The present study aimed to investigate dentists’ decision-making processes regarding the implementation of selective caries removal and pulp exposure in cases involving immature and fully developed teeth displaying signs of reversible pulpitis. According to the results of this study, less invasive and conservative treatment options including selective caries removal have not been fully implemented into the everyday clinical practice of Greek dentists for managing reversible pulpitis. It has been indicated that treatment preferences are influenced by the tooth developmental status, vary significantly and there is no clear preference for a more conservative approach to preserving as much healthy pulp tissue as possible.

Surveys are a reliable tool frequently used to evaluate dentists’ knowledge, attitudes, and decision-making processes. The treatment preferences of dentists regarding DCLs have been the subject of many surveys in different countries, most of which have included various clinical scenarios of fully developed teeth presenting signs and symptoms of reversible pulpitis (Oen et al. 2007, Koopaeei et al. 2017, Crespo-Gallardo et al. 2018, Alnahwi et al. 2018, Stangvaltaite et al. 2013, Schwendicke et al. 2017, Chai et al. 2020, Croft et al. 2019, Jurasic et al. 2022, Bjørndal et al. 2010, Schwendicke et al. 2016, Maltz et al. 2018). Total caries removal was the prevalent choice among dentists in the USA (Oen et al. 2007; Koopaeei et al. 2017; Jurasic et al. 2022), Spain (Crespo-Gallardo et al. 2018), Saudi Arabia (Alnahwi et al. 2018), Norway (Stangvaltaite et al. 2013), France and Germany (Schwendicke et al. 2017). However, a more conservative approach like selective caries removal was preferred by dentists in Australia (Chai et al. 2020), Finland (Croft et al. 2019) and Norway (Schwendicke et al. 2017).

Dental caries in children and adolescents is a common issue for paediatric dentists (Stecksen-Blicks et al. 2004) with the posterior teeth being the most frequently affected (Mejare et al. 2004). Vital pulp treatment modalities represent viable options for treating DCLs in primary and immature permanent teeth (Duggal et al. 2022; Tong et al. 2022). The European Academy of Paediatric Dentistry (EAPD) guidelines recommend that in such cases the least invasive technique leading to the optimal result should be used (Duggal et al. 2022). According to the ESE position statement, selective carious-tissue removal is highly recommended for managing DCLs in mature or immature teeth with reversible pulp damage. The procedure indicates that soft or firm dentin is left on the pulpal aspect of the cavity, whilst peripheral carious dentin is removed to hard dentin to achieve ideal bonding and sealing of the defect (ESE 2019). The biological rationale behind selective caries removal lies in the fact that sealing off the lesion from the oral environment inactivates caries progression and induces the formation of reparative dentin avoiding pulp exposure, a fact having a significant impact on the long-term prognosis of the tooth and treatment costs (Ricketts et al. 2013, Schwendicke et al. 2013, Bjørndal et al. 2010). The International Caries Consensus Collaboration (ICCC) report also recommends selective caries removal (Schwendicke et al. 2016). These recommendations are also supported by clinical trials on mature teeth showing that selective caries removal resulted in a 60–80% five-year survival rate of the pulp compared to the 46% five-year survival rate in the non-selective removal group (Maltz et al. 2018; Bjørndal et al. 2017).

In contrast, the AAE position statement suggests total caries removal for all cases using caries detectors or laser fluorescence as adjunct tools irrespectively of the root maturation stage (Glickman et al. 2009, AAE 2021). Total caries removal and complete elimination of bacteria from dentin are essential for the healing process. This decision is based on the fact that any remaining bacteria in the firm dentin cavity floor by the selective carious removal method could be a source of pathogen-associated molecular pattern irritants that may induce persistent inflammatory effects on pulp tissue limiting the regenerative or reparative potential of the pulp (AAE 2021). The potential for pulp exposure is not considered a disadvantage since direct visualization of the pulp can assist in evaluating haemostasis and the level of inflammation. As a result, other VPT modalities such as direct pulp capping or partial pulpotomy present as equally effective alternatives. So far there is limited evidence about success rates of VPT procedures in immature teeth. In the meta-analysis of Tong et al. it has been concluded that there is no clear evidence of the superiority of a VPT technique regarding clinical and radiographic success rates of immature teeth (Tong et al. 2022). A total of 12 studies were finally reviewed, with one of them being a randomized clinical trial. VPT treatment modalities included selective (in one or two steps) or total carries removal, direct pulp caping and partial or total pulpotomy. Indirect pulp capping was evaluated only in one paper, a fact evidencing the lack of experimental data regarding the management of DCLs in immature teeth.

