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
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.
REF: Early Development of Pulp
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
The differentiation of odontoblasts from undifferentiated
ectomesenchymal cells is initiated and controlled by the ecto-
dermal cells of the inner dental epithelium of the enamel
organ.
REF: Early Development of Pulp
ANS: c
Epithelial cell rests of Malassez are cell remnants of the epi-
thelial root sheath that persist in the periodontium in close
proximity to the root after root development has been com-
pleted. They are normally functionless, but in the presence of
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
After the first dentin in the root has formed, the basement
membrane beneath Hertwig’s sheath breaks up, and the inner-
most root sheath cells secrete a hyaline material over the
newly formed dentin. After mineralization has occurred, this
becomes the hyaline layer of Hopewell-Smith, which helps
bind the soon to be formed cementum to dentin
REF: Root Formation
10. What morphologic changes occur over time due to the
dental pulp?
a. The root canal diameter increases.
b. The pulp horns grow higher into the cup tips.
c. The overall size of the pulp chamber is reduced.
d. The layer of cementum thickens.
ANS: c
The pulp space becomes asymmetrically smaller over time
due to continued, albeit slower, production of dentin. There
is a pronounced decrease in the height of the pulp horn and a
reduction in the overall size of the pulp chamber. In molars,
the apical-occlusal dimension is reduced more than the
mesial-distal dimension.
REF: Anatomic Regions and Their Clinical Importance
11. The apical foramen is:
a. surrounded by dentin
b. narrowest in young teeth
c. variable in size and location
d. the widest portion of the canal
ANS: b
Variation in the size and location of the apical foramen influ-
ences the degree to which blood flow to the pulp may be
compromised after a traumatic event.
REF: Anatomic Regions and Their Clinical Importance
ANS: a
In the mature tooth, the odontoblasts form dentin in response
to injury, particularly when the original dentin thickness has
been reduced due to caries, attrition, trauma or restorative
procedures.
REF: Pulp Function (Defense)
14. Approximately how many odontoblasts are present in the
crown of a newly erupted tooth?
a. 10,000 to 20,000/mm2
b. 45,000 to 65,000/mm2
c. 100,000 to 150,000/mm2
d. 200,000 to 250,000/mm2
ANS: b
In the coronal part of the pulp space, the odontoblasts are
numerous, relatively large, and columnar in shape. They
number between 45,000 and 65,000/mm2 in that area.
REF: Cells of the Dental Pulp (Odontoblasts)
15. Which of the following cell types is an antigen-recognition
cell in the dental pulp?
a. odontoblasts
b. macrophages
c. neutrophils
d. all of the above
ANS: a
The odontoblast has several types of receptors on or within
its cell membrane. Toll-like receptors (TLR2 and TLR4),
when activated by components of gram-positive bacteria
(lipoteichoic acid), cause the odontoblasts to release proin-
flammatory cytokines (Fig. 1.12). This indicates that the
odontoblasts can act as antigen-recognition cells when bacte-
rial products penetrate the dentin.
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
pulp?
a. type I
b. type II
c. type III
d. type IV
ANS: a
The predominant collagen in dentin is type I, whereas both
type I and type III collagen are found within pulp in a ratio
of approximately 55 : 45. Odontoblasts produce only type I
collagen for incorporation into the dentin matrix, whereas
fibroblasts produce both types I and III. Pulpal collagen is
present as 50 nm-wide fibrils several microns long. They form
bundles that are irregularly arranged, except in the periphery,
where they lie approximately parallel to the predentin surface.
The only fibers present in the pulp are tiny, 10-15 nm-wide
beaded fibrils of fibrillin, a large glycoprotein. Elastic fibers
are absent from the pulp. The proportion of collagen types is
constant in the pulp, but with age there is an increase in the
overall collagen content and an increase in the organization
of collagen fibers into collagen bundles. Normally, the apical
portion of pulp contains more collagen than the coronal pulp.
REF: Extracellular Components (Fibers)
18. Which of the following is not a type of pulp stone?
a. free
b. attached
c. embedded
d. floating
ANS: d
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
APPENDIX B  Chapter review questions
20. What would be a typical level for interstitial pressure in
an area of inflammation in a dental pulp?
a. −20 mmHg
b. −6 mmHg
c. +6 mmHg
d. +20 mmHg
ANS: d
Swelling results from increased formation of interstitial tissue
fluid because of increased permeability of the capillaries. In
other tissues, such as skin (in which inflammation was first
described), the increased production of tissue fluid results in
swelling. Because the dental pulp is within a rigid, noncom-
pliant chamber, it cannot swell, and the increased interstitial
fluid formation results in an increase in tissue fluid pressure.
REF: Vascular Changes During Inflammation
21. Which type of nerves can be recruited to the pain system
of the dental pulp in inflammation?
a. Aα
b. Aβ
c. Aδ
d. C
ANS: b
A small percentage of the myelinated axons (1% to 5%) are
faster-conducting Aβ axons (6 to 12 µm in diameter). In other
tissues, these larger fibers can be proprioceptive or mechano-
receptive. Their role in the pulp is uncertain, but it is now
known from other tissues that in inflammation, these Aβ fibers
can be recruited to the pain system.
REF: Pulpal and Dentinal Nerves
e3
 APPENDIX B  Chapter review questions
Chapter review questions
Ashraf F. Fouad, Anthony J. Smith
CHAPTER 2
Protecting the Pulp and Promoting
Tooth Maturation
1. What is a “pulp cap”?
a. an early stage of tooth development
b. capping of the exposed pulp with a thin layer of inert
lining or base material
c. capping of exposed vital pulp tissue by placing a layer
of mineral trioxide aggregate (MTA)
d. a method of isolation used during root canal
treatment
ANS: c
The exposed pulp may be protected immediately by covering
it and placing a restoration. Pulp capping is the treatment of
an exposed vital pulp by sealing the pulpal wound with a
dental material, such as calcium hydroxide or mineral trioxide
aggregate (MTA), to stimulate the formation of reparative
dentin and maintenance of a vital pulp.
REF: Vital Pulp Therapy
2. What is the effect on blood flow to the pulp when anesthet-
ics with vasoconstrictors are used during restorative
procedures?
a. It is reduced by 10% of its normal rate.
b. It is reduced to less than half of its normal rate.
c. It is unchanged.
d. It is increased by 25% because of stress on the pulp
tissue.
ANS: b
When most local anesthetics containing vasoconstrictors are
used in restorative dentistry, the blood flow to the pulp is
reduced to less than half of its normal rate. In the case of
lidocaine with epinephrine, this effect is entirely due to the
vasoconstrictor.
