-κB); plasma concentrations of interleukin-1β (IL-1β) and lipopolysaccharide (LPS); and lipid profile of rats with apical periodontitis (AP) fed on a high-fat diet (HFD). Eighty 60-day-old rats were divided into eight groups: control, AP, HFD, HFDAP, CNMEL, APMEL, HFDMEL and HFDAPMEL. HFD groups were fed on a HFD for 107 days. On day 7, experimental AP was induced in the AP groups, and after 70 days, MEL (5 mg/kg) was administered to the MEL groups for 30 days. Plasma concentrations of LPS and IL-1β were analyzed using enzyme-linked immunosorbent assay, and the lipid profile was analyzed using biochemical tests. The expression of proteins involved in the TLR4 pathway (TLR4, MyD88, TRIF, IRF-3 and NF-κB) in the gastrocnemius muscle (GM) was evaluated using western blotting and qRT-PCR. Treatment with MEL decreased IRF-3 protein expression in GM and IL-1β plasma concentration in the APMEL and HFDMEL groups. Reduction in LPS plasma concentration was reported only in the HFDMEL group. Additionally, a decrease in LDL and an increase in HDL were observed in the HFDMEL and HFDAPMEL groups. Treatment with MEL exhibited anti-inflammatory and anti-hyperlipidemic effects attributed to HFD and AP by reducing the plasma concentrations of IL-1β and LPS in addition to reducing IRF-3 protein expression in the GM, which is associated with the production of inflammatory cytokines.

Automatic Detection of Periapical Osteolytic Lesions on CBCT Using Deep CNNs

INTRODUCTION

Cone beam computed tomography (CBCT) is an essential diagnostic tool in oral radiology. Radiolucent periapical lesions (PALs) represent the most frequent jaw lesions. However, the description, interpretation, and documentation of radiological findings, especially incidental findings, are time-consuming and resource-intensive, requiring a high degree of expertise. To improve quality, dentists may use artificial intelligence in the form of deep learning tools. This study was conducted to develop and validate a deep convolutional neuronal network for the automated detection of osteolytic PALs in CBCT datasets.

METHODS

CBCT datasets from routine clinical operations (maxilla, mandible, or both) performed from January to October 2020 were retrospectively screened and selected. A two-step approach was used for automatic PAL detection. First, tooth localization and identification were performed using the SpatialConfiguration-Net based on heatmap regression. Second, binary segmentation of lesions was performed using a modified U-Net architecture. A total of 144 CBCT images were used to train and test the networks. The method was evaluated using the four-fold cross-validation technique.

RESULTS

The success detection rate of the tooth localization network ranged between 72.6% and 97.3%, whereas the sensitivity and specificity values of lesion detection were 97.1% and 88.0%, respectively.

CONCLUSIONS

Although PALs showed variations in appearance, size, and shape in the CBCT dataset, and a high imbalance existed between teeth with and without PALs, the proposed fully automated method provided excellent results compared with related literature.

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.

Proteomic analysis of infected root canals with apical periodontitis in patients with type 2 diabetes mellitus: A cross-sectional study

AIM

This study aimed to quantitatively and qualitatively determine the proteomic profile of apical periodontitis (AP) in type 2 diabetes mellitus (T2DM) patients in comparison with systemically noncompromised patients and to correlate the protein expression of both groups with their biological functions.

METHODOLOGY

The sample consisted of 18 patients with asymptomatic AP divided into two groups according to the presence of T2DM: diabetic group-patients with T2DM (n = 9) and control group-systemically healthy patients (n = 9). After sample collection, the root canal samples were prepared for proteomic analysis using reverse-phase liquid chromatography-mass spectrometry. Label-free quantitative proteomic analysis was performed by Protein Lynx Global Service software. Differences in protein expression between groups were calculated using t-test (p < .05). Biological functions were analysed using the Homo sapiens UniProt database.

RESULTS

A total of 727 human proteins were identified in all samples. Among them, 124 proteins common to both groups were quantified, out of which 65 proteins from the diabetic group showed significant differences compared with the control: 43 upregulated (p < .05) and 22 downregulated (p < .05) proteins. No significant differences in protein expression were seen for the remaining 59 proteins (p > .05). Most proteins with differences in expression were related to immune/inflammatory response. Neutrophil gelatinase-associated lipocalin, Plastin-2, Lactotransferrin and 13 isoforms of immunoglobulins were upregulated. In contrast, Protein S100-A8, Protein S100-A9, Histone H2B, Neutrophil defensin 1, Neutrophil defensin 3 and Prolactin-inducible protein were downregulated.

CONCLUSIONS

Quantitative differences were demonstrated in the expression of proteins common to diabetic and control groups, mainly related to immune response, oxidative stress, apoptosis and proteolysis. These findings revealed biological pathways that provide the basis to support clinical findings on the relationship between AP and T2DM.

