Int Endodontic J - 2021 - Tib Rcio Machado

doi:10.1111/iej.
13467
REVIEW
The global prevalence of apical periodontitis: a
systematic review and meta-analysis
rcio-Machado1 , C. Michelon2
C. S. Tibu , F. B. Zanatta1,3 , M. S. Gomes4,5 ,
J. A. Marin6 & C. A. Bier1,3
1
Graduate Program in Dental Science, Federal University of Santa Maria (UFSM), Santa Maria; 2Medical and Dental Center of
the Brazilian Army, Santa Maria; 3Department of Stomatology, Federal University of Santa Maria (UFSM), Santa Maria;
4
Graduate Program in Dentistry, School of Health and Life Sciences, Pontifıcia Universidade Cat
olica do Rio Grande do Sul
(PUCRS), Porto Alegre; 5Medical and Dental Center of the Military Police, Porto Alegre; and 6Universidade Franciscana (UFN),
Santa Maria, Brazil
Abstract were included. No language restriction was applied.

An adaptation of the Newcastle-Ottawa Scale was
rcio-Machado CS, Michelon C, Zanatta FB,
Tibu
used to evaluate the quality of the studies. A meta-
Gomes MS, Marin JA, Bier CA. The global prevalence
analysis was performed to determine the pooled
of apical periodontitis: a systematic review and meta-analysis.
prevalence of AP at the individual level. Secondary
International Endodontic Journal, 54, 712–735, 2021.
outcomes were the frequency of AP in all teeth, non-
Background Apical periodontitis (AP) frequently treated teeth and root filled teeth. Subgroup analyses
presents as a chronic asymptomatic disease. To arrive using random-effect models were carried out to anal-
at a true diagnosis, in addition to the clinical exami- yse the influence of explanatory covariables on the
nation, it is mandatory to undertake radiographic outcome.
examinations such as periapical or panoramic radio- Results The search strategy identified 6670 articles,
graphs, or cone-beam computed tomography (CBCT). and 114 studies were included in the meta-analysis,
Thus, the worldwide burden of AP is probably under- providing data from 34 668 individuals and 639 357
estimated or unknown. Previous systematic reviews teeth. The prevalence of AP was 52% at the individ-
attempted to estimate the prevalence of AP, but none ual level (95% CI 42%–56%, I2 = 97.8%) and 5% at
have investigated which factors may influence its the tooth level (95% CI 4%–6%; I2 = 99.5%). The fre-
prevalence worldwide. quency of AP in root-filled teeth and nontreated teeth
Objectives To assess: (i) the prevalence of AP in was 39% (95% CI 36%–43%; I2 = 98.5%) and 3%
the population worldwide, as well as the frequency of (95% CI 2%–3%; I2 = 99.3%), respectively. The
AP in all teeth, nontreated teeth and root filled teeth; prevalence of AP was greater in samples from dental
(ii) which factors can modify the prevalence of AP. care services (DCS; 57%; 95% CI 52%–62%;
Methods A search was conducted in the PubMed- I2 = 97.8%) and hospitals (51%; 95% CI 40%–63%;
MEDLINE, EMBASE, Cochrane-CENTRAL, LILACS, I2 = 95.9%) than in those from the general popula-
Google scholar and OpenGrey databases, followed by tion (GP; 40%; 95% CI 33%–46%; I2 = 96.5%); it
hand searches, until September 2019. Cross-sec- was also greater in people with a systemic condition
tional, case–control and cohort studies reporting the (63%; 95% CI 56%–69%, I2 = 89.7%) compared to
prevalence of AP in humans, using panoramic or healthy individuals (48%; 95% CI 43%–53%;
periapical radiograph or CBCT as image methods I2 = 98.3%).
Correspondence: Camilla dos Santos Tib

urcio-Machado, Federal University of Santa Maria, Rua Floriano Peixoto, 1184, Centro,
Zip Code: 97015 372, Santa Maria, RS, Brazil (Tel.: +55 (055) 3220-9210; e-mail: camilla_tiburcio@hotmail.com).
Registration The protocol registration in the Prospero is under the number CRD42019137771
712 International Endodontic Journal, 54, 712–735, 2021 © 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd
13652591, 2021, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13467 by Cochrane Portugal, Wiley Online Library on [16/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tib
urcio-Machado et al. Apical periodontitis in the adult population
Discussion The subgroup analyses identified community representative samples from the general
explanatory factors related to the variability in the population. The present findings should bring the
prevalence of AP. However, the high clinical hetero- attention of health policymakers, medical and dental
geneity and high risk of bias across the primary stud- communities to the hidden burden of endodontic dis-
ies indicate that the findings must be interpreted with ease in the population worldwide.
caution.
Keywords: epidemiology, periapical lesion, preva-
Conclusions Half of the adult population world-
lence, survey.
wide have at least one tooth with apical periodontitis.
The prevalence of AP is greater in samples from the Received 24 February 2020; accepted 24 December 2020
dental care services, but it is also high amongst
level. More recently, Miri et al. (2018) compiled data

Introduction
from different communities and reported that 52% of
Apical periodontitis (AP) is an inflammatory response individuals had endodontic disease, without, however,
related to pathogens and their toxins occupying the identifying which factors may modify the prevalence
root canal system (Kakehashi et al. 1965, Sundqvist of AP worldwide.
1976). As AP is usually asymptomatic, its diagnosis In the reviews conducted by Pak et al. (2012) and
is based on radiographic examinations (Abbott 2004), Miri et al. (2018), only cross-sectional studies pub-
and the burden of endodontic disease is probably lished in English were selected. The cross-sectional
underestimated or even unknown. In contrast, clini- design is the most appropriate study design to provide
cally visible oral conditions such as caries and peri- data on the prevalence of a disease (Fletcher &
odontal disease have been demonstrated to contribute Fletcher 2005). However, baseline data from cohort
substantially to the global burden of diseases (Marce- studies can also give the necessary information (Hul-
nes et al. 2013, Vos et al. 2017). Acknowledging the ley et al. 2001) and modify the global prevalence of
periapical health status of populations is essential for AP. Language restrictions may also increase the pub-
policymakers, as it will result in better management lication bias, and essential pieces of evidence can be
of resources for the prevention and treatment of missed (Gregoire et al. 1995). Therefore, the existing
endodontic diseases. systematic reviews on this topic lack methodological
The worldwide prevalence of people with at least techniques to capture the global prevalence of AP
one tooth with AP has been reported to range from and its risk indicators.
16% (Skudutyte-Rysstad & Eriksen 2006) to 86% The aim of this study was to conduct a systematic
(Georgopoulou et al. 2005, Al-Zahrani et al. 2017). review and meta-analysis with a broader search strat-
The differences in the reported prevalence rates vary egy to verify: (i) the worldwide pooled prevalence of
according to age (Kirkevang et al. 2007), level of edu- AP (main outcome: person as the unit of analysis), as
cation, access to dental care (Aleksejuniene et al. well as the frequency of AP in all teeth, nontreated
2000) and the radiographic techniques applied during teeth and root filled teeth (secondary outcomes: tooth
diagnosis (Kruse et al. 2019). Attempts to pool the as the unit of analysis); (ii) the factors affecting the
available data by using systematic review approaches prevalence of AP, by undertaking subgroup analyses
have been made in previous studies. However, some related to the socioeconomic status of the country,
focused only on root filled teeth (Hamedy et al. 2016, the location of recruitment, the presence of systemic
Segura-Egea et al. 2016) and others on specific popu- conditions, the risk of bias of the primary studies, the
lation groups, such as smokers (Walter et al. 2012), image method used to assess the AP, as well as the
elderly people (Hamedy et al. 2016) and individuals method of assessing the AP.
with systemic conditions (Khalighinejad et al. 2016,
Segura-Egea et al. 2016, Berlin-Broner et al. 2017).
Material and methods
Pak et al. (2012) considered a more general popula-
tion, but the authors included only studies where the This study was reported according to the Preferred
tooth was the unit of analyses, and did not provide Reporting Items for Systematic Reviews and Meta-
information on the prevalence of AP at the individual Analyses checklist (Moher et al. 2009), and
© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 54, 712–735, 2021 713
Apical periodontitis in the adult population Tib
urcio-Machado et al.
the protocol was registered in the International

Study selection
Prospective Register of Systematic Reviews
(CRD42019137771). Included studies were selected following a two-phase pro-
cess. In phase one (screening phase), two reviewers (C.T-
M. and C.M.) independently screened titles and abstracts
Search strategy
of all identified electronic databases for studies that ful-
The study aimed to answer the following research filled the inclusion criteria. Articles without abstracts but
question: ‘What is the prevalence of apical periodonti- with titles suggesting some relation to the objectives of
tis in the population worldwide?’ (main outcome: per- this review were also preselected and submitted to the
son as the unit of analysis). Secondary outcomes full-text analysis of eligibility. Both reviewers indepen-
were also considered (tooth as the unit of analysis): dently applied the same selection criteria in phase two
frequency of AP in all teeth, frequency of AP in root (eligibility phase) to confirm or refute their eligibility. In
filled teeth and frequency of AP in nontreated teeth. advance of phase one and two, the reviewers undertook
An electronic search was undertaken with no date a pilot step, in which 30 studies were randomly chosen
or language restrictions for studies published up to from the retrieved search (inter-agreement kappa = 0.93
13th September 2019 in the US National Library of for eligibility decision). Disagreements between the
Medicine (PubMed-MEDLINE; 1946-present), Excerpta reviewers were discussed until a consensus was reached.
Medica (EMBASE; 1947-present), Cochrane-CENTRAL If a disagreement persisted, the judgment of a third
(1945-present) and Latin American and Caribbean reviewer (F.B.Z.) was considered decisive.
Center on Health Sciences (LILACS; 1982-present)
databases. The search strategies were carried out
Data collection and risk of bias (quality
using free-text terms and keywords, and are presented
assessment)
in the Supplemental Material 1. Grey literature was
also searched through Google scholar (first 400 links; Both reviewers (C.T-M. and C.M.) extracted the fol-
Haddaway et al. 2015) and OpenGrey repository. Ref- lowing data from the selected studies independently:
erence lists of the selected studies for full-text reading (i) article identification: authors, country and year of
were screened manually. publication; (ii) participants: gender, age, sample size,
systemic conditions and location of recruitment; (iii)
methods: method of image acquisition and method of
Eligibility criteria
assessing AP; (iv) results: number of people with at
Cross-sectional, case–control and cohort studies were least one AP, total number of teeth, number of root
included if they reported the occurrence of AP using filled teeth, number of nontreated teeth, number of
periapical radiographs, panoramic radiographs or teeth with AP, number of nontreated teeth with AP
cone-beam computed tomography (CBCT) images. In and number of root filled teeth with AP. In case of
cohort studies, only the baseline prevalence data was disagreement, the main reviewer (C.T-M.) double-
collected. In repeated cross-sectional studies, the first checked the information in the primary study. The
and the last study of the series were selected. In case same was carried out for the quality assessment.
of the first or the last study of a repeated cross-sec- The methodology used for the quality assessment
tional series did not fill the eligibility criteria, then the was based on the Newcastle-Ottawa Scale adapted for
intermediate studies of the series were included. The cross-sectional studies proposed by Herzog et al. (2013).
following exclusion criteria were applied: (i) studies The proposed scale was further adapted to the outcome
that did not provide information to calculate the of interest of this systematic review, and the items were
prevalence or frequency of AP (person or tooth level), divided into three domains [selection (representative-
(ii) studies that did not provide full mouth data; (iii) ness of the sample, sample size and nonresponders),
studies in which the sample included mixed dentition, comparability (confounding factors) and outcome
(iv) studies in which the method of assessing the peri- (blinding and calibration of the examiners) - Details in
apical status was not clearly defined (e.g. it did not Supplemental Material 2)]. The scale was also used to
state if they used PAI score, Strindberg criteria, analyse cohort and case–control studies, as the other
amongst others), (v) reviews, letters, posters, confer- specific items from the original Newcastle-Ottawa Scale
ence abstracts, case reports or case series and disser- were not crucial in light of the outcome of interest of
tation/thesis with data available in a journal article. this review. The second domain was only applied to
Tib
studies with a group of comparison (e.g. comparing the be found (Hakala 1967, Ayad 1977); the journals where
prevalence of AP in diabetic and nondiabetic individu- the articles were published were contacted, but no reply
als). Studies with some group of comparison could was received. Data from 34 668 individuals and
achieve a maximum score of nine stars. On the other 639 357 teeth were available. Five articles were pub-
hand, those without any group of comparison could lished in languages other than English: three in Por-
only achieve a maximum score of five stars since the tuguese (Vidigal et al. 2010, Diogo et al. 2014, Maniglia
second domain was not applied. Studies with a group of Ferreira et al. 2014), one in Norwegian (Kerekes & Ber-
comparison were arbitrarily defined as high risk of bias vell 1976) and one in Polish (Bołtacz-Rzepkowska &
if they scored between zero and three stars, moderate Laszkiewicz 2005). Seventy-four studies had information
risk between four and six and low risk between seven to answer the main research question (Table 1), whilst
and nine. Studies without a group of comparison were 66, 61 and 84 articles provided data regarding the fre-
rated as high risk of bias if they scored between zero quency of AP in all teeth, in nontreated teeth and in root
and two stars, moderate risk if they scored three and filled teeth, respectively (Supplemental Material 3).
low risk if they scored four or five. Six studies were cohort studies (Frisk & Hakeberg
2005, Kim 2010, Zhong et al. 2010, Hommez et al.
2012, Gomes et al. 2016, Timmerman et al. 2017). From
Data analysis
the prospective ones (Frisk & Hakeberg 2005, Zhong
A meta-analysis was performed to determine the preva- et al. 2010, Timmerman et al. 2017), only data from
lence of individuals having at least one tooth with AP, baseline were collected. Seven studies were mistakenly
as well as the frequency of all teeth, nontreated teeth classified by their authors as retrospective studies, when
and root filled teeth with AP using the statistical soft- in fact they were cross-sectional (Bołtacz-Rzepkowska &
ware R (Foundation for Statistical Computing, Vienna, Laszkiewicz 2005, Gumru et al. 2011, Ureyen Kaya et al.
Austria) version 1.2.5019, packages meta and metafor. 2013, Willershausen et al. 2014, Hussein et al. 2016,
Subgroup analyses were carried out to analyse whether Jalali et al. 2017, Piras et al. 2017). Four studies were
the socioeconomic status of the country (UN/DESA classified as case–control, but based on their design, they
2014), the location of recruitment, the presence of sys- were also cross-sectional studies (Hommez et al. 2008,
temic conditions, the risk of bias, the image method and Pasqualini et al. 2012, Leal et al. 2015, Poyato-Borrego
the method of assessing AP influenced the prevalence of et al. 2019). Only one study was a real case–control
the disease at the individual level and tooth level. A ran- (Khalighinejad et al. 2017a).
dom-effects model was employed in all analyses because Three serial cross-sectional studies were included:
the heterogeneity was considered high (I2 > 50%). one from the Netherlands (Peters et al. 2011), which
In the subgroup analyses, smoking was included in is the series study from De Cleen et al. (1993), and
the group of systemic condition since it seems to modify two (Eriksen et al. 1995, Skudutyte-Rysstad & Eriksen
the inflammatory response (Palmer et al. 2005). Also, 2006) from Norway, which are the third and fourth
in order to facilitate the data clustering, other methods series cross-sectional studies of Oslo citizens. The first
of assessing AP were converted into PAI scores and the second study were excluded as they did not
(Ørstavik et al. 1986). Alterations such as ‘widening of provide any information on how AP was defined.
the periodontal ligament not exceeding two times the
width of the lateral periodontal ligament space’ and
Risk of bias
‘condensing osteitis’ were considered compatible with
PAI ≥ 2. ‘Apical periodontal ligament exceeding at Six studies were classified as low risk of bias, 25 as
least two times the width of its lateral part’, ‘broken moderate and 83 as high. A detailed description of
lamina dura’ and ‘discernible apical radiolucency’ were the quality assessment is shown in Supplemental
considered compatible with PAI ≥ 3. Material 4.
Results Meta-analysis
Main outcome (prevalence of individuals with at least one
Study selection and study characteristics
tooth with AP)
A flowchart with a detailed description of the screening According to the results of the pooled data, the global
process is presented in Figure 1. Two articles could not prevalence of individuals with at least one AP was 52%
Records identified through

