Dental Traumatology 2014; 30: 188–192; doi: 10.1111/edt.

12074

Pulpal response to sensibility tests after

traumatic dental injuries in permanent teeth

Juliana Vilela Bastos1, Eugenio
Marcos Andrade Goulart2, Maria Ilma
de Souza Co ^ rtes1
1
Department of Restorative Dentistry, School of
Dentistry, Federal University of Minas Gerais;
2
Department of Pediatrics, School of Medicine,
Federal University of Minas Gerais, Belo
Horizonte, Brazil
Key words: tooth luxation; crown fractures;
pulpal healing; pulp sensibility tests accuracy
Correspondence to: Juliana Vilela Bastos,
Faculdade de Odontologia, UFMG, Campus
^nio Carlos
Pampulha Av.Presidente, Anto
6627, CEP. 31270-901, Brazil
Tel.:+55 31 3409 2454
Fax: +55 31 3409 2454
e-mail: jvb@ufmg.br
Accepted 20 July, 2013
Abstract – Background/Aim: The assessment of pulp vitality is one of the
major challenges in dental traumatology due to the temporary loss of sen-
sibility after trauma and because of the limitations of conventional pulp
tests. The aim of this study was to evaluate pulpal response to sensibility
tests and to determine their accuracy after crown fractures and luxation
injuries. Materials and methods: A total of 121 permanent anterior teeth
from 78 patients treated at the Dental Trauma Clinic of the Federal Uni-
versity of Minas Gerais were evaluated. Responses to pulp sensibility tests
were monitored for a minimum period of 24 months or until the diagnosis
of pulp necrosis. Results: At the first appointment, 68 teeth responded
positively to sensibility tests, one tooth was necrotic and 52 teeth did not
respond to sensibility tests but showed no other signs of necrosis. The ini-
tial lack of response was not associated with age (P = 0.18), but was
related to the presence of luxation (P < 0.001). At the final appointment,
87 teeth were classified as vital and 31 were classified as non-vital. While a
positive response shortly after trauma was a good predictor of vitality, a
lack of response was not associated with subsequent necrosis. The final
pulpal condition of the teeth that initially did not respond was associated
with the type of injury, as displaced teeth tended to develop necrosis
(P = 0.008). The accuracy of each sensibility test at the initial and final
appointments was, respectively, 55.1% and 67.8% for the heat test, 55.9%
and 77.9% for the cold test, and 57.6% and 89% for the electrical test.
Conclusions. A temporary loss of sensibility was a frequent finding during
post-traumatic pulpal healing, especially after luxation injuries. All sensibil-
ity tests presented low accuracy shortly after trauma. The electrical test
provided the best support for pulpal diagnosis after long-term follow up.
The clinician must be aware of additional signs of crown discoloration and
radiographic changes before initiating endodontic treatment.

Traumatic dental injuries may damage hard dental tis-
sues and pulpal and periodontal structures, compromis-
ing function and aesthetics and cause emotional
problems, especially among children and adolescents
(1, 2). Immediately after an acute dental trauma, heal-
ing events begin in an attempt to regenerate nerves and
vessels and to replace damaged pulpal tissue (3–12).
Within this period, there is also an urgent need to
define the pulpal condition in order to restore the aes-
thetics and function of the affected teeth. However, this
diagnosis is a challenge for the clinician due to the tem-
porary loss of pulpal sensibility after trauma (13–26)
and to the limitations of conventional pulp tests
(27–29). Despite its controversial value after traumatic
dental injuries, pulp sensibility testing still represents
the most widely used diagnostic procedure for the
assessment of pulp vitality. Accuracy is a characteristic
used to describe the quality and usefulness of a diagno-
sis test. This characteristic can be defined as the pro-
portion of all correct results of a diagnostic test, both
positive and negative, and is expressed through sensi-
tivity and specificity, negative predictive values (NPV)
and positive predictive values (PPV) (30–33). Neverthe-
less, studies concerning the accuracy of pulp sensibility
tests after trauma are non-existent. Therefore, the pur-
pose of this study was to evaluate the pulpal response
to thermal and electrical sensibility tests, determining
the accuracy of such tests after traumatic dental inju-
ries.
Materials and methods
The sample comprised 78 patients with 121 teeth with
crown fractures and luxations, either isolated or associ-
ated, which were treated at the Dental Trauma Clinic
of the School of Dentistry at the Federal University of
Minas Gerais in Belo Horizonte, Brazil. The subjects’
ages at the time of injury ranged from 6.3 to 22.5 years
(mean 10.6  3.3). The distribution by injured tooth
group was as follows: 86% maxillary central incisors,
11.6% maxillary lateral incisors and 2.4% mandibular
incisors. Teeth were grouped into five categories as fol-
lows: Group 1 (G1) – 39 teeth with enamel and dentin
fractures (32.2%); Group 2 (G2) – 30 teeth with

