Inttmatianal Endodontic Journal (1985) 18,41-54
The relationship between periodontal and pulpal disease
p. H. A. G U L D E N E R , Hehetiastrasse 9, Berne, Switzerland
Summary. The relationship hetween periodotital
disease and pulpal disease is reviewed byfirstconsi-
dering their pathogenesis and differetitial diagnosis.
The author then proposes a classification of lesions
based mainly on their aetiolog}'; this is primary
endodontic lesion, primary periodontal lesion and
combined lesion. The treatment of the various types
is described in detail.
Introduction
It Is well known that the dental pulp and the
periodontal tissues have a close interrelation-
ship, both anatomically and functionally (Hiatt
1959, 1964, 1977, Schilder 1963, Seltzer «ai.
1963, Simon & Jacobs 1969, Seltzer 1971, Ross
1972, Blair 1972, Cliacker 1974, Guldener
1975, Simon 1980). The apical foramen is the
most itnportant but by no means the only
location where these tissues meet. Lateral and
accessory canals, mainly in the apical area and
in the furcation of molars, also connect the
detital pulp with the periodontal ligament. In
addition, a great nuniiber of dentinal tubules
extend from the pulp to the cementum on tbe
root surface. If the cementum is removed, e.g.
scraped away by root planing, toxic substances
can be transmitted from the pulp to the
periodontal ligament or vice versa.
Many dentists consider endodontic and
periodontal lesions as separate entities. Obvi-
ously, because periodontal disease and pulpal
infections are treated diflFerently, naany den-
tists in the last 40 years have specialized
in ]}eHodontics or endodontics. Combined
periodontal-endodontic lesions require both
root canal therapy and periodontal treatment
to save the tooth involvwl.
Pertodonttsts, being mainly concerned with
treating gin^val and periodontal disease,
have little specialized knowledge about the
problems of the diseased pulp. On the other
Correspondence: P. H. A. Guldener, Helvetia-
strasse 9, 3005 Berne, Switzerland.
hand, endodontists fi-equentiy have a lack of
understanding concerning the treatment of the
diseased periodontal tissues.
Therefore, it is important to correlate these
two entities, as confusion exists with regard
to aetiology, diagnosis and therapy (Sinai &
Soltanoff 1973).
Pathogenesis
The effect of periodontal lesions on pttlp tissue
Investigations on teeth in man and animals
(rat, dog and monkey) have shown that the
pulp may react in a variety of ways in the pres-
ence of periodontal disease (Mazur & Massler
1964, Seltzer et al. 1967, Bender & Seltzer
1972, Langeland tfa/. 1974, Seltzer & Bender
1975). The pulpal reaction may be infiuenced
not only by the stage of periodontal disease,
but also by the type of periodontal treatment,
such as scaling, root planitig and admitiis-
tratlon of medicaments (Stallard 1967). The
size, number and location of accessory canals,
the area of exposed root and the amount of
toxic substrates being transmitted into the
pulp may also be important in the consequent
severity of puipal damage (Sinai & Soltanoff
1973, Bergenholtz & Lindhe 1975). Pulpal
changes due n periodontal disease may occur
in teeth with or without caries or restorations
(Seltzer et al. 1%3). The predominant pulpal
changes due to toxic agents and medicaments
which penetrate into the pulp via lateral catials
or dentinal tubules are degenerative in nature
(secondary dentine formation, internal resorp-
tion, fitHosis) (Rubach & Mitchdl 1965a).
Inflammatory lesions of varying severity and
necrotic pulp tissue are usually found in teeth
with large canats or in cases where the
periodonol breakdown has extended to the
apex (Stahl 1966). In these inst^ces, apical
granulomata, necrotic putp tissue in the
apical region and enemal root resorpticHi
can be diagnosed (Simring & GtJdberg 1964,
4i
