DIAGNOSTIC PULP TESTING

-SEMINAR BY G.SREE HARSHA

17081036
BDS 4TH YEAR
 CONTENTS

• INTRODUCTION
• USES AND REQUIREMENTS

• CLASSIFICATION OF PULP TESTING

• PULP SENSIBILITY TESTS
• SAFETY CONCERNS OF PULP SENSIBILITY TESTS
• PULP VITALITY TESTS
• LIMITATIONS OF PULP TESTING
• RECENT DEVELOPMENTS IN PULP TESTING

• REFERENCES
 INTRODUCTION

• Dental pulp tests are investigations that provide valuable diagnostic and treatment planning
information to the dental clinician.
• Dental pulpal testing is a clinical and diagnostic aid used in dentistry to help establish the health
of dental pulp within pulp chamber and root canals of tooth.
• Pulp testing combined with information taken from history,examination,and other investigations
such as radiographs leads to diagnosis of underlying disease which can usually be reached
relatively easily.
 USES

• Diagnosis of endodontic pathology

• Localisation of tooth pain
• Differentiating between odontogenic and non-odontogenic pain
• Assessing pulpal status following dental trauma
• Establishment of pulpal health prior to prosthodontic treatment
 IDEAL REQUIREMENTS OF PULP TESTING

• Simple
• Non painful and non injurious
• Reproducible
• Standardized
• Accurate
• Inexpensive
 CLASSIFICATION OF PULP TESTING

• ACCORDING TO COMPONENT OF TEST :-

1. PULP VITALITY TESTING:
Assessment of pulp’s blood supply
2.PULP SENSIBILITY TESTING:
Assessment of the pulp’s sensory response
3.PULP SENSITIVITY:
condition of the pulp being very responsive to a stimulus
 PULP SENSIBILITY TESTING

1.THERMAL TESTS:
• First reported by Jack in 1899
• Two types of thermal tests are available:
a)Cold tests
b)Heat tests
 HEAT TESTS

Indications:
• Mainly performed when patients complaints of pain while taking hot food or liquid Agents
used:
1. Hot gutta –percha stick
2. Heated impression compound
3. Rubber polishing cups
4. Heated ball end instruments
5. Hot water
APPLICATION:
• Care should be taken before testing with heated gutta percha stick or impression compound as these
materials stick to tooth in order to prevent it lubricant is added
• Heated ball end instruments should not touch the tooth surface
• Heat tests should be applied not more than 5sec as it may result in lingering pain
DISADVANTAGES:
• Test may be difficult to use on posterior teeth because of limited access
• Major disadvantage is that excessive heat may result in pulp damage
 COLD TESTS

INDICATIONS:
• Patient complaints pain causes by taking cold food
Agents used:
1. Ice stick
2. Refrigerant spray/endo ice(1,1,1,2 tetrafluoro ethane)
3. Carbon dioxide snow/dry ice
4. Ethyl chloride spray
APPLICATION:
• Direct application of ice can be difficult and problematic so ice sticks is used and it is applied for
5sec on facial surface of teeth
• Carbon dioxide snow and endo ice can also be applied on full coverage restorations like
porcelain jacket crowns
ADVANTAGES:
• Pulp vitality can be noticed and less armentarium is needed
HEAT TEST
COLD TEST
 RESPONSES TO THERMAL TEST

1.No response to test - NON VITAL PULP

2.Mild response subsides in 1to 2 sec- NORMAL PULP
3.Strong –momentary pain subsides in1 to 2 sec-REVERSIBLE PULPITIS
4.Moderate to strong painful response that lingers for several seconds after stimulus has been
removed-IRREVERSIBLE PULPITIS
 ELECTRIC PULP TESTING

WORKING PRINCIPLE:
• Electric pulp testing works on premise that electrical stimuli cause an ionic change across neural
membrane there by inducing an action potential with a rapid hopping action at nodes of ranvier
in myelinated nerves
• The pathway for electric current is thought to be from the probe tip of test device to tooth along
the lines of enamel prisms and dentinal tubules and then through pulp tissue . The circuit is
completed via the patient wearing a lip clip or by touching the probe handle with his or her hand
• A tingling sensation will be felt by patient once the increasing voltage reaches the pain
threshold , but this threshold level varies between patients and teeth and is affected by factors
such as individual age ,perception ,tooth surface condition and resistance
• Jacobson found in an in vitro experiment involving incisors and premolars that placing probe tip
labially within the incisal or occlusal two thirds of crown gave more consistent results
• Electrolyte is used
 PROCEDURE OF EPT