Local immunomodulatory effects of intracanal medications in apical periodontitis

The immune system is an extremely complex biological network that plays a crucial role in the hemostasis of periapical tissue, pathogenesis of apical periodontitis (AP) as well as periapical tissue healing. The successful elimination of microbial infections remains a significant challenge, mostly due to the ever-growing development of antimicrobial-resistant pathogens. The bacterial endurance in the root canal system contributes to features ranging from altered post-treatment healing to exacerbation of chronic periradicular immune response, that compromise the outcome of endodontic treatment. A highly effective strategy for combating infectious diseases and the associated inflammation-mediated tissue damage is to modulate the host immune response in conjunction with antimicrobial therapy. There are several medications currently used in endodontic treatment, however, they suffer various levels of microbial resistance and do not deliver all the required characteristics to simultaneously address both intracanal bacteria and periapical inflammation. Interaction of antimicrobial agents with the immune system can impact its function, leading to immune-suppressive or immune-stimulatory effects. The group of non-conventional antimicrobial medications, such as antimicrobial peptides, propolis, and nanomaterials, are agents that provide strong antimicrobial effectiveness and concomitant immunomodulatory and/or reparative effect, without any host tissue damages. Herein, we provide an overview of local immune modulation in AP and a comprehensive review of the immunomodulatory effect of antimicrobials intracanal medications applied in endodontics with specific emphasis on the antimicrobial nanomaterial-based approaches that provide immunomodulatory potential for successful clinical deployment in endodontics.

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.

Comparison of postoperative pain followings ingle-visit and two-visit root canal therapy inc ontrolled diabetic patients with irreversible pulpitis: A randomized control trial

Aim:

The aim of this study was to evaluate and compare the prevalence of postoperative pain after single- and two-visit endodontic therapy in controlled Type 2 diabetic and nondiabetic individuals in multirooted teeth with irreversible pulpitis.

Materials and Methods:

Ninety patients with irreversible pulpitis (30 controlled diabetics and 60 nondiabetics), between 18 and 60 years were included in the study. After obtaining initial pain scores, patients were randomly allocated to single-visit or two-visit root canal treatment (RCT) groups to receive standardized treatment. After the first visit, patients were given visual analog scale form to mark pain intensity at 1 h, 6 h, 12 h, 24 h, 48 h, 72 h, and 1 week. The compiled data collected were statistically analyzed using 20 SPSS software.

Results:

In both groups, for patients undergoing single-visit and multi-visit RCT, pain intensity was highest on 1^st day of treatment and dropped afterward. A comparison of pain between single-visit and two-visit patients revealed no significant difference in pain scores for the respective time intervals. Intergroup comparison between controlled diabetics and nondiabetics showed no significant difference in pain reported between both groups.

Conclusion:

According to the results of this study, being diabetic or nondiabetic, no difference in pain perception was seen between single- and multiple-visit endodontics suggesting that single-visit as well as two-visit endodontic treatment can be done in controlled diabetic patients.

Aging as a Risk Factor on the Immunoexpression of Pro-Inflammatory IL-1β, IL-6 and TNF-α Cytokines in Chronic Apical Periodontitis Lesions

Persistent inflammatory responses in the elderly may act as modifiers on the progression and repair of chronic apical periodontitis lesions (CAPLs). While the involvement of IL-1β, IL-6 and TNF-α in inflammatory responses and, particularly, in CAPL has been documented, their expression in elderly patients needs to be further characterized. Therefore, the purpose of this study was to evaluate and compare the expressions of pro-inflammatory cytokines in CAPL from elderly individuals with young/middle-aged individuals. Thirty CAPL (15 cysts and 15 granulomas) from elderly patients (>60 years) and 30 CAPL (15 cysts and 15 granuloma) from young/middle-aged individuals (20–56 years) were selected. Immunohistochemical reactions were performed against IL-1β, IL-6 and TNF-α. The slides were subdivided into five high-magnification fields and analyzed. The number of positive stains was evaluated for each antibody. There was no significant difference between the cytokines when the cysts and granuloma were compared in the two groups. In the young/middle-aged, only IL-1β showed a difference and was significantly higher in granulomas (p = 0.019). CAPL pro-inflammatory cytokine levels in the elderly were significantly higher than in young/middle-aged individuals (p < 0.05). The pro-inflammatory cytokines IL-1β, IL-6 and TNF-α were significantly higher in CAPL in the elderly compared with the young/middle-aged group. Further elaborate research studies/analyses to elucidate the reasons for and consequences of inflammation in the elderly are recommended.

Apical periodontitis promotes insulin resistance and alters adaptive immunity markers in rats

•

Periapical lesions promotes higher T-bet expression and lower GATA3 and FOXP3 expression.

