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

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

AIM AND BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL SIGNIFICANCE

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

Association between oral infections, triglyceride-glucose index, and in-stent restenosis

OBJECTIVES

To investigate oral infections in patients suffering in-stent restenosis (ISR) and non-ISR and analyze the possible correlation between the oral infection and triglyceride-glucose (TyG) index, a clinical surrogate indicator of insulin resistance (IR).

MATERIALS AND METHODS

A cross-sectional design was used, in which 586 patients with acute coronary syndrome who underwent coronary angiography 6-24 months after coronary stent implantation were recruited. The modified total dental index (TDI) was used to evaluate the status of oral inflammation.

RESULTS

In both univariate analyses, TDI scores [3 (1.5, 4.5) vs. 2.5 (1.5, 4.0), p < 0.01] and a multivariate regression model (OR = 1.202, 95% CI = 1.085-1.333, p < 0.01), the TDI significantly correlated with ISR. The TyG index was positively associated with ISR (OR = 1.766, 95% CI = 1.055-2.957, p < 0.05). Correlation analysis showed that TDI was positively correlated with TyG index (r = 0.190, p < 0.01). Using linear regression analysis, higher TDI scores were significantly associated with IR (95% CI = 0.029-0.063, p < 0.01).

CONCLUSIONS

Oral infections and TyG index were independently and positively correlated with ISR in patients with acute coronary syndrome. Oral inflammatory burden assessed by TDI score was associated with IR.

Low-Diversity Microbiota in Apical Periodontitis and High Blood Pressure Are Signatures of the Severity of Apical Lesions in Humans

(1) Background: In developed countries, the prevalence of apical periodontitis (AP) varies from 20% to 50% for reasons that could be associated with the apical periodontitis microbiota ecology. (2) Methods: We performed a clinical study in the Odontology department of Toulouse hospital in France, to sequence the 16S rRNA gene of AP microbiota and collect clinical parameters from 94 patients. Forty-four patients were characterized with a PAI (periapical index of AP severity) score lower or equal to 3, while the others had superior scores (n = 50). (3) Results: The low diversity of granuloma microbiota is associated with the highest severity (PAI = 5) of periapical lesions (Odds Ratio 4.592, IC 95% [1.6329; 14.0728]; p = 0.001; notably, a lower relative abundance of Burkholderiaceae and a higher relative abundance of Pseudomonas and Prevotella). We also identified that high blood pressure (HBP) is associated with the increase in PAI scores. (4) Conclusions: Our data show that a low diversity of bacterial ecology of the AP is associated with severe PAI scores, suggesting a causal mechanism. Furthermore, a second risk factor was blood pressure associated with the severity of apical periodontitis.

Genetic polymorphism in the tumour necrosis factor alpha gene (G-308A) is associated with persistent apical periodontitis in Brazilians

AIM

To investigate if there was an association between genetic polymorphisms in tumour necrosis factor (TNF)-⍺ and its receptors TNFRSF1A and TNFRSF1B with persistent apical periodontitis (PAP) in Brazilian subjects.

METHODOLOGY

Patients who had pulpal necrosis and apical periodontitis at the time of treatment, with at least 1-year of follow-up after non-surgical root canal treatment were recalled. Three hundred and seventy eight subjects were included, 150 subjects with signs/symptoms of PAP and 228 subjects with root canal-treated teeth exhibiting healthy perirradicular tissues (healed). Genomic DNA was extracted from saliva and used for TNF-⍺ (rs1800629), TNFRSF1A (rs1800693) and TNFRSF1B (rs1061622) genotyping by real-time PCR. Genotypes and alleles frequencies were evaluated by c2 or Fisher's exact tests and odds ratios were implemented (α = 5%).

RESULTS

The genetic polymorphism in TNF-α (rs1800629) was associated as a protective factor for the development of PAP (p < .05), once subjects who presented at least one allele A (AA+AG X GG), had a higher chance to lesion repair (p < .05). The polymorphisms rs1800693 and rs1061622 in TNF receptors (TNFRSF1A and TNFRSF1B, respectively) were not associated with the development of PAP (p > .05).

CONCLUSIONS

The observed results demonstrate that polymorphism in TNF-α but not in its receptors is associated with PAP.

