Endodontics MCQs

APPENDIX B
Chapter review questions

Graham Rex Holland, Mahmoud Torabinejad
CHAPTER 1 5. From where does the signal initiating enamel formation

The Biology of Dental Pulp and originate?
Periradicular Tissues a. odontoblasts
1. What stage of tooth formation involves the beginning of b. undifferentiated cells
invagination of the developing tooth structure? c. inner enamel epithelium
a. bud stage d. outer enamel epithelium
b. cap stage
c. bell stage ANS: a
d. follicular stage Once dentin formation has begun, the cells of the inner dental
epithelium begin to respond to a signal from the odontoblasts
ANS: b and begin to deposit enamel.
The bud becomes invaginated at the cap stage. REF: Early Development of Pulp
REF: Early Development of Pulp
6. When does the dental papilla become the dental pulp?
2. What is the bell-shaped structure that develops from the a. bud stage
tooth bud? b. cap stage
a. dental papilla c. early bell stage
b. dental follicle d. late bell stage
c. odontoblast layer
d. enamel organ ANS: d
Odontoblasts begin to lay down dentin in the late bell stage.
ANS: d From this point on, the tissue within the invagination is known
The bell-shaped downgrowth is the enamel organ. It is ecto- as the dental pulp.
dermal in origin and will be responsible for amelogenesis. REF: Early Development of Pulp
7. What is the first thin layer of dentin that is formed?
3. From what are odontoblasts derived? a. predentin
a. neural crest b. primary dentin
b. local stem cells c. mantle dentin
c. osteoblasts d. root sheath
d. internal dental epithelium
ANS: c
ANS: a The first thin layer of dentin formed is called mantle dentin.
The odontoblasts are derived from cells originating and The direction and size of the collagen fibers in mantle dentin
migrating from the neural crest. differ from those in the subsequently formed circumpulpal
REF: Early Development of Pulp dentin.
4. From where is differentiation of the odontoblasts
controlled? 8. Epithelial cell rests of Malassez are remnants of what?
a. outer dental epithelium a. odontoblasts
b. inner dental epithelium b. cementoblasts
c. dental papilla c. epithelial root sheath
d. dental follicle d. dental follicle
ANS: b ANS: c
The differentiation of odontoblasts from undifferentiated Epithelial cell rests of Malassez are cell remnants of the epi-
ectomesenchymal cells is initiated and controlled by the ecto- thelial root sheath that persist in the periodontium in close
dermal cells of the inner dental epithelium of the enamel proximity to the root after root development has been com-
organ. pleted. They are normally functionless, but in the presence of
REF: Early Development of Pulp inflammation, they can proliferate and under certain condi-
tions may give rise to a radicular cyst.
REF: Root Formation
e1
APPENDIX B Chapter review questions
9. Which cells secrete the hyaline layer of Hopewell- 13. What does the dental pulp form as a defensive
Smith? response?
a. inner cells of Hertwig’s epithelial root sheath a. tertiary dentin
b. outer cells of Hertwig’s epithelial root sheath b. secondary dentin
c. cells of the dental follicle c. globular dentin
d. cells of the dental papilla d. peritubular dentin
ANS: a ANS: a
After the first dentin in the root has formed, the basement In the mature tooth, the odontoblasts form dentin in response
membrane beneath Hertwig’s sheath breaks up, and the inner- to injury, particularly when the original dentin thickness has
most root sheath cells secrete a hyaline material over the been reduced due to caries, attrition, trauma or restorative
newly formed dentin. After mineralization has occurred, this procedures.
becomes the hyaline layer of Hopewell-Smith, which helps REF: Pulp Function (Defense)
bind the soon to be formed cementum to dentin
REF: Root Formation 14. Approximately how many odontoblasts are present in the
crown of a newly erupted tooth?
10. What morphologic changes occur over time due to the a. 10,000 to 20,000/mm2
dental pulp? b. 45,000 to 65,000/mm2
a. The root canal diameter increases. c. 100,000 to 150,000/mm2
b. The pulp horns grow higher into the cup tips. d. 200,000 to 250,000/mm2
c. The overall size of the pulp chamber is reduced.
d. The layer of cementum thickens. ANS: b
In the coronal part of the pulp space, the odontoblasts are
ANS: c numerous, relatively large, and columnar in shape. They
The pulp space becomes asymmetrically smaller over time number between 45,000 and 65,000/mm2 in that area.
due to continued, albeit slower, production of dentin. There REF: Cells of the Dental Pulp (Odontoblasts)
is a pronounced decrease in the height of the pulp horn and a
reduction in the overall size of the pulp chamber. In molars, 15. Which of the following cell types is an antigen-recognition
the apical-occlusal dimension is reduced more than the cell in the dental pulp?
mesial-distal dimension. a. odontoblasts
REF: Anatomic Regions and Their Clinical Importance b. macrophages
c. neutrophils
11. The apical foramen is: d. all of the above
a. surrounded by dentin
b. narrowest in young teeth ANS: a
c. variable in size and location The odontoblast has several types of receptors on or within
d. the widest portion of the canal its cell membrane. Toll-like receptors (TLR2 and TLR4),
when activated by components of gram-positive bacteria
ANS: b (lipoteichoic acid), cause the odontoblasts to release proin-
Variation in the size and location of the apical foramen influ- flammatory cytokines (Fig. 1.12). This indicates that the
ences the degree to which blood flow to the pulp may be odontoblasts can act as antigen-recognition cells when bacte-
compromised after a traumatic event. rial products penetrate the dentin.
REF: Anatomic Regions and Their Clinical Importance REF: Cells of the Dental Pulp (Odontoblasts)
12. The apical constriction is: 16. What is the most prominent antigen-presenting cell in the
a. easily located radiographically dental pulp?
b. the ideal end point of root canal cleansing a. lymphocyte
c. present in all teeth b. odontoblast
d. formed by Hertwig’s epithelial root sheath c. stem cell
d. dendritic cell
ANS: b
The narrowest portion of the canal is referred to as the apical ANS: d
constriction. A constriction is not clinically evident in The most prominent immune cell in the dental pulp is the
all teeth.7 Theoretically, it is the point where the pulp termi- dendritic cell. These are antigen-presenting cells present most
nates and the PDL begins and would be the ideal point for densely in the odontoblast layer and around blood vessels.
a procedure aimed at removing the pulp. However, clinically, REF: Cells of the Immune System
it is not always possible to locate that point.
REF: Anatomic Regions and Their Clinical Importance
e2
17. What type of collagen is most prominent in the dental 20. What would be a typical level for interstitial pressure in
pulp? an area of inflammation in a dental pulp?
a. type I a. −20 mmHg
b. type II b. −6 mmHg
c. type III c. +6 mmHg
d. type IV d. +20 mmHg
ANS: a ANS: d
The predominant collagen in dentin is type I, whereas both Swelling results from increased formation of interstitial tissue
type I and type III collagen are found within pulp in a ratio fluid because of increased permeability of the capillaries. In
of approximately 55 : 45. Odontoblasts produce only type I other tissues, such as skin (in which inflammation was first
collagen for incorporation into the dentin matrix, whereas described), the increased production of tissue fluid results in
fibroblasts produce both types I and III. Pulpal collagen is swelling. Because the dental pulp is within a rigid, noncom-
present as 50 nm-wide fibrils several microns long. They form pliant chamber, it cannot swell, and the increased interstitial
bundles that are irregularly arranged, except in the periphery, fluid formation results in an increase in tissue fluid pressure.
where they lie approximately parallel to the predentin surface. REF: Vascular Changes During Inflammation
The only fibers present in the pulp are tiny, 10-15 nm-wide
beaded fibrils of fibrillin, a large glycoprotein. Elastic fibers 21. Which type of nerves can be recruited to the pain system
are absent from the pulp. The proportion of collagen types is of the dental pulp in inflammation?
constant in the pulp, but with age there is an increase in the a. Aα
overall collagen content and an increase in the organization b. Aβ
of collagen fibers into collagen bundles. Normally, the apical c. Aδ
portion of pulp contains more collagen than the coronal pulp. d. C
REF: Extracellular Components (Fibers)
ANS: b
18. Which of the following is not a type of pulp stone? A small percentage of the myelinated axons (1% to 5%) are
a. free faster-conducting Aβ axons (6 to 12 µm in diameter). In other
b. attached tissues, these larger fibers can be proprioceptive or mechano-
c. embedded receptive. Their role in the pulp is uncertain, but it is now
d. floating known from other tissues that in inflammation, these Aβ fibers
can be recruited to the pain system.
ANS: d REF: Pulpal and Dentinal Nerves
Three types of pulp stones have been described: free stones,
which are surrounded by pulp tissue; attached stones, which
are continuous with the dentin; and embedded stones, which
are surrounded entirely by dentin, mostly of the tertiary type.
REF: Calcifications
19. What would be a typical level for interstitial pressure in a

dental pulp?
a. −20 mmHg
b. −6 mmHg
c. +6 mmHg
d. +20 mmHg
ANS: b
The hydraulic pressure in the pulpal capillaries falls from
35 mmHg at the arteriolar end to 19 mmHg at the venular
end. Outside the vessel, the interstitial fluid pressure varies,
but a normal figure would be 6 mmHg.
REF: Vascular Physiology
e3

Ashraf F. Fouad, Anthony J. Smith
CHAPTER 2 4. Why are deeper carious lesions more injurious to the

Protecting the Pulp and Promoting dental pulp?
Tooth Maturation a. increased dentin permeability in deeper areas and
1. What is a “pulp cap”? greater cellular injury to odontoblasts
a. an early stage of tooth development b. increased length of the dentinal tubule in deeper areas
b. capping of the exposed pulp with a thin layer of inert c. decreased density of dentinal tubules in deeper areas
lining or base material d. decreased diameter of dentin tubules in deeper areas
c. capping of exposed vital pulp tissue by placing a layer
of mineral trioxide aggregate (MTA) ANS: a
d. a method of isolation used during root canal Dentin permeability increases exponentially with increasing
treatment cavity depth, as both the diameter and density of dentinal
tubules increase with cavity depth (Fig. 2.5).17 Thus the deeper
ANS: c the cavity, the greater the tubular surface area into which
The exposed pulp may be protected immediately by covering potentially toxic substances can penetrate and diffuse to the
it and placing a restoration. Pulp capping is the treatment of pulp. The length of the dentinal tubules beneath the cavity is
an exposed vital pulp by sealing the pulpal wound with a also important. The farther substances have to diffuse, the
dental material, such as calcium hydroxide or mineral trioxide more they will be diluted and buffered by the dentinal fluid.
aggregate (MTA), to stimulate the formation of reparative A remaining dentin thickness of 1 mm is often regarded as
dentin and maintenance of a vital pulp. sufficient to shield the pulp from most forms of irritation. As
REF: Vital Pulp Therapy cavity depth increases, odontoblast survival is increasingly
compromised and there is a greater likelihood of local odon-
2. What is the effect on blood flow to the pulp when anesthet- toblast death.
ics with vasoconstrictors are used during restorative REF: Cavity Depth/Remaining Dentin Thickness
procedures?
a. It is reduced by 10% of its normal rate. 5. Why does a blast of compressed air directed at freshly
b. It is reduced to less than half of its normal rate. exposed dentin create a sensation of pain?
c. It is unchanged. a. It frightens the patient.
d. It is increased by 25% because of stress on the pulp b. The air is cold.
tissue. c. It causes a rapid outward movement of fluid in patent
dentinal tubules.
ANS: b d. It causes a rapid inward movement of fluid in patent
When most local anesthetics containing vasoconstrictors are dentinal tubules.
used in restorative dentistry, the blood flow to the pulp is
reduced to less than half of its normal rate. In the case of ANS: c
lidocaine with epinephrine, this effect is entirely due to the A prolonged blast of compressed air aimed onto freshly
vasoconstrictor. exposed vital dentin causes a rapid outward movement of fluid
REF: Local Anesthesia in patent dentinal tubules through strong capillary forces.
Rapid outward flow of fluid in the dentinal tubules stimulates
3. What is dentin “blushing”? nociceptors in the dentin pulp, thus producing pain.
a. the color of newly erupted teeth due to large pulp REF: Cavity Drying and Cleansing
chambers
b. the use of a masking color during restorative 6. What is the most important characteristic of any restor-
procedures ative material in determining its effect on the pulp tissue?
c. vascular injury (hemorrhage) of pulp tissue, often a. heat generated by the material
during crown preparation b. speed with which the material sets
d. an esthetic concern requiring laminate restorations c. ability to form a marginal seal
d. life expectancy of the restorative material
ANS: c
The “blushing” of dentin during cavity or crown preparation ANS: c
is thought to be due to frictional heat resulting in vascular The most important characteristic of any restorative material
injury (hemorrhage) in the pulp. The dentin takes on an under- in determining its effect on the pulp is its ability to form a
lying pinkish hue soon after the operative procedure. seal that prevents the leakage of bacteria and their products
REF: Cavity/Crown Preparation onto dentin and then into the pulp.
e4 REF: Microleakage
7. What effect does orthodontic tooth movement have on the 10. Which of the following steps is used in step-wise evacu-
dental pulp? ation of caries?
a. It produces no clinically significant changes. a. removal all the caries in a single visit
b. Electric pulp testing remains reliable. b. placement of a calcium hydroxide base at the initial
c. Extrusion reduces pulpal blood flow for a few minutes. visit
d. Intrusive forces have no effect on pulpal blood flow. c. placement of a glass ionomer base at each visit
d. removal of only a superficial layer of caries at the first
ANS: a visit
Orthodontic tooth movement of a routine nature has not been
considered to cause clinically significant changes in the dental ANS: c
pulp. Some experimental studies have reported vascular A step-wise evacuation of caries is a suggested technique in
changes in the pulp after application of orthodontic forces,66,67 which caries is removed in increments in two or three appoint-
which may be associated with the release of proangiogenic ments over a few months to a year rather than in a single
growth factors from pulp and dentin in response to these sitting, which might result in accidental exposure and con-
forces.68 Modeling of external application of forces to the tamination of the pulp. The deeper affected but noninfected
tooth has indicated that these forces may be transmitted to the dentin may remineralize, and tertiary dentin may form. Each
pulp, leading to fibroblast proliferation and up-regulation of time caries is removed, a glass ionomer base is placed, which
genes associated with cellular proliferation and extracellular may contribute to mineralization, followed by a well-sealing
matrix components.69 temporary restoration. For this to be successful, careful case
REF: Orthodontic Tooth Movement selection is necessary. There must be no signs or symptoms
of irreversible pulpitis, which is frequently asymptomatic. If
8. What is the primary reason for placement of a liner the caries has already penetrated to the pulp, the treatment
between biocompatible restorative materials and the will be unsuccessful because the pulp is already irreversibly
dentin? damaged. Therefore, it is critical that follow-up evaluation
a. to provide thermal insulation include pulp testing and radiographs, because pulp necrosis
b. to provide a cushion against which to condense restor- may occur even years later.
ative materials REF: Capping the Vital Pulp – Step-wise excavation of caries
c. to eliminate microleakage
d. to reduce the amount of restorative material needed 11. What factors should be considered in case selection for
direct pulp capping procedures?
ANS: c a. asymptomatic teeth with vital pulp
A liner is routinely placed between restorative materials and b. clinical signs of irreversible pulpitis
the dentin, primarily to eliminate microleakage. In vitro c. uncontrolled hemorrhage of the exposed pulp tissue
studies suggest that most liners show some degree of leakage,65 d. contaminated exposure site
but it is unknown what level of dye leakage would relate to
clinical problems. One 3-year clinical study73 compared three ANS: a
common dentin treatments but found no recurrent caries Case selection for direct pulp capping should focus on asymp-
around any of the restorations, including those for which no tomatic teeth with no clinical signs or symptoms of irrevers-
liner had been used. All liners and bases reduce dentin perme- ible pulpitis. The size of the exposure should be small,
ability, but to different extents. Bases provide the largest preferably less than 0.5 mm; hemorrhage should be ade-
reduction, varnishes the least.74 Dentin is also an excellent quately controlled; great care should be taken to avoid con-
thermal insulator of the pulp; additional insulation is rarely. tamination of the area of exposure, using best clinical practice,
if ever, needed. In fact, thick cement bases are no more effec- including a rubber dam; and a permanent restoration with a
tive than just a thin layer of varnish in preventing thermal good marginal seal should be placed.
sensitivity, indicating that postrestorative sensitivity is at least REF: Direct Pulp Capping
partly a result of microleakage.75
REF: Cavity Varnishes, Liners, and Bases 12. When does apical closure occur in the developing root?
a. at the time of eruption
9. Vital pulp therapies have variable rates of success. What b. approximately 6 months after eruption
is the most significant determinant of the success of vital c. approximately 2 to 3 years after eruption
pulp therapy? d. approximately 5 years after eruption
a. size of the periapical lesion
b. periodontal status before the procedure ANS: c
c. pulp status before the procedure Apical closure occurs approximately 2 to 3 years after erup-
d. type of restorative material used tion in the developing root.
REF: The Open Apex
ANS: c
The success rate of vital pulp procedures is variable. Proper
diagnosis and clinical judgment are crucial, but success
depends primarily on the status of the pulp before the
procedure.
REF: Vital Pulp Therapies e5
13. If the pulp becomes necrotic before root growth is com- 15. What is apexification?
plete, the resultant root is: a. continued physiologic root formation
a. short with thick dentin walls b. induction of a calcific barrier across an open apex
b. short with thin dentin walls c. removal of inflamed vital tissue
c. normal length with thick dentin walls d. the completing step of apexogenesis
d. normal length with thin dentin walls
ANS: b
ANS: b Apexification is the induction of a calcific barrier (or the
If the pulp becomes necrotic before root growth is complete, creation of an artificial barrier) across an open apex in a case
dentin formation ceases and root development is arrested. The involving pulp necrosis, with or without a periapical lesion.
resultant root is short with thin, and consequently weakened, Apexification involves removal of the necrotic pulp, followed
dentin walls. by débridement of the canal and placement of an antimicro-
REF: The Open Apex bial medicament.
REF: Apexification
14. What is apexogenesis?
a. induction of a calcific barrier across an open apex
b. removal of the necrotic pulp
c. determination of the corrected working length
d. continued physiologic root formation
ANS: d
Apexogenesis is defined as a vital pulp therapy procedure
performed to encourage continued physiologic development
and formation of the root end. The objective is to maintain
the vitality of the radicular pulp. Therefore the pulp must be
vital and capable of sustaining continued development, which
is often the case when an immature tooth sustains a small
coronal exposure after trauma.
REF: Apexogenesis
e6

José F. Siqueira Jr., Ashraf F. Fouad
CHAPTER 3 5. Root canals can become infected through anachoresis.

Endodontic Microbiology a. true
1. What is the ultimate goal of endodontic treatment? b. false
a. to relieve pain in symptomatic teeth
b. to provide space for intraradicular restorative ANS: b
materials There is no clear evidence showing that this process can rep-
c. to prevent or treat apical periodontitis resent a route for root canal infection. It has been shown that
d. to allow disinfection of contaminated root canal spaces bacteria could not be recovered from unfilled root canals,
when the blood stream was experimentally infected, unless
ANS: c the root canals were overinstrumented during the period of
The ultimate goal of endodontic treatment is either to prevent bacteremia, with resulting injury to periodontal blood vessels
the development of apical periodontitis or to create adequate and blood seepage into the canal. Although anachoresis has
conditions for periradicular tissue healing. Taking into account been suggested to be the mechanism through which trauma-
the microbial etiology of apical periodontitis, the rationale for tized teeth with seemingly intact crowns become infected,
endodontic treatment is unarguably to eradicate the occurring current evidence indicates that the main pathway of pulpal
infection or to prevent microorganisms from infecting or rein- infection in these cases is dentinal exposure due to enamel
fecting the root canal or the periradicular tissues. cracks.
REF: Microbial Causation of Apical Periodontitis REF: Anachoresis
2. Why is there greater dentin permeability near the pulp? 6. Which of the following is not a category of intraradicular
a. increased thickness of peritubular dentin infections?
b. smaller diameter of dentinal tubules a. primary
c. higher density of dentinal tubules b. secondary
d. longer length of odontoblastic process c. tertiary
d. persistent
ANS: c
Dentin permeability is increased near the pulp because of the ANS: c
larger diameter and higher density of tubules. Intraradicular infections can be subdivided into three catego-
REF: Dentinal Tubules ries (primary, secondary, or persistent infection), depending
upon when participating microorganisms established them-
3. Bacterial invasion of dentinal tubules occurs more rapidly selves within the root canal.
in which teeth? REF: Microbiota of Endodontic Infections
a. vital teeth
b. nonvital teeth 7. The most common microorganisms in primary endodontic
infections are:
ANS: b a. gram-negative bacteria
Bacterial invasion of dentinal tubules occurs more rapidly in b. gram-positive bacteria
nonvital teeth than in vital ones.6 c. facultative anaerobes
REF: Dentinal Tubules d. facultative aerobes
4. What is anachoresis? ANS: a

a. artificial formation of an apical barrier Gram-negative bacteria appear to be the most common micro-
b. induction of a biologic calcific apical barrier organisms in primary endodontic infections. Species belong-
c. microorganism transport from blood vessels into ing to several genera of gram-negative bacteria have been
damaged tissue consistently found in primary infections associated with dif-
d. systemic infection resulting from infected pulp tissue ferent forms of apical periodontitis, including abscesses.
These genera include Dialister (e.g., D. invisus and D. pneu-
ANS: c mosintes), Treponema (e.g., T. denticola and T. socranskii),
Anachoresis is a process by which microorganisms are trans- Fusobacterium (e.g., F. nucleatum), Porphyromonas (e.g.,
ported in the blood or lymph to an area of tissue damage, P. endodontalis and P. gingivalis), Prevotella (e.g., P. inter-
where they leave the vessel, enter the damaged tissue, and media, P. nigrescens and P. tannerae), and Tannerella (e.g.,
establish an infection. T. forsythia). Other gram-negative bacteria are detected more
REF: Anachoresis sporadically in primary infections.
REF: Gram-Negative Bacteria e7
8. Which of the following is not a source of nutrients for likely to harbor E. faecalis than cases of primary infection.
bacteria within the root canal system? Candida species are fungi only sporadically found in primary
a. necrotic pulp tissue infections, but detection frequencies in persistent and second-
b. inflamed vital pulp tissue ary infections range from 3% to 18% of cases. Both E. fae-
c. proteins and glycoproteins from tissue fluids and calis and C. albicans have a series of attributes that may allow
exudate that seep into the root canal system via apical them to survive in treated canals, including resistance to
and lateral foramina intracanal medications and the ability to form biofilms,
d. components of saliva that penetrate the pulp tissue invade dentinal tubules, and endure long periods of nutrient
deprivation.
ANS: b Despite its high prevalence in treated canals of teeth with
In the root canal system, bacteria can use the following as post-treatment apical periodontitis, the status of E. faecalis as
sources of nutrients: (1) necrotic pulp tissue, (2) proteins and the main pathogen associated with treatment failures has been
glycoproteins from tissue fluids and exudate that seep into the questioned. This is because this species, if present, is rarely
root canal system via apical and lateral foramina, (3) compo- the most dominant species in the bacterial community of
nents of saliva that may coronally penetrate the root canal, treated canals. In addition, it has been detected in root canal–
and (4) products of the metabolism of other bacteria. Because treated teeth with no disease in a similarly high prevalence.
the largest amount of nutrients is available in the main canal, Streptococcus species, which are also very frequently detected
which is the most voluminous part of the root canal system, and in many cases are the dominant bacterial group, in addi-
most of the infecting microbiota, particularly fastidious anaer- tion to P. alactolyticus, Propionibacterium species, F. alocis,,
obic species, are expected to be located in this region. At later T. forsythia, D. pneumosintes, and D. invisus, can also be
stages of the infection process, nutritional conditions favor the involved in persistent and secondary intraradicular infections
establishment of bacteria that metabolize peptides and amino (Table 3.2).27
acids. REF: Microbiota in Root Canal–Treated Teeth
REF: Available Nutrients
10. Gram-positive bacteria have been demonstrated to:
9. Which of the following microorganisms is commonly a. have a higher occurrence in post-instrumentation
present in large percentages of root canal–treated teeth samples
that present with persistent apical periodontitis, indicative b. be more resistant to antimicrobial treatments
of failed treatment? c. adapt to harsh environmental conditions
a. Enterococcus faecalis d. all of the above
b. Pseudoramibacter alactolyticus
c. Tannerella forsythia ANS: d
d. Dialister invisus Diligent antimicrobial treatment can occasionally fail to
promote total eradication of bacteria from root canals, with
ANS: a consequent selection of the most resistant segment of the
The microbiota in root canal–treated teeth with post-treatment microbiota. Gram-negative bacteria, which are common
apical periodontitis lesions is composed of a more restricted members of primary intraradicular infections, are usually
group of microbial species compared to primary infection. eliminated by endodontic treatment. Most studies on this
Studies evaluating samples taken from retreatment cases have subject have clearly revealed a higher occurrence of gram-
revealed that apparently well-treated canals harbor up to five positive bacteria (e.g., streptococci, lactobacilli, Enterococcus
species; canals with inadequate treatment can harbor 10 to 30 faecalis, O. uli, P. micros, P. alactolyticus, and Propionibac-
species, a number very similar to that found in untreated terium species) in both post-instrumentation and post-
canals. Bacterial counts in treated canals vary from 103 to 107 medication samples. This gives support to the notion that
cell equivalents. gram-positive bacteria can be more resistant to antimicrobial
Enterococcus faecalis is a facultative anaerobic gram- treatment measures and have the ability to adapt to the harsh
positive coccus that has been frequently found in root canal– environmental conditions in instrumented and medicated
treated teeth in prevalence values ranging from 30% to 90% canals.
of cases. Root canal–treated teeth are about nine times more REF: Bacteria at the Root Canal–Filling Stage
e8

