AAE decision guide for the compromised tooth: favorable, questionable, unfavorable, criterion by criterion

What it says#

The guide is a picture book with a scoring system. Sixteen pages, eight groups of clinical conditions, and on every page the same three-column table: Treatment Considerations/Prognosis, sorted into Favorable, Questionable and Unfavorable, with preoperative, postoperative and recall radiographs of real cases beside it.

The eight groups are root amputation, hemisection and bicuspidization; endodontic-periodontic lesions; external resorption; internal resorption; tooth fractures, split into crown fractures, horizontal root fractures and cracked teeth; apical periodontitis; procedural complications, covering missed canals, altered anatomy such as ledges and apical transportation, separated instruments, perforations, post perforations and strip perforations; and retreatment of posts, silver points, pastes and carrier-based obturation.

The criteria are concrete. Before a root resection, greater than 1.5 mm of remaining ferrule is favorable, 1.0 to 1.5 mm is questionable, and less than 1 mm is unfavorable; crown lengthening that would compromise the esthetics or the osseous support of adjacent teeth pushes the case to unfavorable. For an endodontic-periodontic lesion, a normal periodontium with probing depths of 3 mm or less and isolated bone loss to the involved tooth is favorable, moderate disease with an isolated probing defect is questionable, and advanced disease with generalized probing defects and generalized bone loss is unfavorable. For a cracked tooth, a crack in enamel, or in enamel and dentin, that does not extend apical to the cemento-enamel junction and has no associated periodontal probing defect is favorable; a crack that may extend apical to the junction but has no probing defect, with an osseous lesion of endodontic origin, is questionable; a crack extending apical to the junction onto the root with an associated probing defect is unfavorable. Perforations are scored on three axes at once: location, time of repair (immediate, delayed, or none) and size.

Two of the narrative notes are worth reading out loud to a nervous patient or a junior associate. On apical periodontitis: the presence of a periapical radiolucency is not an absolute indicator of a poor long-term prognosis, the vast majority of teeth with apical periodontitis can be expected to heal after nonsurgical or surgical endodontic treatment, and data indicate the presence of a lesion prior to treatment only decreases the prognosis slightly. On separated instruments: in general, cases that have a separated instrument in the apical one-third of the root have favorable outcomes. On posts, the guide says that with modern endodontic techniques most posts can be retrieved with minimal damage to the tooth and root, and that in some instances the post does not have to be removed because the problem can be resolved with root-end surgery.

The decision rule is on the back cover, and it is the reason the document exists. If the patient's condition falls into a category other than Favorable, referral to an endodontist, who has expertise on alternate treatment options that might preserve the natural dentition, is recommended. If the prognosis is Questionable or Unfavorable in multiple areas of evaluation, extraction should be considered after appropriate consultation with a specialist. The guide then lists what else belongs in the decision: local and systemic case-specific issues, economics, the patient's desires and needs, esthetics, potential adverse outcomes, ethical factors, and a history of bisphosphonate use or radiation therapy.

Who it applies to#

General dentists and their teams, at the moment a compromised tooth is being planned. It is written for the practitioner deciding whether a tooth is theirs to treat, an endodontist's to treat, or a candidate for extraction, and it assumes a permanent tooth in an adult mouth.

It is not a standard of care, a survival table, or an implant comparison. There are no numbers in it about how long treated teeth last or how implants perform; the scoring is qualitative. Patient-level factors are named but not weighted. And nothing in it addresses primary teeth, trauma protocols or the restorative sequence after the endodontic work is done.

What changed#

The guide is a companion to the AAE's case difficulty assessment form, and it fills a different gap. The difficulty form asks how hard a case will be for the operator; this one asks how good the outcome is likely to be for the tooth, which is the question the patient is actually asking when an implant is on the table. Against the common habit of treating a periapical radiolucency, a crack line or a separated instrument as an automatic extraction, the guide takes each of those to a row in a table and, in most rows, puts a favorable column first.

Where the source is#

The document is Treatment Options for the Compromised Tooth: A Decision Guide, published by the American Association of Endodontists; the link under the title opens the AAE's Treatment Options Guide page, which describes the guide and links the PDF. The PDF is 16 pages and carries a 2017 AAE copyright line on the back cover, while the file name the AAE uses begins with 2014, so the edition year is reported both ways here. Note that aae.org refuses automated tools: the page and the PDF returned 403 to every request in this session except a browser-style fetch, and the Internet Archive's capture of the same file refuses them too, so no direct link to the document appears among the download buttons. The PDF itself sits at aae.org/specialty/wp-content/uploads/sites/2/2017/06/2014treatmentoptionsguidefinalweb.pdf and opens in a browser; the text reported here was read from that file, and the Internet Archive's July 7, 2024 capture of it was extracted and compared with the live file in this session, matching exactly. The download buttons point instead to the AAE's online store, where the printed guide and the patient brochure, Your Guide to Treatment Options for the Diseased Tooth, are sold, and to the AAE's EndoCase app, the companion case difficulty tool. Two case figures in the guide are reprinted from Elsevier titles and are copyright Elsevier; the guide itself is copyright the AAE.