REF: Local Anesthesia
3. What is dentin “blushing”?
a. the color of newly erupted teeth due to large pulp
chambers
b. the use of a masking color during restorative
procedures
c. vascular injury (hemorrhage) of pulp tissue, often
during crown preparation
d. an esthetic concern requiring laminate restorations
ANS: c
The “blushing” of dentin during cavity or crown preparation
is thought to be due to frictional heat resulting in vascular
injury (hemorrhage) in the pulp. The dentin takes on an under-
lying pinkish hue soon after the operative procedure.
REF: Cavity/Crown Preparation
e4
4. Why are deeper carious lesions more injurious to the
dental pulp?
a. increased dentin permeability in deeper areas and
greater cellular injury to odontoblasts
b. increased length of the dentinal tubule in deeper areas
c. decreased density of dentinal tubules in deeper areas
d. decreased diameter of dentin tubules in deeper areas
ANS: a
Dentin permeability increases exponentially with increasing
cavity depth, as both the diameter and density of dentinal
tubules increase with cavity depth (Fig. 2.5).17 Thus the deeper
the cavity, the greater the tubular surface area into which
potentially toxic substances can penetrate and diffuse to the
pulp. The length of the dentinal tubules beneath the cavity is
also important. The farther substances have to diffuse, the
more they will be diluted and buffered by the dentinal fluid.
A remaining dentin thickness of 1 mm is often regarded as
sufficient to shield the pulp from most forms of irritation. As
cavity depth increases, odontoblast survival is increasingly
compromised and there is a greater likelihood of local odon-
toblast death.
REF: Cavity Depth/Remaining Dentin Thickness
5. Why does a blast of compressed air directed at freshly
exposed dentin create a sensation of pain?
a. It frightens the patient.
b. The air is cold.
c. It causes a rapid outward movement of fluid in patent
dentinal tubules.
d. It causes a rapid inward movement of fluid in patent
dentinal tubules.
ANS: c
A prolonged blast of compressed air aimed onto freshly
exposed vital dentin causes a rapid outward movement of fluid
in patent dentinal tubules through strong capillary forces.
Rapid outward flow of fluid in the dentinal tubules stimulates
nociceptors in the dentin pulp, thus producing pain.
REF: Cavity Drying and Cleansing
6. What is the most important characteristic of any restor-
ative material in determining its effect on the pulp tissue?
a. heat generated by the material
b. speed with which the material sets
c. ability to form a marginal seal
d. life expectancy of the restorative material
ANS: c
The most important characteristic of any restorative material
in determining its effect on the pulp is its ability to form a
seal that prevents the leakage of bacteria and their products
onto dentin and then into the pulp.
REF: Microleakage

7. What effect does orthodontic tooth movement have on the
dental pulp?
a. It produces no clinically significant changes.
b. Electric pulp testing remains reliable.
c. Extrusion reduces pulpal blood flow for a few minutes.
d. Intrusive forces have no effect on pulpal blood flow.
ANS: a
Orthodontic tooth movement of a routine nature has not been
considered to cause clinically significant changes in the dental
pulp. Some experimental studies have reported vascular
changes in the pulp after application of orthodontic forces,66,67
which may be associated with the release of proangiogenic
growth factors from pulp and dentin in response to these
forces.68 Modeling of external application of forces to the
tooth has indicated that these forces may be transmitted to the
pulp, leading to fibroblast proliferation and up-regulation of
genes associated with cellular proliferation and extracellular
matrix components.69
REF: Orthodontic Tooth Movement
8. What is the primary reason for placement of a liner
between biocompatible restorative materials and the
dentin?
a. to provide thermal insulation
b. to provide a cushion against which to condense restor-
ative materials
c. to eliminate microleakage
d. to reduce the amount of restorative material needed
ANS: c
A liner is routinely placed between restorative materials and
the dentin, primarily to eliminate microleakage. In vitro
studies suggest that most liners show some degree of leakage,65
but it is unknown what level of dye leakage would relate to
clinical problems. One 3-year clinical study73 compared three
common dentin treatments but found no recurrent caries
around any of the restorations, including those for which no
liner had been used. All liners and bases reduce dentin perme-
ability, but to different extents. Bases provide the largest
reduction, varnishes the least.74 Dentin is also an excellent
thermal insulator of the pulp; additional insulation is rarely.
if ever, needed. In fact, thick cement bases are no more effec-
tive than just a thin layer of varnish in preventing thermal
sensitivity, indicating that postrestorative sensitivity is at least
partly a result of microleakage.75
REF: Cavity Varnishes, Liners, and Bases
9. Vital pulp therapies have variable rates of success. What
is the most significant determinant of the success of vital
pulp therapy?
a. size of the periapical lesion
b. periodontal status before the procedure
c. pulp status before the procedure
d. type of restorative material used
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
APPENDIX B  Chapter review questions
10. Which of the following steps is used in step-wise evacu-
ation of caries?
a. removal all the caries in a single visit
b. placement of a calcium hydroxide base at the initial
visit
c. placement of a glass ionomer base at each visit
d. removal of only a superficial layer of caries at the first
visit
ANS: c
A step-wise evacuation of caries is a suggested technique in
which caries is removed in increments in two or three appoint-
ments over a few months to a year rather than in a single
sitting, which might result in accidental exposure and con-
tamination of the pulp. The deeper affected but noninfected
dentin may remineralize, and tertiary dentin may form. Each
time caries is removed, a glass ionomer base is placed, which
may contribute to mineralization, followed by a well-sealing
temporary restoration. For this to be successful, careful case
selection is necessary. There must be no signs or symptoms
of irreversible pulpitis, which is frequently asymptomatic. If
the caries has already penetrated to the pulp, the treatment
will be unsuccessful because the pulp is already irreversibly
damaged. Therefore, it is critical that follow-up evaluation
include pulp testing and radiographs, because pulp necrosis
may occur even years later.
REF: Capping the Vital Pulp – Step-wise excavation of caries
11. What factors should be considered in case selection for
direct pulp capping procedures?
a. asymptomatic teeth with vital pulp
b. clinical signs of irreversible pulpitis
c. uncontrolled hemorrhage of the exposed pulp tissue
d. contaminated exposure site
ANS: a
Case selection for direct pulp capping should focus on asymp-
tomatic teeth with no clinical signs or symptoms of irrevers-
ible pulpitis. The size of the exposure should be small,
preferably less than 0.5 mm; hemorrhage should be ade-
quately controlled; great care should be taken to avoid con-
tamination of the area of exposure, using best clinical practice,
including a rubber dam; and a permanent restoration with a
good marginal seal should be placed.
