EndoPedia

by Dr. Ahmed Khaled

Evidence-Based Learning

The Wikipedia
of Endodontics

Cases · Anatomy · MCQs · Procedures · AI
For students, GPs & specialists worldwide.

Dr. Ahmed Khaled

Endodontist · Cairo, Egypt

"Every answer in this app is sourced — not assumed."

Endo Fact of the Day

⚡ Daily Challenge — 3 Questions

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Day Streak

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All Modules

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Orifice Atlas

Accurate orifice maps per Vertucci

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Nomenclature

FDI · Universal · Palmer

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MCQ Bank

Randomized · AAE-aligned bank

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Procedure Guides

Access · Irrigation · Obturation

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Clinical Cases

Interactive · AAE-based diagnosis

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Pulp Diagnosis

Symptoms → AAE diagnosis

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Dr. Endo — AI Assistant

PRO Evidence-graded answers

Trained on Cohen's Pathways 11th & 12th Ed., AAE guidelines, JOE, IEJ, EEJ, and landmark literature. Ask any clinical endo question.

Maxillary

Mandibular

Select tooth

Tooth Nomenclature

Three Numbering Systems

FDI — International

Two-digit. Quadrant (1=UR, 2=UL, 3=LL, 4=LR) + position 1–8. Used in all international journals.

16 = Upper right first molar

Universal — American (ADA)

Numbers 1–32 starting upper right 3rd molar, sweeping upper arch, then lower right to left.

#3 = Upper right first molar

Palmer — Clinical

Bracket symbol showing quadrant + number 1–8. Widely used in UK, Europe, and clinical notes.

⌐6 = Upper right first molar

Look Up Any Tooth

1. Quadrant

Full Permanent Dentition

Tooth

FDI

Univ.

Palmer

MCQ Bank — Randomized

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Session score

0/0

Q 1/5

Procedure Guides

Protocols aligned with AAE Guidelines · ESE Position Statements · Cohen's Pathways 12th Ed.

Access Cavity Preparation

AAE Guidelines · 6 steps

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Rubber dam isolation

Mandatory before access. Reduces microbial contamination and prevents irrigant accidents — non-negotiable per AAE position statement. (Cohen's 12th Ed. Ch.8)

Initial penetration

High-speed round bur #4–6 through deepest fossa, directed toward the pulp chamber. Aim toward the pulp horn, not the root canals. (Cohen's 12th Ed. Ch.8)

Complete roof removal

Safe-ended bur (Endo-Z) removes entire pulp chamber roof. Tactile "drop" confirms entry. Never leave pulp horns — causes discoloration and microleakage. (Cohen's 12th Ed. Ch.8)

Locate all orifices — Krasner & Rankow laws

DG-16 explorer probes all corners. Law of centrality: floor at CEJ level. Law of colour: floor always darker than walls. In maxillary first molars, MB2 lies mesial to the MB1–palatal line in 60–95% of cases. (Cohen's 12th Ed. Ch.8)

Straight-line access

Modify walls until files enter canals without contacting cavity walls. Reduces file fatigue, transportation, and ledging. (Cohen's 12th Ed. Ch.8)

Conservative / ninja access

Preserves pericervical dentin improving fracture resistance — but increases MB2 miss-rate. ESE 2022 position: use only with CBCT guidance and magnification. (EEJ 2022 · Chan et al.)

Irrigation Protocol

AAE Clinical Considerations · 5 steps

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Primary irrigant — NaOCl

2.5–5.25% NaOCl is the gold-standard primary irrigant. Dissolves organic tissue, broad antimicrobial spectrum. Minimum 20mL per canal per session. (Zehnder — JOE 2006)

EDTA — smear layer removal

17% EDTA final rinse for minimum 60 seconds. Chelates inorganic smear layer. Never mix directly with NaOCl — chlorate precipitate forms. (Cohen's 12th Ed. Ch.9)

Passive Ultrasonic Irrigation (PUI)

PUI significantly improves debridement — acoustic streaming disrupts biofilm in isthmi and lateral canals unreachable by needles. 30–60s per canal per cycle. (van der Sluis — IEJ 2007)

Final rinse sequence

NaOCl → EDTA 60s (activated) → final NaOCl flush → dry with paper points. CHX 2% only when specifically indicated — never mix directly with NaOCl (precipitate). (AAE Clinical Considerations 2023)

Safety — prevent extrusion

Side-vented needle placed 2mm short of WL minimum. Never bind the needle. NaOCl extrusion causes severe tissue necrosis — immediate saline flooding and urgent OMFS referral. (Cohen's 12th Ed. Ch.9)

Warm Vertical Compaction

Schilder Technique · 5 steps

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Master cone fit

GP cone matching master apical file size. Confirm tugback at exact working length. Verify with periapical radiograph — GP tip 0–0.5mm from radiographic apex. (Cohen's 12th Ed. Ch.10)

Sealer application

Thin coat on canal walls. AH Plus (gold standard for seal) or bioceramic sealers (BioRoot RCS — biocompatible, sets in moisture). Sealer is supplemental to GP, not a substitute. (Cohen's 12th Ed. Ch.10)

System B down-pack

Heat carrier at 200°C. Sear and compact to 5mm from WL in one firm stroke. Seals apical delta and lateral canals under heat and pressure. (Cohen's 12th Ed. Ch.10)

Thermoplastic backfill

Obtura III / Elements at 160°C. Inject in 3–4mm increments with vertical condensation between each. Continuous GP flow eliminates voids. (Cohen's 12th Ed. Ch.10)

Coronal seal — same visit

Place IRM or GIC base immediately after obturation. Bacteria penetrate unsealed canals within 30 days on average. Definitive restoration as soon as possible. (Torabinejad et al. — JOE 1990)

Working Length Determination

ESE Position Statement · 4 steps

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Radiographic estimate

Measure root length on paralleling-technique periapical radiograph. Estimated working length ± 2mm. (Cohen's 12th Ed. Ch.7)

Electronic apex locator

Multi-frequency EALs (Root ZX, Propex Pixi, Raypex 6) achieve 90–95% accuracy within ±0.5mm. Canal must be irrigated and free of blood for accurate readings. (Duran-Sindreu — IEJ 2012)

Radiographic verification

Confirm EAL reading radiographically. File tip should appear 0.5–1mm short of radiographic apex in fully developed teeth. (Kuttler 1955)

Special scenarios

Open apices: CBCT + tactile. Resorption: CBCT essential — apex locators unreliable. Curved canals: pre-curve files, verify carefully. (AAE Position Statement 2022)

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Retreatment · REP · Microsurgery · Trauma · Pharmacology
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Obturation — Bioceramic Sealer + Single ConePRO

BioC Sealer · TotalFill · 6 steps

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Canal drying

Dry the canal with one paper point only — bioceramic sealers require residual moisture from dentin for hydraulic setting. Do NOT overdry.

Sealer application

Apply a thin coat of bioceramic sealer using a paper point or lentulo spiral to the apical third and canal walls.

Master cone selection

Select the matched master cone (same taper as the final rotary file used). Confirm tugback at WL before sealer application.

Cone insertion

Insert the sealer-coated master cone to WL in a single smooth motion. Avoid excessive apical pressure.

Sear and condense

Sear the cone at the orifice level with a heated plugger. Vertical condensation of the coronal GP — no spreader needed.

Coronal seal

Clean the access floor immediately. Place 2 mm GIC base + definitive composite restoration same day where possible. (Cohen's 12th Ed. Ch.9)

Non-Surgical Retreatment ProtocolPRO

Cohen's 12th Ed. Ch.8 · ESE Guidelines · 7 steps

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Assess cause of failure first

CBCT before retreatment: identify missed canals, short fills, VRF, or extraradicular pathology. Treating without identifying the cause leads to repeat failure.

Remove the coronal restoration

Remove crown/bridge/post to gain straight-line access. Ultrasonic vibration for post removal — do not use high-speed burs on posts.

Dissolve coronal GP

Apply solvent (chloroform or eucalyptol) on a paper point for 30 sec to soften the coronal GP before rotary retreatment files engage it.

Rotary retreatment files

ProTaper Retreatment D1 (coronal), D2 (middle), D3 (apical). Use continuous clockwise brushing motion — no apical force. Recapitulate with #10 K-file between each file.

Solvent + hand file apical segment

Apply solvent again. Use H-files to engage and pull apical GP remnants. Confirm patency with a #10 K-file to full WL.

Full irrigation protocol

Copious NaOCl + 17% EDTA x 1 min + final NaOCl. PUI activation. The canal must be cleaner than the original treatment.

Ca(OH)2 dressing for two-visit approach

For retreatment of infected cases: Ca(OH)2 dressing x 4 weeks before obturation. Obturate at visit 2. (Cohen's 12th Ed. Ch.8)

Regenerative Endodontic Procedure (REP)PRO

AAE REP Considerations 2021 · 8 steps

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Patient selection

Indication: necrotic immature permanent tooth with open apex. Confirm with CBCT (open apex, thin walls, periapical lesion).

Visit 1 — Access and irrigation

Under rubber dam: access, irrigate with ≤1.5% NaOCl only (higher concentrations kill SCAP). Final rinse: 17% EDTA x 1 min. Dry with paper points.

Antibiotic dressing

Anterior teeth: DAP (ciprofloxacin + metronidazole — no minocycline to avoid discolouration). Posterior: TAP acceptable. Place to 2 mm below CEJ. Seal with GIC.

Visit 2 — Re-irrigation

4 weeks later: remove dressing, irrigate with 17% EDTA only (no NaOCl at visit 2 — preserves SCAP). Dry with paper points.

Evoke bleeding

Pre-curve a #25 K-file, pass 3 mm beyond the WL to disrupt the apical papilla. Bleed to the CEJ level. Allow 15 min for blood clot formation.

Alternative scaffold if no bleeding

If bleeding cannot be evoked: use PRF membrane or collagen sponge as scaffold material introduced to the CEJ level.

MTA barrier

Place 3-4 mm of white MTA over the blood clot/scaffold using a MAP system. Moist cotton pellet over MTA. Seal access with GIC.

Final restoration

At the following visit: composite restoration. Monitor at 6, 12, 18, 24 months with PA. (AAE REP 2021)

Periapical Microsurgery ProtocolPRO

Cohen's 12th Ed. Ch.11 · Kim SG 2006 · 8 steps

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Pre-operative CBCT planning

Mandatory: assess lesion size, root anatomy, proximity to IAN/sinus/mental foramen. Plan osteotomy approach and flap design.

Flap design and reflection

Sulcular or Ochsenbein-Luebke flap. Full-thickness mucoperiosteal elevation. Identify and protect mental foramen.

Osteotomy

Round bur #6 or piezo tip under sterile saline irrigation. Create a bony window over the apex — minimum 4 mm diameter.

Curettage of lesion

Curette all granulation/cystic tissue. Submit for histopathology — mandatory. Achieve haemostasis with Racellet pellets + 1:50,000 epi.

Root-end resection

Resect 3 mm of the root apex perpendicular (0° bevel) to the long axis. Removes 93% of apical lateral canals and the entire apical delta.

Ultrasonic retropreparation

Under the surgical microscope: ultrasonic Class I cavity 3 mm deep, parallel to the long axis. Inspect for isthmus, cracks, and number of canals.

Retrograde fill — MTA or bioceramic

Dry the retroprep cavity. Deliver MTA or bioceramic putty in increments. Condense and verify complete 360° fill under the microscope before closing.

Flap closure

5-0 or 6-0 monofilament sutures. Interrupted pattern. Remove at 48-72 hours. Review at 6 months and 4 years. (Cohen's 12th Ed. Ch.11)

Pulp Vitality Testing — Full ProtocolPRO

AAE Consensus 2009 · Cohen's 12th Ed. Ch.1 · 5 steps

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Thermal test — cold

Refrigerant spray (Endo-Ice) on cotton pellet. Apply to middle third of facial surface. Normal: transient <5 sec. IRP: prolonged >30 sec. Necrotic: no response. Always compare to a control tooth.

Thermal test — heat

Heated GP stick or heated ball burnisher applied to the middle facial third (petroleum jelly barrier). Heat pain relieved by cold = late-stage IRP.

Electric pulp test (EPT)

Dry the tooth, toothpaste as conductor. Start at zero and increase slowly. Normal: mid-range. Early IRP: low threshold. Necrotic: no response at maximum setting.

Percussion and palpation

Percussion (mirror handle): tests PDL status, not pulp. Palpation (finger pad over apical mucosa): tests periapical bone. Always compare to contralateral.

Probing and selective anaesthesia

6-point probing for endo-perio lesions. Selective anaesthesia (IANB) when pain cannot be localised to an arch. Confirm all 4 tests before making pulp diagnosis. (AAE 2009)

Post-Endodontic Pain Management ProtocolPRO

AAE Pain Management 2022 · 5 steps

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First-line: NSAID + APAP combination

Ibuprofen 400 mg + paracetamol 500-1000 mg every 6 hours for 48 hours. Start BEFORE the local anaesthetic wears off (pre-emptive dosing). Outperforms opioids consistently in meta-analyses.

Pre-operative corticosteroid

For high flare-up risk (acute IRP): dexamethasone 4-8 mg orally 1 hour pre-operatively. Significantly reduces post-operative pain intensity.

Hot tooth — supplemental anaesthesia

IANB failure for IRP: PDL injection 0.2 mL lidocaine 2% + epi 1:100,000 at mesial and distal roots. Intraosseous as alternative. Intrapulpal as absolute last resort.

