Endodontic Topics 2004, 7, 213 Printed in Denmark.

All rights reserved

Copyright r Blackwell Munksgaard

ENDODONTIC TOPICS 2004

Technical equipment for assessment of dental pulp status

THOMAS R. PITT FORD & SHANON PATEL
Assessment of dental pulp status is normally undertaken using thermal or electrical tests that indicate the functioning of Ad nerve bers. The tests are quick and usually reliable, although nothing is absolute. Newer tests have involved assessment of blood ow, and of these laser Doppler owmetry has been the most widely used and benecial to patients particularly after traumatic injury. The high cost of owmeters and the time-consuming procedure have limited uptake.

The diagnosis of dental pulp status should be seen as a synthesis of history, clinical examination, special tests, and radiological examination, and not as the outcome of one specic test. Too often dentists base treatment decisions on limited information that may be contradictory; this is not in the best interests of patients. Vitality testing is an important aid in the diagnosis of pulp disease and apical periodontitis. If the pulp is deemed to be unhealthy as a result of the diagnostic synthesis, then endodontic treatment is indicated. In particular, pulp vitality testing should be carried out on traumatized teeth over an extended period to monitor their vitality following the traumatic incident, as teeth which may initially not respond to testing may well do so after a period of months (1, 2). It is important to assess pulp vitality prior to undertaking extensive tooth preparation in order to improve the prognosis of the restoration (3). It is also desirable to conrm periodically continued pulp vitality in teeth that have undergone pulp preservation procedures or have had extensive restorations (4). As the dental pulp is enclosed in an opaque tooth, the assessment of pulp vitality is undertaken by: looking for clinical or radiological evidence of pulp necrosis or apical periodontitis; investigating nerve conduction; or examining blood ow. Diagnosis must not be made on the strength of one piece of evidence, but from all the evidence derived from the history and the examination.

Sensitivity testing
Currently, the most widely used vitality testers assess the integrity of the Ad nerve bers in the dentinepulp complex by briey applying the stimulus to the outer surface of the tooth. If the Ad nerve bers are successfully stimulated, the patient will respond by acknowledging a brief sharp sensation/tingling from the tooth. The test indicates that the nerve bers are functioning but does not give any indication of blood ow in the pulp, or whether it is partially damaged. If there is no blood ow in the pulp, it will rapidly become anoxic and the Ad bers will cease to function. However, there are instances, for example, after trauma, where there is blood ow in the pulp but the Ad nerve bers are not functioning.

Thermal testing
Thermal testing relies upon applying heat or cold to a localized part of the tooth to stimulate Ad nerve bers within the dental pulp. When the test is applied to a healthy pulp it results in a sharp localized pain/tingling sensation for the duration of the applied test and for a few seconds after removal of the stimulus (positive response). A pulp response lasting more than half a minute after the stimulus has been removed is frequently interpreted as indicating an irreversibly inamed pulp. No response from the patient to such

Assessment of dental pulp status

stimulation is normally regarded as an indication of a necrotic pulp (negative response). The outcome of such testing is never absolutely certain, and that is why diagnosis must not rely on a single test.

Cold tests
It is believed that cold thermal testing causes contraction of the dentinal uid within the dentinal tubules; this results in rapid outward ow of uid within the patent tubules (5, 6). The rapid movement of dentinal uid results in hydrodynamic forces acting on the Ad nerve mechanoreceptors within the pulpdentine complex leading to a sharp sensation lasting for the duration of the thermal test (7). Currently, there are several different cold tests that may be applied to teeth, the major difference between them being the degree of cold. Ice sticks can be made in the dental surgery by freezing water in local anesthetic needle sheaths, which have not been contaminated or have been adequately disinfected. When required, they may be taken out of the freezer and briey run under the tap to melt the surface thus allowing the ice stick to be removed from the plastic sheath. One half of the ice stick is then wrapped with gauze to act as a handle; the other end may then be applied to the tooth under investigation. Ethyl chloride (boiling point 41C) may be sprayed on to a cotton pledget resulting in the formation of ice crystals; it is then applied to the tooth. Dichlorodiuoro-methane (DDM) (boiling point 501C) is a compressed refrigerant spray (Fig. 1), which can similarly be sprayed on to a cotton pledget and applied to the tooth under investigation (Fig. 2). More recently, ozone friendly non-chlorouorocarbon sprays have been introduced in certain countries (8). Another effective cold test is carbon dioxide (CO2) snow (boiling point 721C). The CO2 gas is released from a gas cylinder into a plastic plunger mechanism (Fig. 3) and compressed to produce a stick of CO2. By using a special applicator it may then be applied to the tooth under investigation (Fig. 4). This investigation is especially effective when attempting to assess teeth that have been restored with full coverage metal restorations (9). Concerns regarding possible damage to enamel and healthy pulps of teeth from the extreme cold of this test appear to be unfounded (10). The colder tests (DDM and CO2 snow) appear to be the more reliable than ethyl chloride (8, 11) in stimulating vital teeth;