database searching (n = 6,655)
Pubmed = 4,091
Identification
Embase = 239
Lilacs = 1,613
Cochrane = 310
Google Scholar = 400
Open Gray = 2
Duplicates removed
(n = 732)
Records screened by title

and abstract
(n = 5,923) Records excluded and
Screening
main reasons
(n = 5,708):
literature and systematic
reviews; case reports; case
series; editorials; in vitro studies;
animal studies; other endodontic
outcomes.
Full-text articles assessed

for eligibility
(n = 215) Articles excluded, with reasons
(n = 114):
Additional records identified - Method of assessing AP not clear= 46

through manual search - Deciduos teeth= 9
Eligibility
- No data to calculate the prevalence or

(n = 15)
frequency of AP= 32
- No full-mouth data= 26
- Dissertation/thesis with data provided in an
article= 4
- Longitudinal data from a cohort study/
Same data from other article/ It was not the
first or the last study of a repeated cross-
sectional series= 20
Articles not found

(n = 2)
Included
Studies included in the

qualitative and quantitative
syntheses (meta-analysis)
(n = 114)
Figure 1 Flowchart of the selection process.
(95% CI 42%–56%; I2 = 97.8%; Figure 2). The preva- I2 = 98.3%), lower than that of individuals with a
lence of AP was higher amongst individuals from devel- systemic condition (63%; 95% CI 56%–69%;
oping and in transition countries than amongst those I2 = 89.7%; Supplemental Material 7). The most fre-
from developed countries (developing = 53%; 95% CI quent systemic conditions were diabetes (n = 6), car-
44%–62%; I2 = 98.1%; in transition = 80%; 95% CI diovascular disease (CVD; n = 5) and smoking
78%–82%; developed = 51%; 95% CI 47%–56%; (n = 4). The subgroup analysis of these conditions
I2 = 97%; Supplemental Material 5). revealed that the pooled prevalence of individuals
AP was more prevalent when individuals were with at least one tooth with AP in type-2 diabetic
recruited from dental care services (DCS) than from patients was 75% ([66%; 83%]; I2 = 63.8%; Segura-
the general population (GP); studies using samples Egea et al. 2005, L opez et al. 2011, Marotta
opez-L
from hospitals yielded results almost as high as those et al. 2012, Maniglia Ferreira et al. 2014, S anchez-
using samples from DCS (DCS = 57%; 95% CI 52%– Domınguez et al. 2015, Al-Zahrani et al. 2017). Non-
62%; I2 = 97.8%; GP = 40%; 95% CI 33%–46%; diabetic individuals had a prevalence of 62% (95% CI
I2 = 96.5%; hospitals = 51%; 95% CI 40%–63%; 40%–79%; I2 = 86.5%; Segura-Egea et al. 2005,
I2 = 95.9%; Supplemental Material 6). L
opez-Lopez et al. 2011, Marotta et al. 2012, Maniglia
The prevalence of healthy individuals with at least Ferreira et al. 2014). The prevalence of AP in individ-
one tooth with AP was 48% (95% CI 43%–53%; uals with CVD was 57% (95% CI 35%–76%;
Table 1 Characteristics of the selected studies (main outcome: prevalence of AP – person level)
Patients
with ≥ 1AP Age mean Image Location of
Study Country N N (%) Gender (SD/range) Systemic condition Method of assessing AP method recruitment
Europe
Kerekes & Norway 200 69 (35) n/m 19–81 Discernible apical Periapical rx Dental care
Bervell (1976) radiolucency + condensing service
osteitis (in nontreated teeth)
Allard & Sweden 183 132 (72) ♂ = 95 >65 De Moor (2000)a Periapical rx General
Palmqvist ♀ = 88 population
(1986)
Bergstro €m Sweden 250 117 (47) n/m 21–60 De Moor (2000)a Periapical rx Musicians
et al. (1987)
Eckerbom Sweden 200 126 (63) ♂ = 93 ≥20 Discernible apical radiolucency Periapical rx Dental care
et al. (1987) ♀ = 107 service
Falk et al. Sweden 82 50 (61) ♂ = 40 20–70 Long-duration De Moor (2000)a Periapical rx General
(1989) ♀ = 42 type-1 diabetes population
72 30 (42) ♂ = 38 Short-duration
♀ = 34 type-1 diabetes
77 39 (51) ♂ = 34 Nondiabetes
© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd
♀ = 43
Petersson Sweden 567 434 (77) ♀♂ >20 Discernible apical radiolucency Periapical rx Dental care
Tib
et al. (1989) service

€
Odesj o
€ et al. Sweden 743 321 (43) ♂ = 392 >20 Radiolucent area in connection Periapical rx General
(1990) ♀ = 351 with the root population
De Cleen et al. Netherlands 184 82 (45) ♂ = 94 >20 PL exceeding at least two times Panoramic rx Dental care
(1993) ♀ = 90 the width of the lateral part or service
apical radiolucency
Eriksen et al. Norway 118 17 (14) ♀♂ 35 years old PAI ≥ 3 Panoramic + General
(1995) periapical population
rx
Soikkonen Finland 169 70 (41) ♂ = 54 76–86 De Moor (2000)a Panoramic + General
(1995) ♀ = 115 periapical population
rx
Marques et al. Portugal 179 47 (26) n/m 30–39 PAI ≥ 3 Panoramic rx General
(1998) population
Sidaravicius Lithuania 147 103 (70) n/m 35–44 PAI ≥ 3 Panoramic + General
et al. (1999) periapical population
rxb
De Moor et al. Belgium 206 130 (63) ♀♂ >18 De Moor (2000)a Panoramic rx Dental care
(2000) service
International Endodontic Journal, 54, 712–735, 2021

717
718
Table 1 Continued
Patients
Kirkevang Denmark 614 260 (42) ♂ = 311 ≥20 PAI ≥ 3 Periapical rx General
et al. (2001) ♀ = 303 population
Bołtacz- Poland 439 168 (38) ♂ = 174 18–86 PL exceeding at least two times Panoramic rx Dental care
Rzepkowska ♀ = 265 the width of the lateral part or service
& Laszkiewicz apical radiolucency
(2005)
Frisk & Sweden 1220 511 (42) ♀ 38–60 De Moor (2000)a Panoramic rx General
Hakeberg population
(2005)
Georgopoulou Greece 320 275 (86) ♂ = 111 16–77 PL exceeding at least two times Periapical rx Dental care

et al. (2005) ♀ = 209 the width of the lateral part or service

apical radiolucency
Kabak & Republic of 1423 1141 (80) n/m ≥15 PL exceeding at least two times Panoramic rx Dental care
Abbott (2005) Belarus the width of the lateral part or service
apical radiolucency
Loftus et al. Ireland 302 100 (33) ♂ = 127 16–98 PAI ≥ 4 Panoramic rx Dental care
(2005) ♀ = 175 service

Segura-Egea Spain 32 26 (81) ♂ = 12 43–74 type-2 diabetes PAI ≥ 3 Periapical rx Dental care
et al. (2005) ♀ = 20 service
38 22 (58) ♂ = 16 43–74 Nondiabetes
♀ = 22
Skudutyte- Norway 146 23 (16) ♀♂ 35–year–old PAI ≥ 3 Panoramic + General
Rysstad & periapical population
Eriksen (2006) rx
Sunay et al. Turkey 375 141 (38) ♂ = 147 16–82 PL exceeding at least two times Panoramic rx Dental care
(2007) ♀ = 228 the width of the lateral part service
Gulsahi et al. Turkey 1000 238 (24) ♂ = 393 16–80 PL exceeding at least two times Panoramic rx Dental care
(2008) ♀ = 607 the width of the lateral part or service
apical radiolucency
Hommez et al. Belgium 43 20 (47) ♂ = 36 53 9.9 Head and neck De Moor (2000)a Panoramic rx Dental care
(2008) ♀=7 irradiated patients service
43 32 (74) ♂ = 36 53 10.2 Nonirradiated
♀=7
Segura-Egea Spain 109 81 (74) ♂ = 66 35 2.6 Smokers PAI ≥ 3 Periapical rx Dental care
et al. (2008) 71 29 (41) ♀ = 114 40 3.1 Nonsmokers service
Table 1 Continued
Patients
Lo
pez-Lo pez Spain 50 37 (74) ♂ = 20 61 10.3 Type-2 diabetes PAI ≥ 3 Panoramic rx Dental care
et al. (2011) ♀ = 30 service
50 21 (42) ♂ = 22 62 10.4 Nondiabetes
♀ = 28
Peters et al. Netherlands 178 65 (37) ♂ = 84 >18 PL exceeding at least two times Panoramic rx Dental care
Segura-Egea Spain 50 46 (92) ♂ = 53 60 9.6 Smokers PAI ≥ 3 Periapical rx Dental care
et al. (2011) ♀ = 47 service
50 22 (44) 58 9.6 Nonsmokers
Lo
pez-Lo pez Spain 397 135 (34) ♂ = 194 52 15.7 PAI ≥ 3 Panoramic rx Dental care
et al. (2012) ♀ = 203 service
Pasqualini Italy 51 43 (84) ♂ = 40 48 5.7 Cardiovascular Broken lamina dura + PL >2 mm Periapical rx Hospital
et al. (2012) ♀ = 11 disease of diameter
49 26 (53) ♂ = 39 47 7.1 Noncardiovascular
♀ = 10 disease
Castellanos- Spain 58 39 (67) ♂ = 41 36 11 Bleeding disorders PAI ≥ 3 Panoramic rx Dental care
Cosano et al. ♀ = 17 service
(2013a) 58 28 (48) ♂ = 41 34 10.2 Nonbleeding
Tib
♀ = 17 disorders
Castellanos- Spain 42 33 (79) ♂ = 30 59 8.6 Liver disease PAI ≥ 3 Panoramic rx Hospital
Cosano et al. ♀ = 12
(2013b) 42 21 (50) ♂ = 30 59 8.7 Nonliver disease Dental care
♀ = 12 service
Jersa & Latvia 312 224 (72) n/m 35–44 PAI ≥ 3 Panoramic rx Dental care
Kundzina service
(2013)
Kalender et al. Turkey 1006 684 (68) ♂ = 423 18–50 PAI ≥ 2 Panoramic + Dental care
(2013) ♀ = 583 periapical service
rx
Di Filippo et al. England 136 67 (49) ♂ = 63 >16 PL exceeding at least two times Panoramic rx Dental care
Diogo et al. Portugal 157 46 (29) ♂ = 68 18–84 PAI ≥ 3 Panoramic rx Dental care
(2014) ♀ = 89 service
Willershausen Germany 248 95 (38) ♂ = 201 62 10.1 Acute myocardial PL exceeding at least two times panoramic rx Hospital
et al. (2014) ♀ = 47 infaction the width of the lateral part or
249 59 (24) ♂ = 179 63 10.5 Nonacute periapical Dental care
♀ = 70 myocardial rx or service
infaction CBCT

