Chapter 8 Ice-Cold Water: Rubber dam
isolation required; useful across all
tooth types.
General Concepts
Advantages:
Pulp Status Assessment: One of the most
challenging diagnostic tasks in clinical High specificity to individual teeth
dentistry. (due to gas phase of
refrigerants/CO₂).
Types of Diagnostic Validity:
Cold tests are more reliable than
Sensitivity: Ability of a test to heat tests.
identify diseased teeth.
Colder = More effective in
Specificity: Ability of a test to evaluating tooth innervation.
identify healthy teeth.
Predictive Value: Ability of a test to
accurately predict the diagnosis. Heat Test
Pulpal Response vs. Vitality Testing: Less commonly used due to:
Pulpal Response: Reactivity to Greater patient sensitivity to cold.
stimulation (e.g.,
thermal/electrical). Practical difficulties in application.
Vitality Testing: Assesses blood Application Methods:
supply (circulation) to the pulp.
Heated Gutta-Percha:
Softens at 65°C; heated to
Cold Tests ~150°C.
Mechanism: Causes contraction of dentinal Risk of pulp damage with
fluid, activating Aδ nerve fibers via excessive/prolonged heating.
hydrodynamic forces, producing a sharp,
brief pain. Limited use on posterior
teeth due to access issues.
Application Methods:
Stimulates Aδ first, then C
Ice in Gauze / Ice Pencil: Simple, fibers, which can cause
inexpensive. lingering pain.
Ethyl Chloride: −41°C, sprayed onto Hot Water: Syringe delivery under
cotton pledget. rubber dam.
Dichlorodifluoromethane (ddM): Frictional Heat: Generated via
−50°C, refrigerant spray. rubber prophylaxis cup.
Dry Ice (Frozen CO₂): −78.5°C, System B Device:
effective on metal restorations, but
may damage porcelain (pitting in 5 Allows pre-set temperatures.
seconds).
Requires Vaseline coating to Goal: Achieve summation effect by
avoid stickiness. stimulating high nerve-density
areas.
Diagnostic Insight:
Best Sites:
If pain is relieved by cold but
triggered by heat → likely nonvital Anterior Teeth: Incisal third
pulp. near pulp horn.
Posterior Teeth: Mid-third
region or mesiobuccal cusp
Electric Pulp Test (EPT) in molars.
Mechanism: Applies electric current to Response Threshold:
elicit Aδ nerve response.
Lowest in incisors, higher in
Response: Due to ionic shift, local premolars, highest in
depolarization, and action potential molars.
generation.
Device:
Electric
Heat
Battery-operated with probe. Feature Cold Test Pulp Test
Test
(EPT)
Pulsating stimulus begins low, Biphasic Ionic shift
Hydrodyna
increased until response. Aδ then →
Mechan mic
C fiber depolarizat
ism stimulation
Readout is not a measure of pulp stimulati ion of Aδ
of Aδ fibers
health, only nerve function. on fibers
Possible
Stimulation Modes: lingerin
Pain Tingling or
Sharp, g if C
Charact warm
Bipolar: More accurate; current brief fibers
er sensation
confined to coronal pulp. activate
d
Monopolar: More common in Most Bipolar
practice. Effectiv Heated mode
Frozen CO₂
e gutta- placement
(−78.5°C)
Application Requirements: Materia percha on pulp
l horn areas
Tooth Isolation: Essential to avoid Effective
Limited Can be
conduction to adjacent teeth. Use on (especially
(access, affected by
Restore CO₂ with
risk of metallic
Dry enamel, interproximal d Teeth metal
damage) contacts
plastic strips, rubber dam. crowns)
Risk of Interpretat
Conducting Medium: Ensures Risk of pulp ion
maximum current transfer. Limitati porcelain damage, depends
ons pitting hard to on
Study results vary on (CO₂) control multiple
medium importance. heat factors
Best Buccal Buccal Incisal
Electrode Placement: Sites surface or third
Electric Less signal contamination from periodontal
Heat
Feature Cold Test Pulp Test flow compared to Laser Doppler Flowmetry
Test
(EPT) (LDF).
occlusal
(anterior), Successfully used in animal and human
for (isolated with
MB cusp
Testing tooth) Vaseline studies.
