DEPARTMENT OF ORAL MEDICINE

RADIOLOGY & DIAGNOSIS

PULP VITALITY TEST WITH

PULPAL
LESIONS

SUBMITTED BY
ASWATHY SIVADAS .P
REG.No : 54084008
IVth BDS
Vivekananda Dental College For Women

CONTENTS
INTRODUCTION
PULP VITALITY TESTS
VISUAL AND TACTILE INSPECTION
PERCUSSION
PALPATION
MOBILITY AND DEPRESSIBILITY
RADIOGRAPH
THERMAL TESTING
ELECTRICAL TEST
SPECIAL TESTS
BITE TEST
STAINING AND TRANSILLUMINATION
SELECTIVE ANAESTHESIA
TEST CAVITY
LASER DOPPLER FLOW METRY
PULSE OXIMETRY
DISEASSES OF PULP
CONCLUSION
REFERENCES

INTRODUCTION
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Pulp vitality test is crucial in monitoring the state of health of dental pulp,
especially after traumatic injuries. The traditional pulp testing methods such as
thermal and electric pulp testing methods depend on the innervation and often
yield false positive and negative response. The newer pulp testing devices, some
of which are still under development stage, detect the blood supply of the pulp,
through light absorption and reflection, are considered to be more accurate and
non-invasive).

PULP VITALITY TESTS

Visual and tactile inspection[2]
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 Simple clinical test

Examination
Colour - discoloration of tooth associates with necrotic,
gangrenous
Pulps internal & external, resorption carious resorption
CONTOUR - fractures
Wear facets
Restorations
CONSISTENSY - relates to presence of caries
External resorption
Internal resorption

Percussion
Evaluate status of periodontium surrounding tooth

By using handle of instrument, to determine whether tooth is tender

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 Vertical percussion - apical periodontitis

Horizontal percussion - chronic periododintis

Palpation
Done with fingertip using light pressure to
examine tissue
consistency & pain response.
Determining Whether tissue is fluctuant & enlarged

Intensity & location of pain

Presence & location of adenopathy

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Presence of bone crepitus

Mobility and depressibility[2]

MOBILITY TEST -to evaluate integrity of attachment apparatus
surrounding tooth
Moving tooth laterally in its socket by using fingers or handles of
two instruments
DEPRESSIBILITY TEST - moving tooth vertically in its socket
endodontic tratment should not be carried out on teeth with
third degree mobility

Radiography[2]
To use radiographs properly , clinician must have knowledge & skills
To interpret them correctly
Through understanding of normal anatomical structures & changes
occur due to aging , trauma , healing
Contain information

on presence of caries that may involve pulp

or
not Radiographs may show number ,course ,length ,& width of root
canals
Presence of calcified material in root canal
Internal resorption
External resorption
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 Calcification or obliteration of pulp cavity

Thickening of periodontal ligament
Nature & extent of periapical &alveolar bone destruction

Thermal Pulp Test

Various methods

[4]

and materials have been used to test the pulp s

response to thermal stimuli.

The baseline or normal response to either hot or cold is a patients report
that a sensation is felt but disappear immediately upon removal of the
thermal stimulus .
Heat testing is most useful when a patients complaint is intense dental
pain upon contact with any hot liquid or food.in instances where a
patients is unable to identify which tooth is sensitive ,a heat test is
appropriative.
Starting with the most posterior tooth in that area of the mouth , each
tooth is individually isolated with the rubber dam.
An irrigating syringe is filled with a liquid that has a temperature similar
to that which would cause the painful sensation.
The liquid is then express from the syringe onto the isolated tooth to
determine whether the response is normal or abnormal.
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 The tooth will exhibit an immediate , intense painful responds to the

