Chronic apical periodontitis, an inflammation of the apical periodontium, typically results in an osteolytic apical lesion of endodontic origin, most frequently presenting as asymptomatic apical periodontitis. Studies have shown an epidemiological connection between apical lesions of endodontic origin (ALEOs) and cardiovascular diseases, including endothelial dysfunction, atherosclerosis and coronary heart disease. While an elevated systematic inflammatory burden significantly influences the development and progression of cardiovascular disease, no study has yet established a biologic connection between cardiovascular disease and chronic apical periodontitis.

Many inflammatory bioactive molecules associated with cardiovascular disease can be used to predict future events. In particular, elevated levels of high-sensitivity C-reactive protein (hsCRP) represent the only valid standardized biomarker to predict risk of cardiovascular disease. But the studies that might link elevated hsCRP levels with apical periodontitis failed to control for other cardiovascular risk factors and age. To establish or reject a biologic link between apical periodontitis and cardiovascular disease, Garrido et al from Universidad de Chile measured inflammatory serum markers for cardiovascular risk, including hsCRP, in young adults with and without ALEOs.

The study included patients 18 to 40 years of age who were treated at a university dental clinic between 2012 and 2017. Patients with a clinical diagnosis of asymptomatic apical periodontitis who had never undergone endodontic treatment and were free of current acute or chronic systemic disease met the inclusion criteria; obese patients and those with moderate-to-severe marginal periodontal disease were excluded.

An ALEO was defined as 1 radiographic radiolucency (3 mm) in a tooth with extensive caries and negative clinical tests of pulp sensitivity.

The cohort was then split into 2 groups:

  • patients with ALEOs
  • patients without ALEOs (controls)

Classic cardiovascular risk factors, including sex, level of education completed, smoking status, body mass index (BMI), blood pressure, lipid profile and glycated hemoglobin, were assessed.

The 2 groups were statistically similar for traditional cardiovascular risk factors as well as for pathobiological determinants of atherosclerosis in youth score, a methodology that estimates cardiovascular risk in young adults. The ALEO group had higher rates of mild periodontitis, as well as a significantly worse decayed/missing/ filled teeth (DMFT) index, probing depths and clinical attachment levels, as would be expected because these measures are associated with poorer oral health status. ALEO patients had a 6.8× greater risk for higher levels of hsCRP; each additional apical lesion of endodontic origin increased the risk 3.3×. Multivariate analyses controlling for classic cardiovascular risk factors and for oral risk factors also showed that the ALEO presence significantly increased hsCRP levels (Table 1).


This study demonstrated that ALEO presence is significantly associated with elevated inflammatory serum markers of cardiovascular risk in young adults. These results strongly support a mechanistic connection between periodontal disease and cardiovascular risk. To minimize risk of future cardiovascular disease, young adults with ALEOs should be referred for treatment.

Garrido M, Cárdenas AM, Astorga J, et al. Elevated systemic inflammatory burden and cardiovascular risk in young adults with endodontic apical lesions. J Endod 2019;45:111-115.