Vital pulp therapy in permanent teeth: a comparative analysis of six contemporary international guidance documents with a unified clinical decision framework

2.1 Information sources and search strategy

Guidance documents addressing deep or extremely deep caries management, VPT, or both, in permanent teeth, published between January 2019 and February 2026, were identified through targeted searches of the official websites of the AAE, ESE, EFCD, ORCA, AAPD, and IAPD. The websites of the American Dental Association, the British Society of Paediatric Dentistry, and the DGZ were also screened. Where an organization issued more than one eligible document during this period, all were included. To contextualize and interpret these documents, supporting literature was identified through PubMed and Scopus using terms related to VPT, pulp capping, pulpotomy, permanent teeth, calcium silicate cements, deep caries, caries removal, hemostasis, restoration, and follow-up. Additional candidate documents were identified by hand-searching the reference lists of the included documents, of relevant systematic reviews, and of published appraisals of guidance documents on VPT; these were then screened against the same eligibility criteria. Guidance-document searches were last conducted on 25 February 2026, and searches for supporting literature were updated on 09 May 2026. No additional eligible guidance documents were identified in the updated search.

2.2 Document selection

One author (CM) conducted the searches and applied the eligibility criteria to all identified documents. The included documents and the reasons for exclusion were then verified independently by each of the two remaining authors (PC and NC), who reviewed the full text of each document and returned written comments. Any difference of interpretation was to be resolved by discussion until consensus was reached, with reference back to the original wording of the document concerned; in practice, no disagreement arose regarding the documents selected.

Documents were eligible if they (1) were published or formally endorsed by a major professional organization in endodontics, pediatric dentistry, conservative dentistry, or cariology; (2) provided explicit guidance on deep or extremely deep caries management, VPT, or both, in permanent teeth; (3) were published between January 2019 and February 2026; and (4) were available in English. Documents limited exclusively to primary teeth, local institutional protocols, and publications that did not provide clinical recommendations were excluded.

Six documents met the eligibility criteria: the AAE 2021 position statement [3]; the ESE 2019 position statement [4]; the ESE 2023 S3-level clinical practice guideline [5]; the AAPD 2025 clinical practice guideline [6]; the IAPD 2026 Consensus-Based Recommendations [8]; and the EFCD-ESE-ORCA 2026 S3-level clinical practice guideline [9]. The IAPD Porto Declaration [7] was used as a related contextual publication, but was not counted as a separate guidance document. For the IAPD recommendations [8], only Working Group 3 recommendations concerning permanent teeth were included.

Two documents included in the AGREE II appraisal by Sachdeva et al. [14] were considered, but were not retained as primary comparison documents. The review by Yong and Cathro [16], although published in the Australian Dental Journal, is an individually authored narrative review rather than a document issued or formally endorsed by a professional organization, and therefore did not meet criterion (1). The GSEDT 2019 scientific communication [15] met all eligibility criteria; however, it was excluded as a separate comparison document by consensus of all three authors, as it is a national narrative summary that overlaps in scope and period with the ESE 2019 position statement and does not constitute an independent evidence stream.

2.3 Data extraction

Recommendations were extracted from each document by one author (CM) and recorded in a structured extraction table. Source wording was retained verbatim during extraction and was paraphrased only at the writing stage. The extracted content was then checked against the source documents by the two remaining authors (PC and NC), each working separately, and their written comments were returned. Discrepancies were resolved by discussion with reference to the original text. Consistent with the narrative design of this review, selection and extraction were each performed by a single author and then checked by the other two, rather than being carried out twice in parallel by independent reviewers with statistical measurement of agreement.

Recommendations were extracted across six principal clinical decision points: (1) pulpal and periapical diagnosis; (2) case selection for VPT; (3) caries-removal strategy according to lesion depth and pulpal presentation; (4) management when pulp exposure occurs; (5) procedure selection according to exposure characteristics and pulp status; and (6) hemostasis assessment. Root maturity was examined as a cross-cutting modifier of treatment goals, alternative options, and follow-up. Cavity lining, definitive restoration, and follow-up were examined as additional management domains.

