Day 2 Practice

📚 Day 2–Style INBDE Mock Exam (Testlets)

Below is a mock “Day 2” exam with 4 testlets, each built around a realistic patient scenario. Questions are case-based, integrated, and reflect clinical reasoning, ethics, and biomedical knowledge.

Answers for ALL testlet questions are at the end.

🧩 TESTLET 1 – Middle-Aged Diabetic with Perio and Endo Issues

Patient:

  • 52-year-old male
  • Chief complaint: “My lower right tooth hurts when I chew.”
  • Medical history: Type 2 diabetes (HbA1c 9.5%), hypertension, BMI 32.
  • Medications: Metformin, Lisinopril, Atorvastatin.
  • Social: Smokes 1 pack/day.
  • Dental history: Irregular care, last visit 5 years ago.

Clinical findings:

  • Tooth #30: Large MOD amalgam, deep pocketing (7 mm) on distal root, furcation involvement Class II, mobility Grade I.
  • Percussion: tender.
  • Palpation: mild tenderness.
  • Thermal: cold – no response.
  • Radiograph: periapical radiolucency at mesial and distal roots, horizontal bone loss across mandibular posteriors.

Q1.1

Based on the findings for #30, the most likely pulpal diagnosis is:
A. Normal pulp
B. Symptomatic irreversible pulpitis
C. Necrotic pulp
D. Reversible pulpitis

Q1.2

The most likely periapical diagnosis for #30 is:
A. Normal apical tissues
B. Asymptomatic apical periodontitis
C. Acute apical abscess
D. Condensing osteitis

Q1.3

Which factor MOST negatively affects prognosis of periodontal therapy for this patient?
A. Hypertension
B. Smoking
C. Age
D. Atorvastatin use

Q1.4

What is the best initial step in managing his overall periodontal condition?
A. Immediate surgery
B. Scaling and root planing with oral hygiene instruction
C. Extraction of all posterior teeth
D. Local antibiotic alone

Q1.5

Regarding #30, which combined treatment plan offers the best chance to retain the tooth?
A. RCT + periodontal surgery + maintenance
B. Extraction and implant
C. RCT only
D. Perio surgery only

Q1.6

Given his diabetes (HbA1c 9.5%), what is the MOST appropriate management?
A. Proceed without discussion
B. Inform him of increased risk and encourage better glycemic control, but proceed with necessary dental care
C. Refuse all treatment until HbA1c < 7%
D. Provide only emergency care forever

Q1.7

Which systemic effect is most strongly associated with uncontrolled diabetes and periodontitis?
A. Reduced caries
B. Decreased risk of infection
C. Delayed wound healing
D. Increased salivary flow

Q1.8

If after RCT and periodontal surgery #30 remains mobile and painful, what is the next best step?
A. Splint permanently
B. Re-do RCT
C. Extract #30 and consider implant or prosthetic replacement
D. Continue to observe for 2 years

🧩 TESTLET 2 – Pediatric Trauma & Behavior

Patient:

  • 8-year-old girl
  • Chief complaint: “My front tooth hurts after I fell.”
  • Accident: Fell off bike 2 hours ago, struck maxillary incisors.
  • Medical: Healthy, no meds, no allergies.

Clinical findings:

  • Tooth #8: Crown fracture with pulp exposure; mobile (Class I).
  • Tooth #9: Tender to percussion, no visible fracture, not mobile.
  • Soft tissue: Laceration of upper lip.
  • Radiograph: Immature apices on #8 and #9, no root fractures seen.

Q2.1

What is the MOST appropriate treatment for #8 (immature tooth with recent pulp exposure)?
A. Extraction
B. Direct pulp cap with Ca(OH)₂ or MTA and restore
C. Partial pulpotomy (Cvek pulpotomy) and restore
D. Full pulpectomy and gutta-percha RCT

Q2.2

Tooth #9 shows no fracture, is tender to percussion, and responds normally to cold. Likely diagnosis?
A. Concussion
B. Subluxation
C. Intrusion
D. Avulsion

Q2.3

Which is the BEST radiographic follow-up schedule for traumatized anterior immature teeth?
A. None needed
B. 1 month, 3 months, 6 months, 1 year, then yearly
C. Only at 1 year
D. Every week for 6 months

Q2.4

If #8 later becomes non-vital with open apex, what is the preferred treatment?
A. Extraction
B. Traditional RCT
C. Apexification with Ca(OH)₂ or MTA or revascularization procedure
D. No treatment