Fig. 1. A container of compressed refrigerant spray, dichloro-diuoro-methane (Endo-Frost, Roeko, Langenau, Germany).

Fig. 2. Iced cotton pellet in tweezers following spraying of Endo-Frost.

this may be due to their greater rate of temperature reduction (12). Ice-cold water is another useful and inexpensive test. The tooth under investigation is isolated with rubber dam and then bathed with water from a syringe (Fig. 5).

Pitt Ford & Patel

very clear response from the patient (8). Cold tests should be applied until the patient denitely responds to the stimulus or for a maximum of 15 s, whichever comes rst (12). Cold tests have appeared to be more reliable than heat tests (3, 13). There is a general consensus that the colder the stimulus, the more effective the investigation is in assessing the status of the nerve supply within the tooth (8, 9, 12, 14).

Heat tests
A gutta-percha stick may be heated with a naked ame or an electric heater until it becomes soft and glistens (15) and applied to the Vaseline-coated surface of the tooth under investigation (Fig. 6). It has been believed that a tooth-surface temperature as high as 1501C could be achieved with this technique (16); guttapercha softens at 651C and may be heated in delivery devices up to 2001C. This test may be difcult to use on posterior teeth because of limited access (3). The disadvantage of using heated gutta-percha is that prolonged heating could result in pulp damage (17). Prolonged heat application will result in bi-phasic stimulation of initially Ad bers and then C bers within the pulp (18) resulting in a lingering pain; therefore, heat tests should be applied for no more than 5 s. Inadequate heating of the gutta-percha stick could result in the stimulus being too weak to elicit a response from the pulp (19). The tooth under investigation may be isolated with rubber dam and submerged with hot water from a syringe (20); this is not only the most effective method of testing the entire crown instead of just one aspect but

Fig. 3. Plastic cartridge attached to a cylinder of CO2.

Fig. 4. A stick of dry ice in its applicator on the tooth.

Fig. 5. Tooth isolated with rubber dam and bathed in cold water.

The advantages of this cold test are that the entire tooth is cooled down and teeth restored with full coverage metal restorations may be evaluated, thus resulting in a

Fig. 6. Heated stick of gutta-percha (Obtura) applying heat to a tooth.

Assessment of dental pulp status

Fig. 8. An isolated tooth undergoing electric pulp testing. Electrical conducting gel is present between the electrode and the tooth.

Fig. 7. A rubber cup applied to a tooth to generate frictional heat.

also allows rapid heating of the tooth. Frictional heat may be generated by using a rubber cup intended for prophylaxis (without paste) against the buccal aspect of a tooth (Fig. 7) (20, 21). The normal use of thermal tests on teeth has been shown not to be harmful to healthy pulp tissue (10, 22).

Electric pulp testing

The objective of electric pulp testing is to stimulate intact Ad nerves in the pulpdentine complex by applying an electric current on the tooth surface. A positive result from electric pulp testing is a result of an ionic shift in the dentinal uid within the tubules causing local depolarization and subsequent generation of an action potential from the intact nerve (23). The electric pulp tester consists of a battery-operated unit, which is connected to a probe that is applied to the tooth under investigation. The electrical circuit is completed by the patient holding the rear end of the handle of the probe (Fig. 8), or by placing a hook over the patients lower lip (Fig. 9). Two widely used pulp testers are the Analytic Technology pulp tester and the Vitality Scanner (Analytic Sybron Dental Specialities, Orange, CA, USA). Electric pulp testers function by producing a pulsating electrical stimulus, the intensity of which automatically begins from a very low value to
Fig. 9. An isolated tooth undergoing electric pulp testing. A hook on the patients lip completes the circuit. Rubber dam has been used to isolate the tooth from those adjacent.

prevent unnecessarily excessive stimulation and discomfort. The intensity of the electrical stimulus steadily increases at a preselected rate; a note is made of the reading on the digital display when the patient acknowledges a warm or tingling sensation. The output characteristics of this unit have been investigated (24). The rate of voltage increase was also found to vary depending on the device used. A further investigation concluded that there was no consistency in threshold excitation values for healthy teeth (25). The readout is not a quantitative measurement of the health of the pulp, and therefore does not indicate to what extent the pulp is healthy/unhealthy; a response only implies that the Ad bers are sufciently healthy to function.