Antibiotic indication

Antibiotics are NOT analgesics. Prescribe only for systemic signs: fever >38°C, trismus, cellulitis, lymphadenopathy. First-line: amoxicillin 500 mg q8h x 5 days.

Metronidazole addition

Add metronidazole 400 mg q8h for spreading infections not responding to amoxicillin alone. Warn patient: no alcohol during course + 48h after. (AAE 2023)

Avulsion — Emergency Management ProtocolPRO

IADT Guidelines 2020 · 6 steps

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On-scene management

Do NOT scrub the root. Rinse gently with saline or milk. Ideal storage: HBSS. Next best: cold milk. Emergency: buccal vestibule. Time is critical — every minute counts.

Extra-oral time assessment

<60 min moist storage (closed apex): replant immediately — PDL cells viable. >60 min dry: PDL non-viable — ex-vivo RCT + fluoride soak protocol.

Immediate replantation (<60 min, closed apex)

Local anaesthesia. Saline socket irrigation. Gently replant with digital pressure. Flexible splint x 2 weeks. RCT within 7-10 days.

Open apex (<60 min)

Replant immediately. Revascularisation may occur — do NOT perform RCT unless infection signs develop. Monitor cold test and PA at 4 wk, 8 wk, 6 mo, 12 mo.

Non-viable PDL (>60 min dry, closed apex)

Soak in 2% sodium fluoride for 20 minutes. Ex-vivo RCT. Replant to maintain alveolar bone for future implant. Expect progressive replacement resorption.

Post-replantation monitoring

PA at 2 wk, 4 wk, 8 wk, 6 mo, 12 mo, annually x 5 years. Monitor for EIR, replacement resorption, and ankylosis. (IADT 2020)

CBCT — Indications and ProtocolPRO

AAE/AAOMR Position Statement 2015 · 5 steps

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Justification principle

CBCT is indicated ONLY when conventional radiography is insufficient AND the diagnostic information will change clinical management. Always document the clinical indication.

FOV selection

Always use the SMALLEST FOV that covers the area of interest (typically 4x4 cm or 5x5 cm for endodontic cases). Smaller FOV = higher resolution + lower dose.

Key endodontic indications

Pre-surgical planning, VRF diagnosis (halo sign), C-shaped canals, calcified canals, extra roots (MB2, radix entomolaris), complex resorption, and failed RCT evaluation.

CBCT cannot diagnose pulpitis

CBCT is a hard tissue tool only. Cannot detect pulpal inflammation. Pulp diagnosis always requires clinical testing. CBCT answers anatomical questions only.

Dose minimisation (ALARA)

Lowest dose that provides adequate diagnostic information. Rectangular collimation. Avoid repeat imaging within 12 months unless clinically indicated. (AAOMR 2015)

Warm Vertical Condensation — Advanced TechniquePRO

Schilder H 1967 · Cohen's 12th Ed. Ch.9 · 7 steps

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Master cone selection

Select a master cone that exactly matches the final rotary instrument taper. Confirm tugback at WL. No tugback = re-gauge and refit before proceeding.

Plugger pre-fitting

Pre-fit three pluggers at 3, 5, and 7 mm from WL. Working plugger should bind 3-5 mm short of WL. Never force to WL — risk of root fracture.

Sealer application

Coat the canal walls and master cone with a thin film of sealer using a paper point or lentulo. Insert the master cone immediately.

Down-pack (System B)

Apply heat burst at 200°C at the orifice level. Advance plugger in 1-2 mm increments with heat-cut-condense cycles. Final condensation 3-5 mm from WL.

Verify apical seal

Take a check radiograph after the down-pack. The apical fill should be homogeneous, void-free, and within 0.5-2 mm of the radiographic apex.

Backfill (thermoplastic injection)

Inject warm GP in 2-3 mm increments from the bottom of the down-pack space to the orifice. Condense each increment before the next injection.

Coronal seal

Clean the access floor of sealer and GP. GIC base 2 mm. Composite restoration. Document with PA. (Schilder 1967)

Vertical Root Fracture — Diagnosis ProtocolPRO

Cohen's 12th Ed. Ch.8 · 5 steps

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Clinical triad

VRF triad: (1) isolated narrow deep probing pocket (buccal or lingual), (2) parulis/sinus tract adjacent to a treated tooth, (3) J-shaped or halo periradicular bone loss on imaging.

Percussion sound test

Tap with a mirror handle: metallic/high-pitched percussion note vs adjacent teeth = VRF or ankylosis sign. Compare bilaterally.

CBCT assessment

Halo sign: circumferential bone loss around the fractured root. CBCT is the most diagnostic non-invasive test — review axial and coronal slices for the fracture line.

Surgical exploration

When CBCT is inconclusive: reflect a full-thickness flap. The fracture line is often stained brown by endotoxins. Methylene blue staining may highlight the line.

Prognosis

Single-rooted tooth: hopeless — extraction. Multi-rooted molar: hemisection of the affected root may salvage the remaining sound root. (Cohen's 12th)

Root Resorption — Diagnosis and ClassificationPRO

Heithersay 1999 · IADT 2020 · Cohen's 12th Ch.16 · 5 steps

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Internal vs external — CBCT

Internal: centred within the canal, enlarges canal outline, intact external surface. External: off-centre, originates from external root surface, does not respect the canal outline.

ECR — Heithersay classification

Class I: small, superficial. Class II: near the pulp, no canal involvement. Class III: extends into the coronal root canal. Class IV: involves the entire canal — usually non-restorable.

External inflammatory resorption (EIR)

EIR post-trauma: rapid ragged resorption from an infected necrotic pulp. Urgent RCT + Ca(OH)2 is the only way to stop progression. Every week of delay worsens the prognosis.

Replacement resorption (ankylosis)

Metallic percussion + loss of PDL space + bony fusion. Irreversible. In children: decoronation to preserve alveolar bone. In adults: extract when infraocclusion becomes significant.

Internal resorption — management

Non-perforating: RCT with warm obturation to fill the irregular cavity. Perforating: MTA orthograde or surgical repair. CBCT determines extent and restorability. (Cohen's 12th Ch.16)

Separated Instrument — Management ProtocolPRO

Cohen's 12th Ed. Ch.8 · 5 steps

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Initial assessment

PA radiograph immediately. Note: position (coronal/middle/apical third), length, canal curvature, diameter, and whether the apical third can be instrumented around the fragment.

Non-surgical retrieval (coronal third, straight)

Ultrasonic trephination creates a trough around the coronal end. IRS kit or Masserann system grasps and removes. Best success in straight, coronal-third fragments.

Bypass (mid-root to apical third)

Pre-curve a #08 K-file to attempt bypass around the fragment. If bypass established: shape around it, irrigate, obturate beyond the fragment if possible.

Leave in situ

If retrieval and bypass both fail, fragment is in a well-instrumented canal with no periapical lesion: obturate to the fragment, monitor. Success comparable to bypass in low-risk cases.

Surgical removal

If all non-surgical options fail and fragment is associated with persistent periapical pathology: apical resection removes the fragment with the apex. Retrograde + MTA retrofill. (Cohen's 12th)

Canal Transportation — Prevention ProtocolPRO

Cohen's 12th Ed. Ch.8 · 5 steps

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Understanding transportation

Files removing dentin from the outer wall of a curved canal straighten it artificially. Causes: ledges, zips, elbows, perforations. Prevention is far easier than management.

Glide path establishment

Always establish a patent, smooth glide path before rotary NiTi. Minimum: #10 K-file passively reaching WL with smooth in-out motion. Ideal: #15 K-file glide path confirmed.

Crown-down instrumentation

Work from coronal to apical third sequentially. Remove coronal interferences first. Reduces lateral pressure on files in the curved segment.

Anti-curvature filing

Hand files: direct pressure away from the outer curvature. In mesial roots of lower molars: file toward the buccal/lingual walls, away from the furcation danger zone.

Ledge bypass

Pre-curve a #08 K-file 30° at 1 mm from the tip. Watch-winding motion with EDTA lubricant. Patience — not force. Progressive enlargement past the ledge once bypassed. (Cohen's 12th)

Vital Pulp Therapy — Direct Pulp Cap ProtocolPRO

ESE VPT Position Statement 2019 · 5 steps

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Patient and tooth selection

Ideal DPC: carious or mechanical exposure <1 mm, bleeding controlled within 3-5 min with cotton pressure, no spontaneous pain, no periapical changes. Mature or immature vital tooth.

Haemostasis

Sterile cotton pellet moistened with saline applied for 3-5 minutes. Do NOT use electrosurgery or ferric sulfate on the pulp — causes tissue necrosis.

Material selection

MTA or Biodentine are first-line (75-95% success at 5 years). Ca(OH)2 (Dycal) acceptable but lower long-term success (50-70%). Never use ZOE directly on the pulp.

Placement technique

Apply 2-3 mm of MTA or Biodentine directly over the exposure under magnification. GIC base over the CSC. Restore same day with composite.

Follow-up monitoring

Cold test and PA at 6 weeks, 6 months, 1 year. Success: vital, asymptomatic, calcific bridge visible at 6-12 months. Failure: IRP or necrosis → proceed to RCT. (ESE 2019)

Endodontic Emergencies — Clinical ProtocolPRO

AAE Emergency Guidelines 2023 · 6 steps

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Triage and diagnosis

History, clinical tests (cold, EPT, percussion, palpation, probing), PA radiograph. Establish accurate AAE pulp and periapical diagnosis before any treatment.

Acute IRP — emergency pulpotomy

If single-visit RCT is not possible: emergency pulpotomy (remove coronal pulp + Ca(OH)2/cotton + IRM seal) provides excellent short-term pain relief. Schedule complete RCT within 2 weeks.

Hot tooth management

IANB first. If inadequate: PDL injection 0.2 mL x mesial and distal. Intraosseous injection as alternative. Intrapulpal injection as last resort once the chamber is accessed.

Acute apical abscess with swelling

Localised fluctuant: I&D + drain through the canal. Systemic signs (fever >38°C, trismus): amoxicillin 500 mg + metronidazole 400 mg q8h. Hospitalise if Ludwig's angina suspected.

Phoenix abscess (post-visit flare)

Re-enter the canal for drainage. Irrigate copiously. New Ca(OH)2 dressing. Antibiotics if systemic involvement. Reassure patient — predictable complication of necrotic tooth treatment.

Post-treatment instructions

Expected post-op soreness 24-72 hours is normal. Ibuprofen 400 mg + APAP 500 mg q6h. Soft diet. Contact details if swelling develops or pain worsens beyond 72 hours. (AAE 2023)

Endo-Perio Lesion — Diagnosis and TreatmentPRO

Cohen's 12th Ed. Ch.7 · 5 steps

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Pulp test first — always

The single most important test: vital pulp = primary periodontal lesion. Non-vital pulp = primary endodontic lesion. Never treat without establishing pulp status first.

Primary endo lesion

Source: infected root canal. Signs: non-vital pulp, periapical lesion, possible lateral bone loss from lateral canals. Treatment: RCT first — perio component often resolves spontaneously.

Primary perio lesion

Source: periodontal disease. Signs: vital pulp, generalised pocketing consistent with periodontitis. Treatment: periodontal therapy only. No RCT.

Combined endo-perio lesion

Both pathologies coexist independently. Non-vital pulp + true periodontal pocket. RCT first, re-evaluate at 3 months. If perio component persists: periodontal surgery + GTR.

Palatogingival groove — special case

Upper lateral incisors: probe for a palatogingival groove. The groove creates a combined endo-perio lesion requiring RCT + surgical groove sealing (MTA/composite) + GTR. (Cohen's 12th Ch.7)

Smear Layer Removal — Irrigation ProtocolPRO

McComb & Smith 1975 · Pashley 1984 · 5 steps

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What is the smear layer?

A 1-5 µm layer of organic and inorganic debris created by instrumentation. Occludes dentinal tubule orifices, harbours bacteria, and prevents sealer penetration. Must be removed.

EDTA — inorganic component

17% EDTA chelates the inorganic calcium phosphate smear layer. Minimum contact time: 1 minute. Agitate with ultrasonic tip or EndoActivator during contact time.

Final NaOCl — organic component

After EDTA: final NaOCl flush removes the exposed organic matrix left after the inorganic component is dissolved by EDTA.

Sequence matters

Correct sequence: NaOCl throughout shaping → 17% EDTA x 1 min → final NaOCl flush → paper point dry → obturate. Never use EDTA and NaOCl simultaneously — they neutralise each other.

Ultrasonic activation enhances removal

PUI during the EDTA step significantly improves smear layer removal from lateral canals and isthmuses vs passive syringe irrigation alone. (Van der Sluis 2007)

NaOCl Accident — Emergency ProtocolPRO

Cohen's 12th Ed. Ch.9 · 5 steps

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Recognition

Sudden severe burning pain, rapid soft tissue swelling (sublingual, submandibular, infraorbital), patient distress, metallic taste, possible paraesthesia.

Immediate action

Stop irrigation immediately. Do NOT continue. Remove the rubber dam and assess the patient. Attempt gentle aspiration of the irrigant from the canal.

Pain and swelling management

Ice packs immediately (20 min on, 10 min off). Strong analgesics. Corticosteroids: dexamethasone 8 mg IM/IV to reduce swelling.

Antibiotic prophylaxis and monitoring

Amoxicillin 500 mg + metronidazole 400 mg q8h x 5 days. Monitor closely for airway compromise — hospitalise if swelling is progressive.

