C: Initial pulpitis with normal apical tissues is correct. Initial pulpitis is characterized by a heightened but not prolonged response to cold, with no spontaneous pain and no percussion sensitivity . That matches this scenario. The pulp inflammation is very mild (often considered a reversible pulpitis) and the periapical tissues are healthy (no percussion pain or radiographic changes)

Mild pulpitis with normal apical tissues is correct. Mild pulpitis is defined by an exaggerated response to
stimuli that lasts up to ~20 seconds before subsiding
. This matches the ~10-second lingering cold
sensitivity. There are no signs of periapical involvement (percussion is normal), so the apical tissues are
normal. The pulpitis is reversible at this stage, confined to the crown, and could be managed with
appropriate caries removal and a filling.

– A: Mild pulpitis with normal apical tissues is incorrect because the tooth has percussion tenderness, which
indicates involvement of periapical tissues. “Normal apical tissues” would mean no pain to percussion. In
this case, there is percussion sensitivity, so the apical diagnosis can’t be normal.
– B: Moderate pulpitis with symptomatic apical periodontitis is incorrect. The pulpitis in this scenario is not
moderate but mild. The pain lingers around 15–20 seconds and there are no spontaneous or prolonged
night pains reported. Moderate pulpitis usually features pain lasting minutes and possibly spontaneous
dull aches requiring analgesics
, which is more severe than what’s described here.
– C: Mild pulpitis with symptomatic apical periodontitis is correct. The lingering sensitivity (up to 20 seconds)
fits Mild pulpitis. The slight pain on chewing and percussion indicates symptomatic apical periodontitis
(inflammation of the apical periodontal ligament causing tenderness). There is no swelling or sinus tract,
just tenderness, which is characteristic of symptomatic apical periodontitis. This combination is likely due to
the inflamed pulp irritating the apical area.
– D: Pulp necrosis with symptomatic apical periodontitis is incorrect because the pulp is still alive and
responding (albeit painfully) to cold. A necrotic pulp would have no response to cold. Also, the pain
described is stimulus-dependent (cold/sweet) rather than spontaneous constant pain; this suggests a vital
inflamed pulp, not a necrotic one. Therefore, the pulp is not necrotic, and option D can be ruled out.

– A: Severe pulpitis with normal apical tissues is correct. This tooth’s pulp is exhibiting signs of Severe pulpitis
(essentially symptomatic irreversible pulpitis): spontaneous, long-lasting throbbing pain, intense response
to thermal changes, and night pain
. However, the lack of percussion sensitivity indicates that the
inflammation has not (yet) significantly extended into the periapical periodontal ligament – meaning the
apical tissues are still normal in terms of symptoms. There’s no periapical radiographic change either. So
the periapical diagnosis is “normal apical tissues.” This combination can occur in a case of advanced pulpitis
that hasn’t spread beyond the confines of the tooth. The pulp is on the verge of necrosis, but as of now the
PDL is not inflamed (no biting pain).
– B: Severe pulpitis with symptomatic apical periodontitis is incorrect because, despite the pulpitis being
severe, the tooth is not percussion tender. Symptomatic apical periodontitis is ruled out by the fact that
tapping or chewing on the tooth does not cause pain. This is a key detail: the patient’s pain is all pulpally
driven and not periodontal. Therefore the apical tissues cannot be labeled as “symptomatic AP” in this
scenario.
– C: Moderate pulpitis with normal apical tissues is not correct because the symptoms described are more
intense than moderate. The pain is spontaneous, long-lasting, and not effectively managed by mild
analgesics – these are hallmarks of Severe pulpitis, not just moderate. Moderate pulpitis generally would
have shorter durations of pain or at least some relief with medication. Here it’s clearly very severe. So the
pulp status should be categorized as severe pulpitis. The apical tissues being normal part is fine, but the
pulp status is under-characterized if calling it moderate.
– D: Pulp necrosis with asymptomatic apical periodontitis is wrong on both accounts. The pulp is not necrotic –
it’s very much alive and in agony (necrotic pulp would not feel cold or have any sensation). And the apical
tissues are not in a state of apical periodontitis (asymptomatic or otherwise) because there is no
radiographic lesion or percussion sensitivity; they are simply normal. So option D doesn’t fit this case at all.

