4804
4804
_____ Follow the link below to get your download now _____
https://ebookball.com/product/mosby-review-for-the-nbde-
part-ii-1st-editon-by-mosby-
isbn-032307992x-9780323079921-7352/
https://ebookball.com/product/mosby-review-for-the-nbde-part-ii-2nd-
edition-by-mosby-isbn-0323225683-9780323225687-7366/
Mosby Review for the NBDE Part I 1st Edition by Mosby ISBN
0323079911 9780323079914
https://ebookball.com/product/mosby-review-for-the-nbde-part-i-1st-
edition-by-mosby-isbn-0323079911-9780323079914-7356/
https://ebookball.com/product/first-aid-for-the-nbde-part-ii-1st-
edition-by-jason-portnof-timothy-leung-
isbn-0071482539-9780071482530-7364/
https://ebookball.com/product/first-aid-for-the-nbde-part-ii-1st-
edition-by-jason-portnof-timothy-leung-
isbn-0071482539-9780071482530-7362/
Mosby Dental Dictionary 2nd Edition by Mosby ISBN
032304963X 9780323049634
https://ebookball.com/product/mosby-dental-dictionary-2nd-edition-by-
mosby-isbn-032304963x-9780323049634-7344/
https://ebookball.com/product/mosby-comprehensive-review-of-dental-
hygiene-6th-edition-by-michele-leonardi-darby-
isbn-0323037135-9780323037136-6848/
https://ebookball.com/product/mosby-anatomy-physiology-study-and-
review-cards-2nd-edition-by-dan-
matusiak-9780323187268-0323187269-2120/
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by
any means, electronic or mechanical, including photocopying, recording, or any information stor-
age and retrieval system, without permission in writing from the publisher. Permissions may be
sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA:
phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: [email protected].
You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com),
by selecting ‘Customer Support’ and then ‘Obtaining Permissions.’
Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current information provided (i) on proce-
dures featured or (ii) by the manufacturer of each product to be administered, to verify the rec-
ommended dose or formula, the method and duration of administration, and contraindications. It
is the responsibility of the practitioner, relying on his or her own experience and knowledge of the
patient, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the
Publisher nor the Editor assumes any liability for any injury and/or damage to persons or property
arising out or related to any use of the material contained in this book.
The Publisher
ISBN-13: 978-0-323-02565-2
M. John Novak, BDS, LDS, MS, PhD Stuart C. White, DDS, PhD
Professor and Associate Director Professor and Chair, Section of Oral Radiology
Center for Oral Health Research University of California, Los Angeles—School of
College of Dentistry Dentistry
University of Kentucky Center for Health Sciences
Lexington, Kentucky Los Angeles, California
v
This page intentionally left blank
Contributors
vii
This page intentionally left blank
Preface
How to Use This Text your grades from the courses that relate to the exam
Examinations are a means of strengthening our intellect. topics. These will help point to areas that need more
This text is a tool to help prepare students for taking the attention. Also, use this book as a trial run to help
National Board Dental Exams and to point out strengths point to content areas that may need more review.
and weaknesses so they can better use their study time. 2. Practice makes perfect. Just re-reading old course
This text is not meant to replace years of professional notes may not be enough. The skill of taking an exam
training nor give away questions so that students may is more about pulling information from your brain, not
pass exams if they memorize the answers. Instead, this stuffing more information into it. Therefore, when
book will help direct students to the topic areas that they practicing to take board exams, consider practicing
may need to review and strengthen knowledge and retrieving information from your brain by taking prac-
exam-taking skills. tice exams. You can do this in several ways: study
Dental schools do well in preparing their students for with others by asking each other questions, test your-
practice as well as board exams. In addition, for many col- self with flashcards or notes that are partially covered
leges there is a good correlation between students who do from view, or answer questions from this text. In each
well in their dental courses and those who score well on case, be sure to check your answer to find out if you
their board exams. Therefore, to best prepare for board achieved the correct answer.
exams, students should focus on doing well in their 3. Practice answering examination questions in the
courses. It is also in the best interest of the student to focus same environment that the test will be given. In other
more study time for their board exams on the areas on words, most board exams are not given in your living
which they have not scored as well in their dental course- room with the TV or stereo blaring; therefore, do not
work. This is good news for students, since most are aware practice in this environment. Consider practicing in
of their areas of weakness and therefore have the oppor- an environment like the exam location using the
tunity to focus more resources on these areas when study- exam questions from this text.
