# Free DLOSCE-style practice questions These are original Dentovio practice items. They are not recalled examination content, and none is taken from JCNDE or ADEX practice materials. Each patient's findings are stated in words in a Patient Box, and teeth use the ADA Universal numbering system. Multiple-answer items follow the official rule: any incorrect selection earns no credit for the item; otherwise the score is the sum of the credit for the correct options selected, up to 1 point, and neutral options do not change the score. The prescription task is scored out of 4 on Dentovio's training rubric because the official key is not published, and practice scores are not DLOSCE scaled scores. ## Patient dlosce-pt-res-8001: Root caries after head-and-neck radiation | Patient Box | Details | | --- | --- | | Age / sex | 71-year-old man | | Chief complaint | "My mouth is always dry, and my teeth keep decaying near the gums." | | Medical history | Oropharyngeal cancer treated with radiation therapy to the head and neck, completed 2 years ago; hypertension | | Current medications | Lisinopril 20 mg daily | | Vital signs | BP 132/80 mm Hg; pulse 72/min | | Dental history | Four new carious lesions restored in the last 24 months; brushes twice a day with an over-the-counter fluoride toothpaste; wears a mandibular removable partial denture | | Clinical findings | Severe dry mouth with no pooled saliva; visible plaque at the gingival margins; generalized gingival recession with exposed root surfaces; several interproximal restorations; noncavitated carious lesions on the facial root surfaces of #21, #22, #27 and #28 | | Radiographic findings | No cavitated lesions; no periapical radiolucencies | ### Question 1 - **Item ID:** dlosce-res-8001 - **Patient:** dlosce-pt-res-8001 - **Topic:** RES-DX - **Type:** multiple - **Prompt:** On the ADA Caries Risk Assessment Form for patients older than 6 years, which findings in this patient are high-risk conditions? A. Radiation therapy to the head and neck B. Brushing twice a day with a fluoride toothpaste C. Exposed root surfaces D. Visible plaque E. Four new lesions restored in the last 24 months F. Interproximal restorations G. Severe dry mouth H. A removable partial denture - **Credit:** A = 0.34; E = 0.33; G = 0.33 - **Neutral:** none - **Why:** On the form, one or more conditions in the High Risk column make the overall caries risk high. Chemo/radiation therapy, three or more carious lesions or restorations in the last 36 months, and severe dry mouth are all High Risk conditions. [^B499] - **Option notes:** B: incorrect — fluoride exposure through toothpaste is a low-risk finding. C: incorrect — exposed root surfaces are a moderate-risk condition. D: incorrect — visible plaque is a moderate-risk condition. F: incorrect — one or more interproximal restorations is a moderate-risk condition. H: incorrect — fixed or removable dental appliances are a moderate-risk condition. - **Source:** [ADA Caries Risk Assessment Form (Age >6)](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/topic_caries_over6.pdf), General Health Conditions II, Clinical Conditions I to IX and the scoring instructions. [^B499] ### Question 2 - **Item ID:** dlosce-res-8002 - **Patient:** dlosce-pt-res-8001 - **Topic:** RES-DX - **Type:** single - **Prompt:** Which nonrestorative treatment is most appropriate for the noncavitated root-surface lesions? A. 1.1% sodium fluoride (5,000 ppm) toothpaste daily B. 0.2% sodium fluoride mouthrinse once a week C. 10% casein phosphopeptide–amorphous calcium phosphate paste D. 0.12% chlorhexidine gluconate mouthrinse twice a day E. Resin infiltration F. Pit-and-fissure sealant - **Answer:** A - **Why:** For noncavitated and cavitated root-surface lesions on permanent teeth, the ADA guideline suggests prioritizing 5,000 ppm fluoride (1.1% sodium fluoride) toothpaste or gel used at least once a day. Its lower-priority alternatives are 5% sodium fluoride varnish every 3–6 months, 38% silver diamine fluoride with or without potassium iodide once a year, and 1% chlorhexidine plus 1% thymol varnish every 3–6 months. [^B389] - **Option notes:** B: A weekly 0.2% sodium fluoride rinse is listed only as an alternative for noncavitated occlusal lesions. C: Casein phosphopeptide–amorphous calcium phosphate paste is not a root-surface option, and the guideline suggests against it for noncavitated coronal lesions when fluoride, sealants or resin infiltration are available. D: A chlorhexidine mouthrinse is not among the root-surface options; the chlorhexidine option is a 1% chlorhexidine plus 1% thymol varnish. E: Resin infiltration is an option for noncavitated approximal coronal lesions, not root surfaces. F: Sealants are options for occlusal and approximal coronal lesions, not root surfaces. - **Source:** [ADA chairside guide, nonrestorative treatments for carious lesions on permanent teeth](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/chairside_guide_nonrestorative_treatments_for_carious_lesions_on_permanent_teeth.pdf), root-surface recommendation and clinical pathway. [^B389] ## Patient dlosce-pt-res-8002: Deep proximal caries during pregnancy | Patient Box | Details | | --- | --- | | Age / sex | 29-year-old woman | | Chief complaint | "Food keeps getting stuck between my lower left back teeth." | | Medical history | Pregnant, 22 weeks; uncomplicated pregnancy | | Current medications | Prenatal multivitamin daily | | Vital signs | BP 112/70 mm Hg; pulse 84/min | | Dental history | Last dental visit 3 years ago; no spontaneous pain; brief sensitivity to cold drinks | | Clinical findings | Cavitated carious lesion with visible dentin (ICDAS code 5) on the distal surface of #19; the tooth needs a Class II restoration; no swelling or sinus tract; probing depths 2–3 mm | | Radiographic findings | Distal radiolucency of #19 extending into the inner third of the dentin, with a layer of dentin still visible between the lesion and the pulp; normal periapical tissues | | Tooth | Percussion | Palpation | Cold | EPT | | --- | --- | --- | --- | --- | | 19 | - | - | + (resolves within 2 s) | 28/80 | | 18 | - | - | + | 30/80 | ### Question 3 - **Item ID:** dlosce-res-8003 - **Patient:** dlosce-pt-res-8002 - **Topic:** RES-PREP - **Type:** multiple - **Prompt:** Which approaches to the carious lesion on #19 are appropriate? A. Deferring all treatment until after delivery B. Non-selective removal to hard dentin C. Selective removal to soft or firm dentin D. Stepwise removal over two visits E. Pulpotomy F. Pulpectomy G. Extraction - **Credit:** C = 1 - **Neutral:** B; D - **Why:** For an advanced lesion on a vital permanent tooth that needs a restoration without pulp therapy, the ADA guideline suggests prioritizing selective carious tissue removal, to soft or firm dentin, over stepwise or non-selective removal. Restorative treatment is safe throughout pregnancy. [^B500][^B272] - **Option notes:** A: incorrect — preventive, diagnostic and restorative treatment is safe throughout pregnancy, and delaying treatment may lead to more complex problems. B: neutral — the guideline lists non-selective removal as a lower-priority alternative when selective removal is not feasible. D: neutral — stepwise removal is the other lower-priority alternative for advanced