Lege Artis

A: Correct. The spontaneous, intense, and lingering pain (especially sensitivity to heat and night pain) indicates Severe pulpitis – the pulp is irreversibly inflamed and causing continuous pain. The tooth is also very tender to touch/percussion, which means the inflammation has spread to the periapical area, consistent with symptomatic apical periodontitis.
B: Incorrect. Moderate pulpitis would not typically produce such extreme, unrelenting pain or strong heat sensitivity. Additionally, asymptomatic apical periodontitis is wrong here because the apical tissues are clearly symptomatic (the tooth is percussion-sensitive and painful).
C: Incorrect. In an acute apical abscess, the pulp is necrotic and there is usually swelling with pus. Here, the pulp is still alive (though in agony) – evidenced by the severe thermal sensitivity – and there is no swelling; thus it’s not an abscess situation. So, necrotic pulp/acute abscess does not match the clinical picture.
D: Incorrect. Mild pulpitis with normal apical tissues would be a much less intense condition (short-lived pain from cold, no percussion pain). This patient’s symptoms are far beyond mild pulpitis, and the presence of significant percussion pain means apical tissues are involved (not normal).

A: Correct. The best course is to initiate root canal therapy by opening the tooth and removing the inflamed pulp (pulpectomy). This will relieve pressure and pain by eliminating the source of inflammation. An emergency endodontic access to extirpate the pulp, followed by placement of a medicated dressing inside the canals, will give the patient quick relief and is the indicated treatment for severe pulpitis.
B: Incorrect. A sedative filling alone will not stop the severe throbbing pain because the pulp tissue inside is irreversibly inflamed and needs to be removed. Simply medicating or sealing the cavity without pulp removal would leave the patient in pain.
C: Incorrect. Antibiotics are generally not indicated for a vital pulpitis (there’s no bacterial abscess yet – the issue is inflamed pulp tissue). Painkillers alone won’t resolve the cause of pain, they’ll just temporarily mask it. Waiting a week would unnecessarily prolong the patient’s suffering and risk the condition worsening (the pulp could necrose and possibly lead to an abscess). Immediate intervention is a better approach.
D: Incorrect. Extraction will indeed remove the source of pain, but it’s not the first choice when the tooth can be saved. A root canal can alleviate the pain while preserving the tooth. Pulling the tooth is an extreme measure for a condition that is very treatable with endodontic therapy. Extraction should only be considered if the tooth were not restorable or if the patient opts for it; otherwise, saving the tooth is preferable.

A: Correct. After relieving the pain by removing the pulp, the full root canal treatment must be completed (cleaning, shaping, and obturating the canals) in the next visits. The tooth should then be restored (often with a crown, given a large cavity) to protect it. Long-term, the tooth should be monitored – typically a follow-up exam and radiograph at 6–12 months – to confirm that the periapical tissues are healing and no new problems have arisen. This comprehensive approach gives the tooth the best prognosis.
B: Incorrect. It’s not enough to just stop at pain relief. Leaving the root canals partially treated or unfilled can lead to infection. The treatment must be completed; simply monitoring an incompletely treated tooth would likely result in eventual failure (infection of the canals).
C: Incorrect. If the root canal is done properly the first time, there is no expectation to re-treat it at 6 months. The goal is a successful initial treatment. A 6-month appointment would be for follow-up, not retreatment. Retreatment is only needed if the initial root canal fails (signs of persistent or new infection).
D: Incorrect. There is no reason to extract the tooth later if the root canal is successful. Teeth with severe pulpitis generally respond very well to root canal therapy, with a high success rate. As long as the tooth is properly treated and restored, it should not “cause problems again” in most cases. Extraction would only be considered if the root canal fails and other options (like retreatment or apical surgery) also fail or are not feasible.

The most appropriate diagnosis is Pulp necrosis with Acute (Symptomatic) Apical Periodontitis on tooth #46.

The tooth shows no response to cold testing, confirming a (probably) non-vital pulp, consistent with pulpal necrosis likely due to long-standing caries and loss of coronal seal following restoration failure. The severe pain on vertical percussion indicates acute inflammation of the periapical periodontal ligament caused by bacterial toxins diffusing from the necrotic pulp. On the periapical radiograph, a slight widening can be seen. Tooth #47 remains vital and asymptomatic, ruling it out as the source. The absence of swelling or purulence distinguishes this condition from an acute apical abscess. Therefore, the findings—non-vital pulp, marked tenderness to percussion, and no swelling—are diagnostic of Acute Apical (Symptomatic) Periodontitis affecting tooth #46.

Gangreana simplex is a radiograhic diagnosis, which represents no visible periapical lesion on the current x-ray capture but a necrotic pulp. In our case this is not true. From this, Gangreana simplex corresponds to “Necrotic pulp with normal periapical tissues”, which is not true in this case.

