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Endodontic Topics 2004, 7, 2–13 Copyright r Blackwell Munksgaard

Printed in Denmark. All rights reserved 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 fibers. The tests are quick and usually reliable, although nothing is absolute. Newer tests
have involved assessment of blood flow, and of these laser Doppler flowmetry has been the most widely used and
beneficial to patients particularly after traumatic injury. The high cost of flowmeters and the time-consuming
procedure have limited uptake.

The diagnosis of dental pulp status should be seen as a Sensitivity testing


synthesis of history, clinical examination, special tests,
Currently, the most widely used vitality testers assess
and radiological examination, and not as the out-
the integrity of the Ad nerve fibers in the dentine–pulp
come of one specific test. Too often dentists base
complex by briefly applying the stimulus to the outer
treatment decisions on limited information that may be
surface of the tooth. If the Ad nerve fibers are
contradictory; this is not in the best interests of
successfully stimulated, the patient will respond by
patients.
acknowledging a brief sharp sensation/tingling from
Vitality testing is an important aid in the diagnosis of
the tooth. The test indicates that the nerve fibers are
pulp disease and apical periodontitis. If the pulp is
functioning but does not give any indication of blood
deemed to be unhealthy as a result of the diagnostic
flow in the pulp, or whether it is partially damaged. If
synthesis, then endodontic treatment is indicated. In
there is no blood flow in the pulp, it will rapidly become
particular, pulp vitality testing should be carried out on
anoxic and the Ad fibers will cease to function.
traumatized teeth over an extended period to monitor
However, there are instances, for example, after
their vitality following the traumatic incident, as teeth
trauma, where there is blood flow in the pulp but the
which may initially not respond to testing may well do
Ad nerve fibers are not functioning.
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
Thermal testing
restoration (3). It is also desirable to confirm periodi-
cally continued pulp vitality in teeth that have under- Thermal testing relies upon applying heat or cold to a
gone pulp preservation procedures or have had localized part of the tooth to stimulate Ad nerve fibers
extensive restorations (4). within the dental pulp. When the test is applied to a
As the dental pulp is enclosed in an opaque tooth, the healthy pulp it results in a sharp localized pain/tingling
assessment of pulp vitality is undertaken by: looking for sensation for the duration of the applied test and for a
clinical or radiological evidence of pulp necrosis or few seconds after removal of the stimulus (positive
apical periodontitis; investigating nerve conduction; or response). A pulp response lasting more than half a
examining blood flow. Diagnosis must not be made on minute after the stimulus has been removed is
the strength of one piece of evidence, but from all the frequently interpreted as indicating an irreversibly
evidence derived from the history and the examination. inflamed pulp. No response from the patient to such

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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 contrac-
tion of the dentinal fluid within the dentinal tubules;
this results in rapid outward flow of fluid within the
patent tubules (5, 6). The rapid movement of dentinal
fluid results in ‘hydrodynamic forces’ acting on the Ad
nerve mechanoreceptors within the pulp–dentine
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 briefly 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 Fig. 1. A container of compressed refrigerant spray,
stick is then wrapped with gauze to act as a handle; the dichloro-difluoro-methane (Endo-Frost, Roeko, Langenau,
other end may then be applied to the tooth under Germany).
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. Dichloro-
difluoro-methane (DDM) (boiling point 501C) is a
compressed refrigerant spray (Fig. 1), which can simi-
larly be sprayed on to a cotton pledget and applied to
the tooth under investigation (Fig. 2). More recently,
ozone friendly non-chlorofluorocarbon 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 Fig. 2. Iced cotton pellet in tweezers following spraying
especially effective when attempting to assess teeth that of Endo-Frost.
have been restored with full coverage metal restorations
(9). Concerns regarding possible damage to enamel this may be due to their greater rate of temperature
and healthy pulps of teeth from the extreme cold of this reduction (12).
test appear to be unfounded (10). The colder tests Ice-cold water is another useful and inexpensive test.
(DDM and CO2 snow) appear to be the more reliable The tooth under investigation is isolated with rubber
than ethyl chloride (8, 11) in stimulating vital teeth; dam and then bathed with water from a syringe (Fig. 5).

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Pitt Ford & Patel

very clear response from the patient (8). Cold tests


should be applied until the patient definitely responds
to the stimulus or for a maximum of 15 s, whichever
comes first (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 flame
or an electric heater until it becomes soft and glistens
Fig. 3. Plastic cartridge attached to a cylinder of CO2. (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); gutta-
percha softens at 651C and may be heated in delivery
devices up to 2001C. This test may be difficult 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 fibers and then C fibers
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
Fig. 4. A stick of dry ice in its applicator on the tooth. 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. 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 Fig. 6. Heated stick of gutta-percha (Obtura) applying
metal restorations may be evaluated, thus resulting in a heat to a tooth.

