The report of the Swedish Council on Health Technology Assessment on the Methods of Diagnosis and Treatment in Endodontics (2012), disclosed “Extensive shortcomings in the scientific basis underlying methods applied for endodontic diagnoses and treatment.” Along the same lines, primarily written for practicing dental hygienists, the author analyzes the conventional patient examination diagnoses methods used in endodontics, periodontics, and restorative dentistry and presents a patient examination and diagnosis protocols, which are clinical- efficient, evidence-based, and patient-centered.

Educational Objectives

The content of unit one is organized to accomplish three objectives:

1. Identify the shortcomings of the conventional diagnostic tests used in clinical Endodontic, Periodontic, and Restorative Dentistry.
2. Describe the technical and biologic limitations of the Diagnostic Imaging of Periapical, Bitewing, Panoramic Radiographs.
3. Describe the components of the evidence-based, biology- oriented best practices in Endodontic-Periodontic -Restorative diagnostic process.

The author identifies seven reasons or factors that complicate the diagnosis of oral and dental pain.

1. The clinicians' insufficient application of biologic principals in dental practice.
2. Heavy reliance on technical and inadequate diagnostic tests.
3. The variance of Patient's pain threshold.
4. The anatomic density of oral-maxillofacial structures may cause intermingling of the signs and patterns of pain
5. Lack of correlation between pain and pathology.
6. The Radiographic findings do not correlate with Pathologic findings.
7. Overlapping and mixing of Pulpal and Periodontal Pathologies.

Fortunately, 90% of the Patient's oral and dental pains encountered in dental practice are "Toothaches." Therefore, the author recommends two clinical approaches for making accurate diagnosis of Dental pain. The first requires understanding of the anatomic and pathologic basis of dental pain, selecting specific tests, identifying and taking account of the above seven influencing factors. The second approach embraces Walden Bell's advice: "A good rule for any Examiner is to consider all pains about the mouth and face to be of dental origin. A Toothache until proven otherwise."

Learning the unit content empowers practicing dental hygienists with the academic knowledge and diagnostic skills to converse with and educate patients, collaborate with dentists to deliver quality dental care effectively.

Educational Objectives

The content of unit two is organized to accomplish the following objectives:

1. List the seven reasons that complicate the diagnosis of oral and dental pain.
2. Describe the normal and abnormal diagnostics of the 10 ADI
3. Explain how do tooth sensibility and toothache occurs as explained by the hydrodynamic theory
4. Identify the factors that Influence the Patient's pain threshold.

According to the ADA- statistics, an average of 22 million endodontic treatments performed is performed annually in the USA. Therefore it is destined that the practicing dental hygienists have to interpret OPG, PA, and BW radiographs of patients with one or more of the followings : Endodontic pathologies, Standard Endodontic Treatments, Substandard and Failing Endodontic Treatments, Endodontic Posts and Cores, and Surgical Endodontic Treatments.

Dental Hygienists should be able to inform, dialogue, and educate patients about their endodontic problems and efficiently collaborate with the dentists in the provision of proper, efficient, and quality care.

Endodontics, Periodontics, and Restorative Dentistry constitute the core of the General Dentistry Practice. The author presents more than 200 radiographs that espouse that concept. 

"The 10 Areas of Diagnostic Interest" (10 ADI).is used for the assessment and interpretation of the radiographs presented in this unit. The protocol offers an evidence-based, systematic approach for radiographic examination of the standard and abnormal anatomic component of the Endodontium and Periodontium of teeth imaged with Periapical (PA) and Bite-wing (BW) radiographs. 

Educational Objectives

Unit 5 content has been organized to achieve the following objectives:

1. List the Ten Areas of Diagnostic Interest (10 ADI) protocol.
2. Describe the radiographic features in the health and disease for each area of the 10ADI protocol 
3. Interpret (PA) and (BW) radiographs of the dental Pulp, periapical, periradicular disease, and Standard and substandard endodontic treatments 
4. Use the collected diagnostic data to converse and educate patients about their problem
5. Communicate the diagnostic findings to the attending dentist and collaborate in the provision of efficient Quality care.

The detection and diagnosis of the TSC is perhaps the most difficult aspect in the management of the cracked, fissured and fractured teeth in dental practice. In this five parts series the 4Rs operational diagnosis protocol(4Rs OD) is used as a best dental diagnosis practice.

The protocol was specifically developed to remedy the shortcomings of the conventional Endodontic diagnosis tests.

The protocol helps the clinician to use the skills of: hearing, seeing and acting to accurately learn the patient problem.

The(4Rs OD) protocol provides the clinician with multidisciplinary, systematic approach for collecting, analyzing, and synthesizing the examination data into diagnostic, treatment planning, and prognostic decisions.

The 4Rs OD consists of the followings assessment tests:

R1: Report of the patient assessment
R2: Radiographic assessment
R3: Response testing assessment
R4: Restorative and tooth structure assessment

Clinical management of cracked teeth in dental practice is an area replete with misunderstanding and misinformation. First, the literature lacks prospective studies and clinically useful universal definitions. Second, although cracked teeth problems vary significantly in diagnosis, treatment and prognosis. The literature terminology does not specifically differentiate between “Fractured teeth”, “Cracked teeth”, “Cracked Tooth Syndrome”, “Green stick fractures” and “Incomplete coronal fractures”.

The author’s 3x3 Tooth Structure Cracks (TSC) classification, grouped the various terminologies which relate to the cracked or fractured teeth problems, under one term “Tooth Cracks”. Then defined and classified the “cracks” according to their anatomic, physical and pathologic characteristics.

Physically, “Tooth Cracks” are classified into:

• Line Cracks
• Fissure Cracks
• Fracture Cracks

Anatomically, “Tooth Cracks” are classified into:

• Marginal Ridges
• Grooves
• Surfaces

Pathologically, “Tooth Cracks “are classified into:

• Contributory
• Noncontributory
• Partially Contributory

The webinar presentation shows how to differentiate between the harmless “noncontributory crack” and the harmful “contributory crack”.

Contributory cracks cause reversible and irreversible pulpitis, pulp calcification, pulp necrosis, periapical and periradicular lesions. On the other hand, noncontributory cracks could be microscopically visible microcracks or clinically visible line. These cracks remain at the early initiation or development stages for years. They remain still and stationery, cause no pulpal or periodontal pathology as long as they are not pressured, and stressed by new forces or loads. Forces such as root filling condensation or traumatic fitting of a post.

Updated information about the etiology and initiation mechanism of tooth cracks is presented focusing on:

• Abusive restorative procedures that cause coronal cracks
• Abusive mechanical endodontic procedures that cause radicular cracks
• Abusive post placement procedures
• Dental occlusion factors

In the introduction of the program, the author reveals an alarming 24%-60% global prevalence of Apical lesions in teeth with inadequate root canal treatment. The literature’s histopathologic term used in describing these lesions is Apical Periodontitis. (AP). The statistics are alarming because the “Standard Normal” prevalence of Apical lesions in endodontically untreated teeth is 1½% - 7%.

This program stands for the management of teeth with substandard endodontic treatment failures because of the evidence-based relationship between abusive endodontic treatment, and root structure cracks initiation and propagation. Abusive endodontic treatment is one form and a principal cause of substandard endodontic treatment. More on this relationship discussed in Part III of the master class series.

The program is composed of Seven (7) Chapters planned to include the most clinically relevant facets of the inadequate or sub-standard endodontic treatment.

This program offers concepts, methods and guiding principles based on evidence, and tested clinical practices. The goal is to enhance the clinicians understanding of endodontic treatment diagnostics and the relationship between endodontic treatment and tooth structure cracks.