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The validity of pulp testing A clinical study

Article in The Journal of the American Dental Association · August 2009

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Rebeca Weisleder Martin Trope

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R E S E A R C H

The validity of pulp testing

A clinical study
Rebeca Weisleder, DDS; Shizuko Yamauchi, DDS, MS; Daniel J. Caplan, DDS, PhD;
Martin Trope, DMD; Fabricio B. Teixeira, DDS, MS, PhD

he most important part

T ABSTRACT D
of a treatment plan is A A
J
diagnosis, and in endo- ✷ ✷
®
dontics the accurate

N
CON
determination of pulpal Objective. In this article, the authors report on

IO
an in vivo study in which they assessed the validity

T
vitality or nonvitality is essential.

A
N

I
The pulpal tissue cannot be directly of two commonly used cold pulp tests (carbon dioxide U U
C

A ING ED 3
[CO2] and 1,1,1,2-tetrafluoroethane) and an electrical RT
inspected before endodontic treat- ICLE
ment commences because the pulp pulp tester (EPT) in determining pulp vitality by using
is enclosed within a calcified bar- direct inspection of the pulp as the reference standard.
rier. Therefore, indirect methods Methods. One hundred fifty patients undergoing endodontic therapy
must be used to determine pulpal at the University of North Carolina School of Dentistry (Chapel Hill)
vitality. The most commonly used undergraduate clinic participated in this study. Before routine endodontic
tests are thermal and electrical treatment, the authors classified participants by means of EPT, CO2 and
tests that stimulate the pulp by tetrafluoroethane as having either vital or necrotic pulps. Students
means of either dentin liquid move- recorded true pulpal status (vital/necrotic) by observing blood within the
ment as temperature changes or an pulp chamber after an access cavity was made. The authors calculated
electrical current conducted through the sensitivity, specificity and positive and negative predictive values of
the tooth, providing electrical stim- each test and the test combinations to describe their validity and clinical
ulation of the pulpal nerves.1 usefulness.
According to Seltzer and col- Results. Ninety-seven percent of teeth responding positively to all
leagues,2 pulpal inflammation may three tests contained vital pulps, whereas 90 percent of the teeth that
develop after the application of irri- failed to respond to any of the tests contained necrotic pulps. Ten percent
tants to the teeth. If the irritant is of the teeth not responding to any of the tests contained vital pulps. For
mild, this inflammation may all other combinations of test results, 54 percent of teeth contained vital
resolve; when the action of the irri- pulps, and 46 percent contained necrotic pulps.
tant continues for a long time, the Conclusions. These findings support the use of either of the cold tests
response may become chronic. and the EPT for diagnosis of pulpal status.
Eventually, pulp repair or necrosis Clinical Implications. Cold test and EPT used in conjunction
may occur. The inflammation also resulted in a more accurate method for diagnostic testing.
may be partial or total, depending Key Words. Endodontic therapy; diagnostic tests; dental pulp test.
on the amount of tissue involved. JADA 2009;140(8):1013-1017.

Dr. Weisleder is a postdoctoral trainee, Department of Endodontics, School of Dentistry, University of North Carolina, 1180 Old Dental Building, Campus Box
7450, Chapel Hill, N.C. 27599, e-mail “rebeca_weisleder@[Link]”. Address reprint requests to Dr. Weisleder.
Dr. Yamauchi is a clinical assistant professor, Department of Endodontics, School of Dentistry, University of North Carolina, Chapel Hill.
Dr. Caplan is a professor and the chair, Department of Preventive and Community Dentistry, University of Iowa, Iowa City.
Dr. Trope is an endodontist in private practice in Philadelphia, and adjunct professor, Department of Endodontics, School of Dentistry, University of North
Carolina, Chapel Hill.
Dr. Teixeira is an associate professor, Department of Endodontics, Dental School, University of Texas Health Science Center at San Antonio.

