Prevalence and factors associated with pulp stones: a systematic review with meta-analysis and meta-regression

Sanches, Yasmin Alves; Weissheimer, Theodoro; Haas, Alex Nogueira; Rosa, Ricardo Abreu da; Só, Gabriel Barcelos; Só, Marcus Vinicius Reis

doi:10.1590/1678-7765-2026-0252

person Yasmin Alves Sanches

Writing – original draft (Equal)

schoolUniversidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Odontologia, Departamento de Odontologia Restauradora, Porto Alegre, RS, Brasil.

0009-0008-9804-6010

person Theodoro Weissheimer

Project administration (Equal) · Supervision (Equal)

school University of Texas Health Science Center at San Antonio, School of Dentistry, Department of Endodontics, San Antonio, Texas, United States of America.

0000-0001-6810-1877

person Alex Nogueira Haas

Data curation (Equal) · Investigation (Equal)

schoolUniversidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Odontologia, Departamento de Odontologia Restauradora, Porto Alegre, RS, Brasil.

0000-0003-0531-6234

person Ricardo Abreu da Rosa

Validation (Equal) · Writing – review & editing (Equal)

schoolUniversidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Odontologia, Departamento de Odontologia Restauradora, Porto Alegre, RS, Brasil.

0000-0001-6568-7403

person Gabriel Barcelos Só

Software (Equal) · Visualization (Equal)

schoolUniversidade Federal de Santa Maria (UFSM), Faculdade de Odontologia, Departamento de Estomatologia, Santa Maria, RS, Brasil.

0000-0003-1565-4907

person Marcus Vinicius Reis Só

Conceptualization (Equal) · Formal analysis (Equal)

schoolUniversidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Odontologia, Departamento de Odontologia Restauradora, Porto Alegre, RS, Brasil.

0000-0002-1393-5900

personCorrespondence. Gabriel Barcelos Só - Av. Roraima nº 1000 Cidade Universitária Bairro – Prédio 26F Odontologia - Camobi, Santa Maria - RS, 97105-900 - E-mail:
gabrielso5@hotmail.com - Phone: (+55) 51 996130026

Editor:

Linda Wang

Associate Editor:

Leonardo Rigoldi Bonjardim

Conflict of interest

The authors declare no conflict of interest.