188 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

enamel and dentin fractures associated with concussion
or subluxation (24.8%); Group 3 (G3) – 6 teeth with
enamel and dentin fracture associated with tooth dis-
placement (5.0%); Group 4 (G4) – 29 teeth with con-
cussion or subluxation (24.0%); Group 5 (G5) – 17
teeth with lateral or extrusive luxation (14.0%).
Patients were treated and underwent follow-up examin-
ations to observe the pulpal condition according to
established guidelines (34). The following clinical data
concerning the pulpal condition were collected at the
initial visit and during the follow-up appointments:
tooth colour, response to pulp sensibility tests, tender-
ness to percussion and the presence of swelling or
fistula. The sensibility tests consisted of thermal (refrig-
erant spray and hot gutta-percha) and electrical pulp
tests. All teeth were tested with all three methods, and
the tests were performed by one of the authors (JVB)
after drying the tooth with air and isolating it with a
cotton roll. A 2-min interval between different tests
was observed. The cold test with refrigerant spray con-
sisted of placing a cotton pellet soaked with a pressur-
ized mixture of butane, propane and isobutane
(Endo-Frost; Roeko, Langenau, Germany) on an intact
surface of the tooth. The heat test consisted of the
application of Gutta-percha, heated to melting tempera-
ture, on a previously lubricated intact surface of the
tooth. Thermal tests were applied for up to 10 s, and
patients were instructed to indicate when they felt a
light sensation of pain, which was recorded as a posi-
tive response. A negative response was recorded if the
tooth failed to respond twice consecutively in the same
section. For the electrical test, the Analytic Technology
Pulp Tester (Analytic Technology Redmond, WA,
USA) was used. The tooth was lubricated with tooth-
paste to facilitate the conduction of electrical impulses,
and the probe tip was placed on an intact surface
within the incisal two-thirds of the crown. The rate of
voltage increase was set midway between fast and slow,
and this rate was used throughout the study. A ‘tin-
gling’ sensation felt by the patient, at any level of the
scale, was considered to be a positive response. A nega-
tive response was established after the digital display
reached its maximum level of 80, with no reaction from
the patient, twice consecutively in the same section.
Radiographic data collected during the initial and fol-
low-up examinations included the presence and type
of root resorption, periapical lesions and pulp canal
obliteration (PCO). The standardization of radiographs
was based on previously defined criteria (34). Occlusal
radiographs were taken in the first examination with
the bisecting angle technique, using a large film (size 4;
KodakâUltra-speed, Eastman Kodak Company, Roche-
ster, NY, USA). The orientation of the central beam was
directed between the two central incisors. Periapical
radiographs were taken in the first visit and during the
follow-up examination, with the paralleling technique,
using a small film (KodakâUltra-speed DF 58, size 2),
and film holders with a fixed object–focus distance of
33 cm (Coneâ; Maquira Dental Products, Maring a, PR,
Brazil). The orientation of the central beam was directed
between the two central incisors or between the right
or left lateral and central incisors depending upon the
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pulpal sensibility after traumatic injuries 189
traumatized teeth. All radiographs were taken at
70 kVp, 8 mA (Spectro 70X Eletronicâ Dabi Atlante
S/A – Medical & Dental Industry, Ribeir~ ao Preto – SP,
Brazil). The diagnosis of necrosis was based on the pres-
ence of dark coronal discoloration, the absence of a
response to pulp sensibility tests, the presence of fistulas,
or the presence of radiographic signs of periapical bone
resorption or inflammatory external root resorption.
The absence of a response to pulpal sensibility tests was
considered to be a criterion for the diagnosis of necrosis
only when associated with one of the other signs
described above. Patients were first seen up to 1 month
after the trauma and were followed for at least
24 months or until teeth became necrotic. Patients
whose teeth initially responded positively to tests were
evaluated every 3 months for a minimum period of
24 months. Patients whose teeth did not respond ini-
tially were followed monthly until necrosis was con-
firmed or a positive response to sensibility tests was
obtained; after a positive response, patients were
re-evaluated every 3 months for a minimum period of
24 months. Therefore, the mean follow-up period was
20.2 months, ranging from 2 to 67 months. Patients
who had suffered previous trauma were not included.
Similarly, those patients who suffered a second injury
during the follow-up period were excluded. For these
cases, only data obtained up to the moment of the
second trauma were recorded.
Statistical analysis was performed using Epi-info
software (35). To determine the frequency distribution,
the Chi-squared (v2) test and Fisher’s exact test were
used. The confidence interval at 95% was calculated
for measures of association, sensitivity, specificity, PPV
and NPV. All tests showing p values less than 5.0%
(0.05) were considered to be significant. Approval
was obtained from the Human Ethics Committee of
the Federal University of Minas Gerais (COEP-
UFMG).
Results
During the first month after trauma, 53 teeth did not
respond positively to sensibility tests. Of these, one
tooth showed a grey–brown discoloration and was con-
sidered to be necrotic. The other 52 teeth did not show
any other signs of necrosis. Sixty-eight teeth responded
positively to at least one of the sensibility tests applied.
During the follow-up period, 31 teeth developed necro-
sis (25.6%) and 87 teeth were considered to be vital
(71.9%). Three teeth could not have their pulp condi-
tion defined because the patients abandoned the study
and were excluded from the analysis. Table 1 shows
the correlation between the initial response to sensibil-
ity tests and the final pulpal status. The initial response
was considered to be negative when teeth showed an
absence of sensibility to all tests and positive when
teeth responded to at least one of the tests performed.
Only 19 teeth that had an initial negative response were
classified as non-vital in the final visit (38%). The
majority of teeth that showed a positive initial response
to pulp sensibility tests were vital at the final appoint-
ment (82.4%).
190 Bastos et al.

