doi:10.1111/iej.

13506

The Endodontic Complexity Assessment Tool

(E-CAT): A digital form for assessing root canal
treatment case difficulty

O. Essam1 , E. L. Boyle1, J. M. Whitworth2 & F. D. Jarad1

1
Department of Restorative Dentistry, School of Dentistry, University of Liverpool, Liverpool; and 2School of Dental Sciences,
Newcastle University, Newcastle-upon-Tyne, UK

Abstract 15 dentists to evaluate the same clinical cases and by

Essam O, Boyle EL, Whitworth JM, Jarad FD. The
Endodontic Complexity Assessment Tool (E-CAT): A digital
form for assessing root canal treatment case difficulty.
International Endodontic Journal.
Aims To develop an evidence-based, valid and reli-
able assessment tool that educational establishments
and dental practitioners may use to assess the com-
plexity of root canal treatment (RCT) utilizing digital
advancements. The study also aimed to provide a
more objective definition of the term ‘uncomplicated’
root canal treatment as described by the Association
for Dental Education in Europe (ADEE) and the Euro-
pean Society of Endodontology (ESE) undergraduate
curriculum guidelines for Endodontology.
Methodology The development process involved a
narrative review of the literature to identify the com-
plexity factors associated with root canal treatment on
permanent teeth; an iterative development and analy-
sis process to assess the weighting of these factors; and
the programming of digital software to enhance the
efficiency and user interface of the assessment form.
Validation of the tool was sought with a panel of 35
specialist endodontists to assess clinical scenarios and
assess the consensus inter-examiner agreement with
the outcomes provided by the E-CAT. The inter-user
and intra-user reliability studies were conducted with
repeating the experiment 9 months later. The ease of
use of the form was also assessed.
Results The E-CAT was successfully developed with
a total of 19 complexity criteria and hosted on a secure
server under the domain of www.e-cat.uk. The tool
provides a smart interactive filtering mechanism and
automatic background calculation of the risk scores.
Three levels of complexity were defined: class I (uncom-
plicated), class II (moderately complicated) and class III
(highly complicated). The consensus of the panel of
endodontists had excellent agreement with the out-
come of the E-CAT. The inter-user and intra-user relia-
bility was found to be 0.80 and 0.90, respectively. The
average time to assess a case was 1:36 min.
Conclusion The E-CAT gave promising results pro-
viding an efficient and reliable platform to assess the
complexity of cases undergoing root canal treatments.
The study design allowed the formulation of a more
objective definition to describe ‘uncomplicated’ root
canal treatment as referred to by the ESE and ADEE
guidelines. This study is advantageous for educa-
tional, public health and referral pathways.
Keywords: endodontic complexity assessment,
nonsurgical root canal therapy difficulty assessment,
case assessment form.
Received 9 March 2020; accepted 2 March 2021

Correspondence: Obyda Essam, Department of Restorative Dentistry, School of Dentistry, Pembroke Place, Liverpool, L3 5PS,
UK (e-mail: obyda.essam@gmail.com).

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits
use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial
purposes.

© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd International Endodontic Journal 1
on behalf of British Endodontic Society.
 The Endodontic Complexity Assessment Tool (E-CAT) Essam et al.
Introduction
The provision of endodontic treatment can vary signifi-
cantly in its complexity. Some cases can be relatively
uncomplicated and require the skills of an undergradu-
ate student or recent graduate to achieve a predictable
outcome, whilst others demand advanced management
skills, knowledge and technical expertise (AAE 2005).
However, judging the level of endodontic complexity
can be seen as subjective (Rosenberg & Goodis 1992),
with cases considered complex in the opinion of one
clinician appearing uncomplicated in the view of
another. Dentists in primary care continuously face
ethical and legal dilemmas whilst attempting to deter-
mine the complexity of cases presenting to them and
balancing the skills and facilities at their disposal with
the need to deliver a favourable clinical outcome for
their patients. Formal case assessment before com-
mencing treatment may pre-empt challenges by identi-
fying potential difficulties, thus avoiding higher risk of
iatrogenic damage and treatment failure and fulfilling
the critical dictum of ‘first do no harm’. Such informa-
tion may inform discussions with patients about the
challenges of securing a predictable outcome, the ideal
environment to undertake treatment, the financial
costs and risks to be considered if a referral is required,
or is not possible (Dietz & Dietz 1992, De Cleen
et al. 1993). Furthermore, from a clinical governance
perspective, the ability to classify treatment complexity
more predictably using a validated tool may efficiently
facilitate clinical audits and service evaluations.
In educational settings, an objective and structured
assessment process may also help undergraduate stu-
dents to actively look for a range of factors that may
complicate the management of a clinical case beyond
the remit of uncomplicated care (ESE et al. 2013, GDC
2015, Field et al. 2017). One challenge for educators is
finding an objective definition of complexity. Expert
bodies such as the Association for Dental Education in
Europe (ADEE) and the European Society of Endodon-
tology (ESE) have recommended that graduating den-
tists are competent in the endodontic management of
‘uncomplicated’ anterior and posterior teeth, but with-
out spelling out their definitions in any detail
(ESE 2013, Qualtrough 2014, Al Raisi et al. 2019).
This openness to interpretation poses a challenge to
educators and practitioners alike who are responsible
for appropriate case allocation to secure safe and effec-
tive care and a satisfactory patient and practitioner
(student) experience. Finding a standardized process to
2 International Endodontic Journal © 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
define the ‘uncomplicated’ may be advantageous (Dietz
& Dietz 1992, Messer 1999).
Although several case assessment tools already
exist (CAE 1998, Falcon et al. 2001, Ree et al. 2003,
AAE 2005), little work has been undertaken to assess
their validity and reliability. Despite their potential
benefits, they may be time-consuming to administer
and less user-friendly than ideal (Curry 2010). A sys-
tem promoted by the American Association of
Endodontists (AAE 2005) applies a comprehensive list
of parameters to identify cases within the general
dentist’s scope of practice and those cases in which
advanced and specialist skills may be recommended
(AAE 2005). In an attempt to develop a more stream-
lined triaging tool, Ree et al. (2003) introduced the
Dutch Endodontic Treatment Index (DETI) and the
Endodontic Treatment Classification (ETC), though
even these versions were reported to need simplifica-
tion to improve their utility. The Restorative Index of
Dental Treatment Need (RIOTN) (Falcon et al. 2001)
was also introduced as an easy system to administer,
with no scores to add up, but the process of simplify-
ing this tool omitted important criteria such as medi-
cal history, previous treatment and patient-related
factors. Muthukrishnan et al. (2007) highlighted the
drawbacks of this simplification and suggested that
the system was incomplete with moderate to poor
reproducibility.
Therefore, this study aimed to develop a reliable
and intuitive digital case complexity assessment tool
for assessing teeth for root canal treatment; the
Endodontic Complexity Assessment Tool (E-CAT).
Materials and Methods
The development process was conducted over 5 stages
(Figure 1).
Stage 1: Narrative review of the factors which may
impact on endodontic case complexity
Online databases (MEDLINE (OVID) database,
PUBMED database, the EMBASE database, the
Cochrane Central Register of Controlled Trials (CEN-
TRAL), Scopus, Web of Knowledge and Google Scho-
lar) were searched for English language publications
from 1945 until October 2018, using combinations of
keywords shown in Table 1. The first author con-
ducted this process. Each keyword from the first
group was combined with every keyword of the
on behalf of British Endodontic Society.