heat.with the heat testing a delayed response may occur ,so waiting 1o
seconds between each heat test will allow sufficient for any onset or
symptoms.another metho for heat testing is applie heated gutta
purcha.or compound stick to the surface of the tooth.
If this method is used, a light layer of lubricant should be placed onto the
tooth surface prior to applying the heated material to prevent the hot
gutta purcha or compound from adhering to the dry tooth surface.
Cold is the primary pulp testing method for many practitioners today.
Cold testing should be used in conjunction with the electric pulp tester so
that results from one test will verify the findings of the other test.
It can be accomplished similarly to heat testing by individually isolating
teeth with a rubber dam.
Another benefit of this technique for cold testing is that it requires no
armamentarium except for a rubber dam.
If a clinician choose to perform this test with sticks of ice , then the
use of the rubber dam is recommended because melting ice will run
onto adjacent teeth and gingiva, yielding potentially false positive
responses.
Frozen carbon dioxide (co2)also known as dry ice or carbon dioxide
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snow, has been found to very reliable in eliciting a positive response if

vital pulp tissue is present in the tooth. Carbon dioxide has also been
found to be effective in evaluating the pulp response in teeth with full
coverage crowns for which electric pulp testing is not possible.
For testing purposes a solid stick of co2 gas into a specially design
plastic cylinder.
The resulting co2 is stick is applied to the facial surface of either natural
tooth structure or crown.several tooth can be tested with single stick.
The tooth should be isolated with a 2*2gauze or cotton.so co2 will not
come into contact with these structures.
The most popular method of testing is with a refrigerant spray.
It is readily available and easy to use,and provides test result that are
reproducible, reliable and equivalent to that co2 .
The current product contain 1,1,1,2-tetrafluroethane,which has zero
ozone depletion potential and is environmentally safe.
It has temperature -26.2c .
The spray is most effective or testing purpose when it is applied to the
tooth on large #2 cotton pellete.
The sprayed cotton pellete should be applied to the midfacial of the Crown.
.
The sensitivity which is the ability of a test to identify teeth that are
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diseased , was 0.83 for cold and 0.86 for heat and 0.72 for the electric test.
This means the cold test correctly identified 83% of the teeth that had
anecrotic pulp while heat test where correct 86% of the time and
electric pulp test were correct only 72% of the time.

REFRIGERATOR SPRAY CONTAINER

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A COTTON ROLL CAN BE USED TO FORM A LARGE COTTON PELLET

Electric Pulp Test

Assessment of the pulp vitality test with is most frequently accomplished [4]
by electric pulp testing or cold testing.
The vitality of the pulp is determined by the intactness and health of the
the vascular supply, not the status of the pulpal nerve fibres.
Even though advances are being made with regard to determine the
vitality of the pulp regard to the blood supply, this technology is not
accurate enough to be used on a routine basis in clinical setting
The electric pulp tester has limitations in providing information about the
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pulp .

ELECTRI
WITH

PULP TESTER
PROBE

The
to electric
reflecting

response of the pulp

testing is not
the histologic

health

status of the pulp.

A response by the pulp to the electric current only denotes that some
viable nerve fibres are present in the pulp and are capable of responding.
The lack of response has been found most frequently when an electric
pulp is present.
The electric pulp tester will not work unless the probe can be placed in
contact with the natural tooth.
With the advent of universal precautions for infection control, the patient
may be required to place a finger on the tester probe to complete the
electric circuit for the models, however lip clips are an alternative to
having patients hold the tester.
The use of rubber gloves prevents the clinician from completing the
circuit.
purpose use of the electric pulp tester requires that the tooth to be
evaluated be isolated and dried.
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 A control tooth of similar tooth type and location in the arch should be
tested first in order to establish a base line response and to inform the
patients with a normal sensations.
The suspected tooth should be tested at least twice to confirm the results.
The tip of the testing probe that will be placed in contact with the tooth
structure must be coated with the water or petroleum based media.

The most commonly used media is toothpaste.