•

Periapical lesion promotes increased GATA3 and decreased FOXP3 expression in the group with 4 periapical lesions (4PL)

•

The adaptive immune system, with a predominance of the Th1 polarization, may be involved in the development of insulin resistance in rats with Periapical lesions.

Objective

Apical periodontitis (AP) is a chronic or acute inflammatory disease usually developed from endodontic infections, predominantly due to gram-negative anaerobic bacteria invading the dental pulp. This study aimed to evaluate lymphocyte markers to assess the involvement of adaptive immunity in insulin resistance (IR) in a rat model of AP.

Design.

Forty-five male Wistar albino rats were divided into 3 groups (control, 1AP and 4AP). AP was induced in the upper right first molar (1AP), and in the first and second upper and lower right molars (4AP). The spleen was collected to evaluate the expression of transcription factors involved in lymphocyte polarization, including T-bet (Th1), GATA3 (Th2), and FOXP3 (Treg). Blood samples were assessed for serum cytokine levels transcribed by the respective lymphocyte polarizations, INF-γ (Th1), IL-4 (Th2) and TGF-β (Treg). In addition, glucose and insulin levels were measured to evaluate IR by the HOMA-IR method.

Results

The results showed higher T-bet expression on AP groups, along with lower GATA3 and FOXP3 expression in the 1AP, in addition to increased GATA3 and decreased FOXP3 expression in the 4AP group compared to the CN group. There was no difference in the INF-γ levels, while IL-4 was decreased in the AP groups. Taken together, these results suggest that the adaptive immune system, with a predominance of the Th1 polarization, may be involved in the development of IR in rats with AP.

Conclusions

AP promotes increase in the expression of T-bet (4AP) and decrease of FOXP3 expressions and IL-4 levels (1AP and 4AP). However, depending on the number of lesions (1 or 4 lesions), the expression of GATA3 appears differently. Thus, innate immunity and adaptive immunity may contribute to the IR observed in rats with AP.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.

Periapical lesions in two inbred strains of rats differing in immunological reactivity

AIM

To investigate the influence of strain differences in immune responses on the pathogenesis of experimental periapical lesions in Dark Agouti (DA) and Albino Oxford (AO) inbred strains of rats.

METHODOLOGY

Periapical lesions were induced in male DA and AO rats by pulp exposure of the first mandibular right molars to the oral environment. Animals were killed 21 days after pulp exposure. The mandibular jaws were retrieved and prepared for radiographic, pathohistological, immunohistochemical analysis, real-time PCR and flow cytometry. Blood samples and the supernatant of periapical lesions were collected for measurement of cytokines and oxidative stress marker levels. Statistical analysis was performed using the Kruskal-Wallis H and Mann-Whitney U non-parametric tests or parametric One-Way anova and Independent Samples T-test to determine the differences between groups depending on the normality of the data. A significant difference was considered when p values were <.05.

RESULTS

DA rats developed significantly larger (p < .05) periapical lesions compared to AO rats as confirmed by radiographic and pathohistological analysis. The immunohistochemical staining intensity for CD3 was significantly greater in periapical lesions of DA rats compared to AO rats (p < .05). In DA rats, periapical lesions had a significantly higher (p < .05) percentage of CD3+ cells compared to AO rats. Also, the percentage of INF-γ, IL-17 and IL-10 CD3+CD4+ cells was significantly higher in DA rats (p < .05). DA rats had a significantly higher Th17/Th10 ratio. RT-PCR expression of IL-1β, INF-γ and IL-17 genes was significantly higher in periapical lesions of DA compared to AO rats (p < .05). The receptor activator of nuclear factor kappa-Β ligand/osteoprotegerin ratio was higher in DA compared to AO rats with periapical lesions (p < .05). Systemic levels of TNF-α and IL-6 were significantly higher in DA compared to AO rats (p < .05). Levels of lipid peroxidation measured as thiobarbituric acid reactive substances and reduced glutathione were significantly higher (p < .05) in the supernatant in the periapical lesions of DA rats.

CONCLUSION

After pulp exposure, DA rats developed much larger periapical lesions compared to AO rats. Genetically determined differences in immunopathology have been demonstrated to be a significant element defining the severity of periapical lesions.

Serum levels of inflammatory markers and HbA1c in patients with type 2 diabetes and apical periodontitis: Preliminary findings

This pilot study assessed the glycaemic control and the serum levels of inflammatory mediators in type 2 diabetes (T2DM) patients with apical periodontitis (AP). Thirty individuals were divided into four groups: Healthy (H); with AP (AP); with T2DM (T2DM); and with T2DM and AP (T2DM-AP). Demographic and pharmacological data were registered. The body mass index (BMI) and the levels of glycated haemoglobin (HbA1c) and IL-1β, IL-6, IL-10, CCL3 and CCL4 were evaluated. AP areas were determined radiographically. Mean age was 64 ± 12 years, with 63% females. Most T2DM patients were under treatment with metformin and antihypertensives. BMI and H1bAc were significantly higher in T2DM patients in relation to H and AP groups. The AP areas were larger in the T2DM-AP group, compared with the AP group. These preliminary findings suggest no influence of AP on glycaemic control or inflammatory levels amongst T2DM patients, although T2DM increased the AP severity.

