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INTRODUCTIONTOTHEUSEOFTHENEWDIAGNOSISANDTREATMENTPLANNINGFORMS

DefinitionsTheComprehensiveExamination:MultidisciplinaryDiagnosisandTreatment
Planning
TheComprehensiveExamination(axiUmcode01201)isasupervisedstudentprocedure
wherebystudentsareresponsibleforallaspectsofpatientexamination,includingprovidinga
diagnosisofconditionsanddisordersbaseduponallclinicalfindings,andformulatinga
treatmentplanwhichaddresses,inasystematicmanner,andasagreeduponbythepatient
andconfirmedwithcompletionoftheinformedconsentform,findingsofthepatient
examination.Itisamultidisciplinaryapproachtodiagnosisandtreatmentplanning.
Elementsofthecomprehensiveexaminationwouldincludethepatientschiefconcern,health
andmedicationhistory,recordingofvitalsigns,dentalhistory,extraoralandintraoralsoftand
hardtissueexamination,radiographsandotherdiagnostictestingandspecialtyconsultationsas
necessaryandmakingadiagnosis.Thiswouldbefollowedbytheformulationofa
comprehensivetreatmentplan,whichincludesthecompilationofaproblemlist,referstothe
diagnosis,andisbaseduponthepatientschiefconcernandfindingsoftheexamination.
Treatmentoptionsarethenofferedandasystematiccourseoftreatmentisagreeduponbythe
patient.Appointmentschedulingishelpfultoprovideanorganizedroadmaptotreatment.
Treatmentoptionsaregiveninsuchanorderthatfirstaddressesanyurgentcareorprimary
estheticconcernsrequiredbythepatient(PhaseOne).Thisisfollowedbythemedical
managementofanydisordersordiseases(includingcariesmanagement/cariescontrol
protocol),smokingcessationcounseling,immediateoralsurgeryprocedures,stabilizationof
thepatientsperiodontalcondition(inadentatepatient),andfollowsbyaddressingbasic
dentalneedsprovisionofdirectrestorationsandnonsurgicalendodontictherapy.If
necessary,followingtheseinitialtherapyprocedure,areevaluationofthepatientscariesand
periodontalstatusispreformed,andifdeemedstable,definitivefixedandremovable
prosthodonticprocedurescanbeperformed(PhaseTwo).
PhaseTwomayincludeperiodontalsurgery,implantsitepreparation,andfinalrestorative
proceduressingleandmultipleindirectrestorations,implantplacement,fixedandremovable
prostheses,andhabitmanagingappliances(e.g.bruxingguards).
Ifunstable,transitionalformsoftreatmentmaybenecessarypriortoembarkingonPhase
Two.NoPhaseTwotreatmentshouldcommenceifthereisanunstabledentition.
Followingcompletionofdefinitivetreatment,thepatientmaybeplacedonarecurring
scheduleofexaminationandperiodontalmaintenancetherapy(PhaseThree).
OUTCOMESFORALLTHREEPHASESOFTREATMENTSHOULDBERECORDEDONTHELASTPAGE

HOWTOPROPERLYCOMPLETETHEDIAGNOSISANDTREATMENTPLANNINGFORM:
PRIORTOFILLINGOUTTHEFORM,THEPATIENTMEDICALANDDENTALHISTORYMUSTBE
COMPLETEDINAXIUM,ANDAPPROVED(SWIPED)BYANINSTRUCTOR.
CHIEFCONCERN:Inthepatientsownwords,thereason(s)forthepatientattendingthatday.
SUMMARYOFMEDICALHISTORY:AfterreferringtothenewlyenteredmedicalhistoryAxiUm
record,asummaryofsignificantfindings,forquickreference,includingmedicationsandtheir
implicationstodentistry,oralmanifestationsorspecialprecautionsfordentaltreatmentis
recorded.
SUMMARYOFDENTALHISTORY:Asummaryofthesignificantfindingsrelatingtothepatients
pastdentalexperience,includingdailyoralhygieneroutine,extensiverehabilitativedental
treatment,periodontalsurgery,etc.

SUMMARYOFSOCIALHISTORY:Includepertinentinformationthatmayaffectorhashadan
effectondentaltreatment.Alsoincludehistoryoforcurrentuseoftobacco,including
frequency,lengthoftime,andwhetherornotthepatientmaybeamenabletoatobacco
cessationprogram.