1. ELECTRIC PULP TESTER/PROBE:

• Placed at incisal third on anterior teeth and middle third of posterior teeth as it having high nerve
density
2.Electrolyte is used- tooth paste or petroleum jelly
3. Circuit should be closed-by patient wearing a lip clip or by touching the probe handle with his
hand
 Describe the test to patient in a way that will reduce anxiety

Isolate the area of teeth be tested with cotton rolls and saliva ejectors
and air dry all teeth
Check the electric pulp tester for function and determine current
passing

Apply electrolyte on teeth electrode and place it against enamel

Retract the patient cheek or lip away from tooth electrode with free
hand

Introduce minimal current on tooth and increase the current slowly

asking patient when tingling /warmth sensation occurs

Record the results according to numerical scale

ELECTRIC PULP TESTING
EPT
 LIMITATIONS OF EPT

• Electric pulp testing depends on the vital sensory fibers present in the pulp .Its disadvantage is that it
does not provide any information about the vascular supply of pulp , which is true determinant of pulp
vitality.
• Electric pulp tests are known to be unreliable in many instances producing false results in healthy
immature teeth with incompletely formed roots which may be erupting since the teeth may take up to
5years before the maximum number of myelinated fibres reaches the pulp Dentin border at the plexus
of Raschkow
• Recently traumatized teeth undergoing pulp repair may also have false results and thus may not
respond to EPT. In humans many clinical observations from dental trauma studies have indicated
that it can take pulp a minimum of 4 to 6 weeks following trauma for sufficient recovery of
sensation to obtain valid pulp testing results
• They are not recommended for use on crowned teeth are in patients wearing orthodontic bands
• Anxious or young patients may have premature are false positive response due to expectation of
feeling an unpleasant situation
• False positive response: this means that the pulp is necrotic yet the patient will signal that there
is sensation in the tooth .This may be due to electrode contact with metal restoration or the
gingiva, patient anxiety ,liquefaction necrosis and failure to isolate tooth before testing
• False negative response :
This means that the pulp is vital yet the patients will be unresponsive to electric pulp test . This
may be seen in inadequate contact between the electrode and enamel ,recently traumatized tooth
,calcification of root canal, recently erupted tooth with an immature apex ,partial necrosis and in a
patients who has been heavily premedicated with analgesics, narcotics or alcohol tranquilizers
 SAFETY CONCERNS OF PULP SENSIBILITY
TESTS

Safety concerns of heat test:

• Zach etal, noted that damn increase of 11 degree centigrade that occurs during restorative
procedures without adequate cooling can harm the pulp therefore prolonged contact with heat is
a safety concern
• Fuss etal in vitro study, show that heat testing using gutta percha increased pulp temperature by
less than 2 degrees with less than 5 seconds of application- a temperature change that is unlikely
to have caused pulp damage
SAFETY CONCERNS OF COLD TESTS:
• Concerns have been raised in the past about the possible damaging effects of coal testing agents
• However subsequent studies by peter et al and fuss et al concluded that these concern were
insignificant
• Lutz etal, found that cracks maybe formed on enamel surfaces from direct carbon dioxide snow
contact
SAFETY CONCERNS OF EPT:
• In EPT, the current produced by testing device may cause danger to patients who have cardiac
pacemakers, with the risk of precipitating cardiac arrhythmia via pacemaker interference, but
more recent studies have shown no interference from EPT are similar electrical dental devices
 PULP VITALITY TESTS

Laser Doppler Flowmetry:

• It is a new method of evaluating pulp vitality by measuring the velocity of RBC in capillaries
• Laser Doppler Flowmetry technique was first described in dental literature in 1986 by GAZELIUS
ET AL
• This electro optical technique uses laser source that is aimed at pulp and laser light travels to the
pulp using dentinal tubules as guides. The total backscattered reflected light from circulating blood
cells is Doppler shifted and has different frequency to static surrounding tissues
• The total back scattered light is processed to produce an output signal
• In order to record the Doppler shift of blood cells both the probe and tooth need to be
completely still. Hence ,stabilizing splint made of polyvinyl siloxane is usually used
• 2to 3 millimetre from the gingival margin is the ideal position for the probe tip probe as it creates
a balance between minimising the noise and having a recognisable signal volume
LASER DOPPLER FLOWMETRY
LASER DOPPLER FLOWMETER TEST
 PULSE OXIMETRY