For each document, relevant recommendations, qualifying conditions, supporting evidence, and reported grades of recommendation or consensus were tabulated. Where wording was unclear, explanatory text and supporting evidence cited within the document were consulted. The six documents differ in whether and how they grade their recommendations, drawing variously on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the grading scheme of the German Association of the Scientific Medical Societies (AWMF), and Delphi consensus; each scheme was retained as reported in the source and is summarized in Supplementary Table 1 (Ref. [3, 4, 5, 6, 8, 9]), Panel A. Where recommendation grades and consensus categories are reported, the capitalization used in the source document is retained; AWMF consensus categories (Strong consensus, Consensus) are, therefore, capitalized when reported as formal labels, and lower case is used in running prose.

2.4 Data synthesis

Recommendations were compared to identify areas of convergence, divergence, and topics not addressed. Convergent recommendations were synthesized into a unified clinical decision framework extending from diagnosis to long-term follow-up. Areas of divergence were retained as alternative pathways or points requiring clinical judgment. The framework was constructed using five rules, according to how the documents relate at each decision point. (1) Where all six documents converged, the shared recommendation entered the algorithm as a single pathway. (2) Where documents differed only in terminology, terms were first mapped (Table 1, Ref. [3, 4, 5, 6, 8, 9]) and a single node was used. (3) Where documents diverged substantively, no single document was privileged, and the available options were retained as parallel choices. When a choice would affect the pathway taken (e.g., caries-removal strategy or hemostasis time thresholds), the divergence was marked in a clinical note; when it would not (e.g., cavity lining; see Section 6), the step was presented as optional. (4) Where a default was required for the algorithm to be operable, a pragmatic default was adopted and identified by source, with advice to individualize (follow-up schedule, based on ESE 2019). (5) Where no document addressed a decision point, an author-derived operational convention was applied, expressed qualitatively and labeled as such (exposure-size categories for procedure selection). Cross-cutting considerations on which the documents converged, such as the influence of root maturity and the preoperative criteria for considering VPT in symptomatic irreversible pulpitis, are presented as clinical notes alongside the relevant decision points. The clinical algorithm is presented as Fig. 1. Overlap in authorship, methodological frameworks, and supporting evidence sources across the six guidance documents were also examined to assess whether apparent agreement reflected fully independent guideline-development processes.

Fig. 1.Unified clinical treatment algorithm (flowchart) for vital pulp therapy in deep and extremely deep carious permanent teeth. The framework synthesizes six contemporary guidance documents into a single chairside pathway from pulpal and periapical diagnosis to follow-up. Dashed callouts contain clinical notes of three kinds: points at which the guidance documents diverge and the available options are retained; conventions or defaults adopted by the authors where the documents differ or are silent; and cross-cutting considerations on which the documents converge. Author-derived conventions and defaults are identified as such within the note and are not graded recommendations. Box colors are defined in the figure key. Ca(OH)₂, calcium hydroxide; CSC, calcium silicate cement; GIC, glass ionomer cement; IPC, indirect pulp capping; IPT, indirect pulp treatment; MTA, mineral trioxide aggregate; NP, normal pulp; RP, reversible pulpitis; SIP, symptomatic irreversible pulpitis; VPT, vital pulp therapy; ESE, European Society of Endodontology.

3.1 Overarching term

The AAE, AAPD, and IAPD use “vital pulp therapy” [3, 6, 8], whereas the ESE and EFCD-ESE-ORCA documents [4, 5, 9] generally use “vital pulp treatment”. Because these terms refer to the same overarching concept, “vital pulp therapy” (VPT) is used throughout this review.

3.2 Procedural terminology

Differences in terminology are greatest in the management of deep caries without pulp exposure (Table 1). The terms “direct pulp capping” and “partial pulpotomy” are used across all six documents. For removal of the entire coronal pulp to the level of the canal orifices, five documents use “full pulpotomy” [4, 5, 6, 8, 9], whereas the AAE uses “complete pulpotomy”; these terms describe the same procedure [3]. Accordingly, “full pulpotomy” is used throughout this review, with “complete pulpotomy” retained when referring specifically to the AAE document. The distinction between indirect pulp treatment (IPT) and IPC is primarily procedural, rather than material-based. IPT is an exposure-avoidance strategy based on selective caries removal [6, 8], whereas IPC, as narrowly defined by the ESE 2019 [4], follows non-selective removal to a hard dentin barrier.

