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The Relation between Periodontal and Pulpal Disorders
T h e relation betw een periodontal and pulpal disorders
Ira Franklin Ross, DDS, M illb u rn , NJ
How periodontal and p u lpal disorders a ffe c t each other
C oncurrent p erio don ta l and p u lp al disorders may be related to, or independent of, each other. For exam ple, p ro d u cts o f a ne cro tic p u lp m ay drain through th e gingiva l sulcus and produce a p e ri odontal pocket. In fe c tio n and in fla m m a tio n asso c ia te d w ith ch ro n ic d e stru ctive p eriodontal d is ease m ay cause p u lp a l degeneration. Pain, altered v ita lity o f th e pu lp , suppuration, periodontal pockets, and radiographic changes m ay be asso c ia te d w ith both disorders.
Many individuals have both periodontal and pulpal disorders that involve the same teeth. When this occurs, it is frequently difficult for the clinician to determine which disorder produced a specific sign or symptom. Concurrent periodon tal and pulpal disorders may be completely inde pendent of each other. Or, the disorders may be interrelated so that one is either the result or the cause of the other. Therefore, the clinician must ask: Are the concurrent disorders related? Which disorder is causing which of the existing signs and symptoms? The objective of this article is to describe situ ations of concurrent periodontal and pulpal dis orders, to explore the mechanisms, and to sug gest appropriate treatment. 134 ■ JADA, Vol. 84, January 1972
Periodontal and pulpal disorders can be related to each other.1-4 This relation can occur in one of several ways.2-5 In one relation, a periapical abscess (the result of pulpal pathosis) may drain through the gingi val sulcus, by means of a fistula, and produce a periodontal pocket. A fistula that develops after degeneration of a pulp may follow one of several routes: It may burrow through the bone and open directly into the mouth; it may travel through the periodontal ligament in a coronal direction and open into the gingival sulcus; or it may travel in a coronal direction to the furcation, and then directly into the mouth or into the sulcus.1-3 If the path of the fistula is from the apex or from the furcation into the gingival sulcus, a re verse periodontal pocket is formed. The reverse pocket forms in a direction opposite to that of the common periodontal pocket.3-6 The common pocket is associated with inflammation that re sults from periodontal irritants. The common pocket begins at a more cervical position on the tooth and moves toward the apex, whereas the pocket that results from pulpal degeneration be gins in the periapical region and moves toward the cervix of the tooth. In a second relation, chronic periodontal in flammation and infection may produce changes in the pulp. The destructive factors (either the by-products of inflammation or the bacteria and their toxins) may pass through the apical foramen or through accessory foramens.5-7 The accessory
foramens may be found along the roots or in the furcation. Invasion by the destructive factors can cause necrosis of the pulp. It can result in an ab scess or granuloma. A third relation may occur if occlusal forces are sufficiently powerful to produce severe injury in the periodontal ligament or alveolar bone, or both.8-9 The destructive forces may produce changes in the periapical and lateral regions, and initiate changes in the pulp.10 This can lead to necrosis of the pulp. A fourth relationship can result from concurrent extensive chronic periodontal inflammation and trauma from occlusion. Each may affect the pulp. It is also possible that a pulpal disorder, a chronic inflammatory periodontal disorder, and trauma from occlusion may all be present and that they may be unrelated.
D iffe re n tia l diagnosis o f periodontal and pulpal disorders In all instances of concurrent periodontal and pulpal disorders, the clinician must determine whether the existing tissue changes came from one or both processes so that appropriate treat ment can be given. One process may have started the destruction and the second may have contrib uted at a later time. Or, the lesion may be the re sult of one process alone, although it may appear that both processes are involved. Several factors should be considered in differ ential diagnosis.7-11-12 The most significant are pain, altered vitality of the pulp, suppuration, periodontal pockets, and radiographic changes. These factors may occur with both types of pathosis. ■ Pain: Several aspects of pain should be con sidered by the clinician as he differentiates be tween periodontal and pulpal pathosis. These include the type, intensity, frequency, duration, and the activators of the pain. Questions such as these should be answered by the patient. Is the pain sharp or dull, throbbing or steady (type of pain)? Is the pain mild, moderate, or severe (inten sity of pain)? Is the pain constant or intermittent? If inter mittent, how long are the painless intervals (fre quency of pain)? How long (days, weeks, months, years) has the patient had pain in the region? What is the dur
ation of the pain? Is the pain caused by heat, cold, or both stimuli? Is the pain felt at all temperatures? Is the pain related to biting (activators of pain)? Is the pain felt all the time? Or, does the pain occur when the patient eats? Primarily when he goes to bed? Primarily when he gets up (occur rence of pain)? Is the pain felt in one tooth? In several teeth? Over the side of the face? In the region of the temporomandibular joint (location of pain)? In the early stages of pulpal inflammation, cold frequently causes pain that is mild and of short duration. The pain usually stops when the cold is removed, or soon after. At a later stage, heat produces pain that is sharper, more severe, and of longer duration than the pain precipitated by cold. Pain caused by heat may continue after the heat is removed. As the inflammation increases in intensity, the pain becomes more severe, is of longer dur ation, and is felt with either heat or cold. Finally, continuous, severe pain may be felt even at room temperature. Although this sequence does not occur in all cases of pulpal degeneration, it does occur frequently and should be