lesions. E: incorrect — cold sensitivity that resolves within 2 seconds, with no spontaneous pain, does not indicate irreversible pulpitis, so no pulp therapy is needed. F: incorrect — pulpectomy treats irreversible pulpitis or pulp necrosis. G: incorrect — the tooth is restorable. - **Source:** [ADA chairside guide, carious tissue removal and direct restorative materials for permanent teeth](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/13406_chairside_guide_caries_lesions_permanent_teeth.pdf), carious tissue removal recommendations and footnotes 4, 5, 7 and 8. [ADA Oral Health Topics, Pregnancy](https://www.ada.org/resources/ada-library/oral-health-topics/pregnancy), Key Points. [Edwards et al., Br Dent J 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11991903/), Table 1, pulp diagnoses. [^B500][^B272][^B102] ### Question 4 - **Item ID:** dlosce-res-8004 - **Patient:** dlosce-pt-res-8002 - **Topic:** RES-DIR - **Type:** multiple - **Prompt:** Which direct restorative materials are appropriate for the Class II restoration of #19 in this patient? A. Dental amalgam B. Resin composite C. Resin-modified glass ionomer D. Conventional (non-resin) glass ionomer E. Compomer F. Resin infiltration - **Credit:** B = 1; C = 1 - **Neutral:** D - **Why:** For Class II restorations of moderate and advanced lesions on vital posterior permanent teeth, the ADA guideline suggests prioritizing dental amalgam, resin composite or resin-modified glass ionomer over conventional glass ionomer, with no ranking among the three. The FDA recommends that pregnant women avoid amalgam whenever possible and appropriate, so either resin composite or resin-modified glass ionomer alone is a complete answer. [^B500][^B501] - **Option notes:** A: incorrect — the FDA lists pregnant women among the high-risk groups who should avoid amalgam when possible, and suitable non-mercury materials are available. D: neutral — conventional glass ionomer is the guideline's lower-priority alternative for Class II restorations when the prioritized materials are not feasible. E: incorrect — compomer is not among the materials suggested for posterior Class II restorations. F: incorrect — resin infiltration is a nonrestorative option for noncavitated approximal lesions, not a restoration for a cavitated lesion. - **Source:** [ADA chairside guide, carious tissue removal and direct restorative materials for permanent teeth](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/13406_chairside_guide_caries_lesions_permanent_teeth.pdf), posterior Class II recommendation and clinical pathway. [FDA, recommendations for high-risk groups regarding dental amalgam](https://www.fda.gov/news-events/press-announcements/fda-issues-recommendations-certain-high-risk-groups-regarding-mercury-containing-dental-amalgam), list of high-risk groups. [ADA chairside guide, nonrestorative treatments on permanent teeth](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/chairside_guide_nonrestorative_treatments_for_carious_lesions_on_permanent_teeth.pdf), approximal recommendation. [^B500][^B501][^B389] ## Patient dlosce-pt-res-8003: Fractured cusp restored with a ceramic onlay | Patient Box | Details | | --- | --- | | Age / sex | 45-year-old woman | | Chief complaint | "A piece of my upper right back tooth broke off." | | Medical history | Migraine | | Current medications | Sumatriptan 50 mg as needed | | Vital signs | BP 118/74 mm Hg; pulse 70/min | | Dental history | Large mesio-occlusal-distal composite restoration on #3, placed 9 years ago | | Clinical findings | Fractured mesiolingual cusp of #3; no caries; normal response to cold; no tenderness to percussion. #3 has been prepared, and a milled lithium disilicate onlay is ready for adhesive resin cementation under rubber dam isolation | | Radiographic findings | No caries; normal periapical tissues | ### Question 5 - **Item ID:** dlosce-res-8005 - **Patient:** dlosce-pt-res-8003 - **Topic:** RES-IND - **Type:** single - **Prompt:** Which treatment of the onlay's intaglio (internal) surface is most appropriate before adhesive cementation? A. Silane coupling agent alone, without etching B. Hydrofluoric acid etching alone C. Hydrofluoric acid etching, then a silane coupling agent D. Airborne-particle abrasion with alumina, then an MDP-containing primer - **Answer:** C - **Why:** Lithium disilicate is a glass-ceramic. Hydrofluoric acid etching followed by silane is the standard conditioning for glass-ceramics: the acid creates micromechanical retention, and the silane bonds chemically to the etched silica surface and copolymerizes with the resin. [^B455][^B369][^B468] - **Option notes:** A: Single-component silanes need prior hydrofluoric acid etching of the ceramic to activate the bond. B: Applying silane after hydrofluoric acid etching increases bond strength; etching alone leaves out the chemical bond. D: Alumina abrasion with an MDP primer is the clinically validated protocol for high-strength zirconia, which has no glassy phase; it is not the conditioning for a glass-ceramic. - **Source:** [Rojas-Rueda et al., Biomimetics 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11940404/), section 4.3, Ceramic Surface Treatment. [van den Breemer et al., Biomed Res Int 2015](https://pmc.ncbi.nlm.nih.gov/articles/PMC4628770/), Introduction and section 3.1.1. [Lupu et al., Biomimetics 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC12468000/), Introduction and section 4.7. [^B455][^B369][^B468] ## Patient dlosce-pt-pro-8001: Bleeding around a molar implant | Patient Box | Details | | --- | --- | | Age / sex | 63-year-old woman | | Chief complaint | "The gum around my implant bleeds when I brush, and I get a bad taste." | | Medical history | Type 2 diabetes (HbA1c 8.6% last month); hypertension; former smoker of 20 pack-years who quit 4 years ago | | Current medications | Metformin 1,000 mg twice daily; amlodipine 5 mg daily | | Vital signs | BP 134/82 mm Hg; pulse 76/min | | Dental history | Periodontitis treated 9 years ago, when #30 was lost to periodontitis; implant placed at #30 6 years ago and restored with a screw-retained crown 5 years ago; no dental visits since the crown was placed | | Clinical findings | Implant #30: probing depths of 7 mm on the buccal and distal (3 mm one year after crown placement), with bleeding and suppuration on gentle probing; no mobility; mucosal margin at the same level as at crown placement; keratinized mucosa 3 mm wide; platform-switched abutment with a transmucosal height of 3 mm | | Radiographic findings | Compared with the radiograph taken one year after crown placement, the crestal bone around implant #30 has receded a further 3.5 mm mesially and distally | ### Question 6 - **Item ID:** dlosce-pro-8001 - **Patient:** dlosce-pt-pro-8001 - **Topic:** PRO-IMP - **Type:** single - **Prompt:** What is the most likely diagnosis for implant #30? A. Peri-implant health B. Peri-implant mucositis C. Peri-implantitis D. Peri-implant soft-tissue dehiscence E. Physiologic marginal bone remodeling F. Loss of osseointegration - **Answer:** C - **Why:** Peri-implantitis is persistent inflammation of the peri-implant mucosa with subsequent loss of supporting bone. Bleeding and suppuration on gentle probing, probing depths that increased from 3 mm to 7 mm, and 