AAE Endodontic Case Difficulty Assessment Form (2022): the low, moderate, high worksheet that decides treat or refer

What it says#

The form is two pages. The first carries the patient information block, the guidelines for use, the three level definitions and the disposition line; the second carries the scoring grid. The AAE's stated purpose is narrow: it designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula, because the form makes case selection more efficient, more consistent and easier to document, and dentists may also choose to use it to help with referral decision making and record keeping. The conditions listed are to be considered potential risk factors that may complicate treatment and adversely affect the outcome, and the levels of difficulty are sets of conditions that may not be controllable by the dentist. New on the current form is a single sentence of imaging advice: consider using cone beam computed tomography (CBCT) for assessing moderate and high difficulty cases.

The three levels are defined by counting. Low difficulty: the preoperative condition indicates routine complexity (uncomplicated), the case exhibits only factors listed in the low difficulty category, and achieving a favorable treatment outcome should be attainable by a competent practitioner with limited experience. Moderate difficulty: the preoperative condition is complicated, exhibiting one or two factors listed in the moderate difficulty category, and a favorable outcome may be challenging for a competent, experienced practitioner. High difficulty: the 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, and a favorable outcome may be challenging for even the most experienced practitioner with an extensive history of favorable outcomes. The form then says to review the assessment of each case to determine the level, and that if the level of difficulty exceeds your experience and comfort, you might consider referral to an endodontist. A disposition line records treat in office, yes or no, refer patient to, and the date.

The grid has three groups. A, patient considerations: medical history (no medical problem, ASA class 1 or 2, is low; one or more medical problem, ASA class 3, is moderate; complex medical history, serious illness or disability, ASA class 4, is high); anesthesia (no history of problems; vasoconstrictor intolerance; difficulty achieving or maintaining anesthesia); patient disposition (cooperative and compliant; anxious but cooperative; uncooperative); ability to open mouth (no limitation; slight limitation; significant limitation); gag reflex (none; gags occasionally with radiographs or treatment; extreme gag reflex which has compromised past dental care); emergency condition (minimum, moderate or severe pain or swelling). A footnote gives the ASA class descriptions the form relies on, in an older five-class wording.

B, diagnostic and treatment considerations: diagnosis (signs and symptoms consistent with recognized pulpal and periapical conditions; extensive differential diagnosis required; confusing and complex signs and symptoms or a history of chronic oral or facial pain); radiographic difficulties (minimal; moderate, such as a high floor of mouth, narrow or low palatal vault or tori; extreme, such as superimposed anatomical structures); position in the arch by tooth type (anterior or premolar; first molar; second or third molar), inclination (under 10 degrees; 10 to 30 degrees; over 30 degrees) and rotation (the same three bands); tooth isolation (routine rubber dam; simple pretreatment modification; extensive pretreatment modification); crown morphology (normal; full coverage, porcelain, bridge abutment or moderate deviation from normal form such as taurodontism or microdens; extensive coronal destruction, a restoration that does not reflect original anatomy, or significant deviation such as fusion or dens in dente); canal morphology (slight or no curvature under 10 degrees and a closed apex under 1 mm; moderate curvature of 10 to 30 degrees, crown axis differing moderately from root axis, or an apical opening of 1 to 1.5 mm; C-shaped morphology, extreme curvature over 30 degrees or an S-shaped curve, a mandibular premolar or anterior with two roots, a maxillary premolar with three roots, a canal that divides in the middle or apical third, a very long tooth over 25 mm, anomalies such as radix entomolaris or paramolaris, or an open apex over 1.5 mm); radiographic appearance of the canals (visible and not reduced; visible but reduced, or pulp stones; indistinct canal path or canals and chamber not visible); proximity of the root apices to vital structures such as the inferior alveolar nerve or mental foramen (5 mm or more; 3 to 5 mm; under 3 mm); resorption (none; minimal apical; extensive apical, internal or external).

C, additional considerations: trauma history (none, or an uncomplicated crown fracture; a complicated crown fracture of a mature tooth or subluxation; a complicated crown fracture of an immature tooth, horizontal root fracture, alveolar fracture, luxation or avulsion); endodontic treatment history (none; previous access without complications; previous access with complications such as perforation, a non-negotiated canal, ledge or separated instrument, or previous surgical or nonsurgical treatment completed); periodontal-endodontic condition (none, mild or concurrent moderate periodontal disease; a combined endodontic-periodontic lesion; concurrent severe periodontal disease, a cracked tooth with periodontal complications, or root amputation before endodontic treatment).

Who it applies to#

Any dentist who opens a pulp chamber and wants a defensible, repeatable answer to whether this tooth belongs in this chair. The AAE built it for teaching, which is why the wording is about competence and experience rather than about specialists and generalists: a low case is meant to be within reach of a competent practitioner with limited experience, and a high case may challenge the most experienced practitioner regardless of title. The 2005 newsletter that introduced the form makes the practice-level point explicit: practitioners electing to perform endodontic treatment are held to the same standard of care as endodontists, and cases that exceed the comfort level or skill set of the dentist should be referred.

It is not a rule and not a prognosis. The form's disclaimer says the AAE neither expressly nor implicitly warrants any positive results associated with its use, and the level it produces is advice to the practitioner, not an instruction to a board or an insurer. It also may not be altered: the AAE allows reproduction but not amendment, so an office that wants extra criteria keeps them on a separate sheet.

What changed#

The form has been around for two decades. The AAE's Spring/Summer 2005 newsletter, Endodontics: Colleagues for Excellence, presented it with the same three groups of considerations and the same counting logic, but called the bottom rung minimal difficulty; the current PDF calls it low difficulty. The 2005 text also gave the reasoning that still stands behind the form: nonhealing of root canal treatment can be traced to misdiagnosis, errors in treatment planning and poor case selection, and the ADA survey it cites estimated some 15.8 million endodontic procedures in the United States in 1999, up from an estimated six million 30 years earlier.

What the 2022 version adds is the CBCT sentence for moderate and high cases and, on the AAE's page, two distribution changes: a Spanish translation, and the AAE EndoCase app, which the AAE describes as a digital version of the form that makes case selection more efficient, consistent and easier to document. The AAE's Treatment Standards white paper, covered separately in this directory, puts this form in front of its treatment standards, which is the clearest sign of how the association expects a general dentist to use it.

Where the source is#

The link under the title is the AAE's Case Assessment Tools page on aae.org, which lists the form and guidelines (a two-page PDF at aae.org/specialty/wp-content/uploads/sites/2/2022/01/CaseDifficultyAssessmentFormFINAL2022.pdf), the Spanish translation, the 2005 Colleagues for Excellence article, a reading list and links to the EndoCase app. Note that aae.org refuses automated download tools, so the page and PDFs open in a browser and only the app store listings appear as download buttons here; the form text above was read from the AAE's 2022 PDF and the history from the AAE's 2005 newsletter PDF. The form is copyright the American Association of Endodontists and, in its own words, may be reproduced but may not be amended or altered in any way.