719
720
Table 1 Continued
Patients
Lemagner France 100 78 (78) ♂ = 47 47 15.8 Discernible apical CBCT Dental care
et al. (2015) ♀ = 53 radiolucency > 0.5 mm service
Lo
pez-Lo pez Spain 12 3 (25) ♀ 62 1.7 Osteoporosis Discernible apical radiolucency Panoramic rx Dental care
et al. (2015) 36 9 (25) Osteopenia service
27 2 (7) Nonbone problem
Sa
nchez- Spain 59 40 (68) ♂ = 41 66 10.6 Poor-controlled PAI ≥ 3 Panoramic rx Dental care
Domınguez ♀ = 42 type-2 diabetes service
et al. (2015) 24 12 (50) 66 10.6 Good-controlled
type-2 diabetes
Grønkjær et al. Denmark 110 51 (46) ♂ = 84 39–82 Cirrhosis PL exceeding at least two times Panoramic rx Hospital

(2016) ♀ = 26 the width of the lateral part or

apical radiolucency
Liljestrand Finland 353 266 (75) ♂ = 261 33–82 Stable CAD or ACS PAI ≥ 3 Panoramic rx Hospital
et al. (2016) ♀ = 92
123 76 (62) ♂ = 63 No significant CAD
♀ = 60
Persic Bukmir Croatia 108 93 (86) ♂ = 82 38.8 13.6 Smokers PAI ≥ 3 Panoramic + Dental care
et al. (2016) 151 118 (78) ♀ = 177 41.9 16.2 Nonsmokers periapical service
rx
Huumonen Finland 5335 1440 (27) ♂ = 2828♀ = 2507 30–95 PL exceeding at least two times Panoramic rx General
et al. (2017) the width of the lateral part or population
broken lamina or apical
radiolucency
Kielbassa et al. Austria 1000 605 (61) ♂ = 430 19–91 PAI ≥ 2 Panoramic rx Dental care
(2017) ♀ = 570 service
Piras et al. Italy 110 70 (64) ♂ = 49 46 13.8 Inflammatory PAI Panoramic + Hospital
(2017) ♀ = 61 Bowel Disease (threshold not mentioned) periapical
110 65 (59) ♂ = 53 41 13.1 Noninflammatory rx Dental care
♀ = 57 Bowel Disease service
Vengerfeldt Estonia 486 1914 (39) ♂ = 256e ≥20 PAI ≥ 3 Panoramic rx Dental care
et al. (2017) ♀ = 3989e service
Virtanen et al. Sweden 42 25 (60) ♂ = 57 51 2.9 Smokers PAI ≥ 2 Periapical rx General
(2017) 78 24 (31) ♀ = 63 (patients Nonsmokers population
w/o AP)
53 2.7
(patients
w/AP)
Table 1 Continued
Patients
B€
urklein et al. Germany 500 305 (61) ♂ = 203 50.2 12.4 PDL exceeding at least twice the CBCT Dental care
(2020) ♀ = 297 width of the lateral part or service
radiolucency in connection with
the apical part of the root or a
lateral root canal
Persic Bukmir Croatia 599 455 (76) ♂ = 190 19–70 PAI ≥ 3 Panoramic + Dental care
et al. (2019) ♀ = 409 periapical service
rxd
Poyato- Spain 54 19 (35) ♂ = 31 43.1 14.0 Inflammatory PAI ≥ 3 Panoramic rx Hospital
Borrego et al. ♀ = 23 Bowel Disease
(2019) 54 9 (17) ♂ = 31 43.1 13.8 noninflammatory Dental care
♀ = 23 Bowel Disease service
North America
Chen et al. USA 206 94 (46) ♂ = 103c 55–94 PL exceeding at least two times Panoramic rx General
(2007) ♀ = 121c the width of the lateral part or population
broken lamina dura
Gomes et al. USA 62 18 (29) ♂ = 143 22–89 Cardiovascular De Moor (2000)a Panoramic rx General
(2016) ♀ = 135 disease population
Tib
216 43 (20) Noncardiovascular

disease
Jalali et al. USA 131 65 (50) ♂ = 19 22–83 Rheumatoid PAI ≥ 3 Panoramic + Dental care
(2017) ♀ = 112 arthritis periapical service
131 71 (54) ♂ = 19 24–83 Nonrheumatoid rx
♀ = 112 arthritis
Khalighinejad USA 50 27 (54) ♀ 26 3.2 Pre-eclampsia PAI ≥ 3 Panoramic rx Hospital
et al. (2017a) 50 16 (32) ♀ 24 2.8 Non-pre-eclampsia
Khalighinejad USA 40 29 (73) ♂ = 28 59 4.5 End-stage renal PAI ≥ 3 Panoramic + Hospital
et al. (2017b) ♀ = 12 disease pulp test
40 16 (40) ♂ = 26 52 3.1 nonEnd-stage Dental care
♀ = 14 renal disease service
Latin America
Tercßas et al. Brazil 200 135 (68) ♂ = 88 ≥20 PAI ≥ 3 Periapical rx Dental care
(2006) ♀ = 112 service
Marotta et al. Brazil 30 24 (80) ♂ = 12 40–69 Type-2 diabetes Discernible apical radiolucency Panoramic + Dental care
(2012) ♀ = 18 periapical service
60 52 (87) ♂ = 24 41–70 Nondiabetes rx
♀ = 36

721
722
Table 1 Continued
Patients
Costa et al. Brazil 67 34 (51) ♂ = 38 64 10.1 Cardiovascular PAI ≥ 3 Periapical rx Hospital

(2014) ♀ = 29 disease
36 9 (25) ♂ = 14 57 10.6 Noncardiovascular
♀ = 22 disease
Hebling et al. Brazil 98 42 (43) ♂ = 41 60–94 PAI ≥ 3 Periapical rx Institutionalized
(2014) ♀ = 57 people
Maniglia Brazil 40 32 (80) ♂ = 13 37–68 Type-2 diabetes PAI ≥ 3 Panoramic + Dental care
Ferreira et al. ♀ = 27 periapical service
(2014) 40 21 (53) ♂ = 16 35–70 Nondiabetes rx
♀ = 24

Leal et al. Brazil 33 18 (55) ♀ 15–40 Low-birth weight PAI (threshold not mentioned) Periapical rx Hospital
(2015) preterm births
30 6 (20) ♀ 15–41 Normal-birth
weight and term
births
Hoppe et al. Brazil 112 27 (24) ♂ 20–53 De Moor (2000)a Periapical rx Military police
(2017) officers
Africa and Middle East
Marmary & Israel 889 394 (44) n/m n/m Discernible apical radiolucency Periapical rx Dental care
Kutiner (1986) service
Toure et al. Senegal 208 124 (60) ♂ = 114 32 11.2 PAI ≥ 3 Periapical rx Dental care
(2008) ♀ = 94 service
Al-Omari et al. Jordan 294 246 (84) ♂ = 158 16–59 De Moor (2000)a Panoramic rx Dental care
(2011) ♀ = 136 service
Harjunmaa Malawi 1024 241 (24) ♀ 25 6.2 Discernible apical Panoramic rx Hospital
et al. (2015) radiolucency > 1 mm
Oginni et al. Nigeria 756 508 (67) ♂ = 414 ♂ = 48 10.7 PAI ≥ 3 Periapical rx Dental care
(2015) ♀ = 342 ♀ = 45 12.6 service
Ahmed et al. Sudan 200 95 (47) ♂ = 47 34 12.9 PL exceeding at least two times Panoramic + Dental care
(2017) ♀ = 153 the width of the lateral part or periapical service
apical radiolucency rx
Al-Zahrani Saudi 100 86 (86) ♂ = 60 49 8.5 Type-2 diabetes PAI ≥ 3 Panoramic + Dental care
et al. (2017) Arabia ♀ = 40 periapical service
rx
Asia and the Pacific
Tsuneishi et al. Japan 672 469 (70) ♂ = 244 ♂ = 53 14.9 PAI ≥ 3 Periapical rx Dental care
(2005) ♀ = 428 ♀ = 51 14.9 service
Tib
I2 = 96.4%; Pasqualini et al. 2012, Costa et al. 2014,
ACS, Acute Coronary Syndrome; AP, apical periodontitis; CAD, Coronary Artery Disease; n/m, not mentioned; PAI, periapical index (Ørstavik et al. 1986); PL, periodontal ligament;
Willershausen et al. 2014, Gomes et al. 2016, Liljes-
recruitment
Dental care
Dental care
Dental care
Location of
trand et al. 2016). Control individuals from the same
service
service
service
studies revealed a prevalence of individuals with at
least one tooth with AP of 35% (95% CI 20%–55%;
I2 = 94.7%). Smokers were also taken into account in
Panoramic rx
Panoramic rx
Panoramic +
the analysis, and the pooled proportion was 80%

periapical
(95% CI 65%–89%; I2 = 83.1%); nonsmokers had a

method
Image
prevalence of AP of 49% (95% CI 26%–72%;

rx
I2 = 94.5%; Segura-Egea et al. 2008, 2011, Persic

Bukmir et al. 2016, Virtanen et al. 2017).
Studies presenting a moderate or high risk of bias
were associated with a higher prevalence of individu-
Method of assessing AP
als with at least one AP than those with low risk of

bias (high risk 52%; 95% CI 47%–57%; I2 = 98.4%;
moderate risk 57%; 95% CI 50%–64%; I2 = 92.5%;
low risk 29%; 95% CI 20%–41%; I2 = 94%).
Regarding the image method used to evaluate the
PAI ≥ 3
PAI ≥ 3
PAI ≥ 3
periapical area, studies that used periapical radio-

graph had a higher prevalence of people with at least
one tooth with AP (56%; 95% CI 50%–62%;
Systemic condition
I2 = 95.3%) than studies that used panoramic radio-

graph (46%; 95% CI 40%–52%; I2 = 98.3%). Results
from the combination of both image methods yielded
a proportion similar to the periapical radiograph
alone (60%; 95% CI 49%–70%; I2 = 95.3%; Supple-
mental Material 8), and the use of CBCT images was
associated with a prevalence of AP of 70% (95% CI
(SD/range)
Age mean
51%–84%; I2 = 90%).
16–70
10–88
Using methods of assessing AP compatible with

>18
Periapical Rx only in root filled teeth or in teeth with AP on the panoramic.
PAI ≥ 2 resulted in almost the same prevalence of AP

as using methods compatible with PAI ≥ 3 (53%;
95% CI 45%–60%; I2 = 96.3% vs. 52%; 95% CI
48%–57%; I2 = 98%). However, assessing AP with
♂ = 290
Gender
♀ = 147
♀ = 405
PAI ≥ 4 decreased the prevalence of individuals with

♂ = 86
n/m
Including patients from the categories <20 years of age.
at least one tooth with AP substantially (33%; 95%

Method according to De Moor et al. (2000) or similar.
CI 28%–39%).
with ≥ 1AP
Patients
865 (65)
179 (26)
59 (25)
N (%)
Secondary outcomes (frequency of all teeth, nontreated

and root filled teeth with AP)
Periapical Rx only in root filled teeth.
In general, the frequency of teeth with AP was 5%

1340
233
695
(95% CI 4%–6%; I2 = 99.5%). Nontreated teeth had a

N
frequency of 3% of periapical lesions, whereas 39% of

the root filled teeth had AP (nontreated = 3%; 95%
Malaysia
Australia
Country
CI 2%–3%; I2 = 99.3%; root filled = 39%; 95% CI

India
Including edentulous.
36%–43%; I2 = 98.5%; Supplemental material 9,

Table 1 Continued
Rx, radiography.
Supplemental material 10 and Supplemental material

Archana et al.
Hussein et al.
11).
et al. (2017)
Timmerman
People from developing countries had 2% more AP

(2015)
(2016)
Study
in all teeth than people from developed countries (de-

veloping = 6%; 95% CI 5%–8%; I2 = 99.7%; in
b
d
a
e
c
Study IDs Events Sample size Prevalence (%) Weight