Documentation and prevention

Document fully. Prevention: side-vented needle, never binding, 2-3 mm short of WL, gentle syringe pressure. Confirm free needle movement before each irrigation. (Cohen's 12th Ch.9)

Antibiotic Stewardship in EndodonticsPRO

AAE Antibiotic Stewardship 2023 · 5 steps

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When NOT to prescribe

Localised abscess with drainage, symptomatic IRP, symptomatic SAP, reversible pulpitis, post-RCT soreness. Antibiotics cannot reach the avascular necrotic pulp.

When TO prescribe

Systemic signs: fever >38°C, trismus, spreading cellulitis, lymphadenopathy, dysphagia, or progressive swelling despite adequate drainage.

First-line: amoxicillin

500 mg q8h x 5 days. If no improvement at 48h: add metronidazole 400 mg q8h. Do NOT simply extend the duration — investigate the source.

Penicillin allergy

Clindamycin 300-450 mg q6-8h x 5 days. Prior C. diff colitis: clindamycin contraindicated — consider moxifloxacin 400 mg daily with physician consultation.

Drug interactions

Metronidazole + warfarin: increases INR significantly — monitor. Metronidazole + alcohol: disulfiram-like reaction — warn the patient. (AAE 2023)

Post and Core Restoration after RCTPRO

Cohen's 12th Ed. Ch.10 · Ray & Trope 1995 · 5 steps

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When is a post needed?

A post retains a core, NOT the tooth. Needed only when <50% coronal structure remains. With ≥2 mm ferrule and ≥3 walls: post may not be needed.

Ferrule effect is critical

A 2 mm ferrule of sound coronal dentin at the crown margin is the single most important factor preventing root fracture. No ferrule = high fracture risk regardless of post type.

Fibre post vs metal post

Fibre posts: modulus of elasticity matches dentin (~18 GPa), distributes stress physiologically. Metal posts: 5-10x stiffer, concentrate stress → root fracture. Fibre posts are first choice.

Post length and diameter

Equal to crown length or 2/3 of root length. Leave 4-5 mm of apical GP seal. Diameter: as narrow as possible.

Timing of restoration

Permanent restoration within 1 month of obturation. Full crown for all RCT-treated posterior teeth. (Ray & Trope 1995)

Dental Trauma — Splinting GuidelinesPRO

IADT Guidelines 2020 · 5 steps

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When to splint

Subluxation (if mobile), extrusive luxation, lateral luxation, replanted avulsed teeth, alveolar fracture. NOT required for concussion or stable horizontal root fractures.

Flexible splinting

0.016 stainless steel wire + composite bonded to 2-3 teeth on either side of the injured tooth. Allows physiological movement to prevent ankylosis.

Duration guidelines

Subluxation: 2 weeks. Extrusion: 2 weeks. Lateral luxation: 4 weeks. Avulsion: 2 weeks. Root fracture (middle/apical): 4 weeks flexible. Root fracture (cervical): 4 months rigid.

Rigid splinting — exceptions

Cervical third root fractures and alveolar fractures: rigid immobilisation for 4 weeks (heavy stainless steel wire + acrylic or titanium trauma splint).

Monitoring during splinting

Cold test at splint removal. Non-vital at removal: initiate RCT immediately. PA at 4 wk, 8 wk, 6 mo, 12 mo, annually x 5 years. (IADT 2020)

Calcium Hydroxide Dressing ProtocolPRO

Cohen's 12th Ed. Ch.5 · 5 steps

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Indications

Necrotic teeth with periapical lesion (two-visit RCT), avulsion (arrests EIR), persistent exudate at visit 2.

Preparation

Ca(OH)2 powder + sterile water/saline to a creamy paste. Do NOT mix with eugenol — inactivates the hydroxyl ions.

Placement

Lentulo spiral at low RPM to within 1 mm of WL, or MAP system. Confirm with PA — must fill the full prepared canal length to be effective.

Duration and renewal

Most effective in first 1-4 weeks. Renew if delayed beyond 4 weeks. Long-term use >3 months weakens dentin (Doyon 2005). Maximum 3 months.

Removal

Copious NaOCl + size 35 K-file to mechanically disrupt Ca(OH)2. Final 17% EDTA x 1 min removes remnants. Confirm complete removal — Ca(OH)2 remnants impair sealer adhesion. (Cohen's 12th)

Electronic Apex Locator — Accuracy ProtocolPRO

4th Generation EAL · Cohen's 12th Ed. · 5 steps

▼

How 4th generation EALs work

Ratio method: two AC frequencies measure canal impedance. The ratio is constant at the minor foramen regardless of canal contents. Accuracy within 0.5 mm in >90% of cases.

Optimal canal conditions

Moist but not flooded: too dry = over-reading. Flooded with NaOCl = erratic OVER reading. One paper point to remove excess irrigant before measuring.

Clip position

Lip clip should contact moist lip mucosa, not dry lip or skin. Poor clip contact causes erratic readings.

Reading interpretation

EAL '0' = minor foramen (clinical WL). '0.5' = 0.5 mm short. 'OVER' = file is beyond the foramen. Confirm with a confirming PA film.

Special situations

Open apices: EAL unreliable — use paper point bleeding point or CBCT measurement. Perforations: EAL reads 'OVER' when file contacts moist tissue through a perforation. (Cohen's 12th)

Full Irrigation Protocol — Step by StepPRO

AAE · Boutsioukis 2010 · 6 steps

▼

NaOCl throughout shaping

Use 2.5-5.25% NaOCl throughout all shaping steps. Replenish after every 2-3 files — NaOCl is consumed by organic tissue and loses activity.

Side-vented needle technique

27-30 gauge side-vented needle, placed loose (non-binding) 2-3 mm short of WL. Never force the needle apically. Slow gentle plunger pressure.

Ultrasonic activation (PUI)

After shaping: flood canal with NaOCl, activate ultrasonic file (20-30 kHz) passively for 3 x 1-minute cycles. Most effective debridement method available.

EDTA — smear layer removal

17% EDTA x 1 minute minimum. Agitate with ultrasonic or sonic device. Do not use simultaneously with NaOCl — they neutralise each other.

Final NaOCl flush

After EDTA: final NaOCl flush to remove the exposed organic matrix.

Paper point drying

Dry with appropriate size paper points to WL. One paper point for bioceramic sealers (leave slightly moist). Two or more until fully dry for resin sealers. (Boutsioukis 2010)

Working Length — Combined EAL + Radiographic MethodPRO

Kuttler 1955 · AAE · 5 steps

▼

Anatomy reference

The apical constriction (CDJ/minor foramen) is the ideal terminus. It averages 0.5-1 mm short of the radiographic apex. The foramen exits at the radiographic apex in only ~17% of teeth.

Pre-flaring

Pre-flare the coronal and middle thirds BEFORE measuring WL. Removes the coronal dentinal triangle, improves EAL accuracy, and allows straighter file access.

EAL measurement

Flood canal with NaOCl. Advance #10 or #15 K-file until EAL reads '0' (minor foramen). Clinical WL = EAL '0' reading (retract to '0.5' = 0.5 mm short for the conservative approach).

Confirming radiograph

PA with file at the measured EAL WL. File should appear 0.5-2 mm short of the radiographic apex. Adjust only if significantly discrepant.

Reconfirm at obturation visit

After Ca(OH)2 treatment: always re-confirm WL with EAL — tissue changes may alter the measured length. (Kuttler 1955 · Cohen's 12th)

REP — Follow-up and Success CriteriaPRO

AAE REP 2021 · 5 steps

▼

Review schedule

PA at 6, 12, 18, and 24 months minimum. Annual PA thereafter for 5 years. Cold test at each visit. Primary success criterion: resolution of infection — not root development.

Radiographic success criteria

Complete: PAI 1-2, increased root length, increased wall thickness, apical closure. Partial: infection resolved, some root changes. Failure: persistent or new periapical lesion.

Positive cold test after REP

Return of cold sensitivity at 6-12 months = regeneration of pulp-like tissue. Rare but possible — confirms true pulp tissue regeneration.

If REP fails

At 12-18 months with no improvement: MTA apical plug (apexification) or apical surgery with retrofill. REP failure does not preclude subsequent apexification.

Root development expectations

Root lengthening and wall thickening occur in ~60-75% of successful REP cases. Apical closure in ~80% of successful cases at 24 months. (AAE REP 2021)

Perforation Repair — MTA ProtocolPRO

Cohen's 12th Ed. Ch.9 · 5 steps

▼

Classification

Location determines prognosis: cervical (worst), mid-root (intermediate), furcal (poor — immediate bacterial contamination), apical (best).

Immediate management

Time from perforation to repair is the strongest prognostic factor. Seal IMMEDIATELY with MTA.

MTA placement — orthograde

Identify the perforation with EAL (reads OVER). Dry with micro-suction or paper point. Deliver MTA with MAP system. Avoid MTA extrusion beyond the perforation.

Biodentine as alternative

Biodentine (12-min set vs 2.5h for MTA) is effective for furcal and cervical perforations where rapid setting is beneficial.

Surgical approach for cervical perforations

Cervical perforation communicating with the sulcus: MTA alone insufficient. Surgical flap + MTA + collagen membrane/GTR + primary closure. Prognosis is guarded. (Cohen's 12th Ch.9)

Endodontic Prognosis AssessmentPRO

Ørstavik 1996 · AAE · 5 steps

▼

Pre-operative factors

Periapical status is the strongest prognostic factor. No periapical lesion: ~90-95% success. With periapical lesion: ~75-85%.

Technical quality factors

Adequate preparation (length, shape, cleanliness), obturation quality, and coronal restoration quality. Ray & Trope (1995): coronal restoration quality > root filling quality for 4-year success.

Tooth-specific factors

Strategic value, restorability, ferrule, periodontal support, root anatomy complexity, VRF risk.

Outcome classification

At 4 years: PAI 1-2, asymptomatic = success. Progressive healing at 2 years = healing. PAI unchanged or worsening = failure.

When to refer

Complex anatomy, retreatment, periapical surgery, separated instruments, perforations, traumatised immature teeth. Early referral improves outcomes. (Cohen's 12th)

RCT in Special Medical PatientsPRO

Little JW · AAE · Malamed · 5 steps

▼

Pregnancy

RCT safe in all trimesters. Emergency treatment at any stage. Elective: second trimester preferred. LA: lidocaine + 1:100,000 epi safe at standard doses. Limit PA radiographs with shielding.

Diabetes mellitus

Well-controlled DM (HbA1c <8%): outcomes comparable to healthy patients. Poorly controlled: impaired healing, higher infection risk. More aggressive treatment + close follow-up.

Bisphosphonate patients

Prefer RCT over extraction. IV bisphosphonates (oncology): very high MRONJ risk — specialist referral for any surgical procedure.

Cardiac patients

Anticoagulants (warfarin INR <3.5): no modification for non-surgical RCT. IE prophylaxis: amoxicillin 2g pre-op for highest-risk patients (prosthetic valve, prior IE).

Immunocompromised patients

Neutropenia (WBC <1.5 x10^9/L): defer elective treatment. HIV (CD4 >200, HAART): standard RCT — outcomes comparable to immunocompetent. (Little JW)

Glide Path Establishment ProtocolPRO

Berutti 2009 · Cohen's 12th Ed. · 5 steps

▼

Definition and importance

A smooth, reproducible path from orifice to apical foramen. Without it, rotary NiTi files bind, deform, and separate. Most critical step before rotary instrumentation.

Hand file technique

#08 K-file: gentle watch-winding (90° CW, relax, advance 0.5 mm). Never force. Irrigate with NaOCl frequently. Once #08 reaches WL passively: advance to #10, then #15.

Patency filing

After each hand file: recapitulate with a #10 K-file to full WL to prevent apical debris compaction. This is the patency file — not a shaping file.

Mechanical glide path files

PathFile, ProGlider, or WaveOne Gold Glider after #10 hand file to WL. Expands the glide path to ISO 16-19 before the primary shaping file. Reduces rotary file stress significantly.

Confirmation

A glide path is confirmed when a #10 or #15 K-file slides passively to WL with minimal tactile resistance. Any binding = glide path NOT established — do not introduce rotary NiTi files. (Berutti 2009)

Reciprocating File Systems ProtocolPRO

WaveOne Gold · Reciproc · Cohen's 12th · 5 steps

▼

Principle of reciprocation

CCW cutting stroke (150°) engages and cuts dentin. CW release stroke (30°) disengages the file. Reduces angular fatigue per cycle — allowing safer use in curves.

WaveOne Gold system

Primary (25/.07): most canals. Small (20/.07): narrow/calcified. Medium (35/.06): larger canals. Large (45/.05): very large. One file per patient — single use only.

Motion technique

Slow, gentle in-out pecking motion (3-4 mm amplitude). Activate the motor BEFORE entering the canal. Withdraw and irrigate/recapitulate with #10 K-file every 3-4 cycles.

Checking for cyclic fatigue

Inspect the file after each use for unwinding, deformation, or bright spots. Single use only — do not re-sterilise and reuse reciprocating NiTi files.

When to use reciprocating vs rotary

Reciprocating: high curvature (>30°), narrow canals, high-risk cases. Continuous rotation: moderate curvature, established glide path, predictable anatomy. (Yared 2008)

RCT vs Implant — Decision FrameworkPRO

McGill 2008 · Cohen's 12th Ed. · 5 steps

▼

McGill Consensus

The natural dentition with successful endodontic treatment is the gold standard. An implant replaces a missing tooth — it is not a better alternative to a saveable tooth.