42 P. H. A. Guldener
Langeland et til. 1974). In about 40 per cent
of cases the pulp remains normal (Mandi
1972).
The effect of pulpal lesions on periodontal tissue
Obviously, an infected or necrotic pulp may
cause a periodontai lesion (Bergenholtz 1977,
Sinai & Soltanoff" 1973). Endodontically-
induced periodontal changes are referred to as
periradicular lesions (periapical, lateral, furca-
tional). The periodontal response is always
inflammatory in nature, either acute (alveolar
abscess, apical periodontitis) or chronic (granu-
loma, cyst) (Stahl 1966). The lesion can. be
localized at the root apex or at the orifice of
a lateral canal within the periodontal ligament.
In addition, a sinus tract can develop which
may extend from the apex to the furcation area
or even to the gingival sulcus. Such a sinus
tract must be distiogaished from a periodontal
pocket. Endodontic treatment alone will cause
the resolution of the sinus tract and healing of
the damaged periodontal tissue.
Combined periodontal and endodontic lesions
First one has to distinguish separate periodon-
tal and endodontic lesions which may occur
independently on a tooth from those endodon-
tic and pedodontic lesions which join {Rubach
& Mitchell 1965b, Simon & Jacobs 1969). At
the latter stage both lesions are indistinguish-
able froHi each other and it is not possible to
tell whether the primary lesion was endodontic
or periodontal.
Diagnosis
Diagnosis of periodontal lesions
Periodontitis is detected by clinical examin-
ation (tissue colour and texture, pocket depth,
bleeding tests), by radiographic interpretation
and by histological findings. Tooth mobility is
a frequent observation of moderate and ad-
vaeced periodontitis, frequently in combination
with occiusal trauma.
Diagnosis of endodontic lesions
Clinically, the condition of the pulp can be
classified as a normal puip, reversible pulpitis,
irreversible pulpitis or pulpal necrosis. Peri-
apical lesions of pulpal origin can be clas.iiified
as apical periodontitis, acute alveolar abscess.
granuloma, radicular cyst, and chronic alveolar
abscess.
Acute pulpitis is detected by clinical signs
and symptoms (pain), including thermal and
electrical pulp tests. Radiographs are important
for the detection of caries.
Clinically, pulp degeneration is not an im-
portant lesion under ordinary circumstances.
Pain is generally absent when degeneration is
limited to puipal tissue. Degenerative changes
such as reactionary dentine formation and
intertia! resorption can be detected radio-
graphically. However, hyalinization, atrophy
and fibrosis are degenerative changes which
cannot be detected on radiographs since they
are radiolucent.
Histopathologically, the various stages of
acute and chronic pulpitis or degenerative
changes do not affect the treatment plan; in al!
these situations pulpectomy is indicated.
Classification
The classification of teeth with pulpo-
periodonrai changes suggested by the author is
based mainly on the aetiology of the disease
(Guldener 1975, Hiatt 1977,""Simoo 1980).
Class I: primary endodsntic lesion
Class l(al. Accidental perforations (intra-
alveolar) or resorptive perforations (internal
resorption).
Class 1(B). Chronic periradicular lesion
(granuloma or cyst) or acute periradicular
lesion (alveolar absce.ss).
Class 11: primary periodatmJ lesions
Class n(A). Advanced periodontal disease
with or without extension to the apicai area
{pulp vital).
Class 11(B). Secondary' endodontic involve-
ment. Infection through lateral canals or
dentinal tubules. Pulpal necrosis with or with-
out secondary periapicai Involvement {pulp
non-vital).
Class HI: combined lesion
True combined lesion (coalescence between
periodontal and endodontic lesion) or vertical
crown-root fracture with pulpal iavolvement.
 Rdatwmhip betmeen periodontai and pulpal disease 43