95% CI
Kerekes & Bervell 1976 69 200 34 [28 - 42] 1.0%
Allard & Palmqvist 1986 132 183 72 [65 - 78] 1.0%
Marmary & Kutiner 1986 394 889 44 [41 - 48] 1.1%
Bergström et al 1987 117 250 47 [40 - 53] 1.1%
Eckerbom et al 1987 126 200 63 [56 - 70] 1.0%
Falk et al 1989 50 82 61 [50 - 72] 1.0%
Falk et al 1989 30 72 42 [30 - 54] 1.0%
Falk et al 1989 39 77 51 [39 - 62] 1.0%
Petersson et al 1989 434 567 77 [73 - 80] 1.1%
Ödesjö et al 1990 321 743 43 [40 - 47] 1.1%
De Cleen et al 1993 82 184 45 [37 - 52] 1.0%
Eriksen et al 1995 17 118 14 [9 - 22] 1.0%
Soikkonen 1995 70 169 41 [34 - 49] 1.0%
Marques et al 1998 47 179 26 [20 - 33] 1.0%
Sidaravicius et al 1999 103 147 70 [62 - 77] 1.0%
De Moor et al 2000 130 206 63 [56 - 70] 1.0%
Kirkevang et al 2001 260 614 42 [38 - 46] 1.1%
Bołtacz−Rzepkowska & Laszkiewicz 2005 168 439 38 [34 - 43] 1.1%
Frisk & Hakeberg 2005 511 1220 42 [39 - 45] 1.1%
Georgopoulou et al 2005 275 320 86 [82 - 90] 1.0%
Kabak & Abbott 2005 1141 1423 80 [78 - 82] 1.1%
Loftus et al 2005 100 302 33 [28 - 39] 1.1%
Segura−Egea et al 2005 26 32 81 [64 - 93] 0.8%
Segura−Egea et al 2005 22 38 58 [41 - 74] 0.9%
Tsuneishi et al 2005 469 672 70 [66 - 73] 1.1%
Skudutyte−Rysstad & Eriksen 2006 23 146 16 [10 - 23] 1.0%
Terças et al 2006 135 200 68 [61 - 74] 1.0%
Chen et al 2007 94 206 46 [39 - 53] 1.0%
Sunay et al 2007 141 375 38 [33 - 43] 1.1%
Gulsahi et al 2008 238 1000 24 [21 - 27] 1.1%
Hommez et al 2008 20 43 47 [31 - 62] 0.9%
Hommez et al 2008 32 43 74 [59 - 86] 0.9%
Segura−Egea et al 2008 81 109 74 [65 - 82] 1.0%
Segura−Egea et al 2008 29 71 41 [29 - 53] 1.0%
Touré et al 2008 124 208 60 [53 - 66] 1.0%
Al−Omari et al 2011 246 294 84 [79 - 88] 1.0%
López−López et al 2011 37 50 74 [60 - 85] 0.9%
López−López et al 2011 21 50 42 [28 - 57] 1.0%
Peters et al 2011 65 178 37 [29 - 44] 1.0%
Segura−Egea et al 2011 46 50 92 [81 - 98] 0.8%
Segura−Egea et al 2011 22 50 44 [30 - 59] 1.0%
Lopez−Lopez et al 2012 135 397 34 [29 - 39] 1.1%
Marotta et al 2012 24 30 80 [61 - 92] 0.8%
Marotta et al 2012 52 60 87 [75 - 94] 0.9%
Pasqualini et al 2012 43 51 84 [71 - 93] 0.9%
Pasqualini et al 2012 26 49 53 [38 - 67] 1.0%
Jersa & Kundzina 2013 224 312 72 [66 - 77] 1.1%
Kalender et al 2013 684 1006 68 [65 - 71] 1.1%
Castellanos−Cosano et al 2013a 39 58 67 [54 - 79] 1.0%
Castellanos−Cosano et al 2013a 28 58 48 [35 - 62] 1.0%
Castellanos−Cosano et al 2013b 33 42 79 [63 - 90] 0.9%
Castellanos−Cosano et al 2013b 21 42 50 [34 - 66] 0.9%
Costa et al 2014 34 67 51 [38 - 63] 1.0%
Costa et al 2014 9 36 25 [12 - 42] 0.9%
Di Filippo et al 2014 67 136 49 [41 - 58] 1.0%
Diogo et al 2014 46 157 29 [22 - 37] 1.0%
Hebling et al 2014 42 98 43 [33 - 53] 1.0%
Maniglia Ferreira et al 2014 32 40 80 [64 - 91] 0.9%
Maniglia Ferreira et al 2014 21 40 52 [36 - 68] 0.9%
Willershausen et al 2014 95 248 38 [32 - 45] 1.1%
Willershausen et al 2014 59 249 24 [19 - 29] 1.0%
Archana et al 2015 865 1340 65 [62 - 67] 1.1%
Harjunmaa et al 2015 241 1024 24 [21 - 26] 1.1%
Leal et al 2015 18 33 55 [36 - 72] 0.9%
Leal et al 2015 6 30 20 [8 - 39] 0.8%
Lemagner et al 2015 78 100 78 [69 - 86] 1.0%
López−López et al 2015 3 12 25 [5 - 57] 0.6%
López−López et al 2015 9 36 25 [12 - 42] 0.9%
López−López et al 2015 2 27 7 [1 - 24] 0.6%
Oginni et al 2015 508 756 67 [64 - 71] 1.1%
Sánchez−Dominguez et al 2015 40 59 68 [54 - 79] 1.0%
Sánchez−Dominguez et al 2015 12 24 50 [29 - 71] 0.9%
Gomes et al 2016 18 62 29 [18 - 42] 1.0%
Gomes et al 2016 43 216 20 [15 - 26] 1.0%
Grønkjær et al 2016 51 110 46 [37 - 56] 1.0%
Hussein et al 2016 59 233 25 [20 - 31] 1.0%
Liljestrand et al 2016 266 353 75 [71 - 80] 1.1%
Liljestrand et al 2016 76 123 62 [53 - 70] 1.0%
Peršić Bukmir et al 2016 93 108 86 [78 - 92] 1.0%
Ahmed et al 2017 95 200 48 [40 - 55] 1.0%
Al−Zahrani et al 2017 86 100 86 [78 - 92] 1.0%
Hoppe et al 2017 27 112 24 [17 - 33] 1.0%
Huumonen et al 2017 1440 5335 27 [26 - 28] 1.1%
Jalali et al 2017 65 131 50 [41 - 58] 1.0%
Jalali et al 2017 71 131 54 [45 - 63] 1.0%
Kielbassa et al 2017 605 1000 60 [57 - 64] 1.1%
Piras et al 2017 70 110 64 [54 - 73] 1.0%
Piras et al 2017 65 110 59 [49 - 68] 1.0%
Timmerman et al 2017 179 695 26 [23 - 29] 1.1%
Vengerfeldt et al 2017 1914 4865 39 [38 - 41] 1.1%
Virtanen et al 2017 25 42 60 [43 - 74] 0.9%
Virtanen et al 2017 24 78 31 [21 - 42] 1.0%
Khalighinejad et al 2017a 27 50 54 [39 - 68] 1.0%
Khalighinejad et al 2017a 16 50 32 [20 - 47] 0.9%
Khalighinejad et al 2017b 29 40 72 [56 - 85] 0.9%
Khalighinejad et al 2017b 16 40 40 [25 - 57] 0.9%
Poyato−Borrego et al 2019 19 54 35 [23 - 49] 1.0%
Poyato−Borrego et al 2019 9 54 17 [8 - 29] 0.9%
Bürklein et al 2020 305 500 61 [57 - 65] 1.1%
Random effects model 34668 52 [48 - 56] 100%

