JOURNAL OF DENTISTRY AND DENTAL MEDICINE (ISSN:2517-7389)

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Prevalence of Apical Periodontitis in Teeth Not Treated Endodontically Evaluated in CBCT

Sandra Milena Buitrago Rojas1*, Yeny Zulay Castellanos Domínguez2

1 Faculty of Dentistry,  Santo Tomás University Bucaramanga section, Colombia
2 Oral Comprehensive Health Group,  Santo Tomás University, Bucaramanga section, Colombia

CitationCitation COPIED

Buitrago Rojas SM, Castellanos YZ. Prevalence of Apical Periodontitis in Teeth Not Treated Endodontically Evaluated in CBCT. J Dents Dent Med. 2020 Apr;3(4):158.

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© 2020 Buitrago Rojas SM, et al.. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 international License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

The early diagnosis of apical periodontitis is made through diagnostic images. Cone beam computed tomography (CBCT) is currently considered the radiographic technique with the best capabilities to identify this event. The objective of this study was to determine the prevalence of apical periodontitis in 1858 teeth without endodontic treatment, evaluated in 152 CBCT taken from patients who attended a dental practice in a region of Colombia. Through a cross-sectional analytical study, CBCT of permanent teeth of people of both sexes taken between 2016 and 2017 were included. The presence of apical periodontitis was evaluated using the CBCT PAI index. The association between the event and variables such as gender, age, affected tooth and number of teeth that presented the pathology by assessed tomography, was performed by Chi2 test, p de 0.05 values were considered of statistical significance. The prevalence of apical Periodontitis was 19.7%. 83.6% of these lesions (n = 306) were located in the CBCT PAI I ((> 0.5 mm-1mm). The most affected teeth were 13, 24 and 23 respectively. With respect to the total number of affected teeth in evaluated tomography, it was evidenced that 19.7% of the CBCT analyzed (n = 30) had one tooth with evidence of the pathology and 19.1% (n = 29) two affected teeth. The prevalence found (19.7%) was relatively high compared with other studies reported. In a CBCT it is possible to observe apical Periodontitis of incipient size.

Keywords

Apical periodontitis, Radiographic technique

Introduction

Apical Periodontitis (AP) is a multifactorial, microbial pathology that mainly originates from an infected necrotic pulp or from the failure of endodontic treatment. In most cases it is asymptomatic and when it is detected early, the prognosis is favorable. One Global research refers to the prevalence of PA that has been considered a public health problem. In the case of teeth with endodontic treatment, it could be found in 30% to 50% of individuals. For teeth without endodontic treatment, studies are scarce and have been associated with causal factors such as dentoalveolar trauma, inadequate crown restorations, caries, among others; calculating the prevalence at 2%, however, it should be noted that these studies have been carried out using two-dimensional diagnostic images [1-3]. BP, as it is considered pathology of infectious origin, could induce in the host the compromise of vital organs by direct dissemination that, depending on its severity, would evolve into chronic processes. On the other hand, since it is not symptomatically manifested, this condition could be present in the individual without being diagnosed for years, promoting systemic inflammation that increases susceptibility to other pathologies; reason for which its timely diagnosis is necessary [4,5]. The early diagnosis of BP is routinely performed through diagnostic imaging, this due to the location (periapice) and its asymptomatic nature. Cone Beam Computed Tomography (CBCT) is currently considered the most effective diagnostic test for its detection, because it projects a three-dimensional image of the teeth, adjacent tissues and has the advantage of minimizing the overlapping of structures. Scientific evidence has demonstrated the superiority of CBCT in detecting AP over conventional radiographs [6,7]. AP is a clinical event of special interest by professionals in the endodontic area, however in Colombia, there is no evidence from studies documenting this finding diagnosed from three-dimensional images. The objective of this investigation was to determine the prevalence of AP in teeth without endodontic treatment. The CBCT used were taken at a clinical institution in an intermediate city in Colombia.

