doi:10.1111/j.1365-2591.2012.02016.

Review

Diagnosis of the condition of the dental pulp: a

systematic review

I. A. Mejàre1,2, S. Axelsson2, T. Davidson2,3, F. Frisk4,5, M. Hakeberg6, T. Kvist5, A. Norlund2,

A. Petersson7, I. Portenier8, H. Sandberg9, S. Tranæus2 & G. Bergenholtz5
1
Department of Pediatric Dentistry, Faculty of Odontology, Malmö University; 2SBU (Swedish Council on Health Technology
Assessment), Stockholm; 3Center for Medical Technology Assessment, Linköping University, Linköping; 4Department of
Endodontology/Periodontology, The Institute for Postgraduate Dental Education, Jönköping; 5Department of Endodontology,
Institution of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg; 6Department of Behavioral and
Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg; 7Department of
Oral and Maxillofacial Radiology, Faculty of Odontology, Malmö University, Malmö, Sweden; 8Division of Cariology and
Endodontics, School of Dentistry, University of Geneva, Geneva, Switzerland; and 9Karolinska Institutet, Stockholm, Sweden

Abstract tially relevant. Altogether, 155 articles were read in full

Mejàre IA, Axelsson S, Davidson T, Frisk F, Hakeberg M,
Kvist T, Norlund A, Petersson A, Portenier I, Sandberg
H, Tranæus S, Bergenholtz G. Diagnosis of the condition of
the dental pulp: a systematic review. International Endodontic
Journal, 45, 597–613, 2012.
The aim of this systematic review was to appraise the
diagnostic accuracy of signs/symptoms and tests used
to determine the condition of the pulp in teeth affected
by deep caries, trauma or other types of injury.
Radiographic methods were not included. The elec-
tronic literature search included the databases PubMed,
EMBASE, The Cochrane Central Register of Controlled
Trials and Cochrane Reviews from January 1950 to
June 2011. The complete search strategy is given in an
Appendix S1 (available online as Supporting Informa-
tion). In addition, hand searches were made. Two
reviewers independently assessed abstracts and full-text
articles. An article was read in full text if at least one of
the two reviewers considered an abstract to be poten-
text. Of these, 18 studies fulfilled pre-specified inclusion
criteria. The quality of included articles was assessed
using the QUADAS tool. Based on studies of high or
moderate quality, the quality of evidence of each
diagnostic method/test was rated in four levels accord-
ing to GRADE. No study reached high quality; two were
of moderate quality. The overall evidence was insuffi-
cient to assess the value of toothache or abnormal
reaction to heat/cold stimulation for determining the
pulp condition. The same applies to methods for
establishing pulp status, including electric or thermal
pulp testing, or methods for measuring pulpal blood
circulation. In general, there are major shortcomings in
the design, conduct and reporting of studies in this
domain of dental research.
Keywords: accuracy, dental pulp disease, dental
pulp test, diagnosis, sensitivity, specificity.
Received 30 September 2011; accepted 30 December 2011

treatment decision. Important information in this

Introduction
An accurate diagnosis of the condition of the pulp in
teeth compromised by caries, dental procedures or
other forms of injury is crucial for arriving at a proper
Correspondence: Ingegerd Mejàre, SBU, Statens Beredning för
medicinsk Utvärdering, PO Box 3657, 103 59 Stockholm,
Sweden (tel.: +46 84123242; e-mail address: mejare@sbu.se).
respect is whether the pulp is vital or necrotic. It is
equally important to be able to determine whether the
pulp is reversibly or irreversibly inflamed, especially in
connection with a carious or traumatic exposure of the
tissue. In other words, can the pulp heal and survive in
a long-term perspective or is it damaged to the extent
that it is not treatable and that root canal treatment is
required?

ª 2012 International Endodontic Journal International Endodontic Journal, 45, 597–613, 2012 597
 Diagnosis of dental pulp Mejàre et al.
Diagnostic information is gained from the patient’s
history of pain or discomfort, experience of trauma or
restorative procedures, clinical examinations, results of
clinical tests and radiographic examination of the teeth
and the surrounding tissues. A diagnosis is seldom
based on a single finding, rather on a set of observa-
tions. The clinical situation may be so complex that a
proper diagnosis and treatment decision requires a
diagnostic process consisting of several steps.
A variety of methods are used to assess the condition
of injured or diseased dental pulp. Whilst such methods
have been reviewed thoroughly and repeatedly in
many textbooks and narrative reviews, no consensus
has been reached as to which method or combination
of methods will give the most accurate information
(Levin et al. 2009). The aim of this systematic review
was to assess the diagnostic accuracy of contemporary
methods used to assess the condition of the pulp in
injured or diseased teeth. The review does not include
assessments of the accuracy of radiographic methods;
that is presented in a separate article (Petersson et al.
2011). This review is part of a more comprehensive
systematic review published in Swedish by SBU (Swed-
ish Council on Health Technology Assessment) cover-
ing methods of diagnosis and treatment in endodontics
(The Swedish Council on Health Technology Assess-
ment (SBU) 2010). SBU is an independent government
agency for the critical evaluation of methods for
preventing, diagnosing and treating health problems.
The following questions were addressed:
• How accurate are different diagnostic methods for
determining the condition of exposed vital pulps in
teeth with different types of damage or injury
(caries, trauma, restorative interventions or other
causes)?
• Are there clinical or biological markers that can
determine the degree, severity and extent of inflam-
mation of exposed vital pulp?
• Are there methods that can predict the outcome of a
treatment that aims at keeping the pulp vital,
healthy and without symptoms?
• How accurate are methods used to determine the
sensibility and vitality of dental pulps, including
methods to determine vascular function?
Materials and methods
Literature search and selection of articles
The electronic literature search included the databases
PubMed, EMBASE, The Cochrane Central Register of
598 International Endodontic Journal, 45, 597–613, 2012
Controlled Trials and Cochrane Reviews from January
1950 to April 2010. A complementary search was
made in June 2011. All languages were accepted,
provided there was an abstract in English. The Mesh
terms were ‘Dental pulp diseases/classification’, ‘Dental
pulp diseases/diagnosis’, ‘Dental pulp test’ and ‘Tooth
discoloration’. The complete search strategy is given in
the Appendix S1 (available online as Supporting
Information). The electronic searches resulted in
2131 abstracts (Fig. 1). Two reviewers (GB and IM)
read the abstracts independently. An article was read in
full text if at least one of the two reviewers considered
an abstract to be potentially relevant. In addition to the
electronic search, a hand search was made and
references of narrative reviews, text books and articles
in international journals not identified in the main
search were included. The hand search resulted in
another 33 articles. Grey literature was not included.
The pre-specified inclusion/exclusion criteria are given
in Table 1. Altogether, 155 articles were read in full
text and assessed independently by the same two
reviewers. Of the 155 articles, 137 did not fulfil the
inclusion criteria and were excluded from further
analysis. A list of excluded articles with the main
reason for exclusion is given in the Appendix S2
(available online as Supporting Information). The
remaining included articles (n = 18) were assessed
using the QUADAS tool (Whiting et al. 2003).
Data analysis
Measures used to assess diagnostic accuracy
The diagnostic accuracy (validity) of a test (index test)
requires a reference standard (reference test) for com-
parison. Such a reference standard should reflect the
true condition as closely as possible. For pulp, histo-
logical examination has often been used as the refer-
ence standard.
The relationship between positive and negative test
results and the presence or absence of diseased pulp can
be expressed as sensitivity and specificity. Sensitivity is
the number of true positive tests divided by the total
number of diseased pulps. Specificity is the number of
true negative tests divided by the total number of
healthy pulps. Other measures are predictive values
and likelihood ratios. The positive predictive value is
the number of true positive tests divided by the total
number of positive tests, and the negative predictive
value is the number of negative tests divided by the
total number of negative tests. Likelihood ratio com-
bines sensitivity and specificity and states how many
ª 2012 International Endodontic Journal
 Mejàre et al. Diagnosis of dental pulp