Pitt Ford & Patel

may result in a lowering of the response threshold due to increased exposure of dentine (28). Multi-rooted teeth which give a negative result on one aspect may be tested on the opposite surface to ensure that as much of the pulp as possible has been stimulated.

General considerations of sensitivity tests

The patient should be advised of the purpose of the test, what to expect, and also reassured that the aim of the test is not to elicit an unpleasant response. A vital contralateral tooth should be tested prior to assessing the tooth under investigation. First, this allows the patient to learn what to expect with the test, and secondly gives the clinician an idea of the duration of the thermal test and also the patients response. To improve objectivity the tests should be repeated after a recovery period of 1 min, unless too much discomfort has been caused. The teeth on either side of the tooth being assessed should also be tested as this will aid in diagnosis. A large clinical study assessed by thermal and electric pulp testing 166 teeth, which were subsequently extracted and examined histologically (21). Although it was concluded that there was a poor overall correlation between clinical signs and the pathological state of the pulp, there did appear to be a relationship between a negative response to electric pulp tester and total pulp necrosis. A similar investigation (33) that assessed 75 teeth also found no relationship between the condition of the pulp from the clinical examination and investigation using the same complex histological classication (seven pulp state categories). However, when the data from this investigation were examined at a broader level, a correlation was apparent between total necrosis and a negative response to thermal testing. With both investigations there is no mention of how soon after the clinical examination the teeth were extracted. In one investigation (33) only stepserial histological sections were examined; thus, potentially useful information may not have been evaluated. A retrospective evaluation was carried out on the results of ve studies in which teeth had been clinically assessed, extracted and examined histologically (34). It was concluded that the results of diagnostic investigations were more likely to be correct in cases of diseasefree teeth rather than in teeth with pulp disease. Responses from thermal and electric pulp testing are not quantitative and therefore do not give information on how healthy or to what degree the pulp is inamed.

Fig. 10. A small tip for the electric pulp tester can be used under crown margins.

The electric pulp tester is technique sensitive (26, 27). The tooth to be assessed should be sufciently dry to prevent electrical conduction to adjacent teeth, or to the periodontium although the current is unlikely to be sufcient (24). A conducting medium should be applied to the electrode to ensure maximum current passes from the electrode to the tooth surface (27). It is important to make sure that the electrode lies at against the surface of the tooth (therefore maximising electrode contact area) as this also reduces the response threshold value (27). Cellulose strips or rubber dam strips may be used interproximally to prevent electrical conduction to adjacent teeth (Fig. 9). Direct contact with tooth tissue is required, and this may be a problem with extensively restored teeth (9). However, a small tip is available that may be used instead of the standard electrode tip; this allows tooth contact below a crown margin where there is slight gingival recession (Fig. 10). The threshold excitation value is inuenced by the position of the electrode on the tooth; for example, the lowest threshold for response and therefore most desirable area of assessment in incisor teeth is at the incisal edge, where the enamel is thinnest or absent (28). The tester should be applied on the tooth surface adjacent to a pulp horn, that is, the region of highest nerve density within the pulp (2931); this is the incisal-third of anterior teeth and the mid-third of posterior teeth. The threshold for response may be inuenced by the thickness of the enamel and dentine overlying the pulp (18, 32); therefore, it has been considered that the response threshold in healthy teeth may be lowest in incisors, slightly greater in premolars and greatest in molar teeth. However, in one study using two pulp testers, the threshold was lower in premolars than incisors (25). Signs of tooth surface loss

Assessment of dental pulp status

Problems with current devices/assessing pulp status

At present the techniques that are commonly used in everyday practice (i.e. thermal and electric pulp testing) assess whether the nerve supply within the tooth is intact. A positive result conrms that the Ad nerves in this region of the pulp chamber are responsive; the inference is that this can be interpreted as there being an intact blood supply within the tooth. However, the only true means of assessing the health of the pulp is to determine that there is a normal ow of blood within the tooth (Table 1). Thermal tests are highly subjective as they are wholly dependent on the patients response to testing. There is no accurate or objective method of assessing how responsive the tooth under investigation is to testing, nor of comparing with a previous measurement. In contrast, electric pulp testers have numerical digital displays, which allow the operator to note down the reading, and compare with a previous reading.

