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ENDO (Lond Engl) 2008;2(4):259266
259 REVIEW
The dental pulp is a fascinating tissue that has always attracted much attention within the dental pro-
fession. Pulp vitality testing is crucial in monitoring the state of health of the dental pulp and although
pulp vitality is just a function of vascular health, traditional methods are based on stimulation of nerve
fibres and demonstrate further limitations. However, these methods have been unreliable in children
over the years. The recent advances in pulp vitality testing mean that the pulpal blood flow is as-
sessed, which is a true indicator of pulp vitality. This review article discusses the advantages and lim-
itations of traditional and recent methods of pulp vitality testing in children. This article is clinically rel-
evant, as understanding of both the usefulness and limitations of pulp testing methods is essential for
effective endodontic diagnosis and treatment planning in children.
Gurusamy Kayalvizhi
Reliability of pulp-vitality testing in children:
a review
children, neural stimulation, pulpal blood flow, reliability, vitality Key words
Gurusamy Kayalvizhi
MDS, Senior Lecturer,
Department of Pedodontics
and Preventive Dentistry,
M.R Ambedkar Dental
College, Cooke Town,
Bangalore, 560005,
India
Email:
drfisheyes22@gmail.com
Introduction
This is a big issue about a little tissue and this little
tissue has created a big issue (Samuel and Bender)
1
.
The dental pulp is a richly vascularised and innervated
connective tissue of mesodermal origin contained in
the central cavity of a tooth, delineated by dentine and
having formative, nutritive, sensory and protective
functions. The traditional methods of pulp vitality
testing rely on neural stimulation, that is, they depend
on innervation and stimulation of nerve fibres,
whereas recent methods record the pulpal blood flow
to assess pulp vitality.
The traditional methods of pulp vitality testing are
based on neural stimulation. Assessing the vitality of
the pulp is a crucial diagnostic procedure in distinguish-
ing or identifying disease
2
, which helps in effective
treatment planning. This review discusses the reliability
of traditional and recent advances of pulp vitality
testing in children, highlighting the advantages and
limitations, with the focus mainly on newer strategies.
Traditional pulp vitality testing
methods
Electric pulp testing
Marshall and Woodward
3
were the first to use elec-
tricity to demonstrate the vitality of teeth in 1896.
Electric pulp testers
3
(EPT) act directly by stimulating
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sensory nerves in the pulp, thereby measuring the
excitation threshold of these nerves (Fig 1).
EPT is useful when used on elderly patients whose
teeth have a large amount of secondary dentine. EPT
can also be used in post-trauma assessment of tooth
vitality, provided the tester can be applied to the
enamel. EPT requires tooth isolation and may also elicit
a response from the periodontium. However, it cannot
be used on crowned teeth without cavity preparation
or in patients with full orthodontic bands or metallic
restorations, because of the risk of conduction.
Thermal pulp testing
The first reference to the use of the thermal pulp test
was made by Jack in 1899
4
. These tests involved either
heating or removing heat from a tooth. Early work
suggested that the response of pulpal nerve fibres is
due to the direct effect of the temperature change on
the pulp, causing expansion and pressure or vaso-
motor changes, and, thus, stimulating nerves. This
was carried out using heated gutta-percha, ethyl
chloride, dichlorotetrafluoroethane and dry ice (Fig 2).
Thermal pulp testing can be used on metallic restor-
ations and orthodontically banded teeth. It requires no
tooth isolation and allows full-mouth vitality testing to
be carried out quickly, therefore apparently over-
coming the problems related to electrical testing. Dis-
advantages of the thermal pulp test are that it may not
be effective for teeth of elderly patients with a large
amount of secondary dentine and is not reliable for
teeth restored with full-coverage acrylic or porcelain
crowns. Thermal pulp testing is also not as useful as the
EPT in post-trauma assessments, as thermal tests are
unable to determine threshold values.
Mechanical tests
Mechanical stimulation tests
3
include percussion tests
as well as probing or blowing air onto exposed dentine
and test cavities.
Probing or drying dentine causes pain by initiating
hydrodynamic pressure changes in dentinal tubules,
thus affecting the pulp. Therefore, these methods are
limited in their usefulness
6
. Test cavities are advocated
as the last option when other attempts of sensitivity
testing are uncertain. A sensation of pain when the
dentine is pierced is an indication of the presence of
vital pulp. However, this does not imply the absence
of pulpal inflammation and is indicated for use in teeth
that are covered with full crowns or if hard tissue has
formed in the pulpal space. However, these tests do
not provide reliable results in anxious patients.