Therapy 6. Diodontic implant

Treatment of a tooth with pulpo-perlodontal 7. Hemisection, tooth separation, root ampu-
changes should not he started before a defini- tation
tive diagnosis has been established. Then, it 8. Intentional replantation
must he determined whether or not the tooth 9. Extraction
involved can he sa%'ed. If the tooth or part of
a multirooted tooth can he saved, success may /. Root cana! treatment
he influenced by the technique used and the Root canal treatment only in the presence of
sequence of therapy (Chacker 1974, Schilder periradicular lesions is discussed here. Fre-
& Grossman 1978)' quently, the lesion, if chronic, is located peria-
pically and consists of a widened periodontai
Therapy of primar)' endodontic lesions with
ligament, a granuioma or a cyst. Less fre-
involvement of the periodontal tissue and
quently, lateral or interradicular lesions on
therapy of primarj' periodontai lesions with
multirooted teeth may also occur, when the
secondary pulp infection may be identical; this
pulpal inflammation extends through lateral
is also true for the treatment of combined
canals into the periodontai ligament space and
lesions. Therefore, the following therapeutic
causes resorption of the adjacent bone. Perira-
procedures will be discussed.
dicular lesions of endodontic origin are always
Root canal treatment
caused hy pulpal infection. Root canal treat-
Treatment of accidental perforations
ment without surgerj- is indicated regardless of
non-surgical
the size ofthe radiolucency (Fig. 1).
surgical
Schilder's 1962 study (Schilder & Grossman
Treatment of resorptive perforations
1978) in which 100 anterior teeth with
Incision for drainage
periapical radiolucencies (diameter 8-30 mm)
tndodontic apical surgerj*
were treated non-surgically, demonstrated
— periapical curettage
complete bone regeneration in all cases but one
— root resection (apicectomy)
after 2 vears. The treatment which failed was
— apical fistulation

Fig. 1. (a) l.iwcr first premolar with periapical radiolucency. (b) Two years after root canal treatment
of the alveolar hone mav be noted.
44 P. H. A. GuMener
•'1
Fig. 2. (a) Perforation in the middle third of the riiot ol J. (.cment t..n :H .icitUL-.l .uii.Kfi;- M ihc pcrlur-
atioo (bi THo-and-a-hail~}ears after surfncal treatmcar o! the perlfirarion with silver amaR^am. Nutc alsn
tht root canai liiiinK was redone.
on a maxillary lateral incisor with two roots,
in which only one root canal had been filled.
2. Therapy of acciderMiperforations
Accidental perforations are treated surgically
or non-surgically, depending on their size and
location (Seltzer et al. 1970). They can be
classified into four groups:
Class 1: Cromi or root perforations coronal to
the epithelial attachment. If the perforation
occurs corona! to the gingiVal tissue, it is
visible and can easily be sealed from the out-
side using composite resin. This is the only
perforation which does not damage the perio-
dontal tissue. If the perforation is located with-
in a periodontal pocket, a small flap is raised
to allow the perforation to be treated in a
similar manner.
Class II: Perforations in the middle third of the
root. The treatment is either surgical or non-
surgical, depending on the size and location of
the perforation. If the perforation was created
with a root canal instrument, it is usualh"
small. The perforation canal is then treated
like an additional root canal. Care has to be
taken not to overfill this artificial canal into the
periodoMa! ligatnent space. If, on the other
hand, the perforation is made with z bur during
preparation for a post hole, the perforation
should he sealed from the outside with zinc-
free silver amalgam (Fig. 2).
Class US: Perforations in the apical third of the
root. Class III perforations are the most fre-
quent type, often due to the 'zipping effecf
described by Weine et al. (1976). In many
instances, the perforation can be sealed con-
servatively. If the perforated canal is slightly
overfilled and the symptom-free periapical
lesion heals uneventfully, no further treatment
is indicated. But, if clinical symptoms occur
or an area can be detected radiographically,
endodontic surgery is indicated (Fig. 3).
 Relationship hetmem periodonlal and pulpa! disease
Fig. = . I • •I i h e tooth was sensitive lo percussion, (b) Ten months after
apkt
Ciasi IV: Perforatiims in the interradicular
space of multirooted teeth. The rype of treatment
iodicated depends on the size of the perfor-
ation and also on the health of the periodontal
tissue. Perforations of small diameter are
treated non-surgically. The perforation may be
sealed with stiver atnalgam, gold foil or gutta-
percha and root canal sealer. If, however, the
perforation is large ( > 2 mtn) root separation
or hemisection is the treatment of choice.
i. Therapy of resorptive perforations
Internal resorptions that have perforated
into the pedodonta! ligament space mtist be
distinguished from e.xternal resorptions that
perforate into the pulp.
Perforated internal resorptions can be
treated non-surgically, but more frequently
require surgical therapy. The conservative
approach, suggested by Frank (1967), consists
of filling the entire root canal with calcium
hydroxide, after the root canal systetn has been
thoroughly cleaned and shaped, to induce
cememogenesis. .4fter 2—3 months, calcium
45
hydroxide is replaced by the definitive root
canal filling: gutta-percha and sealer. The
surgical treatment consists of reflecting a flap
and sealing the perforation from the outside
with silver amalgatn (Fig. 4).
External resorptions which are caused by
pulp infection, in many instances can be
successfully treated by root canal therapy.
The resorptive lesion will cease to progress.
External resorptions caused by trauma require
surgical intervention (Fig. S).
4. Incision for drainage
In the presence of an acute alveolar ahscess,
periodontal tissue is destroyed because of
pulpal infection. If the abscess has perforated
through the periosteum, there will be a fluc-
tuaot STvelling of pus which can be displaced
by palpation. To establish drainage, a sharp
incision with a scalpel is tnade through the
alveolar inucosa to bone. A drain (gauze strip
or T-shape rubber dam) is placed into the
wound to provide a channel for discharge of
pus and blood.
46 P. H. A. Guldener

