Unfinished root canal can cause cardiovascular disease!!! True or False....

2. Presented By:
Dr. M.Arsalan Zubair
MDS Trainee (Semester III)
Operative Dentistry Department
Dow Dental College
DUHS
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

3. Contents
• Background
• Approach and Prerequisites
• Results
• Analysis
• Limitation of the study
• Outcome

4. Background
Atherosclerosis
Low grade
chronic
Inflammation +
Bacteria and
virus causing
inflammation
Cardiovascular
disease

5. Low-grade chronic
inflammation in
oral cavity
Periodontal
Pulpal
Pulpal
Inflammation
treatment of Choice
Complete
debridement of root
canal system-Root
Canal Treatment (RCT)

6. R.C.T C.V.D 

7. 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

8. Spread of Infection in unfinished Rct
Unfinished
RCT
Dead Space
Bacterial
Growth
Spread to other
body
compartments
Cellulitis

9. 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
Unfinished
R.C.T
C.V.D

10. 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

11. 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

12. 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 RCT
Disease included in C.V.D are:
• Ischemic Stroke
• Coronary heart Disease
• Acute myocardial infarction

13. 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

15. Data rectification by Statistical
Methods
Factors:
• Demographic
• C.V.D hospitalization incidence
• Clinical Characteristics
• Mean observed days
Test 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

16. Confounding factors:
• Age
• Sex
• Annual Scaling frequency after R.C.T
• Periodontal disease
• Systemic Disease
Test used:
• Cox regression Analyses
P value:
• < 0.5

17. Results of demographic and clinical
Characteristics

18. 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

19. • 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.T
receive 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

20. Cumulative Hazard Probabilities

21. 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

22. Cox proportional hazard regression
Analyses

23. 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

24. 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 male
0.15 for female

25. • 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

26. 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

27. • 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

28. 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

29. • 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

30. 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

31. THANK YOU