Evidence comparison

10-year survival: RCT + crown ~85-95%. Single implant ~90-95%. Comparable outcomes. RCT maintains proprioception, preserves alveolar bone, and is reversible.

When extraction is justified

Non-restorable crown-root ratio. Grade III furcation with >50% bone loss. Vertical root fracture. Persistent failure after adequate retreatment and surgery.

Alveolar bone preservation

If extraction is necessary: socket preservation graft immediately after extraction to maintain ridge dimensions for future implant placement.

Cost-effectiveness

RCT + crown is more cost-effective per tooth-year. Extraction + implant carries higher initial cost, maintenance costs, and surgical complication risks. (McGill 2008)

Mandibular First Molar — Anatomy GuidePRO

Cohen's 12th Ed. Ch.7 · De Pablo 2010 · 5 steps

▼

Root system

2 roots in >95%: mesial root (MB + ML canals, isthmus common) and distal root (1 or 2 canals). Radix entomolaris (3rd root, distolingual): 5% Europeans, up to 40% in some Asian groups.

Mesial root — key anatomy

MB and ML canals almost always present. Isthmus connects them — target for PUI. The furcal (inner) wall is dangerously thin (~0.2 mm). File away from the furcation (anti-curvature technique).

Distal root — large oval canal

Wide and oval in many cases. Two canals (DB + DL) in 30-40%. A large round access to the distal orifice alone may miss the distal-lingual canal. Probe with DG-16.

Access shape

Trapezoidal: wider mesially (MB + ML side by side), narrower distally. Extend the access to expose all orifices per Krasner & Rankow Laws of Symmetry.

Middle mesial canal

Present in ~15% of lower first molars. Located between MB and ML orifices. Negotiate with a pre-curved #08 K-file. Usually joins MB or ML apically. (De Pablo 2010)

Maxillary First Molar — Anatomy GuidePRO

Cohen's 12th Ed. Ch.7 · Krasner 2004 · 5 steps

▼

Root system

3 roots: mesiobuccal (MB), distobuccal (DB), palatal. The palatal root is the longest and largest. The MB root is the most curved and complex.

MB2 — the key canal

MB2 present in 60-95% of maxillary first molars. Located along the developmental groove from MB1 toward the palatal orifice. Technique: DG-16 explorer along the groove, then LN bur trough if not found.

Access shape

Rhomboidal: 4 corners for MB1, MB2, DB, and palatal. The access must be extended to expose MB2 — a small round access will miss it routinely.

Palatal root canal

Large, oval/round, often #40-60 at the apex. Easiest to negotiate but requires large shaping. Ultrasonic activation essential for the oval cross-section.

MB root danger zones

Curves sharply distolingually. Risk of transportation at the curvature. Use flexible NiTi, crown-down technique, and anti-curvature pressure. (Krasner 2004)

Crown-Down Instrumentation TechniquePRO

Cohen's 12th Ed. Ch.8 · Schilder 1974 · 5 steps

▼

Principle

Work from coronal to apical third in sequential steps. Remove coronal and middle third interferences first. Reduces force at the curve and prevents apical debris compaction.

Step 1 — Coronal pre-flaring

Gates Glidden #2 and #3 in the coronal third. Removes the dentinal triangle, provides straight-line access, and improves EAL accuracy. Never force GG burs — passive brushing outward.

Step 2 — Middle third

NiTi rotary files in the middle third until resistance is felt. Recapitulate with #10 K-file after each file. Irrigate copiously between files.

Step 3 — Measure WL

After coronal and middle third preparation, measure WL accurately with EAL + confirming PA. Coronal resistance is now gone, allowing a more accurate EAL reading.

Step 4 — Apical shaping

Advance through the apical third sequentially with copious irrigation and recapitulation between each file. Stop at the file that achieves the desired apical size. (Schilder 1974)

Managing Calcified CanalsPRO

Cohen's 12th Ed. Ch.4 · 5 steps

▼

Pre-operative assessment

CBCT mandatory for significantly calcified canals. Measure the distance from the occlusal/incisal reference to the calcified region.

Access modification

Conservative access. Use CBCT measurements as a guide — go to the calculated depth, then switch to ultrasonic. Never drill blindly beyond CBCT-guided depth.

Ultrasonic technique

Start-X #1 or #2 ultrasonic tip at LOW power. Work in a brushing motion following the dentinal colour change (yellow → grey → brown = canal).

Micro-tools for negotiation

#06 or #08 K-file pre-curved at 1 mm from the tip. Watch-winding motion. EDTA lubricant. Extreme patience — do not force any instrument.

Trephination as last resort

Only if all other methods fail and CBCT confirms the canal path. The risk of perforation is highest here — always confirm with CBCT-guided measurements. (Cohen's 12th)

Endodontic Diagnosis — Systematic ApproachPRO

AAE Classification 2009 · Cohen's 12th Ed. Ch.1 · 5 steps

▼

Step 1 — Chief complaint

Character (sharp/dull/throbbing), duration, triggers, timing (nocturnal/diurnal), previous treatment, relevant medical history.

Step 2 — Clinical examination

Extra-oral: asymmetry, swelling, lymphadenopathy. Intraoral: soft tissue, sinus tracts (trace with GP cone), visual inspection. 6-point probing.

Step 3 — Pulp tests

Cold → EPT → heat (if cold negative and spontaneous heat pain). Always test a control tooth first. Document: no response / normal / hyperresponsive / prolonged.

Step 4 — Periapical tests

Percussion (mirror handle). Palpation (finger pad over apical mucosa). Bite test (Tooth Slooth on each cusp for suspected CTS).

Step 5 — Radiographic assessment

PA radiograph. Angled PA for suspected extra canals. CBCT when indicated. Assign formal AAE pulp and periapical diagnosis before treatment. (AAE 2009)

Endodontic Flare-Up PreventionPRO

Cohen's 12th Ed. Ch.5 · 5 steps

▼

High-risk case identification

Pre-operative spontaneous pain + necrotic tooth with periapical lesion = highest flare-up risk. Two-visit protocol with Ca(OH)2 dressing recommended.

Pre-operative corticosteroid

Dexamethasone 4-8 mg orally 1 hour pre-operatively. Significantly reduces post-operative pain intensity in vital inflamed teeth (IRP). Single dose — no systemic adverse effect.

Meticulous debridement

Thorough mechanical and chemical debridement is the single most important prevention strategy. Copious NaOCl + EDTA + PUI activation.

Avoid over-instrumentation

Do not instrument beyond WL. Apical extrusion of debris is the most common cause of post-treatment flare-up.

Post-operative analgesia

Ibuprofen 400 mg + paracetamol 500-1000 mg BEFORE the LA wears off (pre-emptive). Continue q6h x 48h. Antibiotics only if systemic signs present. (Cohen's 12th)

Rubber Dam Isolation ProtocolPRO

AAE Position Statement 2016 · 5 steps

▼

Rubber dam is mandatory

Standard of care for all endodontic procedures per AAE, ESE, and ADA. Prevents NaOCl aspiration, maintains a sterile field, improves visibility, and protects the airway.

Clamp selection

Molar: #8, #7, #56. Premolar: #2, #4, #14. Anterior: #9. Tilted/partially erupted: butterfly clamps (W8A). ALWAYS floss-tie all clamps.

Latex allergy

Use non-latex rubber dam (nitrile/vinyl) for documented latex allergy. Non-latex clamps also available. Document the allergy and dam material used.

Difficult isolation

Broken-down teeth: apply Oraseal/caulk around the dam margins. Build up the coronal structure with GIC before dam placement if needed.

Antimicrobial supplementation

After dam placement: scrub the access site with NaOCl or CHX before cutting through enamel. Decontaminates the surface microbiome before entering the pulp chamber. (AAE 2016)

Endodontic Outcome Measurement — PAI ScalePRO

Ørstavik PAI 1986 · ESE Quality Guidelines · 5 steps

▼

PAI scoring

PAI 1: normal. PAI 2: small bone changes. PAI 3: changes with mineral loss. PAI 4: well-defined radiolucency. PAI 5: severe periodontitis with exacerbating features.

Success criteria at 4 years

Complete healing: PAI 1-2 with no clinical symptoms = healed/success. Healing: progressive PAI reduction. Failure: PAI unchanged or worsening at 18-24 months.

Clinical success criteria

No pain, no swelling, no sinus tract, no loss of function, no probing defects, normal periapical structures on PA.

Success rates

Initial RCT without lesion: ~90-95%. With lesion: ~75-85%. Retreatment with lesion: ~65-75%. Periapical surgery (modern microsurgery): ~85-95%.

Documentation standard

Record pre-treatment and post-treatment PA with the same technique. Document PAI score at each review. Objective clinical records are essential for medicolegal protection. (Ørstavik 1986)

C-Shaped Canal System ProtocolPRO

Fan 2004 · Cohen's 12th Ed. Ch.7 · 5 steps

▼

Recognition and prevalence

Most common in mandibular second molars. Prevalence: ~8% in Caucasians, up to 44% in Chinese/Korean populations. Fan classification: Type I-III based on shape continuity.

CBCT pre-operatively

Always use CBCT for suspected C-shaped systems to map the ribbon extent and classify the type before treatment.

Access modification

The access must expose the full C-shaped orifice outline. An oval or C-shaped access is required — a round access will leave a portion of the ribbon unexposed.

Irrigation is the key treatment step

Round files cannot clean the connecting ribbon. PUI (3 x 1-min NaOCl cycles) + XP-endo Finisher are essential. The ribbon harbours biofilm unreachable by files.

Obturation

Cold lateral condensation is inadequate. Warm vertical condensation or carrier-based thermoplastic obturation can fill the irregular C-shaped cross-section. (Fan 2004)

Sinus Tract Tracing ProtocolPRO

Cohen's 12th Ed. Ch.1 · 5 steps

▼

Never assume the nearest tooth

The stoma may be far from the source tooth. A mandibular molar sinus tract can originate from a premolar. Always trace.

GP cone tracing technique

Insert a #25 or #30 GP cone gently into the stoma until resistance is felt. Take a PA with the cone in situ. The cone tip will be at the source tooth apex.

Multiple tracing

If the PA shows the cone tracks to an unexpected tooth: test the identified tooth with cold, EPT, and percussion. Confirm with CBCT if inconclusive.

What the sinus tract tells you

Confirms chronic apical abscess. The sinus tract is the drainage pathway. Closure after RCT = successful outcome. Persistent sinus tract at 3 months = failure.

Post-RCT sinus tract closure timeline

Most sinus tracts close within 2-6 weeks of adequate RCT. If still present at 3 months: suspect missed canal, microleakage, or extraradicular biofilm. (Cohen's 12th)

Obturation Quality AssessmentPRO

Cohen's 12th Ed. Ch.9 · 5 steps

▼

Radiographic assessment criteria

Homogeneous fill without voids, GP terminating 0.5-2 mm from the radiographic apex, appropriate taper, no sealer extrusion.

Void identification

Voids appear as radiolucencies within the GP fill. Apical third voids are most clinically significant. Warm techniques virtually eliminate voids.

Length assessment

Short fill (<2 mm from apex) in necrotic teeth: significant failure risk. Overfill (beyond apex): slight reduction in success; sealer extrusion less problematic than GP extrusion.

Immediate retreatment indications

GP clearly beyond apex by >2 mm, significant void in apical third, or underfill by >3 mm: consider immediate re-obturation before the patient leaves.

Post-obturation coronal seal

A well-sealed access is as important as the quality of the root filling. Recontamination occurs within 30 days without a proper coronal seal. (Torabinejad 1990)

Vital Pulp Therapy — Pulpotomy in Primary TeethPRO

AAPD Guidelines 2023 · 5 steps

▼

Indications

Deep carious exposure in a vital primary molar with controlled bleeding. No spontaneous pain, no furcal radiolucency, no internal resorption, at least 2/3 root length remaining.

Armamentarium

Rubber dam (mandatory). Round bur #6 high-speed for access. Sterile cotton pellets. MTA or Biodentine. GIC base. Stainless steel crown ideally placed at the same appointment.

Pulp removal technique

Remove the entire coronal pulp with a round bur or spoon excavator. Saline irrigation of the chamber. Cotton pellet pressure for 3-5 minutes until haemostasis.

Material placement

MTA or Biodentine directly over all radicular pulp stumps. 2-3 mm thickness. GIC base over the MTA same appointment. Crown preparation.

Crown placement

Stainless steel crown at the same appointment. Composite alone without SSC in primary molars has significantly higher failure rates. (AAPD 2023)

Mandibular Premolar Anatomy ChallengesPRO

Cohen's 12th Ed. Ch.7 · 5 steps

▼

Canal configuration

Type I (single canal): ~65-70%. Type V (1-2, dividing apically): ~20%. Type II (2-1, merging): ~5%. Always take an angled PA to reveal potential bifurcation.

Identifying Type V

EAL: two different readings as the file advances. Two separate orifices visible on the floor. Two separate foramina on angled PA or CBCT. Both canals must be independently treated.

Three-rooted maxillary first premolar

Rare variant (~1%): three roots (MB, DB, palatal). CBCT confirms. All three roots must be located and treated.

Access shape for bifurcated lower premolar

An oval, buccal-lingual access extension reveals the lingual canal orifice. A small round access will miss the lingual orifice in Type V cases.