considered in the differential diagnosis.2-5>7>12 Uusually, there is no severe pain from chronic periodontal inflammation. There may be soreness or itching, but the pain is not comparable to that caused by pulpal degeneration. If severe pain does develop with a periodontal lesion, the dis comfort probably is the result of one of these mechanisms: either there is an acute periodontal abscess, or the pulp is degenerating. The pain that results from destructive occlusal forces usually occurs when contact is made be tween the maxillary and mandibular teeth, or soon after.13 Although pain caused by occlusal forces can be severe, it is usually less severe than the pain associated with a degenerating pulp. Pain that results from destructive occlusal forces is usually of short duration. The occurrence of the pain is also significant. If the pain occurs while the patient chews, it is probably related to the occlusion. If the patient feels discomfort on awakening or during periods of tension during the day, it is probably due to clenching or grinding the teeth. However, if it is continuous and occurs during all activities, the pain usually is related to pulpal degeneration. Pain of pulpal origin may be either diffuse or localized to one tooth. If it is diffuse, it becomes localized as the pulp degenerates further. Pain Ross: PERIODONTAL AND PULPAL DISORDERS ■ 135
associated with a periodontal disorder may or may not localize to one tooth. ■ Vitality o f the pulp: Testing the vitality of the pulp often helps the clinician differentiate be tween pulpal and periodontal pathosis. The pulp may be tested with an electric pulp tester or with heat and cold, or both. However, results of heat and cold are frequently more accurate than those pbtained with an electric pulp tester.2-5-7 Testing the pulp may clarify the cause of the problem when one or more of these disorders is present: pain, swelling, suppuration, periqdontal pocket formation, and radiographic changes such as periapical or lateral radiolucency. However, the value of pulp testing is questionable in many instances. A tooth may respond positively to an electric pulp tester even though only a portion of the pulp is vital. Other sections of the pulp may have degenerated and may have either no vitality or diminished vitality. Or, a tooth may have a vital pulp that has diminished in size because of age or because of an irritant that stimulated the for mation of secondary dentin. Such a tooth could react in one of three ways to temperature changes or to the pulp tester: no response, diminished response, or an average response. Neither application of heat or cold, nor testing of the pulp will always indicate the true condition of the pulp. ■ Suppuration: Suppuration may occur with either periodontal or pulpal pathosis. If it is as sociated with periodontal destruction, it may be linked with an acute periodontal abscess, a chronic periodontal disorder (usually a deep pocket), or $n acute exacerbation of a chronic dis order. Occasionally, a fistula that leads from a deep periodontal pocket may be noted in the presence of a clinically vital pulp. Suppuration in association with pulpal path osis may be seen with either an acute or a chrqnic condition. An acute alveolar abscess may have considerable suppuration along with the other signs of acute infection. A chronic alveolar ab scess may be encapsulated completely or it may drain through a fistula, as discussed. ■ Periodontal pockets: It is frequently more diffi cult for the clinician to determine the cause of a pocket that results from pulpal degeneration than one caused by periodontal irritants. A pocket that has developed because of irritants usually is 136 ■ JADA, Vol. 8 4 , January 1972
treated initially by the removal of calculus by supragingival and subgingival scaling. This often results in an improvement in the gingival con dition, some reduction in pocket depth, and a lessening or elimination of suppuration. However, if degeneration of the pulp is the principal cause of the pocket, scaling will not improve the con dition unless calculus is present and is contribut ing to the total problem. Unfortunately, in many instances the vitality of the pulp is not investi gated until repeated scaling fails to decrease sup puration. Therefore, pulpal degeneration should be con sidered as a cause of suppuration and periodontal pockets whenever the pulp of the involved tooth has altered vitality. ■ Radiographic changes: Radiographic changes may be important to the differentiation between periodontal and pulpal pathosis. However, the many limitations of radiographs must be con sidered. The actual bony defect is usually more extensive and is not shaped the way it appears to be on the films. The film is a two-dimensional representation of a three-dimensional region. In addition, the structures may be distorted in the radiograph because of incorrect angulation of the tube, or placement or processing of the film. Therefore, these observations are offered. It may be difficult to determine the cause of a peri apical or lateral radiolucent region seen on radio graphs. These radiographic changes usually result from pulpal pathosis but they also may occur be cause of periodontal pathosis.10 The most important point of differential diag nosis when a periapical or lateral radiolucent region is seen is vitality of the pulp. If the pulp is nonvital, the radiolucent region is usually the re sult of pulpal pathosis. If the pulp is vital, the radiolucent regiori probably is caused by peri odontal pathosis. However, it is possible that both pathoses may be present. The pulp may be nonvital because of pulpal pathosis, and yet the radio lucent region may be the result of periodontal pathosis. When the situation suggests concurrent pathoses, the differential diagnosis should be based on the history and the signs and symptoms such as pain, vitality of the pulp, suppuration, and pocket formation. One of the less common types of radiolucent regions is one that appears as a halo around the palatal root of maxillary molars. The halo repre sents extensive bone loss, and may occur in the presence of a clinically vital pulp. It is often the
result of chronic periodontal destruction associ ated with destructive occlusal forces.
