ENDO FINAL_endofbookquestions_4,5,9,10

Instrumentation and filling to what level elicits the most favorable response in periapical tissues? a. 0 to 2 mm short of the radiographic apex b. 3 to 5 mm short of the radiographic apex c. at the radiographic apex d. 0 to -2 mm beyond the radiographic apex

0-2mm short of the radiographic apex. * It has been demonstrated histologically that the most favorable response of periapical tissues occurs when both instrumentation and filling were short of the apical constriction. A clinical study found that the best treatment outcome in infected teeth with periradicular lesions occurred when the apical terminus of the filling was 0 to 2 mm short of the radiographic apex. The same study determined that the prognosis was decreased with significant underfill and overfill. (Torabinejad, 040114, p. e28) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is the incidence of exacerbations as reported in the literature? a. 0% to 6.5% b. 1.5% to 20% c. 6.5% to 20% d. 15% to 25%

1.5% to 20% *The incidence of exacerbations has been estimated to be as low as 1.5%8 and as high as 20%.9 This wide range of estimates may be attributed to different definitions of exacerbations, varying study designs, and other procedural variations. (Torabinejad, 040114, p. e27) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What factors may impact and influence whether periradicular lesions heal completely or incompletely? a. size of the lesion b. blood supply c. systemic disease d. all of the above

ALL OF THE ABOVE!! *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 regeneration 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 resolution of an inflammatory infiltrate to considerable reorganization and repair of a variety of tissues. (Torabinejad, 040114, p. e12) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What subjective findings are common with a diagnosis of bruxism? a. spontaneous pain without a stimulus b. The patient awakens with pain during sleep but feels better as the day progresses. c. periapical swelling that comes and goes d. a periapical sinus tract

AWAKENS with PAIN * A patient who relates having been awakened by pain at night, feeling better as the day progressed, only to have the pain return again during sleep, does not fit the most common profile of an irreversible pulpitis. This patient will require a differential diagnosis for bruxism, TMD, or an irreversible pulpitis. (Torabinejad, 040114, p. e27) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

An intense and prolonged response to thermal stimulus... *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 manifestations 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. Depending on the degree of hard tissue destruction inflicted by irritants, radiographic features of AAA range from no changes to widening of the PDL space to an obvious radiolucent lesion. (Torabinejad, 040114, p. e12) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which statement is true about the effect of needle bevel orientation on the success of an inferior alveolar nerve block? a. Orienting the needle bevel toward the mandibular ramus improves success. b. Orienting the needle bevel away from the mandibular ramus improves success. c. Half the cartridge should be injected with the bevel toward the ramus; the needle should then be rotated and the other half of the cartridge injected with the bevel away from the ramus. d. The direction of the needle bevel does not affect the success of the block.

NO EFFECT *Needle deflection has been theorized as a cause of failure with the inferior alveolar nerve block. However, two studies have shown that needle bevel orientation (away from or toward the mandibular foramen or ramus) does not affect the success of the inferior alveolar nerve block. (Torabinejad, 040114, p. e24) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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.

Operative procedures without water coolant cause more irritation than those performed under water spray. *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 previous restorative procedures. If proper precautions are not taken, cavity or crown preparations may damage subjacent odontoblasts. The number of tubules per unit of surface area and their diameter increase closer to the pulp (Fig. 4.2). As a result, dentinal 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 proportional 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 demonstrated 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. (Torabinejad, 040114, p. e9) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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 mandibular 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.

localize a PAINFUL tooth in a SPECIFIC arch. *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. (Torabinejad, 040114, pp. e14-e15) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What are the most difficult teeth to anesthetize with irreversible pulpitis? a. maxillary molars b. mandibular molars c. maxillary anterior teeth d. maxillary premolars

mandibular molar *With irreversible pulpitis, the teeth most difficult to anesthetize are the mandibular molars, followed by (in order) the mandibular and maxillary premolars, maxillary molars, mandibular anterior teeth, and maxillary anterior teeth. (Torabinejad, 040114, p. e26) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is a major factor causing dental unit waterlines to harbor bacteria? a. The nature of the plastic material in the dental tubing aids bacterial attachment. b. Large-diameter lines have a high flow rate. c. The length of tubing from the unit to the air-water syringe d. Use of an antibacterial agent in the water supply reservoir

nature of the plastic material in the dental tubing aids bacterial attachment *Questions have been raised about the use of water from dental units during endodontic irrigation. It is well documented that water taken from the dental unit is often contaminated and may pose a problem. Dental unit waterlines harbor bacteria at alarming rates. This is due to two major factors. First, the narrow-diameter lines have low flow rates, and biofilms form within a few days, shedding bacterial colonies into the stream with each use. Second, the nature of the plastic material in the dental tubing aids bacterial attachment. Atlas and colleagues40 found the pathogen Legionella pneumophila and other species of Legionella in 68% of dental units they tested. Concentrations were greater than 1,000/mL in 36% and greater than 10,000 in 19%. Fotos' team41 noted a higher incidence of antibodies to Legionella organisms in dental workers. Shepherd's research team42 found that failure to follow the regimen of a commercial preparation of hydroperoxide ion-phase transfer catalyst cleaner/disinfectant resulted in persistence of the infection. Interestingly, they also found that oral streptococci were present in 80% of their samples, interpreted as having come from other patients, in spite of antiretraction valves on the dental units. Sterile water is readily available in sterile IV bags, and several dental equipment manufacturers have pressure chambers for expressing the water under pressure. Tubing for delivery must be sterilized, which currently is not possible with most dental units, making this an alternative for dedicated surgical irrigation. (Torabinejad, 040114, p. e29) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is a common presentation of a patient with an exacerbation of a tooth with symptomatic irreversible pulpitis? a. characterized by mild pain b. pain subsides with time c. pulp tissue is well colonized with bacteria d. pain may occur with or without provocation

