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To evaluate the use of two forms to assess the risks and difficulty of root-canal treatment. Two criterion-based forms, containing 15 and 16 items, respectively, were distributed to 83 general dentists to evaluate the potential difficulty of root-canal treatment. The participants were asked to assess the difficulty of 15 endodontic cases using the Dutch Endodontic Treatment Index (DETI) and the Endodontic Treatment Classification (ETC) forms. A questionnaire was also provided to evaluate the time needed to complete the two forms, their ease of use, the clarity and/or appropriateness of the criteria and any other comments. The outcomes of the assessment were compared with the assessment of each case as carried out by the authors. The response rate was 53%. The DETI was an easy and rapid way to differentiate between uncomplicated and complicated cases. In 13 of the 15 cases, 88-100% of the dentists scored the cases in agreement with the authors. Use of the ETC form was more complicated, as a result of the larger number of variables. However, most respondents recognized the complicated cases, and 91% found the ETC form valuable to help in assessing the difficulty of endodontic cases. These two forms may help general practitioners to assess the difficulty of endodontic problems and to decide whether to treat the case or to refer it to a specialist.
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An evaluation of the usefulness of two endodontic
case assessment forms by general dentists
M. H. Re e
& P. R. We s selink
Departme nto f
Cariology Endodontology Pedodontology and
Periodontology, Academic Ce ntre for DentistryA msterdam (AC TA),
Amsterdam, the Netherlands.
Ree MH, Timmer ma n MF, Wess elin k PR. An evaluation
of the usefulness of two endodontic case assessment forms by
general dentists. International Endodontic Journal,36, 545^555,
Aim To evaluate the use of two forms to assess the risks
and di ¤culty of root-canal treatment.
Methodology Two criterion-based forms, containing
15 and 16 items, respectively, were distributed to 83gen-
eral dentists to evaluate the potential di¤culty of root-
canal treatment. The participants were asked to assess
the di¤culty of 15 endodontic cases using the Dutch
Endodontic Treat ment Index (DETI) and t he Endodontic
Treatment Classi¢cation (ETC) forms. A questionnaire
was also provided to evaluate the time needed to com-
plete the two forms, their ease of use, the clarity and/or
appropriateness of the criteria and any other comm-
ents. The outcomes of the assessment were compared
with the assessment of each case as carried out by the
Results The response rate was 53%.The DETI was an
easy and rapid way to di¡erentiate between uncompli-
cated and complicated cases. In 13 of the 15 cases,
88^100% of the dentists scored the cases in agreement
with the authors. Use of the ETC form was more c ompli-
cated, as a result of the larger number of variables. How-
ever, most respondents recogniz ed the complicated
cases, and 91% found the ETC form valuable to help in
assessing the di¤culty o f endodontic cases.
Conclusions These two forms may help general prac-
titioners to assess the di¤culty of endodontic problems
and to decide whether to treat the case or to refer it to a
Keywords: case classi¢cation, di¤culty, endodontic
Receive d11 Septem ber 2002; acc epted 11Apri l 2003
Although longitudinal studies of root-canal treatment
outcomes have shown high success rates of up to 96%
(Strindberg 1956, Kerekes & Tronstad 1979, Sjo« gren et al.
1990), the succe ss rate s noted bycross-se ctional surveys
are substa ntia lly lower (O
«desjo«et al.1990, de Cleen et al.
1993, Eckerbom 1993, Buckle y & SpÔngberg 1995,Weiger
et al. 1997, S a u n d e r s et al. 19 97, Ma r q u e s et al. 1998, d e
Moor et a l. 2000, K irkevang et al. 2000, 2001). The major-
ity of these studies have indicated a signi¢cant correla-
tion between the presence of an apical radiolucency
and a radiographically inadequate root ¢lling (de Cleen
et al. 1993, Buckley & SpÔngberg 1995, Saunders et al.
1997, Marques et al. 1998, de Mo or et al. 2000, K irkevang
et al. 2000). Several studies have indicated that there is
a substa ntial need for endod ontic treatment i n the popu-
lation, and a considerable amount of this need will be
in the form of retreatment (de Cleen et al. 1993, We iger
et al.1997, Saunders et al. 1997, de Moor et al. 2000).
In order to improve the success rate of root-c anal treat-
ment in general dental practice, the referral of di¤cult
cases to de ntists with advance d knowledge and trai ning
in endodontics should be made possible for the bene¢t
of patients (de Cleen et al. 1993, Saunde rs et al.1997, de
Moor et al. 2000). In order to be able to refer patie nt sw ith
complex end odontic problems, at lea st two requirements
should be met: (i) su¤cient endodontists must be avail-
able to handle the de mand for spec ialist endodontic ca re;
Correspond ence: Dr M. H. Ree, Meeuwstraat110, 1444 VH Purmerend,
the Netherlands (Tel.: 31 2 99 687131 ; f a x : 31 2 99 697132; e- m a i l :
ß2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 545^555, 2003 545
and (ii) general practit ioners must be able to judge the d if-
¢culty of t reatme nt required.
In a previous paper, it has been shown that there is a
substantial need in a group of Dutch general practi-
tioners for referring a patient with an endodontic pro-
blem to a specialist. In this survey, 93% of the
respondents felt the considered need for referral, and
the majorit y of dentist s prefer red to refe r to an e ndodon-
tist rather than to an oral surgeon (Ree et al. 2003).
There are no established guidelines as to when a gen-
eral practitioner should refer to an endodontist. Little
information is available regarding the use of standar-
dized forms in general dental practice to assess the di¤-
culty o f endodontic cases.
Falcon et al. (2001) have described the development of
an index of restorative dental treatment need.With this
index, which also comprised the components of need
and priority for treatment, clinicians determined levels
of complexity of treatment for endodontics, periodon-
tics, and ¢xed and removable prosthodontics. The
authors found that the treatment complexity compo-
nent was a practical tool capable of being used by a
range of dentists.
The American Association of Endodontists has pub-
lished a form which describes 17 areas that should be
assessed when evaluating the potential di¤culty of an
en dod ont ic s ituat ion ( Curt i s & Si mon 1999). This f orm
was originally generated as an educational tool for stu-
dents i n general dentist ry, and t here are no data available
concerning the use of this Endodontic Case Di¤culty
Assessment Form in general dental practice.