Materials and Methods

Study design and target population
An analytical cross-sectional study was carried out from CBCT taken between 2016 and 2017. As inclusion criteria, permanent teeth with closed apex were considered, images corresponding to adults over 18 years of age who signed informed consent. Those images where it was not possible to visualize the apex and those that presented poor quality in such a way as to prevent their reading were excluded. No sample size estimation was made considering that once the selection criteria were applied; it was possible to evaluate the total images available at the Diagnostic Imaging Center of the Universidad Santo Tomás Seccional Bucaramanga.

Variables
The output variable was the presence of PA according to the CBCT PAI index; as independent variables, the sex and age of the patient, the most affected teeth, and also the number of teeth affected with PA in each tomography evaluated were considered. The presence of AP was evaluated by direct observation of the tomographies and any case in which a hypodense area at the apex level was evident, which could be observed with at least twice the width of the periodontal ligament space and was considered positive will alter the continuity of the lamina dura [8-10].

Procedures
Training was carried out in the reading of the images and later calibration with an expert in tomography analysis, considering the expert’s reading as true. The researcher was considered to be prepared to carry out the image readings if the agreement, evaluated using the kappa index, compared to the expert was equal to or greater than 0.8. The evaluation of agreement was 0.86 [95% CI 0.54-1.00]. To obtain data, the tomographic interpretation was performed on the same computer screen, in a dark room with a calm environment, during daylight hours. The presence and classification of the apical lesion was performed according to the PAICBCT index, to reduce false negative diagnoses as well as observer interference and increase the reliability of epidemiological data, especially those referring to the prevalence and severity of BP. All the CBCT images came from the GalileosComfort® team of the Sirona commercial house of the Santo Tomás University Bucaramanga sectional. The information resulting from the review of the images was typed independently and in duplicate; it was validated in Microsoft Excel 2018 software. After validation, the database was exported to the STATA 14.0 Program to execute the data analysis.

Analysis Plan
Data of a quantitative nature are presented as the mean and range (minimum and maximum value); the qualitative ones like frequency and percentage. The prevalence of BP was accompanied by the 95% confidence interval (95% CI). The association between BP and variables such as gender, age, affected tooth and number of teeth that presented the pathology by evaluated tomography, was performed using the Chi2 test, values of p≤0.05 were considered to be of statistical significance.

 Ethical Considerations
For the execution of this study, the guidelines established in Resolution 8430 of 1993 that currently governs the investigation in Colombia were respected. Likewise, the research protocol was approved by the ethics committee of the Faculty of Dentistry of the Santo Tomás University.

Results

A total of 152 cone beam tomographies were included, 85 corresponded to bimaxillary images, 42 were of the upper jaw and 25 of the lower jaw. Of these diagnostic images 88 (57.9%) were of women and 64 (42.1%) of men. The total number of teeth analyzed was 1858. The median age was 48 years (RIQ: 32-57 years), the lower and upper extremes of age were 20 and 82 years, respectively. The prevalence of AP found was 19.7%, with the right upper canine (13) being the tooth with the highest prevalence (40.9%), followed by the first upper left premolar tooth (24) (39.7%) (Table 1). Regarding the number of teeth affected by tomography, 33 had no teeth with the pathology, in 30 diagnostic images 1 affected tooth was observed (19.7%). According to the CBCT PAI index, the prevalence for each item was analyzed, showing that 83.6% of the teeth affected by PA were in criterion 1 (> 0.5mm-1mm) (Table 2). Regarding gender, the presence of AP is not different between men and women (p> 0.05). However, in the case of the age variable, the BP does have a differential behavior, apparently the older the younger the BP (p = 0.016) (Table 3).


Table 1: Prevalence of apical periodontitis according to the tooth and the number of teeth present


Table 2: Extension of PA according to the CBCT PAI index and prevalence found in the affected teeth


*P value calculated using Chi2 test with statistical significance.
Table 3: Relationship between the presence of AP with gender and age

