Apical periodontitis is an inflammatory disease caused by infection of the pulp chamber, and leads to the loss of periapical bone. It exists as a local infection, with pathogens in periapical tissues entering the blood stream and triggering immune responses and leading to systemic disease. Therefore, it is likely that periapical disease is linked to systemic illnesses. This may include osteoporosis, with the prevalence of apical periodontitis significantly higher in osteoporotic patients.[i]
Osteoporosis and periapical infections
Apical periodontitis has a prevalence of 50% in patients under 50, with research suggesting risk increases with age. It is the same with bone pathologies, such as osteoporosis.[ii] Some research also suggests that osteoporosis may lead to an increased incidence of apical periodontitis. Common in post-menopausal patients with low oestrogen levels, bones become more fragile. Therefore, osteoporosis decreases the total skeletal mass, including that of the jaw bone, leading to decreased alveolar bone density and height of the alveolar ridge. This may also lead to tooth loss.[iii]
Because of these links, commonly patients presenting with apical periodontitis are also being treated with antiresorptive medications for osteoporosis. Research suggests that, worryingly, those being treated with this type of medication are more likely to develop osteonecrosis of the jaw when they undergo procedures like dental extractions and implant placement. As such, it is important to explore other treatment options for these patients, to help reduce the risk.[iv]
Root canal treatment as a favourable procedure
Research suggests that half of the adult population worldwide has at least one tooth with an apical periodontitis diagnosis. To reduce the risk of the spread of infection to other areas, there are a number of treatment options offered to patients. These are: retain the tooth with root canal treatment, or extract the tooth with or without a replacement.[v]
Root canal treatment, therefore, can be considered a viable option for the treatment of apical periodontitis in patients being medicated for osteoporosis. However, it’s important to consider carefully the patient’s unique circumstances, and the clinician’s own ability to remove infected tissue from the root canal in a non-invasive and non-surgical way. Current research suggests the tooth survival rate in cases like this is 85%, with a 74% 12-month healing rate.[vi] However, the greatest clinical benefit of providing endodontic treatment in these cases is the minimised risk of medication-related osteonecrosis of the jaw (MRONJ), making it the favourable treatment option for patients with osteoporosis.[vii]
As with any case, clinicians should ensure they comprehensively record each patient’s medical history to enable them to make informed decisions about their care. Additionally, clinicians should use this information to decide whether to consult with a specialist in the field, and which treatment approach is most appropriate for the individual.[viii]
Building a network
By becoming a member of the British Endodontic Society (BES), clinicians who have an interest in endodontics become a part of a likeminded community. The BES is passionate about promoting education in the field, and sharing research to help its membership and those who provide endodontic treatment offer their patients the best outcomes. The Society hosts educational and social events every year, bringing together its members to share their knowledge and experiences, and to network in fantastic venues across the country.
By joining a network of clinicians with an interest in endodontics, as well as specialists, those who may require consultation on certain cases which are more challenging, or who require referral to a specialist, have contacts who are willing and able to help. This community can also act as a supportive environment, helping those who are new to the field to grow their careers and expand their knowledge.
Osteoporosis presents unique challenges when a patient develops apical periodontitis. As such, it is important to understand the treatment options available in such cases, and why root canal treatment is usually the preferred avenue. Clinicians must then be aware of the complexities surrounding medication, and how to manage these cases in a non-invasive way. Further, clinicians should consider the difficulty of each individual case, and carefully consider whether it is appropriate to treat the patient themselves, or whether to refer to a specialist for care.
For more information about the BES, or to join, please visit the website www.britishendodonticsociety.org.uk or call 07762945847
[i] Ye, Lanxiang, et al. “Interaction between apical periodontitis and systemic disease.” International Journal of Molecular Medicine 52.1 (2023): 1-19.
[ii] Oral health. Why Endodontic Therapy is the Treatment of Choice in Patients on Anti-Resorptive Drug Therapy. July 24. https://www.oralhealthgroup.com/features/why-endodontic-therapy-is-the-treatment-of-choice-in-patients-on-anti-resorptive-drug-therapy/
[iii] Ye, Lanxiang, et al. “Interaction between apical periodontitis and systemic disease.” International Journal of Molecular Medicine 52.1 (2023): 1-19.
[iv] Oral health. Why Endodontic Therapy is the Treatment of Choice in Patients on Anti-Resorptive Drug Therapy. July 24. https://www.oralhealthgroup.com/features/why-endodontic-therapy-is-the-treatment-of-choice-in-patients-on-anti-resorptive-drug-therapy/
[v] Oral health. Why Endodontic Therapy is the Treatment of Choice in Patients on Anti-Resorptive Drug Therapy. July 24. https://www.oralhealthgroup.com/features/why-endodontic-therapy-is-the-treatment-of-choice-in-patients-on-anti-resorptive-drug-therapy/
[vi] Oral health. Why Endodontic Therapy is the Treatment of Choice in Patients on Anti-Resorptive Drug Therapy. July 24. https://www.oralhealthgroup.com/features/why-endodontic-therapy-is-the-treatment-of-choice-in-patients-on-anti-resorptive-drug-therapy/
[vii] Oral health. Why Endodontic Therapy is the Treatment of Choice in Patients on Anti-Resorptive Drug Therapy. July 24. https://www.oralhealthgroup.com/features/why-endodontic-therapy-is-the-treatment-of-choice-in-patients-on-anti-resorptive-drug-therapy/
[viii] Stanev, Evgeni, and Radosveta Ivanova Vasileva. “Influence of Osteoporosis on the Course of Apical Periodontitis.” European Journal of Dentistry (2024).