The E ndodontic Department of the University of Ca li-
fornia, San Francisco, has developed a similar tool for
assessing endodontic cases for undergraduate care. This
case-selection system, which has been used for several
years, is reco mmended for u se in general dental pract ice
to provide a method for assessing whether to treat or to
refer (Rosenberg & Go odis 1992).
The Canadian Academyof Endodonticshas designed a
case-classi¢cation system based on the degrees of di¤-
culty and risk. This case-classi¢cation form has been
used since 1997 in several Canadian dental schools to
select cases that are too di¤cult for undergraduate stu-
dents (Morand, personal communication). An attempt
was made to test the validity of this to ol, but the statist i-
cal method used covered too many variables and the
results were not conclus ive (Morand 1992).
The purpose of the present study was to evaluate
the use of two standardiz ed forms by general practi-
tioners to assess the risks and di¤culties of endodontic
Materials and methods
The case-classi¢cation system developed by the Cana-
dian Academy of Endodontics (CAE) was used after
adjusting several ite ms on the form (Fig. 1a). The follow-
ing criteria were added: (i) the presence of a composite
core in the pulp chamber that may have a higher risk
when being removed than an amalgam build-up; (ii)
iatrogenic incidents such as the presence of a ledge or
an apical transportation; and (iii) the presence of a sec-
tional silver cone. The criterion whether it is possible to
place a stable clamp for isolation was omitted, as this is
covered by the criterion whether pretreatment is
required for obtaining adequate isolation. The number
of categories in the section `tooth considerations' and
the condit ions that belongauto matically to Clas s III were
In the case -classi¢cation syste mo f the CA E,t hephysi-
cal status of the patie nti s determined by us e of a physical
examination system that has been proposed by the
American Society of Anaesthesiology (ASA) (McCarthy
& Melame d1979). Th is physical statu s classi ¢cation s ys-
tem of the ASA has been adopted in the Netherlands
(de Jong et al.1993), and therefo re this cr iterion was used
in the same way without further explanation.
With this ca se-clas si¢cation syst em, endodontic ca ses
can be divided into Class I, II or III. An explanation of
how to use the ETC form is outlined in Fig. 1(b).
In order to avoid the ne ed for every endodontic ca se to
be assessed with this comprehensive E ndodontic Treat-
ment Classi¢cation (ETC), an additional short screening
list, the Dutch Endodontic Treatment Index (DETI), was
designe d (Fig. 2). The DET I consist s of 15 item s and can
be used to distinguish between an uncomplicated case
(DETI score A) and a complicated one (DETI score B). If
none of the15 items of the DETI are applicable, the endo-
dontic treatment can be considered as uncomplicated
(DETI score A). In that case, there is no need for assess-
ment in a more detailed manner with the ETC form. If
one or more items of the DETI are applicable, the chance
of complications is present when performing the endo-
dontic treatment (DE TI score B) and the ETC form s hould
be used t oa ssess the ri sks and di¤cu ltyo f the root-canal
Initially, a pilot study was conducted amongst a
group of 14 general practitioners and three endodon-
tists to evaluate the ease of use of the two criterion-
based tools in general dental practice and to obtain
comments from the participating dentists. As the den-
tists in the pilot study assessed endodontic cases from
their own practice with the two standardized forms, it
Endodontic case difficulty assessment Ree e t al.
546 International Endodontic Journal, 36, 545^ 555, 2003 ß2003 Blackwell Publishing Ltd
Figure 1 (a) Endodontic Treatment Classi¢cation. (b) Case classi¢cation according to degrees of di¤ culty and risks.
Ree e t al. Endodontic case difficulty assessment
ß2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 545^555, 2003 547
Figure 1 continued
Endodontic case difficulty assessment Ree e t al.
548 International Endodontic Journal, 36, 545^ 555, 2003 ß2003 Blackwell Publishing Ltd
was not possible to compare the results between the
dentists. It was only appropriate to evaluate the com-
ments o f the participating dentists concerning the use
of the t wo lists. Adjust ments were then made acc ording
to their recommendations.
Participating dentist swere recruited by advertising in
a newsletter provided by the Dutch Dental Association
to the members of so -called `alpha study groups'. These
study groups were fou nded by t he Dutch D ental Associa-
tion in order to enhance quality by a process of intercol-
legial c onsultation a nd tes ting. Twenty out of 152 study
groups responded to the request in the newsletter, from
which10 study groups (consisting of 83 general dentists)
were selected for the study. A meeting was held for each
study group, in which t he purpose of the study was out-
lined and a selection of endodontic cases was presented
so that the dentists could practise the use of the DETI
and the ETC forms.
In order to compa re the ratings of the par ticipants and
to investigate the validit yof the two cr iterion-based t ools,
15 cases were selected for all participants to evaluate
the risks and di¤culty of treatment. At the end of the
Figure 2 Guidelines for as sessing the di¤ culty of e ndodontic cases.
Ree e t al. Endodontic case difficulty assessment
ß2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 545^555, 2003 549
lecture, each dentist received a CD-ROM that contained
the 15 endodontic cases. Each case had a brief history
of the s igns and sympt oms and one or more radiograph s.
Where appropriate, cases were illustrated with clinical
slides. A short explanation was provided, and the den-
tists were asked to assess the cases with the aid of the
DETI and the ETC forms.
After completing the assessment of all 15 cases, the
dentists were asked to complete a short questionnaire
concerning the time needed to complete the screening
forms, the ease of use, the clar itya nd/or appropriateness
of the criteria and possible comments. Ease of use was
asse ssed wit h av isual analogue s cale (VAS) from 0 (easy)
to 10 (di¤cult).
The dentists were asked to return the papers and the
CD-ROM within 2 weeks. Nonrespondents were sent a
reminder by mail 4 weeks later.
In order to obtain a rating with which all the outc omes
could be compared, two of the authors (MHR and
PRW) assess ed t he 15 cases using t he DE TI and the ETC
forms. Where di¡erences occurred, consensus was
reached by discussion. The outcome was used as an
experts'score with which the participants'assessments
were compared.
Completed scoring lists and questionnaires were
coded a nd entered in a database prior to a na lysis, which
was performed using frequencies and mean values
where appropriate.
