Answer Key for Sample Answer Key • Sample Examination 429

Examination
Endodontics knowledge and understanding of the risks and
bene ts to treatment. is principle is the basis
1. A. Acute apical (periradicular) periodontitis is char- for the practice of “informed consent” in the
acterized by pain, commonly triggered by chewing physician-patient transaction regarding health
or percussion. Acute periradicular periodontitis care.
alone is not indicative of irreversible pulpitis. It 7. B. e pulp contains two types of sensory nerve bers:
indicates that apical tissues are irritated, which myelinated (A bers) and unmyelinated (C bers).
may be associated with an otherwise vital pulp. A bers include A-beta and A-delta, of which
2. C. e most important part of the restored tooth is A-delta are the majority. A-delta bers are princi-
the tooth itself. No combination of restorative pally located in the region of the pulp-dentin junc-
materials can substitute for tooth structure. Posts tion, are associated with a sharp pain, and respond
do not reinforce the tooth, but rather weaken it to relatively low-threshold stimuli. C bers are dis-
further by additional removal of dentin and by tributed throughout the pulp, are associated with a
creating stress that predisposes to root fracture. throbbing pain sensation, and respond to relatively
3. A. Lingering spontaneous pain is evidence of C- ber high-threshold stimuli.
stimulation. Even in degenerating pulps, C bers 8. A. e paralleling, not right-angle, technique is best
may respond to stimulation. e excitability of C for endodontics. e lm is placed parallel to the
bers is less a ected by disruption of blood ow long axis of the tooth, and the beam is placed at a
compared with A bers. C bers are o en able to right angle to the lm. e technique allows for the
function in hypoxic conditions (e.g., at the early most accurate and reproducible representation of
stage of pulpal necrosis). tooth size.
4. A. Nasopalatine duct cyst is a circular radiolucent 9. C. e principles of ap design are as follows: (1) ap
area seen as a marked swelling in the region of the design should ensure adequate blood supply, and
palatine papilla. It is situated mesial to the roots of the base of the ap should be wider than the apex;
the central incisors, at the site of the incisive (2) re ection of the ap should adequately expose
foramen. e pulps of the anterior teeth test vital the operative eld; and (3) ap design should
(whereas a periapical cyst tests nonvital). is is permit atraumatic closure of the wound.
the most common type of maxillary developmental 10. D. Studies have shown that 50% of the roots of maxil-
cyst. ey o en remain limited in size and are lary lateral teeth were distally dilacerated. Over-
asymptomatic; they may become infected and sight of the distal direction of root dilaceration
show a tendency to grow extensively. of upper lateral incisors can be a contributing
5. E. A patient’s immune response to a periradicular factor in the failure of endodontic treatment of
infection varies according to the individual. e these teeth.
size and volume of the pulp, the number and 11. B. EDTA is the chelating solution customarily used in
quality of the nerves, and the pulpal vascularity endodontic treatment. Chelators remove inorganic
and cellularity all are unique to the individual components, leaving the organic tissue elements
patient. e di erent virulence of organisms intact.
causing the infection may cause di erences in pain 12. D. Periodontal disease can have an e ect on the
experienced and di erences in the amount of pulp through dentinal tubules, lateral canals, or
orthoclastic activity. Sheer numbers of organisms both. Primary periodontal lesions with second-
can in uence their virulence. ary endodontic involvement di er from primary
6. B. Any notion of moral decision making assumes that endodontic lesions with secondary periodontic
rational agents are involved in making informed involvement in their temporal sequence. Primary
and voluntary decisions. In health care decisions, periodontal problems have a history of extensive
respect for the autonomy of the patient would, in periodontal disease.
common parlance, mean that the patient has the 13. D. e buccal object rule (Clark’s rule or “SLOB” rule
capacity to act intentionally, with understanding, [Same Lingual, Opposite Buccal]) is used to iden-
and without controlling in uences that would mit- tify the buccal or lingual location of objects in
igate against a free and voluntary act. It implies relation to a reference object. If the image of the

429
430 Answer Key • Sample Examination

object moves mesially when the x-ray tube is splinting period is completed, follow-up is as with
moved mesially, the object is located on the lingual. all dental traumatic injuries, at 3, 6, and 12 months
If the image of the object moves distally when the and yearly therea er.