4.1 Normal pulp and reversible pulpitis

All six guidance documents support pulp-preserving management for vital permanent teeth diagnosed with normal pulp or reversible pulpitis, whether or not pulp exposure occurs during treatment. For deep caries without symptoms suggestive of irreversible pulpitis, most documents favor selective or stepwise caries removal to avoid exposure [4, 5, 6, 7, 8, 9], whereas the AAE 2021 position statement [3] emphasizes complete caries removal to permit direct visualization; these caries-removal strategies are detailed in Section 5. When carious or mechanical pulp exposure occurs, DPC, PP, or FP may be considered according to the clinical presentation, exposure characteristics, pulpal appearance, and ability to achieve hemostasis.

The ESE 2019 position statement is the only document to formalize the distinction between carious and traumatic exposure. It defines Class I DPC as that following traumatic or iatrogenic exposure through sound dentin, and Class II DPC as that following carious exposure through bacterially contaminated dentin, for which an enhanced aseptic protocol is recommended [4]. The other five documents do not adopt this classification, although the systematic review underpinning the AAPD 2025 guideline examines the reason for pulp exposure (caries or trauma) as an outcome moderator [6]. Because the evidence underlying most recommendations in these documents derives from carious exposure, the recommendations should not be assumed to transfer directly to traumatic exposure, where the surrounding dentin is sound and bacterial contamination is not established at the time of injury.

4.2 Symptomatic irreversible pulpitis

The AAE 2021 position statement describes pulpitis as a temporally and spatially graded disease. It notes that symptomatic pulps may be candidates for VPT when viability is confirmed through direct visualization. It cites 1- to 2-year success rates of 85–100% for VPT with CSCs in teeth diagnosed with irreversible pulpitis, but does not provide a graded recommendation [3].

The ESE 2019 position statement states that FP may be successful when irreversible inflammation is considered confined to the coronal pulp; however, it cautions that stronger long-term prospective randomized evidence is required before this can be regarded as the treatment of choice [4]. The ESE 2023 S3-level clinical practice guideline provides a weak recommendation, based on low-quality evidence and Consensus, that either root canal treatment or FP may be offered for permanent teeth with spontaneous pain; for this recommendation, 21.2% of panel members abstained because of conflicts of interest [5]. The recommendation presents FP as a treatment alternative to root canal treatment, but does not establish equivalence between the two interventions.

The EFCD-ESE-ORCA 2026 S3-level clinical practice guideline provides a Grade B recommendation, based on low-certainty evidence and Strong consensus, that either PP or FP for the exposed pulp may be performed after non-selective caries removal in permanent teeth with pulp exposure and signs and symptoms of irreversible pulpitis [9].

The AAPD 2025 guideline strongly recommends non-selective caries removal in teeth with extremely deep caries or deep caries accompanied by spontaneous, nocturnal, or lingering pain, provided that no radiographic signs of infection are present (moderate certainty); the purpose of this is to expose and assess the pulp. When pulpotomy is indicated, FP with a CSC is conditionally preferred over PP, based on low-certainty evidence [6].

The IAPD 2026 Porto Forum provides consensus-based recommendations, graded as strong on the basis of Delphi agreement above 70%. It supports FP with a CSC as an alternative to non-surgical root canal treatment for mature permanent teeth with carious pulp exposure and signs and symptoms of irreversible pulpitis, provided that no signs of pulp necrosis are present. It also recommends FP for immature permanent teeth with extremely deep caries and irreversible pulpitis without necrosis to preserve vitality and support continued root development [8].

4.3 Contraindications

The AAPD 2025 guideline is the only document to provide a discrete graded recommendation against pulpotomy. It strongly recommends, based on moderate-certainty evidence, that pulpotomy should not be performed in permanent teeth with irreversible pulpitis when pulpal bleeding cannot be controlled or in the presence of preoperative periapical involvement attributable to infection [6]. The other guidance documents generally express contraindications through eligibility criteria, procedural prerequisites, or treatment-escalation rules, rather than through formal contraindication lists.

Recurring findings that generally preclude VPT or require escalation of treatment include confirmed pulp necrosis, purulent exudate, a sinus tract or soft-tissue swelling, inability to achieve hemostasis after appropriate removal of inflamed pulp tissue, and a non-restorable tooth. Periapical radiolucency should not, however, be regarded as an automatic contraindication across all documents; its interpretation is dependent on the associated clinical findings and the diagnostic criteria applied.

The AAPD 2025 and IAPD 2026 documents also emphasize patient- and tooth-related factors and treatment-feasibility considerations. These include medical complexity or special healthcare needs, difficulty achieving local anesthesia, limited mouth opening, inability to cope with treatment, severe gag reflex, facial swelling, diagnostic uncertainty, complications from previous pulp therapy, periodontal conditions, patient or parent preferences, esthetic considerations, and financial cost [6, 8]. These factors may influence case selection or necessitate an alternative treatment approach, especially in pediatric patients. They are retained in the unified clinical decision framework presented in Section 14.