Q2.5

The patient becomes anxious and refuses to sit in the chair. What is the MOST appropriate behavior management technique?
A. Physical restraint without explanation
B. Tell-show-do with positive reinforcement
C. Threaten to call parents in
D. Yell to gain control

Q2.6

Which complication is MOST important to monitor after trauma to immature anterior teeth?
A. Root caries
B. Root resorption and pulp necrosis
C. Gingival recession
D. Tooth discoloration only

Q2.7

If the child’s parents ask to “just pull the tooth” because it looks bad, what should you do ethically?
A. Extract as requested
B. Explain long-term consequences and recommend preserving the tooth when possible
C. Refuse to treat the child at all
D. Ignore their request

Q2.8

What is the most appropriate initial management of the lip laceration?
A. Ignore it
B. Irrigate, assess for foreign bodies, and suture if necessary
C. Only prescribe antibiotics
D. Wait to see if it heals

🧩 TESTLET 3 – Elderly Patient, Polypharmacy, Extraction & Ethics

Patient:

  • 74-year-old female
  • Chief complaint: “This upper tooth has been hurting for weeks; I want it out.”
  • Medical: Atrial fibrillation, hypertension, history of MI 3 years ago, osteoarthritis.
  • Medications: Warfarin, Metoprolol, Nitroglycerin (PRN), Aspirin 81 mg, Acetaminophen.
  • Allergies: Penicillin.

Dental findings:

  • Tooth #14: Large carious lesion to pulp, tenderness to percussion, furcation involvement, poor crown-root ratio.
  • Radiograph: Significant bone loss around #14, periapical radiolucency, poor prognosis for RCT and perio therapy combined.

Q3.1

Given the dental findings, the BEST treatment option for #14 is:
A. RCT and crown
B. Extraction
C. Watch and wait
D. Antibiotics only

Q3.2

Which lab test is MOST important to evaluate before extraction?
A. Hemoglobin
B. Platelet count
C. INR
D. WBC count

Q3.3

The patient’s INR is 2.5. What is the appropriate course of action?
A. Cancel extraction; INR is too high
B. Proceed with extraction using local hemostatic measures
C. Stop warfarin immediately for 1 week
D. Give aspirin before extraction

Q3.4

Which local hemostatic measure is MOST appropriate after extraction?
A. Nothing special
B. Pressure with gauze only
C. Local hemostatic agents (gelatin sponge, sutures) and pressure
D. Systemic heparin

Q3.5

She reports chest pain during the appointment, similar to her past angina episodes. FIRST action?
A. Continue working quickly
B. Stop treatment and give nitroglycerin if indicated
C. Give oxygen and continue extraction
D. Tell her it’s anxiety and ignore

Q3.6

Which of the following is MOST appropriate to prescribe for post-op pain in this patient?
A. High-dose ibuprofen and aspirin together
B. Acetaminophen
C. NSAIDs only
D. No analgesics

Q3.7

She asks you not to document her chest pain episode to avoid “medical drama.” Ethically, you should:
A. Respect her wishes and omit it
B. Document objectively despite her request
C. Document but alter the facts
D. Not chart anything that day

Q3.8

She later asks if you can write falsified documentation stating “no complications” for insurance. Best response?
A. Agree to help if she pays more
B. Politely refuse and explain legal/ethical duties
C. Ignore and proceed
D. Change the chart but hide it

🧩 TESTLET 4 – Implant & Sinus Case

Patient:

  • 45-year-old male
  • Chief complaint: “I want to replace my missing upper right molar with an implant.”
  • Medical: Healthy, no meds, non-smoker.
  • Dental: Missing tooth #3, extracted 2 years ago.

Radiographic / CBCT findings:

  • Residual ridge height in #3 area: 5 mm of bone between crest and sinus floor.
  • Adequate width of bone.
  • No sinus pathology.

Q4.1

What is the main concern when placing an implant in the area of #3?
A. Mandibular canal proximity
B. Maxillary sinus proximity
C. Mental foramen proximity
D. Lingual artery injury

Q4.2

With 5 mm of bone height, what is the MOST appropriate implant-related procedure?
A. Place standard length implant without augmentation
B. Sinus lift/augmentation (lateral or crestal) before or during implant placement
C. Do nothing and use a short implant only
D. Place a mini implant without grafting

Q4.3

Which imaging modality is BEST to evaluate sinus floor and bone dimensions for implant planning?
A. Periapical radiograph only
B. Panoramic radiograph only
C. CBCT
D. Bitewing radiographs