Mahmoud Torabinejad, Shahrokh Shabahang
CHAPTER 4 bacteria in the development of periradicular lesions by sealing
Pulp and Periapical Pathosis noninfected and infected pulps in the root canals of monkeys.24
1. A direct pulp exposure of a carious lesion is necessary to After 6 to 7 months, clinical, radiographic, and histologic
have a pulpal response and inflammation. examinations of teeth sealed with noninfected pulps showed
a. true an absence of pathosis in apical tissues, whereas teeth sealed
b. false with necrotic pulps containing certain bacteria showed peri-
apical inflammation. The bacteriologic investigation by Sun-
ANS: b dqvist25 examining the flora of human necrotic pulps supports
Direct pulp exposure to microorganisms is not a prerequisite the findings of Kakehashi and associates23 and those of Möller
for pulpal response and inflammation. Microorganisms in and colleagues.24 These studies examined previously trauma-
caries produce toxins that penetrate to the pulp through tized teeth with necrotic pulps, with and without apical patho-
tubules. Studies have shown that even small lesions in enamel sis. Teeth without apical lesions were aseptic, whereas those
are capable of attracting inflammatory cells in the pulp. As a with periapical pathosis had positive bacterial cultures.
result of the presence of microorganisms and their byproducts REF: Microbial Irritants
in dentin, pulp is infiltrated locally (at the base of tubules
involved in caries), primarily by chronic inflammatory cells 4. Which of the following statements is true regarding
such as macrophages, lymphocytes, and plasma cells. mechanical irritants?
REF: Microbial Irritants a. Changes to the underlying pulp, such as odontoblast
aspiration, are irreversible.
2. What factor is the most important in determining whether b. The potential for pulp injury decreases as more dentin
pulp tissue becomes necrotic slowly or rapidly after is removed.
carious pulp exposure and pulpal inflammation? c. Operative procedures without water coolant cause
a. virulence of bacteria more irritation than those performed under water spray.
b. host resistance d. There is decreased permeability and constriction of
c. amount of circulation blood vessels in the early stages of pulpitis.
d. lymph drainage
ANS: c
ANS: d Mechanical irritants, such as deep cavity preparations, removal
The factors that determine whether pulp tissue becomes of tooth structure without proper cooling, impact trauma,
necrotic slowly or rapidly after carious pulp exposure and occlusal trauma, deep periodontal curettage, and orthodontic
pulpal inflammation are (1) the virulence of the bacteria; (2) the movement of teeth, may lead to alterations in the underlying
ability to release inflammatory fluids to avoid a marked increase pulp. Transient changes, such as aspiration of odontoblasts into
in intrapulpal pressure; (3) host resistance; (4) the amount of the dentinal tubules, are usually reversible in healthy pulps
circulation; and, most important, (5) lymph drainage. (Fig. 4.1). In typical clinical situations, however, the pulpal
REF: Microbial Irritants tissue is already inflamed due to the presence of caries or previ-
ous restorative procedures. If proper precautions are not taken,
3. What is necessary for pulp and periradicular pathosis to cavity or crown preparations may damage subjacent odonto-
develop? blasts. The number of tubules per unit of surface area and their
a. exposure of pulp tissue diameter increase closer to the pulp (Fig. 4.2). As a result, den-
b. exposure of dentin tinal permeability is greater closer to the pulp than near the
c. presence of bacteria dentinoenamel junction (DEJ) or cementodentinal junction
d. trauma (CDJ).1 Therefore, the potential for pulp irritation increases as
more dentin is removed (i.e., as cavity preparation deepens and
ANS: c reaches closer to the pulp). Pulp damage is roughly propor-
Bacteria play an important role in the pathogenesis of pulpal tional to the amount of tooth structure removed and to the depth
and periradicular pathoses. A number of investigations have of removal.2 Also, operative procedures without water coolant
established that pulpal or periradicular pathosis does not cause more irritation than those performed under water spray.3
develop without the presence of bacterial contamination.23-25 A study of the reactions and vascular changes occurring in
Kakehashi and associates created pulp exposures in conven- experimentally induced acute and chronic pulpitis demon-
tional and germ-free rats.23 This procedure in the germ-free strated increased permeability and dilation of blood vessels in
rats caused only minimal inflammation throughout the 72-day the early stages of pulpitis.4 Investigations in rodent models
investigation period. Pulpal tissue in these animals was not designed to determine the impact of heat generation on the
devitalized but rather showed calcific bridge formation by day dental pulp have shown that elevation of pulpal temperature
14, with normal tissue apical to the dentin bridge (Fig. 4.7, above 42°C up-regulate heat shock proteins (HSP).5 HSP-70
A). In contrast, infection, pulpal necrosis, and abscess forma- plays a protective role, and its levels return to baseline within a
tion occurred by the eighth day in conventional rats (Fig. 4.7, few hours after removal of the heat stimulus.
B). Other investigators have examined the importance of REF: Mechanical Irritants e9
5. What nonspecific inflammatory mediators are not present 8. Which of the following is true in reversible pulpitis?
when the dental pulp is irritated? a. severe inflammation of pulp tissue
a. histamine b. yields a negative response to electric pulp testing
b. epinephrine c. yields a positive response to thermal pulp testing
c. bradykinin d. requires root canal treatment
d. arachidonic acid metabolites
ANS: c
ANS: b By definition, reversible pulpitis is a clinical condition associ-
Irritation of the dental pulp results in the activation of a variety ated with subjective and objective findings indicating the pres-
of biologic systems, such as nonspecific inflammatory reac- ence of mild inflammation in the pulp tissue. If the cause is
tions mediated by histamine, bradykinin, and arachidonic acid eliminated, inflammation will reverse and the pulp will return
metabolites. Also released are PMN lysosomal granule prod- to its normal state.
ucts (elastase, cathepsin G, and lactoferrin), protease inhibi- Mild or short-acting stimuli, such as incipient caries,
tors (e.g., antitrypsin), and neuropeptides (e.g., calcitonin cervical erosion, or occlusal attrition; most operative proce-
gene-related peptide [CGRP] and substance P [SP]). dures; deep periodontal curettage; and enamel fractures
REF: Inflammatory Process resulting in exposure of dentinal tubules can cause reversible
pulpitis.
6. What cell type associated with immune response is not Reversible pulpitis is usually asymptomatic. However,
present in severely inflamed dental pulp? when present, symptoms usually follow a particular pattern.
a. T lymphocytes Application of stimuli, such as cold or hot liquids or air, may
b. B lymphocytes produce sharp, transient pain. Removal of these stimuli, which
c. macrophages do not normally produce pain or discomfort, results in imme-
d. odontoclasts diate relief. Cold and hot stimuli produce different pain
responses in normal pulp.55 When heat is applied to teeth with
ANS: d uninflamed pulp, the initial response is delayed; the intensity
In addition to nonspecific inflammatory reactions, immune of pain increases as the temperature rises. In contrast, pain
responses also may initiate and perpetuate deleterious pulpal in response to cold in normal pulp is immediate; the
changes.31 Potential antigens include bacteria and their intensity tends to decrease if the cold stimulus is maintained.
byproducts within dental caries, which directly (or via the Based on these observations, pulpal responses in both health
dentinal tubules) can initiate various types of reactions. and disease apparently result largely from changes in
Normal and uninflamed dental pulps contain immunocompe- intrapulpal pressures.
tent cells, such as T and B (fewer) lymphocytes, macrophages, REF: Reversible Pulpitis
and a substantial number of class II molecule-expressing den-
dritic cells, which are morphologically similar to macro- 9. What is irreversible pulpitis?
phages.20 Elevated levels of immunoglobulins in inflamed a. a severe inflammatory process
pulps (Fig. 4.10) show that these factors participate in the b. a condition that precedes reversible pulpitis
defense mechanisms involved in protection of this tissue.48 c. a condition that resolves when the causative agent is
Arthus-type reactions do occur in the dental pulp.49 In addi- removed
tion, the presence of immunocompetent cells, such as T lym- d. a condition that yields a negative response to thermal
phocytes, macrophages, and class II molecule-expressing pulp testing
cells appearing as dendritic cells (Fig. 4.11) in inflamed pulps,
indicates that delayed hypersensitivity reactions can also ANS: a
occur in this tissue.20 Despite their protective mechanisms, Irreversible pulpitis may be classified as symptomatic or
immune reactions in the pulp can result in the formation of asymptomatic. It is a clinical condition associated with sub-
small necrotic foci and eventual total pulpal necrosis. jective and objective findings indicating the presence of severe
REF: Immunologic Responses inflammation in the pulp tissue. Irreversible pulpitis is often
a sequel to and a progression of reversible pulpitis. Severe
7. What is the cause of pain during the progression of pulpal pulpal damage from extensive dentin removal during opera-
injury? tive procedures or impairment of pulpal blood flow as a result
a. elevation of the sensory nerve threshold of trauma or orthodontic movement of teeth may also cause
b. decrease of arteriole vasodilation irreversible pulpitis. Irreversible pulpitis is a severe inflamma-
c. increase of venule vascular permeability tory process that will not resolve even if the cause is removed.
d. decrease of pulp tissue pressure The pulp is incapable of healing and slowly or rapidly becomes
necrotic. Irreversible pulpitis can be symptomatic, with spon-
ANS: c taneous and lingering pain. It can also be asymptomatic, with
Pain is often caused by several factors. The release of media- no clinical signs and symptoms.
tors of inflammation causes pain directly by lowering the Irreversible pulpitis is usually asymptomatic. However,
sensory nerve threshold. These substances also cause pain patients may report mild symptoms. Irreversible pulpitis may
indirectly by increasing both vasodilation in arterioles and also be associated with intermittent or continuous episodes of
vascular permeability in venules, resulting in edema and ele- spontaneous pain (with no external stimuli). Pain resulting
vation of tissue pressure. This pressure acts directly on sensory from an irreversibly inflamed pulp may be sharp, dull, local-
e10 nerve receptors. ized, or diffuse and can last anywhere from a few minutes up
REF: Lesion Progression to a few hours.
Localization of pulpal pain is more difficult than localiza- pulp necrosis ensues, and treatment of the tooth becomes
tion of periradicular pain and becomes more difficult as the more difficult.
pain intensifies. Application of an external stimulus, such as REF: Pulp Calcification; Internal (Intracanal) Resorption
cold or heat, may result in prolonged pain. Accordingly, in the
presence of severe pain, pulpal responses differ from those of 11. What are the signs and symptoms associated with symp-
uninflamed teeth or teeth with reversible pulpitis. For example, tomatic apical periodontitis (SAP)?
application of heat to teeth with irreversible pulpitis may a. normal sensation on mastication
produce an immediate response; also, occasionally with the b. normal sensation on finger pressure
application of cold, the response does not disappear and is c. marked or excruciating pain on tapping with a mirror
prolonged. Application of cold in patients with painful irre- handle
versible pulpitis may cause vasoconstriction, a drop in pulpal d. presence of a large periapical lesion
pressure, and subsequent pain relief. Although it has been
claimed that teeth with irreversible pulpitis have lower thresh- ANS: c
olds to electrical stimulation, Mumford found similar pain Clinical features of SAP are moderate to severe spontaneous
perception thresholds in inflamed and uninflamed pulps.56 discomfort and also pain on biting or percussion. If SAP is an
REF: Irreversible Pulpitis extension of pulpitis, its signs and symptoms will include
responsiveness to cold, heat, and electricity. Cases of SAP
10. Which of the following is not a hard tissue change that caused by a necrotic pulp do not respond to vitality tests.
may result from pulpal irritation or inflammation? Application of pressure by the fingertip or tapping with
a. calcification of pulp tissue spaces the butt end of a mirror handle (percussion) can cause marked
b. resorption of pulp tissue spaces to excruciating pain. SAP is not associated with an apical
c. formation of pulp stones radiolucency. Occasionally, there may be slight radiographic
d. thickening of the periodontal ligament changes, such as a “widening” of the PDL space or a very
small radiolucent lesion; however, usually there is a normal
ANS: d PDL space with an intact lamina dura.
Extensive calcification (usually in the form of pulp stones or REF: Symptomatic Apical Periodontitis
diffuse calcification) occurs as a response to trauma, caries,
periodontal disease, or other irritants. Thrombi in blood 12. What histologic feature differentiates a periapical granu-
vessels and collagen sheaths around vessel walls are possible loma from a periapical cyst?
sources of these calcifications. a. presence of mast cells
Another type of calcification is the extensive formation of b. presence of lymphocytes
hard tissue on dentin walls, often in response to irritation or c. presence of plasma cells
death and replacement of odontoblasts. This process is called d. presence of an epithelium-lined cavity
calcific metamorphosis (Fig. 4.14). As irritation increases, the
amount of calcification may also increase, leading to partial ANS: d
or complete radiographic (but not histologic) obliteration of Histologically, AAP lesions are classified as either granulo-
the pulp chamber and root canal.57 A yellowish discoloration mas or cysts. A periapical granuloma consists of granuloma-
of the crown is often a manifestation of calcific metamorpho- tous tissue infiltrated by mast cells, macrophages, lymphocytes,
sis. The pain threshold to thermal and electrical stimuli usually plasma cells, and occasionally, PMN leukocytes (Fig. 4.21).
increases; often the teeth are unresponsive. Multinucleated giant cells, foam cells, cholesterol clefts, and
Palpation and percussion are usually within normal limits. epithelium are often found.
In contrast to soft tissue diseases of the pulp, which have no The apical (radicular) cyst has a central cavity filled with
radiographic signs and symptoms, calcification of pulp tissue an eosinophilic fluid or semisolid material and is lined by
is associated with various degrees of pulp space obliteration. stratified squamous epithelium (Fig. 4.22). The epithelium is
A reduction in coronal pulp space followed by a gradual nar- surrounded by connective tissue containing all cellular ele-
rowing of the root canal is the first sign of calcific metamor- ments found in the periapical granuloma. Therefore an apical
phosis. This condition is not pathologic in nature and does not cyst is a granuloma that contains a cavity or cavities lined with
require treatment. epithelium. The origin of the epithelium is the remnants of
Inflammation in the pulp may initiate resorption of adjacent Hertwig’s epithelial sheath, the cell rests of Malassez. These
hard tissues. The pulp is transformed into a vascularized cell rests proliferate in response to inflammatory stimuli. The
inflammatory tissue with dentinoclastic activity; this condi- actual genesis of the cyst is unclear.
tion leads to the resorption of the dentinal walls, advancing REF: Symptomatic Apical Periodontitis (Histologic
from its center to the periphery.58 Most cases of intracanal Features)
resorption are asymptomatic. Advanced internal resorption
involving the pulp chamber is often associated with pink spots
in the crown.
Teeth with intracanal resorptive lesions usually respond
within normal limits to pulpal and periapical tests. Radio-
graphs reveal radiolucency with irregular enlargement of the
root canal compartment (Fig. 4.15). Immediate removal of the
inflamed tissue and completion of root canal treatment are
recommended; these lesions tend to be progressive and even- e11
tually perforate to the lateral periodontium. When this occurs,
13. Which of the following is not associated with acute apical ANS: c
abscess (AAA)? A number of radiolucent and radiopaque lesions of nonendodon-
a. moderate to severe discomfort tic origin simulate the radiographic appearance of endodontic
b. an intense and prolonged response to thermal lesions. Because of their similarities, dentists must use their
stimulus knowledge and perform clinical tests in a systematic manner to
c. a negative response to electrical pulp testing arrive at an accurate diagnosis and avoid critical mistakes. Pulp
d. pain on percussion and palpation vitality tests are the most important aids in differentiating
between endodontic and nonendodontic lesions. Teeth associ-
ANS: b ated with radiolucent periradicular lesions have necrotic pulps
AAA is characterized by a rapid onset and spontaneous pain. and therefore generally do not respond to vitality tests. In con-
Depending on the severity of the reaction, patients with AAA trast, lesions of nonpulpal origin usually do not affect the blood
usually have moderate to severe discomfort and/or swelling. or nerve supply to adjacent tooth pulp; therefore, the vitality
There often is no swelling if the abscess is confined to bone. (responsiveness) of these teeth remains unaffected.
In addition, patients occasionally have systemic manifesta- Unfortunately, many clinicians rely solely on radiographs
tions of an infective process, such as an elevated temperature, for diagnosis and treatment, without obtaining a complete
malaise, and leukocytosis. Because these findings are only history of the signs and symptoms and performing clinical
observed in association with a necrotic pulp, electrical or tests. Many nonendodontic radiolucencies (including those
thermal stimulation produces no response. However, these resulting from pathoses and those with normal morphology)
teeth are usually painful on percussion and palpation. Depend- mimic endodontic pathoses and vice versa. To avoid grievous
ing on the degree of hard tissue destruction inflicted by irri- mistakes, all relevant vitality tests, radiographic examinations,
tants, radiographic features of AAA range from no changes clinical signs and symptoms, and details of the patient history
to widening of the PDL space to an obvious radiolucent should be used.
lesion. REF: Nonendodontic Periradicular Pathosis (Differential
REF: Acute Apical Abscess (Signs and Symptoms) Diagnosis)
14. What factors may impact and influence whether perira- 16. Localization of pulpal pain is more difficult than localiza-
dicular lesions heal completely or incompletely? tion of periradicular pain.
a. size of the lesion a. true
b. blood supply b. false
c. systemic disease
d. all of the above ANS: a
Localization of pulpal pain is more difficult than localization
ANS: d of periradicular pain and becomes more difficult as the pain
The level of healing is proportional to the degree and extent intensifies.
of tissue injury and the nature of tissue destruction. When REF: Irreversible Pulpitis (Symptoms)
injury to the underlying tissues is slight, little repair or regen-
eration is required. On the other hand, extensive damage 17. What is the distinguishing characteristic of a chronic
requires substantial healing (Fig. 4.23). In other words, pulp apical abscess (CAA)?
and periradicular repair ranges from a relatively simple reso- a. a positive response to thermal pulp testing
lution of an inflammatory infiltrate to considerable reorgani- b. a negative response to thermal pulp testing
zation and repair of a variety of tissues. c. the presence of an apical radiolucency
REF: Healing of Pulp and Periapical Tissues (Extent of d. the presence of an abscess that is draining to a mucosal
Healing) or skin surface
15. What is the most important aid in distinguishing between ANS: d

endodontic and nonendodontic periradicular lesions? CAA is an inflammatory lesion of pulpal origin that is char-
a. radiographic location acterized by the presence of a long-standing lesion that has
b. radiographic appearance resulted in an abscess that is draining to a mucosal (sinus
c. pulp vitality testing tract) or skin surface.
d. patient’s history REF: Chronic Apical Abscess
e12

Richard E. Walton, Ashraf F. Fouad
CHAPTER 5 oral bisphosphonates compared with those seen in other

Diagnosis, Treatment Planning, and patients.85
Systemic Considerations REF: Risk for Osteoradionecrosis or Osteonecrosis of the Jaw
1. Which of the following is not one of the five basic steps
in the diagnostic process? 4. When pain is one of the patient’s complaints, what ques-
a. chief complaint tion is less relevant regarding the pain and does not need
b. medical and dental history to be asked of the patient?
c. oral examination a. When did the pain begin?
d. review of insurance coverage b. Is the pain always in the same place?
c. Why did you not seek treatment when the pain began?
ANS: d d. Once initiated, how long does the pain last?
The basic steps in the diagnostic process are:
(1) chief complaint ANS: c
(2) history (medical and dental) The following questions should be asked:
(3) oral examination. (1) When did the pain begin?
(4) data analysis, leading to a differential diagnosis (2) Where is the pain located?
(5) treatment plan (3) Is it always in the same place?
REF: Introduction (4) What is the character of the pain (short, sharp, long
lasting, dull, throbbing, continuous, occasional)?
2. Are patients who seek endodontic treatment usually (5) Does the pain prevent you from sleeping or working?
younger or older than the general population? (6) Is it worse in the morning?
a. Age has not been shown to be a factor. (7) Is it worse when you lie down?
b. younger (8) Did or does anything initiate the pain (trauma,
c. older biting)?
(9) Once initiated, how long does the pain last?
ANS: c (10) Is it continuous (spontaneous) or intermittent?
The population seeking and requiring endodontic treatment is (11) Does anything make it worse (hot, cold, biting)?
older, on average, than the general population and shows a Does anything make it better (cold, analgesics)?
higher and more complex incidence of systemic medical REF: The Pain Referral Phenomenon
problems.
REF: Health and Medical History 5. Why is it important to use control teeth during the clinical
tests?
3. During a review of the patient’s health history, the clini- a. to calibrate the patient’s response
cian notes that the patient is on a regimen of intravenous b. so that the patient can indicate which tooth is being
bisphosphonate medication. What significance does this tested
hold for the patient and the treatment plan? c. so that teeth can be tested repeatedly
a. possible side effect of bleeding disorders d. to test whether isolation is adequate
b. possible side effect of osteonecrosis of the jaw
c. lowered pain threshold ANS: a
d. inability to obtain adequate anesthesia In using any test, it is important to include control teeth of a
type similar to that of the suspect tooth or teeth (e.g., upper
ANS: b molar, lower incisor). The result of tests on these teeth “cali-
Over the past decade, it has been recognized that patients brates” and provides a baseline for the patient’s responses to
undergoing bisphosphonate therapy may be at risk of osteo- tests on suspected teeth. The patient should not be told whether
necrosis of the jaw (BRONJ). This risk is greater with intra- the tooth being tested is a control or suspect tooth. The clini-
venous bisphosphonates, particularly if more than one agent cian should be aware that a patient may not respond in the
is used simultaneously, and it increases with the duration of same way or to the same extent when tests are repeated. The
bisphosphonate use and with surgical procedures such as first application of the test is the most significant.
extractions.82 Although rare, BRONJ may occur after end- REF: Clinical Tests (Control Teeth)
odontic treatment83 or endodontic surgery.84 When nonsurgi-
cal endodontic treatment is performed on a patient undergoing
IV bisphosphonate therapy, care should be taken not to injure
the soft tissue. For example, the clamps should be carefully
placed to avoid injury to the soft tissues and alveolar bone.
Oral bisphosphonates pose a much lower risk of BRONJ; no e13
difference in endodontic outcome is seen in patients taking
6. A painful response obtained by pressing or by tapping whether there is partial necrosis. Electrical pulp testers with
on the crown indicates the presence of which of the digital readouts are popular (Fig. 5.10). These testers are not
following? inherently superior to other electrical testers but are more user
a. periapical inflammation friendly. High readings usually indicate necrosis. Low read-
b. pulpal inflammation ings indicate vitality. Testing of normal control teeth estab-
c. both pulpal and periapical inflammation lishes the approximate boundary between the two conditions.
The exact number of the reading is of no significance and does
ANS: a not detect subtle degrees of vitality, nor can any electrical pulp
Percussion is performed by different means. One way is tester indicate inflammation.30
tapping on the incisal or occlusal surface of the tooth with the REF: Pulp Vitality Tests (Electrical Pulp Testing)
end of a mirror handle held either parallel or perpendicular to
the crown. This should be preceded by gentle digital pressure 10. Which of the following is a characteristic of a periapical
to detect teeth that are very tender and should not be tapped lesion of endodontic origin?
with the mirror handle. If a painful response is obtained, this a. The lamina dura of the tooth socket is intact.
may indicate the presence of periapical inflammation. Periapi- b. The lucency remains at the apex in radiographs made
cal inflammation may produce a sharp pain. at different cone angles.
REF: Percussion and Palpation of Supporting Tissues c. The lucency tends to resemble a round circle.
d. The lesion is usually associated with an irreversible
7. What is palpation testing used to determine? pulpitis.
a. pulpal inflammation
b. periapical inflammation ANS: b
c. periodontal inflammation Periapical lesions of endodontic origin usually have four char-
d. periapical histology acteristics: (1) the lamina dura of the tooth socket is lost api-
cally; (2) the lucency remains at the apex in radiographs made
ANS: b at different cone angles; (3) the lucency tends to resemble a
Palpation is firm pressure on the mucosa overlying the apex. hanging drop; and (4) the lesion is usually seen with a necrotic
Like percussion, palpation determines how far the inflamma- pulp.
tory process has extended periapically. A painful response to REF: Periapical Lesions
palpation indicates periapical inflammation.
REF: Palpation and Percussion 11. In which situation is caries removal necessary to obtain a
definitive pulpal diagnosis?
8. Which of the methods of cold testing is preferred for pulp a. deep radiographic caries with no symptoms and nega-
testing? tive pulp testing
a. regular ice (frozen water) b. deep radiographic caries with no symptoms and posi-
b. refrigerant spray or CO2 ice tive pulp testing
c. flooding the arch with chilled water c. shallow radiographic caries with mild symptoms and
d. a blast of air from the air/water syringe positive pulp testing
d. shallow radiographic caries with mild symptoms and
ANS: b negative pulp testing
Three methods are generally used for cold testing: frozen
water (ice), carbon dioxide (CO2) ice (dry ice), and refriger- ANS: b
ant. CO2 ice requires special equipment, whereas refrigerant Determining the depth of caries penetration is necessary in
in a spray can is more convenient (Fig. 5.8). Regular ice some situations for definitive pulp diagnosis. A common clini-
delivers less cold and is not as effective as refrigerant or cal situation is the presence of deep caries on radiographs with
CO2 ice. One study found that refrigerant sprayed on a large no significant history or presenting symptoms and a pulp that
cotton pellet was the most effective in reducing the tempera- responds to clinical tests. All other findings are normal. The
ture within the chamber under full-coverage restorations.24 final definitive test is complete caries removal to establish
Overall, refrigerant spray and CO2 ice are equivalent for pulp pulp status. Exposure by soft caries is irreversible pulpitis;
testing. nonexposure is reversible pulpitis.
REF: Cold Tests REF: Caries Removal
9. How does electrical pulp testing determine the degree of 12. How may selective anesthesia be an aid in diagnosis?
pulpal inflammation? a. It can localize a painful tooth to a specific arch.
a. Higher readings indicate a healthier pulp. b. It can localize an individual painful tooth in the man-
b. Lower readings indicate a healthier pulp. dibular arch.
c. A midrange response indicates partial necrosis. c. It can confirm the tooth the patient identifies as the
d. It cannot determine whether pulp tissue is inflamed. offending tooth.
d. PDL injection will only anesthetize one tooth at a time.
ANS: d
An electrical pulp test, conducted correctly, will usually deter- ANS: a
mine whether there is vital tissue within the tooth. It cannot Selective anesthesia can be useful in localizing a painful tooth
e14 determine whether that tissue is inflamed, nor can it indicate when the patient cannot identify the offender. If a mandibular
tooth is suspected, a mandibular block will confirm at least ANS: c

the region if the pain disappears after the injection. Selective It is generally known that diabetics have an increase preva-
anesthesia of individual teeth is not useful in the mandible. lence of teeth with periapical lesions.67-70 The longitudinal
The periodontal ligament injection will often anesthetize treatment outcome is generally no different between diabetics
several teeth. However, it is marginally more effective in the and nondiabetics.71-73 However, if the outcomes of cases with
maxilla. Anesthetic should be administered to individual teeth and without preoperative periapical lesions are separated, a
in an anterior to posterior sequence because of the pattern of notable difference is observed. In cases with preoperative
distribution of the sensory nerves. lesions, diabetics are significantly less likely to have success-
REF: Selective Anesthesia ful treatment than nondiabetics, especially when the study
controls for a number of other confounding factors.72 More
13. What type of resorption may alter the geometry of the recently it has been shown that in cases with preoperative
apex? lesions that were adequately treated endodontically, the area
a. internal of the residual lesions 2 to 4 years after treatment correlated
b. inflammatory cervical significantly with the degree of glycemia in both diabetics and
c. external apical nondiabetics, as measured by the hemoglobin A1c test.74 This
d. regenerative is consistent with older observations that healing of periapical
lesions correlated with postprandial glycemia at the time of
ANS: c treatment.75
Resorption may be either internal or external. Perforat- REF: Diabetes Mellitus
ing (pulp-periodontal communication) resorptions are often
complex. Tooth resorption, whether internal or external, is 15. What conditions present the practitioner with a diagnostic
high risk and should be referred for evaluation and treatment challenge?
(Fig. 5.20). Limited internal resorption may not present treat- a. pain of an isolated nature
ment complications, but external apical resorption may drasti- b. inability to reach a definitive diagnosis
cally alter the geometry of the apex or the root surface. c. patients with a low level of anxiety
Extensive apical or root surface resorption is best referred. d. patients requiring premedication for an artificial
REF: Resorption prosthesis
14. During a review of the patient’s health history, the clini- ANS: b
cian notes that the patient is diabetic. What significance Appropriate treatment follows accurate diagnosis. Many pro-
does this hold for the patient and the treatment plan? cedures are done inappropriately (or not done) because of
a. Diabetic patients have a decreased prevalence of teeth diagnostic errors. The endodontist is experienced, and the
with periapical lesions. generalist may be unfamiliar with that particular problem.
b. The longitudinal treatment outcome is improved in dia- Referred pain is a good example of a condition that often
betic patients. presents the practitioner with a significant diagnostic chal-
c. Residual lesions 2 to 4 years after treatment correlate lenge. Unless a definitive diagnosis is obtained, no treatment
significantly with the degree of glycemia. should be rendered and the patient should be referred
d. Diabetic patients are significantly more likely to have (Box 5.6).
flare-ups. REF: Treatment Planning Considerations
e15

Ashraf F. Fouad, Mahmoud Torabinejad
CHAPTER 6 5. The standard of care in endodontics is set by:

Interaction between the General Dentist and a. attorneys
the Endodontist b. endodontists
1. The definition of the standard of care in endodontics dic- c. The American Dental Association
tates that the level of care provided by a general dentist d. The Commission on Dental Accreditation
should be similar to that provided by an endodontist.
a. true ANS: b
b. false Students and general dentists should know where information
on the standard of care in endodontics can be obtained when
ANS: a needed.
It is critical that the general dentist understand that he or she REF: Standards of Endodontic Care and Case Documentation
is held to the same standard as an endodontist when rendering
endodontic treatment. 6. Which of the following is a departure from the standard
REF: Introduction of care?
a. failure to perform pulp testing prior to diagnosing
2. How many specialties are recognized by the American pulpal disease
Dental Association (ADA)? b. not using a rubber dam during endodontic treatment
a. 7 c. not following aseptic technique and infection control
b. 9 guidelines
c. 11 d. all of the above
d. 12
ANS: d
ANS: b All of the circumstances described represent failures to follow
The recognition of a specialty area of practice is the purview treatment steps that must be taken to ensure that the procedure
of the ADA, and the specialty must be recognized according is performed according to accepted standards.
to the standards established. REF: Standards of Endodontic Care and Case Documentation
REF: Specialty Qualifications in the United States
7. Which of the following statements applies to a tooth with
3. The proportion of endodontic treatment performed by a cast restoration?
general dentists in the United States is approximately: a. Endodontic access should be straightforward.
a. 10% b. The anatomy of the restoration may not accurately
b. 30% reflect the anatomy of the tooth.
c. 50% c. The pulp chamber is often readily visible
d. 75% radiographically.
d. Angulation of the tooth will be accurately represented
ANS: d by the cast restoration.
The responsibility for 75% of endodontic treatment lies in the
hands of the general dentist; therefore, it is important that ANS: b
these clinicians know which cases are appropriate for them The complexities of access through a cast restoration should
and which should be referred. be recognized before treatment is started, and referral often is
REF: Endodontic Practice Figures in the United States advisable in this situation.
REF: Existing Restorations
4. According to insurance company databases, the retention
rate for endodontically treated teeth is:
a. 80% to 83%
b. 60% to 65%
c. 94% to 97%
d. 90% to 92%
ANS: c
Endodontics has a very high success rate and should always
be considered as a treatment option.
e16 REF: Endodontic Practice Figures in the United States
8. Which of the following is classified as a procedural 10. A referral to an endodontist should include:
accident? a. a description of how the specific tooth fits into the
a. Extensive caries preventing adequate rubber dam overall treatment plan
isolation b. pertinent findings from the examination
b. Inability to obtain reliable pulp testing results c. written instructions on which tooth is to be evaluated
c. A separated instrument and treated
d. Swelling after nonsurgical root canal treatment d. All of the above.
ANS: c ANS: d
Procedural accidents are one reason for referral and are a A complete referral makes communication easier and elimi-
direct result of treatment rather than preoperative conditions, nates the need for follow-up phone calls for clarification.
diagnostic testing, or postoperative symptoms. A separated REF: What is Expected of a General Practitioner
instrument is one of the most difficult accidents to correct.
REF: Referral During Treatment (Procedural Accidents)
9. Persistent pathosis after initial root canal treatment should

be evaluated by an endodontist for possible retreatment or
surgical intervention.
a. true
b. false
ANS: a
Whenever persistent pathosis is present, the patient should be
given all options for treatment, including retreatment or end-
odontic surgery, not just extraction.
REF: Referral After Treatment
e17

