The Development of The Endodontic Complexity Assessment Tool (E-CAT) - 2018

THE DEVELOPMENT OF THE ENDODONTIC COMPLEXITY ASSESSMENT TOOL
(E-CAT) FOR ASSESSING ENDODONTIC COMPLEXITY AND ITS PREVALENCE IN
GENERAL DENTAL PRACTICE
By
Obyda Essam
Supervised by
Dr Liam Boyle
Prof Fadi Jarad
Thesis
Submitted to the
University Of Liverpool
In partial fulfilment of the requirements for the
Degree of
Doctor of Dental Science in Endodontics
June 2018
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ABSTRACT
THE DEVELOPMENT OF THE ENDODONTIC COMPLEXITY ASSESSMENT TOOL
(E-CAT) FOR ASSESSING ENDODONTIC COMPLEXITY AND ITS PREVALENCE IN
O. Essam* BDS, E. L. Boyle BSc BDS PhD and F. D. Jarad BDS PhD (Department of Restorative
Dentistry, University of Liverpool, United Kingdom)
Introduction: The need for endodontic treatment in dental care is a well-established in the
literature. A substantial perceived need for referring endodontic cases to endodontic specialists
has been reported. In order to improve the success rate for endodontic treatment by general
dental practitioners (GDPs), the referral of the more complex cases to an experienced endodontist
should be made possible in the best interest of the patient. In order to be able to refer such cases
appropriately, two requirements need to be satisfied. Firstly, GDPs need to be able to predictably
identify the cases with higher complexity and higher risk of adverse outcomes, then treat or refer
to the appropriate practitioner. Secondly, there needs to be a sufficient number of endodontic
specialists or endodontic workforce with appropriate referral pathways available.
Aims: The aims of this project are therefore twofold. First is to develop a valid and reliable digital
assessment tool that can help GDPs assess and classify complex non-surgical root canal
treatments (NSRCT). Secondly is to determine the prevalence of endodontic complexity in general
dental practice to help assess the level of need for endodontic treatment, training and therefore
inform commissioning within the health system.
Methodology: The first part of the research focused on the development of the Endodontic
Complexity Assessment Tool (E-CAT). This included a review of the current literature, iterative
analysis of the complexity factors and the development of digital software to enhance the tool’s
efficiency and practicality. Inter-observer and intra-observer reliability studies were conducted
with 15 dentists utilising the tool to assess 15 clinical cases and repeating the experiment 9
months later. External validation of the tool was sought with a panel of 35 endodontists to assess
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the same 15 cases. The consensus of the panel on the complexity of each case was considered as
“gold standard” assessment and was compared to the outcome of achieved by the E-CAT.
For the prevalence study, 30 fully qualified dentists working within general dental practice across
the UK were recruited. Each dentist assessed 10-15 consecutive potential endodontic cases as
encountered in their day-to-day clinical practice. The data was collected using the online E-CAT.
The tool allowed the data to be recorded into a secure database. Information on tooth-related
factors, systemic factors, oral diagnosis and patient-related factors was recorded. Three levels of
complexity were defined for the analysis; class I (uncomplicated), class II (moderately
complicated) and class III (highly complicated). The data was analysed to express period
prevalence with a 95% confidence interval using SPSS statistical software.
Results: The E-CAT was successfully developed with a total of 22 complexity criteria; the tool
was hosted on a secure university server under the domain of www.e-cat.uk. The inter-user and
intra-user reliability was found to be 0.80 and 0.90 respectively. The consensus of the
endodontists panel matched to all 15 cases assessed. The inter-examiner correlation of the panel
was 0.51. The average time to assess a case was 01:36 minute.
A total of 435 endodontic cases were recorded for the prevalence study. The distribution of
complexity over classes I, II and III was 39.8%, 31.9% and 28.3% respectively. History of previous
root canal intervention formed 22.9% of the cases encountered. The majority of the cases
(64.4%) appeared to have <15 degree root curvature, 30.6% had 15-40 degree curvature and only
4.0% had > 40° curvature. Teeth with existing extra-coronal restorations formed 18.8% of the
cases encountered. Radiographically, visible or moderately reduced canal space was reported in
76.9% of the cases, while 20.9% had severely reduced canal space and only 3.2% were perceived
to have invisible canal space. History of trauma was encountered in 8.9% of the evaluated cases.
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Conclusion: The E-CAT provides an efficient and reliable platform to assess the complexity of
NSRCT. The results obtained in the prevalence study provide a good resource and databank for
researchers, public health commissioners and academic institutions to access wide range of
information concerning the prevalence and distribution of endodontic complexity. The results
obtained in this research indicate a possible shortage of endodontic specialist service in the UK,
especially within the National Health Service.
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TABLE OF CONTENTS
The development of the Endodontic Complexity Assessment Tool (E-CAT) for assessing endodontic complexity
and its prevalence in general dental practice .......................................................................................................... 1
Abstract ................................................................................................................................................................... 2
Table of Contents .................................................................................................................................................... 5
List of tables ............................................................................................................................................................ 9
List of Figures ....................................................................................................................................................... 12
ACKNOWLEDGEMENT........................................................................................................................................ 13
Chapter 1 : INTRODUCTION ................................................................................................................................ 14
Chapter 2 : LITERATURE REVIEW ...................................................................................................................... 21
2.1 Factors influencing endodontic treatment complexity; an evidence based approach ................................. 27
2.1.1 Patient related factors ......................................................................................................................... 28
2.1.2 Tooth position and angulation ............................................................................................................. 29
2.1.3 Pre-treatment to commencing endodontic treatment .......................................................................... 30
2.1.4 Radiography related factors ................................................................................................................ 31
2.1.5 Diagnostic complexities ....................................................................................................................... 32
2.1.6 Pulp and root canal morphology factors .............................................................................................. 32
2.1.7 Canal sclerosis and radiographic visibility ........................................................................................... 33
2.1.8 Root curvature ..................................................................................................................................... 34
2.1.9 Presence of direct and indirect restorations related risk factors .......................................................... 35
2.1.10 Previous endodontic treatment related risk factors ........................................................................... 37
2.1.11 Root resorption related risk factors.................................................................................................... 38
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2.1.12 History of dentoalveolar trauma......................................................................................................... 39
2.1.13 Periodontics-Endodontics related risk factors ................................................................................... 39
2.2 Prevalence of complex endodontic cases and influencing factors .............................................................. 41
2.3 Digitalisation of assessment tools ............................................................................................................... 44
2.4 Conclusion .................................................................................................................................................. 47
2.5 Research Aims ........................................................................................................................................... 49
Chapter 3 : THE DEVELOPMENT OF THE ENDODONTIC COMPLEXITY ASSESSMENT TOOL (E-CAT) ...... 50
3.1 Introduction and Aims ................................................................................................................................. 50
3.2 Methodology ............................................................................................................................................... 53
3.2.1 Complexity Criteria .............................................................................................................................. 53
3.2.2 Iterative development .......................................................................................................................... 54
3.2.3 Software development......................................................................................................................... 55
3.2.4 Pilot validity study ................................................................................................................................ 64
3.2.5 Reliability ............................................................................................................................................. 65
3.2.6 External Validity................................................................................................................................... 66
3.3 Results........................................................................................................................................................ 67
3.3.1 Complexity Criteria .............................................................................................................................. 67
3.3.2 Iterative development .......................................................................................................................... 72
3.3.3 Pilot Validation..................................................................................................................................... 78
3.3.4 Reliability ............................................................................................................................................. 80
3.3.5 External Validity................................................................................................................................... 85
3.4 Discussion .................................................................................................................................................. 87
3.5 Conclusion ................................................................................................................................................ 103
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Chapter 4 : THE PREVALENCE OF ENDODONTIC COMPLEXITY IN GENERAL DENTAL PRACTICE ........ 104
4.1 Introduction and Aims ............................................................................................................................... 104
4.2 Methodology ............................................................................................................................................. 107
4.2.1 Ethical Approval ................................................................................................................................ 107
4.2.2 Sample size calculation ..................................................................................................................... 107
4.2.3 Participants recruitment ..................................................................................................................... 108
4.2.4 Data collection ................................................................................................................................... 109
4.2.5 Funding ............................................................................................................................................. 111
4.3 Results...................................................................................................................................................... 112
4.3.1 Participants and total number of data collected................................................................................. 112
4.3.2 Prevalence and distribution of complexity factors ............................................................................. 114
4.3.3 The overall prevalence and distribution of complexity classes in general practice ............................ 119
4.3.4 The distribution of proposed dental treatment in relation to the complexity levels and factors .......... 119
4.4 Discussion ................................................................................................................................................ 124
4.5 Conclusion ................................................................................................................................................ 132
Chapter 5 : Clinical implications and FUTURE RESEARCH ............................................................................... 133
5.1 Clinical implications .................................................................................................................................. 133
5.2 DEFINITION OF UNCOMPLICATED ROOT CANAL TREATMENT ........................................................ 134
5.3 Future research ........................................................................................................................................ 137
5.4 Conclusion ................................................................................................................................................ 140
Chapter 6 : BIBLIOGRAPHY............................................................................................................................... 141
Chapter 7 : APPENDICES .................................................................................................................................. 158
7.1 Examples of existing complexity assessment forms ................................................................................. 158
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7.1.1 The AAE form .................................................................................................................................... 158
7.1.2 The Dutch DETI and ETC.................................................................................................................. 160
7.1.3 The Restorative Index Of Treatment Need form ............................................................................... 162
7.2 Letter of invitation to general dental practitioners ..................................................................................... 163
7.3 Participant information leaflet ................................................................................................................... 164
7.4 Trust Sponsorship Letters......................................................................................................................... 168
7.5 Ethical Approval Letter.............................................................................................................................. 169
7.6 European Society of Endodontology Educator Grant ............................................................................... 174
7.7 Invitation letter to endodontic specialists .................................................................................................. 176
7.7 Clinical Cases scenarios used in the study............................................................................................... 177
7.8 Poster presentation at the ESE 18th Biennial ESE Congress - Brussels, Belgium - September 2017. .... 192
7.9 Abstract published in the IEJ following poster presentation...................................................................... 193
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LIST OF TABLES
Table ‎3-1 showing the pilot study results utilising E-CAT version 1.0. The overall average time require for each
case was 4:31 minutes.......................................................................................................................................... 58
Table ‎3-2 showing the compiled feedback from the dentists using E-CAT version 1.0, all participants commented
positively on the concept, but reported negatively on the length and the user interface. ..................................... 59
Table ‎3-3 Results of literature search on endodontic criteria affecting endodontic treatment complexity. A total of
19 categories were identified to be associated with the risk of encountering complexity or adverse outcomes. .. 67
Table ‎3-4 showing the complexity factors reported to be linked to the complexity of non-surgical root canal
therapy .................................................................................................................................................................. 72
Table ‎3-5 showing the range of E-CAT score to describe the class of each case. An E-CAT score up to 5 was
found to be of relatively low risk of encountering complexity and is thought to be associated with relatively
uncomplicated cases. A score of 12 or above is found to have a high risk of complication and adverse outcome
.............................................................................................................................................................................. 73
Table ‎3-6 showing breakdown of the E-CAT score associated with the risk of encountering complexity or adverse
outcomes. A score of zero represents low or no relative risk, 10 represents very high risk. ................................. 74
outcomes. 0 represents low or no relative risk, 10 represents very high risk. ....................................................... 75
outcomes. 0 represents low or no relative risk, 10 represents very high risk. ....................................................... 76
Table ‎3-9 showing the main key areas dictating the factors which could impose higher risk of encountering
complexity and the questioning required to be assessed should one those areas be involved in the case. For
example, if the tooth being assessed has only had previous endodontics and direct restorations, then only
questions 4, 6 and 7 will be shown on the surveying forms, in addition to the default questions of 18 to 22. ....... 77
Table ‎3-10 showing the results of the pilot validation which involved a panel of three endodontists assessing 15
clinical cases, and the results of the panel compared to the results reported by E-CAT. ..................................... 78
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Table ‎3-11 Primary data of reliability study showing the results of 15 dentists using the E-CAT to assess 15
clinical cases. The overall kappa for the first study was 0.75. The mean time taken to assess the cases was 97s
with (SD±31s) ....................................................................................................................................................... 80
Table ‎3-12 Repeated study data of reliability study 9 months later showing improved results of 15 dentists using
the E-CAT to assess the same 15 clinical cases. The overall kappa for this study was 0.8. The mean time taken
to assess the cases was 89s with (SD±32s) ........................................................................................................ 81
Table ‎3-13 showing the cases which showed disagreement between the dentists and the reasons for the
disagreement ........................................................................................................................................................ 83
Table ‎3-14 showing the inter-rater reliability of the 15 dentists taking part in this study, the overall mean kappa
was found to be (k= 0.90) ..................................................................................................................................... 84
Table ‎3-15: the most common variations and errors encountered by the dentists while utilising the E-CAT.
Assessing canal visibility and root curvature were found to be the most prevalant variation between the group
despite the lack of confounding factors. ................................................................................................................ 85
Table ‎3-16 showing the results of the external validation study utilising a panel of 35 endodontists independently
assessing the same clinical 15 scenarios for their complexity. Rating them 1 (uncomplicated), 2 (moderately
complicated) and 3 (highly complicated). The overall panel consensus agreed with the outcome of the E-CAT in
all 15 cases. .......................................................................................................................................................... 86
Table ‎3-16 showing K value interpretation as described by Altman in 1991 ......................................................... 92
Table ‎3-17 proposed suggestion for the division of endodontic complexity classes into 5 classes rather than 3.
This may help identify those “in between” categories as suggested by the panel of endodontists, but may also
add further confusion to the ease of use of the tool .............................................................................................. 95
Table ‎4-1 showing the surveyed categories of endodontic complexities as recorded by the endodontic complexity
assessment tool .................................................................................................................................................. 109
Table ‎4-2 Showing the participants demographic data of gender, location post graduate endodontic experience,
practice type and years post qualification. .......................................................................................................... 112
Table ‎4-3 showing the average numbers of root canal treatments encountered by a GDP practicing in the UK (full
time). The average number of potential RCT encountered by a GDP practicing in the UK taking into account
bank holidays and annual leave. ......................................................................................................................... 113
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Table ‎4-4 showing the prevalence and distribution of numerous factors which may potentially affect the
complexity of non-surgical root canal treatment .................................................................................................. 115
Table ‎4-8 the overall prevalence of class I, II and III (uncomplicated, moderately complicated and highly
complicated) non-surgical root canal treatment in general dental practice. ........................................................ 119
Table ‎4-9 showing the distribution of proposed dental treatment in relation to the complexity levels across the
three complexity classes ..................................................................................................................................... 120
Table ‎4-10 showing the distribution of proposed dental treatment in relation to the anterior and posterior teeth 122
Table ‎4-11 showing the distribution of proposed dental treatment in relation to history of previous endodontic
treatment ............................................................................................................................................................. 123
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LIST OF FIGURES
Figure ‎3-1 showing introduction page as developed for the E-CAT version 1.0. This included a series of 15
questions to tick. If none of those are selected at all, the case is automatically considered uncomplicated. ........ 56
Figure ‎3-2 showing individual question page as developed for the E-CAT version 1.0. Each page contained the
question alongside demonstrations of the question criteria .................................................................................. 56
Figure ‎3-3 showing the summary page in E-CAT version 1.0, all questions were required to be answered and all
information was shown in the summary page. ...................................................................................................... 57
Figure ‎3-4 showing the simple welcome page of version of E-CAT version 2.0 ................................................... 62
Figure ‎3-5 showing the screening page of version of E-CAT version 2.0 containing 12 keywords and simple yes
or no questions, with the ability to show more information if hovered over the (i) icon. ........................................ 62
Figure ‎3-6 showing the surveying page of version of E-CAT version 2.0 only the relevant questions to the case
as determined from the filtering page, with the ability to show more information if hovered over the (i) icon........ 63
Figure ‎3-7 showing the summary page of version of E-CAT version 2.0, containing only the relevant information
to the case, with colour highlighted risk factors. Factors having moderate risk of complications are highlighted in
amber, whilst those posing a higher risk are in dense orange. ............................................................................. 64
Figure ‎4-1 shows the trends of proposed dental treatments in relation to the complexity levels. An upward trend
can be clearly seen for tooth extraction in relation to the complexity, as well as upward trends for the referrals.
............................................................................................................................................................................ 121
Figure ‎4-2 shows higher proportion of teeth being extracted observed in relation to posterior teeth and teeth with
previous endodontic intervention. ....................................................................................................................... 123
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ACKNOWLEDGEMENT
Firstly, I would like to express my deep gratitude to my supervisors Dr Boyle and Dr Jarad for
their support and patient guidance, and for their valuable and constructive advice and
encouragement during the planning and development of this research. Their help and willingness
to give their time generously has been very much appreciated, I will always be indebted.
My sincere thanks also go to all the dentists and endodontic specialists who volunteered to
participate in my research and enabled the data collection for this research. The time taken out of
their day in order to assess the cases, record and provide data for the studies is sincerely
appreciated. The development of the tool would not have been possible without their efforts.
I would also like to extend my gratitude to the European Society of Endodontology for awarding
the educator grant to support the development of the E-CAT. Their faith and trust in this research
is highly valued.
I would like to thank our statistician Mr Girvan Burnside for his time and support with the
analysis of the data. His statistical knowledge has been invaluable in making sense of all the
numbers this research produced!
I would like to thank my parents for all the support and the amazing opportunities they have
given me over the years. Thank you for having faith in me and standing behind me with love and
support.
I wish to thank my beloved wife for her endless love, patience, support and encouragement during
the many hours of planning, writing and discussing my research at home. Thank you for helping
me achieve my goals. The completion of this would not have been possible without you.
Last, I would also like to include a special mention to all the baristas for the endless cups of coffee
they brewed for me while I sat in the various coffee shops finalising my write-up! They certainly
helped keeping a smile on my face whilst going through this.
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CHAPTER 1 : INTRODUCTION
Endodontics is a branch of dentistry concerned with the cause, diagnosis, prevention and treatment of
diseases and injuries of the root canal of the tooth, dental pulp, and the surrounding tissue
Torabinejad (2009). It is a recognised dental speciality in the United Kingdom and numerous other
countries worldwide. The term endodontics originates from a Greek word; “endo” meaning the “the
inside” while “odont” means “tooth”.
In general, endodontic treatment is advisable in situations where a tooth is either already infected, or
considered highly susceptible to future infection, as a result of tooth decay, fracture or other forms of
trauma. If left untreated, it can result in dental abscesses, pain, swelling and other related
complications (Grossman, 1976).
Endodontic therapy or root canal treatment (RCT), usually involve a sequence of clinical procedures to
help remove the infected pulp tissue, clean the root canals and seal the decontaminated parts of the
tooth from future bacterial invasion. The aim is to preserve the tooth as a functional unit within a
functioning dentition. The most common alternative to endodontic treatment is extraction.
The need for endodontic treatment in dental care has been long emphasised in the literature with
several studies reporting a substantial need for RCT within the population (Saunders et al 1997, de
Moor et al 2000). A systematic review with a meta-analysis conducted by Pak et al in 2012 of
numerous worldwide studies included over 300,000 teeth revealed the prevalence of root canal
treated teeth to be around 10% of all teeth included in the review. When applied to the general
population, the prevalence of endodontically treated teeth was found to be very high, equating to 2
treatments per patient. The authors concluded that billions of teeth are retained through endodontic
treatment globally.
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The American Dental Association (ADA) 1999 conducted a survey which reported that over 14 million
root canal treatments were performed in 1998. General dental practitioners performed about 77% of
these treatments. Specialist endodontists performed just over 22%. A more recent US survey was
conducted in late 2005-2006 and published in August 2007. Information from the survey was collected
using questionnaires and patient care logs. The estimated number for all endodontic procedures was
22.3 million performed annually, and the number of root canal treatments went up to 15.2 million,
with a lower number of 72% performed by GDPs and about 28% were performed by endodontists. This
trend shows a significant increase in the number of endodontic treatment being performed over this
10 year period. The British Dental Association (BDA) published a report in 2012 titled “Oral healthcare
for Older People - 2020 Vision” reporting on the demographics of dental treatment. The population is
now living longer, becoming more educated about oral health, the demand for keeping teeth longer is
increasing, and subsequently the complexity of saving these teeth is also increasing across all fields of
dentistry, including endodontics (BDA, 2012)
No official survey information is available concerning the number of root canal treatments carried out
in the UK. However, the dental practice board reported over 1 million root canal fillings performed
within the general dental service in the year to March 2004, at an estimated cost of £50.5 million (DPB,
2004). More recently, the Health and Social Care Information Centre in association with the
Department of Health published a report on the NHS dental statistics in England for the year 2016/17,
reporting the number of endodontic treatments for adults to be around 522,000 (HSCIC, 2017). This
figure does not include endodontic treatments carried out in the private sector or secondary care.
Endodontic treatments can vary significantly in their complexity. Some cases can be straightforward
and command minimal risk of complication; others can take much longer time and require much
higher technical skills and expertise. There are numerous factors which may affect the complexity of
RCT. These are discussed in more detail later in this section. Generally, single rooted anterior teeth
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with closed root apices and wide uncalcified canals are considered relatively simple to treat
(Rosenberg and Goodis, 1992). Accessing the root canal system in those cases is easier due to the
relatively uncomplicated root anatomy, making it easier to locate, shape, clean and fill the canals. On
the other hand, multi-rooted teeth with very narrow calcified canals, curved roots, previous history of
unsuccessful root canal treatments and unusual root anatomy are much more difficult to access,
disinfect and fill appropriately. The complexity of each case needs to be assessed individually.
The GDC – “Preparing for Practice” guidelines state that newly qualified dentists should be able to
“1.14.9 recognises the risks of non-surgical root canal treatment and how to manage them” and
“1.14.10 evaluate the need for more complex treatment and refer accordingly” (GDC, 2015).
Endodontic training forms a vital part of undergraduate training in dentistry. Despite large variations in
the teaching approach, dental practitioners are expected to graduate with a working knowledge to be
competent in “uncomplicated” endodontic cases (ESE, 2001).
The term complexity itself requires an English definition for the purpose of this research. The word
"complexity" stems from “complex”, which combines the Latin roots “com” (meaning "together") and
plex (meaning "woven"). A complex system is therefore characterised by its inter-dependencies,
whereas a complicated system is characterised by its layers. It is seen as subjective topic, as what may
be complex to one clinician, may not be complex to another. In addition, what may be complex for one
clinician at one point in time may not seem complex for them a year later.
The Association for Dental Education in Europe (ADEE) and the European Society of Endodontology
(ESE) undergraduate competency guidelines refer to the graduating European dentist as being
competent in the management of 'uncomplicated' anterior and posterior teeth, yet neither clearly
defines what is meant by the term uncomplicated (ESE, 2001). This issue cause a wide range of
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variation in the level of undergraduate teaching across the teaching establishments in Europe
(Qualtrough, 2014).
Numerous postgraduate training pathways have been formulated for those who wish increase their
experience and skills in endodontics. The ESE recommends a minimum period of 3 years of further
postgraduate training in order to become a certified specialist in endodontics tackling the more
“complex” cases (Gulabivala et al., 2010). More detailed information is provided within the
postgraduate training curriculum on the process, however, a clear definition of the level of complexity
is again not available.
There is always an ethical, moral and legal obligation when determining the complexity of any form of
dental treatment. In order to improve the chances of success for endodontic treatments in general
dental practice, the referral of the more complex cases to an experienced endodontist should be made
possible for the best interest of the patient and best treatment outcome (De Cleen et al., 1993,
Saunders et al., 1997, De Moor et al., 2000, Caplan et al., 1999). Dietz and Dietz studied the pattern of
referrals between American GDPs and endodontists in 1992 and reported that 60% of GDPs selectively
choose which cases to treat or refer, 20% never refer their endodontic cases while the other 20%
always refer their cases.
The aim of the healthcare system is ultimately to provide the highest possible standard of treatment
and place the patient’s best interest first. Endodontics is not simply the action of performing root canal
treatment. A vital part is arriving at an accurate endodontic diagnosis and good case selection via
predictable cost against benefit analysis. In order to achieve that quality of care, a reliable and
predictable method of determining when to treat or refer is needed.
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More recent surveys indicated a rise in the number of referrals to specialist services. In a Dutch survey
2003, the authors looked into the perceived need of a group of GDPs to refer the more complex
endodontic cases to specialist practitioners. The study found 93% of the respondents reporting on the
need for a referral pathway (Ree et al., 2003b). An American survey carried out at the University of
North Carolina in 2010 covering over 1400 dentists in the United States revealed that 96.2% of
practicing GDPs refer at least some of their endodontic treatments to a specialist (Curry, 2010). Only
3% were found not referring any cases and 15% reported referring all cases. There are currently no
official guidelines to advise general practitioners when to refer a case or to treat it. The general
consensus is for dentists to assess their own abilities and tackle each case accordingly.
In order to be able to manage and refer endodontic cases appropriately, two requirements should
ideally be satisfied:
 General dental practitioners need to be able to predictably identify cases with higher
complexities and decide whether to treat or refer to an appropriate practitioner.
 There needs to be a sufficient number of endodontic specialists or dentists with further
advanced skills in endodontics.
The referral pattern discussed earlier can probably be attributed to clinical judgement being a
subjective matter. One practitioner may attempt endodontic treatment on a tooth which another
would regard as hopeless. A GDP with more experience and enhanced skills may be eager to undertake
treatment of endodontic cases which other GDPs would refer to a specialist. In contrast, teeth with a
guarded prognosis or difficult endodontic cases may be underestimated because of inadequate
preoperative assessment (Messer, 1999). The difficulty here lies in deciding whether to manage the
case in general practice or to refer to a specialist should be balanced with the experience and skills of
the practitioner. To help addressing this, the use of a standard forms for assessing the difficulty of each
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endodontic case was suggested to aid in consistent, systematic assessment of the cases (Messer,
1999).
The decision to do endodontic therapy should not be made in isolation, without comprehensive
consideration of the patient related factors, final restoration, and periodontal condition. The challenge
is to become more impartial and objective in the decision making by developing a methodical
approach to the assessment of endodontic cases, providing a realistic prognosis and ensuring that the
treatment is suitable for the patient.
The use of a standardised assessment tool provides a systematic approach to case assessment and
help eliminating the subjectivity that may lead to less compromised outcomes (Caplan et al., 1999).
The advantages of such tools are thought to having greater consistency in assessing difficulty and the
ability to document the assessed degree of difficulty. Consequently, a more objective decision on
whether to treat or refer the case should help reduce the risk of being confronted with unexpected
problems that may seriously compromise the final result.
From a public health point of view, there have been no studies conducted to determine the prevalence
of complex endodontic cases in the population or the level of complexity and degree of expertise
required. This makes it very difficult to estimate the number endodontic specialists required within the
health system.
In 2009, an independent review of the NHS dental services in England led by Professor Steele was
published (Steele et al., 2009). The report provided a comprehensive overview of the problems with
the current arrangements from the points of view of patients, the profession and the NHS. The
recommendations made were pointing towards a reform of the system to provide better quality
treatments rather than concentrating on numbers and output. A few pilot schemes have been trialled
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over the last few years attempting to provide more efficient delegation of resources. Further
publications (DOH, 2012, DOH, 2014) provided updates on these pilots and reported growing interest
in favour of reforming the dental care provision into three levels of care, 1, 2 and 3. It is proposed that
level 1 can be carried out by GDPs who have no further post graduate training, level 2 by GDPs with
“additional competencies and enhanced skills” and level 3 by “specialist services”. The degree of
complexity of endodontic treatment increases from level 1 to 3. However, the reports debate the issue
of defining the boundaries of those levels and whether the current health system has enough qualified
dentists with expertise for each level.
Being able to classify endodontic treatment complexity into different levels predictably and reliably
may help in facilitating this delegation of care levels, whilst identifying the prevalence of each level in
general practice may help indicate the number of practitioners required in each category.
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CHAPTER 2 : LITERATURE REVIEW
Several tools have been formulated by different bodies to enable dentists to classify which cases are
straightforward and within “recently qualified” dental practitioner range and the ones that are more
difficult and may require further endodontic training and experience (Ree et al., 2003a, AAE, 2005a,
Falcon et al., 2001). Most assessment forms are designed to aid a more systematic and comprehensive
approach to this process. The particular dilemma of difficulty and risk assessment in endodontics has
been addressed in the literature in several studies formulating assessment tools which will be
discussed in this part of the research. The literature appears to have several research articles
evaluating the usefulness of the assessment tool determining the complexity of each endodontic case.
A recurrent theme in most of those studies can be noticed. There appears to be little research looking
into the validity of those tools and the criteria determining the level of difficulty.
Rosenburg and Goodis from the University of California at San Francisco (UCSF) reported in 1992 in the
ADA Journal on the topic of endodontic referrals. Case selection was discussed in details. The authors
described a systematic approach of assessing cases for GDPs in an effort to avoid a variety of iatrogenic
damage and suboptimal treatment results. The UCSF Endodontic Case Selection provided simple
means of determining the complexity of endodontic cases. Each consideration was categorised as
complicated, moderately complicated or uncomplicated. Based on the result of the categorisation,
GDPs can assess whether a case should be treated or referred to an endodontist. This tool was mainly
based on experts’ opinion rather than scientific research. The tool appears to have inspired other
bodies to develop similar more comprehensive tools which are discussed later. This form currently
seems outdated and not widely used probably due to the availability of the more recent forms.
The Canadian Academy of Endodontics (CAE) put together a case difficulty assessment form in 1998.
The tool represented a combination of several assessment tools widely used by several dental schools
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in Canada at the time. A copy of the form can be found in appendix 7.1.1. Those protocols proved to be
valuable, both for teaching and instilling clinical judgment. This form took the shape of thirteen
contributing factors that involved the patient, the tooth, and the dental history. Three risk groups were
defined, average risk, high risk, and very high risk, which corresponds to class I, II and III respectively.
Each contributing factor carried an option to fit those groups where applicable. The average risk group
was given the value of 1 unit; the high risk was given a value of 2 units, whilst the very high risk group
carried a value of 5 units. There was no clear evidence-based explanation given as to why those points
corresponded to each classification. Users of this tool were asked to systematically go through the list
and tick each option, then add up all the points to achieve a total sum. The sum then determines the
degree of the difficulty or risk. If the total sum added up to be of 15 to 17 units, the case is deemed to
be Class I. Class II is given to the range from 18 to 25 units. Any case that exceeds 25 units is classified
as Class III difficulty assessment group. This form was found to be user-friendly and widely used in
Canadian dental schools and to a lesser extent by Canadian GDPs (CAE, 1998). No attempt has been
made to validate this system despite its wide use.
The American Association of Endodontists (AAE) formulated a case difficulty assessment form in 1999
designed for use in endodontic curricula adapting the CAE form. This categorised conditions relevant to
endodontic treatments on a non-point based scale. The system was based on several evidence based
articles and publication which supported the classification of each difficulty. It attempted to make case
selection more consistent, more efficient and easier to document. It also aimed to help dentists with
referral decision making and clinical record keeping. A copy of this form is attached in appendix 7.1.2
of this research.
The form also listed conditions which are considered potential risk factors that may complicate
treatment and adversely affect the outcome. Risk factors are conveyed to reduce the chance of
providing an unpredictable outcome. In this original form, there was no point value attached to any of
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the conditions listed, probably in an attempt to avoid assigning points without having the evidence
base explanation behind it. The AAECAF was more proactive than the CAE form in attempting to
provide more evidence base references to some of the categories that can affect the treatment,
however, no real attempt was made to validate this form or assess its reliability.
Nonetheless, this form is speculated to be the most widely known worldwide probably due to the
influence of the AAE internationally rather than its practicality (Messer, 1999).
The overall assessment enables dentists to assign a level of difficulty to a particular case. The general
outline is similar to the Canadian form in categories and classification; with the three classes of
difficulty, minimal, moderate and high. The AAE recommends minimal difficulty cases have predictable
outcome if treated by limited expertise practitioner. For higher difficulties the AAE states that a
specialist with more clinical experience should treat the case to ensure a predictable outcome.
In 2005, the AAE revisited their difficulty assessment form and added an “educational guide” for the
use of the AAE existing form with minor modifications. It was aimed to assist clinical teachers and
students in the evaluation and decision-making related to endodontic cases. The intention was for the
guidelines to provide a more objective evaluation tool to use in assessing the difficulty and assist in the
decision whether to refer or treat. The points and score system was again introduced here in a very
similar manner to the previous tools, carrying 1 point for “minimal difficulty”, 2 points for “moderate”
and 5 points for “high”. The distinction was made here for the use of this scoring purely for dental
students and not recommending it for clinical practice. No justification was made as why this could not
be used with GDPs, but the assumption is this could be too time consuming or requires more guidance.
Three ranges were recommended in guiding the decision to refer or treat. When the sum was less than
20 points, it was suggested that junior students may treat. For 20 – 40 points, a more experienced
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dental student may treat with very close specialist supervision, or refer to a post-graduate student or
endodontist. Above 40 points cases were not recommended as suitable to be treated by an
undergraduate student, and should be referred to a specialist in endodontics.
Research carried out at the University of California (Curry, 2010) was designed to assess the
effectiveness of the AAE difficulty assessment form in determining whether GDPs would treat or refer
a case and the prevalence of its use. 1,434 US dentists completed an electronic survey addressing
several aspects related to the use of tool and the pattern of referral. Respondents reported 30.5% of
the contributing factors and conditions present on the AAE form were “mostly” important to dentists
when deciding to treat or refer an endodontic case. The study did not address a point value system and
recommended further research into the validity of the topic. The authors did however suggest that
points-based systems may allow a more uniform determination of the difficulty. It was speculated that
dentists will have different educational philosophy, experience, and confidence regarding endodontic
treatments. Consequently, there will be differences between determining whether to treat or refer. A
point based system may help reducing these issues and allow the form to be more reproducible and
reliable.
The author also discussed that the comprehensiveness of the AAE may itself be its downfall. They
reported that the convoluted information, the length of time it takes to complete and the complexity
are likely to be the reason behind the dentists consequently deciding to forego the usage of this form.
Another method of classifying the complexity in restorative dentistry has been described in the Index
of Restorative Dental Treatment Need, RIOTN (Falcon et al., 2001). The RIOTN complexity index for
endodontic treatment outlined the complexity in three levels, described as complexity 1, 2 and 3. This
index was aiming to provide a very simple and quick approach to classification. In the process of
simplifying this tool the authors seem to have eliminated important factors to be taken in
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consideration in endodontic treatments. Factors not considered in the RIOTN index included patient
factors, medical history, retreatment specific consideration, trauma and other factors which both the
AAE and CAE implemented within their tools.
Muthukrishnan et al conducted a study in 2006 to evaluate the reproducibility of the RIOTN when
applied to endodontic cases. The RIOTN was used to assess all cases referred for a period of one year
in a UK dental hospital. The investigation was led by a restorative consultant and a vocational trainee
who was trained for six months to randomly analyse selected cases. The examiners inter-observer
agreements were analysed with weighted Kappa analysis. The reproducibility was found to be
moderate to poor. It was concluded that the tool was easy to use but incomplete due to the lack of the
contributing factors mentioned above. The authors suggested the RIOTN may be used as a valuable
tool in risk management or to select suitable cases of endodontic treatment for undergraduate
students, but questioned its suitability for general practice.
In 2003, Ree et al. published research assessing the usefulness of two case assessment forms among
Dutch dentists (figures 5 and 6 in the appendix). The Dutch Endodontic Treatment Index (DETI) and the
Endodontic Treatment Classification (ETC) were designed. The DETI is a very simple 2 outcome index
which lists 15 conditions. If none of them is met, the case is deemed of straightforward difficulty; if any
is met then a full ETC assessment form is to be followed. The ETC form is yet again very similar to the
Canadian assessment form with a few minor modifications. The authors of the ETC decided to omit the
criterion of whether it is possible to place a stable clamp for isolation as this was thought to render the
tooth unrestorable.
The authors also added three of other criteria to the form: (i) the presence of a “composite” core
within the pulp chamber possessing higher difficulty, (ii) the presence of iatrogenic incidences such as
ledges and apical transportation, and finally (iii) the presence of silver cone sectional obturation. The
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ETC authors also expanded the numbers of criteria and tooth considerations which resulted in the case
automatically belonging to class III classification.
The ETC adopted a similar approach to the CAE form, contributing factors where defined into three
groups, the sum of all criteria with corresponding scoring of 1, 2 or 5 is added up to give an indication
of the difficulty or “risk” of the case. The authors used different terms to classify the three levels,
average, high and very high risk. A survey was formulated and distributed with the two case
assessment forms that questioned the clarity, ease of use, and usefulness of each case assessment
form. The respondents agreed with the authors in determining the degree of complexity in 13 out of
15 cases. Despite the increased complexity of using the ETC, 91% of the participants indicated that the
form was helpful. It was concluded that case assessment difficulty forms were useful in determining
the complexity of endodontic cases. As a result, these forms could assist in determining the need for
referral to the endodontic specialist. The participants also reported however that there is a need to
