PULP VITALITY TESTS

DR SHABEEL PN
 INTRODUCTION

• Pulp Vitality Testing :

Assessment of the pulp's blood supply.

• Pulp Sensibility Testing :

Assessment of the pulp's sensory response.

• Pulp Sensitivity :
Condition of the pulp being very responsive to a stimulus.
 USES -

1. Prior to operative procedures-

• Particularly where pulp health may be in question
• Pulpal degeneration can occur without accompanying symptoms.
Hence, absence of symptoms or radiographic changes alone may not
be taken as conclusive evidence of pulp vitality
2. Diagnosis of pain-
• Pain localization
• Differentiating from other conditions - myofascial pain dysfunction
syndrome and referred pain

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3. Investigation of radiolucent areas
• Pathologic - periodontal lesions, cysts, fibrous lesions, congenital
abnormalities, neoplastic processes
• Normal – mental foramen, incisive canal
4. Assessment of anaesthesia
• Grossman advocated the use of pulp testers to assess whether a
tooth is completely anaesthetized following LA
5. Assessment of teeth which have been pulp capped or
required deep restoration
• Clinically assessed on the basis of reported symptoms; clinical
palpation; and percussion, radiographs, and pulp testing

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 CLASSIFICATION -

(a) Neural sensibility tests (b) Pulp vascularity tests

(i) Thermal tests (i) Pulse oximetry
• Heat testing (ii) Laser Doppler flowmetry
• Cold testing (iii) Recent technologies
(ii) Electric pulp test (EPT) • Dual-wavelength
(iii) Anesthetic test spectrophotometry
(iv) Test cavity • Thermography
• Crown surface temperature
• Transmitted light
photoplethysmography

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PULPAL INNERVATION -
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 A. NEURAL SENSIBILITY TESTS

These are the tests that indirectly tell us about the vitality status
of the pulp. They work on the principle of stimulating the neural
fibers present in the pulp.
(i) Thermal tests
• Heat testing
• Cold testing
(ii) Electric pulp test (EPT)
(iii) Anesthetic test
(iv) Test cavity

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 I. THERMAL TESTS

Heat test
Materials used are as follows:
• Electrical heat carrier
• Hot gutta-percha stick (>65.5°C)
• Others
– Hot water under rubber dam isolation
– Hot burnisher Electric Heat Carrier

– Dry rubber polishing wheel

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 Area to be tested is isolated and dried

Suitable lubricant (Vaseline) is applied

Heat directed to the exposed surface of tooth (occlusobuccal 3rd)

Patient’s response is noted

If there is no response, move the hot substance

• to the central portion of the crown (or)
• closer to the tooth cervical margin

Remove heat source immediately after response

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 HEAT TEST

Diagnostic Accuracy = 71%

Jafarzadeh, H. and Abbott, P.V., 2010. Review of pulp sensibility tests. Part I: general information and thermal tests. International endodontic journal, 43(9), pp.738-762.
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practice. Wolters Kluwer India Pvt Ltd;
Disadvantages :
• Difficult to use on posterior teeth because of limited access.
• Excessive heating may result in pulp damage .

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 COLD TEST

Materials used are as follows:

• Endo-Ice → 1,1,1,2-tetrafluoroethane*
• CO2 snow
• Pencil of ice
• Ice cold water under rubber dam isolation
• Ethyl chloride

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 COLD TEST

Diagnostic
Accuracy =
86%

Jafarzadeh, H. and Abbott, P.V., 2010. Review of pulp sensibility tests. Part I: general information and thermal tests. International endodontic journal, 43(9), pp.738-762.
Chandra S. Grossman’s endodontic
practice. Wolters Kluwer India Pvt
 EPT
ANAESTHETIC TEST

T E S T C AV IT Y

Diagnostic Accuracy = 81%

Jafarzadeh, H. and Abbott, P.V., 2010. Review of pulp sensibility tests. Part ΙΙ: electric pulp tests and test cavities. International Endodontic Journal, 43(11), pp.945-958.
 II. ELECTRIC PULP TEST (EPT)

Objective – To Stimulate a pulpal response by subjecting the tooth

to an increasing degree of electric current.

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 Method -

Area to be tested is isolated and dried

Apply an electrolyte (prophy paste or toothpaste) on the tooth electrode

Place tooth electrode against the dried enamel of crown surface

• Anterior teeth → junction of incisal & middle 3rd
• Posterior teeth → mid-third of the mesiobuccal cusp of molars and
buccal cusp of premolars

Completion of the circuit

By Placing Lip Clip (or) Instructing the patient to rest a finger on the metal
sheath of the pulp tester

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 Turn Rheostat slowly  To introduce minimal current into the tooth.
and increase current gradually.

