Asociación entre la diabetes y la pérdida de dientes endodonciados: revisión sistemática y meta-análisis

Introducción. La influencia de la diabetes mellitus sobre el éxito del tratamiento endodóncico (TE) sigue siendo un interrogante. El objetivo de este estudio es realizar una revisión sistemática y un meta-análisis que analice la posible asociación entre la diabetes y el fracaso del tratamiento endodóncico, evaluado como la prevalencia de dientes endodonciados extraídos. Métodos. La pregunta PICO planteada fue: ¿en pacientes adultos con dientes tratados endodóncicamente (problema e intervención), la ausencia o presencia de diabetes mellitus (comparación) influye en la prevalencia de extracción de dientes endodonciados (resultado)? Se llevó a cabo una búsqueda sistemática en MEDLINE / PubMed, Wiley Online Database, Web of Science y Scopus. Se estableció la Odds Ratio (OR) para la prevalencia de dientes endodonciados extraídos de sujetos control y diabéticos como variable de resultado primaria. El estimador OR se calculó utilizando el método de DerSimonian-Laird con efectos aleatorios. Resultados. Se identificaron trescientos títulos, y tres estudios que aportaron datos sobre la prevalencia de extracciones dentales asociadas a dientes endodonciados tanto en sujetos diabéticos como control, cumplieron los criterios de inclusión. Se analizaron los datos de 54,936 tratamientos endodóncicos, 50,301 en sujetos control no diabéticos y 4,635 en pacientes diabéticos. El estimador odds ratio calculado (OR = 2,44; IC del 95% = 1,54 - 3,88; p = 0,0001) indica que los pacientes diabéticos tienen una prevalencia de dientes endodonciados extraídos significativamente mayor que el grupo control. Conclusiones. Los resultados de los estudios disponibles indican una asociación significativa entre la diabetes y una mayor prevalencia de pérdida de dientes endodonciados. La diabetes debe considerarse como un importante factor pronóstico preoperatorio en la terapia endodóntica.Universidad de Sevilla. Grado en Odontología. Máster en Odontología Restauradora, Estética y Funciona

Diabetes mellitus and smoking as prognostic factors of endodontic treatment: systematic review and metaanalysis