The most appropriate diagnosis is Pulp necrosis with Acute (Symptomatic) Apical Periodontitis. The tooth shows a negative response to cold, indicating a non-vital pulp, consistent with necrosis following a history of previous restorative work and intermittent sensitivity that has since ceased. The severe pain on vertical percussion reflects acute inflammation of the periodontal ligament caused by bacterial toxins from the necrotic pulp. The reported “crack” likely allowed additional irritation, exacerbating apical inflammation. Radiographically, early cases may only show a widened periodontal ligament space without a distinct lesion. In contrast, pulpitis diagnoses require a positive thermal response, and acute apical abscess would present with swelling or purulence, which are absent here. Therefore, the clinical picture—non-vital pulp, severe percussion pain, and no swelling, widened periapical ligaments on the PA radiograph—is characteristic of acute/symptomapic apical periodontitis.

This patient has generalized severe alveolar bone loss (to the mid-third of roots and beyond), multiple deep pockets (≥6–8 mm), and ≥5 teeth lost due to periodontitis, which meet criteria for Stage IV periodontitis. Stage IV includes extensive tooth loss and the need for complex rehabilitation (evidenced by drifting and function loss).

The pattern of destruction suggests a rapid rate of progression (Grade C). The patient is young (28 years) with extensive bone loss, and there is a significant systemic risk factor (chronic neutropenia) that exacerbates tissue destruction. These factors (high bone loss relative to age and impaired host defense) indicate a Grade C classification (rapid progression). Under the 2018 AAP/EFP classification, this patient’s periodontal condition is best described as: A. Necrotizing periodontitis B. Gingivitis (systemic-related) C. Periodontitis as a manifestation of a systemic disease D. Localized Stage II periodontitis Answer: C. The patient’s periodontitis is associated with a systemic condition (chronic neutropenia/immunodeficiency). In the 2018 AAP/EFP framework, such cases are classified as “periodontitis as a manifestation of systemic diseases”. It is neither necrotizing nor localized; it is generalized, associated with a systemic host-response defect.

The scenario describes pulp canal obliteration (PCO), also known as calcific metamorphosis, which often occurs after trauma (especially in younger patients or severe luxations). The tooth turning yellow is a classic sign of progressive dentin deposition inside the pulp chamber. Importantly, PCO usually indicates that the pulp is still vital and has responded by laying down hard tissue. There are no signs of pulp necrosis or infection (no pain, no radiographic lesion), so no endodontic intervention is needed. IADT guidelines advise that teeth with pulp canal obliteration do not require root canal treatment unless other evidence of pulp necrosis arises. The correct approach is to observe the tooth with routine follow-ups. Prophylactic RCT on a calcified but vital pulp is not recommended, as it can unnecessarily weaken the tooth and is technically difficult. Internal bleaching (C) would not be possible without doing RCT (as the canal is obliterated and you can’t place bleach internally unless you create a canal); moreover, minor color change alone, in absence of pathology, is not an indication for invasive treatment. Extraction is obviously not indicated for a functional, asymptomatic tooth. The patient can be reassured that this “yellowing” (calcification) is a common outcome after trauma and that the tooth should be monitored for any future signs of necrosis.

A: Correct. The clinical picture (tooth gradually yellowing, no response to pulp testing, but no pain or radiographic lesions) is characteristic of pulp canal obliteration, also known as calcific metamorphosis. After trauma (especially subluxation or concussion injuries in younger individuals), the pulp can remain vital but respond to the injury by laying down excessive dentin within the canal. This results in a narrowed or obliterated pulp canal and a yellowish tooth color. IADT 2020 guidelines indicate that such teeth do not require root canal treatment unless there are signs of pulp necrosis or pathology. In this case, the tooth is asymptomatic and shows no apical radiolucency, so the recommended approach is to monitor it. No endodontic intervention is needed at this time; the tooth’s pulp, though not responding to tests, is likely still vital and simply calcified.
B: Incorrect. A lack of response to pulp testing in a calcified tooth does not equal pulp necrosis. The pulp may be alive but insulated by the calcified tissue. In fact, a significant number of teeth with calcific metamorphosis never develop necrosis or require any treatment; they just have reduced or no sensibility responses. There are no signs of necrosis such as pain, periapical radiolucency, or infection in this scenario. Performing a root canal on a tooth simply because it does not respond, despite no other issues, is not indicated and would unnecessarily weaken the tooth. The standard of care is to avoid treating calcified but healthy pulps; instead, just observe periodically for any changes.
C: Incorrect. The radiographic finding is a greatly narrowed pulp canal, not external root resorption. External resorption would appear as irregular defects on the external root surface or blurring of the root outline, often accompanied by symptoms or a history of pulp necrosis. In contrast, this radiograph shows a smooth, intact root outline with a very thin or non-visible canal, which is indicative of internal calcification, not resorptive loss of tooth structure. There is no evidence of root resorption or any pathology that would necessitate intervention.
D: Incorrect. Ankylosis is not suggested by the exam findings. The tooth has normal mobility and no mention of a high “metallic” percussion note, and the radiograph still shows a visible (albeit thin) PDL space around the root (except where obliterated by calcification of the pulp chamber – which doesn’t erase the PDL). Ankylosis involves fusion of the tooth root to bone, leading to loss of PDL space and often infra-positioning of the tooth over time (in growing individuals). That is not happening here – the issue is internal (pulpal calcification), not the periodontal ligament. Therefore, ankylosis is not the cause of the cold test non-response or color change; the calcified pulp is.