pain with or without provocation * Basic biologic processes may explain the cause of an exacerbation of a tooth with irreversible pulpitis. Irreversible pulpitis is often due to inflammation of the pulp resulting from a microbial insult caused by caries or microleakage associated with a defective restoration. Exacerbation of a tooth with irreversible pulpitis is characterized by pain, which may be severe. The pain may occur with or without provocation and tends to become increasingly intolerable. A pulp with irreversible pulpitis is usually free of bacteria colonizing in the root canal. Infection is most often confined to the coronal site of the pulp that is exposed to the oral cavity. As long as the radicular pulp remains vital, it usually protects itself against microbial invasion and colonization (Torabinejad, 040114, p. e27) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following factors leads to a higher incidence of post-operative pain? a. partial pulpectomy b. pulpotomy c. male gender d. anterior teeth

partial pulpectomy * It has been demonstrated that removal of the pulp from the pulp chamber (pulpotomy) is a highly predictable approach to alleviating pain at an emergency visit (Fig. 10.12). If time permits, it is considered preferable, after measurement control, to completely remove all pulp tissue from the canal or canals. A clinical study demonstrated that partial pulpectomy resulted in ahigher rate of postoperative pain (13%) compared with pulpotomy (6%). Other important factors associated with postoperative pain were female gender, younger age, and molar teeth. (Torabinejad, 040114, pp. e27-e28) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

presence of an abscess that is draining to a mucosal or skin surface. *CAA is an inflammatory lesion of pulpal origin that is characterized 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. (Torabinejad, 040114, p. e12) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is not an indication to perform drainage of an abscess? a. to bring about rapid resolution of symptoms b. to head off worsening of the infection c. to reduce local vascular flow d. to reduce local tissue acidity

reduce local vascular flow *Drainage of pus from an abscess can speed recovery (Figs. 10.3 and 10.4). The removal of dead lymphocytes and a preponderance of dead bacteria from the center of an infection can bring rapid resolution of symptoms and head off worsening of the infection. Return of local vascular flow can aid in reaching and maintaining antibiotic levels and reduce local tissue acidity, enhancing the action of local anesthetics. Chronic drainage by way of a sinus tract sharply reduces the occurrence of flare-ups due to drainage. Surgical drainage can be quite helpful in treating infections. (Torabinejad, 040114, p. e30) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

refrigerant spray or CO2 ICE *Three methods are generally used for cold testing: frozen water (ice), carbon dioxide (CO2) ice (dry ice), and refrigerant. CO2 ice requires special equipment, whereas refrigerant in a spray can is more convenient (Fig. 5.8). Regular ice delivers less cold and is not as effective as refrigerant or CO2 ice. One study found that refrigerant sprayed on a large cotton pellet was the most effective in reducing the temperature within the chamber under full-coverage restorations. Overall, refrigerant spray and CO2 ice are equivalent for pulp testing. REF (Torabinejad, 040114, p. e14) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is the best way to extend the duration of pulpal anesthesia for a maxillary tooth? a. increase the volume of solution b. increase the concentration of epinephrine c. repeat an infiltration after 30 minutes d. use an anesthetic agent without a vasoconstrictor

repeat infiltration after 30-min.. *A two-cartridge volume of 2% lidocaine with epinephrine extends the duration of pulpal anesthesia, but not for 60 minutes. Increasing the epinephrine concentration to 1 : 50,000 epinephrine increases duration for the lateral incisor but not for the first molar. The duration did not reach 60 minutes in either tooth. Injecting an additional cartridge of 2% lidocaine with epinephrine at 30 minutes in anterior teeth and at 45 minutes in posterior teeth significantly improves the duration of pulpal anesthesia and may be the best way to extend the duration of pulpal anesthesia. (Torabinejad, 040114, p. e24) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is the definition of an emergency? a. It requires a visit within 24 hours of symptoms. b. It is well managed by anti-inflammatory analgesics. c. The patient has the day off work and thus is available for an appointment. d. The patient's insurance has emergency visit coverage.

requires visit within 24-hours of symptoms * An emergency is defined as a visit to the dental emergency clinic within 24 hours of treatment for pain not controlled by ibuprofen, ASA, or Tylenol. (Torabinejad, 040114, p. e28) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

ENDO_Dx,Tx, systemic_5 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

review of insurance coverage --> they should have CA$$H... 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 (Torabinejad, 040114, p. e13) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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.