simplify the ETC and attempt to improve its usability and sensitivity.
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2.1 Factors influencing endodontic treatment complexity; an evidence
based approach
As can be seen from the previous findings, the assessment tools reviewed in the existing endodontic
literature appeared to lack the evidence based approach in their development. Collating the current
available evidence to develop a tool that is based on scientific grounds is likely to be valid and credible.
A widespread literature search was conducted to identify the complexities in endodontic treatment.
The MEDLINE (OVID) database, (PUBMED) database, the EMBASE database, the Cochrane Central
Register of Controlled Trials (CENTRAL), Scopus, Web of Knowledge, Google-Scholar databases, and
peer-reviewed published text-books were electronically searched for available data. Databases were
searched from 1945 up to and including December 2017, using different combinations of the key
words in the table below. English and English-translated publications were included.
Search keywords
• Endodontics
• Complexity, complex, complicated, complication, uncomplicated
• Difficult, difficulty, challenges
• Root canal treatment, retreatment
• Root canal therapy
• Risk assessment, evaluation, valuation, determination
• Non-surgical endodontics, surgical endodontics
The following section will cover a literature review and an evidence based approach to the assessment
factors reported to have an influence on the complexity or adverse outcomes of endodontic
treatments. For ease of presentation and discussion, the results of the search were grouped into 13
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categories presented in no particular order. Based on the results of this search, these results formed
the basis of the methodology described later in chapter 3 of this thesis.
2.1.1 Patient related factors
A review of the most common patient related factors which had possible influence on the complexity
and outcome of endodontic treatment identified medical history, mouth opening, and physical
limitations to be associated with complex endodontic treatment and present a higher risk of adverse
outcomes.
In relation to the medical history, several conditions were reported to require extra precaution in
relation to dental treatments in general (Eliav, 2012). The most relevant of those were allergies,
unstable cardiovascular disease, haematological disorders, immune deficiencies or patients taking
medications such as corticosteroids or anticoagulant that could interfere with intended prescriptions.
Aside from ASA IV or V, no specific medical conditions mentioned in the literature were shown to
specifically contra-indicate endodontic treatment (Daabiss, 2011).
Despite their rarity, allergy to local anaesthetics or vasoconstrictor intolerance is thought to increase
the complexity of endodontic treatments due to the possible high risk of discomfort to the patient
(Tomoyasu et al., 2011). Root canal therapy may be possible without local anaesthetics in non-vital or
root canal retreatment cases (Thomas, 2015, Castellucci and West, 2009), however, extra precautions
need to be taken to keep the instruments within the root canal system and avoid any iatrogenic
damage. Good knowledge and extensive experience of root canal therapy is recommended in those
cases.
Patients with active or history of head and neck cancer, IV bisphosphonate and haemophilia were also
shown to be at to further complicate endodontic treatment (Dudeja et al., 2014, Kumar and Abrol,
2007, Kalra and Jain, 2013). The risk associated with osteonecrosis and excessive bleeding in this group
of patients is well documented in the literature (Nase and Suzuki, 2006, Epstein et al., 1997). A case-
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series presented by (Katz, 2005) demonstrated the importance of careful endodontic approach when
tackling these cases. Specific recommendations were made in relation to applying the rubber dam,
avoidance of over instrumentation, perforations and delayed healing times. This complexity would in
turn risk a higher chance of unsatisfactory outcome. In addition, due to the high risk of complications
associated with dental extractions for those patients, achieving the highest chance of favourable
outcome is particularly more important in these cases. Trained specialists or experienced clinicians
may reduce this risk by having access to micro-instruments and being more efficient in completing the
procedure.
Poorly controlled epilepsy may potentially increase the treatment difficulty of a patient owing to the
possibility of intra-appointment epileptic fits (Joshi et al., 2013).
Other patient related complexity risk factors were reported to be patients’ physical limitations, such as
limited mouth opening, inability to recline, anxiety and cooperation level (Davis, 2013, Greig and
Sweeney, 2013, Eliav, 2012). Medical disorders such as rheumatoid arthritis and other systemic
diseases may influence the difficulty of patient management(Grover et al., 2011) in relation to mouth
opening and lying patient flat. The more severe those medical factors are, the more complex any form
of dental treatment is, including endodontic treatment (Murray, 2015).
2.1.2 Tooth position and angulation
The position of the tooth in the arch, whether it is anterior, premolar, molar or third molar, in addition
to the angulation (tilting or rotation) of the tooth were factors found to be related to the complexity of
endodontic treatment (Mohammadi et al., 2015, Zelikow et al., 2008, Sidow et al., 2000). Those factors
are mostly related to the accessibility of the tooth being treated and the ability to visualise the root
canal anatomy without the need for further magnification or lighting. From that point of view, anterior
teeth are less likely to encounter accessibility issues, while a third molar is reported to be much more
challenging. The anatomy of those teeth may also vary but they are related to have variable degrees of
variation (Vertucci, 2005), however, this subject is addressed in pulp canal morphology related factors.
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Moderate or severe tooth rotation or tilting as a result of crowding or atypical orthodontic movement
may also confuse the clinician further when attempting to access the pulp system. This is particularly
more relevant in the event of that tooth being crowned or having a large restoration masking the
original anatomy, where higher risk of perforation or iatrogenic removal of sound tooth tissue is more
likely (Nayak and Singh, 2013, Darcey et al., 2015). Surprisingly, no evidence was found reporting on
variation in complexity relating to the tooth position being in the upper or lower arches.
2.1.3 Pre-treatment to commencing endodontic treatment
It is common for endodontic cases to present with several issues that require attention prior to the
commencement of endodontic treatment (Castellucci and West, 2009). Many endodontically involved
teeth are carious or heavily broken down. Some involve deep fractures, subgingival proximal caries or
defective margins. The need for appropriate isolation of the tooth during endodontic treatment
requires the use of dental dam (Lin et al., 2014). Adequate isolation can only be achieved when the
portion of the tooth to be clamped is in a reliable condition. Failure to adequately pre-treat a tooth can
result in contamination of the root canal system, clamp disengagement or loss of reference points
(Castellucci and West, 2009). Pre-treatment requires extra effort on the part of the treating clinician
and added expense to the patient. In order to consider any tooth for endodontic treatment, it should
first be determined if it is restorable. The removal of crowns or other extra-coronal restorations prior
to commencing endodontic treatment where possible has been recommended in the literature
(Whitworth et al., 2002, Abbott, 2004, Gorman et al., 2016).
In some cases, caries, fractures or defective restorations are sub-gingival. Teeth with caries just below
the gingival crest can occasionally be treated by judicious use of electrosurgery or gingivoplasty where
hyperplastic or excessive gingival tissue is removed to allow placement of a dental dam clamp. Deep
margin elevation is another technique been described to tackle such challenges, but reported to be
complex in nature itself (Juloski et al., 2017).
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Sometimes a tooth will be heavily broken down so that insufficient solid tooth remains to use a dental
dam clamp and other extensive treatment of the remaining tooth structure may be required. On other
occasions the clamp can be placed, but the post-operative fragility of the remaining tooth poses a
serious risk of fracture, leading to loss of a reference cusp during treatment which can mean inaccurate
working lengths. In those cases, reinforcement of the tooth is necessary. In severe cases, such as those
with those that require osseous recontouring or apical repositioning (e.g. surgical crown lengthening),
the patient may require referral to a Periodontist or suitably trained clinician prior to initiating
endodontic treatment.
2.1.4 Radiography related factors
Radiographs form an integral part of the endodontic treatment. It is widely accepted that at least one
pre-operative and one post-operative radiograph is taken for endodontic treatments (Carrotte, 2005).
The angulation of the X-ray beam in relation to the teeth and film can help diagnosis and treatment by
producing images which provide additional information not always visible on radiographs taken with
standard angulations. Although the use of radiographic techniques increases the diagnostic yield of
films, several complications are reported which may impede the use of standard periapical radiographs
(Fava and Dummer, 1997). Factors reported include those with severe gag reflex, narrow or low palatal
vault or High floor of mouth and hard to solve superimposed anatomical structures.
More recently, the use of cone beam CT scans have revolutionised the amount of information which
could be gathered to help treatment planning endodontic treatments. However, the prescription and
interpretation of CBCT scans are generally still limited to dentists with further training or as part of
postgraduate or specialist training programmes, and therefore expected to be used only in the higher
complexity cases where their use may affect the treatment plan proposed (Patel et al., 2009, Patel et
al., 2010).
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2.1.5 Diagnostic complexities
Endodontic diagnosis is the basis of successful endodontic treatment. It has been described as a puzzle
in the literature (Schweitzer, 2009) , where the pieces must be gathered and pieced together prior to
the clinician seeing the complete picture.
Achieving an accurate endodontic diagnosis can sometimes increase the complexity of the treatment
being proposed. In the majority of cases endodontic diagnosis can be straightforward and relates to
the signs and symptoms clinically encountered. In other cases clinicians can apply some further
investigations such as sensibility testing and parallax imaging differentiating the tooth causing the signs
or symptoms presented (Rosenberg et al., 2009). In some cases however, the signs and symptoms
presented to the clinician may be particularly confusing e.g. fractured tooth syndrome or atypical or
non-odontogenic facial pain, which may increase the risk of complexity or adverse outcomes if treated
without specialised knowledge (Newton et al., 2009) . Furthermore, access and knowledge of further
imaging techniques such as CBCT may also be required in cases with complex endodontic diagnosis and
management (Ee et al., 2014). Those factors should be considered prior to any endodontic treatment.
2.1.6 Pulp and root canal morphology factors
It is not surprising that numerous publications are found reporting on the role of atypical pulp and root
canal morphology associated with increased complexity of non-surgical root canal treatments. These
include increased number of root canals, for example anterior teeth or lower premolars with 2 or more
canals (Zhang et al., 2017), premolar with 3 or more canals (Sathyanarayanan et al., 2017), molars with
4 or more canals (Vertucci, 2005, Acharya et al., 2013). Due to the relatively lower prevalence of those
variations, and the difficulty visualising them without microscope magnifications, those cases are
usually found more complex to manage and are best treated with more experienced endodontists.
Other complex root canal morphology included very long tooth with estimated working length> 30mm
(Vargo and Hartwell, 1992, Abiodun-Solanke et al., 2013, Vertucci, 2005), dens invaginatus or fusion
(Gallacher et al., 2016, Alani and Bishop, 2008, Bishop and Alani, 2008), taurodontism (Nazari and
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MirMotalebi, 2006, Durr et al., 1980) and dentinogenesis imperfecta (Pettiette et al., 1999, Bhandari
and Pannu, 2008). Amelogenesis imperfecta cases were found more difficult to restore in terms of the
patient management overall, but no specific complexity was reported in relation to endodontic
treatment. As with the variations mentioned above, these dental anomalies are also less prevalent and
hence further training in their management is required; they are reported to have a higher risk of
resulting in adverse outcomes, and are more complex to access, shape, clean and obturate.
Finally, atypical root developments such as C-shape (Fan et al., 2004, Martins et al., 2013) and S-shape
roots (Sakkir et al., 2014, Machado et al., 2014a) were also implicated with higher complexity. S-shape
canals were reported to be more complex to negotiate and shape with high risk of iatrogenic damage
such as separated instruments and ledging, while C-shape canals were more challenging to clean
appropriately and obturate.
2.1.7 Canal sclerosis and radiographic visibility
Significant number of publications reported on the complex nature of managing sclerotic canals,
especially with previous history of tooth trauma or in elderly patients (Schilder, 1974, Allen and
Whitworth, 2004). Preoperatively, the level of canal sclerosis is usually assessed by radiographic means
prior to commencing treatment. The pulp chambers may be sclerosed or contain large pulp stones and
the root canals may be so narrow that even when located they are difficult to negotiate.
One classic publication (Molven, 1973) first described three types of root canal visibility on the
radiographs into three categories; canal visible in the whole length of the root, part of the root canal
visible and root canal is invisible. More recent publications followed similar approach of classifying
them into clearly visible, moderately and severely reduced pulp chamber and finally completely
invisible canals (Machado et al., 2014b, McCabe and Dummer, 2012).
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Interestingly, radiographs of teeth showing apparent total canal obliteration can be deceptive. A study
by (Cvek et al., 1982)) attempted to locate and negotiate canals which were not visible on the pre-
operative radiographs. In 54 incisors with periapical lesions, the canal was located and treated in all
but one of them. Despite the radiographic quality being significantly improved over the last 30 years,
radiographic visibility of canal is still not sensitive enough to be 100% accurate (Ki Wei et al., 2013).
The pre-operative radiograph can still provide a useful reference as to the size, curvature and position
of the root canals in relation to the pulp chamber. It is concluded that despite the issue with its
sensitivity, generally speaking, the more visible the canal radiographically, the lower the risk of
encountering difficulty locating and negotiating those canals. This topic is further debated within the
discussion of chapter 3.
2.1.8 Root curvature
One of the most reported factors affecting complexity encountered in this search is the management
of curved canals (Ansari and Maria, 2012). Various curves are present along the length of the canal and
the preparation of these curved root canals can become challenging. Curved canals may also restrict
the chemical irrigation and mechanical preparation or may lead to some iatrogenic damage affecting
the prognosis (Peters, 2004). Preoperative assessment of the curvature is necessary so that the degree
of curvature and radius of the root canals are assessed. Several techniques are described in the
literature to assess root curvature, these include (Schneider, 1971), Weine, Lutein’s (Luiten et al.,
1995) and Cunningham’s (Sonntag et al., 2005) methods of evaluating root curvature as summarised in
Balani et al., (2015). Some authors also looked into considering the radius of the curve rather than the
angle (Estrela et al., 2008). Those methods were all considered for the purpose of the study. Schneider
technique was found to be the most familiar and easier to follow despite the limitations of subjectvitiy
associated with it (Gu et al., 2003, Gunday et al., 2005).
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A trend of progression can be seen in the literature description of mild, moderate and severe root
curvature as technology advances. The canal was originally classified as straight (if the angle was 5° or
less), moderate (10-20°), or having severe curvature (>20°) (Schilder, 1974). This description seems to
shift with the advancement of the NiTi endodontic files flexibility, with the AAE (AAE, 2005a) and Dutch
(Ree et al., 2003a) systems describing mild as <10°, moderate as 10-30° and severe as >30°. The RIOTN
(Falcon et al., 2001) system chose to have the angles set at <15°, moderate as 15-40° and severe as
>40°. In vitro research looking into different file systems with simulated curvature running from 20-40°
seems to support the 40° curvature as threshold for higher risk of file fractures or iatrogenic incidents
with 60° posing highest risk (Capar et al., 2014, Saber et al., 2013).
A recent study looking at the inter-examiner variation when interpreting periapical radiographs
showed significant variation and inaccuracy when dentists were asked to visually assess root canal
curvature (Faraj and Boutsioukis, 2017). Nonetheless, accepting the limitations, as with radiographic
visibility of sclerotic canals, it can still be concluded that the less the perceived curvature of the root is
the lower the risk of encountering difficulty negotiating and shaping the canals. Nonetheless, clinicians
need to exercise care due to the relatively low sensitivity of the radiographic findings.
2.1.9 Presence of direct and indirect restorations related risk factors
The review in this area yielded few factors which may affect the complexity of endodontic
treatment. This included the presence of large direct restorations that mask original crown
morphology, crowns, bridges, onlays or other forms of indirect restorations. Attempting an
endodontic access through such restorations and restoring the access opening rather than removing
the existing restorations is problematic (Abbott, 2004). Even when the restoration may appear to be
clinically and radiographically sound, upon access and further inspection clinically, even in such
radiographically acceptable crowns, it is common to find caries, cracks, and unset restorative
materials that previously were not visualised. In addition, especially in extra-coronal restorations
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that cover the entire chamber of the tooth, it is not at all uncommon to find previously unidentified
small posts and previous endodontic access (Mounce, 2009).
Judging the quality of crown margin integrity on a radiograph is also challenging. Radiographs that
show excellent crown margins or do not show caries may be grossly deficient depending on
radiograph angulation or quality of development. Even though it may not be seen as practical
(mostly due to financial reasons), the ideal endodontic access is one made after a previous crown
has been removed and the tooth carefully examined under a dental microscope for the issues
mentioned earlier (Abbott, 2004).
In certain scenarios, for various reasons it may not possible to remove the crown at least in the short
term. In those cases, the treating clinician will need to take radiographs from more than one angle
and a complete history (general, dental and of the tooth) and evaluate pulpal status (Mounce, 2009).
This may include evaluating the tooth response to percussion, palpation, mobility and probing
depths as well as to cold.
The greatest level of visualisation and magnification must be used to visually inspect the inside of
the tooth should the restoration remain. Such an inspection should seek to identify any areas where
the crown is inadequate (especially when such marginal discrepancies are not visualized outside the
tooth) as well as a visual inspection for all manner of unfavourable events (Trautmann et al., 2000).
In addition, there is a higher risk of perforations associated with endodontic accesses through
existing extra-coronal restorations (Tsesis and Fuss, 2006). This is likely to be due to the loss of
anatomical structures which usually help guiding the endodontic access, or to the difficulty judging
the inclination or rotation of the original tooth underneath. For the reasons mentioned above, the
presence of extra-coronal restoration is seen result in more complex endodontic treatment.
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2.1.10 Previous endodontic treatment related risk factors
The search in this area returned numerous factors which could influence the complexity of non-
surgical root canal retreatment (Gilbert et al., 2010, Carrotte, 2004).
To start with, the type of material used to obturate the canals was one of the frequently reported
factors associated with the complexity of retreatment (ØRstavik, 2005). This may include gutta-
percha (Good and McCammon, 2012), silver or metal cones (Plack and Vire, 1984), root canal
obturating pastes and cements (Tomson et al., 2014, Al-Haddad and Che Ab Aziz, 2016), carrier
based obturation (e.g. Thermafil) (Beasley et al., 2013). Generally, conventional gutta-percha is
considered easier to remove than other non-conventional materials. The use of pastes and hard
setting cements, including the more modern bioceramic cement (Hess et al., 2011), is reported to
further complicate the re-treatment process.
The quality of the obturation is also expected to affect the complexity of the endodontic treatment.
Well obturated, well condensed root canal fillings reaching to within 2mm of the radiographic apex
are generally reported to be more difficult to remove compared to root fillings which are short,
poorly condensed or being single cones (Gordon, 2005). Overfilled root canal fillings are thought to
pose further complexity especially when the overfilling is greater than 2mm in length (Silva et al.,
2012, Jaikailash et al., 2012). The removal of such fillings requires more attention and is ideally done
utilising manual techniques and higher magnifications. Higher risk of severing the apical portion and
having it extra-apically is expected which may compromise the treatment outcome.
The presences of endodontic cores or posts were also reported to further complicate the
retreatment (Castrisos and Abbott, 2002, Dickie and McCrosson, 2014). Amalgam cores were found
to pose a risk of complication, but less than that encountered with composite cores, possibly due to
the colour and adhesive nature of composite cores (Adegbembo and Watson, 2005). The type, width
and length of posts used, in addition to the type of cement used to place them can influence the
complexity of the treatment (Rollings et al., 2013). The wider, longer and the less tapered the post
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placed is, the more complex it is to remove. Generally, posts that are short, more tapered, and those
cemented with non-adhesive cement are thought be easier to manage. Direct posts are found to be
easier to remove than indirect custom-made posts (Abbott, 2002).
Another complexity factor related to previous endodontic treatments, whether obturated or not,
also include the potential presence of iatrogenic damage posing higher risk of difficulty. These may
include significantly misaligned previous endodontic access (Haji-Hassani et al., 2015), ledges
(Jafarzadeh and Abbott, 2007), canal transportation (Mantri et al., 2012), perforations (Tsesis and
Fuss, 2006) and fractured instruments (Simon et al., 2008, McGuigan et al., 2013). Managing
clinically visible, coronally fractured instruments and perforations was reported to be relatively
easier than managing their non-clinically visible and apically positioned equals (Solomonov et al.,
2014). Nonetheless, most iatrogenic damage is recommended to be managed by more experienced
clinicians under high magnification surgical microscope or at least optical loupes.
2.1.11 Root resorption related risk factors
The endodontic management of root resorption was found to be frequently reported as a highly
complex and demanding procedure in the literature (Darcey and Qualtrough, 2013a, Fuss et al.,
2003, Ne et al., 1999). Good understanding of the resorption process, including its aetiology,
classification and the different management technique is paramount. The management of external
and internal resorptions were both reported to be more complex than the management of apical or
surface root resorption (Darcey and Qualtrough, 2013b). Diagnoses, assessing the extent of
resorption (usually requiring the prescription of CBCT), debriding, shaping, cleaning and obturating
the resorption defect are all reported to be challenging and resulting in higher risks of adverse
outcomes (Darcey and Qualtrough, 2016).
In addition to internal and external root resorption, apical surface root resorption may cause enough
tooth surface loss to result in the loss of the apical constriction resulting in an open apex
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(Shabahang, 2013). The management of those cases usually require an apexification procedure,
either conventional or through the use of bioceramic or MTA type apical plug which in turn is best
done under magnification by an experienced clinician.
2.1.12 History of dentoalveolar trauma
Generally, endodontic cases with a history of dental trauma were reported to be more complex and
more challenging to manage due to the higher risk of pulp canal obliteration and root resorption
associated with those cases (Moule and Moule, 2007, Ravn, 1982, Zaleckiene et al., 2014). In
addition, teeth with overt history of root fracture present even higher challenge due to the difficulty
ensuring straight canal negotiating and achieving good obturation. The following types of dental
trauma were reported to affect the complexity of endodontic treatment; concussion and subluxation
(de Cleen, 2002) due to relative risk of pulp canal obliteration and resorption, root fracture, due to
negotiation and obturation challenges (Turgut et al., 2004), complicated crown fracture of mature
teeth which may benefit from vital pulp therapy (Andreasen et al., 2002), complicated crown
fracture of immature teeth which may require vital pulp therapy or apexification (Beslot-Neveu et
al., 2011), avulsion or severe luxation due high risk of root resorption (Rosenblatt, 2010).
Teeth with previous history of trauma are therefore at higher risk of encountering complexity during
the course of their treatment or resulting in adverse long term outcomes.
2.1.13 Periodontics-Endodontics related risk factors
Periodontal-endodontic lesions present challenges to the clinician regarding diagnosis, treatment
planning and prognosis (Rotstein, 2017, Chapple and Lumley, 1999). Aetiological factors including
bacteria and viruses, alongside contributing factors, such as root resorptions, trauma, cracks,
perforations and dental developmental abnormalities all results in a more complex treatment.
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Treatment and prognosis of periodontal-endodontic lesions vary, depending on the correct
diagnosis, aetiology and pathogenesis of each specific condition. The factors most associated with
complexity are true periodontal-endodontic lesions (Simon et al., 1972), tooth mobility (Rotstein and
Simon, 2004), fenestrations or dehiscence and root resection or hemi-section expected or already
completed (Schmidt et al., 2014, Vakalis et al., 2005). The presence of those factors is reported to
lower the chance of successful outcome and to be more challenging to manage.
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2.2 Prevalence of complex endodontic cases and influencing factors
There are several cross-sectional studies describing the prevalence of periapical radiolucency in the
population, a surrogate of necrotic pulp disease. In addition, there are other studies looking into the
prevalence of root canal treatment within the population. Owing however to the level of complexity
being a subjective issue, there does not appear to be any attempt to identify the prevalence of
complex treatment or the reasons behind such complexity.
A cross-sectional study completed in the UK (Saunders et al., 1997) looking into the prevalence of
periapical radiolucency examined full-mouth periapical radiographs from 340 consecutive adult
patients attending two Scottish Dental Hospitals for regular examination. The results showed 54% of
the patient sample had received at least one RCT. When related to the teeth sample, around 5.6% of
the overall examined teeth radiographically had endodontic treatment, and of these, 58.1% had
radiographic signs of periapical disease. Understandably, the authors did not attempt to comment
on the difficulty range of endodontic treatment on these teeth as this would require pre-knowledge
of the status of teeth involved and clinical data. The methodology of this study however may be
particularly relevant to this research. Despite most prevalence studies reporting a sample size with
large number of teeth included, ranging from 1600 teeth and up to 30,000 teeth, the number of
patients sample size is in reality much lower ranging from as little as 70 patients and averaging
around 200-300 patients (Pak et al., 2012).
An attempt to determine the most common endodontic complexities encountered by GDPs in South
Korea was made through a study of referral reasons to endodontic practices (Kim, 2014). This
observational study was conducted to investigate the prevalence of different primary reasons for
endodontic referrals and the clinical symptoms of the referred cases over a period of 2 years. The
study outcome focused more on the symptoms of failed root canal treatment rather than the
technical reasons behind the referrals. It was found that the most common referral reasons were
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persistent pain and presence of a sinus tract following primary RCT. The most common clinical
reasons were found to be canal calcification, broken instruments and posts.
This gap in the knowledge of complexity prevalence within the literature indicated the need for
research to provide the data, which may be used in several applications to deduce the level of need
for endodontic training and commissioning within the health system.
It is evident that in order to collect such information, there needs to be a way of identifying the
relevant complexities first then classifying them, and then a mechanism to gather the information
from the population.
Approaching epidemiological and prevalence studies electronically has been reported to be the
preferred way in the future in epidemiological studies. Several studies have discussed the potential
benefits and disadvantages of web-based surveys and the ongoing developments in the area (van
Gelder et al., 2010). Conventional methods to gather information from study subjects, including
face-to-face, traditional paper and-pencil format questionnaires and telephone interviews are
increasingly failing to generate high-standard qualitative results within the financial parameters
given. Web-based surveys are now frequently used in marketing research and psychological studies,
but their use in epidemiological studies was merely 1% in 2007 (Ekman and Litton, 2007).
There have been a few examples of successful studies conducted using the electronic surveys
approach and are already available, including Danish Web-based Pregnancy Planning Study
(Mikkelsen et al., 2009), the Millennium Cohort Study (Smith et al., 2007) and the Nurses and
Midwives e-Cohort Study (Turner et al., 2009). Those studies succeeded to collect a large sample
number through electronic surveys with meaningful results.
Electronic surveys are becoming increasingly more attractive with the advancement of information
technology and the availability of electronic devices (Dillman and Smyth, 2007). Pop-up windows
combined with visual and audio aids providing additional information may be added to clarify
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responding in those surveys, which would have been much more difficult to implement in paper-
format questionnaires. Electronic surveys can be programmed to automatically analyse and present
the data in a much more user-friendly format. However, the issues with web-based epidemiological
studies usually concern practicality and data safety. A study looking into those issues concluded that
many of those problems related to the use of web-based questionnaires have been solved, but each
case needs to be approached individually (van Gelder et al., 2010). One of the most important
factors to consider is the design of the questionnaire, its practicality and ease of use.
Electronic epidemiological studies could potentially be considered a complementary alternative
mode in the methods of data collection. Further studies and comparisons with the conventional
survey techniques should reveal whether they can fulfil these expectations.
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2.3 Digitalisation of assessment tools
The use of risk assessment tools is not a new concept to the medical field. However, more recently,
the development of a more convenient, time efficient digital forms to simplify their use has been
documented across numerous specialities in healthcare. Aside from the efficiency and the simplicity
advantages of digitalising the assessment tools, there are significant other benefits for adopting a
“paperless” approach to all forms of documentation within the healthcare system. In 2013, the UK
Health Secretary Jeremy Hunt reported in an official statement the NHS should go paperless by 2018
in order to generate vast savings for the NHS.
The report on NHS services in England (Steele et al., 2009) itself also made recommendation for all
general dental practices to use electronic records and adopt a paperless structure in order to
improve the quality of patient records and save valuable time which can then be spent on patients
care.
An official government document was also published by the Department of Health and on GOV.UK
reporting on a study by Price Waterhouse Coopers reviewing the potential benefits of better use of
information technology (Price Waterhouse Coopers, 2013). The study found that measures such as
more use of electronic prescribing, text messages for insignificant test results and electronic patient
records could save in the order of £4.4 million per annum of NHS money and even more in the long
term. It would also facilitate improved care, allowing healthcare personnel to spend more time with
patients. The health secretary report suggested a roadmap detailing several targets. This included
the adoption of paperless referrals, sending an email rather than a letter when referring a patient to
the hospital.
The report itself highlighted a few small trials of interest to this research. In an attempt to increase
their clinical effectiveness, the Royal Liverpool and Broadgreen Hospitals Trust trialled a
computerised paperless system on its dermatology and haematology departments. This meant that
professionals could see letters from clinics, GP referrals, test orders and radiographs on a computer
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system. They found that the process could help saving 30 minutes in a three and a half to four hour
clinical session. In addition, the Royal National Orthopaedic Hospital conducted a trial of a system
that asks patients with spinal surgery to record their progress using an iPad or an online system after
being discharged. This freed up around 300 new outpatient appointment slots per consultant per
year. Around 95% of participants preferred the new online process to the traditional paper format
method. The benefits also include the financial and environmental cost savings on not using wood
papers or ink (Davis, 2013).
In view of the above recommendations, the concept of converting existing endodontic difficulty or
complexity assessment tools into a digital format becomes a matter of natural and logical evolution.
It can be speculated that non-computerised forms would slowly grow out favour and their use will
become more alienated on the long term. Creating an electronic version may revive these tools and
keep their advantages and benefits within clinicians’ reach.
In 2011, a group of young Australian researchers worked together on developing a Computerised
Antithrombotic Risk Assessment Tool (CARAT) to optimise the therapy of atrial fibrillation (Bajorek et
al., 2012). The tool was developed on previously trialled algorithms involving multidisciplinary
feedback. The authors created an item of computer software then made it available to clinicians to
apply it to the management of patient cases and evaluated the software usability. There was an
overall 94% satisfaction reported among the hospital-based clinicians who trailed it, and 85%
reporting the usefulness of the software.
Another use of computerised analysis was reported in the assessment of digital clubbing (Finger nail
clubbing) in medical patients in Switzerland (Husarik et al., 2002). The authors developed a
computerised assessment form and combined it with digital photography to help overcome the
limitation of subjective clinical assessment. The overall outcome showed the use of computerised
analysis to be an easy, fast and inexpensive method for quantifying the condition with good intra
and inter observer reliability. It was concluded that the tool may be useful in further cross-sectional
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or longitudinal studies of finger morphology and exploited it may become an accepted standard in
the diagnosis of digital clubbing.
On the flip side, challenges have been reported when attempting to convert surgical assessment
tools to an electronic version. A recent Canadian study (Dudek et al., 2015) sought to convert a
paper-format assessment tool, the Ottawa Surgical Competency Operating Room Evaluation, to a
computerised version for use in three surgical specialties. Nonetheless, as the research progressed,
the focus of the study had to be altered as it became necessary to explore the issues of transitioning
to a paperless assessment tool rather than reliability. This finding was unexpected as theoretically an
electronic tool should reduce the time taken not the reverse.
The study above highlights important findings. It is important to understand that users require the
tool to be at least as convenient as its counterpart paper version. Transitioning from a paper-format
assessment tool to a computerised one is not necessarily a natural intuitive process. Careful
consideration of potential barriers and taking a step back to solve these barriers is essential to
achieve the many benefits of electronic assessments mentioned in earlier literature.
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2.4 Conclusion
Following the literature research findings presented earlier, the current limitations of the existing
assessment tools appear to be the intricacy and the lack of clarity of the contents, in addition to the
length of time it takes to fill them and then add the sum up. An advance is thought to be to attempt
simplifying those forms or their presentation into a more user-friendly interface and reduce the
amount of time required to complete them where possible.
Conducting a wide literature review of the existing evidence reporting on the factors that may affect
endodontic treatment complexity proved to be a highly time consuming process. Despite few factors
having clear and direct literature links, the majority of the factors evaluated had fewer and lower
quality evidence demonstrated by indirect findings of a larger study, case reports, textbooks and
narrative publications. Due to the wide range of factors involved, it is unlikely this gap in literature
would be filled anytime soon. Aside from complexity being a subjective matter, the perceived
benefit of conducting research purely to assess the level of complexity of each factor does not justify
the cost required to organise the study. Further analysis to evaluate the tools clinical relevance and
external validity may be more beneficial. Adjustment can subsequently be made to fine-tune the
relative complexity of each factor.
Academically, the undergraduate competency guidelines by the ADEE and ESE both referred to the
newly qualified European dentist as being competent in the management of those 'uncomplicated'
non-surgical root canal cases, yet neither guidelines clearly define what is actually meant by
uncomplicated. This results in a wide variation in the standards of qualifying dentists due to different
interpretation of the term. Utilising the results of the literature review above, combined with the
studies conducted in chapter 3 and 4, this thesis will discuss the exact definition of the word in more
details in chapter 5 of this document (5.2).
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Another substantial gap in the knowledge identified was the lack of any good quality research
attempting to validate the existing endodontic complexity assessment forms and tools. Having a
more validated tool may give better credibility to them and may attract more users to utilise them.
From a public health point of view, there is a lack of studies conducted to determine the prevalence of
complex endodontic cases and the factors leading to their encounter. It is therefore difficult to
evaluate the accessibility of endodontic service available and the level of training required within the
health system.
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2.5 Research Aims
Based on the previous findings, the aims of this research were set to be the following
• To develop a novel, more predictable and evidence based complexity assessment tool utilising
the digital advancements
• To evaluate the reliability, validity and practicality of the new tool in comparison to the existing
literature
• To provide a more objective definition of the term “uncomplicated” root canal treatment as
described by the ESE an ADEE undergraduate curriculum guidelines for Endodontology
• To assess the prevalence of complex root canal treatments in general dental practice in the UK
and identify the prevalence and distribution of the specific factors leading to this complexity
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CHAPTER 3 : THE DEVELOPMENT OF THE ENDODONTIC COMPLEXITY
ASSESSMENT TOOL (E-CAT)
3.1 Introduction and Aims
Assessing endodontic complexity is often seen as a subjective, clinician-dependant and widely
variable area. The development of a tool to aid making this process more standardised, more
accurate and less subjective is therefore desired to help clinicians identify more complex cases and
determine whether to refer or treat (Dietz and Dietz, 1992). Rosenburg and Goodis had highlighted
the issues associated with developing an assessment form with the UCSF Endodontic Case Selection
Form in 1992 . These were further emphasised when the Canadian Endodontists and the AAE
created the Case Difficulty Assessment Forms to assist clinicians in determining the complexity of
cases. Ree el al in 2003 demonstrated that the use of a systematic means of assessing endodontic
cases was helpful when assessing case complexity.
As can be seen in the previous chapters, several endodontic assessment tools have been formulated by
different bodies and institutions to enable dentists to classify the complexity of non-surgical root canal
treatments. The main tools reported were the Canadian Academy of Endodontics cases assessment
form, AAE assessment form, the Dutch endodontic treatment index and endodontic treatment
classification in addition to the restorative index of treatment need RIOTN. Most assessment forms
are designed provide a more systematic approach to assessing endodontic treatments.
The overall outcome of the literature review commended the comprehensiveness of the Canadian,
AAE and the ETC in covering the aspects required to be assessed prior to determining endodontic
complexity. On the other hand, criticism was reported regarding the shortfalls of the RCS RIOTN and
the short Dutch DETI being too brief. There was no methodological literature reviews reported to
scientifically support the criteria included in any of the existing tools. There appears to be several
research articles reporting on the usefulness of the assessment tools, but a recurrent theme in most of
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those appears to report the little research looking into evidence behind the production process, in
addition to the reliability and validity of those tools and the criteria determining the level of
complexity.
An outcome of the literature review found the most criticised areas of the existing endodontic
assessment tools is the arbitrary allocation of risk or hazard points to relevant endodontic criteria
with the lack of scientific basis behind it.
For example, the widely used AAE classification divides complexities into three difficulty levels,
minimal, moderate and high. The clinician is advised to review the form following “ticking” the
relevant boxes of the criteria and using self-judgement to assess the difficulty level. One high
difficulty category selection pushes the case difficulty to high complex. The Dutch ETC gives the
value of 1, 2 and 5 points for moderate, high and very high risk criteria. The AAE “educator guide”
uses similar values. However, the current literature does not provide scientifically supported
justification behind giving any of the criteria these values or what value they should add up to prior
to a certain level of complexity being attached to a case.
In order to utilise the information gathered from the literature review and adopt a more scientific
methodology to assigning value to each complexity criteria, an iterative development approach was
implemented.
Iterative development (from Latin iterare ‘to repeat’) is a combination of both iterative design and
incremental build-up model for software development. This well-established approach is widely
used in software development (Larman and Basili, 2003).
In 2009, (Srivastava and Hopwood, 2009) described a framework in which qualitative data, which in
this instance is the reported endodontic complexities in the literature, can be related into more
quantitative data (complexity score, in points) using iterative analysis. The process essentially
involves developing a system through repeated cycles (iterative) and in smaller increments at a time
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(incremental), allowing the software to take advantage of what was learned during development of
earlier cycles of the system. Knowledge comes from both the development process and the
application of the tool, where possible key steps in the process start with a simple implementation
of a subset of the software requirements and iteratively enhance the evolving versions until the full
functional system is implemented. Following each iteration, complexity value modifications were
made and new values added as necessary. The relationship between iterations and the increments is
an integral part of the overall software development process. The exact value and nature of the
increments are specific to each complexity criteria.
Consequently, the aim of this part of the research was the development of an interactive digital tool
utilising reported evidence from the literature as reviewed in the chapter 2 earlier. The tool is aimed
to help clinicians to assess the endodontic complexity of the non-surgical root canal therapy case
they are intending to treat; hence given the title of the Endodontic Complexity Assessment Tool (E-
CAT). The objective here was to take into account the positive aspects of the multiple existing tools
and incorporate them into a new single product, in addition to applying improvements and new
features to address and overcome the drawbacks. In summary, the aim is to establish a tool which is
developed utilising an evidence-based approach and ideally needs to be evaluated for its reliability
and internal and external validity.
The new tool ideally should overcome the drawbacks of the existing tools, being less-intuitive to use
and time consuming. As could be seen from the literature review, when done correctly, digitalising
assessment tools proved to provide positive, more practical user interface and can help increasing its
efficiency by reducing the overall time required for the assessment.
The research hypothesis was therefore set as “it is possible to develop a digital tool to predictably
and reliably identify complex endodontic cases similar to that identified by a group of Endodontist
Specialists”. The null hypothesis was the development of such tool is not possible.
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3.2 Methodology
3.2.1 Complexity Criteria
A comprehensive literature search was conducted to identify the complexities that can be
encountered in endodontic treatment. The MEDLINE (OVID) database, (PUBMED) database, the
EMBASE database, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Web of
Knowledge, Google-Scholar databases, and peer-reviewed published text-books were electronically
searched for available data. Databases were searched from 1945 up to and including October 2017,
using different combinations of the key words in the table below. English and English-translated
publications were included.
Search keywords
 Endodontics
 Complexity, complex, complicated, complication, uncomplicated
 Difficult, difficulty, challenges
 Root canal treatment, retreatment
 Root canal therapy
 Risk assessment, evaluation, valuation, determination
 Non-surgical endodontics, surgical endodontics
The outcomes of this search are reported in the results section of this chapter.
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3.2.2 Iterative development
In this study, a wide range of endodontic cases consisting of 75 pre-assessed real-life clinical cases
classified by the researcher and a supervising clinician (Speciality Registrar in Endodontics and GDC
registered Specialist Endodontist) were used to calibrate the tool and assigns numerical value to
each complexity criteria mentioned above. When disagreement was found, a third specialist in
endodontics was consulted and agreement was achieved. All 75 cases were given a complexity class
of 1, 2 or 3 (uncomplicated, moderately and highly complicated) following to the completion of
treatment. These were treated in a hospital setting. Initially, the arbitrary score of 1, 2 and 5 were
given each selected criteria according to its documented complexity (E-CAT ver 2.0). The range for
the classes was set to
 less than <20 for uncomplicated cases,
 20-25 for moderately complicated and;
 >25 for highly complicated cases.
Those figures were based on similar tools available in the literature such as the AAE and the Dutch
forms.
Each cycle started in the same order of the 75 cases. When a case was found not to fit the clinical
outcome, adjustment to the relevant complexity factor value was made. The case was tested and re-
tested to ensure it fits to the new corrected values. Then the iterative cycle started again from the
first case to ensure the rest of the cases still follow the perfect fit model.
The first cycle or the iterative analysis started with the arbitrary values of 1, 2 and 5 as suggested by
the previous tools. The range of values was changed from 0-10 to allow more flexible iterations.
Repeated cycles were then applied to each of the 75 cases over and over until a fitting model was
produced. This meant if the tool was used correctly to assess any of the 75 cases, it would result in
an outcome matching to that encountered clinically. The number of cycles required and the
outcomes of this analysis will be presented in the results section.
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3.2.3 Software development
The review of the literature reported one of the significant drawbacks of the existing assessment
forms to be time-consuming and less user-friendly. As discussed earlier, building a novel and smart
software for an online digital tool was the proposed approach in this study.
The software was developed over two phases. The first phase was completed in collaboration with
an MSc computer studies student at The University of Liverpool as part of his MSc project. This was
done with simple HTML coding and implemented onto the following website
http://cgi.csc.liv.ac.uk/~m4ll
This first prototype E-CAT (Version 1.0) simply aimed to digitise the Dutch paper forms presented by
(Ree et al., 2003a) into a user friendly online form which automatically adds up the complexity
criteria in the background and generates the answer. The time saving feature was intended to be the
automatic sum up and the addition of photo illustration to relevant questions.
Snapshots of this version can be seen in the figures 1 below.
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Figure ‎3-1 showing introduction page as developed for the E-CAT version 1.0. This included a series of 15 questions to
tick. If none of those are selected at all, the case is automatically considered uncomplicated.
Figure ‎3-2 showing individual question page as developed for the E-CAT version 1.0. Each page contained the question
alongside demonstrations of the question criteria
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Figure ‎3-3 showing the summary page in E-CAT version 1.0, all questions were required to be answered and all
information was shown in the summary page.
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This version was piloted with 5 dentists to assess 5 cases each. The aim was to evaluate the time it
takes for the dentist to assess the cases and gather open feedback from each participant. The results
of the pilot study are reported in table ‎3-1.
Case number Average time taken (Minutes) Case type
1 03:57 Uncomplicated UR1 RCT

