Health Effects of Dental Infections and Root-canaled Teeth.
Prestigious
dental researchers and doctors such as Westin Price(
Recently
there has been renewed interest in the incidence and effects of oral focal
infections. It has been recognized, that oral infection especially periodontitis can cause and affect the course of a number
of systemic diseases, such as: cardiovascular disease, cerebrovascular
disease, atheromatous peripheral vascular disease, bacterial
pneumonia, diabetes mellitus, osteoporosis, and adverse pregnancy outcome(2).
Studies found that treatment of dental infections could bring significant
improvement in insulin resistance and other conditions(2bc).
A
significant association has been demonstrated between periodontal disease or
other dental related infections and cardiovascular disease(3
a-k). Recent studies have demonstrated systemic antibodies to selected
periodontal parthogens (3a). A recent study analyzed the prevalence
of dental treatment and oral infections related to the development of infective
endocarditis (IE)(3b). A retrospective study of 103
cases of IE diagnosed from 1997 to 1999 was conducted in
Chronic dental infections,
even of low intensity, may cause the development of atherosclerotic changes in
arteries, that lead to coronary heart disease(3c) .
There are many risk factors for atherosclerosis, but the most important are
endothelium function disturbances, platelets activation and oxidative changes
of plasmatic lipoproteins. Among factors that can induce the epithelium lesions
bacterial factor may play an important role. In
consequence of the bacterial cell breakdown place the release of endotoxins takes, that lead directly to the damage of
endothelial cells. Apart from this direct effect endotoxins
activate the fagocytes releasing superoxide
reactive radicals, that cause lesions of endothelium.
Probably the most widespread chronic bacterial infections in human are the
diseases of periodontium and teeth and their
inflammatory complications. Oral cavity is colonized by 300-400 bacterial
species. In the case of dental bacterial infections bacteriemia
occurs after such procedures as tooth extraction, endodontic
treatment, therapeutic and hygienic interventions on periodontal tissues. The
results of many investigations show the relationship between the oral status
(dental and periodontal diseases as chronic oral infections) and disorders of
cardiovascular system(3c).
Ford et al (3d) review the
evidence for the interaction of oral disease (more specifically, periodontal
infections) with cardiovascular disease. Cardiovascular disease is a major
cause of death worldwide, with atherosclerosis as the underlying aetiology in the vast majority of cases. The importance of
the role of infection and inflammation in atherosclerosis is now widely
accepted, and there has been increasing awareness that immune responses are
central to atherogenesis. Chronic inflammatory
periodontal diseases are among the most common chronic infections, and a number
of studies have shown an association between periodontal disease and an
increased risk of stroke and coronary heart disease. Although it is recognised that large-scale intervention studies are
required, pathogenic mechanism studies are nevertheless required so as to
establish the biological rationale. In this context, a number of hypotheses
have been put forward; these include common susceptibility, inflammation via
increased circulating cytokines and inflammatory mediators, direct infection of
the blood vessels, and the possibility of cross-reactivity or molecular mimicry
between bacterial and self-antigens. In this latter hypothesis, the progression
of atherosclerosis can be explained in terms of the immune response to
bacterial heat shock proteins (HSPs). Because the
immune system may not be able to differentiate between self-
The main deficit in the
majority of the studies on the relation of periodontal disease to
cardiovascular conditions has been the inadequate control of numerous
confounding factors, and the imprecise measurement of the predictor or overadjustment of the confounding variables, resulting in
underestimation of the risks(3f). A meta-analysis of
prospective and retrospective follow-up studies has shown that periodontal
disease may increase the risk of
Thrombotic thrombocytopenic purpura (
The
term periodontal medicine encompasses the study of the contribution of
periodontal infections on several systemic conditions such as atherosclerosis,
myocardial infarction, stroke, diabetes, and premature delivery. The early
reports of a linkage between periodontitis and
systemic conditions are gaining further support from additional epidemiological
studies. The evidence continues to suggest that maternal periodontitis
may bean important risk factor or risk indicator for pregnancies culminating in
preterm low birth-weight deliveries. Potential mechanisms by which infectious
challenge of periodontal origin and systemic inflammation may serve as a
potential modifier of parturition are discussed. Furthermore, preliminary data
are presented, supporting a hypothetical model in which periodontal pathogens
disseminate systemically within the mother and gain access to the foetal compartment. Several aspects of this hypothetical
model remain to be elucidated. Only the clarification of the mechanisms of
pathogenesis of both periodontitis and premature
deliveries will ultimately allow for accurate diagnoses and successful
therapies. The concept of diagnosing and treating a periodontal patient to minimise the deleterious effects of this chronic infectious
and inflammatory condition on systemic conditions represents both an
unprecedented challenge and opportunity to our profession(4).