Forty-¢ve (53%) of the 85 CD-ROM's, classi¢cation forms
and questionnaires were returned.
DETI score
The percentage of DETI scores matching the experts'
score is shown in Table 1. In 13 of the 15 cases, the den-
tists agreed with the experts 88^100% of the time. In
one case (no.5), a large sinus tract was erroneously con-
sidered by most de ntists to be an endod ontic^periodontal
lesion, resulting i n only 14% of the dentists rating it in
agreement with the expert s'sc ore. In another c ase (no.
9), the radiographic image of an amalgam restoration
was mistaken by most dentis ts as being a cast restoration
(35% matching the experts'score).
Questionnaire concerning the DETI form
The majority (90%) took 1^2 m in to complete the D ETI
form (Table 2).
When asked to consider the clar ityo f the criteria used
on the DETI form, 16 % o f the responde nts regarde d t he
criterion `molar >three canal s/th ird molar' as unclear.
The most frequently given reason for this was that `it
is not always possible to see a fourth canal on a
radiograph'. Ot her crite ria were consid ered to be uncl ear
by 0^9% of the respondents (Table 3). The most frequent
comment was that these criteria are sometimes di¤cult
to assess from a radiograph.
The DETI formwas consideredto be an easy tool to use
by 91% of the respondents (meanVAS score 2.4) for pre-
operative assessment with radiographs and a clinical
examination. Only 9% of the respondents scored in the
di¤cult part (score >5) of the VAS scale. One-third of
the res pondents provide d some co mments, which varied
from negative (too time consuming, should be used in
doubtful cases only) to positive remarks (valuable tool
and quite illustrative to use).
Endodontic treatment classi¢cation
A large variation (20 ^83% in agreement with the exp-
erts' score) was found between cases, when comparing
Table 1 Percentage agreement with the DETI form
Number of dentists
who assessed the case
Agreement with
experts'score (%) Experts'rating
244 98 B
341 93 B
443 97 B
542 14 A
643 98 B
743 88 B
842 98 B
943 35 A
10 41 9 5 B
11 3 8 10 0 B
12 43 98 B
13 3 6 97 B
14 4 2 9 8 B
15 3 4 9 7 B
16 4 2 10 0 B
Table 2 Time needed to ¢ ll out the DETI for m
Number of dentists Time needed in minutes
31 1
Total number: 43 Meantime: 1min 35 s
Endodontic case difficulty assessment Ree e t al.
550 International Endodontic Journal, 36, 545^555, 2003 ß2003 Blackwell Publishing Ltd
the respondents'scores to the experts' score (Table 4).
Because case nos. 5 and 9 were graded by the experts
as DETI score A, they were, according to the instruc-
tion, excluded from further assessment with the
ETC form.Therefore,13 of the15 cases were evaluated
with the ETC form. Six of the 13 cases were rated
according to the experts' score by 69^83% of the den-
tists, ¢ve cases were assessed in agreement with the
expert s' score by 46^64% of the dentist s and the
remai ning two cas es were rated by only 20^24% of
the dentists.
One of the aims of the ETC is to di¡erentiate between
complicated (ETC Class II and III) and uncomplicated
cases (ETC Class I). In 11 of the 13 cases, 70^100% of
the participants were able to di¡erentiate betweenthese
two categories (Table 5).
Questionnaire concerning the endodontic treatment
classi¢cation form
Ninety-three p erc ent of the resp ondents neede d1^5 min
to assess each case with the aid of the ETC form (Table 6).
When asked to consider the clarity of the criteria used
in the ETC form (Table 7), 30% of the respondents
regarded the criterion `canal and root morphology' as
unclear. The most frequently given reason for this was
that `it is not always possible to see a curvature or the
number of canals on a radiograph'. Some respondents
stated that the terminology regarding I-, J-, S- and C-
shaped canals was confusing and could be interpreted
in many ways. The other two criteria that were fre-
quently mentioned as being unclear were the criteria
`morphological aberrations of crown and isolation' by
Table 3 Uncl ear criteria in t he Dutch
Endodontic Treatment Inde x (DET I) for m Respondents who
found each criterion
unclear (%) DETI form
5 Medical problems (ASA score 2)
4 Physical limitations/cooperation of patient limited topoor
5 Difficult diagnosis
9Premolar>two canals
16 M o l a r >three canals/third molar
3 Canal sub di vision in middle/apical third
4 Moderate to extreme rotation and/or inclination of tooth (>10 8)
9 Aberrant crown and/or root morphology/very long tooth (30 mm)
9 Pretreatment required for isolation withrubber dam
3 Crown, core and/or post p resent
9 Moderate to extreme canal curvatures (>10 8)
7 Obstruc tions, resorp tion, calcification, perforation and/or open apices
0 Endodontic^p eriodontal lesion
0 History of trauma
Table 5 Pe rcentage agreement for di¡e rentiation between
uncomplicated a nd complicated cases u sing the ETC form
Number of dentists
who assessed the case
Agreement with
exper ts's core (% )
244 70
342 81
443 98
643 93
743 56
842 98
10 41 2 2
11 3 8 10 0
12 4 3 70
13 3 7 8 9
14 4 2 8 1
15 3 4 9 7
16 4 2 9 0
Table 4 Pe rcentage agreement with the E TC form
Number of dentists
who assessed the case
Agreement with
experts'score (%)
243 72 2
338 46 3
442 69 3
642 81 3
735 53 2
841 78 3
10 3 9 2 0 1
11 3 8 2 4 2
12 42 69 1
13 34 83 3
14 41 6 4 2
15 33 59 3
16 4 2 4 8 2
Ree e t al. Endodontic case difficulty assessment
ß2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 545^555, 2003 551
16% o f the respondents a nd `canal calc i¢cations' by 12 %
of the respondents. As far as isolation was concerned,
some participants stated that, from a radiograph and a
clinic al slide, it was di¤cult t ojudge whethe r application
of a r ubber dam was pos sible without any pret reat ment.
The criterion `canal ca lci¢cations' was considered to be
unclear because this condition can be di¤cult to assess
from a radiograph.
