Endodontics

Lec. 2 ‫ عالء مهدي الحداد‬.‫د‬

Degree of Pretreatment Pulp Status

(Diagnostic Aids)
One of the greatest diagnostic challenges in endodontic practice is the accurate
assessment of pulp status. Dental pulp tests are techniques used to determine the pulpal
health status of a tooth. The diagnostic information obtained from pulpal testing is then
used alongside a patient's history, clinical and radiographic findings to determine a
diagnosis and prognosis of the tooth.
Pulp tests are useful for the following procedures in dentistry:
a) Diagnosis of endodontic pathology
b) Localization of tooth pain
c) Differentiating between odontogenic and non-odontogenic pain
d) Assessing pulpal status following dental trauma
e) Establishment of pulpal health prior to prosthodontic treatment

TYPES OF PULPAL TESTS

Pulpal tests may be conducted via 1) stimulation of the sensory fibers within the pulp (pulp
sensibility tests or pulp sensitivity tests) or by 2) assessing pulpal blood flow (vitality tests
or vascularity tests). All available techniques are reported to have limitations in terms of
accuracy and reproducibility and therefore require careful interpretation in clinical
practice.

I. Assessment of Pulp Sensibility

Pulp stimulation with cold or heat is the oldest method of evaluating the pulp’s health.
Cold Tests
Cold stimuli cause contraction of the dentinal fluid within the dentinal tubules, resulting in
a rapid outward flow of fluid. This rapid movement of dentinal fluid results in
hydrodynamic forces acting on the A-delta nerve fibers within the pulp-dentin complex,
leading to a sharp sensation.
1) The simplest method of applying a cold stimulus to a tooth is to hold a rod of ice in gauze
and place it against the buccal surface, comparing the reaction between the test tooth and
a control tooth (contralateral tooth). Here it is very important that the tooth being tested
should be isolated with a rubber dam so that the cold water from melted ice will not
stimulate adjacent teeth.

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2) Ethyl chloride (−41° C) and Dichlorodifluoromethane (DDM) (−50° C) are compressed
refrigerant spray that can be sprayed onto a cotton pellet, resulting in the formation of ice
crystals prior to application to the tooth.
3) Frozen carbon dioxide (CO2) (−78.5° C), also known as dry ice or carbon dioxide snow.
For testing purposes, a solid stick of CO2 is applied to the buccal surface of the tooth. This
method is particularly effective for teeth with full-coverage metal restorations.
 Cold tests should be applied until the patient definitely responds OR for a maximum of
15 seconds.
 CO2 may cause pitting of the surface of porcelain restorations when applied for as little
as 5 seconds.
 The advantage of refrigerant sprays and frozen CO2 is that the cold stimulus does not
go into a liquid phase but rather a gas phase. This allows testing to be specific to one
tooth at a time.
 Cold tests appear to be more reliable than heat tests, and in general the colder the
stimulus, the more effective the assessment of tooth innervation status.

Heat Test
Heat testing is not employed as often as cold testing because (1) most patients are more
sensitive to cold stimuli, (2) heat tests are more difficult to perform specially on posterior
teeth because of limited access, and (3) excessive heating may result in pulp damage,
therefore heat tests should be applied for no more than 5 seconds.
1) Heated instruments can be used for heat test.
2) A stick of heated gutta-percha heated with a flame or an electric heater until it becomes
soft. It is then applied to the Vaseline-coated surface of the test tooth.
3) Electrical heating devises (used for thermal compaction of gutta-percha).
4) The use of hot water from a syringe under rubber dam isolation.
5) Frictional heat may be generated by using a rubber cup without paste against the buccal
aspect of a tooth.
 Heat application to non-vital tooth increases the pain, in these situations, the
application of cold with relief of pain can be diagnostic for a non-vital pulp.