Odontogenic infection sources represent a predisposing risk
factor for patients with cardiac valvular disease (
Odontogenic infections are a potential risk for patients who
receive cervicofacial radiotherapy and should be
treated before irradiation. Anaerobic microbial infections are the most common
causes. A study (5c) assessed the value of the hypoxic imaging agent
fluorine-18 fluoromisonidazole (FMISO) in detecting
anaerobic odontogenic infections. Positron emission
tomography (PET) imaging was performed at 2 h after injection of 370 MBq (10 mCi) of FMISO in 26
nasopharyngeal carcinoma patients and six controls with healthy teeth.
Tomograms were interpreted visually to identify hypoxic foci in the jaw. All
patients received thorough dental examinations as a pre-radiotherapy work-up.
Fifty-one sites of periodontitis, 15 periodontal
abscesses, 14 sites of dental caries with root canal infection, 23 sites of
dental caries without root canal infection, and seven necrotic pulps were found
by dental examination. Anaerobic pathogens were isolated from 12 patients.
Increased uptake of FMISO was found at 45 out of 51 sites of periodontitis, all 15 sites of periodontal abscess, all 14
sites of dental caries with root canal infection, all seven sites of necrotic
pulp and 15 sites of dental caries without obvious evidence of active root
canal infection. No abnormal uptake was seen in the healthy teeth of patients
or in the six controls. The diagnostic sensitivity, specificity, positive and
negative predictive values, and accuracy of FMISO PET scan in detecting odontogenic infections were 93%, 97%, 84%, 99% and 96%,
respectively. FMISO PET scan is a sensitive method for the detection of
anaerobic odontogenic infections, and may play a
complementary role in the evaluation of the dental condition of patients with
head and neck tumours prior to radiation therapy(5c). A
dental focus usually is a localized chronic infection that under certain
circumstances may result in severe local or systemic disease. The most
important dental foci are periodontitis, periapical lesions, advanced carious lesions, nonvital pulp, partially impacted teeth and root tips(5d). Local effects of dental foci particularly are
processes that may come to expression because of a compromised immunological
defense, such as osteoradionecrosis. Systemic effects
are mainly caused by transient bacteraemia which can
occur spontaneously out of dental foci or after manipulations such as brushing,
flossing and dental treatment. Well known examples are infectious endocarditis, fever during chemotherapy and hematogenous infections of total joint prostheses. For all
patients at risk (a.o. endocarditis,
endoprosthesis, chemotherapy, radiotherapy)
it is important that dental foci are treated. Because in most patients the risk
factors are present lifelong, a healthy dentition and a healthy periodontium are the best way of prevention(5d)
Infections
of the deep neck spaces with accompanying mediastinitis
are still a therapeutic problem with a high mortality(6).
A study reported on three patients with deep neck space infections and accompanying
mediastinitis who had been treated in the Departments
of Otorhinolaryngology at the Universities of Bochum and
A
study reported two cases of septic pulmonary embolism associated with periodontitis (8). Both patients had toothache, fever, and
chest pain, and showed findings of periodontitis at
initial presentation. Antimicrobial agents combined with dental surgery were
successful in treatment. While septic pulmonary embolism from the lesions of periodontitis appears to be rare, periodontitis
remains important in the differential diagnosis of septic pulmonary embolism.
One
study found a positive correlation between higher levels of periodontal disease
and various types of rheumatic conditions, as well as with various alterations
of saliva flow, including slower flow rates and higher levels of immune reactivity(9). This was consistent
with autoimmunity commonly found in some of these rheumatic conditions.
Odontogenic sinusitis is a well-recognized condition and accounts for
approximately 10% to 12% of cases of maxillary sinusitis(10).
An odontogenic source should be considered in
individuals with symptoms of maxillary sinusitis with a history of odontogenic infection, dentoalveolar
surgery, periodontal surgery, or in those resistant to conventional sinusitis
therapy. Diagnosis usually requires a thorough dental and clinical evaluation
including appropriate radiographs. The most common causes of odontogenic sinusitis include dental abscesses and
periodontal disease that had perforated the Schneidarian
membrane, irritation and secondary infection caused by intra-antral foreign bodies, and sinus perforations during tooth
extraction. An odontogenic infection is a polymicrobial aerobic-anaerobic infection, with anaerobes
outnumbering the aerobes. The most common isolates include anaerobic
streptococci and gram-negative bacilli, and Enterobacteriaceae.