Mahmoud Torabinejad, Ilan Rotstein
CHAPTER 7 4. A narrow vertical probing defect associated with a tooth

Endodontic-Periodontic Interrelationship exhibiting pulp necrosis but no or mild periodontal disease
1. Which of the following are potential avenues for com- is most likely a:
munication between the dental pulp and the a. horizontal root fracture
periodontium? b. fistula
a. dentinal tubules c. draining sinus tract
b. apical foramen d. periodontal abscess
c. lateral/accessory canals
d. all of the above ANS: c
Etiology and diagnosis of an isolated probing defect as related
ANS: d to endodontic pathosis.
Understanding that periodontal disease is not limited to just REF: Primary Periodontal Defects of Pulpal (Endodontic)
the sulcus is important. The PDL is one part of the periodon- Origin
tium and can be affected by pulpal disease via any route of
communication between the pulp space and the external root 5. Which of the following is a way that periodontal inflam-
surface. Conversely, the pulp can be affected by any periodon- mation resulting from primary endodontic disease may
tal process that involves or exposes a route of communication mimic periodontal disease?
between the PDL and the pulp space. a. a generalized increase in probing depths in the affected
REF: Pathways of Communication Between the Dental Pulp quadrant
and the Periodontium b. an apical radiolucency
c. a narrow, deep solitary probing defect associated with
2. Which of the following is a characteristic of dentinal an affected tooth
tubules in radicular dentin? d. all of the above
a. The diameter ranges from 1 to 3 µm.
b. The apical tubules are larger than the coronal tubules. ANS: c
c. The diameter increases with age. This feature helps differentiate between the presentation of
d. The density increases in the coronal-to-apical primary periodontal disease and strictly endodontic pathosis
direction. and that of endodontically induced periodontal changes.
REF: Primary Periodontal Defects of Pulpal (Endodontic)
ANS: a Origin
Understanding the anatomy of the tubules and the fact that
dentin has a direct line of communication with the pulp is 6. The classification of periodontic-endodontic disease
important in understanding the effects of restorative and peri- includes which of the following?
odontal procedures. a. endodontic (pulpal) origin
REF: Pathways of Communication Between the Dental Pulp b. periodontal origin
and the Periodontium c. endodontic-periodontic origin (true combined lesion)
d. all of the above
3. Patent accessory canals are characterized by which of the
following? ANS: d
a. They can serve as a pathway for microorganisms from Because this represents a change from the previous classifica-
pulp to periodontium. tions of endodontic-periodontic pathosis, awareness of this
b. They can result in a lateral radiolucency if associated change is important.
with a necrotic pulp. REF: Classification and Differential Diagnosis of Endodontic-
c. They are more common in the apical third of posterior Periodontic Lesions
teeth.
d. All of the above
ANS: d
Understanding the common location of these canals aids
in the diagnosis of lateral radiolucencies and helps the clini-
cian understand the pathogenesis of endodontic-periodontic
lesions.
REF: Pathways of Communication Between the Dental Pulp
e18 and the Periodontium
7. Which of the following best represents similarities 9. What is the best means of differentiating endodontic from
between endodontic apical and periodontal pathosis? periodontal pathosis?
a. Both are often the results of traumatic occlusion. a. pulp vitality testing
b. Both are usually symptomatic. b. percussion
c. Both are mediated by microorganisms. c. radiographs
d. Both are associated with loss of attachment. d. location of swelling
ANS: c ANS: a
The common etiologic factor in both periodontal and end- Pulp testing usually indicates the presence or absence of
odontic disease is the presence and effect of microorganisms pulpal pathosis; therefore, an endodontic origin can be ruled
on the respective tissues. in or out with a high degree of confidence.
REF: Effect of Pulpal Diseases and Endodontic Procedures REF: Clinical and Radiographic Tests for Diagnosis of
on the Periodontium Endodontic-Periodontic Lesions
8. Which of the following is characteristic of the true com- 10. Treatment for primary endodontic disease with concurrent
bined endodontic-periodontic lesion? periodontal disease of pulpal origin is treated best by:
a. It occurs much less frequently than the primary end- a. scaling and root planning followed by endodontic
odontic lesion. treatment
b. It is usually the end result of a severe endodontic lesion b. endodontic treatment followed by scaling and root
that causes loss of attachment. planning
c. It is usually the end result of a severe periodontal c. endodontic treatment followed by periodontal surgery
lesion. d. endodontic treatment followed by reevaluation of peri-
d. It is usually successfully managed with both endodon- odontal status in 2 to 3 months
tic and periodontal treatment.
ANS: d
ANS: a If the pulpal disease created a periodontal defect, that defect
It is important that the clinician understand the distinguishing should resolve with adequate endodontic treatment; therefore,
features of the true combined endodontic-periodontic lesion. the decision to proceed with periodontal treatment should be
REF: Secondary Endodontic-Periodontic Defects made after a reevaluation to determine the effect of the end-
odontic treatment.
REF: Primary Periodontal Defects of Endodontic (Pulpal)
Origin
e19

Eric M. Rivera, Richard E. Walton
ANS: c
CHAPTER 8 The fracture may or may not include the pulp. The more
Longitudinal Tooth Fractures centered the fracture, the greater the chance of pulp exposure,
1. What category of longitudinal tooth fractures is most at the time or later. Occasionally, fractures oriented toward
severe? the faciolingual surface shear away from the pulp, although
a. craze lines this is not likely and is difficult to determine clinically. There-
b. fractured cusp fore, many cracked teeth require root canal treatment, prefer-
c. cracked tooth ably before restoration for coronal protection.
d. vertical root fracture REF: Cracked Tooth (Clinical Features)
ANS: d 5. Do pulp and periapical tests for cracked teeth provide

The types of longitudinal tooth fractures, from least to most consistent and reliable results?
severe, are (1) craze lines, (2) fractured cusp, (3) cracked a. Both pulp and periapical test results are consistent.
tooth, (4) split tooth, and (5) vertical root fracture. b. Pulp test results are consistent, but periapical test
REF: Categories results vary.
c. Pulp test results vary, but periapical test results are
2. What clinical conditions or situations are often associated consistent.
with cusp fractures? d. Both pulp and periapical test results can vary.
a. teeth with minimal caries
b. strong support of the remaining cusps ANS: d
c. missing marginal ridge Cracked teeth show a variety of test results, radiographic find-
d. occlusal composite restorations ings, and signs and symptoms, depending on many factors.
This variety and unpredictability often make the cracked tooth
ANS: c a perplexing diagnostic and treatment entity. Again, cracks are
Cusp fractures often occur in teeth with extensive caries or findings only, and the pulpal/periradicular diagnosis is deter-
large restorations that do not protect undermined cusps. These mined as in other clinical situations.
fractures are related to lack of cusp support. Cusp fractures Often cracked teeth manifest as the so-called cracked tooth
are usually associated with a weakened marginal ridge in syndrome.52 This syndrome is characterized by acute pain on
conjunction with an undermined cusp. These compromise mastication (pressure or release) of grainy, tough foods and
dentin support for the cusp, which is supplied primarily by sharp, brief pain with cold.53,55,56 These findings are also
the marginal ridge. related to cusp fracture. However, cracked teeth may present
REF: Fractured Cusp (Pathogenesis) with a variety of symptoms ranging from slight to severe
spontaneous pain consistent with irreversible pulpitis, pulp
3. Fractures in cracked teeth most often extend in what necrosis, or apical periodontitis.24 Even an acute apical
direction? abscess, with or without swelling or a draining sinus tract,
a. mesiodistal may be present if the pulp has undergone necrosis. In other
b. faciolingual words, once the fracture has extended to and exposed the pulp,
c. apical to coronal severe pulp and/or periapical pathosis will be present. This
d. horizontal explains the variation in signs and symptoms that can be
confusing and misleading in the determination of a diagnosis;
ANS: a therefore, the condition should not be termed a syndrome.57
Cracks in teeth are almost invariably mesiodistal fractures, Pulp and periapical tests also have variable results. The
although mandibular molars occasionally (rarely) fracture pulp is usually responsive (vital)52 but may be nonresponsive
toward the faciolingual surface. (necrosis). On periapical tests, pain usually is not elicited with
REF: Cracked Tooth percussion or palpation if the pulp is vital. Directional percus-
sion is also advocated. Percussion that separates the crack
4. Which statement is true about pulp tissue involvement in may cause pain. Opposite-direction percussion usually is
a cracked tooth? asymptomatic. This pain is probably related to stimulation of
a. The fracture always includes the pulp tissue. the periodontal ligament proprioceptors.
b. The fracture never includes the pulp tissue. REF: Cracked Tooth (Diagnosis; Subjective Findings; Objec-
c. The more centered the fracture, the greater the chance tive Tests)
of pulp exposure.
d. The more facially or lingually oriented the crack, the
e20 greater the chance for pulp exposure.
6. How can transillumination be used to distinguish between 8. What is the preferable restoration of a cracked tooth?
a craze line and a crack line? a. post and core and crown
a. It cannot be used to distinguish between the two b. amalgam core
entities. c. cast inlay
b. Transmitted light readily passes through the air space d. full coverage crown
of a fracture.
c. Transilluminated light is blocked by craze lines. ANS: d
d. Transilluminated light is blocked by a cracked tooth. If the fracture appears to be incomplete (not terminating on a
root surface), the tooth is restored to bind the fractured seg-
ANS: d ments (barrel stave effect) and also to protect the cusps. For
Craze lines in posterior teeth that cross marginal ridges or a permanent restoration, a full crown is preferred, although
buccal and lingual surfaces must be differentiated with transil- an onlay with bevels may suffice. Posts and internally wedging
lumination. With craze lines, transilluminated light from the foundations are to be avoided. Acid-etch dentin bonding
facial or lingual surface is not blocked or reflected and the resins may help provide a foundation for the crown to prevent
entire tooth in a faciolingual orientation is illuminated. crack propagation, although more research is necessary to
When a crack is suspected, it is important to try to visualize support this concept. Amalgam, which tends to expand and
the length and location of the fracture. Direct inspection which requires a wedging effect with condensation, is not a
(again, a microscope is helpful), staining, and transillumina- good choice.
tion are usually effective.24,72,73 Occlusal and proximal restora- REF: Cracked Tooth (Restoration)
tions are first removed.74 Then transillumination (Fig. 8.10),
which often shows a characteristic abrupt blockage of trans- 9. How does a split tooth differ from a cracked tooth?
mitted light, is performed. With transillumination the portion a. A split tooth precedes a cracked tooth.
of the tooth where the light originates illuminates to the frac- b. A split tooth has an incomplete fracture.
ture. A fracture contains a thin air space, which does not c. A split tooth has separable tooth segments.
readily transmit light. Therefore, the crack (or fracture) blocks d. In a cracked tooth, the fracture extends faciolingually.
or reflects the light, causing the other portion to appear dark.
REF: Cracked Tooth (Other Findings) ANS: c
A split tooth is the evolution of a cracked tooth. The fracture
7. After access preparation of a suspected cracked tooth, the is now complete and extends to a surface in all areas.11 The
crack line is seen to extend through the chamber floor. In root surface involved is in the middle or apical third. There
this case, what is the prognosis and recommended are no dentin connections; tooth segments are entirely sepa-
treatment? rate (Fig. 8.14, C). The split may occur suddenly, but it more
a. The prognosis is favorable, and the clinician should likely results from long-term growth of an incomplete fracture
continue with root canal treatment. (Table 8.1).
b. The prognosis is questionable, and the clinician should REF: Split Tooth
inform the patient of this and continue with
treatment. 10. In what direction does a vertical root fracture (VRF) pri-
c. The prognosis is poor, and tooth extraction is usually marily occur?
recommended. a. mesiodistal
d. This finding does not change the original prognosis, b. faciolingual
and the treatment plan is not altered. c. coronal and extending apically
d. no primary direction
ANS: c
After endodontic access, the pulp chamber floor is examined. ANS: b
If the fracture extends through the chamber floor, generally Vertical root fractures occur primarily in the faciolingual
further treatment is hopeless and extraction is preferred (Fig. plane.
8.12).79 An exception is the maxillary molar, which may be REF: Vertical Root Fracture (Clinical Features)
hemisected along the fracture, saving half (or both halves) of
the crown and supporting roots. Many of these treatments are
complex, and the patient should be considered for referral to
an endodontist. If a partial fracture of the chamber floor is
detected, the crown may be bound with a stainless steel or an
orthodontic band (Fig. 8.12) or a temporary crown to protect
the cusps until final restoration is performed.23,80 This also
helps to determine whether symptoms decrease during root
canal treatment. The rationale (unsupported) is that if pain
symptoms are not relieved, the prognosis is significantly
poorer and extraction may be necessary.
REF: Cracked Tooth (Further Examination)
e21
11. Which of the following is a demonstrated major cause of entities, such as periodontal disease or failed root canal treat-
VRFs? ment. This variety of findings often makes VRF a perplexing
a. traumatic occlusion diagnosis.94 Interestingly, because VRFs are often mistaken
b. occlusal biting habits for periodontal lesions or for failed root canal treatment, the
c. loss of one or both marginal ridges dentist may refer these patients with difficult diagnoses to the
d. condensation forces during obturation periodontist or endodontist, presumably for periodontal
therapy or endodontic retreatment.
ANS: d Diagnostic findings of VRF were reported in a series of 42
There are two major causes (the only demonstrated ones) of clinical cases in a study performed by Michelich and col-
vertical root fractures. These are (1) post placement (cementa- leagues.28 Much of the information that follows is derived
tion) and (2) condensation during root canal filling. from the findings in that study, in conjunction with other
REF: Vertical Root Fracture (Etiologies) reports. Evidence-based data on the diagnostic accuracy and
clinical effectiveness of clinical and radiographic dental eval-
12. Which of the following is not a possible treatment for a uation for the diagnosis of VRF in endodontically treated teeth
VRF in a multirooted tooth? are lacking.123
a. tooth extraction Symptoms tend to be minimal. Seldom is the VRF painful;
b. nonsurgical retreatment of the affected root it is often asymptomatic or shows mild, insignificant signs and
c. amputation of the affected root symptoms. Often some mobility is detectable, but many teeth
d. hemisection and extraction of the affected root are stable. Periradicular symptoms (pain on pressure or mas-
tication) are common but mild.
ANS: b Because many VRFs resemble periodontal lesions, a
The only predictable treatment is removal of the fractured periodontal-type abscess (either as a presenting sign or in the
root. In multirooted teeth, this could be done by root resection history) is a common occurrence.93,103 In fact, this localized
(amputation) or hemisection (Fig. 8.22).134 swelling is often what brings the patient to the dentist’s office.
Other surgical and nonsurgical modalities have been sug- Periradicular tests of palpation and percussion are not par-
gested in attempts to reduce the fracture or retain the root; ticularly helpful. Periodontal probing patterns are more diag-
these include placement of calcium hydroxide, ligation or nostic. Significantly, some teeth with VRFs have normal
cementation of the fractured segments; and attempts to bind probing patterns.28,92,100 Most show significant probing depths
the segments using adhesive resins, epoxies, glass ionomer, with narrow or rectangular patterns, which are more typical
or mineral trioxide aggregate (MTA).7,135-137 A unique approach of endodontic-type lesions.94,97,103,124 These deep probing
is to extract the tooth; repair the fracture with a laser, cement, depths are not necessarily evident on both the facial and
or bonding agent; and then replant the tooth.138-141 Another lingual aspects. Overall, probing patterns are not in them-
uncommon approach is to perform intentional replantation of selves totally diagnostic, but they are helpful.
a vertically fractured root with intentional rotation 180 degrees Radiographs show a variety of patterns. At times there are
so that the surface with the fracture and breakdown of bone no significant changes.28,125 However, when present, bone
with granulomatous tissue is positioned against healthy bone resorptive patterns tend to be marked, extending from the apex
on the opposite side, and healthy periodontal ligament fibers along the lateral surface of the root, and often include angular
are positioned along the surface with previous bony break- resorption at the cervical root (Fig. 8.19).92,100,125,126 However,
down; the hope is that both surfaces will be better able to heal many of the resorptive patterns related to VRF mimic other
more effectively.142,143 Many of these suggested methods are entities. The resorptive pattern may extend over the apex and
impractical and have not been shown to have long-term effec- along one root surface, described as a “J-shaped” or “halo”
tiveness. Surgical repairs, such as removal of one of the frac- pattern.92,100,125,126 Lesions may resemble failed root canal
tured segments or repair with amalgam or resin after surgical treatment because they have an apical “hanging drop” appear-
exposure and preparation, have also been suggested, but suc- ance.92,100,125,126 In only a small percentage of teeth is there a
cessful results have limited documentation. visible separation of fractured root segments (Fig. 8.20).28
REF: Vertical Root Fracture (Treatment) Interestingly, VRFs may be more readily identified using CT
rather than conventional radiography.58-68 It is more often the
13. What is a common clinical finding in a tooth with a verti- pattern of bone loss, rather than visualizing an actual fracture,
cal root fracture? that is helpful when using CBCT.
a. moderate to severe pain The idea that a radiolucent line separating the root canal
b. excessive mobility filling material from the canal wall is diagnostic has been
c. a periodontal-type abscess advocated. However, this radiolucent line may be a radio-
d. a wide periodontal defect on the buccal and lingual graphic artifact, incomplete root canal filling, an overlying
aspects bony pattern, or other radiographic structure that is confused
with a fracture. Therefore, radiographs are helpful but are not
ANS: c solely diagnostic except in those few instances in which the
Vertical root fractures become manifest by a variety of signs, fracture is obvious.
symptoms, and other clinical findings. They may mimic other REF: Vertical Root Fracture (Findings)
e22

Al Reader, John M. Nusstein, Richard E. Walton
ANS: c
CHAPTER 9 A common belief is that an anesthetic solution warmed to or
Local Anesthesia above body temperature is better tolerated and results in less
1. What is the allodynia phenomenon? pain during injection. Although some studies have shown that
a. Inflamed tissue has an increased threshold of pain. warming anesthetic solutions did not reduce the pain of injec-
b. Inflamed tissue has a decreased threshold of pain. tion,15-17 others studies have found that warming reduced the
c. Inflamed tissue is much less sensitive to a mild pain of injection.18-20 Therefore, further research is needed on
stimulus. the effects of warming anesthetic solutions.
d. Inflamed tissue responds mildly to a stimulus that REF: Solution Warming
would otherwise be very painful.
4. Which of the following correctly describes the administra-
ANS: b tion of a two-stage injection?
Inflamed tissues have a decreased threshold of pain percep- a. The clinician injects a cartridge of anesthetic, waits 5
tion4; this is called the allodynia phenomenon. In other words, minutes, and then injects a second cartridge of the
a tissue that is inflamed is much more sensitive and reactive same anesthetic solution.
to a mild stimulus.4 Therefore, an inflamed tissue responds b. The clinician injects a cartridge of anesthetic and then
painfully to a stimulus that otherwise would be unnoticed or immediately injects a second cartridge of a different
perceived only mildly. Because root canal procedures gener- anesthetic solution.
ally involve inflamed pulpal or periradicular tissues, this phe- c. The clinician injects a quarter cartridge of anesthetic
nomenon has obvious importance. A related complication is under the mucosal surface, waits until regional anes-
that inflamed tissues are more difficult to anesthetize.5 thesia has been obtained, and then injects the remain-
REF: Tissue Inflammation der of the cartridge to full depth.
d. The clinician injects a quarter cartridge of anesthetic
2. Which of the following is not an element of the psycho- under the mucosal surface, waits until regional anes-
logical approach to pain management? thesia has been obtained, and then injects a cartridge
a. control of a different anesthetic solution to full depth.
b. communication
c. conservation ANS: c
d. confidence A two-stage injection is administered as follows: the clinician
gives an initial, very slow injection of approximately a quarter
ANS: c cartridge of anesthetic just under the mucosal surface; after
The psychological approach involves the four Cs: control, regional numbness has been achieved, the remainder of the
communication, concern, and confidence. Control is impor- cartridge is deposited to the full depth at the target site. The
tant and is achieved by obtaining and maintaining the upper two-stage injection reduces the pain of needle placement for
hand. Communication is accomplished by listening to the females in the inferior alveolar nerve block. This injection
patient and explaining what is to be done and what the patient technique is indicated for apprehensive and anxious patients
should expect. Concern is shown by verbalizing awareness of and for pediatric patients, but it may be used on anyone. It is
the patient’s apprehension. Confidence is expressed in body also effective for any injection including the inferior alveolar
language and in professionalism, which give the patient con- nerve block.
fidence in the management, diagnostic, and treatment skills REF: Two-Stage Injection
of the dentist. Including the four Cs in pain management
effectively calms and reassures the patient, thereby raising the
pain threshold.
REF: Psychological Approach
3. How does warming the anesthetic solution affect the

amount of pain the patient feels during the injection?
a. Warmed anesthetic results in prolonged duration of
anesthesia.
b. Warmed anesthetic solution results in greater pain
during injection.
c. No difference in pain perception has been confirmed
with warming. e23
5. When does the onset of pulpal anesthesia occur after the minutes in either tooth.132 Injecting an additional cartridge of
inferior alveolar injection for a mandibular premolar? 2% lidocaine with epinephrine at 30 minutes in anterior teeth
a. immediately and at 45 minutes in posterior teeth significantly improves the
b. 0 to 5 minutes duration of pulpal anesthesia and may be the best way to
c. 5 to 9 minutes extend the duration of pulpal anesthesia.131
d. 14 to 19 minutes REF: Increasing the Duration of Pulpal Anesthesia
ANS: c 9. Which of the following has been shown to be effective at

Pulpal anesthesia usually occurs in 5 to 9 minutes in the increasing the success rate of mandibular anesthesia?
molars and premolars and 14 to 19 minutes in the anterior a. increasing the volume of anesthetic from one to two
teeth.44-54 In some patients onset occurs sooner, and in others cartridges
it is delayed.44-54 b. increasing the epinephrine concentration from
REF: Onset of Pulpal Anesthesia 1 : 100,000 to 1 : 50,000
c. using articaine instead of lidocaine
6. Which statement is true about the effect of needle bevel d. none of the above
orientation on the success of an inferior alveolar nerve
block? ANS: d
a. Orienting the needle bevel toward the mandibular Increasing the volume of anesthetic from one to two cartridges
ramus improves success. does not increase the success rate of obtaining pulpal anes-
b. Orienting the needle bevel away from the mandibular thesia with the inferior alveolar nerve block.44,45,53,54 There is
ramus improves success. no improvement in pulpal anesthesia with a higher concentra-
c. Half the cartridge should be injected with the bevel tion (1 : 50,000) of epinephrine in an inferior alveolar nerve
toward the ramus; the needle should then be rotated block.54,55 Some alternative solutions to 2% lidocaine with
and the other half of the cartridge injected with the 1 : 100,000 epinephrine are equivalent in providing pulpal
bevel away from the ramus. anesthesia for at approximately 1 hour after an inferior alveo-
d. The direction of the needle bevel does not affect the lar nerve block. These alternative solutions include 2% mepi-
success of the block. vacaine with 1 : 20,000 levonordefrin; 4% prilocaine with
1 : 200,000 epinephrine; and plain solutions (3% mepivacaine
ANS: d and 4% prilocaine).48,51 Articaine (4% articaine with epineph-
Needle deflection has been theorized as a cause of failure with rine) is a safe and effective local anesthetic agent for inferior
the inferior alveolar nerve block.23,109-112 However, two studies alveolar nerve blocks.56-65 Articaine has a reputation of provid-
have shown that needle bevel orientation (away from or ing an improved local anesthetic effect.66 However, clinical
toward the mandibular foramen or ramus) does not affect the trials have failed to detect any superiority of articaine over
success of the inferior alveolar nerve block.113,114 lidocaine in inferior alveolar nerve block anesthesia.61,64 Like
REF: Needle Deflection and Needle Bevel prilocaine, articaine has the potential to cause neuropathies.67
The incidence of paresthesia (involving the lip and/or tongue)
7. Is anesthesia of the maxilla commonly more or less suc- associated with articaine and prilocaine was higher than that
cessful than anesthesia in the mandible? found with either lidocaine or mepivacaine.67-69 Other authors
a. more successful have not found a higher incidence when using articaine.70
b. less successful However, because there is no difference between articaine and
c. comparable lidocaine in the success of pulpal anesthesia for inferior alveo-
lar nerve blocks, and because some attorneys are aware of the
ANS: a proposed association of articaine with paresthesia, it seems
Anesthesia is more successful in the maxilla than in the man- reasonable to use articaine for infiltrations but not for nerve
dible. The most common injection for the maxillary teeth is blocks.
infiltration. REF: Alternative Attempts to Increase Anesthetic Success
REF: Maxillary Anesthesia for Restorative Dentistry
(Anesthesia-Related Factors) 10. What additional anesthetic procedure should be adminis-
tered if the classic signs of anesthesia are present after a
8. What is the best way to extend the duration of pulpal standard injection, but the patient still has sharp pain when
anesthesia for a maxillary tooth? the bur enters the dentin?
a. increase the volume of solution a. repeat the initial injection
b. increase the concentration of epinephrine b. wait an additional 15 minutes and attempt access again
c. repeat an infiltration after 30 minutes c. repeat the injection using a different type of anesthetic
d. use an anesthetic agent without a vasoconstrictor solution
d. use a supplemental injection technique for a second
ANS: c injection
A two-cartridge volume of 2% lidocaine with epinephrine
extends the duration of pulpal anesthesia, but not for 60 ANS: d
minutes.128 Increasing the epinephrine concentration to A supplemental injection is used if the standard injection is
1 : 50,000 epinephrine increases duration for the lateral incisor not effective. It is useful to repeat an initial injection only if
e24 but not for the first molar.132 The duration did not reach 60 the patient is not exhibiting the “classic” signs of soft tissue
anesthesia. Generally, if the classic signs are present, reinjec- 13. What is an important requirement for effectiveness when
tion is not very effective.146 For example, after the inferior giving a periodontal ligament (PDL) injection?
alveolar nerve block, the patient develops lip, chin, and tongue a. ensuring back-pressure during injection
numbness and quadrant “deadness” of the teeth. A useful b. directing the needle bevel toward the root surface
procedure is to pulp-test the tooth with cold (cold refrigerant) c. directing the needle bevel away from the root surface
or an electrica pulp tester before the cavity preparation is d. ensuring that all four line angles receive the injection
begun.42,43 If the patient feels pain to cold, a supplemental
injection is indicated. Assuming that reinjection using the ANS: a
inferior alveolar nerve block approach will be successful is Back-pressure is important. If there is no back-pressure (resis-
wishful thinking; failure the first time is usually followed by tance)—that is, if the anesthetic readily flows out of the
failure on the second attempt. The dentist should go directly sulcus—the needle is repositioned and the technique repeated
to a supplemental technique. Three such injections are (1) the until back-pressure is attained.
infiltration injection, (2) the intraosseous (IO) injection, REF: Periodontal Ligament Injection (Technique)
(3) and the periodontal ligament (PDL) injection.
REF: Supplemental Anesthesia for Restorative Dentistry in 14. A PDL injection can be used for selective anesthesia of
the Mandible and Maxilla (Indications) an individual tooth as an aid in diagnosis.
a. true
11. Which of the following is a consideration with an intraos- b. false
seous (IO) injection?
a. IO injections have not been proved effective. ANS: b
b. IO injection has been recommended as the primary It has been suggested that the PDL injection may be used in
injection technique. the differential diagnosis of poorly localized, painful irrevers-
c. IO injection allows the anesthetic solution to be depos- ible pulpitis. However, adjacent teeth are often anesthetized
ited directly into the pulp tissue of the tooth. with PDL injection of a single tooth. Therefore, this injection
d. IO injection allows the anesthetic solution to be depos- is not useful for differential diagnosis.
ited directly into the cancellous bone adjacent to the REF: Periodontal Ligament Injection (Selective Anesthesia)
tooth.
15. Which of the following is an important consideration with
ANS: d the intrapulpal (IP) injection?
The IO injection is a supplemental technique that has been a. The injection should be given with back-pressure.
shown to be effective through substantial research and clinical b. The injection will require several minutes to take
use. It is particularly useful in conjunction with a conventional effect.
injection when it is likely that supplemental anesthesia will c. The duration of anesthesia is 30 to 45 minutes.
be necessary (e.g., in mandibular second molar teeth).121-123 d. An IP injection should be the first supplemental injec-
The IO injection allows placement of a local anesthetic tion technique attempted.
directly into the cancellous bone adjacent to the tooth. The
Stabident System (Fig. 9.6) is an IO system with two compo- ANS: a
nents. One part is a slow-speed handpiece–driven perforator, After the inferior alveolar nerve block, IO and PDL injections
which drills a small hole through the cortical plate (Fig. 9.7). occasionally do not produce profound anesthesia, even when
The anesthetic solution is delivered into cancellous bone repeated, and pain persists when the pulp is entered. This is
through a matching 27-gauge ultrashort injector needle (Fig. an indication for an IP injection. However, the IP injection
9.8). Another IO system, the X-Tip System (Fig. 9.9), uses a should not be used without first administering an IAN, plus
guide sleeve that remains in the perforation (Fig. 9.10). This an IO or IL injection. The IP injection is very painful without
serves as a guide for the needle, and it may remain in place some other form of supplemental anesthesia.
throughout the procedure in the event that reinjection is neces- Although the IP injection is somewhat popular, it has dis-
sary. The perforation may be made in attached gingiva or advantages, as well as advantages, making it the last supple-
alveolar mucosa with this system.147 mental injection of choice. The major drawback is that the
REF: Intraosseous Anesthesia needle is inserted directly into a vital and very sensitive pulp;
thus the injection may be exquisitely painful. Also, the effects
12. What is the best site for an IO injection of a premolar? of the injection are unpredictable if it is not given under pres-
a. mesial perforation and injection sure. The duration of anesthesia, once attained, is short (5 to
b. apical perforation and injection 15 minutes). Therefore, the bulk of the pulp must be removed
c. distal perforation and injection quickly and at the correct working length to prevent recur-
d. The site of injection is not important. rence of pain during instrumentation. Another disadvantage is
that the pulp must be exposed to permit direct injection; often
ANS: c problems with anesthesia occur before pulpal exposure.
Distal perforation and injection to the tooth result in the best The advantage of the IP injection is the predictability of
anesthesia. Second molars are an exception; for them, a mesial profound anesthesia if the injection is given under back-
site is preferred. When necessary a lingual approach also may pressure. The onset of anesthesia is immediate, and no special
be successful, although this approach has not been studied. syringes or needles are required, although different approaches
REF: Intraosseous Anesthesia (Selection of Perforation may be necessary to attain the desired back-pressure.
Site) REF: Supplemental Intrapulpal Injection e25
16. What are the most difficult teeth to anesthetize with irre- ANS: d
versible pulpitis? Patients tolerate procedures better when some anesthesia is
a. maxillary molars present before incision and drainage of the swelling. However,
b. mandibular molars obtaining profound anesthesia is difficult, which should be
c. maxillary anterior teeth explained to the patient. In the mandible, an inferior alveolar
d. maxillary premolars nerve block plus a long buccal injection (for molars) and
inferior alveolar plus labial infiltration (for premolars and
ANS: b anterior teeth) are administered. In the maxilla, infiltration is
With irreversible pulpitis, the teeth most difficult to anesthe- given mesial and distal to the swelling. For palatal swellings,
tize are the mandibular molars, followed by (in order) the a small volume of anesthetic is infiltrated over the greater
mandibular and maxillary premolars, maxillary molars, man- palatine foramen (for posterior teeth) or over the nasopalatine
dibular anterior teeth, and maxillary anterior teeth. foramen (for anterior teeth). With swelling over either
REF: Anesthetic Management of Pulpal or Periapical Patho- foramen, lateral infiltration is indicated.
ses (Symptomatic Irreversible Pulpitis) Injection directly into a swelling is contraindicated. These
inflamed tissues are hyperalgesic and difficult to anesthetize.
17. Why should an anesthetic agent not be injected directly Traditional beliefs are that the anesthetic solution may be
into a swelling before an incision for drainage? affected by the lower pH and is rendered less effective and
a. The anesthetic will cause a decreased flow of exudate that direct injection will “spread the infection,” although
after incision. neither belief has been proven. Nevertheless, pain from the
b. A direct injection will spread the infection. injection pressure and ineffectiveness are reasons to avoid
c. There is an increased chance of aspirating blood. injection into a swelling. Theoretically, the area of swelling
d. The swelling has an increased blood supply, so the has an increased blood supply, and anesthetic therefore is
anesthetic is transported quickly into the systemic cir- transported quickly into the systemic circulation, diminishing
culation, diminishing the effect. the anesthetic effect. Also, edema and purulence may dilute
the solution.
REF: Anesthesia for Surgical Procedures (Incision for
Drainage)
e26