REF: Direct Pulp Capping
12. When does apical closure occur in the developing root?
a. at the time of eruption
b. approximately 6 months after eruption
c. approximately 2 to 3 years after eruption
d. approximately 5 years after eruption
ANS: c
Apical closure occurs approximately 2 to 3 years after erup-
tion in the developing root.
REF: The Open Apex
e5
 APPENDIX B  Chapter review questions

13. If the pulp becomes necrotic before root growth is com-
plete, the resultant root is:
a. short with thick dentin walls
b. short with thin dentin walls
c. normal length with thick dentin walls
d. normal length with thin dentin walls
ANS: b
If the pulp becomes necrotic before root growth is complete,
dentin formation ceases and root development is arrested. The
resultant root is short with thin, and consequently weakened,
dentin walls.
REF: The Open Apex
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
15. What is apexification?
a. continued physiologic root formation
b. induction of a calcific barrier across an open apex
c. removal of inflamed vital tissue
d. the completing step of apexogenesis
ANS: b
Apexification is the induction of a calcific barrier (or the
creation of an artificial barrier) across an open apex in a case
involving pulp necrosis, with or without a periapical lesion.
Apexification involves removal of the necrotic pulp, followed
by débridement of the canal and placement of an antimicro-
bial medicament.
REF: Apexification

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

Chapter review questions
José F. Siqueira Jr., Ashraf F. Fouad
CHAPTER 3
Endodontic Microbiology
1. What is the ultimate goal of endodontic treatment?
a. to relieve pain in symptomatic teeth
b. to provide space for intraradicular restorative
materials
c. to prevent or treat apical periodontitis
d. to allow disinfection of contaminated root canal spaces
ANS: c
The ultimate goal of endodontic treatment is either to prevent
the development of apical periodontitis or to create adequate
conditions for periradicular tissue healing. Taking into account
the microbial etiology of apical periodontitis, the rationale for
endodontic treatment is unarguably to eradicate the occurring
infection or to prevent microorganisms from infecting or rein-
fecting the root canal or the periradicular tissues.
REF: Microbial Causation of Apical Periodontitis
2. Why is there greater dentin permeability near the pulp?
a. increased thickness of peritubular dentin
b. smaller diameter of dentinal tubules
c. higher density of dentinal tubules
d. longer length of odontoblastic process
ANS: c
Dentin permeability is increased near the pulp because of the
larger diameter and higher density of tubules.
REF: Dentinal Tubules
3. Bacterial invasion of dentinal tubules occurs more rapidly
in which teeth?
a. vital teeth
b. nonvital teeth
ANS: b
Bacterial invasion of dentinal tubules occurs more rapidly in
nonvital teeth than in vital ones.6
REF: Dentinal Tubules
4. What is anachoresis?
a. artificial formation of an apical barrier
b. induction of a biologic calcific apical barrier
c. microorganism transport from blood vessels into
damaged tissue
d. systemic infection resulting from infected pulp tissue
ANS: c
Anachoresis is a process by which microorganisms are trans-
ported in the blood or lymph to an area of tissue damage,
where they leave the vessel, enter the damaged tissue, and
establish an infection.
REF: Anachoresis
APPENDIX B  Chapter review questions
5. Root canals can become infected through anachoresis.
a. true
b. false
ANS: b
There is no clear evidence showing that this process can rep-
resent a route for root canal infection. It has been shown that
bacteria could not be recovered from unfilled root canals,
when the blood stream was experimentally infected, unless
the root canals were overinstrumented during the period of
bacteremia, with resulting injury to periodontal blood vessels
and blood seepage into the canal. Although anachoresis has
been suggested to be the mechanism through which trauma-
tized teeth with seemingly intact crowns become infected,
current evidence indicates that the main pathway of pulpal
infection in these cases is dentinal exposure due to enamel
cracks.
REF: Anachoresis
6. Which of the following is not a category of intraradicular
infections?
a. primary
b. secondary
c. tertiary
d. persistent
ANS: c
Intraradicular infections can be subdivided into three catego-
ries (primary, secondary, or persistent infection), depending
upon when participating microorganisms established them-
selves within the root canal.
REF: Microbiota of Endodontic Infections
7. The most common microorganisms in primary endodontic
infections are:
a. gram-negative bacteria
b. gram-positive bacteria
c. facultative anaerobes
d. facultative aerobes
ANS: a
Gram-negative bacteria appear to be the most common micro-
organisms in primary endodontic infections. Species belong-
ing to several genera of gram-negative bacteria have been
consistently found in primary infections associated with dif-
ferent forms of apical periodontitis, including abscesses.
These genera include Dialister (e.g., D. invisus and D. pneu-
mosintes), Treponema (e.g., T. denticola and T. socranskii),
Fusobacterium (e.g., F. nucleatum), Porphyromonas (e.g.,
P. endodontalis and P. gingivalis), Prevotella (e.g., P. inter-
media, P. nigrescens and P. tannerae), and Tannerella (e.g.,
T. forsythia). Other gram-negative bacteria are detected more
sporadically in primary infections.
REF: Gram-Negative Bacteria e7
 APPENDIX B  Chapter review questions
8. Which of the following is not a source of nutrients for
bacteria within the root canal system?
a. necrotic pulp tissue
b. inflamed vital pulp tissue
c. proteins and glycoproteins from tissue fluids and
exudate that seep into the root canal system via apical
and lateral foramina
d. components of saliva that penetrate the pulp tissue
ANS: b
In the root canal system, bacteria can use the following as
sources of nutrients: (1) necrotic pulp tissue, (2) proteins and
glycoproteins from tissue fluids and exudate that seep into the
root canal system via apical and lateral foramina, (3) compo-
nents of saliva that may coronally penetrate the root canal,
and (4) products of the metabolism of other bacteria. Because
the largest amount of nutrients is available in the main canal,
which is the most voluminous part of the root canal system,
most of the infecting microbiota, particularly fastidious anaer-
obic species, are expected to be located in this region. At later
stages of the infection process, nutritional conditions favor the
establishment of bacteria that metabolize peptides and amino
acids.
REF: Available Nutrients
9. Which of the following microorganisms is commonly
present in large percentages of root canal–treated teeth
that present with persistent apical periodontitis, indicative
of failed treatment?
a. Enterococcus faecalis
b. Pseudoramibacter alactolyticus
c. Tannerella forsythia
d. Dialister invisus
ANS: a
The microbiota in root canal–treated teeth with post-treatment
apical periodontitis lesions is composed of a more restricted
group of microbial species compared to primary infection.
