Pulp calcification and pulp canal obliteration: from biological mechanisms to contemporary clinical management and digital navigation

Pulp calcification and pulp canal obliteration (PCO) can complicate canal identification and endodontic access. This structured narrative review synthesizes current evidence on the biological mechanisms, epidemiology, systemic, medication-related, and genetic associations, and clinical management of pulp calcification and PCO. We searched PubMed/MEDLINE, Scopus, and Web of Science from database inception to August 27, 2026. Literature for the narrative sections was selected for its relevance to the review topics, whereas the clinical comparison of freehand and navigation-assisted access used a focused, structured search with defined eligibility criteria. Case reports and case series meeting the focused-synthesis criteria also informed complex clinical scenarios, failed canal localization, procedural complications, and rescue pathways. The review evaluates the limitations of the available evidence and proposes a clinically oriented framework for treatment indication, preoperative assessment, access planning, technique selection, and complication management. Current evidence suggests that navigation may improve trajectory control in selected cases. However, calcification alone does not indicate treatment, and clinicians should use digital approaches selectively after case-specific assessment and with clinician verification. Further studies should standardize terminology and outcomes and evaluate patient-centered, long-term, safety, and cost-effectiveness outcomes.