JADA, Vol. 140 [Link] August 2009 1013

Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
R E S E A R C H

Although the perfect diagnostic test results They reported the specificities of the tests and
always would be positive in the presence of dis- mentioned sensitivity but did not calculate pre-
ease and always would be negative when no dis- dictive values.4 Peters and colleagues3 reported
ease is present, results of previous studies have only the sensitivity of various testing agents.
shown a high proportion of false-positive and They found that teeth not responding to cold or
false-negative responses associated with electrical EPT had a high probability of being necrotic or
and thermal pulp tests.3 pulpally diseased. Petersson and colleagues1 eval-
Many thermal testing agents have been uated the ability of hot (heated gutta-percha),
studied and found to be effective for diagnosis. cold (ethyl chloride) and electrical tests to register
Fuss and colleagues4 determined that an elec- pulpal vitality; they then calculated the sensi-
trical pulp tester (EPT), carbon dioxide (CO2) and tivity, the specificity and the negative and posi-
dichlorodifluoromethane (DDM) were efficient for tive predictive values by using direct inspection of
this purpose. Dummer and colleagues5 stated the the pulpal tissue as a reference standard. Their
importance of the correct diagnosis for rendering results indicated an 89 percent probability that a
the correct treatment. Correct diagnosis trans- nonsensitive reaction with the cold test repre-
lates to having the correct tooth identified so that sented a necrotic pulp, versus 48 percent with the
the clinician can offer the best treatment and, heat test and 88 percent with the electrical test.
therefore, address the patient’s chief complaint.1 Conversely, the probability that a sensitive reac-
The validity of a diagnostic test is best tion represented a vital pulp was 90 percent with
described by its sensitivity and specificity, the cold test, 83 percent with the heat test and 84
whereas its clinical usefulness in a given popula- percent with the electrical test.
tion is best described by its positive and negative We conducted an in vivo study to assess the
predictive values6: validity of two commonly used cold pulp tests
dSensitivity is the proportion of cases identified (CO2 and 1,1,1,2-tetrafluoroethane) and an EPT in
correctly by means of the diagnostic test. For determining pulpal vitality, and we used direct
example, if EPT had a sensitivity of 80 percent, it inspection of the pulp as the reference standard.
would mean that 80 percent of vital teeth
responded to EPT. MATERIALS AND METHODS
dSpecificity is the proportion of noncases identi- Before we began the study, the protocol was
fied correctly by means of the diagnostic test. For approved by the institutional review board at the
example, if EPT had a specificity of 70 percent, it University of North Carolina at Chapel Hill. We
would mean that 70 percent of necrotic teeth did selected 150 patients undergoing endodontic
not respond to EPT. treatment in the undergraduate clinic at the Uni-
dPositive predictive value is the proportion of versity of North Carolina School of Dentistry.
positive test results that are cases. For example, Inclusion criteria were age of 18 to 76 years and
if EPT had a positive predictive value of 90 per- an American Society of Anesthesiologists medical
cent, it would mean that 90 percent of teeth that status of I or II (status I patients are considered
responded to EPT were vital, so the remaining 10 to be healthy; status II patients have mild to
percent would be false-positive results (that is, moderate systemic disease or are healthy [status
they would be teeth that responded to EPT I] but demonstrate a more extreme anxiety about
despite being necrotic). and fear of dental care).6,7 Exclusion criteria were
dNegative predictive value is the proportion of teeth with full-surface crowns, large restorations,
negative test results that are noncases. For recent trauma, regressed pulpal chambers or cal-
example, if EPT had a negative predictive value cified root canals. We also excluded from the
of 60 percent, it would mean that 60 percent of study patients experiencing moderate or severe
teeth that did not respond to EPT were necrotic, pain.
so the remaining 40 percent would be false- After participants signed the consent forms
negative results (that is, they would be teeth that and agreed to undergo endodontic therapy, they
did not respond to EPT despite being vital).
Few studies related to validity of pulpal vitality ABBREVIATION KEY. CO2: Carbon dioxide.
test devices are found in the literature. DDM: Dichlorodifluoromethane. EPT: Electrical pulp
Fuss and colleagues4 studied the accuracy of tester. NPV: Negative predictive value. PPV: Positive
EPT, CO2 snow, DDM, ethyl chloride and ice. predictive value. SN: Sensitivity. SP: Specificity.

