Relationships between

or occlusal trauma in a tooth may also produce pulpitis.

Endodontics and Periodontics

The initial response of the pulp to the irritant is

hyperemia, the mildest of all deviations from the histologically normal pulp and the first to be given histopathological description. Once the phenomena associated with the hyper-reactive pulp are left behind, the
microscopic aspects of pulpal disease assume the nature
of a spectrum. The process of pupal inflammation is
often reversed and is followed or accompanied by the
laying down of reparative dentin. The first phase of the
degeneration includes vascular dilation, localized edema, displacement of odontoblast cell nuclei, and establishment of the inflammatory infiltrate. The infiltrate
represents cell and fluid inflow, the fluid being a highly
significant part of the connective tissue change resulting
in pulpal death. Pulpal death is thought to be due to
a combination of factors associated with increased intrapulpal tissue pressure:
(1) alternation of cellular
metabolism, (2) interference with the blood supply
resulting in stasis, and (3) decrease in the lymphatic
drainage of toxic metabolites. The spectrum of pulpal
inflammation may result in either acute or chronic pulpitis or in partial or complete necrosis of the pulp. A t
this point the relationships of the pulp and the periodontium become evident. Necrosis of the pulp invariably results in extension of the inflammatory process
into the periapical tissue. The inflammatory process
results in destruction of the periapical portion of the
attachment apparatus.

by
H E R M A N A . BLAIR,* B.S., D.M.D., M.S.D.
A L L DENTAL T R E A T M E N T SEEKS to preserve and main-

tain the teeth and supporting structures in a state of

health and function. Both periodontics and endodontics
are vitally concerned with the health of the supporting
structures of the teeth. Their inter-relationship is noted
in many forms of treatment. For example, some think
of root canal therapy as a specialized form of periodontics, since an intact healthy periodontium is essential in order to provide healthy roots upon which the
forces of occlusion must ultimately be borne.

Periodontists treat damage to the attachment apparatus (cementum, periodontal membrane and alveolar
bone), at its margin, while endodontists treat damage
to these structures in the periapical area. Loss of alveolar bone, either in the form of crestal resorption or
development of infra-bony pockets, is a common result
of periodontal disease, and results in loss of support
and mobility of involved teeth. The endodontically involved tooth usually presents a different pattern of bone
loss. Apical to the normal marginal bone, the attachment apparatus is lost as a result of apical extension
of pulpal pathosis. The attachment apparatus lost due
to crestal resorption is rarely regained, while complete
regeneration of periapical bone is routinely achieved
after endodontic therapy.

The periapical lesion may take several forms depending upon toxicity of the irritant and the resistance
of the surrounding tissue. Many times a suppurative
lesion may develop a fistula or chronic draining sinus
tract with drainage through the alveolar bone into the
oral cavity or the periodontal ligament space.

1-5

Because of the increasing demand for dentition preservation the use of combined therapy has become an
important adjunct to the achievement of this goal. The
inter-relationship of diseases of the periodontium and
of the pulp has been speculated upon for many years.
A brief review of the pathogenesis of the pulpal and
the periodontal lesion will demonstrate their close relationship.

PATHOGENESIS OF PERIODONTAL DISEASE

Diseases of the periodontium are common and are

the greatest cause for loss of teeth in adults. The condition begins as a minor localized disturbance which,
unless adequately treated, may gradually progress until
the alveolar bone is resorbed and the tooth is exfoliated.
A variety of local irritating factors and underlying systemic conditions may alter the progress of the disease.
7

PATHOGENESIS OF P U L P A L DISEASE

Pulpal inflammation, necrosis or dystrophy may be

caused by any of a variety of irritating factors. Many
cases of pulpal disease are a result of dental caries in
which bacterial infection of the pulp tissue occurs.
Chemical irritation of the pulp, severe thermal changes

The initial lesion of periodontal disease is marginal

gingivitis which is generally accepted to be produced
by a local irritant, most commonly calculus and/or its
associated bacterial mass. The irritant induces an i n flammatory response characterized by swelling, loss of
stippling, redness, change of physiologic contours, and
a tendency to bleed easily. Swelling and ulceration of
the sulcular epithelium results in pocket formation. Invasion of micro-organisms and progression of the i n -

* Instructor (Part-Time); University of Kentucky College of

Dentistry; Department of Endodontics; Lexington, Kentucky
40506.