Obturation of Type V

Two separate working lengths, two matched master cones, or warm vertical condensation. Cold lateral condensation with a single cone will not seal both foramina. (Cohen's 12th)

Maxillary Anterior Teeth — Anatomy GuidePRO

Cohen's 12th Ed. Ch.7 · 5 steps

▼

Central incisor

Single canal Type I (>95%). Triangular labiolingual access (MB, ML, incisal pulp horns). Canal is wide labiolingually — use oval master cone or warm technique.

Lateral incisor

Single canal Type I (~90%). Highest prevalence of dens invaginatus and palatal grooves. Always inspect the palatal surface carefully.

Canine

Single canal Type I (~97%). Longest root in the mouth (average 27 mm). Pre-curve files for the apical curvature. WL often longer than expected.

Access outline for all maxillary anteriors

Palatal surface, triangular shape. Remove all three pulp horns to prevent pink discolouration from retained pulp tissue remnants.

Discolouration prevention

After RCT: ensure all pulp horn tissue removed from crown. Avoid grey MTA or minocycline-containing TAP in aesthetic zone cases. (Cohen's 12th)

Mandibular Canine and Incisors — AnatomyPRO

Cohen's 12th Ed. Ch.7 · 5 steps

▼

Key Clinical Point

Lower incisors: ~40% have two canals (Type III). The lingual canal is invisible on standard PA. Always take a mesially angled film. Lower canine: single canal in ~94%, one of the most predictable teeth.

Clinical Application

Lower anterior access: small, oval outline on the lingual surface. Negotiate with a #10-15 K-file. Confirm canal count with angled PA or CBCT before declaring single canal. PUI is essential for the narrow lingual canal.

Maxillary Second Molar — Key DifferencesPRO

Cohen's 12th Ed. Ch.7 · 5 steps

▼

Key Clinical Point

MB2 less frequent (~60% vs 95% for first molar). Canal orifices are more compact and distal. The MB root is less curved. Access outline is smaller and more distal than for the first molar.

Clinical Application

Check for MB2 — still possible in ~60%. More compact access. Watch for fused roots (taurodontism). Confirm all orifices before shaping. (Cohen's 12th Ch.7)

Mandibular Second Molar — AnatomyPRO

Fan 2004 · Cohen's 12th · 5 steps

▼

Key Clinical Point

Highest prevalence of C-shaped canal systems among all teeth. In non-C-shaped cases: 2 roots (mesial + distal), similar to first molar. Radix entomolaris less common than in first molar.

Clinical Application

Always suspect C-shaped anatomy in Asian patients. Pre-op CBCT for second molars in Asian populations is strongly recommended. (Fan 2004)

Thermal Testing — Advanced InterpretationPRO

Cohen's 12th Ed. Ch.1 · 5 steps

▼

Key Clinical Point

Cold test: most clinically reliable pulp test. The 'prolonged' threshold varies: >10-15 seconds is a reasonable clinical cut-off for IRP. 'No response' = necrosis or calcific metamorphosis.

Clinical Application

Combine cold test with clinical history and percussion for accurate diagnosis. A single test in isolation is insufficient. Document the response objectively (seconds, not vague descriptors). (AAE 2009)

Electric Pulp Testing — Protocol and PitfallsPRO

Cohen's 12th Ed. Ch.1 · 5 steps

▼

Key Clinical Point

EPT stimulates A-delta sensory nerve fibres — it tests nerve function, not pulp health. A calcified canal may give false negatives. Recently traumatised teeth may give false negatives for weeks.

Clinical Application

Apply to a dry tooth surface. Use toothpaste as conductor. Test the control tooth first to calibrate the patient's response. Never diagnose necrosis based on EPT alone. (Cohen's 12th Ch.1)

Bite Test — Cracked Tooth ProtocolPRO

Cohen's 12th Ed. Ch.1 · 5 steps

▼

Key Clinical Point

Sharp pain ON biting that RELEASES immediately = cracked tooth syndrome (rebound pain). Pain that persists after biting = different origin. Tooth Slooth applied cusp-by-cusp identifies the offending cusp.

Clinical Application

Transillumination: apply fibre optic light to the buccal surface in a dark room. A crack appears as a dark line interrupting the light transmission. Wedging test also confirms cracks. (Cohen's 12th Ch.1)

Selective Anaesthesia — Diagnostic ProtocolPRO

Cohen's 12th Ed. Ch.1 · 5 steps

▼

Key Clinical Point

When pain cannot be localised to an arch: IANB of the lower arch. If pain stops immediately = lower arch source. If pain persists = upper arch source. Then narrow down by infiltrations.

Clinical Application

Start with the most likely arch based on patient history. An IANB that stops the pain definitively diagnoses a mandibular source. Then systematic infiltrations narrow it to a specific tooth. (Cohen's 12th Ch.1)

Periapical Radiograph — Technique and InterpretationPRO

Cohen's 12th Ed. Ch.3 · 5 steps

▼

Key Clinical Point

Paralleling technique (long-cone paralleling) is more accurate than bisecting angle for endodontic diagnosis. Use film holders. Standard endodontic series: PA + angled PA.

Clinical Application

Read systematically: crown → root canal system → root outline → PDL space (widening?) → lamina dura (continuous?) → periapical region (radiolucency? size?). Classify with PAI. (Cohen's 12th Ch.3)

Post-Treatment Monitoring ProtocolPRO

ESE Quality Guidelines 2006 · 5 steps

▼

Key Clinical Point

Minimum review schedule: 6 months, 12 months, 4 years. Standardised PA technique (same angulation) at each visit for accurate PAI comparison.

Clinical Application

At 4 years: PAI 1-2, asymptomatic = success. Document in the patient record. Discharge to routine dental care with the note to report symptoms. (ESE 2006)

Endodontic Treatment Planning AlgorithmPRO

Cohen's 12th Ed. · AAE · 5 steps

▼

Key Clinical Point

Step 1: establish the diagnosis. Step 2: assess restorability. Step 3: assess strategic value. Step 4: assess patient factors (medical, financial, motivation). Step 5: present all options with evidence-based prognosis.

Clinical Application

Never start RCT without confirming restorability. A non-restorable tooth with a perfect RCT has no long-term benefit — only delays the inevitable and wastes the patient's money. (Cohen's 12th)

Mandibular Anaesthesia — Advanced TechniquesPRO

Malamed SF · 5 steps

▼

Key Clinical Point

IANB is the primary technique but fails in ~15-20% of cases for routine procedures and up to 30% for IRP. Supplemental techniques: PDL, intraosseous (CCLAD/X-tip), intraseptal, intrapulpal.

Clinical Application

PDL injection: 0.2 mL at 30° angle at mesial and distal. Slow pressure (30 seconds per injection). Effective within 30 seconds. Intraosseous (CCLAD): deposits LA directly in cancellous bone — profound anaesthesia. (Malamed)

Coronal Microleakage — Prevention ProtocolPRO

Torabinejad 1990 · Ray & Trope 1995 · 5 steps

▼

Key Clinical Point

Recontamination of the root canal system after obturation occurs within 30 days without an adequate coronal seal. The quality of the coronal restoration is a stronger predictor of 4-year success than root filling quality.

Clinical Application

Place a minimum 3-4 mm GIC or composite access fill immediately after obturation. Schedule permanent restoration (crown for posterior teeth) within 1 month. Inform the patient of this critical timeline. (Ray & Trope 1995)

Apical Gauging TechniquePRO

Cohen's 12th Ed. Ch.8 · 5 steps

▼

Key Clinical Point

Apical gauging determines the true apical diameter — the size of the first file that binds snugly at WL. The master apical file (MAF) should be 2-3 sizes larger than the first binding file for adequate apical preparation.

Clinical Application

After WL measurement: sequentially insert K-files until one binds at WL. The size of the first binding file = the natural apical diameter. Select a MAF that is at least 2 sizes larger than the binding file. (Cohen's 12th)

Endodontic Irrigation — NaOCl Concentration GuidePRO

AAE · Boutsioukis 2010 · 5 steps

▼

Key Clinical Point

1% NaOCl: lowest effective antimicrobial concentration. 2.5-3%: clinical standard. 5.25%: maximum concentration. Higher concentrations = greater tissue dissolution but more toxic. Volume is more important than concentration.

Clinical Application

Warm NaOCl (37-45°C) at 1% is as effective as room-temperature 5.25% for tissue dissolution (Sirtes 2005). Pre-warming is a simple upgrade. Never warm beyond 45°C. (Boutsioukis 2010)

Sonic Irrigation — EndoActivator ProtocolPRO

EndoActivator · Cohen's 12th · 5 steps

▼

Key Clinical Point

EndoActivator operates at 1-6 kHz (sonic) — less powerful than ultrasonic (25-30 kHz) but safer (less risk of file separation or perforation). Most effective for biofilm disruption in the coronal and middle thirds.

Clinical Application

Use a medium or large tip for canals prepared to F2 or larger. Activate with 1 cm up-down motion for 3 x 30-second cycles per irrigant. Do not touch the canal walls. Final rinse with NaOCl after activation. (EndoActivator IFU)

XP-endo Finisher — ProtocolPRO

FKG Dentaire · 5 steps

▼

Key Clinical Point

MaxWire alloy: martensitic at room temperature (flexible), austenitic at body temperature (expands to 1 mm diameter). Contacts the untouched buccal and lingual walls of oval canals missed by round rotary files.

Clinical Application

After final shaping: activate XP-endo Finisher at 800-1000 RPM, torque 1 Ncm, in NaOCl for 60 seconds. Use a 1-2 cm in-out motion. Final irrigation sequence follows. Significant improvement in oval canal debridement vs rotary alone.

ProTaper Gold — Clinical ProtocolPRO

Dentsply Sirona · 5 steps

▼

Key Clinical Point

Shaping files: SX (coronal orifice shaping), S1, S2 (progressive shaping). Finishing files: F1 (20/.07), F2 (25/.08), F3 (30/.09), F4 (40/.06), F5 (50/.05).

Clinical Application

Crown-down: SX → S1 → S2 → measure WL → F1 → F2 → F3 (if needed). Never use PTG files without a confirmed glide path. Continuous clockwise rotation, 300 RPM, 2-3 Ncm torque. One file per patient for F1-F3 (Dentsply Sirona recommendation).

WaveOne Gold — Clinical ProtocolPRO

Dentsply Sirona · 5 steps

▼

Key Clinical Point

WaveOne Gold Small (20/.07), Primary (25/.07), Medium (35/.06), Large (45/.05). Reciprocating motion — one file per patient.

Clinical Application

Establish glide path (#10-15 K-file to WL). Activate WaveOne Gold motor program (400 RPM equivalent reciprocation). Gentle pecking motion 3-4 mm amplitude. Withdraw every 3-4 pecks, wipe the file, recapitulate with #10 K-file, irrigate. (WaveOne Gold IFU)

Reciproc Blue — Clinical ProtocolPRO

VDW · 5 steps

▼

Key Clinical Point

Reciproc Blue R25 (25/.08): most cases. R40 (40/.06): larger canals. R50 (50/.05): very large canals. Blue heat treatment improves flexibility compared to original Reciproc.

Clinical Application

Glide path mandatory (#10 K-file to WL minimum). VDW.SILVER reciproc motor programme. 3-4 mm gentle pecking amplitude. Never force apically. Withdraw and recapitulate with #10 K-file every 3-4 pecking cycles. One file per patient. (VDW IFU)

Bioceramics in Endodontics — OverviewPRO

Cohen's 12th Ed. · 5 steps

▼

Key Clinical Point

Calcium silicate cements (CSCs): MTA, Biodentine, BioAggregate, BioC Sealer, TotalFill. All share: high pH on setting (~12-13), calcium ion release, and cementum/bone regeneration stimulation.

Clinical Application

Applications: pulp caps, pulpotomies, apexification (MTA plug), REP (MTA barrier), perforation repair, retrograde fill, sealer (BioC Sealer). The most biologically active class of endodontic materials. (Cohen's 12th)

MTA — Clinical Handling ProtocolPRO

ProRoot MTA · Cohen's 12th · 5 steps

▼

Key Clinical Point

Mix ratio: 3:1 powder to liquid (distilled water). Consistency: sand-castle texture (not too wet or too dry). Setting time: 2.5-4 hours in the presence of moisture.

Clinical Application

Delivery: MAP system in 2 mm increments. Condense with a moistened micro-plugger. Place a moist cotton pellet over the MTA and temporise. Review at next visit to confirm setting. Grey MTA: risk of discolouration — use white MTA or Biodentine in aesthetic zones. (Cohen's 12th)

Biodentine — Clinical Handling ProtocolPRO

Septodont · 5 steps

▼

Key Clinical Point

Capsule system: mix for 30 seconds in a triturator. Setting time: 12 minutes (initial) — significantly faster than MTA. Working time: 6 minutes.

Clinical Application

Deliver with a MAP system or a plastic instrument. Condense in increments. Place a moist cotton pellet over Biodentine. Can restore directly over set Biodentine with composite (no GIC intermediate needed). Less discolouration risk than grey MTA — use in aesthetic zones. (Septodont IFU)

AH Plus Sealer — Protocol and PropertiesPRO

De Munck 2003 · Cohen's 12th · 5 steps

▼

Key Clinical Point

Epoxy-amine resin, two-paste system. Mix equal volumes for 30 seconds. Working time: 8 hours. Setting time: 36 hours. Radiopacity: high. Shrinkage: minimal.