Dental health assessed using panoramic radiograph and adverse events in chronic kidney disease stage 4-5 patients transitioning to dialysis and transplantation-A prospective cohort study

Background and aims

Oral health could potentially be a modifiable risk factor for adverse outcomes in chronic kidney disease (CKD) patients transitioning from predialysis treatment to maintenance dialysis and transplantation. We aimed to study the association between an index of radiographically assessed oral health, Panoramic Tomographic Index (PTI), and cardiovascular and all-cause mortality, major adverse cardiovascular events (MACEs) and episodes of bacteremia and laboratory measurements during a three-year prospective follow-up in CKD stage 4–5 patients not on maintenance dialysis at baseline.

Methods

Altogether 190 CKD stage 4–5 patients without maintenance dialysis attended panoramic dental radiographs in the beginning of the study. The patients were followed up for three years or until death. MACEs and episodes of bacteremia were recorded during follow-up. Laboratory sampling for C-reactive protein and leukocytes was repeated tri-monthly.

Results

PTI was not associated with baseline laboratory parameters or C-reactive protein or leukocytes examined as repeated measures through the 3-year follow-up. During follow-up, 22 patients had at least one episode of bacteremia, but only 2 of the bacteremias were considered to be of oral origin. PTI was not associated with incident bacteremia during follow-up. Thirty-six patients died during follow-up including 17 patients due to cardiovascular causes. During follow-up 42 patients were observed with a MACE. PTI was independently associated with all-cause (HR 1.074 95% CI 1.029–1.122, p = 0.001) and cardiovascular (HR 1.105, 95% CI 1.057–1.157, p<0.0001) mortality, as well as, incident MACEs (HR 1.071 95% CI 1.031–1.113, p = 0.0004) in the multivariable Cox models adjusted for age and kidney transplantation or CKD treatment modality during follow-up.

Conclusions

Radiographically assessed dental health is independently associated with all-cause and cardiovascular mortality and MACEs but not with the incidence of bacteremia in CKD stage 4–5 patients transitioning to maintenance dialysis and renal transplantation during follow-up.

Interrelationship between the Microbial Communities of the Root Canals and Periodontal Pockets in Combined Endodontic-Periodontal Diseases

Periodontal and Endodontic diseases are biofilm-related diseases. The presence of microorganisms in root canals (RCs) and the complex microbiota of periodontal pockets (PPs) contribute to the development of endodontic-periodontal diseases. This study performed a systemic analysis using state-of-the-art sequence data to assess the microbial composition of infected RCs and PPs to further assess the microbiota and verify the possibility of cross-infection between these sites. The microbiomes of these combined diseases were examined with a focus on the V3-V4 hypervariable region of the 16S rRNA gene. The number of species in PP was higher than in RC, and there was a predominance of obligate anaerobes and gram-negative bacteria. In the RCs, the genera Enterococcus, Parvimonas, Stomatobaculum predominated, in contrast, the PPs revealed a predominance of Enterococcus, Parvimonas, Stomatobaculum, Peptostreptococcus and Mogibacterium. The RC and PP microbiome was not similar with regards to the sharing of OTUs for phyla and genera (8 and 67, respectively). The evaluation of molecular markers revealed a large number of markers for resistance to antibiotics of the carbapenem and beta-lactam type (broad spectrum). Another relevant finding of this study was the markers related to systemic diseases related to cardiac muscle and rheumatology, among others. In conclusion, the RC microbiota was less complex and diverse than PP. Interactions between microbial communities were present. The shared genus can signal communication between the endodontic and periodontal microbiomes.

Efficacy of i-PRF in regenerative endodontics therapy for mature permanent teeth with pulp necrosis: study protocol for a multicentre randomised controlled trial

BACKGROUND

Dental pulp necrosis, a common health problem, is traditionally treated with root canal therapy; however, it fails in restoring the vitality of damaged pulp. Most studies regarding regenerative endodontic therapy (RET) are limited to the treatment of immature necrotic teeth. Given that injectable platelet-rich fibrin (i-PRF) has shown great potential in regenerative medicine as a novel platelet concentration, this study is designed to explore whether i-PRF can serve as a biological scaffold, extending the indications for RET and improving the clinical feasibility of RET in mature permanent teeth with pulp necrosis.