Surgical and dental treatment of the odontogenic
pathological conditions combined with medical therapy is indicated. When
present, an odontogenic foreign body should be
surgical removed(10a).
Although odontogenic sinusitis is a rare
entity when compared to sinus disease of rhinogenic
origin, it is extremely important to identify a dental aetiology
when it occurs. The offending tooth or teeth would thus require endodontic treatment or extraction, and the sinus disease
carefully assessed and appropriately managed(10c).
Certain lesions such as cysts and tumours may involve
the jaws and hence the maxillary antrum; some of
these, such as a radicular cyst are quite
common.
The
association of alopecia areata and infectious foci of
dental origin is relatively common, and may be explained by the autoimmune
nature of the disorder(12). A study described a case
of alopecia areata with no apparent cause and that
was effectively resolved by eliminating a focalized dental infection via endodontic treatment. The presence of common immune
mediators in the pathogenesis of both alopecia areata
and dental infection could account for the dental origin of the hair loss. In
this sense, patients with localized alopecia should be subjected to careful
exploration of the oral cavity in search of possible dental infections.
Health Effects Related to
Root Canals
Studies have found that all
root canaled teeth with asymptomatic apical periodontitis contain anaerobic bacteria and are a
significant source of bacteria and fungi in the circulating blood, and thus a
potential source of systemic focal infections (13). One study (13a) used phenotypic and genetic methods to
trace microorganisms released into the bloodstream during and after endodontic treatment back to their presumed source--the
root canal. Microbiological samples were taken from the root canals of 26
patients with asymptomatic apical periodontitis of
single-rooted teeth. The blood of the patients was drawn during and 10 minutes
after endodontic therapy. All root canals contained
anaerobic bacteria. The frequency of bacteremia
varied from 31% to 54%. The microorganisms from the root canal and blood
presented identical phenotype and genetic characteristics within the patients
examined. The study demonstrated that endodontic
treatment can be the cause of anaerobic bacteremia
and fungemia. In
another study (13b) quantitation of circulating
immune complexes (CIC) was done in 45 patients with chronic periapical
lesions. The levels were compared with those of age-matched healthy
individuals. Both patients with chronic periapical granuloma and periapical cysts
showed significantly higher levels of CIC than the controls. This observation
indicates that the continuous presence of root canal antigens may cause
elevated levels of circulating immune complexes. The possibility of chronic periapical lesions acting as foci of infection is
discussed, and the importance of early treatment of these conditions is
emphasized. The so-called focal infections are today considered to be polyetiologic manifestations, in which there is a summation
of various aggressions(13c). Bacterial products, toxic
or antigenic substances originating from different foci are but one of the
elements susceptible of causing disease. Scientific evidence shows that the histologic result of an apicectomy
is considerably worse than the radiological evidence might lead to believe(13c). Inflammation may persist for years before it
disappears. Radiographs are therefore only a coarse criterion for judging
results of healing. When facing a disease caused by focal infection, the
possible foci should be eliminated quickly and as radically as possible(13c). Another
study found root-canaled teeth to be a risk factor in
hospital treatment of conditions such as heart valve replacement and cancer treatment(4c).
Endodontic infections have been traditionally studied by
culture methods, but recent reports showing that over 50% of the oral microbiota is still uncultivable(13d) (B. J.
Paster et al., J. Bacteriol.
183:3770-3783, 2001) raise the possibility that many endodontic
pathogens remain unknown. This study investigated the prevalence of several
uncultivated oral phylotypes, as well as newly named
species in primary or persistent endodontic infections
associated with chronic periradicular diseases.
Samples were taken from the root canals of 21 untreated teeth and 22
root-filled teeth, all of them with radiographic evidence of periradicular bone destruction. Genomic
A study (13e) developed to
assess the differences in sealed versus unsealed root-canals followed the
development of periapical lesions both radiographically and histologically
in infected teeth with open and sealed root canals. The mandibular
premolars from five adult monkeys were used in the experiment. Sealed infected
teeth developed radiographic signs of periapical pathosis significantly earlier than unsealed teeth.
Although, histological signs of pathology could be seen periapically
at earlier observation periods, sealed teeth consistently developed these
changes earlier than unsealed teeth. Furthermore, the histological periapical pathology differed somewhat between the two
groups in that unsealed teeth showed a multi-focal diffuse pattern of
spreading.