Ask the patient to indicate when sensation occurs by using such words
as “tingling” or “warmth.”

Record the result according to the numeric scale on the pulp tester.

Repeat the foregoing for each tooth to be tested

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 CLINICAL INTERPRETATIONS OF
PULPAL RESPONSE TO EPT

• Normal response: A positive response is a response that occurs at the same

neural excitation threshold as the control tooth.
• Negative response: This denotes a nonvital tooth, which fails to respond even
when the tester is set to the highest electrical excitation value.
• Early response: This denotes a diseased state of pulp as the tooth responds to
a threshold which is less than that of the control tooth.
• Delayed response: This also denotes a diseased state of the pulp wherein the
tooth responds at a significantly higher electrical excitation level compared to
the control tooth.

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 False-positive response False-negative response
• When gangrenous necrotic pulp is • Extensive calcification in pulp tissue
present in a root canal or dentin
• Multirooted teeth in which the pulp is • In a tooth with increased reparative
partially necrotic, with some nerve dentin and a diminishing pulp cavity
fibers still vital in one or more of the • Fibrotic pulp
root canals
• Teeth with extensive restorations and a
pulp-protecting base
• Recently traumatized teeth
• Recently erupted teeth with incomplete
root formation
• Sedative medication
• Unusually high pain threshold
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 III. ANESTHETIC TEST

This test is restricted to patients who are in pain at the time of the test when the
usual tests have failed to identify the tooth.
Objective - to anesthetize one tooth at a time until the pain disappears and is
localized to a specific tooth

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Method –
• Using either infiltration or the intraligament injection, inject the
most posterior tooth in the area suspected of being the cause of
pain.
• If pain persists when the tooth has been fully anesthetized,
anesthetize the next tooth mesial to it and continue to do so until
the pain disappears.
• If the pain cannot be identified as from maxillary or mandibular
origin, an inferior alveolar block (mandibular block) is given.

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 IV. TEST CAVITY

Performed when other methods of diagnosis have

failed.

Method –
• The test cavity is made by drilling through the
enamel–dentin junction of an unanesthetized
tooth.
• The drilling should be done at high speed and
with a water coolant.

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• Sensitivity or pain felt by the patient is an indication of pulp
vitality; no endodontic treatment is indicated. Sedative cement is
then placed in the cavity, and the search for the source of pain
continues.
• If no pain is felt, cavity preparation may be continued until the
pulp chamber is reached. If the pulp is completely necrotic,
endodontic treatment can be continued painlessly in many cases
without anesthesia.

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Chandra S. Grossman’s endodontic practice. Wolters Kluwer India Pvt Ltd; 2014.
Chandra S. Grossman’s endodontic practice. Wolters Kluwer India Pvt Ltd; 2014.
 L I M I TAT I O N S O F S E N S I T I V I T Y T E S T I N G

• False positive results • Effect of dental development

• False negative results • Multi-rooted teeth
• Correlation with pulp • Effect of drugs
histopathology • Age influence
• Objectivity • Effect of periodontal disease
• Reproducibility • Effect of trauma
• Unpleasant sensation

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
 L I M I TAT I O N S O F S E N S I T I V I T Y T E S T I N G

• False positive results

• Anxious or young patients who may report a premature response
because they are anticipating an unpleasant sensation
• Necrotic breakdown products in one part of a root canal system can
conduct electric currents to viable nerve tissue in adjacent areas
• Contact with metal restorations may also result in conduction of the
current to the periodontium

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
 L I M I TAT I O N S O F S E N S I T I V I T Y T E S T I N G

• False negative results

• Incomplete root development, which have a higher threshold to testing, and
require a stronger stimulation than normal to elicit a response. This is
because teeth erupt and become functional before completion of neural
development. In these conditions, cold testing has proved more reliable than
EPT.
• Following injury, traumatized teeth may not respond to thermal or ept due
to nerve rupture. The pulps of these teeth, however, may still be vital as
their blood vessels remain intact or have revascularized. Therefore,
traumatized teeth should always be carefully monitored at periodic intervals
as their nerve fibres may subsequently regain function.