METHODS

This is a randomised, double-blind, controlled, multicentre clinical trial designed to evaluate the clinical feasibility of RET for mature permanent teeth with pulp necrosis and to compare the efficacy of i-PRF and blood clots as scaffolds in RET. A total of 346 patients will be recruited from three centres and randomised at an allocation ratio of 1:1 to receive RET with either a blood clot or i-PRF. The changes in subjective symptoms, clinical examinations, and imaging examinations will be tracked longitudinally for a period of 24 months. The primary outcome is the success rate of RET after 24 months. The secondary outcome is the change in pulp vitality measured via thermal and electric pulp tests. In addition, the incidence of adverse events such as discolouration, reinfection, and root resorption will be recorded for a safety evaluation.

DISCUSSION

This study will evaluate the clinical feasibility of RET in mature permanent teeth with pulp necrosis, providing information regarding the efficacy, benefits, and safety of RET with i-PRF. These results may contribute to changes in the treatment of pulp necrosis in mature permanent teeth and reveal the potential of i-PRF as a novel biological scaffold for RET.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04313010 . Registered on 19 March 2020.

Allergic rhinitis and dental-supporting tissue diseases in children

The etiology of dental-supporting tissue diseases in children is multi factorial and not merely related to oral hygiene. Therefore, in the present study, we investigated the relationship between children <18 years old with allergic rhinitis (AR) and the risk of dental-supporting tissue diseases.Data from the National Health Insurance Research Database (NHIRD) of Taiwan were used to conduct a retrospective longitudinal cohort study. The study cohort comprised 378,160 patients with AR (AR group) and 378,160 patients without AR (non-AR group), who were selected through frequency matching based on age, sex, and the index year. The study patients were followed until dental-supporting tissue diseases occurrence, withdrawal from the National Health Insurance program, or December 31, 2013. Cox proportional hazards regression analysis was conducted to calculate the risk of dental-supporting tissue diseases in the AR group after adjustment for age, sex, and relative comorbidities.The adjusted HRs of periodontal, pulp, and periapical diseases in AR children were higher than those in the non-AR controls (1.51, 95% CI: 1.50 to 1.53; 1.06, 95% CI: 1.05 to 1.07, respectively). The AR to non-AR HRs of these inflammatory dental diseases were particularly higher in children <6 years old and in boys. The HRs of periodontal, pulp, and periapical diseases were greatest in those with >5 AR-related medical visits/year (5.57, 95% CI: 5.50 to 5.56; 4.06, 95% CI: 4.00 to 4.12, respectively).Children with AR had a greater risk of inflammatory dental-supporting tissue diseases, particularly those <6 years old with primary teeth, boys, and those with severe persistent AR.

Blockade of fatty acid signalling inhibits lipopolysaccharide-induced macrophage recruitment and progression of apical periodontitis

AIM

To examine the role of palmitic acid in lipopolysaccharide (LPS)-stimulated chemotaxis of macrophages and the potential contribution of saturated fatty acid in signalling during the pathogenesis of apical periodontitis.

METHODOLOGY

J774, a mouse macrophage cell line, was used in the experiments. After treatment with LPS, proteolytic maturation of sterol regulatory element-binding protein-1c (SREBP-1c) and expression of fatty acid synthase (FASN) were examined by Western analysis. Levels of palmitic acid were measured by reverse phase-high performance liquid chromatography-mass spectrometry. Knockdown of SREBP-1c and FASN was accomplished by small interfering RNA technology. Secretion of CC-chemokine ligand 2 (CCL2) and cellular chemotaxis were assessed by enzyme-linked immunosorbent assay and transwell migration assay, respectively. Sulfo-N-succinimidyl oleate (SSO) treatment was used to inhibit fatty acid signalling in vitro and also in a rat model of apical periodontitis. All data were first subjected to Levene's test. In vitro data were then analysed using ANOVA followed by Tukey's multiple comparison test. Data from animal experiments were analysed by independent t-tests. The significant level was set at 0.05.

RESULTS

LPS stimulated proteolytic maturation of SREBP-1c and FASN expression in macrophages and significantly enhanced palmitic acid synthesis (P < 0.05). Knockdown of SREBP-1c attenuated LPS-enhanced FASN expression. Knockdown of FASN significantly suppressed LPS-enhanced palmitic acid synthesis (P < 0.05). LPS and exogenous palmitic acid significantly enhanced CCL2 secretion and macrophage chemotaxis (all P < 0.05). Inhibition of FASN expression significantly alleviated LPS-augmented CCL2 secretion (P < 0.05). SSO significantly suppressed CCL2 secretion and macrophage chemotaxis augmented by LPS and palmitic acid (all P < 0.05). In a rat model of induced apical periodontitis, SSO treatment significantly attenuated progression of apical periodontitis and macrophage recruitment (all P < 0.05).

CONCLUSIONS

LPS/SREBP-1c/FASN/palmitic acid signalling contributed to tissue destruction caused by bacterial infection. Modulation of lipid metabolism and signalling may be helpful for the management of apical periodontitis.