Clinical Application

AH Plus bonds to dentin amino groups (covalent bond) — the best adhesive of all sealers. Does NOT contain eugenol — composite restoration is safe. Most extensively studied sealer — positive control in most comparative research. (Cohen's 12th)

Gutta-Percha — Properties and HandlingPRO

Cohen's 12th Ed. Ch.9 · 5 steps

▼

Key Clinical Point

Composition: ~20% GP polymer, ~65-70% zinc oxide, ~10% barium sulfate (radiopaque), ~1-2% wax/antioxidants. Two crystalline phases: alpha (thermoplastic) and beta (room temperature, used in cones).

Clinical Application

GP cannot be autoclaved (deforms). Disinfect with 5.25% NaOCl x 1 min or 70% IPA before use. Store in cool, dark conditions. Check cones for brittleness before use — brittleness indicates degradation. (Cohen's 12th)

Silver Points — Historical Context and RetreatmentPRO

Cohen's 12th Ed. Ch.8 · 5 steps

▼

Key Clinical Point

Silver points (introduced 1930s-1970s): unable to adapt to the oval canal cross-section and corrode over time (silver sulfide formation causes microleakage). No longer indicated for obturation.

Clinical Application

Silver point retreatment: ultrasonic vibration to break the coronal seal. Stieglitz or Masserann forceps to grasp and withdraw. The apical portion may have fused to dentin — bypass is the alternative if retrieval fails. (Cohen's 12th Ch.8)

Carrier-Based Obturation — Thermafil ProtocolPRO

Dentsply Sirona · 5 steps

▼

Key Clinical Point

Thermafil: plastic carrier coated with alpha-phase GP. The Thermafil Verifier confirms the apical preparation size before the heated obturator is introduced.

Clinical Application

Oven: 15 seconds for #25 carrier. Insert to WL in a single motion — do not hesitate once inserted. Sear the carrier at the orifice with a heated plugger. Cut the plastic shank. Backfill with additional warm GP or composite. (Dentsply Sirona IFU)

Endodontic Sealer Types — ComparisonPRO

Cohen's 12th Ed. Ch.9 · 5 steps

▼

Key Clinical Point

ZOE sealers (Pulp Canal Sealer): most soluble, most shrinkage, easiest to remove in retreatment. Epoxy resin (AH Plus): best adhesion, minimal shrinkage, moderate retreatability. Bioceramic (BioC): best biocompatibility, hardest to remove. GIC-based: hydrophilic, poor adhesion to GP.

Clinical Application

Select the sealer based on the clinical situation. AH Plus: best evidence, easiest retreatment balance. Bioceramic: primary obturation in ideal anatomy (single cone). ZOE: least preferred — high shrinkage. (Cohen's 12th Ch.9)

Root Canal Obturation — Historical EvolutionPRO

Cohen's 12th Ed. · 5 steps

▼

Key Clinical Point

1847: Maynard introduces GP. 1914: cold lateral condensation described. 1967: Schilder introduces warm vertical condensation. 1978: Thermafil carrier-based technique. 1990s: resin sealers (AH Plus). 2010s: single cone + bioceramic sealer.

Clinical Application

Understanding the historical context helps evaluate current evidence. Schilder's principles — continuously tapering funnel, smallest cross-section apically, original shape maintained — remain the gold standard regardless of technique. (Cohen's 12th)

Endodontic Instruments — Metallurgy OverviewPRO

Cohen's 12th Ed. Ch.8 · 5 steps

▼

Key Clinical Point

Standard NiTi (nitinol): austenitic at body temperature. M-Wire: austenitic + martensitic mixture — more flexible. CM Wire (controlled memory): fully martensitic — very flexible, shape memory. Gold/Blue heat treatment: austenitic but phase-shifted — increased flexibility, lower cyclic fatigue.

Clinical Application

Gold/Blue/R-Phase alloys have significantly lower cyclic fatigue than standard NiTi in severe curvatures. Choose heat-treated alloys for canals with curvature >20°. (Cohen's 12th)

Cyclic Fatigue — Prevention and ManagementPRO

Cohen's 12th Ed. · 5 steps

▼

Key Clinical Point

Cyclic fatigue: repeated tension-compression cycles at the point of maximum curvature accumulate metal fatigue until fracture. No torsional engagement is needed — the file fractures even when not binding.

Clinical Application

Prevention: heat-treated alloys (Gold, Blue, CM), reduce canal curvature with crown-down, limit number of uses, inspect files after each use, use reciprocating motion to reduce angular accumulation. (Cohen's 12th)

Torsional Fatigue and File Fracture PreventionPRO

Cohen's 12th Ed. · 5 steps

▼

Key Clinical Point

Torsional fracture: the file tip is locked in the canal while the shank continues rotating. Risk: narrow canals, files used without a glide path, aggressive apical pressure.

Clinical Application

Prevention: always establish a glide path, never force rotary NiTi files apically, respect the manufacturer's recommended torque setting, withdraw and recapitulate frequently, inspect files after each use. (Cohen's 12th)

Sodium Hypochlorite — Properties and OptimisationPRO

Zehnder 2006 · Cohen's 12th · 5 steps

▼

Key Clinical Point

NaOCl is the only irrigant that dissolves both vital and necrotic organic tissue. Active component: hypochlorous acid (HOCl). Consumed by organic matter — must be replenished. Volume > concentration.

Clinical Application

Warm NaOCl (37-45°C) significantly improves tissue dissolution. Side-vented needle 2-3 mm short of WL. Maximum safe concentration: 5.25%. For hypersensitive patients: 1-2% still effective when combined with PUI. (Zehnder 2006)

Chlorhexidine — Role in EndodonticsPRO

Cohen's 12th Ed. Ch.5 · 5 steps

▼

Key Clinical Point

CHX: broad-spectrum antimicrobial, substantivity (binds to hydroxyapatite and releases slowly for up to 12 weeks). Cannot dissolve organic tissue — NOT a replacement for NaOCl.

Clinical Application

Use as a final rinse in retreatment cases (for E. faecalis coverage). IMPORTANT: CHX + NaOCl = orange precipitate (para-chloroaniline) — a cytotoxic reaction. Separate with a saline flush between NaOCl and CHX. (Cohen's 12th)

EDTA — Properties and Correct UsePRO

Pashley 1984 · Cohen's 12th · 5 steps

▼

Key Clinical Point

17% EDTA: chelates calcium ions from the inorganic smear layer component. Contact time: 1 minute minimum. Does NOT have antimicrobial properties — purely a chelating agent.

Clinical Application

Use AFTER final NaOCl shaping, not throughout. Agitate with ultrasonic. Follow immediately with a final NaOCl rinse to remove the exposed organic matrix. Do not use EDTA and NaOCl simultaneously — the chlorine is neutralised. (Pashley 1984)

Passive Ultrasonic Irrigation (PUI) — TechniquePRO

Van der Sluis 2007 · 5 steps

▼

Key Clinical Point

PUI: ultrasonic file oscillates freely (passively — not engaging the walls) in a canal flooded with irrigant. Creates acoustic streaming (fluid movement) and cavitation (microbubble formation).

Clinical Application

Technique: flood the canal with NaOCl. Insert the ultrasonic file (D1 or endo tip) without engaging the canal walls. Activate at 20-30 kHz for 3 x 1-minute cycles. Agitation drives irrigant into fins, isthmuses, and lateral canals. (Van der Sluis 2007)

Apical Negative Pressure Irrigation — EndoVacPRO

Boutsioukis 2010 · 5 steps

▼

Key Clinical Point

EndoVac: negative pressure draws irrigant apically via a micro-cannula suction tip rather than positive pressure delivery. Virtually eliminates the risk of NaOCl extrusion beyond the apex.

Clinical Application

Technique: macro-cannula for coronal third, micro-cannula (0.32 mm) placed at WL for apical third. Simultaneously dispense NaOCl from a needle in the coronal chamber while the suction draws it apically. Follow with PUI. (Boutsioukis 2010)

Smear Layer — Is Removal Beneficial?PRO

McComb 1975 · Pashley 1984 · 5 steps

▼

Key Clinical Point

Removal: allows better sealer penetration into dentinal tubules, eliminates bacteria harboured in the smear layer, and improves the sealer-dentin bond. The majority of evidence supports removal.

Clinical Application

Counterargument: some argue the smear layer acts as a physical barrier preventing bacteria from re-entering tubules. However, the consensus based on systematic reviews supports smear layer removal for optimal obturation quality. (Cohen's 12th)

Endodontic Microbiology — Key PathogensPRO

Nair 2006 · Cohen's 12th · 5 steps

▼

Key Clinical Point

Primary infection (untreated necrotic teeth): polymicrobial — Fusobacterium, Porphyromonas, Prevotella, Streptococcus, Treponema. Anaerobes predominate.

Clinical Application

Persistent infection (post-treatment disease): Enterococcus faecalis is the most commonly recovered species — resistant to Ca(OH)2 due to its proton pump. Also: Candida albicans (fungal). These require CHX as a final rinse in retreatment. (Nair 2006)

Biofilm in Root Canals — Clinical ImplicationsPRO

Ricucci & Siqueira 2010 · 5 steps

▼

Key Clinical Point

Biofilm bacteria are 100-1000x more resistant to antimicrobials than planktonic bacteria. The extracellular polymeric matrix physically protects embedded cells. NaOCl disrupts the matrix.

Clinical Application

Clinical implication: passive irrigation with NaOCl is insufficient to disrupt biofilm. Active agitation (PUI, EndoActivator, XP-endo Finisher) is essential. This is why multi-visit treatment with Ca(OH)2 further reduces biofilm load. (Ricucci 2010)

Enterococcus faecalis — Why It PersistsPRO

Sundqvist 1998 · Cohen's 12th · 5 steps

▼

Key Clinical Point

E. faecalis resists Ca(OH)2 via a proton pump that maintains intracellular pH against external alkalinity. It can survive as a monoinfection in treated root canals and cause post-treatment disease.

Clinical Application

Management: 2% CHX final rinse in retreatment cases (for E. faecalis substantive coverage). Ca(OH)2 alone is insufficient. CHX + NaOCl interaction: precipitate formation — always separate with a saline flush. (Sundqvist 1998)

Periapical Lesion — PathogenesisPRO

Nair 2006 · Cohen's 12th · 5 steps

▼

Key Clinical Point

The periapical lesion is the host immune response to bacterial toxins (LPS, lipoteichoic acid) leaking from the infected root canal. It is NOT the bacteria themselves — it is the immune reaction.

Clinical Application

Implication: eliminate the intracanal infection and the periapical immune response resolves on its own. This is why RCT heals periapical lesions. The bone regeneration that follows represents resolution of the immune lesion. (Nair 2006)

Apical Delta Anatomy — Clinical SignificancePRO

Kuttler 1955 · Cohen's 12th · 5 steps

▼

Key Clinical Point

The apical delta: multiple small accessory canals branching from the main canal in the apical 3 mm. Present in ~75% of teeth. These cannot be mechanically instrumented.

Clinical Application

Clinical significance: the apical delta is the primary reason for using chemical disinfection (NaOCl + PUI) rather than relying on mechanical preparation alone. Periapical surgery resects this complex (3 mm resection removes ~93% of the delta). (Kuttler 1955)

Lateral and Accessory Canals — SignificancePRO

Cohen's 12th Ed. · 5 steps

▼

Key Clinical Point

Lateral canals: present throughout the root at the mid-root level. Furcal canals: open into the furcation floor (up to 46% of multi-rooted teeth). All are potential portals of exit for pulpal disease.

Clinical Application

Lateral canals cannot be mechanically cleaned — chemical disinfection (NaOCl) and obturation with warm techniques that drive sealer and GP into them are essential. A lateral canal visible as sealer-filled on the PA is a positive finding. (Cohen's 12th)

Cementodentinal Junction — Why It MattersPRO

Kuttler 1955 · Cohen's 12th · 5 steps

▼

Key Clinical Point

The CDJ (cementodentinal junction) is the internal anatomical endpoint of the root canal at the junction of cementum and dentin. It corresponds to the apical constriction and averages 0.5-1 mm from the radiographic apex.

Clinical Application

Prepare and obturate to the CDJ for the best tissue response and seal. Working short of the CDJ leaves untreated canal space. Working beyond it creates a periapical irritant. The EAL '0' reading identifies the minor foramen at the CDJ. (Kuttler 1955)

Pulp Anatomy — Development and Clinical ApplicationPRO

Cohen's 12th Ed. Ch.7 · 5 steps

▼

Key Clinical Point

The pulp chamber reflects the external crown form — where the enamel rises, the pulp horn follows. Knowledge of the pulp horn positions prevents perforation during access preparation.

Clinical Application

The pulp recedes throughout life with secondary dentin deposition: the older the patient, the narrower the chamber. Elderly patients and heavily restored teeth need CBCT before difficult access preparation. (Cohen's 12th)

Dental Pulp Stem Cells — Clinical RelevancePRO

Gronthos 2000 · Cohen's 12th · 5 steps

▼

Key Clinical Point

Dental pulp stem cells (DPSCs) and stem cells of the apical papilla (SCAP) are the regenerative cell populations in vital pulp therapy and REP respectively.

Clinical Application

SCAP survive pulp necrosis because they have their own blood supply from the periapical tissues — the reason REP is feasible. Protecting SCAP during REP (low-concentration NaOCl, 17% EDTA final rinse) is the biological rationale for the gentle irrigation protocol. (Gronthos 2000)

Pulp Inflammation — HistopathologyPRO

Cohen's 12th Ed. Ch.1 · 5 steps

▼

Key Clinical Point

Reversible pulpitis: hyperaemia, initial inflammation confined to near the stimulus — no necrosis. Irreversible pulpitis: irreversible cell damage, inflammation extends deeper, internal pressure rises. Necrosis: liquefactive necrosis, no vital cells remaining.