Introducción El tratamiento de conductos es el procedimiento mediante el cual se erradica la contaminación endodóntica causante de la periodontitis apical, conduciendo a la curación y restitución de los tejidos periapicales. Si el tratamiento endodóntico fracasa, la lesión radiolúcida periapical persiste alrededor del diente endodonciado, pudiendo ser necesario el retratamiento endodóntico e incluso la extracción del diente afectado. Los factores habitualmente relacionados con el fracaso de este tratamiento son de carácter intra-operatorios, propios de una técnica endodóntica incorrecta, como una instrumentación inadecuada, irrigación deficiente o defecto del sellado y obturación tridimensional. Por otro lado, la “Medicina Endodóntica” analiza posibles implicaciones de enfermedades y/o hábitos sistémicos en la pulpa y los tejidos periapicales, así como de las consecuencias sistémicas que puedan tener la pulpitis y la periodontitis apical, a la vez que intenta esclarecer los mecanismos biológicos involucrados en esta conexión. En este sentido, se ha estudiado la asociación entre la patología endodóntica y factores generales del paciente, como pueden ser condiciones médicas sistémicas como la diabetes mellitus, las enfermedades cardiacas o el tratamiento con corticoides, así como hábitos nocivos como el consumo de tabaco o alcohol. 2 Sin embargo, la relación entre el estado sistémico del paciente y la respuesta reparadora periapical y el resultado del tratamiento endodóntico sigue siendo una controversia en la actualidad. Objetivos El objetivo de esta tesis doctoral es investigar la posible asociación entre el estado sistémico del paciente enfermo con diabetes mellitus o con hábito tabáquico, y el pronóstico del tratamiento de conductos mediante la realización de revisiones sistemáticas y metaanálisis. Material y métodos La metodología empleada comprende la realización de una revisión sistemática y metaanálisis para cada una de las posibles variables de asociación, analizando los datos de los diferentes estudios disponibles en la literatura. En este sentido, se lleva a cabo una revisión de la evidencia científica disponible de forma planificada y meticulosa, incluyendo un plan y una estrategia de búsqueda bien definidos, analizando los estudios relevantes sobre la variable en cuestión. Además, el metaanálisis añade el uso de técnicas estadísticas para analizar y sintetizar cuantitativamente los datos de varios estudios similares, combinándolos en una estimación global ponderada. Primera parte: Diabetes mellitus y pronóstico del tratamiento de conductos La revisión sistemática con metaanálisis llevada a cabo para analizar la prevalencia de lesiones radiolúcidas periapicales en dientes endodonciados en pacientes diabéticos y en sujetos controles sanos analiza los datos de 1.593 tratamientos de conductos, 1.011 en pacientes control no diabéticos y 582 en 3 pacientes con diabetes, indicando que la diabetes mellitus se asocia significativamente con una mayor prevalencia de lesiones radiolúcidas periapicales en dientes endodonciados (OR = 1.42; IC 95% = 1.11–1.80; p < 0.05). Del mismo modo, para la prevalencia de dientes endodonciados extraídos en pacientes diabéticos y en sujetos controles sanos se analizaron los datos de 54.936 tratamientos de conductos, 50.301 en controles no diabéticos y 4.635 en pacientes con diabetes, resultando en una mayor prevalencia significativa de dientes endodonciados extraídos en pacientes con diabetes respecto de pacientes sanos (OR = 2.44; IC 95% = 1.54–3.88; p < 0.05). Entre los mecanismos biológicos que parecen explicar esta asociación encontramos que la diabetes mellitus predispone a la inflamación crónica mediante un deterioro de la inmunidad innata, los productos finales de glicación avanzada (AGEs) y la hiperglucemia; disminuyendo la capacidad reparativa de los tejidos y predisponiendo al fracaso del tratamiento endodóncico. Por otro lado, la inflamación crónica periapical puede inducir o perpetuar un estado inflamatorio crónico sistémico, favoreciendo un aumento de la resistencia general a la insulina y una alteración del control metabólico en pacientes con diabetes mellitus, predisponiendo a su vez al fracaso del tratamiento de conductos y al mantenimiento de la periodontitis apical persistente. Segunda parte: Hábito tabáquico y pronóstico del tratamiento de conductos La revisión sistemática acerca de la prevalencia de lesiones radiolúcidas periapicales en dientes endodonciados en pacientes con y sin hábito tabáquico analiza un total de 9.257 dientes, siendo 4.465 en personas no fumadoras y 4.792 en pacientes con hábito tabáquico. El metaanálisis combinando los diferentes estudios indica una asociación significativa entre el tabaquismo y una mayor prevalencia de los dientes endodonciados con lesiones periapicales radiolúcidas (OR = 1.16; IC 95% = 1.07-1.26; p < 0.05). 4 Respecto a la relación de la prevalencia de dientes endodonciados extraídos con el hábito tabáquico, la literatura existente aporta datos de 516 tratamientos, 351 en sujetos no fumadores y 165 en pacientes con hábito de fumar, estimando el metaanálisis una razón de probabilidades combinada que indica una asociación significativa entre el tabaquismo y la prevalencia de dientes con tratamiento de conductos extraídos (OR = 3.43, IC 95% = 1.17-10.05, p < 0.05). Una alteración de la vascularización, una reparación tisular deficiente, una alteración de la respuesta inmune, una reacción inflamatoria sistémica y/o una reacción inflamatoria local son las posibles alteraciones biológicas producidas por el hábito tabáquico que pueden estar relacionadas con el retraso de la curación de las lesiones periapicales y, por tanto, con el pronóstico del tratamiento de conductos. Conclusiones Tanto la diabetes mellitus como el hábito tabáquico se asocian significativamente con una mayor prevalencia de