Figure 1 An overview of the E-CAT development stages.
Table 1 Search keywords for narrative review
Search keywords
Endodontics OR root canal therapy OR non-surgical
endodontics, OR surgical endodontics OR root canal
treatment OR root canal retreatment
AND
Complexity OR complex OR complicated OR complication,
uncomplicated OR difficult OR difficulty OR challenges OR
risk assessment OR evaluation OR valuation OR
determination
second group. The abstracts of the articles revealed in
the search were reviewed. Where the abstract men-
tions factors relating to endodontic complexity, the
full text was read.
The literature search also included a cross-check of
the factors reported in previous case assessment forms
(CAE 1998, Falcon et al. 2001, Ree et al. 2003, AAE
2005).
All articles containing one or more reported factors
affecting the complexity of root canal treatment were
reviewed. The factors included were those that could
impact the overall management of the case and not
just the endodontic procedure’s technical challenges.
All reported factors were included regardless of the rel-
ative level of complexity they may impose. However, a
note was made about the relative risk reported within
the publication when available. All factors identified
were tabulated and assigned a relative risk level (low,
medium and high) according to the description of the
article. Factors judged to be similar were grouped into
a larger category (e.g. factors related to medical his-
tory, canal identification and negotiation).
© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
on behalf of British Endodontic Society.
Essam et al. The Endodontic Complexity Assessment Tool (E-CAT)
The results were then uploaded to software devel-
oped by a programmer for the iterative development
stage. This is described further in Stage 2 below.
Stage 2: Developing software algorithm to measure
the level of risk factors
Having identified a broad range of risk factors that
could complicate endodontic treatment, an iterative
development process was followed to assign each with
an objective risk level for the software, indicating the
risk factor’s seriousness (Larman & Basili 2003, Sri-
vastava & Hopwood 2009).
In collaboration with two specialists in Endodontics,
the principal author selected a total of 75 pre-assessed
real-life clinical cases. This was the number of cases
required to ensure that all the complexity factors
identified in Stage 1 were covered. These cases were
assessed by the dentist managing the case (first-year
postgraduate endodontic trainee) and their clinical
supervisor (specialist in Endodontics) following discus-
sion. The rationale for having the treating clinician
and supervising consultant assess the complexity was
that they had actual clinical exposure to the case and
theoretical knowledge of risk factors. In cases of dis-
agreement, a third clinician (specialist in Endodontics)
was consulted to arrive at a final decision. The cases
were assigned to one of 3 complexity levels (uncom-
plicated, moderate complexity and high complexity),
based on the clinicians’ experience treating the case.
The guidelines given to assist with grading are pro-
vided in Table S1.
The complexity levels assigned for each of the 75
cases were tabulated, before assessing the cases
International Endodontic Journal 3
 The Endodontic Complexity Assessment Tool (E-CAT) Essam et al.
Figure 2 The iterative process of developing the algorithm.
within the software application described in Stage 1.
The operator was blinded to the answer of the case
until after the software revealed the complexity level.
Figure 2 below illustrates the cyclic process of devel-
oping the case complexity assessment algorithm.
All of the factors identified in Stage 1 were inputted
into the software. Provisionally, the Endodontic Treat-
ment Classification (ETC) risk scores and AAE case
assessment forms were used as a baseline (Ree
et al. 2003, AAE 2005). Therefore, the software was
instructed to initially have an algorithm of 1 for fac-
tors with minimal or no reported impact on complex-
ity, 2 for moderate, and 5 for the highest reported
complexity. The baseline was set for a range of 19 or
below as class 1 complexity, 20–25 as class 2, and
26 or above for class 3. The software was then run to
process each of the 75 cases against the set algorithm.
When the algorithm did not match the score of clini-
cians managing the case, the software highlighted the
factors which led to the score assigned, which were
then manually adjusted. The case was then re-tested
using the tool to ensure the adjustment matched the
clinical assessors’ consensus.
Adjusting the value of one factor to match one case
had the potential to change the overall outcome of
other cases. Therefore, whenever an adjustment was
made in one case, the author went back to the begin-
ning and started assessing the cases again using the
new values assigned. This resulted in repeated appli-
cations of the tool to evaluate the 75 cases in a cyclic
(iterative) manner until the outcome of all 75 cases
following the adjustment of all the factors’ values was
in agreement with that encountered by the clinicians
managing the case.
4 International Endodontic Journal © 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
Stage 3: Software development
The software was developed over two phases. The
prototype, named the Endodontic Complexity Assess-
ment Tool ‘E-CAT’ (version 1.0), simply aimed to digi-
tize the paper forms used by Ree et al. (2003) into a
user-friendly online format which automatically added
up the complexity scores in the background and gen-
erated a summative answer. The time-saving features
were intended to be the automatic summation of
scores and hiding any questions that were irrelevant
to the case. This version was piloted with five general
dentists; all participants commented positively on the
concept but reported negatively on the length of time
for assessment and difficulties with user interface
despite its digital nature. The average time taken for
participants to fully assess a case was 4 min 31 s
(34 s).
Version 2.0 of the software was subsequently devel-
oped with two software programmers and contained
a novel approach to filtering and surveying questions.
This meant that the tool’s first page included simple
keywords with short questions to help keep the
assessment questions minimum. If a domain was not
relevant (e.g. no history of previous endodontic treat-
ment), then the questions related to that domain were
hidden to help reduce the assessment time. A list of
the topics warranting their individual domains can be
found as an electronic copy in Table S2.
The filtering questions were designed to ensure that
all the relevant questions were displayed in each case.
This was tested as part of the iterative process
described in Stage 2.
Stage 4: Assessing the validity of E-CAT
One hundred independent endodontic specialists were
invited to participate in a validation exercise by digital
random selection from the UK specialist list (n = 287
registrants). These were approached by email and
direct contact at a national endodontic meeting in the
UK. Their age, years of experience, gender and geo-
graphic location were noted. A panel of 35 indepen-
dent UK-registered endodontic specialists was
subsequently recruited to assess the validity of the
tool. Their experience varied between 2 and 20 years,
including both specialist practice and university- or
hospital-based practice. Each specialist was provided
with 15 anonymized clinical cases with clinical pho-
tographs, radiographs and pre-treatment clinical
on behalf of British Endodontic Society.