x-ray tube moves mesially, the object is located on 19. B. Radiographic examination for root fractures is
the buccal (facial). extremely important. Because a root fracture is
14. D. Ledges can sometimes be bypassed; the canal typically oblique (facial to palatal), one periapical
coronal to the ledge must be su ciently straight- radiograph may easily miss its presence. It is
ened to allow a le to operate e ectively. is imperative to take at least three angled radiographs
straightening may be achieved by anticurvature (45, 90, and 110 degrees) so that in at least one
ling ( le away from the curve). e dentist pre- angulation the radiographic beam passes directly
curves the le severely at the tip and uses it to through the fracture line and makes it visible on
probe gently past the ledge. Otherwise, the dentist the radiograph.
cleans to the ledge and lls; the patient is warned 20. D. For decades, controversy has surrounded the valid-
of the poorer prognosis. ity of thermal and electrical tests on traumatized
15. D. Factors a ecting the long-term prognosis of teeth teeth. Only generalized impressions may be gained
a er perforation repair include the location of from these tests a er a traumatic injury. ey
the defect in relation to the crestal bone, the length are sensitivity tests for nerve function and do
of the root trunk, the accessibility for repair, not indicate the presence or absence of blood cir-
the size of the defect, the presence or absence of a culation within the pulp. It is assumed that a er
periodontal communication to the defect, the traumatic injury, the conduction capability of the
time lapse between perforation and repair, the nerve endings or sensory receptors is su ciently
sealing ability of the restorative material, and tech- deranged to inhibit the nerve impulse from an
nical skill. Early recognition and repair improve electrical or thermal stimulus; this makes the trau-
the prognosis. Smaller perforations (<1 mm) matized tooth vulnerable to false-negative readings
cause less destruction. Subcrestal lesions, espe- from these tests. Teeth that give a positive response
cially lesions closer to the apex, have a better at the initial examination cannot be assumed to be
prognosis. healthy or that they will continue to give a positive
16. B. If an instrument is broken at the lling stage, it is response over time. Teeth that yield a negative
not necessary to remove or bypass the instrument response or no response cannot be assumed to
because the canal has already been cleaned and have necrotic pulps because they may give a posi-
shaped. Prognosis depends largely on the extent of tive response at later follow-up visits. It may take 9
undébrided material remaining within the canal. months for normal blood ow to return to the
e dentist should attempt to obturate as much of coronal pulp of a traumatized, fully formed tooth.
the canal as possible. As circulation is restored, responsiveness to pulp
17. D. Teeth that have been endodontically treated have tests returns.
lost much of their coronal dentin in the access 21. A. e K- le and K-reamer are the oldest instruments
formation, regardless of the caries state before end- for cutting and machining dentin. ey are made
odontic treatment. is loss of dentin compro- from a steel wire that is ground to a tapered square
mises the internal architecture of the tooth. Less or triangular cross section and then twisted to
internal tooth structure, combined with the absorp- create either a le or a reamer. A le has more utes
tion of external forces (usually occlusal) may per unit length than a reamer. e K-Flex le is a
exceed the strength of dentin and result in fracture. modi cation of the shape of the K- le, with a non-
Endodontic treatment and loss of pulp vitality are cutting tip design.
no longer thought to desiccate the tooth to the 22. B. e indications for a direct pulp cap for a tooth
point of increasing risk of fracture. are (1) asymptomatic tooth, (2) with little or no
18. C. When a root fractures horizontally, the coronal hemorrhaging, (3) small (<1 mm), and (4) well-
segment is displaced to a varying degree, but gen- isolated traumatic pulp exposure. A direct pulp cap
erally the apical segment is not displaced. Because acts to stimulate the formation of a reparative
the apical pulpal circulation is not disrupted, pulp dentin bridge over the exposure site and to preserve
necrosis in the apical segment is extremely rare. the underlying pulpal tissue. It is especially suc-
Pulp necrosis in the coronal segment results cessful in immature teeth. Failure of direct pulp
because of its displacement; this occurs in only capping is indicated by (1) symptoms of pulpitis at
about 25% of cases. Because 75% do not lose vital- any time and (2) lack of vital pulp response a er
ity, emergency treatment involves repositioning several weeks. Failures result in pulpal necrosis
the segments in as close proximity as possible (continual pulpal insult), calci cation of the pulp,
and splinting the teeth for 2 to 4 weeks. A er the or (rarely) internal resorption. Direct pulp capping
 Answer Key • Sample Examination 431

is primarily used on permanent teeth. It is not used cells adjacent to granulation tissue, and necrotic
o en in primary teeth because of the alkaline pH pulp coronal to resorptive defect. Only prompt
of calcium hydroxide. It can cause either mild or endodontic therapy can stop the process and
(o en) severe pulp irritation. With severe irrita- prevent further tooth destruction.