1014 JADA, Vol. 140 [Link] August 2009

Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
 R E S E A R C H

underwent diagnostic tests administered by a the reference standard evaluation.1 We conducted

member (R.W. or S.Y.) of the Department of all analyses by using statistical software (SAS
Endodontics who was blinded to the patients’ 9.0, SAS, Cary, N.C.).
chief complaints, recent dental history and radi-
ographic findings. Each participant was instruct- RESULTS
ed to raise his or her hand the moment he or she The figure describes the validity and clinical use-
felt a cold or tingling sensation during the fulness of the three diagnostic tests as used indi-
testing. vidually in this sample. Sensitivity for the Endo-
First, the researcher sprayed a no. 2 cotton Ice test, the CO2 test and EPT were 76 percent, 76
pellet with a refrigerant (1,1,1,2-tetrafluoro- percent and 92 percent, respectively (for example,
ethane) (Hygenic Endo-Ice Green [Endo-Ice], 92 percent of vital teeth responded to EPT).
Coltène Whaledent, Cuyahoga Falls, Ohio) and Specificities for the three tests, respectively, were
placed it on the crown of the tooth for approxi- 92 percent, 89 percent and 75 percent (for
mately 15 seconds or until the participant raised example, 75 percent of necrotic teeth did not
a hand to indicate that he or she felt a cold sensa- respond to EPT). Positive predictive values for
tion (a protocol similar to one used in other the three tests, respectively, were 93 percent, 90
studies3,4,8-10). Second, the researcher, using Odon- percent and 83 percent (for example, 83 percent of
totest plastic cylinders (Miltex, York, Pa.), pre- teeth that responded to EPT were vital). Negative
pared CO2 sticks and applied them to the crowns predictive values for the three tests, respectively,
for either 15 seconds or until participants raised were 74 percent, 73 percent and 87 percent (for
their hands. Third, the researcher isolated the example, 87 percent of teeth that did not respond
teeth by using cotton rolls, dried them and then to EPT were necrotic).
used an EPT (Analytic Technology Pulp Tester, The table shows that two diagnostic test combi-
Analytic Technology, Redmond, Wash.) to apply nations composed 75 percent of the eight possible
an electrical impulse to the tooth. Teeth test combinations. A total of 42 percent of teeth
responding at a level lower than 80 were consid- responded positively to all three tests; of these
ered vital.3 The researcher allowed at least two teeth, 97 percent were vital. A total of 33 percent
minutes to elapse after each pulp test because of teeth responded negatively to all three tests,
investigators conducting in vitro studies have and of these teeth, 90 percent were necrotic. Of
reported that after application of thermal stimuli, the remaining teeth (25 percent), 54 percent were
the pulpal border of the dentin returns to its vital and 46 percent were necrotic.
normal temperature within this period.3,4
After conclusion of the tests, the students DISCUSSION
administering treatment anesthetized the teeth We designed this clinical study to assess the
by using 2 percent lidocaine with 1:100,000 epi- validity of three commonly used pulpal vitality
nephrine administered as either inferior alveolar tests. Our findings suggest that, when used to
nerve block or local infiltration. The students iso- evaluate pulpal vitality before accessing a tooth,
lated the teeth by using a rubber dam and EPT in combination with CO2 or Endo-Ice spray
accessed the chamber, then recorded whether or provides more accurate results than does any of
not the pulp was hemorrhagic. If the students the tests alone. However, EPT helps determine
observed vital tissue in the apexes of teeth with pulpal vitality or necrosis rather than the histo-
necrotic tissue in the chamber, they considered logic condition of the pulp, but even necrotic pulp
the teeth partially necrosed (and thus necrotic) in occasionally evinces painful responses. Further-
the analysis. We used 10 endodontically treated more, no clinical sign or symptom designates the
teeth as negative controls. histopathologic status of the pulp with certainty.
Each participant contributed one tooth to the Our findings suggest that both CO2 and EPT
analysis. We calculated the sensitivity, specificity or Endo-Ice and EPT testing should be used to
and positive and negative predictive values of obtain more accurate results for evaluation of
each test and compared each possible variation of pulpal vitality. For example, only 83 percent of
results for the tests in combination to describe teeth responding positively to EPT alone were
each test’s validity and clinical usefulness; clin- vital, compared with 97 percent when both EPT
ical pulpal status (that is, presence or absence of and the cold tests were used. In our study, there
hemorrhage at access of the pulpal chamber) was was no significant difference in the accuracy of