Percussion only tests if there is significant peri-
odontal inflammation in the apical region. However,
lack of a positive percussion test does not give assur-
ance that inflammation has not extended into the
periapical tissues. Thus, mechanical tests are not very
reliable in assessing pulp vitality.
Palpation test
Palpation tests are performed by exerting digital press-
ure on the tooth and on the soft tissue adjacent to the
root apices. If soreness of mucosa is felt over the root
ENDO (Lond Engl) 2008;2(4):259266
260 Kayalvizhi Reliability of pulp-vitality testing in children
Fig 1 Electric pulp tester.
Fig 2 Thermal pulp testing using warm gutta-percha
(courtesy of Edgar Schfer, Mnster, Germany).
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of the tooth, it may indicate traumatic occlusion or
periodontal ligament inflammation of pulpal origin.
The palpation test helps in the planning of treatment,
but does not assess pulp vitality.
Anaesthetic test
The anaesthetic test is used in cases where pain is
diffuse, radiating or referred. Injection of a local anaes-
thetic should be made in the region of the tooth
thought to be affected by pulpitis to determine the
origin of the pain. The anaesthetic test is only useful
in cases where pain is present at the time of exami-
nation, and this test does not indicate the pathological
state of the pulp.
Ultrasonics
In 1966 Kossoff and Sharpe
7
attempted to detect
pulpitis using ultrasonics, but were unsuccessful. The
problem was the availability of information relative to
the acoustic properties of dental hard tissues, mainly
because of the crudity of instrumentation. Later with
an improved instrument, the transmission and reflec-
tion of sound from the dentineenamel junction and
dentinepulp interface were recorded. However, this
tool still needs to be further perfected
8
.
Ultraviolet light
Foreman
9
investigated the usefulness of ultraviolet
light as a diagnostic tool in endodontics. Ultraviolet
fluorescence as a test of vitality, accentuates the colour
changes that occur in a tooth when the pulp is altered
by trauma or inflammation. The loss of ultraviolet fluor-
escence in a natural tooth indicates pulpal damage or
the presence of a root canal filling, but the presence of
ultraviolet light of normal intensity does not indicate if
the pulp is vital or non-vital. The ultraviolet light
method allows checking of a number of teeth in rapid
succession. If a tooth is heavily restored or crowned,
this may be the only method that can be used to assess
the loss of vitality. The greatest problem with ultraviolet
light is the installation of efficient blinds to the surgery
or the availability of a suitably dark room. The time
required for the light source to warm up (3 to 5 min)
and the necessity to provide ultraviolet protective
goggles for patient, operator and dental surgery
assistant must also be taken into account. As an
isolated test ultraviolet fluorescence is unreliable. How-
ever, when used in conjunction with other vitality tests
it may serve as a diagnostic aid.
Transillumination
Hill
9
assessed the usefulness of transillumination for
assessing tooth vitality and found that the tooth loses
its translucency as the pulp becomes non-vital. It is an
independent and inexpensive technique, but the effects
of large amalgam restorations on translucency are
difficult to assess. Teeth become less translucent as pulp
becomes non-vital and transillumination test results
elicited a positive response in some non-vital teeth.
Although this technique has limitations, it can still
be considered as a useful adjuvant to conventional
methods of pulp vitality testing, particularly in assess-
ing anterior or posterior teeth with minimal restorations.
A paradigm shift
Chambers suggested that the technique for evaluation
of dental pulp status must be simple, objective, stan-
dardised, reproducible, non-painful, non-injurious,
accurate, and inexpensive. Unfortunately the trad-
itional methods fall short of nearly all of the above
criteria
3
.
Pulp testing in children below the age of 10 years
is unreliable, because children may not co-operate for
the test and the incomplete innervation of newly
erupted teeth may affect the results (as neural sensi-
tivity in primary teeth varies according to the stage of
root development and resorption)
11
. False positive or
false negative results may occur if the clinician asks the
child leading questions. In addition, the unpleasant
stimuli produced by the tester may affect behaviour
management and co-operation in paediatric patients
10
.
Though the use of traditional tests establish an empiri-
cal diagnosis, none of these tests are completely reli-
able. Recent studies have shown that blood circulation
and not root innervation is the most accurate determi-
nant in assessing pulp vitality, as it provides an objective
ENDO (Lond Engl) 2008;2(4):259266
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differentiation between necrotic and vital pulp tissue.