Chronic Obstructive Pulmonary Disease and Apical Periodontitis and Other Oral Health Variables: A Case-Control Study

Background: The relationship between chronic inflammatory diseases and their comorbidities and correlation with periodontal diseases has become an increasing focus of research. Objectives: The aim of this case-control study was to conclude if patients suffering from COPD (Chronic Obstructive Pulmonary Disease) tend to have more AP (Apical Periodontitis) than non-COPD patients. Materials and Methods: The study was conducted on 30 patients assigned as cases, associated with 30 control patients linked by age (+/−5 years) and sex. Results: A total of 60 patients were recorded, and a total of 12 radiographic variables were analyzed. A total of 43 (71.7%) patients were registered with PAI (Periapical Index) ≥ 3, and there was a slightly tendency in the patients from the control group 22 (73.3%) compared to those from the cases 21 (70%), respectively (p > 0.05). Conclusions: It was concluded that there was not a significant association between the levels of PAI (Periapical Index) ≥ 3 per patient in those suffering from COPD. In fact, it could be concluded that patients diagnosed with COPD tend to have more teeth with PAI ≥ 3, more endodontic treatments and their periodontitis tended to accumulate more caries. Clinical Significance: This study establishes, in a case-control study, some specific aspects of oral health in patients with COPD, as well as analyzing the importance of oral health in this disease.

Genetic, Cellular and Molecular Aspects involved in Apical Periodontitis

The development, establishment and repair of apical periodontitis (AP) is dependent of several factors, which include host susceptibility, microbial infection, immune response, quality of root canal treatment and organism's ability to repair. The understanding of genetic contributions to the risk of developing AP and presenting persistent AP has been extensively explored in modern Endodontics. Thus, this article aims to provide a review of the literature regarding the biochemical mediators involved in immune response signaling, osteoclastogenesis and bone neoformation, as the genetic components involved in the development and repair of AP. A narrative review of the literature was performed through a PUBMED/MEDLINE search and a hand search of the major AP textbooks. The knowledge regarding the cells, receptors and molecules involved in the host's immune-inflammatory response during the progression of AP added to the knowledge of bone biology allows the identification of factors inherent to the host that can interfere both in the progression and in the repair of these lesions. The main outcomes of studies evaluated in the review that investigated the correlation between genetic polymorphisms and AP in the last five years, demonstrate that genetic factors of the individual are involved in the success of root canal treatment. The discussion of this review gives subsides that may help to glimpse the development of new therapies based on the identification of therapeutic targets and the development of materials and techniques aimed at acting at the molecular level for clinical, radiographic and histological success of root canal treatment.

Periapical and Endodontic Status of Patients with Inflammatory Bowel Disease: Age- and Sex- matched Case-control Study

AIM

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

METHODOLOGY

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

RESULTS

In the CG, only 17 subjects (61%) had at least one tooth with AP, while in the SG group they were 23 patients (82%) (OR = 2.98; CI 95% = 0.87 - 10.87; p = 0.08). The number of subjects with one or more root filled teeth (RFT) in the CG was 14 (50%), while in the SG they were 22 (79%) (OR = 3.67; 95% CI = 1.14 - 11.79; p = 0.026). At least one RFT with AP was evident in 3 subjects (10.7%) in the control group, while in the study group 15 patients (53.6%) showed RFT with AP (OR = 9.60; 95% CI = 2.35 - 39.35; p = 0.001). In the multivariate logistic regression analysis, only endodontic status was found to be associated with IBD (OR = 1.86; 95% CI = 1.24 - 2.80; p = 0.003).

CONCLUSION

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

Unexpected Relationships: Periodontal Diseases: Atherosclerosis-Plaque Destabilization? From the Teeth to a Coronary Event

Atherosclerotic cardiovascular disease (ASCVD) and periodontal disease (PD) are global health problems. High frequency of ASCVD is associated with the spread of many risk factors, including poor diet, sedentary lifestyle, diabetes, hyperlipidemia, obesity, smoking, hypertension, chronic kidney disease, hypertension, hyperhomocysteinemia, hyperuricemia, excessive stress, virus infection, genetic predisposition, etc. The pathogenesis of ASCVD is complex, while inflammation plays an important role. PD is a chronic, multifactorial inflammatory disease caused by dysbiosis of the oral microbiota, causing the progressive destruction of the bone and periodontal tissues surrounding the teeth. The main etiological factor of PD is the bacteria, which are capable of activating the immune response of the host inducing an inflammatory response. PD is associated with a mixed microbiota, with the evident predominance of anaerobic bacteria and microaerophilic. The "red complex" is an aggregate of three oral bacteria: Tannerella forsythia Treponema denticola and Porphyromonas gingivalis responsible for severe clinical manifestation of PD. ASCVD and PD share a number of risk factors, and it is difficult to establish a causal relationship between these diseases. The influence of PD on ASCVD should be treated as a factor increasing the risk of atherosclerotic plaque destabilization and cardiovascular events. The results of observational studies indicate that PD significantly increases the risk of ASCVD. In interventional studies, PD treatment was found to have a beneficial effect in the prevention and control of ASCVD. This comprehensive review summarizes the current knowledge of the relationship between PD and ASCVD.