The coated probe tip is placed in the incisal third of buccal or facial area
of the tooth to be tested.
once the probe is contact with the tooth the patient is asked to touch the
tester probe.
This completes the circuit and initiates the delivery of electric current to
the tooth.
The patient is instructed to remove his or her finger from the probe when
a tingling or warming sensation is felt in the tooth.
The readings from the pulp tester are recorded and will be evaluated once
all the appropriate teeth have been tested and the result obtained from
other pulp testing methods.
If a complete coverage crown or extensive restoration is present, a
bridging technique can be attempted to deliver current to any exposed
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natural tooth structure.

The tip of the endodontic explorer is coated with tooth paste or other
appropriate media and placed in contact with the natural tooth.
The tip of the electric pulp tester probe is coated with a small amount of
tooth paste and placed in contact with the side of the explorer.
However, unlike electric pulp testing, cold testing can reveal the health
and integrity of pulp tissue response.
Until such time that testing method used to assess the vascular supply of
the pulp become less time consuming and technique sensitive to thermal
and electric pulp testing will continue to be the primary methods for
determining pulp vitality.

PULP NERVE TESTER

SPECIAL TEST
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Bite test
Identifying cracked tooth or fractured cusp[4].
It also helpful in diagnosing cases where in pulpal pathosis is
extended to periradicular region causing apical periodontitis
Tooth slooth & Frac Finder are available devices for bite test
Pain on biting -- apical periodontitis
Pain on release of bite force - cracked tooth

To determine which tooth is sensitive to mastication

and which part of the tooth is sensitive,having the
patients bite on a specialy designed bite stick often
helpful.

For the bite test to be meaningful a device should be used that will
allow practitioners to apply pressure to individual cusp or areas of tooth.

Variety of devices have been used for the bite test including cotton
applicators , tooth picks, orange wood sticks, rubber polishing
wheels.
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As with all the pulp test, adjacent teeth should be use as controls
so that the patient is aware of the normal response to these test.

The small cupped out areas on the instruments is placed in contact

with the cusp to be tested.

The patient is then asked to apply biting pressure with opposing

teeth to the flat surface on the opposing side of the device.

The biting pressure should be applied slowly until full closure is

achieved.

The firm pressure should be applied for few seconds, the patient is
then asked to release the pressure quickly.

Each individual pressure on a tooth can be tested in a like manner.

The practitioner should note if the pain is elicited during the

pressure phase or upon quick release of pressure.

A common finding is with fractured cusp or cracked tooth is

frequent presence pain upon release of biting pressure

Staining and transillumination

Inorder to determine the presence of crack in the surface of the

tooth,the application of a stain to the area is often of great
assistants[4].
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Shining a bright light on the surface of the tooth is also very

helpful.

Selective anaesthesia

When symtops are non localised or reffered,the diagnosed may be

very challenging[4].

Sometimes the patients may not even able to specify whether the
symptoms are emanating from the maxillary or mandibular arch.

This test is restricted to the patient who are in pain at the

time of the test when the usual tests have failed to identify
the tooth

The objective is to anesthetize one tooth at a time until the pain.

disappears and is localized to a specific tooth

TECHNIQUE

Using either infiltration or intraligament injection, inject the

most posterior tooth in the area suspected of being the cause
of pain[2]

If the pain persist 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 is given
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Cessation of pain naturally indicates involment of mandibular

tooth

ADVANTAGE
This test is obviously a last resort and has an advantage over
the test cavity during which iatrogenic damage is possible[2]

Test cavity

This method is used only when all other test methods are deamed
impossible or the result of the other test are inconclusive [2].

