Apical periodontitis (AP) refers to a polymicrobial root canal infection resulting in the resorption of periapical bone. This canal system infection and the periapical defense reactions commonly reach an equilibrium resulting in an established periapical lesion. The prevalence of  ≥1 periapical lesions has been reported to be present in up to 61% in a population study.

The biofilm of these necrotic and infected root canals commonly consists of the genera  Fusobacterium, Prevotella, Eubacterium, Peptostreptococcus and Porphyromonas. A black-pigmented gram-negative rod, Porphyromonas endodontalis is a key pathogen in AP. Among the typical endodontic pathogens, only P endodontalis has been shown to be able to invade vascular endothelial and smooth muscle cells, potentially linking endodontic infection with systemic cardiovascular complications. Patients with periapical lesions have consistently shown an increase in systemic inflammatory markers.

The association between marginal periodontal disease and cardiovascular diseases is well established. Liljestrand et al from the University of Helsinki, Finland, delineated the associations between radiographically evident periapical lesions and angiographically verified coronary artery disease outcomes. The presence of subgingival P endodontalis, its humoral immune response and serum lipopolysaccharide activities were examined as potential mediators
between these 2 diseases.

The study included 508 Finnish patients who underwent an oral examination after coronary angioplasty. AP was determined by panoramic tomography. A score was assigned for each patient:

  • 1: no AP (n = 210, including 32 edentulous patients)
  • 2: ≥1 widened periapical space and/or 1 apical rarefaction (n = 222)
  • 3: ≥2 apical rarefactions (n = 76)

The groups were selected to reflect a continuum of the patients’ infectious endodontic status. In this population, 50.4% had widened periapical spaces; 22.8% had apical rarefactions. A total of 51.2% of all teeth with apical rarefactions had prior endodontic procedures. Subgingival P endodontalis levels and serum immunoglobulin G were associated with a higher AP score, notably in patients with untreated teeth with apical rarefactions.


These findings supported the hypothesis that periapical radiolucencies are independently associated with coronnary artery disease and, in particular, with acute coronary syndrome. This is an important public health issue.

Liljestrand JM, Mc‘intylc‘i P, Paju S, et al. Association of endodontic lesions with coronary artery disease. J Dent Res 2016;doi: 10.1177/0022034516660509.