5.1 Normal pulp or reversible pulpitis

For deep caries in teeth with a pulpal diagnosis of normal pulp or reversible pulpitis, most guidance documents favor an exposure-avoidance strategy [4, 5, 6, 8, 9]. The ESE 2019 position statement recommends either selective one-stage removal to soft or firm dentin or stepwise excavation, and states that non-selective removal is no longer the treatment of choice [4].

The ESE 2023 S3-level clinical practice guideline, whose primary scope is the treatment of pulpal and apical disease rather than caries removal, does not include an evidence-based recommendation on caries removal strategy due to a lack of identified eligible studies. Its linked expert consensus-based recommendation states that either selective or stepwise removal to avoid pulp exposure, or DPC or pulpotomy after non-selective removal and pulp exposure, may be considered (expert consensus-based recommendation; expert-based evidence; grade Strong; Consensus) [5]. The ESE 2023 guideline, therefore, does not establish a preference, and the ESE 2019 position statement remains the more detailed ESE source for caries-removal protocols.

The EFCD-ESE-ORCA 2026 guideline suggests both selective removal to soft dentin and stepwise removal over non-selective removal for deep caries associated with no symptoms or reversible pulpitis (both Grade B; Strong consensus; certainty very low to low across outcomes) [9, 10]. The guideline does not grade selective against stepwise removal; its accompanying text notes that this choice is not fully resolved, and is best guided by patient- and dentist-related factors (preferences, effort, and availability) together with caries penetration depth. Selective removal may be preferred for lesions radiographically extending into the inner third, but not the inner quarter of dentin, whereas stepwise removal may also be used for lesions reaching the inner quarter [9].

The AAPD 2025 guideline provides the strongest recommendation, favoring selective removal over both non-selective and stepwise removal (strong recommendation; high certainty; 60-month evidence) [6]. The IAPD 2026 Porto Forum similarly supports selective or stepwise removal for deep caries, but does not extend this to extremely deep lesions [8].

5.2 Extremely deep caries or findings suggestive of irreversible pulpitis

Recommendations diverge for extremely deep caries and those accompanied by signs or symptoms suggestive of irreversible pulpitis. The AAPD 2025 guideline aligns with the AAE approach, strongly recommending non-selective removal to allow assessment of the pulp in teeth with extremely deep caries or deep caries accompanied by spontaneous, nocturnal, or lingering pain (moderate certainty; 24- to 60-month evidence) [6].

The EFCD-ESE-ORCA 2026 guideline does not recommend non-selective removal solely on the basis of extremely deep caries. Instead, it notes that pulp exposure is highly likely and should be anticipated, while evidence remains insufficient to determine the roles of selective and stepwise removal in this subgroup [9]. The guideline further notes that the radiographic sign used to define extremely deep caries (the absence of a residual dentin band over the pulp) depends on radiographic projection and is, therefore, unreliable. Because of this diagnostic uncertainty, it applies the same caries-removal recommendation whether or not the band is visible. Clinicians are advised to prepare for possible pulp exposure and subsequent management [9]. Nevertheless, when pulp exposure occurs in teeth with signs and symptoms suggestive of irreversible pulpitis, the guideline suggests PP or FP after non-selective excavation [9].

Overall, for deep caries with normal pulp or reversible pulpitis, several documents prefer an exposure-avoidance strategy using selective or stepwise removal. The AAE 2021 favors non-selective removal throughout, and the ESE 2023 states no preference. For extremely deep caries or teeth with signs and symptoms suggestive of irreversible pulpitis, several documents affirmatively recommend non-selective removal to expose and assess the pulp. They differ, however, on the cases for which this is indicated: whether lesion depth alone is sufficient, or whether findings suggestive of irreversible pulpitis are also required. Divergence, therefore, persists across both scenarios rather than resolving into a single agreed strategy.

7.1 Hemostasis agents

Sodium hypochlorite (NaOCl) is the hemostatic and antimicrobial agent most frequently specified across the guidance documents, although the strength of recommendation and specified concentration vary. The AAPD 2025 guideline strongly recommends NaOCl irrigation or NaOCl-soaked cotton pellets over saline for DPC (moderate certainty; 36- to 42-month data) based on success rates of 83% with NaOCl and 67% with saline. For pulpotomy, NaOCl is conditionally suggested over saline, based on very-low-certainty evidence; no concentration is specified [6].