Database	Search strategy	Results
MEDLINE/PubMed	#1: (Dental Pulp Calcification) OR (Calcification, Dental Pulp) OR (Pulp Calcification, Dental) OR (Dental Pulp Stone) OR (Pulp Stones, Dental) OR (Stone, Dental Pulp) OR (Pulp Stones) OR (Dental Pulp Stones) OR (Denticles) OR (Denticle) OR (Pulp Stone, Dental) OR (Stones, Dental Pulp) OR (Coronal Dentin Dysplasia) OR (Dentin Dysplasia, Shields Type 2) OR (Anomalous Dysplasia of Dentin) OR (Dentin Dysplasia, Type II) OR (Dentin Dysplasia, Shields Type II) OR (Dentin Dysplasia, Coronal) OR (Pulpal Dysplasia)	2.342
	#2: (Prevalence) OR (Period Prevalence) OR (Point Prevalence) OR (Cross-Sectional Studies) OR (Cross Sectional Analysis) OR (Disease Frequency Surveys) OR (Cross-Sectional Survey) OR (Surveys, Disease Frequency) OR (Analysis, Cross-Sectional) OR (Prevalence Studies)	4,020,072
	#1 AND #2	173
Cochrane Library	#1: Dental Pulp Calcification OR Calcification, Dental Pulp OR Pulp Calcification, Dental OR Dental Pulp Stone OR Pulp Stones, Dental OR Stone, Dental Pulp OR Pulp Stones OR Dental Pulp Stones OR Denticles OR Denticle OR Pulp Stone, Dental OR Stones, Dental Pulp OR Coronal Dentin Dysplasia OR Dentin Dysplasia, Shields Type 2 OR Anomalous Dysplasia of Dentin OR Dentin Dysplasia, Type II OR Dentin Dysplasia, Shields Type II OR Dentin Dysplasia, Coronal OR Pulpal Dysplasia	46
	#2: Prevalence OR Period Prevalence OR Point Prevalence OR Cross-Sectional Studies OR Cross-Sectional Analysis OR Disease Frequency Surveys OR Cross-Sectional Survey OR Surveys, Disease Frequency OR Analysis, Cross-Sectional OR Prevalence Studies	69.594
	#1 AND #2	2
Scopus	#1: ( TITLE-ABS-KEY ( dental AND pulp AND calcification ) OR TITLE-ABS-KEY ( calcification, AND dental AND pulp ) OR TITLE-ABS-KEY ( pulp AND calcification, AND dental ) OR TITLE-ABS-KEY ( dental AND pulp AND stone ) OR TITLE-ABS-KEY ( pulp AND stones, AND dental ) OR TITLE-ABS-KEY ( stone, AND dental AND pulp ) OR TITLE-ABS-KEY ( pulp AND stones ) OR TITLE-ABS-KEY ( dental AND pulp AND stones ) OR TITLE-ABS-KEY ( denticles ) OR TITLE-ABS-KEY ( denticle ) OR TITLE-ABS-KEY ( pulp AND stone, AND dental ) OR TITLE-ABS-KEY ( stones, AND dental AND pulp ) OR TITLE-ABS-KEY ( coronal AND dentin AND dysplasia ) OR TITLE-ABS-KEY ( dentin AND dysplasia, AND shields AND type 2 ) OR TITLE-ABS-KEY ( anomalous AND dysplasia AND of AND dentin ) OR TITLE-ABS-KEY ( dentin AND dysplasia, AND type AND ii ) OR TITLE-ABS-KEY ( dentin AND dysplasia, AND shields AND type AND ii ) OR TITLE-ABS-KEY ( dentin AND dysplasia, AND coronal ) OR TITLE-ABS-KEY ( pulpal AND dysplasia ) )	4.919
	#2: ( TITLE-ABS-KEY ( prevalence ) OR TITLE-ABS-KEY ( period AND prevalence ) OR TITLE-ABS-KEY ( point AND prevalence ) OR TITLE-ABS-KEY ( cross-sectional AND studies ) OR TITLE-ABS-KEY ( cross AND sectional AND analysis ) OR TITLE-ABS-KEY ( disease AND frequency AND surveys ) OR TITLE-ABS-KEY ( cross-sectional AND survey ) OR TITLE-ABS-KEY ( surveys, AND disease AND frequency ) OR TITLE-ABS-KEY ( analysis, AND cross-sectional ) OR TITLE-ABS-KEY ( prevalence AND studies ) )	2,046,073
	#1 AND #2	172
Web of Science	#1: TS=(Dental Pulp Calcification OR Calcification, Dental Pulp OR Pulp Calcification, Dental OR Dental Pulp Stone OR Pulp Stones, Dental OR Stone, Dental Pulp OR Pulp Stones OR Dental Pulp Stones OR Denticles OR Denticle OR Pulp Stone, Dental OR Stones, Dental Pulp OR Coronal Dentin Dysplasia OR Dentin Dysplasia, Shields Type 2 OR Anomalous Dysplasia of Dentin OR Dentin Dysplasia, Type II OR Dentin Dysplasia, Shields Type II OR Dentin Dysplasia, Coronal OR Pulpal Dysplasia)	2.776
	#2: TS=(Prevalence OR Period Prevalence OR Point Prevalence OR Cross-Sectional Studies OR Cross Sectional Analysis OR Disease Frequency Surveys OR Cross-Sectional Survey OR Surveys, Disease Frequency OR Analysis, Cross-Sectional OR Prevalence Studies)	1,648,330
	#1 AND #2	131
EMBASE	#1: dental AND pulp AND calcification OR (calcification, AND dental AND pulp) OR (pulp AND calcification, AND dental) OR (dental AND pulp AND stone) OR (pulp AND stones, AND dental) OR (stone, AND dental AND pulp) OR (pulp AND stones) OR (dental AND pulp AND stones) OR denticles OR denticle OR (pulp AND stone, AND dental) OR (stones, AND dental AND pulp) OR (coronal AND dentin AND dysplasia) OR (dentin AND dysplasia, AND shields AND type AND 2) OR (anomalous AND dysplasia AND of AND dentin) OR (dentin AND dysplasia, AND type AND ii) OR (dentin AND dysplasia, AND shields AND type AND ii) OR (dentin AND dysplasia, AND coronal) OR (pulpal AND dysplasia)	1.566
	#2: prevalence OR (period AND prevalence) OR (point AND prevalence) OR (‘cross sectional’ AND studies) OR (cross AND sectional AND analysis) OR (disease AND frequency AND surveys) OR (‘cross sectional’ AND survey) OR (surveys, AND disease AND frequency) OR (analysis, AND ‘cross sectional’) OR (prevalence AND studies)	1.890.256
	#1 AND #2	113
OpenAIRE Graph	#1: Dental Pulp Calcification OR Calcification, Dental Pulp OR Pulp Calcification, Dental OR Dental Pulp Stone OR Pulp Stones, Dental OR Stone, Dental Pulp OR Pulp Stones OR Dental Pulp Stones OR Denticles OR Denticle OR Pulp Stone, Dental OR Stones, Dental Pulp OR Coronal Dentin Dysplasia OR Dentin Dysplasia, Shields Type 2 OR Anomalous Dysplasia of Dentin OR Dentin Dysplasia, Type II OR Dentin Dysplasia, Shields Type II OR Dentin Dysplasia, Coronal OR Pulpal Dysplasia	0
	#2: Prevalence OR Period Prevalence OR Point Prevalence OR Cross-Sectional Studies OR Cross-Sectional Analysis OR Disease Frequency Surveys OR Cross-Sectional Survey OR Surveys, Disease Frequency OR Analysis, Cross-Sectional OR Prevalence Studies	0
	#1 AND #2	0

