SYSTEMATIC REVIEW
Systemic Comorbidities and Apical Periodontitis: Influence on Endodontic
Treatment Outcomes
Comorbilidades sistémicas y
periodontitis apical: Influencia en los resultados del tratamiento endodóntico
Tatiana Cecibel
Elizalde Sarango1. María Angélica Terreros
de Huc2. Jenny Guerrero Ferreccio3
1 Postgraduate Resident in Endodontics. Catholic
University of Santiago de Guayaquil. https://orcid.org/0009-0006-4243-2698
2 PhD in Dentistry. MSc in Clinical and Epidemiological Research.
Professor, Catholic University of Santiago de Guayaquil. https://orcid.org/0000-0002-5761-851X
3 Specialist in Endodontics. Director of the Postgraduate Program in
Endodontics. Catholic University of Santiago de Guayaquil. https://orcid.org/0009-0006-3755-6645
Correspondence:
tatyeli_snoopy@hotmail.com
Received: 21/12/2025 Accepted: 27/02/2026
ABSTRACT
Introduction: Systemic
diseases are those that affect various parts of the body and do not allow
successful treatment or repair due to the involvement of the immune system. At
the oral level, these diseases manifest signs and symptoms, which, combined
with the deficiency in defense mechanisms and alterations in the healing
processes, directly influence the effectiveness of treatments aimed at
addressing endodontic pathologies. Objective: To analyze the association
between apical periodontitis and various systemic diseases, as well as to evaluate
its impact on the quality of life of patients. Materials and methods:
Documentary approach research, cross-sectional and retrospective type,
descriptive-analytical design, and deductive method; following inclusion and
exclusion criteria, 35 articles were included from 2016 to 2024. The
information was obtained from databases such as PubMed, Google Scholar,
Science, Elsevier, and Dialnet. Through PICO analysis, the keywords were
obtained, Mesh and DeCS search terms were added.
Results: All systemic diseases analyzed in this study can interfere with the
repair process of periapical tissues after conventional root canal treatment.
Conclusions: The systemic health of patients can affect favorable results in
the treatment of endodontic infections, hence the importance of knowledge for
the management of each disease and to promote preventive measures in the
patient's oral health.
Keywords: Systemic diseases.
Apical periodontitis. Diabetes. Endodontics.
RESUMEN
Introducción:
Las enfermedades sistémicas son aquellas que afectan diversas partes del cuerpo
y no permiten la reparación exitosa del tratamiento debido a la afectación del
sistema inmunológico. A nivel bucal, estas enfermedades manifiestan signos y
síntomas, los cuales, combinados con la deficiencia en los mecanismos de
defensa de los pacientes y alteraciones en los procesos de cicatrización,
influyen directamente en la eficacia de los tratamientos dirigidos a abordar
las patologías endodónticas. Objetivo: Analizar la asociación entre la
periodontitis apical y diversas enfermedades sistémicas, así como evaluar su
afectación a la calidad de vida de los pacientes. Materiales y métodos:
Investigación enfoque documental,
tipo transversal y retrospectivo,
diseño descriptivo-analítico
y método deductivo; siguiendo criterios de inclusión y exclusión se incluyeron 35 artículos desde el año
2016 a 2024. La obtención de información
se seleccionó de bases de datos
como PubMED, Google Académico, Science, Elsevier y Dialnet. A través del análisis PICO, se obtuvieron las palabras clave, se agregaron
términos de búsqueda de
Mesh y DECS. Resultados: Todas
las enfermedades sistémicas
analizadas en este estudio pueden
interferir en el proceso de reparación
de los tejidos periapicales después del tratamiento de conducto convencional. Conclusiones: La salud sistémica de los pacientes pueden
llegar afectar resultados favorables al tratamiento de infecciones endodónticas por ende la importancia del conocimiento para el manejo de cada enfermedad e impulsar a medidas preventivos en la salud bucal
del paciente.
Palabras clave: Enfermedades sistémicas. Periodontitis
apical. Diabetes. Endodoncia.