– A: Initial pulpitis with normal apical tissues is correct. The tooth is experiencing a reversible, mild pulpitis
due to the crack – evidenced by a sharp pain to cold that does not linger. This is essentially an Initial
pulpitis scenario (heightened but not prolonged response) likely caused by the crack leakage/stimulus. The
periapical tissues are normal (no constant percussion pain or radiographic lesion; the pain on biting is due
to the crack flexing, not inflammation of the apex). So the best fitting diagnosis is initial (reversible) pulpitis
with normal apical tissues.
– B: Mild pulpitis with normal apical tissues is not chosen here because the cold pain truly does not linger at
all; it stops immediately when the stimulus is removed. That points to Initial pulpitis rather than Mild (mild
would linger a few seconds). In cracked tooth cases, often the pulp is either healthy or only in the earliest
stage of irritation (initial). So initial pulpitis is a closer match. Regardless, in either case the apical tissues are
normal. The key is that there’s no indication the pulp is beyond reversible stage.
– C: Pulp necrosis with normal apical tissues is incorrect. The pulp is clearly not necrotic: the tooth responds to
cold (albeit briefly) and produces pain on biting release (which indicates some vitality and innervation). A
necrotic pulp wouldn’t feel the cold at all, and usually a cracked tooth with necrosis would develop apical
periodontitis or other signs. Here everything points to the pulp still being alive.
– D: Normal pulp with symptomatic apical periodontitis is incorrect. The pulp isn’t exactly normal – it’s showing
signs of irritation (though mild). And the pain on bite is not from apical periodontitis; it’s from the crack
movement. Symptomatic apical periodontitis would imply inflammation at the apex causing percussion
pain. In this case, percussion (vertical tapping) is normal; the pain is specifically on release of biting due to
the crack flex. So calling it symptomatic AP would be wrong. The apical tissues are actually healthy; the issue
is structural (crack) with a slightly irritated pulp.
This scenario is indicative of a cracked tooth syndrome. The correct diagnoses reflect that the pulp has a reversible
inflammation (initial pulpitis) and the periapex is normal. The management would involve addressing the crack
(e.g., crown or onlay) before it progresses.

– A: Previously treated with asymptomatic apical periodontitis is correct. The tooth has been previously
treated (it has a root canal), and the radiograph shows a periapical radiolucency but the patient has no
symptoms, which by definition is asymptomatic apical periodontitis. This usually indicates the root canal,
while keeping the patient symptom-free, has not completely eliminated the infection (a chronic periapical
lesion remains). So this is the classic scenario of a failing or inadequate RCT that is asymptomatic.
– B: Previously treated with symptomatic apical periodontitis is incorrect because the patient has no
symptoms. Symptomatic AP would mean the patient feels pain or tenderness. But here, the finding is only
radiographic, with the patient completely unaware. So it’s asymptomatic, not symptomatic.
– C: Previously treated with chronic apical abscess is not indicated here because there is no sinus tract or gum
boil reported. A chronic abscess implies drainage (sinus tract) is present. In this case, we just have a silent
radiolucency. Without a sinus tract, we call it asymptomatic apical periodontitis (a chronic periapical lesion
without active drainage).
– D: Pulp necrosis with asymptomatic apical periodontitis is not the best phrasing since we know the tooth had
a root canal. The pulp isn’t necrotic anymore; it’s been removed. The correct classification for a root-filled
tooth is “previously treated.” While functionally a previously treated tooth that’s failing behaves like a
necrotic pulp scenario, we use the term previously treated for the pulpal diagnosis. Therefore, option A is
the proper way to describe it.