Author(s) - year of publication - country of origin	Participants sample size (per group/gender)	Teeth sample size (per group/gender)	Evaluated teeth	Age (in years)	Diagnostic methods	Associated diseases	Main findings (Individual level)	Main findings (Tooth level)
Alaajam WH, et al.¹⁹ (2021) - Saudi Arabia	n = 600 (F = 300; M = 300)	n = 9600 (not reported)	Pre-molars and molars	20-50	Panoramic and interproximal radiographs	Not evaluated	Overall prevalence: 14.7% (88/600). Gender was not a predictor (F: 48/300 – 16%, M: 40/300 – 13.3%). Age was a predictive factor: 20–30y (23/199 – 11.6%), 31–40y (43/201 – 21.4%), 41–50y (22/200 – 11%)	Tooth prevalence: 4.6% (437/9600). Higher prevalence in molars (14% - 84/600)
Alqahtani AS²⁰ (2024) - Saudi Arabia	n = 228 (F = 93; M = 135)	Not evaluated	Pre-molars and molars	19-60	Cone-beam computed tomography	Periodontal disease	Overall prevalence: 17.5% (40/228). Male gender was a significant predictor (F: 13/93 – 5.7%; M: 27/135 – 11.8%). Age was not a predictive factor	Higher prevalence in molars (37/228 – 16.2%) No significant differences in periodontitis patients
Alsweed A, et al.⁵ (2019) - Saudi Arabia	n = 2013 (F = 801; M = 1212)	Not evaluated	Pre-molars and molars	18-77	Panoramic radiograph	Atherosclerosis	Overall prevalence: 4.6% (93/2013). Gender was not a predictor (F: 32/801 – 4%; M: 61/1212 – 5%). Age was a predictor: 18–25y (49/712 – 6.9%), 26–40y (28/624 – 4.5%), 41–54y (11/473 – 2.3%), ≥55y (5/204 – 2.5%). No significant differences between atherosclerosis and pulp stones	-
Bains SK, et al.²¹ (2014) - India	n = 500 (F = 243; M = 257)	n = 5333 (not reported)	Molars	18-67	Interproximal radiograph	Dental carious lesions, restored teeth; periodontal disease, atherosclerosis, cholelithiasis, kidney stones	Overall prevalence: 41.8% (209/500). Female gender was a significant predictor (F = 111/243 – 45.7%; M = 98/257 – 38.1%). Age was not a predictive factor. Pulp stones prevalence and systemic diseases were not significant.	Tooth prevalence: 9.09% (485/5333). Higher prevalence in periodontal patients (16.41%)
Calero-Hinostroza GC, et al.²² (2021) - Peru	n = 67 (F = 36; M = 31)	n = 1263 (not reported)	All teeth	18+	Cone-beam computed tomography	Dental carious lesion and teeth restoration	Overall prevalence: 82.08% (55/67). Female gender was a significant predictor (F = 18.4%; M = 12.4%). Age was a significant predictor: 18–28y (63/253 – 5%), 29–38y (64/234 – 5.1%), 39–48y (127/354 – 10.1%), 49–58y (77/229 – 6.1%), ≥59y (58/193 – 4.6%).	Tooth prevalence: 30.8% (389/1263). Highest prevalence in maxillary first molars (10.7%). Higher prevalence in teeth with carious lesion (11%).
Silva EJ, et al.²³ (2016) - Brazil	n = 382 (F = 222; M = 160)	n = 2833 (not reported)	All teeth (except third molars)	19-75	Cone-beam computed tomography	Teeth restoration	Overall prevalence: 31.9% (122/382). Gender was not a predictive factor (F = 32.5%; M = 31.2%)	Tooth prevalence: 9.5% (270/2833). Highest prevalence in maxillary molars (29.1%). Restored teeth showed higher prevalence (13%) than sound (6.4%) teeth.
Tarim Ertas E, et al.²⁴ (2014) - Turkey	n = 232 (Study group: 116; Control group: 116) (F = 106; M = 126)	n = 2795 (F = 1341; M = 1454)	Pre-molars and molars (except third molars)	20-74	Interproximal radiograph	Kidney stones	Overall prevalence per condition: kidney stone group (72.4% - 84/116), control group (74.1% - 86/116). Female gender was a significant predictor (kidney stone group: F=83.3%, M=67.5%; control control: F=77.1%, M=69.6%). Age was not a predictive factor.	Tooth prevalence: 20.9% (585/2795). Highest prevalence in first (45% and second (34%) molars.
Ezoddini-Ardakani F, et al.²⁵ (2010) - Iran	n = 61 (Study group: n = 38; Control group: n = 23) (F = 29; M = 32)	Not evaluated	Not specified	20-55	Panoramic radiograph	Atherosclerosis	Overall prevalence per condition: atherosclerotic group 82% (31/38), control group 48% (11/23). Female gender was a predictor in the atherosclerotic group (15/29 – 51.7%). Age ≥40 years (23/33 – 69.7%) in the atherosclerotic group was a predictive factor.	-