JADA, Vol. 140 [Link] August 2009 1015

Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
R E S E A R C H

percent of the teeth testing

100 positive with Endo-Ice
truly were vital, whereas
90 only 83 percent of the teeth
80 testing positive to EPT
truly were vital. Our clin-
70 ical findings were in agree-
60 ment with those of Fuss
EPT and colleagues,4 who
50 showed that DDM, CO2
Endo-lce
40 and EPT tests were
CO2 equally valid when used to
30
test the pulpal vitality in
20 adult patients.
Our study improves on
10
previously published
0 studies because our sample
SN SP PPV NPV
size of 150 patients is
larger than that of other
Figure. Characteristics of individual diagnostic tests (N = 150). EPT: Electrical pulp tester. Endo-Ice:
Hygenic Endo-Ice Green, Coltène Whaledent, Cuyahoga Falls, Ohio. CO2: Carbon dioxide. SN: Sensi-
studies; in addition, the
tivity (the percentage of all vital teeth that tested positive on the diagnostic test). SP: Specificity (the pulpal diagnostic tests
percentage of all necrotic teeth that tested negative on the diagnostic test). PPV: Positive predictive used in this study are used
value (the percentage of all teeth testing positive on the diagnostic test that were vital). NPV: Nega-
tive predictive value (the percentage of all teeth testing negative on the diagnostic test that were commonly in clinical prac-
necrotic). tice. For example, in our
study, we used Endo-Ice
TABLE and CO2 to test the
Combined predictive ability of diagnostic tests response to cold. Ethyl
chloride and ice have been
(N = 150). reported to be less reliable
TESTING METHOD NO. (%) OF TEETH PULP STATUS (%) by Jones9 and by Rickoff
Vital Necrotic and colleagues.11 Augs-
EPT,* Endo-Ice, †
burger and Peters12 and
CO ‡
2 Peters and colleagues3 con-
Positive 63 (42) 97 3 cluded that CO2 snow pro-
Negative 50 (33) 10 90
duced a statistically
§
greater intrapulpal tem-
Other Combinations 37 (25) 54 46
perature decrease than did
either ice or skin refrig-
* EPT: Electrical pulp tester.
† Endo-Ice: Hygenic Endo-Ice Green, Coltène Whaledent, Cuyahoga Falls, Ohio. erant. Georgopoulou and
‡ CO : Carbon dioxide.
2 Kerani13 showed that there
§ The authors calculated the sensitivity, specificity and positive and negative predictive values of each test
and compared each possible variation of results for the tests combined to describe each test’s validity and is no significant difference
clinical usefulness. Clinical pulpal status (that is, presence or absence of hemorrhage at access of the pulpal in the reliability of any of
chamber) was the reference standard evaluation.
the methods used.
Petersson and colleagues1
either Endo-Ice or CO2 for diagnostic testing. evaluated the ability of heat (heated gutta-
Sensitivity and specificity describe the accu- percha), cold (ethyl chloride) and EPT to register
racy of the diagnostic tests when the true status pulpal vitality and then calculated the sensitivity,
of the teeth is known (that is, they aid in as- the specificity and the negative and positive pre-
sessing the validity of the diagnostic test). Posi- dictive values by using direct inspection of the
tive predictive value and negative predictive pulpal tissue as a reference standard. Their
value describe the accuracy of the diagnostic test results indicated an 89 percent probability that a
when the true status of the teeth is unknown (as nonsensitive reaction with the cold test repre-
would be the situation clinically). For example, 93 sented a necrotic pulp, versus 48 percent with the

