Dental MCQ
Reading the pulp and periapex · Endodontics · INBDE Patient Cases

Pulpal & Periapical Diagnosis INBDE Patient Cases

By Dr. Isaac Sun, DDS

8 ADA INBDE-format patient cases on pulpal & periapical diagnosis. Each case is a shared patient box (chief complaint, history, medications, allergies, exam) followed by linked multiple-choice questions with full distractor explanations. Practice the way the real exam is structured.

8 patient cases40 linked questionsADA INBDE formatFull distractor explanations

Eight ADA INBDE-format patient cases on pulpal and periapical diagnosis: symptomatic irreversible pulpitis with heat-aggravated pain relieved by cold, reversible pulpitis managed restoratively, pulp necrosis with asymptomatic apical periodontitis in a discolored traumatized incisor, an acute apical abscess with facial swelling and an extruded tooth requiring drainage and source control, a chronic apical abscess with a draining sinus tract traced by a gutta-percha cone, symptomatic apical periodontitis from a high restoration on a vital tooth managed by occlusal adjustment, condensing osteitis as a radiopaque reaction to chronic pulpal inflammation, and the pitfalls of pulp testing after trauma and with an open apex where sensibility does not equal vitality. Topics include the pulpal and periapical diagnostic classes, pulp vitality testing, percussion and palpation, and reading the periapical radiograph.

Case Coverage Map
What each case is testing
Throbbing made worse by hot coffee:
Symptomatic irreversible pulpitis, heat-aggravated/cold-relieved pain, early symptomatic apical periodontitis, and confirming vitality before root canal therapy.
A quick zing from cold and sweets:
Reversible pulpitis with normal apical tissues, restorative (not endodontic) management, and the operative pulp-protection link.
A dark front tooth with a spot on the x-ray:
Pulp necrosis from old trauma, asymptomatic apical periodontitis, control-tooth testing, discoloration, and the need to treat a painless lesion.
A swollen face and a tooth that feels high:
Acute apical abscess, the extruded tender tooth, the necrotic source, drainage and source control, and the limits of antibiotics alone.
A painless gum boil that keeps coming back:
Chronic apical abscess with a sinus tract, tracing with a gutta-percha cone, why it is painless, and treating the necrotic source tooth.
It hurts to bite, but cold is normal:
Symptomatic apical periodontitis with a vital pulp from a high restoration, why percussion is the key test, and occlusal adjustment first.
A dense spot under a long-aching molar:
Condensing osteitis as a radiopaque marker of chronic pulpal inflammation, the sclerotic bone reaction, and treating the pulpal cause.
A test result that doesn't add up:
Pulp-test pitfalls after trauma and with an open apex, sensibility versus vitality, false negatives, and monitoring before deciding on necrosis.
Patient case: Throbbing made worse by hot coffee
0 of 5 answered, 0 correct
Patient
Female, 39 years old
Chief Complaint
"It throbs on its own, and hot drinks make it unbearable. Ice water helps."
Background and/or Patient History
  • Deep caries on a lower molar
  • Spontaneous, lingering pain; wakes her at night
  • Pain aggravated by heat and relieved by cold
Allergies
NKDA
Medications
  • Ibuprofen as needed
Current Findings
  • Lingering, exaggerated response to cold; pain provoked by heat
  • Mild tenderness to percussion; no swelling; periapex near normal on film
  1. Question 1
    Moderate
    The lingering, spontaneous pain points to a pulpal diagnosis of:
  2. Question 2
    Hard
    Heat aggravation relieved by cold is explained by:
  3. Question 3
    Moderate
    The mild percussion tenderness suggests the periapical diagnosis is moving toward:
  4. Question 4
    Moderate
    The appropriate treatment for this tooth is:
  5. Question 5
    Moderate
    Which test result would most help confirm the pulp is still vital (not necrotic) before treatment?

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Patient case: A quick zing from cold and sweets
0 of 5 answered, 0 correct
Patient
Male, 24 years old
Chief Complaint
"A quick zing with cold and sweet that goes away right away."
Background and/or Patient History
  • Moderate caries at the margin of an old restoration on a premolar
  • Brief, sharp sensitivity; no spontaneous or night pain
  • Symptoms stop as soon as the stimulus is removed
Allergies
NKDA
Medications
  • None
Current Findings
  • Brief response to cold that resolves immediately
  • No percussion tenderness; normal periapical radiograph
  1. Question 1
    Easy
    The brief, non-lingering response indicates a pulpal diagnosis of:
  2. Question 2
    Moderate
    The normal radiograph and lack of percussion tenderness give a periapical diagnosis of:
  3. Question 3
    Moderate
    The appropriate management is:
  4. Question 4
    Easy
    This case connects directly to which operative dentistry concept?
  5. Question 5
    Moderate
    If, after restoration, the tooth instead developed lingering spontaneous pain, the diagnosis would shift to:

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Patient case: A dark front tooth with a spot on the x-ray
0 of 5 answered, 0 correct
Patient
Male, 31 years old
Chief Complaint
Asymptomatic discolored upper incisor noted at a checkup.
Background and/or Patient History
  • History of trauma to the front tooth years ago
  • No current pain; tooth looks grayer than its neighbors
  • A rounded radiolucency is seen at the apex on the radiograph
Allergies
NKDA
Medications
  • None
Current Findings
  • No response to cold or electric pulp testing; adjacent teeth respond normally
  • Well-defined apical radiolucency; not tender to percussion
  1. Question 1
    Moderate
    No response to cold or electric testing in this tooth indicates:
  2. Question 2
    Moderate
    The asymptomatic apical radiolucency gives a periapical diagnosis of:
  3. Question 3
    Moderate
    Comparing with the adjacent normally responding teeth serves to:
  4. Question 4
    Moderate
    The discoloration of the tooth is best explained by:
  5. Question 5
    Moderate
    The appropriate treatment for this necrotic tooth with apical periodontitis is:

