Pulp and Periapical Biology: The Foundations of Personalized Endodontics

Endodontic care has traditionally focused on the management of local disease conditions and long-term function. As the burden of pulpal and periapical disease remains significant, the concept of P4 Medicine (predictive, preventive, personalized, and participatory) may offer a strategic opportunity to reframe endodontics as driven by the notion of risk and its management. Based on the prevalence of caries, the global prevalence of untreated pulpal disease is likely substantial, leading to about 50% prevalence of apical periodontitis (AP). Integration of P4 principles requires linking insights from pulp biology, including inflammation and regenerative responses, with risk assessment tools and minimally invasive interventions. This paper proposes a precision care framework for the endodontic patient, rooted in biology. For example, emerging models challenge conventional diagnostic terms, such as "irreversible pulpitis," as not meaningful and promote vital pulp therapy (VPT) where feasible. The notion of prevention is extended to endodontics, since established intracanal microbiota is unlikely to be eradicated. Personalized interplay between microbial burden and immune competence leads to AP. Then, untreated AP, specifically when associated with molars, may lead to serious, even life-threatening conditions. However, emerging evidence suggests that even subclinical AP may have systemic health consequences such as a higher risk of cardiovascular diseases. Therefore, this paper outlines clinical, and policy shifts needed to operationalize personalized endodontics in diverse healthcare settings. A biologically grounded, predictive and preventive model of care may elevate the standard of endodontic treatment while addressing current gaps in access, education, and outcomes.