Table 2. False responses from pulp testing

False positives  Anxious patients  Liquefaction necrosis  Contact with metal restorations  Vital tissue still present in partially necrotic root canal system False negatives  Incomplete root development  Recently traumatized teeth  Sclerosed canals  Recent orthodontic activation  Patients with psychotic disorders

False-positive results (i.e. non-vital teeth responding positively to testing)

These are summarized in Table 2. Because sensitivity tests are reliant on the patients response, a premature response or even a false-positive response may occur in anxious or young patients who are expecting to feel an unpleasant sensation (27, 28). It has been suggested that localized breakdown products in one part of the root canal system may be able to conduct the electric current from an electric pulp tester to viable nerve tissue in adjacent areas thereby resulting in a falsepositive result (33). Contact with metal restorations may possibly result in conduction of the current to the
Table 1. Ideal features of a pulp vitality tester
Assesses pulp blood ow Objective measurements Free from error Effective for heavily restored teeth Effective when the pulp size is reduced Quick and easy to use Inexpensive

periodontium, giving a false-vital response (14); the same may occur with inadequately dried teeth prior to testing (14, 35). Multi-rooted teeth pose an additional problem because the pulp in the tooth under investigation may be partially necrotic; therefore, part of the root canal system may still possess relatively healthy pulp tissue (36). There has been a report of three previously root-treated maxillary molars, which responded positively to testing, and on root canal retreating the teeth untreated second mesio-buccal canals were identied (36); it was concluded that viable tissue in the second mesio-buccal canal resulted in the positive response.

False-negative results (i.e. vital teeth responding negatively to testing)

These are also summarized in Table 2. Teeth with incomplete root development may have a higher threshold to testing; thus, a stronger stimulation may be needed to elicit a response compared with teeth with complete root development (37). This is because teeth erupt and become functional before the completion of neural development (38, 39). In these situations cold testing with DDM or CO2 snow appears to be more reliable than electric pulp testing (12, 37). It has also been suggested that cold tests may not be reliable in teeth with obliteration of the coronal pulp as the excessive dentine may act as an insulator to cold tests (40). Traumatized teeth may not initially respond to

Pitt Ford & Patel

thermal and/or electric pulp testing or only respond weakly (28). It has been postulated that non-responsive recently traumatized immature teeth do not respond to sensitivity testing because the nerves have been ruptured (41). However, the pulps of the teeth may still be vital as their blood vessels may remain intact or have revascularized. Therefore, traumatized teeth should always be carefully monitored at periodic intervals as their pulps may revascularize and their nerve bers regain function. The vitality of teeth after the activation of xed orthodontic appliances has been assessed by thermal and electric pulp testing for up to 2 months afterwards (42). A lack of response was found to the electric pulp tester for up to 2 months after activation of the appliances; however, thermal testing appeared more reliable. This may be due to a reduction in blood ow and possible anoxia of the Ad nerves (43). Patients with psychotic disorders may not respond to pulp testing (27). It has been reported that individuals who are under the inuence of sedative drugs/alcohol may either not respond or respond to stronger stimulation due to their increased threshold to nerve excitation (44). allow for future comparison of thermographic imaging with laser Doppler owmetry (LDF) in order to determine pulp blood ow (49). A disadvantage of this technique is that teeth must be isolated with rubber dam, after which a period of acclimatization is necessary prior to imaging (50). The technique is complex and also requires the subjects to be rested for 1 h prior to testing (50).

Photoplethysmography
The detection of blood ow within the pulp by passing light through the tooth has been reported (51). Hemoglobin absorbs certain wavelengths of light, while the remaining light passes through the tooth and is detected by a receptor. Photoplethysmography has been compared with LDF in experiments on skin, and found to be of similar value (52). The technique has not been successfully developed further for dental application apart from one recent investigation (53).