Discussion

The emergence of new and better diagnostic strategies as support tools has favored clinical decision making in areas such as endodontics and periodontics. Traditionally, panoramic radiography has been the most widely used test for the diagnosis of AP. However, with the appearance of the CBCT, several researchers have worked to document the superiority of the latter for the diagnosis of events such as BP. Thus, Estrela (2008) in Brazil, Paula Silva (2009,) Patel (2011) in London, Abella (2012) in Spain and more recently Torabinejad (2018) in the United States, have shown that better results of sensitivity and specificity are obtained. for the diagnosis of BP with CBCT, compared with panoramic radiography [7,9,11-13]. Therefore, the present study only used CBCT as a diagnostic means of AP in teeth without endodontic treatment, recognizing that factors such as the presence or absence of endodontic treatment, radiographic parameters, methodological aspects, among others, can modify the estimate of the actual prevalence of event [14-16]. According to the review of the published data for AP evaluated by CBCT, in teeth without endodontic treatment, the figures identified present values ranging between 1.2% and 2.2% [17,18]. On the contrary, in teeth with endodontic treatment the figures are much higher and range from 44.7% to 53.3% [7,17]. The result of PA prevalence in the present study was 19.7%, much higher than the data described in teeth without endodontic treatment but lower than those of teeth with endodontic treatment. These findings could be due to the total number of teeth evaluated as well as the number of teeth evaluated.

Regarding the gender variable, both the number of patients (n = 88) and the prevalence of pathology (57.9%) in the female sex was higher. This data is similar to that obtained in the study by Patel et al. In 2011, in which 58% of patients included in the sample were women. Despite the fact that female patients are the ones who attend the dental consultation the most (60.4%), the higher prevalence of AP could be explained because women have shown higher figures in pathologies such as periodontal disease (59.2%) and oral lesions in tissues. soft (54.3%), probably due to hormonal disturbances [9,11]. Regarding the extension of the lesion and the condition of the cortical bone, we observed that most of the lesions were incipient, with a diameter of 0.5 to 1 mm (CBCT PAI 1 score) (82.7%), which leads us to conclude that due to for this reason, only 2.4% of the teeth with PA presented evidence of expansion and 1.9% of destruction; and with respect to the total of the analyzed sample (1858 teeth) the expansion was only observed in 0.48% and the destruction in 0.37%. It is also worth noting the importance of using this diagnostic means, since in the initial stages the lesions cannot be observed through an x-ray. This is in accordance with what was affirmed by Paula Silva in 2009, where she concluded that periapical lesions with a meso distal diameter equal to or less than 2.8 mm cannot be detected by periapical radiographs but only on CBCT [12]. It must be considered that factors related to the Lifestyle such as cigarette smoking may in turn be implicated with the size of the periapical lesion, however, to date studies have not been able to establish this association [19].

The teeth that were most affected by BP were 13, 23, 14 and 24 respectively. This result is in accordance with what Nardi explained in 2017, where he states that in the upper jaw the identification of PA at the canine level can be easier due to the bone thickness, since it is thinner due to the absence of cortical bone in area. Another factor that could influence this figure is the absence of anatomical structures that can cause confusion at the time of observation. Regarding premolars, the high prevalence coincides with Estrela’s study in 2008, where in CBCT premolars were the second group with the highest figures found (after molars). Rohlin carried out a study through radiographs, evidencing the superiority of the detection of lesions at the premolar level and, more recently, Nascimiento determined by CBCT that the maxillary molars and the anterior teeth have a higher prevalence of periapical lesions [11,14,15,20]. In addition to this, the size of the lesion will be directly proportional to the number of microbial species it contains. This result is similar to that found by Torabinejad in 2018, where 80% of the evaluated lesions had a diameter less than 1 mm (ERI 1 and 2), in which the author suggests that they could be healing injuries, persistent injuries and / or fibrous tissue [7]. It is worth highlighting the importance of using the CBCT for the interpretation of BP, since in the initial stages the lesions cannot be observed through an x-ray. This is in accordance with what was affirmed by Paula Silva in 2009, where she concluded that periapical lesions with a meso distal diameter equal to or less than 2.8 mm cannot be detected by periapical radiographs but only on CBCT [12]. A limitation of this study was the lack of knowledge of the state of the tooth to be able to make associations with these results, as well as the nature of the lesion, considering that there are some factors that could generate false positives in the radiographic diagnosis of BP. One of the associated factors could be the presence of caries, which by inducing neurogenic inflammation generates a widening of the periodontal ligament space; Occlusal trauma and movements produced during orthodontic treatment have also been related aspects.

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