information including medical history, physical limita-
tions and degree of mouth opening. This was the
minimum number of cases required to have a repre-
sentative sample of cases to include most of the litera-
ture review’s risk factors. Each specialist was asked to
independently assess the complexity of each case and
assign it to case complexity 1 (uncomplicated), 2
(moderate complexity), or 3 (high complexity). Judge-
ments were made without any objective criteria from
the research team.
The results for each specialist and each case were
recorded by dual entry to a Microsoft Excel spread-
sheet (MS Excel 2016, version 14.0; Microsoft, Seat-
tle, WA, USA). The inter-rater correlation of each
case was calculated. The consensus was assessed by
calculating the mode and the weighted kappa.
The specialists’ consensus on each case’s complex-
ity was considered the ‘gold standard’ assessment and
was compared to the outcome achieved with E-CAT.
The same 15 cases were further randomized and
analysed using E-CAT version 2.0 with the primary
author’s data input before obtaining the results of the
35 endodontic specialists. E-CAT and specialist scores
were comparison at a later date.
The specialist consensus (class 1, 2 or 3) and the E-
CAT classification outcome (1, 2 or 3) were entered
into a Microsoft Excel spreadsheet as before. The
tool’s validity was then assessed by calculating agree-
ment (Cohen’s kappa coefficient) between the consen-
sus of the panel and the independent outcome
recoded with E-CAT assessment.
Stage 5: Assessing the reliability of E-CAT
A study was designed to assess the inter-rater and
intra-rater reliability of the E-CAT tool. An advert
posted at the University of Liverpool and Social Media
invited local general dental practitioners (GDPs) to
participate in this study. A total of 15 GDPs were
recruited, none with endodontic speciality status.
Each was provided with a short tutorial on the E-CAT
tool’s use and allowed the opportunity to assess three
independent standardized cases provided by the
research team before starting the study. Each partici-
pant was provided with the same 15 anonymized
clinical cases as in Stage 4. They were then asked to
independently use E-CAT version 2.0, inputting the
clinical information provided with each of the 15 clin-
ical scenarios.
The E-CAT class (1, 2 or 3), the time required to
complete the assessment of each case (seconds), E-
© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
on behalf of British Endodontic Society.
Essam et al. The Endodontic Complexity Assessment Tool (E-CAT)
CAT score (value in points), criteria selected and the
participants’ subjective judgement of case complexity
(1, 2 or 3) were recorded in a Microsoft Excel spread-
sheet (MS Excel 2016, version 14.0).
The users were also asked to rate their experience
using the tool on a 0-10 Visual Analogue Scale
(VAS), where 0 was very simple and 10 was very dif-
ficult.
To assess the tool’s intra-rater reliability, the study
was repeated nine months after the initial study. Data
were recorded and analysed with the inter-class coeffi-
cient agreement (kappa) to each rater was assessed.
Results
Stage 1: Narrative review of the factors which may
impact on endodontic case complexity
The literature search identified 112 articles of relevance.
Detailed examination of manuscripts yielded factors
relating to case complexity (Table 2), included in the E-
CAT assessment form. The quality of available evidence
on endodontic case complexity factors ranged from low,
including case reports, narrative reviews, expert opin-
ions and textbooks, to higher quality systematic reviews
with meta-analysis. No studies were excluded based on
study design, as the aim was to identify all the potential
factors which may affect complexity. The weighting of
these factors was then decided in the iterative develop-
ment and validation stages.
Stage 2: Developing software algorithm to measure
the level of impact of the risk factors
A total of 32 iterative cycles were conducted before
achieving a fitting algorithm model for the 75 clinical
cases. A table with the factors can be found as an
electronic copy in Table S3. The software was pro-
grammed to contain all the factors with the ability to
adjust the algorithm scores should this be necessary
for the future.
Table 3 shows the model of classification which fit-
ted the iterative development. The E-CAT score, how-
ever, is kept hidden in the background at this stage.
Stage 3: Software development
The E-CAT software was successfully developed with
19 complexity categories and 22 complexity factors to
address them. The tool is currently hosted on a secure
server under the domain of www.e-cat.uk, where full
International Endodontic Journal 5
 The Endodontic Complexity Assessment Tool (E-CAT) Essam et al.