– A: Normal pulp with normal apical tissues is correct for the teeth in question. All tests indicate the teeth
themselves are healthy: normal responses to cold (no pulpitis) and essentially no true percussion pain
originating from the teeth (the slight tenderness is diffuse and likely from the sinus issue, not an inflamed
PDL from pulp infection). There are no radiographic lesions. So the most likely conclusion is that the tooth
pulps are normal and the apical tissues are normal – the pain is not of endodontic origin at all, but
rather referred from sinusitis.
– B: Mild pulpitis with symptomatic apical periodontitis is incorrect. There is no evidence of pulpitis (no
lingering thermal pain, no decay, etc.) in the scenario. Also, symptomatic apical periodontitis doesn’t really
fit because the percussion tenderness is not from a specific tooth’s PDL inflammation, but from sinus
pressure on the area. Each tooth by itself tests normal. Thus, labeling any tooth with pulpitis or apical
periodontitis would be wrong.
– C: Pulp necrosis with symptomatic apical periodontitis is incorrect. All teeth responded normally to vitality
testing, so none are necrotic. And none show periapical radiolucencies or localized percussion pain that
would indicate an infected pulp.
– D: Normal pulp with symptomatic apical periodontitis is also incorrect in this context. While the pulps are
normal, true symptomatic apical periodontitis implies the PDL of a tooth is inflamed due to pulpal
issues. Here the slight tenderness is generalized and coming from sinus inflammation on multiple teeth,
not from an individual tooth’s pulp infection. Therefore, we do not diagnose any specific tooth with
“symptomatic apical periodontitis.” The correct finding is essentially no endodontic disease in the teeth
themselves (normal/normal).
This case illustrates a non-odontogenic toothache. The teeth are normal; the pain was referred from the maxillary
sinus. In practice, recognizing normal pulp/normal apical tissues (and thus searching for a non-dental cause) is
important.

– A: Initial pulpitis with normal apical tissues is not the best choice because the patient’s cold sensitivity lasts
a bit longer (5–10 seconds) after the stimulus is removed. Initial pulpitis by definition has no prolonged
linger – the response is heightened but stops immediately when the stimulus is gone
. Here there is a
noticeable short-term linger, which moves it into the “mild” category.
– B: Mild pulpitis with normal apical tissues is correct. This scenario is typical of a reversible pulpitis (mild
pulpitis) often seen after a deep filling. The cold causes pain that lingers only several seconds (well
under 20 seconds) and then subsides
. There’s no spontaneous pain, and importantly the tooth is not
percussion sensitive, so the periapical tissues are normal. The pulp is irritated from the recent dental work
but there is no indication of irreversible damage. This mild pulpitis should resolve on its own or with minor
adjustments if needed.
– C: Severe pulpitis with normal apical tissues is incorrect. Severe pulpitis would involve spontaneous, intense
pain (often unprovoked or lingering far longer, and typically with more severe symptoms as in this patient’s symptoms are nowhere near “severe” – they are mild and only provoked by cold, and short in duration. Also severe pulpitis usually eventually affects the apical tissues if it’s that intense (and often the patient would have sought help sooner due to pain). So this is not severe pulpitis. – D: Normal pulp with normal apical tissues is incorrect because the pulp is clearly not normal: it’s responding abnormally to cold (a normal pulp might feel cold but would not produce pain that lingers seconds after). The recent restorative trauma has induced a reversible pulpitis. If the pulp were truly normal, the patient wouldn’t be getting this post-op sensitivity. Therefore, labeling it “normal pulp” is not accurate given the symptoms.

