Presented By:Dr. M.Arsalan Zubair

MDS Trainee (Semester III)Operative Dentistry Department

Dow Dental CollegeDUHS

Unfinished Root Canal Treatments and the Risk Of Cardiovascular Disease

Authors:Po-Yen Lin, Kuo-Liong Chien, Hong-Ji Chang, Lin-Yang Chi

Published in:Journal Of Endodontics — Volume 41, Number 12, December 2015

Contents• Background

• Approach and Prerequisites

• Results

• Analysis

• Limitation of the study

• Outcome

BackgroundAtherosclerosis

Low grade chronic

Inflammation + Bacteria and virus causing

inflammation

Cardiovascular disease

Low-grade chronic inflammation in oral cavity

Periodontal

Pulpal

R.C.T

C.V.D

Does Inflamed pulp leads to risk of C.V.D????

Inflamed Pulp

Cytokine production and Systemic inflammatory mediators

May travel to other body compartments through anatomic pathways

Spread of Infection in unfinished Rct

Unfinished RCT

Dead Space

Bacterial Growth

Spread to other body

compartmentsCellulitis

Objective Of the Study

Investigate using a nation-wide population data base, Possible association between unfinished R.C.T and the risk of cardio vascular disease hospitalization

UnfinishedR.C.T C.V.D

Approach & Prerequisites Source of Data: • Taiwan National Health Insurance Database.

Sampling Method: • Simple Random sampling

No of Persons Selected: • 1000,000 selected from 2001 to 2011 with no age or sex

distribution

Type of Study: • Retrospective cohort study

Population Selection criteria:• 1 Rct done during 2001-2011• No C.V.D History during 2001-2004 • Root canal treatment was started but was not

completed( no completion codes)

Participant Exclusion Criteria:• Less than 20yr of age• Abnormal registry data

Teeth Exclusion Criteria:• Extraction before C.V.D events• Root canal started after C.V.D events

Entry Date:• Pt with 1 unfinished RCT: Start date of 1st RCT• Pt with 2 unfinished RCT: Start date of 2nd RCT• Pt with 3 unfinished RCT: Start date of 3rd RCTDisease included in C.V.D are:• Ischemic Stroke• Coronary heart Disease• Acute myocardial infarction

Followed from 2005-2011 Mean Observation period was:

• 6.01 yr

Co morbidities• Periodontal disease• Diabetes mellitus (Type1 and Type 2)• Hypertension• Subclinical atherosclerosis• Chronic kidney disease• Hyperlipidemia

Validity of co morbidities: • Only outpatients were included with 3 or more repeat diagnosis of

above mentioned disease from 2005-2011

Data rectification by Statistical Methods

Factors:• Demographic• C.V.D hospitalization incidence• Clinical Characteristics• Mean observed daysTest used: • Variance test Mantel-Haenszel Chi Square:• Univariate and multivariate Cox proportional hazard models –

effect of unfinished R.C.T on risk of C.V.D

Confounding factors:• Age• Sex• Annual Scaling frequency after R.C.T• Periodontal disease• Systemic Disease

Test used: • Cox regression Analyses

P value:• < 0.5

Results of demographic and clinical Characteristics

Results of Participants

No of unfinished R.C.T Incidence Rate

1 0.21 person/yr

2 0.28 person/yr

3 or more 0.58 person/yr

• Men and older patient have 3 or more unfinished R.C.T

• Higher incidence of C.V.D hospitalization in men and older patient

• Participants with 3 or more unfinished R.C.Treceive average of 5.17 rct during 2001 and 2011

• 3 or more unfinished Rct patients also found to have more co-morbidities periodontal disease hyperlipidemia and diabetes mellitus

Cumulative Hazard Probabilities

No of unfinished R.C.T Cumulative probability after 11 yr

0 0.026

1 0.037

2 0.037

3 or more 0.061

Cox proportional hazard regression Analyses

No of unfinished R.C.T H.R (univariate) H.R (multivariate)

1 or 2 vs. 0 1.36 1.22

3 vs. 0 2.92 3.61

Analysis

• Joshipura et al conducted a study to see relationship also showed association

• Caplan et al also reported that patients with 1 or 2 rcts were 1.62 times more likely to develop coronary heart disease

This study reveals Cheng et al also conducted a study from 1996-2001 from same data base which reveals

0.21 person per year incidence rate among people with 1 rct

0.24 for male0.15 for female

• Study also showed participants with high number of rct between 2001 -2011 have low risk of c.v.d which leads to a result that, where unfinished rct can be a risk at the same time finishing an rct lower the risk of c.v.d hospitalization

• High number of unfinished R.C.T independently associated with high risk of C.V.D.

• Rct left unfinished for several reasons including symptomatic teeth infected with gram negative anaerobes

Mechanism Necrotic pulp +Clinically intact crown

Predominant by obligate an aerobes fusobacterium prevotella etc

Unfinished rct

Anaerobes indirectly increase inflammatory mediators IL-6 and IL_ 2

Cause low grade inflammation

Endothelial dysfunction

Atherosclerosis

Cardiovascular disease

• Patient with 3 or more unfinished rct may be non compliant

• Unfinished R.C.T involving temporary restoration can cause bacterial infection of root canal system which leads to apical peridontitis. Unbalanced peridontitis can spread infection

• Unfinished RCT also indicate poor oral health which it self is a risk factor of cardiovascular disease.

• In this study higher annual frequency of tooth scaling was associated with a reduce risk of cvd evidence

Iimitation of the study

• Crucial risk factors of C.V.D

• They do not consider latent period of C.V.D events

Smoking

BMI

Alcohol consumption

Dietary status

Family history

• Does not contain clinical parameters of R.C.T such as type of irritant used, cleaning and shaping technique etc

• So we don’t know inflammatory status and reason for unfinished R.C.T

• We cannot ensure the absence of bacterial and pulpal inflammation in completed R.C.T

Outcome

After adjusting the confounding factors( age, sex, number of rct etc) the participants with unfinished rct were associated with increase risk of CVD hospitalization

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