INTRODUCTION
Apical
periodontitis (AP) is a multifactorial inflammatory disease of bacterial
origin. It is characterized by microorganisms present within the root canal. If
left untreated, AP may cause radicular bone resorption, cyst formation,
granulomas, or periapical lesions. These consequences can compromise the
prognosis of endodontic treatment.¹–²
Apical periodontitis not
only affects the tissues surrounding the tooth but may also contribute to
systemic alterations, as bacteria, endotoxins, and inflammatory mediators can
disseminate from the root canal into the bloodstream.³ This phenomenon promotes
the activation of systemic immune responses that negatively impact the body,
exacerbating diseases such as diabetes mellitus, cardiovascular diseases, and
rheumatoid arthritis, as well as associated factors such as smoking and alcohol
consumption.⁴ This process of microbial dissemination from the dental infection
focus to other body systems promotes a systemic inflammatory state, which may
aggravate or predispose individuals to these diseases.⁵–⁷
Systemic disorders and oral
infections share several risk factors.⁸ This
interrelationship may influence the prognosis of endodontic treatment.⁹
Although inflammation is a defense mechanism of the body, the continuous
release of inflammatory mediators may exacerbate preexisting inflammatory
processes.¹⁰ Furthermore, there is a relevant connection between autoimmune
diseases and endodontic disease, as both share pathogenic mechanisms mediated
by microbial elements that promote bone loss.¹¹–¹³
Among systemic diseases,
there is an association between apical periodontitis (AP) and diabetes mellitus
(DM); both conditions may interact with each other.¹⁴
AP is a chronic infection affecting the apical region of the tooth and
surrounding tissues, caused by various bacteria.¹⁵ Meanwhile, individuals with
diabetes exhibit an altered innate immune response, which is associated with
endodontic disease.
On the other hand, the
association between apical periodontitis (AP) and rheumatoid arthritis (RA)
involves chronic inflammatory diseases that share pathogenic mechanisms and may
exert mutual influence. ¹⁶
The association between smoking
and apical periodontitis is crucial, as smoking significantly increases the
risk and severity of injury.¹⁷ Smokers often present a
compromised immune response, facilitating the progression of bacterial
infections and reducing the effectiveness of endodontic treatments. ¹⁸
Furthermore, the
association between alcoholism and apical periodontitis (AP) is significant.
Chronic alcohol consumption aggravates inflammation and periapical lesions,
altering the oral microbiota and promoting the proliferation of pathogens that
contribute to AP.¹⁹
According to
epidemiological literature reviews, the association between apical
periodontitis and various systemic diseases has received increasing attention
in recent years. It is estimated that up to 52% of the global population may be
affected by this chronic inflammatory condition. ²⁰
In patients with diabetes
mellitus, studies have shown that between 39% and 56% present significant involvement.
²¹ Similarly, among those with rheumatoid arthritis, 47.9% show a direct
relationship with this pathology. ²² in individuals with cardiovascular
disease, the incidence reaches 42.6%, demonstrating a relevant association with
chronic inflammation. ²³
Studies revealed that
approximately 75.7% of smoking patients presented apical periodontitis.²⁴
Research has found that up to 57% of patients with periodontal health problems
were regular alcohol consumers.²⁵ Scientific data indicate that approximately
35–40% of hypertensive patients present periodontitis, and this relationship
may influence the development or persistence of AP, although additional studies
are needed to determine this percentage specifically in AP cases.²⁶
Systemic diseases may
compromise the outcome of endodontic treatment, as they can increase the risk
of infections, delay recovery, modify the inflammatory response, and affect
coagulation processes. Likewise, endodontic conditions may impact systemic health
status. ²⁷
The purpose of this
research is to analyze the association between apical periodontitis and various
systemic diseases, as well as to evaluate their impact on patients’ quality of
life.
MATERIALS AND METHODS
The present research work
employed a documentary, cross-sectional, and retrospective methodology, with a
descriptive-analytical design and a deductive method. The PRISMA flowchart was
used for the search, review, analysis, and selection of articles. A total of
560 articles were initially identified; following the inclusion and exclusion
criteria, 44 articles with significant contributions to the research were
selected.