Heterogeneity: I−squared=97.8%, tau−squared=0.6379, p<0.0001
0 20 40 60 80 100
Figure 2 Prevalence of AP (main outcome) in the population worldwide.
Tib
transition = 12%; 95% CI 12%–12%; devel- nontreated teeth (all teeth periapical radio-
oped = 4%; 95% CI 4%–5%; I2 = 99.1%). This pat- graph = 5%; 95% CI 4%–6%; I2 = 99.5%; panoramic
tern remained consistent when the analysis was made radiograph = 5%; 95% CI 4%–6%; I2 = 99.6%;
separately for nontreated teeth (2% of difference; panoramic + periapical radiograph = 4%; 95% CI
developing = 4%; 95% CI 3%–5%; I2 = 99.6%; in 3%–6%; I2 = 98.8%; nontreated teeth periapical
transition = 3%; 95% CI 3%–3%; developed = 2%; radiograph = 3%; 95% CI 2%–4%; I2 = 99.4%;
95% CI 2%–3%; I2 = 98.7%), and it was more pro- panoramic radiograph = 3%; 95% CI 2%–4%;
nounced when considering root filled teeth (11% of I2 = 99.3%; panoramic + periapical radiograph = 2%;
difference; developing = 46%; 95% CI 40%–51%; 95% CI 2%–3%; I2 = 97.4%). On the other hand, in
I2 = 98.3%; in transition = 48%; 95% CI 42%–55%; root filled teeth, the frequency of AP using periapical
developed = 35%; 95% CI 31%–39%; I2 = 98.3%). radiograph was 8% higher than using only panora-
People recruited from DCS had 2% more teeth with mic radiograph and 3% higher than using panoramic
AP than those from the GP (DCS = 5%; 95% CI 4%– radiograph complemented with periapical radiograph
6%; I2 = 99.5%; GP = 3%; 95% CI 2%–4%; (root filled teeth periapical radiograph = 43%; 95% CI
I2 = 99.1%). Individuals recruited from hospitals had 38%–48%; I2 = 97.6%; panoramic radiograph = 35%;
a frequency of AP in all teeth of 7% (95% CI 2%– 95% CI 31%–40%; I2 = 98.8%; panoramic + periapi-
19%; I2 = 99.7%). The difference between the fre- cal radiograph = 40%; 95% CI 32%–49%;
quency of AP in individuals from DCS and GP was I2 = 97.7%). Using CBCT to evaluate root filled teeth
higher when considering only root filled teeth com- yielded a much higher frequency of AP than the
pared to nontreated teeth (9% vs. 2%; root filled teeth other methods (65%; 95% CI 44%–81%; I2 = 97.2%);
DCS = 40%; 95% CI 37%–43%; I2 = 97.8%; the same as not apparent when analysing nontreated
GP = 31%; 95% CI 22%–41%; I2 = 98.6% vs. non- and all teeth (nontreated 1%; 95% CI 0%–3%;
treated DCS = 3%; 95% CI 2%–3%; I2 = 99.3%; I2 = 96.9%; all teeth 6%; 95% CI 2%–13%;
GP = 1%; 95% CI 1%–2%; I2 = 98.4%). I2 = 98.9%).
Healthy individuals had a lower frequency of teeth Using PAI ≥ 4 (or similar approaches) to determine
with AP than individuals with a systemic condition AP decreased the frequency of endodontic lesions in
(healthy = 4%; 95% CI 4%–5%; I2 = 99.5%; systemic all teeth compared to studies that considered PAI ≥ 2
condition = 8%; 95% CI 6%–11%; I2 = 96.7%). This or ≥ 3 (PAI ≥ 2 = 6%; 95% CI 5%–8%; I2 = 99.5%;
difference was similar in nontreated and in root filled PAI ≥ 3 = 5%; 95% CI 4%–6%; I2 = 99.5%;
teeth (nontreated healthy individuals = 2%; 95% CI PAI ≥ 4 = 2%; 95% CI 1%–2%; I2 = 66.5%). In non-
2%–3%; I2 = 99.3%; systemic condition = 6%; 95% treated teeth and in root filled teeth the same pattern
CI 3%–9%; I2 = 97.7%; root filled teeth healthy indi- was observed (nontreated teeth PAI ≥ 2 = 4%; 95%
viduals = 39%; 95% CI 36%–43%; I2 = 98.6%; sys- CI 3%–6%; I2 = 99.1%; PAI ≥ 3 = 2%; 95% CI 2%–
temic condition = 44%; 95% CI 33%–56%; 3%; I2 = 99.4%; PAI ≥ 4 = 1%; 95% CI 1%–2%;
I2 = 90.4%). I2 = 90.5%; root-filled teeth PAI ≥ 2 = 48%; 95% CI
As demonstrated in the person-level analysis, high- 41%–55%; I2 = 98.2%; PAI ≥ 3 = 38%; 95% CI
and moderate-risk studies had a greater frequency of 35%–42%; I2 = 98.3%; PAI ≥ 4 = 14%; 95% CI, 4%–
AP in all teeth and nontreated teeth than low-risk 39%; I2 = 97.4%).
studies (all teeth high risk = 5%; 95% CI 4%–6%;
I2 = 99.5%; moderate risk = 6%; 95% CI 4%–8%;
Discussion
I2 = 99.1%; low risk = 3%; 95% CI 1%–5%;
I2 = 98.7%; nontreated high risk = 3%; 95% CI 2%– The pooled data from the primary studies revealed
3%; I2 = 99.3%; moderate risk = 3%; 95% CI 1%– that 52% of the adult population worldwide have at
5%; I2 = 99.4%; low risk = 2%; 95% CI 1%–3%; least one tooth with AP. The present findings arise
I2 = 98%). However, in root filled teeth the opposite from a comprehensive search of the literature on the
pattern was noticed (high risk = 39%; 95% CI 36%– topic, confirming that AP is a highly prevalent dis-
43%; I2 = 98.6%; moderate risk = 37%; 95% CI ease. In addition, this review is novel in detecting
30%–45%; I2 = 97.6%; low risk = 48%; 95% CI socioeconomic, medical and methodological factors
41%–55%; I2 = 80.1%). affecting the prevalence of AP. Importantly, the high
Periapical radiograph or panoramic radiograph did prevalence of AP should prompt health policymakers,
not influence the frequency of AP in all teeth or in medical and dental communities to take action with
regard to the hidden burden of the endodontic disease not seem appropriate, but it is possible to infer that
in the global population. the prevalence of AP would be higher in the GP from
A nondiagnosed AP may lead to future tooth loss developing countries.
(Frisk & Hakeberg 2005). This is especially relevant The frequency of AP was higher in root filled teeth
in developing countries where tooth loss in the adult than in nontreated teeth regardless of where the indi-
population remains high (Seerig et al. 2015), compro- viduals were recruited. The nature of the cross-sec-
mising their quality of life (Haag et al. 2017). Fur- tional studies, from which the majority of the data
thermore, a nontreated AP may be a source of was collected, does not allow to identify whether the
systemic inflammation (Gomes et al. 2013), and stud- lesions were developing and progressing or in the pro-
ies have hypothesized that its presence may be associ- cess of healing; thus, some of the AP associated with
ated with systemic illness such as cardiovascular root filled teeth may not represent active diseases.
disease and diabetes (Khalighinejad et al. 2016). Furthermore, some detected AP might be scar tissues
Preventive measures, for example caries control, without any sign of inflammation (Kruse et al. 2017).
should be taken at the population level. At the indi- Individuals recruited from hospitals had a preva-
vidual level, teeth that could be more prone to AP lence of AP similar to those from DCS. It can be spec-
(restored and root filled teeth, teeth with carious ulated that people recruited from hospitals already
lesion; Kirkevang et al. 2004) are condidates for a have other illness and treatments as a priority in their
periapical radiographic examination, in conjunction lives, and oral health issues thus tend to be neglected.
with clinical tests, for AP screening. On the other hand, it can also be argued that this
The prevalence of AP was slightly higher in the result might be a consequence of the so-called associ-
developing countries than in the developed ones. The ation between the endodontic disease and systemic
same was observed in the secondary analyses using conditions, which has been the focus of several inves-
the tooth as the unit of observation. It is well known tigations in the past decades. Out of the 114 included
that people from developed countries have lower rates articles, twenty-seven explored some systemic condi-
of tooth loss than those living in poorer countries tion (at the individual level). The pooled data of this
(Seerig et al. 2015). The remaining teeth are sub- meta-analysis showed that 63% of the participants
jected to dental problems such as caries, and treat- with some systemic condition had at least one AP,
ments such as root canal treatment, characteristics whilst 48% of healthy individuals had endodontic
closely associated with the presence of AP (Kirkevang lesions. At the tooth level, the general health status
et al. 2004). It is reasonable to assume that the small also affected the frequency of AP in both nontreated
difference in the frequency of teeth with AP between and root filled teeth. Most studies included in this cat-
the subgroups may be related to these factors. egory were related to diabetes, CVD and smoking
Another possible reason for this small difference habits. However, the present analysis does not allow
may be related to the recruitment of samples from to infer whether the association of systemic diseases
DCS in the majority of the studies included in the with AP exists since no attempt at controlling con-
meta-analysis. Irrespective of the country, samples founders was made. Also, the studies included in the
from DCS are more likely to present oral problems healthy category cannot exclude the possibility of
than the GP (Kirkevang 2018). In fact, the subgroup having participants with some systemic condition
analysis revealed that people from DCS had a higher since this information was not available in the major-
prevalence of AP compared to those from the GP; the ity of them.
same was noticed at the tooth level. However, even Previous systematic reviews tried to answer the
in the GP, the prevalence of AP was very high, question of whether the mentioned assumption can
around 40%. Studies exploring data from individuals be valid. Berlin-Broner et al. (2017) performed a sys-
that seek dental treatment may be useful for planning tematic review of the association between CVD and
the amount of human and financial resources needed AP. The authors concluded that the majority of the
to treat this specific group of individuals but not for primary studies found a positive relationship between
planning preventive and treatment health policies at the dental and the systemic conditions, but the evi-
a broader level (Hulley et al. 2001). All studies per- dence was not strong enough to guarantee the associ-
taining to the GP subgroup included in this meta- ation. In another systematic review of the literature
analysis were from developed countries. Generalizing which included CVD, diabetes, liver disease, blood dis-
these results to countries with more inequalities does orders and osteoporosis, Khalighinejad et al. (2016)
Tib
stated that there might be an association between with real AP, Kruse et al. (2019) found that CBCT
some of these systemic conditions and the endodontic was associated with a higher risk of false-positive and
disease, but the majority of the studies had a moder- false-negative diagnosis than periapical radiograph,
ate or a high risk of bias. The same was concluded by especially in root-filled teeth. Combining the evidence
Tiburcio-Machado et al. (2017) in a literature review collected so far with the ALARA and ALADA princi-
after evaluating the quality of the studies about dia- ples, CBTC should not be the method of choice for AP
betes. In the quality assessment analysis carried out diagnosis in epidemiologic studies.
in the included articles, only two studies had a low Seventy-one out of 114 included articles carried
risk of bias; fourteen had moderate risk, whilst 11 out the periapical assessment using the Periapical
had a high risk of bias. Index (PAI). The index, developed by Ørstavik et al.
AP usually presents without symptoms, and its (1986), was based on the study of Brynolf (1967),
diagnosis is mainly made through radiographic which compared the histological progression of an AP
images. Based on the data included here, fifty-six with the appearance of the lesion in the radiographic
studies used exclusively panoramic radiograph, 33 image. The 5-point ordinal scale is usually dichoto-
only periapical radiograph, 20 panoramic with peri- mized into ‘healthy’ and ‘diseased’ using the cut-off
apical radiograph, one periapical radiograph with between PAI 2 and PAI 3, but some studies prefer to
pulp test, three studies CBCT and one study used one use the threshold between PAI 1 and PAI 2. In order
of the three image methods on a case-by-case basis. to facilitate the subgroup analysis, studies that consid-
Studies that made the diagnosis using periapical ered an AP if the tooth presented a condensing ostei-
radiograph had 10% more people with at least one tis or a periodontal ligament not exceeding two times
AP than the ones using panoramic radiograph. the width of its lateral part were clustered with stud-
Panoramic with periapical radiograph was associated ies that considered a diseased tooth if the tooth pre-
with a slightly higher prevalence of AP than the peri- sented small changes in the bone structure (PAI 2).
apical radiograph alone. In the tooth-based analyses, Teeth with a periodontal ligament exceeding two
the difference was only noticed in root filled teeth, to times the width of its lateral part, a broken lamina
which the majority of the lesions are related. As dura or a discernible AP were grouped with studies
already expected, the studies that used CBCT reported that considered an AP if the tooth showed a PAI ≥ 3.
higher proportions of individuals and root filled teeth The prevalence of individuals having at least one
with AP compared to those that used panoramic and AP was similar when considering the AP being either
periapical radiograph. PAI ≥ 2 or PAI ≥ 3. However, the prevalence of the
Self-reported validated tools for predicting the pres- disease was lower if only PAI ≥ 4 were considered.
ence of root canal treatments have been demonstrated PAI 4 is characterized by a well-defined radiolucent
to be accurate, but the same has not been observed area, whereas PAI 5 is apical periodontitis with exac-
for the presence of AP (Gomes et al. 2012, Francis- erbating features; thus, the results were already
catto et al. 2019). Magnetic resonance imaging (MRI) expected since a smaller portion of radiographically
has been shown to be a promising nonionizing identifiable periapical lesions has these characteristics
method to detect AP, but coils to apply in tooth-based (Brynolf 1967). In the secondary analyses, the fre-
protocols have not been developed (Di Nardo et al. quency of all teeth and nontreated teeth was only 1%
2018). Thus, periapical radiograph, panoramic radio- and 2% higher, respectively, in the subgroup PAI ≥ 2
graph and CBCT are still the conventional methods compared to PAI ≥ 3. This difference increased in the
used in AP diagnosis. Panoramic images are less root filled teeth (8%), which can be explained by the
effective for the evaluation of the periapical area of all fact that a treated tooth has more chances of being
teeth, except for the maxillary second molars and classified as PAI 2 than a nontreated one (Brynolf
both maxillary and mandibular third molars (Ridao- 1967).
Sacie et al. 2007), from which it could be inferred There are some limitations related to the present
that the use of panoramic images alone is not ade- meta-analysis which deserve to be discussed. The high
quate for the purpose of AP screening. Pooled data clinical heterogeneity identified in the primary studies
from in vitro studies using artificial periapical lesions hampered the attempt to cluster only studies with
has revealed that CBCT has better diagnostic accuracy similar characteristics since their variability had mul-
than periapical radiograph (Leonardi Dutra et al. tiple sources. Another limitation is related to the com-
2016). In an ex vivo study using human mandibles parison of the AP prevalence between healthy
individuals and individuals with systemic diseases. data from the predictor is obtained from information
Some data were extracted from between-study com- collected in the past, and the aim is to verify the
parisons, and others combined estimates from within- influence of this predictor on the outcome of interest.
study comparisons. This approach may be prone to When data from the predictors and the outcome are
bias; however, it allowed the estimation of the effect from the same time-point, the study is classified as
of systemic conditions on the prevalence of AP, cross-sectional (Hulley et al. 2001). Four out of five
emphasizing the need of the medical history investiga- studies described as case–control were, in fact, cross-
tion of the patients in the endodontic setting. In addi- sectional paired with control groups (Hommez et al.
tion, most of the primary studies were carried out in 2008, Pasqualini et al. 2012, Leal et al. 2015, Poy-
Europe using nonrepresentative samples, and the ato-Borrego et al. 2019); only one study was a real
gathered information was obtained from studies pub- case–control, in which the AP was the predictor
lished in a period of more than 40 years. Thus, it is (Khalighinejad et al. 2017a). The case–control design
acknowledged that the pooled data in the present is usually given to a study in which the outcome is
meta-analysis may not truly represent the worldwide rare, and the predictor is collected based on informa-
current scenario on the prevalence of AP. However, tion from the past; in this situation, a group without
the present review followed a careful and comprehen- the outcome of interest is controlled by important
sive literature search strategy, which resulted in a characteristics to be compared to the case group (Hul-
robust identification of the best available evidence ley et al. 2001).
about this topic. Finally, the high risk of bias across The quality assessment of the primary studies was
the primary studies also indicates that the findings carried out using a tool based on a modified New-
must be interpreted with caution, meaning that they castle-Ottawa Scale for cross-sectional studies because
may be overestimated, especially due to the scarcity a valid scale for this study design has not been devel-
of community representative samples. oped yet. The cohort and case–control studies as well
A methodological strength of this systematic review were evaluated using this scale, since only the preva-
is the high sensitivity of the search. Considering arti- lence data was necessary for this meta-analysis. The
cles in other languages than English allowed the main detected flaws were regarding the sample selec-
inclusion of five studies that would have been missed tion process. Amongst the studies that collected data
if a language restriction had been applied. Moreover, in DCS, some of them stated that the aim was to eval-
the inclusion of cohort and case–control studies uate the prevalence of AP in their city/country,
allowed the inclusion of more articles since the base- which is not a suitable way to achieve representative-
line of a cohort gives information about the preva- ness of an entire population. Sample calculation or
lence, and the two groups of a case–control also data collection from an entire subpopulation was pro-
provide this data. Nonetheless, even with a more vided by 33 studies, and only one reported the nonre-
restricted search strategy, Miri et al. (2018) also sponse rates.
found the same prevalence of AP in the population Regardless of the outcome being measured either
worldwide. Probably, the inclusion of articles in Eng- by an objective or subjective method, training and
lish and with cross-sectional design provided sufficient calibration of the observers are mandatory to avoid