– A: Previously treated with chronic apical abscess is correct. The tooth has been previously treated (it has a
completed root canal). The presence of a persistent sinus tract with drainage and no significant pain is
the classic presentation of a chronic apical abscess. So the periapical diagnosis is chronic apical abscess.
Putting it together: previously treated (pulpal status) + chronic apical abscess (periapical status) matches the
scenario. This indicates a long-term failure of the root canal with drainage through a sinus tract.
– B: Previously treated with asymptomatic apical periodontitis is not the best answer because the presence of a
sinus tract means it’s specifically a chronic abscess. Asymptomatic apical periodontitis would mean a quiet
radiolucency without any sinus tract. While both conditions are “asymptomatic” in terms of pain, the correct
term when a sinus tract is present is “chronic apical abscess.” So A is more accurate.
– C: Previously treated with acute apical abscess is incorrect. An acute abscess would involve pain, swelling,
and usually no ready drainage pathway. In this case, the abscess is chronic and draining (hence no pain or
swelling). So it’s not acute.
– D: Pulp necrosis with chronic apical abscess is not the preferred terminology here. While the scenario
functionally behaves like a necrotic tooth with a chronic abscess, the tooth has had a root canal, so by
diagnostic terms we label it “previously treated” rather than “pulp necrosis.” Option D also ignores the fact
that the tooth’s pulp was removed in the past. Therefore, A (with the proper “previously treated” term) is the
correct way to describe it.

– A: Previously treated with symptomatic apical periodontitis is correct. “Previously treated” indicates the tooth
has had complete endodontic treatment (a finished root canal fill is present). The patient now has
symptoms (pain on biting/percussion) and a radiographic periapical lesion, which means symptomatic
apical periodontitis is present. This is essentially a failing root canal case where the tooth is having a flare-
up or persistent infection at the apex. The combination fits: pulpal status = previously treated, apical
status = symptomatic apical periodontitis.
– B: Previously treated with asymptomatic apical periodontitis is incorrect because the apical periodontitis is
not asymptomatic – the patient is actually having symptoms (ache and percussion pain). Asymptomatic AP
would mean the patient feels nothing and the lesion was found on X-ray only. Here we clearly have
symptoms, so it’s symptomatic AP.
– C: Previously initiated therapy with symptomatic apical periodontitis is incorrect. The pulpal diagnosis
“previously initiated therapy” would apply if the root canal wasn’t finished (only started), but in this case it
was finished 5 years ago. The correct term for a completed root canal is “previously treated,” not
“initiated.” So this option uses the wrong pulpal category.
– D: Pulp necrosis with symptomatic apical periodontitis is not the best description here because it ignores the
fact that the tooth was already treated endodontically. Technically, a previously treated tooth could be seen
as having no pulp or a necrotic status, but on diagnostic forms, if a root canal is present, we label it
“previously treated.” The exam question clearly expects the use of the “previously treated” term given the
scenario. So while the periapical part (symptomatic AP) is right, calling the pulp “necrosis” is not accurate in
context; it should be “previously treated.”
13

– A: Previously initiated therapy with acute apical abscess is correct. “Previously initiated therapy” means the
tooth has been started on endodontic treatment but not completed (for example, a pulpotomy or partial
pulpectomy was done). This fits the scenario (the patient had partial RCT done). Now the tooth has an acute
apical abscess – evidenced by the significant pain, swelling, and pus. The acute apical abscess results from
the canals being reinfected after the incomplete treatment. So the combination is correct: pulpal diagnosis
= previously initiated therapy, periapical diagnosis = acute apical abscess.
– B: Previously initiated therapy with chronic apical abscess is incorrect. The presence of active swelling and
pain means this is acute, not chronic. A chronic abscess would have a sinus tract and little to no pain, which
is not the case here. This case is an active flare-up (acute).
– C: Previously treated with acute apical abscess is not correct for the pulpal part. “Previously treated” implies a
completed root canal treatment in the past. Here, treatment was not completed – it was initiated but not
finished. Therefore, the proper term is “previously initiated therapy,” not “previously treated.” The periapical
abscess part is right but the pulpal status term is wrong.
– D: Pulp necrosis with acute apical abscess is not the best description here because we have a specific history
of partial endodontic therapy. While it’s true the remaining pulp tissue is necrotic and there is an acute
abscess, the preferred way to label the pulpal diagnosis given the history is “previously initiated
therapy” (since the tooth had a pulpotomy started). On an exam or differential, if a tooth has had some
endo intervention already, we use that terminology. Simply calling it “pulp necrosis” would ignore the
treatment history evident on the radiograph.