EXTRAORALEXAM:Indicatewhetherfindingsarewithinnormallimits(WNL)orcommenton
anyunusualorabnormalfindings.Seekanoralpathologyconsultasneeded.Areastoconsider
areheadandneck,skinandextremitiesandlips.ThenmovetotheTMJtomakesobservations
onpresenceofclicking/crepitus(checkmark),limitationonopening(inmms.),deviationon
opening/closing(totherightorleft),persistentpresenceofpainoronpalpationof(onrightor
leftside)temporalis,masseter,pterygoid(medial/lateral).Alsonotethepresenceorsuspicion
ofunusualhabits(e.g.clenching,bruxing,nailbiting),andhistoryofthehabit.Makeadditional
commentsasrequired,whichmayincludepresenceofheadaches.

INTRAORALEXAM:IndicatewhetherWNLorcommentonunusualfindingsoflabialand
buccalmucosa,palate(e.g.tori),oropharynx,floorofmouth,tonguedorsalandventral,
Gingivalcolour,contour,consistencyaswellasunusuallocalizedorgeneralizedgingival
changes.Makeadditionalcommentsasnecessary.

OCCLUSION:(Angle'sClassification)Usingthefirstmolarswhenpossibleandthecuspids
whenneeded,classifytheocclusionintoAngle'sClassI,ClassII,DivisionI,DivisionIIorClassIII
forthepatient'srightandleftsides.Overbite:Expressinmillimetersofoverlapoflower
incisorswhichwouldbeapositivemeasurement.Overjet:Expressexcessiveoverjetinmm
(millimeters).Openbite:Expressthisasanegativeamount.Crossbite:Stipulatewhichteethare
involved.Faceting: Althoughsubjective,estimatewhethertheamountofocclusalandincisal
wearisnormalorexcessiveforthepatientinvolved.Alsomakenotationsforobservationsof
teethinvolvedwithattrition,abrasion,anderosion.Otherareastonotearecentricrelation

(CR)andmaximumintercuspation(MI),measurementoftheinterocclusaldistance(IOD),and
significantinterferencesinrightlateral,leftlateralandprotrusiveexcursions.

DiagnosticTesting:Aspartofdiagnosisanddiagnostictesting,radiographswillbeprescribed
dependingonthepatientsneedsandbaseduponALARA(AsLittleAsReasonablyAccepted)
principles.RadiographsarestoredinMiPacsprogram,butthewritteninterpretationisdone
andrecordedinAxiUm.Assummaryofpertinentfindings(boneloss,impactions,possible
cariouslesions,unfavorablecrownrootratios,pathology)iswritteninthespacesprovidedon
theform.Whenconsideringbonelossforperiodontalsituations,thefollowingshouldbe
considered:
A.

BoneLoss:

No significant Finding (NSF): If the bone crest appears to be


about 1mm from the cementoenamel junction on the
radiograph,noevidenceofbonelosscanbedescribed.

Generalized:Bonelossin2ormoresextants.

Localized:Bonelossinone,twoorthreeareasinvolvingoneortwo
teeth

Furcationboneloss:Dependinguponthefollowingcriteria,use
symbolssuchasS(slight),M(moderate)orA(advanced)for
furcationboneloss.Furcationboneloss(F):isindicatedbya
radiolucencyinthefurcationarea.Thismaybeslight(S)boneloss
(lessthan1/3ofthedistancefromthedomeofthefurcationtothe
apexoftheroot),moderate(M)(upto2/3ofthedistancefrom
dometotheapex)oradvanced(A)(toorbeyondtheapex).

Horizontalboneloss:Horizontalbonelossisindicatedwhenthe
bone loss interproximally on two adjacent teeth is equidistant
from the cementoenamel junction on each tooth. Use the
following symbols for horizontal bone loss based on the above
criteria:

S =

Slight includes loss of crestal cortication and/or


bluntingofinterdentalbone

M =

Moderate<1/3oftherootlength

A =

Advanced1/3ormoreofthelengthoftheroot

Verticalboneloss(V):isindicatedwhenthecrestoftheboneislocated
more apical to the cementoenamel junction of one tooth than to the
adjacenttooth.

B.