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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 fric-


tional 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


Fig. 9. An isolated tooth undergoing electric pulp
The objective of electric pulp testing is to stimulate testing. A hook on the patient’s lip completes the
intact Ad nerves in the pulp–dentine complex by circuit. Rubber dam has been used to isolate the tooth
applying an electric current on the tooth surface. A from those adjacent.
positive result from electric pulp testing is a result of an
ionic shift in the dentinal fluid within the tubules prevent unnecessarily excessive stimulation and dis-
causing local depolarization and subsequent generation comfort. The intensity of the electrical stimulus steadily
of an action potential from the intact nerve (23). increases at a preselected rate; a note is made of the
The electric pulp tester consists of a battery-operated reading on the digital display when the patient
unit, which is connected to a probe that is applied to the acknowledges a warm or tingling sensation. The output
tooth under investigation. The electrical circuit is characteristics of this unit have been investigated (24).
completed by the patient holding the rear end of the The rate of voltage increase was also found to vary
handle of the probe (Fig. 8), or by placing a hook over depending on the device used. A further investigation
the patient’s lower lip (Fig. 9). Two widely used pulp concluded that there was no consistency in threshold
testers are the Analytic Technology pulp tester and the excitation values for healthy teeth (25). The readout is
Vitality Scanner (Analytic Sybron Dental Specialities, not a quantitative measurement of the health of the
Orange, CA, USA). Electric pulp testers function by pulp, and therefore does not indicate to what extent the
producing a pulsating electrical stimulus, the intensity pulp is healthy/unhealthy; a response only implies that
of which automatically begins from a very low value to the Ad fibers are sufficiently healthy to function.

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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
Fig. 10. A small tip for the electric pulp tester can be used
under crown margins. 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
The electric pulp tester is technique sensitive (26, secondly gives the clinician an idea of the duration of the
27). The tooth to be assessed should be sufficiently dry thermal test and also the patient’s response. To improve
to prevent electrical conduction to adjacent teeth, or to objectivity the tests should be repeated after a recovery
the periodontium although the current is unlikely to be period of 1 min, unless too much discomfort has been
sufficient (24). A conducting medium should be caused. The teeth on either side of the tooth being
applied to the electrode to ensure maximum current assessed should also be tested as this will aid in diagnosis.
passes from the electrode to the tooth surface (27). It is A large clinical study assessed by thermal and electric
important to make sure that the electrode lies flat pulp testing 166 teeth, which were subsequently
against the surface of the tooth (therefore maximising extracted and examined histologically (21). Although
electrode contact area) as this also reduces the response it was concluded that there was a poor overall
threshold value (27). Cellulose strips or rubber dam correlation between clinical signs and the pathological
strips may be used interproximally to prevent electrical state of the pulp, there did appear to be a relationship
conduction to adjacent teeth (Fig. 9). Direct contact between a negative response to electric pulp tester and
with tooth tissue is required, and this may be a problem total pulp necrosis. A similar investigation (33) that
with extensively restored teeth (9). However, a small tip assessed 75 teeth also found no relationship between
is available that may be used instead of the standard the condition of the pulp from the clinical examination
electrode tip; this allows tooth contact below a crown and investigation using the same complex histological
margin where there is slight gingival recession (Fig. classification (seven pulp state categories). However,
10). The threshold excitation value is influenced by the when the data from this investigation were examined at
position of the electrode on the tooth; for example, the a broader level, a correlation was apparent between
lowest threshold for response and therefore most total necrosis and a negative response to thermal
desirable area of assessment in incisor teeth is at the testing. With both investigations there is no mention
incisal edge, where the enamel is thinnest or absent of how soon after the clinical examination the teeth
(28). The tester should be applied on the tooth surface were extracted. In one investigation (33) only step-
adjacent to a pulp horn, that is, the region of highest serial histological sections were examined; thus, poten-
nerve density within the pulp (29–31); this is the tially useful information may not have been evaluated.
incisal-third of anterior teeth and the mid-third of A retrospective evaluation was carried out on the
posterior teeth. The threshold for response may be results of five studies in which teeth had been clinically
influenced by the thickness of the enamel and dentine assessed, extracted and examined histologically (34). It
overlying the pulp (18, 32); therefore, it has been was concluded that the results of diagnostic investiga-
considered that the response threshold in healthy teeth tions were more likely to be correct in cases of disease-
may be lowest in incisors, slightly greater in premolars free teeth rather than in teeth with pulp disease.
and greatest in molar teeth. However, in one study Responses from thermal and electric pulp testing are
using two pulp testers, the threshold was lower in not quantitative and therefore do not give information
premolars than incisors (25). Signs of tooth surface loss on how healthy or to what degree the pulp is inflamed.