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Patient case: A swollen face and a tooth that feels high
0 of 5 answered, 0 correct
Patient
Female, 47 years old
Chief Complaint
"My face is swollen and the tooth feels like it's sticking up; it really hurts."
Background and/or Patient History
  • Two days of rapidly worsening pain and facial swelling
  • The tooth feels 'high' and is painful to any touch
  • Feels feverish and unwell
Allergies
NKDA
Medications
  • None
Current Findings
  • Marked tenderness to percussion and palpation; localized swelling with pus
  • No response to pulp testing; low-grade fever
  1. Question 1
    Moderate
    The rapid swelling, pus, severe pain, and fever indicate:
  2. Question 2
    Moderate
    The tooth feeling 'high' and painful to touch reflects:
  3. Question 3
    Moderate
    The pulp testing result expected in the offending tooth is:
  4. Question 4
    Moderate
    The most important immediate priority in management is to:
  5. Question 5
    Hard
    Antibiotics alone, without addressing the tooth, are generally:

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Patient case: A painless gum boil that keeps coming back
0 of 5 answered, 0 correct
Patient
Male, 52 years old
Chief Complaint
"There's a little bump on my gum that drains and comes back, but it doesn't hurt."
Background and/or Patient History
  • A recurring pimple-like lesion on the gingiva near a molar
  • Occasional salty drainage; essentially no pain
  • The molar has a large old restoration
Allergies
NKDA
Medications
  • None
Current Findings
  • A stoma (sinus tract opening) on the attached gingiva; no response to pulp testing
  • Apical radiolucency on the radiograph
  1. Question 1
    Moderate
    A painless draining sinus tract with a necrotic pulp indicates:
  2. Question 2
    Moderate
    To confirm which tooth is the source, the clinician should:
  3. Question 3
    Moderate
    The reason the lesion is painless is that:
  4. Question 4
    Moderate
    The expected pulp testing result in the source tooth is:
  5. Question 5
    Moderate
    Definitive treatment of the source tooth is:

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Patient case: It hurts to bite, but cold is normal
0 of 5 answered, 0 correct
Patient
Female, 35 years old
Chief Complaint
"It hurts when I bite on this tooth, but it isn't sensitive to cold."
Background and/or Patient History
  • A composite was placed on the molar three weeks ago
  • Pain on biting and chewing; cold sensitivity is normal and brief
  • No swelling or spontaneous pain
Allergies
NKDA
Medications
  • None
Current Findings
  • Tender to percussion and to biting; brief normal response to cold
  • A premature occlusal contact is detected on the restoration
  1. Question 1
    Moderate
    A vital (normally cold-responsive) tooth that is tender to percussion and biting has a periapical diagnosis of:
  2. Question 2
    Moderate
    Because the pulp still responds normally to cold, the likely cause of the apical periodontitis is:
  3. Question 3
    Moderate
    The most appropriate first management step is to:
  4. Question 4
    Moderate
    Why is percussion, rather than the cold test, the key test in this case?
  5. Question 5
    Hard
    If symptoms persisted after occlusal adjustment and the pulp later became non-responsive, the diagnosis would evolve toward:

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Patient case: A dense spot under a long-aching molar
0 of 5 answered, 0 correct
Patient
Male, 28 years old
Chief Complaint
Mild, long-standing intermittent ache in a lower molar.
Background and/or Patient History
  • Years of low-grade, intermittent discomfort in a molar with deep restoration
  • No swelling; minimal symptoms most of the time
  • Radiograph shows a focal area of increased bone density at the apex
Allergies
NKDA
Medications
  • None
Current Findings
  • Focal apical radiopacity (not radiolucency)
  • Pulp gives a lingering response to cold; mild percussion sensitivity
  1. Question 1
    Hard
    A focal radiopacity at the apex of a tooth with chronic low-grade pulpal inflammation is:
  2. Question 2
    Moderate
    Condensing osteitis represents the bone's reaction of:
  3. Question 3
    Moderate
    The lingering response to cold suggests the pulp is:
  4. Question 4
    Moderate
    Appropriate treatment for the tooth driving the condensing osteitis is:
  5. Question 5
    Moderate
    Condensing osteitis is important to recognize because it:

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Patient case: A test result that doesn't add up
0 of 5 answered, 0 correct
Patient
Female, 16 years old
Chief Complaint
Follow-up of a front tooth injured in a fall two weeks ago.
Background and/or Patient History
  • An upper central incisor was traumatized recently; the apex is still immature (open)
  • No pain currently; the tooth has not discolored
  • Cold test currently elicits no response
Allergies
NKDA
Medications
  • None
Current Findings
  • No response to cold at this visit; tooth not tender, not discolored
  • Open apex on radiograph; no periapical radiolucency
  1. Question 1
    Hard
    The lack of cold response shortly after trauma in this tooth most likely reflects:
  2. Question 2
    Hard
    Pulp tests can mislead here because they measure:
  3. Question 3
    Hard
    An immature (open) apex also makes the electric pulp test:
  4. Question 4
    Moderate
    The most appropriate approach for this recently traumatized immature tooth is to:
  5. Question 5
    Moderate
    Which later finding would convert the working diagnosis to pulp necrosis?

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Pulpal & Periapical Diagnosis core recall

Refresh the anatomy facts these cases depend on: nerve numbers, foramina, functions, and lesion findings.

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