209

210

J. Periodontol.
April, 1972

Blair

flammatory process results in derangement of the gingival fiber apparatus, and apical migration of the
epithelial attachment. Once the gingival and transeptal
fibers are destroyed the inflammatory process spreads
apically via the perivascular channels into the marrow
spaces of the alveolar bone, with resulting resorption
in the area. Once bone resorption has occurred, the
process has proceeded from gingivitis to early periodontitis. A s this resorptive process continues, additional
destruction of supporting bone occurs with further
apical migration of the epithelial attachment, leading
to an extension of the marginal periodontitis to an
apical periodontitis. Once the lesion extends to the
periapical area, the possibility of invasion of the pulpal
tissue through the apical foramen by micro-organisms
is obvious and pulpal death may result. The presence
of accessory canals may be the primary channel through
which micro-organisms may communicate from the pulp
to the periodontal tissues or vice v e r s a .
8

912

RATIONALE OF THERAPY

Since both pulpal and periodontal lesions have been

shown to affect the attachment apparatus, before therapy can be instituted a determination must be made
as to whether a pulpal, periodontal or combined lesion
is present. Therapy is directed toward the removal of
the etiologic factors responsible for the tissue destruction. A variety of techniques are employed to minimize
tissue destruction, to institute repair of the supporting
structures, to prevent tooth loss, and maintain the i n tegrity of the dental arch.
Depending on etiology, the lesion may respond to
either endodontic or periodontal therapy alone. Other
more complicated measures are required to treat the
co-existant pulpal and periodontal lesions, again indicating the close relationship between endodontics and
periodontics.
The treatment of choice is the simplest procedure
that will obtain the most ideal therapeutic result. T o
this end, endodontic therapy assumes a position of
great importance. Through its utilization many objectives of therapy can be satisfied.
Situations i n which combined periodontal and endodontic therapy are commonly employed include the
prevention of periodontal destruction and certain treatment procedures.
Maintenance of arch continuity is among the most
important steps in preventing the development of periodontal lesions. Many times the loss of a single tooth
(with or without replacement) results in the initiation
of periodontal disturbances. Tooth loss results i n drifting and tipping of adjacent teeth and the development
of local environmental conditions favoring the develop-

FIGURE 1A. Periapical radiograph showing massive loss

of bone related to the non-vital teeth.

ment of marginal periodontal disease. Many times the

loss of the all important first tooth may be prevented
via routine root canal therapy, thus preserving the integrity of the dental arch, removing the necessity of
prosthetic replacement and preventing the periodontal
problem from developing.
Traumatic injury of anterior teeth frequently results
in pulpal death, and all too often the unnecessary extraction of these teeth produces both periodontal and
restorative problems. This is especially true i n the case
of mandibular incisors, which present an unusually
difficult replacement problem. Here the advantages of
root canal therapy are obvious. The importance of
maintenance of arch continuity can not be over emphasized in the prevention of periodontal disease.
The typical periapical lesion responds well to routine
endodontic therapy. The lesion is shown by a roentgenographic radiolucency limited to the apical region
(Figure 1 A ) . Repair of the attachment apparatus and
bone repair is a predictable result once the etiologic
factors are removed and the root canal is adequately
filled (Figure I B ) . Thus the tooth is maintained and
arch continuity is preserved. It is important to note
that the integrity of the supporting structures, and not

Endo.-Perio. Relationships 211

Volume 43
Number 4

FIGURE 2A. Often one finds the presence of an apical

area of rarefaction communicating with the margin via the
gingival sulcus.

FIGURE 1B. Apical repair following routine endodontic

therapy is predictable as illustrated by this one year posttreatment radiograph.

the vitality of the pulp, is the determining factor in

tooth maintenance.
In more advanced lesions of pulpal origin, i n addition to the apical radiolucency, there is evidence of
alveolar bone destruction by extension of the radiolucency into the crestal bone (Figure 2 A ) . The clinical
picture usually seen is that of a non-vital tooth with
surrounding gingival tissues in good position with minimal inflammation present. There is suppuration present
via a periodontal pocket indicating the presence of a
combined pulpal-periodontal lesion, and apparent damage to the attachment apparatus. Many of these cases
will respond to endodontic therapy alone. After routine root canal therapy is completed, resolution of the
radiolucency and reattachment usually occurs, restoring the tooth to health and function (Figure 2 B ) .

FIGURE 2B. Post-treatment radiograph shows repair of

the communicating lesion with endodontic therapy alone.