2 04:24 Uncomplicated LR6 RCT
3 04:05 Uncomplicated UR2 ReRCT
4 04:45 Complicated UR6 RCT
5 05:11 Complicated UR4 ReRCT
Mean 04:31 (±34s)
Table ‎3-1 showing the pilot study results utilising E-CAT version 1.0. The overall average time require for each case was
4:31 minutes.
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The compiled feedback from participating dentists is summarised in table 3-2 below
Complied feedback
Commendation
o Automatically adds points to arrive assessment (5)
o Allowed reproducible frame-work (3)
o Illustration help grasping the subject (2)
o Good to have summary page (2)
o Would use again but requires improvement (3)
Criticism
o Poor user-interface (5)
o Too lengthy, takes too long (5)
o Several irrelevant questions (4)
o Would not use again, prefer using paper format! (2)
Table ‎3-2 showing the compiled feedback from the dentists using E-CAT version 1.0, all participants commented
positively on the concept, but reported negatively on the length and the user interface.
The pilot study and (E-CAT version 1.0) demonstrated a proof of concept that simply converting the
existing forms (e.g. AAE or ETC Dutch system) onto an online or digital tool without further
modification does not provide a practical solution to the time-consumption issue. The existing paper
forms aim to be comprehensive through including criteria and questions to address previous root
canal treatment, trauma, patient factors etc. These may not be relevant to cases which do not have
those complications e.g. primary endodontic treatment. Reading, answering and adding up those
values can add unnecessary time to the process.
The new E-CAT version 2.0 was subsequently developed with the help of two qualified computer
programmers. This version contained novel approach to the filtering and surveying questions as
deduced from the literature review done in this research, and was not a direct adaptation of the AAE
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or the Dutch existing tools as it was in version 1.0. The feedback obtained from the pilot study was
taken into account to produce an even more user friendly and less time consuming tool. The
language used was PHP MySQL. The idea is for the tool to be available for use across most platforms
through a web-based page. Clinicians should be able to access this from desktop computers, laptops
or other portable mobile devices.
The tool can be accessed through the following web address:
www.e-cat.uk
A smart filtering mechanism was proposed in order to filter out any irrelevant questions to the case
being assessed. The concept was set to have a first page which has a set of surveying questions to
help filtering the relevant questions to be asked. This approach is similar to the DETI simple system
of determining whether the use of the Endodontic Treatment Classification (ETC) is required (Ree et
al., 2003a). Each option selected will only trigger the relevant questions to ask in order to streamline
the process and save time on irrelevant questions.
For example, if the endodontic case being assessed was a de novo treatment, all the questions
related to root canal retreatment or iatrogenic damage would not be relevant. This makes an
obvious opportunity to cut down the number of questions and save on the time of reading and
answering them. This method of decluttering is an attempt to simplify the tool without
compromising on any other endodontic cases where the questions could be relevant.
Iterative development was used again here in order to ensure the correct filtering mechanism is
implemented. The filtering questions were tested several times until a perfect model was achieved.
Example of filtering charts can be found in the appendix.
This was implemented through a brief screening page placed prior to the complexity assessment
details. The default answer to the screening questions was set as “no” so the user does not need to
actively interact prior to going to the next page unless modification is required. When the user
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selects yes to any of the screening questions, the relevant complexity criteria will be included on
their assessment form.
If the user did not answer yes to any of the screening questions, only the universal questions such as
tooth position, canal visibility, root curvature and form would get asked universally, rendering the
time required for straightforward cases to be very short.
Each option will carry a certain number of points determined through the iterative development
process; the software will be programmed to automatically and efficiently add up those points and
come up with an answer to the dentist of how difficult the root canal treatment is expected to be.
Once all questions are answered, a summary page is displayed at the end, stating the level of
complexity of the case and flagging out in red, amber and whites the factors that have led to that
classification. The clinician or the user will also be able to generate and print out a summary report
of the case which may be used for referral or patient information purposes.
In summary, in order for the tool to maintain a user-friendly and time efficient interface, the tool
was designed into three parts. The first part of the tool contained simple “yes or no” screening
questions, following which question filtering mechanism took place. The answers to the screening
part will determine the questions appearing on the second part; the surveying questions. Once the
user completes their answer to the relevant questions, they are taken to a summary page displaying
the classification alongside highlighted complexities if present.
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Screen shots of the model can be seen in figures 3-4 to 3-7 below.
Figure ‎3-4 showing the simple welcome page of version of E-CAT version 2.0
Figure ‎3-5 showing the screening page of version of E-CAT version 2.0 containing 12 keywords and simple yes or no
questions, with the ability to show more information if hovered over the (i) icon.
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Figure ‎3-6 showing the surveying page of version of E-CAT version 2.0 only the relevant questions to the case as
determined from the filtering page, with the ability to show more information if hovered over the (i) icon.
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Figure ‎3-7 showing the summary page of version of E-CAT version 2.0, containing only the relevant information to the
case, with colour highlighted risk factors. Factors having moderate risk of complications are highlighted in amber, whilst
those posing a higher risk are in dense orange.
3.2.4 Validity study
A panel of three endodontic experts (GDC registered Specialists in Endodontics) was assembled. The
panel was provided with 15 anonymised clinical cases with radiographs and pre-treatment clinical
information providing the details required to make a pre-treatment judgment on the complexity of
the case. Members of the panel were sat together and asked to agree on the complexity of each
case with a numerical score of 1, 2 or 3 according to its complexity. The levels were defined as their
own judgment of uncomplicated, moderately complicated, and highly complicated respectively.
Where members of the panel disagreed on its complexity level, a discussion between them was held
until a consensus was achieved.
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Those same 15 cases were then analysed using E-CAT version 2.0 with independent inputting
(independent calibrated Speciality Registrar in Endodontics) of the clinical information provided into
the tool. The results of the panel consensus (class 1, 2 or 3) and the E-CAT classification outcome (1,2
or 3) were recorded on Microsoft Excel spreadsheet (MS Excel 2016, Version 14.0) assessed and the
inter-rater kappa utilising Statistical Package for Social Sciences (SPSS) software (version 25, SPSS,
Inc., Chicago, IL, USA) correlation results were recorded as shown in the results section.
3.2.5 Reliability
A study was designed to assess the inter-rater and intra-rater reliability of the tool. A total of 15
general dental practitioners were recruited through an advert at the University of Liverpool. They
were provided with a short tutorial of how to use the tool and allowed the opportunity of assessing
3 independent cases prior to starting the study. Each participant was provided with 15 anonymised
clinical cases with radiographs and pre-treatment details required to make a pre-treatment
judgment on the complexity of the case. They were then asked to use the E-CAT Version 2.0 tool
independently through inputting the clinical information provided with each of the 15 clinical
scenarios. All participants were provided with digital radiographs on similar computer screens and
the same lighting conditions (HP Probook Laptop 13.3 inch screen). The participants were blinded to
the outcome of each case.
The following outcomes were observed and recorded on Microsoft Excel spreadsheet (MS Excel
2016, Version 14.0); the E-CAT class (1, 2 or 3), the time taken for the assessment of each case
(seconds), E-CAT score (value in points), criteria selected and the participants own judgement of the
case complexity (1, 2 or 3). The users were also asked to rate their experience on how they found
the use of the tool on a 0-10 Visual Analogue Scale (VAS), where 0 is very simple and 10 is very
difficult.
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In order to assess the intra-rater reliability of the tool, the exact same study with the same 15
participants and 15 cases was repeated under the same conditions 9 months after the initial study.
The data were recorded and analysed in Statistical Package for Social Sciences (SPSS) software
(version 25, SPSS, Inc., Chicago, IL, USA) to each rater as shown in the results section.
3.2.6 External Validity
A panel of 35 independent “experts” in the field of endodontics were recruited. All participants had
to be GDC registered endodontic specialists and still practicing endodontics on regular basis.
Members were recruited through direct invitation to randomly selected 100 GDC registered
specialists (email or post) and direct contact at a regional endodontic scientific meeting in the UK.
Similar to the internal validation process, each specialist was again provided with anonymised
clinical cases with radiographs and pre-treatment clinical details. Members of the panel were asked
to independently assess the complexity of each case with a numerical score of 1, 2 or 3 according to
its complexity. The levels were defined as the expert’s own judgment of uncomplicated, moderately
complicated, and highly complicated respectively.
The results for each panel member and each case was collected and recorded individually on
Microsoft Excel spreadsheet (MS Excel 2016, Version 14.0). The inter-rater correlation of each case
was calculated and the consensus was assessed by calculating the mode and the weighted kappa for
each case.
The validity of the tool was then re-assessed by calculating inter-rater agreement utilising SPSS
software (version 25, SPSS, Inc., Chicago, IL, USA) between the 35 members’ panel consensus and
the independent outcome recoded by using the tool to assess the same cases.
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3.3 Results
Following a literature review of the existing tools, a decision was made to produce a web-based
digital tool with HTML coded application. HTML was found to be the most diverse language which
can be used across different platforms (Microsoft OS or Mac OS) and mobile devices (Mac iOS and
Android). It is also the programming language familiar to most computer programmers. The web
domain of www.e-cat.uk was purchased and dedicated as the web address for the tool.
3.3.1 Complexity Criteria
Following a wide search of the reported endodontic complexities, numerous complexity factors were
determined. The following assessment criteria shown in table 3-3 were most commonly reported
and were therefore included on the E-CAT assessment form. These were all discussed in details
within section 2.1 of the previous chapter.
Results of literature search on endodontic criteria affecting endodontic treatment complexity