This test allows one to determine the pulp vitality

It is performed when other methods of diagnosis have failed

The test cavity is made by drilling through the enamel-dentin

junction of an un-anesthetized tooth

The drilling should be done at slow speed and without a

water coolant

Sensitivity or the pain felt by the patient is an indication of

pulp vitality

No endodontic treatment is indicated

Sedative cement is then placed in the cavity ,search for

source of pain continues

If no pain is felt -cavity preparation may be continued until

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the pulp chamber is reached ,If pulp is completely necroticendodontic treatment can be continued

RECENT PULP VITALITY

ASSESSMEMT

The two technologies which are being developed and which

could potentially prove to be an effective and objective vitality

assessment tools are follows

Laser Doppler flowmetry

Laser Doppler flowmetry is a method used to assess blood flow in

micro vascular system[3,4].

Attempts are being made to adapt this technology to assess pulpal

blood flow.

A diode is used to project a infrared light beam through the crown

and pulp chamber of a toot.

The Doppler principle states that the light beam will be frequencyshifted by moving red blood cells but will remain un-shifted as it
passes through static tissue.

.This technique is accurate ,reliable en reproducible method of

assessing pulpal blood flow.

Even with this positive findings ,the technology is not advanced

enough for this method to be used on a routine basis in a dental
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practice.

If technology can be developed whereby the testing with the LDF

can be accomplished in minutes ,it will likely replace the thermal
and electric pulp testing methods

Pulp oximetry
Another non-invasive method[4,5] that has been investigated as a method to
determine pulpal blood flow uses a pulse oximeter ,which is designed to
measure the oxygen concentration of the blood and the pulse rate.
It works on the principle that two wavelengths of light transmitted by a
photoelectric diode detect oxygenated and deoxygenated haemoglobin as
they pass through a body part to a receptor.
The diffrences between the light emitted and the light received is
calculated by a microprocessor to provide the pulse rate and oxygen
concentrations in the blood.
Attempts to use the pulse oximeter to diagnose pulp vitality have met
mixed results .
The device used for pulp testing are too cumbersome and complicated to
be used on a basis in a dental practice.

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Meanism of dental pulp oximeter: (a).light emitting diode emitting red light at
660nm.(b).light emitting diode emitting infra red light at .940nm.(c)photo
etector.(d)pulse oimeter monitor.(e)pulse oimeter sensor.(f).custom made pulse
oximeter sensor holder.HbO2 ,oxygenated haemoglobin.HbR,deoxygenated
haemoglobin ;SpO2, oxygen saturation of arterial blood.

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DISEASES OF PULP
1.Inflammatory diseases of dental pulp
(a)Reversible pulpitis
(i)Symptomatic(acute)
(ii)Asymptomatic(chronic)
(b)Irriversible pulpitis
(i)Syptomati(acute)
Abnormally response to cold
Abnormally response to heat
(ii)Asymptomatic (chronic)
Hyperplastic pulpitis
Internal resorption
2.Pulp regeneration
(a)Calcific
(b)Others
3.Necrosis

Reversible pulpitis

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 Reversible pulpitis[2,4] is a mild to moderate inflammatory condition of the

pulp caused by the noxious stimuli in which the pulp caused by capable of
returning to the uninflamed state following removal of the stimuli.
Symptomatic reversible pulpitis is characterised by sharp pain lasting for a
moment,and generally disappears when the stimulus is removed
Cold , sweet, or sour usually causes it
Pain may become chronic.
The pulp may recover completely or the pain may last longer each time and
intervals of relief may become shorter ,until the pulp finally succumbs
The pulp is sensitive to temperature changes,particularly cold,application of
cold is an excellent method of locating and diagnosing the involved tooth.
A tooth with reversible pulpitis reacts normally to percussion,palpation and
mobility.
Thermal test are useful in locating the affected tooth if unknown.
The electric pulp test, using less current than on a control tooth, is an excellent
corroborating test.