the RL remains at the APEX in XR's made at different cone angles. *Periapical lesions of endodontic origin usually have four characteristics: (1) the lamina dura of the tooth socket is lost apically; (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. (Torabinejad, 040114, p. e14) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is an indication for prescribing antibiotics? a. in case there is an infection b. to prevent a disease from turning into an infection c. to "clear up" an infection on their own d. to treat an active infection

to treat an active infection *There is no indication for prescribing antibiotics "in case there is an infection" or "to prevent a condition from turning into an infection." Well-controlled research has shown that painful pulpitis is not relieved by systemic antimicrobial therapy.21 The 40 participants experienced the same need for pain relievers regardless of whether they took penicillin or placebo. The patients' pain intensity scores were similar over the 7-day study prior to definitive endodontic treatment. Another researcher noted that total pulp removal gave the most reliable pain relief. Antibiotics do not make the infection go away. They merely work as an adjunct to the patient's defenses. Most infections have multiple bacteria species present, and elimination of only key ones in the commensal or symbiotic relationship is needed.32 Two main indications exist for use of these drugs; namely, to treat an active infection and to prevent infection. The use for these different approaches is quite different. In therapy for active infections, antibiotics have been used locally and/or systemically. Grossman51 originally recommended intracanal antibiotics, a technique that has seen a recent resurgence for the purpose of eliminating all canal bacteria prior to stimulation of periapical stem cells in pulp regeneration. Most often, oral antibiotics are prescribed for systemic infection. Clearly we are witnessing a failure of these drugs due to overuse, both in patients and in farm animals. Research is underway to develop new types, but they will surely be overcome in time, given the powerful resources of the huge variety of microorganisms. In addition to mutation, bacterial cells can share genetic material with each other, even across species. The astute practitioner avoids the use of antibiotics when they are not clearly indicated. Such conservation warrants education of patients and follow-up after treatment. For treatment of active infection, the ideal drug would focus only on the pathogens for a particular patient, and therapy would last only until the host defenses were in control. The concept of culturing and antibiotic sensitivity testing should become part of this approach. (Torabinejad, 040114, p. e30) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which factor is not a predictor of postobturation pain? a. tenderness to finger pressure b. tenderness to percussion c. ability to bite comfortably on the tooth d. treatment completed in a single visit

treatment completed in a single visit * Postobturation emergencies may include pain and diffuse swelling. Tenderness to finger pressure or percussion or an inability to bite comfortably on the tooth is often a predictor of postobturation pain. In such cases it is strongly recommended that obturation be deferred until the patient is pain free and the tooth can be used in function. (Torabinejad, 040114, p. e28) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

In which situation is caries removal necessary to obtain a definitive pulpal diagnosis? a. deep radiographic caries with no symptoms and negative pulp testing b. deep radiographic caries with no symptoms and positive pulp testing c. shallow radiographic caries with mild symptoms and positive pulp testing d. shallow radiographic caries with mild symptoms and negative pulp testing

DEEP CARIES/NO SYMPTOMS and POSITIVE PULP TESTING.. *Determining the depth of caries penetration is necessary in some situations for definitive pulp diagnosis. A common clinical situation is the presence of deep caries on radiographs with 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. (Torabinejad, 040114, p. e14) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What nonspecific inflammatory mediators are not present when the dental pulp is irritated? a. histamine b. epinephrine c. bradykinin d. arachidonic acid metabolites

EPINEPHRINE --- *Irritation of the dental pulp results in the activation of a variety of biologic systems, such as nonspecific inflammatory reactions mediated by histamine, bradykinin, and arachidonic acid metabolites. Also released are PMN lysosomal granule products (elastase, cathepsin G, and lactoferrin), protease inhibitors (e.g., antitrypsin), and neuropeptides (e.g., calcitonin gene-related peptide [CGRP] and substance P [SP]). (Torabinejad, 040114, p. e10) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What are the signs and symptoms associated with symptomatic 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

EXCRUCIATING PAIN ON TAPPING with a mirror. *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. (Torabinejad, 040114, p. e11) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What type of resorption may alter the geometry of the apex? a. internal b. inflammatory cervical c. external apical d. regenerative

EXTERNAL APICAL *Resorption may be either internal or external. Perforating (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 treatment complications, but external apical resorption may drastically alter the geometry of the apex or the root surface. Extensive apical or root surface resorption is best referred. (Torabinejad, 040114, p. e15) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

ENDO_LOCAL_9 What is the allodynia phenomenon? a. Inflamed tissue has an increased threshold of pain. b. Inflamed tissue has a decreased threshold of pain. c. Inflamed tissue is much less sensitive to a mild stimulus. d. Inflamed tissue responds mildly to a stimulus that would otherwise be very painful.

INFLAMED TISSUE HAS A decreased threshold of pain. *Inflamed tissues have a decreased threshold of pain perception; this is called the allodynia phenomenon. In other words, a tissue that is inflamed is much more sensitive and reactive to a mild stimulus. Therefore, an inflamed tissue responds painfully to a stimulus that otherwise would be unnoticed or perceived only mildly. Because root canal procedures generally involve inflamed pulpal or periradicular tissues, this phenomenon has obvious importance. A related complication is that inflamed tissues are more difficult to anesthetize. (Torabinejad, 040114, p. e23) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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.