1. Complex diagnosis
2. Pre-treatment prior to commencement
3. Radiographic difficulties
4. Medical history, anaesthesia and patient management
5. History of trauma
6. Physical and psychological limitations
7. Mouth opening
8. The position of the tooth
9. Inclination and rotation of tooth
10. Crown morphology and presence of extra-coronal restoration (crown or onlay)
11. Access to root canal system
12. Root curvature
13. Root canal morphology
14. Apical morphology
15. Canal radiographic visibility
16. Previous endodontic treatment
17. Iatrogenic incidents
18. Root resorption
19. Perioendo (Periodontic-Endodontic) lesion involvement
Table ‎3-3 Results of literature search on endodontic criteria affecting endodontic treatment complexity. A total of 19
categories were identified to be associated with the risk of encountering complexity or adverse outcomes.
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The following two criteria were encountered on the search but were not included on the E-CAT form
 Shape form of the canal (e.g. I shape, J shape)
 Presence and size of periapical pathology
 Canal subdivision in middle or apical third
The presence of S-shape canal was incorporated into root formation as universal question. The
reasons for not including them will be further discussed in the discussion section later.
Each criterion was further researched and sub-divided into different level of complexities as
determined by the relevant literature. A total number of 22 surveying questions were decided.
These are presented in the table 3-4 below.
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Surveying questions for endodontic complexity assessment of non-surgical root canal treatment
1. What is the position of the tooth?
 Anterior or Premolar
 1st or 2nd Molar
 3rd Molar
2. Root curvature
 Small or no curvature (< 15°)
 Moderate curvature (15 - 40°)
 Severe curvature (> 40°)
 Extremely severe curvature (> 60°)
3. Apical morphology
 Closed (fully formed) apex
 Open apex (> size 60 k-file)
 Open apex with history of failed surgical retrograde root end fill
4. Canal radiographic visibility (Multiple Answers Possible)

 Large pulp chamber and clearly visible canals to apex
 Reduced pulp chamber volume , narrow yet visible canal space to apex
 Indistinct pulp chamber or canal space in part or throughout
 Completely invisible canal in part or throughout
5. Root canal system morphology (Multiple Answers Possible)

 No known complication in canal morphology
 Pulp stones present
 S shape canal
 C shape or ribbon shape root canal system (this can only be assessed clinically or with CBCT)
6. Inclination of tooth (degree of tooth tilt)

 No/small inclination (< 10°)
 Moderate inclination (10 - 40°)
 Extreme inclination (> 40°)
7. Rotation of tooth
 No/mild rotation (< 10°)
 Moderate rotation (10 - 40°)
 Extreme rotation (> 40°)
8. Crown Morphology
 No known developmental abnormality
 Taurodontism or microdontism
 Dens invaginatus or Fusion
 Dentinogenesis imperfecta
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9. Pre-treatment prior to commencement
 No pre-treatment required for isolation
 Simple pre-treatment required for isolation (e.g. supra-gingival caries)
 Extensive pre-treatment required for isolation (e.g. sub-gingival caries, margin elevation)
 Removal of crown or bridge prior to treatment
10. Access to root canal system

 Direct (plastic) restoration but clear crown morphology
 Direct (plastic) restoration masking crown morphology
 Amalgam build up in pulp chamber without post or crown
 Composite core build-up in pulp chamber without post or crown
11. Root Canal Morphology

 Anterior tooth or premolar with one canal
 Anterior tooth or lower premolar with 2 canals
 Premolar with 3 canals
 Very long tooth (> 30mm)
 Molar with ≤ 3 canals
 Molar with ≥ 4 canals
12. Previous endodontic treatment

 Previously initiated but not obturated, endodontic treatment
 Canal(s) obturated with gutta-percha
 Canal (s) obturated with gutta-percha with >2mm overfill
 Canal(s) obturated with other materials (e.g. Silver cones, resin based filling, bioceramic material)
13. Root resorption

 Apical root resorption
 Internal root resorption
 External root resorption
14. Iatrogenic incidents (Multiple Answers Possible)

 No known incident
 Supra-osseous perforations
 Sub-osseous perforations
 Broken instrument
 Ledging
 Apical transportation
 Significantly misaligned previous endodontic access
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15. Medical history, anaesthesia and patient management (Multiple Answers Possible)
 No medical problem or well controlled MH - ASA Class II
 Diabetes (poorly controlled)
 Vasoconstrictor intolerance
 Complex MH ASA III or VI including Haemophilia
 IV bisphosphonate or had history of head and neck radiotherapy
 Allergy to anaesthesia
16. Mouth opening

 Normal mouth opening (>35mm)
 Reduced mouth opening (25-35mm)
 Extremely reduced mouth opening (<25mm)
17. Physical and Psychological limitations (Multiple Answers Possible)

 None
 Lack of cooperation/ nervous patient
 Extremely nervous – needs sedation
 Moderate Limited reclination
 Unable to recline
18. Radiographic difficulties (Multiple Answers Possible)

 Normal conditions
 Severe gag reflex
 Narrow or low palatal vault/High floor of mouth
 Hard to solve superimposed anatomical structures
19. Diagnosis
 Uncomplicated clear diagnosis
 Differential diagnosis of usual signs and symptoms possible, but adjacent teeth could be involved
 Confusing and complex signs of symptoms: difficult or unable to achieve clear diagnosis
20. History of trauma (Multiple Answers Possible)

 Unknown type of trauma in the past
 Uncomplicated crown fracture
 Root fracture in apical third
 Concussion
 Complicated crown root fracture of mature teeth
 Root fracture in middle third
 Subluxation /alveolar fracture
 Complicated crown root fracture of immature teeth
 Root fracture in cervical third
 Other luxations/avulsions
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21. Is there any Perioendo (Periodontic-Endodontic) lesion involvement (Multiple Answers Possible)
 Furcation involvement
 Perio-endo lesion
 Mobility, fenestrations or dehiscence
 Root resection or hemi-section expected or completed
22. Extra-coronal restoration

 Crown, bridge or onlay present but planned to be removed prior to commencing treatment
 Core build-up in pulp chamber
 Access required through crown or onlay
 Poorly adapted post
 Well adapted and firmly cemented post or cast post and core
Table ‎3-4 showing the complexity factors reported to be linked to the complexity of non-surgical root canal therapy
3.3.2 Iterative development
A total of 32 iterative cycles were conducted prior to achieving a perfectly fitting model for the 75
clinical cases as described in the methods section. The iterative cycles did not change the questions
being asked but rather the value and impact of each of those factors.
Following the first few cycles, it immediately became evident a wider range of values was required.
The range was changed to 0-10 E-CAT points for each factor depending on its complexity (E-CAT
version 2.1). The range of values for classification outcome also needed to change. The E-CAT total
score range for cases was changed to start from 0 for ultimate very low risk of complication case,
and as high up as 50 for the ultimate realistically encountered complex endodontic treatment. The
true maximum E-CAT score if all the complexities were to combine and occur in one case is 185
points. However, such a case is highly unrealistic or practically impossible to encounter.
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Table 3-5 below shows the model of classification which is a perfect fit to the iterative development.
Class score Terminology and significance
1 0-5 Uncomplicated; low risk of complexity and adverse outcomes
2 6-11 Moderately complicated; moderate risk of complexity and adverse outcomes
3 >11 Highly complicated; high risk of complexity and adverse outcomes
Table ‎3-5 showing the range of E-CAT score to describe the class of each case. An E-CAT score up to 5 was found to be of
relatively low risk of encountering complexity and is thought to be associated with relatively uncomplicated cases. A
score of 12 or above is found to have a high risk of complication and adverse outcome
Tables 3-6, 3-7 and 3-8 on the following 3 pages show the model of E-CAT score weighting for each
criterion and complexity factor which is a perfect fit to the iterative development stage.
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Question Surveying questions for endodontic complexity assessment of non-surgical root canal treatment E-CAT points
1 Diagnosis
 Uncomplicated clear diagnosis 0

