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AAE Endodontic Case Difficulty

Assessment Form and Guidelines

Patient Information Disposition

Treat in Office: Yes No
Full Name

Refer Patient to:

Street Address Suite/Apt

City State/Country Zip

Phone Date

Email

Guidelines for Using the AAE Endodontic Case Difficulty Assessment Form
The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula. The Assessment Form makes case selection more efficient, more consistent and
easier to document. Dentists may also choose to use the Assessment Form to help with referral decision making and record keeping.

Conditions listed in this form should be considered potential risk factors that may complicate treatment and adversely affect the outcome. Levels of difficulty are sets of conditions that may
not be controllable by the dentist. Risk factors can influence the ability to provide care at a consistently predictable level and impact the appropriate provision of care and quality
assurance.

The Assessment Form enables a practitioner to assign a level of difficulty to a particular case.

Consider using cone beam computed tomography (CBCT) for assessing moderate and high difficulty cases.

Levels of Difficulty
LOW DIFFICULTY
Preoperative condition indicates routine complexity (uncomplicated). These types of cases would exhibit only those factors listed in the LOW DIFFICULTY category. Achieving a favorable
treatment outcome should be attainable by a competent practitioner with limited experience.

MODERATE DIFFICULTY
Preoperative condition is complicated, exhibiting one or two factors listed in the MODERATE DIFFICULTY category. Achieving a favorable treatment outcome may be challenging for a
competent, experienced practitioner.
HIGH DIFFICULTY
Preoperative condition is exceptionally complicated, exhibiting three or more factors listed in the MODERATE DIFFICULTY category or at least one in the HIGH DIFFICULTY category.
Achieving a favorable treatment outcome may be challenging for even the most experienced practitioner with an extensive history of favorable outcomes.

Review your assessment of each case to determine the level of difficulty. If the level of difficulty exceeds your experience and comfort, you might consider referral to an endodontist.

Criteria and Subcriteria LOW DIFFICULTY MODERATE DIFFICULTY HIGH DIFFICULTY

A. PATIENT CONSIDERATIONS

MEDICAL HISTORY No medical problem (ASA Class 1 or 2*) One or more medical problem Complex medical history/serious illness/
(ASA Class 3*) disability (ASA Class 4*)

ANESTHESIA No history of anesthesia problems Vasoconstrictor intolerance Difficulty achieving and/or maintaining anesthesia

PATIENT DISPOSITION Cooperative and compliant Anxious but cooperative Uncooperative

ABILITY TO OPEN MOUTH No limitation Slight limitation in opening Significant limitation in opening

GAG REFLEX None Gags occasionally with radiographs/ Extreme gag reflex which has
treatment compromised past dental care

EMERGENCY CONDITION Minimum pain or swelling Moderate pain or swelling Severe pain or swelling

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Criteria and Subcriteria LOW DIFFICULTY MODERATE DIFFICULTY HIGH DIFFICULTY

B. DIAGNOSTIC AND TREATMENT CONSIDERATIONS

DIAGNOSIS Signs and symptoms consistent with Extensive differential diagnosis of usual signs Confusing and complex signs and
recognized pulpal and periapical conditions and symptoms required symptoms: difficult diagnosis
History of chronic oral/facial pain

RADIOGRAPHIC DIFFICULTIES Minimal difficulty obtaining/interpreting radiographs Moderate difficulty obtaining/interpreting radiographs Extreme difficulty obtaining/interpreting radiographs
(e.g., high floor of mouth, narrow or low palatal (e.g., superimposed anatomical
vault, presence of tori) structures)

POSITION IN THE ARCH – Anterior/premolar 1st molar 2nd or 3rd molar

TOOTH TYPE

POSITION IN THE ARCH – Slight inclination (<10°) Moderate inclination (10-30°) Extreme inclination (>30°)
INCLINATION

POSITION IN THE ARCH – Slight rotation (<10°) Moderate rotation (10-30°) Extreme rotation (>30°)
ROTATION

TOOTH ISOLATION Routine rubber dam placement Simple pretreatment modification required for rubber Extensive pretreatment modification required
dam isolation for rubber dam isolation

CROWN MORPHOLOGY Normal original crown morphology Full coverage restoration Restoration does not reflect original anatomy/
Porcelain restoration alignment
Bridge abutment Significant deviation from normal tooth/
Moderate deviation from normal tooth/root root form (e.g., fusion dens in dente)
form (e.g., taurodontism microdens)
Teeth with extensive coronal destruction

CANAL MORPHOLOGY Slight or no curvature (<10°) Moderate curvature (10-30°) C-shaped morphology
Closed apex (<1 mm in diameter) Crown axis differs moderately from root axis. Extreme curvature (>30°) or S-shaped
curve
Apical opening 1-1.5 mm in diameter Mandibular premolar or anterior with 2 roots

Maxillary premolar with 3 roots Canal

divides in the middle or apical third
Very long tooth (>25 mm)
Other anomalies such as radix ento/para molaris

Open apex (>1.5 mm in diameter)

RADIOGRAPHIC APPEARANCE Canal(s) and chamber visible and not Canal(s) and chamber visible but reduced Indistinct canal path
OF CANAL(S) reduced in size in size Canal(s) and chamber not visible
Pulp stones

PROXIMITY OF THE ROOT APICES Vital structures 5 or more millimeters from apices 3-5 millimeters <3 millimeters
TO VITAL STRUCTURES SUCH AS
THE IAN OR MENTAL FORAMEN

RESORPTION No resorption evident Minimal apical resorption Extensive apical resorption

Internal resorption
External resorption

C. ADDITIONAL CONSIDERATIONS

TRAUMA HISTORY No history of trauma, or Complicated crown fracture of mature teeth Complicated crown fracture of immature teeth
Uncomplicated crown fracture of mature or immature Subluxation
teeth Horizontal root fracture
Alveolar fracture
Intrusive, extrusive or lateral luxation
Avulsion

ENDODONTIC No previous treatment Previous access without complications Previous access with complications (e.g.,
TREATMENT HISTORY perforation, non-negotiated canal, ledge,
separated instrument)
Previous surgical or nonsurgical
endodontic treatment completed

PERIODONTAL-ENDODONTIC None or mild periodontal disease or Combined endodontic/periodontic lesion Concurrent severe periodontal disease
CONDITION concurrent moderate periodontal disease Cracked teeth with periodontal
complications
Root amputation prior to endodontic treatment

The contribution of the Canadian Academy of Endodontics and others to the development of this form is gratefully acknowledged. The AAE Endodontic Case Difficulty Assessment Form is designed to aid the practitioner in
determining appropriate case disposition. The American Association of Endodontists neither expressly nor implicitly warrants any positive results associated with the use of this form. This form may be reproduced but may not be
amended or altered in any way. © American Association of Endodontists, 180 N. Stetson Ave., Suite 1500, Chicago, IL 60601; Phone: 800-872-3636 or 312-266-7255; Fax: 866-451-9020 or 312-266-9867;
E-mail: [email protected]; Website: aae.org
*American Society of Anesthesiologists (ASA) Classification System Class 1: No systemic illness. Patient healthy. Class 2: Patient with mild degree of systemic illness, but without functional restrictions, e.g., well-controlled
hypertension. Class 3: Patient with severe degree of systemic illness which limits activities, but does not immobilize the patient. Class 4: Patient with severe systemic illness that immobilizes and is sometimes life threatening.
Class 5: Patient will not survive more than 24 hours whether or not surgical intervention takes place. www.asahq.org/ clinical/ physicalstatus.htm

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