Paul Duncan Eleazer, Paul A. Rosenberg
CHAPTER 10 ANS: a
Endodontic Emergencies and Therapeutics Patient anxiety is an important factor in achieving a satisfac-
1. What is the immediate goal of an emergency visit? tory endodontic outcome, especially at an emergency visit.
a. to prescribe the appropriate antibiotic medication More than 200 studies indicate that behavioral intervention to
b. to assess the patient’s history reduce anxiety before and after surgery reduces postoperative
c. to eliminate the patient’s primary cause of distress pain intensity and the intake of analgesics and also accelerates
d. to place calcium hydroxide as an intracanal medication recovery.10 A clinical study determined that the higher the
level of anxiety, as measured by a visual analogue anxiety
ANS: c scale, the less likely it was that pain would be eliminated by
The immediate goal of an emergency visit is to bring the case the administration of local anesthetics.11 A conversation with
under control by eliminating the patient’s primary cause of the patient to discuss the clinician’s pain preventive strategy,
distress, which is most often pain with or without swelling. including the use of profound local anesthesia, is an important
REF: Introduction prelude to treatment.
REF: Patient Management
2. What subjective findings are common with a diagnosis of
bruxism? 5. What is a common presentation of a patient with an exac-
a. spontaneous pain without a stimulus erbation of a tooth with symptomatic irreversible
b. The patient awakens with pain during sleep but feels pulpitis?
better as the day progresses. a. characterized by mild pain
c. periapical swelling that comes and goes b. pain subsides with time
d. a periapical sinus tract c. pulp tissue is well colonized with bacteria
d. pain may occur with or without provocation
ANS: b
A patient who relates having been awakened by pain at night, ANS: d
feeling better as the day progressed, only to have the pain Basic biologic processes may explain the cause of an exacer-
return again during sleep, does not fit the most common bation of a tooth with irreversible pulpitis. Irreversible pulpitis
profile of an irreversible pulpitis. This patient will require a is often due to inflammation of the pulp resulting from a
differential diagnosis for bruxism, TMD, or an irreversible microbial insult caused by caries or microleakage associated
pulpitis. with a defective restoration. Exacerbation of a tooth with
REF: Diagnosis and Treatment Planning irreversible pulpitis is characterized by pain, which may be
severe. The pain may occur with or without provocation and
3. What is the incidence of exacerbations as reported in the tends to become increasingly intolerable. A pulp with irre-
literature? versible pulpitis is usually free of bacteria colonizing in the
a. 0% to 6.5% root canal. Infection is most often confined to the coronal site
b. 1.5% to 20% of the pulp that is exposed to the oral cavity. As long as the
c. 6.5% to 20% radicular pulp remains vital, it usually protects itself against
d. 15% to 25% microbial invasion and colonization.12
REF: Management of Irreversible Pulpitis
ANS: b
The incidence of exacerbations has been estimated to be as 6. Which of the following factors leads to a higher incidence
low as 1.5%8 and as high as 20%.9 This wide range of of post-operative pain?
estimates may be attributed to different definitions of exacer- a. partial pulpectomy
bations, varying study designs, and other procedural b. pulpotomy
variations. c. male gender
REF: Incidence of Exacerbations d. anterior teeth
4. Which of the following is particularly important to achiev- ANS: a

ing a satisfactory endodontic outcome at an emergency It has been demonstrated that removal of the pulp from the pulp
visit? chamber (pulpotomy) is a highly predictable approach to alle-
a. the patient’s level of anxiety viating pain at an emergency visit (Fig. 10.12).13 If time permits,
b. the patient’s medical history it is considered preferable, after measurement control, to com-
c. selection of an appropriate antibiotic pletely remove all pulp tissue from the canal or canals. A clini-
d. completion of root canal treatment in a single visit cal study demonstrated that partial pulpectomy resulted in a e27
higher rate of postoperative pain (13%) compared with pulp- 9. Which of the following is an appropriate treatment to
otomy (6%). Other important factors associated with postop- address a necrotic exacerbation with swelling?
erative pain were female gender, younger age, and molar teeth. a. prescribing antibiotics alone
REF: Management of Irreversible Pulpitis b. prescribing antibiotics and then seeing the patient after
the swelling has subsided to begin treatment
7. What is the definition of an emergency? c. incision and drainage of the swelling
a. It requires a visit within 24 hours of symptoms. d. incision and drainage of the swelling with concomitant
b. It is well managed by antiinflammatory analgesics. instrumentation and irrigation
c. The patient has the day off work and thus is available
for an appointment. ANS: d
d. The patient’s insurance has emergency visit coverage. Treatment of the necrotic exacerbation is focused on the root
canal if there is no swelling. Reinstrumentation and irrigation
ANS: a are the basic treatments directed at reducing the intracanal
An emergency is defined as a visit to the dental emergency level of microorganisms. If swelling exists, the clinician
clinic within 24 hours of treatment for pain not controlled by should consider incision and drainage followed by instrumen-
ibuprofen, ASA, or Tylenol. tation and irrigation of the canal. Antibiotics alone should not
REF: Management of Irreversible Pulpitis be used without concomitant instrumentation and irrigation.
Incision and drainage are directed at reducing periapical tissue
8. Which of the following has not been found to be a con- pressure and eliminating pus; reinstrumentation and irrigation
tributing cause in a flare-up? are directed at the primary cause of the problem, which is the
a. iatrogenic irritation of the tissues beyond the apical remaining intracanal bacteria.
terminus REF: Biology of the Necrotic (Nonvital) Exacerbation
b. pushing dentin chips into the periapical tissues
c. pushing remnants of infected pulp tissue into the peri- 10. Instrumentation and filling to what level elicits the most
apical tissues favorable response in periapical tissues?
d. difficulty obtaining profound anesthesia a. 0 to 2 mm short of the radiographic apex
b. 3 to 5 mm short of the radiographic apex
ANS: d c. at the radiographic apex
There are a number of hypotheses concerning the true cause d. 0 to -2 mm beyond the radiographic apex
of flare-ups, which have been described as multifactorial.
Causes include iatrogenic mechanical irritation of the tissues ANS: a
beyond the apical terminus and/or pushing dentin chips and It has been demonstrated histologically that the most favor-
remnants of infected pulp tissue into the periapical tissues. A able response of periapical tissues occurs when both instru-
procedural accident often impedes therapy or makes it impos- mentation and filling were short of the apical constriction.22
sible for therapy to be completed, such as by preventing a A clinical study found that the best treatment outcome in
thorough mechanical débridement or creating a bacteria-tight infected teeth with periradicular lesions occurred when the
seal of a root canal system. An increased risk exists when a apical terminus of the filling was 0 to 2 mm short of the
procedural accident occurs during treatment of infected radiographic apex. The same study determined that the prog-
teeth.15 There are also chemical factors, including irrigants, nosis was decreased with significant underfill and overfill.
intracanal dressings, and sealers.7 Endodontic procedural REF: Postobturation Emergencies
errors are not the direct cause of treatment failure. They
increase the risk of failure because of the clinician’s inability 11. Which factor is not a predictor of postobturation pain?
to eliminate microorganisms from the infected root canals.16 a. tenderness to finger pressure
The number of treatment visits has also been examined as b. tenderness to percussion
a factor in flare-ups. In a retrospective study the flare-up rate c. ability to bite comfortably on the tooth
in necrotic molars in one-visit versus two-visit endodontic d. treatment completed in a single visit
treatment was examined.17 Treatment records of 402 consecu-
tive patients with pulpally necrotic first and second molars ANS: d
were compared. One-visit treatment showed an advantage at Postobturation emergencies may include pain and diffuse
the 95% confidence level. However, retrospective analyses do swelling. Tenderness to finger pressure or percussion or an
not control for the reason that a case took one or more appoint- inability to bite comfortably on the tooth is often a predictor
ments to complete, and some other studies have shown no of postobturation pain. In such cases it is strongly recom-
differences between single and multiple visits in the incidence mended that obturation be deferred until the patient is pain
of flare-ups. free and the tooth can be used in function.
REF: Causes of Flare-Up REF: Postobturation Emergencies
e28
12. Which gender is at a substantially greater risk for many 15. Which of the following is a major factor causing dental
clinical pain conditions? unit waterlines to harbor bacteria?
a. female a. The nature of the plastic material in the dental tubing
b. male aids bacterial attachment.
b. Large-diameter lines have a high flow rate.
ANS: a c. The length of tubing from the unit to the air-water
Evidence clearly demonstrates that women are at substantially syringe
greater risk for many clinical pain conditions. A growing body d. Use of an antibacterial agent in the water supply
of evidence over the past 10 to 15 years indicates that there reservoir
are substantial gender differences in clinical and experimental
pain responses. ANS: a
REF: Postobturation Emergencies (Gender) Questions have been raised about the use of water from dental
units during endodontic irrigation. It is well documented that
13. Which of the following is the typical means by which water taken from the dental unit is often contaminated and
bacteria enter the canal space? may pose a problem.
a. periodontal disease Dental unit waterlines harbor bacteria at alarming rates.
b. caries This is due to two major factors. First, the narrow-diameter
c. fractures lines have low flow rates, and biofilms form within a few days,
d. trauma shedding bacterial colonies into the stream with each use.
Second, the nature of the plastic material in the dental tubing
ANS: b aids bacterial attachment. Atlas and colleagues40 found the
In the natural history of endodontic disease, bacteria typically pathogen Legionella pneumophila and other species of Legio-
arrive in the canal space from caries, generally regarded as nella in 68% of dental units they tested. Concentrations were
the most common source of pulpal infection. Periodontal greater than 1,000/mL in 36% and greater than 10,000 in 19%.
disease, fractures, abrasion, and even trauma to a pulpally Fotos’ team41 noted a higher incidence of antibodies to Legio-
intact tooth have also been demonstrated to be avenues of nella organisms in dental workers. Shepherd’s research team42
entry for microbes. In their typical narrow dimension, bacteria found that failure to follow the regimen of a commercial
are about 1 µm; dentinal tubules are almost four times that preparation of hydroperoxide ion-phase transfer catalyst
diameter. Increased peritubular dentin may impede but not cleaner/disinfectant resulted in persistence of the infection.
eliminate bacteria ingress with age. Interestingly, they also found that oral streptococci were
REF: Sources of Microbes in the Canal Space present in 80% of their samples, interpreted as having come
from other patients, in spite of antiretraction valves on the
14. What is the primary agent of endodontic disease? dental units. Sterile water is readily available in sterile IV
a. caries bags, and several dental equipment manufacturers have pres-
b. trauma sure chambers for expressing the water under pressure. Tubing
c. bacteria for delivery must be sterilized, which currently is not possible
d. fracture with most dental units, making this an alternative for dedi-
cated surgical irrigation.
ANS: c REF: Sources of Microbes in the Canal Space
The significance of bacteria and other microorganisms to end-
odontic pathology was elegantly demonstrated by Kakehashi, 16. What is a sufficient time for an intracanal disinfectant to
Stanley, and Fitzgerald in their classic work from 1965.35 With be present to accomplish disinfection?
no microbial presence, simply accessing the pulp canals a. There is no minimum time, as long as the canal is
without pulp débridement resulted in no disease. Remaining débrided of detectable pulp tissue.
pulp tissue remained vital in spite of food and debris impac- b. A minimum of 5 minutes should be allowed after the
tion into the canal spaces. The control group of conventional canal has been débrided of detectable pulp tissue.
animals showed microbial invasion through the teeth into c. A minimum of 10 minutes should be allowed after the
periapical structures, as is typically seen in patients. The only canal has been débrided of detectable pulp tissue.
difference was the absence of bacteria, clearly demonstrating d. A minimum of 15 minutes should be allowed after the
that bacteria are the primary agent of endodontic disease. canal has been débrided of detectable pulp tissue.
Thus it behooves practitioners to eliminate bacteria from the
canal system and prevent their penetration into the periapical ANS: d
tissues. There should be no bravado about how fast one can perform
REF: Sources of Microbes in the Canal Space endodontic therapy. Sufficient time for disinfectant is likely
a minimum of 15 minutes after the canal has been débrided
of detectable pulp tissue.
REF: Intracanal Disinfectants
e29
17. Which of the following is not an indication to perform the purpose of eliminating all canal bacteria prior to stimula-
drainage of an abscess? tion of periapical stem cells in pulp regeneration. Most often,
a. to bring about rapid resolution of symptoms oral antibiotics are prescribed for systemic infection. Clearly
b. to head off worsening of the infection we are witnessing a failure of these drugs due to overuse, both
c. to reduce local vascular flow in patients and in farm animals. Research is underway to
d. to reduce local tissue acidity develop new types, but they will surely be overcome in time,
given the powerful resources of the huge variety of microor-
ANS: c ganisms. In addition to mutation, bacterial cells can share
Drainage of pus from an abscess can speed recovery (Figs. genetic material with each other, even across species. The
10.3 and 10.4). The removal of dead lymphocytes and a pre- astute practitioner avoids the use of antibiotics when they are
ponderance of dead bacteria from the center of an infection not clearly indicated. Such conservation warrants education
can bring rapid resolution of symptoms and head off worsen- of patients and follow-up after treatment.
ing of the infection. Return of local vascular flow can aid in For treatment of active infection, the ideal drug would focus
reaching and maintaining antibiotic levels and reduce local only on the pathogens for a particular patient, and therapy
tissue acidity, enhancing the action of local anesthetics. would last only until the host defenses were in control. The
Chronic drainage by way of a sinus tract sharply reduces the concept of culturing and antibiotic sensitivity testing should
occurrence of flare-ups due to drainage. Surgical drainage can become part of this approach.
be quite helpful in treating infections. REF: Antimicrobial Drugs
REF: Drainage
19. What analgesics have been shown to have superior per-
18. Which of the following is an indication for prescribing formance in pain reduction?
antibiotics? a. acetaminophen and ibuprofen
a. in case there is an infection b. ibuprofen plus an opioid
b. to prevent a disease from turning into an infection c. acetaminophen plus an opioid
c. to “clear up” an infection on their own d. dopioids alone
d. to treat an active infection
ANS: a
ANS: d Drugs to diminish pain perception can be divided into two
There is no indication for prescribing antibiotics “in case there broad categories, opioids and others. Whether bacterial or
is an infection” or “to prevent a condition from turning into otherwise, almost all dental pain arises from inflammation.
an infection.” Well-controlled research has shown that painful Opioids and acetaminophen are considered to act primarily
pulpitis is not relieved by systemic antimicrobial therapy.21 on the central nervous system. In contrast, inflammation-
The 40 participants experienced the same need for pain reliev- suppressing drugs, such as corticosteroids and nonsteroidal
ers regardless of whether they took penicillin or placebo. The antiinflammatory drugs (NSAIDs), are very effective in reduc-
patients’ pain intensity scores were similar over the 7-day ing pain through their action at the site of injury. The combi-
study prior to definitive endodontic treatment. Another nation of NSAIDs with acetaminophen, which apparently acts
researcher noted that total pulp removal gave the most reliable centrally, is even more effective.
pain relief. A recent dental extraction study found the combination of
Antibiotics do not make the infection go away. They merely acetaminophen and ibuprofen superior to either ibuprofen
work as an adjunct to the patient’s defenses. Most infections plus an opioid or acetaminophen plus an opioid. It has long
have multiple bacteria species present, and elimination of only been known that classic opioids (e.g., codeine and hydroco-
key ones in the commensal or symbiotic relationship is done), although often prescribed, are less effective than drugs
needed.32 directed specifically at inflammation. Opioids have harsh side
Two main indications exist for use of these drugs; namely, effects, such as sedation, diminution of protective reflexes,
to treat an active infection and to prevent infection. The use and an additive effect with all CNS depressants, in addition
for these different approaches is quite different. In therapy for to addiction. A simplified analgesic strategy for the use of
active infections, antibiotics have been used locally and/or these medications is shown in Fig. 10.6.
systemically. Grossman51 originally recommended intracanal REF: Opioids, Acetaminophen, and Nonsteroidal Antiinflam-
antibiotics, a technique that has seen a recent resurgence for matory Drugs
e30

Nestor Cohenca
(partial) pulpotomy. Vital pulp therapy followed by an acid-

CHAPTER 11 etched composite restoration or reattachment of the fractured
Management of Traumatic Dental Injuries segment also is often feasible in mature teeth. However, if the
1. Why does age affect the prognosis in dental trauma? extent of tooth loss dictates restoration with a crown, root
a. Pulps in children have an incomplete and decreased canal treatment is recommended. The amount of time that has
blood supply. elapsed between injury and examination may directly affect
b. Pulps in children are better able to recover and have a pulpal health. Generally, the sooner a tooth is treated, the
better repair potential. better the prognosis for preserving the pulp. However, as a
c. Root development is not affected by pulpal pathosis. rule, pulps that have been exposed for less than a week can
d. Dentin has more strength in younger teeth. be treated by pulpotomy. Successful pulpotomy procedures
after pulp exposure of several weeks’ duration have been
ANS: b reported.
Age is an important factor in trauma to teeth. By the time they REF: Crown Fractures with Pulp Exposure - description
reach the age of 14, about 25% of children will have had an
injury involving their permanent teeth. The significance of age 3. Which of the following is not a step in the technique for
is a “good news/bad news” situation. The good news is that a shallow (partial) pulpotomy?
pulps in children’s teeth have a better blood supply than those a. rubber dam isolation
in adults and better repair potential. The bad news is that root b. removal of pulp tissue to about 2 mm below the
development will be interrupted in teeth with damaged pulps, exposure
leaving the roots thin and weak. Cervical fractures often occur c. use of a Gates-Glidden bur in the slow-speed hand-
either spontaneously or from even minor injuries because of piece to remove tissue
thin dentin walls (Fig. 11.1). Therefore, when dental injuries d. restoration of the cavity with a hard-setting cement
occur in children, every effort must be made to preserve pulp
vitality. ANS: c
REF: Introduction The shallow (partial) pulpotomy procedure (Fig. 11.7) starts
with anesthesia and rubber dam isolation. Exposed dentin is
2. Which of the following factors does not need to be con- washed with saline or sodium hypochlorite solution. Extrud-
sidered when evaluating a crown fracture with pulp ing granulation tissue is removed with a spoon excavator
exposure? from the pulp wound site. This provides an opportunity to
a. extent of fracture determine more accurately the size and location of the
b. stage of root development exposure. Next, pulp tissue is removed to a depth of about
c. position in the arch 2 mm below the exposure. This relatively small amount
d. time that has passed since the injury of pulp removal is the reason for calling this procedure a
shallow or partial pulpotomy. The procedure is accomplished
ANS: c using a water-cooled small round diamond (about the size
This type of fracture involves enamel, dentin, and pulp. of a No. 2 or 4 round bur) in the high-speed handpiece.
Because the pulp is exposed, the fracture becomes “compli- Gently and gradually, the surface layers of pulp tissue are
cated.” The extent of fracture, the stage of root development, wiped away, beginning at the exposure site and extending into
and the length of time since injury are noted. Considering the the pulp to a depth of about 2 mm below the exposure site.
extent of fracture helps to determine pulpal treatment and After the pulp has been amputated to the desired level, a
restorative needs; a small fracture may undergo vital pulp dentin shelf is created surrounding the pulp wound. The
therapy and can be restored by an acid-etched composite wound is gently washed with sterile saline, and hemostasis
restoration. An extensive fracture may require root canal treat- can usually be expected within 5 minutes. The wound then is
ment with a post and core–supported crown, depending on the washed again to remove the clot and is dressed with calcium
age of the patient (Fig. 11.6). The stage of root maturation is hydroxide. The remainder of the cavity is carefully sealed
an important factor in choosing between pulpotomy and pulp- with hard-setting cement, such as glass ionomer. When the
ectomy. Immature teeth have thin-walled roots; every effort cement has set, the tooth may be restored with acid-etched
should be made to preserve the pulp to allow continued root composite.
development. The best way to this goal is with a shallow REF: Treatment of Crown Fractures (Technique) e31
surrounding alveolar bone, the tooth may be quite firm. A