 Other adjacent teeth could be involved. Requires simple further investigation. 1
 Confusing and complex signs of symptoms: difficult or unable to achieve clear diagnosis 10
2 Medical history, anaesthesia and patient management (Multiple Answers Possible)
 No medical problem or well controlled MH - ASA Class II 0

 Uncontrolled diabetes 1
 Vasoconstrictor intolerance 2
 Complex MH ASA III or VI including Haemophilia 10
 Patient is on IV bisphosphonate or had history of head and neck radiotherapy 6
 Allergy to anaesthesia 10
3 Pre-treatment prior to commencement

0
 Simple or no pre-treatment required for isolation (e.g. supra-gingival caries) 3
 Extensive pre-treatment required for isolation (e.g. sub-gingival caries, margin elevation) 10
 Surgical crown lengthening or orthodontic extrusion (existing margins are crestal level) 0
 Removal of crown or bridge prior to treatment
4 Access to root canal system

0
 Average size restoration. Routine access. 1
 Large plastic restoration masking crown morphology 1
 Amalgam build up in pulp chamber without post or crown 2
 Composite build up in pulp chamber – no crown placed
5 Extra-coronal restoration
2
 Crown, bridge or onlay present but planned to be removed prior to commencing treatment 2
 Composite core build-up in pulp chamber 4
 Access required through crown or onlay 4
 Poorly adapted post 8
 Well adapted and firmly cemented post/cast post and core
6
Previous endodontic treatment
2
 Previously initiated but not obturated, endodontic treatment 4
 Canal(s) sub-optimally obturated with gutta-percha 9
 Canal (s) well-obturated with gutta-percha or obturation is >2mm overfilled 10
 Canal(s) obturated with other materials (e.g. Silver cones, resin based filling, bioceramic material)
7 Iatrogenic incidents (Multiple Answers Possible)
 No known incident 0
 Supra-osseous perforations 4
 Sub-osseous perforations 10
 Coronally separated instrument or clinically visible 6
 Apically separated instrument or clinically not visible 10
 Overt ledge or apical transportation 10
 Significantly misaligned previous endodontic access 3
8 Inclination of tooth (degree of tooth tilt)

0
 No/small inclination (< 10°) 1
 Moderate inclination (10 - 40°) 4
 Extreme inclination (> 40°)
Table ‎3-6 showing breakdown of the E-CAT score associated with the risk of encountering complexity or adverse outcomes. A score of
zero represents low or no relative risk, 10 represents very high risk.
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9 . Rotation of tooth
 No/mild rotation (< 10°) 0

 Moderate rotation (10 - 40°) 1
 Extreme rotation (> 40°) 4
10 Crown Morphology
 No known developmental abnormality 0

 Taurodontism or microdontism 2
 Fusion or dens invaginatus 10
 Dentinogenesis imperfecta 10
11 Root Canal Morphology

 Anterior tooth or premolar with one canal 0
 Anterior tooth or lower premolar with 2 canals 6
 Premolar with 3 canals 8
 Very long tooth (estimated working length> 30mm) 5
 Molar with ≤ 3 canals 0
 Molar with ≥ 4 canals 4
12 . Root resorption
 Apical root resorption 2

 Internal root resorption 10
 External root resorption 10
13 Is there any Perioendo (Periodontic-Endodontic) lesion involvement (Multiple Answers Possible)
 Furcation involvement 1
 Perio-endo lesion 5
 Mobility/fenestrations/dehiscence 2
 Root resection/hemi-section expected or completed 10
14 Dental trauma (Multiple Answers Possible)
 Unknown type of trauma in the past 2

 Uncomplicated crown fracture 1
 Root fracture in apical, mid root or cervical 10
 Concussion or Subluxation 2
 Complicated crown root fracture of mature teeth 5
 Complicated crown root fracture of immature teeth 10
 Other luxations/avulsions 10
10
15 Mouth opening
 Normal mouth opening (>35mm) 0

 Reduced mouth opening (25-35mm) 2
 Extremely reduced mouth opening (<25mm) 6
16 Physical and Psychological limitations (Multiple Answers Possible)
 None 0
 Lack of cooperation or significantly nervous patient 2
 Patient requires sedation 6
 Moderate limited reclination 1
 Unable to recline 6
17 Radiographic difficulties (Multiple Answers Possible)
 Normal conditions 0
 Severe gag reflex 4
 Narrow or low palatal vault/High floor of mouth 1
 Hard to solve superimposed anatomical structures 6
outcomes. 0 represents low or no relative risk, 10 represents very high risk.
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18 What is the position of the tooth?
 Anterior or Premolar 0
 1st or 2nd Molar 2
 3rd Molar 6
19 Root curvature
 Small or no curvature (< 15°) 0

 Moderate curvature (15 - 40°) 1
 Severe curvature (> 40°) 4
 Extremely severe curvature (> 60°) 9
20 Apical morphology
 Closed (fully formed) apex 0

 Open apex (> size 60 k-file) 8
 Open apex with history of failed surgical retrograde root end fill 10
21 Canal radiographic visibility (Multiple Answers Possible)
 Clearly visible canals throughout 0

 Moderately reduced pulp chamber or canal space but still visible throughout 1
 Severely reduced or indistinctive canal space or pulp chamber in part or throughout 6
 Completely invisible canal in part or throughout 10
22 Root canal shape and pulp stones (Multiple Answers Possible)
 No known complication 0
 Pulp stones present 2
 S shape canal 6
 C shape or ribbon shape root canal system (this can only be assessed clinically or with CBCT) 7
outcomes. 0 represents low or no relative risk, 10 represents very high risk.
As previously anticipated, it can be seen from the tables that the level of details required for a
comprehensive complexity assessment form would result in a lengthy, time consuming and
mathematically demanding form. Iterative development cycles were used to develop the screening
questions. A total of 17 iterative cycles were required to develop a perfect fit model. Fourteen
questions were selected to be included on the screening section.
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Screening criterion Question Linked
questions
1 Complex Diagnosis Are there any confusing or complex signs or symptoms in diagnosing 1
this case?
2 Medical History Are there any medical history factors related to this treatment? 2
3 Pre-Treatment Does the tooth need any further treatment prior to commencing 3
endodontic treatment or allowing dental dam placement?
4 Direct Restorations Does the tooth have any form of direct dental restoration present? 4
5 Indirect Restorations or Posts Does the tooth currently have an existing crown/onlay or post 5
present?
6 Previous Endodontics Has this tooth had any previous Endodontic treatment (including 6,7
attempts to access canal or pulp extirpation)?
7 Tooth angulation Is the tooth particularly tilted or rotated? 8,9
8 Development factors Does the tooth have any developmental abnormality? 10
9 Complex morphology Is it known if the tooth has increased number of canals or root length? 11
10 Root resorption Does the tooth have any signs of root resorption? 12
11 Periodontics Are there any localised deep periodontal involvement? 13
12 Trauma Has the tooth had known history of dental trauma? 14
13 Patient factors Are there any patient related factors that could interfere with this 15,16
treatment?
14 Radiographs Are there any restrictions to taking or interpreting radiographs? 17
Table ‎3-9 showing the main key areas dictating the factors which could impose higher risk of encountering complexity
and the questioning required to be assessed should one those areas be involved in the case. For example, if the tooth
being assessed has only had previous endodontics and direct restorations, then only questions 4, 6 and 7 will be shown
on the surveying forms, in addition to the default questions of 18 to 22.
Question 18,19,20,21 and 22 of the surveying questions were found to be universal and can be
linked to any endodontic treatment regardless of the clinical history, they were therefore not linked
to any screening questions. If the user was not to select any “yes” answers from the screening page,
only those 5 would automatically show on the surveying page.
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3.3.3 Pilot Validation
The panel of three endodontic specialists assessed 15 digitally randomised cases independently. The
results of each panel member were recorded. Cases are attached in appendix 7.7. The panel
disagreed on a total of 3 cases out of the 15. A consensus was agreed following discussion on
reasoning. The cases were then assessed independently by the author using the latest E-CAT version
following the iterative development process. The results of this study are shown in table 3-10.
Case Observer Observer Observer Consensus E-CAT Consensus in

number 1 2 3 outcome agreement with
E-CAT
1 1 1 1 1 1 Yes
2 3 2 2 2 2 Yes
3 3 3 3 3 3 Yes
4 3 3 3 3 3 Yes
5 1 1 1 1 1 Yes
6 2 2 2 2 2 Yes
7 2 2 2 2 2 Yes
8 2 2 2 2 2 Yes
9 3 3 3 3 3 Yes
10 3 3 3 3 3 Yes
11 1 1 1 1 1 Yes
12 3 3 3 3 3 Yes
13 3 3 3 3 3 Yes
14 3 3 3 3 3 Yes
15 2 2 2 2 2 Yes
Table ‎3-10 showing the results of the pilot validation which involved a panel of three endodontists assessing 15 clinical
cases, and the results of the panel compared to the results reported by E-CAT.
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The radiographs of the three cases the panel disagreed on and achieved consensus, are in the table
below.
Case Discussion
One member of the panel felt the presence of

the crown and failed endodontic treatment
would significantly complicate case and rated it
3. However, following discussion the member
agreed due to the presence of suboptimal
obturation and if the crown was to be removed
or with the use of portable magnification, this
case complexity would not be “high”. The
member agreed to rate this as 2.
One member of the panel felt the severe

misalignment of the endodontic access in the
LR3 and the severity of canal reduction would
class this case as 3. Following discussion to state
there is no perforation, tooth is anterior and
canal is radiographically still visible, the rating
was lowered to 2.
One member of the panel felt the position of the

tooth being second molar (LR7) and moderately
reduced mouth opening would push this to class
3. The panel commented on the mouth opening
not being “severely” reduced but “moderately”
reduced, and no other significant complications
being present. The rating was agreed to be 2.
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3.3.4 Reliability
A total of 15 dentists were recruited to assess the reliability of the E-CAT. The mean age for the
dentists was 29.7 years, and mean number of years post qualification being 5.6 years. There were 9
male dentists and 6 female dentists. At the time of their inclusion, those were dentists with no
further formal qualifications in endodontics. The same 15 dentists repeated the same study 9
months later. The results of the first study are shown in table ‎3-13. The inter-rater kappa was
calculated to be (k= 0.75) for the first experiment.
Case Dentists Dentists Dentists Average E-CAT Agreement

number achieving achieving achieving Time taken outcome
outcome outcome outcome for
of Class 1 of Class 2 of Class 3 assessment
1 15 0 0 01:08 1 100%
2 2 13 0 01:28 2 86%
3 0 15 0 01:15 3 100%
4 0 2 13 01:57 3 86%
5 15 0 0 00:32 1 100%
6 0 13 2 02:33 2 86%
7 0 13 2 01:23 2 86%
8 2 13 0 01:20 2 86%
9 0 1 14 01:45 3 93%
10 0 3 12 01:13 3 80%
11 15 0 0 02:05 1 100%
12 0 1 14 02:10 3 93%
13 0 1 14 02:16 3 93%
14 0 0 15 01:38 3 100%
15 0 13 2 01:36 2 83%
Mean 01:37 SD±31s 91%
Table ‎3-11 Primary data of reliability study showing the results of 15 dentists using the E-CAT to assess 15 clinical cases.
The overall kappa for the first study was 0.75. The mean time taken to assess the cases was 97s with (SD±31s)
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The results of the repeated study are shown in table ‎3-12. The inter-rater kappa was calculated to be
(k= 0.80) for the second experiment.
Case Dentists Dentists Dentists Average E-CAT Interclass

number achieving achieving achieving Time taken outcome Coefficient
outcome outcome outcome for agreement
of Class 1 of Class 2 of Class 3 assessment
1 15 0 0 01:35 1 100%
2 0 14 1 01:55 2 93%
3 0 15 0 01:22 3 100%
4 0 2 13 01:55 3 86%
5 15 0 0 00:31 1 100%
6 0 13 2 02:25 2 86%
7 0 14 1 01:45 2 93%
8 2 13 0 01:37 2 86%
9 0 1 14 01:40 3 93%
10 0 2 13 00:32 3 86%
11 15 0 0 01:27 1 100%
12 0 1 14 00:55 3 93%
13 0 1 14 01:35 3 93%
14 0 0 15 01:30 3 100%
15 0 13 2 01:18 2 86%
Average 01:29 SD±32s 93%
Table ‎3-12 Repeated study data of reliability study 9 months later showing improved results of 15 dentists using the E-
CAT to assess the same 15 clinical cases. The overall kappa for this study was 0.8. The mean time taken to assess the
cases was 89s with (SD±32s)
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As can be seen, the participants failed to achieve perfect agreement on few cases. A summary of the
reasons are explained below.
Case Reasons
Variation due to selection of “optimal

obturation” for this case. Selection of apical
resorption or forgetting to add indirect
restoration.
Aside from open apex and previous endodontic

treatment, some dentist did not select history of
trauma, child cooperation level and reduced
mouth opening as related factors to assess here.
Some dentists selected “severely” reduced canal

space here as opposed to the majority selecting
moderately reduced. Selection of C-shape
instead of S-shape.
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One dentist selected completely invisible canal
space where another selected clearly visible
canal space. Another dentist selected
perforation as iatrogenic damage. One dentist
did not select significantly misaligned access.
Variation in not selecting history of previous

endodontic access, not assessing degree of tilt or
choosing severely reduced or indistinct canal
space over moderate reduction here.
Table ‎3-13 showing the cases which showed disagreement between the dentists and the reasons for the disagreement
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The dentists were also asked to rate their experience of ease of use of the tool on a scale of 0 (very
simple) to 10 (very difficult). The results for the intra-rater reliability and participant’s perception of
ease of use were as shown in table 3-14.
Dentists Intra-rater reliability Ease of use rating

Weighted kappa (CI 95%) (0 –simple, 10 difficult)
1 0.91 (0.75 -1) 1
2 0.91 (0.75 -1) 1
3 0.83 (0.61 -1) 2
4 0.73 (0.47 -1) 3
5 1 1
6 1 0
7 0.91 (0.75 -1) 4
8 0.91 (0.75 -1) 3
9 1 2
10 0.83 (0.61 -1) 2
11 1 1
12 0.83 3
13 0.91 (0.75 -1) 2
14 1 1
15 0.83 (0.61 -1) 4
Mean 0.90 (0.74-1) 2
Table ‎3-14 showing the inter-rater reliability of the 15 dentists taking part in this study, the overall mean kappa was
found to be (k= 0.90)
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Further analysis of the reliability study results shows that participants seem to have good intra-rater
reproducibility when repeating the assessment. However, the most common reasons for not
achieving higher inter-rater reliability were the subjectivity of some of the complexity factors when
assessed by the observer. The most common reasons for inter-variation across the participants are
listed in the table below.
Most common factors resulting in inter-rater variability Frequency of error % (n= 450 assessments)
Canal visibility 16%
Root curvature 11%
Degree of inclination of tooth 3%
Not stating
 History of trauma 3%
 Previous endodontic treatment 3%
 Iatrogenic damage 2%
 Reduction in mouth opening 1%
 Medical history 1%
Overstating apical root resorption 1%
Accidently stating unrelated factors 3%

Other miscellaneous errors 3%
Table ‎3-15: the most common variations and errors encountered by the dentists while utilising the E-CAT. Assessing
canal visibility and root curvature were found to be the most prevalant variation between the group despite the lack of
confounding factors.
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3.3.5 External Validity
Utilising the GDC specialist list register, a total of 100 email and post invitations were sent. A total 35
GDC registered endodontic specialists volunteered and were recruited to be on the panel giving an
initial response rate of 35%. All participants received a participant information letter and 15 cases as
attached in the appendix. All volunteers completed the assessment successfully. The results of this
validation process are shown in table 3-15 below.
Case Experts Experts Experts Agreement Overall E-CAT Consensus

number rating rating rating Panel independent in
Class 1 Class 2 Class 3 Consensus valuation agreement
with E-CAT
1 29 5 1 82% 1 1 Yes
2 6 24 5 68% 2 2 Yes
3 0 0 35 100% 3 3 Yes
4 0 6 29 82% 3 3 Yes
5 28 6 1 80% 1 1 Yes
6 1 21 13 60% 2 2 Yes
7 1 18 16 51% 2 2 Yes
8 6 22 7 62% 2 2 Yes
9 0 2 33 94% 3 3 Yes
10 0 1 34 97% 3 3 Yes
11 23 9 3 65% 1 1 Yes
12 0 2 33 94% 3 3 Yes
13 1 6 28 80% 3 3 Yes
14 1 2 32 91% 3 3 Yes
15 3 25 7 71% 2 2 Yes
Table ‎3-16 showing the results of the external validation study utilising a panel of 35 endodontists independently
assessing the same clinical 15 scenarios for their complexity. Rating them 1 (uncomplicated), 2 (moderately complicated)
and 3 (highly complicated). The overall panel consensus agreed with the outcome of the E-CAT in all 15 cases.
The overall average of panel agreement was 78%. The inter-rater reliability was found to be
moderate (Kappa = 0.51, 95% CI: 0.49 to 0.52).
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3.4 Discussion
The study design and methodology overall succeeded in meeting the aims and objectives set in the
introduction of this research. Producing a comprehensive list of the factors associated with
endodontic treatment complexity was found to be a challenging process. Despite the Canadian, AAE,
EDTI, ETC and the RIOTN forms all reporting similar criteria, little high-quality evidence was found to
support them. The criteria included for this research were selected following an in-depth review of
the literature. Evidence selected ranged from case reports, narrative reviews, expert opinions up to
the utilisation of systematic reviews reporting on prognostic factors affecting the success and
survival of endodontic outcomes.
The 19 criteria listed in the results and the 22 questions designed to address them appeared to be
fairly comprehensive and address all possible factors which may affect endodontic complexity. The
iterative development process did not reveal missing factors, and the feedback received from the
dentists and specialists who took part in the study commented on the comprehensiveness of the
questions with no suggestions being made to add further complexity factors.
The participants did however comment on possible superfluous factors which were initially included
in E-CAT version 1.0 and were rather confusing to the users. The main criteria that were
subsequently omitted were the form or shape of the root and the presence of large periapical lesion.
Four out of the 5 dentists included in the pilot study commented on the confusion associated with
“J-shaped” and “I-shaped” roots. The literature review did not show any evidence to support
whether and I shape or J shape roots would affect the complexity of the case. The degree of root
curvature usually would account for the present of “J-shaped” rooted. Evidence however was
present for the complexity of managing C-shape canals and S-shaped roots (Machado et al., 2014a,
Sakkir et al., 2014, Martins et al., 2013). This was included as a universal question. The criterion of C-
shape canals however can only realistically be assessed from clinical information or if a CBCT
radiograph were available (Fan et al., 2004). A decision to omit I and J shape criteria was therefore
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made. The S-shape and C-shape criteria were included under complex morphology of the root canal
system.
The presence of a periapical lesion and the size of periapical lesions prior to endodontic treatment
were well documented as prognostic factors in endodontic outcomes (Ng et al., 2008, Marquis et al.,
2006). Those studies both reported a statistically significantly lower strict criteria success rate (ESE,
2006) when the teeth were associated with the presence of pre-operative periapical lesions. The
technical complexity of endodontic treatment itself however, or even the technical quality of the
endodontic treatment did not appear to have a statistically significant difference on the overall
outcome and tooth survival as opposed to success outcome (Ng et al., 2010, Pak et al., 2012). It can
be concluded from the current literature review that even though the presence of a periapical lesion
is a prognostic factor in achieving a successful outcome, it is not reported to complicate the technical
aspects of endodontic treatment any further. A decision was therefore made not to include the
presence of a periapical lesion as a complexity factor in this tool.
The final omission of complexity made was canal subdivision in the middle or apical third. This was
found to be a reported complexity in several publications (Albuquerque et al., 2014, Wu et al., 2017,
Reddy et al., 2012). However, those same publications reported on the difficulty of diagnosing those
using pre-apical radiographs or other 2-D imaging. The evaluation of the DETI tool (Ree et al., 2003a)
reported on the vagueness of this criterion as reported by the dentists. Usually this appears as an
indistinct area where the canals disappear in the radiograph or as two distinct canals within the root
canal system if the radiographic angle was favourable. Both of these factors are accounted for within
the “canal visibility” criteria or the “root canal morphology” criteria surveying questions.
Incorporating the question into those was thought to be less ambiguous for the less experienced
clinicians.
The use of iterative development in the medical field for the development of assessment or scoring
tools is not uncommon. A group of orthopaedic surgeons (Haugen et al., 2014), published data on
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the usefulness of this approach for their development of “OMERACT”, hand osteoarthritis MRI
scoring system. They reported “good to very good” inter-rater reliability. Another pharmacological
group (Melton et al., 2016) used the same approach to develop a clinical decision support system,
“CDSS”, for pharmacogenomic-guided warfarin dosing designed for physicians and pharmacists; they
reported “good” overall satisfaction and a significant time-saving improvement. In the development
of E-CAT, the iterative development process proved time consuming to achieve a perfect fit model.
The number of iterations required proved higher than those reported in the above two research
studies but this is possibly due to the higher number of factors involved and the high number of
calibrating cases selected to ensure a fitting model.
In comparison to the existing endodontic assessment forms (AAE, 2005a, Ree et al., 2003a), the
score values and the complexity score range for the classes were significantly transformed. Rather
than adhering to the 1,2 and 5 points scoring system, the range of values was changed to be
anywhere between 0-10, adding 8 further possible scoring points to the range. This was found
necessary early on the iterative development process as the arbitrary values of 1, 2 and 5 could not
provide a fitting model to the first 8 assessed cases. It is speculated that the existing AAE and other
paper forms used those values purely for the ease of use on the paper-format forms in order to help
their users to easily sum-up the points without the need for a calculator or lengthy mathematical
additions. As this research uses an automatic calculating system, the use of simple values was no
longer required, and increasing the score range to increase the accuracy of the assessment was
made possible.
As a direct consequence of increasing the choice of possible scores, the range of values associated
with the other published assessment tools did not match. Rather than having a range of values
starting at 15-19, 20-25 and above 25, for the relevant complexity classes, the range that best fit the
iterative development model was changed here to be 0-5, 6-11 and >11.
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This change has enabled the tool to add another dimension to complexity assessment. The ability to
produce a score value (E-CAT score), makes it possible to add more depth and character to the
classes rather than being plain 1, 2 and 3.
It is important to understand however that the E-CAT is not yet designed to form a “linear”
relationship with the complexity expected. Further research would be required to validate the exact
relationship between the score and the clinical complexity. The E-CAT score is therefore kept hidden
at this stage.
The range of endodontic complexity is documented to vastly vary between cases (Caplan et al.,
1999, Falcon et al., 2001, Messer, 1999, Muthukrishnan et al., 2007). It was found particularly
challenging to agree to group all those in only 3 classes. This can be clearly seen from the results
obtained following having the 35 endodontists giving their judgment on a sample of 15 clinical cases.
Some assessment tools argued the usefulness of using scores and numbers all together (AAE, 2005a,
Falcon et al., 2001) and attempted producing algorithms which uses factors such as x, y or z in
combination, independent of any scores. An example of that is the RIOTN or the classic AAE form. An
advantage of that was thought to be simplifying the form itself and the difficulty of assigning a
realistic value to each factor. However, this study, agrees with the finding of (Muthukrishnan et al.,
2007, Ree et al., 2003a) and (Curry, 2010) that completely abandoning a point-scoring system would
be too simplistic and will results in less sensitive and reproducible results overall. For example, if a
case had moderate root curvature in addition to moderate canal space reduction and moderate
tooth tilt and rotation in addition to uncontrolled diabetes and moderate reduction in mouth
opening – all these factors carry different weighting, and in isolation may seem to moderately
complicate a case, but all together would probably result in higher risk of complexity and adverse
outcomes. The simplest way producing an algorithm to assess whether these factors will combine
into a high complexity, was to give them a score value which can be added up in the background. To
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overcome the issue of assigning a realistic value to each complexity factor, the iterative
development process was followed in this research and proved successful.
Strictly speaking however, the clinicians do not need to know these exact values are as long as it is
automated in the background. Informing the clinicians the weighting of and value of each factor is
likely to complicate the platform and confuse the clinicians.
One of the main aims of this research was to be able to produce a more accurate and detailed
definition of the term “uncomplicated” endodontic or non-surgical root canal therapy as described
by the ESE and ADEE. Strictly speaking, the literal definition of this term based on the results above is
those cases which score 0 utilising the tool. Those are well and truly uncomplicated cases with very
low risk adverse outcome. However, it is important to make it clear that the term “uncomplicated”
refers to a wider range of cases in educational environments. Generally it used to define those cases
which have a low risk of encountering technical difficulty or an adverse outcome.
Based on the results from the literature review, iterative development and the large specialist panel,
an E-CAT score of ≤5 (Class 1) would be a reasonable definition of uncomplicated non-surgical root
canal treatment. In this research, these are described as “uncomplicated cases, with low risk of
adverse treatment outcome”. This defines those cases suitable to be carried out by dental student,
recent dental graduates or dentists without any further form of post-graduate training in
endodontics.
The definition of “uncomplicated” is discussed in more depth in Chapter 5 (5.2).
As for classes 2 (moderately complicated) and 3 (highly complicated), the results obtained from the
external validation study clearly showed that the view of grouping the wide range of endodontic
complexity into 3 classes is relatively too simplistic. This is discussed in more details later.
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In statistical terms, the inter-rater agreement statistic kappa and weighted Kappa as described by
(Cohen, 1968) were calculated. Computation details are also given in (Altman, 1991). The standard
error and 95% confidence interval were also calculated.
The K value can be interpreted as follows (Altman, 1991).
Value of K Strength of agreement
< 0.20 Poor