– A: Normal pulp with symptomatic apical periodontitis is correct. The tooth has a healthy pulp (no thermal
sensitivity, normal cold test, and the issue started after a mechanical procedure – the new crown). The
soreness on biting and percussion sensitivity indicates the periodontal ligament is inflamed, which is
symptomatic apical periodontitis. In this case, the cause is likely occlusal trauma (the “high” crown) rather
than pulpal infection. So the pulp is normal/vital, but the apical tissues are inflamed from the biting trauma
– a classic case of a normal pulp with symptomatic apical periodontitis. Adjusting the occlusion should
resolve the PDL inflammation.
– B: Mild pulpitis with symptomatic apical periodontitis is incorrect because there is no evidence the pulp is
inflamed at all – the tooth isn’t sensitive to cold or sweets, and the only complaint is related to biting.
There’s no indication of even mild pulpitis; all signs point to the pulp being normal and the pain coming
from the PDL.
– C: Pulp necrosis with symptomatic apical periodontitis is incorrect. The pulp tests normal (vital) and there’s a
clear mechanical reason (recent high crown) for the percussion pain. There’s no reason to think the pulp is
necrotic – there were no severe pain episodes, no deep caries, and the tooth responds normally to cold.
Necrotic pulp would also usually eventually show a radiolucency if symptomatic for some time, which is not
present. So necrosis is not plausible here.
– D: Normal pulp with acute apical abscess is incorrect because while the pulp may be normal, there is no
abscess. An acute apical abscess would involve pus and swelling, which this case does not have. We only
have inflammation (pain on biting) without infection or swelling. So the correct periapical diagnosis is just
symptomatic apical periodontitis, not an abscess.
11

– A: Pulp necrosis with condensing osteitis is correct. Condensing osteitis is a reaction of bone to a low-grade
chronic infection or irritation from the pulp. It appears as a radiopaque (sclerotic) area at the apex. In most
cases, the pulp of the involved tooth is either necrotic or has a chronic irreversible pulpitis. Here, the tooth
tests necrotic (no vitality) and the radiograph shows the characteristic bone densification. The lack of
symptoms is common in these cases. So a necrotic pulp with condensing osteitis is the accurate diagnosis.
– B: Pulp necrosis with asymptomatic apical periodontitis is not the best choice because the radiographic
finding is not a radiolucency but a radiopacity. Asymptomatic apical periodontitis typically presents with
a radiolucent lesion (granuloma or cyst). In condensing osteitis, instead of bone destruction, there’s bone
formation. While both are asymptomatic and involve necrotic pulps, the correct radiographic diagnosis
given the opacity is condensing osteitis, not the usual radiolucent apical periodontitis.
– C: Moderate pulpitis with condensing osteitis is incorrect. Condensing osteitis generally means the pulp has
been chronically inflamed or necrotic for a long time; by the time you see that much bone reaction, the pulp
is usually dead. Here the pulp shows no vital response. Also, moderate pulpitis implies the pulp is still vital
and in an active symptomatic state, which doesn’t align with an asymptomatic presentation with a sclerotic
bone reaction. Thus, moderate pulpitis is not appropriate; the pulp is past that stage (necrosis).
– D: Normal pulp with condensing osteitis is incorrect. A normal, healthy pulp would not cause any periapical
bone reaction. Condensing osteitis is the result of chronic pulp pathology (persistent irritation/infection). So
the pulp cannot be normal if condensing osteitis is present. In this case, the pulp is clearly not normal (it’s
non-responsive/necrotic). Therefore, this option is wrong on the pulpal diagnosis.
10