information, as these articles constitute the most sig- introducing bias in the study (Hulley et al. 2001).
nificant part of the body of evidence regarding the The diagnosis of an AP is subjective, and a consistent
prevalence of AP. Another important strength of this training programme is time-consuming but strictly
meta-analysis is the subgroup analyses. They brought necessary. One of the advantages of applying the PAI
essential characteristics that can be involved in the system is the existing training material provided by
prevalence of the endodontic disease. Dr. Ørstavik (upon request), with which the observer
Interestingly, it seems that 12 included studies were has the opportunity to learn the fundamentals of the
classified incorrectly regarding the study design in the scale, to practice and to calibrate the results with the
original publications. Six articles described as retro- standard reference established through a consensus
spectives or cohort had, in fact, a cross-sectional between five endodontists, one dental radiologist, four
design (Bołtacz-Rzepkowska & Laszkiewicz 2005, general practitioners and one dental assistant
Gumru et al. 2011, Willershausen et al. 2014, Grønk- (Ørstavik et al. 1986). Only 36 studies undertook the
jær et al. 2016, Hussein et al. 2016, Piras et al. training process adequately, and 52 went through
2017). A study is classified as retrospective when this phase partially. Another precaution to avoid bias
Tib
for studies using control groups is the observer being translated into a reduction in the prevalence of the
blind to the predictors. Only six out of 25 studies endodontic disease in the world.
were careful in taking this precaution. Also, when
using a control group, the comparability between the
Conclusion
participants is relevant. This meta-analysis selected
two essential characteristics that, once not respected, The results from this meta-analysis confirmed a high
could become the control group noncomparable to global prevalence of AP, with 52% of pooled samples
the study group: location of recruitment and age. As worldwide reporting at least one tooth with AP. Sub-
already mentioned, the prevalence of the endodontic group analysis revealed the following factors have an
disease depends on where people are recruited and influence on the prevalence of AP: socioeconomic sta-
their age (Kirkevang 2018). Comparing the AP preva- tus of the country (greater prevalence of AP in sam-
lence between people from hospitals and DCS may ples from developing countries); location of
introduce selection bias, and many primary studies recruitment (greater prevalence of AP in samples from
undertook this comparison. Even though it was not DCS); the systemic conditions (greater prevalence of
possible to analyse the effect of ageing in the preva- AP amongst individuals with one or more systemic
lence and frequency of AP since the majority of the conditions); the risk of bias of the primary studies
studies did not provide the data stratified by age, it (greater prevalence of AP in studies with higher risk
seems that the prevalence is higher as the age of bias); the image method used (higher prevalence of
increases, especially in populations with low rates of AP in studies using CBCT); the method used to assess
tooth extractions and accumulation of dental treat- the AP (methods compatible with PAI ≥ 4 decreased
ments, for example root canal treatments (Kirkevang the prevalence of AP). The present findings should
2018). bring the attention of health policymakers, medical
Some additional considerations are necessary. First, and dental communities to the hidden burden of the
adjustments made in the statistical analyses of the endodontic disease in the population worldwide.
studies were not considered, because only the descrip-
tive data were required for this meta-analysis. More-
References
over, until recently, there was no checklist to describe
observational studies (i.e. Strobe checklist). Thus, stud- Abbott PV (2004) Classification, diagnosis and clinical mani-
ies previously published could have followed the festations of apical periodontitis. Endodontic Topics 8, 36–
required steps but failed to report the information. The 54.
authors acknowledge the effort of all researchers in Ahmed I, Ali RW, Mudawi AM (2017) Prevalence of apical
periodontitis and frequency of root-filled teeth in an adult
carrying out the studies on the prevalence of the
Sudanese population. Clinical and Experimental Dental
endodontic disease and stress that more studies are
Research 3, 142–7.
needed, especially those where representative samples Alafif H (2014) Impact of the quality of coronal restoration
are recruited, which could provide deeper knowledge and root canal filling on the Periapical health in adult Syr-
on the endodontic status at a broader population level. ian subpopulation. Indian Journal of Dentistry 5, 75–80.
In addition, it is recommended that future research on Aleksejuniene J, Eriksen HM, Sidaravicius B, Haapasalo M
this topic should provide information on the prevalence (2000) Apical periodontitis and related factors in an adult
of AP at both tooth and individual levels, preferably Lithuanian population. Oral Surgery, Oral Medicine, Oral
stratified by age, as well as information on sociodemo- Pathology, Oral Radiology, and Endodontics 90, 95–101.
graphic, oral and medical covariables as possible risk Alfouzan K, Baskaradoss JK, Geevarghese A, Alzahrani M,
indicators. A careful sample selection process will pro- Alhezaimi K (2016) Radiographic Diagnosis of periapical
status and quality of root canal fillings in a Saudi Arabian
vide unbiased data, which would be more relevant for
subpopulation. Oral Health & Preventive Dentistry 14,
researchers, dental practitioners and policymakers.
241–8.
Finally, the present systematic review should be Alkis HT, Kustarci A (2019) Radiographic assessment of the
updated regularly to analyse the trends of modification relationship between root canal treatment quality, coronal
in the pooled estimates of the prevalence of AP world- restoration quality, and periapical status. Nigerian Journal
wide. Ultimately, this information will be essential to of Clinical Practice 22, 1126–31.
evaluate whether all the scientific and technological Allard U, Palmqvist S (1986) A radiographic survey of peri-
progress experienced by Endodontology, associated apical conditions in elderly people in a Swedish county
with the public health strategies, will be, in fact, population. Endodontics & Dental Traumatology 2, 103–8.
Al-Nazhan SA, Alsaeed SA, Al-Attas HA, Dohaithem AJ, Al- coronal restoration by using cone-beam computed tomog-
Serhan MS, Al-Maflehi NS (2017) Prevalence of apical raphy. Nigerian Journal of Clinical Practice 19, 673–7.
periodontitis and quality of root canal treatment in an Castellanos-Cosano L, Machuca-Portillo G, S anchez-Domın-
adult Saudi population. Saudi Medical Journal 38, 413–21. gues B, Torres-Lagares D, L opez-Lopez J, Segura-Egea JJ
Al-Omari MA, Hazaa A, Haddad F (2011) Frequency and (2013a) High prevalence of radiolucent periapical lesions
distribution of root filled teeth and apical periodontitis in a amongst patients with inherited coagulation disorders.
Jordanian subpopulation. Oral Surgery, Oral Medicine, Oral Haemophilia 19, e110–5.
Pathology, Oral Radiology, and Endodontics 111, e59–65. Castellanos-Cosano L, Machuca-Portillo G, Segura-Sampedro
Al-Zahrani MS, Abozor BM, Zawawi KH (2017) The relation- JJ et al. (2013b) Prevalence of apical periodontitis and fre-
ship between periapical lesions and the serum levels of quency of root canal treatments in liver transplant candi-
glycosylated hemoglobin and C-reactive protein in type 2 dates. Medicina Oral, Patologia Oral y Cirugia Bucal 18,
diabetic patients. Saudi Medical Journal 38, 36–40. e773–9.
Archana D, Gopikrishna V, Gutmann JL, Savadamoorthi KS, Chen CY, Hasselgren G, Serman N, Elkind MS, Desvarieux
Kumar AR, Narayanan LL (2015) Prevalence of periradic- M, Engebretson SP (2007) Prevalence and quality of
ular radiolucencies and its association with the quality of endodontic treatment in the Northern Manhattan elderly.
root canal procedures and coronal restorations in an adult Journal of Endodontics 33, 230–4.
urban Indian population. Journal of Conservative Dentistry Correia-Sousa J, Madureira AR, Carvalho MF, Teles AM,
18, 34–8. Pina-Vaz I (2015) Apical periodontitis and related risk fac-
Asgary S, Shadman B, Ghalamkaspour Z et al. (2010) Peri- tors: cross-sectional study. Revista Portuguesa de Estoma-
apical status and quality of root canal fillings and coronal tologia 56, 226–32.
restorations in Iranian population. Iranian Endodontic Jour- Costa TH, Neto JAF, de Oliveira AEF, Maia MFL, de Almeida
nal 5, 74–82. AL (2014) Association between chronic apical periodonti-
Ayad SS (1977) The frequency and distribution of periapical tis and coronary artery disease. Journal of Endodontics 40,
lesions in Saudi Arabia. Alexandria Dental Journal 2, 37–44. 164–7.
Bergstr€om J, Eliasson S, Ahlberg KF (1987) Periapical status Covello F, Franco V, Schiavetti R et al. (2010) Prevalence of
in subjects with regular dental care habits. Community apical periodontitis and quality of endodontic treatment in
Dentistry and Oral Epidemiology 15, 236–9. an Italian adult population. Oral & Implantology 3, 9–14.
Berlin-Broner Y, Febbraio M, Levin L (2017) Association Da Silva K, Lam JM, Wu N, Duckmanton P (2009) Cross-
between apical periodontitis and cardiovascular diseases: a sectional study of endodontic treatment in an Australian
systematic review of the literature. International Endodontic population. Australian Endodontic Journal 35, 140–6.
Journal 50, 847–59. De Cleen MJ, Schuurs AH, Wesselink PR, Wu MK (1993)
Berlinck T, Tinoco JM, Carvalho FL, Sassone LM, Tinoco EM Periapical status and prevalence of endodontic treatment
(2015) Epidemiological evaluation of apical periodontitis in an adult Dutch population. International Endodontic Jour-
prevalence in an urban Brazilian population. Brazilian Oral nal 26, 112–9.
Research 29, 1–7. De Moor RJ, Hommez GM, De Boever JG, Delme KI, Martens
Bołtacz-Rzepkowska E, Laszkiewicz J (2005) Endodontic GE (2000) Periapical health related to the quality of root
treatment and periapical health in patients of the Institute canal treatment in a Belgian population. International
of Dentistry in Lodz. Przeglad Epidemiologiczny 59, 107–15. Endodontic Journal 33, 113–20.
Boucher Y, Matossian L, Rilliard F, Machtou P (2002) Department of Economic and Social Affairs of the United
Radiographic evaluation of the prevalence and technical Nations Secretariat (UN/DESA) (2014) Country classifica-
quality of root canal treatment in a French subpopulation. tion. Data sources, country classifications and aggregation
International Endodontic Journal 35, 229–38. methodology. https://www.un.org/en/development/desa/
Brynolf I (1967) Histological and roentgenological study of policy/wesp/wesp_current/2014wesp_country_classifica
the periapical region of human upper incisors (PhD The- tion.pdf. [accessed on 7 May 2019].
sis). Odontologisk Revy 18, 11. Di Filippo G, Sidhu SK, Chong BS (2014) Apical periodontitis
Buckley M, Sp angberg LS (1995) The prevalence and techni- and the technical quality of root canal treatment in an
cal quality of endodontic treatment in an American sub- adult sub-population in London. British Dental Journal
population. Oral Surgery, Oral Medicine, Oral Pathology, 216, E22.
Oral Radiology, and Endodontics 79, 92–100. Di Nardo D, Gambarini G, Capuani S, Testarelli L (2018)
B€
urklein S, Sch€afer E, J€ ohren HP, Donnermeyer D (2020) Nuclear magnetic resonance imaging in endodontics: a
Quality of root canal fillings and prevalence of apical radi- review. Journal of Endodontics 44, 536–42.
olucencies in a German population: a CBCT analysis. Clini- Diogo P, Palma P, Caramelo F, Marques dos Santos JM
cal Oral Investigations 24, 1217–27. (2014) Prevalence of apical periodontitis in an adult Por-
Cakici EB, Yildirim E, Cakici F, Erdogan AS (2016) Assess- tuguese population. Revista Portuguesa de Estomatologia,
ment of periapical health, quality of root canal filling, and Medicina Dentaria e Cirurgia Maxilofacia 55, 36–42.
Tib
Dugas NN, Lawrence HP, Teplitsky PE, Pharoah MJ, Fried- Grønkjær LL, Holmstrup P, Schou S et al. (2016) Presence
man S (2003) Periapical health and treatment quality and consequence of tooth periapical radiolucency in
assessment of root-filled teeth in two Canadian popula- patients with cirrhosis. Hepatic Medicine: Evidence and
tions. International Endodontic Journal 36, 181–92. Research 8, 97–103.
Eckerbom M, Andersson JE, Magnusson T (1987) Frequency Gulsahi K, Gulsahi A, Ungor M et al. (2008) Frequency of
and technical standard of endodontic treatment in a Swed- root-filled teeth and prevalence of apical periodontitis in
ish population. Endodontics & Dental Traumatology 3, 245–8. an adult Turkish population. International Endodontic Jour-
Eriksen HM, Berset GP, Hansen BF, Bjertness E (1995) nal 41, 78–85.
Changes in endodontic status 1973–1993 among 35- Gumru B, Tarcin B, Pekiner FN, Ozbayrak S (2011) Retro-
year-olds in Oslo, Norway. International Endodontic Journal spective radiological assessment of root canal treatment in
28, 129–32. young permanent dentition in a Turkish subpopulation.
Eriksen HM, Bjertness E (1991) Prevalence of apical peri- International Endodontic Journal 44, 850–6.
odontitis and results of endodontic treatment in middle- G€
und€ uz K, Avsever H, Orhan K et al. (2011) Cross-sectional
aged adults in Norway. Endodontics & Dental Traumatology evaluation of the periapical status as related to quality of
7, 1–4. root canal fillings and coronal restorations in a rural adult
Falk H, Hugoson A, Thorstensson H (1989) Number of male population of Turkey. BMC Oral Health 11, 20.
teeth, prevalence of caries and periapical lesions in insu- Haag DG, Peres KG, Balasubramanian M, Brennan DS
lin-dependent diabetics. Scandinavian Journal of Dental (2017) Oral conditions and health-related quality of life: a
Research 97, 198–206. systematic review. Journal of Dental Research 96, 864–74.
Fletcher R, Fletcher S (2005) Frequency. In: Fletcher R, Haddaway NR, Collins AM, Coughlin D, Kirk S (2015) The
Fletcher S, eds. Clinical Epidemiology: The Essencials, 4th role of google scholar in evidence reviews and its applicabil-
edn. Philadelphia, USA: Lippincott Williams & Wilkins, pp ity to grey literature searching. PLoS One 10, e0138237.
59–74. Hakala PE (1967) Dental and oral changes in congenital
Franciscatto GJ, Koppe BTF, Hoppe CB et al. (2019) Valida- heart disease. Suomen Hammaslaakariseuran Toimituksia 63,
tion of self-reported history of root canal treatment in a 284–324.
southern Brazilian subpopulation. Brazilian Oral Research Hamedy R, Shakiba B, Pak JG, Barbizam JV, Ogawa RS,
33, e007. White SN (2016) Prevalence of root canal treatment and
Frisk F, Hakeberg M (2005) A 24-year follow-up of root periapical radiolucency in elders: a systematic review.
filled teeth and periapical health amongst middle aged and Gerodontology 33, 116–27.
elderly women in G€ oteborg, Sweden. International Endodon- Harjunmaa U, J€ arnstedt J, Alho L et al. (2015) Association
tic Journal 38, 246–54. between maternal dental periapical infections and preg-
Gencoglu N, Pekiner FN, Gumru B, Helvacioglu D (2010) nancy outcomes: results from a cross-sectional study in
Periapical status and quality of root fillings and coronal Malawi. Tropical Medicine & International Health 20, 1549–
restorations in an adult Turkish subpopulation. European 58.
Journal of Dentistry 4, 17–22. Hebling E, Coutinho LA, Ferraz CC, Cunha FL, Queluz DP
Georgopoulou MK, Spanaki-Voreadi AP, Pantazis N et al. (2014) Periapical status and prevalence of endodontic
(2005) Frequency and distribution of root filled teeth and treatment in institutionalized elderly. Brazilian Dental Jour-
apical periodontitis in a Greek population. International nal 25, 123–8.
Endodontic Journal 38, 105–11. Heppeler J, H€ ulsmann JH (2010) Prevalence of root canal
Gomes MS, Blattner TC, Sant’Ana Filho M et al. (2013) Can fillings, apical periodontitis, and endodontic treatment
apical periodontitis modify systemic levels of inflammatory needs in a selected German population in 1994 and 2004.
markers? A systematic review and meta-analysis. Journal ENDO - Endodontic Practice Today 4, 189–200.
of Endodontics 39, 1205–17.
Herzog R, Alvarez-Pasquin MJ, Dıaz C, Del Barrio JL, Estrada
Gomes MS, Hugo FN, Hilgert JB et al. (2012) Validity of self- JM, Gil A (2013) Are healthcare workers’ intentions to
reported history of endodontic treatment in the Baltimore vaccinate related to their knowledge, beliefs and attitudes?
Longitudinal Study of Aging. Journal of Endodontics 38, A systematic review. BMC Public Health 13, 154.
589–93. Hommez G, De Meerleer G, Vakaet L, De Neve W, Vermeer-
Gomes MS, Hugo FN, Hilgert JB et al. (2016) Apical peri- sch H, De Moor R (2008) Prevalence of apical periodonti-
odontitis and incident cardiovascular events in the Balti- tis and associated coronal factors in head and neck
more Longitudinal Study of Ageing. International irradiated patients. ENDO - Endodontic Practice Today 2,
Endodontic Journal 49, 334–42. 105–15.
Gregoire G, Derderian F, Le Lorier J (1995) Selecting the lan- Hommez GM, De Meerleer GO, De Neve WJ, De Moor RJ
guage of the publications included in a meta-analysis: is (2012) Effect of radiation dose on the prevalence of apical
there a tower of babel bias? Journal of Clinical Epidemiology periodontitis–a dosimetric analysis. Clinical Oral Investiga-
48, 159–63. tions 16, 1543–7.
Hoppe CB, Oliveira JAP, Grecca FS, Haas AN, Gomes MS Khalighinejad N, Aminoshariae MR, Aminoshariae A, Kulild
(2017) Association between chronic oral inflammatory bur- JC, Mickel A, Fouad AF (2016) Association between sys-
den and physical fitness in males: a cross-sectional observa- temic diseases and apical periodontitis. Journal of Endodon-
tional study. International Endodontic Journal 50, 740–9. tics 42, 1427–34.
Hulley SB, Cummings SR, Browner WS, Grady D, Hearst N, Khullar P, Raisingani D, Gupta S, Khatri RK (2013) A sur-
Newman TB (2001) Designing clinical research: an epidemio- vey report on effect of root canal fillings and coronal
logic approach, 2nd edn. Philadelphia, USA: Lippincott Wil- restorations on the periapical status of endodontically trea-
liams & Wilkins. ted teeth in a selected group of population. International
Hussein FE, Liew AK, Ramlee RA, Abdullah D, Chong BS Journal of Clinical Pediatric Dentistry 6, 89–94.
(2016) Factors associated with apical periodontitis: a mul- Kielbassa AM, Frank W, Madaus T (2017) Radiologic assess-
tilevel analysis. Journal of endodontics 42, 1441–5. ment of quality of root canal fillings and periapical status
Huumonen S, Suominen AL, Vehkalahti MM (2017) Preva- in an Austrian subpopulation - an observational study.
lence of apical periodontitis in root filled teeth: findings PLoS One 12, e0176724.