"b

Fig. 4. (a) Internal resorption affecting 1/, labial perforation of the internal resorption cannot be seen on
the radiograph, (b) The defect was filled with silver amalgam, and an apicectomy was nho performed,
(c) Radiograph several weeks after surgery.
 Relationship helween periodontal and pulpal disease 47

Fig. $. (a) External lateral resuvpiioi: ,nid apit. I-- itcly

hair the root was resected to eiiriiruitc iicsth ks.- • .',-up
radiograph 2 | years after surgery.

T a b l e I. The effect of the clinical condition on treatment

Treatment

Apical Root Periapical Retro- Root canai

Clinical condition Symptoms
Svmpton: fistulation resection curettage filling treatment

Canai blocked Acute

Chronic
Canal patent
Canal underfilled Acute
Canal not Bcgotiatak Acute
due to severe ciin-aturc Chroaic
Apical perforation None-
Acute
Apical lesion which Chronic _/ 4,! __/ ^
does not heal
Canal which cannot Chronic
be dried
Canal overfilled
with symptoms Acute

4- —Treatment indicated.
—^=:Treatment not indicated.
^The tooth mav l>e treated sureicaMv instead ofbv root canal treatmeot.
 48 P. H. A. Guldmer

• •

< - • , • ••

Fi^;. 0. l;ii !loot canal filling with hot gutta-percha and vertical condensation (Schilder). Two lateral canals
wert rilk-d near the apex; overextended root canal filling material is present within the periapica! lesion,
(b) Periapical healing U years after periapical curettage.

5. Endodontic apical surgery (i) Periapical curettage. PeriapicaS curertage

This term, suggested by the author is more
precise than the term '.A.picectoray'. Apicec-
tomy is only one step in a procedtire which also
requires periapical curettage and in many but
not al! itistances, a retrofilling. Sometimes,
apical surgery is performed without apicec-
tomy. Finally, the root is not always resected
at the tip. .Access in the molar and premolar
area for placing a retrofilling is often only
gained if mid-root resection is performed;
hence the term 'root resection' should be
substituted for the term 'apicectomv' (Table
I)-
Endodontic apical surgerj' may be divided
into:
(i) periapical curettage;
(ii) root resection with periapical curettage;
and
(iii) apicai fistulation.
is indicated mainly when root canal is over-
filled, persistent pain exists and a root canal
retreattnent is usually not feasible. A small flap
is raised and surgical fenestration of the alveo-
lar bone at the apex is performed. With a small
periodontal curette, the excess root filling
material and granulation tissue, if present, is
removed. In most instances, resection of the
root tip is not required (Fig. 6).
(ii) Root' resection. When root resection is
done, periapical curettage is always performed
as well. The Indication for this common surgi-
cal treatment is mainly limited to the following
situations.
1. Obstruction of the root canal (posts, broken
instruments, calcifications).
2. Tortuous root canal that cannot be pre-
pared to the apex.
 Relalionship iietwecn periodental and pulpal disease 49