Report of cases Aspects of the differential diagnosis of concur rent periodontal and pulpal pathoses are illustrated by five cases. The difficulty of determining the causes of alveolar destruction is illustrated by the case in Figure 1. The patient had had endodontic treat m ent for pulpal pathosis. Six months later, the tooth was quite mobile and had extensive peri apical and distal bone loss (Fig 1, center). There was destructive occlusal force. In another radio graph taken at the same time (Fig 1, bottom), a gutta-percha point shows the extent of the de struction. Was the bone loss the result of the pul pal disorder, the destructive occlusal force, the chronic inflammation, or a combination o f these factors? Pain was an important factor in the diagnosis of the condition of these patients. One patient had had severe pain for several days in the p re molar and molar region (Fig 2); however, there was no history o f pain on the introduction o f heat or cold, and no increased pain on biting. Exten sive periodontal disease was apparent. The deep restorations had been placed several years before. Investigation revealed that the source of pain was degeneration of the pulp of the maxillary first molar. Another patient, one year after insertion of a fixed bridge, felt severe pain on biting. The pain centered in the mandibular molar region. Later, severe continuous pain developed that was unrelated to occlusal contact. A radiograph re vealed an extensive radiolucent periapical region (Fig 3). Although testing of the pulp may resolve some differential diagnoses, it will not always indicate the true condition of the pulp. For example, the mandibular first and second molars in Figure 4 responded slightly to the electric pulp tester. They exhibited moderate mobility and extensive peri odontal destruction. A radiograph showed peri apical radiolucent regions. However, the pulps were found to be vital when the teeth were drilled. Radiographic changes, another aspect o f the differential diagnosis, may result from either pulpal or periodontal pathosis. When he distin guishes between the two, the clinician must con sider the vitality o f the pulp, as described before.
Fig 1 ■ Top: Radiograph o f region after endodontic tre a t ment. Center: Six m onths later. Radiograph shows extensive periapical and distal bone loss. Bottom : Gutta-percha p oint shows extent of destruction.
For example, in Figure 5, there is a large radio lucent halo around the palatal root of the first molar. When tested, the pulp o f this maxillary molar responded adequately to heat and cold. The radiographic changes were the result o f ex tensive periodontal disease.
Treatm ent The treatment o f a tooth that has both a peri odontal and a pulpal disorder may vary con Ross: PERIODONTAL AND PULPAL DISORDERS ■ 137
Fig 2 ■ Left: Radiograph o f m axillary prem olar region. Right: Radiograph o f m axilla ry m olar region. Pain in both regions wascaused by degeneration o f p u lp o f m axilla ry firs t molar.
siderably among patients. It will depend on an swers to several significant questions. Can the tooth be treated satisfactorily? Is there enough periodontal support to warrant treatment of the tooth? If treated, will the tooth function satis factorily? Will the tooth be acceptable esthetically
Fig 3 ■ Radiograph o f extensive radiolucent periapical region.
Fig 4 ■ Radiograph o f m andibular firs t and second molars. Although electric pulp tester recorded dim inished response, teeth had v ita l pulps. 138 ■ JADA, Vol. 84, January 1972
to the patient? If the answer to these questions is “ yes,” the tooth should be treated. The objec tives of treatment should be the elimination of the causes o f the existing signs and symptoms, restor ation of the function of the tooth to maximum efficiency, and creation of an esthetic appearance. If pain is present, the clinician should deter mine the cause of the pain and eliminate it. A p propriate endodontic therapy should be instituted if degenerative changes in the pulp cause the pain. If the pain is the result o f a periodontal abscess, the abscess should be incised and drained. Any destructive occlusal forces that are the source of discomfort should be eliminated. If there is a periodontal pocket, with or with out suppuration, the tooth should be scaled care fully. All supragingival and subgingival deposits should be removed and the roots should be planed. The vitality of the pulp should be determined and the radiograph examined for periapical or lateral radiolucent regions. If the pulp is nonvital and if a periapical or
Fig 5 ■ Large radiolucent halo around palatal root o f firs t molar.
lateral radiolucent region is seen in the radio graph, endodontic therapy should be initiated. A pocket that is caused by a fistula from a pulpal abscess frequently will close after successful end odontic therapy. Scaling, root planing, and curet tage of the pocket lining will aid in the healing. If the pulp is vital, the pocket probably is caused by irritants, such as bacteria and their toxins, plaque and calculus, food debris, and faulty restorations. If the pocket around a vital tooth remains after supragingival and subgingi val scaling and root planing have been accom plished and after defective margins have been corrected, periodontal surgery often is indicated to eliminate the residual portion of the pocket.
