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1 "#$$#&()#*&+,--./#0+&1.2&--.1 # /- 7/"..$.28& (10$:&0$+" ;0<1.=&>3#?&1-# &3.3C DDDEF#*&35.E/. * "#$$#&()#*&+,--./#0+&1.2&--.1 # /- 7/"..$.28& (10$:&0$+" 8035&3.3C DDDEF#*&35.E/. * Declaration of potential conflict and pecuniary interest: "#$$#&()#*&+,--./#0+&1.2&--.1 # /- 7/"..$.28& (10$:&0$+" 8035&3.3C DDDEF#*&35.E/. * YES have received various sponsorships NO financial reward or gain or endorsement from any product $

2 On conclusion of this lecture participants will: On conclusion of this lecture participants will: 1. determine the purpose for diagnosis and treatment planning. 2. understand the disease progression through the pulpodentinal-pdl complex. 3. determine how to assess deviations from health the diagnostic process. 4. be able to classify the deviations from endodontic health (Clinical Diagnosis). 5. determine how does the clinical differential diagnosis translates into treatment (Treatment Plan). 1. determine the purpose for diagnosis and treatment planning. 2. understand the disease progression through the pulpodentinal-pdl complex. 3. determine how to assess deviations from health the diagnostic process. 4. be able to classify the deviations from endodontic health (Clinical Diagnosis). 5. determine how does the clinical differential diagnosis translates into treatment (Treatment Plan). What are the problems we face in the real world? 1. If the patient complain of a concern what is the cause of the concern? 2. Is periapical disease a cause for concern? 3. What is the treatment required for each diagnosis? 4. When should we consider removal of a tooth? What is the purpose of the diagnosis and treatment planning? What is the aim of the diagnosis? To determine the status of the patients oral health and determine the patient s concern. The objective of the diagnosis: to provide a basis for the treatment plan as well as form a basis for discussion with other practitioners. &

3 From the diagnosis we demonstrate an understanding of disease progression which allows the practioner to: 1. facilitate treatment 2. assess of outcome. 3. determine a treatment plan. 4. permit discussion with patients and dentists using a common nomenclature. Once a diagnosis is made, a treatment plan can then be formulated. The aim of the treatment plan is to implement treatment to manage the diagnosis. The objective of the treatment plan is to create a plan to manage the patient s condition and provide a resolution to the patient s concern while maintaining the aims and objectives required for that discipline. Purpose of treatment plan: Create an approach to arrive at an expected outcome. The expected outcome is determined by the: 1.underlying principles and philosophy of the practitioner 2.knowledge base of the practitioner 3.technical skill of the operator 4.the influence of patient expectations Henry and Rosie tell the city bus driver that they want him to take them home. When he teases them that maybe they dont know the address of where they live, Henry rises to the occasion and tells the driver precisely where he lives: 12 Main Street, Gumbridge, Australia, Southern Hemisphere, Earth, solar system, solar neighborhood, Orion Arm, Milky Way Galaxy, local group of galaxies, Virgo Supercluster, the universe. During Henrys description, we also get a brief description of each part of the address. The result is a clear picture of our "place in space.

4 Similarly diagnosis and treatment planning does not develop in a vacuum. Diagnosis and treatment planning is only a small step of the continuum we call dentistry. Dentistry Endodontics The Root Canal Treatment Process: The root canal treatment can be seen as a process or continuum with a number of individual procedures. Step 1: Presenting complaint Medical History Dental history Examination Diagnosis Treatment planning Step 2: Pain control Rubber dam Step 3: Access and length determination Step 4: Mechanical instrumentation of the root canal system Irrigation Step 5: Medication Temporization Step 6: Obturation Step 7: Restoration Step 8: Recall,#* of dental treatment: Preserve, maintain, or restore the patients the orofacial environment to a state of health. Objective of dental treatment: Determine a patients orofacial health. Maintain and preserve the patients state of orofacial health. Remove disease and return the patient to a state of orofacial health. But this does not answer what orofacial health is? WHO definition of Health? Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. There is no absolute consensus on what oral health is. Is it the number of teeth present? What is the desired number of teeth? What is the minimum number of teeth? Is it the state of periodontal health? Is it the presence of caries? Is it associated with dental and/or periodontal pain? Is it aesthetically related? Who determines aesthetics? Fashion? How do we define the objectives of dental treatment? (