When asked to comment about super£uous criteria
(Table 8), 7^9% thought that the criterion `patient con-
siderations' was not relevant, whilst 12% of the respon-
dents cons idered `canal a nd root morphology' as being
an unnecessary criterion. The ETC formwas considered to be an easy tool to use
by 71% of the respondents (meanVAS score 3.8) for pre-
operative assessment of cases with radiographs and a
clinical examination.Twenty-nine per cent of the respon-
dents scored in t he di ¤cult part of the VAS sca le ( >5).
The majority of the participants (91%) found the ETC
form a valuable aid in asse ssing the di¤ culty o f an endo -
dontic case.
Half of the respondents provided some comments,
which varied from negative to positive remarks. Some
respondents stated that the ETC form was too compre-
hensive and rather subjective, whereas other respon-
dents found it to be a valuable tool to assess cases in
a systematic way. Some participants found the layout
di¤c ult to read, and s ome suggeste d leaving out the aver-
age-risk items and scoring only the high- and extreme-
risk items.
The degree to which endodontic referral patterns a¡ect
the outcome of the root-canal treatment is unknown.
One may speculate that, if a general practitioner treats
a case beyond his or her level of expertise, then there
may be a greater likelihood of iatrogenic incidents that
can result in an unsuccessful treatment outcome. It
Table 8 Super£uous cr iteria in the ETC f orm
Respondents who
found each criterion
superfluous (%) ETC form
Patient considerations
7 Medical problems (ASA score 2)
7 Physical limitations/lack of patient
9 Radiographic difficulties
Tooth cons iderations
5 Position in the arch
5 Inclination and rotation tooth
5 Morphological aberrations of crown
and isolation
7 Access root-canal system
12 Canal and root morphology
2 Apical mo rpholog y
2 Resorption
Additional factors
2 Retreatment of previously completed
root-canal treatment
3 Endodontic-periodontal les ion
Table 7 Unclear criteria in the ETC f orm
Respondents who found
each criterion unclear (%)
ETC form
Patient considerations
0 Medicalproblems (ASA score 2)
2 Physicallimitations/lack of patient
2 Radiographic difficulties
Tooth cons iderations
7 Inclination and rot ation tooth
16 Morphological aberrations of crown
and isolation
9 Access root-canal system
30 Canal and ro ot morphology
2 Apical morphology
12 Canal calcifications
7 Resorption
Additional factors
0 Retreatment of previously completed
root-canal treatment
0 Endodontic^periodont al lesion
Table 6 Time needed t o ¢ll out the ETC fo rm
Number of dentists Time neededin minutes
14 5
Total number: 43 Mean time: 3 min 46 s
Endodontic case difficulty assessment Ree e t al.
552 International Endodontic Journal, 36, 545^555, 2003 ß2003 Blackwell Publishing Ltd
has bee n shown that case s treated de novo yield a higher
success rate than retreatment cases (Bergenholtz et al.
1979, Sj o«gren et al. 1990, Sundqvist et al. 1998). Henc e, i f
a general practitioner can recognize a di¤cult or com-
plex case before treatment is initiated, then referral to a
specialist can be instituted and retreatment may be
avoided. In addition, if mid-treatment referral becomes
necessary, then there are additional costs for the patient
and the outcome of treatment may be compromised by
the problem that has arisen during the general dentist's
initial treatment.
The DETI form proved to be an easy and rapid tool to
discr iminate betwe en uncomplicated (score A) and co m-
plicated (score B) ca ses. In13 o f the15 ca ses, the major ity
of the dentists scored the same grade as the examiners,
but it was evident that it was not always possible to ass ess
every crite rion from a radiograph.
The evaluation of the ETC form appeared to be more
complicated, probably because of the large number of
variables. There was considerable variation between
cases, when comparing the respondents' scores to the
exper ts'score.The present st udys hows conclusions si mi-
lar to tho se of Morand (1992), who also attempted to t est
the validity of this form, but the statistical method used
in that study covered too many variables and the results
were not conclusive.
The assessments with the DETI and the ETC forms
were not independent of each other. In case of a DETI
score A (uncomplicated), there is no need for a more
detailed assessment with the ETC form. When a case
was erroneously considered as a DETI score A, then no
further assessment with the ETC form took place. This
might expla in the disc repancy in the numbe r of dentist s
(Tables1 and 4) that assessed the cases with the DETI
and the ETC forms. On the contrary, when a case with
DETI score Awas mistaken for a DETI score B, then the
participants did use the ETC form. This explains why in
case nos. 5 and 9 (experts'grade: DETI score A),35 and
26 respondents, respectively, completed the ETC form.
When evaluating the ability to di¡erentiate between
complicated (ETC Class II and III) and uncomplicated
cases (ETC Class I), the majority of t he participants were
able to di¡e rentiateb etween these t wocategori es in more
thantwo-thirdsof the cases. In thisrespect, the ETCform
served its purpose, but the number of uncomplicated
cases (E TC Clas sI) i nthe present study was sma ll. There-
fore, data on the discriminative power to discern
between uncomplicated and complicated cases must be
interpreted with caution.
Although the ETC form contains many criteria and
appears to be time consuming to ¢ll out, the majority
of the participants needed less than 5 min to complete
the form. Some participants commented that, after scor-
ing half of the cases with the ETC form, they started to
get fam iliar wit h the crit eria and it to ok les s and les s time
to score the last cases.
Additional canals (e.g. a fourth canal in a molar or a
third canal in a premolar), anatomical con¢guration,
the degree of curvatures, canal calci¢cations and very
long teeth were considered to be di¤cult to determine
on a radiograph. In the present study, the participants
had to judge the presence of an extra canal from one
preop erative radiograph only. In practice, this problem
can be partly solved by taking two or three radio-
graphs from di¡erent horizontal angles in order to cre-
ate more of a three -dimensional picture o f the root
and its ca nal con¢guration. As up to 95% of maxillary
¢rst molars have four canals (Kulild & Peters 1990,
Stropko1999), the maxillary ¢ rst molar could be elimi-
nated f rom the DETI screening and root-canal treat-
ment of th is tooth could always be regarded as
complicated (DETI score B), with the result that addi-
tional evaluation with the aid of the ETC form would
be required.