Table 2 Results of literature search on endodontic factors affecting endodontic treatment complexity

Factors affecting Related article

management complexity Details in appendix

1. Complex diagnosis
2. Pre-treatment prior to
commencement
3. Physical barrier to
conventional radiographs
4. Medical history,
anaesthesia and patient
management
5. History of dental 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
11. Access to root canal
system
12. Root curvature
13. Root canal morphology
14. Apical morphology
15. Canal calcification/
radiographic visibility
16. Previous endodontic
treatment
17. Iatrogenic incidents
18. Root resorption
19. Periodontic–endodontic
lesion involvement
Diagnosis complicated by conflicting signs or symptoms, possible non- (1–4)
odontogenic orofacial pain, further specialist investigation necessary
Caries removal, restorative build-up to allow isolation, margin elevation, (5–10)
crown removal, etc.
High floor of mouth, severe gag reflex or superimposition of teeth or other (11–14)
structures
For example, diabetes, bisphosphates, cancer therapy (5, 15–26)
All types of dental trauma, including fractures, avulsion or luxation injuries (27–33)
Physical limitations (unable to recline) or psychological (anxiety) (15, 34–36)
restrictions
For example, reduced or limited mouth opening or intra-occlusal distance (15, 34)
Position of tooth within the arch (37–39)
Proclined or retroclined teeth, buccally or lingually displaced teeth or (40, 41)
rotation due to crowding or previous orthodontic treatment
Presence of large direct restorations masking original morphology, indirect (8, 42–44)
onlays or crowns
Presence of pulp stones, post or core build-up (45–48)
Degree of root curvature (49–56)
Number of canals within the root, shape of canal, presence of invagination (57–73)
etc.
Immature apices, open apex, etc. (27, 74–79)
Degree of canal calcification, visibility of pulp chamber, etc. (53, 80–85)
This includes obturated canals or attempts to access canal, pulp (86–95)
extirpation or surgical endodontics
Perforations, ledges, separated instrument, etc. (44, 96–100)
Internal or external root resorption, apical root resorption (101–106)
Perioendo lesions, increased mobility or furcation involvement. (107–112)

A total of 19 categories were identified to be associated with the risk of encountering complexity or adverse outcomes. An elec-
tronic file (Table S3) can be found with the articles used.

Table 3 The range of E-CAT score to describe the class of each case

Class Range Terminology and significance

1 0-5 Uncomplicated, low risk of management difficulty and adverse outcomes

2 6–11 Moderately complicated, moderate risk of management difficulty and adverse outcomes
3 >11 Highly complicated, high risk of management difficulty and adverse outcomes

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 rel-
atively uncomplicated cases. A score of 12 or above is found to have a high risk of complication and adverse outcome.