• This is an oxygen saturation monitoring device widely used in medical practice for recording blood oxygen
saturation levels during the administration of intravenous anaesthesia
• It was invented by AOYAGI in early 1970
• Pulse oximetry sensor consists of 2 light emitting diodes one to transmit red light another to transmit
infrared light and a photodetector on the opposite side of the vascular bed. The light emitting diode
transmits light through vascular bed such as finger or ear. oxygenated haemoglobin and deoxygenated
haemoglobin absorbs different amount of red/ infrared light
• The pulsatile changes in the blood volume causes periodic changes in amount of red/infrared light absorbed
by vascular bed before reaching the photodetector
• Compared to laser Doppler flowmeters, pulse oximeters are relatively expensive
PULSE OXIMETRY TEST
 LIMITATIONS OF PULP TESTING

False positive result:

• A false positive response is where a non vital tooth appears to respond postively to testing
• This may occur in anxious or young patients who may report a premature response because they are
anticipating an unpleasant condition
• Necrotic breakdown products in one part of root canal system can conduct electric currents to viable
nerve tissue in adjacent areas thereby resulting in a false positive result
• Contact with metal restorations may result in conduction of current to periodontium giving false
vital response
False negative results:
• A false negative result means that a vital tooth has not responded was positively to testing
• This may be seen in teeth with incomplete root development, which have a higher threshold to testing
and require a stronger stimulation than normal to elicit response
• Patients with psychotic disorders may not respond to pulp testing

Sensitivity:
• Sensitivity denotes the ability of a test to detect diseases in patients who actually have a disease. Thus,
the sensitivity of pulp vitality test indicates the test’s ability to identify non vital tooth
sensitivity=number of persons with positive result of disease
total number of persons with disease who were tested
Specificity:
• Specificity on the other hand describes the ability of a test to detect the absence of disease .
Thus, the specificity of a pulp vitality test indicates test stability to identify vital teeth.
• It is defined as ratio of number of patients with negative test result who do not have disease
divided by total no. of tested patients without disease
 RECENT DEVELOPMENT IN PULP TESTING

Detection of interleukins:
• Interleukins are involved in modulating bone cell activity. Interleukin 1 has shown to be potent
stimuli of bone resorption in in organ culture
• periapical sample exhibited significant activity of interleukin 1 beta whereas normal pulp had no
activity
Gas desaturation:
• GOHO conducted a study on permanent and deciduous teeth, and found that SaO2 an average
was in the range of 93 - 94% in comparison to the the SaO2 taken from index fingers which is
approximately 97%.10 root filled teeth as controls all of which record 0%SaO2
Thermographic imaging:
• A colour image is produced which indicates a relative difference in temperature in both superficial
and deep areas
• Computerized controlled infrared TI for human teeth is under investigation to assess pulp vitality
Optical reflection vitalometry:
• In this method, one can see the pulse of pulp or oral mucosa.This device is yet to be clinically
accepted and commercially available
Colour powder Doppler:
• Colour power Doppler flowmetry allows the presence of blood flow with in the tissue of
interest to be observed .The intensity of Doppler signal is represented by changes in real time
on a graph and is also shown in form of colour spots on grayscale image(color)
• Positive Doppler shifts are caused by blood moving toward the transducer and are represented in
red, whereas negative Doppler shift are caused by blood moving in the opposite direction and are
represented in blue
• It is based on integrated power spectrum and can disclose minor vessels
Radiolabelled microsphere
• pulpal blood flow has been estimated in intact teeth using radiolabelled microspheres are found
to be in the range 20- 60ml/min/100 gram tissue
Xenon133:
• The tooth to be tested has to be injected with 0.2 mci xenon133 in saline by buccal intra ligament
injection then radiation counts where detected from teeth using a small cadmium telluride
radiation probe
• pulp less teeth had relative constant counts for the duration of experiment in vital teeth the initial
counts where much higher than a gradual decrease that occurs with time
• CHOLESTERIC LIQUID CRYSTALS:
• When applied on tooth surface the crystals went through color changes that were compared with
adjacent or contra lateral teeth
• Their usage in detecting pulp vitality is based on principle that teeth in intact blood supply have
higher tooth surface temperature compared with teeth that had no blood supply.
 REFERENCES

• MARWAH, NIKHIL. TEXTBOOK OF PEDIATRIC DENTISTRY. JAYPEE BROTHERS,

MEDICAL PUBLISHERS PVT. LIMITED, 2018.
• TANDON, SHOBHA. TEXTBOOK OF PEDODONTICS. PARAS MEDICAL PUBLISHER,
2009.
• MUTHU SWAMY. PEDIATRIC DENTISTRY PRINCIPLES AND PRACTICE ,2009.
THANK YOU