It CANNOT determine whether the pulp tissue is inflamed. *An electrical pulp test, conducted correctly, will usually determine whether there is vital tissue within the tooth. It cannot determine whether that tissue is inflamed, nor can it indicate whether there is partial necrosis. Electrical pulp testers with 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 readings indicate VITALITY. Testing of normal control teeth establishes 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. (Torabinejad, 040114, p. e14) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

LYMPH DRAINAGE.... *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. (Torabinejad, 040114, p. e9) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Is anesthesia of the maxilla commonly more or less successful than anesthesia in the mandible? a. more successful b. less successful c. comparable

MORE *Anesthesia is more successful in the maxilla than in the mandible. The most common injection for the maxillary teeth is infiltration. (Torabinejad, 040114, p. e24) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

When pain is one of the patient's complaints, what question 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?

Why did you not seek treatment when the pain began? ("what the hell is wrong with you?") *QUESTIONS should be pointed at determining timing and characteristics of the pain. 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)? (Torabinejad, 040114, p. e13) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

When does the onset of pulpal anesthesia occur after the inferior alveolar injection for a mandibular premolar? a. immediately b. 0 to 5 minutes c. 5 to 9 minutes d. 14 to 19 minutes

5-9 min.. *Pulpal anesthesia usually occurs in 5 to 9 minutes in the molars and premolars and 14 to 19 minutes in the anterior teeth.44-54 In some patients onset occurs sooner, and in others it is delayed. (Torabinejad, 040114, p. e24) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is a sufficient time for an intracanal disinfectant to be present to accomplish disinfection? a. There is no minimum time, as long as the canal is débrided of detectable pulp tissue. b. A minimum of 5 minutes should be allowed after the canal has been débrided of detectable pulp tissue. c. A minimum of 10 minutes should be allowed after the canal has been débrided of detectable pulp tissue. d. A minimum of 15 minutes should be allowed after the canal has been débrided of detectable pulp tissue.

15 minutes... *There should be no bravado about how fast one can perform endodontic therapy. Sufficient time for disinfectant is likely a minimum of 15 minutes after the canal has been débrided of detectable pulp tissue. (Torabinejad, 040114, p. e29) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

A SEVERE INFLAMATORY PROCESS... *Irreversible pulpitis may be classified as symptomatic or asymptomatic. It is a clinical condition associated with subjective 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 operative 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 inflammatory 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 spontaneous 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, localized, or diffuse and can last anywhere from a few minutes up to a few hours. Localization of pulpal pain is more difficult than localization 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 irreversible 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 thresholds to electrical stimulation, Mumford found similar pain perception thresholds in inflamed and uninflamed pulps. (Torabinejad, 040114, pp. e10-e11) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is not an element of the psychological approach to pain management? a. control b. communication c. conservation d. confidence

CONSERVATION *The psychological approach involves the four Cs: 1. control 2. communication 3. concern 4. confidence. Control is important and is achieved by obtaining and maintaining the upper hand. Communication is accomplished by listening to the patient and explaining what is to be done and what the patient should expect. Concern is shown by verbalizing awareness of the patient's apprehension. Confidence is expressed in body language and in professionalism, which give the patient confidence in the management, diagnostic, and treatment skills of the dentist. Including the four Cs in pain management effectively calms and reassures the patient, thereby raising the pain threshold. (Torabinejad, 040114, p. e23) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

ENDO__PA PATHOSIS_4 T/F -- A direct pulp exposure of a carious lesion is necessary to have a pulpal response and inflammation.

FALSE *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. (Torabinejad, 040114, p. e9) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

T/F -- A PDL injection can be used for selective anesthesia of an individual tooth as an aid in diagnosis.

FALSE *It has been suggested that the PDL injection may be used in the differential diagnosis of poorly localized, painful irreversible pulpitis. However, adjacent teeth are often anesthetized with PDL injection of a single tooth. Therefore, this injection is not useful for differential diagnosis. (Torabinejad, 040114, p. e25) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which gender is at a substantially greater risk for many clinical pain conditions? a. female b. male

FEMALES * Evidence clearly demonstrates that women are at substantially greater risk for many clinical pain conditions. A growing body of evidence over the past 10 to 15 years indicates that there are substantial gender differences in clinical and experimental pain responses. (Torabinejad, 040114, p. e29) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is an appropriate treatment to address a necrotic exacerbation with swelling? a. prescribing antibiotics alone b. prescribing antibiotics and then seeing the patient after the swelling has subsided to begin treatment c. incision and drainage of the swelling d. incision and drainage of the swelling with concomitant instrumentation and irrigation

I&D with concomitant instrumentation and irrigation * Treatment of the necrotic exacerbation is focused on the root canal if there is no swelling. Reinstrumentation and irrigation are the basic treatments directed at reducing the intracanal level of microorganisms. If swelling exists, the clinician should consider incision and drainage followed by instrumentation and irrigation of the canal. Antibiotics alone should not be used without concomitant instrumentation and irrigation. Incision and drainage are directed at reducing periapical tissue pressure and eliminating pus; reinstrumentation and irrigation are directed at the primary cause of the problem, which is the remaining intracanal bacteria. (Torabinejad, 040114, p. e28) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Why should an anesthetic agent not be injected directly into a swelling before an incision for drainage? a. The anesthetic will cause a decreased flow of exudate after incision. b. A direct injection will spread the infection. c. There is an increased chance of aspirating blood. d. The swelling has an increased blood supply, so the anesthetic is transported quickly into the systemic circulation, diminishing the effect.