3.5 mm of bone loss beyond the level recorded after initial remodeling fit that definition. [^B502][^B504] - **Option notes:** A: Bleeding and suppuration on probing exclude peri-implant health. B: Peri-implant mucositis is inflammation without marginal bone loss beyond the initial biological remodeling. D: A soft-tissue dehiscence is an apical shift of the mucosal margin, and the margin has not moved. E: Initial physiologic remodeling takes place in about the first 12 months after loading; this loss is measured from the 1-year radiograph. F: The implant is not mobile. - **Source:** [Wang et al., AO/AAP consensus summary report, J Periodontol 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC12273748/), Introduction and Focused Questions 3 and 4. [MSD Manual Professional, Peri-Implant Diseases and Conditions](https://www.msdmanuals.com/professional/dental-disorders/periodontal-disorders/peri-implant-diseases-and-conditions). [^B502][^B504] ### Question 7 - **Item ID:** dlosce-pro-8002 - **Patient:** dlosce-pt-pro-8001 - **Topic:** PRO-IMP - **Type:** multiple - **Prompt:** Which findings in this patient are risk indicators for peri-implantitis? A. History of periodontitis B. Smoking history, quit 4 years ago C. HbA1c of 8.6% D. Hypertension E. No maintenance visits since the crown was placed F. Keratinized mucosa 3 mm wide G. Transmucosal abutment height of 3 mm H. Platform-switched abutment - **Credit:** A = 0.25; B = 0.25; C = 0.25; E = 0.25 - **Neutral:** D - **Why:** The 2025 AO/AAP consensus links a history of periodontitis, current or recent former smoking (quit within the last 10 years) and uncontrolled diabetes (HbA1c above 7%) to peri-implant disease, including peri-implantitis. Its risk workgroup reported the highest peri-implantitis incidence in patients with a history of periodontitis and in erratic maintenance compliers. [^B502][^B503] - **Option notes:** D: neutral — the consensus panel did not reach consensus that hypertension increases the risk of peri-implantitis. F: incorrect — the local risk factor is keratinized mucosa narrower than 2 mm. G: incorrect — a transmucosal abutment height of 2 mm or more is associated with a lower risk of marginal bone loss. H: incorrect — platform-switched abutments lower the risk of marginal bone loss; platform-matched abutments carry the higher risk. - **Source:** [Wang et al., J Periodontol 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC12273748/), Conclusions, risk factor assessment, and Focused Question 3. [Kumar et al., AO/AAP workgroup 1 report, Clin Adv Periodontics 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC12266310/), Results, risk markers for peri-implantitis and risk of peri-implantitis. [^B502][^B503] ## Patient dlosce-pt-pro-8002: Red palate under an upper denture | Patient Box | Details | | --- | --- | | Age / sex | 81-year-old woman | | Chief complaint | Her daughter says, "Her upper denture looks dirty, and the roof of her mouth is red." | | Medical history | Parkinson disease with hand tremor and limited manual dexterity; type 2 diabetes (HbA1c 7.4%) | | Current medications | Carbidopa-levodopa 25 mg/100 mg three times daily; metformin 500 mg twice daily | | Vital signs | BP 128/76 mm Hg; pulse 68/min | | Dental history | Maxillary complete denture made 6 years ago and worn day and night; natural mandibular teeth | | Clinical findings | Painless, diffuse, red, velvety mucosa confined to the denture-bearing area of the palate; no ulceration or mass; plaque covers the tissue surface of the denture; the denture is retentive and stable; a smear from the palate shows branching hyphae | ### Question 8 - **Item ID:** dlosce-pro-8003 - **Patient:** dlosce-pt-pro-8002 - **Topic:** PRO-REM - **Type:** multiple - **Prompt:** Which measures are appropriate for the inflamed mucosa under this patient's denture? A. Wearing the denture day and night so the palate can adapt B. Leaving the denture out overnight C. Daily cleaning of the denture, with her daughter's help D. Nystatin suspension on the denture's tissue surface E. Relining the existing denture F. Amoxicillin 500 mg three times a day for 7 days G. Incisional biopsy of the palate before any treatment - **Credit:** B = 0.34; C = 0.33; D = 0.33 - **Neutral:** E - **Why:** Candidal infection, poor denture hygiene, poor fit and, most frequently, wearing a denture 24 hours a day contribute to inflammation of the mucosa under a denture. Treatment includes better oral and denture hygiene, removing the denture for extended periods, and antifungal therapy such as nystatin suspension applied to the tissue surface of the denture. [^B505] - **Option notes:** A: incorrect — round-the-clock wear is the most frequent contributing factor. E: neutral — refitting is a listed treatment, but this denture is already retentive and stable, so the findings do not settle whether a reline would help. F: incorrect — the smear shows fungal hyphae, and an antibacterial drug is not among the treatments. G: incorrect — biopsy is indicated if the inflammation persists after treatment. - **Source:** [MSD Manual Professional, Dental Appliances](https://www.msdmanuals.com/professional/dental-disorders/common-dental-disorders/dental-appliances), Denture problems. [MSD Manual Professional, Stomatitis](https://www.msdmanuals.com/professional/dental-disorders/symptoms-of-dental-and-oral-disorders/stomatitis), candidal stomatitis. [^B505][^B175] ## Patient dlosce-pt-pro-8003: Congenitally missing lateral incisor | Patient Box | Details | | --- | --- | | Age / sex | 17-year-old boy | | Chief complaint | "I want a fixed tooth where my upper right tooth never grew in." | | Medical history | No significant findings | | Current medications | None | | Vital signs | BP 116/72 mm Hg; pulse 64/min | | Dental history | Congenitally missing #7; orthodontic treatment completed 2 months ago, with space for #7 maintained | | Clinical findings | Caries-free, unrestored #6 and #8 with healthy gingiva; adequate space for a #7 pontic | | Radiographic findings | No caries; normal periodontal and periapical tissues | | Plan | A single-retainer resin-bonded fixed dental prosthesis made of high-strength zirconia (3 mol% yttria, 3Y-TZP) has been fabricated to replace #7 | ### Question 9 - **Item ID:** dlosce-pro-8004 - **Patient:** dlosce-pt-pro-8003 - **Topic:** PRO-FIX - **Type:** multiple - **Prompt:** Which treatments of the zirconia retainer's bonding surface support a durable adhesive bond? A. Hydrofluoric acid etching, as for glass-ceramics B. Alumina airborne-particle abrasion at low pressure C. Silane coupling agent alone, without a silica layer D. Tribochemical silica coating E. An MDP-containing primer or resin cement F. Zinc phosphate cement without surface treatment - **Credit:** B = 0.5; E = 0.5 - **Neutral:** D - **Why:** For high-strength zirconia, airborne-particle abrasion with alumina (for example, 50 µm at low pressure) combined with an MDP-based primer or cement is the clinically validated standard with the strongest long-term clinical evidence. The phosphate group of MDP bonds chemically to the zirconia surface oxides. [^B468] - **Option notes:** A: incorrect — zirconia is a polycrystalline ceramic with no glassy phase, so the acid etching used for silica-based ceramics does not