OtherRadiographicObservations:

Recordthetoothnumberandsurfacewhereanyofthefollowingareidentified:
furcation, periapical pathology, widened PDL space, poor crown to root ratio,
root proximity, root morphology, impaction, caries, overhang restorations,
calculus,andother.

OtherDiagnostictests,includingspecialtyconsults(asneeded):Eachspecialtyhasprovided
guidelinesastotheprocessesinvolvedwhenrequestingaspecialtyconsultdeterminingwhen
oneisneeded,andtheprerequisiteinformationthatneedstobegatheredpriortorequestinga
consult.Theguidelinesarepostedonthefacultywebsiteat
http://umanitoba.ca/faculties/dentistry/student_resources/index.htmlunderguidelinesfor
consults.Pleaseensurethetraditionalforms/sheetsareusedforendotesting,all
prosthodonticforms(implants,removablepros),estheticevaluation(whenaonelinecomment
isinsufficient),andotherformsthatareavailable.
DIAGNOSTICRECORDS:Pleasecheckoffwhetherphotoshavebeentakenandcastshave
beenmade.
SPECIALTYCONSULT:Consultantscomments,signatureanddateinspaceprovided

ADDITIONALCONSIDERATIONS,andcommentswritteninspaceprovided.
MissingteethmustberecordedintheAxiUmodontogramaswell.Thisisimportant,asinthe
caseofafixedbridgereplacingamissingtooth,unlessthetoothismarkedasmissing,AxiUm
willnotallowthefeeforabridgetogothrough.
ODONTOGRAM:Chartingtoinclude:Existingrestorations/defectiverestorationsopen
margins,overhangs,caries(visible+radiologicalevidenceof),missing,impacted,chipped,
fractured,wornteeth,etc.
Periodontalcharting:Thefollowingshouldbeclearlyindicated:

Missingteeth:Crossoutmissingteethwithaverticalline.

e.g.

18

17

16

B
L

PocketBleedingIndex:
(PBI): Bleeding on probing will be recorded as present if the
gingivalunit(pocket)bleedswithin30secondsafterinitialprobing
(Vandervelden,1979).Thelocationofthebleedingisdocumented
inred.Thetotalnumberofbleedingsites(n)isdividedbythetotal
numberofunitsprobed(n#teethX4)toobtainthePBI.

e.g.

18

17

B
L

ProbingDepth:

Probingdepthshouldberecordedforeachtooth,(BuccalMBDand
LingualMLD).Recordmeasurementsof4mmandgreater.

Recession:

Apparentgingivalrecessionshouldberecordedforeachtooth.The
extent of recession is measured from the CEJ to the free gingival
margin.ThegreatestmmreadingfortheBuccalandfortheLingual
isrecorded.

E.g.

18

17

2 mm

2 mm

3 mm

2 mm

Furcation:Classificationoffurcationinvolvementshouldberecordedinthefollowing
manner:

ClassI(Dip):Furcationconcavityispresent.Furcationconcavitycan
be detected with the probe; however, the furcation probe cannot
enterthefurcationarea.Inmanycases,thistypeofdefectcannot
be detected radiographically. Charted as I in appropriate box on
diagram.

Class II (Cave): This lesion is essentially acaveor culdesac lesion


withtheroofofthefurcationclinicallydetectable.Furcationprobe
will enter the furcation area but cannot pass through to the
oppositesideofthetooth.

ClassIII(Tunnel):Itisessentiallyathroughandthroughortunnel
lesion. Furcation probe will pass between the roots through the
entire furcation. In this type of furcation involvement, the inter
radicularboneiscompletelyabsent.Adefiniteradiolucencyinthe
furcationareaisusuallyvisibleontheradiograph.ChartedasIIIin
appropriateboxondiagram.
*Please note that this is a classification of the extent of furcation
involvement.ThenumeralsI,II,andIIIdonotrepresentmillimeter
measurements.

e.g.

B
L

I
I

II

II/D

II/S

II

III
III

Mobility:

Mobilityisrecordedforeachtooth.

Normal = movementofthecrownofthetooth,lessthan.5mm
inbuccallingualdirection

ClassI

ClassII = movementofthecrownofthetooth1.0mmto2.0
mminbuccallingualdirection

ClassIII = movementofmorethan2.0mminmedialdistalor
buccallingualdirectionand/orverticaldepression.