from a nationwide survey in Finland. International Kim S (2010) Prevalence of apical periodontitis of root
Endodontic Journal 50, 229–36. canal-treated teeth and retrospective evaluation of symp-
c L, Milic-Lemic A (2014)
Ilic J, Vujaskovic M, Tihacek-Soji tom-related prognostic factors in an urban South Korean
Frequency and quality of root canal fillings in an adult population. Oral Surgery, Oral Medicine, Oral Pathology,
Serbian population. Srpski Arhiv za Celokupno Lekarstvo Oral Radiology, and Endodontics 110, 795–9.
142, 663–8. Kirkevang L-L (2018) Clinical epidemiology: measuring
Jalali P, Glickman GN, Schneiderman ED, Schweitzer JL endodontic disease and treatment outcome. In: Bjørndal L,
(2017) Prevalence of Periapical Rarefying Osteitis in Kirkevang L-L, Whitworth J, eds. Textbook of Endodontol-
Patients with Rheumatoid Arthritis. Journal of Endodontics ogy, 3rd edn. Hoboken, USA: Wiley, pp 315–26.
43, 1093–6. Kirkevang L-L, H€ orsted-Bindslev P, Ørstavik D, Wenzel A
Jersa I, Kundzina R (2013) Periapical status and quality of (2001) Frequency and distribution of endodontically trea-
root fillings in a selected adult Riga population. Stoma- ted teeth and apical periodontitis in an urban Danish pop-
tologija 15, 73–7. ulation. International Endodontic Journal 34, 198–205.
Kabak Y, Abbott PV (2005) Prevalence of apical periodonti- Kirkevang L-L, Vaeth M, Wenzel A (2004) Tooth-specific risk
tis and the quality of endodontic treatment in an adult indicators for apical periodontitis. Oral Surgery, Oral Medi-
Belarusian population. International Endodontic Journal 38, cine, Oral Pathology, Oral Radiology, and Endodontics 97,
238–45. 739–44.
Kakehashi S, Stanley HR, Fitzgerald RJ (1965) The effects of Kirkevang L-L, Vaeth M, H€ orsted-Bindslev P, Bahrami G,
surgical exposures of dental pulps in germ-free and con- Wenzel A (2007) Risk factors for developing apical peri-
ventional laboratory rats. Oral Surgery, Oral Medicine, and odontitis in a general population. International Endodontic
Oral Pathology 20, 340–9. Journal 40, 290–9.
Kalender A, Orhan K, Aksoy U, Basmaci F, Er F, Alankus A Kruse C, Spin-Neto R, Reibel J, Wenzel A, Kirkevang L-L
(2013) Influence of the quality of endodontic treatment (2017) Diagnostic validity of periapical radiography and
and coronal restorations on the prevalence of apical peri- CBCT for assessing periapical lesions that persist after
odontitis in a Turkish Cypriot population. Medical Princi- endodontic surgery. Dentomaxillofacial Radiology 46,
ples and Practice 22, 173–7. 20170210.
Kamberi B, Hoxha V, Stavileci M, Dragusha E, Kucßi A, Kqiku Kruse C, Spin-Neto R, Evar Kraft DC, Vaeth M, Kirkevang L-
L (2011) Prevalence of apical periodontitis and endodontic L (2019) Diagnostic accuracy of cone beam computed
treatment in a Kosovar adult population. BMC Oral Health tomography used for assessment of apical periodontitis: an
11, 32. ex vivo histopathological study on human cadavers. Inter-
Kerekes K, Bervell SF (1976) A radiological evaluation of national Endodontic Journal 52, 439–50.
need for endodontic treatment. Den Norske Tannlaegeforen- Leal AS, de Oliveira AEF, Brito LM et al. (2015) Association
ings Tidende 86, 248–54. between chronic apical periodontitis and low-birth-weight
Khalighinejad N, Aminoshariae A, Kulild JC, Mickel A preterm births. Journal of Endodontics 41, 353–7.
(2017a) Apical periodontitis, a predictor variable for Lemagner F, Maret D, Peters OA, Arias A, Coudrais E, Geror-
preeclampsia: a case-control study. Journal of Endodontics gelin-Gurgel M (2015) Prevalence of apical bone defects
43, 1611–4. and evaluation of associated factors detected with cone-
Khalighinejad N, Aminoshariae A, Kulild JC, Sahly K, Mickel beam computed tomographic images. Journal of Endodontics
A (2017b) Association of end-stage renal disease with 41, 1043–7.
radiographically and clinically diagnosed apical periodonti- Leonardi Dutra K, Haas L, Porporatti AL et al. (2016) Diag-
tis: a hospital-based study. Journal of Endodontics 43, nostic accuracy of cone-beam computed tomography and
1438–41. conventional radiography on apical periodontitis: a
Tib
systematic review and meta-analysis. Journal of Endodontics and meta-analyses: The PRISMA statement. PLoS Medicine
42, 356–64. 6, e1000097.
Liljestrand JM, M€ antyl€a P, Paju S et al. (2016) Association of Moreno JO, Alves FR, Goncßalvez LS, Martinez AM, R^ oßcas IN,
endodontic lesions with coronary artery disease. Journal of Siqueira JF Jr (2013) Periradicular status and quality of
Dental Research 95, 1358–65. root canal fillings and coronal restorations in an urban
Loftus JJ, Keating AP, McCartan BE (2005) Periapical status Colombian population. Journal of Endodontics 39, 600–4.
and quality of endodontic treatment in an adult Irish pop- Mukhaimer R, Hussein E, Orafi I (2012) Prevalence of apical
ulation. International Endodontic Journal 38, 81–6. periodontitis and quality of root canal treatment in an
Lopez-Lopez J, Castellanos-Cosano L, Estrugo-Devesa A, adult Palestinian sub-population. Saudi Dental Journal 24,
Gomez-Vaquero C, Velasco-Ortega E, Segura-Egea JJ (2015) 149–55.
Radiolucent periapical lesions and bone mineral density in €
Odesj€ o B, Hellden L, Salonen L, Langeland K (1990) Preva-
post-menopausal women. Gerodontology 32, 195–201. lence of previous endodontic treatment, technical standard
Lopez-Lopez J, Jane-Salas E, Estrugo-Devesa A, Velasco- and occurrence of periapical lesions in a randomly selected
Ortega E, Martın-Gonz alez J, Segura-Egea JJ (2011) Peri- adult, general population. Endodontics & Dental Traumatol-
apical and endodontic status of type 2 diabetic patients in ogy 6, 265–72.
Catalonia, Spain: a cross-sectional study. Journal of Oginni AO, Adeleke AA, Chandler NP (2015) Root canal
Endodontics 37, 598–601. treatment and prevalence of apical periodontitis in a nige-
Lopez-Lopez J, Jane-Salas E, Estrugo-Devesa A et al. (2012) rian adult subpopulation: a radiographic study. Oral Health
Frequency and distribution of root-filled teeth and apical & Preventive Dentistry 13, 85–90.
periodontitis in an adult population of Barcelona, Spain. Ørstavik D, Kerekes K, Eriksen HM (1986) The periapical
International Dental Journal 62, 40–6. index: a scoring system for radiographic assessment of api-
Lupi-Pegurier L, Bertrand MF, Muller-Bolla M, Rocca JP, cal periodontitis. Endodontics & Dental Traumatology 2, 20–
Bolla M (2002) Periapical status, prevalence and quality 34.
of endodontic treatment in an adult French population. € ß H, Asci S, Aydin Y (2011) Examination of the preva-
Ozbas
International Endodontic Journal 35, 690–7. lence of periapical lesions and technical quality of
Maniglia Ferreira C, de Almeida GF, Cristovam Uchoa C endodontic treatment in a Turkish subpopulation. Oral
(2014) Preval^encia de les~ ao endod^ ontica em pacientes Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and
diabeticos. Revista Brasileira em Promocß~ao da Sa ude 27, Endodontics 112, 136–42.
163–8. Pak JG, Fayazi S, White SN (2012) Prevalence of periapical
Marcenes W, Kassebaum NJ, Bernabe E et al. (2013) Global radiolucency and root canal treatment: a systematic
burden of oral conditions in 1990–2010: a systematic review of cross-sectional studies. Journal of Endodontics 38,
analysis. Journal of Dental Research 92, 592–7. 1170–6.
Marmary Y, Kutiner G (1986) A radiographic survey of peri- Palmer RM, Wilson RF, Hasan AS, Scott DA (2005) Mecha-
apical jawbone lesions. Oral Surgery, Oral Medicine, and nisms of action of environmental factors–tobacco smoking.
Oral Pathology 61, 405–8. Journal of Clinical Periodontology 32(Suppl. 6), 180–95.
Marotta PS, Fontes TV, Armada L, Lima KC, R^oßcas IN, Pasqualini D, Bergandi L, Palumbo L et al. (2012) Associa-
Siqueira JF Jr (2012) Type 2 diabetes mellitus and the tion among oral health, apical periodontitis, CD14 poly-
prevalence of apical periodontitis and endodontic treat- morphisms, and coronary heart disease in middle-aged
ment in an adult Brazilian population. Journal of Endodon- adults. Journal of Endodontics 38, 1570–7.
tics 38, 297–300. Peciuliene V, Rimkuviene J, Maneliene R, Ivanauskaite D
Marques MD, Moreira B, Eriksen HM (1998) Prevalence of (2006) Apical periodontitis in root filled teeth associated
apical periodontitis and results of endodontic treatment in with the quality of root fillings. Stomatologija 8, 122–6.
an adult, Portuguese population. International Endodontic Persic Bukmir R, Jurcevic Grgicc M, Brumini G, Spalj S,
Journal 31, 161–5. Pezelj-Ribaric S, Brekalo Prso I (2016) Influence of
Matijevic J, Cizmekovic Dadic T, Prpic Mehicic G, Ani I, Slaj tobacco smoking on dental periapical condition in a sam-
M, KrmekS J (2011) Prevalence of apical periodontitis and ple of Croatian adults. Wiener Klinische Wochenschrift 128,
quality of root canal fillings in population of Zagreb, Croa- 260–5.
tia: a cross-sectional study. Croatian Medical Journal 52, Persic Bukmir R, Vidas J, Mance D, Pezelj-Ribaric S, Spalj S,
679–87. Prso B (2019) Socio-economic and health status as a pre-
Miri SS, Khademi A, Amirkhani Z, Amiri SM, Goodarzi M, dictor of apical periodontitis in adult patients in Croatia.
Khazaei S (2018) Prevalence of apical periodontitis in dif- Oral Diseases 25, 300–8.
ferent communities: a meta-analysis. Iranian Endodontic Persic R, Kqiku L, Brumini G et al. (2011) Difference in the
Journal 13, 438–45. periapical status of endodontically treated teeth between
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group the samples of Croatian and Austrian adult patients. Croat-
(2009) Preferred reporting items for systematic reviews ian Medical Journal 52, 672–8.
Peters LB, Lindeboom JA, Elst ME, Wesselink PR (2011) in a sample of Spanish adults. International Endodontic Jour-
Prevalence of apical periodontitis relative to endodontic nal 41, 310–6.
treatment in an adult Dutch population: a repeated cross- Segura-Egea JJ, Martın-Gonz alez J, Cabanillas-Balsera D,
sectional study. Oral Surgery, Oral Medicine, Oral Pathology, Fouad AF, Velasco-Ortega E, L opez-Lopez J (2016) Associ-
Oral Radiology, and Endodontics 111, 523–8. ation between diabetes and the prevalence of radiolucent
Petersson K, Lewin B, Hakansson J, Olsson B, Wennberg A periapical lesions in root-filled teeth: systematic review
(1989) Endodontic status and suggested treatment in a and meta-analysis. Clinical Oral Investigations 20, 1133–
population requiring substantial dental care. Endodontics & 41.
Dental Traumatology 5, 153–8. Sidaravicius B, Aleksejuniene J, Eriksen HM (1999)
Piras V, Usai P, Mezzena S et al. (2017) Prevalence of apical Endodontic treatment and prevalence of apical periodonti-
periodontitis in patients with inflammatory bowel diseases: tis in an adult population of Vilnius, Lithuania. Endodon-
a retrospective clinical study. Journal of Endodontics 43, tics & Dental Traumatology 15, 210–5.
389–94. Skudutyte-Rysstad R, Eriksen HM (2006) Endodontic status
Poyato-Borrego M, Segura-Sampedro JJ, Martın-Gonz alez J, amongst 35-year-old Oslo citizens and changes over a
Torres-Domınguez V-O, Segura-Egea JJ (2019) High Preva- 30-year period. International Endodontic Journal 39,
lence of apical periodontitis in patients with inflammatory 637–42.
bowel disease: an age- and gender- matched case-control Smadi L (2017) Apical periodontitis and endodontic treat-
study. Inflammatory Bowel Diseases 26, 273–9. ment in patients with type II diabetes mellitus: compara-
Ridao-Sacie C, Segura-Egea JJ, Fernandez-Palacın A, tive cross-sectional survey. The Journal of Contemporary
Bull
on-Fern andez P, Rıos-Santos JV (2007) Radiological Dental Practice 18, 358–62.
assessment of periapical status using the periapical Soikkonen KT (1995) Endodontically treated teeth and peri-
index: comparison of periapical radiography and digital apical findings in the elderly. International Endodontic Jour-
panoramic radiography. International Endodontic Journal nal 28, 200–3.
40, 433–40. Stassen IG, Hommez GM, De Bruyn H, De Moor RJ (2006)
Rocha JL, Braga AC, Carvalho MF, Pina-Vaz I (2012) Preva- The relation between apical periodontitis and root-filled
lence of apical periodontitis and endodontic treatment in teeth in patients with periodontal treatment need. Interna-
Portuguese adult population. Archives of Oral Research 8, tional Endodontic Journal 39, 299–308.
219–27. Sunay H, Tanalp J, Dikbas I, Bayirli G (2007) Cross-sectional
Rodriguez FR, Taner B, Weiger R, Walter C (2013) Is smok- evaluation of the periapical status and quality of root
ing a predictor of apical periodontitis? Clinical Oral Investi- canal treatment in a selected population of urban Turkish
gations 17, 1947–55. adults. International Endodontic Journal 40, 139–45.
Sanchez-Domınguez B, L opez-L
opez J, Jane-Salas E, Castel- Sundqvist G (1976) Bacteriological studies of necrotic dental
lanos-Cosano L, Velasco-Ortega E, Segura-Egea JJ (2015) pulps (PhD Thesis). Ume a, SE: University of Umea
Glycated hemoglobin levels and prevalence of apical peri- Tavares PB, Bonte E, Boukpessi T, Siqueira JF Jr, Lasfargues
odontitis in type 2 diabetic patients. Journal of Endodontics JJ (2009) Prevalence of apical periodontitis in root canal–
41, 601–6. treated teeth from an urban French population: influence
€
Sarıyılmaz E, Keskin C, Ozcan € (2016) Retrospective analy-
O of the quality of root canal fillings and coronal restora-
sis of post-treatment apical periodontitis and quality of tions. Journal of Endodontics 35, 810–3.
endodontic treatment and coronal restorations in an Tercßas AG, de Oliveira AEF, Lopes FF, Maia Filho EM (2006)
elderly Turkish population. Journal of Clinical Gerontology Radiographic study of the prevalence of apical periodonti-
and Geriatrics 7, 17–20. tis and endodontic treatment in the adult population of
Seerig LM, Nascimento GG, Peres MA, Horta BL, Demarco FF S~ao Luıs, MA, Brazil. Journal of Applied Oral Science 14,
(2015) Tooth loss in adults and income: systematic review 183–7.
and meta-analysis. Journal of Dentistry 43, 1051–9. Thampibul P, Jantarat J, Arayasantiparb R (2019) Post-
Segura-Egea JJ, Castellanos-Cosano L, Velasco-Ortega E et al. treatment apical periodontitis related to the technical qual-
(2011) Relationship between smoking and endodontic ity of root fillings and restorations in Thai population. Aus-
variables in hypertensive patients. Journal of Endodontics tralian Endodontic Journal 45, 163–70.
37, 764–7. Tib
urcio-Machado CS, Bello MC, Maier J, Wolle CFB, Bier
Segura-Egea JJ, Jimenez-Pinz on A, Rıos-Santos JV, Velasco- CAS (2017) Influence of diabetes in the development of
Ortega E, Cisneros-Cabello R, Poyato-Ferrera M (2005) apical periodontitis: a critical literature review of human
High prevalence of apical periodontitis amongst type 2 dia- studies. Journal of Endodontics 43, 370–6.
betic patients. International Endodontic Journal 38, 564–9. Timmerman A, Calache H, Parashos P (2017) A cross sec-
Segura-Egea JJ, Jimenez-Pinz on A, Rıos-Santos JV, Velasco- tional and longitudinal study of endodontic and periapical
Ortega E, Cisneros-Cabello R, Poyato-Ferrera M (2008) status in an Australian population. Australian Dental Jour-
High prevalence of apical periodontitis amongst smokers nal 62, 345–54.
Tib
Tolias D, Koletsi K, Mamai-Homata E, Margaritis V, Kontaki- Affairs Dental Longitudinal Study. Journal of Endodontics
otis E (2012) Apical periodontitis in association with the 36, 1943–9.
quality of root fillings and coronal restorations: a 14-year
investigation in young Greek adults. Oral Health & Preven-
tive Dentistry 10, 297–303. Supporting Information
Toure B, Kane AW, Sarr M, Ngom CT, Boucher Y (2008) Additional Supporting Information may be found in
Prevalence and technical quality of root fillings in Dakar,
the online version of this article:
Senegal. International Endodontic Journal 41, 41–9.
Tsuneishi M, Yamamoto T, Yamanaka R et al. (2005) Radio-
Supplementary Material 1. Search strategies.
graphic evaluation of periapical status and prevalence of
Supplementary Material 2. Quality assessment
endodontic treatment in an adult Japanese population.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
tool used to analyse the risk of bias of the included
and Endodontics 100, 631–5. studies.
Ureyen Kaya B, Kececi AD, Guldas HE, Orhan H (2013) A Supplementary Material 3. Characteristics of the
retrospective radiographic study of coronal-periapical sta- selected studies (secondary outcomes: prevalence of
tus and root canal filling quality in a selected adult Turk- AP in all teeth, nontreated teeth and root-filled teeth).
ish population. Medical Principles and Practice 22, 334–9. Supplementary Material 4. Quality assessment of
Vengerfeldt V, M€ andar R, Nguyen MS, Saukas S, Saag M the primary studies.
(2017) Apical periodontitis in southern Estonian popula- Supplementary Material 5. Subgroup analysis of
tion: prevalence and associations with quality of root canal
prevalence of AP (main outcome) according to the
fillings and coronal restorations. BMC Oral Health 17, 147.
socioeconomic status of the country.
Vidigal BCL, Lopes HP, Manzi FR, Nunes E, Soares JA, Sil-
veira FF (2010) Condicßa ~o periapical e sua correlacßa
~o entre Supplementary Material 6. Subgroup analysis of
a qualidade das restauracß~oes coron ~o do
arias e a obturacßa prevalence of AP (main outcome) in the different
sistema de canais radiculares na populacßa ~o de Belo Hori- locations of recruitment.
zonte/MG. Revista Brasileira de Odontologia 67, 266–9. Supplementary Material 7. Subgroup analysis of
Virtanen E, Nurmi T, S€ € Airila-M
oder PO, ansson S, S€ oder B, prevalence of AP (main outcome) in healthy individu-
Meurman JH (2017) Apical periodontitis associates with als and with systemic conditions.
cardiovascular diseases: a cross-sectional study from Swe- Supplementary Material 8. Subgroup analysis of
den. BMC Oral Health 17, 107.
prevalence of AP (main outcome) according to the
Vos T, Abajobir AA, Abate KH et al. (2017) Global, regional,
method of image.
and national incidence, prevalence, and years lived with
disability for 328 diseases and injuries for 195 countries,
Supplementary Material 9. Prevalence of AP in
1990–2016: a systematic analysis for the Global Burden all teeth (secondary outcome) in the population
of Disease Study 2016. Lancet 390, 1211–59. worldwide.
Walter C, Rodriguez FR, Taner B, Hecker H, Weiger R Supplementary Material 10. Prevalence of AP in
(2012) Association of tobacco use and periapical pathosis nontreated teeth (secondary outcome) in the popula-
- a systematic review. International Endodontic Journal 45, tion worldwide.
1065–73. Supplementary Material 11. Prevalence of AP in
Willershausen I, Weyer V, Peter M et al. (2014) Association root-filled teeth (secondary outcome) in the popula-
between chronic periodontal and apical inflammation and
tion worldwide.
acute myocardial infarction. Odontology 102, 297–302.
Zhong Y, Garcia R, Kaye EK et al. (2010) Association of
endodontic involvement with tooth loss in the Veterans