0.21 - 0.40 Fair
0.41 - 0.60 Moderate
0.61 - 0.80 Good
0.81 - 1.00 Very good
Table ‎3-17 showing K value interpretation as described by Altman in 1991
The inter-user and intra-user reliability in this study was found to be 0.80 and 0.90 respectively,
which can both be interpreted as very good reliability results.
The development and validation of E-CAT can be compared against other well-established clinical
assessment tools in Dentistry. For instance, the Index of Orthodontic Treatment Need (IOTN) is a
widely used tool in the orthodontic community. It became a public health commissioning tool and a
contractual requirement in the NHS in England and Wales since the introduction of the most recent
dental contract in 2006 (Jawad et al., 2015) . The tool was first developed in 1989 following
modification of the index used by the Swedish Dental Health Board (Brook and Shaw, 1989). The
validation process was sought in several studies. The accuracy or validity of the IOTN index was
assessed against the mean opinion of the orthodontic raters (panel of 18 orthodontists) as a “gold
standard” (Younis et al., 1997) . The overall agreement obtained for IOTN was 83% for inter-
examiner for the dental health component.
In comparison, this study had a panel of 35 endodontists. The overall inter-examiner agreement
achieved was 78%. Perfect agreement was only achieved in one case (case 3) out of the 15 cases
provided. Very good agreement was achieved in 8 cases (1, 3, 4, 5, 9, 12, 13 and 14). Good
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agreement was obtained on 4 cases (2, 8, 11 and 15), one moderate agreement with case 7 and one
poor agreement with case 6. The possible reasons for the variation in agreement are discussed
below.
Case Discussion
The only case that achieved 100%

agreement from the panel with all members
rating it as highly complex or class 3. This
case is classified as class 3 using the tool with
an E-CAT score of 20.
Case number 3 as discussed above scored 20 points on E-CAT assessment. The majority of the other
cases had very good or good agreement within the panel.
Cases 6 and 7 had moderate and poor agreement respectively. The cases are discussed in more
details below.
Case Discussion
Case 6.
Panel achieved moderate to poor agreement in
this case, with 1 panel member rating class 1, 21
members reporting it class 2 and 13 members
reporting it class 3. This consensus agreed on class
2 which agrees with the ECAT classification and
scores ECAT score of 10 points.
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Case 7.
Panel achieved poor agreement in this case, with
1 panel member rating class 1, 18 members
reporting it class 2 and 16 members reporting it
class 3. This consensus agreed on class 2 which
agrees with the ECAT classification and scores
ECAT score of 11 points.
Cases 6 and 7 as discussed above generated the most debate within the panel. Several comments
giving 2/3 as classification initially but settling on one class after being given instruction to only
choose one class. These results are in are agreement with the E-CAT score (10-11) bordering on Class
3. The agreement within the panel was much more straightforward with the uncomplicated or more
complex cases. When E-CAT score was higher than 15 or less than 4 – excellent agreement was
achieved (Kappa 0.9-1.0).
The results from the external validation study show the cases with lowest interclass agreement
values where those cases with E-CAT scores ranging between 6-7 or 10-13 points. The feedback
obtained from the 35 panel members stressed their need to classify some cases as “in-between”
classes. The fact that only three classes were possible to choose from, forced some raters to choose
one over the other. Several panel members suggested having an “in-between” class, and the
management of such cases depends on the clinicians’ experience and the equipment available for
them (magnifications, flexible files etc.).
This limitation can be improved. One solution could be to be more radical and completely abandon
the classes system. In this way the value obtained from E-CAT score can be used to describe the
complexity of the case. The higher the E-CAT score the more complex the case is. However this
approach may be confusing to users if no reference is given. For example, an E-CAT score of 15 is
highly complex, but if no guide is given, the value will certainly mean very little for novice users.
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Dividing the classes into uncomplicated, moderately complicated and highly complicated was the
original aim of this research, and it is likely to be more useful than simply having a value or class
number. However, adding the E-CAT score as integral part of this description proved to be useful
further information. E-CAT scores of 6 and 11 can both count as moderately complicated. But it is no
surprise that a moderately complicated case with an E-CAT score of 6 points is potentially less
complicated than that which scores 11, even though this relationship is not “linear”.
It therefore seems sensible to suggest either using the E-CAT score as in an indication of how “sub-
complex” the case is within the classification. Another approach would be to further divide the
classification into 5 classes, similar to the IOTN levels (Brook and Shaw, 1989), adding “moderate-
low” complication and “moderate-high” risk of complexities and adverse outcomes as new sub-
classification. The suggested revision to the classification would therefore be as shown in table 3-21.
Class E-CAT score Terminology and significance
1 0-5 Uncomplicated; low risk of complexity and adverse outcomes
2 6,7 Moderate-low risk of complexity and adverse outcomes
3 8-10 Moderate risk of complexity and adverse outcomes
4 11-13 Moderate-high risk of complexity and adverse outcomes
5 >14 Highly complicated; high risk of complexity and adverse outcomes
Table ‎3-18 proposed suggestion for the division of endodontic complexity classes into 5 classes rather than 3. This may
help identify those “in between” categories as suggested by the panel of endodontists, but may also add further
confusion to the ease of use of the tool
When assessing the validity of the tool and comparing the results obtained from the endodontic
panel consensus to the results obtained utilising E-CAT achieved perfect agreement for the 15 cases.
These results are very encouraging but should be interpreted with caution. Despite having 15 cases
being a meaningful sample to derive statistical outcomes, a larger sample of cases may have shown
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less than perfect agreement. The number of members on the panel however is believed to be
adequate, and little variation is expected with a larger panel. Future research could look into having
a similar panel looking into larger number of cases, though financial compensation may be required
for the time of the experts for such tasks.
An alternative approach to validate the tool can look into clinically evaluating the sensitivity and the
specificity of the tool to prospectively assess endodontic cases. Clinical cases can be assessed with
the use of the tool, then a treating clinician could feed back their experience of how complex the
case clinically actually was. The challenge would be the subjectivity of what is seen complex by the
treating clinician. What is complex to one dentist or endodontist may not be complex at all to
another treating dentist or endodontist. The utilisation of 3D-printing to standardise a set number of
sample being treated by a large panel of different clinicians could be a further research to improve
the validity this tool.
Since further research would require further time and financial cost, it is important to address
whether the utility of the Endodontic Complexity Assessment Tool would justify further studies. A
study carried out by Fox, Kay and O’Brien (2000) investigated the utility of the IOTN in measuring the
value of anterior tooth alignment to adolescents in the UK. The group concluded that it is possible to
develop utilities that reflect how patients value the appearance of anterior teeth. When applying
this to the context of the current study, further research is suggested to develop utilities that reflect
how GDPs, public health commissioners and educational establishment value such assessment tools.
When analysing the reliability study data, the weighted Kappa was found to be 0.80 for the inter-
rater and 0.90 intra-rater. This is considered as very good reliability. The agreement ranged from
73% (one participant) to 100% (4 participants) and an average of 90.1% agreement. A study
evaluating the reliability of the RIOTN as developed in the RCS guide has been described by
(Muthukrishnan et al., 2007) The system was applied to endodontic referrals to a department of
restorative dentistry in a district general hospital within a period of one year. In comparison to our
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study, intra-rater as well as inter-rater agreement with a consultant in restorative dentistry and a
foundation training dentist was assessed. Weighted Kappa for intra-rater agreement was 0.636.
Weighted Kappa for inter-observer agreement with a restorative consultant was 0.570 and that for
agreement with the foundation training dentist was 0.22.
In a more recent study assessing the reliability of IOTN by dental registrants (Jawad et al., 2016) ,
participants from six different registrant groups were asked to score the IOTN for 14 cases based on
study models and photographs as well as completing a short questionnaire. The specialist
orthodontists and the qualified orthodontic therapist groups achieved a mean Kappa ≥0.60
indicating 'acceptable' agreement with the expert panel scores. The dental foundation trainee (DFT)
and general dental practitioner (GDP) group achieved a mean kappa of 0.20 and 0.22 respectively
indicating poor and fair agreement. This study demonstrated lower reliability across different groups
of further postgraduate training, and the probability of further knowledge in the topic affecting the
reliability of the tool. The 15 dentists who took part in this study were general dental practitioners.
Further research is required to assess the reliability of the E-CAT across different registrant groups.
Further analysis of the reliability study results shows that participants seem to have good intra-rater
reproducibility when repeating the assessment. However, the most common reasons for not
achieving higher inter-rater reliability were the subjectivity of some of the complexity factors when
assessed by the observer. The most common reasons for inter-variation across the participants are
listed in the table 3.18.
The most common variation (16%) was found to be the interpretation of canal visibility on
radiographs. The study clearly demonstrated the variation amongst dentists in what they perceive as
clearly visible, sclerotic or invisible canals. In some instances (e.g. case 6) the variation ranged from
reporting that the canal was clearly visible to completely invisible across two different participants.
The majority however did have reasonable agreement. As all participants were provided with digital
radiographs on similar computer screens and the same lighting conditions, it can be inferred that
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those variation is due to individual perception rather than other confounding factors (Schriewer et
al., 2013). However, the degree of variation may vary even further in clinical scenarios with different
type of radiographs being available. Conflicting evidence in the literature demonstrated different
superiority of digital radiographs verses conventional wet-film radiographs (Ajmal and Elshinawy,
2014, Ki Wei et al., 2013). It is no surprise however that different radiographical techniques,
angulation, type of films and radiation dose will results in different quality of radiographs for the
same clinical case. No research was found to specifically address the effect of the quality of
radiographs on canal visibility or clarity of other endodontic complexities. Further research is
required to identify the best radiographic protocol to ensure best image outcome for the
assessment of preoperative radiographs in endodontic treatment.
The second most common variation was the perceived assessment of root curvature. The
participants had the option to choose between, small or no curvature (< 15°), moderate curvature
(15 - 40°), severe curvature (> 40°) and extremely severe curvature (> 60°). Most variations occurred
between the “small or no curvature” and “moderate curvature” categories (Kappa = 0.67). Severe
and extremely severe curvature recorded very good agreement (Kappa = 0.951) in this sample. This
result is in agreement with a recent study conducted to evaluate the inter- and intra-observer
agreement between training/trained endodontists regarding the ex vivo classification of root canal
curvature (Faraj and Boutsioukis, 2017). Periapical radiographs of extracted human posterior teeth
with varying degrees of curvature were exposed ex-vivo. Twenty endodontists were asked to classify
the root canal curvature into three categories (<10°, 10-30°, >30°), to measure the curvature using
the radiographs utilising three quantitative methods (Schneider, 1971, Gu et al., 2003) and to draw
angles of 10° or 30°, as a control experiment. The procedure was repeated after six weeks. Inter- and
intra-observer agreement was evaluated by the intra-class correlation coefficient (ICC) and weighted
Kappa were recorded. The inter-observer agreement on the visual classification of root canal
curvature was significantly variable (ICC = 0.65, P < 0.018). However, when quantitative methods
were used, the inter- and intra-observer agreement on the angle measurements was considerably
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better (ICC = 0.76-0.82, P < 0.001) than on the radius measurements (ICC = 0.16-0.19, P > 0.895). The
study concluded that visual estimation of root canal curvature was not reliable. The use of
computer-based quantitative methods was recommended. The measurement of radius of curvature
was more subjective than angle measurement. Those results are consistent with the findings of this
study. This calls for the utilisation of a digital approach to build-in a feature within the E-CAT
software to allow clinicians to upload an anonymous copy of their radiograph into a secured server
to allow the measurement of the curvature angle electronically. Further research for the production
of this feature or tool is required.
Other researchers have demonstrated the limitation of the use of periapical radiographs to assess
root curvature generally speaking (Patel et al., 2010). The angulation of the radiograph,
superimposition and the contrast in 2D radiographs are all variables which limit the ability of
clinicians to accurately estimate the root curvatures in clinical setting. A group led by (Michetti et al.,
2010) demonstrated the advantages of using CBCT radiography as a tool to allow more accurate
estimation of root curvature. Considering the relatively higher radiation dose of CBCT, further
research is required in this area to evaluate the risks and benefits of such approach to incorporate
root curvature assessment as in indication of CBCT to preoperative complexity assessment in
endodontics.
Despite the relatively high degree of variation associated with either overstating or understating
some complexity factors or slight variation in the information being stated, the results did not seem
to significantly be affected in the sample of 15 cases assessed. This is likely to be due to having a
range of E-CAT score values, which means a small variation may still yield the correct classification or
can be related to this specific sample of cases being assessed.
However, considering the variation obtained above, it is seen possible to improve the reliability of
the E-CAT through a more thorough tutorial and calibration process on the use of the tool prior to
embarking with case assessments. It has been shown that calibration exercises can significantly
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improve the reliability of assessment tool. For example, a study was conducted by an orthodontic
group to assess the effect of calibration on reducing subjective bias and standardising criteria for the
use of occlusal indices (Richmond et al., 1995). The results of that study demonstrated that a group
of dentists can easily be trained to record the Aesthetic and Dental Health Components of the Index
of Orthodontic Treatment Need (IOTN) and the PAR index to a more satisfactory level. Another study
(Hancock and Blinkhorn, 1996) of similar objectives comparing calibrated and non-calibrated users of
IOTN showed similar results. This suggests that a calibration process for E-CAT can be done either
through sessional courses or an online tutorial or a combination of both. Further research into this
topic is required.
In terms of time-efficiency, the average time taken to assess one case was 1 min 33 seconds (M =
1:33, SD = 33 seconds) with range start at 22 seconds (case 5, uncomplicated molar) and up to 3
minute 54 seconds (case 14, complicated molar with perforation). The average time taken for the
participants to complete a case improved from 1 minute 36 seconds in the first round to 1:29
seconds in the second round. It is also noticeable that the average time improves in the last 5 cases
(1 minute 28 seconds) compared to the first 5 cases (1 minute 40 seconds), suggesting novice
operators may take longer to assess the cases compared to experienced users. In comparison to the
study done to evaluate the Dutch assessment system (Ree et al., 2003a), a larger range of variation
was encountered (20-83%). The mean time taken was 3 minutes 46 seconds. The ease of use of ECAT
was found to be simple with a mean score of 2.0 using VAS (0 very simple, 10 very difficult) in
comparison to VAS mean score of 3.8 utilising the ETC.
The usefulness of assessment tools has varied significantly in the literature. Most of the endodontic
assessment tools mentioned earlier were used for clinical decision purposes, referral purposes
within the general dentists’ community (Ree et al., 2003b), some reported to use the complexity
forms for fee setting in private practice (Kabir and Mellor, 2004) or for educational purposes in
educational establishments to identify the level of complexity for undergraduate and postgraduate
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trainees (AAE, 2005b). Considering the improved results obtained using the E-CAT in terms of its
reliability, validity and time-efficiency, this thesis supports its use for all the purposes mentioned
above. The summary page provided at the end of each E-CAT assessment can also be used for dental
record keeping as tangible evidence to show the clinicians systematic assessment and consent
process.
In the United Kingdom, some assessment or treatment need tools are incorporated into public
health domains. For instance, the IOTN was first piloted as a public health tool in 1993 (Lunn et al.,
1993) which suggested its usefulness in that domain following some modifications. It became more
of a commissioner tool and a contractual requirement in the NHS in England and Wales since the
introduction of the new contract dental contract in 2006 (Jawad et al., 2015). Whether the E-CAT
can be used in similar manner is a question that requires further research to address its clinical
relevance and any modification that may be required prior to that transformation.
In order to clarify the value of risk assessment tools, it is imperative to explain the tangible
implications of the classes and their meanings. It is important for all users to understand that a
certain class of complexity level as indicated by the E-CAT does not directly reflect which clinician
(general dentist, DWSI or specialist) should be treating the case. The purpose of those classifications
is rather to indicate the level of risk of potentially encountering difficulty while treating that
particular case, or indeed the risk of generating adverse outcomes. A case that is classified as
“uncomplicated” has a low risk of encountering difficulty or causing adverse outcomes if treated.
However, there is still a low probability of those happening. On the contrary, a highly complicated
case has a high risk of adverse outcome being encountered, but there is still a chance, be it a small
chance, it may be treated by a general dentist with no further qualifications without encountering
real difficulty or adverse results. The intention is therefore for the user to use their judgement, given
the level of risk indicated, whether they would feel comfortable to accept it, or refer it on, in order
to offer their patients the best possible treatment outcome.
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This research helped defining the type of non-surgical root canal treatment cases which can be
classified as uncomplicated or having low risk of adverse outcomes, but did not look into the
distinction of level of competence or qualifications required to confidently manage moderately and
highly complicated cases. Further research into this topic will be required.
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3.5 Conclusion
In comparison to the existing data of the assessment tools available in the literature, the E-CAT
appears to fulfil the study aim of developing a more predictable, more reliable, time-efficient, user-
friendly tool and helped defining the meaning of “uncomplicated” non-surgical endodontic
treatments. The null hypothesis was therefore rejected.
However, this part of the study demonstrated that despite best efforts, the development of a
perfect and 100% accurate tool at all times to assess endodontic complexity is at best extremely
challenging, if not impossible. Further research is required to further validate the E-CAT’s clinical
relevance, evaluate its sensitivity and specificity in identifying complex endodontic cases in a clinical
setting, and finally produce a more scientific guide on the degree of competence and training
required to tackle the different classes of complexities assessed.
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CHAPTER 4 : THE PREVALENCE OF ENDODONTIC COMPLEXITY IN
4.1 Introduction and Aims
As can be seen from the previous chapters, the scope of endodontic treatment can significantly vary
in its complexity owing to numerous factors and conditions. There are several cross-sectional studies
describing the prevalence of periapical radiolucency in the population, a surrogate of necrotic pulp
disease. In addition, there are other studies looking into the prevalence of root canal treatment
within the population. However, probably due to “complexity” being a subjective issue, there does
not appear to be any attempt in the literature to identify the prevalence of complex treatment or
the reasons behind such complexity.
A South Korean study made an attempt to determine the most common endodontic complexities
encountered by general dentists through a study of referral reasons to endodontic practices (Kim,
2014). The most common referral reasons were found to be persistent pain and presence of a sinus
tract following primary RCT. Most common clinical reasons were found to be canal calcification,
broken instruments and posts.
In order to collect information related to the factors influencing root canal treatments complexity,
there needs to be a way of identifying those factors then classifying them, and then a mechanism to
gather the information from the population. The development of the Endodontic Complexity
Assessment Tool E-CAT (Chapter 3.2) required thorough research of the factors affecting endodontic
complexity, hence why the E-CAT itself, following its validation in the previous chapter, may be able
to serve the purpose of collecting information, rather than relying on the existing paper format
tools.
General dentists have, and most probably, will always provide the majority of root canal treatments
within the population. The numerous complexity factors, however, will cause GDPs to refer some
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cases to endodontic specialists. The outcomes of endodontic treatment carried out by endodontists
compared to those by general dental practitioners seem to be higher in most reports (Imura et al.,
2007, Ng et al., 2008).
There have been no studies reporting on the prevalence of complex endodontic cases in general
dental practice. In addition, there is currently no data on the levels of endodontic complexities or
specific complexity factors could affect the clinical decision of the proposed treatment to the case
being assessed. For example, it is unknown whether a highly complicated root canal treatment, or
teeth with severe root curvature, are more likely to be extracted, referred to secondary care or
treated in general practice. Such information may help identifying shortfalls, if any, within the health
system and help guiding future research to resolve such areas.
This gap in the knowledge of complexity prevalence indicated the need for this study. The results
may be used in several applications to assess the level of need for endodontic training and
commissioning required. Without such information, it is difficult to estimate the number of
endodontic specialists or the level of advanced training necessary within the public health system. It
is also difficult for educational establishments to tailor their endodontic training to target the most
prevalent complexities and the level at which this training is provided.
Electronic surveys are becoming increasingly more attractive with the advancement of information
technology and the availability of electronic devices (Dillman and Smyth, 2007). Pop-up windows
combined with visual and audio aids providing additional information may be added to clarify
responding in those surveys, which would have been much more difficult to implement in paper-
format questionnaires. Electronic surveys can be programmed to automatically analyse and present
the data in a much more user-friendly format. However, the issues with web-based epidemiological
studies usually concern practicality and data safety. A study looking into those issues concluded that
many of those problems related to the use of web-based questionnaires have been solved, but each
case needs to be approached individually (van Gelder et al., 2010).
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This chapter is therefore concerned with attempting to identify the prevalence of endodontic
complexity utilising the endodontic complexity assessment tool as an electronic survey platform.
Aims
This study was designed to assess the prevalence of non-surgical root canal treatment complexity in
general dental practice, to help assess the level of need for advanced endodontic treatment within
the health system.
The objectives of this study were as follows:
1. Determine the prevalence and distribution of the factors influencing endodontic
complexities in general dental practice.
2. Determine the overall prevalence of class I,II and III (uncomplicated, moderately complicated
and highly complicated) non-surgical root canal treatment in general dental practice
3. Assess the distribution of proposed dental treatment (NSRCT, referral or extraction) in
relation to the complexity levels and factors.
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4.2 Methodology
4.2.1 Ethical Approval
As this part of the study required access to anonymised clinical data and indirect access to patient-
related information, an application was submitted through the Integrated Research Application
System (IRAS) prior to the launch of the study in order to obtain research ethical committee
approval for the process. The committee was of favourable opinion to the design of the study, and
approval was granted on 30th October 2015 (REC reference: 15/NE/0372). A copy of the protocol was
also submitted to the local Research and Development team (RND) for assessment and hospital’s
sponsorship for the study was gained.
4.2.2 Sample size calculation
In order to collect the data required, recruitment of general dental practitioners practicing in the
United Kingdom was essential. Statistical advice was sought to assess the required number of cases
required to provide a meaningful prevalence study. Extrapolating from the prevalence studies
conducted on similar topic (Pak et al., 2012, Hebling et al., 2014), a sample size of around 300-400
endodontic cases would be required.
Assuming an infinite number of population (>100,000) to determine the appropriate sample size for
estimating the proportion of the population that possesses a particular endodontic complexity with
95% confidence interval (CI= 95%), the sample size was calculated using the following formula
Sample size is calculated using the formula:
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Where z is the z score, ε is the margin of error, N is population size, p̂ is the population proportion.
The total number required was calculated to be 385.
4.2.3 Participants recruitment
An advert on several platforms including dental online forums and dental societies (GDPUK, D4D and
UK Dentists groups) was published inviting dentists to volunteer for this part of the study.
The inclusion criteria were defined as general dental practitioners (GDP) working full time in general
dental practice in any of the United Kingdom regions. Cases treated by specialist endodontists or
dentists with special interest in endodontics who accepted dental referrals were excluded from the
study. Practice management approval was sought prior to accepting the participant into the study. A
total of 30 GDPs of variable demographics across the United Kingdom were recruited.
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4.2.4 Data collection
Utilising the digital nature of E-CAT version 2.0, the computer programmers designed to incorporate
a password protected and secure feature to tool to enable the GDPs inputting their data into the
tool which is then recorded into a secure database.
The information recorded included cases encountered with the complexity criteria as shown in table
4.1.
Surveyed categories of endodontic complexities
o Pre-treatment prior to commencement

o Radiographic difficulties
o Medical history, anaesthesia and patient management
o History of trauma
o Diagnosis
o Physical and psychological limitations
o Mouth opening
o The position of the tooth
o Inclination and rotation of tooth
o Crown morphology and presence of extra-coronal restoration
o Access to root canal system
o Root curvature
o Root canal morphology
o Apical morphology
o Canal radiographic visibility
o Previous endodontic treatment
o Iatrogenic incidents
o Root resorption
o Perioendo (Periodontic-Endodontic) lesion involvement
Table ‎4-1 showing the surveyed categories of endodontic complexities as recorded by the endodontic complexity
assessment tool
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In addition to the criteria mentioned in the table 4.1, the participants were also asked to report on
the outcome of the cases assessed; whether they were treated in general dental practice, referred
to a dentists with special interest in endodontics, private endodontist, secondary NHS hospital care
or extracted.
Each participating dentist was requested to include and record 10-15 consecutive cases where
endodontic treatment was indicated as a treatment option. Using the tool all the responses were
anonymised, no patient data was required or included. The dentists had 4 months to complete their
data collection.
Prior to starting the study, every participant was contacted either through email or phone and was
given an overview of the tool and its functionality in addition to the Participant Information Leaflet
(PIL) (attached in appendix). They were then calibrated through a series of 5 anonymised endodontic
cases provided to them. When a participant did not achieve a 100% calibration initially, a series of 5
further cases were sent to them with the relevant advice until 100% calibration was achieved.
All recruited cases were included regardless of whether patients chose to receive treatment or not.
The cases where patients chose to extract their tooth instead or defer the treatment for personal or
financial reasons (e.g. cannot afford treatment or referral) were included. Cases where pulp
extirpation was done or the case was referred to secondary care or private specialist were also
included.
The participating GDP’s GDC number, qualification year, practice address and nature of practice
(NHS or private) were recorded on a secure password protected database. In order to ensure the
accuracy of the data, each GDP was provided with a personal identification number (PIN) code to
match their details when the data were recorded. Without the PIN, no data could be entered onto
the research database.
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The prevalence of individual complexities were analysed and the prevalence of the three endodontic
classifications were assessed utilising the tool programming as encountered by GDP in general
dental practice.
This study did not include any patient-related personal information. The collected information was
stored on a password encrypted database. The data was reviewed in a secured environment at The
University of Liverpool.
4.2.5 Funding
The development of E-CAT was awarded a grant from the European Society of Endodontology to
assist in the development and programming of the tool and host it on a secure permanent server. In
addition small monies were sought from the DDSc research fund (Restorative Department) that were
used to buy appropriate stationary for the patient information leaflets, and consent or assent forms.
The RLUBH sponsored the research throughout its conduct period.
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4.3 Results
4.3.1 Participants and total number of data collected
A total of three adverts were sent out. Overall, 44 general dentists responded to the adverts, of
which 30 were successfully enrolled onto the study. A total of three dentists were excluded due to
working in a hospital environment, a further two were only accepting endodontic referrals, five did
not complete the calibration exercise and the remaining four did not contribute with cases following
their enrolment.
The demographic distribution of the participants were as follows
Participants demographic data Distribution (N=30)