= movementofthecrownofthetooth.5mmto1.0mm
inbuccallingualdirection

e.g.

18
I

17
II

PlaqueControl
Record:

(PCR):Thepresenceofdentalplaqueisrecordedonfoursurfacesof
eachtooth(DBML).If,afterswishingwithaplaquedisclosingtablet,
disclosedplaqueincontactwiththegingivalmargincanberemoved
withtheexplorer/probefromthetoothsurface,thatsurfaceshould
bedocumentedinblackontherecordform.

Plaque control score: the presence of dental plaque is recorded on


foursurfacesofeachtooth(DBML).Thepresenceisgentlyconfirmed
with the explorer/probe, if it is absent that surface should be
documentedinblackontherecordform.

The PC score is determined by dividing the total number of marked


surfaces(n)bythetotalnumberofavailablesurfaces(n#teethX4)
present.(O'Leary,etal,1972).

Our goal in teaching plaque control procedures is to reduce plaque


accumulation until it is found on 15% or less of the available tooth
surfaces.Surgicalproceduresshouldnotbeinitiateduntilthepatient
reachesthatlevel.

PROBLEMLISTING:Thisisaproblemlistwhichsummarizesthepatientsneedsandclinical
findingsoftheexam.Itwillhelptoformulatethediagnoses.
Periodontalclassification(circle):PSR1PSR2

PSR3PSR4

PeriodontalClassification: Circleappropriateclassification:

PSR2=slightchronicperiodontitis

PSR3=moderatechronicperiodontitis

PSR4=advancedchronicperiodontitis/aggressiveperiodontitis

PSR1 =

gingivitis

PeriodontalScreeningandRecording(PS&RSystem)

Description:

Theobjectiveofthisscreeningsystemistoexamineeverytoothindividually.Implants
are examined in the same manner as naturally occurring teeth. For screening, the
dentitionisdividedintosextantsasshown:

Theuseofaperiodontalprobeismandatory.Therecommendedprobehasaballend
0.5mmindiameter.Acolorcodedareaextendsfrom3.5to5.5mm.Agentleprobing
forceshouldbeused.

The probe tip is gently inserted into the gingival crevice until resistance is met. The
depthofinsertionisreadagainstthecolorcoding.Thetotalextentofthecreviceshould
beexploredbywalkingtheprobearoundthecrevice.Atleastsixareaineachtooth
should be examined: mesiofacial, midfacial, distofacial, and the corresponding
lingual/palatalareas.

Foreachsextantwithoneormoreteethorimplants,onlythehighestscoreisrecorded.
AnXisrecordedifthesextantisedentulous.Asimpleboxchartisusedtorecordthe
scoresforeachsextant(seeFig.1).

Code0:

Coloredareaofproberemainscompletelyvisibleinthedeepestcrevicein
thesextant.Nocalculusordefectivemarginsaredetected.Gingivaltissues
arehealthywithnobleedingaftergentleprobing.

Code1:

Coloredareasofproberemainscompletelyvisibleinthedeepestprobing
depth in the sextant. No calculus or margins are detected. There is
bleedingaftergentleprobing.

Code2:

Colored area of probe remains completely visible in the deepest probing


depth in the sextant. Supra or subgingival calculus and/or defective
marginsaredetected.

Code3:

Coloredareaofproberemainspartlyvisibleinthedeepestprobingdepth
inthesextant.

Code4:

Coloredareaofprobecompletelydisappears,indicatingprobingdepthof
greaterthan5.5mm.

TheexaminermaypasstothenextsextantwheneverCode4isrecordedorthesextantis
completelyexamined.

Inadditiontothesescores,thesymbol*shouldbeaddedtothesextantscorewhenever
individualfindingsindicateclinicalabnormalities.

Code*:

Denotesclinicalabnormalitiesincludingbutnotlimitedto:

a)

furcationinvolvement

b)

mobility

c)

mucogingivalproblems

d) recessionextendingtothecoloredareaoftheprobe(3.5mmor
greater)

Themanagementofpatientsaccordingtotheirsextantscoresshouldbeatthediscretion
oftheexaminingdentist.Thepractitionersclinicaljudgmentwilldeterminetheneedfor
consultation with a periodontist. The following guidelines for patient management are
suggested:

Code0:

Appropriatepreventivecare.