The AAE 2021 position statement describes NaOCl as suitable for direct contact with pulp tissue at concentrations ranging from dilute solutions to full-strength commercial preparations [3]. The ESE 2019 position statement recommends cotton pellets soaked with NaOCl (0.5–5%) or chlorhexidine (0.2–2%) for disinfection and hemostasis. Saline is noted to have limited disinfecting activity, while ferric sulfate, although hemostatically effective, may interfere with assessment of pulpal bleeding [4].

The IAPD 2026 Porto Forum emphasizes the importance of achieving hemostasis, but does not recommend a specific agent or concentration [8]. Likewise, the EFCD-ESE-ORCA 2026 guideline provides no graded recommendation for a specific hemostatic agent; its expert-based recommendation instead supports an enhanced VPT protocol incorporating dental dam isolation, intraoperative antimicrobial lavage, magnification, and a suitable pulp-dressing material [9].

7.2 Hemostasis time thresholds

The guidance documents differ in whether they specify a time threshold for achieving hemostasis. The AAPD 2025 guideline conditionally recommends PP or FP when hemostasis can be achieved within 6 minutes, based on low-certainty evidence from studies with 12- to 24-month follow-up. Its supporting systematic review reported a mean hemostasis time of 4.25 minutes for PP and a range of 4.25–5.78 minutes for FP [6, 17].

The ESE 2019 position statement specifies that, if hemostasis cannot be achieved within 5 minutes, additional pulp tissue should be removed, with escalation from DPC or PP to a deeper or FP. If bleeding remains uncontrolled after FP, pulpectomy and root canal treatment are indicated [4].

The AAE 2021 position statement indicates that NaOCl is typically applied to the resected pulp for 5–10 minutes, although durations may vary [3]. This represents the usual duration of NaOCl application rather than a defined threshold for determining VPT eligibility or treatment escalation.

The ESE 2023, EFCD-ESE-ORCA 2026, and IAPD 2026 documents do not specify a fixed numerical time threshold. Instead, they emphasize the ability to achieve hemostasis and the intraoperative appearance and condition of the remaining pulp. Evidence supporting any specific cutoff remains limited [8, 18]; this issue is considered further in Section 15.1.

8.1 Materials for exposed pulp

The EFCD-ESE-ORCA 2026 guideline suggests that DPC or pulpotomy should be performed using an HCSC rather than calcium hydroxide in permanent teeth with no symptoms or reversible pulpitis (Grade B; moderate certainty for absence of clinical symptoms and radiographic pathology; Strong consensus) [9]. Its supporting systematic review included five randomized controlled trials involving 552 teeth; HCSCs were associated with a higher probability of absence of pathology than calcium hydroxide (odds ratio (OR) 2.68, 95% confidence interval (CI) 1.70–4.22) [13].

The ESE 2023 guideline provides an expert consensus-based recommendation (grade Strong; Consensus) for an enhanced operative protocol incorporating an HCSC when DPC or pulpotomy is performed in immature or mature permanent teeth with no or non-spontaneous pain [5]. The ESE 2019 position statement similarly recommends placement of an HCSC directly on exposed pulp during DPC, PP, or FP and cautions against direct pulp contact with resin-based composites or dentin-bonding agents [4].

The AAPD 2025 guideline strongly recommends CSC over calcium hydroxide for DPC in teeth with normal pulp or reversible pulpitis (moderate certainty; 36-month success, 88% versus 70%) [6]. Following pulp exposure, DPC, PP, or FP may be performed using CSC regardless of root maturation (conditional recommendation; low certainty) [6]. For permanent teeth in esthetic areas, a non-staining CSC is strongly recommended (high certainty after 12 to 24 months); the supporting systematic review reported discoloration in 83% of teeth treated with bismuth oxide–containing mineral trioxide aggregate (MTA) and none of those treated with Biodentine [6, 17].

The IAPD 2026 Porto Forum recommends CSCs for VPT in permanent teeth with deep caries and for PP or FP in teeth with irreversible pulpitis without necrosis [8]. The AAE 2021 position statement identifies CSCs, including MTA and other tricalcium silicate–based materials, as contemporary VPT materials and reports 1- to 2-year success rates of 85–100% in teeth with symptomatic or asymptomatic irreversible pulpitis. Calcium hydroxide, glass ionomer cements, and resin-based materials are reported to have lower and more variable success rates of 43–92%; however, these ranges were derived from heterogeneous studies and clinical contexts and should not be interpreted as direct comparative estimates [3].