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
 L I M I TAT I O N S O F S E N S I T I V I T Y T E S T I N G

• False negative results

• Orthodontic tooth movement has been shown to produce changes in tissue
respiration with a resultant reduction in blood flow and possible anoxia of
aδ nerves. Cave and co-workers reported that orthodontic force increased
the response threshold to EPT. The effect was almost instantaneous and
could persist for up to 9 months following treatment
• Patients with psychotic disorders may not respond to pulp testing. It has
also been reported that individuals who are under the influence of sedative
drugs/alcohol may either not respond or respond to stronger stimulation
due to their increased threshold to nerve excitation

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
 L I M I TAT I O N S O F S E N S I T I V I T Y T E S T I N G

• Correlation with pulp histopathology

• The traditional view that a lowered threshold to pulp testing
indicates hyperaemia or acute pulpitis, and an increased threshold
indicates chronic pulpitis is questionable.
• It must also be remembered that there is a poor correlation
between symptoms and pulpal histopathology.

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
 L I M I TAT I O N S O F S E N S I T I V I T Y T E S T I N G

• Objectivity
• Ingle and Beveridge have proposed that patient responses to pulp
testing procedures may be considered objective. Many other authors,
however, would disagree due to the subjective nature of pain.
• The use of a ‘control’ tooth, on the opposite side of the mouth, has
been proposed to remove subjectivity from an individual’s response.

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
• Reproducibility
Reiss and Furedi, and Schaffer have reported that patients respond differently to
pulp tests on different days, and at different hours of the same day.

• Unpleasant sensation
• All methods of pulp testing require patient to indicate when they feel a sensation.
• Naylor and Greenwood consider that pain is the only sensation elicited by
stimulation of pulpal nerves.
• This has been challenged by Mumford and Newton, who reported that patients
use many words other than ‘pain’ to describe the sensation.
• In most cases, however, the resultant sensation is perceived as ‘unpleasant’, and
this is a considerable disadvantage when full-mouth vitality testing is performed .

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
• Effect of dental development
• Many authors have observed that erupting teeth show an increased threshold
value to EPT or may give no response, even though their vitality is assured.
• Sensitivity to electrical stimulation - related to the stage of root development.
• Primary teeth with resorbed roots may also have an increased threshold, but
this has been disputed in children over 10 years of age. (Kaletsky and Furedi)
• Thermal testing with carbon dioxide snow gave consistently positive
responses irrespective of the stage of dental development. (Fulling and
Andreasen)
• Nonetheless, the stage of dental development should certainly be taken into
consideration when undertaking pulp testing in young patients, especially
following trauma to immature permanent incisors.

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
• Multi-rooted teeth
Grossman has noted the problems of assessing the vitality of multi-rooted
teeth when the pulp is vital in one root canal but not in another.
• Effect of drugs
Several authors have stated that sedative, tranquillizing, or analgesic
medications increase the threshold of stimulation of pulpal nerves in some
patients
• Age influence
With the exception of newly erupted teeth, the age of the patient (10–73
years) appears to have no effect on thresholds to pulp testing; even in view
of histological findings of pulpal nerve calcification and decreased neural
density with increased age

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
• Effect of periodontal disease
No increase in pulpal stimulus threshold has been reported in the
presence of periodontal disease or bone loss
• Effect of trauma
• Immediately following traumatic injury, teeth often fail to respond to
conventional pulp testing methods.
• This temporary loss of response is caused by injury, inflammation,
pressure, or tension to apical nerve fibres. It may take 8 weeks, or
longer, before a normal pulpal response can be elicited

Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: a review. International journal of paediatric dentistry. 2009 Jan;19(1):3-15.
PULP VITALITY TESTS
 B. PULP VASCULARITY TESTS

The vitality of the pulp is determined according to the health of the vascular
supply, not of the sensory fibres.
These include –
(i) Pulse oximetry
(ii) Laser Doppler flowmetry
(iii) Recent technologies
• Dual-wavelength spectrophotometry
• Thermography
• Crown surface temperature
• Transmitted light photoplethysmography
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practice. Wolters Kluwer India Pvt Ltd;
 IMPORTANCE OF ASSESSING THE BLOOD SUPPLY
AS AN INDICATION FOR PULP VITALITY

• As Cohen and Burns reported, response to current clinical tests indicates only
that sensory fibres are vital. However, 10%–16% of the results of these tests are
false.
• The nervous system, which is highly resistant to inflammation, may remain
reactive, even though all surrounding tissues have degenerated; therefore testing
the sensory supply may give a positive response when the pulp is damaged (i.e.,
a false-positive result). This test may also leave the patient with an unpleasant
sensation.
• A false-negative result (i.e., no response) may be obtained in cases of calcific
metamorphosis, recently traumatized teeth and incomplete root formation.