Electric Pulp Test

The electric pulp tester (EPT) is a battery-operated instrument connected to a probe that
is applied to the tooth. It functions by producing a pulsating electrical stimulus that
stimulates the A-delta fibers. EPTs are of two types bipolar and monopolar. The bipolar
mode is presumably more accurate because the current is confined to the coronal pulp.
The initial intensity of the EPT should be set at a very low value and then increased
gradually until the patient feels a tingling sensation.
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Tooth isolation during EPT is essential. Drying the enamel, placement of an interproximal
plastic strip, and use of a rubber dam can prevent the spread of electrical impulses to
adjacent teeth or gingival tissue.
The probe should be applied on the tooth surface adjacent to a pulp horn, the area of
highest nerve density within the pulp, which means incisal third region of anterior teeth
and the mid-third region of posterior teeth.
Responses to sensitivity testing
There are three possible outcomes of a pulp sensitivity test:
a) Normal Response: Healthy pulps are expected to respond to sensitivity testing by
producing a short, sharp pain which subsides when the stimulus is removed, indicating that
the nerve fibers are present and responsive.
b) Increased or Prolonged Response: An exaggerated or lasting response to sensitivity
testing indicates some degree of pulpal inflammation. If the pain is increased but subsides
once the stimulus has been removed, a diagnosis of reversible pulpitis is suggested.
However, a lasting pain which continues after the removal of the stimulus is indicative of
irreversible pulpitis.
c) No Response; A lack of response to sensitivity testing suggests that the nerve supply to
the tooth has been diminished, as in the case of pulpal necrosis or in previously root
treated canals.
Limitations of Sensitivity Testing
1. Pulpal sensitivity testing does not definitively prove that the tooth has a blood supply
and is vital.
2. The degree of inflammation or innervation cannot be determined from these tests.
3. False positive or false negative results can occur. False positive responses may occur due
to (A) response from adjacent teeth due to inadequate isolation of the tooth being tested,
or in (B) anxious or excited patients, or (C) in multi-rooted teeth which still have residual
pulpal tissue residing in canals.
False negative results can occur in (A) recently traumatized teeth, (B) teeth with
incomplete root development, (C) teeth with heavy restorations or (D) teeth that have
significantly reduced pulp size due to production of tertiary or sclerotic dentin.

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II. Assessment of Pulp Vascularity
Vitality testing requires the measurement of pulpal blood flow.
Crown Surface Temperature
This technique is based on the hypothesis that vital teeth are warmer than
non-vital teeth. Using an infrared thermographic camera. Helpful to assess
the blood supply of the tooth and distinguish between vital and non-vital
teeth.
Laser Doppler Flowmetry
LDF was developed to assess blood flow in different parts of the body and recently it has
been used in teeth. LDF utilizes red light beam which is scattered by moving red blood cells.
This light beam undergoes a frequency shift according to the Doppler principle. The
backscattered light is picked up by photodetectors and produces a signal that can be used
as a measure of pulpal blood flow.
The technique appears objective, noninvasive, accurate, and is promising as a pulp vitality
tester, but its high cost and difficulty of use in clinical situations have prevented
widespread use.

Pulse Oximetry
This process measures oxygen saturation in the examined tissue. The device utilizes red
and infrared light that passes through the tissue and received by a photodetector. Since
oxygenated and deoxygenated hemoglobin absorb different amounts of each light.
It must be stressed that LDF and pulse oximetry can only be used on natural tooth
structure, never on restorations. When used clinically a rubber dam should isolate the test
teeth, and the gingival tissue below the dam should be blocked with an opaque substance
(tin foil).

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Dual Wavelength Spectrophotometry

This technique uses a dual wavelength light source (760 and 850 nm) to determine the
blood oxygenation and volume. The instrument might be useful not only in determining
pulp necrosis but also the inflammatory status of the pulp.
It shows promise as a pulp tester because it is noninvasive, objective, small, and portable.

Sometimes it is difficult to examine accurately the pulp blood circulation because:

1) The circulatory system of the pulp is encased in a rigid structure and therefore is difficult
to study without the removal of hard tissue.
2) The interference of extrapulpal circulatory systems (signal contamination from the
periodontal blood flow).

Selective Anesthesia Testing

When pulp testing results are inconclusive and that patients cannot localize or specify the
pain, an anesthetic would be helpful and. Give anesthesia to the most posterior tooth in
the area where the pain is felt by either infiltration or intraligamentary injection until pain
diminishes. If the pain is still present, the procedure is repeated on the mesial teeth, one
by one until the pain diminishes and is gone. If the pain still felt, the procedure will be
repeated on the opposite arch.
In the case that the pain cannot be localized to either the maxillary or mandibular arch, an
inferior alveolar nerve block would be used. If the pain stops, it means that it involves teeth
of the mandibular arch.