5 What does NAD and WNL mean and what does it mean to you? A state of health implies: harmony equilibirium maximum consistency maximum predictability maximum stability maximum comfort which may include self image minimum adverse response Let us first define our aim and objective: To determine what is the desired result in endodontics we need to narrow our spectrum further define our aim and objective of endodontic treatment. The aim of endodontics is to remove disease and maintain and preserve or restore oral health in the most conservative means possible. Let us first define our aim and objective: Why be conservative? In general only natural tissue can accommodate change and growth. So compromise between managing and conserving tissue. What are our objectives? Retention, periapical healing? Patients are now asking for FAB and HIP teeth as part of their personal makover. )

6 IN RESPONSE TO CHANGES IN TREATMENT OUR OBJECTIVES HAVE NOT CHANGED? Functional Analgesic Pain free Beautiful aesthetic Healthy disease free Indefinite - long lasting understand restorative management Psychological they want to retain their own dentition. While the objectives for each patient are the same the priorities may vary. This is the conflict between the science and the art. Functional Analgesic Pain free Beautiful aesthetic Healthy disease free Indefinite - long lasting understand restorative management Psychological they want to retain their own dentition. On conclusion of this lecture participants will: <"&-/#&3/&#-+.*0G&+"&5#0C3.-#-E <"&01+#-+.5&+&1*#3&D#+"+"&06&3++"& 1#.1#6&-.2+"&.=H&/6?&-D"&3 5&+&1*#3#3C+"&+1&0+*&3+$03E 1. determine the purpose for diagnosis and treatment planning. 2. understand the disease progression through the pulpodentinal-pdl complex. 3. determine how to assess deviations from health the diagnostic process. 4. be able to classify the deviations from endodontic health (Clinical Diagnosis). 5. determine how does the clinical differential diagnosis translates into treatment (Treatment Plan). PERIODONTAL Acute Chronic Pericoronitis What are the sources of orofacial PAIN/SWELLING? Referred DENTAL Dentinal - to what extent is pulp involved (includes exposed root, occlusal trauma, CTS, some caries Pulpal Periapical EXTRADENTAL Myofascial/TMJ Maxillary Sinus Cardiac Neural Thyroid Mucosal Salivary Gland Lymphatic Osteogenic (dry socket) Oncogenic Atypical Phantom Ear Idiopathic Infection of fascial planes and spaces "#$"&&#() #*)+,-+.-).(/) +"+0.-) /&.&) 1"#2)34.()5,) Pulpal inflammation (physical chemical, bacterial) Inflammatory spread with possible pulp necrosis and possibly pulpal infection If pulp becomes infected/inflamed -Bacterial toxins released into periapical tissues Periapical acute inflammation Enzyme release Periapical bone destruction Periapical chronic inflammation If microorganisms spread into periapex an abscess results. Persistance of peripacal disease

7 "#$"&&#() #*)+,-+.-).(/) +"+0.-) /&.&) 1"#2)34.()5,) The terminology and nomenclature used to define endodontic deviation from health is clinically and not histologically based. The nomenclature is clinically founded, based on expected cause and anticipated outcome. "#$"&&#() #*)+,-+.-).(/) +"+0.-) /&.&) 1"#2)34.()5,) As pulpo-dentinal-pdl complex is a continuum must have a pulpal and periapical diagnosis Plaque Caries CTS Reversible Pulpitis Irreversible Pulpitis Pulp Necrosis Periapical involvement What is pulpal disease? There is little concnsus on the clinical response of the pulp to caries. Plaque Caries CTS Reversible Pulpitis Irreversible Pulpitis Pulp Necrosis Periapical involvement What is periapical disease? Initially the periapical disease is an inflammatory response to usually an intrapulpal infection and is therefore known as apical periodontitis. +$0IA& +J#3C#?#6- Distinguish between endodontic/dental +&1# and periodontal causes Why focus on high quality root canal treatment? Rossite r *