Studies have demonstrated
an association between infective endocarditis and
dental procedures including root canals and gum scaling(14).
A study was undertaken to assess the relative risk of infective endocarditis associated with various dental problems and
procedures and the protective efficacy of antibiotic prophylaxis by a
case-control study(14a) . Cases (n = 171) and controls
were matched as regards sex, age and underlying cardiac condition. They were
requested to indicate all the medical, surgical or dental procedures within the
previous 3 months. Dental scaling and root canal treatment showed a trend
towards a higher risk of infective endocarditis (P =
0.065). The 46% protective efficacy of antibiotic prophylaxis was not
significant. Our data suggest that surgery should be more clearly mentioned in
future guidelines regarding dental conditions, and reemphasize that a rigorous
treatment of any focal infection in cardiac patients is mandatory. From the
efficacy rate of antibiotic prophylaxis,it
can be estimated that the overall incidence of infective endocarditis
might be reduced by 5 to 10% in
Many researchers and cancer
treatment clinics have observed or documented a connection between cancer and
root-canals. Many cancer treatment
clinics require elimination of root-canals before treatment due to their experience
with the cancer/root-canal connection(22,25)
One
study(15)
described a remission of rheumatoid arthritis (RA) of 16 years duration,
apparently caused by the extraction of endodontically
well-treated, healthy looking root-canaled
teeth. After extraction, a small pus layer
was found to cover the apices of the clinically healthy looking teeth. The
rheumatoid factor (RF) became negative and the patient remained symptom free
for the next 16 years.
In another study (16) a
severe periodontal condition occurred in 58% of 77 rheumatic patients of various
rheumatoid conditions compared with only 26%
of the controls (p < 0.0001). The severity of focal sialadenitis correlated significantly with salivary
IgA, IgG, and IgM concentrations. Salivary albumin, total protein, IgG, and IgM concentrations were
higher in all patient groups than in the controls. The number of patients with
low salivary flow rates was higher in all patient groups compared to controls.
Patients with rheumatic diseases, irrespective of specific diagnosis, thus had
various alterations in salivary flow and composition and oral health. The
findings may reflect the autoimmune inflammation of the salivary glands
frequently observed in these patients
A
possible and diagnostically difficult source of bacterial sepsis appears to be
pus related foci of odontogenic character. One study (17) describes a case of a pregnant
woman, in whom an untreated purulent focus within the oral cavity led to severe
systemic infection
characterized by persistent hectic fever with accompanying
features of intravascular coagulation, anemia and erythema
nodosum and no response to antibiotic treatment. It
was the second episode of sepsis in this patient in a period of one year, the
source of the infectious process not being recognized previously. Dental
examination revealed presence of the apical abscess of the tooth 6-, extraction
of which led to spectacular clinical improvement, accompanied by the healing of
erythema nodosum. Purulent
foci within oral cavity, including apical abscesses, constitute significant
clinical problems and must be taken into consideration as a potential source of
severe and recurrent systemic infections.
Cavitations
Ischemic jawbone lesions
were first discussed in the dental literature more than a century ago, but then
seemingly forgotten. In recent years, there has been considerable resurgence in
interest and studies in this unique pathological condition(19).
Controversy surrounds the subject. Some proclaim these lesions to be mere
fabrications of the imaginations of non-traditional or alternative dental
surgeons. Others attribute many human maladies to these maxillofacial lesions.
Aside from these philosophical and metaphysical arguments, a study (19a)
attempted to assess if
there are common diagnoses of jawbone pathologies that produce
pain? A review was made of the clinicopathologic features of 500 consecutive jawbone
surgeries with pathological confirmation in patients with idiopathic facial
pain. Four hundred seventy-six (476) of the 500 lesions (95.2%) were directly
attributed to impaired blood flow in the jawbone, tooth, or both, according to histopathological analysis and confirming Cavitat (bone ultrasound) examination. Statistical data
concerning the location, frequency, and pathological diagnoses of these bony
lesions was presented, as are brief methods of diagnosis, and treatment was
also discussed(19a).