Su m m ary A periodontal and a pulpal disorder may be pres ent in the same tooth. These two disorders may be related in one of several ways, or they may be completely independent of each other. As an example of their possible interrelation, products of the degeneration of a pulp may drain through the gingival sulcus or the furcation and produce a periodontal pocket. Or, infection and inflam mation associated with chronic destructive peri odontal disease may cause degeneration of the pulp. The route of infection would be through the apical foramen or accessory foramens along the root or in the furcation. Destructive occlusal force that may cause injury in the pulp is another example of the interrelationship. Periodontal dis ease and altered vitality of the pulp may concur as a result of interrelated causes, or the two pro cesses may be unrelated. Several factors may be associated with both pulpal and periodontal disorders. The principal factors to be considered in the differential diag nosis of periodontal and pulpal disorders are:
pain, vitality of the pulp, suppuration, periodon tal pockets, and radiographic changes. The objectives of treatment of a tooth that has both a periodontal and pulpal disorder are: the elimination of the causes of the existing signs and symptoms, restoration of the tooth function to maximum efficiency, and creation of an esthetic appearance.
D o c to r R oss is fo rm e r p ro fe s s o r a n d c h a irm a n o f th e d e p a rtm e n t o f p e rio d o n tic s , N e w Jers e y C o lle g e o f M e d ic in e a n d D e n tis try . H is a d d re s s is 1 1 6 M illb u rn A v e n u e , M illb u rn , NJ 07041. 1. H ia tt, W .H . P e rio d o n ta l p o c k e t e lim in a tio n by c o m bin e d e n d o d o n tic -p e rio d o n tic th e ra p y . P e rio d o n tic s 1 :1 5 2 Ju ly -A u g 1 9 6 3 . 2. S e ltz e r, S.; B e n d e r, I.B .; a n d Z io n tz, M . In te r r e la tio n ship o f p u lp a n d p e rio d o n ta l d is e a se . O ra l S u rg 1 6 :1 4 7 4 D ec 1 9 6 3 . 3. S im rin g , M ., a n d G o ld b e rg , M . T h e p u lp a l p o c k e t a p p ro ach : re tro g ra d e p e rio d o n titis . J P e rio d o n t 3 5 :2 2 J a n -F e b 1964. 4 . S ta h l, S .S. P u lp a l re s p o n s e to g in g iv a l in ju r y in a d u lt rats. O ral S u rg 1 6 :1 1 1 6 S e p t 1 9 6 3 . 5. S e ltz e r, S., a n d B e n d e r, I.B . T h e d e n ta l p u lp ; b io logic c o n s id e ra tio n s in d e n ta l p ro c e d u re s . P h ila d e lp h ia , J. B. L ip p in c o tt C o ., 1 9 6 5 . 6. H ia tt, W .H . R e g e n e ra tio n o f th e p e rio d o n tiu m a fte r e n d o d o n tic th e ra p y a n d fla p o p e ra tio n . Oral Surg 1 2 :1 4 7 1 Dec 1 9 5 9 . 7 . S e ltz e r, S.; B e n d e r, I.B .; a n d Z io n tz, M . D y n a m ic s o f p u lp in fla m m a tio n : c o rre la tio n s b e tw e e n d ia g n o s tic d a ta a n d a c tu a l h is to lo g ic fin d in g s in th e p u lp . O ra l S u rg 1 6 :8 4 6 Ju ly, 9 6 9 A ug 1 9 6 3 . 8 . In g le , J .l. A lv e o la r o s te o p o ro s is a n d p u lp a l d e a th a s s o c ia te d w ith c o m p u ls iv e b ru x is m . O ral S u rg 1 3 :1 3 7 1 N ov 1960. 9 . R a m fjo rd , S .P ., and A sh, M .M ., Jr. O c c lu s io n . P h ila d e lp h ia , W. B. S a u n d e rs C o., 1 9 6 6 . 10. Ross, l.F . P a in , a lv e o la r re s o rp tio n , a n d p e rio d o n ta l tr a u m a tis m (P a ra p t). P e rio d o n tic s 3 :3 8 J a n -F e b 1 9 6 5 . 11. B a u m e , L.J. D ia g n o s is o f d is e a se s o f t h e p u lp . O ral S u rg 2 9 :1 0 2 Jan 1 9 7 0 . 12. S o lta n o ff, W . R e la tio n s h ip o f c lin ic a l a n d h is to p a th o lo g ic c la s s ific a tio n s to v a rio u s d ia g n o s tic te s ts . R e v is e d 1 9 6 9 , N e w J e rs e y C o lle g e o f D e n tis try . 13. Ross, l.F . O c c lu s io n ; a c o n c e p t fo r th e c lin ic ia n . S t Louis, C . V . M o s b y C o., 1 9 7 0 .