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Assessment of dental pulp status

Problems with current devices/assessing


Table 2. False responses from pulp testing
pulp status
At present the techniques that are commonly used in False positives
everyday practice (i.e. thermal and electric pulp testing)
 Anxious patients
assess whether the nerve supply within the tooth is
intact. A positive result confirms that the Ad nerves in  Liquefaction necrosis
this region of the pulp chamber are responsive; the  Contact with metal restorations
inference is that this can be interpreted as there being
an intact blood supply within the tooth. However, the  Vital tissue still present in partially necrotic root canal
system
only true means of assessing the health of the pulp is to
determine that there is a normal flow of blood within False negatives
the tooth (Table 1).
 Incomplete root development
Thermal tests are highly subjective as they are wholly
dependent on the patient’s response to testing. There is  Recently traumatized teeth
no accurate or objective method of assessing how  Sclerosed canals
responsive the tooth under investigation is to testing,
nor of comparing with a previous measurement. In  Recent orthodontic activation
contrast, electric pulp testers have numerical digital  Patients with psychotic disorders
displays, which allow the operator to note down the
reading, and compare with a previous reading.
periodontium, giving a false-vital response (14); the
False-positive results (i.e. non-vital teeth same may occur with inadequately dried teeth prior to
responding positively to testing) testing (14, 35). Multi-rooted teeth pose an additional
These are summarized in Table 2. Because sensitivity problem because the pulp in the tooth under investiga-
tests are reliant on the patient’s response, a premature tion may be partially necrotic; therefore, part of the root
response or even a false-positive response may occur in canal system may still possess relatively healthy pulp
anxious or young patients who are expecting to feel an tissue (36). There has been a report of three previously
unpleasant sensation (27, 28). It has been suggested root-treated maxillary molars, which responded posi-
that localized breakdown products in one part of the tively to testing, and on root canal retreating the teeth
root canal system may be able to conduct the electric untreated second mesio-buccal canals were identified
current from an electric pulp tester to viable nerve (36); it was concluded that viable tissue in the second
tissue in adjacent areas thereby resulting in a false- mesio-buccal canal resulted in the positive response.
positive result (33). Contact with metal restorations
may possibly result in conduction of the current to the False-negative results (i.e. vital teeth
responding negatively to testing)
Table 1. Ideal features of a pulp vitality tester These are also summarized in Table 2. Teeth with
incomplete root development may have a higher
Assesses pulp blood flow threshold to testing; thus, a stronger stimulation may
be needed to elicit a response compared with teeth with
Objective measurements
complete root development (37). This is because teeth
Free from error erupt and become functional before the completion of
neural development (38, 39). In these situations cold
Effective for heavily restored teeth
testing with DDM or CO2 snow appears to be more
Effective when the pulp size is reduced reliable than electric pulp testing (12, 37). It has also
Quick and easy to use
been suggested that cold tests may not be reliable in
teeth with obliteration of the coronal pulp as the
Inexpensive excessive dentine may act as an insulator to cold tests
(40). Traumatized teeth may not initially respond to