Studies evaluating samples taken from retreatment cases have
revealed that apparently well-treated canals harbor up to five
species; canals with inadequate treatment can harbor 10 to 30
species, a number very similar to that found in untreated
canals. Bacterial counts in treated canals vary from 103 to 107
cell equivalents.
Enterococcus faecalis is a facultative anaerobic gram-
positive coccus that has been frequently found in root canal–
treated teeth in prevalence values ranging from 30% to 90%
of cases. Root canal–treated teeth are about nine times more
e8
likely to harbor E. faecalis than cases of primary infection.
Candida species are fungi only sporadically found in primary
infections, but detection frequencies in persistent and second-
ary infections range from 3% to 18% of cases. Both E. fae-
calis and C. albicans have a series of attributes that may allow
them to survive in treated canals, including resistance to
intracanal medications and the ability to form biofilms,
invade dentinal tubules, and endure long periods of nutrient
deprivation.
Despite its high prevalence in treated canals of teeth with
post-treatment apical periodontitis, the status of E. faecalis as
the main pathogen associated with treatment failures has been
questioned. This is because this species, if present, is rarely
the most dominant species in the bacterial community of
treated canals. In addition, it has been detected in root canal–
treated teeth with no disease in a similarly high prevalence.
Streptococcus species, which are also very frequently detected
and in many cases are the dominant bacterial group, in addi-
tion to P. alactolyticus, Propionibacterium species, F. alocis,,
T. forsythia, D. pneumosintes, and D. invisus, can also be
involved in persistent and secondary intraradicular infections
(Table 3.2).27
REF: Microbiota in Root Canal–Treated Teeth
10. Gram-positive bacteria have been demonstrated to:
a. have a higher occurrence in post-instrumentation
samples
b. be more resistant to antimicrobial treatments
c. adapt to harsh environmental conditions
d. all of the above
ANS: d
Diligent antimicrobial treatment can occasionally fail to
promote total eradication of bacteria from root canals, with
consequent selection of the most resistant segment of the
microbiota. Gram-negative bacteria, which are common
members of primary intraradicular infections, are usually
eliminated by endodontic treatment. Most studies on this
subject have clearly revealed a higher occurrence of gram-
positive bacteria (e.g., streptococci, lactobacilli, Enterococcus
faecalis, O. uli, P. micros, P. alactolyticus, and Propionibac-
terium species) in both post-instrumentation and post-
medication samples. This gives support to the notion that
gram-positive bacteria can be more resistant to antimicrobial
treatment measures and have the ability to adapt to the harsh
environmental conditions in instrumented and medicated
canals.
REF: Bacteria at the Root Canal–Filling Stage

Chapter review questions
Mahmoud Torabinejad, Shahrokh Shabahang
CHAPTER 4
Pulp and Periapical Pathosis
1. A direct pulp exposure of a carious lesion is necessary to
have a pulpal response and inflammation.
a. true
b. false
ANS: b
Direct pulp exposure to microorganisms is not a prerequisite
for pulpal response and inflammation. Microorganisms in
caries produce toxins that penetrate to the pulp through
tubules. Studies have shown that even small lesions in enamel
are capable of attracting inflammatory cells in the pulp. As a
result of the presence of microorganisms and their byproducts
in dentin, pulp is infiltrated locally (at the base of tubules
involved in caries), primarily by chronic inflammatory cells
such as macrophages, lymphocytes, and plasma cells.
REF: Microbial Irritants
2. What factor is the most important in determining whether
pulp tissue becomes necrotic slowly or rapidly after
carious pulp exposure and pulpal inflammation?
a. virulence of bacteria
b. host resistance
c. amount of circulation
d. lymph drainage
ANS: d
The factors that determine whether pulp tissue becomes
necrotic slowly or rapidly after carious pulp exposure and
pulpal inflammation are (1) the virulence of the bacteria; (2) the
ability to release inflammatory fluids to avoid a marked increase
in intrapulpal pressure; (3) host resistance; (4) the amount of
circulation; and, most important, (5) lymph drainage.
REF: Microbial Irritants
3. What is necessary for pulp and periradicular pathosis to
develop?
a. exposure of pulp tissue
b. exposure of dentin
c. presence of bacteria
d. trauma
ANS: c
Bacteria play an important role in the pathogenesis of pulpal
and periradicular pathoses. A number of investigations have
established that pulpal or periradicular pathosis does not
develop without the presence of bacterial contamination.23-25
Kakehashi and associates created pulp exposures in conven-
tional and germ-free rats.23 This procedure in the germ-free
rats caused only minimal inflammation throughout the 72-day
investigation period. Pulpal tissue in these animals was not
devitalized but rather showed calcific bridge formation by day
14, with normal tissue apical to the dentin bridge (Fig. 4.7,
A). In contrast, infection, pulpal necrosis, and abscess forma-
tion occurred by the eighth day in conventional rats (Fig. 4.7,
B). Other investigators have examined the importance of
APPENDIX B  Chapter review questions
bacteria in the development of periradicular lesions by sealing
noninfected and infected pulps in the root canals of monkeys.24
After 6 to 7 months, clinical, radiographic, and histologic
examinations of teeth sealed with noninfected pulps showed
an absence of pathosis in apical tissues, whereas teeth sealed
with necrotic pulps containing certain bacteria showed peri-
apical inflammation. The bacteriologic investigation by Sun-
dqvist25 examining the flora of human necrotic pulps supports
the findings of Kakehashi and associates23 and those of Möller
and colleagues.24 These studies examined previously trauma-
tized teeth with necrotic pulps, with and without apical patho-
sis. Teeth without apical lesions were aseptic, whereas those
with periapical pathosis had positive bacterial cultures.
REF: Microbial Irritants
4. Which of the following statements is true regarding
mechanical irritants?
a. Changes to the underlying pulp, such as odontoblast
aspiration, are irreversible.
b. The potential for pulp injury decreases as more dentin
is removed.
c. Operative procedures without water coolant cause
more irritation than those performed under water spray.
d. There is decreased permeability and constriction of
blood vessels in the early stages of pulpitis.