Abstracts from electronic search

1. 2009-09-01 (n = 1883)
2. 2010-04-07 (n = 119)
3. 2011-06-28 (n =129)

Excluded abstracts
(not relevant)
n = 2009

Articles in full text

n = 122

Articles from other sources, Excluded articles (not

i.e. reference lists relevant or not fulfilling
n = 33 inclusion criteria)
n = 137

Included articles
n = 18

Study quality: High Study quality: Moderate Study quality: Low

n=0 n=2 n =16

Figure 1 Flow chart showing the search strategy, excluded and included articles and study quality of included articles.

times more likely particular test results are in patients
with disease than in those without disease. The positive
likelihood ratio = the odds of a positive test result in
patients with disease (sensitivity/1- specificity), and the
negative likelihood ratio = the odds of a negative test
result in patients with disease (1- sensitivity/specific-
ity).
The main outcome measures of this systematic
review were sensitivity and specificity of individual
studies. The intention was to pool sensitivity and
specificity of reasonably homogeneous studies with
high or moderate study quality.
Rating quality of individual studies
Each included study was rated high, moderate or low
quality according to pre-specified criteria given in
Table 2.
Rating evidence across studies
The quality of evidence of the diagnostic accuracy of
each method/test was rated in four levels according to
GRADE (Schünemann et al. 2008, Guyatt et al. 2011):
• High (¯¯¯¯): based on high- or moderate-quality
studies containing no factors that weaken the
overall judgement.
• Moderate (¯¯¯s): based on high- or moderate-
quality studies containing isolated factors that
weaken the overall judgement.
• Limited (¯¯ss): based on high- or moderate-
quality studies containing factors that weaken the
overall judgement.
• Insufficient (¯sss): the evidence base is insuffi-
cient when scientific evidence is lacking, the quality
of available studies is low or studies of similar
quality are contradictory.
GRADE amounts to asking how much confidence
one can have in a particular estimate of effect. Is it built
on solid ground, or is it likely that new research
findings will change the evidence in the foreseeable
future? The rating starts at high, but confidence in the
evidence may be lowered for several reasons, including
limitations in study design and/or quality, inconsis-
tency or indirectness of results, imprecision of estimates
and probability of publication bias.
Any disagreements about inclusion/exclusion criteria,
rating quality of individual studies or quality of evidence
of test methods were solved by consensus. A flow chart
showing the results of the literature search and the
outcome of the selection procedures is given in Fig. 1.
Results
Eighteen studies were included (Seltzer et al. 1963,
Guthrie et al. 1965, Eidelman et al. 1968, Hasler &
Mitchell 1970, Johnson et al. 1970, Koch & Nyborg
1970, Tyldesley & Mumford 1970, Garfunkel et al.

ª 2012 International Endodontic Journal International Endodontic Journal, 45, 597–613, 2012 599
 Diagnosis of dental pulp Mejàre et al.

Table 1 Pre-specified inclusion and exclusion criteria

Inclusion criteria
Study design Cross-sectional, case–control, prospective cohort
Population Patients that can be expected to undergo the examination or the tests in clinical praxis
Index test Clinical signs or symptoms, other clinical information, clinical tests or biological markers
Reference test Histological examination of the extracted tooth
Histological examination of extirpated pulp tissue
For deciding pulp vitality: the same criteria as above or inspecting/probing the exposed pulp tissue
Immature teeth: radiographic examination combined with observing continued root development
Prospective study design: symptoms combined with clinical and radiographic information were accepted
Outcome measures Sensitivity, specificity, likelihood ratio, odds ratio (from multivariate analysis), ROC
curves or AUC (area under the curve)
Exclusion criteria
Study design Retrospective
Population In vitro or animal studies, cracked teeth
Index test Product comparisons, tooth bleaching procedures
Reference test Not defined or not acceptable according to inclusion criteria
Outcome measures Other than inclusion criteria. An article was accepted if sensitivity and specificity were not reported,
but contingency tables enabled calculation of these measures

Table 2 Criteria of high, moderate and low study quality, mainly according to QUADAS (Whiting et al. 2003)

High: small risk of bias Study design either cross-sectional or prospective. A case–control design was not accepted,
because it usually overestimates diagnostic accuracy (Lijmer et al. 1999). Particular emphasis was put
on the following items:

Randomly or consecutively selected, adequately described patients involving a representative and

clinically relevant sample (QUADAS items 1, 2)
The index test should not form part of the reference standard (item 7)
The index test and the reference standard should each be interpreted without knowledge of the results
of the other (items 10, 11)
The tests should be described in sufficient detail to permit replication (items 8, 9)
Sample size in subgroups ‡30
Diagnostic accuracy presented as sensitivity and specificity

Moderate: moderate A case–control design was accepted as well as nonrandom or nonconsecutive enrolment of patients.
risk of bias Otherwise the same criteria as for high quality. A sample size of ‡20 in subgroups was accepted