Q4.4

He asks if smoking “a little” would affect implant success. Assuming he starts smoking, what is true?
A. Smoking has no effect on implants
B. Smoking is associated with increased implant failure and peri-implantitis
C. Smoking improves osseointegration
D. Smoking only affects natural teeth, not implants

Q4.5

After implant placement, which hygiene instruction is MOST appropriate during early healing?
A. Aggressive brushing directly on the surgical site
B. Gentle brushing around area, avoiding direct trauma to incision
C. No oral hygiene at all for 2 weeks
D. Use sharp toothpicks around the implant

Q4.6

If the implant shows mobility at 4 months and radiolucency around it, this suggests:
A. Normal integration
B. Early implant failure
C. Peri-implantitis that will resolve on its own
D. Tight osseointegration

Q4.7

The MOST common long-term complication affecting implants is:
A. Caries
B. Peri-implant mucositis / peri-implantitis
C. Pulp necrosis
D. Root resorption

Q4.8

He later develops localized gingival inflammation around the implant with no bone loss. This is:
A. Peri-implant mucositis
B. Peri-implantitis
C. Gingival hyperplasia
D. Normal

Q4.9

Which factor is MOST under the patient’s control to maintain long-term implant health?
A. Bone density
B. Oral hygiene and maintenance visits
C. Implant surface design
D. Surgical torque

Q4.10

If you accidentally perforate the sinus membrane during a lateral window sinus lift, the MOST appropriate action is:
A. Abort grafting immediately and close
B. Repair with a resorbable membrane and proceed if stable
C. Ignore and continue without repair
D. Place no graft and still place implant

📝 Testlet Answer Key

Testlet 1 (Q1.1–1.8)
1.1 C – Necrotic pulp (no cold response + periapical lesion)
1.2 B – Asymptomatic apical periodontitis (radiolucency, mild tenderness)
1.3 B – Smoking (strong modifier of perio prognosis)
1.4 B – SRP + OHI as initial therapy
1.5 A – RCT + perio surgery + maintenance gives best retention chance
1.6 B – Proceed with care but address poor control; can’t indefinitely refuse needed tx
1.7 C – Delayed wound healing strongly associated with uncontrolled diabetes
1.8 C – Extraction and consider implant/prosthesis when combined tx fails

Testlet 2 (Q2.1–2.8)
2.1 C – Partial pulpotomy (Cvek) is best for recent traumatic pulp exposure in immature tooth
2.2 A – Concussion = tenderness, normal mobility and vitality
2.3 B – Standard trauma follow-up intervals: 1, 3, 6, 12 months, etc.
2.4 C – Apexification or revascularization for non-vital open apex
2.5 B – Tell-show-do + positive reinforcement is first-line behavior mgmt
2.6 B – Root resorption and necrosis are key complications
2.7 B – Ethically explain and recommend tooth preservation when reasonable
2.8 B – Irrigate, check for foreign bodies (e.g., tooth fragments), and suture if needed

Testlet 3 (Q3.1–3.8)
3.1 B – Extraction; tooth has poor restorative and periodontal prognosis
3.2 C – INR is critical for warfarin management
3.3 B – INR 2.5 is within therapeutic range; proceed with local hemostasis
3.4 C – Use local hemostatic agents + sutures + pressure
3.5 B – Stop treatment and give nitroglycerin as indicated for suspected angina
3.6 B – Acetaminophen safest with anticoagulants, avoids increased bleed risk
3.7 B – You must chart accurately; events like chest pain are legally relevant
3.8 B – Refuse to falsify records; explain legal and ethical obligations

Testlet 4 (Q4.1–4.10)
4.1 B – Maxillary sinus proximity is the main anatomical concern in #3 area
4.2 B – Sinus lift/augmentation needed with only 5 mm bone height
4.3 C – CBCT best for 3D bone/sinus evaluation
4.4 B – Smoking clearly linked to higher implant failure/peri-implantitis
4.5 B – Gentle hygiene around the site, avoiding direct trauma
4.6 B – Mobility + radiolucency at 4 months = early implant failure
4.7 B – Peri-implant mucositis/implantitis is primary long-term complication
4.8 A – Inflammation without bone loss = peri-implant mucositis
4.9 B – Patient’s oral hygiene and regular maintenance visits
4.10 B – Repair sinus membrane with a resorbable membrane and proceed if stable

🧩 TESTLET 1 – Diabetic Patient with Endo + Perio Problems

Q1.1 – Necrotic pulp

No cold response + radiolucency + percussion tenderness strongly indicates pulpal necrosis.

Q1.2 – Asymptomatic apical periodontitis

Chronic periapical lesion with mild symptoms corresponds to AAP, not acute abscess.

