Epidemiological Aspects on Apical Periodontitis Studies based on the Prospective Population Study of Women in Göteborg and the Population Study on Oral Health in Jönköping, Sweden Fredrik Frisk Department of Endodontology/Oral Diagnosis Institute of Odontology, The Sahlgrenska Academy at Göteborg University and Institute for Postgraduate Dental Education, Jönköping ______________________________ Göteborg 2007 Abstract The objectives of this thesis were to describe endodontic status in Swedish populations, to study clinical and socio-economic risk factors for apical periodontitis (AP) and to explore a possible association between AP and coronary heart disease (CHD). In papers I, III and IV the Prospective Study of Women in Göteborg (PSWG) was used. In paper I dentate women examined in 1968-69 (N=1220), 1980-81 (N=1023) and 1992-93 (N=867) were included for cross-sectional and longitudinal (N=586) analysis of endodontic status over 24 years in individuals aged 38-84 years. In papers III and IV a cross-sectional sample (N=844 and N=867, respectively) from 1992-93 was used for exploring associations between AP, socio-economic risk factors and CHD in multivariate logistic regression models. In paper II random samples of dentate individuals aged 20-70 years from the Population Study on Oral Health in Jönköping (PSJ) were used. The first examination in 1973 (N=498) was followed by new examinations in 1983 (N=530), 1993 (N=547) and 2003 (N=491). Full mouth radiographic examinations were restudied, yielding 3981 root filled teeth for the analysis. AP was recorded according to the Periapical Index (PAI) and the root filling quality was assessed with respect to length and seal. The association between root filling quality and AP was studied on the tooth-level as well as on the individual level. The results from multivariate logistic regression analysis did not reveal a significant association between AP and CHD and socio-economic risk factors and AP, respectively. The ratio of root filled teeth increased with age longitudinally and cross- sectionally, but decreased over time for comparable age groups. The ratio of AP increased with age cross-sectionally, but decreased with age longitudinally and for comparable age groups over time. Inadequate root filling quality was predictive of AP with an odds ratio of 4.5. The root filling quality was improved over time without a concomitant decrease in ratio of root filled teeth with AP. Keywords: Apical periodontitis, Coronary heart disease, Cross-sectional, Endodontics, Epidemiology, Health, Longitudinal, Root filling, Socio-economic status, Treatment quality, Women. ISBN: 978-91-628-7280-9 ISSN: 0348-6672 Correspondence: Fredrik Frisk, Institute for Postgraduate Dental Education, Box 1030, 551 11 Jönköping, Sweden. E-mail: [email protected] Contents Preface…………………………………………………………………………………9 Introduction…………………………………………………………………………11 Clinical features of apical periodontitis Health effects of apical periodontitis……………………………………….13 Treatment…………………………………………………………………...14 Epidemiology of apical periodontitis Cross-sectional studies……………………………………………………..15 Repeated cross-sectional studies…………………………………………...16 Longitudinal studies………………………………………………………..16 Presence of apical periodontitis…………………………………………….17 Presence of root filled teeth and treatment quality…………………………17 Methodological considerations Apical periodontitis………………………………………………………...19 Treatment quality………………………………………………………….. 