ing for boards. 4. If possible, eat and sleep well during the weeks
before the exam. It is difficult to compete
Board Examinations Are Like Marathons successfully in a marathon if one is malnourished or
Taking most board exams is similar to running a sleep deprived. Set regular bed times and eating
marathon; they take both mental and physical stamina schedules so that your routine stays as familiar and
and they should be prepared for like one is preparing to comfortable as possible.
partake in a long endurance event. If one has never run 5. If you have a regular exercise routine, stick to it. It
a mile before, he or she cannot expect to prepare ade- will help you deal with the additional stress and pro-
quately in only 1 week for a 26-mile race. Therefore, vide consistency in your life.
preparation in advance is essential. 6. Block off time for practice examinations, such as
the review questions and sample exam in this text.
Helpful Hints for Preparing to Take Your Board Try to use the same amount of time and number of
Examinations questions that will be given during the actual exam.
1. Know your weaknesses and focus more of your This will help prepare you for the amount of pres-
resources on strengthening these areas. Look back at sure in the exam environment.
ix
x ▼ Preface
7. Stay away from naysayers and people who create hype returning to the more difficult questions later. This
around the board exams. Some of these people may helps to build up confidence during the exam. This
have their own interests in mind (e.g., Are they repre- also helps the test taker avoid spending too much
senting a board review company? Are they the type of time on a few questions and running out of time on
person who feels better by making others feel worse?). the easy questions that may be at the end.
Instead, find people who are positive and demonstrate 8. Pace yourself on the exam. Figure out ahead of time
good study behaviors. Consider making a study group how much time each question will take to answer.
of people who are able to help the other members in Do not rush but do not spend too much time on only
the group stay positive. one question. Sometimes it is better to move to the
8. If your school offers board reviews, consider taking next question and come back to the difficult ones
them. These may help you build confidence with later, since a fresh look is sometimes helpful.
what material you have already mastered and may 9. Bring appropriate supplies to the exam. If you get
help you focus on materials that you need to spend distracted by noise, consider bringing ear plugs. It is
more time studying. inevitable that someone will take the exam next to
the guy in the squeaky chair or the one with the
Helpful Hints for Taking Practice Examinations sniffling runny nose. Most exams will provide you
and Full Examinations with instructions on what you may or may not bring
1. It is important to note that questions that are consid- to the exam. Be sure to read these instructions in
ered “good” questions by examination standards will advance.
have incorrect choices in their answer bank that are 10. Make sure that once you have completed the exam,
very close to the correct answer. These wrong all questions are answered. The computerized exam
choices are called “distracters” for a reason; they are should tell you how many questions you left blank
meant to distract the test taker. Because of this, and will allow you to return to specific questions so
some test takers do better by reading the question you can complete them.
and trying to guess the answer before looking at the
answer bank. Therefore, consider trying to answer Helpful Hints for the Post-Examination Period
questions without looking at the answer bank. It may be a good to think about what you will be doing
2. Cross out answers that are obviously wrong. This will after the exam.
allow a better chance of picking the correct answer 1. Most people are exhausted after taking board exams.
and reduce distraction from the wrong answers. Some reasons for this exhaustion may be the
3. Only go back and change an answer if you are amount of hours, mental focus, and anxiety that
absolutely certain you were wrong with your previ- exams cause some people. Be aware that you may
ous choice, or if a different question in the same be tired, so avoid planning anything that one should
exam provides you with the correct answer. not do when exhausted, such as driving across coun-
4. Read questions carefully. Circle, or underline, nega- try, operating heavy machinery/power tools, or
tive words in questions, such as “except,” “not,” studying for final exams. Instead, plan a day or two to
“false,” etc. If these words are missed when reading recuperate before you tackle any heavier physical or
the question, it is nearly impossible to get the correct mental tasks.
answer; marking these key words will make sure 2. Consider a debriefing or “detoxification” meeting
you do not miss them. with your positive study partners after the exam.