4. How long should horizontal root fractures be splinted if metallic sound on percussion might indicate that the root tip
the coronal section was displaced and repositioned? has been forced into the alveolar bone.
a. not indicated These teeth are forced into their sockets in an axial (apical)
b. 7 to 10 days direction, at times to the point of being not visible clinically.
c. 4 to 6 weeks They have no mobility, resembling ankylosis.
d. 3 months REF: Injuries to the Periodontium
ANS: c 6. What is recommended with pulp testing for teeth with
Initial treatment for root fractures (i.e., repositioning and sta- traumatic injuries?
bilization) should be of acute priority for best results (Fig. a. use of electrical pulp testing or carbon dioxide snow/
11.15). Repositioning of displaced coronal tooth segments is Endo-Ice to evaluate sensory response
easier if performed soon after the injury; delayed reposition- b. testing of opposing teeth
ing may require orthodontic intervention to be able to move c. retesting in 4 to 6 weeks
the coronal segment into desirable position. After reposition- d. all of the above
ing, the coronal tooth segment must be splinted to allow repair
of the periodontal tissues (Fig. 11.15). Four to 6 weeks of ANS: d
stabilization is usually sufficient, unless the fracture location Sensitivity tests, including cold (dichlorodifluoromethane
is close to the crest of the alveolar bone; in such cases, a [Endo-Ice]) and EPT, are used to evaluate the sensory response
longer splinting time may be advisable. The outcome of the of teeth that have been injured; several adjacent and opposing
emergency care must be monitored periodically. teeth are included in the test. An initial lack of response is not
REF: Root Fractures (Emergency Care) unusual, nor is a high reading on the pulp tester. Retesting is
done in 4 to 6 weeks; the results are recorded and compared
5. Which of the following traumatic events causes injury to with the initial responses.
the periodontium? REF: Luxation Injuries (Pulp Testing)
a. concussion
b. intrusion 7. What information does a color change in the clinical
c. extrusion crown provide?
d. all of the above a. There has been a pulp exposure.
b. The initial change is gray in color, which always indi-
ANS: d cates pulp necrosis.
Injuries to the periodontium involve trauma to the supporting c. Initial pink discoloration may be reversed without
structures of the teeth and often affect the neural and vascular treatment.
supply to the pulp. The cause is usually a sudden impact, such d. Calcific metamorphosis discoloration tends to be
as a blow or striking a hard object during a fall. Generally, yellow to brown and always indicates pulp necrosis.
the more severe the degree of displacement, the greater the
damage to the periodontium and to the dental pulp. Table 11.1 ANS: c
provides a summary of the typical clinical and radiographic Pulpal injury may cause discoloration, even after only a few
findings associated with different types of injuries to the days. Initial changes tend to be pink. Subsequently, if the pulp
periodontium. does not recover and becomes necrotic, there may be a grayish
The tooth is sensitive to percussion only. There is no darkening of the crown, often accompanied by a loss in trans-
increase in mobility, and the tooth has not been displaced. The lucency (Fig. 11.19). Also, color changes may take place from
pulp may respond normally to testing, and no radiographic calcific metamorphosis of the pulp. Such color changes are
changes are found. likely to be yellow to brown and do not indicate pulp pathosis.
Teeth with subluxation injuries are sensitive to percussion Other signs, findings, or symptoms are necessary to diagnose
and also have increased mobility. Sulcular bleeding might be pulp necrosis. Finally, discoloration may be reversed. This
present. The teeth are not displaced, and the pulp may respond usually happens relatively soon after the injury and indicates
normally to testing, sometimes after initially failing to respond. that the pulp is vital. Because of unpredictable changes
Radiographic findings are unremarkable. associated with traumatized teeth, long-term evaluation is
An injury to the supporting structures with loosening and recommended.
clinical or radiographic displacement. The injury may dis- REF: Luxation Injuries (Crown Color Changes)
place the tooth in three possible directions: extrusive, lateral,
and intrusive.
In an extrusion injury, the teeth have been partially dis-
placed from the socket along the long axis. Extruded teeth
have greatly increased mobility, and radiographs show dis-
placement. The pulp usually does not respond to testing.
By definition, the teeth may be displaced lingually, buc-
cally, mesially, or distally; that is, away from their normal
position in a horizontal direction. However, because the
impact always comes from the facial direction, the crown is
displaced lingually and the apex buccally, creating a subse-
e32 quent alveolar fracture. If the apex has been displaced into the
8. What factor should be considered that determines the a soft toothbrush after every meal, and use a chlorhexidine
treatment of an intrusive luxation injury? mouth rinse (0.12%) twice a day for a week.
a. depth of intrusion REF: Avulsion (Patient Instructions)
b. stage of root development
c. availability of adjacent teeth for stabilization 11. What additional treatment has been shown to increase the
d. amount of soft tissue injury chance of pulp revascularization of an avulsed tooth with
an open apex (replanted within the first hour after
ANS: b avulsion)?
Treatment of intrusive luxation injuries depends on root matu- a. thorough scrubbing
rity. If the tooth is incompletely formed with an open apex, it b. topical application of Emdogain
may reposition spontaneously. Recent data showed that in c. covering the root surface topically with a tetracycline-
young patients 12 to 17 years of age with complete root for- based antibiotic
mation, spontaneous reeruption is possible and is the best d. soaking the tooth in 2.4% doxycycline for 5 to 20
treatment with regard to marginal periodontal healing. In minutes
older patients (i.e., older than17 years) with completed root
formation, either surgical or orthodontic extrusion should be ANS: C
attempted. Root canal treatment is indicated for intruded teeth Timing is crucial in preventing the onset and progression of
with the exception of those with immature roots, in which external inflammatory root resorption. The exceptions to
case the pulp may revascularize. The patient must be moni- routine root canal therapy are immature teeth with wide-open
tored carefully because complications, such as failure of apices; they may revascularize but must be evaluated at regular
pulpal healing, will usually be symptomless. If radiographic intervals of 2, 6, and 12 months after replantation. If subse-
evidence indicates pulp necrosis (lack of continued root devel- quent evaluations indicate pulp necrosis, root canal treatment,
opment), root canal treatment should be performed. probably including apexification, is indicated.
REF: Treatment of Luxation Injuries REF:
9. Which of the following is the best transport medium for 12. Which type of external resorption has not been identified
an avulsed tooth? with replanted avulsed teeth?
a. saliva a. surface
b. distilled water b. inflammatory
c. tissue wrapping c. refractory
d. milk d. replacement
ANS: d ANS: c
If replantation is not feasible at the place of injury, the injured External root resorption is a frequent occurrence in replanted
person should be brought to the dental office and the tooth avulsed teeth. Three types have been identified: surface, inflam-
transported in such a way as to keep it moist. The most matory and replacement. Surface resorption, also called “repair
common storage medium is Hanks Balanced Salt Solution related resorption,” is transient and shows as lacunae of resorp-
(HBSS), which is commercially available as a kit (Save-a- tion in the cementum of replanted teeth. The lacunae are not
Tooth). However, if HBSS is not available, milk is an excel- usually visible on radiographs. If resorption does not continue,
lent alternative. Saliva is acceptable, but water is not good for the lacunae are repaired by deposition of new cementum.
maintaining root-surface cell vitality. Inflammatory (infection-related) resorption occurs as a response
REF: Avulsion (Replantation Within 1 Hour of Avulsion) to the presence of infected necrotic pulp tissue in conjunction
with injury to the periodontal ligament. It occurs with replanted
10. Which type of medication is indicated for patients with teeth (Fig. 11.21) and with other types of luxation injuries. It is
avulsed teeth? characterized by loss of tooth structure and adjacent alveolar
a. narcotic analgesic bone. Resorption usually subsides after removal of the necrotic
b. steroid infected pulp, so the prognosis is good. Root canal treatment
c. systemic antibiotics therefore is recommended routinely for replanted teeth with
d. all of the above closed apices to prevent the occurrence of inflammatory resorp-
tion. In external replacement (PDL-related) resorption, the
ANS: c tooth structure is resorbed and replaced by bone (Fig. 11.22),
Antibiotics are recommended for patients with replanted resulting in ankylosis, in which bone fuses directly to the root
avulsed teeth. In patients 12 years of age or older, doxycycline surface. The characteristics of ankylosis are lack of physiologic
100 mg two times per day for 7 days is the current recom- mobility, failure of the tooth to erupt along with adjacent teeth
mendation. Alternatively, amoxicillin 500 mg three times per (leading to infraocclusion in young individuals), and a “solid”
day for 7 days can be prescribed. Children under the age of metallic sound when the tooth is percussed. Currently, no known
12 can be prescribed penicillin V 25 to 50 mg/kg of body treatment is available for replacement resorption, which tends
weight in divided doses every 6 hours for 7 days. A tetanus to be continuous until the root is replaced by bone. In teeth that
booster injection is recommended if the last one was admin- have had long extraalveolar dry periods, the resorptive process
istered more than 5 years previously. Supportive care is is apparently slowed (but not halted) by immersing the tooth in
important. The patient (and parents) should be instructed that fluoride before replantation.
the patient is to eat a soft diet for up to 2 weeks, brush with REF: Sequelae to Replantation e33
13. When is root canal treatment indicated in a mature avulsed, 14. A deciduous tooth that has suffered an intrusive luxation
replanted tooth if replanted within 1 hour of avulsion? should be extracted under which of the following
a. at the time of replantation circumstances?
b. within 7 to 10 days after replantation a. The child cries but is compliant.
c. after 3 months if there is no response to pulp testing b. The permanent successor is partially erupted.
d. when periapical pathosis is noted c. The intruded tooth appears foreshortened on the
radiograph.
ANS: b d. The intruded tooth appears elongated on the
Root canal treatment is indicated for mature teeth and should radiograph.
be done optimally after 1 week and before the splint is
removed (the splint stabilizes the tooth during the procedure). ANS: d
Timing is crucial to preventing the onset and progression of Teeth with intrusive luxation should be carefully evaluated to
external inflammatory root resorption. In the mature replanted determine the direction of intrusion. Radiographs provide
tooth, root canal treatment is definitely indicated and should valuable information to confirm the intruded position of the
ideally be started 7 to 10 days after replantation. The splint tooth and its proximity to the permanent successor.117 If the
may remain during treatment for stability. intruded tooth appears foreshortened on the film, the apex is
REF: Avulsion (Root Canal Treatment) oriented toward the x-ray cone. Therefore, these teeth should
present no danger to the permanent successor and may be left
to reerupt. If the tooth appears elongated, the apex is oriented
toward the permanent successor and may pose a risk to the
permanent tooth bud. The tooth should be carefully extracted
if it impinges on the permanent successor. The permanent
tooth buds should also be evaluated for symmetry.
REF: Management of Traumatic Injuries in the Primary Den-
tition (Luxation Injuries)
e34

Richard E. Walton, Ashraf F. Fouad
4. Radiographs are useful for evaluating for success or

CHAPTER 12 failure at recalls because they do which of the
Endodontic Radiology following?
1. Diagnostic radiology is helpful for all of the following a. record subjective symptoms
except: b. show pulp vitality
a. identifying the presence of pathosis c. show failures that often occur without adverse signs or
b. determining root anatomy symptoms
c. determining pulp anatomy d. accurately diagnose apical pathosis
d. determining pulp responsiveness
ANS: c
ANS: d Ultimate success is verified at specified intervals of months
Diagnostic radiology involves not only identifying the pres- or years after treatment. Because failures often occur without
ence and nature of pathosis, but also determining root and signs or symptoms, radiographs are essential to evaluate peri-
pulp anatomy and characterizing and differentiating other apical status.11
normal structures. REF: Follow-Up Evaluation (Recall)
REF: Diagnosis
5. The most accurate radiographs are made by doing which
2. What are working length radiographs? of the following?
a. radiographs made by removing the rubber dam a. having the patient hold the film in place with the index
b. radiographs placed using an XCP positioning device finger
c. radiographs that help establish an estimated working b. using a paralleling device
length c. increasing or decreasing the vertical angulation to
d. radiographs to determine the distance from the radio- move superimposed objects out of the field of vision
graphic apex to a reference point d. having the rubber dam in place for isolation
ANS: d ANS: b
Working radiographs are made while the rubber dam is in Unquestionably, the most accurate radiographs are made
place, which creates problems with film placement and cone using a paralleling technique.13 The advantages are (1) less
positioning. These radiographs are exposed during the treat- distortion and more clarity and (2) reproducibility of film and
ment phase and have special applications. The distance from cone placement with preliminary and subsequent radiographs.
a reference point to the radiographic apex is determined pre- Reproducibility is important when assessing whether changes
cisely. This establishes the distance from the apex at which occurring in the periapex indicate healing or nonhealing. Par-
the canal is to be prepared and obturated.10 alleling devices enhance reproducibility.
REF: Treatment; Determining Working lengths REF: Diagnostic Radiographs (Angulation)
3. Radiographs are useful for evaluating all of the following 6. Use of a paralleling technique may not be feasible when
qualities of an obturation except: which of the following occurs?
a. length a. There is a high palatal vault.
b. density b. There are maxillary tori.
c. sealer thickness c. A fixed prosthesis is present.
d. apical seal d. There are exceptionally short roots.
ANS: c ANS: b
Postoperative radiographs provide a lot of information on There may be special situations in which the paralleling tech-
canal preparation and obturation. Length from the apex, nique is not feasible, such as a low palatal vault, maxillary
density, taper, preservation of original canal shape, and the tori, exceptionally long roots, or an uncooperative or gagging
general quality of obturation in each canal are determined patient, and these may necessitate an alternative technique. A
from these radiographs. Seal is a microscopic phenomenon. second choice is the modified paralleling technique; the least
REF: Evaluating Obturation accurate technique is the bisecting angle.
REF: Diagnostic Radiographs (Angulation)
e35
7. What does the cone-image shift do? 9. What is a disadvantage of the cone-image shift?
a. It gives a clear two-dimensional image. a. Lingual objects become more distorted than buccal
b. It superimposes facial and lingual structures. objects.
c. It assists in identifying superimposed canals. b. There is excessive contrast between radiolucent and
d. It moves apical endodontic lesions away from the root radiopaque objects.
apex. c. It may superimpose normal anatomic structures over
the root apices.
ANS: c d. It does not reveal additional canals within a root.
The cone-image shift technique separates and identifies the
facial and lingual structures.5 An example is the mesiobuccal ANS: c
root of a maxillary molar that contains two superimposed The cone-image shift has inherent problems and therefore on
canals. The cone shift separates and permits visualization of occasion should not be used or the angulation of the cone
both canals. Varying either the vertical or, particularly, the should be minimized. The clearest radiograph with the most
horizontal cone angulation from parallel alters images and definition is a parallel or modified parallel projection.23 When
enhances interpretation.5,12 These shifts reveal the third dimen- the central beam changes direction relative to object and film
sion and superimposed structures. Shifts also permit identifi- (passing through the object and striking the film at an angle),
cation and positioning of objects that lie in the faciolingual the object becomes blurred (Fig. 12.16). Distinctions between
plane. radiolucent and radiopaque objects show less contrast. This
REF: Cone-Image Shift blurred or fuzzy appearance increases as the cone angle
increases, and other structures are more likely to be superim-
8. What occurs as the cone position moves away from posed. Therefore, for maximum clarity, the cone angle should
parallel? deviate only to the extent necessary to obtain sufficient shift
a. Objects on the film shift toward the direction of the for interpretive purposes.
cone. REF: Disadvantages
b. The facial or buccal object shifts less than the lingual
object. 10. Which of the following is a distinguishing characteristic
c. The lingual object moves relatively in the same direc- of a radiolucent lesion of endodontic pathosis?
tion as the cone. a. An apical/radicular lamina dura is present and intact.
d. The buccal object moves relatively in the same direc- b. A round shape is characteristic.
tion as the cone. c. The radiolucency stays at the apex regardless of cone
angulation.
ANS: c d. There is no apparent cause of pulpal necrosis.
When two objects and the film or sensor are in a fixed position
buccal and lingual from each other and the radiation source ANS: c
(cone) is moved in a horizontal or vertical direction, images Radiolucent lesions have four characteristics that help dif-
of both objects move in the opposite direction (Fig. 12.9). The ferentiate them from nonendodontic pathoses (Fig. 12.18): (1)
facial (buccal) object shifts farthest away; the lingual object an apical/radicular lamina dura is absent, having been
moves in the direction of the cone movement. The resulting resorbed; (2) a “hanging drop of oil” shape is characteristic
radiograph shows a lingual object that moved relatively in the of the radiolucency, although this is a generalization because
same direction as the cone and a buccal object that moved in these lesions may have a variety of appearances; (3) the radio-
the opposite direction.22 This principle is the origin of the lucency “stays” at the apex regardless of cone angulation; and
acronym SLOB (same lingual, opposite buccal). One way to (4) a cause of pulpal necrosis is usually (but not always)
visualize this is to close one eye and hold two fingers directly evident.
in front of the open eye so that one finger is superimposed on REF: Differential Diagnosis (Endodontic Pathosis, Radiolu-
the other. By moving the head one way and then the other, cent Lesions)
the position of the fingers relative to each other shifts. The
same effect is produced with two superimposed roots (the 11. If a developed, sizable radiolucency is an endodontic
fingers) and the way in which they move relative to the radia- lesion, what must the pulpal diagnosis be?
tion source (the eye) and the central beam (the line of sight). a. normal pulp
When the cone-shift technique is used, it is critical to know b. reversible pulpitis
in which direction the shift was made and to determine what c. symptomatic irreversible pulpitis
is facial and what is lingual. Otherwise, serious errors may d. necrotic pulp
occur.
REF: SLOB Rule ANS: d
The ultimate differentiation is not the radiograph but the pulp
test. If a developed, sizable radiolucency is an endodontic
lesion, it must result from a necrotic (hence nonresponsive)
pulp.
REF: Differential Diagnosis (Endodontic Pathosis, Radiolu-
cent Lesions)
e36
12. What normal anatomic structure may overlie a mandibular 15. Which of the following is not an advantage of cone beam
premolar apex? computed tomography (CBCT)?
a. incisive canal a. Involves approximately half the radiation exposure of
b. nasal fossa one periapical digital radiograph
c. zygomatic process b. Allows better viewing of the extent of resorptive lesions
d. mental foramen c. Has a higher sensitivity in detecting periapical lesions
d. Identifies and localizes bony structures
ANS: d
The classic example of a radiolucency that may overlie an ANS: a
apex is the mental foramen over a mandibular premolar.34 This CBCT is a form of computed tomography in which only a
is easily identified by noting movement on angled radiographs focused cone-shaped beam of x-rays is projected at the imaged
and by identifying the lamina dura (Fig. 12.21).35 The maxilla tissues. The diameter of the exposed tissues varies from 40 ×
region contains several structures (both radiolucent and radi- 40 to 170 × 120 mm (or more in certain machines); however,
opaque) that may be confused with endodontic pathosis. the limited volume significantly reduces the amount of radia-
Examples are the maxillary sinus, incisive canals, nasal fossa, tion compared with traditional computed tomography. More-
zygomatic process, and anterior nasal spine. The characteris- over, the resolution of the CBCT image volume can be as low
tics of the structure, in addition to pulp responsiveness to tests, as 76 m, which allows very small objects, such as hard to find
are important in differentiation. canals, to be seen (Fig. 12.15). The amount of exposure from
REF: Anatomic Structures one periapical digital radiograph is estimated to be equivalent
to 1 day of background radiation; the exposure from a CBCT
13. A mesial projection cone adjustment during working image varies from 0.7 to 8 day, and that from a full mouth
length radiographs is indicated for what teeth? series of F-speed film is about 21 days.52-54
a. maxillary anterior teeth Because CBCT provides three-dimensional imaging, it is
b. maxillary molars with a mesiolingual canal very useful in special situations. Examples are diagnosis and
c. mandibular incisors treatment planning for teeth with a complex anatomy or exten-
d. mandibular molars with a second distal canal sive resorptive lesions (Fig. 12.33). In cases in which previous
treatment was not successful, there is a need to identify the
ANS: b etiology of failure and whether retreatment or surgery would
The mesial projection is indicated for maxillary and mandibu- be more appropriate (Fig. 12.15). This is also useful in assess-
lar premolars and for mandibular canine teeth. A mesial pro- ing the diagnosis or treatment outcome if the patient has
jection is used for maxillary molars to identify and treat a symptoms but no apparent etiology can be determined. The
mesiolingual (MB2) canal. sensitivity of CBCT is higher than that of periapical radiog-
REF: Cone Alignment (Mesial Projection) raphy in detecting periapical lesions55,56 and in identifying
vertical root fractures.57 Cone bean computed tomography is
14. Digital radiography has not been proven to do which of also superior to digital radiographs in assessing healing
the following? (lesion resolution) on follow-up examination.58 In addition, it
a. provide superior image quality is useful for identifying and localizing bony structures, such
b. reduce radiation to the patient as the mandibular canal.59
c. increase the speed of obtaining an image REF: Cone Beam Computed Tomography
d. be accurately and reliably transmitted between
computers
ANS: a
A variety of digital radiographic systems have been com-
pared, although none has been shown to be significantly supe-
rior as to image quality.43 These systems are of considerable
interest, offering the advantages of reduced radiation to the
patient, increased speed of obtaining the image, ability to be
transmitted, computer storage and enhancement, and a system
that does not require a darkroom or x-ray processor.44 However,
these systems generally show no superiority to conventional
radiographs for diagnosis or for working films.45-50 Further-
more, computer image enhancement does not seem to improve
diagnostic interpretation significantly.51
REF: Digital Radiography
e37

Van T. Himel, Kent A. Sabey
5. What is the diameter at point D0 and at point D16 for a

CHAPTER 13 0.02 taper No. 20 file?
Endodontic Instruments a. 0.20 mm at D0 and 0.36 mm at D16
1. What must an instrument do to completely clean the canal b. 0.20 mm at D0 and 0.52 mm at D16
space? c. 0.02 mm at D0 and 0.18 mm at D16
a. It must be deflected at the canal orifice. d. 0.02 mm at D0 and 0.34 mm at D16
b. It must stop 2 to 3 mm short of the radiographic apex.
c. It must fit loosely into the canal. ANS: b
d. It must contact all walls and surfaces. Taper can be defined as the rate of change of cross-sectional
diameter. A file with a taper of 0.02 (2%) increases in diam-
ANS: d eter at a rate of 0.02 mm per running millimeter of length,
To mechanically débride a region of the canal space com- beginning at D0 through D16. Likewise, a file with a taper of
pletely, an instrument must contact and plane all walls. 0.04 (4%) increases in diameter at a rate of 0.04 mm per
REF: Intracanal Preparation Instruments running millimeter of length beginning at D0 through D16.
For example, a 0.02 taper No. 20 file is 0.20 mm in diameter
2. What motion is used with a reamer to clean and shape at D0, tapers 0.32 mm over 16 mm, and has a diameter of
canal walls? 0.52 mm at D16.
a. pushing REF: Instrument Design and Standardization (Taper)
b. planing
c. twisting 6. What is torsional limit?
d. vibration a. the amount of apical pressure that can be applied to a
file to the point of breakage
ANS: c b. the beginning of plastic deformation of an instrument
Files can be effective when used in both filing (pulling and c. the amount of rotational torque that can be applied to
planing) and reaming (twisting and cutting) motions; reamers a “locked” instrument to the point of breakage
are least effective when used in a filing motion. d. the amount of force necessary to prevent a file from
REF: Hand-Operated Instruments returning to its original shape upon unloading of the
force
3. Nickel-titanium alloy has increased flexibility over stain-
less steel. How does the modulus of elasticity for nickel- ANS: c
titanium alloy compare to that of stainless steel? Torsional limit is the amount of rotational torque that can be
a. It is similar to that of stainless steel. applied to a “locked” instrument to the point of breakage
b. It is one fourth to one fifth that of stainless steel. (separation).
c. It is one half that of stainless steel. REF: Physical Characteristics
d. It is two to three times that of stainless steel.
7. What is the approximate ratio of nickel to titanium in
ANS: b nickel-titanium endodontic instruments?
Nickel-titanium alloy has a modulus of elasticity that is one a. 25% nickel/75% titanium
fourth to one fifth that of stainless steel, allowing a wide range b. 75% nickel/25% titanium
of elastic deformation. c. 45% nickel/55% titanium
REF: Physical Properties d. 55% nickel/45% titanium
4. Which design variable is used to provide greater flexibility ANS: d

of instruments? New metal alloys have been incorporated in an attempt to
a. changing the cross section from triangular to square improve the quality of files. Nickel-titanium instruments are
b. changing the cross section from rhomboidal to square composed of approximately 55% nickel and 45% titanium,
c. increasing the number of flutes per millimeter although this can vary by manufacturer.
d. decreasing the number of flutes per millimeter REF: Physical Properties
ANS: d
Many design variables can affect the function, efficacy, and
efficiency of instruments. By changing the cross-sectional
design from square to triangular or rhomboid and decreasing
the number of flutes per millimeter, greater flexibility is
gained.
e38 REF: Instrument Design and Standardization
8. What canal configuration provides the greatest physical 11. Nickel-titanium undergoes what surface alteration or pro-
advantage for nickel-titanium instruments over stainless cessing to enhance its properties?
steel instruments in cleaning and shaping? a. Teflon coating
a. fine, small canals b. electropolishing
b. large canals c. magnetization
c straight canals d. demagnetization
d. irregular canal shapes
ANS: b
ANS: a Efforts to enhance the properties of nickel-titanium alloy are
Nickel-titanium instruments are more flexible and adapt more ongoing; it has been demonstrated that altering surface char-
readily to fine, curved canals10 but have no advantage over acteristics and the process of manufacturing may increase the
stainless steel files in straight and irregular canal spaces. durability and flexibility of these instruments. Electropolish-
REF: Physical Properties ing, surface coatings, and surface implantation have been tried
for this purpose.
9. How do Gates-Glidden drills differ from Peeso reamers? REF: Physical Characteristics
a. Gates-Glidden drills have a greater length of cutting
surface. 12. Regular inspection of hand files may aid in avoidance of
b. Gates-Glidden drills are more aggressive cutters. instrument separation. For what defect should a file be
c. Gates-Glidden drills have an elliptical-shaped cutting inspected?
area. a. unwinding of the flutes
d. Gates-Glidden drills are less flexible. b. rolling up or tightening of the flutes
c. distortion of the tip
ANS: c d. all of the above
Gates-Glidden rotary drills are elliptically (flame) shaped burs
with a thin shank and latch attachment and are used to open ANS: d
the orifice. They also achieve straight-line access by removing Signs that instrument separation may occur are unwinding of
the dentin shelf and rapidly flaring the coronal third of the the flutes (twisting clockwise and opening of the flutes),
canal. Gates-Glidden drills are designed to break high in the roll-up of the flutes (excessive continued clockwise twisting
shank region. This allows easier removal of the broken instru- after unwinding), tip distortion (an excessively bent tip), wear,
ment from a tooth; fracture near the cutting head may block and corrosion (Fig. 13.15). If any of these signs are observed,
a canal.33,41,42 It is important to note that these drills must be the file should be discarded.
continuously rotated. If they stop, the head may lock in the REF: Avoidance of Instrument Separation
canal, with torsional failure and fracture. Peeso rotary reamers
(originally designed for post preparation) are similar to Gates- 13. What are the characteristics of finger spreaders and plug-
Glidden drills but have longer cutting sides with or without gers, compared to handled instruments, when used for
safe tips, which are parallel rather than an elliptical shape. lateral condensation?
Peeso reamers have been suggested as a means of improving a. They are annealed to give them greater strength.
straight-line access, although they are less well-controlled b. They are best suited for straight canals.
than Gates-Glidden drills.42 c. They are more rigid, to access the canal orifice.
REF: Mechanically Operated Instruments (Rotary) d. They have greater flexibility.
10. How are broaches intended to be used in the canal? ANS: d

a. to plane canal walls with a push-pull motion The main instrument used for cold lateral compaction is the
b. to plane canal walls with a reaming motion spreader, the function of which is to laterally compact and
c. to be placed to the corrected working length around adapt gutta-percha and create space for accessory cones. Two
canal curvatures types are handle spreaders and finger spreaders (Fig. 13.17).
d. to entangle and remove canal contents by rotation The handled instruments are stiffer and are made of annealed
stainless steel. As with canal preparation instruments, spread-
ANS: d ers come in various tip sizes and tapers. Standard spreaders
Barbed broaches are stainless steel instruments with plastic increase diameter at the same rate as a file with 0.02 taper,
handles. Manufacturers create barbs on tapered wire broaches whereas highly tapered spreaders increase at a higher rate.
by scoring and prying a tag of metal away from the long axis The greater the taper, the more the canal space must be
of the wire (Fig. 13.9). The barbs entangle and allow removal enlarged or flared to facilitate spreader penetration. Both
of canal contents. This instrument should be neither bound in stainless steel and nickel-titanium spreaders are available. The
the canal nor aggressively forced around a canal curvature obvious advantage of nickel-titanium over stainless steel is
because the barbs may engage the canal wall, with instrument greater spreader penetration in highly curved canals.56 Nickel-
fracture. Barbed broaches should never be reused. The use of titanium spreaders also create less stress in curved canals
broaches has decreased in popularity. compared with stainless steel.57 Handled instruments are
REF: Hand-Operated Instruments capable of generating more force within a canal space during
obturation, so finger spreaders should be considered when
obturating curved canals (Fig. 13.18). All spreaders should be
used cautiously with regard to the amount of applied force. e39
REF: Instruments for Obturation – lateral condensation
14. How does pressure sterilization compare to dry heat ster- 16. What property of nickel-titanium allows it to be an effec-
ilization for the sterilization of sharp-edged instruments? tive rotary file in curved canals ?
a. The two types are comparably effective. a. corrosion resistance
b. Neither should be used for sterilization. b. variable taper
c. Pressure sterilization is superior. c. shape memory
d. Dry heat sterilization is superior. d. torsional strength
ANS: d ANS: c
Dry heat is superior for sterilizing sharp-edged instruments, Due to the unique crystalline structure and phase change
such as scissors, to best preserve their cutting edge. capability of nickel-titanium, most NiTi files have shape
REF: Disinfection and Sterilization memory; this is the important ability of a file to return to its
original shape after being deformed. Shape memory affords
15. What are the time, temperature, and pressure requirements nickel-titanium alloys the flexibility and toughness necessary
for sterilization of gauze-wrapped instruments using pres- for routine use as effective rotary endodontic files in curved
sure sterilization? canals.14
a. 10 minutes at 121°C and 15 psi REF: Physical Properties
b. 10 minutes at 100°C and 15 psi
c. 20 minutes at 121°C and 15 psi
d. 20 minutes at 100°C and 15 psi
ANS: c
Instruments that have been wrapped in gauze should be auto-
claved for 20 minutes at 121°C and 15 psi.58 This kills all
bacteria, spores, and viruses.
REF: Disinfection and Sterilization
e40

Richard E. Walton, Eric J. Herbranson
5. Alterations in the anatomy of the pulp space occur because