ANS: c
Mechanical irritants, such as deep cavity preparations, removal
of tooth structure without proper cooling, impact trauma,
occlusal trauma, deep periodontal curettage, and orthodontic
movement of teeth, may lead to alterations in the underlying
pulp. Transient changes, such as aspiration of odontoblasts into
the dentinal tubules, are usually reversible in healthy pulps
(Fig. 4.1). In typical clinical situations, however, the pulpal
tissue is already inflamed due to the presence of caries or previ-
ous restorative procedures. If proper precautions are not taken,
cavity or crown preparations may damage subjacent odonto-
blasts. The number of tubules per unit of surface area and their
diameter increase closer to the pulp (Fig. 4.2). As a result, den-
tinal permeability is greater closer to the pulp than near the
dentinoenamel junction (DEJ) or cementodentinal junction
(CDJ).1 Therefore, the potential for pulp irritation increases as
more dentin is removed (i.e., as cavity preparation deepens and
reaches closer to the pulp). Pulp damage is roughly propor-
tional to the amount of tooth structure removed and to the depth
of removal.2 Also, operative procedures without water coolant
cause more irritation than those performed under water spray.3
A study of the reactions and vascular changes occurring in
experimentally induced acute and chronic pulpitis demon-
strated increased permeability and dilation of blood vessels in
the early stages of pulpitis.4 Investigations in rodent models
designed to determine the impact of heat generation on the
dental pulp have shown that elevation of pulpal temperature
above 42°C up-regulate heat shock proteins (HSP).5 HSP-70
plays a protective role, and its levels return to baseline within a
few hours after removal of the heat stimulus.
REF: Mechanical Irritants e9
 APPENDIX B  Chapter review questions
5. What nonspecific inflammatory mediators are not present
when the dental pulp is irritated?
a. histamine
b. epinephrine
c. bradykinin
d. arachidonic acid metabolites
ANS: b
Irritation of the dental pulp results in the activation of a variety
of biologic systems, such as nonspecific inflammatory reac-
tions mediated by histamine, bradykinin, and arachidonic acid
metabolites. Also released are PMN lysosomal granule prod-
ucts (elastase, cathepsin G, and lactoferrin), protease inhibi-
tors (e.g., antitrypsin), and neuropeptides (e.g., calcitonin
gene-related peptide [CGRP] and substance P [SP]).
REF: Inflammatory Process
6. What cell type associated with immune response is not
present in severely inflamed dental pulp?
a. T lymphocytes
b. B lymphocytes
c. macrophages
d. odontoclasts
ANS: d
In addition to nonspecific inflammatory reactions, immune
responses also may initiate and perpetuate deleterious pulpal
changes.31 Potential antigens include bacteria and their
byproducts within dental caries, which directly (or via the
dentinal tubules) can initiate various types of reactions.
Normal and uninflamed dental pulps contain immunocompe-
tent cells, such as T and B (fewer) lymphocytes, macrophages,
and a substantial number of class II molecule-expressing den-
dritic cells, which are morphologically similar to macro-
phages.20 Elevated levels of immunoglobulins in inflamed
pulps (Fig. 4.10) show that these factors participate in the
defense mechanisms involved in protection of this tissue.48
Arthus-type reactions do occur in the dental pulp.49 In addi-
tion, the presence of immunocompetent cells, such as T lym-
phocytes, macrophages, and class II molecule-expressing
cells appearing as dendritic cells (Fig. 4.11) in inflamed pulps,
indicates that delayed hypersensitivity reactions can also
occur in this tissue.20 Despite their protective mechanisms,
immune reactions in the pulp can result in the formation of
small necrotic foci and eventual total pulpal necrosis.
REF: Immunologic Responses
7. What is the cause of pain during the progression of pulpal
injury?
a. elevation of the sensory nerve threshold
b. decrease of arteriole vasodilation
c. increase of venule vascular permeability
d. decrease of pulp tissue pressure
ANS: c
Pain is often caused by several factors. The release of media-
tors of inflammation causes pain directly by lowering the
sensory nerve threshold. These substances also cause pain
indirectly by increasing both vasodilation in arterioles and
vascular permeability in venules, resulting in edema and ele-
vation of tissue pressure. This pressure acts directly on sensory
e10 nerve receptors.
REF: Lesion Progression
8. Which of the following is true in reversible pulpitis?
a. severe inflammation of pulp tissue
b. yields a negative response to electric pulp testing
c. yields a positive response to thermal pulp testing
d. requires root canal treatment
ANS: c
By definition, reversible pulpitis is a clinical condition associ-
ated with subjective and objective findings indicating the pres-
ence of mild inflammation in the pulp tissue. If the cause is
eliminated, inflammation will reverse and the pulp will return
to its normal state.
Mild or short-acting stimuli, such as incipient caries,
cervical erosion, or occlusal attrition; most operative proce-
dures; deep periodontal curettage; and enamel fractures
resulting in exposure of dentinal tubules can cause reversible
pulpitis.
Reversible pulpitis is usually asymptomatic. However,
when present, symptoms usually follow a particular pattern.
Application of stimuli, such as cold or hot liquids or air, may
produce sharp, transient pain. Removal of these stimuli, which
do not normally produce pain or discomfort, results in imme-
diate relief. Cold and hot stimuli produce different pain
responses in normal pulp.55 When heat is applied to teeth with
uninflamed pulp, the initial response is delayed; the intensity
of pain increases as the temperature rises. In contrast, pain
in response to cold in normal pulp is immediate; the
intensity tends to decrease if the cold stimulus is maintained.
Based on these observations, pulpal responses in both health
and disease apparently result largely from changes in
intrapulpal pressures.
REF: Reversible Pulpitis
9. What is irreversible pulpitis?
a. a severe inflammatory process
b. a condition that precedes reversible pulpitis
c. a condition that resolves when the causative agent is
removed
d. a condition that yields a negative response to thermal
pulp testing
ANS: a
Irreversible pulpitis may be classified as symptomatic or
asymptomatic. It is a clinical condition associated with sub-
jective and objective findings indicating the presence of severe
inflammation in the pulp tissue. Irreversible pulpitis is often
a sequel to and a progression of reversible pulpitis. Severe
pulpal damage from extensive dentin removal during opera-
tive procedures or impairment of pulpal blood flow as a result
of trauma or orthodontic movement of teeth may also cause
irreversible pulpitis. Irreversible pulpitis is a severe inflamma-
tory process that will not resolve even if the cause is removed.
The pulp is incapable of healing and slowly or rapidly becomes
necrotic. Irreversible pulpitis can be symptomatic, with spon-
taneous and lingering pain. It can also be asymptomatic, with
no clinical signs and symptoms.
Irreversible pulpitis is usually asymptomatic. However,
patients may report mild symptoms. Irreversible pulpitis may
also be associated with intermittent or continuous episodes of
spontaneous pain (with no external stimuli). Pain resulting
from an irreversibly inflamed pulp may be sharp, dull, local-
ized, or diffuse and can last anywhere from a few minutes up
to a few hours.