Gender
Male 21
Female 9
Location
London and South of England 5
Midlands 5
North West 10
North East 4
Scotland 3
Wales 3
Post graduate endodontic training

Yes 8
No 22
Practice type
NHS 19
Private 11
Post qualification experience (years)

0-5 10
5-10 9
10-15 6
15+ 5
Table ‎4-2 Showing the participants demographic data of gender, location post graduate endodontic experience, practice type and years
post qualification.
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Collectively, the GDPs input a total of 437 non-surgical endodontic cases onto the E-CAT database.
Two dentists reported two separate mistakes in their input via email. Those two results were
deleted leaving a total of 435 cases.
On average the GDPs required on average 6.25 weeks (pro rata; taking part-time working dentists
and those who took annual leave) to complete collecting 10 cases, the range was a low as 4 weeks
and up to 11 weeks leading to the assumption of full-time GDPs to have an average of 1.6 potential
root canal treatment a week. The summary is shown in table 4.3.
Potential RCTs encountered per GDP Per week (range) Per annum (range)
Average (n) 1.6 (0.9-2.5) 70.4 (39.6- 100)
Table ‎4-3 showing the average numbers of root canal treatments encountered by a GDP practicing in the UK (full time).
The average number of potential RCT encountered by a GDP practicing in the UK taking into account bank holidays and
annual leave.
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4.3.2 Prevalence and distribution of complexity factors
In total, 435 non-surgical root canal treatment cases were assessed and recorded. All cases were
based in general dental practice and excluded any referral cases.
The results showed relatively equal distribution of posterior and anterior teeth potentially requiring
root canal treatment. Root canal retreatments formed a relatively high number (22.9%) of the cases
encountered. The majority of the cases (64.4%) appeared to have <15o root curvature, 30.6% had
15-40o curvature and only 4.1% had > 40° curvature. Teeth with existing extra-coronal restorations
formed 18% of the cases encountered.
Radiographically, visible and moderately reduced canal space was reported in 76.9% of the cases,
while 20.9% had severely reduced canal space and only 3.2% were perceived to have invisible canal
space. History of trauma was encountered in 9.0% of the evaluated cases.
Tables 4.4 - 4.7 below show the distribution of the data recorded in endodontic cases in general
dental practice.
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Factors/categories Number of Prevalence
entries within general
(N=435) practice
Tooth position
Anterior or Premolar 207 48.6%

1st or 2nd Molar 222 50.2%
3rd Molar 6 1.2%
Root curvature
Small or no curvature (< 15°) 282 64.4%

Moderate curvature (15 - 40°) 133 30.6%
Severe curvature (> 40°) 18 3.5%
Extremely severe curvature (> 60°) 2 0.5%
Canal radiographic visibility
Large pulp chamber and clearly visible canals to 148 34.3%

apex
Reduced pulp chamber volume , narrow yet visible 182 42.6%
canal space to apex
Indistinct pulp chamber or canal space in part or 91 20.9%
throughout
Completely invisible canal space in part or 14 3.2%
throughout
Mouth opening
Normal mouth opening (>35mm) 406 93.4%

Reduced mouth opening (25-35mm) 26 5.9%
Extremely reduced mouth opening (<25mm) 3 0.7%
Inclination of tooth (degree of tooth tilt)
No or small inclination (< 10°) 379 87.1%

Moderate inclination (10 - 35°) 52 12.0%
Extreme inclination (> 35°) 4 0.9%
Table ‎4-4 showing the prevalence and distribution of numerous factors which may potentially affect the complexity of
non-surgical root canal treatment
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Factors/categories Number of Prevalence in
entries general
(N=435) practice
Radiographic difficulties
Normal conditions 413 94.9%

Severe gag reflex 6 1.4%
Narrow or low palatal vault or High floor of mouth 12 2.8%
Hard to solve superimposed anatomical structure 4 0.9%
Medical history, anaesthesia and patient management
No medical problem or well controlled MH - ASA 412 94.7%

Class II
Diabetes (poorly controlled) 7 1.6%
Complex MH ASA III or VI including Haemophilia 6 1.3%

Vasoconstrictor intolerance 1 0.3%
IV bisphosphonate or history of head and neck 9 2.0%

radiotherapy
Allergy to anaesthesia 0 0%
Diagnosis
Uncomplicated clear diagnosis 386 88.9%

Other adjacent teeth could be involved. Requires 40 9.1%
simple further investigation
Confusing and complex signs of symptoms: difficult 9 2.0%
or unable to achieve clear diagnosis
Rotation of tooth
No or mild rotation (< 10°) 413 94.9%
Moderate rotation (10 - 35°) 21 4.8%
Extreme rotation (> 35°) 1 0.3%
Apical morphology
Closed (fully formed) apex 424 96.5%

Open apex (> size 60 k-file) 9 2.1%
Open apex with history of failed surgical retrograde 2 0.4%
root end fill
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Factors/categories Number of Prevalence in Prevalence within
entries general category
(N=435) practice
Pre-treatment prior to commencement 143 32.9%

Simple pre-treatment required for isolation 73 16.7% 51%
(e.g. supra-gingival caries, restoration
replacement)
Extensive pre-treatment required for isolation 37 8.5% 25%
(e.g. sub-gingival caries, margin elevation)
Removal of crown or bridge prior to treatment 33 7.5% 24%
Obstructed access to root canal system with direct 282 64.8%

restorations
Direct restoration with clear crown morphology 119 27.3% 42%
Direct restoration affecting crown morphology 142 32.6% 50%
Amalgam core build-up in pulp chamber 10 2.3% 4%
without post or crown
Composite core build-up in pulp chamber 11 2.5% 4%
without post or crown
Extra-coronal restoration 80 18%

Crown, bridge or onlay present but planned to 35 8.0% 43%
be removed prior to commencing treatment
Access required through crown or onlay 37 8.5% 46%
Poorly adapted post 4 0.9% 5%
Well adapted and firmly cemented post/cast 4 0.9% 5%
post and core
Previous endodontic treatment 101 22.9%
Previously initiated but not obturated, 33 7.5% 32%

endodontic treatment
Canal(s) sub-optimally obturated with gutta- 58 13.3% 58%
percha
Canal (s) well-obturated with gutta-percha or 5 1.1% 5.0%
obturation is >2mm overfilled
Canal(s) obturated with other materials (e.g. 5 1.1% 5.0%

Silver cones, resin based filling, bioceramic
material)
Iatrogenic incidents 26 5.9%
Supra-osseous perforations 3 0.6% 11%

Sub-osseous perforations 2 0.4% 7%
Separated instrument: clinically visible 3 0.6% 11%
Separated instrument: clinically not visible 5 1.1% 19%
Overt ledge or apical transportation 10 2.2% 38%
Significantly misaligned previous endodontic 3 0.6% 11%
access
Table ‎4-6 showing the prevalence and distribution of numerous factors which may potentially affect the complexity of non-surgical root
canal treatment
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Factors/categories Number of Prevalence in Prevalence within
entries general category
(N=435) practice
Root resorption 16 3.6%
Apical root resorption 10 2.2% 58%

Internal root resorption 5 1.1% 24%
External root resorption 3 0.7% 18%
Complex root canal morphology 51 11.7%
Very long tooth (working length> 30mm) 1 0.3% 2%

Anterior tooth or lower premolar with 2 canals 7 1.6% 14%
Premolar with 3 canals 3 0.69% 6%
Molar with ≥ 4 canals 40 9.2% 78%
Crown Morphology abnormality 4 0.9%
Dens invaginatus or fusion 3 0.7% 75%

Dentinogenesis imperfecta 1 0.3% 25%
History of trauma 39 9.0%
Unknown type of trauma in the past 17 3.9% 43.3%

Uncomplicated crown fracture 4 0.9% 10.0%
Root fracture 1 0.3% 2.5%
Concussion 7 1.5% 17.9%
Complicated crown fracture of mature teeth 6 1.3% 13.8%
Subluxation 1 0.3% 2.5%
Complicated crown fracture of immature teeth 1 0.3% 2.5%
Severe luxation or avulsion 2 0.5% 5.0%
Root canal shape and pulp stones 62 14.3%
Pulp stones present 38 8.7% 61.3%

S shape canal 21 4.7% 33.9%
C shape or ribbon shape root canal system 3 0.6% 4.8%
(confirmed clinically or with CBCT)
Physical and Psychological limitations 64 14.7%
Lack of cooperation or significantly nervous 47 10.9% 74%

patient
Patient requires sedation 4 0.9% 6%
Moderately limited reclination 9 2.3% 14%
Unable to recline 4 0.9% 6%
(Periodontic-Endodontic) lesion involvement 34 7.8%
Perio-endo lesion 19 4.3% 56%

Furcation involvement 7 1.6% 21%
Mobility, fenestrations or dehiscence 7 1.6% 21%
Root resection/hemi-section expected or 1 0.3% 3%
completed
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4.3.3 The overall prevalence and distribution of complexity classes in general
practice
The distribution of the classes across the three endodontic complexities is shown in table 4.8.
Uncomplicated cases or those with low risk of complications were relatively more prevalent than
those of 2 then 3 respectively. The distribution of complexity over classes 1, 2 and 3 was found to be
39.8%, 31.9% and 28.3% respectively.
Class Number (N= 435) Prevalence (%)
Class 1 (Uncomplicated) 173 39.8%
Class 2 (Moderately complicated) 139 31.9%
Class 3 (Highly complicated) 123 28.3%
Table ‎4-8 the overall prevalence of class I, II and III (uncomplicated, moderately complicated and highly complicated)
non-surgical root canal treatment in general dental practice.
4.3.4 The distribution of proposed dental treatment in relation to the complexity
levels and factors
To further analyse the results and enable more meaningful interpretation, the study also looked into
assessing the proposed treatment destination of each case encountered. The results are shown in
table 4-9 below.
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Classes/outcomes Number of Distribution
entries (%)
All cases (N=435)
RCT in general dental practice 244 60%

Treatment to dentists with special interest in 28 6%
endodontics
Referred to a private specialist in 22 5%
endodontics
Referred to NHS hospital or secondary care 43 9%
Extraction 77 18%
Patient still undecided 11 2%
Class 1 (N=173)
RCT in general dental practice 148 85.4%

Treatment to dentists with special interest in 3 1.9%
endodontics
Referred to a private specialist in 0 0%
endodontics
Referred to NHS hospital or secondary care 4 2.3%
Extraction 16 9.3%
Patient still undecided 2 1.1%
Class 2 (N=139)

endodontics
Referred to a private specialist in 7 5.0%
endodontics
Extraction 22 15.8%
Class 3 (N=123)

endodontics
endodontics
Extraction 39 31.7%
Table ‎4-9 showing the distribution of proposed dental treatment in relation to the complexity levels across the three
complexity classes
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The variation in the proposed dental treatment in relation to the complexity levels is shown in figure
4.1. A decreasing proportion of treatment in general practice can also be observed the higher the
complexity level.
90%
80% RCT in general dental practice
70%
Treatment to dentists with
60% special interest in endodontics
50% Referred to a private specialist in

endodontics
40%
Referred to NHS hospital or
30% secondary care
Extraction
20%
10% Patient still undecided

0%
All Cases Class I Class II Class III
Figure ‎4-1 shows the trends of proposed dental treatments in relation to the complexity levels. An upward trend can be
clearly seen for tooth extraction in relation to the complexity, as well as upward trends for the referrals.
The distribution of proposed treating clinicians in relation to the type of tooth (anterior or posterior)
being assessed for treatment. This is shown in table 4-10 below. Despite relatively equal distribution
of cases encountered with potential root canal treatment across anterior and posterior teeth, the
proposed treatment of extraction for posterior teeth is double that of anterior teeth..
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Classes/outcomes Number of Prevalence
entries
Anterior teeth (including premolars) (N=207)

endodontics
Referred to a private specialist in endodontics 7 3.5%
Extraction 22 10.6%
st nd
Posterior teeth (1 and 2 molars) (N=222)

endodontics
Referred to a private specialist in endodontics 14 6.3%
Extraction 53 23.8%
Table ‎4-10 showing the distribution of proposed dental treatment in relation to the anterior and posterior teeth
The results in the table 4-11 show the distribution of proposed treatment outcomes in relation to
cases with failed endodontic treatment (previously obturated cases). A relatively high percentage of
previously root canal treated teeth are either referred secondary care or extracted in general
practice.
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Classes/outcomes Number of Prevalence
entries
Failed RCT (previously obturated) (N=68)
endodontics
endodontics
Extraction 22 32.4%
Table ‎4-11 showing the distribution of proposed dental treatment in relation to history of previous endodontic
treatment
The trends can also better demonstrated utilising column chart as shown in figure 4-2.
70%
60%
RCT in general dental practice
50%
Treatment to dentists with
special interest in endodontics
40%
Referred to a private specialist in
30% endodontics
Referred to NHS hospital or
20% secondary care
Extraction
10%
Patient still undecided