Oral Health Messiers: Diabetes Mellitus Relevance

This article aims to narrate the various oral complications in individuals suffering from diabetes mellitus. Google search for "diabetes mellitus and oral complications" was done. The search was also carried out for "diabetes mellitus" and its oral complications individually. Diabetes mellitus is a chronic metabolic disorder that is a global epidemic and a common cause of morbidity and mortality in the world today. Currently, there are about 422 million cases of diabetes mellitus worldwide. Diabetic patients can develop different complications in the body such as retinopathy, neuropathy, nephropathy, cardiovascular disease. Complications in the oral cavity have been observed in individuals suffering from diabetes mellitus. A study noted that more than 90% of diabetic patients suffered from oral complications. Another research has shown a greater prevalence of oral mucosal disorders in patients with diabetes mellitus than non-diabetic population: 45-88% in patients with type 2 diabetes compared to 38.3-45% in non-diabetic subjects and 44.7% in type 1 diabetic individuals compared to 25% in the non-diabetic population. Oral complications in people with diabetes are periodontal disease, dental caries, oral infections, salivary dysfunction, taste dysfunction, delayed wound healing, tongue abnormalities, halitosis, and lichen planus. The high glucose level in saliva, poor neutrophil function, neuropathy, and small vessel damage contribute to oral complications in individuals with uncontrolled diabetes. Good oral health is imperative for healthy living. Oral complications cause deterioration to the quality of life in diabetic patients. Complications like periodontal disease having a bidirectional relationship with diabetes mellitus even contribute to increased blood glucose levels in people with diabetes. This article intends to promote awareness regarding the oral health of diabetics and to stress the importance of maintaining proper oral hygiene, taking preventive measures, early detection, and appropriate management of oral complications of these patients through a multidisciplinary approach.

Omega-3 Fatty Acids Alter Systemic Inflammatory Mediators Caused by Apical Periodontitis

INTRODUCTION

This study investigated the effects of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) on serum inflammatory mediators of rats with pulp exposure-induced apical periodontitis.

METHODS

Forty male Wistar rats were divided into the following groups: control, untreated rats (C); control rats treated with ω-3 PUFAs (C-O); rats with pulp exposure-induced apical periodontitis (AP); and rats with pulp exposure-induced apical periodontitis treated with ω-3 PUFAs (AP-O). ω-3 PUFAs were administered orally once a day for 15 days before pulp exposure and continued for 30 days after pulp exposure. The rats were sacrificed, and then blood and jaw samples were collected. Blood analysis was conducted to determine the total number of leukocytes including neutrophils, monocytes, and lymphocytes. Proinflammatory cytokines tumor necrosis factor alpha, interleukin (IL) 6, and IL-17 were quantified by enzyme-linked immunosorbent assay. Histologic analysis was performed to confirm the development of apical periodontitis. The data were statistically evaluated using analysis of variance and the Tukey posttest. The significance level was set at 5%.

RESULTS

The development of apical periodontitis was confirmed in all infected groups. Bone destruction was larger in the AP group compared with the AP-O group (P < .05). Blood analysis showed that the AP and AP-O groups showed higher numbers of lymphocytes, leukocytes, monocytes, eosinophils, and expressions of tumor necrosis factor alpha and IL-6 compared with the C and C-O groups (P < .05). In contrast, the presence of leukocytes, lymphocytes, and the expression of IL-6 decreased in the AP-O group compared with the AP group (P < .05).

CONCLUSIONS

ω-3 PUFA supplementation influences the systemic effects caused by apical periodontitis, decreasing the number of leukocytes, lymphocytes, and IL-6 in rat blood.

Competing interplay between systemic and periodontal inflammation: obesity overrides the impact of oral periphery

Objectives

We aimed at investigating whether the interaction between the local inflammation, periodontitis, and obesity is independently associated with systemic inflammation.

Methods

From the population-based Study of Health in Pomerania, 3366 participants, without (2366) and with (1000) obesity, were studied for the association of periodontitis, measured as probing depth (PD) and plaque together with body mass index (BMI) on C-reactive protein (CRP). Quantile regression was used to evaluate the association between periodontal, anthropometric, and inflammatory variables (outcomes).

Results

The overall prevalence of obesity in this adult population was 31.4% in men and 28.1% in women. Both PD and plaque were positively associated with CRP, revealing an increasing impact across the CRP concentration distribution. Adjusting the regression of CRP or fibrinogen on PD for waist circumference attenuated but did not abolish the PD coefficients. Dental plaque was similarly associated with these interrelations. Association between PD and a dental plaque was different among participants with low-, medium-, or high-risk CRP concentrations.