– A: Pulp necrosis with chronic apical abscess is correct. The tooth has a necrotic pulp (no vitality response)
and there is a sinus tract (gum pimple) with intermittent drainage, which is the hallmark of a chronic
apical abscess. The patient has no pain because the abscess is draining through the sinus tract, relieving
pressure. This fits the definition: a chronic apical abscess is a long-term infection from a necrotic pulp that
drains to the surface, usually with minimal symptoms besides the drainage.
– B: Pulp necrosis with asymptomatic apical periodontitis is close, but not the best answer because the
presence of a draining sinus tract specifically designates a chronic abscess. Asymptomatic apical
periodontitis would describe a silent radiolucency without any sinus tract. While the condition here is
indeed asymptomatic (no pain), the correct terminology when a sinus tract is present is “chronic apical
abscess.” So option A is more precise.
– C: Pulp necrosis with acute apical abscess is incorrect. An acute apical abscess would present with pain,
swelling, and no established drainage sinus (until perhaps it becomes chronic or is drained). In this
scenario, we have a chronic, draining lesion (and no pain or significant swelling), which indicates it is not an
acute scenario but a chronic one.
9
– D: Mild pulpitis with chronic apical abscess is impossible and thus incorrect. A chronic apical abscess
requires a necrotic or previously treated pulp to form; a tooth with a vital pulp (even if mildly inflamed) would
not produce a chronic abscess. The pulp here is clearly necrotic (no response to tests), not “mild pulpitis.” So
this option is way off – the pulp status is wrong.

– A: Pulp necrosis with acute apical abscess is correct. The tooth has a necrotic pulp (no cold response, large
caries, history of pain that likely started as pulpitis and then the pulp died). The swelling, severe throbbing
pain, and presence of pus indicate an acute apical abscess. An acute apical abscess is an active infection
spreading into the periapical tissues with pus accumulation, causing pain and swelling (and often systemic
signs like fever). This scenario fits perfectly: necrotic pulp and an acute abscess.
– B: Pulp necrosis with chronic apical abscess is incorrect because a chronic apical abscess is characterized by
a long-standing draining sinus tract and typically minimal to no pain or swelling (the pressure is being
relieved via drainage). Here we have an acute swelling, lots of pain, and no mention of a sinus tract
(instead, pus had to be expressed by pressure). That is acute, not chronic.
– C: Pulp necrosis with symptomatic apical periodontitis is also incorrect in this context. While an acute abscess
is indeed a form of symptomatic apical periodontitis (since it’s symptomatic and periapical), the term
“symptomatic apical periodontitis” usually refers to inflammation that has not yet led to abscess formation
(no significant pus/swelling). In this case, the situation has progressed to an abscess with frank swelling and
8
pus. Simply calling it “symptomatic apical periodontitis” would understate the severity. The presence of
swelling and pus means it should be classified as an acute apical abscess.
– D: Moderate pulpitis with acute apical abscess is incorrect. You cannot have an acute apical abscess unless
the pulp is necrotic (or in rare cases of teeth with pulp removed or sinus tract from another source).
Moderate pulpitis means the pulp is still alive and inflamed, which would not produce pus at the apex. The
scenario clearly indicates the pulp is necrotic (no response to cold, presence of pus and radiolucency), so it’s
not a case of pulpitis anymore but rather pulp necrosis. Therefore, moderate pulpitis is not an accurate
pulpal diagnosis here.