INCREASED blood supply in the swelling *Patients tolerate procedures better when some anesthesia is present before incision and drainage of the swelling. However, obtaining profound anesthesia is difficult, which should be explained to the patient. In the mandible, an inferior alveolar nerve block plus a long buccal injection (for molars) and inferior alveolar plus labial infiltration (for premolars and anterior teeth) are administered. In the maxilla, infiltration is given mesial and distal to the swelling. For palatal swellings, a small volume of anesthetic is infiltrated over the greater palatine foramen (for posterior teeth) or over the nasopalatine foramen (for anterior teeth). With swelling over either foramen, lateral infiltration is indicated. Injection directly into a swelling is contraindicated. These inflamed tissues are hyperalgesic and difficult to anesthetize. Traditional beliefs are that the anesthetic solution may be affected by the lower pH and is rendered less effective and that direct injection will "spread the infection," although neither belief has been proven. Nevertheless, pain from the injection pressure and ineffectiveness are reasons to avoid injection into a swelling. Theoretically, the area of swelling has an increased blood supply, and anesthetic therefore is transported quickly into the systemic circulation, diminishing the anesthetic effect. Also, edema and purulence may dilute the solution. (Torabinejad, 040114, p. e26) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

INCREASED venule vascular permeability..... *Pain is often caused by several factors. The release of mediators 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 elevation of tissue pressure. This pressure acts directly on sensory nerve receptors. (Torabinejad, 040114, p. e10) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is a consideration with an intraosseous (IO) injection? a. IO injections have not been proved effective. b. IO injection has been recommended as the primary injection technique. c. IO injection allows the anesthetic solution to be deposited directly into the pulp tissue of the tooth. d. IO injection allows the anesthetic solution to be deposited directly into the cancellous bone adjacent to the tooth.

IO injection allows the anesthetic solution to be deposited directly into the cancellous bone adjacent to the tooth. *The IO injection is a supplemental technique that has been shown to be effective through substantial research and clinical use. It is particularly useful in conjunction with a conventional injection when it is likely that supplemental anesthesia will be necessary (e.g., in mandibular second molar teeth). The IO injection allows placement of a local anesthetic directly into the cancellous bone adjacent to the tooth. The Stabident System (Fig. 9.6) is an IO system with two components. One part is a slow-speed handpiece-driven perforator, which drills a small hole through the cortical plate (Fig. 9.7). The anesthetic solution is delivered into cancellous bone through a matching 27-gauge ultrashort injector needle (Fig. 9.8). Another IO system, the X-Tip System (Fig. 9.9), uses a guide sleeve that remains in the perforation (Fig. 9.10). This serves as a guide for the needle, and it may remain in place throughout the procedure in the event that reinjection is necessary. The perforation may be made in attached gingiva or alveolar mucosa with this system. (Torabinejad, 040114, p. e25) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following has been shown to be effective at increasing the success rate of mandibular anesthesia? a. increasing the volume of anesthetic from one to two cartridges b. increasing the epinephrine concentration from 1 : 100,000 to 1 : 50,000 c. using articaine instead of lidocaine d. none of the above

NONE of the ABOVE **Increasing the volume of anesthetic from one to two cartridges does not increase the success rate of obtaining pulpal anesthesia with the inferior alveolar nerve block. There is no improvement in pulpal anesthesia with a higher concentration (1 : 50,000) of epinephrine in an inferior alveolar nerve block.54,55 Some alternative solutions to 2% lidocaine with 1 : 100,000 epinephrine are equivalent in providing pulpal anesthesia for at approximately 1 hour after an inferior alveolar nerve block. These alternative solutions include 2% mepivacaine with 1 : 20,000 levonordefrin; 4% prilocaine with 1 : 200,000 epinephrine; and plain solutions (3% mepivacaine and 4% prilocaine).48,51 Articaine (4% articaine with epinephrine) is a safe and effective local anesthetic agent for inferior alveolar nerve blocks.56-65 Articaine has a reputation of providing an improved local anesthetic effect.66 However, clinical trials have failed to detect any superiority of articaine over lidocaine in inferior alveolar nerve block anesthesia.61,64 Like prilocaine, articaine has the potential to cause neuropathies.67 The incidence of paresthesia (involving the lip and/or tongue) associated with articaine and prilocaine was higher than that found with either lidocaine or mepivacaine.67-69 Other authors have not found a higher incidence when using articaine.70 However, because there is no difference between articaine and lidocaine in the success of pulpal anesthesia for inferior alveolar nerve blocks, and because some attorneys are aware of the proposed association of articaine with paresthesia, it seems reasonable to use articaine for infiltrations but not for nerve blocks. (Torabinejad, 040114, p. e24) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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.