CHAPTER 14
of:
Internal Anatomy a. resorption
1. Lack of knowledge of pulp anatomy is the _________ b. age
common cause of treatment failure. c. calcifications
a. least d. all of the above
b. second most
c. third most ANS: d
d. fourth most Understanding the changes that often occur during the life
span and experience of a tooth will alert the practitioner to
ANS: b potential difficulties in locating the pulp space and/or root
This fact emphasizes the important of anatomic knowledge in canals during treatment
executing endodontic treatment. REF: Alterations in Internal Anatomy
REF: Introduction
6. Calcifications encountered in the pulp space:
2. Which of the following is the most predictable technique a. represent additional dentin formation
for determining whether a root contains two canals? b. can always be detected by radiograph
a. an apex locator c. are always attached to the chamber or canal walls
b. viewing the access with a microscope d. often prevent instruments from negotiating canals
c. searching with an explorer
d. interpreting angled radiographs ANS: a
Familiarity with the location and type of calcifications present
ANS: d in the pulp space helps the clinician locate canal orifices and
Varied angulations in radiographs are the most predictable negotiate to working length.
method to elucidate anatomic features such as multiple canals REF: Alterations in Internal Anatomy (Calcifications)
and curvatures.
REF: Methods of Determining Pulp Anatomy (Radiographic 7. Which of the following is not associated with the radicular
Evidence) pulp?
a. lateral canals
3. The shape of the canal in cross section is variable through- b. apical foramen
out the root; however, it is almost always round in the c. pulp horns
apical third. True or false? d. canal orifices
a. Both parts of the sentence are true.
b. The first part of the sentence is false; the second part ANS: c
is true. A knowledge of the location of anatomic features of the pulp
c. The first part of the sentence is true; the second part is space.
false. REF: Components of the Pulp System
d. The entire sentence is false.
8. Accessory canals are more common in the apical third;
ANS: c they also are more common in posterior teeth. True or
The cross section of the canal is rarely round and to make this false?
assumption can lead to errors in canal preparation. a. The entire sentence is true.
REF: General Considerations (Root and Canal Anatomy) b. The first part of the sentence is true, the second part is
false.
4. Multiple canals in mandibular premolars occur most often c. The first part of the sentence is false, but the second
in which population? part is true.
a. Asians d. The entire sentence is false.
b. African-Americans
c. Caucasians ANS: a
d. There is no difference by ethnicity. Knowledge of the anatomic features of the pulp space
REF: Components of the Pulp System (Accessory Canals)
ANS: b
Knowledge of common variations, either by tooth type or by
ethnicity, aid in detection of those variations and in their suc-
cessful treatment.
REF: General Considerations (Root and Canal Anatomy) e41
9. Which statement is true about the apical foramen? 11. The lingual groove defect is found most frequently in
a. The diameter remains constant throughout life. maxillary central incisors; it has a poor prognosis for treat-
b. The position of the apical foramen is often visible on ment. True or false?
radiographs. a. Both parts of the sentence are true.
c. The foramen is most commonly located 0.5 mm to b. The first part of the sentence is true, the second part is
1 mm from the anatomic root apex. false.
d. None of the above c. The first part of the sentence is false, the second part
is true.
ANS: c d. Both parts of the sentence are false.
A knowledge of the common location of the apical foramen
helps the clinician determine the proper working length. ANS: c
REF: Apical Region (Apical Foramen) The lingual groove is most commonly found in maxillary
lateral incisors, and the clinician should check for it when
10. Dens invaginatus (dens in dente) occurs most commonly performing periodontal probing.
in which teeth? REF: Variations of Root and Pulp Anatomy (Lingual Groove)
a. maxillary canines
b. maxillary lateral incisors 12. A C-shaped canal is characterized by which of the
c. maxillary and mandibular lateral incisors following?
d. mandibular first premolars a. It is most commonly found in Asian populations.
b. It usually occurs in mandibular second molars.
ANS: b c. It should be referred to an endodontist for treatment.
A knowledge of the common anomalies and where they occur d. all of the above
aids in diagnosis and treatment planning or referral.
REF: Variations of Root and Pulp Anatomy (Dens Invaginatus ANS: d
[Dens in Dente]) Identification and referral of this complex anatomic variation
maximizes the prognosis.
REF: Variations of Root and Canal Anatomy (Other
Variations)
e42

William T. Johnson, Anne E. Williamson
3. What is the recommended rubber dam weight for end-

CHAPTER 15
odontic procedures?
Isolation, Endodontic Access, and a. light
Length Determination b. medium
1. Rubber dam use indicates that the clinician understands c. heavy
what aspects of endodontic treatment? d. extra heavy
a. the microbial nature of disease
b. protection of the patient from aspirating or swallowing ANS: b
instruments The thickness of rubber dams also varies (i.e., light, medium,
c. a decreased success rate for endodontic treatment when heavy, and extra heavy). A medium-weight dam is recom-
strict asepsis is not followed mended for endodontic procedures because a light-weight
d. all of the above dam is easily torn during the application process. Also, the
medium-weight material fits better at the gingival margin and
ANS: d provides good retraction.
Application of the rubber dam for isolation during endodontic REF: Isolation (Rubber Dam Application)
treatment has many distinct advantages and is mandatory for
legal considerations.1 Failure to use a rubber dam indicates 4. Which of the following clamps is designed for an anterior
that the clinician does not understand the microbial nature of tooth?
the disease process, the need to protect the patient from aspi- a. No. 8
rating or swallowing instruments, the protection afforded the b. No. 212
dental staff from contaminated aerosols, and the decreased c. No. 0
success rate for treatment when strict asepsis is not followed. d. No. 24/25
In the United States, use of the rubber dam is considered the
standard of care; thus expert testimony is not required in cases ANS: b
in which patients swallow or aspirate instruments or materials, Anterior teeth: No. 9 or No. 212
because juries are considered competent to determine negli- REF: Rubber Dam Retainers (Types)
gence. Evidence exists that many general dentists unnecessar-
ily place themselves at risk by not using the rubber dam when 5. What is an advantage of a provisional crown used to
performing endodontic procedures.2 replace missing tooth structure before root canal
REF: Isolation (Rubber Dam Application) treatment?
a. It accurately reproduces tooth anatomic landmarks.
2. What is an advantage of using a plastic rubber dam retainer b. It maintains tooth orientation for access and canal
clamp? location.
a. It is radiopaque. c. It is easily removed and replaced during root canal
b. It must be removed when exposing a radiograph. treatment appointments.
c. It is less likely to damage tooth structure or existing d. It increases visibility of the root canal chamber.
restorations.
d. It obscures visibility when the chamber is calcified. ANS: c
Placement of temporary crowns is an option; however, they
ANS: c decrease visibility, result in the loss of anatomic landmarks,
The design of the rubber dam frames is also variable. For and may change the orientation for access and canal location.
endodontics, plastic frames are recommended; they are radio- Often temporary crowns are displaced during treatment by the
lucent and do not require complete removal during exposure rubber dam clamp. In general, when provisional crowns are
of interim films such as the working length and master cone placed, they should be removed during root canal treatment
radiographs/digital images. and replaced after the procedure to increase visibility, provide
REF: Isolation (Rubber Dam Application) adequate orientation, and maintain the remaining tooth
structure
REF: Replacement of Coronal Structures (Provisional
Crowns) e43
6. What is the preferred method of rubber dam placement on 9. What is an advantage of caries removal during access?
molars? a. It enhances the effectiveness of NaOCl.
a. placement as a single unit b. It reduces interappointment pain.
b. placement of a clamp and rubber dam, followed by c. It strengthens tooth structure.
attachment of the frame d. It allows assessment of restorability prior to the end-
c. placement of a clamp, followed by the dam and then odontic treatment.
the frame
d. placement of the rubber dam and frame, followed by ANS: d
placement of the clamp Caries removal is essential for several reasons. First, remov-
ing caries permits the development of an aseptic environment
ANS: a prior to entering the pulp chamber and radicular space.
Placement of the rubber dam, clamp, and frame as a unit is Second, it allows assessment of restorability prior to treat-
preferred. This is most efficient and is applicable in most ment. Third, it provides sound tooth structure so that an ade-
cases. quate provisional restoration can be placed. Unsupported
REF: Rubber Dam Placement (Placement as a Unit) tooth structure is removed to ensure a coronal seal during and
after treatment and so that the reference point for length
7. What is a major objective of the access opening? determination is not lost should fracture occur.
a. to locate the primary or largest canal REF: General Principles—caries removal
b. to achieve unimpeded straight-line access of the instru-
ments to the first canal curvature or apical one third 10. Estimated depth of access is a measurement from which
c. to expose the pulp horns of the following?
d. to remove all restorative materials a. the incisal edge of anterior teeth to the coronal portion
of the pulp chamber
ANS: b b. the occlusal reference of posterior teeth to the coronal
The major objectives of the access openings include portion of the pulp chamber
(1) removal of the chamber roof and all coronal pulp tissue, c. the incisal edge of anterior teeth to the radiographic
(2) location of all canals, (3) unimpeded straight-line access apex of the tooth
of the instruments in the canals to the apical one third or the d. the occlusal reference of posterior teeth to the radio-
first curve (if present), and (4) conservation of tooth graphic floor of the chamber
structure.
REF: Access Openings ANS: b
Before the access is begun, the preoperative radiographs
8. Which statement best describes the outline form for should be assessed to determine the degree of case difficulty.
access? At this stage, the estimated depth of access is calculated. This
a. It mimics the shape of the canal or canals. is a measurement from the midlingual surface of anterior teeth
b. It is toward the distal on the occlusal surface in molars. and the occlusal surface of posterior teeth to the coronal
c. It is a projection of the internal tooth anatomy onto the portion of the pulp chamber. Calculated in millimeters, this
external surface. information is then transferred to the access bur and provides
d. It is a constant and unchanging shape regardless of age. information on the depth necessary to expose the pulp. If the
estimated depth of access is reached and the pulp has not been
ANS: c encountered, the access depth and orientation must be reeval-
Endodontic access openings are based on the anatomy and uated. A parallel radiograph exposed with the rubber dam
morphology of each individual tooth group. In general, the removed helps in determining the depth and orientation so
pulp chamber morphology dictates the design of the access that perforations and unnecessary removal of tooth structure
preparation. The internal anatomy is projected onto the exter- can be avoided (Fig. 15.33). The estimated depth of access
nal surface. Internal pulp chamber morphology varies with the for anterior teeth is similar.41 The maxillary central and lateral
patient’s age and secondary dentin deposition. In anterior incisors average 5.5 mm for the central incisor and 5 mm for
teeth and premolars with a single root, calcification occurs in the lateral incisor. The mandibular central and lateral incisors
a coronal to apical direction with the chamber receding into average 4.5 mm for the central incisor and 5 mm for the
the root. In posterior teeth with bifurcations and trifurcations, lateral incisor. The maxillary canine averages 5.5 mm, and the
secondary dentin is deposited preferentially on the floor of the mandibular canine, with its longer clinical crown, averages
chamber, reducing the cervical to apical dimension of the 6 mm. In maxillary furcated premolars, the average distance
chamber.32,33 The mesial-distal and buccal-lingual dimensions from the buccal cusp tip to the roof of the chamber is 7 mm.42
remain relatively the same, as does the cusp to roof distance. For maxillary molars the distance is 6 mm, and for the man-
Dystrophic calcifications related to caries, restorations, attri- dibular molars it is 6.5 mm. With an average pulp chamber
tion abrasion, and erosion also can occur. In general, the pulp height of 2 mm, the access depth for most molars should not
chamber is located at the cementoenamel junction. extend beyond 8 mm (the floor of the chamber).35
REF: Access Openings REF: General Considerations
e44
11. Which of the following is not a general principle for end- molar may even exhibit a distinct separate extra distal root.
odontic access? Because of these anatomic relationships, the access outline
a. outline form form is rectangular or trapezoidal and positioned in the mesio-
b. compensation form buccal portion of the crown (Fig. 15.37).
c. caries removal REF: Access Openings and Canal Location (Mandibular
d. toilet of the cavity Molars)
ANS: b 15. Which of the following is not a major canal

The general principles for endodontic access are outline form, morphology?
convenience form, caries removal, and toilet of the cavity. a. ribbon/figure eight
REF: General Principles b. triangular
c. bowling pin
12. What is the shape of the access opening of a maxillary d. kidney bean shape
central incisor in a young patient?
a. round ANS: b
b. triangular Five major canal morphologies have been identified (Fig.
c. trapezoidal 15.7)28,40: round, ribbon or figure eight, ovoid, bowling pin,
d. square kidney bean, and C-shape. With the exception of the round
morphologic shape, each presents unique problems for ade-
ANS: b quate cleaning and shaping.
The maxillary central incisor has one root and one canal. REF: Canal Morphologies
Young individuals have prominent pulp horns, requiring
a triangular outline form to ensure that tissue and obtu- 16. To obtain an accurate measurement, the working length
ration materials are removed that might cause coronal radiographs should be made with:
discoloration. a. a loosely fitting file in place
REF: Access Openings and Canal Location (Maxillary Central b. a minimum of a No. 20 file
and Lateral Incisors) c. a positioning device and a parallel technique
d. the rubber dam removed for visibility and access
13. What is the outline shape of the access for a maxillary first
molar? ANS: b
a. round The working length is defined as the distance from a prede-
b. triangular termined coronal reference point (usually the incisal edge in
c. trapezoidal anterior teeth and a cusp tip in posterior teeth) to the point
d. square where the cleaning and shaping and obturation should termi-
nate. The reference point must be stable so that fracture does
ANS: b not occur between visits. Unsupported cusps that are weak-
The maxillary first and second molars have similar access ened by caries or restorations should be reduced. The point
outline forms. The outline form is triangular and is located in of termination is empirical; based on anatomic studies, it
the mesial half of the tooth with the base to the facial and the should be 1 mm from the radiographic apex.51,52,66,67 This
apex toward the lingual. accounts for the deviation of the foramen from the apex and
REF: Access Openings and Canal Location (Maxillary the distance from the major diameter of the foramen to the
Molars) area where a dentinal matrix can be established apically.
After access preparation, a small file is used to explore the
14. What is the outline shape of the access for a mandibular canal and establish patency to the estimated working length.
first molar with four distinct separate roots? The largest file to bind is then inserted to this estimated length
a. round because a file that is loose in the canal may be displaced
b. triangular during film exposure or forced beyond the apex if the patient
c. trapezoidal bites down inadvertently. Millimeter markings on the file shaft
d. square or rubber stops on the instrument shaft are used for length
control. A sterile millimeter ruler or measuring device can be
ANS: c used to adjust the stops on the file. To ensure accurate mea-
The coronal reference points for canal location in the man- surement and length control during canal preparation, the stop
dibular molar roots are influenced by the position of the crown must physically contact the coronal reference point. To obtain
on the root and by the lingual tipping of these teeth in the arch an accurate measurement, the minimum size of the working
(Fig. 15.36). The mesiobuccal canal orifice is located slightly length should be a No. 20 file. With files smaller than No. 20,
distal to the mesiobuccal cusp tip. The mesiolingual canal it is difficult to interpret the location of the file tip on the
orifice is located in the area of the central groove area and working length film or digital image. In multirooted teeth,
slightly distal when compared to the mesiobuccal canal. The files are placed in all canals before exposing the film.
distal canal is located near the intersection of the buccal, Angled films/images are necessary to separate superim-
lingual, and central grooves. When a distobuccal canal is posed files and structures (Fig. 15.40)58,73 to provide an effi-
present, the orifice can be found buccal to the main distal cient method of determining the working length and to reduce
canal and often is slightly more mesial. The mandibular first radiation to the patient. It is imperative that the rubber dam e45
be left in place during working length determination to ensure ANS: b

an aseptic environment and to protect the patient from swal- The coronal reference points for canal location in the man-
lowing or aspirating instruments. The film/digital sensor can dibular molar roots are influenced by the position of the crown
be held with a hemostat or a positioning device (Fig. 15.41). on the root and by the lingual tipping of these teeth in the arch
REF: Length Determination (Radiographic Evaluation) (Fig. 15.36).
REF: Access Opening and Canal Anatomy (Mandibular
17. What direction is a mandibular molar commonly tipped Molars)
in the normal mandibular arch?
a. buccal
b. lingual
e46

Ove A. Peters, W. Craig Noblett
4. To prevent extrusion of obturating material, cleaning and

CHAPTER 16
shaping procedures must be confined to the radicular
Cleaning and Shaping space. Canals filled to the radiographic apex would be
1. What is the preferred method to evaluate whether a canal considered the perfect result.
has been adequately cleaned? a. Both statements are true.
a. The canal is three files sizes larger than the initial b. The first statement is true; the second statement is false.
master apical file. c. The first statement is false; the second statement is true.
b. The canal walls are “glassy smooth” when explored d. Both statements are false.
with a file.
c. Dentin shavings obtained are clean and white. ANS: b
d. Irrigant runs clear with no visible debris. It should be recognized that obturation to the radiographic
apex is usually slightly overextended clinically. The principle
ANS: b of confining the material to the canal space would prevent this
There is no perfect way to assess cleaning in a clinical situa- result from being considered ideal.
tion. The most predictable method is to explore the walls with REF: Apical Canal Preparation (Termination of Cleaning and
tactile sense to determine whether they are smooth; smooth- Shaping)
ness indicates that the walls have been planed by the instru-
ments and are likely as clean as possible. 5. Which of the following is the most widely used irrigating
REF: Principles of Cleaning solution?
a. sodium hypochlorite
2. The degree of canal enlargement during shaping is dic- b. ethylenediaminetetraacetic acid (EDTA)
tated by which of the following? c. citric acid
a. method of obturation d. QMix
b. anatomy of the root
c. restorative treatment plan ANS: a
d. all of the above Although several irrigants are available, sodium hypochlorite
remains the gold standard because it accomplishes many of
ANS: d the desired effects of an irrigant.
Several factors enter into the determination that an adequate REF: Elimination of Etiology
shape has been achieved. Considering just one of the criteria
listed could result in overenlargement and/or procedural 6. The best description of the difference between nickel-
accidents. titanium and stainless steel instruments is which of the
REF: Principles of Shaping following?
a. Nickel-titanium tends to result in better shaping (less
3. The apical termination point for cleaning and shaping of transportation) in curved canals.
the root canal should be which of the following? b. Nickel-titanium usually results in better débridement.
a. the radiographic apex c. Nickel-titanium can usually be reused many more
b. the point that is the major diameter of the apical times than stainless steel.
foramen d. Nickel-titanium has sharper cutting edges.
c. within 0.5 to 2 mm of the radiographic apex
d. 0.5 mm beyond the radiographic apex ANS: a
Students should be aware of the primary advantage of nickel-
ANS: c titanium over stainless steel.
Summaries of anatomic and prognostic studies have shown REF: Principles of Cleaning and Shaping Techniques
that the most favorable outcome is achieved when the point
that is the major diameter of the apical foramen is used as the
apical termination point.
REF: Apical Canal Preparation (Termination of Cleaning and
Shaping) e47
7. What is the primary purpose of an irrigant such as sodium 11. How does the step-down technique differ from the step-
hypochlorite? back technique?
a. to kill bacteria a. It creates a funnel-shaped preparation.
b. to dissolve tissue remnants b. It facilitates tissue removal.
c. to flush out debris c. It requires fewer instruments.
d. to lubricate instruments d. It creates coronal flare early, removing interferences.
ANS: c ANS: d
Although some irrigating solutions may have other desirable Familiarity with different techniques and the differences
properties, the primary purpose of any irrigant is to flush out between them is important in selecting a technique for a spe-
the debris generated by the mechanical action of the instru- cific case.
ments used to prepare the canal. REF: Hand Instrumentation
REF: Irrigants (Sodium Hypochlorite)
12. Recapitulation is defined as:
8. Removal of the smear layer after cleaning and shaping a. the removal of accumulated debris using a small file at
does which of the following? the corrected working length
a. promotes coronal leakage b. confirmation of the working length after completion of
b. reduces dentin permeability cleaning and shaping
c. allows better adaptation of obturating materials to c. the last irrigation before drying of the canal
canal walls d. verification of the master apical file after cleaning and
d. forces bacteria into dentinal tubules shaping
ANS: c ANS: a
Improved adaptation to the canal walls reduces the opportu- Physical removal of debris is important for several reasons. If
nity for leakage along the obturating material. debris accumulates at the apical extent of the canal, it will
REF: Smear Layer Management affect adaptation of the gutta-percha cone and will harbor
irritants immediately adjacent to the apical foramen. Obtura-
9. EDTA is most effective for which of the following? tion to the working length requires removal of this debris.
a. decalcifying small canals to allow instruments to nego- REF: Recapitulation
tiate to length
b. lubricating canals to facilitate instrumentation 13. Evaluation of the canal preparation after cleaning and
c. eliminating bacteria in the canals shaping should include:
d. removing the smear layer after cleaning and shaping a. confirming that walls are “glassy smooth”
b. assessing the taper
ANS: d c. configuring the apical preparation
The use of EDTA should be limited to smear layer removal. d. all of the above
It should not be used as a primary irrigant due to its chelating
action and potential excessive erosion of dentin with extended ANS: d
exposure time. Keeping in mind what constitutes a properly prepared canal
REF: Irrigants (EDTA) leads to a realistic evaluation of the procedure and allows
correction of any deficiencies prior to obturation.
10. Which of the following is a major advantage of using a REF:
lubricant with hand instruments?
a. It ensures that canal transportation will not occur. 14. With a temporary restoration, the most important consid-
b. It aids initial canal negotiation in small, curved canals. eration is that it must be:
c. It minimizes debris production. a. at least 4 mm thick
d. It reduces operator fatigue. b. antimicrobial
c. resistant to acids
ANS: b d. placed over a cotton pellet
The use of a lubricant should be considered when difficulty
in negotiating a canal is encountered. ANS: a
REF: Lubricants Placement of a temporary restoration to prevent coronal
leakage between appointments requires adequate thickness.
REF: Temporary Restorations
e48

Harold H. Messer, Charles J. Goodacre
5. Which of the following is crucial to a definitive restoration

CHAPTER 17 after endodontic treatment?
Preparation for Restoration a. It should be placed at the time of obturation.
1. Which of the following results in the greatest loss of end- b. It should allow cuspal flexure to absorb occlusal forces.
odontically treated teeth? c. It should provide a coronal seal.
a. inadequate cleaning and shaping of the canals d. It should always be a full-coverage crown on posterior
b. inadequate obturation teeth.
c. caries and periodontal disease
d. vertical root fracture ANS: c
A critical feature of a restoration is the coronal seal, which
ANS: c prevents leakage, a major cause of failure.
Realizing that factors other than the quality of endodontic REF: Requirements for an Adequate Restoration
treatment can lead to tooth loss is an important concept in
diagnosis. 6. Which statement is most important with regard to expo-
REF: Risks to Survival of Root-Filled Teeth sure of obturating materials to oral fluids?
a. It is not a factor if a sealer is used during
2. Dentin becomes more brittle after endodontic treatment obturation.
due to loss of moisture content. b. It is a major cause of failure.
a. true c. It leads to rapid failure.
b. false d. It many cause pain with thermal changes.
ANS: b ANS: b
It is important to realize that the mechanical properties of Contamination of obturating material by oral fluids is a major
dentin change very little due to endodontic treatment. cause of failure, and every step should be taken to avoid its
REF: Structural Changes in Dentin occurrence.
REF: Coronal Seal
3. How does the survival rate for a tooth restored with cusp
protection compare to that for a tooth without cusp 7. Which statement describes the ideal timing for placement
protection? of the definitive restoration?
a. Survival rates are about the same for the two types of a. It should be placed as soon as practical.
restoration. b. It should be placed at the 6-month recall visit to ensure
b. Survival rates are better for teeth restored with pro- that symptoms do not recur.
tected cusps. c. It should be placed when radiographic evidence of
c. Survival rates are better for teeth restored without pro- healing is present.
tected cusps. d. If should be delayed if there is a questionable
d. Restorations have no effect on tooth survival rates. prognosis.
ANS: b ANS: a
Cuspal coverage is of paramount importance when restoring Delay in placement of a definitive restoration may compro-
endodontically treated posterior teeth. mise the prognosis of the tooth; therefore, placement as soon
REF: Biomechanical Factors as practical is important.
REF: Restoration Timing
4. The most significant contributing factor to reduced cuspal
stiffness (strength) that can predispose to fracture is: 8. What is the only reason to delay the definitive
a. occlusal access opening restoration?
b. loss of one or both marginal ridges a. to maximize the patient’s insurance benefits
c. an amalgam restoration placed after root canal b. if the patient is unable to pay for the restoration
treatment c. to wait for radiographic evidence of healing
d. a bonded composite restoration placed after root canal d. if there is a questionable prognosis and failure would
treatment lead to extraction
ANS: b ANS: d
Understanding the contributing factors helps prevent tooth Only a specific set of circumstances indicates a delay in
fracture if the tooth is properly restored in a timely manner. placing a definitive restoration.
REF: Loss of Tooth Structure REF: Restoration Timing e49
9. The practical principles for function and durability when 12. Which statement is most accurate about the removal of
designing a definitive restoration include all the following gutta-percha for post space?
except: a. It is performed immediately after obturation.
a. conservation of tooth structure b. It is performed only after the sealer has completely set.
b. retention c. It should leave 2 to 3 mm of gutta-percha apically.
c. placement of a post d. It is performed using a solvent solution.
d. protection of the remaining tooth structure
ANS: a
ANS: c Removal of gutta-percha at the time of obturation is optimal
A post is placed only when retention is needed for the core; due to familiarity with the canal anatomy and reference points
it is not a basic principle of restoration. The other principles used to measure length. It is not necessary to wait for the
listed apply to all restorative procedures. sealer to set completely, and there should be at least 5 mm of
REF: Restoration Design (Principles and Concepts) gutta-percha remaining. No solvents should be used for this
procedure.
10. Which of the following is an indication for placing only REF: Preparation of Tooth and Canal Space for Post and Core
a direct restoration (amalgam or composite)? (Removal of Gutta-Percha)
a. Excessive loss of tooth structure is a factor.
b. The opposing arch has been restored with full-coverage 13. When a prefabricated post system is used to restore a
crowns. posterior tooth, the most desirable post design is:
c. Esthetics is not a concern. a. tapered, passively cemented
d. The marginal ridges are intact. b. tapered, threaded, screw type
c. parallel sided, passively cemented
ANS: d d. parallel sided, threaded, screw type
An anterior or posterior tooth with intact marginal ridges and
a conservative endodontic access preparation is minimally ANS: c
compromised structurally, so a simple direct restoration may Familiarity with the post design that will maximize retention
be adequate. but minimize stress on the root dentin is critical.
REF: Planning the Definitive Restoration (Posterior Teeth, REF: Post Type, Retention, and Core Systems (Posterior
Direct Restorations) Teeth)
11. Fewer root fractures have been recorded in laboratory 14. Which statement applies to the placement of a dowel or
studies with what type of post? post through a crown or an existing restoration?
a. carbon fiber post a. It adds support for the existing restoration.
b. stainless steel post b. It helps maintain the integrity of the existing
c. titanium post restoration.
d. cobalt chromium post c. It improves the seal of the root canal.
d. It is rarely indicated.
ANS: a
The greater flexure of a carbon fiber post may be advanta- ANS: d
geous in certain restorative situations. A post adds little to an existing crown, and placement may
REF: Post Selection require additional removal of tooth structure unnecessarily.
REF: Restoring Access Through an Existing Restoration
e50

James C. Kulild, Bekir Karabucak
CHAPTER 18 5. What factors should be considered in determining the