condition it. C: incorrect — silane bonds to silica, and zirconia has none unless a silica layer is first applied. D: neutral — tribochemical silica coating gives high bond strengths in laboratory studies, but its clinical validation is less robust than that of alumina abrasion. F: incorrect — a resin-bonded prosthesis depends on adhesion, and debonding is a leading cause of failure. - **Source:** [Lupu et al., Bonding strategies for zirconia fixed restorations, Biomimetics 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC12468000/), Introduction, sections 4.2 and 4.7, and Conclusions. [^B468] ## Patient dlosce-pt-opt-8001: White patch on the tongue | Patient Box | Details | | --- | --- | | Age / sex | 58-year-old man | | Chief complaint | "I noticed a white patch on the side of my tongue about 6 weeks ago." | | Medical history | Hypertension; has smoked a pack of cigarettes a day for 30 years; drinks 4 beers a day; HIV test negative 3 months ago | | Current medications | Hydrochlorothiazide 25 mg daily | | Vital signs | BP 138/86 mm Hg; pulse 80/min | | Dental history | Regular dental visits; no removable prosthesis | | Clinical findings | Flat, homogeneous white plaque, 1.5 × 1.0 cm, on the left lateral border of the tongue; it does not wipe off and is not indurated or ulcerated; unchanged in size and position over 6 weeks; adjacent teeth have smooth, intact restorations with no sharp edges; no cheek- or tongue-biting habit; buccal mucosae normal, with no white striae; dorsum of the tongue normal; no cervical lymphadenopathy | ### Question 10 - **Item ID:** dlosce-opt-8001 - **Patient:** dlosce-pt-opt-8001 - **Topic:** OPT-PATH - **Type:** single - **Prompt:** What is the most likely clinical diagnosis? A. Pseudomembranous candidiasis B. Oral hairy leukoplakia C. Geographic tongue D. Hairy tongue E. Oral lichen planus F. Leukoplakia G. Erythroplakia - **Answer:** F - **Why:** Leukoplakia is the clinical term for a white lesion of the oral mucosa that cannot be characterized as any other definable lesion. This plaque does not wipe off, has persisted for 6 weeks without a source of friction, and has none of the features of the other white lesions; tobacco and alcohol use are associated factors. [^B174] - **Option notes:** A: Candidal plaques wipe off and leave red erosions. B: Oral hairy leukoplakia is usually associated with immunodeficiency, especially HIV infection, and this patient tested negative. C: Geographic tongue shows red, smooth areas with white borders that migrate over weeks; this plaque has not moved. D: Hairy tongue affects the dorsum, where keratin accumulates on the filiform papillae, and the dorsum is normal. E: Oral lichen planus typically shows lacy white striae, especially on the buccal mucosae, which are normal. G: Erythroplakia is a red lesion. - **Source:** [MSD Manual Professional, Oral Growths](https://www.msdmanuals.com/professional/dental-disorders/symptoms-of-dental-and-oral-disorders/oral-growths), Etiology, oral candidiasis, oral potentially malignant disorders and leukoplakia. [MSD Manual Professional, Tongue Discoloration and Other Changes](https://www.msdmanuals.com/professional/dental-disorders/lip-and-tongue-disorders/tongue-discoloration-and-other-changes), geographic tongue, hairy tongue and hairy leukoplakia. [MSD Manual Professional, Lichen Planus](https://www.msdmanuals.com/professional/dermatologic-disorders/psoriasis-and-other-papulosquamous-disorders/lichen-planus), Symptoms and Signs. [^B174][^B506][^B507] ### Question 11 - **Item ID:** dlosce-opt-8002 - **Patient:** dlosce-pt-opt-8001 - **Topic:** OPT-PATH - **Type:** single - **Prompt:** What is the most appropriate next step? A. Reexamination at the next 6-month recall B. Toluidine blue staining to decide whether a biopsy is needed C. Brush cytology to decide whether a biopsy is needed D. Biopsy, or referral to a specialist for biopsy E. Autofluorescence examination to decide on biopsy F. A salivary test to decide whether a biopsy is needed - **Answer:** D - **Why:** The ADA guideline advises biopsy or referral when an oral mucosal abnormality has not resolved 10 to 14 days after the initial evaluation without a definitive diagnosis; for a mucosal abnormality, the pathway is biopsy or referral to a specialist to establish the diagnosis. Leukoplakia that does not resolve must be biopsied because it can progress to carcinoma. [^B172][^B174] - **Option notes:** A: The lesion has already persisted for 6 weeks; waiting delays the diagnosis. B: The guideline suggests against toluidine blue to determine the need for biopsy. C: The guideline suggests against cytology adjuncts to determine the need for biopsy; cytology is offered only when biopsy is not possible, advisable or indicated. E: The guideline suggests against light-based adjuncts, such as autofluorescence, to determine the need for biopsy. F: Salivary adjunct tests should be used only in research settings. - **Source:** [ADA, Oral Cancer Guideline (updated August 31, 2026)](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/2026/ada_oral_cancer_guideline.pdf), Good Practice Statement 3, Recommendations 1.1, 1.2, 2.1, 3.1 and 4.1, and clinical pathway B. [MSD Manual Professional, Oral Growths](https://www.msdmanuals.com/professional/dental-disorders/symptoms-of-dental-and-oral-disorders/oral-growths), Leukoplakia. [^B172][^B174] ## Patient dlosce-pt-opt-8002: Jaw that suddenly stopped clicking | Patient Box | Details | | --- | --- | | Age / sex | 31-year-old woman | | Chief complaint | "My jaw used to click. Ten days ago the clicking stopped, and now I can't open wide enough to bite into a sandwich." | | Medical history | Generalized anxiety disorder | | Current medications | Sertraline 50 mg daily | | Vital signs | BP 110/70 mm Hg; pulse 72/min | | Dental history | Clicking of the left temporomandibular joint on opening for about 2 years, with no locking until 10 days ago | | Clinical findings | Maximum unassisted opening 27 mm and maximum assisted opening 30 mm, both including 2 mm of vertical incisal overlap; the mandible deviates to the left on opening and does not correct; right lateral movement 4 mm and left lateral movement 9 mm; no clicking or crepitus on opening, closing or lateral movements; jaw movements and palpation of the masseter, temporalis and both joints do not produce familiar pain; the jaw closes normally | | Radiographic findings | Panoramic radiograph: normal condylar contours | ### Question 12 - **Item ID:** dlosce-opt-8003 - **Patient:** dlosce-pt-opt-8002 - **Topic:** OPT-PAIN - **Type:** single - **Prompt:** Which DC/TMD diagnosis best fits the left temporomandibular joint? A. Arthralgia B. Disc displacement with reduction C. Disc displacement with reduction with intermittent locking D. Disc displacement without reduction with limited opening E. Disc displacement without reduction without limited opening F. Degenerative joint disease G. Subluxation H. Myalgia - **Answer:** D - **Why:** A history of jaw locking or catching so that the mouth would not open fully, severe enough to interfere with eating, together with a maximum assisted opening below 40 mm including the vertical incisal overlap, meets the DC/TMD criteria for disc displacement without reduction with limited opening ("closed lock"). This