The search for articles
related to the research topic was conducted using the PICO analysis to
determine keywords from PubMed and DeCS, using
various information sources, including specialized scientific literature search
engines and databases such as PubMed, Google Scholar, Science, Elsevier, and
Dialnet. Meta-analyses, systematic reviews, literature reviews, case reports,
and randomized clinical trials were included.
Figure 1.
Diagram of the article selection process. PRISMA analysis.
The inclusion criteria
considered were full-text publications in English, Spanish, and Portuguese;
articles mentioning the relationship between systemic diseases and apical
periodontitis; analyses describing the relationship between systemic diseases
and endodontics; and studies determining the success and failure of endodontic
treatments in patients with systemic diseases. For this review, gray
literature, studies addressing the topic in a general manner, duplicate
articles, limited-access articles, and incomplete information were excluded.
The following variables
were analyzed: diabetes, cardiovascular diseases, rheumatoid arthritis, smoking
patients, and patients with alcoholism.
RESULTS
Table 1.
Systemic Diseases and Apical Periodontitis
|
Author |
Characteristics |
Relevant
Factors |
|
Segura-Egea J
et al., 2023¹ |
Systemic
diseases – Apical periodontitis |
Influences
the clinical outcomes of root canal treatment. |
|
Tiburcio-Machado
M et al., 2021² |
Tissue
healing and regeneration. |
|
|
Ambreen-Niazi;
Aziz-B et al., 2022³ |
Immunological
and microbiological aspects. |
|
|
Segura-Cabanillas
G et al., 2023⁴ |
Inflammatory
mediators and metabolic alterations. |
Table 2.
Association Between Diabetes and Apical Periodontitis
|
Author |
Characteristics |
Relevant
Factors |
|
Yip et al.,
2021⁵ |
Diabetes
Mellitus – Apical periodontitis |
Elevated
glucose levels negatively affect the effectiveness of endodontic treatment. |
|
Segura-Egea
et al., 2022⁶ |
Root canal
treatment in patients with DM and AP |
DM reduces
success rates in endodontic treatment due to metabolic complications. |
|
Ríos-Muñoz A
et al., 2020⁷ |
Pulpal and
periapical pathology |
The
progression of endodontic pathologies is more complex in patients with DM due
to systemic alterations. |
|
Shengming
Wang S et al., 2023⁸ |
Clinical
evaluation of endodontic treatment in patients with DM |
Endodontic
treatment may have a positive effect on glycemic control in patients with DM
and AP. |
|
Pinto-Alves M
et al., 2023⁹ |
Bacterial resistance
in patients with DM |
Immunological
and microbiological factors hinder the response in patients with AP. |
|
Smadi Uinm L,
2017¹⁰ |
Comparison of
AP prevalence in diabetics vs. non-diabetics |
DM increases
the prevalence of AP and affects periapical health. |
|
Khalighinejad-Navid
M et al., 2016¹¹ |
Association
between DM and periapical healing |
Host-modifying
factors associated with diabetes. |
Table 3.
Association Between Rheumatoid Arthritis and Apical Periodontitis
|
Author |
Characteristics |
Relevant
Factors |
|
Ertuğrul
Karatas T et al., 2020¹² |
Relationship
between Rheumatoid Arthritis and Apical Periodontitis |
RA increases
risk and accelerates apical destruction due to inflammation. |
|
Ertuğrul
Karata et al., 2023¹³ |
RA makes
patients more prone to AP. |
|
|
Yilmaz M;
Fatma T, 2023¹⁴ |
RA and
ankylosing spondylitis in periapical lesions |
RA and AS are
associated with a higher frequency of radiopaque and mixed lesions. |
|
Marwa
Allihaibi S et al., 2023¹⁵ |
Prevalence of
AP in RA |
RA increases
the prevalence of AP in autoimmune patients. |
|
Huili Wu L et
al., 2024¹⁶ |
Genetic
relationship between RA and AP |
Shared
genetic factors between RA and AP contribute to tissue damage. |
Table 4.