The diagnostic interpretation of a radiograph is far
from an object iveproc ess. Large i ntraobserver variations
(Brynolf 1970, Goldman et al. 1974) and even greater
interobser ver variations have been repor ted in oral radi-
ology (Goldman et al. 1974 , Ha l s e & Mo l v e n 1986 ). I n
the present st udy, images of the radiographs and cli nical
photographs of the cases to be assessed were placed on
a CD-ROM, and the participants used their own compu-
ter and monitor to view the images. The type and siz e
of the monitor screen might have in£uenced the quality
of the image and t herefore the inte rpretation of the radio -
graphs (Versteeg et al. 1998). Additionally, there is a
learning curve associated with assessing radiographs
that have been digitally processed (Moystad et al. 1994,
Wallace et al. 2001).
In the present study, the participating dentists had to
assess the cases using clinical pictures, radiographs
and a brief patient history. They were not able to perform
an oral examination; so, patient factors and some of
the othe rc riteria (e.g. isolation) were di¤c ult to interp ret
and might have di¡ered from the clinical setting.
The dec ision whether to refer or to t reat a ca se is prob-
ably often base d on a cursory evaluation of a radiograph.
General practitioners make personal evaluations as to
whether to treat a case or to refer it for specialist endo-
dontic care. This is a subjective process because every
dentist has a di¡erent perspective of his or her own
technic al abilities. It may be a rg ued that it wil l therefore
Ree e t al. Endodontic case difficulty assessment
ß2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 545^555, 2003 553
be unrealistic to develop a strict protocol for referral.
However, dentists may rely on factors listed in the DETI
and the ETC forms, and they may make a decision along
with subjective factors such as:
level of con¢ dence of t he dentist about hi s competenc e
to perform the procedure;
ability of t he dentist to manage any pos sible compl ica-
tions during treatment;
availability of the nec essary equ ipment, materials a nd
expertise for the procedure and
possible e motionala nd ¢nancial consequence s for the
patient if mid-treatment referral becomes necessary
and additional costs are incurred.
These two standardized forms may be helpful in the
decision process. In addition, there is potential for
them to be used as indicators for quality monitoring.
No data were gathered to assess whether respondents
would adopt this procedure in general dental practice.
The use of the DETIand the ETC forms has been intro-
duced recently in the undergraduate programme of
the Academic Centre for Dentistry Amsterdam to
sele ct case s that are too di¤cult for undergraduate
students. The use of the forms in dental schools and
their introduction in postgraduate education may
encourage more widespread use in general dental
The DET I form is an easy and rapid way to di¡erenti-
ate an uncomplicated case from a potentially c ompli-
cated one. In order to gather more information about
a potentially complicated case, it might then be bene¢-
cial to ¢ll out the ETC form and to further di¡erentiate
between a complicated and an exceptionally compli-
cated case.The ETC form was judged as bei nga valuable
form f or asse ssing t he di¤ culty o f root-ca nal treat ment
by 91% of the respondents. It may not always be neces-
sary to ¢ll out all criteria of the ETC form to recognize
an extremely complicated case. When dentists become
familiar with recognizing more complex endodontic
problems, they may relyon the form less often to assess
case di¤culty.
The present results indicate that the DETI form is use-
ful to di¡erentiate between uncomplicated and poten-
tially complicated cases on the basis of a rapid
evaluation. In addition, the ETC form was valuable for
assessing cases in a more detailed manner. Results
showed that this form enabled the majority of respon-
dents to recognize extremely complicated cases. Both
form s may therefore be useful for general pract itioners
to assess whether a case should be treated or referred
for specialist care.
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... Various international endodontic organizations have developed their own forms for assessing the difficulty of RCTs. However, there are only few studies on how frequently they are used and how helpful they are [5]. The majority of studies have explored the American Association of Endodontists' (AAE) Endodontic Case Difficulty Assessment Form [6]. ...
... The DETI contains 15 criteria or factors contributing to the difficulty of the RCT. It has been found that the DETI form enables dentists to differentiate simple/uncomplicated cases from complicated ones [5]. ...
... In their article, Ree et al. [5] evaluated two different endodontic case difficulty assessment forms: the Dutch Endodontic Treatment Index (DETI) and the Endodontic Treatment Classification (ETC). According to them, the DETI can be used to quickly separate easy cases from difficult ones, whereas the ETC helps to assess the difficulty of a RCT more precisely. ...
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According to current care guidelines, it would be beneficial to evaluate the difficulty of a root canal treatment (RCT) after the decision of an indicated RCT. For this matter, several difficulty assessment forms have been developed. In this pilot study, fifth-year dental students evaluated the usefulness of the Endodontic Case Difficulty Assessment Form (ECAF) presented in the Finnish Current Care Guidelines for Endodontic Treatment (2014). Another aim was to postoperatively investigate how well the evaluation by dental students using the ECAF associated with the outcome of RCT evaluated by a specialist in endodontics. The dental students’ (n = 33) and the supervisor’s assessments of the RCTs were compared postoperatively at the Dental Educational Unit, Oulu, Finland. After completing the ECAF, the students’ experiences of its use were explored with a structured form. In ECAF, patient-derived factors, such as gagging, deviant crown morphology, and complications in previous endodontic treatment, were all significantly associated with complications in RCTs by the dental students (p < 0.05). The assessments by students and the supervisor differed in 55% of cases, especially in moderately difficult cases. In the majority of these cases (71%), the students evaluated the case to be easier than the teacher. Students found the ECAF user-friendly, even if it did not demonstrate their competence in accomplishing RCTs. The ECAF appears useful for junior dentists, specifically in terms of distinguishing the least and most difficult cases. A simpler form could be useful for students and clinicians.
... The Commission of Dental Accreditation (CODA), the Association of Dental Education in Europe (ADEE), and the European Society of Endodontology (ESE) recommended competency-based education in a comprehensive clinical care environment [15,22,23]. Furthermore, an endodontic difficulty assessment form or tool has been developed to help guide students and general dentists in case selection [24][25][26]. ...