5. If you are stuck on one question, consider treating Talking about the exam afterward may help reduce
the answer bank like a series of true/false items rel- stress. However, remember that feelings one has
evant to the question. Most people consider after an exam may not always match the exam score
true/false questions easier than multiple choice. At (e.g., someone who feels they did poorly may have
least if you can eliminate a few choices, you will done well or someone who feels they did well may
have a better chance at selecting the correct answer not have.)
from whatever is left. 3. Consider planning on doing something nice for your-
6. Never leave blanks, unless the specific exam has a self. After all, you will have just completed a major
penalty for wrong answers. It is better to guess wrong exam. It is important to celebrate this accomplish-
than leave an item blank. Check with those giving ment.
the examination to find out if there are penalties for We wish you the very best with taking your exams
marking the wrong answer. and hope that this text provides you with an excellent
7. Some people do better on exams by going through training tool for your preparations!
the exam and answering known questions first, then
Additional Resources
This review text is intended to aid the study and retention Management of Pain & Anxiety in the Dental Office,
of dental sciences in preparation for the National Board Fifth Edition
Dental Examination. It is not intended to be a substitute Raymond A. Dionne, James C. Phero, Daniel E. Becker
for a complete dental education curriculum. For a truly
comprehensive understanding of the basic dental sci- Management of Temporomandibular Disorders and
ences, please consult these supplemental texts. Occlusion, Fifth Edition
Jeffrey P. Okeson
Biomechanics and Esthetic Strategies in Clinical Medical Emergencies in the Dental Office, Sixth Edition
Orthodontics Stanley F. Malamed
Ravindra Nanda
Oral Radiology: Principles and Interpretation,
Carranza's Clinical Periodontology, Tenth Edition Fifth Edition
Michael G. Newman, Henry Takei, Perry R. Klokkevold, Stuart C. White, Michael J. Pharoah
Fermin A. Carranza
Orthodontics: Current Principles & Techniques,
Color Atlas of Dental Implant Surgery, Second Edition Fourth Edition
Michael S. Block Thomas M. Graber, Robert L. Vanarsdall, Jr., Katherine
W. L. Vig
Contemporary Fixed Prosthodontics, Fourth Edition
Stephen F. Rosenstiel, Martin F. Land, Junhei Fujimoto Pathways of the Pulp, Ninth Edition
Stephen Cohen, Kenneth M. Hargreaves
Dental Management of the Medically Compromised
Patient, Sixth Edition Periodontics: Medicine, Surgery, and Implants
James W. Little, Donald Falace, Craig Miller, Louis F. Rose, Brian L. Mealey, Robert J. Genco,
Nelson L. Rhodus Walter Cohen
Dentistry, Dental Practice, and the Community, Pharmacology and Therapeutics for Dentistry,
Sixth Edition Fifth Edition
Brian A. Burt, Stephen A. Eklund John A. Yagiela, Frank J. Dowd, Enid A. Neidle
Functional Occlusion: From TMJ to Smile Design Principles and Practice of Endodontics, Third Edition
Peter E. Dawson Richard E. Walton, Mahmoud Torabinejad
Handbook of Local Anesthesia, Fifth Edition Sturdevant’s Art & Science of Operative Dentistry, Fifth
Stanley F. Malamed Edition
Theodore M. Roberson, Harald O. Heymann, Edward J.
Jong’s Community Dental Health Swift, Jr.
George M. Gluck, Warren M. Morganstein
Wong’s Essentials of Pediatric Nursing, Seventh Edition
Marilyn Hockenberry-Eaton
xi
This page intentionally left blank
1
Endodontics
JARSHEN LIN, PEGGY LEONG, LOUIS M. LIN, TOM C. PAGONIS,
DOREEN F. TOSKOS
c. The pulp possesses unique, hard-tissue-secreting response that subsides as soon as the stimulus is
cells, or odontoblasts, as well as mesenchymal removed.
cells that can differentiate into osteoblasts that b. Any irritant that can affect the pulp may cause
form more dentin in an attempt to protect itself reversible pulpitis, including:
from injury. (1) Early caries/recurrent decay.