Low: high risk of selection Criteria of moderate quality not met

and/or verification bias

1973, Dummer et al. 1980, Klausen et al. 1985, Olgart
et al. 1988, Georgopoulou & Kerani 1989, Matsuo
et al. 1996, Evans et al. 1999, Petersson et al. 1999,
Kamburoğlu & Paksoy 2005, Gopikrishna et al. 2007,
Weisleder et al. 2009). Their main characteristics and
quality rating are presented in Table 3. None of the
studies satisfied the criteria for high quality, two were
of moderate quality (Hasler & Mitchell 1970, Gop-
ikrishna et al. 2007), and the remaining 16 studies
were of low quality. Owing to the scarcity of studies of
sufficient quality, no meta-analysis was performed.
Based on the two studies of moderate quality, each
investigated test method was rated for the quality of
evidence according to the GRADE approach (Schüne-
mann et al. 2008), Tables 4 and 5. The 18 included
studies can be divided into two categories: those
designed to assess the accuracy of signs and symptoms
of the inflammatory status of pulp, and those investi-
gating the accuracy of methods for testing pulp vitality.
Signs and symptoms as indicators of the
inflammatory status of pulp
Of 11 included studies, 10 were of low quality (Seltzer
et al. 1963, Guthrie et al. 1965, Eidelman et al. 1968,
Johnson et al. 1970, Koch & Nyborg 1970, Tyldesley &
Mumford 1970, Dummer et al. 1980, Klausen et al.
1985, Matsuo et al. 1996, Kamburoğlu & Paksoy
2005). The study of moderate quality (Hasler &
Mitchell 1970) recorded normal or abnormal responses
to cold, heat, electric pulp test (EPT) and percussion in
47 asymptomatic teeth with deep caries. The findings

600 International Endodontic Journal, 45, 597–613, 2012 ª 2012 International Endodontic Journal

were compared with the degree of pulp inflammation as
assessed by histological examination after extraction of
the tooth. There was no obvious association between
any of the test results and the inflammatory condition
of the pulp. Tenderness to percussion occurred in 80%
(37/47) of the teeth without regard to the inflamma-
tory status. All teeth having minimal or no pulp
inflammation responded abnormally to either cold or
heat provocation or both. The range of inflammation
was substantial; 28% (13/47) of the teeth displayed
either moderate or severe pulp inflammation. Thus,
absence of painful symptoms such as toothache did not
exclude the presence of a severe inflammatory involve-
ment of the pulp. The histological examination revealed
that 30% (14/47) of the teeth had carious pulp
exposure (with no dentine separating the pulp from
the caries lesion as measured histologically). Moderate
to severe pulp inflammation was more frequent in these
teeth (71%) compared with teeth without caries
reaching the pulp. The sample is, however, relatively
small, and the results have wide confidence intervals.
Table 4 is based on the results of this study.
The accuracy of isolated clinical symptoms or
combinations of symptoms for differentiating between
pulpitis, apical periodontitis and marginal periodon-
titis was assessed in 74 patients with acute dental
pain (Klausen et al. 1985). Probing the pulp after
exposure was used as the reference test to distinguish
between vital and nonvital pulps. Bursts of pain
initiated by thermal provocation (cold or heat) were
associated with vital pulp (pulpitis) in >75% of the
teeth. Constant pain combined with a tooth that felt
extruded was associated with pulp necrosis in >80%
of the cases.
Presence of toothache, response to percussion, cold
or heat provocation or EPT were compared with the
histological status of the pulp in 166 teeth extracted
because of caries or other causes (Seltzer et al. 1963).
The relationship between any of the signs and symp-
toms and the inflammatory condition of the pulp (either
low sensitivity or low specificity) was poor. The study
has methodological shortcomings.
The ability of various clinical signs and symptoms to
predict the outcome of pulp capping was assessed in a
prospective study (Matsuo et al. 1996). The material
comprised 44 permanent teeth with pulp exposure after
excavating deep caries. Pulps with profuse and linger-
ing bleeding had a significantly poorer outcome than
those with modest bleeding or a bleeding of short
duration. Pre-operative pain of minor intensity did not
affect the success rate. The sample is relatively small
ª 2012 International Endodontic Journal
Mejàre et al. Diagnosis of dental pulp
with wide confidence intervals, and the study has
methodological shortcomings.
To sum up, there is insufficient evidence to determine
whether the presence, nature and duration of tooth-
ache offer accurate information about the extent to
which dental pulp is inflamed. The evidence base is also
insufficient to assess the accuracy of other commonly
used clinical markers of pulp inflammation (Table 4).
Sensibility and vitality testing
Electric pulp testing
One study of moderate quality (Gopikrishna et al. 2007)
examined 80 patients who had a single-rooted tooth
affected by deep caries, indicating irreversible pulpitis,
or in need of endodontic therapy for other reasons.
Using direct visual inspection as the reference test, EPT
correctly identified 71% of the necrotic pulps (sensitiv-
ity) and 92% of the vital pulps (specificity). Table 5 is
based on the results of this study. With one exception
(Georgopoulou & Kerani 1989), all included studies on
EPT (Seltzer et al. 1963, Johnson et al. 1970, Dummer
et al. 1980, Olgart et al. 1988, Evans et al. 1999,
Kamburoğlu & Paksoy 2005, Weisleder et al. 2009)
had a similar, high specificity (>90%). Sensitivity varied
substantially in all included studies (range = 21–87%).
Cold test
In the same sample of 80 patients as described earlier
(Gopikrishna et al. 2007), cold test with tetrafluoroe-
thane correctly identified pulp necrosis in 81% of the
teeth (sensitivity) and vital pulps in 92% (specificity). In
the other included studies (Seltzer et al. 1963, Tyldesley
& Mumford 1970, Garfunkel et al. 1973, Dummer et al.
1980, Olgart et al. 1988, Georgopoulou & Kerani
1989, Evans et al. 1999, Petersson et al. 1999, Kam-
buroğlu & Paksoy 2005, Weisleder et al. 2009), the
specificity of a variety of cold tests ranged from 10 to
98%, whilst sensitivity with one exception reached
>75%.
Heat test
Six studies (Seltzer et al. 1963, Garfunkel et al. 1973,
Dummer et al. 1980, Olgart et al. 1988, Georgopoulou
& Kerani 1989, Petersson et al. 1999), all of low
quality, reported highly variable values of sensitivity
and specificity for thermal provocation by heat.
Combining tests
Two studies examined the accuracy of combining tests
(Seltzer et al. 1963, Weisleder et al. 2009). In one
International Endodontic Journal, 45, 597–613, 2012 601
602
Table 3 Main characteristics, results and quality rating of the 18 included studies on pulp diagnosis

Study design and

population Study
References Aim characteristics Index test Reference test Main results quality

Dummer Accuracy of Cross-sectional: Markers of pulp status: Histology of pulp after Loss of sleep because of pain:a Low
et al. (1980) clinical markers 75 permanent teeth to be Presence/absence of pain extraction: Se (nonsaveable) = 0.74, Sp = 0.74
of saveable/ extracted mainly because Character of pain Classification according Presence of pain:
Diagnosis of dental pulp Mejàre et al.

