Master Class

PART I: Introducing the 4Rs Operational Diagnosis Protocol
A Comprehensive Systematic Approach for Endodontic Diagnosis

Preview Only, Purchase Required For Full Program Access.

Effective Date: September 1, 2017
Expiration Date: August 31, 2020
Format: Self Instructional - Audio Visual Voice-Over with Slides
Estimated Completion Time: 3 hours

Getting Started

Read all the information presented below. When ready select the Introduction or appropriate tab above.

Program Summary

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(4RsOD) 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(4RsOD) 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
A key assessment step which require the patient to document his or her chief complaint and pain history details. The Patient Pain Profile developed in this step is essential to help the doctor in selecting the best radiographs to obtain and the most appropriate pulp. Periodontal or periapical tests to perform.

R2: Radiographic assessment
The 10 (ADI) Areas of Diagnostic Interest is a list of 10 diagnostic imaging interpretation guidelines. The interpretation findings will help the clinician determine the need for additional or alternative radiographs and confirm the most appropriate response testing needed.

R3: Response testing assessment
The dental pulp response to CO2 Ice is routinely performed on all teeth with pulp. Periodontal or periapical diseases or problems. Gingival, periodontal probing, alveolar socket bone sounding and fistula tracking are conducted following pulp testing and preferably under local anesthesia. Endodontically treated teeth are physically evaluated during the R4 step when the patient is anesthetized.

R4: Restorative and tooth structure assessment
Here, all the R1 & R3 subjective findings are supported or refuted through the objective findings obtained through restoration removal and/or the debridement of diseased or damaged tooth structure. R4 is the most objective and operational step of the protocol. R4 assists the clinician in determines tooth restorability, tooth structure cracks presence, treatment feasibility and alternative treatment options.

Target Audience

The target audience for this course is Dentists and Dental Specialists from novice to advanced. No prerequisites required.


Marwan Abou-Rass DDS. MDS. Ph.D

Marwan Abou-Rass DDS, MDS, Ph.D

Professor Emeritus,
Herman Ostrow School of Dentistry
University of Southern California

Dr. Abou-Rass brings nearly fifty years of cutting edge innovations in the field of endodontics and dental education. He pioneered the concept teaching molar versus central teeth as the best sequence for learning endodontic skills and developed the critical error approach to clinical performance evaluation.

In clinical endodontics, Dr. Abou-Rass has made a number of significant new concept and methodology contributions including:

  • Stressed pulp concept
  • Anti-curvature filing method
  • 4R Operational Diagnosis Protocol
  • Composite Post and Core buildup protocol
  • Endodontic Treatment Finalization Protocol
  • Interim Endodontic Therapy for native bone regeneration before implant placement

In addition to his DDS, Dr. Abou-Rass holds a Master’s degree in Dental Science in Prosthodontics , a certificate in Endodontics and a Ph.D., in Higher Education from the University of Pittsburgh, Pennsylvania. Dr. Abou-Rass served as Endodontic Department Chairman and Director of the Advanced Endodontic program at the University of Southern California, School of Dentistry (1971-2000). Dr. Abou-Rass moved to Riyadh, Saudi Arabia in 2000, where he directed the AEGD program at PAADI from 2000 to 2012.

Currently he is USC Professor Emeritus and publisher of Dental Economics MENA Journal and

Educational Objectives

Following participation and listening to the webinar the dental professional should be able to:

  1. Identify three shortcomings of the electric pulp testing.
  2. Identify shortcomings of the thermal pulp testing with heat.
  3. Explain the dental pulp sensory mechanism according to the hydrodynamic theory.
  4. Identify the 2-dimensional nature, partial mineral loss and anatomic structure overlapping as being the three biologic limitations of conventional, periapical radiographs.
  5. Describe the relationships between the 4Rs segments of the Operational Diagnosis protocol.
  6. List the 10 Areas of Diagnostic Interest, used in periapical radiographs interpretation.
  7. Develop Patient Pain Profiles (PPP) for a patient complaining Symptomatic Irreversible Pulpitis.
  8. Develop Patient Pain Profiles (PPP) for a patient complaining Symptomatic Reversible Pulpitis.
  9. Develop Patient Pain Profiles (PPP) for a patient complaining of Symptomatic Apical Periodontitis.
  10. Adopt the Use of carbon dioxide (CO2) ice as a best practice in eliciting a valid pulp response to thermal testing.
  11. List the pain profiles factors
  12. Recognize the presence of isolated periodontal pocket (IPP) as a form of Periradicular Apical Periodontitis,
  13. Perform fistula tracking test
  14. Adopt complete removal of defective and old restorations as a best practice in endodontic and restorative diagnostic decision-making
  15. Develop a 4RsOD working diagnosis
  16. Present the 4RsOD diagnosis to the patient with the appropriate treatment plan

Recognition and Credits

ADA CERP and PennWell Logos

PennWell Corporation is an ADA CERP recognized provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Continuing education credits awarded for participating in the CE activity may or may not apply toward license renewal or specific license requirements in all states. It is the responsibility of each participant to verify the requirements of his/her state licensing board(s).

PennWell designates this activity for 3 credit hours of continuing education credits.

Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at

AGD PACE LogoThe PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (12/31/2019) Provider ID# 320452.

Dental Board of California: Provider 4527, course registration number 01-4527-15160.
“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

Requirements For Successful Completion

To receive credit for your participation in this webinar you will be required to complete the online program examination. To complete the online examination participants must be registered and signed-in to this website and have reviewed the program in its entirety. At the end of the program a link will be provided directing you to the program course exam. Once completed and submitted an immediate grade report will be displayed. All participants scoring at least 70% on the examination will receive a CE Verification Form verifying 3 CE credits. Verification forms may be viewed and printed immediately as well as accessed anytime in the future (24/7) from within the user records page of this website.

Not enough time to complete your online examination? No problem, online examinations may be completed anytime during the effective period of the program. Participants requiring more time to complete an examination may return to this website, sign-in and complete the online examination.

Disclosure Declaration

Presenter Disclosure: Dr. Abou-Rass, has no financial interest in any of the products or manufacturers mentioned

Commercial Support: This course was developed without commercial support.

Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity, No manufacturer or third party has had any input into the development of course content.

CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with any commercial supporter, or with products or services discussed in this educational activity. Heather can be reached at

Image Authenticity: No images in this educational activity have been modified or altered.

Scientific Basis: All content has been derived from references listed and/or the author’s clinical experience.

Known Benefits and Limitations: Information presented in this educational activity represents best practices in evidenced based dentistry with potential benefit for the patient and clinician. No off label or experimental treatments are discussed.

Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

Viewing Information

System Hardware/Software and Internet Connection Requirements

The following information is provided for your reference in conjunction with review of this program.

General System and Internet Requirements:  Speakers or Headphones, High Speed Internet connection, Wireless 3G and 4G,
Web browsers: Internet Explorer 7.x or higher, Firefox 4.x or higher, Safari 2.x or higher and Chrome.

Operating Systems:  Windows 2000 or higher, (MS Surface and other MS mobile devices compatible), MAC OSX 10.3 or higher, Mac iOS 5.0 or higher (iPad, iPhone compatible), Android 4.3 or higher (most Android mobile devices compatible).