Case Selection Criteria Case selection criteria refer to considerations that should be accounted for when selecting a case for treatment. Case selection criteria include risks factors or preoperative conditions that are difficult to manage, each of which could contribute to a higher risk of adverse outcomes. The American Association of Endodontists (AAE) provides a Case Difficulty Assessment Form, which is available from its website. This self-assessment tool guides dentists through the case selection process and assigns a level of difficulty to the tooth in question. The dentist can then determine, based on their comfort level and clinical experience, if treatment should be provided or referred. The assessment form can be saved into the patient records or shared with an endodontist to streamline the referral process. The AAE’s selection criteria includes: 1) patient considerations, 2) diagnostic and treatment considerations, and 3) other considerations, which include concomitant periodontal involvement, a history of trauma, or past endodontic treatment. 1) Patient Considerations Patient considerations include emergency conditions, medical history, extent of opening, and patient disposition. Some of the most complex patients to treat are those with severe pain and significant swelling. Profound anesthesia is difficult to obtain without the use of an adjunct technique, such as an intraosseous injection. Trismus, or a significant limitation to opening, creates challenges in taking pre- and intra-operative radiographs without the use of a handheld device. The management of patients with limited opening requires pre-bending of K files and the use of rotary instruments at atypical angles, which significantly increases the risk of file separation. A severe gag reflex can make it nearly impossible to radiograph posterior teeth and may prevent the placement of a rubber dam. Patients with severe anxiety may require behaviour management techniques, sedation, or treatment that is more expedient than the norm, placing additional pressure and stress on the dentist. 2) Diagnostic and Treatment Considerations Diagnostic and treatment considerations include ease of isolation, tooth rotation, location in the arch, inclination, complexity of anatomy, extent of curvature, radiographic presentation of pulp chamber/canals, the proximity to vital structures, and the presence of resorption. Complex anatomy can include the presence of a radix (Fig. 1). Accessory roots typically have severe curvatures making it harder to treat without increased risk of complications, such as instrument separation (Fig. 2), transportation, or strip perforation. Resorption, Figure 1. There is the presence of radix on tooth 36 and tooth 46. Note the faint periodontal ligament (PDL) in between the mesial and distal roots. Figure 2. Radix with severe curvature leading to file separation. Figure 3. External Invasive Resorption (EIR) on tooth 46. Figure 4. CBCT shows multiple areas of EIR in different stages. 28 | 2025 | Issue 1 Supporting Your Practice
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