Present status and future directions - microbiology of endodontic infections

Apical periodontitis has a microbial aetiology and is one of the most common inflammatory diseases that affect humans. Fungi, archaea and viruses have been found in association with apical periodontitis, but bacteria are by far the most prevalent and dominant microorganisms in endodontic infections. Bacterial infection of the root canal system only occurs when the pulp is necrotic or was removed for previous treatment. In some specific cases, including acute and chronic abscesses, the bacterial infection may reach the periradicular tissues. Intracanal bacteria are usually observed as sessile multispecies communities (biofilms) attached to the dentinal root canal walls. Infection in the main root canal lumen can spread to other areas of the root canal system. Although more than 500 bacterial species have been detected in endodontic infections, a selected group of 20 to 30 species are most frequently detected and may be considered as the core microbiome. There is a high interindividual variability in the endodontic microbiome in terms of species composition and relative abundance. Obligate anaerobic species are more abundant in the intraradicular bacterial communities of teeth with primary apical periodontitis, while both anaerobes and facultatives dominate the communities in post-treatment apical periodontitis. Bacterial interactions play an essential role in determining the overall virulence of the community, which has been regarded as the unit of pathogenicity of apical periodontitis. This article reviews the microbiologic aspects of endodontic infections and provides perspectives for future research and directions in the field.

The association between periodontitis and cardiovascular risks in asymptomatic healthy patients

Background

Periodontitis is a chronic multifactorial inflammatory disease of the supportive tissues of the teeth. Pathophysiological evidence suggests a possible common inflammatory background between periodontitis and cardiovascular diseases (CVD). Pathological and epidemiological associations between these two diseases have been presented, but are still debated. This study aimed to investigate the association between the inflammatory burden of periodontitis and the presence and extent of coronary calcification. Secondary aims were to study other cardiovascular parameters and cardiovascular risk predictors in relation to periodontitis and dental health.

Methods

Healthy periodontitis or non-periodontitis patients 45-70 years of age were included in a prospective cross-sectional study. Full-mouth examinations were performed by a periodontist to determine their Periodontal Inflamed Surface Area (PISA) score and other dental parameters. To assess the cardiovascular conditions, Coronary Artery Calcium (CAC) scores, endothelial function assessments by the EndoPAT ™, and several physical and biochemical examinations were performed.

Results

Seventy-one patients were included. Elevated CAC scores and endothelial dysfunction were not significantly related to PISA or dental health. PISA was significantly related to the Framingham and Reynolds CVD risk predictors, but were no longer significant after correction for confounders. The same applied to the significant relations between tooth loss, dental plaque and bleeding scores and the CVD risk predictors.

Conclusions

Periodontitis is associated with increased CVD risk, but is not an independent risk factor. This link is still important to make to bridge the gap between dentistry and general medicine and to identify patients at risk for CVD in an earlier stage.

Chronic apical periodontitis exacerbates atherosclerosis in apolipoprotein E-deficient mice and leads to changes in the diversity of gut microbiota

Aim

To investigate the impact of chronic apical periodontitis (CAP) on atherosclerosis and gut microbiota by establishing a Porphyromonas gingivalis (P. gingivalis)‐induced CAP in an apolipoprotein E‐deficient (apoE^−/−) mice model.

Methodology

Twenty‐eight male apoE^−/− mice were divided into two groups with 14 in each: CAP group and control group. In the CAP group, sterile cotton wool containing 10⁸ colony‐forming units of P. gingivalis was placed into the pulp chamber after pulp exposure followed by coronal resin filling in bilateral maxillary first and second molars. The mice were fed with a chow diet to induce atherosclerosis. Animals were euthanized 16 weeks after the operation, and the periapical lesions of bilateral maxillary first and second molars were assessed by micro‐CT. After collection of aortic arches, atherosclerotic lesions were measured by Oil Red O staining. Serum levels of high‐density lipoprotein cholesterol (HDL‐C), low‐density lipoprotein cholesterol (LDL‐C), total cholesterol (TC), and triglycerides (TG) were measured. Stools were collected to detect alterations in gut microbiota by 16S rRNA gene sequencing. Independent samples t‐test was used to calculate the difference between the two groups.

Results

CAP was observed in 98.2% of molars. A significant increase in atherosclerotic plaque formation in the aortic arches was found in the CAP groups (CAP: 2.001% ± 0.27%, control: 0.927% ± 0.22%, p = .005). No significant difference was observed between sevum level of HDL‐C (CAP: 2.295 ± 0.31 mmol/L, Control: 3.037 ± 0.55 mmol/L, p = .264) or LDL‐C (CAP: 17.066 ± 3.95 mmol/L, Control: 10.948 ± 1.69 mmol/L, p = .177) in CAP group and Control group. There were no significant differences in TG (CAP: 1.076 ± 0.08 mmol/L, control: 1.034 ± 0.13 mmol/L, p = .794) or TC (CAP: 6.372 ± 0.98 mmol/L, control: 6.679 ± 0.75 mmol/L, p = .72) levels between the two groups (p > .05). The alpha diversity was elevated in the CAP group. In terms of beta diversity, the CAP and control groups were clearly distinguished by the microbial community.