nonsaveable of pain Tenderness at apex to criteria by Seltzer Se (nonsaveable pulp) = 0.88, Sp =

pulps, and Intraoral swelling et al. (1963) 0.60
vitality tests Tenderness to percussion Dichotomized into: Tenderness to percussion:

International Endodontic Journal, 45, 597–613, 2012

Hypersensitivity to cold saveable pulp (chronic Se (nonsaveable) = 0.66, Sp = 0.88
and heat partial pulpitis) (n = 50) Hypersensitivity to heat:
Vitality test: and nonsaveable Se (nonsaveable) = 0.18, Sp = 0.92)
EPT (Scoonés Unipolar) pulp (severe Hypersensitivity to cold:
Cold (ethyl chloride) inflammation/necrosis) Se (nonsaveable) = 0.40, Sp = 0.84
Heated gutta-percha (n = 25) EPT:
Disease prevalence: Se (nonvital) = 0.21, Sp = 1.0
Nonsaveable pulp: 67% Cold test:
Nonvital pulp: 25% Se (nonvital) = 0.68, Sp = 0.70
Heat test:
Se (nonvital) = 0.95, Sp = 0.41
Eidelman Accuracy of Cross-sectional: Markers of pulp status: Histology of pulp after Correct classification of Low
et al. (1968) clinical markers 32 primary teeth in children Presence/absence, nature, extraction: histological diagnoses from all
of treatable/ aged 6–12 years duration and quality of Classification according to clinical markers:a 18 : 32 = 56%
nontreatable pain criteria by Seltzer et al. (1963) Combining clinical symptoms
pulps Pulp exposed during Dichotomized into: treatable (dull pain, pain upon percussion,
excavation pulp (chronic partial pulpitis): pulp exposure, radiographic evidence
Tenderness to percussion n = 10 and nontreatable pulp of deep caries, widened periodontal
Hypersensitivity to heat and (severe inflammation/necrosis): membrane):
cold (pain continued after n = 22 Se (nontreatable pulp) = 0.91,
stimulus removal) Disease prevalence: Sp = 0.40
Radiographic findings Nontreatable pulps: 69%
Vitality tests:
EPT, cold, heat

ª 2012 International Endodontic Journal

 Table 3 (Continued).

Study design and

population Study
References Aim characteristics Index test Reference test Main results quality

Evans et al. Accuracy of Cross-sectional: Markers of pulp status: Visual examination after pulp LDF with flux values at <7.0 and Low
(1999) clinical markers Sample 1: 67 teeth in 55 patients History of pain exposure amplitude values at <1.6:

ª 2012 International Endodontic Journal

of pulp vitality aged 8–35 years. Anterior teeth
subjected to dental trauma with
at least two signs of pulp
necrosis (loss of pulp
sensitivity, discoloration,
radiographic signs of
pathology)
Sample 2: 77 noninjured intact
teeth from the same or other
patients
Garfunkel et al. Accuracy of Cross-sectional:
(1973) clinical markers 132 teeth with painful pulp
of pulp status conditions in need of
endodontic therapy
Exclusion criteria: Teeth with
radiographic signs of apical
periodontitis, incomplete case
history, technical difficulties
(n = 23)
Georgopoulou & Accuracy of pulp Cross-sectional:
Kerani (1989) vitality test Patients scheduled for
methods endodontic treatment
168 patients (one tooth per
patient) aged 11–78 years
Presence of sinus tract
Tenderness to percussion
Coronal discoloration
Apical radiolucency
Inflammatory external
root resorption
Vitality test:
1. Laser Doppler
flowmetry (LDF)
2. EPT (Analytic Technology)
3. Cold (ethyl chloride)
Markers of pulp status:
Character of pain
Percussion tenderness
Cold test
Heat test
Character of pulp bleeding
Vitality tests:
EPT
Cold (ethyl chloride)
Heated gutta-percha
Markers of pulp status:
Vitality test:
EPT
Cold (ice)
Heated gutta-percha
Classification: Se = 1.0, Sp = 1.0
Whole pulp necrotic (n = 60) Cold:
Coronal pulp necrotic (n = 7) Se = 0.92, Sp = 0.89
Disease prevalence: EPT:
(Sample 1)Total pulp necrosis: Se = 0.87, Sp = 0.96
90% Discoloration:
Coronal pulp necrotic: 100% Se = 0.49, Sp = 0.97
Histology of extirpated pulp Clinical and histological diagnoses Low
Classification: correlated ina
Acute pulpitis (n = 35) 54 of 109 cases = 50%
Chronic pulpitis (n = 27) Cold:
Chronic pulpitis with partial Se (total necrosis) = 0.75, Sp = 0.57
necrosis (n = 39) Heat:
Total necrosis (n = 8) Se (total necrosis) = 0.63, Sp = 0.61
Disease prevalence:
Pulpitis = 57%
Partial or total necrosis = 43%
Visual examination after pulp EPT: Low
exposure Se = 0.94, Sp = 0.73
Classification: Cold:
Vital (n = 100) Se = 1.0, Sp = 0.62
Necrotic (n = 68) Heat:
Disease prevalence: Se = 1.0, Sp = 0.66
Necrotic pulp: 40%

International Endodontic Journal, 45, 597–613, 2012

Mejàre et al. Diagnosis of dental pulp

603
604
Table 3 (Continued).

Study design and

population Study
References Aim characteristics Index test Reference test Main results quality

Gopikrishna et al. Accuracy of pulp Cross-sectional:
(2007) vitality test 80 patients with one
methods single-rooted incisor, canine
or pre-molar requiring
endodontic therapy because
of either deep caries or
Markers of pulp status: Visual examination after pulp Pulse oximetry: Moderate
Vitality test: exposure (test sample only) Se = 1.0, Sp = 0.95
Blood oxygen saturation Classification: PPV = 0.95, NPV = 1.0
level by pulse oximeter Bleeding (vital) (n = 38) Cold:
monitor. Value <75% No bleeding (necrotic) (n = 42) Se = 0.81, Sp = 0.92
= nonvital Disease prevalence: PPV = 0.92, NPV = 0.81
Diagnosis of dental pulp Mejàre et al.

prosthodontics No bleeding (necrotic) 53%

EPT (Parker vitality tester) EPT:
Control: Contra-lateral Cold (tetrafluoroethane) Controls subjected to EPT and Se = 0.71, Sp = 0.92
sound tooth cold test only PPV = 0.91, NPV = 0.74