Table 1. Association between the initial response to pulp Table 4. Association between the type of the injury and final
sensibility tests and final pulp condition pulp condition in teeth with initial negative response to pulp
sensibility tests
Final pulpal condition
Initial response to Final pulp condition
pulp sensibility tests Non-vital n(%) Vital n(%) Total n(%)
Type Non-vital n(%) Vital n(%) Total n(%)
Negative 19 (38.0) 31 (62.0) 50 (100)
Positive 12 (17.6) 56 (82.4) 68 (100) Crown fractures – 6 (100) 6 (100)
Total 31 (26.3) 87 (73.7) 118 (100) Crown fractures associated 4 (40.0) 6 (60) 10 (100)
with concussion or
v2 = 5.16; P = 0.02. subluxation
Concussion or subluxation 4 (22.2) 14 (77.8) 18 (100)
Crown fractures associated 9 (64.3) 5 (35.7) 14 (100)
with lateral or extrusive
Table 2. Association between the age at the moment of
luxation
trauma and pulp response to sensibility tests at the first visit
Lateral or extrusive luxation 2 (100.0) – 2 (100)
Initial response to pulp sensibility tests Total 19 (38.0) 31 (62) 50 (100)

Age at trauma Negative n(%) Positive n(%) Total n(%) Fisher’s exact test P = 0.008.

< 9 years 23 (51.1) 22 (48.9) 45 (100)

≥9 years 27 (37.0) 46 (63.0) 73 (100) The accuracies of pulp sensibility tests performed
Total 50 (42.4) 68 (57.6) 118 (100) just after trauma (Table 5) and at the final appoint-
v2 = 1.73; P = 0.18. ment (Table 6) were calculated using the sensitivity,
specificity and predictive values.