21 Socio-economic risk factors and health………………………………………..23 Methodological considerations…………………………………………….24 Dental infection and cardiovascular disease…………………………………..25 Methodological considerations…………………………………………….27 Aims…………………………………………………………………………………..29 Material The Prospective Population Study of Women in Göteborg, Sweden Setting………………………………………………………………………31 Subjects……………………………………………………………………..31 Non-participation…………………………………………………………...32 The Populations Study on Oral Health in Jönköping, Sweden Setting………………………………………………………………………34 Subjects……………………………………………………………………..34 Method The Prospective Population Study of Women in Göteborg, Sweden Examinations……………………………………………………………….37 Variables (papers I, III, IV)………………………………………………...37 The Populations Study on Oral Health in Jönköping, Sweden Radiographic examination (paper II)………………………………………4.0 Statistical methods………………………………………………………………42 Results and Discussion Epidemiology of apical periodontitis (papers I, II) Cross-sectional findings Number of teeth…………………………………………………………………45 Prevalence of apical periodontitis………………………………………………45 Prevalence of root filled teeth…………………………………………………..47 Longitudinal findings Number of teeth…………………………………………………………………47 Prevalence of apical periodontitis………………………………………………48 Prevalence of root filled teeth…………………………………………………..48 Association of root filling quality with apical periodontitis (paper II)………48 Socio-economic factors and apical periodontitis (paper III)…………………52 General health and apical periodontitis (Paper IV)………………………….54 Methodological considerations PSWG (papers I, III, IV)……………………………………………..57 PSJ (paper II)…………………………………………………………58 Conclusions…………………………………………………………………………59 References…………………………………………………………………………...61 Abbreviations………………………………………………………………………76 Acknowledgements……………………………………………………………….7.7 P apers I-IV Preface This thesis is based on the following papers, which will be referred to in the text by their Roman numerals: I. Frisk F, Hakeberg M. A 24-year follow-up of root filled teeth and periapical health amongst middle aged and elderly women in Göteborg, Sweden. Int Endod J. 2005 Apr;38(4):246-54 II. Frisk F, Hugoson A, Hakeberg M. Technical quality of root fillings and periapical status in root filled teeth. Submitted. III. Frisk F, Hakeberg M. Socio-economic risk indicators for apical periodontitis. Acta Odontol Scand. 2006 Apr;64(2):123-8. IV. Frisk F, Hakeberg M, Ahlqwist M, Bengtsson C. Endodontic variables and coronary heart disease. Acta Odontol Scand. 2003 Oct;61(5):257-62. Published articles have been reprinted with permission from the copyright holders (Taylor & Francis, www.informaworld.com, papers III, IV. Blackwell Publishing, paper I) 9 Introduction Apical periodontitis (AP) is an inflammatory response directed mainly to a root canal infection in teeth (Örstavik & Pitt Ford 1998). The condition is commonly a result of caries and its related restorative treatments. As indicated by the term, the primary location is in the periapical area of the tooth where bone tissue may be lost to a varying extent. Overt clinical signs are sporadic. Radiography is, therefore, an important tool for detection of AP. There are several synonymous terms, essentially describing the same disease but may vary with regard to clinical and radiological expressions. Throughout this text, the term AP will be used for any periradicular lesion of endodontic origin. Epidemiological surveys, mainly from Scandinavia but with a growing number of studies from other parts of the world, demonstrate that AP certainly is a common disease in the adult population (Table 1). However, data on the prevalence of AP vary between populations and countries and depend on differences in caries prevalence, access to dental care and methodological issues such as measurement and sampling variation. Thus, it is important to conduct epidemiological surveys on oral health in different settings using established scientific methods, in order to get results valid for different populations. Root canal treatment (RCT), is aimed to prevent and eradicate root canal infections. Clinical follow-up studies demonstrate that RCT has the potential of being highly successful given that the treatment meets high demands on technical quality (Sjögren et al. 1990, Strindberg 1956, Grahnen et al. 1961, Kerekes et al. 1979, Kojima et al. 2004). Yet endodontic treatment is widely recognised as a delicate task and epidemiological studies report on high frequencies of root filled teeth with