Fig. 7. (a) Incomplete root cana! filling of 6^-. The t^o huccal canals contain silver cones, the palatal canal
a post and gutta-percha filling. Note the periapical lesion around the apices of the mesiobuccai and palatal
roots, (h) Two years after apicectomy of both buccai roots. Goldfoil used as retrofilling. Palatailv. an
apicectomy and periapicaJ corettage without retrograde fillmg was performed.

3. Canal that cannot be dried because of
continuous exudate.
4. Periapical lesion that does not heal despite
apparently correct root canal treatment
having been performed.
5. Apical perforation with symptoms.
6. Apical external resorption.
In all cases in which the root canal cannot
he negotiated to the apex (Figs 7 and 8) the
sequence of treatment is as follows:
1. Reflection of the flap.
2. Location of the apex and surgical perfor-
ation of the alveolar bone.
3. Root resection.
4. Periapical curettage.
5. Retrograde cavity preparation and retro-
grade filling, preferably with zinc-free
silver amalgam or a high-copper silver
amalgam and varnish (Tronstad et al.
1983).
6. Suturing of the flap.-'
If, however, the canal can be prepared to the
apex, but cannot be dried, retrofilling is not
required (Fig. 9). The sequence of treatment
in one visit is as follows:
1. Reflection of the flap.
2. Location of the apex and surgical perfor-
ation of the alveolar bone.
3. Root resection.
4. Periapical curettage.
5. Drj'ing of the root canal.
6. Root canal filling with overextension.
7. Removal of excess filling material periapi-
cally.
8. Suturing of the flap.
Endodontic apical surgerj' may be combined
with periodontai surgery. In most instances,
a full thickness flap is made at the gingiv'al
margin, both on the lingual and buccal aspect.
(iii) .Apical fistulation. This is the surgical
creation of a hole through the alveolar mucosa
 50 P. H. A. Guldener
Fig. 8. (a) Perforatioa in the apical third of the mesial root of 6/ which has a periapical lesion, (b) Ten
months after apicectomy and retrograde filling witli silver amalgam, the bony lesion has healed.
and cortical plate at the apex of a tooth with
acute sy'Hiptoms to relieve pain. The technique
is dangerous if it is performed without raising
a flap and first locating the apex. Anatomical
landmarks such as the maxillar}' sinus, the
mandibular canal or meotal nen'e in the neigh-
bourhood of root apices of posterior teeth
should be identified. In addition, apical fistula-
tion is never a definitive treatment, but only
for emergency use in very rare cases. The
author does not recommend this procedure.
6. Diodentic implants
This rather rare procedure is occasionally per-
formed on a mobile lower anterior tooth with
advanced periodontal disease (Frank 1967).
After normal preparation of the root canal, a
drill is used through the root canal to create
a space 6—8 mm into the alveolar bone. Dio-
dontic implants function primarily by improv-
ing the crown—root ratio, thereby stabilizing
the compromised tooth. Pocket elimination is
performed when necessary, and healing should
be complete prior to the implant procedure.
Where the puip of the tooth is non-vital, the
implant should not be inserted at the first visit
of endodontic treatment.
7. Hemisection, tooth separation and root
amputation
These techniques are performed on multi-
rooted teeth, mainly on first and second molars
(Basaraba 1969, Abrams & Trachtenberg
1974). These procedures are indicated if
periodontal disease or caries prevent other
surgical intervention and the remaining root
or roots are needed for reconstruction of the
dentition.
There are several pathological conditions
which require one of these procedures.
(a) Periodontal
.Advanced vertical bone loss around one
root.
Furcation involvement.
Dehiscence extending to the apical third of
the root.
Close proximity of adjacent roots with miss-
ing interdental septum.
(b) Endodontic
Obliterated canal with periapical lesion
where surgerj- is not feasible.
Large perforation in the furcation (Class
IV).
Advanced external resorption of one root.
(c) Cronm—root fracture
(d) Extensive root caries of one root
Before considering a hemisection or root
amputation, it is advantageous to perform
endodontic treatment of the remaining root
canals first, otherwise the pulp will be exposed
during root resection.
 Relationship hetrpeen periodontai and pulpal disease 51