International Endodontic Journal, 45, 597–613, 2012

Guthrie et al. Accuracy of Cross-sectional: Markers of pulp status: Histology of pulp after Hemogram:a Low
(1965) biological and 44 primary and nine permanentWhite blood cell count extraction Se (total pulpitis) = 0.36, Sp = 0.64
clinical markers teeth in 27 children aged 4– (haemogram). Rise in Classification: Profuse bleeding:
of pulp 11 years with carious pulp neutrophils or Coronal (inflammation Se (total pulpitis) = 0.40, Sp = 0.89
inflammation exposure and bleeding pulp lymphocytes (‡10% = restricted History of spontaneous pain:
(coronal versus upon caries excavation elevated count) compared to pulp chamber) (n = 28) Se (total pulpitis) = 0.63, Sp = 0.79
total pulpitis) Controls: 14 primary and with peripheral counts Total (inflammation extending
permanent teeth with normal (finger punch). Character of into root canals) (n = 25)
pulps bleeding at exposure site Disease prevalence:
History of pain Total pulpitis: 47%
EPT
Hypersensitivity to ice, warm
gutta-percha
Percussion test
Tooth mobility test
Hasler & Mitchell Accuracy of Cross-sectional: Markers of pulp status: Histology of pulp after Abnormal reaction to heat:a Moderate
(1970) clinical markers 47 patients age 13–56 years EPT extraction Se (moderate/severe pulpitis) = 0.54,
as indicators of (mean 28 years).One tooth per Cold (ethyl chloride, Classification: Sp = 0.21
pulp status in patient ice) Heated gutta-percha No or minimal pulpitis (n = 34) Abnormal reaction to cold:
asymptomatic Control: Adjacent or Percussion test Moderate/severe pulpitis Se (moderate/severe pulpitis) = 0.85,
teeth with contra-lateral sound tooth Radiographic findings (n = 13) Sp = 0.12
extensive caries Disease prevalence: Abnormal reaction to percussion:
and suspected Moderate/severe pulpitis: 28% Se (moderate/severe pulpitis) = 0.77,
pulpitis Sp = 0.21
Pulp exposed by caries:
Se (moderate/severe pulpitis) = 0.77,
Sp = 0.88

ª 2012 International Endodontic Journal

 Table 3 (Continued).

Study design and

population Study
References Aim characteristics Index test Reference test Main results quality

Johnson et al. Accuracy of Cross-sectional: Markers of pulp status: Histology of pulp after Significant correlation of hyperaemia Low
(1970) clinical markers 706 extracted teeth in 94 Hypersensitivity to heat extraction with sensitivity to heata
of pulp status consecutive patients because (heated gutta-percha) and Classification: Cold:
and EPT in of full-mouth extraction or be cold (ethyl chloride) Hyperaemic stage (no Se (irreversible inflammation) = 0.35,
diagnosis of cause of caries, tooth ache, Vitality test: inflammatory cell infiltrates) Sp = 0.49
pulp marginal periodontitis, and EPT (Burton vitalometer) ‘Irreversible’ cellular Heat:

ª 2012 International Endodontic Journal

hyperaemia, prosthodontics inflammation or necrosis Se (irreversible inflammation) = 0.59,
irreversible 361 teeth pulp vitality tested Disease prevalence: Sp = 0.39
pulpitis, Hyperaemia: 31% EPT:
pulp necrosis Severe inflammation: 10% Se (pulp necrosis) = 0.57, Sp = 0.99
Necrosis: 7%
Kamburoğlu & Accuracy of Cross-sectional: Markers of pulp status: Visual inspection of exposed Sensibility to probing: Low
Paksoy (2005) clinical markers 93 teeth in 97 patients aged History of pain pulp Se (necrotic) = 1.0, Sp = 0.76
of vital and 15–65 years (mean 33 years) in Caries removal without Classification: Sensibility on caries removal:
necrotic pulp need of endodontic therapy anaesthesia Bleeding (n = 50) Se (necrotic) = 1.0, Sp = 1.0
because of caries Sensibility to probing No bleeding (necrotic) (n = 43) EPT
Comparison group: Adjacent or exposed pulp Disease prevalence: Se (necrotic) = 0.84, Sp = 0.96
contra-lateral sound teeth Percussion test Necrotic pulp: 46% Cold:
(n = 49) Radiographic examination Se (necrotic) = 0.93, Sp = 0.98
Vitality test: Percussion:
EPT (Parker electronics) Se (necrotic) = 0.19, Sp = 0.81
Cold (butan-propan gas) Widened lamina dura:
Se (necrotic) = 1.0, Sp = 0.80
Klausen et al. Significance of Cross-sectional: Markers of pulp status: Visual examination and Combined signs and symptoms, Low
(1985) clinical markers 74 patients with acute dental Ability to point out tooth probing of exposed pulp that is, constant pain, tenderness
in differential pain Interference with sleep Classification: to temperature changes, tooth feels
diagnosis of Exclusion criterion: Patients with Constant pain vital or necrotic pulp extruded, impaired mouth opening,
pulpitis, apical dubious or mixed diagnosis Tenderness to temperature radiography: normal or apical tenderness to palpation in apical
periodontitis changes and chewing rarefaction, marginal bone loss. region and mobility discriminated
(AP), marginal Tooth feels extruded Marginal periodontium: normal between diagnoses in 82% of the
periodontitis Impaired mouth opening. or deepened pocket cases
(MP) Reddening of the apical oral Disease prevalence: No or limited differential diagnostic
mucosa 1. Pulpitis 38% value of pain to sweet and sour,
Tenderness at apex, 2. AP 41% character or duration of pain, fever,
percussion, digital pressure 3. MP 12% colour of tooth, tenderness to
Tooth mobility 4. Pulpo-periodontitis 9% percussion, swelling of regional
Swollen regional lymph (excluded from analysis) lymph node, patient ability to point
nodes out tooth

International Endodontic Journal, 45, 597–613, 2012

Mejàre et al. Diagnosis of dental pulp

605
606
Table 3 (Continued).

Study design and

population Study
References Aim characteristics Index test Reference test Main results quality

Koch & Nyborg Accuracy of Cross-sectional: Markers of pulp status: Histology of pulp after Clinical assessments correlated with Low
(1970) clinical markers 48 painful primary lower molars Frequency and duration of extraction histological classification in 88%
of pulp status in tooth ache Classification: of the casesa
deciduous teeth Character of bleeding at pulp Inflammation restricted to Se (total pulpitis) = 0.90, Sp = 0.86
with deep caries exposure coronal pulp (n = 28)
Diagnosis of dental pulp Mejàre et al.

