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Over the past century, the pulpal-periodontal relationship has been a topic of controversy and extensively studied. From a periodontal perspective, it has been suggested that the cumulative effect of biofilm-induced pocket formation might cause pulp inflammation via exposed accessory canals.^147,154,155 Nonetheless, a complete disintegration of the pulp may occur only when all main apical foramina are challenged by bacterial biofilm.¹⁵⁶

Conversely, Mazur and Massler demonstrated that the pulp condition could vary from almost normal to advanced degeneration despite the presence of periodontal disease.¹⁵⁷ Their findings suggest that the periodontal status does not exert any great influence on the pulp and addressed possible systemic factors as the cause for pulp degeneration.

On the other hand, advanced stages of pulpitis can cause periodontal breakdown.^158–161 As such, endodontic treatment often leads to healing of untreated periodontal lesions in the presence of a endodontic-periodontal defect and supports the idea that accessory canals may act as a passageway for endodontic irritants.^158,162,163