8 Poor quality root canal treatment is related to periapical disease. Root fillings of substandard technical quality are prevalent findings in most population studies and are associated with a high rate of periapical inflammation. Kirkevang et al. 2001, Boucher et al. 2002, Lupi-Pegurier et al. 2002, Boltacz-Rzepkowska & Pawlicka 2003, Siqueira et al. 2005, Tsuneishi et al. 2005, Tavares et al 2009 Why is there a focus on periapical disease? Periapical disease is associated with instability, disease, disharmony and lack of predictabilty. Of the teeth with apical periodontitis and no root fill 6 years later: 25 extracted 30 root treated Kirkevang et al. Int Endod J 39, , 2006 Why is there a focus on periapical disease? 29.3 of teeth with apical periodontitis had received dental treatment for pain relief. Evaluation of the prognostic factors indicated that inadequacy of endodontic treatment was more predictive of apical periodontitis. Kim et al Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110: ) On conclusion of this lecture participants will: 1. determine the purpose for diagnosis and treatment planning. 2. understand the disease progression through the pulpodentinal-pdl complex. 3. determine how to assess deviations from health the diagnostic process. 4. be able to classify the deviations from endodontic health (Clinical Diagnosis). 5. determine how does the clinical differential diagnosis translates into treatment (treatment plan). How do you assess a patient? 1. CHIEF COMPLAINT: Symptoms 2. HISTORY: Symptoms Medical (e.g. latex allergy) Past Dental - specific - general 3. CLINICAL EXAM: Signs Specifically Chief Complaint Symptoms, Caries, Fillings Abrasions, Attrition Occlusion, Mobility, Percussion Palpation, Sinus Tract, Swelling Lymphadenopathy, Fever, Periodontal 4. SPECIAL TESTS: Signs a. RADIOGRAPH: Bitewing Periapical Cone beam,

9 b. PULP TESTING: Pulp sensibility EPT, Thermal (CO2, thermal spray) Pulp sensitivity Iced water, Hot water c. CROWN FRACTURE Staining Transilluminator Bite Test Diagnosis Symptoms Listen and learn Location where Onset when did it begin Timing how often, constant (on/off), morning, night./ Radiating factors does it radiate to ear, upper or lower jaw Aggravating hot, cold, biting (what sort of biting-every time special angle) Duration - secs, mins, hours Inhibiting hot, cold, biting Other intensity (mild, moderate, severe) Describing the different clinical exams and special tests: It is often difficult to describe one test without taking into account other test. Diagnosis - Signs 1. Clinical Examination Each aspect of the clinical exam and special test is taken into consideration to make a diagnosis. If the results are not clear cut we may make a differential diagnosis. 1. Clinical Examination Periodontal probing: Deep periodontal probing indicates infection. Is it periodontal or endodontic in origin? The type of probing indicates if the origin is periodontal, endodontic or anatomical. Check pulp sensibilty -

10 Mobility - is it periodontal or endodontic in origin? Probable defect resolves with RCT Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: 1. Periodontal with positive sensibility test :4/;9<7 Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: 2. Combined endodontic and periodontal origin with negative sensibility test. Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: 2. Combined endodontic and periodontal origin with negative sensibility test Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: 2. Combined endodontic and periodontal origin with negative sensibility test Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: 3. Anatomical palatal groove $#

11 Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: 3. Anatomical fractured root 3. Anatomical enamel pearl Determining periodontal, endodontic or anatomic cause of a deep periodontal probing: 3. Anatomic fractured root Signs 2. Special tests 2. Special tests 2.1 Thermal Pulp Sensibility Tests Isolate area with cotton rolls Dry teeth to be tested Ask patient to: Raise hand on feeling cold Lower hand when cold feeling goes away Record: + or sensitivity to cold The time until cold sensitivity was felt is not relevant. Time that cold sensitivity lingered is generally not relevant Thermal Tests 2.1 Thermal Pulp Sensibility Tests Classic Responses to Thermal Sensibility Testing: Positive response indicates vital Pulp: Moderate transient pain. Does not describe quality of pulp e.g. Reversible Pulpitis; Irreversible pulpitis. No respones may indicate pulpal necrosis with or without infection, pulpal neuropraxia, pulpal calcification: (Note false positive and false negative responses common) $$