Thermal sensitivity Inflammation of one or more

Tenderness to percussion radicular pulps (total pulpitis)
and pressure (n = 20)

International Endodontic Journal, 45, 597–613, 2012

Gingival swelling and fistula Disease prevalence:
Radiographic findings Total pulpitis: 42%
Matsuo et al. Significance of Prospective cohort: Markers of pulp status: Success of treatment (pulp Overall success rate:a 80–83% Low
(1996) clinical markers 44 teeth in 38 patients History of pain capping) Character of bleeding the only
as predictors of (age 20–69 years) with Heat, cold and Criteria: significant predictor
the outcome of carious exposure and percussion test No clinical signs or symptoms Se (conspicuous bleeding not
pulp capping without extensive pain Colour, hardness of dentin of irreversible pulpitis, arresting at 30 s past
Exclusion criteria: surrounding pulp exposure tooth sensitive to EPT exposure) = 0.50, Sp = 0.86
Severe damage to the pulp Pulp exposure size Follow-up: ‡12 months
during caries excavation Bleeding character
(n = 3) Vitality tests:
EPT (Dentotest)
Cold (ethyl chloride,
temporary stopping)
Percussion
Olgart et al. Accuracy of Laser Cross-sectional/longitudinal Markers of pulp status: Visual examination and Sample 1 (pulp necrosis):a Low
(1988) Doppler study Vitality test: probing pulp exposure Se (necrosis) = 0.88, Sp = 1.0
flowmetry (LDF) Sample 1: 33 teeth in 25 Laser Doppler flowmetry Classification: Sample 2: LDF indicated recovering
in diagnosis of patients aged 7–20 years with Vital (n = 37) blood circulation in luxated teeth
pulp vitality in 1 year history of injury from Necrotic (n = 16) before regaining response to EPT in
traumatized trauma scheduled for Disease prevalence: (controls 16/20 teeth 3 weeks–28 months after
young endodontic excluded): traumatic injury
permanent treatment Necrotic pulp (no bleeding): 70%
anterior teeth Control: 33 noninjured teeth
Sample 2: 20 teeth in 18 patients
aged 7–16 years subjected to
moderate trauma and initially
nonsensitive to EPT

ª 2012 International Endodontic Journal

 Table 3 (Continued).

Study design and

population Study
References Aim characteristics Index test Reference test Main results quality

Petersson et al. Accuracy of pulp Cross-sectional Markers of pulp status: Visual inspection after pulp EPT: Low
(1999) vitality test Sample 1: Vitality test: exposure. (not sample 2) Se (nonvital) = 0.72, Sp = 0.90

ª 2012 International Endodontic Journal

methods 59 teeth in 56 patients EPT(Analytic Technology) Classification: Cold:
(21–79 years) scheduled for Cold (ethyl chloride) Vital (bleeding pulp) (n = 46) Se (nonvital) = 0.83, Sp = 0.90
endodontic treatment. Heated gutta-percha Nonvital (no bleeding) (n = 29) Heat:
Sample 2: (controls): 16 Disease prevalence: (sample 2 Se (nonvital) = 0.86, Sp = 0.57
teeth in nine included):
dental students with intact Nonvital pulp: 38%
teeth
Seltzer et al. Correlation of Cross-sectional: Markers of pulp status: Histology of pulp Localized pulpitis (a–d) versus total Low
(1963) clinical markers 166 teeth scheduled for Presence and character of after extraction pulpitis or necrosis (e–g):a
of pulp status extraction because of tooth pain Classification: Pain:
and tests with ache, orthodontic, periodontal Sensibility to percussion a. Intact uninflamed (n = 23) Se (total pulpitis) = 0.65, Sp = 0.76
histological or prosthetic reasons Radiographic signs. b. Atrophic (n = 40) Abnormal reaction to heat: Se (total
status of pulp Abnormal reaction to heat c. Intact with scattered pulpitis) = 0.31, Sp = 0.84
or cold inflammatory cells (n = 19) Abnormal reaction to cold:
EPT d. Chronic partial pulpitis with Se (total pulpitis) = 0.23, Sp = 0.80
Vitality test: partial necrosis (n = 24) Sensibility to percussion:
Pain (presence /absence) e. Chronic total pulpitis with Se (total pulpitis) = 0.38, Sp = 0.92
Percussion partial necrosis (n = 14) Vital versus necrotic pulp:
EPT (Burton vitalometer) f. Chronic total pulpitis (n = 22) Pain (presence/absence):
Cold (ice or ethyl chloride) g. Total necrosis (n = 22) Se (necrotic) = 0.36, Sp = 0.46
Heated gutta-percha or ball Dichotomized in EPT:
burnisher a–d = nonsuppurative (n = 106) Se (necrotic) = 0.72, Sp = 0.92
Heat and cold and Response to cold:
combined e–g = suppurative (n = 60) Se (necrotic) = 0.89, Sp = 0.24
Disease prevalence: Response to heat:
Total pulpitis/necrosis Se (necrotic) = 0.94, Sp = 0.29
(e–g): 35% Response to heat and cold: Se
(necrotic) = 0.78, Sp = 0.86

International Endodontic Journal, 45, 597–613, 2012

Mejàre et al. Diagnosis of dental pulp

607
608
Table 3 (Continued).

Study design and

population Study
References Aim characteristics Index test Reference test Main results quality

Tyldesley & Accuracy of Cross-sectional: Markers of pulp status: Histology of pulp after Localized (a–b) versus generalized Low
Mumford (1970) clinical markers 142 teeth scheduled for Character of pain extraction pulpitis/necrosis(c–d):a
as indicators of extraction because of Heat, cold and percussion Classification: Mild versus severe pain:
pulp status toothache test a. Normal/hyperaemic (n = 16) Se (c–d) = 0.68, Sp = 0.41
Vitality test: b. Acute localized pulpitis Intermittent versus constant pain:
Cold (n = 25) Se (c–d) = 0.37, Sp = 0.61
Heat c. Acute generalized and or Cold:
Diagnosis of dental pulp Mejàre et al.

Percussion chronic pulpitis (n = 69) Se (c–d) = 0.92, Sp = 0.12

d. Degeneration or necrosis Heat:
(n = 32) Se (c–d) = 0.92, Sp = 0.02

International Endodontic Journal, 45, 597–613, 2012

Disease prevalence: Percussion:
Localized pulpitis: 18% Se (c–d) = 0.16, Sp = 0.93
Generalized pulpitis: 49% Vital(a–c) versus necrotic(d):
Degenerated/ Cold:
necrotic pulp: 23% Se (necrotic) = 0.94, Sp = 0.10
Heat:
Se (necrotic) = 0.89, Sp = 0.05
Percussion:
Se (necrotic) = 0.28, Sp = 0.89
Weisleder et al. Diagnostic Cross-sectional: Markers of pulp status: Visual inspection after pulp EPT: Low
(2009) accuracy of EPT 150 patients (18–76 years) Vitality test: exposure Se (necrotic) = 0.75, Sp = 0. 92
and two cold undergoing endodontic EPT (Analytic Technology) Classification: Cold:
tests, separately treatment. One tooth per Cold (carbon dioxide, Vital (bleeding) (n = 64) Endo-ice: Se (necrotic) = 0.92, Sp = 0.76
and combined as patient Endo-ice) Necrotic (no bleeding, Carbon dioxide: Se (necrotic) = 0.89,
indicators of bleeding Sp = 0.76
pulp vitality in apical part only) (n = 86) All three test combined:
Disease prevalence: Se (necrotic) = 0.96, Sp = 0.92
Necrotic pulp: 57%

Se, sensitivity; Sp, specificity; EPT, electric pulp testing.

a
Sensitivity and specificity calculated by us from contingency tables reported in the original article.