Localization of pulpal pain is more difficult than localiza-
tion of periradicular pain and becomes more difficult as the
pain intensifies. Application of an external stimulus, such as
cold or heat, may result in prolonged pain. Accordingly, in the
presence of severe pain, pulpal responses differ from those of
uninflamed teeth or teeth with reversible pulpitis. For example,
application of heat to teeth with irreversible pulpitis may
produce an immediate response; also, occasionally with the
application of cold, the response does not disappear and is
prolonged. Application of cold in patients with painful irre-
versible pulpitis may cause vasoconstriction, a drop in pulpal
pressure, and subsequent pain relief. Although it has been
claimed that teeth with irreversible pulpitis have lower thresh-
olds to electrical stimulation, Mumford found similar pain
perception thresholds in inflamed and uninflamed pulps.56
REF: Irreversible Pulpitis
10. Which of the following is not a hard tissue change that
may result from pulpal irritation or inflammation?
a. calcification of pulp tissue spaces
b. resorption of pulp tissue spaces
c. formation of pulp stones
d. thickening of the periodontal ligament
ANS: d
Extensive calcification (usually in the form of pulp stones or
diffuse calcification) occurs as a response to trauma, caries,
periodontal disease, or other irritants. Thrombi in blood
vessels and collagen sheaths around vessel walls are possible
sources of these calcifications.
Another type of calcification is the extensive formation of
hard tissue on dentin walls, often in response to irritation or
death and replacement of odontoblasts. This process is called
calcific metamorphosis (Fig. 4.14). As irritation increases, the
amount of calcification may also increase, leading to partial
or complete radiographic (but not histologic) obliteration of
the pulp chamber and root canal.57 A yellowish discoloration
of the crown is often a manifestation of calcific metamorpho-
sis. The pain threshold to thermal and electrical stimuli usually
increases; often the teeth are unresponsive.
Palpation and percussion are usually within normal limits.
In contrast to soft tissue diseases of the pulp, which have no
radiographic signs and symptoms, calcification of pulp tissue
is associated with various degrees of pulp space obliteration.
A reduction in coronal pulp space followed by a gradual nar-
rowing of the root canal is the first sign of calcific metamor-
phosis. This condition is not pathologic in nature and does not
require treatment.
Inflammation in the pulp may initiate resorption of adjacent
hard tissues. The pulp is transformed into a vascularized
inflammatory tissue with dentinoclastic activity; this condi-
tion leads to the resorption of the dentinal walls, advancing
from its center to the periphery.58 Most cases of intracanal
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-
tually perforate to the lateral periodontium. When this occurs,
APPENDIX B  Chapter review questions
pulp necrosis ensues, and treatment of the tooth becomes
more difficult.
REF: Pulp Calcification; Internal (Intracanal) Resorption
11. What are the signs and symptoms associated with symp-
tomatic apical periodontitis (SAP)?
a. normal sensation on mastication
b. normal sensation on finger pressure
c. marked or excruciating pain on tapping with a mirror
handle
d. presence of a large periapical lesion
ANS: c
Clinical features of SAP are moderate to severe spontaneous
discomfort and also pain on biting or percussion. If SAP is an
extension of pulpitis, its signs and symptoms will include
responsiveness to cold, heat, and electricity. Cases of SAP
caused by a necrotic pulp do not respond to vitality tests.
Application of pressure by the fingertip or tapping with
the butt end of a mirror handle (percussion) can cause marked
to excruciating pain. SAP is not associated with an apical
radiolucency. Occasionally, there may be slight radiographic
changes, such as a “widening” of the PDL space or a very
small radiolucent lesion; however, usually there is a normal
PDL space with an intact lamina dura.
REF: Symptomatic Apical Periodontitis
12. What histologic feature differentiates a periapical granu-
loma from a periapical cyst?
a. presence of mast cells
b. presence of lymphocytes
c. presence of plasma cells
d. presence of an epithelium-lined cavity
ANS: d
Histologically, AAP lesions are classified as either granulo-
mas or cysts. A periapical granuloma consists of granuloma-
tous tissue infiltrated by mast cells, macrophages, lymphocytes,
plasma cells, and occasionally, PMN leukocytes (Fig. 4.21).
Multinucleated giant cells, foam cells, cholesterol clefts, and
epithelium are often found.
The apical (radicular) cyst has a central cavity filled with
an eosinophilic fluid or semisolid material and is lined by
stratified squamous epithelium (Fig. 4.22). The epithelium is
surrounded by connective tissue containing all cellular ele-
ments found in the periapical granuloma. Therefore an apical
cyst is a granuloma that contains a cavity or cavities lined with
epithelium. The origin of the epithelium is the remnants of
Hertwig’s epithelial sheath, the cell rests of Malassez. These
cell rests proliferate in response to inflammatory stimuli. The
actual genesis of the cyst is unclear.
REF: Symptomatic Apical Periodontitis (Histologic
Features)
e11
 APPENDIX B  Chapter review questions
13. Which of the following is not associated with acute apical
abscess (AAA)?
a. moderate to severe discomfort
b. an intense and prolonged response to thermal
stimulus
c. a negative response to electrical pulp testing
d. pain on percussion and palpation
ANS: b
AAA is characterized by a rapid onset and spontaneous pain.
Depending on the severity of the reaction, patients with AAA
usually have moderate to severe discomfort and/or swelling.
There often is no swelling if the abscess is confined to bone.
In addition, patients occasionally have systemic manifesta-
tions of an infective process, such as an elevated temperature,
malaise, and leukocytosis. Because these findings are only
observed in association with a necrotic pulp, electrical or
thermal stimulation produces no response. However, these
teeth are usually painful on percussion and palpation. Depend-
ing on the degree of hard tissue destruction inflicted by irri-
tants, radiographic features of AAA range from no changes
to widening of the PDL space to an obvious radiolucent
lesion.
REF: Acute Apical Abscess (Signs and Symptoms)
14. What factors may impact and influence whether perira-
dicular lesions heal completely or incompletely?
a. size of the lesion
b. blood supply
c. systemic disease
d. all of the above
ANS: d
The level of healing is proportional to the degree and extent
of tissue injury and the nature of tissue destruction. When
injury to the underlying tissues is slight, little repair or regen-
eration is required. On the other hand, extensive damage
requires substantial healing (Fig. 4.23). In other words, pulp
and periradicular repair ranges from a relatively simple reso-
lution of an inflammatory infiltrate to considerable reorgani-
zation and repair of a variety of tissues.