Table 3. Association between the type of the injury and Discussion

initial response to pulp sensibility tests The assessment of pulp vitality is one of the major
Initial response to challenges in dental traumatology, especially during the
pulp sensibility tests period immediately after trauma, and important factors
that affect this assessment must be considered. The
Negative Positive temporary loss of pulpal sensibility is an important
Type n(%) n(%) Total n(%)
issue (13–25) and was confirmed in the present study.
Crown fractures 6 (15.4) 33 (84.6) 39 (100) An initial negative response to sensibility tests was not
Crown fractures associated 10 (33.3) 20 (66.7) 30 (100) associated with the later development of pulp necrosis.
with concussion or subluxation Although an immediate negative response indicated
Crown fractures associated 2 (33.3) 4 (66.7) 6 (100) pulpal damage, this response did not predict pulp
with lateral or extrusive luxation necrosis because sensibility tests assess nerve activity
Concussion or subluxation 18 (64.3) 10 (35.7) 28 (100)
rather than the vascular supply, which is ultimately
Lateral or extrusive luxation 14 (93.3) 1 (6.7) 15 (100)
Total 50 (42.4) 68 (57.6) 118 (100) responsible for pulp survival (27, 29). As neural regen-
eration in traumatized teeth is slower than vascular
v2 = 34.30; P < 0.001. regeneration or is even absent, the tooth may remain
vital even though it does not respond to sensibility tests
(10, 36, 37). The present findings showed that most of
No significant association between age and the the teeth with concussion or subluxation that did not
response to sensibility tests was found when the cut-off respond to initial tests recovered a positive response,
point was established at the age of 9 years (Table 2). while displaced teeth tended to develop necrosis. This
Initial negative response to the sensibility tests was outcome is in accordance with previous clinical (15,
found to be related to the occurrence of tooth luxation 19–21, 23, 26) and experimental data and corroborates
injuries (Table 3). When examining the final pulp con- the theory that transient damage to pulpal nerve fibres
dition of the 50 teeth that did not respond to sensibility explains the transition from a negative to a positive
tests at the first visit, a significant association was response to sensibility tests (37).
found between tooth displacement and the develop- The time elapsed from the moment of trauma should
ment of necrosis (Table 4). also be considered when evaluating the pulp’s response
The time of obtaining vitality for teeth that initially after trauma. This study analysed the time interval
responded negatively to pulp sensibility tests ranged between trauma and the definitive diagnosis of the pulp
from 2 to 67 months. The time for conclusive diagnosis condition. It is important to stress that only teeth that
of necrosis ranged from 2 to 30 months. There was a initially responded negatively to pulp sensibility tests
significant difference between the median months for were included. Necrosis was confirmed significantly ear-
vitality and necrosis diagnosis (the 12th month and the lier than pulp vitality, and these results are consistent
4th month, respectively) (Kruskal–Wallis = 7.9, with results presented in the literature. (18, 19, 21).
P = 0.005). In this study, there was no association Another factor that must be taken into account is
between the type of the injury and the time of diagno- that pulp testing in young patients has technical and
sis of necrosis (v2 = 0.00, P = 0.97). psychological limitations (27, 29, 38–40). Studies