Obturation timing of obturation?
1. What is a possible outcome with overfill of obturation a. current signs and symptoms
materials? b. pulp and periapical status
a. decreased periapical inflammation c. difficulty of the procedure
b. improved and rapid healing of periapical tissues d. all of the above
c. inadequate apical seal
d. decreased postobturation discomfort ANS: d
Several factors enter into the decision on when obturation is
ANS: c indicated. Keeping these factors in mind helps the clinician
Overfill or overextension results in increased periapical determine the optimal timing for obturation.
inflammation and delayed healing and may cause greater post- REF: Timing of Obturation
operative discomfort. The lack of a matrix against which to
compact the obturating material, as is often encountered in 6. What pulp/periapical diagnosis may result in completed
overfills, results in an inadequate seal. treatment in a single visit?
REF: Potential Causes of Failure (Overextension [Overfill]) a. symptomatic apical periodontitis
b. asymptomatic apical periodontitis
2. The optimal preparation/obturation length relative to the c. acute apical abscess
radiographic apex is: d. painful irreversible pulpitis
a. flush with the apex
b. 0.5 to 1 mm short of the apex ANS: d
c. slight extrusion of sealer but not gutta-percha Removal of inflamed pulp tissue addresses the symptoms of
d. 2 to 3 mm short of the apex endodontic pathosis in the case of painful irreversible pulpitis,
so obturation in a single visit would be acceptable.
ANS: b REF: Timing of Obturation (Patient’s Symptoms)
Prognosis studies show that the most favorable prognosis
occurs when obturating materials are contained within the 7. Which of the following is currently the only universally
canal space and within 1 mm of the apical foramen. accepted solid core obturation material?
REF: Obturation Short of the Apical Constriction (Underfill) a. gutta-percha
b. synthetic polyester resin–based polymers
3. Prognosis and outcome studies show that if there is a c. silver cones
length error, fewer problems result with which of the d. solid core (carrier-based) gutta-percha
following:
a. overfill ANS: a
b. underfill Although there are some alternatives, the most widely accepted
c. fill flush with the apex core material is gutta-percha.
REF: Core Obturating Materials
ANS: b
Containing all materials within the tooth structure and avoid- 8. Which of the following is a disadvantage of
ing extrusion into the periapical tissues carries a more favor- gutta-percha?
able prognosis. a. poor adaptation to irregularities of the canal with
REF: Obturation Short of the Apical Constriction (Underfill) compaction
b. shrinkage if altered by heat or solvents
4. Which statement best describes lateral canals? c. not easily managed and manipulated
a. They connect adjacent canals within the same root. d. difficult to partially remove from a canal
b. They may allow bacterial and necrotic debris access to
the periodontium. ANS: b
c. They are débrided with copious irrigation. The clinician should be familiar with the limitations of any
d. They are significant determinants of the prognosis in material so that the advantages can be maximized and the
endodontic outcomes. influence of the disadvantages can be minimized.
REF: Gutta-Percha (Sealability)
ANS: b
Lateral canals have little impact on the prognosis, so extraor-
dinary efforts to force obturating material into these ramifica-
tions is not necessary.
REF: Lateral Canals e51
9. Which of the following is an advantage of gutta-percha? 13. With which type of sealer might long-term solubility be a
a. adhesiveness to dentin problem?
b. slight elasticity and rebound effect a. ZnOE-based sealers
c. expansion on cooling when warmed b. plastic sealers
d. adaptation to canal irregularities with compaction c. glass ionomer sealers
d. calcium hydroxide sealers
ANS: d
The clinician should be knowledgeable about the advantages ANS: d
of gutta-percha as an obturating material. Solubility is an undesirable property in a sealer, so it would
REF: Gutta-Percha (Advantages) be appropriate to choose a less soluble material.
REF:
10. What have recent studies shown regarding synthetic poly-
ester resin–based polymers? 14. Which of the following describes lateral compaction of
a. They are adhesive to canal walls throughout their gutta-percha?
length. a. It is the technique of choice in cases involving internal
b. They are inflammatory to periapical tissues. resorption.
c. They are mutagenic. b. It involves multiple steps and an extensive
d. There is no difference in resistance to leakage com- armamentarium.
pared to gutta-percha. c. It provides good length control.
d. It is difficult to retreat.
ANS: d
Advantages over another material would be the reason for ANS: c
selecting a new or different material. If no advantage is Selection of an obturation technique should be based on the
present, then a change need not be made. advantages relative to the specific case in treatment. Length
REF: Core Obturating Materials (Resin) control is a hallmark of lateral compaction.
REF: Obturation Techniques with Gutta-Percha (Lateral
11. Which of the following is characteristic of semisolid obtu- Compaction)
ration materials (pastes or cements)?
a. They allow for easy control of obturation length. 15. What is an advantage of finger spreaders compared to
b. They exhibit no shrinkage upon setting. standard long-handled spreaders?
c. They are unpredictable and inconsistent in creating an a. better tactile sense
apical seal. b. instrument control
d. They are biocompatible and nonirritating to periapical c. less dentin stress during obturation
tissues. d. all of the above
ANS: c ANS: d
The disadvantages and limitations of semisolid materials Selection of the instrument should be based on ease of use
should be understood and recognized as factors that make and advantages over other instruments. Finger spreaders have
them unsuitable for obturation of a root canal. more advantages compared with long-handled spreaders.
REF: Pastes (Semisolids) REF: Technique of Lateral Compaction: Spreader or plugger
selection
12. What is a disadvantage of zinc oxide–eugenol (ZnOE)–
based sealers?
a. slow setting time
b. lack of adhesion to dentin
c. staining of dentin
d. all of the above
ANS: d
Disadvantages are present with each material, but the disad-
vantages of ZnOE sealers are minor compared with their
advantages.
REF: Sealers (ZnOE-Based Sealers)
e52

Mahmoud Torabinejad, James D. Johnson
CHAPTER 19 ANS: a
Procedural Accidents Options b, c, and d, are indications of a perforation. Pain upon
1. What should a patient be told when a procedural accident entering the pulp chamber may just indicate inadequate anes-
occurs? thesia. Only pain while negotiating a “canal” might indicate
a. the nature of the incident a perforation.
b. possible procedures needed for correction and also REF: Perforations During Access Preparation (Recognition
alternatives and Treatment)
c. the effect of the incident on the prognosis
d. all of the above 5. If a lateral root perforation occurs, what is the most favor-
able location for perforation repair?
ANS: d a. at or above the height of crestal bone
It is important to keep the patient informed of outcomes, good b. below the crestal bone in the coronal third of the root
or bad, and of any alternative procedures that may be neces- c. on the furcal side of the coronal root surface
sary. Hiding information from patients can only lead to d. a zipping perforation at the apex
misunderstandings.
REF: Introduction ANS: a
A perforation with minimal or no communication with the
2. All of the following are potential causes of a perforation alveolar bone can be repaired with little or no damage to the
during access preparation except: bone itself. Perforations below the level of crestal bone often
a. a mandibular molar with a lingual axial inclination of initiate an inflammatory response that can result in loss of
the tooth bone support and periodontal attachment.
b. searching for canal orifices through an underprepared REF: Lateral Root Perforation
access cavity
c. directing the bur parallel to the long axis of the tooth 6. What are the ideal time and material for nonsurgical repair
d. a misaligned cast restoration of a furcation perforation?
a. immediate repair with amalgam
ANS: c b. immediate repair with MTA
Keeping the bur oriented in the long axis of the tooth helps c. delayed repair with amalgam
prevent perforations during access cavity preparations. The d. delayed repair with MTA
other options are all common causes of misdirection of the
access cavity, which increases the chance of a perforation. ANS: b
REF: Perforations During Access Preparation (Causes) Immediate repair prevents irritants from initiating inflamma-
tion and attachment loss adjacent to the perforation. MTA is
3. Which of the following is crucial to preventing perforation a biocompatible material compared to amalgam and would be
during access preparation? the preferred choice.
a. examining tooth angulations independent of the adja- REF: Furcation Perforation
cent teeth
b. using only straight-on radiographs 7. What is a common cause of ledge formation during clean-
c. always placing a rubber dam prior to initiating an ing and shaping?
access preparation a. straight-line access into the canal
d. having a thorough knowledge of both the surface and b. excess irrigating solution
internal tooth anatomies c. overenlargement of a curved canal using files
d. constant recapitulation and irrigation into the apical
ANS: d portion of the canal
A thorough knowledge of the external and internal tooth anat-
omies and how they reflect each other is critical in understand- ANS: c
ing the placement and preparation of an access cavity. Overenlargement using successively larger instruments often
REF: Perforations During Access Preparation (Prevention) transports a canal within the root, creating a ledge that is dif-
ficult or even impossible to bypass with smaller instruments.
4. Which of the following would not be an early sign or The other options are all measures that can help prevent ledge
indication of a perforation? formation.
a. pain during access preparation REF: Accidents During Cleaning and Shaping (Ledge
b. sudden appearance of hemorrhage Formation)
c. burning pain and a bad taste during irrigation with
NaOCl
d. a malpositioned file as viewed on a radiograph e53
8. What type of canal is most prone to ledge formation? 12. Which approach may be used to treat a case involving a
a. long, small, and curved separated instrument?
b. incomplete apex formation, curved a. attempt to remove the fragment
c. large and long b. attempt to bypass the fragment
d. short and straight c. prepare and obdurate to the level of the fragment
d. all of the above
ANS: a
Identification of canals that are more prone to ledge formation ANS: d
helps prevent the occurrence of ledges. All the options are possible treatment alternatives. Selection
REF: Prevention of a Ledge of the method of management should be made with an eye
toward preserving as much tooth structure as possible.
9. What is a possible etiology for an apical root REF: Instrument Separation (Treatment)
perforation?
a. inability to negotiate canals with ledges 13. Which scenario yields the most favorable prognosis in
b. working length determination with radiographs only cases involving a separated instrument?
c. trying to locate canals in a small chamber a. a small instrument short of the working length
d. failure to adjust the working length after curved canals b. a small instrument beyond the apical foramen
have been straightened during cleaning and shaping c. a large instrument at the early stages of cleaning and
shaping
ANS: d d. a large instrument close to the working length
The realization that working length can change during clean-
ing and shaping prevents apical perforations because the clini- ANS: d
cian verifies the working length during the cleaning and The cleaner the canal at the time of instrument separation, the
shaping process. more favorable the prognosis. A larger file close to the working
REF: Apical Perforations length would indicate a point close to completion of cleaning
and shaping.
10. Which type of perforation has the poorest long-term REF: Instrument Separation (Prognosis)
prognosis?
a. apical root perforation 14. Which of the following causes extrusion of sodium hypo-
b. stripping perforation in the apical third of the root chlorite (NaOCl ) irrigating solution into the periapical
c. stripping perforation in the coronal third of the root tissues?
below the crest of bone a. fitting irrigation needles loosely in the canal space
d. direct floor to furcation perforation in a multirooted b. wedging the irrigation needle in the canal space
tooth c. using perforated needles during irrigation
d. using regular needles during irrigation
ANS: c
The poorest prognosis results when the coronal periodontium ANS: b
is affected, causing attachment loss. The other types of per- Extrusion of irrigant is easy to avoid by making sure that the
foration can be managed either by correcting errors through needle never binds in the canal while the solution is expressed.
modification of the cleaning and shaping regimen or by surgi- REF: Extrusion of Irrigant
cal repair.
REF: Coronal Root Perforations (Treatment and Prognosis) 15. Which sequela is most likely to occur after minor extru-
sion of obturating materials into the periapical tissue?
11. Which of the following is not a common cause of file a. significant swelling
separation? b. significant symptoms
a. limited flexibility c. some tissue inflammation
b. manufacturing defects d. more apical leakage.
c. amount of use
d. amount of force applied ANS: c
Most obturating materials are biologically inert or cause a
ANS: b mile inflammatory response, so some minor extrusion should
Manufacturing defects are rare. It is the habits of the practi- result only in minor discomfort for the first few days.
tioner that contribute more to file separation. REF: Overfilling
REF: Instrument Separation (Etiology)
e54

Robert Handysides, George Bogen
ANS: c
CHAPTER 20 Restorability is a critical step in treatment and is best evalu-
Retreatment ated by removing prior restorations and caries.
1. In which case should nonsurgical retreatment be the first REF: Endodontic Retreatment Procedures
treatment option considered for correction?
a. A large, well-fitted post and core is present. 5. Which statement correctly describes the steps in the
b. A separated instrument is present that cannot be retrieval of a prefabricated post during retreatment?
retrieved. a. The clinician uses short bursts of ultrasonic energy
c. External resorptive root defects are present. with water initially to loosen the post.
d. A negotiable canal was not initially treated. b. The clinician sections and removes the core material
and the post to the level of the chamber floor.
ANS: d c. The clinician uses short bursts of ultrasonic energy
Recognition of correctable deficiencies in the original treat- without water initially to loosen the post.
ment lead the practitioner to the proper choice in treatment d. The clinician grasps the post with a hemostat or
planning. Likewise, recognition of situations that have a poor Steiglitz forceps and rocks it back and forth to break
chance of being addressed by nonsurgical retreatment is criti- the cement seal.
cal prior to initiating any treatment.
REF: Treatment Options ANS: c
Ultrasonic energy can be used to help break the cement seal,
2. Which of the following poses the least concern for expe- but heat is generated when ultrasonic energy is applied without
rienced clinicians considering nonsurgical root canal water, so very short bursts without water should be used.
treatment on a tooth? Lateral “rocking” of the post may result in root fracture.
a. a large, well-fitted cast post and core Removing the post to the chamber floor would leave nothing
b. ledges in the root canal to be grasped by forceps.
c. an amalgam core restoration in the chamber REF: Post and Core Removal
d. a separated root canal instrument
6. Which method is least appropriate in attempting removal
ANS: c of a canal ledge during retreatment?
Amalgam in the chamber is not particularly difficult to remove a. removing all obstructions coronal to the ledge
to gain access to the root canal orifices. Cast posts can be quite b. bypassing the ledge using a flexible nickel-titanium
difficult to remove, particularly if they fit well and precisely. hand file
Ledges are often difficult or impossible to bypass and correct, c. filing in a circumferential motion after bypassing the
as are separated instruments. ledge
REF: Contraindications to Nonsurgical Endodontic Retreat- d. proceeding from small to larger files
ment (Indications for Surgical Treatment)
ANS: b
3. Which of the following potential risks is associated more A stiffer instrument is more likely to bypass a ledge than is
with surgical treatment than with nonsurgical retreatment? an extremely flexible file. Once the ledge has been bypassed,
a. thinning and weakening of the root canal walls circumferential filing is used to smooth it out and secure the
b. inability to remove the initial root canal obturating path to the apical portion of the canal.
material REF: Management of Ledges
b. creation of an unfavorable crown-to-root ratio
d. fracture of a porcelain crown during access 7. Which of the following is least likely to affect the suc-
cessful removal of a separated instrument fragment?
ANS: c a. the size of the fragment
Creation of an unfavorable crown-to-root ratio is a potential b. the length of the fragment
complication of surgical treatment. c. the location of the fragment
REF: Risks and Benefits of Retreatment d. the length of time the fragment has been in place
4. Which statement applies to the removal of coronal restora- ANS: d

tions before nonsurgical retreatment? The time that a fragment has been in place is irrelevant in the
a. Removal may prolong retreatment procedures. prognosis for removal.
b. Removal complicates the removal of post and core REF: Instrument Fragment Removal
restorations.
c. Removal may be necessary to assess restorability.
d. Removal should rarely be done if the previous restora-
tion is a full-coverage crown. e55
8. What method has been used to remove gutta-percha from 12. What is the key to success in the retrieval of silver cones?
root canals successfully? a. engaging the silver cone with the ultrasonic tip
a. heat b. removing the silver cone and core material
b. solvents simultaneously
c. rotary instruments c. retaining as much of the coronal portion of the silver
d. all of the above cone as possible
d. removing the core material and silver cone to the level
ANS: d of the canal orifice first
A combination of methods and techniques is often required
to remove gutta-percha successfully. All of the methods listed ANS: c
are helpful in achieving this goal Preserving the coronal portion of the cone allows the practi-
REF: Removal of Gutta-Percha tioner to grasp it with forceps and exert traction force on the
cone.
9. When should Hedstrom or hand reamers be the instru- REF: Removal of Silver Cones (Points)
ments of choice for gutta-percha removal without the
addition of solvents? 13. Which statement is not true about the removal of hard-
a. when the root canal is well sealed with gutta-percha setting pastes during retreatment?
b. when the gutta-percha is well adapted to the canal a. Hard-setting pastes are more difficult to remove than
walls soft pastes.
c. when a space can be created between the gutta-percha b. Hard-setting pastes may be impossible to remove.
and canal wall c. Solvents have been shown to effectively soften hard-
d. when gutta-percha fills the pulp chamber setting pastes.
d. The use of ultrasonics is the most predictable method
ANS: c for removal.
If a space can be created along side the gutta-percha, it is
possible to engage the mass of gutta-percha, especially with ANS: c
a Hedstrom file, and attempt to remove the gutta-percha as a Solvents have been shown to be of little benefit in the removal
complete mass. of the hard-setting pastes, so they should not be used.
REF: Removal of Gutta-Percha REF: Removal of Soft and Hard Pastes
10. Which solvent has been shown to be the most efficient in 14. Which statement is true regarding interappointment flare-
softening gutta-percha? ups with nonsurgical retreatment?
a. chloroform a. Flare-ups occur less frequently compared to initial root
b. halothane canal treatment.
c. methylchloroform b. Flare-ups occur frequently, even when debris and
d. xylene microorganisms are confined to the canals.
c. Flare-ups occur less frequently if irrigation is kept to a
ANS: a minimum.
Efficiency of time during retreatment is a consideration. The d. Flare-ups occur more frequently compared to initial
use of chloroform has been shown to be the fastest method to root canal treatment.
soften gutta-percha, and the risk to the patient is low when
chloroform is used in the small amounts required. ANS: d
REF: Removal of Gutta-Percha An awareness of the incidence of flare-ups can assist the clini-
cian in taking measures to minimize the risk of flare-ups.
11. During removal of a carrier-based gutta-percha obturator, REF: Post-Treatment Complications
which of the following is the best method to remove the
carrier? 15. The prognosis for nonsurgical retreatment is:
a. A Hedstrom file is used to remove the solid core mate- a. more favorable when an apical lesion is present
rial of the obturator. b. less favorable when there is no apical lesion
b. A combination of techniques may be necessary to c. markedly higher than with initial root canal treatment
remove the solid core material of the obturator. d. best when the etiology of failure can be identified and
c. A small rotary file may be necessary to remove the corrected
solid core material of the obturator.
d. Different solvents may be necessary to remove the ANS: d
solid core material of the obturator. The retreatment strategy should be aimed at correcting an
identified etiology for failure.
ANS: b REF: Prognosis
Using a rotary instrument carries a high risk of instrument
separation. The same solvents can be used to remove carrier-
based gutta-percha as gutta-percha alone. It is rare that a carrier
can be removed without removing the gutta-percha first.
e56 REF: Removal of Carrier-Based Gutta-Percha Obturators

Mahmoud Torabinejad, Brad Johnson
4. Which of the following is a contraindication to periapical

CHAPTER 21
surgery?
Endodontic Surgery (1) anatomic structures in the area
1. What is the purpose of incision for drainage? (2) medical conditions or complications
a. to evacuate inflammatory exudates from a soft tissue (3) lip paresthesia
swelling (4) previous malignancies
b. to obtain a biopsy specimen (5) unidentified cause of treatment failure
c. to prevent a postoperative swelling a. 1, 2, and 3
d. to avoid emergency cleaning and shaping of the root b. 1, 3, and 5
canals c. 1, 2, and 5
d. 2, 3, and 4
ANS: a e. all of the above
Removing accumulated exudates allows the swelling to
resolve much faster, increasing the patient’s comfort. ANS: c
REF: Incision for Drainage A previous malignancy is not a contraindication; in fact, a
biopsy might be helpful in ruling out a recurrence. A preexist-
2. Profound anesthesia is difficult to attain before incision ing paresthesia also would not be a contraindication. Damage
for drainage. What is a preferred approach for a maxillary to anatomic structures in the field is a consideration in plan-
canine with extensive swelling? ning any surgical procedure. Some medical conditions can
a. start with an infraorbital block and then infiltrate at the pose difficulty in surgery, but surgical treatment should
margins of the swelling involve a known etiology for which correction is planned.
b. start with a posterior superior alveolar block and then REF: Contraindications
use refrigerant spray
c. inject buffer and anesthetic directly into the swelling 5. Which statement is true about an incision over a bony
d. use topical anesthetic and then refrigerant spray; no defect?
injection is necessary a. It should be avoided.
b. It may cause a postsurgical fenestration.
ANS: a c. It may prevent healing of the incision.
Due to changes in the local tissue pH and already distended d. All of the above
tissue, injection into the swelling often is ineffective and quite
painful, so regional anesthesia is indicated. ANS: d
REF: Incision for Drainage (Procedures, Anesthesia) Flap design should consider not only access, but also postop-
erative healing. An incision placed over a bony defect lacks
3. All of the following are indications for periapical surgery support for the tissue on either side of the incision, and prob-
except: lems may occur with healing of both the soft tissue and the
a. a nonnegotiable or blocked canal associated with bone.
symptomatic periapical pathosis REF: Flap Design
b. gross overextension of obturating material
c. obtaining a specimen for histopathology 6. Which statement is true about a submarginal flap design?
d. resolving any endodontic treatment failure a. It is ideal for mandibular posterior teeth.
b. It causes less scarring.
ANS: d c. It is associated with less gingival recession because it
Not all endodontic treatment failures are amenable to surgical does not involve the marginal gingiva.
treatment. d. It causes less intraoperative hemorrhage.
REF: Periapical Surgery (Indications)
ANS: c
The choice of a submarginal design should be considered in
the maxillary anterior area where gingival esthetics are of
great importance
REF: Flap Design (Submarginal Curved Flap, Submarginal
Triangular and Rectangular Flaps) e57
7. What is the purpose of root-end resection? 11. With root amputation, the factor that most affects success
a. to remove irritants encased in the apical portion of the is:
root a. occlusal force patterns
b. to examine the root anatomy b. the type of restoration
c. to expose additional canals or fractures c. the length of the root
d. all of the above d. the patient’s oral hygiene
ANS: d ANS: d
A root-end resection removes the irritants remaining in the After root amputation, one of the most common causes of
apical portion of the root. Also, the cross-sectional view of failure is the development of caries at the resection site.
the root allows examination of the canal anatomy and inspec- REF: Root Amputation, Hemisection, and Bicuspidization
tion for vertical fractures. (Prognosis)
REF: Root-End Resection
12. All of the following procedures should be referred to a
8. Which statement is true about a root-end cavity specialist with specific training in endodontic surgery
preparation? except:
a. It should be as shallow as possible to preserve tooth a. root-end resection/root-end filling
structure. b. incision for drainage
b. It should be made to a minimum depth of 3 mm. c. root amputation
c. It should encompass only the main portion of the canal. d. perforation repair
d. It should be made with a very small bur.
ANS: b
ANS: b Incision for drainage is a relatively simple procedure and is
The depth is important to create an adequate seal, and all best performed without delay when indicated. The other
visible portions of the canal space should be included in the procedures demand specialized techniques and materials
preparation. and should be performed only by those with specialized
REF: Root-End Cavity Preparation and Filling training.
REF: Conditions Indicating Referral
9. Which of the following is not a criterion for an ideal root-
end filling material?
a. well tolerated by the periradicular tissues
b. easily placed
c. absorbable
d. visible radiographically
ANS: c
An absorbable material would not provide a proper seal.
REF: Root-End Cavity Preparation and Filling
10. All of the following cell types are important in the healing
process except:
a. epithelial cells
b. macrophages
c. dendritic cells
d. fibroblasts
e. osteocytes
ANS: c
The healing process is complex and involves several cell types
to heal both hard and soft tissues. Dendritic cells play a role
in antigen recognition, not in healing.
REF: Healing
e58

Mahmoud Torabinejad, Shane N. White
5. To allow valid comparisons of radiographs to assess

CHAPTER 22 healing, films should be made:
Evaluation of Endodontic Outcomes a. in a reproducible manner
1. What is the primary determinant of successful endodontic b. 6 months apart
treatment? c. at different angles
a. selection of the proper obturation technique d. by the same person to ensure consistency
b. effective elimination of microorganisms from the pulp
space ANS: a
c. use of rotary instruments to shape the canals Attention to radiographic technique results in reproducible
d. use of an effective irrigation regimen images that allow valid comparison over time.
REF: Methods for Evaluation of Endodontic Outcomes
ANS: b (Radiographic Findings)
All efforts during endodontic treatment are oriented toward
eliminating microorganisms from the pulp space. 6. Which of the following is not considered a predictor of
REF: Introduction success or failure?
a. the patient’s medical history
2. What are the major indicators of successful endodontic b. apical pathosis
treatment? c. the quality of the coronal restoration
a. lack of discoloration and absence of tenderness on d. the extent and quality of obturation
biting
b. absence of swelling and redness of the gingiva ANS: a
c. absence of symptoms and of apical radiolucency The quality of treatment and restoration are the main predic-
d. a happy patient who has paid the bill tors of prognosis. The patient’s medical history has little
impact.
ANS: c REF: Prognostic Indicators
Success is best defined as the absence of symptoms and a
return to function. Absence of a periapical radiolucency also 7. Common preoperative causes of endodontic treatment
indicates successful treatment. failure include all of the following except:
REF: Definition of Success and Failure a. misdiagnosis
b. a leaking coronal restoration
3. A patient presents for a post-treatment examination with c. poor case selection
no complaint of symptoms; however, the apical radiolu- d. an error in treatment planning
cency present prior to treatment is still present, although
it appears smaller. The treatment outcome for this patient ANS: b
would be classified as which of the following? A leaking restoration would be a postoperative cause. Errors
a. failure in diagnosis and treatment planning often lead to inappropri-
b. success ate treatment
c. clinical success but radiographic failure REF: Causes of Nonhealed, Failed Root Canal Treatment
d. a functional tooth with an uncertain prognosis (Preoperative Causes)
ANS: d 8. The most common postoperative cause of endodontic

If the radiolucency is smaller but still present at the recall treatment failure is:
exam, it may be in the process of resolving. In the absence of a. overextension of obturating material
any symptoms, no further treatment is indicated, but further b. a separated instrument
recall evaluations are indicated to monitor progress. c. coronal leakage
REF: Definition of Success and Failure d. placement of a post unnecessarily
4. Which of the following is not a clinical criterion for evalu- ANS: c

ating treatment outcomes? The importance of a coronal seal, formed by a definitive res-
a. absence of a radiolucency toration, has been often ignored. Timely placement of a defini-
b. no evidence of a sinus tract tive restoration prevents leakage and contamination of the
c. no swelling present obturating material.
d. no response to percussion or palpation REF: Causes of Nonhealed, Failed Root Canal Treatment
(Postoperative Causes)
ANS: a
Radiographs are not part of the clinical exam.
REF: Methods for Evaluation of Endodontic Outcomes e59
9. The prognosis for nonsurgical retreatment depends pri- 10. Which statement is true about endodontic surgery?
marily on which of the following? a. Surgery has a less favorable long-term prognosis com-
a. identifying and correcting the cause of failure pared to nonsurgical retreatment.
b. using a different obturation technique b. Surgery should be considered the primary treatment
c. placing the definitive restoration at the obturation option in cases of endodontic failure.
appointment c. Surgery can be performed both by general dentists and
d. all of the above by endodontists.
d. All of the above
ANS: a
Without identifying the etiology of failure, correction of that ANS: a
etiology may or may not be addressed by retreatment. Treat- Although the initial success rate for endodontic surgery is
ment of a failed endodontic procedure should be aimed at higher than for retreatment, in the long-term, retreatment has
correcting that etiology. a higher success rate; therefore, retreatment should be consid-
REF: Outcomes of Treatments After Failure of Initial Nonsur- ered the primary treatment option if it is feasible for the
gical Endodontics (Nonsurgical Retreatment) specific case. Retreatment and surgery require specialized
training and should be performed only by an endodontist.
REF: Outcomes of Treatments After Failure of Initial Nonsur-
gical Endodontics (Endodontic Surgery)
e60

Mohammed A. Sabeti, Mahmoud Torabinejad
4. What may result from the loss of a tooth?