details of its functionality can be found. The language

used was PHP MySQL. The idea was for the tool to be
available for use across most platforms through a
web-based page, with clinicians able to access from
internet-enabled hand-held and desktop devices.
The software was designed to allow authorized
administrative staff to update the tool with new fac-
tors or algorithms should that be necessary.
Stage 4: Assessing the validity
A total of 35 endodontic specialists participated. The
age range was between 31 and 68, with 60% male and
40% female. The inter-rater reliability was moderate
(Kappa = 0.51, 95% CI: 0.49–0.52). The most fre-
quently rated result (the mode) was taken to be the
consensus of the panel of endodontic specialists. When

6 International Endodontic Journal © 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
on behalf of British Endodontic Society.
 Essam et al. The Endodontic Complexity Assessment Tool (E-CAT)

Table 4 The most common miss input or omitted factors quality evidence was found to support them. The cri-
Frequency of
teria included in the current research were selected
Most common factors resulting in error % (n = 450 following an in-depth search of the literature. It is
inter-rater variability assessments) acknowledged that a systematic review would have
Canal visibility 16%
been ideal, however, considering the subject being
Root curvature 11% investigated and the multiple factors involved, the
Degree of inclination of tooth 3% authors felt that a systemic review involving only
Not stating ‘high quality’ publication might not be feasible. It
History of trauma 3%
might also result in missing some less widely reported
Previous endodontic treatment 3%
Iatrogenic damage 2%
factors that may be more readily picked up in a nar-
Reduction in mouth opening 1% rative review. It is the intention that the tool can be
Medical history 1% updated regularly as further, and better quality evi-
Overstating apical root resorption 1% dence becomes available. The tool is designed to allow
Accidently stating unrelated factors 3%
risk scores to be easily adjustable to accommodate
Other miscellaneous errors 3%
evidence and technology changes. As such, a research
Assessing canal visibility and root curvature were found to be committee has been established at the University of
the most inconsistent factors within the group.
Liverpool, whose role is to review and re-evaluate the
tool annually. This will include updates in the litera-
compared to the result that the E-CAT outcome ture, comments from users and ongoing future
recorded, the consensus was in full agreement (100%) research.
with E-CAT in all 15 cases. The factors included were all of those reported to
affect the overall management cases, where more spe-
cialized knowledge, skill and experience may be neces-
Stage 5: Assessing the reliability
sary to deliver a predictable outcome. Therefore, even
A total of 15 general dental practitioners participated. though a complex diagnosis or medical history may
The age of the participants was between 24 and not directly impact the root canal treatment’s techni-
60 years, eight males and seven females. The inter- cal difficulty, the case’s overall management may
user and intra-user reliability were found to be very demand more significant expertise and knowledge on
good (Kappa = 0.80, 95% confidence interval: 0.77– how those factors may affect the endodontic outcome.
0.83 and 0.90, 95% confidence interval: 0.85–0.92 Four out of the five dentists included in the pilot
respectively). study commented on the confusion associated with J-
The average time taken to assess a case was 1 min shaped and I-shaped roots. The literature review did
36 s (SD  32 s). The ratings related to the ease of not reveal direct evidence to support whether I- or J-
use of the tool ranged from 0 to 4, with an average shaped roots would affect case complexity. However,
of 2 (1.1). The median and the mode were 1 (on a evidence was identified for the complexity of manag-
scale from (0 = very simple to 10 = very difficult). ing C-shaped canals and S-shaped roots (Martins
However, the most common reasons for not achiev- et al. 2013, Machado et al. 2014, Sakkir et al. 2014).
ing excellent inter-rater reliability were the subjectiv- The I- and J-shaped roots were incorporated into the
ity of some of the complexity factors assessed by root anatomy and curvature assessment. The S-shape
the observer. The most common reasons for inter- and C-shape criteria were included under complex
variation across the participants are listed in Table 4. morphology of the root canal system.
The presence and size of a periapical lesion were
well documented to negatively affect the outcome of
Discussion
endodontic therapy (Marquis et al. 2006, ESE 2006,
The study design and overall methodology were found Ng et al. 2008). However, it was concluded from the
satisfactory to meet the objective set for this study. current literature review that even though the pres-
Producing a comprehensive list of the factors associ- ence of a periapical lesion is a prognostic factor in
ated with endodontic treatment complexity was chal- achieving a successful outcome, it does not seem to
lenging. Despite the listing of similar case complexity require further knowledge or complicate the overall
criteria in several assessment tools (Falcon management or the technical aspects of root canal
et al. 2001, Ree et al. 2003, AAE 2005), little high- treatment any further. Therefore, a decision was

© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd International Endodontic Journal 7
on behalf of British Endodontic Society.
 The Endodontic Complexity Assessment Tool (E-CAT) Essam et al.
made not to include the presence of a periapical
lesion as a complexity factor in this tool (Ng
et al. 2010, Pak et al. 2012).
Another alteration made related to the canal subdi-
vision in the middle or apical third. This was a
reported complicating factor in several publications
(Reddy et al. 2012, Albuquerque et al. 2014, Wu
et al. 2017). However, those same publications
reported the difficulty of diagnosis using conventional
periapical radiographs and other 2-D imaging. Evalu-
ation of the DETI tool (Ree et al. 2003) reported on
this criterion’s vagueness. These factors are now
accounted for within the ‘canal visibility’ criteria or
the ‘root canal morphology’ criteria surveying ques-
tions.
A significant modification implemented in this tool
compared to the endodontic case assessment forms
(Ree et al. 2003, AAE 2005) is the background auto-
mated algorithm calculating the risk level. 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 assigned in
other systems, the range of values was changed to be
anywhere between 0 and 10, adding 8 further possi-
ble scoring points to the range. The more complex
software algorithm may have led to good level of
validity and reliability achieved.
Prior to this study, the iterative development of this
sort has been successfully applied in medicine. Two
groups with medical and pharmacological back-
grounds (Haugen et al. 2014, Melton et al. 2016)
used a similar approach to develop clinical decision
support systems, reporting ‘good’ to ‘very good’ over-
all satisfaction and significant time-saving improve-
ments. In the E-CAT’s development, the iterative
development process proved time-consuming to
achieve a fitting model. The number of iterations
required proved higher than those reported above,
but this is possibly due to the higher number of fac-
tors involved and the high number of calibrating
cases selected to ensure a fitting model. The develop-
ment process to produce the algorithms appeared to
be advantageous in determining a more accurate
overall risk assessment.
One of the aims of this study was to derive a more
objective definition for the term ‘uncomplicated root
canal treatments’ described by the ESE and ADEE (ESE
2013, Field et al. 2017) undergraduate curriculum
guidelines. Reviewing the diverse factors that can
impact endodontic treatment complexity, it is not sur-
prising that achieving a precise definition is
8 International Endodontic Journal © 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
challenging. Despite its lengthy nature, the following
description is a simplified definition of what may consti-
tute an uncomplicated case for endodontic treatment:
Anterior or posterior teeth (excluding 3rd molars)
exhibiting the following conditions
• Straightforward clinical diagnosis
• No patient-related medical conditions, or having
well-controlled medical conditions – ASA Classes I
and II
• Patients with no physical limitations (i.e. normal
mouth opening, good cooperation, no restriction
to reclining in the dental chair)
• Patients with no psychological limitations (i.e.
cooperative patient, able to receive treatment with-
out sedation)
• No radiographic challenges, including no struc-
tures causing radiographic superimposition, no
severe gag reflex, regular 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
• Tooth length or working length no longer than
31mm.
• No extra-coronal restoration present, or cases
where a crown, bridge or onlay are present but
planned to be removed before commencing treat-
ment
• No post or core present
• No or minimal tooth inclination and rotation (<
15°)
• Teeth with minimal or no root curvature (< 15°)
• Closed (fully formed) apical morphology (<size
60 k-file)
• Radiographically clearly visible pulp chamber and
canal space from pulp chamber to apex
• No known atypical root canal shape (e.g. S- or C-
shaped 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 dental trauma
• No previous endodontic treatment
• No history of iatrogenic tooth injury during previ-
ously initiated endodontic treatment
on behalf of British Endodontic Society.