tion, the risk of internal resorption is increased. 31. C. e best treatment of symptomatic irreversible pul-
With primary teeth, severe resorption is more pitis with a corresponding bony lesion is removal
common; in permanent teeth, formation of repara- of the source of infection via pulpectomy.
tive dentin occurs more o en. 32. B. e current recommendation for patients with a
23. E. If an immature tooth is nonvital, the diseased tissue recent MI is to postpone dental or surgical treat-
must be removed via pulpectomy. Apexi cation is ment for at least 6 months. Risk for a second MI in
the treatment of choice. patients with recent MI if given a general anes-
24. A. Internal bleaching alone causes 3.9% of external thetic is as follows: 0 to 3 months a er MI, 31%
cervical root resorption (also referred to as periph- risk of reinfarction; 3 to 6 months a er MI, 15%
eral in ammatory root resorption). A barrier (base risk of reinfarction; more than 6 months a er MI,
material) of approximately 4 mm between the root 5% risk of reinfarction.* defer elective care for at
lling material and the internal bleaching material least 6 months a er MI.
should be present to prevent this resorption. 33. D. Incision and drainage techniques work best for
25. B. Sodium perborate is more easily controlled and uctuant abscesses, so as to release purulent
safer than concentrated hydrogen peroxide solu- exudate. Local anesthesia should be obtained rst.
tions and should be the material of choice for inter- An incision should be placed at the most depen-
nal bleaching. dent part of the swelling. e incision should be
26. C. In newly erupted teeth, the apical root end has not wide enough to facilitate drainage and allow blunt
fully formed, allowing for greater blood supply to dissection. A er irrigation, a drain may be placed
the tooth. Subsequent pulpal regeneration leads to to maintain patency of the wound.
greater long-term success. 34. C. Many studies have shown de nitively the predomi-
27. C. e physical and chemical properties of zinc oxide nant role of gram-negative obligate anaerobic bac-
eugenol are bene cial in preventing pulpal injury teria in endodontic periapical infections. Earlier
and in reducing postoperative tooth sensitivity. studies generally implicated facultative organisms,
Zinc oxide eugenol provides a good biologic but improved culturing techniques established the
seal; also, its antimicrobial properties enable it predominance of obligate anaerobes.
to suppress bacterial growth, reducing formation 35. C. “Danger zone” refers to the distal area in the mesial
of toxic metabolites that might result in pulpal root in mandibular molars. Usually a straight layer
in ammation. of dentin, it becomes a preferable site for strip per-
28. C. When endodontic treatment is done properly, foration during instrumentation. “Safety zone” is
healing of the periapical lesion usually occurs with described as the mesial area of the root, with a
osseous regeneration, which is characterized by thicker layer of dentin, slightly touched by the
gradual reduction and resolution of the radiolu- endodontic instruments.
cency on follow-up radiographs. e rate of bone 36. D. In an intrusive dental injury, the patient may com-
formation is slow, and complete resolution may plain of pain. e patient’s tooth is misaligned, or
take longer than the standard 6-month follow-up, there is no sense of tooth mobility. is type of
especially with elderly patients. As long as the displacement has the worst prognosis. For intruded
radiolucency appears to be resolving as opposed to primary teeth, teeth should be allowed to reerupt
enlarging, an extended reevaluation is in order. before possible repositioning. For intruded adult
29. B. Pulpotomy is normally not recommended in per- teeth, treatment is allow reeruption and then
manent teeth unless root development is incom- stabilize.
plete. If incomplete, calcium hydroxide pulpotomy 37. A. Internal resorption begins on the internal dentin
is recommended. is procedure is performed in surface and spreads laterally. It may or may not
permanent teeth with immature root development reach the external tooth structure. e process is
and with healthy pulp tissue. e success is indi- o en asymptomatic and becomes identi able only
cated when the root apex, if not completely formed, a er it has progressed enough to be detectable
completes its full development. is procedure is radiographically. e etiology is unknown. Trauma
done only on teeth free of symptoms. is o en, but not always, implicated. Resorption
30. B. Internal resorption is most commonly identi ed that occurs in in amed pulps is characterized his-
during routine radiographic examination. Histo- tologically by dentinoclasts, which are specialized,
logically, it appears with chronic pulpitis, including multinucleated giant cells similar to osteoclasts.
chronic in ammatory cells, multinucleated giant Treatment is prompt endodontic therapy. However,
432 Answer Key • Sample Examination

once external perforation has caused a periodontal 9. A. e rst number is the width of the blade or primary
defect, the tooth is o en lost. cutting edge in tenths of a millimeter (0.1 mm).