diagnosis is valid on clinical criteria without imaging. [^B205] - **Option notes:** A: Arthralgia requires familiar pain provoked by jaw movement or joint palpation, and none was provoked. B: Disc displacement with reduction requires a click detected on examination; the clicking has stopped. C: Intermittent locking means the jaw locks with limited opening and then unlocks; this limitation has persisted for 10 days. E: Without limited opening, the assisted opening is 40 mm or more. F: Degenerative joint disease requires crepitus on examination. G: Subluxation is locking in the wide-open position so that the jaw cannot close. H: Myalgia requires familiar pain on palpation of the masseter or temporalis, and none was provoked. - **Source:** [Schiffman et al., DC/TMD, J Oral Facial Pain Headache 2014](https://pmc.ncbi.nlm.nih.gov/articles/PMC4478082/), Tables 4 and 6; Results, disc displacement recommendations; Discussion, history and examination protocol and changes to TMJ diagnoses. [^B205] ## Patient dlosce-pt-per-8001: Bleeding gums in a smoker with diabetes | Patient Box | Details | | --- | --- | | Age / sex | 44-year-old man | | Chief complaint | "My gums bleed when I brush." | | Medical history | Type 2 diabetes (HbA1c 6.6% last month); smokes 15 cigarettes a day | | Current medications | Metformin 500 mg twice daily | | Vital signs | BP 126/80 mm Hg; pulse 78/min | | Dental history | #3 was extracted 2 years ago because of periodontitis; third molars were removed at age 20; no previous radiographs are available | | Clinical findings | 27 teeth present; generalized bleeding on probing; interdental clinical attachment loss of 5–6 mm on 16 of 27 teeth (maximum 6 mm); probing depths up to 7 mm; Class II furcation involvement of #30; degree 1 mobility of #19 and #30 and no other mobility; no drifting, flaring, bite collapse or masticatory dysfunction; healed #3 site without a severe ridge defect; moderate plaque and calculus | | Radiographic findings | Horizontal bone loss on most teeth; at the worst site, #19 mesial, bone loss extends to the middle third of the root (about 50% of the root length) with a 4 mm vertical defect | ### Question 13 - **Item ID:** dlosce-per-8001 - **Patient:** dlosce-pt-per-8001 - **Topic:** PER-DX - **Type:** single - **Prompt:** Which stage and extent best describe this patient's periodontitis? A. Localized stage II B. Generalized stage II C. Localized stage III D. Generalized stage III E. Localized stage IV F. Generalized stage IV G. Stage III with a molar/incisor pattern - **Answer:** D - **Why:** Interdental attachment loss of 5 mm or more at the worst site, with bone loss reaching the middle third of the root, places this patient in stage III or IV. One tooth lost to periodontitis, probing depths of 6 mm or more, a 4 mm vertical defect and a Class II furcation are stage III features. No stage IV feature is present, and attachment loss on more than 30% of teeth makes the disease generalized. [^B120] - **Option notes:** A: Stage II is limited to 3–4 mm of interdental attachment loss with bone loss in the coronal third. B: Extent does not change the stage, and the severity exceeds stage II. C: Localized means fewer than 30% of teeth are involved; 16 of 27 teeth are. E: Stage IV requires loss of 5 or more teeth to periodontitis or a need for complex rehabilitation, such as masticatory dysfunction, mobility of degree 2 or more, bite collapse, drifting or flaring, or fewer than 20 remaining teeth. F: None of the stage IV features is present, whatever the extent. G: A molar/incisor pattern is confined to those teeth, and this disease is widespread. - **Source:** [AAP, Staging and Grading Periodontitis](https://sites.perio.org/wp-content/uploads/2019/08/Staging-and-Grading-Periodontitis.pdf), Periodontitis: Staging table. [^B120] ### Question 14 - **Item ID:** dlosce-per-8002 - **Patient:** dlosce-pt-per-8001 - **Topic:** PER-DX - **Type:** multiple - **Prompt:** Which findings support assigning grade C? A. Smoking 15 cigarettes a day B. HbA1c of 6.6% with type 2 diabetes C. Bone loss of about 50% at age 44 D. Probing depths up to 7 mm E. Class II furcation involvement of #30 F. Loss of #3 to periodontitis G. A 4 mm vertical bony defect - **Credit:** A = 0.5; C = 0.5 - **Neutral:** none - **Why:** Without earlier radiographs, percentage bone loss divided by age is the indirect evidence of progression: 50 ÷ 44 is about 1.1, above the grade C threshold of 1.0. Smoking 10 or more cigarettes a day is a grade C modifier. [^B120] - **Option notes:** B: incorrect — an HbA1c below 7.0% in a patient with diabetes is a grade B modifier. D: incorrect — probing depth is a stage complexity factor, not a grading criterion. E: incorrect — furcation involvement is a stage complexity factor. F: incorrect — tooth loss due to periodontitis modifies the stage. G: incorrect — vertical bone loss of 3 mm or more is a stage complexity factor. - **Source:** [AAP, Staging and Grading Periodontitis](https://sites.perio.org/wp-content/uploads/2019/08/Staging-and-Grading-Periodontitis.pdf), Periodontitis: Grading table. [^B120] ## Patient dlosce-pt-osu-8001: Extraction while taking warfarin | Patient Box | Details | | --- | --- | | Age / sex | 76-year-old man | | Chief complaint | "My lower right back tooth broke, and it hurts when I chew." | | Medical history | Nonvalvular atrial fibrillation; hypertension; no liver disease, kidney disease or bleeding disorder | | Current medications | Warfarin 5 mg daily; losartan 50 mg daily | | Vital signs | BP 136/82 mm Hg; pulse 74/min, irregular | | Clinical findings | #30 has a nonrestorable crown fracture with caries extending below the bone crest; adjacent teeth are sound | | Radiographic findings | #30: two separate, normal-appearing roots; no periapical radiolucency | | Laboratory values | INR 2.4 this morning; platelet count 240,000/µL | | Plan | Simple (nonsurgical) extraction of #30 | ### Question 15 - **Item ID:** dlosce-osu-8001 - **Patient:** dlosce-pt-osu-8001 - **Topic:** OSU-TP - **Type:** single - **Prompt:** How should warfarin be managed for the extraction of #30? A. Continue warfarin unchanged and use local hemostatic measures B. Stop warfarin 5 days before the extraction C. Replace warfarin with enoxaparin injections around the extraction D. Give oral vitamin K the evening before the extraction E. Postpone the extraction until the INR is below 1.5 - **Answer:** A - **Why:** Strong evidence supports not altering warfarin before dental procedures in most patients: bleeding is controlled with local measures, while stopping or reducing anticoagulation risks thromboembolism, stroke or myocardial infarction. An INR in the therapeutic range (3.0 or less) allows the regimen to continue, and uncomplicated extraction is considered safe at an INR of 3.5. Any change to the regimen would be made only with the physician. [^B263] - **Option notes:** B: Stopping warfarin exposes the patient to thromboembolism, and that risk outweighs bleeding that local measures can control. C: Bridging with another anticoagulant is an alteration of a regimen that the evidence says need not be altered. D: Vitamin K reverses warfarin, which is likewise an unneeded alteration that raises thromboembolic risk. E: An INR of 2.4 is within the range in