Gulsahi A, Cebeci AI, Ozden S²⁶ (2009) - Turkey	n = 519 (F = 313; M = 206)	n = 13474 (F = 8028; M = 5446)	All teeth	18-54	Periapical radiograph	Dental carious lesions, teeth restorations, cardiovascular diseases, autoimmune diseases and collagen diseases	Overall prevalence: 12% (60/519). Gender was not significant (F=37%, M=63%). Age was a significant predictor: 18y (1.47%), 19–29y (12.38%), 30–39y (13.38%), >40y (18.54%). No differences with systemic diseases.	Tooth prevalence: 5% (627/13,474). No significant differences with caries or restorations. Highest prevalence in molars.
al-Hadi Hamasha A, Darwazeh A²⁷ (1998) - Jordania	n = 814 (F = 332; M = 482)	n = 4573 (not reported)	All teeth	18-69	Interproximal radiograph	Not evaluated	Overall prevalence: 51.4% (418/814). Gender was not significant (F=40%, M=60%). Age was not a predictive factor.	Tooth prevalence: 22.4% (1028/4573). Highest prevalence in first molars (42%). No differences between maxilla and mandible.
Ivanauskaité D, et al.²⁸ (2021) - Lithuania	n = 531 (for analysis of overall pulp stone prevalence); n = 517 (for analysis of pulp stone prevalence by gender)^* (F = 285; M = 232) n = 494 (for analysis of pulp stone prevalence by age)^*	n = 2384 (not reported)	Molars	18-93	Periapical and interproximal radiographs	Not evaluated	Overall prevalence: 58.75% (312/531). Gender was not significant (F=57.9%, M=59.5%). Age was a significant predictor: 18–27y (49.6%), 28–37y (68.3%), >38y (71%).	Tooth prevalence: 34.9% (832/2384). Highest prevalence in first molars (46.53%) and maxillary (42%) teeth.
Kaabi HH, et al.⁶ (2023) - Saudi Arabia	n = 300 (F = 178; M = 122)	n = 3858 (not reported)	All teeth (except third molars)	18+	Cone-beam computed tomography	Dental carious lesion and teeth restoration	Overall prevalence: 98.3% (295/300). Male gender was a significant predictor. Age was not a predictive factor.	Tooth prevalence: 52.1% (2009/3858). Higher prevalence in first molars and maxillary teeth. Highest prevalence in carious/restored teeth.
Sönmez Kaplan S, Kaplan T, Sezgin GP²⁹ (2021) - Turkey	n = 1207 (F = 645; M = 562)	Not evaluated	Not specified	18+	Panoramic radiograph	Atherosclerosis and idiophatic osteoclerosis	Overall prevalence: 23.8% (287/1207). Female gender was a significant predictor (F: 28.5%, M: 18.3%). Age was a significant predictor: 18–29y (15.8%), 30–39y (31.2%), 40–49y (25.2%), 50–59y (25.2%), ≥60y (17.3%). No significant differences between pulp stones and atherosclerosis or idiopathic osteosclerosis.	-
Kenawi LM, et al.³⁰ (2024) - Saudi Arabia	n = 390 (F = 192; M = 198)	n = 10326 (F = 5244; M = 5082)	All teeth	18+	Cone-beam computed tomography	Dental carious lesion and teeth restoration, periodontal diseases, cardiovascular diseases, renal diseases and diabetes mellitus	Overall prevalence: 78.97% (308/390). Prevalence per condition: control group (84.61%), cardiovascular group (76.19%), renal group (62.5%), diabetes group (64.29%). Gender was not significant (F=78.65%, M=79.19%). Age was significant 18–30y (71.78%), 31–40y (82.14%), 41–50y (87.69%), ≥51y (84%)	Tooth prevalence:15.92% (1644/10326). Tooth type was a significant predictor: first molars (46.59%), second molars (34.18%), third molars (19.79%), second (7.56%) and first premolars (6.56%), canine (4.75%), lateral (2.12%), central incisors (1.54%). No differences between maxilla and mandible. Higher prevalence in carious (20.47%) and restored teeth (31.82%).
Mahajan B, et al.³¹ (2023) - India	n = 100 (F = 34; M = 66)	Not evaluated	Not specified	20-50	Not specified	Atherosclerosis and kidney stones	Overall prevalence: 41% (41/100). Prevalence per condition: atherosclerotic group (4%), kidney stone group (2%). Female gender was a significant predictor (F=48.4%; M=37.9%).	-
Mirah MA, et al.³² (2023) - Saudi Arabia	n = 500 (F = 250; M = 250)	n = 3009 (F = 1469; M = 1540)	All teeth	18+	Cone-beam computed tomography	Dental carious lesion, teeth restoration and periodontal disease	Overall prevalence: 26% (130/500). Gender was not significant (F=26.8%, M=25.2%). Age was a significant predictor: 18–24y (16.09%), 25–34y (29.17%), 35–44y (27.87%), 45–54y (34.52%), 55–64y (22.41%), and ≥65y (17.24%)	Tooth prevalence: 9.23% (278/3009; F=11.71%, M=8.75%). Higher prevalence in molars (85.6%), and maxillary teeth (66.9%).