Association Between Cardiovascular Diseases and Apical Periodontitis
|
Author |
Methods
Analyzed |
Relevant
Factors |
|
Sharvi Arora;
Rohit K, 2024¹⁷ |
Cardiovascular
disease and apical periodontitis |
Inflammation
and risk factors induce AP, affecting CVD. |
|
González B et
al., 2020¹⁸ |
Oral
inflammatory burden and metabolic syndrome increase CVD risk. |
|
|
Jakovljevic A
et al., 2020¹⁹ |
AP bacteria
may enter the bloodstream and contribute to CVD. |
|
|
Virtanen E et
al., 2017²² |
AP is linked
to a higher risk of CVD. |
|
|
Giuliat Mal V
et al., 2023²⁰ |
AP and
atherosclerotic cardiovascular disease |
AP is
associated with secondary outcomes in atherosclerotic CVD. |
|
Saimir H et
al., 2024²¹ |
AP and
arteriosclerosis |
AP and
periodontal diseases are risk factors for arteriosclerosis progression in
CVD. |
Table 5. Association
Between Smoking Patients and Apical Periodontitis
|
Author |
Characteristics |
Relevant
Factors |
|
Janardhana A
et al., 2019²³ |
Bone
destruction in smoking patients with AP |
Smokers
present greater bone destruction in AP. |
|
Paljevic E et
al., 2023²⁴ |
Smoking and
AP healing |
Lower
effectiveness of endodontic treatment in smokers. |
|
Rane E et
al., 2021²⁵ |
Impact of
smoking on the apical region |
Smokers
experience apical complications despite treatment. |
|
Ríos N et
al., 2022²⁶ |
Smoking and post-endodontic
AP |
Greater
development of post-endodontic apical complications in smokers. |
|
Shetty K et
al., 2021²⁷ |
Pain
perception in smokers vs. non-smokers with AP |
Smokers
report greater pain during treatment. |
|
Waleed O,
2023²⁸ |
Smoking and delayed
AP healing |
Severe
smoking delays AP healing. |
|
Pinto K et
al., 2020²⁹ |
Smoking and
endodontic treatment |
Impacts
endodontic planning and prognosis. |
Table 6.
Association Between Alcohol and Apical Periodontitis
|
Author |
Methods
Analyzed |
Relevant
Factors |
|
Custódio dos
Santos V et al., 2023³⁰ |
Alcohol and
AP |
Periapical
lesions are more common in patients with poor dental health and systemic
diseases. |
|
Freitas C et
al., 2020³¹ |
Effect of
alcohol on bone destruction |
Increased periapical
bone destruction evaluated with micro-CT. |
|
Pinto P et
al., 2023³² |
Combined
effect of alcohol and nicotine |
Chronic
alcohol and nicotine consumption exacerbates inflammation, bone destruction,
and elevated pro-inflammatory cytokine levels. |
|
Marques F et
al., 2019³⁴ |
Impact of
chronic alcohol consumption |
Increased
osteoclastogenesis and inflammation in AP due to alcohol. |
|
Fabbro R et
al., 2019³⁵ |
Alcohol
concentration and AP development |
High alcohol
levels aggravate inflammation and bone destruction. |
|
Fabbro L et
al., 2021³⁶ |
Effect of red
wine and its polyphenols |
Polyphenols
show protective effects, reducing inflammation and bone resorption. |
ANALYSIS AND DISCUSSION OF
RESULTS
Systemic diseases have a
considerable influence on the clinical, immunological, and microbiological
outcomes of apical periodontitis. ¹ The interaction
between inflammatory mediators and metabolic alterations complicates root canal
repair²–³ due to their significant impact on tissue healing and regeneration. ⁴
Diabetes Mellitus adversely
affects endodontic treatment and periapical healing processes due to elevated
glucose levels and chronic hyperglycemia, which alter the immune response.⁵–⁶
Systemic alterations complicate the progression of periapical pathologies.⁷
However, endodontic treatment may contribute to improved metabolic control in
diabetic patients, demonstrating a bidirectional relationship between both
conditions.⁸ DM is associated with a higher prevalence of periapical lesions
and difficulty in periapical healing compared to non-diabetic patients.⁹–¹⁰
Early recognition of the systemic disease is essential for interdisciplinary
management and the achievement of comprehensive patient improvement.¹¹
Rheumatoid Arthritis (RA)
is associated with a higher prevalence of periapical lesions due to chronic
inflammation and altered immune response that characterize this disease.¹²–¹³