which warfarin is continued; reaching an INR below 1.5 would require stopping or reversing anticoagulation. - **Source:** [ADA Oral Health Topics, Oral Anticoagulant and Antiplatelet Medications and Dental Procedures](https://www.ada.org/resources/ada-library/oral-health-topics/oral-anticoagulant-and-antiplatelet-medications-and-dental-procedures), Key Points; Evidence: Warfarin and Antiplatelet Agents; Summary. [^B263] ### Question 16 - **Item ID:** dlosce-osu-8002 - **Patient:** dlosce-pt-osu-8001 - **Topic:** OSU-EXT - **Type:** multiple - **Prompt:** Which measures are appropriate to control bleeding after the extraction of #30? A. Firm biting pressure on folded gauze for about an hour B. Oxidized cellulose or gelatin sponge in the socket C. Sutures to close the socket D. Tranexamic acid mouthwash E. Aspirin 650 mg every 4 hours for pain F. Removing the gauze every few minutes to check for bleeding G. Stopping warfarin for 3 days after the extraction - **Credit:** A = 0.25; B = 0.25; C = 0.25; D = 0.25 - **Neutral:** none - **Why:** In patients taking anticoagulants, bleeding is controlled with local measures: mechanical pressure, hemostatic agents such as a gelatin sponge or oxidized cellulose, suturing, and antifibrinolytics such as tranexamic acid. Continuous biting pressure on folded gauze for an hour, without checking the site before then, avoids disrupting clot formation. [^B263][^B258] - **Option notes:** E: incorrect — aspirin is an antiplatelet agent, and its adverse effects include prolonged bleeding. F: incorrect — the site should not be checked before 1 hour so that clot formation is not disrupted. G: incorrect — the anticoagulant regimen is not altered, because stopping it raises thromboembolic risk while bleeding can be managed locally. - **Source:** [ADA Oral Health Topics, Oral Anticoagulant and Antiplatelet Medications and Dental Procedures](https://www.ada.org/resources/ada-library/oral-health-topics/oral-anticoagulant-and-antiplatelet-medications-and-dental-procedures), Introduction and Summary. [MSD Manual Professional, Postextraction Problems](https://www.msdmanuals.com/professional/dental-disorders/dental-emergencies/postextraction-problems), Bleeding. [^B263][^B258] ## Patient dlosce-pt-end-8001: Pain on biting in a lower molar | Patient Box | Details | | --- | --- | | Age / sex | 47-year-old man | | Chief complaint | "My lower left back tooth hurts when I bite down." | | Medical history | Gastroesophageal reflux disease; no immunocompromising conditions | | Current medications | Omeprazole 20 mg daily | | Vital signs | BP 124/78 mm Hg; pulse 70/min; temperature 98.4 °F | | Dental history | Cold sensitivity in #19 several months ago that later stopped; pain on biting for 4 days | | Clinical findings | Deep distal caries on #19; no swelling, sinus tract or lymphadenopathy; probing depths 2–3 mm; no mobility | | Radiographic findings | Caries on #19 reaching the pulp; widened periodontal ligament space at the apex of the mesial root; no distinct periapical radiolucency | | Tooth | Percussion | Palpation | Cold | EPT | | --- | --- | --- | --- | --- | | 19 | + | - | No response | No response (80/80) | | 18 | - | - | + | 32/80 | | 20 | - | - | + | 26/80 | ### Question 17 - **Item ID:** dlosce-end-8001 - **Patient:** dlosce-pt-end-8001 - **Topic:** END-DX - **Type:** single - **Prompt:** What is the most likely apical diagnosis for #19? A. Normal apical tissues B. Symptomatic apical periodontitis C. Asymptomatic apical periodontitis D. Chronic apical abscess E. Acute apical abscess F. Condensing osteitis - **Answer:** B - **Why:** Well-localized pain on biting with tenderness to percussion is typical of symptomatic apical periodontitis, and a periapical radiolucency may or may not be visible. The pulp is necrotic: #19 does not respond to cold or to the electric pulp test. [^B102] - **Option notes:** A: Normal apical tissues are not sensitive to percussion. C: In asymptomatic apical periodontitis the tooth is not tender to percussion. D: A chronic apical abscess has a sinus tract, and none is present. E: An acute apical abscess produces swelling, and there is none. F: Condensing osteitis is a periapical radiopacity, and none is present. - **Source:** [Edwards et al., Br Dent J 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11991903/), Table 1, pulp and apical diagnoses. [^B102] ### Question 18 - **Item ID:** dlosce-end-8002 - **Patient:** dlosce-pt-end-8001 - **Topic:** END-TP - **Type:** single - **Prompt:** Definitive treatment can be provided at this visit. What is the most appropriate management of #19? A. Amoxicillin 500 mg three times a day and reevaluation in 1 week B. Indirect pulp cap and a definitive restoration C. Pulpectomy (begin root canal treatment) with no antibiotic D. Pulpectomy (begin root canal treatment) plus amoxicillin 500 mg three times a day E. Pulpotomy and a temporary restoration F. Occlusal adjustment and observation - **Answer:** C - **Why:** Pulp necrosis is managed by pulpectomy followed by root canal treatment, or by extraction. When definitive treatment is immediately available, the ADA guideline strongly recommends against adjunctive oral antibiotics for immunocompetent adults with pulp necrosis and symptomatic apical periodontitis. [^B102][^B113] - **Option notes:** A: For pulp necrosis with symptomatic apical periodontitis, the guideline advises dental treatment instead of an antibiotic. B: Indirect pulp capping is vital pulp therapy, and this pulp is necrotic. D: Adding an antibiotic to definitive treatment is recommended against. E: Pulpotomy is an option for a vital, irreversibly inflamed pulp, not a necrotic one. F: Occlusal adjustment does not remove the necrotic pulp that causes the apical inflammation. - **Source:** [Edwards et al., Br Dent J 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11991903/), Table 1, management options. [ADA chairside guide, antibiotic use when dental treatment is immediately available](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf), recommendations and clinical pathway. [ADA Antibiotics for Dental Pain and Swelling Guideline](https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research/antibiotics-for-dental-pain-and-swelling), Key Points. [^B102][^B113][^B508] ## Patient dlosce-pt-ort-8001: Early loss of a primary second molar | Patient Box | Details | | --- | --- | | Age / sex | 5-year-old boy | | Chief complaint | His mother says, "There's a bump on the gum by his lower left back tooth." | | Medical history | Mild intermittent asthma | | Current medications | Albuterol inhaler as needed | | Vital signs | Pulse 96/min; temperature 98.6 °F | | Dental history | #K is nonrestorable and will be extracted today | | Clinical findings | Parulis on the buccal gingiva at #K; #K crown destroyed by caries; #L sound; #19 not erupted; the child is cooperative | | Radiographic findings | Furcation radiolucency at #K; #19 unerupted below the alveolar crest, with a complete crown and early root formation; #20 developing normally | ### Question 19 - **Item ID:** dlosce-ort-8001 - **Patient:** dlosce-pt-ort-8001 - **Topic:** ORT-SPACE - **Type:** single - **Prompt:** Which space management is most appropriate after #K is extracted? A. No space maintainer; monitor the eruption