REF: Healing of Pulp and Periapical Tissues (Extent of
Healing)
15. What is the most important aid in distinguishing between
endodontic and nonendodontic periradicular lesions?
a. radiographic location
b. radiographic appearance
c. pulp vitality testing
d. patient’s history
e12
ANS: c
A number of radiolucent and radiopaque lesions of nonendodon-
tic origin simulate the radiographic appearance of endodontic
lesions. Because of their similarities, dentists must use their
knowledge and perform clinical tests in a systematic manner to
arrive at an accurate diagnosis and avoid critical mistakes. Pulp
vitality tests are the most important aids in differentiating
between endodontic and nonendodontic lesions. Teeth associ-
ated with radiolucent periradicular lesions have necrotic pulps
and therefore generally do not respond to vitality tests. In con-
trast, lesions of nonpulpal origin usually do not affect the blood
or nerve supply to adjacent tooth pulp; therefore, the vitality
(responsiveness) of these teeth remains unaffected.
Unfortunately, many clinicians rely solely on radiographs
for diagnosis and treatment, without obtaining a complete
history of the signs and symptoms and performing clinical
tests. Many nonendodontic radiolucencies (including those
resulting from pathoses and those with normal morphology)
mimic endodontic pathoses and vice versa. To avoid grievous
mistakes, all relevant vitality tests, radiographic examinations,
clinical signs and symptoms, and details of the patient history
should be used.
REF: Nonendodontic Periradicular Pathosis (Differential
Diagnosis)
16. Localization of pulpal pain is more difficult than localiza-
tion of periradicular pain.
a. true
b. false
ANS: a
Localization of pulpal pain is more difficult than localization
of periradicular pain and becomes more difficult as the pain
intensifies.
REF: Irreversible Pulpitis (Symptoms)
17. What is the distinguishing characteristic of a chronic
apical abscess (CAA)?
a. a positive response to thermal pulp testing
b. a negative response to thermal pulp testing
c. the presence of an apical radiolucency
d. the presence of an abscess that is draining to a mucosal
or skin surface
ANS: d
CAA is an inflammatory lesion of pulpal origin that is char-
acterized by the presence of a long-standing lesion that has
resulted in an abscess that is draining to a mucosal (sinus
tract) or skin surface.
REF: Chronic Apical Abscess

Chapter review questions
Richard E. Walton, Ashraf F. Fouad
CHAPTER 5
Diagnosis, Treatment Planning, and
Systemic Considerations
1. Which of the following is not one of the five basic steps
in the diagnostic process?
a. chief complaint
b. medical and dental history
c. oral examination
d. review of insurance coverage
ANS: d
The basic steps in the diagnostic process are:
(1)  chief complaint
(2) history (medical and dental)
(3) oral examination.
(4) data analysis, leading to a differential diagnosis
(5) treatment plan
REF: Introduction
2. Are patients who seek endodontic treatment usually
younger or older than the general population?
a. Age has not been shown to be a factor.
b. younger
c. older
ANS: c
The population seeking and requiring endodontic treatment is
older, on average, than the general population and shows a
higher and more complex incidence of systemic medical
problems.
REF: Health and Medical History
3. During a review of the patient’s health history, the clini-
cian notes that the patient is on a regimen of intravenous
bisphosphonate medication. What significance does this
hold for the patient and the treatment plan?
a. possible side effect of bleeding disorders
b. possible side effect of osteonecrosis of the jaw
c. lowered pain threshold
d. inability to obtain adequate anesthesia
ANS: b
Over the past decade, it has been recognized that patients
undergoing bisphosphonate therapy may be at risk of osteo-
necrosis of the jaw (BRONJ). This risk is greater with intra-
venous bisphosphonates, particularly if more than one agent
is used simultaneously, and it increases with the duration of
bisphosphonate use and with surgical procedures such as
extractions.82 Although rare, BRONJ may occur after end-
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
difference in endodontic outcome is seen in patients taking
APPENDIX B  Chapter review questions
oral bisphosphonates compared with those seen in other
patients.85
REF: Risk for Osteoradionecrosis or Osteonecrosis of the Jaw
4. When pain is one of the patient’s complaints, what ques-
tion is less relevant regarding the pain and does not need
to be asked of the patient?
a. When did the pain begin?
b. Is the pain always in the same place?
c. Why did you not seek treatment when the pain began?
d. Once initiated, how long does the pain last?
ANS: c
The following questions should be asked:
(1) When did the pain begin?
(2) Where is the pain located?
(3) Is it always in the same place?
(4) What is the character of the pain (short, sharp, long
lasting, dull, throbbing, continuous, occasional)?
(5) Does the pain prevent you from sleeping or working?
(6) Is it worse in the morning?
(7) Is it worse when you lie down?
(8) Did or does anything initiate the pain (trauma,
biting)?
(9) Once initiated, how long does the pain last?
(10) Is it continuous (spontaneous) or intermittent?
(11) Does anything make it worse (hot, cold, biting)?
Does anything make it better (cold, analgesics)?
REF: The Pain Referral Phenomenon
5. Why is it important to use control teeth during the clinical
tests?
a. to calibrate the patient’s response
b. so that the patient can indicate which tooth is being
tested
c. so that teeth can be tested repeatedly
d. to test whether isolation is adequate
ANS: a
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
molar, lower incisor). The result of tests on these teeth “cali-
brates” and provides a baseline for the patient’s responses to
tests on suspected teeth. The patient should not be told whether
the tooth being tested is a control or suspect tooth. The clini-
cian should be aware that a patient may not respond in the
same way or to the same extent when tests are repeated. The
first application of the test is the most significant.
REF: Clinical Tests (Control Teeth)
e13
 APPENDIX B  Chapter review questions
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
following?
a. periapical inflammation
b. pulpal inflammation
c. both pulpal and periapical inflammation
ANS: a
Percussion is performed by different means. One way is
tapping on the incisal or occlusal surface of the tooth with the
end of a mirror handle held either parallel or perpendicular to
the crown. This should be preceded by gentle digital pressure
to detect teeth that are very tender and should not be tapped
with the mirror handle. If a painful response is obtained, this
may indicate the presence of periapical inflammation. Periapi-
cal inflammation may produce a sharp pain.
REF: Percussion and Palpation of Supporting Tissues
7. What is palpation testing used to determine?
a. pulpal inflammation
b. periapical inflammation
c. periodontal inflammation
d. periapical histology
ANS: b
Palpation is firm pressure on the mucosa overlying the apex.