LDF
LDF is a non-invasive method of assessing and measuring the blood ow of pulp tissue (54). Laser light is directed onto the tooth under investigation by securing a ber-optic probe against the tooth surface. The laser light from the probe (Fig. 11) passes along the enamel prisms to the enameldentine junction and the S-shaped dentinal tubules, which act as light guides, to the pulp (Fig. 12) (55, 56). Light absorbed by red blood cells in the capillary plexus is scattered and undergoes a shift in frequency according to the Doppler principle; light absorbed by stationary objects does not undergo a shift in frequency. A signal is produced which measures the ux of the blood cells (number of red blood cells times mean velocity). The proportion of Doppler-shifted light is detected by a photodetector. The detected signal is weak and therefore highly amplied; a mathematical calculation using Fourier analysis can be used to gain more meaningful information (57). A trace of signals from vital and nonvital teeth is shown in Fig. 13. Fourier analysis of the traces has revealed a heart beat frequency in the vital tooth, but not in the non-vital tooth (Fig. 14), and is therefore an effective discriminator. This technique is more objective and reliable than sensitivity testing in assessing and following up the pulp status of traumatized teeth (1, 54, 58, 59). It is usually

Physiometric testing
Crown surface temperature/heat registration
The evaluation of tooth-surface temperature as a means of assessing the vitality of teeth has been reported. Cholesteric liquid crystals, which exhibit different colors when heated, have been used in one study to determine pulp vitality (45). It was based on the principle that teeth with an intact pulp blood supply (vital/healthy pulp status) had a warmer tooth-surface temperature compared with teeth that had no blood supply. Surface temperature of teeth has been measured over a period of time at 15-s intervals using an electric thermometer attached to a surface probe, which was placed in contact with the tooth (46, 47). These studies showed that after teeth were cooled, there was only a rise in the temperature of vital teeth. Thermographic imaging has been used to show that when teeth have been cooled, non-vital teeth were slower to rewarm than vital teeth (48). Further work in this area has resulted in the development of an index to

Assessment of dental pulp status

Fig. 12. A LDF probe applied to a sectioned tooth showing the passage of light via the enamel prisms and dentinal tubules to the pulp.

Fig. 11. A LDF probe showing laser light guides.

used when available evidence is contradictory. Several reports have found earlier positive responses with LDF when compared with sensitivity testing in traumatized teeth (2, 60, 61), therefore avoiding unnecessary invasive treatment. In addition, LDF offers the advantage of storing data, allowing initial baseline measurements to be compared objectively with subsequent LDF measurements (61). There has been little use of LDF on decayed or heavily restored teeth (62). Unfortunately there are some drawbacks to LDF. The device is technique sensitive and requires preparation of a putty splint to hold the probes (Figs 15 and 16), and a patient who is relaxed and not anxious. It is necessary to ensure that the reected signal only comes from the pulp; this may be readily achieved with an opaque putty splint (63) or by isolating the teeth with rubber dam (64). In the case of following up teeth that have had traumatic injuries, reusing the putty splint ensures that the probe is reapplied to the same site and therefore to the same part of the pulp unless growth

Fig. 13. A LDF trace showing signals from two teeth; the upper is from a vital tooth while the lower is from a nonvital tooth.

prevents repositioning of the splint. The available LDF equipment has primarily been developed for medical use (Fig. 17) and is expensive. It is probably for this reason that LDF has generally not been used as a routine special investigation in dental practice. It has been used to observe the effects of local anesthetic solutions on pulp blood ow during anesthesia (63, 65).

Pulse oximetry
Pulse oximetry is a non-invasive technique to measure oxygen saturation levels within the blood of patients

Pitt Ford & Patel

Fig. 14. Fourier analysis of the LDF traces reveals the vital tooth to have a heart beat frequency (lower) while there is no such frequency peak for the non-vital tooth (upper).

Fig. 17. A laser Doppler owmeter (Moor Instruments, Axminster, UK).

Fig. 15. Two probes have been placed in a putty impression splint for accurate location on the teeth while the trace is being recorded.

under general anesthesia or sedation; this device has been modied to investigate its suitability for assessing pulp vitality (66, 67). A modied probe has been tted over the tooth, and diodes emit two wavelengths of light (infra-red and red) that are intended to pass through the tooth and are then detected by a photodetector diode. The oxygenation saturation of the pulp blood supply is calculated from the ratio of absorption of the oxygenated and deoxygenated blood (68). One early investigation assessing the possible use of pulse oximetry for pulp vitality testing produced disappointing results (67); this was probably because the equipment being used was not designed, nor suitably adapted, for teeth. In addition, light has been shown not to pass straight through the tooth, but is directed along dentinal tubules (56). More recent investigation has concluded that pulse oximetry has potential for assessing pulp vitality in immature permanent teeth (66) and perhaps traumatized teeth (69).