Irreversible pulpitis

Irreversible pulpitis[2,4] is a persistant inflammatory condition of the pulp,

symptomatic or asymptomatic caused by a noxious stimulus.
A tooth with symptomatic irreversible pulpitis exhibit intermittent or
spontaneous pain,whereby rapid exposure to dramatic temperature changes
(especially to cold stimuli) will elicit heightened and prolonge episodes of pain
even after the source of the pain is removed.
The pain may be sharp or dull localised or referred.
In the early stages the thermal test may elicit pain that persists after removal of
the thermal stimulus.
In the late stages when the pulp is exposed ,it may respond normally to the
thermal stimulus.
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 The electric pulp test induces a response with a marked variation in current
form of normal.
Result of examination for mobility and perussion and palpation tests are
negative.

Chronic Hyperplasic Pulpitis

Chronic hyperplastic pulpitis[2,4] or pulp polyp is a productive pulpal
inflammation due to an extensive carious of a young pulp
Slow , progressive carious exposure of the pulp is the cause.
Mechanical irritation from chewing and bacterial infection often provide the
stimulus.
The tooth may respond feebly or not at all to the thermal test,unless one use
extreme cold, as from an methyl chloride spray.
More current than normal may be required to elicit a response by means of the
electric pulp tester.

Internal resorption

Internal

resorption[2,4] is an

idiopathic slow or fast progressive resorptive

process occurring in the dentin of the pulp chamber or root canals of the teeth
The cause of internal resorption is not known,but such patients often have a
history of trauma
Internal resorption in the root of a tooth is asymptomatic.
In the crown of the tooth ,internal resorption may be manifested as a reddish
area calledpink spot.
Resorptive defect is more extensive in pulpal wall than on the root surface.
The defect is usually is recognised by means of a radiograph.

Necrosis of pulp

Necrosis is death of the pulp[2].

It may be partial or total ,depending on whether part or the entire pulp is
removed.
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 It can be caused by any noxious insult to the pulp ,such as bacteria, trauma ,and
chemical irritation.
A normal tooth with a necrotic pulp cause no painful symptoms.
The presence of necrotic pulp may be discovered only by chance because such
tooth is asymptomatic ,and the and the radiograph is non diagnostic.
The teeth with partial necrosis can respond to thermal changes ,owing to the
presence of vital nerve fibers passing through the adjacent inflamed tissue.
Tooth with necrotic pulp does not respond to cold ,the electric pulp test ,or the
test cavity

Pulpal Diagnosis

Response to cold or heat

Normal

Patient reports a thermal

sensation and stops feeling it
when the stimulus is removed

Reversible pulpitis

Thermal sensation causes

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discomfort/pain and the

magnitude of response is
different from adjacent and/or
contralateral teeth;sensation
may linger briefly
Symptomatic irreversible pulpitis

After thermal stimulus is applied,

patient reports pain/discomfort is
more pronounced than on
adjacent teeth and/or
contralateral tooth;sensation
lingers

Asymptomatic irreversible
pulpitis

Same response as normal or

reversible pulpitis, except the
patient has a
history of pulpal inflammation
such as caries, carious exposure,
or trauma

Necrosis

Patient reports feeling no

sensation when thermal stimulus
is applied for more than 10
seconds

Possible Diagnoses, based on patient responses

to thermal stimuli.

CONCLUSION
The most common methods to assess pulp vitality are based on sensitivity
assessment of the neural tissues of the pulp. These methods include thermal and
electric pulp tests. Vitaliyt can only be assessed when assessment of vascular
and blood supply to the tooth can be done. The above mentioned technologies
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have been proved to be a great help to test the vitality and for further diagnosis
and treatment.

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References
1. Eugene Chen and Paul V. Abbott
Review Article Dental Pulp Testing
Page 2-4
2. Grossman
Text of Grossmans Endodonti practice
12th edition
Page no 84-75
3. Samraj RV
Recent advances in pulp vitality testing
Page no 3
4. Stephen cohen Kenneth M. Hargreaves
Text book of Pathways of the pulp
9th edition.
Page 16-20
5. Velayutham Gopikrishna
Article on Evaluation of Efficacy of a New Custom-Made Pulse Oximeter
Page 1-2

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