lesiones radiolúcidas periapicales en dientes tratados endodónticamente y con una mayor prevalencia de dientes endodonciados extraídos. En consecuencia, podemos concluir que la diabetes mellitus y el hábito tabáquico suponen un factor pronóstico negativo en el resultado del tratamiento de conductos.Introduction Root canal treatment is the procedure by which the endodontic infection that causes apical periodontitis is eradicated, leading to the healing and restitution of the periapical tissues. If endodontic treatment fails, radiolucent periapical lesion persists around the root filled teeth, and root canal retreatment and even extraction of the affected tooth could be necessary. Factors usually related to the failure of this treatment are intra-operative, characteristic of an incorrect endodontic technique, such as inadequate instrumentation, poor irrigation or defect in sealing and three-dimensional obturation. On the other hand, "Endodontic Medicine" analyzes possible implications of diseases and/or systemic habits in the pulp and periapical tissues, as well as the systemic consequences that pulpitis and apical periodontitis could have, while trying to clarify the biological mechanisms involved in this connection. In this sense, the association between endodontic pathology and general factors of the patient has been studied, such as systemic medical conditions such as diabetes mellitus, heart disease or treatment with corticosteroids, as well as bad habits such as smoking or drinking. However, the relationship between the patient's systemic status and the periapical reparative response and the outcome of endodontic treatment remains controversial today. 6 Objectives The objective of this doctoral thesis is to investigate the possible association between the systemic state of the patient with diabetes mellitus or smoking, and the prognosis of root canal treatment by conducting systematic reviews and metaanalyses. Material and methods The methodology used includes conducting a systematic review and metaanalysis for each of the possible association variables, analyzing the data from the different studies available in the literature. In this sense, a planned and meticulous review of the available scientific evidence is carried out, including a well-defined search plan and strategy, analyzing the relevant studies on the variable in question. Furthermore, metaanalysis adds the use of statistical techniques to quantitatively analyze and synthesize data from several similar studies, pooling them into a weighted global estimate. First part: Diabetes mellitus and prognosis of root canal treatment The systematic review with meta-analysis carried out to analyze the prevalence of radiolucent periapical lesions in root filled teeth in diabetic patients and in healthy control subjects analyzes the data of 1,593 root canal treatments, 1,011 in non-diabetic control patients and 582 in patients with diabetes, indicating that diabetes mellitus is significantly associated with a higher prevalence of radiolucent periapical lesions in endodontically treated teeth (OR = 1.42; 95% CI = 1.11–1.80; p <0.05). 7 Similarly, for the prevalence of root filled teeth extraction in diabetic patients and in healthy control subjects, data from 54,936 root canal treatments were analyzed, 50,301 in non-diabetic controls and 4,635 in patients with diabetes, resulting in a significantly higher prevalence of root filled teeth extraction in patients with diabetes compared to healthy patients (OR = 2.44; 95% CI = 1.54–3.88; p <0.05). Biological mechanisms that seem to explain this association could be that diabetes mellitus predisposes to chronic inflammation through a deterioration of innate immunity, advanced glycation end products (AGEs) and hyperglycemia; decreasing the reparative capacity of the tissues and predisposing to endodontic treatment failure. On the other hand, chronic periapical inflammation could induce or perpetuate a chronic systemic inflammatory state, favoring an increase in general insulin resistance and an alteration of metabolic control in patients with diabetes mellitus, predisposing in turn to the failure of root canal treatment and the maintenance of persistent apical periodontitis. Second part: Smoking and prognosis of root canal treatment The systematic review on the prevalence of radiolucent periapical lesions in root filled teeth in patients with and without smoking habit analyzes a total of 9,257 teeth, of which 4,465 were in non-smokers and 4,792 smokers. The metaanalysis pooling the different studies indicates a significant association between smoking and a higher prevalence of radiolucent periapical lesions in endodontically treated teeth (OR = 1.16; 95% CI = 1.07-1.26; p <0.05). Regarding the relationship between the prevalence of root filled teeth extraction and smoking, the existing literature provides data on 516 treatments, 351 in non-smoking subjects and 165 in smokers, and the metaanalysis calculated a pooled odds ratio that indicates a significant association between 8 smoking and the prevalence of root filled teeth extraction (OR = 3.43, 95% CI = 1.17-10.05, p <0.05). An alteration of the vascularization, a deficient tissue repair, an alteration of the immune response, a systemic inflammatory reaction and/or a local inflammatory reaction are the possible biological alterations produced by the smoking habit that could be related to the delay in the healing of periapical lesions and, therefore, with the prognosis of root canal treatment. Conclusions Both diabetes mellitus and smoking are significantly associated with higher prevalence of radiolucent periapical lesions in root filled teeth and with higher prevalence of root filled teeth extraction. Consequently, it could be concluded that diabetes mellitus and smoking are negative prognostic factors in the outcome of root canal treatment