Future developments
For many teeth pulp testing can easily be undertaken using current thermal or electrical tests, be they modern refrigerants or electric pulp testers. For a minority of teeth, these tests are inconclusive and something better is needed. LDF is the most promising alternative as it measures blood ow rather than nerve conduction, and produces data that can be re-examined at a later time. However, in heavily decayed teeth the pulp has a much smaller volume than in a young sound tooth (70); in short all tests are struggling under such adverse conditions and this is an area for further

Fig. 16. The splint in position on the patients teeth.

10

Assessment of dental pulp status

research. The cost of laser Doppler owmeters is high, because they are overspecied for pulp testing; commercial development of a more appropriate owmeter would be welcomed.
12. Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S. Assessment of reliability of electrical and thermal pulp testing agents. J Endod 1986: 12: 301305. 13. Seltzer S, Bender IB, Ziontz M. The dynamics of pulpal inammation: correlation between diagnostic data and actual histological ndings in the pulp. Oral Surg Oral Med Oral Pathol 1963: 16: 973977. 14. Chambers IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod J 1982: 15: 15. 15. Grossman LI. Clinical diagnostic methods. In: Endodontic Practice, 10th edn. Philadelphia: Lea and Febiger, 1981: 1722. 16. Rowe AHR, Pitt Ford TR. The assessment of pulpal vitality. Int Endod J 1990: 23: 7783. 17. Mumford JM. Evaluation of gutta percha and ethyl chloride in pulp-testing. Brit Dent J 1964: 116: 338343. rhi MVO. The characteristics of intradental sensory 18. Na units and their responses to stimulation. J Dent Res 1985: 64(Special issue): 564571. 19. Lundy T, Stanley HR. Correlation of pulpal histopathology and clinical symptoms in human teeth subjected to experimental irritation. Oral Surg Oral Med Oral Pathol 1969: 27: 187201. 20. Pitt Ford TR, Rhodes JS, Pitt Ford H. Endodontics. Problem-Solving in Clinical Practice. London: MartinDunitz, 2002: 12. 21. Walton RE, Torabinejad M. Diagnosis and treatment planning. In: Walton RE, Torabinejad M. Principles and Practice of Endodontics, 3rd edn. Pennsylvania: WB Saunders, 2001: 4970. 22. Rickoff B, Trowbridge H, Baker J, Fuss Z, Bender IB. Effects of thermal vitality tests on human dental pulp. J Endod 1988: 14: 482485. 23. Pantera EA, Anderson RW, Pantera CT. Reliability of electric pulp testing after pulpal testing with dichlorodiuormethane. J Endod 1993: 19: 312314. 24. Dummer PMH, Tanner M, McCarthy JP. A laboratory study of four electric pulp testers. Int Endod J 1986: 19: 161171. 25. Dummer PMH, Tanner M. The response of caries-free, unlled teeth to electrical excitation: a comparison of two new pulp testers. Int Endod J 1986: 19: 172177. 26. Millard HD. Electric pulp testers. Council on Dental Materials and Devices. J Am Dent Assoc 1973: 86: 872 873. 27. Cooley RL, Robison SF. Variables associated with electric pulp testing. Oral Surg Oral Med Oral Pathol 1980: 50: 6673. 28. Bender IB, Landau MA, Fonsecca S, Trowbridge HO. The optimum placement-site of the electrode in electric pulp testing of the 12 anterior teeth. J Am Dent Assoc 1989: 118: 305310. 29. Lilja J. Innervation of different parts of the predentin and dentin in young human premolars. Acta Odontol Scand 1979: 37: 339346. 30. Byers MR, Dong WK. Autoradiographic location of sensory nerve endings in dentin of monkey teeth. Anat Rec 1983: 205: 441454.

Conclusion
The diagnosis of the state of the dental pulp is frequently given insufcient attention by many dentists, and where doubt exists root canal treatment is too often performed, even though it is a costly procedure, and may reduce the prognosis for the restored tooth. The profession needs to re-evaluate its attitude to diagnosis of pulpal and periapical conditions for the benet of patients.