Maranhão de Moura AA, Paiva JG³³ - (1987) - Brazil	n = 50 (Atherosclerosis group = 25; Control group = 25) (Males only)	Not evaluated	Not specified	40-60	Periapical radiograph	Atherosclerosis	Overall prevalence per condition: Atherosclerotic group 92% (23/25), control group 40% (10/25)	-
Patil SR, et al.³⁴ (2018) - Saudi Arabia	n = 428 (F = 236; M = 192)	n = 2982	All teeth	18+	Cone-beam computed tomography	Dental carious lesion, teeth restoration, attrition and periodontal disease	Overall prevalence: 50.93% (218/428). Male gender was a significant predictor (M: 58.9%; F: 41.15%). Age was a significant predictor: 19–28y (38.98%), 29–38y (47.22%), 39–48y (52.47%), 49–58y (62.92%), ≥59y (43.48%).	Tooth prevalence: 13.35% (398/2982). No differences between maxilla-mandible teeth. Sound teeth had lower prevalence (3.25%) than carious (22.46%), restored (20.51%), attrition (26.29%), and periodontally affected teeth (17.34%).
Ravanshad S, Khayat S, Freidonpour N³⁵ (2015) - Iran	n = 652 (F = 450; M = 202)	n = 8244	Pre-molars and molars (except third molars)	18-70	Periapical and interproximal radiographs	Dental carious lesion and teeth restoration	Overall prevalence: 46.9% (306/652). Female gender was a significant predictor (F: 51%, M: 37.6%)	Tooth prevalence: 11.25% (928/8244). Higher prevalence in first molars and maxillary teeth. No differences between dental status and pulp stones
Sezgin GP, Sönmez Kaplan S, Kaplan T³⁶ (2021) - Turkey	n = 637 (F = 362; M = 310)	n = 11494	All teeth	18-75	Cone-beam computed tomography	Teeth restoration	Overall prevalence: 24.2% (163/637). Female gender was a significant predictor (F: 28.9%; M: 18.7%). Age was a significant predictor: 18–29y (18.5%), 30–39y (31.1%), 40–49y (24.2%), 50–59y (24.3%), ≥60y (17.3%).	Tooth prevalence: 3.3% (379/11494). Higher prevalence in molars (92.1%) and in maxilla (69.4%). Medium-depth restorations had higher prevalence (46.8%) than shallow (26.6%) and deep restorations (26.6%).
Srivastava KC, et al.³⁷ (2020) - Saudi Arabia	n = 229 (Cardiovascular group = 73; Diabetes group = 76; Control group = 80) (F = 110; M = 119)	n = 4807 (Cardiovascular group = 1585; Diabetes group = 1564; Control group = 1658)	All teeth	20+	Cone-beam computed tomography	Cardiovascular diseases and diabetes mellitus	Overall prevalence: 22.27% (51/229). Prevalence per condition: cardiovascular group 32.87% (24/73), diabetes group 23.68% (18/76), control group 11.25% (9/80). Gender was not significant. Patients >50y had higher prevalence.	Tooth prevalence: 9.75% (469/4807). Prevalence per condition: cardiovascular group (16.65%), diabetes group (9.01%), control group (3.86%). First molars and maxilla showed significantly more pulp stones.
Tassoker M, Magat G, Sener S³⁸ (2018) - Turkey	n = 202 (F = 127; M = 75)	n = 5656	All teeth (except third molars)	18+	Cone-beam computed tomography and panoramic radiographs	Dental carious lesion and teeth restoration	Overall prevalence: 52% (105/202). Gender was not significant (F=54.3%; M=48%).	Tooth prevalence: 7.7% (434/5656). Restored teeth (73.5%) and carious lesions (62.1%) had significantly higher prevalence.
Yeluri G, Kumar CA, Raghav N³⁹ (2015) - India	n = 50 (F = 20; M = 30)	n = 461	Pre-molars and molars	30-60	Panoramic radiograph	Atherosclerosis and kidney stones	Overall prevalence: 88.28% (44/50). 86% (43/50) had atherosclerosis, renal calcifications, and pulp stones.	Tooth prevalence: 88.28% (407/461)
Gunen Yilmaz S, et al.⁴⁰ (2019) - Turkey	n = 60 (Atherosclerotic = 30; Control = 30) (F = 28; M = 32)	n = 1324	Not specified	22-78	Panoramic radiograph	Atherosclerosis	Overall prevalence: 30% (18/60). Gender was not significant (F=28.5%, M=31.2%). No differences between atherosclerotic (33.3%) and control (26.6%) groups.	Tooth prevalence: 17.9% (237/1324). No differences between or maxilla and mandible.