Code1:

Oralhygieneinstruction(OHI)andappropriatetherapy,includingsubgingival
plaqueremoval.

Code2:

OHI and appropriate therapy, including subgingival plaque removal, plus


removal of calculus and correction of plaqueretentive margins of
restorations.

Patients whose scores for all sextants are Codes 0, 1, and 2 should be screened in
conjunctionwitheveryoralexamination.

Code3:

A comprehensive periodontal examination and charting of the affected


sextant is necessary to determine an appropriate treatment plan. This

examination and documentation should include but not be limited to


identification of probing depths, mobility, gingival recession, mucogingival
problems,andfurcationinvasionsaswellasappropriateradiographs.Iftwo
ormoresextantsscoreCode3,acomprehensivefullmouthexaminationand
charting is indicated. Should therapy be indicated and performed, a
comprehensiveexaminationisnecessarytoassesstheresultsoftherapyand
needforfurthertreatment.

Code4:

A comprehensive full mouth periodontal examination and charting is


necessarytodetermineanappropriatetreatmentplan.Thisexaminationand
documentationshouldincludebutnotbelimitedtoidentificationofprobing
depths, mobility, gingival recession, mucogingival problems, and furcation
invasions as well as appropriate radiographs. It is probable that complex
treatment will be required. Should therapy be indicated and performed, a
comprehensiveexaminationisnecessarytoassesstheresultsoftherapyand
needforfurthertreatment.

Code*:

If an abnormality exists in the presence of Codes 0, 1, 2, specific notation


and/ortreatmentforthatconditioniswarranted.Ifanabnormalityexistsin
thepresenceofCode3or4,acomprehensiveperiodontalexaminationand
chartingisnecessarytodetermineanappropriatetreatmentplan.

Prosthodonticclassification(circle)ACP1ACP2ACP3ACP4theACPclassificationsystemby
McGarryetalcanbefoundbyfollowingthislink:
http://www.gotoapro.org/prosthodonticresources/improveyourpractice
lab/prosthodonticdiagnosticindex/
Cariesriskassessment(fromcompletedform):LOWMEDIUMHIGH
DIAGNOSES,INCLUDINGDIFFERENTIALDIAGNOSES:foreveryproblemlisted,pleaseoffera
diagnosisordifferentialdiagnosisandrelateitdirectlytotheproblem.
TREATMENTOPTIONSANDCOSTS:Foreachproblem,offereveryreasonabletreatment
option,withalternatives,available,includingnotreatment.Foreachoption,proposea
prognosis,eithergood,fairorpoor,(perioalsoaddsquestionableandhopeless),andan
estimatedcostrangeforeachoptionoffered.Itishelpfultouseaworksheetatthisstageto
formulateyourtreatmentoptionspriortorecordingontheform.
FINALIZEDSEQUENCEDTREATMENTPLAN,COSTSANDDATECOMPLETED:Treatmentplans
aredividedintothreebroadphases,1,2and3.
ALLPLANNEDTREATMENTMUSTBEENTEREDINTOAXIUMASP

Phase1,managementofdiseasesanddisorders,includes,inorderandasnecessary:
Consultationwiththepatientsphysician
Othernecessarytreatmentconsiderationsforsystemicdisease,suchaspremedication
needs,stressandfearmanagement.
Acutetreatmentaddressingurgentcareneedsforpainorinfection
Treatmentofurgentchiefcomplaint
Diseasemanagementpatienteducationre:cariesandperiodontaldisease;cariesrisk
assessment;medicalmanagementofcaries;addressparafuntionalandotherhabits
Removalofhopelessteeth
Cariescontrol,provisionaldirectrestorations
Remove/replacedefectiverestorations
Initialperiodontaltherapyscalingandrootplanning
OralHygieneinstructionsOHI
Occlusaladjustment
Endodontictherapyincasesofpulpalpathology
Placementofdefinitivedirectrestorations(alloy,composite,GIC)
Placementofotherprovisionalrestorations(partialorfullcoverage)toallowfor
stabilizationofteeth

REASSESSMENTOFPHASEONETREATMENTISMANDATORYTODETERMINESUCCESSAND
FEASABILITYOFPROCEEDINGTOPHASE2.