No difference in pain perception has been confirmed with warming. *A common belief is that an anesthetic solution warmed to or above body temperature is better tolerated and results in less pain during injection. Although some studies have shown that warming anesthetic solutions did not reduce the pain of injection,15-17 others studies have found that warming reduced the pain of injection.18-20 Therefore, further research is needed on the effects of warming anesthetic solutions. (Torabinejad, 040114, p. e23) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

ODONTOCLASTSSSS>>> *In addition to nonspecific inflammatory reactions, immune responses also may initiate and perpetuate deleterious pulpal changes. 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 un-inflamed dental pulps contain immunocompetent cells, such as T and B (fewer) lymphocytes, macrophages, and a substantial number of class II molecule-expressing dendritic cells, which are morphologically similar to macrophages. 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. Arthus-type reactions do occur in the dental pulp. In addition, the presence of immunocompetent cells, such as T lymphocytes, 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. Despite their protective mechanisms, immune reactions in the pulp can result in the formation of small necrotic foci and eventual total pulpal necrosis. (Torabinejad, 040114, p. e10) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

OLDER *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. (Torabinejad, 040114, p. e13) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

During a review of the patient's health history, the clinician 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

OSTEONECROSIS (BRONJ)..... *Over the past decade, it has been recognized that patients undergoing bisphosphonate therapy may be at risk of osteonecrosis of the jaw (BRONJ). This risk is greater with intravenous 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. Although rare, BRONJ may occur after endodontic treatment or endodontic surgery. When nonsurgical 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 oral bisphosphonates compared with those seen in other patients. (Torabinejad, 040114, p. e13) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

A painful response obtained by pressing or by tapping on the crown indicates the presence of which of the following? a. periapical inflammation b. pulpal inflammation c. both pulpal and periapical inflammation

PERIAPICAL INFLAMATION 1st -- gentle DIGITAL pressure --> if painful DON't TAP 2nd -- TAP with MIRROR --> SHARP Pain = PA inflammation. * 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. Periapical inflammation may produce a sharp pain. (Torabinejad, 040114, p. e14) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is palpation testing used to determine? a. pulpal inflammation b. periapical inflammation c. periodontal inflammation d. periapical histology

PERIAPICAL INFLAMMATION.. *Palpation is firm pressure on the mucosa overlying the apex. Like percussion, palpation determines how far the inflammatory process has extended periapically. A painful response to palpation indicates periapical inflammation. (Torabinejad, 040114, p. e14) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

POSITIVE RESPONCE TO THERMAL PULP TESTING... *By definition, reversible pulpitis is a clinical condition associated with subjective and objective findings indicating the presence 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 procedures; 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 immediate 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. (Torabinejad, 040114, p. e10) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

PRESENCE OF BACTERIA -- *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 conventional 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 formation occurred by the eighth day in conventional rats (Fig. 4.7, B). Other investigators have examined the importance of 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 periapical inflammation. The bacteriologic investigation by Sundqvist25 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 traumatized teeth with necrotic pulps, with and without apical pathosis. Teeth without apical lesions were aseptic, whereas those with periapical pathosis had positive bacterial cultures. (Torabinejad, 040114, p. e9) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

PULP VITALITY TESTING! *A number of radiolucent and radiopaque lesions of nonendodontic 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 associated with radiolucent periradicular lesions have necrotic pulps and therefore generally do not respond to vitality tests. In contrast, 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. (Torabinejad, 040114, p. e12) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What histologic feature differentiates a periapical granuloma 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

Presence of an epithelium-lined cavity!!! *Histologically, AAP lesions are classified as either granulomas or cysts. A periapical granuloma consists of granulomatous 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 elements 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. (Torabinejad, 040114, p. e11) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

During a review of the patient's health history, the clinician 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 diabetic 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.

RESIDUAL LESIONS 2-4 yrs after treatment correlate significantly with the degree of glycemia.. *It is generally known that diabetics have an increase prevalence of teeth with periapical lesions. The longitudinal treatment outcome is generally no different between diabetics and non-diabetics. 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 successful treatment than nondiabetics, especially when the study controls for a number of other confounding factors. 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. This is consistent with older observations that healing of periapical lesions correlated with postprandial glycemia at the time of treatment. (Torabinejad, 040114, p. e15) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What additional anesthetic procedure should be administered if the classic signs of anesthesia are present after a standard injection, but the patient still has sharp pain when the bur enters the dentin? a. repeat the initial injection b. wait an additional 15 minutes and attempt access again c. repeat the injection using a different type of anesthetic solution d. use a supplemental injection technique for a second injection

SUPPLEMENTAL INJECTION TECHNIQUE -->e.g. try infiltration in addition, *A supplemental injection is used if the standard injection is not effective. It is useful to repeat an initial injection only if the patient is not exhibiting the "classic" signs of soft tissue anesthesia. Generally, if the classic signs are present, reinjection is not very effective. For example, after the inferior alveolar nerve block, the patient develops lip, chin, and tongue numbness and quadrant "deadness" of the teeth. A useful procedure is to pulp-test the tooth with cold (cold refrigerant) or an electrica pulp tester before the cavity preparation is begun. If the patient feels pain to cold, a supplemental injection is indicated. Assuming that reinjection using the inferior alveolar nerve block approach will be successful is wishful thinking; failure the first time is usually followed by failure on the second attempt. The dentist should go directly to a supplemental technique. Three such injections are (1) the infiltration injection, (2) the intraosseous (IO) injection, (3) and the periodontal ligament (PDL) injection. (Torabinejad, 040114, pp. e24-e25) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