8.2 Materials when the pulp is not exposed

Material recommendations are less restrictive when caries removal does not result in pulp exposure. The choice of whether to place a liner over unexposed dentin was compared in Section 6; the question here is which material the documents permit when one is used. The AAPD 2025 guideline permits glass ionomer cement, calcium hydroxide, or CSC as the medicament for indirect pulp treatment, because material choice did not significantly affect 24-month success (conditional recommendation; moderate certainty) [6]. The ESE 2019 position statement permits either an HCSC or glass ionomer cement over residual or deep dentin following selective, stepwise, or non-selective caries removal [4]. The IAPD 2026 Porto Forum also permits glass ionomer cement when the pulp remains unexposed [8].

Overall, the six guidance documents consistently favor CSCs or HCSCs when a material is placed directly on exposed pulp. Calcium hydroxide and glass ionomer cement remain acceptable in selected non-exposure applications, but calcium hydroxide is no longer preferred for DPC or pulpotomy. In visible areas, non-staining CSC formulations should be selected to reduce the risk of tooth discoloration.

15.1 Clinical implications and limitations of the evidence

The greatest uncertainty concerns VPT in permanent teeth with signs and symptoms suggestive of irreversible pulpitis. Conventional clinical diagnoses correlate imperfectly with histopathological pulp status [21, 22], and biologically oriented diagnostic systems (such as the Wolters classification [23]) were not used as enrollment criteria in the pivotal clinical trials supporting this indication [24, 25, 26]. Intraoperative assessment of pulp appearance and the ability to achieve hemostasis, therefore, remain important, although neither provides definitive histological confirmation. The documents also express different levels of confidence in pulpotomy for this indication (Section 4.2), and these are not directly comparable, since the documents grade evidence and consensus by different methods (Supplementary Table 1, Panel A).

The supporting trials generally have modest sample sizes, limited follow-up, and predominantly single-center designs [24, 25, 26, 27]. Longer-term multicenter evidence remains limited, and the Pulpotomy for Irreversible Pulpitis feasibility trial has not yet been followed by a completed definitive trial [28]. Clinicians should, therefore, discuss both the potential benefits and the remaining uncertainty when obtaining informed consent, particularly in cases where pulpotomy is considered as an alternative to root canal treatment. Apparent agreement should also be interpreted in light of the authorship and methodological overlap described in Section 13.

15.2 Strengths and limitations of the review

A strength of this review is the side-by-side comparison of all six contemporary guidance documents across a consistent set of clinical decision points. Recommendation wording, evidence grades, consensus levels, and important qualifying conditions were retained where available, and differences in terminology were mapped before developing the unified framework. The framework also distinguishes areas of broad convergence from author-derived operational choices.

Several limitations should be acknowledged. First, this was a narrative review based on targeted rather than fully systematic literature retrieval. Document selection and data extraction performed by a single reviewer and subsequently verified rather than duplicated independently; relevant publications may, therefore, have been missed. Second, no new formal methodological appraisal of the six documents was undertaken, and recommendation strength could not be standardized due to the different development and grading systems they use. Third, supporting literature was selected to contextualize recommendations rather than to generate independent pooled estimates. Finally, several elements of the framework, including the exposure-size categories and the operational handling of divergent caries-removal recommendations, represent the authors’ clinical synthesis rather than uniformly graded recommendations. The framework should, therefore, be used alongside the source documents and updated as new evidence and guidance emerge.

15.3 Future directions for guideline harmonization

Future guideline development should prioritize reducing avoidable divergence among organizations by harmonizing terminology, clinical questions, outcome definitions, follow-up intervals, and evidence-grading methods. Cross-organizational collaboration is particularly needed for areas of persistent disagreement, including caries-removal strategy in deep and extremely deep lesions, VPT eligibility in symptomatic irreversible pulpitis, hemostasis thresholds, procedure selection, restorative management, and follow-up [29]. Shared evidence reviews, core outcome sets, and coordinated or living updates could improve consistency while preserving differences justified by specialty scope or patient population. Research should target these unresolved decision points using standardized diagnostic criteria, treatment protocols, and long-term outcomes, with adequate representation of children and adolescents.