The results of the current study show that over half (53.2%) of dentists prefer total caries removal when treating a permanent mature tooth showing signs and symptoms of reversible pulpitis (Scenario I). This shows that Greek dentists are not clearly aware of the indications for selective caries removal and the ESE position statement is not fully implemented in clinical practice. In the case of pulp exposure, most dentists (82.6%) of the total caries removal group preferred direct pulp capping. Despite most dentists showing a preference for VPT procedures like pulp capping or pulpotomy, there is still a minority (12.4%) who chose root canal treatment. Perhaps this is due to a lack of training and the unfamiliarity of dentists with VPT and related materials (Mejàre and Cvek 1993). The absence of specific equipment could impact decision-making as magnification is necessary to ensure the complete removal of soft dentin and thorough inspection of pulp tissue (Chailertvanitkul et al. 2014).

In the case of immature teeth with symptoms of reversible pulpitis almost half of the respondents (50.6%) opted for indirect pulp capping, and 46.1% chose direct pulp capping or pulpotomy. Compared to scenario I, the increase in preference for VPT options is statistically significant (p < 0.001). This indicates that dentists tend to avoid RCT due to the complexity of cases involving immature roots. In these cases, VPT may be the only viable treatment option that ensures continuing normal root maturation and apical closure. In these cases, a pulpectomy without performing complex procedures, like apexogenesis or apexification, is not a viable option.

However, the preferred VPT options presented a significantly wide range of choices. Overall, less than half of the respondents chose a more conservative approach, while the rest selected a more aggressive treatment option. Specifically, 41% of the respondents shifted from the total caries removal treatment option (scenario I) to the selective caries removal treatment option in scenario II. This decision emphasizes the importance of preserving pulp vitality by using more conservative treatment options to avoid pulp exposure. Conversely, there was also a noticeable shift towards more aggressive VPT options, such as pulpotomy (30.6%) or direct pulp capping (23.2%), among most respondents who originated from the selective caries removal group in scenario I. This indicates that many dentists may not be familiar with treatment options for immature teeth and may instead prefer to choose a more aggressive VPT modality, as a more preventive step, when root canal treatment is not an option for an immature tooth.

A similar study showed that French dentists also discerned between mature and immature teeth; 77% of the respondents preferred a conservative approach to caries removal for permanent immature teeth compared to 21.5% for permanent mature teeth (Muller-Bolla et al. 2021). So far, the ESE and AAE guidelines do not differentiate between cases of fully developed and immature teeth. Therefore, the same guidelines applied for mature teeth with reversible and irreversible pulpitis were also applicable to immature teeth. However, the ESE S3 Level Guidelines indicate that VPT is the first clinical approach for immature teeth with signs and symptoms of pulpitis (symptomatic), whilst root canal therapy or full pulpotomy is suggested for mature teeth (Duncan et al. 2023). This study clearly shows that respondents discriminate between cases based on root maturation stage, indicating that teeth with immature apex present more complex cases.

Clinical decision-making for DCLs in immature permanent teeth should consider the specific clinical conditions found in children and adolescent teeth. Compared to mature permanent teeth, immature teeth have thinner and less mineralized dentin with increased permeability due to the wide dentinal tubules and large pulp chambers with higher pulp horns (Chowdhary et al. 2010). As these factors significantly increase the risk of pulp exposure it is imperative that diagnosis along with the thickness of the remaining dentin is the only key factor in determining the type of intervention needed. It has been indicated that to perform selective caries removal, a clearly defined radiopaque zone of dentin that is calculated no less than a quarter of the full dentin thickness should separate pulp from the cavity floor (ESE 2019). Unfortunately, calculating the remaining dentin thickness can be challenging in periapical radiographs. In such cases, the parallel x-ray technique, specific software tools of a digital imaging system, bitewings, radiograph subtraction as well as the use of magnification may be necessary for more accurate estimations (Kühnisch et al. 2020). Though the regenerative capacity of the young dental pulp of children teeth is superior compared to that of adults, it could not negate the fact that pulp exposure in cases of immature teeth is a prognostic factor that may negatively impact the success rates of VPT treatment. Considering the biological benefits of pulp preservation, the conservative approach to dentin removal is still imperative (Glickman et al. 2009). Consequently, the management of DCLs should be considered otherwise between child and adult patients.