Author(s)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Total
Alaajam WH, et al.¹⁹ (2021)	Y	Y	Y	Y	Y	N	N	Y	Y	7
Alqahtani AS²⁰ (2024)	Y	N	N	Y	N	Y	Y	N	Y	5
Alsweed A, et al.⁵ (2019)	Y	U	N	Y	U	N	Y	N	Y	4
Bains SK, et al.²¹ (2014)	Y	U	N	Y	Y	Y	Y	N	Y	6
Calero-Hinostroza GC, et al.²² (2021	Y	U	Y	N	Y	N	Y	Y	Y	6
Silva EJ, et al.²³ (2016)	U	U	N	Y	N	Y	Y	U	Y	4
Tarim Ertas E, et al.²⁴ (2014)	Y	U	N	N	N	Y	Y	N	Y	4
Ezoddini-Ardakani F, et al.²⁵ (2010	Y	U	N	Y	U	N	Y	U	Y	4
Gulsahi A, Cebeci AI, Ozden S²⁶ (2009)	Y	Y	N	Y	Y	Y	Y	U	Y	7
al-Hadi Hamasha A, Darwazeh A27 (1998)	Y	Y	N	Y	Y	Y	Y	U	Y	7
Ivanauskaité D, et al.²⁸ (2021)	Y	N	N	N	N	Y	U	U	Y	3
Kaabi HH, et al.⁶ (2023)	Y	U	N	N	U	Y	Y	U	Y	4
Sönmez Kaplan S, Kaplan T, Sezgin GP²⁹ (2021)	Y	U	N	Y	Y	N	Y	U	Y	5
Kenawi LM, et al.³⁰ (2024)	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Mahajan B, et al.³¹ (2023)	Y	U	N	N	Y	U	U	N	Y	3
Mirah MA, et al.³² (2023)	Y	U	N	Y	Y	Y	Y	U	Y	6
Maranhão de Moura AA, Paiva JG³³ (1987)	Y	U	N	N	U	Y	U	U	N	2
Patil SR, et al.³⁴ (2018)	Y	U	U	Y	Y	Y	Y	U	Y	6
Ravanshad S, Khayat S, Freidonpour N³⁵ (2015)	Y	Y	N	Y	N	Y	N	U	Y	5
Sezgin GP, Sönmez Kaplan S, Kaplan T³⁶ (2021)	Y	Y	N	Y	Y	Y	Y	Y	Y	8
Srivastava KC, et al.³⁷ ( 2020)	Y	U	N	N	Y	Y	Y	U	Y	5
Tassoker M, Magat G, Sener S³⁸ (2018)	Y	Y	N	Y	Y	N	N	U	Y	5
Yeluri G, Kumar CA, Raghav N³⁹ ( 2015)	Y	U	N	N	N	N	Y	U	Y	3
Gunen Yilmaz S, et al.⁴⁰ ( 2019) - Turkey	Y	U	N	N	Y	N	Y	U	Y	4