12 2. Special tests 2.2 Alternative pulp sensibility test: Electric Pulp Test A direct test of nerve elements of pulpal tissue Vitality versus non-vitality only not whether vital pulp is normal or inflamed In multi-rooted teeth, where one canal is vital tooth usually tests vital False positives and false negatives may occur 2. Special tests 2.3 Thermal Tests Pulp sensitivity Classic Responses to Thermal Sensitivity Testing (cold or hot H2O): Positive response indicates vital Pulp: May describe quality of pulp e.g. Normal Pulp: Moderate transient pain, or no pain Reversible Pulpitis; Sharp pain; subsides quickly Irreversible pulpitis. Pain lingers Necrosis: No response No respones may indicate normal pulpal, pulpal necrosis, pulpal neuropraxia, pulpal calcification: (Note false positive and false negative responses common) Always begin in the lower jaw from the distal 2. Special tests 2.4 Radiograph Remember to consider referred pain Always take your own preoperative radiograph. Never make a diagnosis based on radiographic evidence alone. May need multiple angles SLOB if shift is from mesial. $&

13 Intra Oral PHOTOGRAPH 072 colour SWELLING temp Filling/band HORIZONTAL FRAC fluct/diff Radiographic Endodontic Status Canal (Straight/Curved/Multiple/Visible) Previous RCT - (Quality-underfill; underextended; overfill; WNL) Fractured instrument Fracture Vertical/Horizontal Post Open Apex Perforation Canal/Furcation Resorption (Crown; Root Internal/External) Furcation thickness adequate /inadequate At what point does a periapical lesion become evident? From Pathways of the Pulp second edition Collate the information to allow the formulation of a diagnosis Surname,Title,Firstname Middlename (Preferred Name) CARD No. 1 D.O.B DOB REF: Ref Name PH H: HomPhone ESS: Phone Address PH. B: Work Phone Suburb State Postcode: Postcode MOB: Mobile Current Date Short DB / NoDB / TAC / WC / VA / OTHER Number NTING COMPLAINT Present, since when Location: Asymptomatic Dull Ache Sharp Throbbing Aware d: Ear Neck Cheek/Eye Temple y: Mild Moderate Severe Duration: Secs Mins Hrs On/Off When: Day Night Constant Stimuli: Biting Hot Cold Varies Sweet Spontaneous Palpate Apex Relief: Cold Hot Neither analgesics Previous tx to alleviate pain: No Yes : Recent Trauma No Yes : Hist trauma Recent dent tx No Yes: Antibiot/Analgesics on presenting No Yes Previous RCT: No Yes, when CONSULTATION CONS(30mins+) 017 TOOTH: After Hours Call Out 915 RADIOGRAPH 022 caries Travel to Provide Service 916 PULP TESTING 061 cracks size PERIO 221 occlude with LYMPH NODES SOFT TISSUE cast restoration SINUS TRACT ACCOMP BY PART/FULL, Upper/Lower BRUX CLASS Extra Musc TMJ Intra musc On Examination: Percussion/Palpation 0, Slight(SL), Moderate(M), Severe (V). Palpation Bu/P Percussion EPT Cold Hot CO2 Maxilla Mandible CO2 Hot Cold EPT Percussion Palpation Bu/Li Perio Mobility Recession B/P Depth Buccal Depth Ling Depth Ling Depth Buccal Recession B/P Mobility Radiograph BONE: RESORPTION PAP CANAL height crown OPEN APEX split (multiple) consistency root internal ROOT straight CARIES root external curve visible PERFORATION #INST THIN FURC PREV RCT *canal VERTICAL FRACT POST Under/Over *Furcation DIAGNOSIS: On conclusion of this lecture participants will: 1. determine the purpose for diagnosis and treatment planning. 2. understand the disease progression through the pulpodentinal-pdl complex. 3. determine how to assess deviations from health the diagnostic process. 4. be able to classify the deviations from endodontic health (Clinical Diagnosis). 5. determine how does the clinical differential diagnosis translates into treatment (treatment plan). There are a number of different endodontic diagnostic nomenclatures which does create confusion. The AAE has tried to initiate a new consistancy. La Trobe in describing the clinical appearance of lesions, certain terms have been avoided. Chronic is used to mean long standing. From French chronique, from Greek chronikos of time, from chronos (Date: 1601). Compare to acute. From Middle English, from Latin acutus, past participle of acuere to sharpen, from acus needle; akin to Latin acer sharp (Date: 14th century). Dictionary Online $