References
mberg U. Laser 1. Olgart L, Gazelius B, Lindh-Stro Doppler owmetry in assessing vitality in luxated permanent teeth. Int Endod J 1988: 21: 300306. 2. Odor TM, Pitt-Ford TR, McDonald F. Use of laser Doppler owmetry for pulp testing preliminary ndings (Abstract). Int Endod J 1998: 31: 207. 3. Ehrmann EH. Pulp testers and pulp testing with particular reference to the use of dry ice. Aust Dent J 1977: 22: 272279. 4. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod 1978: 4: 232 237. nnstro m M. A hydrodynamic mechanism in the 5. Bra transmission of pain-producing stimuli in dentine. In: Anderson DJ, ed. Sensory Mechanisms in Dentine. Oxford: Pergamon Press, 1963. nnstro m M. The hydrodynamic theory of dentinal 6. Bra pain: sensation in preparations, caries and dentinal crack syndrome. J Endod 1986: 12: 453457. 7. Trowbridge HO, Franks M, Korostoff E, Emling R. Sensory response to thermal stimulation in human teeth. J Endod 1980: 6: 405412. 8. Cohen S, Burns RC. Pathways of the Pulp, 8th edn. St. Louis, MI, USA: Mosby, 2002, 14, 521. 9. Trope M, Sigurdsson A. Clinical manifestations and diagnosis. In: rstavik D, Pitt Ford TR, eds. Essential Endodontology: Prevention and Treatment of Apical Periodontitis. Oxford: Blackwell Science, 1998: 157178. 10. Ingram TA, Peters DD. Evaluation of the effects of carbon dioxide used as a pulpal test. Part 2. In vivo effect on canine enamel and pulpal tissues. J Endod 1983: 9: 296303. 11. Augsburger RA, Peters DD. In vitro effects of ice, skin refrigerant, and CO2 snow on intrapulpal temperature. J Endod 1981: 7: 110116.

