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There are several ways to obtain information about
the condition of a tooth¶s pulp and supporting
structures. Probably no one test is sufficient in it
self; the result of several test often have to be
obtained to have enough information to support a
likely diagnosis or perhaps a list of differential
diagnoses.

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¢ Yne of the most symptoms associated with the
symptomatic inflamed pulp is pain elicited by
thermal stimulation.

¢ When pulp responds abnormally to thermal

stimulation, either in an exaggerated manner or not
at all, is that it is not in a state of good health.

¢ The rationale for innervation of any bodily structure

is to provide a warning of damage that is occurring
or impending.
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¢ The pain is proportionate to the stimulation;
consequently even teeth with intact enamel will
react to extreme cold, such as ice or carbon dioxide
snow.

¢ When the teeth react to stimuli that do not

normally produced pain, such as tap water, the
probability is that dentin has been exposed by
caries, that the tooth has fractured, or that faulty
restoration, abrassion or attachment loss cause by
periodontal disease.
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¢ When the CC is pain to a thermal stimulus the
clinician must distinguish between thermal testing
to isolate the offending tooth by reproducing the
patients symptoms and attempting to determine if
the suspected tooth has a vital or non vital pulp.

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¢ Cold test may be used in differentiating between
reversible or irreversible pulpitis and in identifying
teeth with a necrotic pulp.

¢ When cold is used to differentiate between

reversible or irreversible pulpitis, one must have to
determine if the effect of the stimulus application
produces a lingering effect or if it subsides
immediately after the removal of the stimulus from
the tooth.

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¢ n testing if the pain lingers, that is taken as
evidence for irreversible pulpitis.

¢ and if pain is subside immediately after stimulus

removal most probably the diagnosis is
hypersensitivity or reversible pulpitis.

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¢ Cold as test for pulp vitality is probably not entirely
reliable since teeth with calcified pulp spaces may
have vital pulp, but cold stimuli may not be able to
excite the nerve endings owing to the insulating
effect of tertiary dentin .

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¢ Ms with cold test, there are some methods for heat
testing teeth have been suggested.

¢ Hot testing can be made with a heated gutta percha

or a hot water bath. ( heated gutta percha is more
convenient to clinicians, but the hot water bath
yield the most accurate patient response.)

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¢ §lectric pulp tester uses electric excitation to
stimulate M delta fibers within the pulp.

¢ M positive response to §PT does not provide any

information about the health or integrity of the pulp
it simply indicates that there are vital sensory fibers
present within the pulp.

¢ Yften, irreversible inflamed pulp is responsive to

§PT because it still contains vital and functional
nerve fibers that can produce a toothache.
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¢ §PT provides only a responsive or non responsive
result that correlates, in many cases, with vital or
non vital pulp status, therefore attempting to
interpret the numerical values produced by §PT is
not recommended.

¢ §PT does not provide any information on the

vascular supply of the pulp which is the true
determinant of pulp vitality.

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¢ Teeth that temporarily or permanently lose their
sensory function will be non responsive to §PT
however they will have intact vasculature.

¢ To achieve consistent result with §PT one must

follow a standard procedure.

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— Êry the tooth to be tested by 2x2 gauze and isolate with
a cotton roll.
— Cover the tip of the electrode with toothpaste or similar
electrical conductor.
— f the tooth has a proximal metallic restoration it is
necessary to used a rubber dam to prevent electrical
conduction to adjacent teeth.
— Clinician should explained the patient about the
sensation of heat or tingling felt during testing.
— The patient should place a finger on the handle of the
testing device to serve a ³switch´.

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— then the electrode is place on the dry enamel of the
tooth being tested on the middle 3rd of the facial surface
of the crown.
— Current flow should increased slowly to allow the
patient time to respond before the attendant tingling
sensation becomes painful.
— §ach tooth should be tested at least two or three times
and an average should be recorded.
— For multi rooted teeth may need to be tested by placing
the electrode on more than one location.

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¢ Palpation testing is using a digital pressure to check
any tenderness in the oral tissue overlying
suspected teeth.

¢ Sensitivity indicates that inflammation in the

periodontal ligament surrounding the affected tooth
has spread to the periodontium overlying the jaw
bone.

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¢ n this manner an
incipient swelling may
be detected before it is
clinically evident by
rolling the index finger
over the mucosa and
pressing it against the
underlying bone.

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¢ Tenderness noted upon percussing a tooth indicates
some degree of inflammation in the periodontal
ligament.

¢ t may be cause by:

— Ycclusion
— Trauma
— Sinusitis
— Periodontal disease
— §xtension of pulpal disease on the periodontal ligament

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¢ Percussion is not a test for pulp vitality.

¢ Before testing the clinician should communicate the

purpose of the test to the patient and explained how
the patient should indicate any tenderness (eg.
Raising a hand)
¢ Testing should begin with gentle tapping

¢ t should be in randomly tap teeth in suspected

quadrant, beginning with one that is not suspected
so the patient is aware of normal sensation
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¢ f the patient is unable to discern a difference in
sensation with digital percussion, the blunt end of
the mouth mirror can be used.

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¢ Tooth mobility indicates the integrity of the
attachment apparatus (whether inflammation of the
periodontal ligament exists.)

¢ The clinician should use 2 mouth mirror handles to

apply alternating lateral forces in a facial lingual
direction to observe the degree of mobility of the
tooth.

¢ Êegree of depressability within its alveolus should

also be tested (by pressing the tooth to its socket
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and any vertical movement should be noted)
¢ Mll movement is subjected to individual differences
— Ôst degree mobility is barely perceptible horizontal
movement
— 2nd degree no more than Ô mm horizontal movement
— 3rd degree greater than Ô mm horizontal movement and
or vertical depressability.

The pressure exerted by the purulent exudates of an acute

periradicular abscess may cause considerable mobility
but it resolves quickly once drainage for exudates is
established.

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¢ M far more sensitive is to use a blunt, calibrated
probe to explore the attachment level in the gingival
sulcus around each tooth.

¢ Mll surface of the roots should be probed along with

any furcas, findings should be recorded.

¢ Probing must be performed throughout the mouth

as with the periodontal screening and recording
technique to appreciate the patients overall
condition.
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¢ Wide gently sloping craters around multiple teeth
characterized periodontal disease.
¢ n some case a sinus tract can drained pus from the
apex of a tooth with a necrotic pulp to the oral
cavity through periodontal ligament.
¢ t is useful for diagnostic confirmation to place a
gutta percha in the sulcular defect and expose a
radiograph film to confirm the depth and the
direction of the periodontal pocket, to distinguish a
periodontal from endodontic etiology.

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¢ Pathways of the pulp 9th edition by: S. Cohen and R.C. Burns
Pages Ô 29
¢ §ndodontics ngle Bakland 5th ed. Êentistry, chapter 6
¢ http://www.acteongroup.com/prod_escl_list.aspx?id_menu=
37
¢ http://images.google.com.ph/images?hl=en&um=Ô&q=tooth
+palpation&sa=N&start=20&ndsp=20
¢ http://books.google.com.ph/books?id=aVÔk§f7mlckC&pg=PM
669&lpg=PM669&dq=percussion+of+teeth&source=bl&ots=T
JmHLNKuTV&sig=Ô7y48zbj
zd6ÊÊTC§tjV9rYlM&hl=en&
ei=kt
nSqf_HY2WkMMx7SFCQ&sa=&oi=book_result&ct=result
&resnum=Ô0#v=onepage&q=percussion%20of%20teeth&f=fa
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