The unpredictability of testing pulp nerve response is
well recognised. When nerve sensations are inhibited
or abolished in the tooth, traditional tests are of little
value. However, using methods based upon the pulpal
vasculature response is a better option. Thus, the
validity of childrens responses in pulp vitality testing
has been questioned
12
.
Finally, one should consider recent methods of pulp
vitality testing that attempt to measure the pulpal
condition objectively. Taylor
13
coined the word physio-
metric to describe such tests. Some of these methods
attempt to assess the state of pulpal circulation rather
than the integrity of nervous tissues and, thus, provide
more valuable information than conventional tests
3
.
Pulp vitality is purely a function of vascular health,
as blood vessels to the pulp supply and mediate the
process of acute and chronic inflammation. Thus,
newer pulp vitality methods have been developed.
These newer pulp-testing devices, which are still under
development, are non-invasive and are considered to
be more accurate. They detect blood supply of the
pulp through light absorption and reflection (photo-
plethysmography), pulse oximetry and dual wave-
length spectrophotometry or the shift in light fre-
quency as it is reflected back from a tooth, as in laser
Doppler flowmetry (LDF)
2
.
Recent advances in pulp vitality
testing
Pulp haemogram
It was suggested that taking the first drop of blood
from an exposed pulp and subjecting it to a differential
white cell count may be useful in diagnosis of pulpal
conditions. However, no clear relationship has been
found
2
. Though this is a traditional test performed by
Guthrie et al
14
, it is included in this review as it was the
preliminary method assessing pulpal vitality and not
sensitivity.
Pulse oximeter
Matthes is often considered the father of oximetry
15
.
Pulse oximetry directly measures blood saturation levels
by comparing amplitudes of the ratio of transmitted
infrared with red light. This ratio varies with relative
fractions of oxygen saturated to unsaturated haemo-
globin and is used to calculate oxygen saturation. These
characteristics infer that the pulse oximeter is also cap-
able of evaluating the blood vasculature status within a
tooth and, therefore, the pulp vitality
16
.
The pulse oximeter is an objective, non-invasive
technique, requiring no subjective response from the
patient. It is useful in case of intrusion (traumatised
teeth) where the blood supply remains intact, but the
nerve supply is damaged.
Limitations of this device include the following:
background absorption associated with venous
blood and tissue constituents should be differen-
tiated; in addition to the absorption, refraction and
reflection, penumbra effect also occurs, which is seen
in patients with strong tissue pulsations where some
of the light reaches the photo detector diode without
passing through the tissue bed; the oxygen saturation
values from the teeth routinely register readings lower
than that from the patients finger (this may be due
to the limitation of using a probe designed for other
body parts and not specifically for the anatomy of a
tooth). The pulse oximeter does not detect arterial
pulse
2
.
The process of developing a design for a dental
sensor, which can be successfully adapted to the tooth
and well suited to detect pulsatile absorbance, is still
under progress.
Optical reflection vitalometer
The optical reflection vitalometer (ORV) is based on
pulse oximetry, that is, this method is based on optical
reflection absorption, which measures arterial pulse.
The difference from conventional pulse oximetry is
that the absorption is measured from reflected light
instead of transmitted light. This device is still being
researched
17
.
Dual wavelength spectrophotometry
Dual wavelength spectrophotometry (DWLS) is a
technique that was developed by Millikan
18
and
improved by Wood and Geraci
19
. It is a method inde-
ENDO (Lond Engl) 2008;2(4):259266
262 Kayalvizhi Reliability of pulp-vitality testing in children
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pendent of pulsatile circulation. The presence of arteri-
oles rather than arteries in the pulp and its rigid encap-
sulation by surrounding dentine and enamel makes it
difficult to detect the pulse in the pulp space. The DWLS
technique uses visible light and measures oxygenation
changes in the capillary bed, rather than in the blood
vessels. The light is filtered to a near infrared range (760
to 850nm) and guided to the tooth by fibre optics. This
means that added eye protection is unnecessary for the
patient and the operator. This test is non-invasive, does
not rely on a subjective patient response and, therefore,
yields objective results. The DWLS instrument is small
and portable, relatively inexpensive and suitable for use
in a private dental office. However, it detects only the
presence of haemoglobin and not the circulation of
blood. Influence of the gingival circulation cannot be
ruled out and data on how large a mass of pulp tissue
is needed for accurate readings to be obtained must be
determined. Still, in vivo tests of this hypothesis are in
progress
20
.
