Pulp and Periapical Biology: The Foundations of Personalized Endodontics

This article seeks to provide a perspective for future developments of endodontic care delivery, based on disease burden und contemporary clinical frameworks. Indeed, endodontic care has traditionally focused on the management of local disease conditions and long-term function. Here 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 data available for caries, the occurrence of untreated pulpal disease is likely substantial, leading to about 50% prevalence of apical periodontitis (AP). Future 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 where feasible. The notion of prevention is extended to endodontics, since established intracanal microbiota is unlikely to be eradicated. Person-specific interplay between microbial burden and immune competence leads to AP. In some cases, untreated AP, specifically when associated with molars, may lead to serious, even life-threatening conditions. Moreover, emerging evidence suggests that even subclinical AP may have systemic health consequences such as an elevated risk of cardiovascular diseases. Collectively, 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.