Association between Endodontic Infection, Its Treatment and Systemic Health: A Narrative Review

Abstract

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.

Hypercitrullination and anti‐citrullinated protein antibodies in chronic apical periodontitis, a laboratory investigation. Does autoimmunity contribute to the pathogenesis?

“…In order to elucidate immune‐inflammatory mechanisms active in chronic apical periodontitis, for the first time, the levels of citrullinated proteins and ACPA in human periapical granuloma samples were investigated. A positive correlation may suggest that there could be an autoimmune pathway in chronic apical periodontitis via peptidylarginine deaminases (PAD) or PPAD activities (Čolić et al, 2007; Niazi & Bakhsh, 2022).…”

Humoral Immune Response Before and After Surgical Therapy in Patients With Odontogenic Inflammatory Cysts

“…There is new evidence in the literature that confirms how in the presence of apical periodontitis the systemic levels of inflammatory markers in patients can be modified, eg. high-sensitivity C-reactive protein (hs-CRP), interleukin-1β (IL-1β) , IL-6, IL-12, IL-10, tumor necrosis factor (TNF-α), matrix metalloproteinases (MMP-8 and MMP-9), soluble vascular cell adhesion molecule 1 (sVCAM-1), endothelial leukocyte adhesion (E-selectin and intercellular adhesion molecule (ICAM)), immunoglobulins IgA, IgM, IgG, asymmetric dimethylarginine (ADMA) and complement-C3 levels [9]. This is significant, not only for the presence of apical periodontitis with symptoms and teeth with unsuccessfully treated root canals, but also to highlight the potential negative impact of asymptomatic apical periodontitis on the systemic immune response of the body.…”

“…12) is a biochemical analyzer of spectrophotometric, immunoturbodimetric and ion selective method of determining the concentrations of biochemical analytes. The values of IgA, IgM and IgG are based on the principle of immune agglutination using specific antibodies -Anti-IgA, Anti-IgM and Anti-IgG that react with the antigen in the sample and form an antigen-antibody complex, which follows agglutination that is measured turbidimetrically along with the use of polyethylene glycol (PEG) which increases and improves the sensitivity, accuracy and precision of the method [9]. The values of immunoglobulins in the serum of the patients were also examined one month after the surgical therapy when complete clinical healing of the wound occurred with no postoperative complications or early relapses.…”

A Micro-CT Analysis of Initial and Long-Term Pores Volume and Porosity of Bioactive Endodontic Sealers

“…Consequently, greater volume of the sealant is needed, which can result in the formation of air bubbles and pores [ 30 , 31 ]. The formation of pores contributes to the persistence of microbial infection in the root canal system and therefore is reported as a major factor associated with endodontic failure [ 32 ]. If the root canal filling does not provide a complete seal, the seepage of tissue fluids may become a substrate for bacterial growth [ 26 , 32 ].…”