– A: Pulp necrosis with asymptomatic apical periodontitis is correct. The tooth’s pulp is non-vital (no response
to vitality tests = pulp necrosis), and there is a clear periapical radiolucency, which indicates apical
periodontitis. Since the patient has no symptoms (no pain or tenderness), it is by definition
asymptomatic apical periodontitis. This is a common finding when a tooth’s pulp dies slowly and a
chronic periapical lesion (often a granuloma) forms without acute flare-ups.
– B: Pulp necrosis with symptomatic apical periodontitis is incorrect because the apical periodontitis in this
case is not causing symptoms. The tooth is not tender or painful. “Symptomatic” would mean the patient
7
feels pain (e.g. pain on percussion), which is not the case here.
– C: Pulp necrosis with chronic apical abscess is incorrect. While a chronic apical abscess can sometimes be
asymptomatic pain-wise, it specifically features a draining sinus tract (and the radiograph often shows a
radiolucency too). In this scenario, there is no sinus tract or gum boil, just a silent radiolucency. That fits
asymptomatic apical periodontitis (often a granuloma or cyst), not a draining abscess.
– D: Mild pulpitis with asymptomatic apical periodontitis is incorrect because pulpitis implies a vital pulp. You
cannot have apical periodontitis (which is a result of pulp necrosis/infection) with a pulp that is only mildly
inflamed – if there’s a chronic apical radiolucency, the pulp is dead. Also, “asymptomatic apical periodontitis”
by nature corresponds to a necrotic or previously treated pulp, not a mildly inflamed vital pulp. Thus, mild
pulpitis is not applicable here.

– A: Pulp necrosis with symptomatic apical periodontitis is correct. The history is telling: a severe toothache
that resolved suddenly suggests the pulp went from inflamed to necrotic (the nerve died, ending the
intense pulp pain). Now the remaining issue is in the periapical area – the tooth is tender to bite on,
6
which indicates symptomatic apical periodontitis (inflammation of the periodontal ligament). The cold
test and EPT are negative, confirming the pulp is non-vital (necrotic). The radiograph even shows an early
periapical radiolucency developing, consistent with necrosis and infection spreading to the apex. So a
necrotic pulp + symptomatic (painful) apical periodontitis is the correct diagnosis.
– B: Severe pulpitis with symptomatic apical periodontitis is incorrect. Severe pulpitis implies the pulp is still
alive and in agony, but in this scenario the pulp is unresponsive (dead). The prior severe pain was likely the
irreversible pulpitis phase, but now we have moved on to pulp necrosis. So calling it pulpitis would be
wrong at this stage.
– C: Pulp necrosis with asymptomatic apical periodontitis is incorrect because the apical periodontitis here is
symptomatic. The tooth is sore on biting/percussion, which is a symptom. “Asymptomatic” apical
periodontitis means there would be no clinical symptoms (the patient wouldn’t feel pain on the tooth),
typically it’s an incidental radiographic finding. But this patient is clearly having symptoms when chewing,
so the apical periodontitis is not asymptomatic.
– D: Pulp necrosis with chronic apical abscess is incorrect. A chronic apical abscess usually presents with a
sinus tract (gum pimple) and little to no pain (because it’s draining). In this case, there is no sinus tract
and the tooth is tender (not drained), so it’s a symptomatic apical periodontitis rather than a chronic
abscess situation.

– A: Severe pulpitis with symptomatic apical periodontitis is incorrect. In severe pulpitis, cold typically triggers
pain (not relief). Here, cold relieves the pain and the pulp test shows no response, which indicates the pulp
is likely dead. Also, severe pulpitis implies a vital pulp, but the exam suggests loss of vitality.
– B: Pulp necrosis with symptomatic apical periodontitis is correct. The combination of no response to cold,
pain that is relieved by cold (often a hallmark of gas buildup in a necrotic pulp), and intense percussion
pain indicates the pulp is necrotic and the periapical tissues are acutely inflamed (symptomatic AP). There’s
a periapical radiolucency and severe throbbing pain without an obvious swelling, which is typical for
symptomatic apical periodontitis arising from a necrotic pulp. The cold water providing relief is a classic sign
of a necrotic pulp with developing apical periodontitis – the cold causes contraction of gases and lessens
pressure, easing pain.
– C: Pulp necrosis with acute apical abscess is not the best choice because we do not see an actual abscess
or swelling in this scenario. An acute apical abscess would usually present with noticeable swelling
(intraoral or facial), possibly pus drainage, and often systemic signs. Here we have a lot of pain and a
necrotic pulp with apical inflammation, but no frank abscess formation (no swelling or pus), so it’s still
symptomatic apical periodontitis rather than an abscess.
– D: Mild pulpitis with symptomatic apical periodontitis is incorrect. Mild pulpitis implies a vital pulp with a
heightened response to stimuli (and cold usually hurts, not helps). In this case, the pulp shows no vital
response and the pain pattern is not consistent with any form of reversible pulpitis. The pulp is past the
“mild” stage — it’s necrotic. So this option misidentifies the pulp status.

