9.1
Apical Periodontitis and Systemic Disease
Shalini Kanagasingam, Abdulaziz A. Bakhsh, and Philip Mitchell
Objectives
At the end of this case, the reader should be able to recognise the potential associations between apical periodontitis and systemic diseases. This includes the effects of diabetes mellitus and cardiovascular disease on endodontic outcomes.
Introduction
A 51‐year‐old male presented for a routine one‐year review after having had root canal treatment of his upper right second molar (UR7).
Chief Complaint
The patient was asymptomatic since the root canal treatment was carried out by an endodontist, followed by restoration with a gold crown by a prosthodontist.
Medical History
The patient has a history of diabetes mellitus (DM), hypertension, high cholesterol levels and a history of myocardial infarction about five years ago. He had been taking multiple medications including metformin, metoprolol succinate, atorvastatin, aspirin and clopidogrel.
Dental History
The patient was a regular attender. The UR6 and UR7 had been restored with gold crowns 11 months previously. He had also recently had implant treatment to replace the missing UR5, with no complications.
Clinical Examination
The patient had a moderately restored dentition and the soft tissues were healthy. Tooth UR7 was not tender to percussion and not painful on biting. Probing depths were within normal limits.
A radiograph of the UR7 revealed the presence of a periapical radiolucency that appeared larger and more distinct when compared to the immediate post‐treatment radiograph taken a year ago (Figure 9.1.1a, b).
A cone beam computed tomography (CBCT) scan was taken to assess the extent of the periapical lesion and any untreated (missed) canals (Figure 9.1.1c–f). The scan revealed that all the root canals had been filled and a periapical radiolucency associated with mesio‐buccal 1, mesio‐buccal 2, disto‐buccal and palatal canals. No missed canals were detected.
Diagnosis and Treatment Planning
A diagnosis of asymptomatic apical periodontitis associated with the previously treated UR7 was made.
The treatment options for the UR7 were:
- No treatment (continue to monitor)
- Non‐surgical root canal retreatment
- Surgical treatment (apicectomy)
- Extraction
The patient was very concerned that the periapical lesion had not healed and, in fact, appeared to have radiographically worsened over the past year. He shared that he was particularly anxious about this due to his medical history, as he had come across information on social media regarding root canal treatment being linked to poor general health.
What are the potential pathways by which apical periodontitis can impact the development of systemic diseases?
Apical periodontitis can act as a reservoir for microbes and/or microbial by‐product dissemination via the periapical vasculature into the patient’s systemic circulation. Raised levels of inflammatory biomarkers can induce a systemic inflammatory response, eventually leading to an increased frequency of cardiovascular events. Endodontic pathogens may directly seed into the arterial wall via bacteraemia. This initiates a local inflammatory reaction including adaptive immune responses, inducing cellular changes, eventually forming atherosclerotic plaques.
Apical periodontitis may go undiagnosed for years, which can potentially lead to increased systemic inflammation. Repeated or chronic infections may be another additional causal element for DM. Inflammatory mediators, especially cytokines, can decrease insulin sensitivity, incur changes to adipocyte function and damping of endothelial nitric oxide production, leading to the development of DM. These mechanisms warrant further investigations (Table 9.1.1).
Table 9.1.1 Potential pathways linking endodontic disease to systemic disorders.
What is the association between apical periodontitis and cardiovascular disease?
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