(molars)
coating
Vitality
vs. Sensibility Sensibili Sensibility
Sensibil only ty only only Laser Doppler Flowmetry (LDF)
ity
Originally used for microvasculature in
retina, skin, renal cortex, etc.
Advanced Bullet-Point Notes: Assessment of Pulp
Vascularity Uses helium-neon light (632.8 nm) or other
wavelengths (600–700 nm).
Pulp Vitality Testing assesses pulpal blood
flow, not nerve response. Light is scattered by moving RBCs,
producing frequency shifts (Doppler
Devices evaluate circulatory changes in principle).
pulp and are primarily experimental or
used in research settings. Backscattered light detected → signal
reflects red cell flux (number × velocity).
Characteristics:
Crown Surface Temperature
Objective, noninvasive, accurate.
Based on the hypothesis that vital teeth are
warmer and rewarm faster than nonvital Effective for young traumatized
teeth. teeth with large pulps unresponsive
to sensitivity tests.
Time/temperature curves between vital
and nonvital teeth provide diagnostic Limitations: High cost, complexity,
value. limited clinical use.
Techniques: Can only be used on natural tooth
structure (not restorations).
Cholesteric liquid crystals: Change
color with temperature, some
success.
Pulse Oximetry
Infrared thermographic camera:
Slower rewarming seen in nonvital Measures oxygen saturation in tissue via
teeth. red (640 nm) and infrared light.
Detects changes in light absorption by
oxygenated/deoxygenated hemoglobin.
Transmitted Light May be used on natural tooth structure,
Photoplethysmography (TLP) not on restorations.
Noninvasive method to measure pulpal Limitations:
blood flow.
Not yet sensitive/specific enough for Doppler: Needs rigid observation point.
reliable pulp vitality diagnosis.
Pulse oximetry & TLP: Affected by
Requires rubber dam isolation and extrapulpal blood flow.
opaque gingival block (e.g., tinfoil).
These methods remain limited in everyday
endodontic practice.
Xenon-133 Radioisotopes
Uses radiolabeled xenon-133 to assess Princi Advant
Method Limitations
blood supply differences between vital and ple ages
nonvital teeth. Vital
Crown Indirect
teeth Simple,
Surface measure;
Effective in research but: rewar noninva
Temperat environment
m sive
ure al influence
Expensive, faster
Detect Noninva
Restricted in human use, s sive,
Still
pulpal less
experimental
Requires special licenses TLP blood periodo
; signal
flow ntal
interference
Not suitable for routine clinical via contami
application. light nation
Dopple
r shift Accurat
Expensive,
from e,
LDF complex, not
Dual Wavelength red cell objectiv
widely used
Spectrophotometry movem e
ent
Uses two light wavelengths (760 and 850 Noninva
Light
nm) to detect oxygen saturation and blood sive, Low
absorp
volume in pulp. Pulse familiar specificity/se
tion by
Oximetry in nsitivity;
hemogl
Preliminary tests show potential for: medicin limited use
obin
e
Diagnosing pulp necrosis, Radioa
Xenon- ctive Effectiv Radiation
Possibly determining inflammatory 133 tracer e in risk, high
status. Radioisot shows researc cost, not for
opes blood h clinical use
Advantages: flow
Measu
Portable
Noninvasive, objective, portable. res
,
oxygen Still under
objectiv
Spectroph ation investigation
e,
otometry with ; clinical use
detects
Limitations Across Vascular dual limited
inflamm
Tests wavele
ation
ngths
Rigid pulp chamber makes blood flow
difficult to assess without removing hard
tissue.