0%
All Cases Anterior teeth Posterior teeth Previous
endodontic
intervention
Figure ‎4-2 shows higher proportion of teeth being extracted observed in relation to posterior teeth and teeth with
previous endodontic intervention.
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4.4 Discussion
This cross-sectional epidemiological study was designed to explore the prevalence of the factors
influencing the complexity of non-surgical root canal treatments in general dental practice.
The study adopted an electronic and digital approach to collect the data. Several studies have
discussed the potential benefits and disadvantages of web-based surveys and the ongoing
developments in the area (van Gelder et al., 2010). Conventional methods to gather information
from study subjects, including face-to-face, traditional paper and-pencil format questionnaires and
telephone interviews are increasingly failing to generate high-standard qualitative results within the
financial parameters given. Web-based surveys are now frequently used in marketing research and
psychological studies, but their use in epidemiological studies was merely 1% in published articles
(Ekman and Litton, 2007).
There have been a few examples of successful studies conducted using the electronic surveys
approach and are already available, including Danish Web-based Pregnancy Planning Study
(Mikkelsen et al., 2009), the Millennium Cohort Study (Smith et al., 2007) and the Nurses and
Midwives e-Cohort Study (Turner et al., 2009). Those studies succeeded to collect a large sample
number through electronic surveys with meaningful results.
An ideal epidemiological study would include a very large sample with as much detail of each
category recorded as possible. The data collection would ideally be standardised through a series of
examiners cross-checking the records to ensure minimal bias or human error occur in recording the
data. In the case of single item prevalence study (e.g. periapical pathology), this is relatively easily
achieved. In contrast, the current study required a comprehensive assessment of root canal
treatment complexity consisting of numerous interdependent factors; including patient-related
factors, tooth related factors and several other miscellaneous factors. Therefore, determining the
prevalence of the root canal treatment complexity was found to be challenging and demanded that
all relevant factors were recorded or accounted for in as much detail as possible.
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Since the development of E-CAT required a thorough research of the factors affecting endodontic
complexity, the process of ensuring most of the key factors are included within the surveying
questions became more achievable.
The data entry needed to be as accurate as possible in order to ensure meaningful results. Since the
nature of this epidemiological study required a national multi-centre design, it was found
exceedingly challenging to have the same examiners going into each centre to record the data. The
challenges included the prospective nature of the study, requiring the patient to be present for
assessment, the frequency of non-surgical endodontic treatment in general dental practice, the
financial aspect of examiners travelling to each centre and most importantly patients’
confidentiality.
In order to ensure practical methodology is followed, maintaining accurate results, only fully
qualified dentists with good knowledge of the factors recorded in the assessment criteria were
selected. However, despite best efforts, it must be acknowledged that the areas where clinician’s
subjective opinion may vary (e.g. root curvature, radiographic canal visibility); the results record may
also vary. This should be taken in consideration while analysing these data. In an attempt to dilute
the effect of these subjective variations, the number of dentists participating, and the number of
cases collected was aimed to be as high as possible. A calibration process was also implemented and
aimed to ensure all dentists had similar views of how to use the tool and when to record each
criterion prior to their recruitment. Example of radiographs showing root canal visibility calibration
and Schneider’s technique, as described in (Gu et al., 2003), of measuring root canal curvature were
provided. On the other hand, the majority of the factors reported (e.g. medical history, presence of
previous endodontic treatment or indirect restorations) were less subjective. The reliability of these
results can be expected to be very good.
Overall, a total of 30 GDPs were recruited. The demographic distribution of those provided a
reasonable representing sample. The number of dentists participating in the North West was higher
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than that of the other regions in the country. This is likely to be due the University of Liverpool being
in the region and the dentist feeling more affiliation or willing to “give back” to the teaching hospital
when invited. The distribution between NHS and private was reasonable given the fact there are
more NHS practices in UK than there are private (BDA, 2013). A higher number of the dentists within
their first 10 years of qualification took part in the study compared to those who graduated longer
than 10 years in their career. This can probably be explained due to the lifestyle of younger dentists
wishing to take part in an electronic study with new tool and still wishing to keep in touch with their
dental research side. However, this variation was still reasonable with at least 5 dentists
representing each category.
Demographically, it was expected that dentist with special interest in endodontics would be more
inclined to take part in this research given the nature of the topic being explored. In order to ensure
a more equal and unbiased distribution of general practice, the participants were asked to declare
any formal post graduate training in endodontics. The sample obtained showed about 25% only of
the participants had attended post graduate training courses (ranging from day courses to
Postgraduate Diploma) in endodontics. None of the participants included any referral cases onto the
study.
Overall, the majority (71%) of the root canal treatments encountered in general dental practice was
found to be either uncomplicated (class I) or moderately complicated (class II) and can be considered
within the remit of general dental practitioners. This is based on the assumption that class 2
complexity cases carry a moderate risk of complication but may still be within the remit of an
experienced general dentist or dentists with further non-specialist training in endodontics. However,
a relatively high proportion (29%) of the cases was found to be of higher complexity and carry higher
risk of complications and therefore ideally requires specialist input. As discussed in the previous
chapter, the boundaries between what specialists and dentists with enhanced skills are expected to
treat is a topic that requires further research in itself and was beyond the remit of this study.
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The results of the current investigation provided new insight into the prevalence of the radiographic
canal visibility, where visible and moderately reduced canal space was reported to be 76.9% of the
cases, while 20.9% had severely reduced canal space and only 3.2% were perceived to have invisible
canal space. These results must not be confused with the prevalence of sclerotic canals. The
periapical radiographs used in the study may not be sensitive enough to deduce this conclusion
(McCabe and Dummer, 2012). It is imperative that the limitations faced in developing the
endodontic complexity assessment tool previously discussed in chapter 3.4 are discussed again here.
The subjectivity of assessing the canal radiographic visibility and the variation in root curvature
assessment are implicated again in this study. Although the results can provide us with a good
insight of the prevalence of reduced radiographic canal space and curved roots, the true prevalence
of those values can vary due to the use of 2-dimesntional radiographs in the assessment of the
endodontic cases. The observer variation in the assessment of root curvature, the angle of the
radiograph, and the method used to measure the curvature may also result in variation from the
true prevalence of anatomically curved canals to the results recorded here. It might be more
accurate to state that the results concerning the prevalence of canal visibility and root curvature
recorded in this study reflect their perceived prevalence by general dental practitioners in the UK
rather than the true value.
The prevalence of severe root curvature was lower than anticipated at only 4.1% having > 40°
curvature. The majority of the cases (64.4%) appeared to have <15o root curvature with 30.6%
exhibiting a 15-40o curvature and. The Schneider, Weine, Lutein and Cunningham’s methods of
evaluating root curvature as summarised in (Balani et al., 2015)) were all considered for the purpose
of the study. As the Schneider techniques was found to be the most commonly familiar and easier to
follow (Gunday et al., 2005), it was selected for this research despite the limitations associated with
it.
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History of trauma accounted for approximately 9% of the cases requiring non-surgical root canal
therapy. No other observational study was found reporting on similar findings or the proportion of
root canal treatment required for adult patients as consequence of dental trauma in general practice
in the UK. On the other hand, a review study looking into the overall prevalence, aetiology and
consequences of dental trauma reported the prevalence varying in different countries and different
age groups ranging from as little as 4.9% and up to 33% (Zaleckiene et al., 2014). In adults, self-
reported trauma was found to be in the region of 15% (Locker, 2007). A Swiss study reported a total
of 23,000 insurance recorded injuries of 2 years in a population close to 8 million people (Brunner et
al., 2009). The authors reported that most trauma recorded did not require immediate root canal
treatment or advanced dental treatment.
The findings in the current study reported on all potential RCT cases where dental trauma was
previously encountered on the tooth, but no distinction was made whether the RCT was required as
a direct consequence of the trauma or not. These results should therefore be interpreted
accordingly.
Cases with history of previous endodontic intervention formed a relatively high number (22.9%) of
the potential root canal treatments encountered in general dental practice. Interestingly, around
60% of those cases were perceived to have sub-optimally obturated root canals with gutta-percha
and only 5% with good obturations. The remaining 35% were either extirpated unfilled teeth or
cases with non-standard root canal obturation. These results may indirectly be linked to the classic
studies reported by (Sjogren et al., 1990) and (Ray and Trope, 1995) on the relative importance of
achieving good obturation in relation to other factors such as coronal seal. However the information
provided in the study does not provide us with sufficient details to draw further conclusions.
The proportion of teeth with class 3 complexity and those with previous endodontic intervention
being extracted was significantly higher than those previously unfilled. The exact reasons behind this
decision in treatment planning were not recorded as part of study. It was found that only 20% of the
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cases with previous endodontic treatment would get planned for treatment in general dental
practice. This study also shed the light on the higher tendency of posterior teeth being extracted in
relation to anterior teeth. May one speculate this could be due to their higher complexity or to do
with dentists adopting the shortened dental arch approach as described by Kaysar (1981).
Despite the results identifying trends for more complex cases exhibiting higher probability of being
extracted, this study was not designed to provide the information behind the reasons influencing
this decision. These can be due to patients’ wishes, financial limitations, shortage of referral service,
clinicians perceived long term outcome or indeed various other factors. Further research is required
to further explore this topic.
Nevertheless, regardless of the underlying motives, as the health system in the UK is facing a more
aging population (Thomson and Ma, 2014), the trend of extracting potentially saveable teeth with
higher complexity root canal treatment will still have its significant implications. These may include
the effect on the older patients’ oral-health-related quality of life and the increase of the restorative
burden within the health systems. In their systematic review, (Gerritsen et al., 2010) demonstrated
fairly strong evidence that tooth loss is associated with impairment of OHRQoL and that the location
and distribution of tooth loss affect the severity of the impairment. An anterior tooth loss was found
to have the highest impact on oral-health-related quality of life (OHQoL). This may explain the trend
of higher extractions rate in posterior teeth than anterior teeth found in results of this study.
The provision and the long-term maintenance of extracted teeth replacements, being dentures,
bridges or implants, could potentially be less cost effective than the provision of root canal
treatment. In a relatively recent study utilising Markov model, Pennington and his group
(Pennington et al., 2009) found that root canal treatment is highly cost-effective as a first line
intervention. Orthograde re-treatment was also found to be cost-effective with implants having a
role as a third line intervention if re-treatment fails. Further research is required in this field to
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assess the potential opportunities in improving the overall healthcare in reducing the extraction rate
of teeth which could potential be endodontically treated.
Teeth with existing extra-coronal restorations formed 18% of the cases encountered. The results
also demonstrated a high tendency of the surveyed general dental practitioners to provide the root
canal treatment through the existing extra-coronal restoration rather than replacing it. Of those
cases recorded with an extra-coronal restoration, only 48% were planned for removal, while 52%
were planned for root canal treatment through the existing crown or bridge. The debate of replacing
extra-coronal restorations or not prior endodontic treatment has been long discussed among
clinicians. A study by (Abbott, 2004) found a very high chance (44%) of missing caries, cracks or
marginal breakdown diagnosis prior to restoration removal. They recommended that all restorations
should be removed prior to endodontic treatment in order to remove the common factors that may
have caused the pulp and periapical disease, and to assess the tooth's prognosis and future
treatment needs. Further research is required to assess the reasons behind general practitioners still
wishing to access the tooth through extra-coronal restorations and whether this truly has an impact
on the long term prognosis of and treatment outcome of endodontic treatments.
It must also be acknowledged that despite the participants all being qualified dentists and calibrated
for the study, the study design did not allow for cross-examination of the data to double check the
accuracy of the records, leading to higher possibility of human error or bias during the data
collection phase. Considering the large number of participants and sample size, this issue is less
probable but the data should still be analysed bearing this limitation in consideration.
Additionally, the results obtained in this research highlighted some public health queries. According
to the latest registration report published by the General Dental Council in September 2017 (GDC,
2017), the total number of registered practicing dentists was 41,631, of which only 287 were
registered specialists in endodontics, which forms 0.69% of the workforce, equating to a ratio of
1:145 endodontist for every registered dentist. In comparison to the United States, there are
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195,722 registered dentists with just over 4000 endodontists equating to a ratio of 1:48 (AAE, 2016).
This shortage is further complicated by non-practicing registered endodontists on the GDC specialist
list in the UK. It is estimated that around 200 out of the 287 registered specialists are restorative
consultants practicing in a hospital setting in other subspecialties and do not provide a direct
endodontic service. For the majority of the UK, aside from the service provided by teaching
hospitals, there is a large shortage of specialist endodontists to refer to within the NHS (BES, 2015).
Privately, the majority of the endodontists are concentrated around the Greater London area with
few in the North West of England. Some regions such as the North East of England have severe
shortage of any registered and practicing private specialists (GDC, 2017). This may explain the
relatively high proportion (6%) of proposed referrals to dentists with special interest (DWSI) or
dentists with “practice limited to endodontics” rather than to NHS secondary care or private
specialists (5%) in endodontics. Many DWSI are now found in the UK and may indeed be helping to
reduce the pressure of the general dental practitioners. However, there are currently no recognised
guidelines or methods of quality assurance of the dentists with such titles.
When linking the above demographics of the endodontic work force in the UK to the results
obtained from this research, with around 28% of the cases encountered requiring specialist input, it
becomes immediately apparent that further research is required to utilise the results obtained here
to assess the level of shortage of endodontic specialists within the UK health system, both within the
national health service and within the private sector. Further research is also required to identify a
more tangible system to recognise those dentists with special interest in the field and the level of
endodontic complexity that could be referred to them.
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4.5 Conclusion
The results obtained in this study provide a good resource and databank for researchers, public
health commissioners and academic institutions to access wide range of information concerning the
prevalence and distribution of endodontic complexity. The results obtained in this research indicate
a shortage of endodontic specialist service in the UK, especially within the National Health Service.
Further research is required to utilise these data to identify the nature of the endodontic work force
required within the United Kingdom health system and help shaping it into a more productive
network.
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CHAPTER 5 : CLINICAL IMPLICATIONS AND FUTURE RESEARCH
5.1 Clinical implications
Following the results of the research presented and discussed in the previous chapters, the created
tool can help general dental practitioners identify those cases with higher potential of encountering
complexity and higher risk of adverse outcomes more predictably. The digital interface will help save
clinical time, be more intuitive and provide more information to clarify the ambiguity of certain
complexity factors. This in turn may aid the effectiveness of decision-making in deciding to treat the
case or to refer it to an appropriate clinician (specialist or dentist with special interest of an
appropriate level of training). Which consequently helps placing patients’ best interest first and
achieving the best treatment outcome for them
This research helped to produce a more objective definition of the term “uncomplicated” root canal
treatment as described by the ESE and ADEE, which will help educational institutes in Europe to tailor
their undergraduate educating programmes and standardise the level of training and case selection.
This is further discussed in section 5.2.
From a public health point of view, the outcome of the prevalence and distribution of factors affecting
the complexity of root canal treatment can help educational institutes, health authorities and
commissioning services assess the level of need for basic training, further training and commissioning
of specialists and dentists with enhanced skills in root canal treatment within the health system.
Linking the research outcomes to the currently proposed prototypes by the Department of Health
schemes, this may also help the commissioning bodies adapt the tool and prevalence findings to
reliably identify the level of the treatment in the proposed current for general dentists, dentists with
enhanced skills, specialist or hospital consultants.
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5.2 DEFINITION OF UNCOMPLICATED ROOT CANAL TREATMENT
One of the aims specified in this research was to derive a more objective definition for the term
uncomplicated root canal treatment as described by the ESE and ADEE undergraduate curriculum
guidelines for Endodontology. This was achieved through a wide-spread literature review and the
process of iterative development and the E-CAT evaluation as described in Chapter 3. Following the
findings reported in the previous chapters concerning the factors involved in endodontic complexity,
it is not surprising that achieving a precise definition is very challenging. Despite its lengthy and
wordy nature, the following definition is regarded as an overly simplified strict definition for
uncomplicated non-surgical root canal treatment.
The term “uncomplicated” is defined as those anterior or posterior teeth (not including 3rd molars)
requiring NSRCT consistent with the following conditions:
 Straightforward clear diagnosis
 No medical conditions reported, or well controlled medical conditions – (ASA Class I and II)
 Patients with no physical or psychological limitations (including normal mouth opening,
good patient’s cooperation, no physical limitation on reclining chair)
 No radiographic obstructions (including no structures causing radiographic superimposition,
no severe gag reflex, normal palatal vault and floor of mouth levels)
 Simple or no pre-treatment required for dental dam isolation (e.g. supra-gingival caries or
simple replacement of restorations)
 Unrestored teeth, or teeth with direct restorations not masking the original crown
morphology
 No extra-coronal restoration present, or crown, bridge or onlay present but planned to be
removed prior to commencing treatment
 No post or core present
 No or small tooth inclination and rotation (< 10°)
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 Teeth with small or no root curvature (< 10°)
 Closed (fully formed) apical morphology (<size 60 k-file)
 Radiographically clearly visible pulp chamber and canal space throughout to the apex
 No known atypical root canal shape (e.g. S or C-shape roots) or pulp stones
 No known developmental abnormality (such as fusion or dens invaginatus, taurodontism or
microdontism, or dentinogenesis imperfecta)
 Anterior tooth or lower premolar with single canals, upper premolars ≤2, molars ≤3 canals
 No signs of pathological root resorption
 No signs of periodontal-endodontic involvement
 No history of previous dental trauma
 No previous endodontic treatment, or previously initiated but not obturated endodontic
treatment with no known iatrogenic damage
 Single rooted (single canals) teeth sub-optimally obturated with gutta-percha (short or
poorly condensed) root fillings
The aforementioned criteria describe those cases which have low risk of encountering technical
complication or causing adverse outcome and expected to be competently treated by the newly
qualified European dentist. Aside from being time-consuming to go through each one of them, these
factors still over simplify the classification process and therefore may lead to an overly cautious
approach to case selection for undergraduate students. On the other hand, as described in chapter 3
and agreed by the panel of 35 certified endodontists, some factors may carry a low or moderate risk
of complexity but may still be suitable to be treated by the newly qualified dentist as long as they are
not combined with other factors which may further influence the complexity. When several
moderate risk factors accumulate, the overall risk of encountering complexity increases. It is
therefore seen more appropriate and time-efficient to utilise the programming built in the E-CAT to
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identify those cases classed as “uncomplicated”, rather than simply having cases which “tick” the
above mentioned criteria.
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5.3 Future research
In order to further investigate the clinical significance of the E-CAT, further research is required to
evaluate the clinical relevance of the tool in identifying complex endodontic cases in a clinical
setting.
Due to the subjectivity and the large number of variation of the complexity topic, it would be
difficult to fully assess the sensitivity of the tool in clinical scenarios. One way of approaching this
would be to roll out the tool in an undergraduate setting and prospectively assess the risk of adverse
outcome prior to the use of the tool and then assess the outcome of the treatment immediately
post operatively and with a specified follow-up period (e.g. 6-12 months). It would also be possible
to conduct qualitative research to assess the user experience of the tool and aim to further improve
it. This type of research can help further validate the clinical relevance of the “uncomplicated” cases
as defined by this research for undergraduate students across the UK and European educational
institutes.
Further research is also suggested to develop utilities that reflect how GDPs, public health
commissioners and educational establishment would use the E-CAT and focus future research into
attaining the highest utility value of the tool.
The above approach can also be rolled out in general dental practice and potentially post-graduate
students or specialists to assess the clinical relevance of the tool there both in the UK and across
Europe.
Another approach could involve a large retrospective cohort in primary or secondary clinical setting
to assess the cases pre-operative clinical data and radiograph using the tool, and then relate it to the
postoperative technical and clinical outcomes.
Alternative possibility to assess the sensitivity of the assessment tools can involve an in vitro design
to involve the utilisation of 3D-printing to standardise a set number of samples being treated by a
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large panel of different clinicians and determining an overall average. However, the limitation of this
would be standardising the clinicians experience and the simulated environment not necessarily
mirroring the clinical settings.
The research also identified a large number of variations when attempting to evaluate root
curvature and radiographic canal visibility. Further research for the production of more accurate
tools and techniques to help achieving more reproducible results is seen beneficial to improve pre-
treatment assessments.
In order to improve the accuracy of the assessment results of the E-CAT, identifying a more
methodological approach to develop a calibration method through face to face sessional training or
online tutorials, or indeed a combination of both, will be beneficial. Improving the calibration
process is thought to provide more accurate assessment results overall.
In the United Kingdom, assessment or treatment need tools such IOTN were successfully
incorporated into public health domains. Whether the E-CAT can be used in similar manner is a
question that requires further research to address its clinical relevance and any modification that
may be required prior to that transformation.
This research did not look into the distinction between the levels of competence or qualifications
required to confidently manage moderately and highly complicated cases. Further research can help
produce a more evidence based guide on the degree of competence and training required to tackle
the different classes of complexities assessed.
The outcomes of the prevalence study indicated a shortage of the endodontic specialist service in
the UK, especially within the National Health Service. Further research is required to utilise these
data to identify the nature of the endodontic work force required within the United Kingdom health
system and help shaping it into a more efficient and productive system.
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The results of the second study also identified trends for more complex cases exhibiting higher
probability of being extracted. The reasons behind those trends can be due to numerous reasons
including patients’ wishes, shortage of referral service, financial limitations, and clinicians perceived
long term outcome or various other factors. Further research is required to explore this topic.
Finally, as a lateral finding, the results indicated higher tendency of general dental practitioners
wishing to keep extra-coronal restoration (crowns, bridges and onlays) in situ prior to commencing
root canal treatments. Despite some literature favouring the removal of crowns, more clinical
research would be beneficial to identify the clinical risks and benefit and long term outcomes of each
school of thought.
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5.4 Conclusion
The development of E-CAT provided a more credible, more efficient and more reliable platform to
assess the complexity of NSRCT compared to currently existing paper-format tools. The literature
review and iterative development of the factors influencing endodontic complexity allowed the
production of a more objective definition to describe “uncomplicated” root canal treatment as
referred to by the ESE and ADEE guidelines.
The outcome of the prevalence study provided a good resource and databank for researchers, public
health commissioners and academic institutions to access wide range of information concerning the
prevalence and distribution of endodontic complexity. The results obtained in this research indicate
a possible shortage within the endodontic specialist service in the UK, especially within the National
Health Service.
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CHAPTER 7 : APPENDICES
7.1 Examples of existing complexity assessment forms
7.1.1 The AAE form
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7.1.2 The Dutch DETI and ETC
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7.1.3 The Restorative Index Of Treatment Need form
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7.2 Letter of invitation to general dental practitioners
Dear Colleagues,
We are currently working on developing a new digital tool to assess the difficulty of root canal treatments in a
form of an online tool which combines the available tools in the literature in a simple intuitive app. The tool will
use the data input to help classifying the Endodontic case in one of the 3 difficulties, uncomplicated, moderately
complicated and highly complicated.
We are inviting all GDPs interested in trialling this new app and helping in the prevalence survey across the
country to take part. We are asking those who are interested to assess 10-15 random cases where endodontic
treatment was offered as a “treatment option” consecutively. Using the tool all the responses will be
anonymised, no patient data is required or included. Each case should not take more than few minutes to
complete; some will take less than a minute.
The tool simply aims to provide a quick and easy way to assess how difficult an endodontic treatment is
predicted to be. For example, “red” outcome would indicate high case complexity and recommend treatment by a
specialist.
We are inviting collaboration of dentists working in general practice to feedback on this tool and help researching
the “prevalence” of complex and difficult endodontic treatments in general dental practice. It is currently difficult
to assess how many endodontists or dentists with enhanced skills are required within the health system, as we
do not have figures of how common or uncommon complex endodontic cases are in general practice in the UK.
Assessing the prevalence may help the commissioning bodies have an idea of how many endodontic referral
centres are required per dentist within your local area for referral services.
If you are interested in taking part or have any further queries, please feel free to email us on o.essam@liv.ac.uk
and we will contact you back to explain the process further. Your valuable time and thoughts on this will be highly
appreciated.
Looking forwards to hearing from you.
Best wishes
Obyda Essam
Speciality Registrar in Endodontics
Liverpool University Dental Hospital
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7.3 Participant information leaflet
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7.4 Trust Sponsorship Letters
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7.5 Ethical Approval Letter
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7.6 European Society of Endodontology Educator Grant
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7.7 Invitation letter to endodontic specialists
Dear (Colleague Name),
I hope this finds you well and you do not mind me approaching you with this email. I would be very grateful for your valuable
input on a new endodontic case assessment tool.
I am a clinical lecturer and honorary registrar in Endodontics at the Liverpool University Dental Hospital. Alongside Dr Liam
Boyle and Dr Fadi Jarad (Restorative consultants at LUDH), we are conducting a national Endodontic study investigating
new complexity assessment tool and determining prevalence of complex Endodontic cases in practice.
Similar to the orthodontic IOTN and implants ITI SAC tools, a new online Endodontic Case Assessment Tool (named E-
CAT) has been developed at Liverpool University Dental Hospital to classify Endodontic treatments. The tool incorporates
existing AAE, Dutch and the RCS treatment assessment forms into a more intuitive evidence based approach. The aim is to
produce a tool to reliably define different level of complexity of endodontic cases for educational purposes, and to aid GDPs
to predictably assess the complexity of endodontic treatment in general dental practice, both NHS and private. The app
provided good results on trial but we now need to validate it. A number of GDPs and specialists helped recently to internally
validate this tool.
The objective now is to get "experts opinion" in Endodontics (Restorative consultants with interest in Endodontics and GDC
registered Endodontist Specialists) to give us their own opinion on the complexity of 15 clinical endodontic cases. The
purpose of the external validation is to correlate GDPs assessment to Endodontic expert and check whether they can use
the tool to arrive to the same or similar assessment. I fully appreciate the busy nature of your schedule. Your help will be
greatly appreciated by the team at Liverpool and the dental community. All that is required is your own assessment of the
attached 15 cases. I would expect each case to take 1-2 minutes so we are estimating 15-20 mins for the exercise.
Based on the radiographs attached and the clinical information, we would appreciate if you could assess those cases using
the judgment of your own clinical experience and grade them on your opinion according to what you expect the complexity
of the endodontic treatment would be if you were to treat it or allocate it; 1, 2 or 3.
1 - Uncomplicated, low risk - treatment to be carried out by recent dental graduates or GDPs without further enhanced
experience in endodontics.
2- Moderately complicated, moderate risk of adverse outcome; treatment to be provided by experienced GDPs or
practitioners who have had further non-specialist training.
3- Highly complicated, high risk of adverse outcome; treatment to be provided by recognised specialists in Endodontics
These can be written in a comment box next to each case. All we need is 1, 2 or 3. Once completed if you could attach the
comments back reply to this email we would be very grateful.
If you would like to check out the tool yourself, you can find it on www.e-cat.uk. But please note that your comment on the
complexity of the cases should come from your own judgment rather than using the tool.
I look forward to hearing from you. Should you have any further queries, comments or feedback on this project please do not
hesitate to contact me. Thank you again.
Best Wishes
Obie - Teaching Fellow and StR in Endodontics @ LUDH
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7.7 Clinical Cases scenarios used in the study
Case 1
 LR5
 Male 28
 Recent deep fill
 No known history of trauma
 No relevant MH
 Normal mouth opening
 EPT and Endofrost – negative
 Straight forward diagnosis: C.A.P
Sinus or Swelling Yes – tracking to

Periodontal condition Normal physiological pocketing
Restorability Assessment Good coronal tooth tissue
Sensibility Tests EPT and Endo-Frost – Negative
Tenderness to Percussion Yes
Crown condition N/A
Terminal Tooth, Denture or Bridge No
abutment
Discolouration No
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Case 2
 UR1
 Male, 25
 Metal Ceramic Crown – no contra-indication to remove crown
 Sinus
 Failed RCT
 History of trauma at young age
 Controlled diabetes. ASA II
Sinus or Swelling Sinus tracking UR1

Restorability Assessment Adequate coronal tooth tissue
Crown condition No deficiencies
abutment
Discolouration N/A
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Case 3
 UR2
 Male, 52
 Metal ceramic crown
 Root resorption
 Clear MH
 Differential diagnosis CAP, internal root resorption with perforation
Sinus or Swelling Yes

Crown condition N/A
abutment
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Case 4
 LR8
 Female, 46
 Long term IV bisphosphonate
 functional tooth – pt wishing for RCT
 No history of trauma
 Differential diagnosis CAP LR8
Sinus or Swelling No
Crown condition N/A
abutment
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Case 5
 LR6
 Female 23
 Recurrent caries occlusal
 No relevant MH
Crown condition N/A
abutment
Discolouration No
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Case 6
 UL5
 Male 38
 Already accessed at emergency dentist
 Could not locate canal
 Mild S shape canals
 No relevant MH
Crown condition N/A
abutment
Discolouration No
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Case 7
 LR3
 Female, 32
 Already accessed by GDP – unable to locate canal
 Canal space not invisible but quite reduced
 No relevant MH
 Straight forward diagnosis
Crown condition N/A
abutment
Discolouration No
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Case 8
 LR7
 Male, 38
 Large fill – traumatic exposure by previous dentist
 Abscess one month later – tooth turned non-vital
 Canal space visible but quite reduced
 Mild 10-20 degree tilted – no rotation.
 Moderately reduced mouth opening of around 25-30mm
 Moderate 10-30 degree curvature
 Controlled diabetes and hypertension. ASA II
 EPT and Endofrost – negative on LR7
Crown condition N/A
abutment
Discolouration No
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Case 9
 UR5
 Male, 47
 Firmly cemented post
 Metal Ceramic Crown – no contra-indication to remove crown
 20-30 degree tilt
 Sclerotic apical third
 Failed RCT
 Clear MH
Sinus or Swelling Sinus tracking UR5

Tenderness to Percussion No
Crown condition No deficiencies
abutment
Discolouration N/A
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Case 10
 LR5
 Female, 35
 Already accessed by GDP – unable to fill further
 Canal space invisible in coronal 2/3 third
 10-30 degree root curvature
 Very sclerotic/indistinctive in apical third
 ASA II MH
Crown condition N/A
abutment
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Case 11
 UR1
 Female, 40
 Chipped tooth at young age.
 No relevant MH
Crown condition N/A
abutment
Discolouration No
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Case 12
 UR4
 Female, 40
 Large composite restoration
 Fractured instrument(s)
 Clear MH
 Differential diagnosis CAP UR4 and failed RCT UR5

Crown condition N/A
abutment
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Case 13
 UL1
 Male, 10 years old
 Large composite restoration
 Trauma with complicated crown fracture 6/12 ago
 Open apex (80+)
 Clear MH
 Reduced mouth opening (20-25mm)
 Nervous child, limited cooperation
 Differential diagnosis CAP UL1

Crown condition N/A
abutment
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Case 14
 LR6
 Female, 34
 Referred with perforation (bifurcation)
 Previously obturated with GP
 Metal Ceramic crown – no contra-indication to remove
 Clear MH
 Differential diagnosis CAP associated with failed RCT LR6

Crown condition N/A
abutment
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Case 15
 UR4
 Male, 62
 Metal ceramic crown
 Already accessed by GDP through crown – unable to locate canals
 Canal space visible but moderately reduced apically
 ASA II - controlled
 Straight forward diagnosis: irreversible pulpitis and been accessed by GDP
 Tooth tilted
Crown condition No leakage
abutment
Discolouration No
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7.8 Poster presentation at the ESE 18th Biennial ESE Congress - Brussels,
Belgium - September 2017.
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7.9 Abstract published in the IEJ following poster presentation
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THE DEVELOPMENT OF THE ENDODONTIC COMPLEXITY ASSESSMENT TOOL

(E-CAT) FOR ASSESSING ENDODONTIC COMPLEXITY AND ITS PREVALENCE IN

GENERAL DENTAL PRACTICE

Prof Fadi Jarad

In partial fulfilment of the requirements for the

Doctor of Dental Science in Endodontics