Variable	Coefficient (SE)	p	Coefficient (SE)	p
	Individual level		Individual level
	Full model		Final model
	Adjusted R²=17.2		Adjusted R²=26.0
Older adults	0.04 (-0.37 – 0.38)	0.98
Country
Others than Saudi Arabia/Turkey	0.18 (-0.12 – 0.48)	0.22
Systemic diseases
Cardiovascular diseases	-0.21 (-0.61 – 0.19)	0.27	-0.33 (-0.65 – 0.02)	0.04
Cardiovascular and renal disease	0.31 (-0.08 – 0.70)	0.11	0.31 (0.01 – 0.61)	0.04
Tooth
All teeth	-0.07 (-0.59 – 0.46)	0.78	-0.29 (-0.67 – 0.10)	0.13
Premolars and molars	-0.30 (-0.78 – 0.18)	0.19	-0.44 (-0.85 - -0.02)	0.03
Molars only	-0.36 (-0.98 – 0.25)	0.23	-0.45 (-0.98 – 0.08)	0.09
Sex
Higher prevalence in males	0.24 (-0.11 – 0.59)	0.17
Higher prevalence in females	0.05 (-0.24 – 0.35)	0.70
Diagnostic method
With tomography	-0.05 (-0.48 – 0.37)	0.78

Certainty assessment
Number of studies	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Overall certainty of evidence
24 studies	Very serious ^a	Very serious^b	Not serious	Very serious^c	None	⨁◯◯◯
24 studies	Very serious ^a	Very serious^b	Not serious	Very serious^c	None	VERY LOW

[TFN1] ^* Participants excluded from the analysis due to missing information on gender or age.