11

Pitt Ford & Patel

31. Byers MR. Dental sensory receptors. Int Rev Neurobiol 1984: 25: 3994. 32. Rubach WC, Mitchell DF. Periodontal disease, age, and pulp status. Oral Surg Oral Med Oral Pathol 1965: 19: 482493. 33. Dummer PMH, Hicks R, Huws D. Clinical signs and symptoms in pulp disease. Int Endod J 1980: 13: 2735. 34. Hyman JJ, Cohen ME. The predictive value of endodontic diagnostic tests. Oral Surg Oral Med Oral Pathol 1984: 58: 343346. 35. Stock CJR. Patient assessment. In: Stock CJR, Gulabivala K, Walker RT, Goodman JR, eds. Endodontics, 2nd edn. London: Mosby-Wolfe, 1995. 36. Peters DD, Baumgartner JC, Lorton L. Adult pulpal diagnosis. 1. Evaluation of the positive and negative responses to cold and electrical pulp tests. J Endod 1994: 20: 506511. 37. Fulling HJ, Andreasen JO. Inuence of maturation status and tooth type of permanent teeth upon electrometric and thermal pulp testing. Scand J Dent Res 1976: 84: 286290. 38. Johnsen DC. Innervation of teeth: qualitative, quantitative and developmental assessment. J Dent Res 1985: 64(Special issue): 555563. 39. Fernhead RW. The histological demonstration of nerve bres in human dentine. In: Anderson DJ, ed. Sensory Mechanisms in Dentine. Oxford: Pergamon Press, 1963: 1526. 40. Bellizzi R, Hartwell GR, Ingle JI, Goerig AC, Nearerth EJ, Marshall FJ, Krasny RM, Frank AL, Gaum C. Diagnostic procedures. In: Ingle JI, Bakland LK, eds. Endodontics, 4th edn. Malvern: Williams and Wilkins, 1994. 41. Bhaskar SN, Rappaport HM. Dental vitality tests and pulp status. J Am Dent Assoc 1973: 86: 409411. 42. Hall CJ, Freer TJ. The effects of early orthodontic force application on pulp test responses. Aust Dent J 1998: 43: 359361. 43. McDonald F, Pitt Ford TR. Blood ow changes in permanent maxillary canines during retraction. Eur J Orthod 1994: 16: 19. 44. Degering CI. Physiological evaluation of dental-pulp testing methods. J Dent Res 1962: 41: 695700. 45. Howell RM, Duell RC, Mullaney TP. The determination of pulp vitality by thermographic means using cholesteric liquid crystals. A preliminary study. Oral Surg Oral Med Oral Pathol 1970: 29: 763768. 46. Fanibunda KB. The feasibility of temperature measurement as a diagnostic procedure in human teeth. J Dent 1986: 14: 126129. 47. Fanibunda KB. Diagnosis of tooth vitality by crown surface temperature measurement: a clinical evaluation. J Dent 1986: 14: 160164. 48. Pogrel MA, Yen CK, Taylor RC. Studies in tooth crown temperature gradients with the use of infrared thermography. Oral Surg Oral Med Oral Pathol 1989: 67: 583 587. 49. Kells BE, Kennedy JG, Biagioni PA, Lamey PJ. Computerized infrared thermographic imaging and pulpal blood ow: part 1. A protocol for thermal imaging of human teeth. Int Endod J 2000: 33: 442447. Kells BE, Kennedy JG, Biagioni PA, Lamey PJ. Computerized infrared thermographic imaging and pulpal blood ow: part 2. Rewarming of healthy human teeth following a controlled cold stimulus. Int Endod J 2000: 33: 448462. Daley J, Boyd E, Cooper J, ODriscoll P. Optical assessment of dental pulp vitality. J Biomed Eng 1988: 10: 146148. Lindberg LG, Tamura T, Oberg PA. Photoplethysmography. Part 1. Comparison with laser Doppler owmetry. Med Biol Eng Comput 1991: 29: 4047. Miwa Z, Ikawa M, Iijima H, Saito M, Takagi Y. Pulpal blood ow in vital and nonvital young permanent teeth measured by transmitted-light photoplethysmography: a pilot study. Pediatr Dent 2002: 24: 594598. Gazelius B, Olgart L, Edwall B, Edwall L. Non-invasive recording of blood ow in human dental pulp. Endod Dent Traumatol 1986: 2: 219221. Odor TM, Watson TF, Pitt Ford TR, McDonald F. Pattern of transmission of laser light in teeth. Int Endod J 1996: 29: 228234. Odor TM, Chandler NP, Watson TF, Pitt Ford TR, McDonald F. Laser light transmission in teeth: a study of the patterns in different species. Int Endod J 1999: 32: 296302. Odor TM, Pitt Ford TR, McDonald F. Effect of wavelength and bandwidth on the clinical reliability of laser Doppler recordings. Endod Dent Traumatol 1996: 12: 915. Mesaros SV, Trope M. Revascularization of traumatized teeth assessed by laser Doppler owmetry: case report. Endod Dent Traumatol 1997: 13: 2430. Roeykens H, Van Maele G, Martens L, De Moor R. A two-probe laser Doppler owmetry assessment as an exclusive diagnostic device in a long-term follow-up of traumatised teeth: a case report. Dent Traumatol 2002: 18: 8691. Roeykens H, Van Maele G, De Moor R, Martens L. Reliability of laser Doppler owmetry in a 2-probe assessment of pulpal blood ow. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999: 87: 742 748. Lee JY, Yanpiset K, Sigurdsson A, Vann WF. Laser Doppler owmetry for monitoring traumatized teeth. Dent Traumatol 2001: 17: 231235. Wilder-Smith PE. A new method for the non-invasive measurement of pulpal blood ow. Int Endod J 1988: 21: 307312. Odor TM, Pitt Ford TR, McDonald F. The effect of inferior alveolar nerve block anaesthesia on the lower teeth. Endod Dent Traumatol 1994: 10: 144 148. Soo-ampon S, Vongsavan N, Soo-ampon M, Chuckpaiwong S, Matthews B. The sources of laser Doppler blood-ow signals recorded from human teeth. Arch Oral Biol 2003: 48: 353360.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

12

Assessment of dental pulp status

65. Pitt Ford TR, Seare MA, McDonald F. Action of adrenaline on the effect of dental local anaesthetic solutions. Endod Dent Traumatol 1993: 9: 3135. 66. Goho C. Pulse oximetry evaluation of vitality in primary and immature permanent teeth. Pediatr Dent 1999: 21: 125127. 67. Kahan RS, Gulabivala K, Snook M, Setchell DJ. Evaluation of a pulse oximeter and customized probe for pulp vitality testing. J Endod 1996: 22: 105109. 68. Schnettler JM, Wallace JA. Pulse oximetry as a diagnostic tool of pulpal vitality. J Endod 1991: 17: 488 490. 69. Radhakrishnan S, Munshi AK, Hegde AM. Pulse oximetry: a diagnostic instrument in pulpal vitality testing. J Clin Pediatr Dent 2002: 26: 141145. 70. Chandler NP, Pitt Ford TR, Monteith BD. Coronal pulp size in molars: a study of bitewing radiographs. Int Endod J 2003: 36: 757763.

13