Endodontics, as a critical branch of dental science, has witnessed substantial evolution in recent years, driven by advances in diagnostic imaging, biomaterials, and clinical research.
However, one of the most transformative developments has been the shift toward evidence-based clinical guidelines that aim to standardize diagnosis and treatment protocols across Europe and globally.
The European Society of Endodontology (ESE), a leading authority in the field, has responded to this need by releasing S3-level clinical guidelines—representing the highest standard of evidence-based recommendations.
These new guidelines provide a framework for clinicians to accurately classify and manage various endodontic lesions, ranging from deep carious lesions and pulpal inflammation to complex resorptive defects such as external cervical resorption (ECR).
Accurate classification is not merely academic—it is vital for achieving predictable treatment outcomes, reducing over- or under-treatment, and preserving dental structures.
The ESE’s updated classifications are the result of extensive systematic reviews and expert consensus, integrating the GRADE methodology to ensure transparency and clinical relevance.
By translating high-quality research into practical recommendations, the ESE empowers endodontists and general dentists alike to make informed clinical decisions grounded in the best available evidence.
In the sections that follow, we will explore the current classification systems for deep caries, pulp exposure, and ECR as defined by the ESE, along with their implications for modern endodontic practice.
1. S3-Level Clinical Guidelines: A New Gold Standard
In 2023, the ESE published its S3-level guidelines for the treatment of pulpal and apical diseases.
These guidelines were developed through a systematic and transparent process, which included 14 systematic reviews and the application of the GRADE methodology to evaluate the quality of evidence.
The primary goal is to provide clinicians with strong, evidence-based recommendations to preserve tooth health over the long term.
2. Updated Classification of Deep Caries and Pulp Exposure
The ESE now classifies deep carious lesions into two key categories:
✔ Deep caries
Lesions that extend to the inner third of dentin, with a risk of pulpal exposure during excavation.
✔ Extremely deep caries
Lesions that penetrate the entire dentin layer, making pulpal exposure inevitable.
This classification informs treatment decisions such as selective caries removal, pulp capping, or pulpotomy.
The emphasis remains on maintaining pulp vitality whenever possible.
► DENTAL BOOK: Cohen's Pathways of the Pulp. Berman and Hargreaves (2020)
3. Classification of External Cervical Resorption (ECR)
ESE also provides a detailed classification for external cervical resorption (ECR), a complex condition often misdiagnosed.
The classification system considers:
✔ Lesion height.
✔ Circumferential spread.
✔ Proximity to the root canal.
This 3D assessment is based on CBCT imaging, allowing for precise diagnosis and tailored treatment planning.
Conclusion
The ESE's updated guidelines and classifications reflect a commitment to advancing clinical excellence in endodontics.
By embracing evidence-based practices, endodontists can offer more accurate, conservative, and effective care, aligned with the latest scientific understanding.
References
- European Society of Endodontology. Resources for Clinicians.
- Duncan HF, et al. Management of deep caries and the exposed pulp: European Society of Endodontology position statement. Int Endod J. 2019;52:923–934.
- ESE Position Statement: External Cervical Resorption. Int Endod J. 2018;51:1323–1326.