Abd-Elmeguid A, Yu DC. Dental pulp neurophysiology: part 2. Current diagnostic tests to assess pulp vitality. Journal of the Canadian Dental Association. 2009 Mar
1;75(2).
 I. PULSE OXIMETRY

Pulse oximetry is a noninvasive method to measure the

oxygen saturation levels during the administration of
anesthesia or other medications with the help of a
finger, ear, or foot probes.
Armamentarium –
1. Monitor  digital display of oxygen saturation values

2. Sensor  designed to anatomically conform to the

area where oxygen saturation values have to be assessed
e.g., ear POS, finger sensor, and toe sensor

3. Photodetector  detect amount of absorbed lights

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Chandra S. Grossman’s endodontic practice. Wolters Kluwer India Pvt
Ltd; 2014.
 Principle -
• The pulse oximeter sensor (POS) consists of two light-emitting diodes, one to
transmit red light (660 nm) and the other to transmit infrared light (940 nm), and
a photodetector on the opposite side of the vascular bed.
• The light-emitting diode transmits red and infrared light through a vascular bed
such as the finger or ear.
• Oxygenated hemoglobin and deoxygenated hemoglobin absorb different
amounts of red and infrared light.
• The pulsatile change in the blood volume causes periodic changes in the amount
of red and infrared light absorbed by the vascular bed before reaching the
photodetector.
• The relationship between the pulsatile change in the absorption of red light and
the pulsatile change in the absorption of infrared light is analyzed by the pulse
oximeter to determine the saturation of arterial blood.
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 II. LASER DOPPLER FLOWMETRY

Laser Doppler flowmetry (LDF) is a noninvasive method of assessing and

accurately measuring the rate of blood flow in a tissue.

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 Principle:
• The laser light is transmitted through a fiberoptic source and placed onto
the tooth surface.
• The light enters the tooth and gets absorbed by the red blood cells which
leads to a shift in the frequency of the scattered light. This occurs due to
the Doppler principle.
• This shift in frequency does not occur in light that is absorbed by
stationary objects.
• The proportion of Doppler shifted light is detected with the help of a
photodetector.
• This principle is used to ascertain the presence of blood movement within
the pulp space. LDF can thus be potentially used to differentiate a healthy,
traumatized tooth with reduced blood supply from a nonvital tooth
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Disadvantages –
• Technique sensitive and requires splints to hold the sensors in place.
• Care has to be taken that there are no other motion artifacts during the
procedure.
• Currently, this device has been developed for medical use and is expensive.
It is probably for this reason that LDF has not been used as routine special
investigation in dental practice

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 DUAL-WAVELENGTH
SPECTROPHOTOMETRY

• Determines level of oxygen saturation in pulpal blood supply with a dual-

wavelength light source (760 and 850 nm). The blood volume or concentration
channel (760 or 850 nm) is arranged to respond linearly to the increase in light
absorption.
• The instrument may be useful for determining pulp necrosis and the
inflammatory status of the pulp.
• Nissan and others did an in vitro study to determine the feasibility of using
DWS to identify teeth with pulp chambers that are either empty, filled with
fixed pulp tissue or filled with oxygenated blood. Their findings indicated that
continuous-wave spectrophotometry may be a useful method for testing pulp.

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 CROWN SURFACE TEMPERATURE

• Temperature measurement, as a diagnostic procedure for human teeth, has

been described with the use of thermistors, infrared thermography, and liquid
crystals.
• Cholesteric liquid crystals, which exhibit different colours when heated, have
been previously employed to determine pulp vitality.
Principle :
Teeth with an intact pulp blood supply (vital/ healthy pulp tissue) had a warmer
tooth surface temperature compared with teeth that had no blood supply.

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Surface temperature of teeth has also been measured over a period of time
at 15 s intervals using an electric thermometer attached to a surface probe,
placed in contact with the tooth.
Inference – Following cooling,
• only vital teeth showed a subsequent rise in surface temperature
• nonvital teeth were slower to rewarm than vital teeth
Disadvantages –
• Rubber dam isolation necessary, after which a period of acclimatization
is needed prior to imaging
• The technique is complex and requires the subjects to be at rest for 1 h
prior to testing

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 CONCLUSION

• An accurate assessment of tooth vitality is of paramount importance

in clinical practice.
• Although sensitivity testing is the de facto standard employed by the
majority of clinicians, it has acknowledged limitations.
• Rapid advances in knowledge and applied technology relating to
pulpal blood flow may lead the way for a more objective, accurate,
and predictable means of pulp vitality assessment.