CHAPTER 23 a. delayed loss or fracture of alveolar bone
Single Implant b. delayed loss of interproximal bone
1. Which of the following was included in Brånemark’s c. loss of papilla
original protocol for dental implant placement in the ante- d. recession of the marginal gingiva
rior parts of an edentulous jaw?
a. a mucobuccal flap ANS: d
b. a single-stage surgical approach The loss of a tooth results in an immediate loss or fracture of
c. 6 to 12 months of healing alveolar bone, interproximal bone, and the papilla and may
d. loading and occlusion during the healing period result in recession of the marginal gingiva, the formation
of interproximal “black triangles” (Fig. 1.10), or a bulky
ANS: a restoration.
Brånemark’s original protocol for dental implant placement REF: Tooth Extraction and Site Preparation
in the anterior parts of edentulous jaws included a mucobuccal
flap; a two-stage surgical approach, followed by 3 to 6 months 5. What is the average loss of bone width that may occur
of stress-free healing to allow for osseointegration; and resto- after loss of a tooth?
ration with complete implant-supported prostheses. a. no noticeable loss
REF: History of Single Tooth Implants b. 1 mm
c. 2 mm
2. Which of the following is not a critical part of the diag- d. 3 mm
nosis of a patient prior to treatment planning for an
implant? ANS: c
a. obtaining the patient’s chief complaint An average loss of 2 mm of bone width may occur after loss
b. a thorough radiographic examination of a tooth.
c. reviewing insurance coverage and arranging a payment REF: Tooth Extraction and Site Preparation
plan
d. reviewing the patient’s dental and health histories 6. What instrument should be used for a minimally traumatic
extraction?
ANS: c a. Cryer elevator
A complete and accurate diagnosis must be performed sys- b. Seldin elevator
tematically. This evaluation should include obtaining the c. periotome
patient’s chief complaint, comprehensive pretreatment evalu- d. forceps only
ation of the patient, a thorough radiographic examination,
necessary tests, and a thorough review of the patient’s dental ANS: c
and health histories to identify any conditions that may inter- The tooth should be removed with a periotome instead of the
fere with implant therapy. The review should include cardio- conventional elevator that is associated with hard and soft
vascular health; history of diabetes, osteopenia, or osteoporosis; tissue trauma. A periotome is typically used for extraction of
anticoagulation therapy; and history of smoking. a tooth in the esthetic area to prevent excess trauma to the
REF: Diagnosis and Treatment Planning for Single Tooth interproximal papilla and marginal gingiva. A periotome has
Implants a thin, flat blade that conveniently facilitates tooth removal by
severing the gingival attachment and luxating the tooth in the
3. What may often complicate the treatment planning for an gingival sulcus. A periotome should be inserted into the peri-
implant? odontal ligament space along the root surfaces with the con-
a. limited finances tinued exertion of apical pressure. This pressure should be
b. previous dental experiences continued with or without using a surgical mallet until the
c. the patient’s ability to maintain oral hygiene periotome penetrates to a sufficient depth in the gingival
d. the patient’s expectations sulcus to initiate tooth mobility (Fig. 1.11). A periotome is
frequently used in the interproximal and palatal aspect of a
ANS: d tooth to prevent damage to the buccal plate to maintain the
The patient’s expectations and desires can often complicate the integrity of the buccal wall and gingival margin.
treatment planning. An ideal treatment plan tackles the patient’s REF: Minimally Traumatic Extraction
chief complaint, effectively meets the patient’s expectations,
addresses the biologic environment and scientific evidence,
and restores or maintains the function and esthetic.
REF: Diagnosis and Treatment Planning for Single Tooth
Implants e61
7. What teeth in the dental arch may be replaced by a single profile of the two adjacent teeth (Fig. 1.14); and (3) the
implant? implant platform is placed in the bone so that it is 1.5 mm
a. any tooth from the adjacent teeth (Fig. 1.15).
b. only functional teeth REF: Surgical Technique
c. only nonfunctional teeth
d. only teeth in esthetic regions 11. What should be placed in the empty space between the
implant and the buccal bone to minimize secondary
ANS: a resorption of the buccal bone?
Single implants can replace any tooth in the dental arch. a. coagulated blood
REF: Single Tooth Implant b. granulomatous tissue
c. autogenous bone
8. Which site is not considered to be in the esthetic zone? d. bone wax
a. maxillary central incisor
b. mandibular central incisor ANS: c
c. maxillary canine After the implant has been properly placed, the empty space
d. maxillary first premolar between the implant and the buccal bone should be filled with
autogenous bone20 or other bone-filling materials to support
ANS: b the buccal osseous plate; this minimizes secondary resorption
For purposes of single implant placement, the various areas of the buccal bone.
of the oral cavity are broadly classified as comprising the REF: Surgical Technique
esthetic zone (i.e., the central, lateral, canine, and first premo-
lar areas in the maxilla) and the nonesthetic zone (i.e., 12. What torque value is necessary before the implant can be
the posterior maxilla, posterior mandible, and anterior placed and a provisional prosthesis manufactured to
mandible). support and preserve the soft tissue position?
REF: Single Tooth Implant a. at least 5 N
b. at least 15 N
9. What important questions must the dental surgeon con- c. at least 25 N
sider before performing implant surgery? d. The provisional prosthesis can be used regardless of
a. Will the implant surgery be immediate? the torque value.
b. If the tooth has already been extracted, how long has
it been since the extraction? ANS: b
c. Are any bony defects present in the area? At this stage, if the insertion torque value is at least 35 N, the
d. All of the above implant can be placed and a provisional prosthesis can be
manufactured to support and preserve the soft tissue position
ANS: d in the area. Otherwise, the implant should be submerged, the
Before performing implant surgery, the dental surgeon must second surgical procedure should be performed, and the pros-
consider three important questions: thesis should be manufactured at the proper time (Fig. 1.16).
(1) Will the implant surgery be immediate? REF: Surgical Technique
(2) If the tooth has already been extracted, how long has
it been since the extraction? 13. What qualitative type of bone is most appropriate for
(3) Are any bony defects present in the area? If so, is the implant placement?
defect vertical, horizontal, or both? a. type A
REF: Single Implants in the Esthetic Zone b. type B
c. type I
10. What characteristic is necessary for a proper implant site d. type II
in the esthetic zone?
a. The implant platform is 1 to 2 mm apical to the cemen- ANS: d
toenamel junction (CEJ) of the two adjacent teeth. In 1985, Zarb and Lekholm created classification systems for
b. The implant platform is 1 to 2 mm palatal to the profile the quality and quantity of jaw bones. They classified bone
of the two adjacent teeth. quality as type I to type IV and bone quantity as type A to
c. The implant platform is 1 to 2 mm lingual to the profile type E (Fig. 1.18). From a qualitative viewpoint, type II
of the two adjacent teeth. and type III bone are the most appropriate for implant
d. The implant platform is placed in the bone so that it is placement. Type I and type IV bone might pose problems in
2.5 mm from the adjacent teeth. osseointegration and regenerative processes. From a quantita-
tive viewpoint, type A and type B bone are ideal; however,
ANS: b more problems are encountered with an increase in bone
During the drilling procedure, care should be exercised to resorption.
ensure that the implant is appropriately placed in its three- REF: Osseous Considerations
dimensional path. A proper implant site in the esthetic zone
has the following characteristics: (1) the implant platform is
3 to 4 mm apical to the CEJ of the two adjacent teeth (Fig.
e62 1.13); (2) the implant platform is 1 to 2 mm palatal to the
14. What is the recommended implant length, which results flap reflection. This improved density also facilitates suture
in an improved prognosis? placement and reduces the incidence of tearing upon comple-
a. 5 mm tion of the procedure (Figs. 1.20 and 1.24).
b. 10 mm The initial incision should extend through the full thickness
c. 13 mm of the gingiva and periosteum to the underlying bony crest.
d. 15 mm This allows for a clean initial reflection of the mucoperiosteal
flap in the surgical site. Failure to incise both layers carefully
ANS: b results in more difficulty with the initial reflection and leads
Generally, the prognosis for the implant improves as the to a higher incidence of tearing and trauma of the flap margin.
implant’s length increases. However, implant lengths exceed- This damage ultimately complicates the final wound closure
ing 13 to 14 mm currently are not recommended. Implants because the blood supply to this critical area may be compro-
less than 8 mm in length belong to the short implant category; mised, resulting in poor tissue stability postoperatively. If
the prognosis for these implants is less favorable than that for papillary reflection is required, the papilla should be split
long implants. Therefore, if bone height is 8 to 14 mm and no evenly to maintain as much thickness as possible in the reflec-
impingement is made on anatomic structures, the condition is tion. By maintaining the integrity of the papilla in the reflec-
ideal for implant placement. It should be noted that a distance tion, compromise is reduced and postoperative vitality is
of at least 2 mm should exist between the apex of the implant enhanced (Figs. 1.21 and 1.24).
and the roof of the mandibular canal. However, contact of the REF: Flap Design
apex of the implant with the floor of the maxillary sinus or its
perforation does not cause problems if the mucous membrane 17. What instruments are recommended for implant débride-
of the sinus is not ruptured. ment as part of a maintenance program?
REF: Osseous Considerations a. metal scalers
b. plastic scalers
15. Which of the following is a disadvantage of use of a tita- c. vitreous carbon–tipped scalers
nium rigid mesh for space maintenance? d. Scaling of implants is not recommended, regardless of
a. biocompatibility the instrument.
b. ease of contouring
c. rigidity under reasonable loading ANS: c
d. requirement for surgical reentry for removal Standard metal scalers and curettes are not recommended for
implant débridement because of the risk of scratching the
ANS: d titanium surface. Although plastic scalers are available, their
Traditionally, the primary rigid mesh material used for space effectiveness in removing hard deposits is limited; gold, tita-
maintenance in GBR has been made from titanium. The nium, or vitreous carbon–tipped instruments are generally
advantages of this material are proven biocompatibility, ease more effective. Ultrasonic and piezoelectric scalers with
of contouring and stabilization at the surgical site, and main- plastic or carbon tips have also proven effective and do not
tenance of rigidity under reasonable load (Fig. 1.22). Although damage the implants’ surfaces (Fig. 1.26).32-34 Air polishing
titanium mesh provides acceptable graft containment and sta- devices and rotary rubber cups can be used to remove plaque
bilization, surgical reentry is always required to remove it. and to smooth implant collars.35 Biofilm disruption in the
Oftentimes removal of the mesh can be a lengthy procedure peri-implant sulcus can be accomplished with air polishing
because soft tissue can invade the latticework of the mesh, devices using either sodium bicarbonate or amino acid glycine
creating difficulty. salt powders.36 In addition to mechanical débridement with
REF: Guided Bone Regeneration for Implant Site scalers and polishing devices, adjunctive local antimicrobial
Development therapy can be administered, although limited and often
equivocal evidence of enhanced clinical outcomes has been
16. How should the incision be placed when designing a flap published.37-42 The peri-implant sulcus can be irrigated with
for surgical implant placement? antiseptic 10% povidone-iodine (Fig. 1.27).
a. slightly lingual to the bony crest REF: Dental Implant Maintenance Program
b. in unattached gingiva
c. in tissue allowing a partial-thickness flap
d. to maintain the integrity of the papilla
ANS: d
When surgical implant placement requires access through the
oral soft tissues to the underlying alveolar bone, proper access
design is important not only at the time of surgery, but also
to minimize postoperative complications related to dehis-
cence or flap retraction. Typically, midcrestal or slightly
palatal placement of the incision is appropriate for osteotomy
preparation. Before this incision is made, however, the quality
and quantity of the attached gingiva should be determined.
When the incision is made in attached gingiva, the improved
tissue density helps minimize marginal trauma during initial e63

Ilan Rotstein, Richard E. Walton
4. What is not a common iatrogenic etiology of tooth

CHAPTER 24 discoloration?
Bleaching Discolored Teeth a. incomplete removal of pulp tissue
1. Which of the following is considered an iatrogenic source b. incomplete removal of obturating materials from the
of discoloration? pulp chamber
a. tetracycline stain c. use of intracanal medicaments
b. intrapulpal hemorrhage d. use of intracanal irrigants during endodontic
c. stain from amalgam treatment
d. calcific metamorphosis
ANS: d
ANS: c Realizing that this source of discoloration is entirely prevent-
An understanding of the source of discoloration helps the able simply by ensuring that all tissue and materials are
clinician explain the origin to the patient, in addition to the cleaned from the pulp chamber helps the practitioner provide
prognosis for long-term success. It also serves to educate the optimal treatment without the complication of discoloration.
practitioner about procedures that may cause discoloration REF: Causes of Discoloration
and measures to prevent this outcome.
REF: Causes of Discoloration 5. Which of the following restorative materials can contrib-
ute to staining?
2. The mechanism of staining caused by fluorosis includes a. amalgam
all of the following except: b. pins and posts
a. hypoplastic defects in the enamel produced by excess c. composite
fluoride d. all of the above
b. stain acquired from chemicals in the oral cavity
c. stain present in the enamel ANS: d
d. stain solely caused by fluoride deposits in the enamel It is important to realize that all materials have the potential
to cause a change in color. It is particularly important to know
ANS: d that composite is not always and is not permanently esthetic,
Understanding that the stain from fluorosis is largely extrinsic and care must be taken to prevent discoloration with this
and can be treated by means of external bleaching is important material.
so that unnecessary endodontic treatment is not rendered for REF: Causes of Discoloration
the purpose of internal bleaching of an extrinsic stain.
REF: Causes of Discoloration 6. Which of the agents recommended for internal bleaching
is preferred?
3. Tetracycline stain is: a. carbamide peroxide
a. classified into three groups based on severity b. sodium perborate
b. often associated with a horizontal banding pattern c. hydrogen peroxide
c. located in the dentin d. sodium peroxyborate monohydrate
d. all of the above
ANS: b
ANS: d The use of sodium perborate has proven effective in internal
Understanding the mechanism of tetracycline staining and its bleaching, and it enjoys a greater safety margin compared to
location is important in planning any bleaching procedure. concentrated hydrogen peroxide preparations. Safety and
External bleaching has limited success; for a definitive effectiveness are important considerations in this procedure.
outcome with long-term results, endodontic treatment fol- REF: Bleaching Materials
lowed by internal bleaching yields superior and more predict-
able esthetic results.
REF: Causes of Discoloration
e64
7. Which of the following is not an indication for internal 9. What is the most common agent used in external
bleaching? bleaching?
a. defective enamel formation a. sodium perborate
b. intrapulpal hemorrhage–induced stain b. hydrochloric acid
c. pulp necrosis c. carbamide peroxide
d. sealer stain d. sodium hypochlorite
ANS: a ANS: c
Differentiation between external and internal location of the Use of the appropriate agent with a proven record of efficacy
discoloration results in the appropriate treatment plan and is important. Although hydrochloric acid is used in the micro-
avoids unnecessary endodontic treatment in cases involving abrasion technique, it carries a certain risk of injury if used
extrinsic staining. improperly. Hypochlorite does not release adequate oxygen
REF: Internal (Nonvital) Bleaching Techniques to effect a significant color change and can also cause soft
tissue injury.
8. A potential complication of internal bleaching is external REF: Bleaching Materials
root resorption, which has been associated with which of
the following? 10. Which statement describes the microabrasion technique?
a. a high concentration of hydrogen peroxide a. It is not a true bleaching technique.
b. heat b. It uses hydrochloric acid.
c. damage to the cementum and periodontal tissues c. It requires meticulous soft tissue isolation.
d. all of the above d. All of the above
ANS: d ANS: d
Minimizing factors that can lead to external resorption helps An understanding of the procedure is an important determi-
prevent its occurrence. nant in whether it should be recommended to a patient. Two
REF: Complications and Safety critical considerations are that it is limited to the enamel
surface and it requires meticulous preparation.
REF: Extrinsic Discolorations
e65

Richard E. Walton
ANS: b
CHAPTER 25 Generally, pulp spaces progressively decrease in size and
Geriatric Endodontics often become very small,17 a phenomenon known as calcific
1. Which of the following are changes that occur in the pulp metamorphosis.18 Dentin formation may be accelerated by
with age? irritation from caries, restorations, and periodontal disease
(1) decreased vascular elements and is not uniform. For example, in molar pulp chambers,
(2) decreased amount of collagen there is more dentin formation on the roof and floor than on
(3) increased number of fibroblasts the walls.10 The result is a flattened (disklike) chamber
(4) decreased number of odontoblasts (Fig. 25.4).
(5) increase in occurrence of calcifications REF: Pulp Response (Dimensional)
a. 1, 2, and 3
b. 1, 3, and 5 4. The healing capacity of older patients is significantly less
c. 1, 4, and 5 than that of younger patients because of a decrease in
d. 2, 3, and 5 periapical vascularity. The vascularity of the periapical
e. all of the above tissues is a critical determinant in healing.
a. The first statement is false; the second statement is true.
ANS: c b. The first statement is true; the second statement is false.
The pulp is a dynamic connective tissue. With age there are c. Both statements are true.
changes in cellular, extracellular, and supportive elements (see d. Both statements are false.
Chapter 1). There is a decrease in cells, including both odon-
toblasts and fibroblasts. There are also fewer supportive ele- ANS: a
ments (i.e., blood vessels and nerves).10,11 Fewer and smaller A popular concept is that healing in older individuals is
vessels result in a decrease in blood flow in the pulp12; the impaired, compromised, or delayed. This is not necessarily
significance of this decrease is unknown. Capillaries show true. Studies in animals have shown remarkably similar pat-
somewhat degenerative changes in the endothelium with terns of repair of oral tissues in young and old, but with a
age.13 There is presumably an increase in the percentage of slight delay in the healing response in older subjects.24 Radio-
space occupied by collagen but less ground substance.14 graphic evidence of healing of younger and older patients
REF: Pulp Response (Structural) after root canal treatment demonstrated no apparent difference
in success and failure.25 No evidence exists that vascular or
2. Which statement is not true regarding calcifications in the connective tissue changes in older individuals result in sig-
pulp space? nificantly slower or impaired healing. Overall, there is little
a. Pulp stones are usually found in the coronal pulp. difference in the nature of healing between the age groups,
b. Pulp stones can increase the incidence of odontogenic including healing of both bone and soft tissue. Vascularity is
pain. critical to healing, and in healthy individuals, periapical blood
c. Calcifications increase with both age and irritation. flow is not impaired with age.26
d. Diffuse calcifications are most commonly found in the REF: Healing
radicular pulp.
5. Which medical condition may directly affect (decrease)
ANS: b pulp resistance to injury?
Calcifications include denticles (pulp stones) and those that a. osteoporosis
are diffuse (linear). These increase both in the aged pulp15 and b. hypertension
in the irritated pulp.16 Pulp stones tend to be found in the c. immunosuppression
coronal pulp, and diffuse calcifications are found in the radic- d. none of the above
ular pulp. It has been speculated that the nidi of calcification
arise from degenerated nerves or blood vessels, but this has ANS: d
not been proved. Another common speculation is that pulp There is no conclusive evidence that systemic or medical
stones may cause odontogenic pain; however, this is not true. conditions directly affect (decrease) pulp resistance to injury.
REF: Pulp Response (Calcifications) One proposed condition is atherosclerosis, which has been
presumed to directly affect pulp vessels21; however, the
3. Which of the following occurs in the pulp chamber in phenomenon of pulpal atherosclerosis could not be
molars with age? demonstrated.22
a. decreases primarily in a mesiodistal dimension REF: Pulp Response (Systemic Conditions)
b. decreases primarily in an occlusal-apical dimension
c. remains the same in volume
e66 d. increases in size in response to irritation
6. How does pulp testing differ between older and younger ANS: d
patients? Subjective findings include information obtained by question-
a. Pulp becomes more responsive to stimuli with aging. ing the patient’s description of current signs and symptoms.
b. Teeth are more responsive with gingival recession. Many older patients are stoic, do not readily express adverse
c. Testing should be done slowly and carefully in older symptoms, and may consider them to be minor relative to
patients. other systemic problems or pains. A careful, concerned dis-
d. Only one type of testing stimuli should be used to avoid cussion about these seemingly minor problems also helps
confusing the elderly patient. establish rapport and confidence.
Overall, symptoms of pulpitis are not as acute in the older
ANS: c patient. One reason may be that there is a reduced pulp volume
Although pulp testing is similar in older and younger patients, and a decrease in sensory nerves,38 particularly in dentin.
there are some differences. The pulp becomes less responsive The absence of significant signs and symptoms is also very
to stimuli with age, particularly with calcific metamorphosis common, more so than the presence. Of course, the absence
(Fig. 25.5).18 Thus testing in older patients should be done of these does not indicate the lack of significant disease; most
slowly and carefully, with the use of different stimuli. It is irreversible pulpal and apical pathoses are asymptomatic at
common for a tooth with a vital pulp to be nonresponsive to any age. Therefore, when pathosis is suspected, objective tests
one form of testing (e.g., cold) but to respond to another are required, regardless of whether significant signs and
stimulus (e.g., electrical stimulus). Also, teeth are less respon- symptoms are present.
sive with gingival recession and attachment loss.39 These REF: Subjective Findings
results must be correlated with other tests and findings and
with radiographic findings. 9. What is a common radiographic factor in older patients?
There is a question of whether electrical pulp tests should a. Bony growths (tori and muscle attachment) make film
be used in patients with pacemakers.40 Although it is unlikely positioning easier.
that these tests could cause a pacemaker to malfunction, other b. Older patients can place and hold the film/sensor more
tests can be used safely to obtain information on pulp status. easily.
It is recommended that electrical tests not be used when the c. The incidence of nonendodontic pathosis of the jaws
patient has a pacemaker. tends to increase with age.
A test cavity is often indicated but may not be as useful in d. Pulps tend to be larger and easier to locate in older
the older patient because of reduced dentin innervation. A patients.
false-negative response (no response/vital pulp) is not unusual,
even with a test cavity. ANS: c
REF: Diagnosis (Objective Tests) Current, good quality periapical films are always necessary,
and the same principles apply as in the younger patient. The
7. Which of the following is a common finding on examina- techniques for making radiographs are similar but have some
tion of geriatric patients? differences. Bony growths, such as tori and muscle attach-
a. extensive restorative experience with multiple large ments (frena), may affect film positioning. Also, the older
restorations and crowns patient may have difficulty placing the film; therefore, holders
b. a lower incidence of periodontal disease should be used. Generally, a parallel film is preferred for
c. exaggerated symptoms associated with pulp pathosis diagnosis, with occasional supplementation of mesially or
d. excessive salivation distally angled cone positioning or a Panelipse or occlusal
view. Often bitewing projections are helpful in showing
ANS: a chamber size and location and relative depths of caries and
There are two considerations: (1) structural (histologic) restorations.
changes that take place as a function of time and (2) tissue Apically, there may be some differences in the older patient.
changes that occur in response to irritation from injury. These The incidence of nonendodontic pathosis of the jaws tends to
tend to have similar appearances in the pulp. In other words, increase with age; careful determination of pulp status is even
injury may prematurely “age” a pulp. Therefore an “old” pulp more important in these situations when the nature of the
may be found in a tooth of a younger person (i.e., a tooth that pathosis is uncertain. If the pulp is vital, a lesion in the apical
has experienced caries, restorations, and so on). Whatever the region is not endodontic.
etiology, these older (or injured) pulps react somewhat differ- Radiographs are studied for pulp size and for root and pulp
ently than do younger (or noninjured) pulps. anatomy. Pulps tend to be smaller and may disappear radio-
REF: Changes with Age graphically (Fig. 25.6). It is important to note that nonvisual-
ization of a pulp space does not mean that a pulp is not
8. Which of the following is a difference between geriatric present. In fact, it has been demonstrated that there is always
and younger patients that may affect the ability to reach a a pulp space,41 even when it is not visible radiographically.
diagnosis? Apical root and canal anatomy tends to be somewhat different
a. Older patients are more stoic. in elderly patients because of continued cementum forma-
b. A decreased response to pulp testing is common. tion.42,43 This may be further complicated by apical root
c. Symptoms of pulpitis are not as acute in older patients. resorption from pathosis.44
d. All of the above REF: Diagnosis (Radiographic Findings)
e67
10. A common modification in performing root canal treat- 12. Which statement is true about factors that may reduce the
ment for older patients is which of the following? rate of success and healing of periapical tissues in older
a. treatment planning for a shorter life span patients?
b. beginning an access cavity without a rubber dam to a. An extensively restored tooth is less likely to have
locate a smaller chamber coronal leakage.
c. a greater need for anesthetic b. Canals may not be negotiated to length and may contain
d. larger restorations to make isolation easier persistent irritants.
c. Tipped or rotated teeth are easier to access.
ANS: b d. Teeth restored with castings are easier to clean, shape,
After differential diagnosis, a definitive treatment plan is and obturate.
determined; this is usually root canal treatment, but additional
procedures may be included. Everything should be considered ANS: b
(restorability, periodontal status, and the overall treatment Although periapical tissues heal as readily in elderly patients
plan). This is also the time to consider referral of the patient as in young ones,45,46 many factors reduce the rate of success.
to an endodontist if the situation is deemed too complex. The same factors that complicate treatment may compromise
The need for anesthesia is somewhat less in the older ultimate success. An extensively restored tooth is more prone
patient. It is necessary for vital pulps but is often unnecessary to coronal leakage. Canals that cannot be negotiated to length
for pulp necrosis, obturation appointments, and retreatments. may contain persistent irritants. Tipped or rotated teeth
Older patients tend to be less sensitive and are more likely to restored with misaligned castings are more difficult to access
prefer procedures without anesthetic. and therefore more difficult to clean, shape, and obturate.
A very small or nonvisible chamber may be an indication REF: Treatment Planning and Case Selection (Prognosis)
for beginning the access without the rubber dam; this aids in
staying in the long axis of the tooth (Fig. 25.12). Once the 13. Which of the following is common in older patients after
canal has been located, the rubber dam is immediately placed, endodontic surgery?
before working length radiographs are made. a. Hard and soft tissues heal more rapidly.
In treatment planning for elderly patients, the tendency is b. Older patients follow postsurgical instructions more
to plan according to anticipated longevity.52 It is natural to easily.
assume that procedures need not be as permanent because the c. Older patients experience more significant adverse
patient may not live for very long. The concept that treatment effects after surgery.
should not outlast the patient is not accepted by most elderly d. Older patients experience more ecchymosis after
patients, who desire health care equivalent to that rendered to surgery.
younger patients. Esthetic and functional concerns may be no
different. ANS: d
REF: Root Canal Treatment (Anesthesia; Access Hard and soft tissues heal as predictably in older patients as
Preparation) in younger ones, although somewhat more slowly.62-64 Post-
surgical instructions should be given both verbally and in
11. Working length determination in elderly patients may be writing to minimize complications. If the patient has cognitive
more difficult because of which of the following? problems, instructions are repeated to the person accompany-
a. increased bone density, making radiographs harder to ing the patient. Even very elderly patients have good healing
interpret provided they follow post-treatment protocols. Ice and pres-
b. increased apical foramen variability, modifying the sure (in particular) applied over the surgical area reduces
apical anatomy bleeding and edema and minimizes swelling. Overall, older
c. differences in tissue electrical resistance, making apex patients experience no more significant adverse effects from
locators less accurate surgery than do younger patients. Outcomes depend more on
d. inability of the patient to sit still for radiographs oral hygiene than on age, as has been shown in periodontal
surgery patients.65
ANS: b One problem that seems to be more prevalent in older
There are some differences in working length in the older patients is ecchymosis after surgery. This is hemorrhage that
patient.53 Because the apical foramen varies more widely (Fig. often spreads widely through underlying tissue and com-
25.13) than in the younger tooth and because of the decreased monly presents as discoloration (Fig. 25-15). Patients should
diameter of the canal apically, it is more difficult to determine be informed that this may occur but is not a concern. Normal
the preferred length.43 In teeth of any age, materials and color may take 1 to 2 weeks or longer to return. In addition,
instruments are best confined to the canal space. One to 2 mm the discoloration may go through different color phases
short of the radiographic apex is the preferred working and (purple, red, yellow, green) before disappearing.
obturation length54; this should be decreased if an apical stop REF: Endodontic Surgery (Healing After Surgery)
is not detected. Electronic apex locators are also useful, par-
ticularly when there is difficulty obtaining adequate working
length radiographs.55
REF: Root Canal Treatment (Working Length)
e68

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APPENDIX B

Chapter review questions

CHAPTER 1 5. From where does the signal initiating enamel formation

19. What would be a typical level for interstitial pressure in a

Chapter review questions

CHAPTER 2 4. Why are deeper carious lesions more injurious to the

Chapter review questions

CHAPTER 3 5. Root canals can become infected through anachoresis.

4. What is anachoresis? ANS: a

Chapter review questions

15. What is the most important aid in distinguishing between ANS: d

Chapter review questions

CHAPTER 5 oral bisphosphonates compared with those seen in other

tooth is suspected, a mandibular block will confirm at least ANS: c

Chapter review questions

CHAPTER 6 5. The standard of care in endodontics is set by:

9. Persistent pathosis after initial root canal treatment should

Chapter review questions

CHAPTER 7 4. A narrow vertical probing defect associated with a tooth

Chapter review questions

ANS: d 5. Do pulp and periapical tests for cracked teeth provide

Chapter review questions

3. How does warming the anesthetic solution affect the

ANS: c 9. Which of the following has been shown to be effective at

Chapter review questions

4. Which of the following is particularly important to achiev- ANS: a

Chapter review questions

(partial) pulpotomy. Vital pulp therapy followed by an acid-

surrounding alveolar bone, the tooth may be quite firm. A

Chapter review questions

4. Radiographs are useful for evaluating for success or

Chapter review questions

5. What is the diameter at point D0 and at point D16 for a

4. Which design variable is used to provide greater flexibility ANS: d

10. How are broaches intended to be used in the canal? ANS: d

Chapter review questions

5. Alterations in the anatomy of the pulp space occur because

Chapter review questions

3. What is the recommended rubber dam weight for end-

ANS: b 15. Which of the following is not a major canal

be left in place during working length determination to ensure ANS: b

Chapter review questions

4. To prevent extrusion of obturating material, cleaning and

Chapter review questions

5. Which of the following is crucial to a definitive restoration

Chapter review questions

CHAPTER 18 5. What factors should be considered in determining the

Chapter review questions

Chapter review questions

4. Which statement applies to the removal of coronal restora- ANS: d

Chapter review questions

4. Which of the following is a contraindication to periapical

Chapter review questions

5. To allow valid comparisons of radiographs to assess

ANS: d 8. The most common postoperative cause of endodontic

4. Which of the following is not a clinical criterion for evalu- ANS: c

Chapter review questions

4. What may result from the loss of a tooth?

Chapter review questions

4. What is not a common iatrogenic etiology of tooth

Chapter review questions

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