ª 2012 International Endodontic Journal

 Mejàre et al. Diagnosis of dental pulp

Table 4 Quality of evidence of the diagnostic accuracy of abnormal reaction to heat, cold, percussion test and discontinuity of
dentin floor over the pulp for determining the status of vital pulp (no/minimal versus moderate/severe inflammation) in teeth with
deep caries. Data from Hasler & Mitchell (1970)
Rating according to
Study design/quality,
Sample size Sensitivity Specificity Quality of indirectness, consistency,
Test method (no of studies) (95% CI) (95% CI) evidence precision, publication bias

Heat 47 (1) 54 (29;77) 21 (10;37) ¯sss Study design/quality –1

(insufficient) Precision – 1
One study – 1
Cold 47 (1) 85 (58;96) 12 (5;27) ¯sss Study design/quality –1
(insufficient) Precision – 1
One study – 1
Percussion 47 (1) 77 (50;92) 21 (10;37) ¯sss Study design/quality –1
(insufficient) Precision – 1
One study – 1
Pulp exposed by caries 47 (1) 77 (50;92) 88 (73;95) ¯sss Study design/quality –1
(discontinuity of dentin (insufficient) Precision – 1
floor over the pulp). One study – 1

Table 5 Quality of evidence of the diagnostic accuracy of electric stimulation, pulse oximetry and cold test for determining pulp
vitality. Data from Gopikrishna et al. (2007)
Rating according to:
Study design/quality,
Sample size Sensitivity Specificity Quality of indirectness, consistency precision,
Test method (no of studies) (95% CI) (95% CI) evidence publication bias

Electric stimulation 80 (1) 71 (56;83) 92 (79;97) ¯sss Study design/quality – 1

(insufficient) Indirectness – 1
One study – 1
Pulse oximetry 80 (1) 100 (91;100) 95 (83;99) ¯sss Study design/quality – 1
(insufficient) Indirectness – 1
One study – 1
Cold 80 (1) 81 (67;90) 92 (79;97) ¯sss Study design/quality – 1
(insufficient) Indirectness – 1
One study – 1

study (Seltzer et al. 1963), combining cold and heat
tests increased specificity compared with the results of
each test separately, whilst sensitivity decreased. In
the other study (Weisleder et al. 2009), the combina-
tion of cold tests (carbon dioxide and Endo-ice) and
EPT improved the ability to correctly identify necrotic
pulps (sensitivity = 96%) and vital pulps (specific-
ity = 92%). Both studies have methodological short-
comings.
Assessment of blood flow
Two studies (Olgart et al. 1988, Evans et al. 1999)
reported high sensitivity and specificity for laser Dopp-
ler flowmetry (88–100% and 100%, respectively). The
reference tests were visual inspection of the pulp in
connection with subsequent endodontic therapy or
conventional pulp vitality tests (cold, heat and EPT).
Both studies suffer from methodological shortcomings.
A study of moderate quality (Gopikrishna et al. 2007)
compared pulse oximetry with direct inspection of the
pulp (reference test). All non-vital pulps were correctly
identified (sensitivity = 100%) and almost all vital
pulps (specificity = 95%).
Other clinical markers
Only one study reported on the accuracy of sensibility to
probing exposed dentin or a radiographically observed
widened periodontal membrane for differentiating be-
tween vital and necrotic pulps (Kamburoğlu & Paksoy
2005). Both tests yielded perfect sensitivity and rela-
tively high specificity (76–80%). The study has, how-
ever, several methodological shortcomings.

ª 2012 International Endodontic Journal International Endodontic Journal, 45, 597–613, 2012 609
 Diagnosis of dental pulp Mejàre et al.
To conclude, there is insufficient evidence to deter-
mine the diagnostic accuracy of tests used to assess
pulp vitality (Table 5).
Biological markers as indicators of pulp’s
inflammatory status
Whilst numerous efforts have been made to link biological
markers of inflammation, including inflammatory medi-
ators, to the inflammatory status of pulp, only one study
satisfied the inclusion criteria (Guthrie et al. 1965). In this
study, blood samples were taken from pulp exposures
induced by caries or other injuries. The samples were
analysed with regard to white blood cell counts. The cell
counts correlated poorly with the extent of pulp inflam-
mation as assessed by histology after tooth extraction
(sensitivity = 36% and specificity = 64%). Hence, there is
no scientific basis on which to assess the diagnostic value
of biological markers to determine the condition of pulp in
terms of reversible and irreversible pulpitis.
Discussion
The literature targeting the problem field addressed in
this systematic review is extensive. However, most of
the publications consist of narrative overviews describ-
ing methods, techniques and materials for the clinical
evaluation of the condition of pulp. In contrast, only a
few studies were designed for assessing the accuracy of
tests or methods. No systematic review that has
critically evaluated the scientific literature correspond-
ing to the research questions could be identified. It is
worth noting that most of the included studies in the
current review are out of date and relatively few have
assessed novel test methods in a clinical context.
A conceivable explanation for the lack of high-
quality studies could be the difficulty in obtaining a
good reference test. Dental pulp tissue is normally not
available for direct inspection or for microscopic or
other examinations, especially if the tooth is healthy
and in no need of endodontic treatment or extraction.
Formerly, such teeth were frequently available as they
were extracted if decayed by caries rather than being
treated endodontically. Healthy teeth were also often
sacrificed for prosthodontic reasons. Today, access to
such teeth is highly limited. Another explanation for
the lack of studies of good quality may be that cross-
sectional data have traditionally been regarded as the
only means, whilst the benefit of a prospective study
design has not been considered. Only one of the
included studies used this design (Matsuo et al. 1996).
610 International Endodontic Journal, 45, 597–613, 2012
Inflammatory mediator substances identified in pulps
exposed by caries or other injuries, for example,
prostaglandins (Cohen et al. 1985, Waterhouse et al.
2002), superoxide dismutase (Tulunoglu et al. 1998),
TNF-alfa (Pezelj-Ribaric et al. 2002), substance P
(Bowles et al. 2003) and MMPs (Zehnder et al. 2011),
may indicate pulp status and have the potential to
predict the outcome of treatment intended to maintain
an exposed pulp vital and asymptomatic, for example,
pulp capping or pulpotomy. Although markers of this
nature have been correlated with clinical symptoms,
no study satisfying the inclusion criteria could be
identified.
It must be recognized that the natural history of a
caries-induced pulpitis is not well delineated and
knowledge concerning the healing potential of injured
pulp is restricted. Considering that infection is often the
cause of inflammation, any inflamed pulp should be
able to heal if the source of infection is eliminated, as is
often the case in other body organs/systems. Thus,
caries-induced pulpitis ought to be reversible and the
pulp able to heal if caries is removed. An important pre-
requisite is, however, that infectious elements have not
established themselves permanently in the pulp cham-
ber. No study of sufficient quality could be identified
that assessed the relationship between markers of pulp
infection and the outcome of conservative treatment
(aimed at preserving pulp exposed by caries or other
forms of injury).
Quite a few studies assessed the accuracy of methods
for testing pulp vitality; tests that initiate pain response
to thermal or electric provocation have attracted most
attention. Intact, healthy teeth are often used as the
reference test without examining the true status of
these pulps (other than a positive response to thermal
and/or electric testing). This limits the value of such
studies in that overall diagnostic studies using a case–
control design overestimate test accuracy (Knottnerus
1995, Rutjes et al. 2006). Furthermore, the prevalence
of pulps with severe inflammation and/or necrosis is
relatively high in most of the studies because the
samples often consist of referred patients or teeth
scheduled for endodontic treatment or extraction.
Results based on such samples have an inherent risk
of so-called spectrum bias, implying that the study
population may not represent patients who would be
exposed to the test in daily clinical practice. Vitality
testing may also already have been performed before
referral. The effect of this is that the value of the test is
partly ‘used-up’, a phenomenon sometimes called
work-up bias (Begg 1987, Panzer et al. 1987). The
ª 2012 International Endodontic Journal