B. Physiology of pulpal pain (2) Periodontal scaling/root planing.
1. The sensibility of the dental pulp is controlled by (3) Deep restorations without a base.
A-delta and C afferent nerve fibers. c. Reversible pulpitis is not a disease; it is a symptom:
2. Dentinal pain (1) If the irritant is removed, it will revert to a
a. A-delta fibers are larger, myelinated nerves that healthy state.
enter the root canal and divide into smaller (2) If the irritant remains, the symptoms may
branches, coursing coronally through the pulp. lead to irreversible pulpitis.
b. A-delta fiber pain is immediately perceived as a d. Reversible pulpitis can be clinically distinguished
quick, sharp, momentary pain that dissipates from a symptomatic irreversible pulpitis in two
quickly on removal of the inciting stimulus (cold ways:
liquids or biting on an unyielding object). (1) Reversible pulpitis causes a momentary,
c. The intimate association of A-delta fibers with the painful response to thermal change that
odontoblastic cell layer and dentin is referred to subsides as soon as the stimulus (usually cold)
as the pulpodentinal complex. is removed. However, symptomatic irre-
3. Pulpitis pain versible pulpitis causes a painful response to
a. In pulpal inflammation, the response is exagger- thermal change that lingers after the stimulus
ated and disproportionate to the challenging is removed.
stimulus (hyperalgesia). This response is induced (2) Reversible pulpitis does not involve a complaint
by the effects of inflammatory mediators that are of spontaneous (unprovoked) pain.
released in the inflamed pulp. e. Frank penetration of bacteria into the pulp
b. Progression of pulpal inflammation can change the frequently is the crossover point to irreversible
quality of the pain response. As the exaggerated pulpitis.
A-delta fiber pain subsides, pain seemingly 3. Irreversible pulpitis
remains and is perceived as a dull, throbbing ache. a. By definition, the pulp has been damaged
This second pain symptom is from C nerve fibers. beyond repair, and even with removal of the irri-
c. C fibers are small, unmyelinated nerves that tant it will not heal.
course centrally in the pulp stroma. b. Microscopically:
d. Unlike A-delta fibers, C fibers are not directly (1) Micro-abscesses of the pulp begin as tiny
involved with the pulpodentinal complex and are zones of necrosis within dense, acute inflam-
not easily provoked. matory cells.
e. C fiber pain occurs with tissue injury and is medi- (2) Histologically intact myelinated and unmyeli-
ated by inflammatory mediators, vascular nated nerves may be observed in areas with
changes in blood volume and blood flow, and dense inflammation and cellular degeneration.
increases in tissue pressure. c. Following irreversible pulpitis, pulp death may
f. When C fiber pain dominates, it signifies irre- occur quickly or may require years; it may be
versible local tissue damage. painful or, more frequently, asymptomatic. The
g. With increasing inflammation of pulp tissues, end result is necrosis of the pulp.
C fiber pain becomes the only pain feature. d. Asymptomatic irreversible pulpitis (possible con-
h. Hot liquids or foods can raise intrapulpal pressure sequences)
to levels that excite C fibers. (1) Hyperplastic pulpitis: a reddish, cauliflower-
i. The pain is diffuse and can be referred to a dis- like growth of pulp tissue through and around
tant site or to other teeth. a carious exposure. The proliferative nature
j. The sustained inflammatory cycle is detrimental of this type of pulp is attributed to a low-
to pulpal recovery, finally terminating in tissue grade, chronic irritation of the pulp and the
necrosis. generous vascular supply characteristically
C. Clinical classification of pulpal diseases found in young people.
1. Within normal limits (2) Internal resorption:
a. A normal pulp is asymptomatic. (a) Most commonly identified during routine
b. A normal pulp produces a mild-to-moderate tran- radiographic examination. If undetected,
sient response to thermal and electrical stimuli internal resorption will eventually perfo-
that subsides almost immediately when the stim- rate the root.
ulus is removed. (b) Histological appearance: chronic pulpitis
c. The tooth does not cause a painful response i. Chronic inflammatory cells.
upon percussion or palpation. ii. Multinucleated giant cells adjacent to
2. Reversible pulpitis granulation tissue.
a. In reversible pulpitis, thermal stimuli (usually iii. Necrotic pulp coronal to resorptive
cold) cause a quick, sharp, hypersensitive defect.