THICKENING OF PDL does NOT result from pulp irritation. *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. A yellowish discoloration of the crown is often a manifestation of calcific metamorphosis. 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 narrowing of the root canal is the first sign of calcific metamorphosis. 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 condition leads to the resorption of the dentinal walls, advancing from its center to the periphery. 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. Radiographs 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 eventually perforate to the lateral periodontium. When this occurs, pulp necrosis ensues, and treatment of the tooth becomes more difficult. (Torabinejad, 040114, p. e11) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is the typical means by which bacteria enter the canal space? a. periodontal disease b. caries c. fractures d. trauma

TRAUMA *In the natural history of endodontic disease, bacteria typically arrive in the canal space from caries, generally regarded as the most common source of pulpal infection. Periodontal disease, fractures, abrasion, and even trauma to a pulpally intact tooth have also been demonstrated to be avenues of entry for microbes. In their typical narrow dimension, bacteria are about 1 µm; dentinal tubules are almost four times that diameter. Increased peritubular dentin may impede but not eliminate bacteria ingress with age. (Torabinejad, 040114, p. e29) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

T/F -- Localization of pulpal pain is more difficult than localization of periradicular pain.

TRUE *Localization of pulpal pain is more difficult than localization of periradicular pain and becomes more difficult as the pain intensifies. (Torabinejad, 040114, p. e12) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following correctly describes the administration of a two-stage injection? a. The clinician injects a cartridge of anesthetic, waits 5 minutes, and then injects a second cartridge of the same anesthetic solution. b. The clinician injects a cartridge of anesthetic and then immediately injects a second cartridge of a different anesthetic solution. c. The clinician injects a quarter cartridge of anesthetic under the mucosal surface, waits until regional anesthesia has been obtained, and then injects the remainder of the cartridge to full depth. d. The clinician injects a quarter cartridge of anesthetic under the mucosal surface, waits until regional anesthesia has been obtained, and then injects a cartridge of a different anesthetic solution to full depth.

The clinician injects a quarter cartridge of anesthetic under the mucosal surface, waits until regional anesthesia has been obtained, and then injects the remainder of the cartridge to full depth. *A two-stage injection is administered as follows: the clinician gives an initial, very slow injection of approximately a quarter cartridge of anesthetic just under the mucosal surface; after regional numbness has been achieved, the remainder of the cartridge is deposited to the full depth at the target site. The two-stage injection reduces the pain of needle placement for females in the inferior alveolar nerve block. This injection technique is indicated for apprehensive and anxious patients and for pediatric patients, but it may be used on anyone. It is also effective for any injection including the inferior alveolar nerve block. (Torabinejad, 040114, p. e23) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is an important consideration with the intrapulpal (IP) injection? a. The injection should be given with back-pressure. b. The injection will require several minutes to take effect. c. The duration of anesthesia is 30 to 45 minutes. d. An IP injection should be the first supplemental injection technique attempted.

The injection should be given with back-pressure *After the inferior alveolar nerve block, IO and PDL injections occasionally do not produce profound anesthesia, even when repeated, and pain persists when the pulp is entered. This is an indication for an IP injection. However, the IP injection should not be used without first administering an IAN, plus an IO or IL injection. The IP injection is very painful without some other form of supplemental anesthesia. Although the IP injection is somewhat popular, it has disadvantages, as well as advantages, making it the last supplemental injection of choice. The major drawback is that the needle is inserted directly into a vital and very sensitive pulp; thus the injection may be exquisitely painful. Also, the effects of the injection are unpredictable if it is not given under pressure. The duration of anesthesia, once attained, is short (5 to 15 minutes). Therefore, the bulk of the pulp must be removed quickly and at the correct working length to prevent recurrence of pain during instrumentation. Another disadvantage is that the pulp must be exposed to permit direct injection; often problems with anesthesia occur before pulpal exposure. The advantage of the IP injection is the predictability of profound anesthesia if the injection is given under back-pressure. The onset of anesthesia is immediate, and no special syringes or needles are required, although different approaches may be necessary to attain the desired back-pressure. (Torabinejad, 040114, p. e25) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