Clinical Application

The histological state cannot be reliably determined from clinical tests alone. 'Irreversible pulpitis' as a clinical diagnosis means the pulp cannot be maintained as a healthy state — not necessarily confirmed histologically. (Cohen's 12th Ch.1)

AAE Classification 2009 — Pulp DiagnosesPRO

AAE Consensus Conference 2009 · 5 steps

▼

Key Clinical Point

Pulp diagnoses: Normal pulp / Reversible pulpitis / Symptomatic irreversible pulpitis / Asymptomatic irreversible pulpitis / Pulp necrosis / Previously treated / Previously initiated therapy.

Clinical Application

Periapical diagnoses: Normal apical tissues / Symptomatic apical periodontitis / Asymptomatic apical periodontitis / Chronic apical abscess / Acute apical abscess. Both pulp AND periapical diagnoses must be recorded for every tooth. (AAE 2009)

AAE Classification 2009 — Periapical DiagnosesPRO

AAE Consensus Conference 2009 · 5 steps

▼

Key Clinical Point

Normal apical tissues: no symptoms, no radiographic changes. SAP: pain to percussion/palpation with or without lesion. AAP: radiolucency, no symptoms. Chronic apical abscess: sinus tract + non-vital tooth, minimal symptoms. Acute apical abscess: rapid onset pain, swelling, systemic signs.

Clinical Application

Assign both a pulp and periapical diagnosis for every tooth requiring endodontic evaluation. This is the foundation of the treatment decision. (AAE 2009)

Endodontic Quality Assurance — Self-Audit ProtocolPRO

ESE Quality Guidelines 2006 · 5 steps

▼

Key Clinical Point

Review your own cases at 6 months and 4 years. Compare the pre-treatment and post-treatment PA using the same angulation. Calculate your personal PAI improvement rate.

Clinical Application

A personal audit rate of PAI 1-2 at 4 years >85% is the target for cases without pre-operative periapical lesion. With lesion: >75%. Regular self-audit is the most powerful driver of clinical improvement and medicolegal protection. (ESE 2006)

Clinical Cases

Diagnoses aligned with the AAE/ESE 2025 Pulpal & Periapical Classification.

Swelling related to mandibular first molar

Easy

👤 35M 🦷 FDI 46

35-year-old male presents with severe spontaneous pain for 3 days, with facial swelling and fever. Tooth 46. No response to cold or electric pulp testing. Diffuse facial swelling, tender submandibular lymph nodes, pain to percussion and palpation. Periapical radiolucency present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary first molar

Easy

👤 27F 🦷 FDI 16

27-year-old female reports sharp pain to cold drinks that disappears within a second or two. Tooth 16. Heightened but non-lingering response to cold; normal to EPT. No tenderness to percussion or palpation. Moderate occlusal caries with sound dentine still visible between the caries and pulp on the radiograph. No apical changes.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gum boil near maxillary lateral incisor

Medium

👤 41M 🦷 FDI 12

41-year-old male notices a small recurring "pimple" on the gum above tooth 12, with little or no pain. No response to pulp testing. No or mild percussion tenderness. A gutta-percha cone traced from the sinus tract points to the apex of tooth 12 on the radiograph, where a periapical radiolucency is present.

What is the most accurate diagnosis? (AAE/ESE 2025)

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Cold-sensitive maxillary central incisor

Easy

👤 18M 🦷 FDI 11

18-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 11 (maxillary central incisor). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary lateral incisor

Easy

👤 23F 🦷 FDI 12

23-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 12 (maxillary lateral incisor). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary canine

Easy

👤 28M 🦷 FDI 13

28-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 13 (maxillary canine). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary first premolar

Medium

👤 33F 🦷 FDI 14

33-year-old female presents with a draining gum boil but no pain. Tooth 14 (maxillary first premolar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary second premolar

Medium

👤 38M 🦷 FDI 15

38-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 15 (maxillary second premolar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary first molar

Medium

👤 43F 🦷 FDI 16

43-year-old female presents with no symptoms — found on routine radiographic review. Tooth 16 (maxillary first molar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary second molar

Hard

👤 48M 🦷 FDI 17

48-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 17 (maxillary second molar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular central incisor

Easy

👤 53F 🦷 FDI 41

53-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 41 (mandibular central incisor). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular lateral incisor

Easy

👤 58M 🦷 FDI 42

58-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 42 (mandibular lateral incisor). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular canine

Easy

👤 63F 🦷 FDI 43

63-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 43 (mandibular canine). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular first premolar

Medium

👤 68M 🦷 FDI 44

68-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 44 (mandibular first premolar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular second premolar

Medium

👤 73F 🦷 FDI 45

73-year-old female presents with a draining gum boil but no pain. Tooth 45 (mandibular second premolar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular first molar

Medium

👤 18M 🦷 FDI 46

18-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 46 (mandibular first molar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular second molar

Hard

👤 23F 🦷 FDI 47

23-year-old female presents with no symptoms — found on routine radiographic review. Tooth 47 (mandibular second molar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary central incisor

Easy

👤 28M 🦷 FDI 11

28-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 11 (maxillary central incisor). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary lateral incisor

Easy

👤 33F 🦷 FDI 12

33-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 12 (maxillary lateral incisor). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary canine

Easy

👤 38M 🦷 FDI 13

38-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 13 (maxillary canine). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary first premolar

Medium

👤 43F 🦷 FDI 14

43-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 14 (maxillary first premolar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary second premolar

Medium

👤 48M 🦷 FDI 15

48-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 15 (maxillary second premolar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary first molar

Medium

👤 53F 🦷 FDI 16

53-year-old female presents with a draining gum boil but no pain. Tooth 16 (maxillary first molar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary second molar

Hard

👤 58M 🦷 FDI 17

58-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 17 (maxillary second molar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular central incisor

Easy

👤 63F 🦷 FDI 41

63-year-old female presents with no symptoms — found on routine radiographic review. Tooth 41 (mandibular central incisor). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular lateral incisor

Easy

👤 68M 🦷 FDI 42

68-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 42 (mandibular lateral incisor). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular canine

Easy

👤 73F 🦷 FDI 43

73-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 43 (mandibular canine). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular first premolar

Medium

👤 18M 🦷 FDI 44

18-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 44 (mandibular first premolar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular second premolar

Medium

👤 23F 🦷 FDI 45

23-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 45 (mandibular second premolar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular first molar

Medium

👤 28M 🦷 FDI 46

28-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 46 (mandibular first molar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular second molar

Hard

👤 33F 🦷 FDI 47

33-year-old female presents with a draining gum boil but no pain. Tooth 47 (mandibular second molar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary central incisor

Easy

👤 38M 🦷 FDI 11

38-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 11 (maxillary central incisor). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary lateral incisor

Easy

👤 43F 🦷 FDI 12

43-year-old female presents with no symptoms — found on routine radiographic review. Tooth 12 (maxillary lateral incisor). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary canine

Easy

👤 48M 🦷 FDI 13

48-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 13 (maxillary canine). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary first premolar

Medium

👤 53F 🦷 FDI 14

53-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 14 (maxillary first premolar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary second premolar

Medium

👤 58M 🦷 FDI 15

58-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 15 (maxillary second premolar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary first molar

Medium

👤 63F 🦷 FDI 16

63-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 16 (maxillary first molar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary second molar

Hard

👤 68M 🦷 FDI 17

68-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 17 (maxillary second molar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular central incisor

Easy

👤 73F 🦷 FDI 41

73-year-old female presents with a draining gum boil but no pain. Tooth 41 (mandibular central incisor). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular lateral incisor

Easy

👤 18M 🦷 FDI 42

18-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 42 (mandibular lateral incisor). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular canine

Easy

👤 23F 🦷 FDI 43

23-year-old female presents with no symptoms — found on routine radiographic review. Tooth 43 (mandibular canine). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular first premolar

Medium

👤 28M 🦷 FDI 44

28-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 44 (mandibular first premolar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular second premolar

Medium

👤 33F 🦷 FDI 45

33-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 45 (mandibular second premolar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular first molar

Medium

👤 38M 🦷 FDI 46

38-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 46 (mandibular first molar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular second molar

Hard

👤 43F 🦷 FDI 47

43-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 47 (mandibular second molar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary central incisor

Easy

👤 48M 🦷 FDI 11

48-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 11 (maxillary central incisor). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary lateral incisor

Easy

👤 53F 🦷 FDI 12

53-year-old female presents with a draining gum boil but no pain. Tooth 12 (maxillary lateral incisor). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary canine

Easy

👤 58M 🦷 FDI 13

58-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 13 (maxillary canine). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary first premolar

Medium

👤 63F 🦷 FDI 14

63-year-old female presents with no symptoms — found on routine radiographic review. Tooth 14 (maxillary first premolar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary second premolar

Medium

👤 68M 🦷 FDI 15

68-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 15 (maxillary second premolar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary first molar

Medium

👤 73F 🦷 FDI 16

73-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 16 (maxillary first molar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary second molar

Hard

👤 18M 🦷 FDI 17

18-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 17 (maxillary second molar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular central incisor

Easy

👤 23F 🦷 FDI 41

23-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 41 (mandibular central incisor). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular lateral incisor

Easy

👤 28M 🦷 FDI 42

28-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 42 (mandibular lateral incisor). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular canine

Easy

👤 33F 🦷 FDI 43

33-year-old female presents with a draining gum boil but no pain. Tooth 43 (mandibular canine). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular first premolar

Medium

👤 38M 🦷 FDI 44

38-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 44 (mandibular first premolar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular second premolar

Medium

👤 43F 🦷 FDI 45

43-year-old female presents with no symptoms — found on routine radiographic review. Tooth 45 (mandibular second premolar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular first molar

Medium

👤 48M 🦷 FDI 46

48-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 46 (mandibular first molar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular second molar

Hard

👤 53F 🦷 FDI 47

53-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 47 (mandibular second molar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary central incisor

Easy

👤 58M 🦷 FDI 11

58-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 11 (maxillary central incisor). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary lateral incisor

Easy

👤 63F 🦷 FDI 12

63-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 12 (maxillary lateral incisor). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary canine

Easy

👤 68M 🦷 FDI 13

68-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 13 (maxillary canine). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary first premolar

Medium

👤 73F 🦷 FDI 14

73-year-old female presents with a draining gum boil but no pain. Tooth 14 (maxillary first premolar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary second premolar

Medium

👤 18M 🦷 FDI 15

18-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 15 (maxillary second premolar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary first molar

Medium

👤 23F 🦷 FDI 16

23-year-old female presents with no symptoms — found on routine radiographic review. Tooth 16 (maxillary first molar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary second molar

Hard

👤 28M 🦷 FDI 17

28-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 17 (maxillary second molar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular central incisor

Easy

👤 33F 🦷 FDI 41

33-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 41 (mandibular central incisor). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular lateral incisor

Easy

👤 38M 🦷 FDI 42

38-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 42 (mandibular lateral incisor). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular canine

Easy

👤 43F 🦷 FDI 43

43-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 43 (mandibular canine). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular first premolar

Medium

👤 48M 🦷 FDI 44

48-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 44 (mandibular first premolar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular second premolar

Medium

👤 53F 🦷 FDI 45

53-year-old female presents with a draining gum boil but no pain. Tooth 45 (mandibular second premolar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular first molar

Medium

👤 58M 🦷 FDI 46

58-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 46 (mandibular first molar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular second molar

Hard

👤 63F 🦷 FDI 47

63-year-old female presents with no symptoms — found on routine radiographic review. Tooth 47 (mandibular second molar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary central incisor

Easy

👤 68M 🦷 FDI 11

68-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 11 (maxillary central incisor). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary lateral incisor

Easy

👤 73F 🦷 FDI 12

73-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 12 (maxillary lateral incisor). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary canine

Easy

👤 18M 🦷 FDI 13

18-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 13 (maxillary canine). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary first premolar

Medium

👤 23F 🦷 FDI 14

23-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 14 (maxillary first premolar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary second premolar

Medium

👤 28M 🦷 FDI 15

28-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 15 (maxillary second premolar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary first molar

Medium

👤 33F 🦷 FDI 16

33-year-old female presents with a draining gum boil but no pain. Tooth 16 (maxillary first molar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary second molar

Hard

👤 38M 🦷 FDI 17

38-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 17 (maxillary second molar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular central incisor

Easy

👤 43F 🦷 FDI 41

43-year-old female presents with no symptoms — found on routine radiographic review. Tooth 41 (mandibular central incisor). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular lateral incisor

Easy

👤 48M 🦷 FDI 42

48-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 42 (mandibular lateral incisor). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular canine

Easy

👤 53F 🦷 FDI 43

53-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 43 (mandibular canine). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular first premolar

Medium

👤 58M 🦷 FDI 44

58-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 44 (mandibular first premolar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular second premolar

Medium

👤 63F 🦷 FDI 45

63-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 45 (mandibular second premolar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular first molar

Medium

👤 68M 🦷 FDI 46

68-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 46 (mandibular first molar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular second molar

Hard

👤 73F 🦷 FDI 47

73-year-old female presents with a draining gum boil but no pain. Tooth 47 (mandibular second molar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary central incisor

Easy

👤 18M 🦷 FDI 11

18-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 11 (maxillary central incisor). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary lateral incisor