•>.' • k
v

Fig. 9. (a) Large penapical lesion and apical rooi lestirption of 3 . The root canal was treated for several
\isit.s bul could niit be dned (b) '\pical curettagt was performed. After the root canal was dry. it was
intentionallj o\trfi!led with gutta-percha which was removed, (c) Radiograph 3 months after surgery,
(d) Radiograph Hi months after surgery.
 p. H. A. Guldmer

Fig. 10. (a) Periapicai lesion and radiolucency in the bifurcation of/S The mesial root canal is blocked
by a post. Second and third molars are missing, (b) Hemisection was carried out. After removinc; the mesial
root, a four unit bridge was made using the distal root as an abutment.

/ ' - •

' • ' ^ -

Fig. 11. (a) Periodontally involved upper right first and second molars with furcation involvement, (b) The
distal root of the second molar and the mesial root of the first molar were amputated, after endodontic
treatment of the remaining roots.

Hemisection. This by defitiinon refers to Root amputation. Root atnputation is the

separation of a two rooted tooth (lower ttiokr
or upper first premolar) atid extraction of one
half. The remaitiitig half is iotended as a
bridge abuttnetit (Fig. 10).
Tooth separation or bicuspidation. Tooth
separation is the division of a two-rooted tooth
without extraction. Both halves are individu-
ally crowned and appear as two premolars.
resection of one or two roots at the furcation
(Smukler & Tagger 1976). Root amputation is
most often performed on maxillary molar teeth
(Fig. 11). Root atnputation in the lower jaw
is rarely indicated and is confined to a molar
which already acts as a bridge abutment.
Amputation of one root should not jeopardize
the stability of the bridge. Root amputated
teeth should be crowned.
 Relationship hetveen periodontal and pulpal disease
8, Intentional replantation
Intentional replantation of a tooth is the last
resort when no other treatment is possible.
This involves extraction of the affected tooth,
apicectomy and retrofilling out of the mouth
and finally replantation of the tooth in its
socket. The replanted tooth should be
stabilized to the adjacent teeth for several
weeks. The prognosis of replanted teeth is not
favourable because more than one-third show
root resorption or ankyiosis after 5—10 years.
Therefore, this procedure can only be
recommended with great reservation,
9. Extraction
Extraction may be indicated, if treatment can
be simplified without loss of function and
aesthetics. Teeth which are frequently sacri-
ficed are those with advanced periodontal
disease or crown-root fractures.
Prognosis
The prognosis is generally better for a primary
endodontic lesion (Qass 1) than if pulpai
infection was caused by advanced periodontal
disease.
If the lesion is solely endodontic in nature,
the prognosis is excellent, whereas true perio-
endo lesions (Class III) have a poor prognosis.
In 1963, Schilder explained this phenomenon
very simply:
'The endodontist is working in a closed system.
Once the rubber dam is placed and access is
gained through the crown of the tooth to its
apex, the noxious protein breakdown products,
tissue debris, bacteria and toxic products can
be eliminated and the eventually sterilized root
canal may be filled. The periodontist has none
of these advantages. He is working in an open
system. In the crevicular space, inflammation
and reinfection, introduction of food particles
and bacteria are constant occurrences and the
permanent arrest of this type of disease is a
monumental project.'
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