13

Less frequently routine root canal therapy appears

to be unsuccessful and the radiolucency either remains
or increases in size, indicating that the lesion was not
purely of pulpal origin. Treatment in this case must
include some type of periodontal therapy.
In a certain number of cases periodontal involvement precludes routine endodontic therapy. In these
instances it is often impossible to obtain negative cultures or even dry the canals as the result of communication with periodontal lesion. In these cases periodon-

tal therapy must precede or accompany the root canal

rilling.
The most important factor to be considered when
treating the combined lesion is to establish the vitality
of the involved tooth or teeth.
Often the clinical picture is that of a funnel shaped
pocket extending from the gingival margin apically,
with communication between the marginal and the apical lesions. The classical signs of gingival inflammation
are present and mobility is present due to loss of attachment. Depending upon the extent of destruction,
extraction may be indicated. In most cases, however,
combined therapy will be successful.

212

Blair

J. Periodontol.
April, 1972

FIGURE 3A. This radiograph illustrates a maxillary first

molar with a combined periodontal and pulpal problem.

The actual therapy planned depends upon form and

extent of bony destruction, location of the tooth in
the dental arch, and the vitality of the pulp. Once the
lack of vitality of the pulp is determined, root canal
therapy may be initiated. The required periodontal
therapy may vary from attempts at reattachment, to
root amputation or hemisection with endodontic therapy
on the remaining roots.
If the tooth is vital and
the bony configuration meets the requirements for infrabony techniques, reattachment is the objective choice.
If the tooth is non-vital or bony topography precludes
the reattachment attempt (Figure 3 A ) , amputation of
the affected root with combined root canal therapy may
be indicated. By use of these combined techniques the
remaining tooth or portion of the tooth (Figure 3B)
may be utilized as a unit, or may serve as an abutment
for fixed prosthesis.
14-20

FIGURE 3B. Following endodontic, periodontal and restorative treatment this tooth has been returned to health
and function.

of the combined periodontic-endodontic lesions has

been discussed.
Today's concept of conservative, preventive dentistry is dedicated to the preservation of the maximum
amount of the supporting structures of the natural dentition in a state of health and function. The techniques
of combined therapy have proven to be a valuable aid
in obtaining this objective.

21

22

Splinting of teeth with advanced periodontal disease

by the use of full coverage occupies a prominent position in dentistry. Many times periodontal prosthesis involves the removal of sound tooth structure. Pulpal
exposure during tooth preparation for the prosthesis is
not uncommon. In these situations endodontic therapy
has become an important part of oral reconstruction.
Many times the clinical position of remaining
teeth dictates the intentional extirpation of vital pulps
in order to improve the parallelism of crown preparations, reduce the crown-root ratio and reorient the
occlusal plane. Splinting periodontally involved teeth
with a metallic post implanted as deeply as possible into
the bone through the root canal has also shown some
success.
2 3 2 4

25

26,

2 7

SUMMARY AND CONCLUSION

The etiology, pathogenesis and rationale of therapy

REFERENCES

1. Hiatt, W. H . : Regeneration of the Periodontium

after Endodontic Therapy and Flap Operation, Oral
Surg, 12:1471, 1959.
2. Hiatt, W. H . : Periodontically and Endodontically
Involved Teeth, Trans. Third Internat. Conf. Endo. Univ.
of Penn. Press, p. 201, 1963.
3. Hiatt, W. H . : Periodontal Pocket Elimination by
Combined Endodontic-Periodontic Therapy, Perio. I, p.
152, 1963.
4. Hiatt, W. H . , and Amen, C. R.: Periodontal
Pocket Elimination by Combined Therapy, D . Clin. N .
Amer, p. 133, 1954.
5. Maxem, H . A . : The Expanding Scope of Endodontics, J. Mich. Dent. Ass, 41:25, 1959.
6. Seltzer, S, et al.: The Inter-relationship of Pulp and
Periodontal Disease, Oral Surg, 16:1475, 1963.
7. Shafer, W. G , Hine, M . K , and Levy, B. M . : A
Textbook of Oral Pathology, ed. 2, Philadelphia 1963,
W. B. Saunders Company.
8. Weinmann, J. P.: Progress of Gingival Inflammation into the Supporting Structures of the Teeth, J. Periodont, 12:71, 1941.
9. Biddington, W. R.: Relation of Endodontics to
Periodontics, W. Va. S. Dent. Ass, J , 37:5,
1963.
10.
Ruback, W. C. and Mitchell, D . F . : Periodontal
Disease, Accessory Canals and Pulp Pathosis, J. Periodont, 36:34, 1965.
11. Scopp, I. W , Heyman, R. A . , and Maiman, D . M . :
Endodontics as Aid to Periodontal Therapy: Report of a
Case, J. A . D . A , 68:685, 1964.