38. A. Internal bleaching alone causes 3.9% of external e second number of a 4-number code indicates
cervical root resorption (also referred to as periph- the primary cutting edge angle, measured from a
eral in ammatory root resorption). e presence of line parallel to the long axis of the instrument
a barrier (base material) between the root lling handle in clockwise centigrades. e angle is
material and the internal bleaching material should expressed as a percent of 360 degrees. e instru-
be approximately 4 mm to prevent this resorption. ment is positioned so that this number always
39. E. Emergency treatment of localized swelling associ- exceeds 50. If the edge is locally perpendicular to
ated with an endodontic infection is to achieve the blade, this number is normally omitted, result-
drainage either through the root canal or by inci- ing in a 3-number code. e third number (second
sion and drainage and to remove the source number of a 3-number code) indicates the blade
of infection. Administration of antibiotics should length in millimeters. e fourth number (third
be considered with the concomitant presentation number of a 3-number code) indicates the blade
of fever and malaise and for di use swelling angle, relative to the long axis of the handle in
(cellulitis). clockwise centigrade.
40. A. e manufacturing process of a K-type instrument 10. D. A tooth preparation for a mandibular molar should
(K- le or K-reamer) is grinding a stainless steel have a narrow isthmus, should be initiated in the
wire to a tapered square or triangular cross section. most carious (or distal) pit, and should establish
the initial pulpal oor depth of 1.5 to 2 mm.
However, it should be oriented parallel to the long
Operative Dentistry axis of the crown, which tilts to the lingual. If pre-
pared in the long axis of the tooth, there is greater
1. D. Altering the organism, its nutrients, and its envi- potential of weakening the lingual cusps.
ronment enhances prevention and treatment 11. C. Retention locks, when needed in class II amalgam
objectives. preparations, should be placed entirely in dentin,
2. B. A restored tooth indicates potential past carious not undermining the adjacent enamel. ey are
activity but not current activity. Plaque presence placed 0.2 mm internal to the DEJ, are deeper gin-
does not indicate caries presence. Sealants are used givally (0.4 mm) than occlusally (i.e., they fade out
for preventive purposes, not caries treatment. as they extend occlusally), and translate parallel
3. C. When an alteration (a break in continuity) occurs to the DEJ. If the axial wall is deeper than normal,
to the tooth surface from a carious attack, restora- the retention lock is not placed at the axiofacial or
tion is usually necessary. When a lesion is evident axiolingual line angles, but rather is positioned
in the dentin with an x-ray, the lesion usually needs 0.2 mm internal to the DEJ. If placed at the deeper
a restoration. location, it may result in pulp exposure, depending
4. D. When doing an indirect pulp cap, some caries may on the location of the axial wall depth.
be le , a liner (probably calcium hydroxide) is 12. C. e guide for axial wall depth for a typical class II
usually placed over the excavated area, and the area preparation that has a gingival margin occlusal to
may be assessed 6 to 8 weeks later. Regardless, the the CEJ is 0.2 to 0.5 mm internal to the dentinoe-
prognosis for indirect pulp caps is better than the namel junction—the greater depth is necessary
prognosis for direct pulp caps. when placing retention locks. However, when there
5. D. Smooth surface caries occurs on any of the axial is no enamel proximally, the axial wall needs to be
(facial, lingual, mesial, distal) tooth surfaces but deep enough internally to provide for adequate
not the occlusal surface. strength of the amalgam material as well as to have
6. C. A nishing bur is designed to provide a smoother room to place retention locks if needed. is depth
surface and has more blades than a cutting bur. e is approximately 0.75 mm.
increased number of blades results in a smoother 13. D. Because of the typical shape of a carious lesion
cut surface. in the cervical area, the resulting restoration is
7. E. e advantages and bene ts of rubber dam usage kidney-shaped or crescent-shaped, and the exten-
are re ected in all of the items listed. e rubber sions are to the line angles, resulting in the mesial
dam isolation increases access and visibility. and distal walls diverging externally. e convexity
8. C. When the rubber dam edge around the tooth is of the tooth in the gingival one third results in the
turned gingivally (inverted), it signi cantly reduces occlusal and gingival walls diverging externally.
the leakage of moisture occlusally, sealing around ere are several retention groove designs that
the tooth better and resulting in a better isolated are appropriate, including four corner coves,
operating area. occlusal and gingival line angle grooves, and