Primary apical periodontitis correlates to elevated levels of interleukin-8 in a Swedish population: A report from the PAROKRANK study.

AIM: To explore associations between root filled teeth, primary and secondary apical periodontitis, and levels of inflammatory markers in blood from patients with a first myocardial infarction and matched controls. METHODOLOGY: Between May 2010 and February 2014, 805 patients with a first myocardial infarction and 805 controls, matched for sex, age, and postal code area, were recruited to the multicentre case-control study PAROKRANK (periodontitis and its relation to coronary artery disease). All participants underwent a physical and oral examination, as well as blood sampling. Using panoramic radiography, root filled teeth, primary apical periodontitis, and secondary apical periodontitis were assessed by three independent observers. Blood samples were analysed with enzyme-linked immunosorbent assay method for the following inflammatory markers: interleukin-1ß (IL-1ß), IL-2, IL-6, IL-8, IL-12p70, tumour necrosis factor-α, and high-sensitivity C-reactive protein (hsCRP). Additionally, white blood cell count and plasma-fibrinogen were analysed. Associations between endodontic variables and the levels of inflammatory markers were statistically analysed with Mann-Whitney U-test and Spearman correlation, adjusted for confounding effects of baseline factors (sex, age, myocardial infarction, current smoking, diabetes, family history of cardiovascular disease, education, marital status, and periodontal disease). RESULTS: Mean age of the cohort was 62 years, and 81% were males. Root fillings were present in 8.4% of the 39 978 examined teeth and were associated with higher levels of hsCRP, fibrinogen, and leukocyte count, but lower levels of IL-2 and IL-12p70. After adjusting for confounders, root filled teeth remained associated with higher levels of fibrinogen, but lower levels of IL-1ß, IL-2, IL-6, and IL-12p70. Primary apical periodontitis was found in 1.2% of non-root filled teeth and associated with higher levels of IL-8 (correlation 0.06, p = .025). Secondary apical periodontitis was found in 29.6% of root filled teeth but did not relate to the levels of any of the inflammatory markers. CONCLUSIONS: This study supports the notion that inflammation at the periapex is more than a local process and that systemic influences cannot be disregarded. Whether the observed alterations in plasma levels of inflammatory markers have any dismal effects on systemic health is presently unknown but, considering the present results, in demand of further investigation.

Endodontic inflammatory disease: A risk indicator for a first myocardial infarction.

AIM: To study the association between endodontic inflammatory disease and a first myocardial infarction (MI). METHODOLOGY: The study comprised 805 patients with recent experience of a first MI, each gender, age and geographically matched with a control. Panoramic radiographs were available for 797 patients and 796 controls. Endodontic inflammatory disease was assessed radiographically. The sum of decayed, missing and filled teeth (DMFT) was calculated, and the number of root filled teeth and teeth with periapical lesions were recorded. The associated risk of a first MI was expressed as odds ratios (OR) with 95% confidence intervals (CI), unadjusted and adjusted for confounders (family history of cardiovascular disease, smoking habits, marital status, education and diabetes). RESULTS: Patients who had suffered a first MI had higher DMFT (mean 22.5 vs. 21.9, p = .013) and more missing teeth (mean 7.5 vs. 6.3; p < .0001) than the healthy controls. The number of missing teeth was associated with an increased risk of a first MI (adjusted OR 1.04; CI 1.02-1.06). Conversely, decay-free, filled teeth were associated with decreased risk (adjusted OR 0.98; CI 0.96-1.00). Analysis based on age disclosed the following variables to be associated with an increased risk of a first MI: number of decayed teeth (adjusted OR 1.18; CI 1.02-1.37, in patients <60 years), any primary periapical lesion (adjusted OR 1.57; CI 1.08-2.29, in patients <65 years) and the proportion of root filled teeth (adjusted OR 1.18; CI 1.03-1.36, in patients ≥65 years). CONCLUSIONS: More missing teeth was independently associated with an increased risk of a first MI. In addition, endodontic inflammatory disease may contribute as an independent risk factor to cardiovascular disease since untreated caries, periapical lesions and root fillings, depending on age, were significantly associated with a first MI.

Calibration improves observer reliability in detecting periapical pathology on panoramic radiographs.