Volume 43
Number 4

Endo.-Perio. Relationships 213

12. Simring, M . , and Goldberg, M . : The Pulpal Pocket Approach; Retrograde Periodontitis, J. Periodont., 35:
22, 1964.
13. Schilder, H . : Periodontically-Endodontically Involved Teeth, Trans. Third Internat. Conf. Endo., Univ.
of Penn. Press, p. 178, 1963.
14. Amsterdam, M . , and Rossman, R. S.: Technique
of Hemisection in Multirooted Teeth, Alpha Omegan,
53:4, 1960.
15. Everett, F. S.: Bifurcation Involvement, Oregon S.
Dent. Ass. J., 28:2, 1959.
16. Farrar, J . : Radical and Heroic Treatment of
Alveolar Abscess by Amputation of Roots of Teeth with
Description and Application of the Cantiliner Crown,
Dent. Cosmos., 26:135, 1884.
17. Lloyd, et al.: Periodontal Therapy by Root Section, J. Pos. Dent., 10:362, 1960.
18. Messinger, T . F., and Orban, B. J . : Elimination of
Periodontal Pockets by Root Amputation, J. Periodont.,
25:213, 1954.

19. Pearson, H . H . : Hemisection of Lower Molar:

A Case Report, Dent. Digest, 61:256, 1955.
20. Salman, L . : Root Amputation, N . Y . State J.
Dent., 24:79-86, 1958.
21. Prichard, J.: The Infrabony Technique as a Predictable Procedure, J. Periodont., 28:202, 1957.
22. Camara, J. A . : Conservation of Teeth Through
Endontia and Periodontia, Dent. Survey, 32:1307, 1956.
23. Leavitt, J. M . : Endodontic Adjuncts to Oral Rehabilitation, D. Clin. N . Amer., p. 723, 1963.
24. Healey, H . J . : The Pulpless Tooth in Rehabilitation of the Mouth, J. A . D. A . , 58:69-74, 1959.
25. Bohannan, H . M . , and Abrams, L . : Intentional
Vital Pulp Extirpation in Periodontal Prothesis, J. Pros.
Dent., 11:781, 1961.
26. Orlay, H . C : Endodontic Splinting in Treatment
in Periodontal Disease, Brit. Dent. J., 108:118, 1960.
27. Frank, A . L . : Endodontic Endosseous Implants
and Treatment of the Wide Open Apex, D. Clin. N .
Amer., p. 675, 1967.

Announcement
"PERIODONTAL PROSTHESIS"
November 2-4, 1972
Gerald M. Kramer, D.M.D.
Myron Nevins, D.D.S.
Howard M. Skurow, D.D.S.
This course is designed to correlate periodontal therapeutics
and advanced restorative procedures in the treatment of pathologic conditions of the teeth and their supporting structures.
This integration will stress a full mouth concept by including
a detailed discussion and demonstration of periodontal diseases
and their treatment, occlusion and articulation, treatment
planning and restorative procedures for fixed and removable
prostheses. Slides will be used to describe all techniques in detail, and presentation of various case types will be included.
Enrollment limited to 12.
Fee: $165.
"CURRENT CONCEPTS IN PERIODONTAL HISTOLOGY
AND PATHOLOGY"

An intensive review of concepts related to the development,

histology, physiology and pathology of the periodontium and
contiguous tissues. Detailed discussions of the healing of periodontal wounds, and oral medicine and pathology, as they pertain to periodontology, will also be presented.
The program is designed as a comprehensive review for the
Certification Examinations given by the American Board of
Periodontology in October, 1972. Course hours: Daily from
8:30 A.M. to 6:00 P.M.
Fee: $300.

CLINICAL PERIODONTAL SURGERY

December 14-16, 1972
Gerald M. Kramer, D.M.D.
Professor and Chairman
Department of Periodontology
J. David Kohn, D.D.S.
Associate Professor of Periodontology

August 28-September 1, 1972

Morris P. Ruben, D.D.S.
Henry M. Goldman, D.M.D.
Richard Stallard, D.D.S., Ph.D.
Sigmund S. Socransky, D.D.S.
Edgar E. Baker, Ph.D.
Sidney M. Schulman, D.D.S.
Melvyn H. Harris, D.M.D.
Sidney Kibrick, M.D.
Stephen Anapolle, D.M.D., D.Sc.D.
Leonard Shapiro, D.M.D., M.Sc.

This course is designed specifically to analyze, discuss, and demonstrate the many-faceted surgical approaches employed in the
management of periodontal disease, and consists principally of
demonstrations of the new variations of accepted surgical techniques. Specific discussion of instruments, and preoperative management of the surgical case will be a major part of the course.
Enrollment limited to 12.
Fee: $ 175
For further information please write to: Assistant Dean for
Continuing Education, Boston University School of Graduate
Dentistry, 100 East Newton St., Boston, Mass., 02118