In a group of 38 patients with chronic
oral pain in the area where teeth had been extracted, approximately 90% of subpontic bone demonstrated either
ischemic osteonecrosis (68%), chronic osteomyelitis (21%), or a combination (11%) (19b) . More than 84% of the patients had abnormal radiographic
changes in subpontic bone, and 5 of 9 (56%) patients
who underwent radioisotope bone scan revealed hot spots in the region. Of the
14 patients who had laboratory testing for coagulation disorders, 71% were
positive for thrombophilia, hypofibrinolysis,
or both (normal: 2% to 7%). Ten pain-free patients with abnormal subpontic bone on radiographs were also reviewed. Intraosseous
ischemia and chronic inflammation were suggested as a pathoetiologic
mechanism for at least some patients with atypical facial pain. These
conditions were also offered as an explanation for poor healing of extraction
sockets and positive radioisotope scans(19b).
All bones of the facial
skeleton and spine are susceptible to osteomyelitis
due to various predisposing conditions(19c) . Current
radiological tools are sufficient to provide adequate diagnosis. Treatment can
be conservative resection of the diseased bone with adequate clearance in all
cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where resection has to be more
radical. Dealing with osteomyelitis in head and neck
bones is not the same as in other bones of the body due to the nature of the
bones, complex anatomy of the region, and esthetics. The study analyzed the
behavior of osteomyelitis in the head and neck bones
and its management. A total of 84 cases
of osteomyelitis in head and neck were reviewed in a
10-year period. Pus for culture, antibiotic sensitivity, and radiology were the
main investigations. A medical line of treatment was effective in acute cases.
Surgery was opted for in chronic cases.
Mandible, frontal bone, cervical spine, maxilla, temporal bones, and
nasal bones were involved, in descending order of frequency, i.e. the mandible
was the most common bone affected. Nine patients were diagnosed as having acute
osteomyelitis (11%); 75 were diagnosed as having
chronic osteomyelitis (89%). Radiation-induced ORN
leading to osteomyelitis was the most common cause of
osteomyelitis of the mandible (13 of the 32 cases;
41%). Odontogenic infections and chronic sinusitis
each gave rise to osteomyelitis in 3 of 10 cases
(30%) of the patients with osteomyelitis of the
maxilla. Chronic sinusitis was associated with frontal bone osteomyelitis
in all 20 cases (100%). Tuberculosis (10 of 15 cases; 67%) and malignancy (5 of
15 cases; 33%) were the main predisposing factors in cervical spine osteomyelitis. Malignant external otitis
(MEO) with diabetes mellitus was associated with all four cases of osteomyelitis of the temporal bone. Of the 18 patients with
a diagnosis of ORN, the mandible was found to be the most susceptible bone (13
cases; 72%), followed by the maxilla (four cases; 22%) and cervical spine (1
case). Acute osteomyelitis responded in some degree to
antibiotics. Sequestrectomy was carried out in all
chronic cases but in cases of ORN more radical surgery was performed(19c).
Cerebral abscess is a rare
but serious and life-threatening infection. Dental infections have occasionally
been reported as the source of bacteria for such an abscess (20). A 54-year-old
man was admitted with a right hemiparesis and
epileptic fits. After clinical, laboratory and imaging examination, the
diagnosis of a cerebral abscess of the left parietal lobe was made. The intraoral clinical examination as well as a panoramic
radiograph confirmed the presence of generalized periodontal disease, multiple
dental caries, and periapical pathology. After removal of the periodontal, decayed and
periapically involved teeth of the patient and
treatment of the abcess the patient recovered.
A
study presented an unusual case of chronic osteomyelitis
with proliferative periostitis
affecting the mandible of a 12-year-old patient (23) .
The source of infection was related to the developing lower left third molar,
which had apparently no communication with the oral cavity. Chronic osteomyelitis with subperiosteal
new bone formation results from periosteal reaction
to chronic inflammatory/infectious stimulation. In the maxillofacial region, it
has traditionally been termed Garrè's osteomyelitis with proliferative periostitis and more recently periostitis
ossificans.
2. (a)[Periodontitis and systemic
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and systemic disease. Clinical information for the practicing dentist.
J Indiana Dent Assoc. 2002 Summer;81(2):15-8,
John V, Kim SJ; & Sudden improvement of
insulin sensitivity related to an endodontic
treatment. J Periodontol. 2007 Dec;78(12):2380-4, Schulze A, Schönauer M, Busse M; & (c) Periodontitis
as a component of hyperinflammation: treating periodontitis in obese diabetic patients. Compend Contin Educ Dent. 2007 Sep;28(9):500-4; quiz 506, 528, Johnson RB;
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Anaerobic bacteremia and fungemia
in patients undergoing endodontic therapy: an
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SSO Schweiz
Monatsschr Zahnheilkd. 1975 Feb;
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