Section 1 Endodontics ▼ 3
(c) Only prompt endodontic therapy will stop dentin during cleaning and shaping the
the process and prevent further tooth canal(s).
destruction.
e. Symptomatic irreversible pulpitis 1.2 Periradicular Diseases
(1) Characterized by spontaneous, unprovoked, A. What is periradicular disease?
intermittent, or continuous pain. 1. Periradicular lesions of pulpal origin are inflamma-
(2) Sudden temperature changes (often to cold) tory responses to irritants from the root canal system.
elicit prolonged episodes of pain that lingers 2. Patient symptoms may range from an asymptomatic
after the thermal stimulus is removed. response to a variety of symptoms, including:
(3) Occasionally, patients may report that a pos- a. Slight sensitivity to chewing.
tural change, such as lying down or bending b. Feeling of tooth elongation.
over, induces pain. c. Intense pain.
(4) Radiographs are generally not sufficient for d. Swelling.
diagnosing irreversible pulpitis: e. High fever.
(a) Radiographs can be helpful in identifying f. Malaise.
suspect teeth only. 3. The sign most indicative of a periradicular inflam-
(b) Thickening of the apical portion of the matory lesion is radiographic bone resorption, but
periodontal ligament may become evi- this is unpredictable. Periradicular lesions are fre-
dent on the radiographs in the advanced quently not visible on radiographs.
stage. 4. Periradicular lesions do not occur as individual
(5) The electric pulp test is of little value in the entities; there are clinical and histologic crossovers
diagnosis of symptomatic irreversible pul- in terminology regarding periradicular lesions
pitis. because the terminology is based on both clinical
4. Necrosis signs and symptoms and on radiographic findings.
a. The death of the pulp, which results from: There is no correlation between histologic findings
(1) An untreated, irreversible pulpitis. and clinical signs, symptoms, and duration of the
(2) A traumatic injury. lesion. The terms acute and chronic apply only to
(3) Any event that causes long-term interruption clinical symptoms.
of the blood supply to the pulp. B. Classification of periradicular diseases
b. Pulpal necrosis may be partial or total: 1. Acute periradicular periodontitis
(1) Partial necrosis may present with some of the a. Acute periradicular periodontitis means painful
symptoms associated with irreversible pulpi- inflammation around the apex (localized inflam-
tis (e.g., a two-canaled tooth could have an mation of the periodontal ligament in the peri-
inflamed pulp in one canal and a necrotic radicular region). It can be the result of:
pulp in the other). (1) An extension of pulpal disease into the peri-
(2) Total necrosis is asymptomatic before it radicular tissue.
affects the periodontal ligament, and there is (2) Canal overinstrumentation or overfill.
no response to thermal or electric pulp tests. (3) Occlusal trauma such as bruxism.
c. In anterior teeth, some crown discoloration may b. Because acute periradicular periodontitis may
accompany pulp necrosis. occur around vital and nonvital teeth, conducting
d. Protein breakdown products along with bacteria pulp tests is the only way to confirm the need for
and their toxins will eventually spread beyond the endodontic treatment.
apical foramen—which will lead to thickening of c. Even when present, the periradicular periodontal
the periodontal ligament. The clinical manifesta- ligament may radiographically appear within nor-
tion presents as tenderness to percussion and mal limits or only slightly widened.
chewing. d. The tooth may be painful during percussion tests.
e. Microscopically: e. If the tooth is vital, a simple occlusal adjustment
(1) As inflammation progresses, tissue continues will often relieve the pain. If the pulp is necrotic
to disintegrate in the center of the pulp to and remains untreated, additional symptoms
form an increasing region of liquefaction may appear as the disease advances to the next
necrosis. stage—acute apical abscess.
(2) Because of the lack of collateral circulation g. Because there is little room for expansion of the
and the unyielding walls of dentin, there periodontal ligament, increased pressure can
is insufficient drainage of inflammatory also cause physical pressure on the nerve
fluids. endings, which subsequently causes intense,
(3) The result is localized increases in tissue throbbing, periradicular pain.
pressure, causing the destruction to h. Histological examination reveals a localized
progress unchecked until the entire pulp is inflammatory infiltrate within the periodontal lig-
necrotic. ament.
(4) Bacteria are able to penetrate and invade 2. Acute periradicular abscess (acute apical abscess)
into dentinal tubules. Therefore, it is neces- a. An acute apical abscess is a painful, purulent
sary to remove the superficial layers of exudate around the apex.
