Dental Literature Watch · Guideline · Cariology
Deep Caries: the EFCD-ESE-ORCA S3 Guideline
TL;DR
- Selective or stepwise caries removal beats non-selective removal in deep lesions, because it reduces the risk of pulp exposure. Leaving soft dentine over the pulp is now the recommended approach, not a compromise.
- Cavity liners are out. Routine liners after caries removal showed no consistent clinical benefit and are not recommended.
- If you do expose the pulp: direct pulp capping and pulpotomy are both effective in teeth without irreversible pulpitis.
- Pulpotomy is an acceptable alternative to pulpectomy even with signs of irreversible pulpitis — that is the most surprising line in the document.
- Hydraulic calcium silicate cements are preferred over calcium hydroxide for both pulp capping and pulpotomy.
- Certainty of evidence ranged from very low to moderate. Direction is clear; precision is not.
What it says, question by question
| Question | Recommendation |
|---|---|
| Caries removal | Selective (SE) or stepwise (SW) removal over non-selective removal, to reduce pulp exposure |
| Cavity liners | Not routinely recommended — no consistent clinical benefit |
| Exposed pulp, no irreversible pulpitis | Direct pulp capping or pulpotomy; both effective |
| Signs of irreversible pulpitis | Pulpotomy is an acceptable alternative to pulpectomy |
| Capping material | Hydraulic calcium silicate cement over calcium hydroxide |
Why the liner recommendation matters more than it looks
The liner step survives in a lot of operatories out of training and habit.
The guideline did not find it harmful — it found no consistent benefit, which makes it a step you can drop.
That is one fewer material, one fewer minute, and one fewer variable under the restoration.
The liner step survives in a lot of operatories out of training and habit.
The guideline did not find it harmful — it found no consistent benefit, which makes it a step you can drop.
That is one fewer material, one fewer minute, and one fewer variable under the restoration.
💎 Insight — what this means chairside
The old instinct was to remove everything, and it was wrong
Excavating to hard dentine over a deep lesion is the single most reliable way to expose a pulp that did not need exposing.
The bacteria left behind under a well-sealed restoration are deprived of substrate; the seal is what arrests the lesion, not the completeness of the excavation.
Excavating to hard dentine over a deep lesion is the single most reliable way to expose a pulp that did not need exposing.
The bacteria left behind under a well-sealed restoration are deprived of substrate; the seal is what arrests the lesion, not the completeness of the excavation.
Pulpotomy for irreversible pulpitis is the genuinely new idea
For decades "irreversible pulpitis" meant root canal, full stop.
The guideline now positions full pulpotomy as an acceptable alternative — which for a general practice means some of these teeth can be managed without endodontic referral.
Note the wording: acceptable alternative, not first choice. Case selection is doing a lot of work here.
For decades "irreversible pulpitis" meant root canal, full stop.
The guideline now positions full pulpotomy as an acceptable alternative — which for a general practice means some of these teeth can be managed without endodontic referral.
Note the wording: acceptable alternative, not first choice. Case selection is doing a lot of work here.
Calcium hydroxide finally loses on evidence, not fashion
Hydraulic calcium silicates (MTA and its successors) demonstrated superior clinical outcomes.
If calcium hydroxide is still your capping material, this is the document that justifies changing the stock order.
Hydraulic calcium silicates (MTA and its successors) demonstrated superior clinical outcomes.
If calcium hydroxide is still your capping material, this is the document that justifies changing the stock order.
It is free to read, in three journals
The authors deliberately made it open access in Caries Research, the International Endodontic Journal, and Clinical Oral Investigations to push dissemination.
No paywall, no institutional login.
The authors deliberately made it open access in Caries Research, the International Endodontic Journal, and Clinical Oral Investigations to push dissemination.
No paywall, no institutional login.
⚠️ The catch
The certainty of evidence is very low to moderate
This is an S3 consensus guideline built on a thin randomised base, not a stack of large trials.
The direction of travel is well supported; the specific choices between SE and SW, or between capping and pulpotomy, are not settled.
This is an S3 consensus guideline built on a thin randomised base, not a stack of large trials.
The direction of travel is well supported; the specific choices between SE and SW, or between capping and pulpotomy, are not settled.
Extremely deep caries is explicitly still an open question
The authors name it as the area most needing research, along with long-term outcomes.
The deeper and more symptomatic the tooth, the more you are operating on judgement rather than evidence.
The authors name it as the area most needing research, along with long-term outcomes.
The deeper and more symptomatic the tooth, the more you are operating on judgement rather than evidence.
Implementation is named as a barrier by the authors themselves
They call out clinician training, patient-centred decision-making, and economic and practical factors.
Leaving caries behind is a conversation with the patient, and in some settings a conversation with an insurer.
They call out clinician training, patient-centred decision-making, and economic and practical factors.
Leaving caries behind is a conversation with the patient, and in some settings a conversation with an insurer.
⚡ Bottom line
- Deep lesion, vital tooth, no irreversible pulpitis → selective removal. Leave the soft dentine over the pulp, seal well.
- Reaching for the liner → skip it. No consistent benefit.
- Pulp exposed during excavation → direct pulp cap or pulpotomy, with a hydraulic calcium silicate.
- Calcium hydroxide in the drawer → calcium silicate is now the preferred material.
- Irreversible pulpitis → pulpotomy is an acceptable alternative to pulpectomy in selected cases.
🧪 Questions
Tap an answer — instant grade, deciding line, and the trap.
A 24-year-old patient has a deep occlusal lesion on a lower first molar. The tooth is vital, responds normally to cold with no lingering pain, and there is no periapical radiolucency. Radiographically the lesion extends into the inner third of dentine. As you excavate, you reach soft, leathery dentine directly over the pulpal wall. What does the 2026 EFCD-ESE-ORCA guideline recommend?
Deciding line: selective removal is recommended over non-selective removal in deep lesions specifically to avoid pulp exposure, and the seal — not the completeness of excavation — is what arrests the lesion. Trap: excavating to hard dentine is the trained reflex and the exact behaviour the guideline is written to change; the calcium hydroxide option gets the concept of preserving the pulp right but picks the material the guideline explicitly ranks below hydraulic calcium silicate.
During excavation of a deep lesion in a vital premolar you create a small pinpoint pulp exposure. The patient reported only brief sensitivity to cold beforehand, with no spontaneous or lingering pain. Bleeding at the exposure is bright red and stops within a few minutes. Which is best supported?
Deciding line: in a tooth without irreversible pulpitis, direct pulp capping is an effective option and hydraulic calcium silicate cements showed superior clinical outcomes to calcium hydroxide. Trap: the pulpectomy option reflects the older teaching that exposure means root canal, which this guideline directly contradicts; calcium hydroxide is right-for-a-neighbour, correct in approach but using the material that lost the comparison.
A patient presents with a lower molar with spontaneous, lingering pain to cold consistent with symptomatic irreversible pulpitis. The tooth is restorable, the patient is anxious about a long appointment, and full root canal treatment cannot be completed today. Which statement reflects the 2026 guideline?
Deciding line: the guideline states that pulpotomy is an acceptable alternative to pulpectomy in teeth with signs of irreversible pulpitis, which is its most significant departure from previous teaching. Trap: the first option is what most of us were taught and is the engineered trap here; note the guideline's wording is acceptable alternative, not first choice, so it widens the options rather than replacing pulpectomy outright.