OBJECTIVE: To determine whether calibration improves observer reliability when assessing DMFT-score, root-filled teeth and periapical lesions on panoramic radiographs. MATERIAL AND METHODS: A sample of 100 panoramic radiographs was selected from a cohort of myocardial infarction patients (n = 797) and matched controls (n = 796). The following variables were assessed: DMFT-score, remaining teeth, root-filled teeth and periapical lesions. Two specialists, an endodontist and a radiologist, served as reference examiners and undertook two separate assessments. Disagreement cases were jointly assessed and the final results were used as the reference standard. Three observers undertook three separate assessments, the first without prior training, the second after calibration against the reference standard and the third with the sample concealed in the complete material. Statistical analysis was made with Wilcoxon Signed rank test and Sign test. Agreement was calculated as Intraclass Correlation Coefficient (ICC) (95% CI) and Weighted Kappa (κ) (95% CI). RESULTS: Periapical lesions disclosed high inter-observer variability for the reference examiners and diverged significantly between the observers and the reference standard. For the reference examiners, inter-observer agreement was κ = 0.53. The observers, in their first assessments had κ values ranging from 0.22 to 0.60 in relation to the reference standard. Following calibration, the κ values increased, ranging from 0.59 to 0.80. For the third assessment, the κ values ranged from 0.54 to 0.75. DMFT-score, remaining teeth and root-filled teeth disclosed high reliability throughout all assessments (ICC = 0.88-0.98 and κ = 0.98-0.99). CONCLUSIONS: DMFT-score, remaining teeth and root-filled teeth can be reliably assessed on panoramic radiographs. Calibration against a reference standard improves observer reliability in the detection of periapical lesions.

Apical periodontitis as potential source of infection in patients with lymphoma treated with chemotherapy.

OBJECTIVES: To investigate signs of infection and infection-related complications of apical periodontitis (AP) in patients who underwent chemotherapy for lymphoma. MATERIALS AND METHODS: Data were collected retrospectively from the dental and medical records of patients receiving chemotherapy for lymphoma. Based on the findings from a dental evaluation made in conjunction with chemotherapy, the patients were divided into two groups, patients with or without teeth with AP. RESULTS: Eighty-six of the 213 patients had one or more teeth with AP and received no planned dental treatment for this condition, while 127 patients had no AP-affected teeth. During chemotherapy, seven patients (8%) developed local symptoms related to teeth with AP, while no patients in the control group developed symptoms of AP. No significant differences were found with respect to the administration of antibiotics related to dental infection or hospital admission events due to fever or infection, between the group with AP and the group without AP. CONCLUSIONS: AP is a common finding and exacerbation seems more common in patients diagnosed with chronic AP than in patients without chronic AP. The presence of chronic AP in patients treated with chemotherapy for lymphoma is not linked to additional medical complications that require hospital admission owing to fever/infection. CLINICAL RELEVANCE: Knowledge regarding infection-related complications of AP in patients with lymphoma treated with chemotherapy will guide clinical decision-making by identifying those patients who warrant treatment. This will allow dental interventions to be postponed until completion of chemotherapy, without serious medical complications. The results of this study serve as a basis for larger prospective studies.

Inflammatory profile of chronic apical periodontitis: a literature review.

Apical periodontitis caused by root canal infection is the most frequent pathological lesion in the jaws, mainly manifested as periapical granulomas and cysts. Understanding of the formation and progression of apical periodontitis as well as the identification of inflammatory biomarkers can help increase the knowledge of pathogenic mechanisms, improve the diagnosis and provide support for different therapeutic strategies. The objective of the present article is to review inflammatory biomarkers such as cytokines, chemokines, inflammatory cells, neuropeptides, RANK/RANKL/OPG system and other inflammatory markers and to relate these systems to the development and progression of pathological conditions related to apical periodontitis.

Vital root resection with MTA: a pilot study.

OBJECTIVES: To investigate the outcome of vital root resection followed by immediate pulp capping with MTA in furcation involved maxillary molars. MATERIAL AND METHODS: This pilot clinical study of 12 months duration was designed to evaluate the outcome of vital root resection in maxillary molars with degree II furcation involvement combined with conservative endodontic treatment by means of pulp capping with mineral trioxide aggregate (MTA). Seven teeth in six adult patients suffering from adult chronic periodontitis were included in this study. RESULTS: At the final 12 month examination interval, one tooth had received root canal therapy subsequent to the 6-month evaluation. The remaining six teeth remained clinically vital for the duration of the study and required no further treatment at 12 months. CONCLUSION: Results of this study provide limited data that can be used in a further investigation with similar methodology and a sufficient sample size in a randomized clinical trial model.