RA and ankylosing spondylitis (AS) are linked to a greater frequency of periapical
lesions.¹⁴ Both diseases may present an inflammatory response that affects not
only periodontal tissues.¹⁵ The presence of periodontal bacteria, such as Porphyromonas gingivalis,
has been implicated in the pathogenesis of RA, suggesting a bidirectional
connection between oral infections and systemic autoimmune diseases.¹⁶
Cardiovascular Disease
(CVD) is associated with a higher risk of AP due to inflammation and
disease-induced risk factors.¹⁷ Oral inflammatory burden and bacterial
dissemination into the bloodstream may contribute to cardiovascular risk.¹⁸–¹⁹
However, this relationship may be influenced by multiple factors such as age,
smoking, diet, body composition, cholesterol levels, family history of CVD, and
socioeconomic factors.²⁰ Tooth loss has been used as a direct indicator of poor
oral health and potential cardiovascular risk.²¹ Finally, it is suggested that
successful endodontic treatment could contribute to reducing systemic
inflammatory burden, thereby potentially decreasing disease progression.²²
Smoking is a risk factor
associated with a higher prevalence and persistence of AP, characterized by
greater bone destruction in the periapical region²³ and lower success rates of
endodontic treatment.²⁴–²⁶ Smoking patients experience more pain during endodontic
procedures and have increased post-endodontic complications;²⁷ therefore, they
present a higher risk of delayed AP healing.²⁸ Smoking is considered a relevant
factor in treatment planning and in the evaluation of endodontic clinical
prognosis.²⁸–²⁹
Alcohol consumption is
associated with a higher risk of prevalence and severity of AP, characterized
by increased periapical bone destruction. An increase in periapical bone
destruction evaluated by micro-CT has also been reported.³⁰–³¹ Chronic alcohol
consumption, especially in combination with nicotine, exacerbates periapical
inflammation, promotes osteoclastogenesis, and increases pro-inflammatory
cytokine levels.³²–³³ High alcohol levels aggravate inflammation in AP and
delay periapical bone repair.³⁴ On the other hand, studies suggest that red
wine polyphenols may also exert modulatory effects on inflammation and bone
resorption.³⁵
CONCLUSIONS
Apical periodontitis is
influenced by various systemic diseases, such as diabetes mellitus, rheumatoid
arthritis, and cardiovascular disease, which affect immune response, healing,
and tissue regeneration. Additionally, factors such as smoking and alcohol
consumption worsen the disease by increasing bone destruction and delaying
healing. Therefore, it is essential to consider patients’ systemic health to
ensure the success of endodontic treatment and prevent complications.
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AUTHOR CONTRIBUTIONS
“Conceptualization and design: Elizalde Tatiana
and Terreros María; Literature review:
Elizalde Tatiana; Methodology and validation: Terreros
María and Guerrero Jenny; Formal analysis: Elizalde Tatiana; Investigation
and data collection: Elizalde Tatiana; Resources: Not applicable; Data
analysis and interpretation: Elizalde Tatiana and Terreros
María; Writing – original draft preparation: Elizalde Tatiana; Writing
– review and editing: Terreros María and Guerrero
Jenny; Supervision: Guerrero Jenny; Project administration: Elizalde
Tatiana; Funding acquisition: Not applicable.”
CONFLICTS OF INTEREST
The authors declare that there were no conflicts of
interest during the conduct of this research. In addition, the manuscript was
submitted exclusively to the Revista Científica “Especialidades Odontológicas UG” for review and publication.
FUNDING
The authors report that personal funds were used to
carry out this research.
COPYRIGHT
HOW TO CITE:
Elizalde Sarango T, Terreros de Huc MA, Guerrero Ferreccio J. Systemic
Comorbidities and Apical Periodontitis: Influence on Endodontic Treatment
Outcomes. Revista Científica Especialidades
Odontológicas UG. 2026;9(1):45-52