Regarding the materials used for indirect or direct pulp capping, MTA and Bioceramics were the most preferred options. This choice aligns with the ESE guidelines (ESE 2019). These materials possess superior anti-inflammatory and anti-bacterial properties, as well as sealing ability and biocompatibility, when compared to traditional capping materials like calcium hydroxide (Chicarelli et al. 2021). Most importantly they present superior histological outcomes in terms of the quality of dentin bridge formation, which is directly correlated with improved clinical results (Nair et al. 2008; Kundzina et al. 2017). While Bioceramics present the gold standard for direct pulp capping it should be noted that there is no definitive evidence supporting a single indirect capping material.

Only 1.9% of dentists prescribed antibiotics. The use of systemic or topical antibiotics is not indicated in cases of reversible pulpitis or pulp exposure (Segura-Egea et al. 2018).

In this study, most dentists work in their own private practice. However, no statistically significant difference was found in treatment preferences between dentists working in private practices and those working in dental clinic settings. Most of the participants had 0–5 years of clinical experience (40%), indicating that they had graduated more recently and tended to prefer VPT with a statistically significant difference (p < 0.05) compared to the group with 15 + years of experience. This could be interpreted as a tendency of dental schools’ curricula to emphasize VPT in recent years. The preference for conservative treatment approaches, including selective caries removal or other VPT modalities, may also be influenced by the perceived novelty and contemporary nature of such methods. On the other hand, dentists with over 15 years of experience tend to prefer RCT, due to their increased confidence and familiarity with this established procedure. Moreover, the rapid dissemination of scientific knowledge through meetings, published statements, and official social media platforms makes updating the dental community quick and effective. In this study, most of the participants (78.8%) chose a combined method of continuing education through congresses, lectures, webinars and social media. Consequently, it is expected that guidelines expressed in official position statements would be widely integrated into the dental community. Perhaps, the discrepancy can be explained by attending low-quality webinars or social media sources that do not accurately represent the official endodontic communities. This highlights the need for educational initiatives within dental curricula or continuing education programmes to promote conservative treatment approaches for dealing with DCLs in Greece.

This study is the first to investigate Greek dentists’ preferences for managing deep carious lesions (DCLs) in mature and immature teeth. It addresses a gap in the literature regarding how clinical decision-making varies depending on root development. The questionnaire presents realistic clinical cases with radiographs and symptom descriptions, enhancing the validity of the responses. A total of 453 respondents participated with varying levels of experience and educational backgrounds, allowing for broader generalizability of the findings. Moreover, the sample size ensured a substantial dataset for meaningful statistical analysis. However, this study is not free from certain limitations. As forementioned, the questionnaire was distributed exclusively through digital channels and links, therefore the precise number of dentists reached could not be accurately determined. Other limitations of the current study include the sample which is not representative of the total dentist’s population and the fact that the information provided is based on self-reporting. Respondents may choose answers that seem theoretically correct but do not reflect their actual clinical practice. Everyday decision-making is affected by numerous factors. Closed-ended questions may not accurately represent real-life management decisions. Finally, specific VPT options like stepwise caries removal were not included in the questionary to clearly emphasize the main dilemma which is the selection between total or selective caries removal. Besides that, it has been shown that one-step selective caries removal yields the same, if not better, results than stepwise excavation since there are several studies recommending one-step selective excavation instead of a two-step (stepwise) procedure where there is still a possibility of pulp exposure during re-intervention (AAPD 2024, Maltz et al. 2018, Hoefer et al. 2016).