Ross: PERIODONTAL AND PULPAL DISORDERS ■ 139
Ira Franklin Ross, DDS, M illb u rn , NJ
How periodontal and p u lpal disorders a ffe c t each other
C oncurrent p erio don ta l and p u lp al disorders may be related to, or independent of, each other. For exam ple, p ro d u cts o f a ne cro tic p u lp m ay drain through th e gingiva l sulcus and produce a p e ri odontal pocket. In fe c tio n and in fla m m a tio n asso c ia te d w ith ch ro n ic d e stru ctive p eriodontal d is ease m ay cause p u lp a l degeneration. Pain, altered v ita lity o f th e pu lp , suppuration, periodontal pockets, and radiographic changes m ay be asso c ia te d w ith both disorders.
Many individuals have both periodontal and pulpal disorders that involve the same teeth. When this occurs, it is frequently difficult for the clinician to determine which disorder produced a specific sign or symptom. Concurrent periodon tal and pulpal disorders may be completely inde pendent of each other. Or, the disorders may be interrelated so that one is either the result or the cause of the other. Therefore, the clinician must ask: Are the concurrent disorders related? Which disorder is causing which of the existing signs and symptoms? The objective of this article is to describe situ ations of concurrent periodontal and pulpal dis orders, to explore the mechanisms, and to sug gest appropriate treatment. 134 ■ JADA, Vol. 84, January 1972
Periodontal and pulpal disorders can be related to each other.1-4 This relation can occur in one of several ways.2-5 In one relation, a periapical abscess (the result of pulpal pathosis) may drain through the gingi val sulcus, by means of a fistula, and produce a periodontal pocket. A fistula that develops after degeneration of a pulp may follow one of several routes: It may burrow through the bone and open directly into the mouth; it may travel through the periodontal ligament in a coronal direction and open into the gingival sulcus; or it may travel in a coronal direction to the furcation, and then directly into the mouth or into the sulcus.1-3 If the path of the fistula is from the apex or from the furcation into the gingival sulcus, a re verse periodontal pocket is formed. The reverse pocket forms in a direction opposite to that of the common periodontal pocket.3-6 The common pocket is associated with inflammation that re sults from periodontal irritants. The common pocket begins at a more cervical position on the tooth and moves toward the apex, whereas the pocket that results from pulpal degeneration be gins in the periapical region and moves toward the cervix of the tooth. In a second relation, chronic periodontal in flammation and infection may produce changes in the pulp. The destructive factors (either the by-products of inflammation or the bacteria and their toxins) may pass through the apical foramen or through accessory foramens.5-7 The accessory
foramens may be found along the roots or in the furcation. Invasion by the destructive factors can cause necrosis of the pulp. It can result in an ab scess or granuloma. A third relation may occur if occlusal forces are sufficiently powerful to produce severe injury in the periodontal ligament or alveolar bone, or both.8-9 The destructive forces may produce changes in the periapical and lateral regions, and initiate changes in the pulp.10 This can lead to necrosis of the pulp. A fourth relationship can result from concurrent extensive chronic periodontal inflammation and trauma from occlusion. Each may affect the pulp. It is also possible that a pulpal disorder, a chronic inflammatory periodontal disorder, and trauma from occlusion may all be present and that they may be unrelated.
D iffe re n tia l diagnosis o f periodontal and pulpal disorders In all instances of concurrent periodontal and pulpal disorders, the clinician must determine whether the existing tissue changes came from one or both processes so that appropriate treat ment can be given. One process may have started the destruction and the second may have contrib uted at a later time. Or, the lesion may be the re sult of one process alone, although it may appear that both processes are involved. Several factors should be considered in differ ential diagnosis.7-11-12 The most significant are pain, altered vitality of the pulp, suppuration, periodontal pockets, and radiographic changes. These factors may occur with both types of pathosis. ■ Pain: Several aspects of pain should be con sidered by the clinician as he differentiates be tween periodontal and pulpal pathosis. These include the type, intensity, frequency, duration, and the activators of the pain. Questions such as these should be answered by the patient. Is the pain sharp or dull, throbbing or steady (type of pain)? Is the pain mild, moderate, or severe (inten sity of pain)? Is the pain constant or intermittent? If inter mittent, how long are the painless intervals (fre quency of pain)? How long (days, weeks, months, years) has the patient had pain in the region? What is the dur
ation of the pain? Is the pain caused by heat, cold, or both stimuli? Is the pain felt at all temperatures? Is the pain related to biting (activators of pain)? Is the pain felt all the time? Or, does the pain occur when the patient eats? Primarily when he goes to bed? Primarily when he gets up (occur rence of pain)? Is the pain felt in one tooth? In several teeth? Over the side of the face? In the region of the temporomandibular joint (location of pain)? In the early stages of pulpal inflammation, cold frequently causes pain that is mild and of short duration. The pain usually stops when the cold is removed, or soon after. At a later stage, heat produces pain that is sharper, more severe, and of longer duration than the pain precipitated by cold. Pain caused by heat may continue after the heat is removed. As the inflammation increases in intensity, the pain becomes more severe, is of longer dur ation, and is felt with either heat or cold. Finally, continuous, severe pain may be felt even at room temperature. Although this sequence does not occur in all cases of pulpal degeneration, it does occur frequently and should be considered in the differential diagnosis.2-5>7>12 Uusually, there