Int Endodontic J - 2021 - Tib Rcio Machado

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Int Endodontic J - 2021 - Tib Rcio Machado

Uploaded by

Copyright:

Available Formats

doi:10.1111/iej.

Abstract were included. No language restriction was applied.

Correspondence: Camilla dos Santos Tib

level. More recently, Miri et al. (2018) compiled data

the protocol was registered in the International

Records identified through

Records screened by title

Full-text articles assessed

Additional records identified - Method of assessing AP not clear= 46

- No data to calculate the prevalence or

Articles not found

Studies included in the

Figure 1 Flowchart of the selection process.

et al. (1989) service

International Endodontic Journal, 54, 712–735, 2021

International Endodontic Journal, 54, 712–735, 2021

et al. (2005) ♀ = 209 the width of the lateral part or service

(2005) ♀ = 175 service

International Endodontic Journal, 54, 712–735, 2021

International Endodontic Journal, 54, 712–735, 2021

(2016) ♀ = 26 the width of the lateral part or

216 43 (20) Noncardiovascular

International Endodontic Journal, 54, 712–735, 2021

Costa et al. Brazil 67 34 (51) ♂ = 38 64  10.1 Cardiovascular PAI ≥ 3 Periapical rx Hospital

International Endodontic Journal, 54, 712–735, 2021

I2 = 96.4%; Pasqualini et al. 2012, Costa et al. 2014,

the analysis, and the pooled proportion was 80%

(95% CI 65%–89%; I2 = 83.1%); nonsmokers had a

prevalence of AP of 49% (95% CI 26%–72%;

I2 = 94.5%; Segura-Egea et al. 2008, 2011, Persic

als with at least one AP than those with low risk of

periapical area, studies that used periapical radio-

I2 = 95.3%) than studies that used panoramic radio-

Using methods of assessing AP compatible with

Periapical Rx only in root filled teeth or in teeth with AP on the panoramic.

PAI ≥ 2 resulted in almost the same prevalence of AP

PAI ≥ 4 decreased the prevalence of individuals with

Including patients from the categories <20 years of age.

at least one tooth with AP substantially (33%; 95%

Secondary outcomes (frequency of all teeth, nontreated

In general, the frequency of teeth with AP was 5%

(95% CI 4%–6%; I2 = 99.5%). Nontreated teeth had a

frequency of 3% of periapical lesions, whereas 39% of

CI 2%–3%; I2 = 99.3%; root filled = 39%; 95% CI

36%–43%; I2 = 98.5%; Supplemental material 9,

Supplemental material 10 and Supplemental material

People from developing countries had 2% more AP

in all teeth than people from developed countries (de-

Study IDs Events Sample size Prevalence (%) Weight

Random effects model 34668 52 [48 - 56] 100%

Figure 2 Prevalence of AP (main outcome) in the population worldwide.

You might also like

Costa et al. Brazil 67 34 (51) ♂ = 38 64 10.1 Cardiovascular PAI ≥ 3 Periapical rx Hospital