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

To CALIBRATE the patient's response... *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 "calibrates" 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 clinician 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. (Torabinejad, 040114, p. e13) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What analgesics have been shown to have superior performance in pain reduction? a. acetaminophen and ibuprofen b. ibuprofen plus an opioid c. acetaminophen plus an opioid d. opioids alone

acetaminophen and ibuprofen * Drugs to diminish pain perception can be divided into two broad categories, opioids and others. Whether bacterial or otherwise, almost all dental pain arises from inflammation. Opioids and acetaminophen are considered to act primarily on the central nervous system. In contrast, inflammation-suppressing drugs, such as corticosteroids and nonsteroidal antiinflammatory drugs (NSAIDs), are very effective in reducing pain through their action at the site of injury. The combination of NSAIDs with acetaminophen, which apparently acts centrally, is even more effective. A recent dental extraction study found the combination of acetaminophen and ibuprofen superior to either ibuprofen plus an opioid or acetaminophen plus an opioid. It has long been known that classic opioids (e.g., codeine and hydrocodone), although often prescribed, are less effective than drugs directed specifically at inflammation. Opioids have harsh side effects, such as sedation, diminution of protective reflexes, and an additive effect with all CNS depressants, in addition to addiction. (Torabinejad, 040114, p. e30) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is the primary agent of endodontic disease? a. caries b. trauma c. bacteria d. fracture

bacteria *The significance of bacteria and other microorganisms to endodontic pathology was elegantly demonstrated by Kakehashi, Stanley, and Fitzgerald in their classic work from 1965.35 With no microbial presence, simply accessing the pulp canals without pulp débridement resulted in no disease. Remaining pulp tissue remained vital in spite of food and debris impaction into the canal spaces. The control group of conventional animals showed microbial invasion through the teeth into periapical structures, as is typically seen in patients. The only difference was the absence of bacteria, clearly demonstrating that bacteria are the primary agent of endodontic disease. Thus it behooves practitioners to eliminate bacteria from the canal system and prevent their penetration into the periapical tissues. (Torabinejad, 040114, p. e29) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following has not been found to be a contributing cause in a flare-up? a. iatrogenic irritation of the tissues beyond the apical terminus b. pushing dentin chips into the periapical tissues c. pushing remnants of infected pulp tissue into the periapical tissues d. difficulty obtaining profound anesthesia

difficulty obtaining profound anesthesia * There are a number of hypotheses concerning the true cause of flare-ups, which have been described as multifactorial. Causes include iatrogenic mechanical irritation of the tissues beyond the apical terminus and/or pushing dentin chips and remnants of infected pulp tissue into the periapical tissues. A procedural accident often impedes therapy or makes it impossible for therapy to be completed, such as by preventing a thorough mechanical débridement or creating a bacteria-tight seal of a root canal system. An increased risk exists when a procedural accident occurs during treatment of infected teeth.15 There are also chemical factors, including irrigants, intracanal dressings, and sealers.7 Endodontic procedural errors are not the direct cause of treatment failure. They increase the risk of failure because of the clinician's inability to eliminate microorganisms from the infected root canals.16 The number of treatment visits has also been examined as a factor in flare-ups. In a retrospective study the flare-up rate in necrotic molars in one-visit versus two-visit endodontic treatment was examined.17 Treatment records of 402 consecutive patients with pulpally necrotic first and second molars were compared. One-visit treatment showed an advantage at the 95% confidence level. However, retrospective analyses do not control for the reason that a case took one or more appointments to complete, and some other studies have shown no differences between single and multiple visits in the incidence of flare-ups. (Torabinejad, 040114, p. e28) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is the best site for an IO injection of a premolar? a. mesial perforation and injection b. apical perforation and injection c. distal perforation and injection d. The site of injection is not important.

distal perforation and injection *Distal perforation and injection to the tooth result in the best anesthesia. Second molars are an exception; for them, a mesial site is preferred. When necessary a lingual approach also may be successful, although this approach has not been studied. (Torabinejad, 040114, p. e25) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

ENDO_emrgencies_10 What is the immediate goal of an emergency visit? a. to prescribe the appropriate antibiotic medication b. to assess the patient's history c. to eliminate the patient's primary cause of distress d. to place calcium hydroxide as an intracanal medication

eliminate primary cause of distress *The immediate goal of an emergency visit is to bring the case under control by eliminating the patient's primary cause of distress, which is most often pain with or without swelling (Torabinejad, 040114, p. e27) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

What is an important requirement for effectiveness when giving a periodontal ligament (PDL) injection? a. ensuring back-pressure during injection b. directing the needle bevel toward the root surface c. directing the needle bevel away from the root surface d. ensuring that all four line angles receive the injection

ensuring back pressure during injection *Back-pressure is important. If there is no back-pressure (resistance)—that is, if the anesthetic readily flows out of the sulcus—the needle is repositioned and the technique repeated until back-pressure is attained. (Torabinejad, 040114, p. e25) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106

Which of the following is particularly important to achieving a satisfactory endodontic outcome at an emergency visit? a. the patient's level of anxiety b. the patient's medical history c. selection of an appropriate antibiotic d. completion of root canal treatment in a single visit

level of anxiety *Patient anxiety is an important factor in achieving a satisfactory endodontic outcome, especially at an emergency visit. More than 200 studies indicate that behavioral intervention to reduce anxiety before and after surgery reduces postoperative pain intensity and the intake of analgesics and also accelerates recovery.10 A clinical study determined that the higher the level of anxiety, as measured by a visual analogue anxiety scale, the less likely it was that pain would be eliminated by the administration of local anesthetics.11 A conversation with the patient to discuss the clinician's pain preventive strategy, including the use of profound local anesthesia, is an important prelude to treatment. (Torabinejad, 040114, p. e27) Torabinejad, M., Fouad, A., Walton, R. (040114). Endodontics: Principles and Practice, 5th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781455754106