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Table 5. Accuracy sensitivity, specificity and predictive values of pulp sensibility tests performed at the first visit
Test Sensitivity Specificity
Heat (Gutta-percha) 50.6% (39.7–61.4) 67.7% (48.5–82.7)
Cold (Endo-Frost) 64.5% (45.4-80.2) 52.9% (41.9–63.6)
Electric 61.3% (42.3–77.6) 56.3% (45.3–66.8)
Confidence interval 95%.
Table 6. Accuracy sensitivity, specificity and predictive values of pulp sensibility tests performed at the final visit
Test Sensitivity Specificity
Heat (Gutta-percha) 87.1% (69.2–95.8) 60.9% (49.8–71.0)
Cold (Endo-Frost) 83.9% (65.5–93.9) 75.9% (65.3–84.1)
Electric 90.3% (73.1–97.5) 88.5% (79.4–94.1)
Confidence interval 95%.
conducted in non-traumatized young permanent teeth
reported an increased threshold to electrical stimulation
(38–40) or the absence of a response (41). In the pres-
ent study, the absence of a response to pulp sensibility
tests in the initial visit could not be linked to age. This
phenomenon corroborates previous results in teeth
bearing crown fractures (13, 18), but conflicts with the
results presented by Rock and Grundy (20), who found
an increase in the temporary loss of sensibility among
children younger than 9 years of age with luxated and
subluxated teeth. Differences in sampling and method-
ology between the previous studies and the present one
may explain the discrepant results.
Finally, it is important to emphasize the limitations
of conventional pulp sensibility tests. Studies that cal-
culated the accuracy of such tests in non-traumatized
teeth demonstrated that these tests were better predic-
tors of the absence of pulp disease than its presence. In
other words, current pulp tests are more valid in identi-
fying vital teeth than necrotic teeth (30–33). Although
many studies have reported the temporary loss of pulp
sensibility after traumatic injuries (13, 14, 17, 18, 20,
21, 23, 26), the present study was the first to calculate
predictive values and accuracy of pulp sensibility tests
carried out in traumatized teeth. Such an analysis was
performed by comparing the initial and final responses
to thermal and electrical tests with the final diagnosis
of pulpal status established during long-term follow up.
The pulp condition was classified as non-vital only
if one of the following signs were found: crown
discoloration, fistula, periapical bone resorption and/or
inflammatory external root resorption. Accuracy was
calculated based on predictive values because the sam-
ple consisted of patients with unknown disease states.
There was a high probability that an initial positive
response would be later confirmed as pulp vitality, as
evidenced by the high NPV found in the first visit.
However, all tests failed to disclose disease (necrosis).
There was a small probability that a non-sensitive reac-
tion observed in the first visit would be associated with
necrosis, as shown by low PPV. This analysis reveals a
low accuracy for all pulp sensibility tests when they are
applied soon after trauma. The present results also
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pulpal sensibility after traumatic injuries 191
Negative Predictive Positive Predictive
Value (NPV) Value (PPV) Accuracy
81.5% (68.1–90.3) 32.8% (21.9–45.8) 55.1% (45.7–64.2)
80.7% (67.7–89.5) 32.8% (21.6–46.1) 55.9% (46.5–65.0)
80.3% (67.8–89.0) 33.3% (21.7–47.2) 57.6% (48.2–66.6)
Negative Predictive Positive Predictive
Value (NPV) Value (PPV) Accuracy
93.0% (82.2–97.7) 44.3% (31.8–57.5) 67.8% (58.5–75.9)
93.0% (83.7–97.4) 55.3% (40.2–69.5) 77.9% (69.2–84.9)
73.7% (56.6–86.0) 96.3% (88.7–99.0) 89.0% (81.6–93.8)
demonstrated that heat tests maintained a low accuracy
over time, whereas cold tests with refrigerant spray and
electrical tests showed higher accuracy values in the
final exam. Electrical tests provided the best support
for pulpal diagnosis due to the high number of correct
results among necrotic teeth in the final visit, demon-
strated by the high PPV. Even though current results
showed similarities and differences with those reported
for non-traumatized teeth, this comparison remains
impaired by the major differences between the samples.
While only traumatized incisors from children with a
mean age of 10.6 years were evaluated in the present
study, previous studies included only non-traumatized
teeth, of all groups, from adult patients. In conclusion,
the present results showed that a positive reaction to
pulp sensibility tests during the period immediately after
trauma represented a good prediction of vitality; how-
ever, the lack of response could not be associated with
the later development of pulp necrosis. Our results con-
firm that the temporary loss of sensibility is a frequent
finding during post-traumatic pulpal healing, especially
after luxation injuries. While all sensibility tests exhib-
ited a low accuracy shortly after trauma, the electrical
test provided the best support for pulpal diagnosis after
traumatic injuries due to its high long-term accuracy.
Acknowledgements
This research was funded by Dean of Extension
PROEX-UFMG.
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