Explanation: – A: Moderate pulpitis with symptomatic apical periodontitis is incorrect because the symptoms described are more extreme than moderate. The patient’s pain is spontaneous, unrelenting, and sleep-disruptive, which goes beyond moderate pulpitis. Moderate pulpitis pain can often be managed with analgesics and typically isn’t as intensely spontaneous or sleep-preventing. Here the severity points to the next level. – B: Severe pulpitis with symptomatic apical periodontitis is correct. This scenario is classic for what the Endolight framework calls Severe pulpitis – there is severe spontaneous pain, pain exacerbated by both cold and heat, and it’s keeping the patient awake at night (worse when lying down) . The tooth is very tender to percussion, indicating inflammation of the apical periodontal ligament, i.e. symptomatic apical periodontitis. The lack of swelling and the presence of a strong response to cold confirm that the pulp is still vital (not necrotic), just irreversibly inflamed. In practice, this would have traditionally been called “symptomatic irreversible pulpitis with symptomatic apical periodontitis.” The combination of severe pulpitis (pulp is irreversibly inflamed) and symptomatic AP fits all the findings. – C: Pulp necrosis with acute apical abscess is incorrect. Although the pain is severe, there is no swelling or pus, which typically would accompany an acute abscess. Moreover, the tooth responds to cold with pain – a necrotic pulp would not respond to cold at all (or the cold might actually feel relieving in a necrotic case). Also, an acute apical abscess usually presents after the pulp has died and often with rapid swelling; here the pulp is still alive (albeit in agony). – D: Severe pulpitis with normal apical tissues is incorrect because the tooth clearly has symptomatic apical involvement (it’s very tender to percussion). Normal apical tissues would mean no pain to percussion. In this case, the percussion sensitivity shows the periodontal ligament is inflamed, so it is not normal.

– A: Mild pulpitis with symptomatic apical periodontitis is incorrect. The described pain is too intense and prolonged for Mild pulpitis, which is limited to pain that subsides within about 20 seconds and typically doesn’t require analgesics. Here, the pain lasts minutes and the patient needs pain medication, indicating a more advanced pulpitis than mild. – B: Moderate pulpitis with symptomatic apical periodontitis is correct. The case presentation matches Moderate pulpitis: the cold-induced pain is strong and prolonged (lasting minutes) and there are occasional spontaneous dull aches that can be somewhat managed with analgesics . The tooth is also percussion-sensitive, meaning there is periapical inflammation i.e. symptomatic apical periodontitis. There is no swelling or pus; the periapical involvement is limited to tenderness on pressure. This diagnosis fits the combination of a significantly inflamed pulp that is still vital (moderate pulpitis) and an inflamed periodontal ligament (symptomatic AP). – C: Severe pulpitis with symptomatic apical periodontitis is not the best choice here because Severe pulpitis usually implies even more extreme symptoms – typically excruciating spontaneous pain that keeps the patient awake at night and often pain that worsens when lying down . While this patient is in a lot of pain, the fact that painkillers provide some relief and the description of “dull throbbing pain” that is somewhat controlled suggests the pulpitis is in the moderate range of severity. (In severe pulpitis, pain is often continuous and harder to control.) – D: Moderate pulpitis with acute apical abscess is incorrect. There is no sign of an acute apical abscess (no swelling, no pus, no fever). The periapical diagnosis in this case is inflammation (symptomatic apical periodontitis), not an abscess. An acute apical abscess would present with significant swelling, possible fluctuance, or pus drainage and typically more severe pain on percussion plus systemic signs, which are not present here.