A Weighted Composite of Endodontic Inflammatory Disease is Linked to a First Myocardial Infarction.

PURPOSE: To explore a weighted composite of endodontic inflammatory disease (EID) as a risk factor for suffering a first myocardial infarction (MI). MATERIALS AND METHODS: Seven tooth-specific conditions related to EID were assessed radiographically in 797 patients suffering a first MI and 796 controls. A weighted composite of EID was calculated as the sum of all teeth, excluding third molars. Using maximum likelihood estimation, each condition was assigned a specific weight. With multivariable conditional regression, EID variables, periodontal disease, and missing teeth were assessed as predictors of a first MI. RESULTS: Periodontal disease (OR 1.38; 95% CI 1.13-1.69, p = 0.0016) and missing teeth (OR 1.03; 95% CI 1.002-1.05, p = 0.034) were related to the risk of a first MI, while none of the EID-related conditions individually were. However, when assessed as an aggregate, a weighted composite of EID (OR 1.97; 95% CI 1.23-3.17, p = 0.0050) and periodontal disease (OR 1.34; 95% CI 1.09-1.63, p = 0.0046) was associated with the risk of MI. Missing teeth did not remain a statistically significant predictor of MI in the final model. CONCLUSIONS: A weighted composite of EID was associated with the risk of MI and strengthens the evidence for a direct connection between oral inflammatory diseases and cardiovascular disorders.

Comparing Quality of Life of Patients Undergoing Root Canal Treatment or Tooth Extraction.

INTRODUCTION: The knowledge of patient-centered outcomes concerning the consequences of root canal treatment in daily life is limited. The treatment option is often tooth extraction with possible prosthetic replacement. This study aimed to achieve a greater understanding of the patient perspective by evaluating the effect of root canal treatment in terms of quality of life and quality-adjusted life year (QALY) weights in comparison with patients who underwent tooth extraction. METHODS: Patients with either root canal treatment or extraction were recruited from 6 clinics in the general public dental service during a predetermined period of 8 weeks. Three different instruments were used: the Oral Health Impact Profile evaluating the oral health-related quality of life (OHRQOL), the EQ-5D-5L evaluating health-related quality of life (HRQOL) and QALY weights, and a disease-specific questionnaire evaluating satisfaction regarding the root canal treatment. The evaluation was assessed at the initiation of treatment and after 1 month. Patient-based and tooth-specific characteristics were obtained from the dental records. RESULTS: Eighty-five patients were included. The distribution between sexes was even, with 43 women and 42 men. The mean age was 51.1 years. Forty-eight patients (56.5%) had a tooth extraction, and 37 patients (43.5%) initiated root canal treatment. The response rate for the questionnaire at baseline was 95.3%, and at the 1-month follow-up, it was 74.1%. Two relevant and comparable groups were obtained after exclusion of the extracted third molars (n = 20), resulting in 65 patients for further analyses. At follow-up, the patients who initiated root canal treatment registered a significant improvement in perceived HRQOL according to the QALY weights (P = .02 and P < .01, respectively). Patients initiating root canal treatment reported generally high satisfaction. CONCLUSIONS: A cohort of patients either initiating root canal treatment or tooth extraction as a control group was established. Initiating root canal treatment had a positive impact on perceived HRQOL. The included patients in general dental practice registered overall high satisfaction regarding root canal treatment.

Presence of langerhans cells, regulatory T cells (Treg) and mast cells in asymptomatic apical periodontitis.