Phase2MajorRehabilitativeProcedures:FollowingtheevaluationofPhaseone,andafter
determiningthesuccessofinitialtherapyandthestabilityofthepatientsdentition,phasetwo
canbeaddressed.Oftentimes,proceduresplannedinPhasetwowillbedependentonthe
successfuloutcomeofphaseonetreatment.Lesssuccessfulresultsinphaseonewilldictate
lesscomplextreatment,ifanyatall,tobeperformedinphasetwo.
Majorrehabilitativeproceduresarecarriedoutinphasetwo.Thisisintheformofdefinitive
treatment,whichincludes,inorderandasnecessary:

Periodontalsurgeryandotheradvancedperiodontaltherapy
Occlusalstabilizationthroughvariousmeans
Orthodonticororthognathictreatment
Electiveremovalofasymptomaticteeth
ElectiveEndodontictreatment
Definitiverestorationofindividualteethendodonticallytreatedandotherkeyteeth
prioritized
Fixedandremovableprosthodonticsforreplacementofmissingteeth,includingesthetic
dentistry.

POSTTREATMENTASSESSMENTOFPHASETWOPROCEDURES.

Phase3Maintenance:Determinationoftypeandfrequencyofperiodicrecallvisits,including
examinationsandsupportiveperiodontaltherapy.Itisimportantthatarecallschedulebe
established,andthatthepatientunderstandstheobligationofcontinuedcare.
Fornewpatients,orforthosethatrequirenewcomprehensivetreatmentplans,forperio
purposes,NPP(NewPeriodontalPatients)(PreviouslycalledPSRPatients)

CLASSIFICATIONOFNPP
o NPP0,NPP1,NPP2,NPP3,NPP4
BasedonPeriodontalScoringRecord(PSR)Classification
FeetoincludeInitialTherapyand1moreevaluation
Whenreevalexam&treatmentiscompleted,dispositionoptionsinclude:
NPPAdditionalAppointment(additionalchargestoapply)
PutonSPT(atdesignatedmonthlyinterval1,3,6,9,12mo)
RefertoGraduatePeriodontics
SPT(SupportivePeriodontalTherapy)Patients
o NewandexistingpatientswhorequireongoingSPTtomaintainperiodontalhealth
SPT0,SPT1,SPT2,SPT3,SPT4,basedonPSRClassification
SPTINTERVALS1mo,3mo,6mo,9mo,12mo

o Individualizedaccordingtotreatmentneeds
o IntervalisdeterminedondaythatSPTtreatmentis
completed
o IntervalisenteredintoAxiumwhenSPTscalingis
complete
o Axiumdropdownmenuoptionswillinclude:
SPT01mo,3mo,6mo,12mo(12modefault)
SPT11mo,3mo,6mo,12mo (6modefault)
SPT21mo,3mo,6mo,12mo (6modefault)
SPT31mo,3mo,6mo,12mo,NPP3,ReferGradPerio
(3modefault)
SPT41mo,3mo,6mo,12mo,NPP4,ReferGrad
Perio(3modefault)

INFORMEDCONSENT:Althoughatreatmentplanhasbeenformulatedandtheprocedures
withcostshasnowbeensignedbythepatient,theprocessofinformedconsentmustbe
formalizedtoensurethatthereisaclearunderstandingbythepatientoftheproposed
treatmentrisksandcostsinvolved.Itissuggestedthatthepatientcompletestheinformed
consentdocumentintheirownwords,asitisoftensurprisingtodiscoverthatthereisnota
clearunderstandingofthesituationbythepatient.Ifthepatientcannotcompletetheformon
theirownorintheirownhandwriting,thedentalstudentmayassistwiththis.Onlythen
shouldtreatmentbecommenced.
APPOINTMENTSCHEDULE:Thisprovidestheboththestudentandthepatientaroadmapfor
treatmentthatthereisaclearunderstandingofthestepsinvolvedintreatmentandthetime

neededfortreatment.Thisway,thepatientwillhaveaclearunderstandingofwhatisrequired
intheprocess,andwillhopefullynothaveanyunrealisticexpectationsinthetimeline.
TREATMENTEVALUATION:Aseachphaseoftreatmentiscompleted,areflectiononandan
evaluationofthefinishedtreatmentshouldberecorded.Thisisnotonlygoodrecordkeeping
policy,butisarequirementoftheaccreditationprocess.
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