Endodontic Case Assessment
& Referral Decisions
Modern endodontic technique routinely produces healing rates of 95% or higher under ideal conditions (Salehrabi & Rotstein, J Endod 2004) — but only when the case is well matched to the operator's experience and equipment. The AAE's Case Difficulty Assessment Form is the simplest, most defensible way to make that match objective.
We've collected the current AAE toolkit on this page, alongside a brief practical summary of the difficulty levels — so you can score a case in a couple of minutes and decide with confidence whether to treat or refer.
The form itself · PDF · AAE
AAE Endodontic Case Difficulty Assessment Form (2022)
The current edition of the CDAF. A one-page worksheet that lets you score a case across patient considerations, diagnostic and treatment considerations, and additional considerations — and arrive at a Low / Moderate / High difficulty rating to support both treatment planning and the referral decision.
Open the 2022 form (PDF)The three difficulty levels at a glance
The form scores patient, diagnostic, and treatment factors and arrives at one of three levels. The summaries below are condensed from the AAE's published guidance — see the form and educator's guide for the full criteria and scoring.
Low Difficulty
Pre-operative condition indicates routine complexity (uncomplicated). Achieving a favorable treatment outcome should be attainable by a competent practitioner with limited experience.
Examples of LOW factors on the form
- •Cooperative patient, ASA Class 1 or 2, no anesthesia or mouth-opening issues
- •Anterior or premolar tooth; slight inclination or rotation (<10°)
- •Canal with slight or no curvature (<10°), closed apex (<1 mm)
- •Canal and chamber visible on radiograph, not reduced in size
- •Normal crown morphology, routine rubber dam isolation
Moderate Difficulty
Pre-operative condition is complicated, exhibiting one or two factors listed in the MODERATE category. Achieving a favorable treatment outcome may be challenging for a competent, experienced practitioner.
Examples of MODERATE factors on the form
- •Anxious but cooperative patient, ASA Class 3, vasoconstrictor intolerance
- •1st molar; moderate inclination or rotation (10–30°)
- •Moderate canal curvature (10–30°); apical opening 1–1.5 mm
- •Canal and chamber visible but reduced in size; pulp stones present
- •Full-coverage restoration, bridge abutment, or extensive coronal destruction
High Difficulty
Pre-operative condition is exceptionally complicated, exhibiting three or more MODERATE factors or at least one HIGH factor. Achieving a favorable outcome may be challenging for even the most experienced practitioner. The AAE notes: if the level of difficulty exceeds your experience and comfort, consider referral.
Examples of HIGH factors on the form
- •Uncooperative patient, ASA Class 4, difficulty achieving or maintaining anesthesia, significant mouth-opening limitation
- •2nd or 3rd molar; extreme inclination or rotation (>30°)
- •Extreme canal curvature (>30°) or S-shaped curve; C-shaped morphology
- •Deep long tooth (>25 mm), open apex (>1.5 mm), or other root anomalies
- •Indistinct canal path or chamber not visible radiographically
- •Confusing/complex signs and symptoms; chronic oro-facial pain
Source: AAE Endodontic Case Difficulty Assessment Form & the Educator's Guide. The examples here are illustrative — refer to the form for the full set of criteria and scoring.
Supporting AAE resources
Background reading and the underlying literature behind the form, all hosted by the AAE on aae.org.
PDF · AAE
Endodontics: Colleagues for Excellence — Case Assessment & ReferralThe AAE newsletter that introduces the CDAF and walks through case assessment from a specialist's perspective. A good companion read the first time you use the form.
PDF · AAE
Reading List — Case Assessment & ReferralComprehensive bibliography of the peer-reviewed literature behind the CDAF and the broader topic of when to treat versus refer.
PDF · AAE
Educator's Guide to the AAE Case Difficulty Assessment FormWritten for predoctoral and residency programs but useful for any practitioner who wants the underlying scoring rationale, point values, and worked examples behind the rating categories.
PDF · AAE
Forging Effective Alliances for Quality Patient CareOn the value of effective referral relationships between general dentists and specialists — communication standards, hand-off, and shared accountability for outcomes.
Scored a high-difficulty case?
Send it to us with your CBCT or PA, and a brief note on the chief complaint and what you'd like us to address. We'll see urgent and trauma cases the same day when the schedule permits.
More for referring doctors
Other pages on this site written for general dentists, residents, and dental students.
Resection decision checklist (PDF)
One-page chairside aid: the seven evidence-based root resection / hemisection case-selection criteria, plus what to send when you refer.
Colleagues for Excellence archive
Full curated archive of the AAE's quarterly newsletter — 29 issues, 2002 to today, with bonus materials and references.
Clinical protocols & case evidence
Microsurgery protocol, magnification table, root-end materials, and the meta-analyses behind them.
Refer a patient
Online referral form with file uploads, urgency selector, and a printable referral pad.
The Case Difficulty Assessment Form and supporting documents on this page are publications of the American Association of Endodontists. We do not author, host, or redistribute these materials — every PDF link opens the original document on aae.org. The summary of difficulty levels is condensed from the AAE's published guidance and is provided for orientation; the form itself remains the authoritative reference. For the AAE's own page on case assessment, visit aae.org/specialty/clinical-resources/treatment-planning.