Asociación entre la Diabetes y la Prevalencia de las Lesiones Radiolúcidas Periapicales en Dientes Endodonciados: Revisión sistemática y Meta-análisis

Universidad de Sevilla. Grado en Odontologí

Outcome of Direct Pulp Capping in Teeth Diagnosed as Irreversible Pulpitis : systematic review and meta-analysis

This review and meta-analysis investigates the outcome of direct pulp capping in teeth diagnosed as irreversible pulpitis. This systematic review includes experimental and descriptive clinical studies according to the PRISMA criteria, using PubMed and S

Prevalence of dens invaginatus assessed by CBCT : systematic review and meta-analysis

Dens invaginatus is a developmental dental anomaly resulting from an invagination of dental tissues folding from the outer surface towards dental pulp. The aim of this systematic review and meta-analysis was to determine the prevalence of dens invaginatu

Dentist´s knowledge, attitudes and determining factors of the conservative approach in teeth with reversible pulpitis and deep caries lesions

The aim of this study was to investigate dentists` knowledge, attitudes and factors regarding the conservative approach in the management of deep caries lesions (DCLs) in teeth with reversible pulpitis. 187 dentists were contacted directly or by mail, and 125 (67%) were finally included in the study. Dentists were requested to answer an open/discursive questionnaire about the routine approach to the diagnosis and treatment of DCLs, including knowledge-related attitudinal items. Total caries excavation was the preferred treatment option for more than 80% of dentists in case of DCL with reversible pulpitis. Only a small percentage (8%) chose partial caries removal, leaving some carious dentin close to the pulp to avoid pulp exposure. More than a half (51%) of respondents considered that cariogenic microorganisms must be removed or caries would progress. Dentists teaching at the University strongly disagreed with this statement (OR = 4.6; 95% C.I. = 1.3 ? 15.8; p = 0.017). Good clinical result was the most chosen reason (83%) to choose a specific treatment. Patient?s oral health (84%) and patient?s age (70%) were the two patient-related factors most taken into account for the choice of treatment. Total caries excavation is still the most frequently chosen treatment in teeth with DCL and reversible pulpitis. The joint assessment of the answers given by respondents allows to conclude that the new knowledge and concepts about caries lesions and the more conservative approach to DCLs have not still been incorporated by dentists into their usual clinical practice

Cardiovascular diseases and apical periodontitis : association not always implies causality

Several studies published in the last two decades have found an association between the prevalence of apical periodontitis (AP) or root canal treatment (RCT) and cardiovascular diseases (CVDs). However, the demonstration of association does not prove by itself the existence of a cause?effect relationship. Two diseases can appear as statistically related without any of them directly affecting the values of the other, resulting in a non-causal relationship. The aim of this narrative review is to summarize the current state of knowledge regarding the association between AP and CVDs, analysing it according to the Hill's causality criteria. Epidemiological studies carried out on the association between CVDs and AP or RCT published in English until 8 December 2019 were identified. Forty-four articles were selected and its results were analysed. Numerous cross-sectional epidemiological studies have found significant relationship between CVDs and AP. The odds ratio values range 1.6 - 5.4. However, other studies have not found significant association. Respect to RCT, some studies found correlation, but others found no association or even found that RCT is a protective factor against CVDs. The results are inconsistent and a causal relationship between CVDS and endodontic disease cannot be stablished. The risk factors common to both diseases can act as confounding factors, biasing the results. To reach definitive conclusions about the type of association (causal or non-causal) between both diseases, longitudinal epidemiological studies must be carried out to establish the temporal relationship and the dose-response gradient

Immediate loading of implants placed by guided surgery in geriatric edentulous mandible patients