Asymptomatic Apical Periodontitis is essentially an inflammatory disease of microbial aetiology. Association and function of the cell components involved, or specific inductive factors and growth mediators associated with development, maintenance and resolution of the periapical lesions are still unknown. The objective of this study was to evaluate the concentration of Regulatory T cells (FoxP3+; Treg), Langerhans cells (CD1a+; LC) and mast cells in asymptomatic apical periodontitis. 73 cases were selected: 30 periapical granulomas, 29 radicular cysts and 14 residual cysts. All groups were submitted to morphological analysis for classification of inflammatory infiltrate and thickness of the epithelial lining as well as to immunohistochemical analysis for detection of LC and Treg cells. Toluidine blue staining was used for detecting mast cells. Analysis showed higher mean numbers of LC (8.2 cells/0.2mm2), and Treg cells in radicular cysts (5.910 cells/0.2mm2). As for mast cells, it was found that radicular cysts had a higher mean number of these cells compared to other periapical lesions (12.68 cells/0.2mm2). The association between thickness of the epithelial lining and inflammatory cells showed that the presence of hypertrophic epithelium in radicular cysts presented higher density of LC. The number of LC and Treg cells play an important role in the control of the inflammatory micro-environment in periapical granulomas and radicular cysts, respectively. The presence of mast cells in radicular cysts may be associated with progression of the lesion. Knowledge regarding the inflammatory cell profile is therefore essential for a better understanding of the pathogenesis of asymptomatic periapical periodontitis.

Long-term survival of endodontically treated teeth at a public dental specialist clinic.

INTRODUCTION: The long-term survival of endodontically treated teeth is an issue of high priority focus in modern restorative dentistry. In available literature, survival is generally high and comparable with implants. For more compromised teeth treated in a specialist clinic, survival rate may be lower. This retrospective study aimed to investigate the 10-year survival rate of teeth treated in a public endodontic specialist clinic. METHODS: From a database of 15,000 examined teeth, 420 teeth in 330 patients were randomly selected and included. Available potential preoperative, intraoperative, and postoperative prognostic factors were registered. Ten-year tooth survival was recorded by scrutinizing records and by contacting referring dentists and patients. RESULTS: The overall Kaplan-Meier estimated 10-year survival rate was 81.5% (95% confidence interval [CI], 76.7%-85.5%). Placement of a crown, adjusted hazard ratio 0.27 (95% CI, 0.12-0.61), P = .0016, and age-adjusted hazard ratio 1.31 per 10 years (95% CI, 1.11-1.55), P = .0012, were significant independent predictors for estimated survival rate. Seventy-three teeth (17.4%) in 69 patients were extracted during the 10-year follow-up period. The declared reason for extraction was related to endodontic diagnoses in only 5 of the cases (6.8%). CONCLUSIONS: Approximately 80% of the teeth treated at this specialist clinic in endodontics survived at least for 10 years. Teeth in young persons and teeth restored with a crown postoperatively survived significantly better. To further explore the importance of the postoperative restoration in endodontically treated teeth, randomized controlled trials need be carried out.

Presence of langerhans cells, regulatory T cells (Treg) and mast cells in asymptomatic apical periodontitis

Abstract Asymptomatic Apical Periodontitis is essentially an inflammatory disease of microbial aetiology. Association and function of the cell components involved, or specific inductive factors and growth mediators associated with development, maintenance and resolution of the periapical lesions are still unknown. The objective of this study was to evaluate the concentration of Regulatory T cells (FoxP3+; Treg), Langerhans cells (CD1a+; LC) and mast cells in asymptomatic apical periodontitis. 73 cases were selected: 30 periapical granulomas, 29 radicular cysts and 14 residual cysts. All groups were submitted to morphological analysis for classification of inflammatory infiltrate and thickness of the epithelial lining as well as to immunohistochemical analysis for detection of LC and Treg cells. Toluidine blue staining was used for detecting mast cells. Analysis showed higher mean numbers of LC (8.2 cells/0.2mm2), and Treg cells in radicular cysts (5.910 cells/0.2mm2). As for mast cells, it was found that radicular cysts had a higher mean number of these cells compared to other periapical lesions (12.68 cells/0.2mm2). The association between thickness of the epithelial lining and inflammatory cells showed that the presence of hypertrophic epithelium in radicular cysts presented higher density of LC. The number of LC and Treg cells play an important role in the control of the inflammatory micro-environment in periapical granulomas and radicular cysts, respectively. The presence of mast cells in radicular cysts may be associated with progression of the lesion. Knowledge regarding the inflammatory cell profile is therefore essential for a better understanding of the pathogenesis of asymptomatic periapical periodontitis.