of #19 B. Band and loop C. Crown and loop D. Lower lingual holding arch E. Distal shoe F. Removable (Hawley-type) space maintainer - **Answer:** E - **Why:** When a primary second molar is lost before the permanent first molar erupts, a distal shoe's intra-alveolar extension guides the unerupted molar into position. Band-and-loop and crown-and-loop appliances need an erupted abutment tooth for anchorage, so they cannot be used until #19 erupts. [^B242][^B509] - **Option notes:** A: Without space management, early loss of the primary second molar before the first permanent molar erupts can lead to mesial drift in up to 73% of cases. B: A band and loop needs an erupted abutment, and #19 has not erupted. C: A crown and loop has the same requirement. D: A lower lingual holding arch is a conventional fixed appliance that needs erupted abutments and cannot guide the unerupted #19. F: A removable appliance does not provide the intra-alveolar guidance of the unerupted molar that the distal shoe gives. - **Source:** [Marqués-Martínez et al., Children 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC12731900/), Introduction and section 4.2. [AAPD, Management of the Developing Dentition and Occlusion in Pediatric Dentistry](https://www.aapd.org/media/Policies_Guidelines/BP_DevelopDentition.pdf), Space maintenance. [^B242][^B509] ## Patient dlosce-pt-med-8001: Hives and wheezing after a rinse | Patient Box | Details | | --- | --- | | Age / sex | 61-year-old man | | Chief complaint | "I'm here for a cleaning." | | Medical history | Hypertension; hyperlipidemia | | Current medications | Metoprolol succinate 50 mg daily; atorvastatin 20 mg daily | | Vital signs | Before treatment: BP 128/78 mm Hg; pulse 66/min. Five minutes after a 0.12% chlorhexidine gluconate preprocedural rinse: BP 84/52 mm Hg; pulse 104/min; respirations 26/min; oxygen saturation 91% on room air | | Clinical findings | Within 5 minutes of the rinse: generalized hives, swelling of the lips, hoarse voice, wheezing and dizziness; he is conscious | ### Question 20 - **Item ID:** dlosce-med-8001 - **Patient:** dlosce-pt-med-8001 - **Topic:** MED-MGMT - **Type:** multiple - **Prompt:** Which are the most important immediate actions? A. Epinephrine 0.3 mg (1 mg/mL) IM in the anterolateral thigh B. Withholding epinephrine because he takes metoprolol C. Calling 911 for transport to an emergency department D. Nitroglycerin 0.4 mg sublingually E. Oral diphenhydramine 50 mg and observation, without epinephrine F. Epinephrine 0.3 mg (1 mg/mL) by rapid IV push G. Diphenhydramine as an adjunct after epinephrine H. Inhaled albuterol if wheezing persists after epinephrine I. Oral prednisone as the first medication - **Credit:** A = 0.5; C = 0.5 - **Neutral:** G; H - **Why:** Hives, lip swelling, wheezing and hypotension minutes after exposure meet the clinical criteria for anaphylaxis, and chlorhexidine is a recognized trigger. Epinephrine is given immediately: the usual adult dose is 0.3–0.5 mL of a 1 mg/mL (1:1,000) solution, with maximal absorption IM in the anterolateral thigh, repeated every 5–15 minutes. Emergency services are called at the same time as epinephrine is given, and because late-phase reactions can follow, a patient with anaphylaxis is observed in an acute care setting for several hours. [^B148][^B510] - **Option notes:** B: incorrect — epinephrine is the most effective therapy and is used regardless of beta-blocker therapy. D: incorrect — nitroglycerin is not part of anaphylaxis treatment, which begins with epinephrine. E: incorrect — epinephrine is the cornerstone of treatment and is given immediately, because symptoms can progress rapidly to airway occlusion or shock; an antihistamine does not replace it. F: incorrect — an IV bolus, used for hypotension or severe airway obstruction, is 0.05–0.1 mg of a 0.1 mg/mL solution given slowly over 1–2 minutes. G: neutral — an H1 antihistamine may be given after epinephrine but does not replace it. H: neutral — an inhaled beta-agonist helps bronchoconstriction that persists after epinephrine. I: incorrect — glucocorticoids have no proven role in treatment and do not replace epinephrine. - **Source:** [MSD Manual Professional, Anaphylaxis](https://www.msdmanuals.com/professional/immunology-allergic-disorders/allergic-autoimmune-and-other-hypersensitivity-disorders/anaphylaxis), Etiology, Diagnosis, Treatment (epinephrine and other treatments) and Key Points. [Cardona et al., World Allergy Organization anaphylaxis guidance 2020](https://pmc.ncbi.nlm.nih.gov/articles/PMC7607509/), Acute treatment of anaphylaxis. [^B148][^B510] ## Patient dlosce-pt-rxt-8001: Abscess with fever and a penicillin rash | Patient Box | Details | | --- | --- | | Age / sex | 39-year-old woman | | Chief complaint | "My upper left back tooth is throbbing, my gum is swollen, and I feel sick." | | Medical history | Hypothyroidism; no immunocompromising conditions | | Current medications | Levothyroxine 75 mcg daily | | Allergies | Amoxicillin: a flat, itchy rash on the trunk at age 8, without hives, swelling of the face or lips, or breathing difficulty | | Vital signs | BP 122/78 mm Hg; pulse 98/min; temperature 101.1 °F | | Dental history | Large restoration on #14, placed 5 years ago | | Clinical findings | #14 does not respond to cold and is tender to percussion; fluctuant swelling of the buccal vestibule next to #14; malaise; no facial swelling, trismus, or difficulty swallowing or breathing | | Radiographic findings | Periapical radiolucency at the mesiobuccal root of #14 | | Plan | Pulp necrosis and acute apical abscess with systemic involvement. Definitive treatment cannot be provided at this visit; the patient is referred for urgent treatment tomorrow, and an antibiotic is prescribed. | ### Prescription Task 1 - **Item ID:** dlosce-rxt-8001 - **Patient:** dlosce-pt-rxt-8001 - **Topic:** RXT-ABX - **Prompt:** Write the most appropriate antibiotic prescription for this patient. - **Medications:** A. Amoxicillin — 250 mg; 500 mg; 875 mg B. Azithromycin — 250 mg; 500 mg C. Cephalexin — 250 mg; 500 mg D. Clindamycin — 150 mg; 300 mg E. Metronidazole — 250 mg; 500 mg F. Penicillin V potassium — 250 mg; 500 mg - **Frequencies:** 1. Once a day 2. Twice a day 3. Three times a day 4. Four times a day 5. Every 4 to 6 hours as needed for pain - **Accept:** C | 500 mg | dispense 12-28 | take 1 | loading no | frequency 4 - **Accept:** C | 250 mg | dispense 24-56 | take 2 | loading no | frequency 4 - **Why:** For an immunocompetent adult with pulp necrosis and an acute apical abscess with systemic involvement, when definitive treatment is not immediately available, the ADA guideline advises an antibiotic and urgent referral. With a penicillin allergy but no history of anaphylaxis, angioedema or hives, the pathway selects cephalexin 500 mg four times a day for 3–7 days: 12 to 28 capsules of the 500 mg strength. Two 250 mg capsules per dose deliver the same 500 mg (24 to 56 capsules), so that regimen is also accepted. The FDA label lists 250 mg and 500 mg capsules and allows up to 4 g a day in two to four divided doses. The guideline adds reevaluation within 3 days and stopping the antibiotic 24 hours after symptoms resolve. [^B114][^B480] - **Errors:** A: Amoxicillin is a penicillin, and she reacted to