Conclusion

In a mouse experimental model, pulp infection with P. gingivalis ‐induced CAP, thus aggravating the development of atherosclerosis. Meanwhile, CAP increased alpha diversity and altered the beta diversity of the gut microbiota.

"Dental Cluster" Versus "Metabolic Cluster": Analyzing the Associations of Planned and Delivered Dental Procedures with Metabolic Syndrome, Utilizing Data from the Dental, Oral, Medical Epidemiological (DOME) Cross-Sectional Record-Based Nationwide Study

Simple Summary

There are conflicting results existing regarding the association between dental status and metabolic syndrome (MetS). This study aimed to analyze the association between the sum of the standard dental unit (SDU) scores of planned (SDU-P) and delivered (SDU-D) dental procedures per patient with MetS. Included were data from the Dental, Oral, Medical Epidemi-ological (DOME) study records-based research, which integrated large socio-demographic, medical, and dental databases of a nationally representative sample of young to middle-aged military personnel (N = 131,927). The present study demonstrated that SDU-P, but not SDU-D, is a better predictor of systemic morbidities related to MetS. In other words, MetS is associated with a higher dental treatment needs burden, rather than with dental treatments performed de facto. The study concludes that dental and general health authorities should collaborate and share in-formation and focus on reducing common health-related risk factors, such as smoking and sugar consumption, in particular among high-risk populations, such as immigrants and those with lower SES and rural locality.

Abstract

There are conflicting results existing regarding the association between dental status and metabolic syndrome (MetS). The present research analyzed the associations of the sum of the standard dental unit (SDU) scores of planned (SDU-P) and delivered (SDU-D) dental procedures per patient with MetS components, consequences, and related conditions. The SDU score of each dental procedure represents the time and complexity of the executed procedure. This cross-sectional study analyzed data from the Dental, Oral, Medical Epidemiological (DOME) repository, which includes comprehensive socio-demographic, medical, and dental databases of a nationally representative sample of 132,529 military personnel. Univariate analyses revealed that SDU-P had statistically significant positive associations with all systemic morbidities related to MetS, while the SDU-D exhibited positive associations with some of the systemic morbidities and with lower ORs. SDU-P and SDU-D were associated with worse scores of auxiliary examinations used in the assessment of MetS components. SDU-P retained significant positive associations in the multivariate analysis with impaired glucose tolerance (IGT) (OR = 7.40 (1.91–28.57)), deep vein thrombosis (DVT) (OR = 5.61 (1.53–20.83)), obstructive sleep apnea (OSA) (OR = 5.05 (2.40–10.63)), and fatty liver (OR = 1.82 (1.17–2.84)). In contrast, obesity was the only systemic parameter retaining a significant association with SDU-D following multivariate analysis (OR = 1.47 (1.23–1.76)). It can be concluded that SDU-P, but not SDU-D, is a better predictor of systemic morbidities related to MetS. In other words, MetS is associated with a higher dental treatment needs burden, rather than with dental treatments performed de facto. Dental and general health authorities should collaborate and share information and focus on reducing common health-related risk factors, such as smoking and sugar consumption, in particular among high-risk populations, such as immigrants and those with lower SES and rural locality.

Influence of a High-fat Diet in the Progression of Apical Periodontitis

INTRODUCTION

This study evaluated the effects of a high-fat diet (HFD) on the progression of apical periodontitis (AP) in rats.

METHODS

Eight-week old Wistar rats (N = 24) were included in this study. Half of the animals received an HFD and the other half a control diet (CD). AP lesions were induced 8 weeks later by creating pulp exposure of the mandibular left first molars. The animal's body mass was verified on a weekly basis. After 21 and 40 days, the animals were sacrificed. Blood was collected for biochemical tests, and the liver was removed for hepatic triglycerides analysis. The left hemimandibles were removed, radiographed, and then prepared for histologic evaluation. The right hemimandibles (region near molars) were removed for bone mineral density analysis by dual-energy X-ray absorptiometry.

RESULTS

Radiographs showed that AP lesions were significantly larger in the HFD group compared with the CD group (P < .05). Histologic analysis confirmed that the AP lesions were larger and revealed a more severe inflammatory infiltrate in the HFD group. Bone mineral density was reduced in the HFD group compared with the CD groups (P < .05). The HFD resulted in a significant increase in body mass (P < .05), liver mass (P < .05), relative liver mass (P < .05), and hepatic triglycerides (P < .05). The levels of triglycerides and very-low-density lipoprotein were significantly higher in the 40-day HFD group compared with the 21-day HFD and 21- and 40-day CD groups (P < .05).

CONCLUSIONS

Findings suggest that an HFD can influence the progression and severity of AP.