Conclusion

Local and systemic sources of inflammation contribute to blood levels of inflammatory markers. The respective contributions depend on the relative rate in each of the inflammation-inducing risks and are dominated by adiposity.

Clinical relevance

Keeping systemic inflammation low in order to prevent age-related disease sequelae.

Electronic supplementary material

The online version of this article (10.1007/s00784-020-03514-y) contains supplementary material, which is available to authorized users.

Association between the gut and oral microbiome with obesity

In recent decades, obesity has become one of the most common lifestyle-associated disorders. Obesity is a major contributing factor for several other lifestyles associated disorders such as type 2 diabetes mellitus, hypertension, and cardiovascular disease. Although genetics and lifestyle have been directly implicated in the onset and progression of obesity, recent studies have established that gut microbiome plays a crucial role in obesity progression. A higher proportion of Firmicutes and a skewed Firmicutes/Bacteroidetes ratio may contribute to gut dysbiosis and subsequent disturbances in the overall body metabolisms. Like gut microbiome, the oral cavity of humans also harbors a characteristic microbial population called "oral microbiome". The oral microbiome has also been implicated in the development of obesity due to its modulating effects on the gut microbiome. Due to its critical role in obesity, alteration in the gut microbiome has been suggested as one of the therapeutic strategies to manage obesity itself. For example, fecal microbiome transfer, or the use of probiotics and prebiotics have been suggested. These therapies not only restore the gut microbiome to the "pre-obese stage" but also ameliorate many functional aspects of the metabolic syndrome such as systemic inflammation, insulin resistance, and fat accumulation. However, the efficacy and safety of some of the methods have not been tested for their long-term implications, and further research in this area is warranted to understand the molecular mechanisms involved in this process completely.

Apical periodontitis induces changes on oxidative stress parameters and increases Na+/K+-ATPase activity in adult rats

OBJECTIVES

Endodontic infection can cause systemic alterations. The involvement of oxidative stress (OS) and transmembrane enzymes compose the pathogenesis of various systemic diseases. However, the relation among apical periodontitis (AP), OS parameters, and Na⁺/K⁺-ATPase (NKA) pump was not reported in the literature. This study evaluated the AP influence on OS parameters and NKA activity in adult rats.

METHODS

Adult male Wistar rats (sixteen weeks old) were randomly assigned to two experimental groups: control (CT group; n = 8) and AP (AP group; n = 9), which was induced in the first right mandibular molar tooth. After 21 days of AP induction, mandibles were dissected for radiographic analysis. In addition, the heart, liver, pancreas, and kidney were collected for analysis of endogenous OS parameters and NKA activity. Data were analyzed by Student's T-test. Values of p < 0.05 were considered statistically significant.

RESULTS

AP presence increased reactive species (RS) generation only in the heart, while the other analyzed organs did not have this parameter modified. Heart and pancreas had a decreased endogenous antioxidant system (catalase activity and vitamin C levels), liver and kidney had an increased one. AP increased NKA activity in the heart, liver, and pancreas, but not in the kidney.

CONCLUSION

The modulation of both endogenous antioxidant defense system and NKA activity in vital organs suggested that alterations in the antioxidant status and cellular electrochemical gradient may be involved in the AP pathophysiology.

Effects of alcohol and nicotine consumption on the development of apical periodontitis in rats: a correlative micro-computed tomographic, histological and immunohistochemical study

AIM

To evaluate the effects of alcohol and nicotine, when used alone or simultaneously, in the development of apical periodontitis induced in rats, using a correlative analytic approach with micro-CT, histological and immunohistochemical analysis.

METHODOLOGY

Twenty-eight male Wistar rats were arranged into four groups: Control, Nicotine, Alcohol and Alcohol + Nicotine. The alcohol groups were exposed to self-administration of a 25% alcohol solution, whilst the other groups drunk only filtered water. The nicotine groups received daily intraperitoneal injections of a solution with 0.19 μL of nicotine per mL, whilst the other groups received saline solution. The pulps of the left mandibular first molars were exposed for 28 days to induce periapical lesions. Throughout the experiment, drug administration was maintained, and the animals had their weight and solid and liquid consumption measured. After euthanasia, the mandibles were removed and the area, volume and major diameter of the periapical lesions were measured using micro-computed tomography images. The samples were submitted to histopathological evaluation and immunohistochemistry for RANKL and PTHrP. Statistical analysis was undertaken with a significance level of 5%. Nonparametric data were analysed using the Kruskal-Wallis test followed by Dunn's test, whilst one-way anova followed by Tukey's test was performed for parametric data.

RESULTS

The alcohol groups had lower solid and liquid consumption and gained less weight when compared to the nonalcohol groups (P < 0.05). The Alcohol + Nicotine group had lesions with significantly larger volume and area when compared to the other groups (P < 0.05), whilst the Alcohol or Nicotine groups had significantly larger lesions than the control group (P < 0.05). There was no significant difference in the largest diameter of the lesions amongst groups (P > 0.05). The experimental groups had greater inflammatory response scores than the control group (P < 0.05), and the representative samples had more pronounced immunoreaction against RANKL and PTHrP antibodies.