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Background Identify the objectives and the instructional design of undergraduate endodontics in dental schools in Saudi Arabia. Methods The online questionnaire was developed from an original survey conducted in the United Kingdom. The questionnaire was modified for purpose of the study and the region of interest. Then it was directed and emailed to the undergraduate endodontic program directors in twenty-six dental schools in Saudi Arabia. The results were analyzed using descriptive statistics and the Chi-square and Fisher’s exact tests. Results The response rate was 96.15%. The number of credit hours for preclinical endodontic courses was up to four credit hours (84%). Students were clinically trained to do vital pulp therapies (92%), root canal treatment (100%), and root canal retreatment (68%). The majority of dental schools define the minimum clinical requirements (92%). Practical and clinical competency exams were used to evaluate students' performance (92% and 84% respectively). The students were trained to treat cases of minimal (52%) to moderate complexity (48%). Endodontic treatment consent and difficulty assessment form were used by 32% and 60% of dental schools respectively. There was no significant difference in the instructional design between public and private dental schools (P > 0.05). Conclusion The endodontic undergraduate objectives were to graduate competent clinicians who acquired basic science of endodontics and who know their limitations as it is necessary for a safe general dental practice. The use of endodontic treatment consent and case difficulty assessment should be wisely considered in clinical training.
... Several oral health measures have been developed based on the professional approach: The dentist can assess oral health in terms of caries by using the DMFT index (sum of decayed, missing and filled teeth), for periodontal situation the CPITN index (Community Periodontal Index of Treatment Needs) or-in the Netherlands-the DPSI index (Dutch Periodontal Screening Index), or using a combination of the measurements for caries and periodontal situation [2][3][4][5]. In addition, there are separate measures for assessing endodontic health and erosion [6][7][8]. ...
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Objectives To assess the oral health of older people who visit the community dental practice from both the dentists’ and the patients’ perspective. Materials and methods In this exploratory cross-sectional study the oral health of Dutch community dwelling older people was assessed. A representative sample of general dental practitioners was asked to randomly and prospectively select one older patient and describe this patient using a specially-developed registration form; in addition the patient was requested to complete a questionnaire. The oral health of older people was described from the perspective of the dentists and the perspective of the older people themselves based on the definition of oral health from the World Dental Federation (FDI]. Relations between oral health of older people and dentist and older patient characteristics were analysed using Spearman’s rank correlation coefficient (rho) and an ordinal regression model. Results In total, 923 dentists were asked to participate in the study; data was available for 39.4% dentist-patient pairs. Dentists assessed the oral health of older patients as good or acceptable in 51.4% of the cases while this was the case in 76.2% of older patients themselves. The assessment of the dentist gets more negative with high treatment intensity and with older patients having certain diseases and more medication, while the assessment is more positive for older patients who visit the dentist on a regular basis. Older people’s assessment of their oral health gets more negative by being female and with high treatment intensity, having certain diseases and higher use of medication. Conclusions and clinical relevance Chronically illness as expressed by the number of diseases and the use of medication, seems to be a risk factor for poor oral health. Older patients themselves assess their oral health differently, mostly more positive, than their dentist.
... Various diagnostic indexes and guidelines using radiographic examination have been proposed to help clinicians evaluate the periapical tissue, treatment outcomes, and survival of root canal-treated or retreated teeth [8][9][10]. However, most of them lack complex evaluation of different diagnostic and treatment-related parameters. ...
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Background Endodontic treatment planning and treatment success evaluation are largely based on radiographic assessment of anatomical and treatment-related parameters of teeth with apical periodontitis (AP). This prospective clinical study aimed to assess radiographically the 2-year endodontic treatment outcomes for teeth with AP, and to evaluate prognostic validity of Periapical and Endodontic Status Scale (PESS). Methods A total of 128 patients, representing 176 teeth with AP were examined by cone-beam computed tomography at baseline and at 24 months after endodontic treatment. Treatment outcome was evaluated using estimates of periapical radiolucency and the relationship between anatomical structures and location. The strength of the associations between these and treatment-related parameters was tested by logistic regression analysis. PESS sensitivity and specificity were calculated for every treatment risk group (low, moderate, high) of teeth. Results One hundred and fifty-seven teeth, representing 350 root canals had a positive treatment outcome, while 19 teeth, representing 53 root canals had a negative treatment outcome at 24 months. The probability of negative outcome was 25 times higher in the moderate/high-risk group than in the mild-risk group of teeth (OR = 25.1; 95%CI [12.2–51.5]). Pre-treatment complications and retreatment cases with radiolucency were associated with negative outcomes (OR = 35.9; 95%CI [12.6–102.4]; OR = 26.437; 95%CI [10.9–64.1], respectively). PESS sensitivity and specificity was over 80% in all risk groups except for high risk group, due to very low number of cases. Conclusions Endodontic treatment outcome depends on the severity of periapical changes. The presence of complications and retreatment cases with periapical lesions are associated with negative treatment outcome. The PESS is a valid instrument to predict outcome of teeth with low-moderate treatment risk of AP.
... There are several case difficulty assessment forms based on pretreatment clinical findings and radiographic examination. The American Association of Endodontists (AAE) Case Difficulty Assessment Form was designed for use in endodontic curricula, and to assist practitioners with endodontic treatment planning, referral decisions and record keeping [2,3]. It has three parts; general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease [4]. ...
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Background A Case Difficulty Assessment Form was designed for use in endodontic curricula, and to assist practitioners with treatment planning, referral and recording. The aim of this study was to determine how endodontic case difficulty factors influence the operating time of single-visit nonsurgical endodontic treatments under general anesthesia. Methods Data on 198 single-visit endodontic treatments (80 anterior teeth, 43 premolars, and 75 molars) performed under general anesthesia by a specialized practitioner were obtained from 119 special needs patients (mean [SD] age = 30.7 [14.7] years). Total duration of operation was analyzed with relation to demographic and dental factors and American Association of Endodontists (AAE) Case Difficulty Assessment factors. Mann–Whitney U test, t-test, and Kruskal–Wallis test were used to assess relationships between operating time and confounding factors (p < 0.05). Results High difficulty cases required significantly longer time to complete operations than treatments of minimal-to-moderate difficulty regardless of tooth type (p < 0.05). Demographic factors of the patients rarely influenced operating time length. Among variables included in the AAE Case Difficulty Assessment Form, tooth position, crown morphology, root morphology, canal appearance, and periodontal condition were significantly associated with increased operating time (p < 0.05). Conclusions A higher level of case difficulty contributed to increased duration of endodontic treatment under general anesthesia indicating that Endodontic Case Difficulty Assessment Form is useful for predicting the duration of nonsurgical endodontic treatment. Among many factors, complicated anatomic features of the treated teeth increased case complexity and extended operating time.