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Pitt Ford & Patel

thermal and/or electric pulp testing or only respond allow for future comparison of thermographic imaging
weakly (28). It has been postulated that non-responsive with laser Doppler flowmetry (LDF) in order to
recently traumatized immature teeth do not respond to determine pulp blood flow (49). A disadvantage of
sensitivity testing because the nerves have been this technique is that teeth must be isolated with rubber
ruptured (41). However, the pulps of the teeth may dam, after which a period of acclimatization is necessary
still be vital as their blood vessels may remain intact or prior to imaging (50). The technique is complex and
have revascularized. Therefore, traumatized teeth also requires the subjects to be rested for 1 h prior to
should always be carefully monitored at periodic testing (50).
intervals as their pulps may revascularize and their
nerve fibers regain function. The vitality of teeth after
Photoplethysmography
the activation of fixed orthodontic appliances has been
assessed by thermal and electric pulp testing for up to 2 The detection of blood flow within the pulp by passing
months afterwards (42). A lack of response was found light through the tooth has been reported (51).
to the electric pulp tester for up to 2 months after Hemoglobin absorbs certain wavelengths of light,
activation of the appliances; however, thermal testing while the remaining light passes through the tooth
appeared more reliable. This may be due to a reduction and is detected by a receptor. Photoplethysmography
in blood flow and possible anoxia of the Ad nerves (43). has been compared with LDF in experiments on skin,
Patients with psychotic disorders may not respond to and found to be of similar value (52). The technique
pulp testing (27). It has been reported that individuals has not been successfully developed further for dental
who are under the influence of sedative drugs/alcohol application apart from one recent investigation (53).
may either not respond or respond to stronger
stimulation due to their increased threshold to nerve
LDF
excitation (44).
LDF is a non-invasive method of assessing and
measuring the blood flow of pulp tissue (54). Laser
Physiometric testing light is directed onto the tooth under investigation by
securing a fiber-optic probe against the tooth surface.
The laser light from the probe (Fig. 11) passes along
Crown surface temperature/heat
the enamel prisms to the enamel–dentine junction and
registration
the S-shaped dentinal tubules, which act as light guides,
The evaluation of tooth-surface temperature as a means to the pulp (Fig. 12) (55, 56). Light absorbed by red
of assessing the vitality of teeth has been reported. blood cells in the capillary plexus is scattered and
Cholesteric liquid crystals, which exhibit different undergoes a shift in frequency according to the
colors when heated, have been used in one study to Doppler principle; light absorbed by stationary objects
determine pulp vitality (45). It was based on the does not undergo a shift in frequency. A signal is
principle that teeth with an intact pulp blood supply produced which measures the flux of the blood cells
(vital/healthy pulp status) had a warmer tooth-surface (number of red blood cells times mean velocity). The
temperature compared with teeth that had no blood proportion of Doppler-shifted light is detected by a
supply. photodetector. The detected signal is weak and there-
Surface temperature of teeth has been measured over fore highly amplified; a mathematical calculation using
a period of time at 15-s intervals using an electric Fourier analysis can be used to gain more meaningful
thermometer attached to a surface probe, which was information (57). A trace of signals from vital and non-
placed in contact with the tooth (46, 47). These studies vital teeth is shown in Fig. 13. Fourier analysis of the
showed that after teeth were cooled, there was only a traces has revealed a heart beat frequency in the vital
rise in the temperature of vital teeth. tooth, but not in the non-vital tooth (Fig. 14), and is
Thermographic imaging has been used to show that therefore an effective discriminator.
when teeth have been cooled, non-vital teeth were This technique is more objective and reliable than
slower to rewarm than vital teeth (48). Further work in sensitivity testing in assessing and following up the pulp
this area has resulted in the development of an index to status of traumatized teeth (1, 54, 58, 59). It is usually

8
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 Fig. 13. A LDF trace showing signals from two teeth; the
upper is from a vital tooth while the lower is from a non-
advantage of storing data, allowing initial baseline vital tooth.
measurements to be compared objectively with sub-
sequent LDF measurements (61). There has been little prevents repositioning of the splint. The available LDF
use of LDF on decayed or heavily restored teeth (62). equipment has primarily been developed for medical
Unfortunately there are some drawbacks to LDF. use (Fig. 17) and is expensive. It is probably for
The device is technique sensitive and requires prepara- this reason that LDF has generally not been used
tion of a putty splint to hold the probes (Figs 15 and as a routine special investigation in dental practice.
16), and a patient who is relaxed and not anxious. It is It has been used to observe the effects of local
necessary to ensure that the reflected signal only comes anesthetic solutions on pulp blood flow during
from the pulp; this may be readily achieved with an anesthesia (63, 65).
opaque putty splint (63) or by isolating the teeth with
rubber dam (64). In the case of following up teeth that
Pulse oximetry
have had traumatic injuries, reusing the putty splint
ensures that the probe is reapplied to the same site and Pulse oximetry is a non-invasive technique to measure
therefore to the same part of the pulp unless growth oxygen saturation levels within the blood of patients

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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 flowmeter (Moor Instruments,
Axminster, UK).

under general anesthesia or sedation; this device has


been modified to investigate its suitability for assessing
pulp vitality (66, 67). A modified probe has been fitted
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
Fig. 15. Two probes have been placed in a putty
the equipment being used was not designed, nor
impression splint for accurate location on the teeth
while the trace is being recorded. 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 per-
manent 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 flow 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
Fig. 16. The splint in position on the patient’s teeth. adverse conditions and this is an area for further

10
Assessment of dental pulp status

research. The cost of laser Doppler flowmeters is high, 12. Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S.
because they are overspecified for pulp testing; Assessment of reliability of electrical and thermal pulp
testing agents. J Endod 1986: 12: 301–305.
commercial development of a more appropriate flow-
13. Seltzer S, Bender IB, Ziontz M. The dynamics of pulpal
meter would be welcomed. inflammation: correlation between diagnostic data and
actual histological findings in the pulp. Oral Surg Oral
Med Oral Pathol 1963: 16: 973–977.
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The diagnosis of the state of the dental pulp is 1–5.
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tic Practice, 10th edn. Philadelphia: Lea and Febiger,
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19. Lundy T, Stanley HR. Correlation of pulpal histopathol-
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