is no severe pain from chronic periodontal inflammation. There may be soreness or itching, but the pain is not comparable to that caused by pulpal degeneration. If severe pain does develop with a periodontal lesion, the dis comfort probably is the result of one of these mechanisms: either there is an acute periodontal abscess, or the pulp is degenerating. The pain that results from destructive occlusal forces usually occurs when contact is made be tween the maxillary and mandibular teeth, or soon after.13 Although pain caused by occlusal forces can be severe, it is usually less severe than the pain associated with a degenerating pulp. Pain that results from destructive occlusal forces is usually of short duration. The occurrence of the pain is also significant. If the pain occurs while the patient chews, it is probably related to the occlusion. If the patient feels discomfort on awakening or during periods of tension during the day, it is probably due to clenching or grinding the teeth. However, if it is continuous and occurs during all activities, the pain usually is related to pulpal degeneration. Pain of pulpal origin may be either diffuse or localized to one tooth. If it is diffuse, it becomes localized as the pulp degenerates further. Pain Ross: PERIODONTAL AND PULPAL DISORDERS ■ 135
associated with a periodontal disorder may or may not localize to one tooth. ■ Vitality o f the pulp: Testing the vitality of the pulp often helps the clinician differentiate be tween pulpal and periodontal pathosis. The pulp may be tested with an electric pulp tester or with heat and cold, or both. However, results of heat and cold are frequently more accurate than those pbtained with an electric pulp tester.2-5-7 Testing the pulp may clarify the cause of the problem when one or more of these disorders is present: pain, swelling, suppuration, periqdontal pocket formation, and radiographic changes such as periapical or lateral radiolucency. However, the value of pulp testing is questionable in many instances. A tooth may respond positively to an electric pulp tester even though only a portion of the pulp is vital. Other sections of the pulp may have degenerated and may have either no vitality or diminished vitality. Or, a tooth may have a vital pulp that has diminished in size because of age or because of an irritant that stimulated the for mation of secondary dentin. Such a tooth could react in one of three ways to temperature changes or to the pulp tester: no response, diminished response, or an average response. Neither application of heat or cold, nor testing of the pulp will always indicate the true condition of the pulp. ■ Suppuration: Suppuration may occur with either periodontal or pulpal pathosis. If it is as sociated with periodontal destruction, it may be linked with an acute periodontal abscess, a chronic periodontal disorder (usually a deep pocket), or $n acute exacerbation of a chronic dis order. Occasionally, a fistula that leads from a deep periodontal pocket may be noted in the presence of a clinically vital pulp. Suppuration in association with pulpal path osis may be seen with either an acute or a chrqnic condition. An acute alveolar abscess may have considerable suppuration along with the other signs of acute infection. A chronic alveolar ab scess may be encapsulated completely or it may drain through a fistula, as discussed. ■ Periodontal pockets: It is frequently more diffi cult for the clinician to determine the cause of a pocket that results from pulpal degeneration than one caused by periodontal irritants. A pocket that has developed because of irritants usually is 136 ■ JADA, Vol. 8 4 , January 1972
treated initially by the removal of calculus by supragingival and subgingival scaling. This often results in an improvement in the gingival con dition, some reduction in pocket depth, and a lessening or elimination of suppuration. However, if degeneration of the pulp is the principal cause of the pocket, scaling will not improve the con dition unless calculus is present and is contribut ing to the total problem. Unfortunately, in many instances the vitality of the pulp is not investi gated until repeated scaling fails to decrease sup puration. Therefore, pulpal degeneration should be con sidered as a cause of suppuration and periodontal pockets whenever the pulp of the involved tooth has altered vitality. ■ Radiographic changes: Radiographic changes may be important to the differentiation between periodontal and pulpal pathosis. However, the many limitations of radiographs must be con sidered. The actual bony defect is usually more extensive and is not shaped the way it appears to be on the films. The film is a two-dimensional representation of a three-dimensional region. In addition, the structures may be distorted in the radiograph because of incorrect angulation of the tube, or placement or processing of the film. Therefore, these observations are offered. It may be difficult to determine the cause of a peri apical or lateral radiolucent region seen on radio graphs. These radiographic changes usually result from pulpal pathosis but they also may occur be cause of periodontal pathosis.10 The most important point of differential diag nosis when a periapical or lateral radiolucent region is seen is vitality of the pulp. If the pulp is nonvital, the radiolucent region is usually the re sult of pulpal pathosis. If the pulp is vital, the radiolucent regiori probably is caused by peri odontal pathosis. However, it is possible that both pathoses may be present. The pulp may be nonvital because of pulpal pathosis, and yet the radio lucent region may be the result of periodontal pathosis. When the situation suggests concurrent pathoses, the differential diagnosis should be based on the history and the signs and symptoms such as pain, vitality of the pulp, suppuration, and pocket formation. One of the less common types of radiolucent regions is one that appears as a halo around the palatal root of maxillary molars. The halo repre sents extensive bone loss, and may occur in the presence of a clinically vital pulp. It is often the
result of chronic periodontal destruction associ ated with destructive occlusal forces.