it. B: Azithromycin is the choice when there is a history of anaphylaxis, angioedema or hives with a penicillin; she has none. D: Clindamycin is likewise reserved for that history. E: Metronidazole is added only when first-line treatment fails. F: Penicillin V potassium is a penicillin. - **Source:** [ADA chairside guide, antibiotic use when dental treatment is not immediately available](https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_tna.pdf), good practice statement, footnote 9 and clinical pathway, penicillin-allergy branch. [DailyMed, cephalexin capsules label](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=19307ff0-71de-477b-965d-ea243e5ede3a), sections 2.1 and 3. [^B114][^B480] [^B499]: American Dental Association. *Caries Risk Assessment Form (Age >6)* (2009, 2011). Contributing, general health and clinical conditions; scoring instructions (High Risk = one or more conditions in the High Risk column). [^B389]: American Dental Association. *Chairside guide: evidence-based clinical practice guideline on nonrestorative treatments for carious lesions, permanent teeth* (2018). Summary of recommendations and clinical pathway. [^B500]: American Dental Association. *Chairside guide: evidence-based clinical practice guideline on restorative treatments for caries lesions, permanent teeth* (2024). Carious tissue removal and direct restorative material recommendations, clinical pathway, footnotes 1–15 and good practice statement. [^B501]: U.S. Food and Drug Administration. *FDA issues recommendations for certain high-risk groups regarding mercury-containing dental amalgam*. September 24, 2020. List of high-risk groups and non-mercury alternatives. [^B272]: American Dental Association. *Pregnancy*, Oral Health Topics, last updated July 14, 2025. Key Points. [^B102]: Edwards D, Allison JR, Coulter J, Durham J, Beecroft EV. *Symptomatic irreversible pulpitis and other orofacial pain: overcoming challenges in diagnosis and management*. Br Dent J. 2025;238(7):517–526. Table 1, AAE-based pulp and apical diagnoses with management options. [^B455]: Rojas-Rueda S, Villalobos-Tinoco J, Conner C, Colvert S, Nurrohman H, Jurado CA. *Bonding protocols for lithium disilicate veneers: a narrative review and case study*. Biomimetics (Basel). 2025;10(3):188. Section 4.3, Ceramic Surface Treatment. [^B369]: van den Breemer CR, Gresnigt MM, Cune MS. *Cementation of glass-ceramic posterior restorations: a systematic review*. Biomed Res Int. 2015;2015:148954. Introduction and section 3.1.1. [^B468]: Lupu IC, Tatarciuc MS, Vitalariu AM, Bobu L, Diaconu DA, Vasluianu RI. *Bonding strategies for zirconia fixed restorations: a scoping review of surface treatments, cementation protocols, and long-term durability*. Biomimetics (Basel). 2025;10(9):632. Introduction, sections 4.2 and 4.7, and Conclusions. [^B502]: Wang HL, Avila-Ortiz G, Monje A, et al. *AO/AAP consensus on prevention and management of peri-implant diseases and conditions: summary report*. J Periodontol. 2025;96(6):519–541. Introduction; Focused Questions 3 and 4; Conclusions, bullet-point risk factor assessment and supportive peri-implant therapy. [^B503]: Kumar PS, Kan J, Galarraga-Vinueza ME, et al. *Risk for peri-implant diseases and defects: report of workgroup 1 of the joint AO/AAP consensus conference on prevention and management of peri-implant diseases*. Clin Adv Periodontics. 2025;15(2):93–102. Results, risk markers for peri-implantitis and risk of peri-implantitis. [^B504]: MSD Manual Professional Edition. *Peri-Implant Diseases and Conditions*, reviewed April 2024. Peri-implant mucositis and peri-implantitis. [^B505]: MSD Manual Professional Edition. *Dental Appliances*, reviewed August 2026. Denture problems. [^B175]: MSD Manual Professional Edition. *Stomatitis*, reviewed March 2026. Candidal stomatitis (denture-induced stomatitis). [^B174]: MSD Manual Professional Edition. *Oral Growths*, reviewed March 2026. Etiology (oral candidiasis, oral potentially malignant disorders, leukoplakia, erythroplakia) and Evaluation. [^B506]: MSD Manual Professional Edition. *Tongue Discoloration and Other Changes*, reviewed April 2026. Geographic tongue, hairy tongue and hairy leukoplakia. [^B507]: MSD Manual Professional Edition. *Lichen Planus*, reviewed November 2025. Symptoms and Signs, oral lichen planus. [^B172]: American Dental Association. *Oral Cancer Guideline: living evidence-informed guideline on the early detection of oral squamous cell carcinoma and potentially malignant disorders*, updated August 31, 2026. Good Practice Statements 1–4, Recommendations 1.1–4.2 and clinical pathway. [^B205]: Schiffman E, Ohrbach R, Truelove E, et al. *Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group*. J Oral Facial Pain Headache. 2014;28(1):6–27. Tables 4 and 6; Results, disc displacement recommendations; Discussion. [^B120]: American Academy of Periodontology. *Staging and Grading Periodontitis*, tables from Tonetti, Greenwell and Kornman, J Periodontol 2018;89(Suppl 1):S159–S172. Staging and grading tables. [^B263]: American Dental Association. *Oral Anticoagulant and Antiplatelet Medications and Dental Procedures*, Oral Health Topics, last updated September 28, 2022. Key Points, Introduction, Evidence: Warfarin and Antiplatelet Agents, and Summary. [^B258]: MSD Manual Professional Edition. *Postextraction Problems*, reviewed August 2026. Bleeding. [^B113]: American Dental Association. *Chairside guide: antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling when definitive, conservative dental treatment is immediately available* (2019). Recommendations and clinical pathway. [^B508]: American Dental Association. *Antibiotics for Dental Pain and Swelling Guideline (2019)*. Key Points. [^B242]: Marqués-Martínez L, Esteve-Ferre C, Galán-López L, et al. *Effectiveness of distal shoe space maintainers for first permanent molar eruption: a systematic review*. Children (Basel). 2025;12(12):1642. Introduction and section 4.2. [^B509]: American Academy of Pediatric Dentistry. *Management of the developing dentition and occlusion in pediatric dentistry*. The Reference Manual of Pediatric Dentistry. 2025:497–515 (latest revision 2024). Space maintenance. [^B148]: MSD Manual Professional Edition. *Anaphylaxis*, reviewed September 2026. Etiology, Diagnosis, Treatment (epinephrine and other treatments) and Key Points. [^B114]: American Dental Association. *Chairside guide: antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling when definitive, conservative dental treatment is not immediately available* (2019). Good practice statement, footnotes 5–9 and clinical pathway, penicillin-allergy branch. [^B480]: DailyMed. *Cephalexin capsules, USP (Teva Pharmaceuticals USA)*, label published October 15, 2026. Sections 2.1 (recommended adult dosage), 3 (dosage forms and strengths) and 5.1 (hypersensitivity). [^B510]: Cardona V, Ansotegui IJ, Ebisawa M, et al. *World Allergy Organization anaphylaxis guidance 2020*. World Allergy Organ J. 2020;13(10):100472. Acute treatment of anaphylaxis: call emergency services while injecting epinephrine IM into the anterolateral thigh. Last updated: 2026-11-08. ## Continue your DLOSCE study - [How to prepare for the DLOSCE](/guide/dlosce/how-to-pass) - [The full DLOSCE course](/products/dlosce)