suboptimal technical quality. As a result, AP is most commonly found in root filled teeth and the healing rate after RCT in general practice may be estimated to 50-75% (Ödesjö et al. 1990, Kirkevang et al. 2000, Kabak & Abbott 2005, Dugas et al. 2003). There are reports indicating an improving technical quality of root fillings over time, however without a decreasing frequency of AP in root filled teeth (Skudutyte-Rysstad & Eriksen 2006, Petersson 1993b, Kirkevang et al 2001b). Explanations as to the reasons for these conflicting results are lacking. Dentistry has a history of a complicated view on dental infections and general health. During the focal infection era, several serious conditions were thought to be 11 Table 1. Number of teeth and proportions of root filled teeth and apical periodontitis from cross-sectional studies. No R R (%) R Samp Samp Details Country teeth end AP endAP end AP (%) (%) (%) (%) (%) Bergenholtz e t al. 1973 22.8 12.7 6.1 30.5 57 N=240. Patients referred to radiologist. Sweden Mean age 45 years(20->70). Lavstedt 1978 22.6 2.5(teeth)1.2 (roots) 72.2 45 N=1391. Random sample. Age 18-65 Sweden years Allard & Palmqvist 1986 14.2 18 10 27 72 N=188. Old subjects >65 years, non- Sweden institutionalized. Random sample. Mean age 73(65->75) Bergström et a l. 1987 26.4 6.5 3.5 28.8%(roots) 46.8 N=250. Patients with regular dental care. Sweden Age 21-60år Eckerbom et al. 1987 24.4 13 5.2 26.4 83.5 63 N=200. Patients referred to radiologist Sweden Mean age 40(20->60) Eriksen et al. 1988 27.8 3.4 1.4 25.6 53 N=141. 35 year olds in Oslo 1973 and Norway 1984. Random samples. Data from 1984 are presented here Ödesjö et al. 1 990 23.5 8.6 2.9 24.5 43.2 N=743. Random sample. Age 20->80 Sweden Eriksen & Bjertness 1991 24.7 6 3.5 36.6 56 N=119. 50 year olds in Oslo. Random Norway sample Imfeld 1991 14.0 20.3 8.0 31 77.6 N=143. 66-year olds in Zurich. Switzerland Random sample DeCleen et al. 1993 22.8 2.3 6.0 39.2 44.6 N=184. Patients referred to oral surgeon. Netherlands Age 20->59 Eriksen et al. 1995 27.8 1.3 0.6 38.1 24 14 N=118. 35 year olds in Oslo 1993. Norway Random sample Soikkonen 1995 13.9 21.5 7.1 16.8 78 41 N=169. Random sample of elderly subjects. Finland Age 76-86 years Saunders et al . 1997 24.6 5.6 4.9 58.1 54 67.7 N=340. Random sample of patients Scotland at a university clinic. Age 20->59 Weiger et al. 1 997 24.7 2.7 3.0 61 N=323. Patients in general practice, Germany Stuttgart Mean age 35.2 (12-89) Marques et al . 1998 24.8 1.5 2.0 22 22 26 N=179. Age 30-39. Random sample Portugal Sidaravicius et al. 1999 26.5 8.2 7.2 35 72 70 N=147. Age 35-44. Random sample Lithuania De Moor et al . 2000 22.4 6.8 6.6 40.4 63.1 N=206. Age 18->59. Patients at a Belgium university clinic. Kirkevang et al. 2001 26.0 4.8 3.4 52.2 52 42.3 N=614. Age 20->60. Random sample Denmark Boucher et al. 2002 25.8 19.1 7.4 29.7 N=208. Age 18->70. Patients seeking France treatment Lupi-Pegurier et al. 2002 22.8 18.9 7.3 31.5 N=344. Age >20. Patients at a university France clinic Dugas et al. 2 003 26.5 2.5 3.1 45.4 34.3 N=610. Age 25-40. Random samples of Canada patients seeking dental care at two university clinics Loftus et al. 2 005 24.6 2.0 2.0 25.0 31.8 33.1 N=302. Age 16->75. Patients seeking Ireland treatment Kabak & Abbott 2005 21.9 20 12 45 80 N=1423. Age 15->65. Patients seeking Belarus emergency dental treatment Tsuneishi et al. 2005 24.2 20.5 9.4 40 86.5 69.8 N=672. Age 20-89. Patients at a university Japan clinic Skudutyte-Rysstad & Eriksen 2006 27.2 1.5 1.1 43 23 16 N=146. 35-year olds in Oslo 2003. Random Norway sample No teeth=mean number of teeth Rend=ratio of endodontically treated teeth R AP=ratio of teeth with periapical destructions RendAP=ratio of endodontically treated teeth with periapical destructions Samp end=sample prevalence ratio of subjects with (cid:149)1 endodontically treated tooth Samp AP=sample prevalence ratio of subjects with (cid:149)1 tooth with periapical destruction N=number of subjects 12