4 ▼ Section 1 Endodontics
b. It is a result of the exacerbation of acute apical (3) The confirmation of pulpal necrosis.
periodontitis from a necrotic pulp. f. A totally necrotic pulp provides a safe harbor for
c. The periodontal ligament may radiographically the primarily anaerobic microorganisms—if there
appear within normal limits or only slightly thick- is no vascularity, there are no defense cells.
ened. g. Chronic periradicular periodontitis traditionally
d. Radiographically, the periapical radiograph has been classified histologically as periradicular
reveals a relatively normal or slightly thickened granuloma or periradicular cyst. The only accurate
lamina dura (because the infection has rapidly way to distinguish them is by histopathological
spread beyond the confines of the cortical plate examination.
before demineralization can be detected radi- 4. Suppurative periradicular periodontitis (chronic
ographically). periradicular abscess)
e. Only swelling is manifest. a. It is associated with either a continuously or inter-
f. The lesions can also result from infection and rapid mittently draining sinus tract without discomfort.
tissue destruction arising from within chronic peri- b. The exudate can also drain through the gingival
radicular periodontitis—often referred to as a sulcus, mimicking a periodontal lesion with a
phoenix abscess. (The symptoms of the phoenix “pocket.”
abscess and the acute apical abscess are identical; c. Pulp tests are negative because of the presence
however, when a periapical radiolucency is evi- of necrotic pulp.
dent, it is called a phoenix abscess.) d. Radiographic examination of these lesions
g. Histopathological findings: shows the presence of bone loss at the periradic-
(1) A central area of liquefaction necrosis con- ular area.
taining disintegrating neutrophils and other e. Treatment: these sinus tracts resolve sponta-
cellular debris. neously with nonsurgical endodontic treatment.
(2) Surrounded by viable macrophages and 5. Chronic focal sclerosing osteomyelitis (condensing
occasional lymphocytes and plasma cells. osteitis)
(3) Bacteria are not always found in the apical a. It is excessive bone mineralization around the
tissues or within the abscess cavity. apex of an asymptomatic, vital tooth.
h. The presenting signs and symptoms of acute api- b. This radiopacity may be caused by low-grade
cal abscess include: pulp irritation.
(1) Rapid onset of swelling. c. This process is asymptomatic and benign. It does
(2) Moderate to severe pain. not require endodontic therapy.
(3) Pain with percussion and palpation.
(4) Slight increase in tooth mobility. 1.3 Endodontic Diagnosis
(5) The extent and distribution of the swelling A. Triage of the pain patient
are determined by the location of the apex 1. Orofacial pain can be the clinical manifestation of a
and the muscle attachments and the thick- variety of diseases involving the head and neck
ness of the cortical plate. region.
(6) Usually the swelling remains localized. 2. The cause must be differentiated between odonto-
However, it also may become diffuse and genic and nonodontogenic:
spread widely (cellulitis). a. Numerous orofacial diseases mimic endodontic
i. The acute apical abscess can be differentially diag- pain (may produce sensory misperception as a
nosed from the lateral periodontal abscess with result of overlapping between the sensory fibers
pulp vitality testing and, sometimes, with periodon- of the trigeminal nerve).
tal probing. b. Characteristics of nonodontogenic involvement:
3. Chronic periradicular periodontitis (1) Episodic pain with pain free remissions.
a. Chronic periradicular periodontitis is a long- (2) Trigger points.
standing, asymptomatic, or mildly symptomatic (3) Pain travels and crosses the midline of the
lesion. face.
b. It is usually accompanied by radiographically vis- (4) Pain that surfaces with increasing mental
ible apical bone resorption. stress.
c. Bacteria and their endotoxins cascading out into (5) Pain that is seasonal or cyclic.
the periradicular region from a necrotic pulp (6) Paresthesia.
cause extensive demineralization of cancellous B. Medical history (developing data)
and cortical bone. 1. Endodontic treatment is not contraindicated with
d. Occasionally, there may be slight tenderness to most medical conditions. The only systemic con-
percussion and/or palpation testing. traindications to endodontic therapy are uncon-
e. The diagnosis of chronic apical periodontitis is trolled diabetes or a very recent myocardial
confirmed by: infarction (within the past 6 months).
(1) The general absence of symptoms. 2. The patient’s medical history enables the clinician
(2) The radiographic presence of a periradicular to determine the need for a medical consultation or
radiolucency. premedication of the patient.