14 Pulpal Normal pulp Reversible pulpitis Symptomatic irreversible pulpitis Asymptomatic irreversible pulpitis Pulp necrosis Previously treated Previously initiated therapy Apical Normal apical tissues Symptomatic apical periodontitis Asymptomatic apical periodontitis Acute apical abscess Chronic apical abscess Condensing osteitis A clinical diagnostic category in which the pulp is symptom-free and normally responsive to pulp testing. A clinical diagnosis based on subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal. A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous pain, referred pain. A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but inflammation produced by caries, caries excavation, trauma. A clinical diagnostic category indicating death of the dental pulp. The pulp is usually nonresponsive to pulp testing. A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal medicaments. A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (eg, pulpotomy, pulpectomy). Teeth with normal periradicular tissues that are not sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact, and the periodontal ligament space is uniform. Inflammation, usually of the apical periodontium, producing clinical symptoms including a painful response to biting and/or percussion or palpation. It might or might not be associated with an apical radiolucent area. Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms. An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain,tenderness of the tooth to pressure,pus formation, and swelling of associated tissues. An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract. Diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth. Recommended Terms AAE December 2009 AAE Consensus Conference Recommended Diagnostic Terminology 1634 JOE Volume 35, Number 12, December 2009 Histological diagnosis of peri-radicular disease (from Ricucci Endo Topics 2004, Abbott Endo Topics 2004): LESIONS OF PULPAL ORIGIN Periapical abscess Periapical granuloma True periapical cyst Pocket cyst NON PULPAL LESIONS Irish" Includes periapical scar, neoplasm" " 1. Pulpal Clinical Differential Diagnosis Rarely radiographic widening of PDL as pulp progresses to pulp necrosis and infection. K09/.3+0#31&*303+?#+0$6--A&#3+"& 105#/A$01A$ When is deep caries treated with pulp capping? Post restoration it may be difficult to determine if the sensitivity is reversible or irreversible. The causes of post operative sensitivity include: air under the resoration chemical irritation of the pulp polymerization stresses cause cusp deflection the destruction of dental structures adhesive failures caused by polymerization stress can affect the integrity of the bonded interface immediately after polymerization of the material $(

15 By 30 days following a restoration the level of post operative sensitivity stabilizes. Sensitivity post restoration can be due to: 1. reversible pulpitis which resolves in 30 days 2. inherent problems with the restoration which resolves after replacement of the restoration. If the sensitivity does not resolve by 30 days and is not severe replace the restoration 3. Irreversible pulpitis which does not resolve and must be treated with root canal treatment. 2. Intra-pulpal previously root treated Clinical Differential Diagnosis Briso (&106?&8&36-+19LMNN@LOMPQLRMSPRMT DIAGNOSIS Previous root canal treatment uninfected. Previous root canal treatment with intra-canal infection CLINICAL AND RADIOGRAPHIC Patient is asymptomatic. The quality of the root canal filling may vary. No radiographic change. Patient may be symptomatic with TTP or show clinical signs of swelling or sinus tract formation. Symptomatic cases may be associated with or without periapical radiographic changes. In asymptomatic cases periapical radiographic changes are be visible. The quality of the root canal filling may vary. TREATMENT Review as appropriate. May need to manage on prosthodontic grounds. Management based on clinical judgment. If it is felt periradicular involvement is related to intra-pulpal infection; perform root canal retreatment via either a coronal or surgical approach. Manage root fracture as appropriate. 3. Peri-apical clinical differential diagnosis If we understand the cause of the disease we can treat the tooth ideally initially. $)