The aim of this study was to show the clinical outcomes of the immediate loading of implants inserted by guided surgery in edentulous mandible patients. Edentulous mandible patients were diagnosed with oral examination, cone beam computerized tomography and diagnostic casts for intermaxillary relations and treated with 8-10 implants for rehabilitation with guided surgery and immediate loading. After flapless surgery, implants were loaded with an immediate acrylic temporary prosthesis. After a period of six months, a ceramic definitive full-arch prosthesis was placed. A total of 22 patients (12 females and 10 males) were treated with 198 implants. Eleven patients (50%) had a previous history of periodontitis. Six patients (27.3%) were smokers. The follow-up was 84.2 ± 4.9 months. Clinical outcomes showed a global success rate of 97.5% of implants. Five implants were lost during the healing phase with provisional prosthesis. Twenty-two fixed full-arch rehabilitations were placed in the patients over the 193 remaining implants. Mean marginal bone loss was 1.44 mm ± 0.45 mm. Six patients (27.3%) showed some kind of mechanical prosthodontic complication. Eighteen (9.3%) of the 193 remaining implants were associated with peri-implantitis. The antecedents of peri-implantitis are critical elements for the survival of the implants. The loss of implants was significant in patients who smoked up to 10 cigarettes, compared to non-smokers. Peri-implantitis is one of the key elements in the long-term follow-up of implants and it was more manifest in smoking patients, and in those with a history of peri-implantitis. Marginal bone loss was more significant in smokers. Full-arch rehabilitation is presented as a predictable alternative with minor fatigue problems that are easily solvable

Antibiotics prescription by spanish general practitioners in primary dental care

The aim of this study was to analyze the antibiotics prescription habits, both prophylactically and therapeutically, of Spanish general dental practitioners in the management of endodontic infections in primary care. Two hundred Spanish general dental practitioners were asked to respond to a survey on indications for antibiotics prescription in the treatment of endodontic infections, being 190 general dentists (95%) included in the study. Data were analyzed using descriptive statistics and the chi-square test. The average duration of antibiotics therapy was 6.5 ± 1.0 days. In patients without medical allergies, most of them (97%) selected amoxicillin as the antibiotic of the first choice, alone (51.1%) or associated with clavulanic acid (45.8%); in patients with penicillin allergies, the drug of choice was clindamycin 300 mg (70%). For cases of symptomatic irreversible pulpitis, 44% of the respondents prescribed antibiotics, in the scenario of prophylactic antibiotic prescription, up to 27% of the general dentists prescribe according to non-current guidelines (1 g 1 h before or 1 g 1 h before and 1 g 1 h after) in non-indicated cases (16% in patients taking oral bisphosphonates). It is necessary to improve the antibiotic prescription habits of Spanish general dentists in endodontics

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

Aim: Both apical periodontitis (AP) and metabolic syndrome (MetS) are associated with atherosclerotic cardiovascular disease (ACVD), the main cause of cardiovascular events. The aim of this study was to investigate the prevalence of AP and the oral inflammatory burden in control subjects and patients suffering cardiovascular events, analyzing the possible association between AP and the oral inflammatory burden with MetS. Materials and methods: Using a cross-sectional design, 83 patients suffering a cardiovascular event were recruited in the study group (SG), and 48 patients without cardiovascular events were included in the control group (CG). Periapical index (PAI) was used to diagnose AP, and total dental index (TDI) was used to assess the total oral inflammatory burden. Diagnosis of MetS was made by meeting three or more American Heart Association Scientific Statement components. Results: In the multivariate logistic regression analysis, the number of teeth with AP (OR = 2.3; 95% C.I. = 1.3-4.3; p = 0.006) and TDI scores (OR = 1.5; 95% C.I. = 1.2-1.9; p = 0.001), significantly correlated with cardiovascular events. MetS was strongly associated (OR = 18.0; 95% C.I. = 6.5-49.7; p = 0000) with cardiovascular events. Higher TDI scores were significantly associated with MetS (OR = 1.3; 95% C.I. = 1.1-1.6; p = 0.003. Neither the number of root-filled teeth (RFT) (OR = 0.9; 95% C.I. = 0.6-1.3; p = 0.61) nor the number of teeth with apical periodontitis (OR = 1.1; 95% C.I. = 0.8-1.7; p = 0.49) were associated with MetS. Conclusions: Apical periodontitis is significantly associated with cardiovascular events. Total oral inflammatory burden assessed by TDI, but not AP alone, is associated with MetS