Report of cases Aspects of the differential diagnosis of concur rent periodontal and pulpal pathoses are illustrated by five cases. The difficulty of determining the causes of alveolar destruction is illustrated by the case in Figure 1. The patient had had endodontic treat m ent for pulpal pathosis. Six months later, the tooth was quite mobile and had extensive peri apical and distal bone loss (Fig 1, center). There was destructive occlusal force. In another radio graph taken at the same time (Fig 1, bottom), a gutta-percha point shows the extent of the de struction. Was the bone loss the result of the pul pal disorder, the destructive occlusal force, the chronic inflammation, or a combination o f these factors? Pain was an important factor in the diagnosis of the condition of these patients. One patient had had severe pain for several days in the p re molar and molar region (Fig 2); however, there was no history o f pain on the introduction o f heat or cold, and no increased pain on biting. Exten sive periodontal disease was apparent. The deep restorations had been placed several years before. Investigation revealed that the source of pain was degeneration of the pulp of the maxillary first molar. Another patient, one year after insertion of a fixed bridge, felt severe pain on biting. The pain centered in the mandibular molar region. Later, severe continuous pain developed that was unrelated to occlusal contact. A radiograph re vealed an extensive radiolucent periapical region (Fig 3). Although testing of the pulp may resolve some differential diagnoses, it will not always indicate the true condition of the pulp. For example, the mandibular first and second molars in Figure 4 responded slightly to the electric pulp tester. They exhibited moderate mobility and extensive peri odontal destruction. A radiograph showed peri apical radiolucent regions. However, the pulps were found to be vital when the teeth were drilled. Radiographic changes, another aspect o f the differential diagnosis, may result from either pulpal or periodontal pathosis. When he distin guishes between the two, the clinician must con sider the vitality o f the pulp, as described before.
Fig 1 ■ Top: Radiograph o f region after endodontic tre a t ment. Center: Six m onths later. Radiograph shows extensive periapical and distal bone loss. Bottom : Gutta-percha p oint shows extent of destruction.
For example, in Figure 5, there is a large radio lucent halo around the palatal root of the first molar. When tested, the pulp o f this maxillary molar responded adequately to heat and cold. The radiographic changes were the result o f ex tensive periodontal disease.
Treatm ent The treatment o f a tooth that has both a peri odontal and a pulpal disorder may vary con Ross: PERIODONTAL AND PULPAL DISORDERS ■ 137
Fig 2 ■ Left: Radiograph o f m axillary prem olar region. Right: Radiograph o f m axilla ry m olar region. Pain in both regions wascaused by degeneration o f p u lp o f m axilla ry firs t molar.
siderably among patients. It will depend on an swers to several significant questions. Can the tooth be treated satisfactorily? Is there enough periodontal support to warrant treatment of the tooth? If treated, will the tooth function satis factorily? Will the tooth be acceptable esthetically
Fig 3 ■ Radiograph o f extensive radiolucent periapical region.
Fig 4 ■ Radiograph o f m andibular firs t and second molars. Although electric pulp tester recorded dim inished response, teeth had v ita l pulps. 138 ■ JADA, Vol. 84, January 1972
to the patient? If the answer to these questions is “ yes,” the tooth should be treated. The objec tives of treatment should be the elimination of the causes o f the existing signs and symptoms, restor ation of the function of the tooth to maximum efficiency, and creation of an esthetic appearance. If pain is present, the clinician should deter mine the cause of the pain and eliminate it. A p propriate endodontic therapy should be instituted if degenerative changes in the pulp cause the pain. If the pain is the result o f a periodontal abscess, the abscess should be incised and drained. Any destructive occlusal forces that are the source of discomfort should be eliminated. If there is a periodontal pocket, with or with out suppuration, the tooth should be scaled care fully. All supragingival and subgingival deposits should be removed and the roots should be planed. The vitality of the pulp should be determined and the radiograph examined for periapical or lateral radiolucent regions. If the pulp is nonvital and if a periapical or
Fig 5 ■ Large radiolucent halo around palatal root o f firs t molar.
lateral radiolucent region is seen in the radio graph, endodontic therapy should be initiated. A pocket that is caused by a fistula from a pulpal abscess frequently will close after successful end odontic therapy. Scaling, root planing, and curet tage of the pocket lining will aid in the healing. If the pulp is vital, the pocket probably is caused by irritants, such as bacteria and their toxins, plaque and calculus, food debris, and faulty restorations. If the pocket around a vital tooth remains after supragingival and subgingi val scaling and root planing have been accom plished and after defective margins have been corrected, periodontal surgery often is indicated to eliminate the residual portion of the pocket.