Objectives The present study aimed to evaluate the significance of the American Association of Endodontics (AAE) Case Difficulty Assessment on the occurrence of endodontic mishaps in an undergraduate student clinic at the Dental College at King Saud University. Methods All teeth endodontically treated by undergraduate dental students in their fourth year at the College of Dentistry, Girls University Campus at King Saud University over 2 years (2018-2019) were selected. Four investigators (3 dental interns and 1 endodontist) recorded the AAE case difficulty level, mishap occurrence, number of treatment visits, type of teeth, and type of instrumentation technique. The associations amongst these variables were analysed. Statistical analysis A point-biserial correlation was used to determine the relationship between the number of visits and the AAE case difficulty and the instrumentation technique. Spearman's rank-order correlation was used to assess the relationship between the number of visits and mishaps. A Mann-Whitney U test was applied to determine any differences in mishaps amongst cases with different difficulty levels. Results A total of 586 teeth were included (54.1% moderate- to high-difficulty cases), and 34.98% of cases experienced mishaps. Molars were significantly more often found in the moderate- to high-difficulty category. The moderate- to high-difficulty cases experienced more mishaps (64.8%; P = .000) and a greater number of treatment visits (3.49 ± 1.27; P = .000) compared to minimal-difficulty cases (35.12%, 2.38 ± 1.24, respectively). The type of instrumentation technique was not associated with mishap occurrence. Conclusions Undergraduate students should use the AAE case classification assessment tool to reduce the number of endodontic treatment mishaps and the number of visits.
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Root canal curvature and calcification introduce factors that increase the risk of procedural accidents during root canal treatment. The inability to achieve patency to the apical third, asymmetrical dentine removal leading to transportation, perforation and instrument fracture inside the curved trajectories are some of the procedural problems that might jeopardize the management of intraradicular infection and result in poor treatment outcomes. In fact, curved and constricted canals introduce such complexity that total instrumentation concepts and specially designed instruments have been developed to deal with the challenge. This narrative review seeks to provide and consolidate the principles necessary for understanding the dynamics of curved and constricted canal management and to improve the understanding for future developments in this field.
The United Kingdom Armed Forces introduced a Managed Clinical Network to transform care provision for military patients referred with complex restorative treatment needs. This article discusses the processes that underpinned this transformation of service, from assessment of populations needs to implementation of clinical delivery. Managed Clinical Networks facilitate health care around patient-centric factors.Applying the Managed Clinical Network model to restorative dental care requires delineated clinical structure and coordinated central hub.Consultant-led care remains a central tenet to care. Managed Clinical Networks facilitate health care around patient-centric factors. Applying the Managed Clinical Network model to restorative dental care requires delineated clinical structure and coordinated central hub. Consultant-led care remains a central tenet to care.
Given the importance of risk management to avoid mishaps, to achieve a quality result and to ensure a favourable outcome, challenging endodontic cases are best treated by clinicians with the appropriate level of training and experience. Digital and technological innovations in endodontics have led to the development of web-based and smartphone-compatible case-difficulty assessment tools that can help less-experienced dentists identify endodontic management complexities. These interactive tools may also be used for other applications, including primary and secondary care triage, research and dental education. Similarly, advances such as artificial intelligence and mixed reality technologies, are predicted to also benefit endodontics and help support dentists in the management of complex endodontic cases. CPD/Clinical Relevance: Digital and technological developments may help improve the management and treatment of endodontic cases.
Aim To compare the treatment planning decisions made by undergraduate and postgraduate dental students before and after training on the use of the Dental Practicality Index (DPI). Methodology One hundred and eight undergraduate and postgraduate dental students were randomly assigned to test (DPI) or control groups. The baseline knowledge was assessed in the first session; both groups were shown 15 clinical scenarios and asked to assign one of four treatment plan options (no treatment, simple treatment, complex treatment or extract). The most appropriate treatment plan had been agreed by a consensus panel of experienced dentists. The test group was then trained on the use of the DPI. In the second session, both groups were shown the same clinical scenarios again in a different order and asked to assign one of the four treatment plan options. Both groups completed the confidence questionnaire. Results Training with the DPI improved the test (DPI) group mean scores from 9.1 in the first session to 10.3 out of 15 in the second session, which was a statistically significant difference (p = 0.005) when compared to the control group mean scores of 8.9 in the first session to 9.2 out of 15 in the second session. The mean confidence score of the students was 6.5 out of 10. There was no correlation between self-reported confidence scores of the students and the treatment planning result scores. Conclusions The DPI aids in the systematic assessment and appropriate treatment planning of dental restorative problems by dental students.
The aim of this study was to investigate the prevalence of endodontically treated teeth and apical periodontitis (AP) in a Danish population. From Aarhus County 614 individuals were radiographically examined, and the frequency of endodontic treatment and periapical status of all teeth were assessed. The year of birth of the subjects ranged from 1935 to 1975. The chi-squared test was used to determine the significance of differences between males and females and amongst age and tooth groups for the following parameters: AP, the number of endodontically treated teeth, and the number of endodontically treated teeth with AP. A total of 15 984 teeth were examined; of these 538 (3.4%) had AP and 773 (4.8%) had been endodontically treated. Of the endodontically treated teeth, 404 (52.2%) had AP. Females had more endodontically treated teeth than males; otherwise, no effect of gender was observed. Significantly more molars (P < 0.01) had been endodontically treated (8.1%) compared to premolars (5.4%) and anterior teeth (2.5%). The prevalence of AP in connection with molars was significantly (P < 0.01) higher (7.0%) than premolars (2.8%) and anterior teeth (1.5%). The prevalence of endodontically treated teeth and of teeth with AP gradually increased with age. The average number of teeth, the number of teeth with AP and the number of teeth with endodontic treatment in Danish adults were comparable to findings in other European countries. The frequency of endodontically treated teeth with AP was found to be high compared to that demonstrated in other epidemiological studies.
