Smoking and Radiolucent Periapical Lesions in Root Filled Teeth: Systematic Review and Meta-Analysis

Abstract

Aim: This systematic review and meta-analysis aimed to investigate the association between smoking habits and the prevalence of radiolucent periapical lesions (RPLs) in root-filled teeth (RFT). Methods: The Population, Intervention, Comparison, and Outcome (PICO) question was: in adult patients who have RFT, does the absence or presence of a smoking habit affect the prevalence of RPLs associated with RFT? Systematic MEDLINE/PubMed, Wiley Online Database, Web of Science, Scopus, and PRISMA protocol were used to evaluate and present the results. Studies comparing smokers with control non-smoker subjects, including RFT, and providing data on the prevalence of RFT with RPLs, were included. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used for certainty in the evidence. The risk of bias was assessed according to Cochrane Collaboration common scheme for bias and ROBINS-I tool. Cumulative meta-analysis was performed with a random effects model. PROSPERO registration code: CRD42020165279. Results: Four studies reported data on inclusion criteria, representing data from 9257 root-filled teeth—4465 from non-smokers and 4792 from smoker patients. The meta-analysis provided an odds ratio indicating a significant association between smoking and higher prevalence of root filled teeth with radiolucent periapical lesions (OR = 1.16; 95% CI = 1.07–1.26; p = 0.0004). The certainty of the literature assessment was moderate per GRADE. The ROBINS-I tool classified three studies as low risk of bias, and the fourth as moderate risk of bias. Conclusions: Moderate, quality scientific evidence indicates a weak but significant relationship between smoking and the prevalence of RPLs in RFT. Smoking can be considered a negative prognostic factor for the outcome of root canal treatment. Endodontic providers should be aware of the relationship between smoking and persistent apical periodontitis, assessed as RPLs, in RFT.

Impact of systemic health on treatment outcomes in endodontics

“…Two systematic reviews with meta‐analysis have analysed the association of smoking habits with the prevalence of RPL in RFT (Cabanillas‐Balsera, Segura‐Egea, Jiménez‐Sánchez, et al, 2020) and with the occurrence of RFT extraction (Cabanillas‐Balsera, Segura‐Egea, Bermudo‐Fuenmayor, et al, 2020). These systematic reviews concluded that low evidence indicates that RFT of smoking patients are three times more likely to be extracted (OR = 3.4; 95% CI = 1.2–10.1; p = .02; Cabanillas‐Balsera, Segura‐Egea, Bermudo‐Fuenmayor, et al, 2020), and moderate quality scientific evidence indicates a weak but significant relationship between smoking and the prevalence of RPLs in RFT (OR = 1.2; 95% CI = 1.1–1.3; p < .001; Cabanillas‐Balsera, Segura‐Egea, Jiménez‐Sánchez, et al, 2020).…”

“…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 (Sasaki et al, 2016). This is not just a possibility, the results of several studies have shown worse success rate of RCT, with higher percentage of post‐operative radiolucent periapical lesions (RPL) and higher proportion of nonretained root filled teeth (RFT), in patients with systemic diseases (Cabanillas‐Balsera, Segura‐Egea, Bermudo‐Fuenmayor, et al, 2020; Cabanillas‐Balsera, Segura‐Egea, Jiménez‐Sánchez, et al, 2020; Nagendrababu et al, 2020; Ng et al, 2011; Segura‐Egea et al, 2015, 2016).…”

Evolution of endodontic medicine: a critical narrative review of the interrelationship between endodontics and systemic pathological conditions

“…Two retrospective studies have found that RCT in smokers had fewer successes and more failures than in non-smoker patients [140,143]. Furthermore, two recent systematic reviews with meta-analysis have found significant association between smoking and higher frequency of periapical lesions in endodontically treated teeth [144], and higher frequency of extraction of root-filled teeth [145].…”

Inflammatory profile of apical periodontitis exacerbated by cigarette smoke inhalation: Histological and immunohistochemical analysis in rats

“…The association between smoking and AP is controversial in the literature. Whilst some authors showed a positive association between smoking and periapical lesions visualized on radiographs (Aleksejuniene et al, 2000; Cabanillas‐Balsera et al, 2020a; Kirkevang & Wenzel, 2003; Krall et al, 2006; Segura‐Egea et al, 2008, 2011). Other studies demonstrated no significant effect (Bergström et al, 2000; Frisk & Hakeberg, 2006; Rodriguez et al, 2013).…”