Su m m ary A periodontal and a pulpal disorder may be pres ent in the same tooth. These two disorders may be related in one of several ways, or they may be completely independent of each other. As an example of their possible interrelation, products of the degeneration of a pulp may drain through the gingival sulcus or the furcation and produce a periodontal pocket. Or, infection and inflam mation associated with chronic destructive peri odontal disease may cause degeneration of the pulp. The route of infection would be through the apical foramen or accessory foramens along the root or in the furcation. Destructive occlusal force that may cause injury in the pulp is another example of the interrelationship. Periodontal dis ease and altered vitality of the pulp may concur as a result of interrelated causes, or the two pro cesses may be unrelated. Several factors may be associated with both pulpal and periodontal disorders. The principal factors to be considered in the differential diag nosis of periodontal and pulpal disorders are:
pain, vitality of the pulp, suppuration, periodon tal pockets, and radiographic changes. The objectives of treatment of a tooth that has both a periodontal and pulpal disorder are: the elimination of the causes of the existing signs and symptoms, restoration of the tooth function to maximum efficiency, and creation of an esthetic appearance.
D o c to r R oss is fo rm e r p ro fe s s o r a n d c h a irm a n o f th e d e p a rtm e n t o f p e rio d o n tic s , N e w Jers e y C o lle g e o f M e d ic in e a n d D e n tis try . H is a d d re s s is 1 1 6 M illb u rn A v e n u e , M illb u rn , NJ 07041. 1. H ia tt, W .H . P e rio d o n ta l p o c k e t e lim in a tio n by c o m bin e d e n d o d o n tic -p e rio d o n tic th e ra p y . P e rio d o n tic s 1 :1 5 2 Ju ly -A u g 1 9 6 3 . 2. S e ltz e r, S.; B e n d e r, I.B .; a n d Z io n tz, M . In te r r e la tio n ship o f p u lp a n d p e rio d o n ta l d is e a se . O ra l S u rg 1 6 :1 4 7 4 D ec 1 9 6 3 . 3. S im rin g , M ., a n d G o ld b e rg , M . T h e p u lp a l p o c k e t a p p ro ach : re tro g ra d e p e rio d o n titis . J P e rio d o n t 3 5 :2 2 J a n -F e b 1964. 4 . S ta h l, S .S. P u lp a l re s p o n s e to g in g iv a l in ju r y in a d u lt rats. O ral S u rg 1 6 :1 1 1 6 S e p t 1 9 6 3 . 5. S e ltz e r, S., a n d B e n d e r, I.B . T h e d e n ta l p u lp ; b io logic c o n s id e ra tio n s in d e n ta l p ro c e d u re s . P h ila d e lp h ia , J. B. L ip p in c o tt C o ., 1 9 6 5 . 6. H ia tt, W .H . R e g e n e ra tio n o f th e p e rio d o n tiu m a fte r e n d o d o n tic th e ra p y a n d fla p o p e ra tio n . Oral Surg 1 2 :1 4 7 1 Dec 1 9 5 9 . 7 . S e ltz e r, S.; B e n d e r, I.B .; a n d Z io n tz, M . D y n a m ic s o f p u lp in fla m m a tio n : c o rre la tio n s b e tw e e n d ia g n o s tic d a ta a n d a c tu a l h is to lo g ic fin d in g s in th e p u lp . O ra l S u rg 1 6 :8 4 6 Ju ly, 9 6 9 A ug 1 9 6 3 . 8 . In g le , J .l. A lv e o la r o s te o p o ro s is a n d p u lp a l d e a th a s s o c ia te d w ith c o m p u ls iv e b ru x is m . O ral S u rg 1 3 :1 3 7 1 N ov 1960. 9 . R a m fjo rd , S .P ., and A sh, M .M ., Jr. O c c lu s io n . P h ila d e lp h ia , W. B. S a u n d e rs C o., 1 9 6 6 . 10. Ross, l.F . P a in , a lv e o la r re s o rp tio n , a n d p e rio d o n ta l tr a u m a tis m (P a ra p t). P e rio d o n tic s 3 :3 8 J a n -F e b 1 9 6 5 . 11. B a u m e , L.J. D ia g n o s is o f d is e a se s o f t h e p u lp . O ral S u rg 2 9 :1 0 2 Jan 1 9 7 0 . 12. S o lta n o ff, W . R e la tio n s h ip o f c lin ic a l a n d h is to p a th o lo g ic c la s s ific a tio n s to v a rio u s d ia g n o s tic te s ts . R e v is e d 1 9 6 9 , N e w J e rs e y C o lle g e o f D e n tis try . 13. Ross, l.F . O c c lu s io n ; a c o n c e p t fo r th e c lin ic ia n . S t Louis, C . V . M o s b y C o., 1 9 7 0 .
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