implication is that both sensitivity and specificity may
change if the test is carried out on another spectrum of
patients not exposed to such a prior selection process
(Sackett & Haynes 2002). It follows that a careful
description of the patient spectrum and how they are
selected is crucial to enable proper assumptions about
whether or not it is acceptable to generalize the results.
Laser Doppler flowmetry was introduced more than
20 years ago and has been proposed as an alternative
means of assessing pulp vitality. Yet, clinical applica-
bility has still not been ascertained. The method is also
expensive and requires technique-sensitive equipment.
A study examining the feasibility of the method in
clinical practice observed variable and uncertain results
when the test conditions were not highly standardized
(Roy et al. 2008). Another limitation is that the method
is useful only in teeth with a pulp chamber positioned
well above the gingival margin. Pulse oximetry is based
on a simpler and less costly technology. Whilst
promising, this method is also limited to teeth with
pulp tissue well within the crown portion of the tooth.
In general, there were major shortcomings in the
design, conduct and reporting of studies. The extent to
which they satisfied important quality criteria is
illustrated in Fig. 2. The population was inadequately
described in nearly all, and only one study used
consecutively chosen patients. The use of nonconsec-
Representative patient spectrum
Population adequately described
Reference test classifies the target condition correctly
Time interval between index- and reference test adequate
Reference test applied on all or on a randomized sample of patients
The same reference test irrespective of results of index test
Index test adequately described
Reference test adequately described
Index test interpreted without knowledge of results of reference test
Reference test interpreted without knowledge of results of index test
Uninterpretable test results reported
At least two independent examiners of reference test
Reliability concerning reference test reported
Precision of test results reported
Figure 2 Reporting of 14 quality criteria, modified after QUADAS (Whiting et al. 2003), of the 18 included studies regarding
accuracy of pulp diagnosis. Percentage distribution of yes/unclear/no of each criterion.
ª 2012 International Endodontic Journal
Mejàre et al. Diagnosis of dental pulp
utive patients tends to overestimate the accuracy of a
diagnostic method (Lijmer et al. 1999, Rutjes et al.
2006). In half of the studies, the index tests and
reference tests were insufficiently described. Few studies
had two independent assessors of the reference test,
which introduces an obvious risk for a biased assess-
ment of the pulp’s condition. Another serious short-
coming is that it was usually not possible to discern
whether the reference test was interpreted indepen-
dently and without knowledge of the results of the
index test. If the assessors interpret the reference test
knowing the results of the index test, there will be an
increased risk of overestimating test accuracy (Lijmer
et al. 1999). Precision (e.g. confidence intervals) of
point estimates was not reported in any of the studies.
In summary, there is a great need for improvement
in the design, conduct and reporting of studies on
diagnostic methods in endodontics. Tools for guiding
the performance of such studies can be found in
Standards for Reporting of Diagnostic Accuracy (Boss-
uyt et al. 2003), which corresponds to the Consort
Statement for randomised clinical studies (Moher et al.
2001).
This systematic review has revealed critical gaps in
knowledge concerning the effect of diagnostic tests
commonly used to determine the condition of pulp.
Thus, available research provides limited information
Yes Unclear No
100
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% %
International Endodontic Journal, 45, 597–613, 2012 611
 Diagnosis of dental pulp Mejàre et al.
about what distinguishes a treatable from a nontreat-
able pulpal inflammation in teeth subjected to deep
caries, trauma or other injury. Future research should
focus on exploring methods that can disclose whether a
vital but injured pulp can be maintained, or whether it
should be removed and replaced with a root filling.
Furthermore, the long-term benefit to the patient,
which is the ultimate goal of any diagnostic procedure,
should be evaluated.
Conclusion
The scientific evidence is insufficient (¯sss) to assess
the accuracy of the following clinical signs, symptoms
or tests used to determine the condition of pulp:
• hypersensibility to heat, response to cold, electric
stimulation or tenderness to percussion in asymp-
tomatic teeth with deep caries lesions,
• presence, character or duration of pain and
• in terms of reversible/irreversible pulp inflamma-
tion.
The evidence base is also insufficient (¯sss) to assess
the accuracy of the following:
• combining tests to determine the condition of pulp,
• electrical or thermal pulp testing or methods for
measuring pulpal blood circulation to determine
whether the pulp is vital or nonvital and
• biological markers of pulp inflammation, infection
or other tissue damage for predicting the outcome of
treatment intended to maintain an exposed pulp
vital and asymptomatic.
Conflict of interest
There were no conflicts of interest.
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Supporting information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1. Search terms for diagnosing the
condition of dental pulp in three databases: PUBMED
(NLM), EMBASE.COM (ELSEVIER) and COCHRANE
CENTRAL REGISTRY OF CONTROLLED TRIALS (WI-
LEY).
Appendix S2. Excluded articles.
Please note: Wiley-Blackwell are not responsible for
the content or functionality of any supporting materials
supplied by the authors. Any queries (other than
missing material) should be directed to the correspond-
ing author for the article.
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