• Single rooted (single canals) teeth sub-optimally
obturated with gutta-percha (short or poorly con-
densed) root fillings
Strictly speaking, the above would be the cases scor-
ing 0 with the E-CAT. However, cases with certain risk
factors may still be classified as ‘uncomplicated’ in an
educational environment. Based on this study’s results,
an E-CAT score of ≤ 5 (Class 1) would be a reasonable
definition of uncomplicated nonsurgical root canal
treatment. This defines those cases suitable to be man-
aged by undergraduate dental students, recent dental
graduates or dentists, without any further postgradu-
ate training in endodontics. However, this would
require additional validation in the context of a
broader study, ideally in multiple centres.
Evaluating the validity of an assessment tool or
index can take numerous forms. This study’s valida-
tion approach can be compared against other clinical
assessment tools and indices in Dentistry. For
instance, the Index of Orthodontic Treatment Need
(IOTN) is a widely used (Brook & Shaw 1989) and
has become a public health commissioning tool for
screening cases in the UK National Health Service
since 2006 (Jawad et al. 2015). The accuracy or
validity of the IOTN index was assessed against the
mean opinion of a panel of 18 orthodontists as a gold
standard (Younis et al. 1997). The agreement
obtained for IOTN was 83% for inter-examiner for the
dental health component. For this study, 35 endodon-
tists were recruited via multiple contact methods,
which may pose a small selection bias risk theoreti-
cally. The authors acknowledge that in an ideal
world, the contact method would have been standard-
ized for all members recruited to minimize selection
bias, but this had to be balanced with the practical
issues of obtaining a large enough panel size. The aim
was to maximize the response rate by using multiple
recruitment methods in a small group of specialists.
Despite the larger panel of 35 specialists, this study
had similar results with 78% inter-examiner agree-
ment. The Kappa score attained for the panel clearly
demonstrates this topic’s subjectivity and is not sur-
prising. The endodontists mostly disagreed when the
case was classed to be moderately complicated.
Finally, the inter-user and intra-user reliability in
this study was found to be good to very good. How-
ever, this study still demonstrated the limitations of
assessment tools due to the variation associated with
dentists either overstating or understating some com-
plexity factors when using the tool (e.g. assessing root
© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
on behalf of British Endodontic Society.
Essam et al. The Endodontic Complexity Assessment Tool (E-CAT)
curvature, level of radiographic canal visibility).
Despite these variations, the results did not signifi-
cantly affect the outcome in the sample of 15 cases.
A larger-scale study with large sample size may show
different results. One solution to tackle the variability
could be to offer the dentists further training to
improve their assessment of the most commonly
reported errors shown in Table 4. Calibration exer-
cises have been shown to significantly improve assess-
ment tools’ reliability (Richmond et al. 1995,
Hancock & Blinkhorn 1996). The training may be
done through workshops or an online tutorial or a
combination of both. Further research is already
underway to develop an educational tool to improve
the utility of this E-CAT.
Conclusion
This study demonstrated that despite best efforts, the
development of a perfectly accurate tool to assess root
canal treatment complexity is challenging. The valid-
ity and reliability of this tool were found to be promis-
ing yet not perfect. The E-CAT provides an efficient
and reliable platform to assess the complexity of teeth
for root canal treatment and presents a smart inter-
face automatic background calculation of the risk
level. The development design allows the tool to be
continuously improved based on new evidence. This
will be highly advantageous for educational establish-
ments, public health use and referral pathways.
Acknowledgement
Partial funding was awarded by the European Society
of Endodontology (ESE) to develop and maintain a
tool to reliably define the different levels of complexity
of endodontic cases for educational and professional
use. This ultimately can define that ’uncomplicated’
category in the ADEE and ESE guidelines and help
provide a baseline level of competence as a reference
point. The funding helped in reimbursing the software
developers and hosting the new digital tool on a
secure server.
Conflict of interest
Dr. Essam reports grants from European Society of
Endodontology during the conduct of the study. The
other authors have stated explicitly that there are no
conflicts of interest in connection with this article.
International Endodontic Journal 9
 The Endodontic Complexity Assessment Tool (E-CAT) Essam et al.
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Supporting Information
Additional Supporting Information may be found in
the online version of this article:
© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd
on behalf of British Endodontic Society.
Essam et al. The Endodontic Complexity Assessment Tool (E-CAT)
Table S1. Guidelines provided to the clinical asses-
sor of the cases, including on stage 2 of the tool
development.
Table S2. Showing the results of literature search
on endodontic criteria affecting endodontic treatment
complexity.
Table S3. Showing the results and articles of nar-
rative literature review on endodontic criteria affect-
ing endodontic treatment complexity.
International Endodontic Journal 11