Q1.3 – Smoking

Smoking is one of the strongest negative prognostic factors in periodontal treatment outcomes.

Q1.4 – SRP + OHI

Initial periodontal therapy always begins with nonsurgical debridement and hygiene instruction.

Q1.5 – RCT + perio surgery + maintenance

Combined endo-perio lesions require treating both components; RCT alone will not resolve bone loss.

Q1.6 – Proceed but address glycemic control

Diabetes does not absolutely contraindicate treatment; the dentist must inform the patient and manage risk.

Q1.7 – Delayed wound healing

Hyperglycemia impairs neutrophil function, collagen formation, and overall healing capacity.

Q1.8 – Extract and replace

If both endodontic and periodontal therapy fail, long-term prognosis is poor; extraction is indicated.

🧩 TESTLET 2 – Pediatric Trauma Case

Q2.1 – Partial pulpotomy (Cvek)

Best treatment for traumatic pulp exposures in immature permanent teeth—maintains vitality for continued root development.

Q2.2 – Concussion

Tenderness without mobility or displacement and normal vitality = concussion injury.

Q2.3 – Trauma follow-up schedule

Standard schedule: 1, 3, 6, 12 months → monitor vitality and root development.

Q2.4 – Apexification / revascularization

For necrotic immature teeth, apexification or revascularization is preferred over traditional RCT to allow continued root formation.

Q2.5 – Tell-show-do + positive reinforcement

Basic, evidence-based pediatric behavior management technique appropriate for an anxious child.

Q2.6 – Root resorption + necrosis

Traumatized immature teeth are especially prone to inflammatory resorption and pulpal necrosis.

Q2.7 – Explain and preserve when possible

Ethically, dentists must recommend the scientifically superior option—premature extraction harms long-term esthetics and occlusion.

Q2.8 – Irrigate + assess + suture

Soft tissue trauma should be cleaned, assessed for embedded debris (such as tooth fragments), and sutured if indicated.

🧩 TESTLET 3 – Elderly Patient, Polypharmacy, Extraction & Ethics

Q3.1 – Extraction

Extensive bone loss + poor crown-root ratio + furcation + poor endo-perio prognosis → extraction is indicated.

Q3.2 – INR

Warfarin therapy requires INR evaluation to estimate bleeding risk.

Q3.3 – Proceed with INR 2.5

INR 2–3 is therapeutic range; extraction is safe with local hemostatic measures—do NOT stop warfarin without physician guidance.

Q3.4 – Local hemostatic agents

Sutures, gelatin sponge, and firm pressure help control bleeding in anticoagulated patients.

Q3.5 – Stop treatment and give nitroglycerin

Chest pain in cardiac patient = potential angina → stop work immediately, administer nitro if indicated.

Q3.6 – Acetaminophen

NSAIDs and aspirin increase bleeding and interact with warfarin; acetaminophen is safest for this patient.

Q3.7 – Document objectively

Legally and ethically you must document all events, including medical emergencies; charting cannot be altered or suppressed.

Q3.8 – Refuse to falsify documentation

Honesty, legality, and professional integrity require refusing the request and explaining why.

🧩 TESTLET 4 – Implant & Sinus Case

Q4.1 – Maxillary sinus proximity

Posterior maxilla implants risk penetrating or violating the sinus floor; this is the primary anatomical concern.

Q4.2 – Sinus lift

With only 5 mm of bone height, a sinus augmentation is needed to place a standard-length implant safely.

Q4.3 – CBCT

CBCT gives precise 3D evaluation of sinus floor, bone height, and width—essential for implant planning.

Q4.4 – Smoking → increased implant failure

Smoking significantly increases the likelihood of failed osseointegration and peri-implantitis.

Q4.5 – Gentle brushing, avoid trauma

Immediate postoperative hygiene requires gentle cleaning to prevent infection while protecting the surgical site.

Q4.6 – Early implant failure

Mobility + radiolucency at 4 months = failed osseointegration; implants should not be mobile.

Q4.7 – Peri-implantitis

Most common long-term complication—an inflammatory process causing bone loss around implants.

Q4.8 – Peri-implant mucositis

Inflammation without bone loss is mucositis, the reversible precursor to peri-implantitis.

Q4.9 – Oral hygiene + maintenance visits

Patient-controlled factors (plaque control, compliance) are the strongest determinants of long-term implant success.

Q4.10 – Repair membrane + proceed

Small sinus membrane perforations can be repaired with a resorbable membrane; if stable, grafting may continue predictably.