Like percussion, palpation determines how far the inflamma-
tory process has extended periapically. A painful response to
palpation indicates periapical inflammation.
REF: Palpation and Percussion
8. Which of the methods of cold testing is preferred for pulp
testing?
a. regular ice (frozen water)
b. refrigerant spray or CO2 ice
c. flooding the arch with chilled water
d. a blast of air from the air/water syringe
ANS: b
Three methods are generally used for cold testing: frozen
water (ice), carbon dioxide (CO2) ice (dry ice), and refriger-
ant. CO2 ice requires special equipment, whereas refrigerant
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
cotton pellet was the most effective in reducing the tempera-
ture within the chamber under full-coverage restorations.24
Overall, refrigerant spray and CO2 ice are equivalent for pulp
testing.
REF: Cold Tests
9. How does electrical pulp testing determine the degree of
pulpal inflammation?
a. Higher readings indicate a healthier pulp.
b. Lower readings indicate a healthier pulp.
c. A midrange response indicates partial necrosis.
d. It cannot determine whether pulp tissue is inflamed.
ANS: d
An electrical pulp test, conducted correctly, will usually deter-
mine whether there is vital tissue within the tooth. It cannot
e14 determine whether that tissue is inflamed, nor can it indicate
digital readouts are popular (Fig. 5.10). These testers are not
inherently superior to other electrical testers but are more user
friendly. High readings usually indicate necrosis. Low read-
ings indicate vitality. Testing of normal control teeth estab-
lishes the approximate boundary between the two conditions.
The exact number of the reading is of no significance and does
not detect subtle degrees of vitality, nor can any electrical pulp
tester indicate inflammation.30
REF: Pulp Vitality Tests (Electrical Pulp Testing)
10. Which of the following is a characteristic of a periapical
lesion of endodontic origin?
a. The lamina dura of the tooth socket is intact.
b. The lucency remains at the apex in radiographs made
at different cone angles.
c. The lucency tends to resemble a round circle.
d. The lesion is usually associated with an irreversible
pulpitis.
ANS: b
Periapical lesions of endodontic origin usually have four char-
acteristics: (1) the lamina dura of the tooth socket is lost api-
cally; (2) the lucency remains at the apex in radiographs made
at different cone angles; (3) the lucency tends to resemble a
hanging drop; and (4) the lesion is usually seen with a necrotic
pulp.
REF: Periapical Lesions
11. In which situation is caries removal necessary to obtain a
definitive pulpal diagnosis?
a. deep radiographic caries with no symptoms and nega-
tive pulp testing
b. deep radiographic caries with no symptoms and posi-
tive pulp testing
c. shallow radiographic caries with mild symptoms and
positive pulp testing
d. shallow radiographic caries with mild symptoms and
negative pulp testing
ANS: b
Determining the depth of caries penetration is necessary in
no significant history or presenting symptoms and a pulp that
responds to clinical tests. All other findings are normal. The
final definitive test is complete caries removal to establish
pulp status. Exposure by soft caries is irreversible pulpitis;
nonexposure is reversible pulpitis.
REF: Caries Removal
12. How may selective anesthesia be an aid in diagnosis?
a. It can localize a painful tooth to a specific arch.
b. It can localize an individual painful tooth in the man-
dibular arch.
c. It can confirm the tooth the patient identifies as the
offending tooth.
d. PDL injection will only anesthetize one tooth at a time.
ANS: a
Selective anesthesia can be useful in localizing a painful tooth
when the patient cannot identify the offender. If a mandibular

tooth is suspected, a mandibular block will confirm at least
the region if the pain disappears after the injection. Selective
anesthesia of individual teeth is not useful in the mandible.
The periodontal ligament injection will often anesthetize
several teeth. However, it is marginally more effective in the
maxilla. Anesthetic should be administered to individual teeth
in an anterior to posterior sequence because of the pattern of
distribution of the sensory nerves.
REF: Selective Anesthesia
13. What type of resorption may alter the geometry of the
apex?
a. internal
b. inflammatory cervical
c. external apical
d. regenerative
ANS: c
Resorption may be either internal or external. Perforat-
ing (pulp-periodontal communication) resorptions are often
complex. Tooth resorption, whether internal or external, is
high risk and should be referred for evaluation and treatment
(Fig. 5.20). Limited internal resorption may not present treat-
ment complications, but external apical resorption may drasti-
cally alter the geometry of the apex or the root surface.
Extensive apical or root surface resorption is best referred.
REF: Resorption
14. During a review of the patient’s health history, the clini-
cian notes that the patient is diabetic. What significance
does this hold for the patient and the treatment plan?
a. Diabetic patients have a decreased prevalence of teeth
with periapical lesions.
b. The longitudinal treatment outcome is improved in dia-
betic patients.
c. Residual lesions 2 to 4 years after treatment correlate
significantly with the degree of glycemia.
d. Diabetic patients are significantly more likely to have
flare-ups.
APPENDIX B  Chapter review questions
ANS: c
It is generally known that diabetics have an increase preva-
lence of teeth with periapical lesions.67-70 The longitudinal
treatment outcome is generally no different between diabetics
and nondiabetics.71-73 However, if the outcomes of cases with
and without preoperative periapical lesions are separated, a
notable difference is observed. In cases with preoperative
lesions, diabetics are significantly less likely to have success-
ful treatment than nondiabetics, especially when the study
controls for a number of other confounding factors.72 More
recently it has been shown that in cases with preoperative
lesions that were adequately treated endodontically, the area
of the residual lesions 2 to 4 years after treatment correlated
significantly with the degree of glycemia in both diabetics and
nondiabetics, as measured by the hemoglobin A1c test.74 This
is consistent with older observations that healing of periapical
lesions correlated with postprandial glycemia at the time of
treatment.75
REF: Diabetes Mellitus
15. What conditions present the practitioner with a diagnostic
challenge?
a. pain of an isolated nature
b. inability to reach a definitive diagnosis
c. patients with a low level of anxiety
d. patients requiring premedication for an artificial
prosthesis
ANS: b
Appropriate treatment follows accurate diagnosis. Many pro-
cedures are done inappropriately (or not done) because of
diagnostic errors. The endodontist is experienced, and the
generalist may be unfamiliar with that particular problem.
Referred pain is a good example of a condition that often
presents the practitioner with a significant diagnostic chal-
lenge. Unless a definitive diagnosis is obtained, no treatment
should be rendered and the patient should be referred
(Box 5.6).
REF: Treatment Planning Considerations
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