CONCLUSIONS

Alcohol and nicotine consumption exacerbated the inflammatory response and the development of periradicular lesions in rats. The association of both substances enhanced their harmful effects.

Childhood Oral Infections Associate with Adulthood Metabolic Syndrome: A Longitudinal Cohort Study

Chronic oral infection/inflammation is cross-sectionally associated with metabolic syndrome (MetS) in adults, but there are few longitudinal studies and studies on childhood oral infections and adult MetS risk. We investigated whether childhood clinical parameters indicative of oral infection/inflammation were associated with adulthood MetS and its components. A total of 755 children aged 6, 9, and 12 y underwent a clinical oral examination in 1980 as part of the Cardiovascular Risk in Young Finns Study. Oral health measures included bleeding on probing (BOP), periodontal probing pocket depth, caries, fillings, and visible plaque. Metabolic parameters were determined at baseline and during follow-up. MetS was diagnosed (n = 588, 77.9%) in the adulthood at 21 y (in 2001), 27 y (in 2007), and 31 y (in 2011) after the oral assessment, when the participants were 27 to 43 y old. Regression analyses were adjusted for childhood age, sex, body mass index, and family income, as well as adulthood smoking and education level. In adulthood, MetS was diagnosed in 11.9% (2001), 18.7% (2007), and 20.7% (2011) of participants at the 3 follow-ups. Childhood caries and fillings were associated with increased risk of adult MetS (risk ratio [95% CI], 1.25 [0.90 to 2.45] and 1.27 [1.02 to 1.99]) and with increased systolic blood pressure (1.78 [1.01 to 4.26] and 2.48 [1.11 to 4.12]) and waist circumference (2.25 [1.02 to 4.99] and 1.56 [1.01 to 3.25]), whereas BOP and visible plaque were associated with plasma glucose (1.97 [1.08 to 3.60] and 1.88 [1.00 to 3.53]). Severity of BOP (P = 0.015) and caries (P = 0.005) and teeth with plaque (P = 0.027) were associated with number of MetS components. No such trends were seen with probing pocket depth. Childhood oral infection/inflammation was associated with adverse metabolic parameters and MetS in adulthood.

IDF Diabetes Atlas: Diabetes and oral health - A two-way relationship of clinical importance

The current scientific evidence for the bi-directional associations between oral health and diabetes is summarized. The universal biologic mechanisms and demographic and behavioral risk drivers underlying these associations in both directions are also described. Dysglycemia, even slightly elevated blood sugar levels, adversely affects oral health, manifesting itself in several oral diseases and conditions. In the opposite direction, any oral infection with its subsequent local and systemic inflammatory responses adversely affects blood glucose levels. Moreover, painful, mobile, or missing teeth may lead to intake of soft food items representing a sub-optimal diet and hence poor nutrition, and thereby contribute to incident type 2 diabetes or to poorer glucose control in existing diabetes. Treatment of inflammation related oral conditions, such as non-surgical periodontal treatment and extraction of infected teeth, can lead to a clinically significant decrease in blood glucose levels. Attention to infectious oral diseases and referral to dental care professionals for treatment can therefore be an important novel tool for medical care professionals in preventing and managing diabetes mellitus. Dental professionals can detect unrecognized potential dysglycemia and refer for medical examination. Such interprofessional, patient centered care may contribute to improved health, wellbeing, and quality of life in people with diabetes.

Teneligliptin inhibits lipopolysaccharide-induced cytotoxicity and inflammation in dental pulp cells

Diabetes mellitus is one of the most common health threatening disorders. Patients with chronic diabetes are at high risk of contracting oral diseases, including dental pulp damage. In this study, we reviewed how Teneligliptin, a commonly used anti-diabetic agent, protected dental pulp cells from lipopolysaccharide (LPS)-induced cytotoxicity and improved their viability. The dental pulp cells treated with Teneligliptin were resistant to LPS-induced reactive oxygen species (ROS) and its byproduct 4-hydroxynonenal (4-HNE) generation. The Teneligliptin recovered LPS-induced a reduction of cellular glutathione and produced cytokine including tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6). Mechanistically, we found that Teneligliptin suppressed LPS- that caused an expression of the cell surface receptor toll like receptor 4 (TLR-4) and the activation of JNK kinase and activator protein 1 (AP1) as well as the nuclear factor-κB (NF-κB) signal pathways. Collectively, our study demonstrates that the molecular mechanism Teneligliptin is a protective anti-diabetic agent in dental pulp cells and it has the potential to treat diabetes-associated dental pulp diseases.