Laser doppler flowmetry
Gazelius et al
21
first reported the ability of LDF to
measure pulpal blood flow in humans and
distinguished between vital and non-vital teeth. Later
Olgart et al
22
and Wilder-Smith
23
considered it as a
gold standard in determining pulpal blood flow. LDF
is a non-invasive, electro-optical technique, which
allows the semi-quantitative recording of pulpal blood
flow. This technique measures blood flow in very small
blood vessels of the microvasculature. It depends on
the Doppler principle, which uses a beam of infrared
(780 to 820nm) or near infrared light (632.8nm) that
is directed into tissue by optical fibres, and the enamel
prisms and dentine tubules guide this light to the pulp.
As light enters the tissue, it is scattered by moving red
blood cells and stationary tissue cells. Photons which
interact with moving red blood cells are scattered and
frequency is shifted according to the Doppler
principle. Photons that interact with the stationary
tissue cells are scattered, but not Doppler shifted. A
portion of light is returned to the photo detector and
a signal is produced
24
. Currently available flowmeters
display the signal on the screen, from which the
clinician can interpret if the pulp is alive and healthy,
or dead
25
.
LDF fulfils most of the requirements as an ideal
pulp tester. It has an immediate clinical application in
the assessment of vascular status of the pulp in pri-
mary teeth
26
and it yields definitive results in recently
traumatised or immature teeth. If a two channel
instrument with a dual probe set up is used, data can
be collected on two teeth simultaneously, so that the
test tooth can be compared with an adjacent and
contralateral tooth
27
.
Limitations of using LDF are that it is too expensive
and time consuming. The sensor should be motionless
and in constant contact with the tooth for accurate
readings, otherwise structures other than blood cells
generate Doppler shifts (this means a custom-
fabricated jig e.g. mouth guard is required). Specific
versions of the LDF for routine dental use are not yet
available
11
. The LDF is unable to quantify blood
volume directly and is adversely affected by move-
ment and saliva contamination. Medications such as
nicotine and those used in cardiovascular diseases (e.g.
anti-hypertensives) may affect blood flow to the pulp,
thus invalidating laser Doppler results
28
. It has also
been found that blood pigments within a discoloured
tooth crown can also interfere with laser light
transmission
29
.
Thus, this technique is useful in young children
whose responses are unreliable, and the non-invasive
nature helps promote patient co-operation and
acceptance.
Transmitted laser light
Transmitted laser light
30
is similar to LDF, but LDF also
records signals from non-pulpal origin. To overcome
this disadvantage of LDF, in 1997 Sasano et al
31
tested
pulpal blood flow using the same method as LDF, but
instead used transmitted laser light, rather than back-
scattered light that is normally used in LDF.
Conventional LDF probes comprise two glass
graded index optical fibres, one transmitting and one
receiving, with a core diameter of 100m. When
using transmitted laser light, a single probe is used,
one fibre of which acts as the transmitter on the labial
side of the tooth, the other held on the palatal side
as the receiver.
An advantage of transmitted laser light over LDF
are that the blood flow signals do not include flow of
ENDO (Lond Engl) 2008;2(4):259266
263 Kayalvizhi Reliability of pulp-vitality testing in children
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non-pulpal origin. Output signals and blood flow
changes were greater and could be easily monitored
with less noise.
The limitations are that it is still not possible to test
in situ because of the position of the splint and the size
of oral opening. At present, this device can only be
usedfor anterior teeth. With further development of
the device, it may be used for posterior teeth and for
teeth from elderly persons with narrow pulp cham-
bers, so that the photons can penetrate deeper and
straight towards the receiving fibre.
Temperature measurement
Diagnosing tooth vitality by temperature measure-
ment can provide valuable information on the integrity
of the underlying pulp. Howell et al
30
used liquid
cholesteric crystals and Fanibunda
32
used a thermistor
unit to measure crown surface temperature and time
temperature graphs to differentiate vital and non-vital
teeth. Vital teeth showed a rise in temperature,
whereas non-vital teeth did not show any increase in
temperature. Little research has been done using this
technique
2
.