1016 JADA, Vol. 140 [Link] August 2009

Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
 R E S E A R C H

heat test and 88 percent with electrical tests. 1. Petersson K, Söderström C, Kiani-Anaraki M, Lévy G. Evaluation
of the ability of thermal and electrical tests to register pulp vitality.
Conversely, the probability that a sensitive reac- Endod Dent Traumatol 1999;15(3):127-131.
tion represented a vital pulp was 90 percent with 2. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflamma-
tion: correlations between diagnostic data and actual histologic find-
the cold test, 83 percent with the heat test and 84 ings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:969-977.
percent with the electrical test. These results 3. Peters DD, Baumgartner JC, Lorton L. Adult pulpal diagnosis,
part I: evaluation of the positive and negative responses to cold and
agree with our clinical findings because we used electrical pulp tests. J Endod 1994;20(10):506-511.
pulpally diseased teeth in the evaluation of the 4. Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S. Assessment
of reliability of electrical and thermal pulp testing agents. J Endod
pulp-testing agents and, therefore, considered 1986;12(7):301-305.
the conditions to resemble the clinical situation 5. Dummer PM, Hicks R, Huws D. Clinical signs and symptoms in
pulp disease. Int Endod J 1980;13(1):27-35.
in which vitality testing is a necessary diagnostic 6. Weinstein MC, Fineberg HV. The use of diagnostic information to
tool. In 10 percent of teeth that tested negative revise probabilities. In: Weinstein MC, Fineberg HV, eds. Clinical Deci-
sion Analysis. Philadelphia: Saunders; 1980:75-130.
on all three tests, pulps were not necrotic; thus, 7. Malamed SF. The ASA physical status classification. In: Malamed
even though vitality tests are accurate tests of SF. Handbook of Local Anesthesia. 4th ed. St. Louis: Mosby; 1997:
37-48.
pulpal status, we still need more precise 8. Pantera EA, Anderson RW, Pantera CT. Reliability of electric pulp
methods. testing after pulpal testing with dichlorodifluoromethane. J Endod
1993;19(6):312-314.
9. Jones DM. Effect of the type carrier used on the results of
CONCLUSION dichlorodifluoromethane application to teeth. J Endod 1999;25(10):
692-694.
The results of this study suggest that the use of 10. Myers JW. Demonstration of a possible source of error with an
EPT in combination with one of the commonly electric pulp tester. J Endod 1998;24(3):199-200.
11. Rickoff B, Trowbridge H, Fuss Z, Bender IB. Effects of thermal
used cold pulp tests will provide more accurate vitality tests on human dental pulp. J Endod 1988;14(10):482-485.
results for the evaluation of pulpal vitality than 12. Augsburger RA, Peters DD. In vitro effects of ice, skin refrigerant,
and CO2 snow on intrapulpal temperature. J Endod 1981;7(3):110-116.
will using one of these methods alone. ■ 13. Georgopoulou M, Kerani M. The reliability of electrical and
thermal pulp tests: a clinical study [in Greek]. Stomatologia (Athenai)
Disclosure. None of the authors reported any disclosures. 1989;46(5):317-326.

JADA, Vol. 140 [Link] August 2009 1017

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