16 DIAGNOSIS Relatively normal Localized apical periodontitis - can be associated with occlusal trauma or a diffuse pulpitis or previous root canal treatment. The pulpal involvement will indicate if root canal treatment is required or not. Diffuse apical periodontitis (i.e. breach in PDL small or large) Diffuse suppurative apical periodontitis (if an apical abscess is suspected). May be associated with facial cellulitis. Diffuse persistent apical periodontitis. (Consideration needs to be given if persistence of the periapical lesion is due only to intracanal infection or if there is an extraradicular contribution to the failure to heal of the lesion e.g. extra-radicular infection or cystic lesion) CLINICAL AND RADIOGRAPHIC APPEARANCE (C) Patient asymptomatic (R) normal PDL (C) Patient TTP, pulp may or may not respond to pulp test. (R) normal PDL. (C) Patient may be TTP, pulp does not respond to pulp tests. May be associated with previous endodontic treatment. (R) widened PDL (C) Pulp does not respond to pulp tests. May be associated with swelling or a sinus tract. May be associated with previous endodontic treatment. (R) widened PDL (C) Pulp does not respond to pulp tests. May be associated with swelling or a sinus tract. May be associated with previous endodontic treatment. (R) widened PDL. Persistent peraipical disease is peripical disease which was initiated by intracanal infection, but the lesion persists despite the initiation of root canal treatment or is not expected to heal with coronal root canal treatment alone. TREATMENT Manage pulpal diagnosis (as above) Manage cause: pulpitis (as above) Mechanical/physical, chemical, infective if associated with previous root canal treatment. mechanical irritation such as occlusal trauma Manage pulpal diagnosis (as above) Manage pulpal involvement with or without surgical intervention Surgery to remove the persistent lesion and I possible the cause. If it is felt persistent periradicular involvement is related to undebridable areas within the canal or extrapulpal infection or lesion, perform periapical curettage with or without apical resection, with or without apical restoration. A true cyst may require surgical intervention The primary cause of initiating apical periodontitis is intracanal microorganisms. Persistent post treatment endodontic disease (PTED) is due to secondary causes which must also be eliminated before the disease will heal. Haapasalo et al Endodontic Topics 2011 Condensing apical periodontitis. (R) Increase in the radio-opacity of the periapical bone Manage pulpal involvement Reasons for Persistence of Apical Periodontitis (clinical assessment) Post Treatment Endodontic Disease Micro-organisms intra-radicular" "(Coronal leakage, apical delta, insufficient cleaning, iatrogenic altered canal)" Micro-organisms extra-radicular " "(actinomyces)" Foreign material (cholesterol, foreign body, GP)" Host response (true cyst)" Fibrous Scar and non endodontic" Fractures (complete/incomplete)" Anatomy/Periodontal (palatal grove, furcation, enamel pearl etc) " From Nair IEJ 2006, Endo Topics 2003; Rud 1972: Wu Endo Topics 2005 " Diffuse Apical Periodontitis" When making a clinical differential diagnosis of odontogenic pain, state: * K&1&5#+"0357&+/"&$$U8&3+SVV@ 1.The clinical pulpal differential diagnosis 2.The clinical peri-radicular differential diagnosis 3.The treatment plan involving the pulp and if necessary the periradicular tissues. On conclusion of this lecture participants will: 1. determine the purpose for diagnosis and treatment planning. 2. understand the disease progression through the pulpodentinal-pdl complex. 3. determin how to assess deviations from health the diagnostic process. 4. be able to classify the deviations from endodontic health (Clinical Diagnosis). 5. determine how does the clinical differential diagnosis translates into treatment (treatment plan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

17 The caveates: 1. When detailing the treatment plan the predictability of the treatment is often related to the ability and dexterity of the practitioner. Will be discussed in risk management. 2. It is important to realise that dentistry is procedurally based, equipment and labour intensive and very technique sensitive, technique specific and technique dependant. 3. When detailing the treatment plan the predictability of the treatment is often related to the ability of the patient to to undergo the treatment. 4. The concepts of normal, and health may vary with new findings. 5. The statistical data detailing long term response to treatment changes as new scientific data is accumulated. 6. Consider restorability including classification of fractures and resorption. 7. For pulpectomy degree of difficulty based on the CAE classification. <"&5#0C3.-#-#-0$-.=0-&5.303 A35&1-+035#3C+"&/0A-&035 &1-#-+&3/&.25#-&0-&E THANK YOU Visit us at Outcome is improved if the practitioner is aware of how disease spreads and what causes persistence. Attention to detail to reduce persistence improves outcome $*