Computerised infrared thermographic
imaging
Computerised infrared thermographic imaging (TI) is
another non-invasive method. To date, only one study
by Pogrel et al
33
has reported the use of TI to measure
human tooth surface temperature. Hughes ProBeye
4300 thermal video system was used, as it detects
temperature changes as small as 0.10C, hence as it is
a highly sensitive technique it was used to measure
pulp vitality. If it is to be used as a research tool, the
operating environment must be carefully controlled to
eliminate any thermal influences, to ensure consistent
data collection and to validate the methodology. This
method requires a high level of patient co-operation
(it takes 40 minutes) and steady head position must be
maintained for 3 min for two recording sequences. At
present this method is under investigation for its suit-
ability to assess pulp vitality in human teeth. Further
research has been carried out with the sole aim of in-
creasing the detectable difference between vital and
non-vital teeth, so that a method of temperature
measurement may be evolved which is of diagnostic
significance under routine clinical conditions
34,35
.
Photoplethysmography (optical
detection of blood flow)
Photoplethysmography has been suggested as a po-
tential non-invasive method to detect vascularisation
of the dental pulp. Recent optical techniques demon-
strate distinct, reproducible intensity changes due to
blood volume within the pulp chamber. Experi-
mentally it has been applied to the pulp in cats, dogs
and adult humans
1
. Diaz-Arnold et al
35
investigated
the influence of blood concentration, blood flow rate
and pulp chamber size on the intensity time profile.
They suggested that photoplethysmography meas-
urements may be sensitive to the amount of blood in
the pulp chamber, as it reflects the pulsatile-related
expansion and contraction of capillaries within the
pulp tissue.
The equipment and techniques used are shown in
Fig 3. The system includes a 5mmx3mmx1mm light
emitting diode (LED) powered by a 3V battery as the
light source, with a peak output of 576nm, with a
36nm bandwidth at half the peak intensity. A silicon
photodiode detector with a special range of 400 to
1100nm is used in a photovoltaic mode that requires no
external power supply. The detector output is interfaced
directly to an 8088-based computer. Polyethylene
tubing is sealed into the coronal access and connected
to syringe infusion pump. The pump is capable of pro-
ducing desired flow rate solutions lengthwise through
the tooth. The LED and detector are positioned on
ENDO (Lond Engl) 2008;2(4):259266
264 Kayalvizhi Reliability of pulp-vitality testing in children
Fig 3 Schematic drawing illustrating the principle of photo-
plethysmography (LED, light emitting diode).
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opposite sides of the tooth. This setup is housed in an
optical carrier and on holders in an optical rail.
As the number of blood cells increase, nearly all
light passing through the pulp chamber is scattered by
1:1 solution/maximum limiting apparent absorbance.
As the relative blood concentration increases, less light
is detected because more incident light is scattered by
the larger number of blood cells in the optical path.
Due to the smaller size of the pulp chamber, a signifi-
cant fraction of the detected light passes through the
tooth, but bypasses the pulp chamber and, therefore,
is not scattered by the blood cells. This non-pulpal light
provides a constant background intensity that is
independent of the relative concentration of blood
cells in the pulp tissue. As the number of blood cells
increases, nearly all light passing through the pulp
chamber is scattered, thereby resulting in a maximum
limiting apparent absorbance. The concept of meas-
urement is to pass a selected band of light through the
tooth, while continuously monitoring the intensity of
the transmitted light.
The advantages of the equipment used in this
method is that signal contamination derived from
periodontal blood flow does not occur. It has less signal
noise (periodontal ligament blood flow) compared
with LDF, due to the pathway of transmitted light. This
method is still under research.
Conclusions
The dental pulp is a vital connective tissue consisting
of blood vessels and nerves. Pulp vitality is a function
of vascular health and pulp vitality testing, although is
only one facet of a proper endodontic diagnosis, is an
integral part. Routine methods of pulp vitality testing
that have been followed over the years rely on stimu-
lation of -nerve fibres and give no direct indication
of blood flow within the pulp tissue. These testing
methods have the potential to produce an unpleasant
sensation and inaccurate results. In addition, each is a
subjective test that depends on patients perceived
response to a stimulus as well as the clinicians inter-
pretation of that response. Thus, its reliability in
children is still questionable.
Recording the pulpal blood flow would be an objec-
tive assessment of the status of the pulpal blood circu-
lation and a true indicator of pulp vitality. Optical
devices that exploit the various absorbance properties
of different substances within the dental pulp are being
studied to determine pulsation and blood volume. They
offer the advantages of being objective, non-invasive
and atraumatic, resulting in greater patient acceptance
and co-operation. Currently, the significance and reli-
ability of these methods are being studied. It is hoped
that with further research these new technologies will
be able to provide reliable results in children.
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