Around one in two adult patients in the UK may have infection beneath their teeth which they are unaware of. This is based on a study at a London teaching hospital which found that 49% of the group had apical periodontitis (AP), the dental name for this kind of oral disease.
Sometimes AP causes the tooth to flare up and sometimes it won’t. Only visible on an X-ray, the chronic disease can remain dormant and painless for years. The dilemma for the dentist is to know whether to intervene and treat the disease when it’s not causing a problem to the patient. Research shows that specialists like myself are more likely to want to treat a tooth when we identify AP from an X-ray, possibly reflecting the confidence that comes from both experience and having a specialist practice fully equipped with specialist technology. This study showed that high quality root canal treatment is crucial to ensure a favourable outcome.
The aim of root canal treatment is to remove all infection from the pulp and root canal system and leave the tooth healthy and functioning in the jaw. Sometimes the attempts to clean out all infection fail. Clearly, the ideal solution would be to improve standards in root canal treatment, reducing the number of people who live with the silent disease.
This bacterial infection spreads from the pulp and into the root canal system. It moves into the bone below the tooth tip where the surrounding tissues respond to the bacteria. This can lead to the bone beneath the tooth reformatting and retreating, leaving a small vacuum. It is this vacuum which can be picked up on an X-ray. The advent of advanced X-ray systems (cone beam computed tomography) makes it easier for dentists to spot the signs of infection.
But there are other reasons why the issue of untreated AP is topical and needs to be resolved. Firstly dental implants are more prevalent and should be placed in strong and healthy bone. Patients who might need and want dental implants shouldn’t be vulnerable to AP.
Furthermore, a link between gum disease and other health issues has been established – http://www.nhs.uk/Livewell/dentalhealth/Pages/gum-disease-and-overall-health.aspx – which suggests that the potential for a link between AP and overall health should either be investigated and proved or, ideally definitively eliminated.
A recent opinion paper in the British Dental Journal sets out the need for such a study. The authors of the paper have helpfully provided a model to help researchers measure the effect of both leaving the disease and treating it.
I believe that as a result of the proposed study, clear guidelines for the benefit of both patients and the profession are almost within our grasp. The debate over whether to intervene when AP is spotted has been simmering for years and needs to be resolved soon.