The association between smoking and periapical periodontitis: a systematic review

  • A AminoshariaeEmail author
  • J Kulild
  • J Gutmann



The purpose of this systematic review was to examine if, in adult patients, the absence or presence of smoking influenced the prevalence of periapical periodontitis (PP).

Materials and methods

Databases were searched, and original research manuscripts up to June 2019 were identified by two reviewers. The Newcastle-Ottawa Scale (NOS) was used for risk of bias. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used for certainty in the evidence. A meta-analysis was performed using RevMan 5 software. Risk ratio (RR) was used for the cohort studies, and odds ratio (OR) was used for the case-control studies with 95% confidence interval (CI).


All the studies had many covariates and confounding variables. Three longitudinal cohort articles discussed radiographic findings as they related to the prevalence of PP in root-filled teeth. The RR of smoking and the prevalence of PP was 2.11 (95% CI 0.88–5.05, p = 0.09). Nine case-control studies focused on the prevalence of PP and smoking. There was a positive association between smoking and the prevalence of PP with an OR of 2.78 and a 95% confidence interval of 2.23–3.48, with p value < 0.05. The quality of the studies was fair per NOS, and the certainty of the literature assessment was moderate per GRADE.


The current best available evidence suggests that smoking was associated with the prevalence of PP but more studies are needed to report this association in the longitudinal cohort studies.

Clinical relevance

Smoking has a positive association with the prevalence of PP.


Periapical periodontitis Prevalence Smoking Apical lesion Systematic review Meta-analysis 


Author contribution

All authors have made substantial contributions to all of the following: (1) the conception and design of this systematic review, or acquisition of data, or analysis and interpretation of data; (2) drafting and revising it critically for important intellectual content; and (3) they are in agreement of the final approval of the version.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not applicable. The information used to perform this review is available online and it is public. Therefore, the analysis performed in this study is in accordance with the ethical standards.

Informed consent

For this type of study, formal consent is not required.

Supplementary material

784_2019_3094_MOESM1_ESM.doc (64 kb)
ESM 1 (DOC 63 kb)
784_2019_3094_MOESM2_ESM.doc (23 kb)
ESM 2 (DOC 23 kb)
784_2019_3094_MOESM3_ESM.doc (57 kb)
ESM 3 (DOC 57 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of EndodonticsCase School of Dental MedicineClevelandUSA
  2. 2.Department of EndodonticsUMKC School of DentistryKansas CityUSA
  3. 3.College of DentistryTexas A & M UniversityDallasUSA
  4. 4.American Board of EndodonticsClevelandUSA

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