Easy

👤 23F 🦷 FDI 12

23-year-old female presents with no symptoms — found on routine radiographic review. Tooth 12 (maxillary lateral incisor). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary canine

Easy

👤 28M 🦷 FDI 13

28-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 13 (maxillary canine). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary first premolar

Medium

👤 33F 🦷 FDI 14

33-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 14 (maxillary first premolar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary second premolar

Medium

👤 38M 🦷 FDI 15

38-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 15 (maxillary second premolar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary first molar

Medium

👤 43F 🦷 FDI 16

43-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 16 (maxillary first molar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary second molar

Hard

👤 48M 🦷 FDI 17

48-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 17 (maxillary second molar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular central incisor

Easy

👤 53F 🦷 FDI 41

53-year-old female presents with a draining gum boil but no pain. Tooth 41 (mandibular central incisor). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular lateral incisor

Easy

👤 58M 🦷 FDI 42

58-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 42 (mandibular lateral incisor). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular canine

Easy

👤 63F 🦷 FDI 43

63-year-old female presents with no symptoms — found on routine radiographic review. Tooth 43 (mandibular canine). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular first premolar

Medium

👤 68M 🦷 FDI 44

68-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 44 (mandibular first premolar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular second premolar

Medium

👤 73F 🦷 FDI 45

73-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 45 (mandibular second premolar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular first molar

Medium

👤 18M 🦷 FDI 46

18-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 46 (mandibular first molar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular second molar

Hard

👤 23F 🦷 FDI 47

23-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 47 (mandibular second molar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary central incisor

Easy

👤 28M 🦷 FDI 11

28-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 11 (maxillary central incisor). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary lateral incisor

Easy

👤 33F 🦷 FDI 12

33-year-old female presents with a draining gum boil but no pain. Tooth 12 (maxillary lateral incisor). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary canine

Easy

👤 38M 🦷 FDI 13

38-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 13 (maxillary canine). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary first premolar

Medium

👤 43F 🦷 FDI 14

43-year-old female presents with no symptoms — found on routine radiographic review. Tooth 14 (maxillary first premolar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary second premolar

Medium

👤 48M 🦷 FDI 15

48-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 15 (maxillary second premolar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary first molar

Medium

👤 53F 🦷 FDI 16

53-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 16 (maxillary first molar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary second molar

Hard

👤 58M 🦷 FDI 17

58-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 17 (maxillary second molar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular central incisor

Easy

👤 63F 🦷 FDI 41

63-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 41 (mandibular central incisor). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular lateral incisor

Easy

👤 68M 🦷 FDI 42

68-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 42 (mandibular lateral incisor). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular canine

Easy

👤 73F 🦷 FDI 43

73-year-old female presents with a draining gum boil but no pain. Tooth 43 (mandibular canine). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular first premolar

Medium

👤 18M 🦷 FDI 44

18-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 44 (mandibular first premolar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular second premolar

Medium

👤 23F 🦷 FDI 45

23-year-old female presents with no symptoms — found on routine radiographic review. Tooth 45 (mandibular second premolar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular first molar

Medium

👤 28M 🦷 FDI 46

28-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 46 (mandibular first molar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular second molar

Hard

👤 33F 🦷 FDI 47

33-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 47 (mandibular second molar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary central incisor

Easy

👤 38M 🦷 FDI 11

38-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 11 (maxillary central incisor). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary lateral incisor

Easy

👤 43F 🦷 FDI 12

43-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 12 (maxillary lateral incisor). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary canine

Easy

👤 48M 🦷 FDI 13

48-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 13 (maxillary canine). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary first premolar

Medium

👤 53F 🦷 FDI 14

53-year-old female presents with a draining gum boil but no pain. Tooth 14 (maxillary first premolar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary second premolar

Medium

👤 58M 🦷 FDI 15

58-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 15 (maxillary second premolar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary first molar

Medium

👤 63F 🦷 FDI 16

63-year-old female presents with no symptoms — found on routine radiographic review. Tooth 16 (maxillary first molar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary second molar

Hard

👤 68M 🦷 FDI 17

68-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 17 (maxillary second molar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular central incisor

Easy

👤 73F 🦷 FDI 41

73-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 41 (mandibular central incisor). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular lateral incisor

Easy

👤 18M 🦷 FDI 42

18-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 42 (mandibular lateral incisor). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular canine

Easy

👤 23F 🦷 FDI 43

23-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 43 (mandibular canine). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular first premolar

Medium

👤 28M 🦷 FDI 44

28-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 44 (mandibular first premolar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular second premolar

Medium

👤 33F 🦷 FDI 45

33-year-old female presents with a draining gum boil but no pain. Tooth 45 (mandibular second premolar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular first molar

Medium

👤 38M 🦷 FDI 46

38-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 46 (mandibular first molar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular second molar

Hard

👤 43F 🦷 FDI 47

43-year-old female presents with no symptoms — found on routine radiographic review. Tooth 47 (mandibular second molar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary central incisor

Easy

👤 48M 🦷 FDI 11

48-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 11 (maxillary central incisor). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary lateral incisor

Easy

👤 53F 🦷 FDI 12

53-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 12 (maxillary lateral incisor). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary canine

Easy

👤 58M 🦷 FDI 13

58-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 13 (maxillary canine). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary first premolar

Medium

👤 63F 🦷 FDI 14

63-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 14 (maxillary first premolar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary second premolar

Medium

👤 68M 🦷 FDI 15

68-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 15 (maxillary second premolar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary first molar

Medium

👤 73F 🦷 FDI 16

73-year-old female presents with a draining gum boil but no pain. Tooth 16 (maxillary first molar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary second molar

Hard

👤 18M 🦷 FDI 17

18-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 17 (maxillary second molar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular central incisor

Easy

👤 23F 🦷 FDI 41

23-year-old female presents with no symptoms — found on routine radiographic review. Tooth 41 (mandibular central incisor). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular lateral incisor

Easy

👤 28M 🦷 FDI 42

28-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 42 (mandibular lateral incisor). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular canine

Easy

👤 33F 🦷 FDI 43

33-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 43 (mandibular canine). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular first premolar

Medium

👤 38M 🦷 FDI 44

38-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 44 (mandibular first premolar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular second premolar

Medium

👤 43F 🦷 FDI 45

43-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 45 (mandibular second premolar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular first molar

Medium

👤 48M 🦷 FDI 46

48-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 46 (mandibular first molar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular second molar

Hard

👤 53F 🦷 FDI 47

53-year-old female presents with a draining gum boil but no pain. Tooth 47 (mandibular second molar). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary central incisor

Easy

👤 58M 🦷 FDI 11

58-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 11 (maxillary central incisor). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary lateral incisor

Easy

👤 63F 🦷 FDI 12

63-year-old female presents with no symptoms — found on routine radiographic review. Tooth 12 (maxillary lateral incisor). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary canine

Easy

👤 68M 🦷 FDI 13

68-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 13 (maxillary canine). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary first premolar

Medium

👤 73F 🦷 FDI 14

73-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 14 (maxillary first premolar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary second premolar

Medium

👤 18M 🦷 FDI 15

18-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 15 (maxillary second premolar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary first molar

Medium

👤 23F 🦷 FDI 16

23-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 16 (maxillary first molar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary second molar

Hard

👤 28M 🦷 FDI 17

28-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 17 (maxillary second molar). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular central incisor

Easy

👤 33F 🦷 FDI 41

33-year-old female presents with a draining gum boil but no pain. Tooth 41 (mandibular central incisor). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular lateral incisor

Easy

👤 38M 🦷 FDI 42

38-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 42 (mandibular lateral incisor). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular canine

Easy

👤 43F 🦷 FDI 43

43-year-old female presents with no symptoms — found on routine radiographic review. Tooth 43 (mandibular canine). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular first premolar

Medium

👤 48M 🦷 FDI 44

48-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 44 (mandibular first premolar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular second premolar

Medium

👤 53F 🦷 FDI 45

53-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 45 (mandibular second premolar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular first molar

Medium

👤 58M 🦷 FDI 46

58-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 46 (mandibular first molar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular second molar

Hard

👤 63F 🦷 FDI 47

63-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 47 (mandibular second molar). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary central incisor

Easy

👤 68M 🦷 FDI 11

68-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 11 (maxillary central incisor). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary lateral incisor

Easy

👤 73F 🦷 FDI 12

73-year-old female presents with a draining gum boil but no pain. Tooth 12 (maxillary lateral incisor). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary canine

Easy

👤 18M 🦷 FDI 13

18-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 13 (maxillary canine). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary first premolar

Medium

👤 23F 🦷 FDI 14

23-year-old female presents with no symptoms — found on routine radiographic review. Tooth 14 (maxillary first premolar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary second premolar

Medium

👤 28M 🦷 FDI 15

28-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 15 (maxillary second premolar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender maxillary first molar

Medium

👤 33F 🦷 FDI 16

33-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 16 (maxillary first molar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary second molar

Hard

👤 38M 🦷 FDI 17

38-year-old male presents with sharp pain to cold and sweet that subsides within 1-2 seconds. Tooth 17 (maxillary second molar). Heightened but non-lingering response to cold. No tenderness to percussion or palpation. Moderate caries; radiopaque dentine still visible between caries and pulp. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful mandibular central incisor

Easy

👤 43F 🦷 FDI 41

43-year-old female presents with severe spontaneous throbbing pain, worse at night, and prolonged pain to cold lasting well beyond the stimulus. Tooth 41 (mandibular central incisor). Prolonged (lingering) response to cold. Mild tenderness to percussion. Extremely deep restoration close to the pulp on radiograph. No or minimal apical change.

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · mandibular lateral incisor

Easy

👤 48M 🦷 FDI 42

48-year-old male presents with no response to any stimulus and a dull ache on biting. Tooth 42 (mandibular lateral incisor). No response to thermal or electric pulp testing. Pain on percussion and palpation. Periapical radiolucency present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to mandibular canine

Easy

👤 53F 🦷 FDI 43

53-year-old female presents with a draining gum boil but no pain. Tooth 43 (mandibular canine). No response to pulp testing. No or mild pain to percussion. Periapical radiolucency extending to the cortical plate. A sinus tract traces to the tooth on a gutta-percha tracing radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · mandibular first premolar

Medium

👤 58M 🦷 FDI 44

58-year-old male presents with rapid facial swelling, fever and malaise over 24 hours. Tooth 44 (mandibular first premolar). No response to pulp testing. Diffuse facial swelling and facial asymmetry. Lymphadenopathy. Pain to percussion and palpation. Periapical radiolucency likely present.

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · mandibular second premolar

Medium

👤 63F 🦷 FDI 45

63-year-old female presents with no symptoms — found on routine radiographic review. Tooth 45 (mandibular second premolar). No response to pulp testing. No pain to percussion or palpation. A well-defined periapical radiolucency is present on the periapical radiograph.

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · mandibular first molar

Medium

👤 68M 🦷 FDI 46

68-year-old male presents with mild sensitivity at the gumline to cold and air, no spontaneous pain. Tooth 46 (mandibular first molar). Heightened, non-lingering response to cold localized to an area of gingival recession and exposed dentine. No percussion tenderness. No apical radiolucency.

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular second molar

Hard

👤 73F 🦷 FDI 47

73-year-old female presents with pain only on biting, sharp and brief, with no thermal sensitivity. Tooth 47 (mandibular second molar). Normal response to pulp testing. Moderate pain on percussion. Slight widening of the lamina dura, no frank apical radiolucency. History of recent high restoration.

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive maxillary central incisor

Easy

👤 18M 🦷 FDI 11

What is the most accurate diagnosis? (AAE/ESE 2025)

Painful maxillary lateral incisor

Easy

👤 23F 🦷 FDI 12

What is the most accurate diagnosis? (AAE/ESE 2025)

Biting pain · maxillary canine

Easy

👤 28M 🦷 FDI 13

What is the most accurate diagnosis? (AAE/ESE 2025)

Swelling related to maxillary first premolar

Medium

👤 33F 🦷 FDI 14

What is the most accurate diagnosis? (AAE/ESE 2025)

Routine finding · maxillary second premolar

Medium

👤 38M 🦷 FDI 15

What is the most accurate diagnosis? (AAE/ESE 2025)

Spontaneous pain · maxillary first molar

Medium

👤 43F 🦷 FDI 16

What is the most accurate diagnosis? (AAE/ESE 2025)

Gumline sensitivity · maxillary second molar

Hard

👤 48M 🦷 FDI 17

What is the most accurate diagnosis? (AAE/ESE 2025)

Percussion-tender mandibular central incisor

Easy

👤 53F 🦷 FDI 41

What is the most accurate diagnosis? (AAE/ESE 2025)

Cold-sensitive mandibular lateral incisor

Easy

👤 58M 🦷 FDI 42

What is the most accurate diagnosis? (AAE/ESE 2025)

Diagnosis Tool

AAE/ESE 2025 Classification. Answer the prompts — the tool guides you to the current pulpal & periapical diagnosis with management.

1. Response to pulp testing (cold / EPT)?

AAE/ESE 2025 — Quick Reference

🦷 Pulpal Diagnoses▼

🔬 Periapical Diagnoses▼

Summarized from the AAE/ESE 2025 Pulpal & Periapical Diagnosis Tables for clinical reference.

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