Section 1 Endodontics ▼ 5
(2) Periodicity: Do the symptoms have a tempo- that characterize the chief complaint.
ral pattern (i.e., sporadic or occasional)? ● Provide an assessment of normal responses for
(3) Frequency: Have the symptoms persisted comparison with abnormal responses.
since they began, or are they intermittent? ● The dentist should include adequate controls for test
How often does this pain occur? procedures. Several adjacent, opposing, and contralat-
(4) Duration: How long do symptoms last eral teeth should be tested before the tooth in question
when they occur (i.e., momentary or lingering)? to establish the patient’s normal range of response.
4. Quality of pain A. Palpation
a. How the patient describes the complaint: 1. When periradicular inflammation develops after
(1) Bony origin: dull, drawing, or aching. pulp necrosis, the inflammatory process may bur-
(2) Vascular response to tissue inflammation: row its way through the facial cortical bone and
throbbing, pounding, or pulsating. begin to affect the overlying mucoperiosteum.
Other documents randomly have
different content
—Il aurait bien mieux valu pour moi rester dans la petite cabane
auprès de ma mère. À quoi bon toute ma gloire, si je dois finir de
cette manière?
Il resta ainsi des heures durant. Le matin parut, le soleil se leva, et
les oiseaux commencèrent leurs chants. Mais lui jouait, jouait sans
trêve.
Comme le jour naissant était un dimanche, Lars Larsson dut rester
seul auprès du vieux moulin. Personne ne prit la route de la forêt.
Tout le monde s'en fut vers l'église dans la vallée ou bien vers les
villages qui bordaient la grand'route.
La matinée s'écoula et le soleil monta toujours plus haut dans le ciel.
Les oiseaux se turent, mais en échange on entendit le bruissement
des longues aiguilles des pins.
Lars Larsson ne se laissa pas arrêter par la chaleur de cette journée
d'été. Il jouait, jouait.
Enfin le soir vint, le soleil se coucha mais son archet n'avait pas
besoin de repos et son bras continua à se mouvoir fébrilement.
—Il est bien certain que cela ne finira que par ma mort, dit-il, et ce
sera là la juste punition de mon orgueil.
Très tard dans la soirée, il vit un être humain s'approcher à travers la
forêt. C'était une pauvre vieille au dos courbé, aux cheveux gris et
au visage ridé par bien des chagrins.
—Voilà qui est singulier, pensa le musicien. Il me semble reconnaître
cette vieille femme. Est-il possible que ce soit ma mère? Est-il
possible qu'elle soit devenue si vieille et si grise?
Il l'interpella à haute voix pour l'arrêter.
—Mère, mère, viens ici! cria-t-il.
Elle s'arrêta comme à contre-cœur.
—Je me rends compte maintenant, par mes propres oreilles, que tu
es le joueur de violon le plus habile du Vermland entier, dit-elle, et je
comprends que tu ne te soucies plus d'une vieille femme comme
moi.
—Mère, mère, ne passe pas! cria Lars Larsson. Je ne suis pas un
joueur habile, je ne suis qu'un vaurien. Viens ici, pour que je puisse
te parler!
Alors, la mère s'approcha de lui et s'aperçut de son état. Son visage
avait une pâleur mortelle, ses cheveux ruisselaient de sueur et le
sang sortait par la racine de ses ongles.
—Mère, je suis tombé dans le malheur à cause de mon orgueil et
maintenant il faut que je me tue à force de jouer. Mais auparavant
dis-moi si tu peux me pardonner, à moi, qui t'ai laissée seule et
pauvre dans tes vieux jours?
La mère se sentit envahir d'une grande pitié pour le fils, et toute la
colère qu'elle avait eue contre lui disparut comme par
enchantement.
—Pour sûr que je te pardonne, dit-elle.
Mais voyant son angoisse, et empressée à lui faire comprendre que
c'était bien là ses sentiments véritables, elle confirma le pardon en
prononçant le nom du Seigneur.
—Au nom du Seigneur Jésus-Christ, je te pardonne, dit-elle.
À ces paroles l'archet s'arrêta, le violon tomba par terre et le joueur
se leva, délivré et sauvé. Car l'enchantement était rompu du
moment que sa vieille mère avait été émue de pitié devant son
malheur, au point de prononcer sur lui le nom du Seigneur.
LE BALLON
Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.
ebookball.com