The process undertaken to establish an initial pilot index for restorative dental treatment is described. Following consultation with a wide range of clinicians and others, an outline framework for the index was developed and comprised three main components: 1. Patient identified need for treatment: the data from the patient perceived need questionnaire were inconclusive; 2. Complexity of treatment (assessed by clinicians): this was found to be a practical tool capable of being used by a range of dentists. A booklet has been produced which describes the process of using the scoring system; 3. Priority for treatment (assessed by clinicians): three levels of priority were identified; the highest priority was assigned to patients with inherited or developmental defects that justify complex care (eg clefts of the lip and palate). The initial development of the index has had some success in a difficult area. The treatment complexity component is the most developed and may allow both referrers and commissioners of specialist restorative dentistry to determine appropriate use of skilled clinicians' expertise.
The objective of this study was to determine the periapical status and the quality of root canal fillings and to estimate the endodontic treatment needs in a German population. Clinical and radiographic data and the operative procedures performed were evaluated on 323 patients coming to a dental surgery in Stuttgart, Germany, in 1993. In 182 individuals at least one tooth exhibited a root canal filling, a necrotic pulp or an irreversible pulpitis. Out of the 7897 teeth examined, 215 (2.7%) had a root canal treatment (category A), 122 being non-endodontically treated (1.5%) did not respond to the sensitivity test (category B) and 53 (0.7%) were diagnosed as having irreversible inflamed pulp tissue (category C). The prevalence of teeth associated with radiographic signs of periapical pathosis was 61% in the group of root canal filled teeth and 88% in the group of pulpless and non-endodontically treated teeth. Using the level and the density of the root canal filling as criteria for evaluating the technical standard, only 14% of the endodontic treatments of non-apicectomized teeth were qualified as adequate. The minimal endodontic treatment need is 2.3% related to all examined teeth when the root canal filled teeth with clinical symptoms of periapical periodontitis (category A) and those of categories B and C are included. The real endodontic treatment need is suggested to be larger when considering that the technical quality of the obturation is poor in most symptomless endodontically treated teeth associated with a periapical lesion. In the case of retreatment of these teeth, the endodontic treatment need would then be calculated at 3.7%.
The physical evaluation system allows the practitioner to rapidly classify each patient according to medical risk and thus to provide dental treatment comfortably and safely. The evaluation system serves as a guide to the level of dental therapy, deisions of management, and modification of treatment for the medically compromised patient. Extensive use of the ADA physical status classification system in dentistry would allow meaningful studies of morbidity and mortality that are related to various management protocols and could conceivably have an impact on insurance schedules associated with psychosedation modalities and general anethesia on an out patient basis. A physical evaluation system cannot substitute for knowledge and good judgment. Recommended categories of physical status and modification of treatment should not be considered as absolutes, but as guides. Wheras the guidelines may appear to be inflexible, they should not be considered as such. Deviation from recommendations is often justified and is expected.
Effects of endodontic retreatment on quality of seal and periapical healing were assessed among 660 previously root-filled roots. The roots were divided into either of two groups according to presence or absence of pathologic alterations in the periapical area. The retreatments, which were carried out by dental students, involved a thorough chemomechanical debridement of the root-canal system aiming to control infection. Following a 2-year observation period 556 roots were reexamined clinically and radiographically. The results showed that root-fillings with technical shortcomings could, following retreatment, be markedly improved as regards effectiveness of seal and distance to the apex. A large number of lumina discernible apical to root-filling could also be treated and filled. Seventy-eight percent of the cases with pathologic lesion present periapically prior to retreatment either completely healed or displayed an obvious size-reduction of the process. Retreatments carried out because of technical inadequacies alone were successful in 94% of the cases. It was concluded that renewed endodontic treatment whenever possible is the method of choice when treating defective endodontic fillings complicated with pathologic processes periapically. Apical surgery may be attempted if no signs of healing are apparent following observation.
The long-term results of endodontic treatment according to Ingle's standardized technique performed by undergraduate students in Oslo during 1971 were assessed. An adequate seal was found in 97% of the roots. Overfilling of the canal with excess of material greater than 1 mm was observed in 3% of the roots. The overall success rate was 91% with no statistically significant difference between the results in anterior teeth, premolars, or molars. Roots without periradicular radiolucencies showed better results than roots with radiolucencies (statistically significant). It was concluded that the standardized endodontic technique led to an improvement in the technical standard of the root fillings, and that the technique may be used regularly in all groups of teeth.
Endodontic treatment in the United States is delivered primarily by general dentists. A dilemma often arises as to which cases should be treated and which should be referred for specialty care. The case selection system described here rates endodontic cases so that practitioners can assess those cases they are best qualified to treat.
The anatomy of the mesiobuccal (MB) root of 51 maxillary first and 32 maxillary second molars was studied. Initially, an attempt was made to locate all canals using a standard access and hand instruments. A bur was next used carefully to locate any additional second mesiobuccal (mesiolingual (ML)) canals. Finally, after crown removal, the teeth were reduced horizontally in 1-mm increments and examined by microscope. A second ML canal was located in the coronal half of 95.2% of the roots: by hand instruments in 54.2%; bur in 31.3%; and microscope in 9.6%. There were no root perforations when the bur was used as described. The ML canal orifice averaged 1.82 mm lingual to the MB canal orifice. The difference in incidence of ML canals between the first and second molars was not statistically significant. The canal systems were type 1, 4.8%; type 2, 49.4%, and type 3, 45.8%.
The influence of various factors that may affect the outcome of root canal therapy was evaluated in 356 patients 8 to 10 yr after the treatment. The results of treatment were directly dependent on the preoperative status of the pulp and periapical tissues. The rate of success for cases with vital or nonvital pulps but having no periapical radiolucency exceeded 96%, whereas only 86% of the cases with pulp necrosis and periapical radiolucency showed apical healing. The possibility of instrumenting the root canal to its full length and the level of root filling significantly affected the outcome of treatment. Of all of the periapical lesions present on previously root-filled teeth, only 62% healed after retreatment. The predictability from clinical and radiographic signs of the treatment-outcome in individual cases with preoperative periapical lesions cases was found to be low. Thus, factors which were not measured or identified may be critical to the outcome of endodontic treatment.