Endodontology, Vol.

15, 2003

Recent advances in pulp vitality testing

*Samraj RV **Indira R **Srinivasan MR ***Kumar A

ABSTRACT
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Pulp vitality test is crucial in monitoring the state of health of dental pulp,
especially after traumatic injuries. The traditional pulp testing methods such
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as thermal and electric pulp testing methods depend on the innervation and
often yield false positive and negative response. The newer pulp testing
devices, some of which are still under development stage, detect the blood
supply of the pulp, through light absorption and reflection, are considered
to be more accurate and non-invasive. The article attempts to discuss issues
related to pulp vitality testing in clinical endodontic practice and describes
the principle on which these newer pulp testing devices are based and its
mode of working.
Key words: Pulp vitality, Pulse oximetry, Laser Doppler flowmetry, Pulpal circulation,
Revascularizaton, Light transmission.

Introduction vitality 3,4 as it provides an objective

The assessment of pulp vitality is a crucial
diagnostic procedure in the practice of
dentistry1. Current routine methods rely on
stimulation of Ad nerve fibers and give no direct
indication of blood flow within the pulp. These
include thermal stimulation, electrical or direct
dentine stimulation. These testing methods
have the potential to produce an unpleasant
and occasionally painful sensation and
inaccurate results (false positive or negative
can be obtained in many instances). In addition,
each is a subjective test that depends on the
patient's perceived response to a stimulus as
well as the dentist's interpretation of that
response2. Recent studies have shown that
blood circulation and not innervation is the most
accurate determinant in assessing pulp
* Post Graduate Student
** Professor
*** Lecturer
Department of Conservative Dentistry and
Endodontics, Ragas Dental College
Chennai-600119
differentiation between necrotic and vital pulp
tissue. This article highlights tests relying on
the passage of light through the tooth to detect
pulp vitality with greater objectivity. They rely
either on the detection of changes in the light
absorption as it passed through the tooth, as
in photoplethysmography, pulse oximetry and
dual wavelength spectrophotometry5 or the
shift in light frequency as it is reflected back
from a tooth, as in laser Doppler flowmetry6.
This paper attempts to review the newer pulp
vitality testing methods.
Pulse Oximetry
The pulse oximeter is a non-invasive
oxygen saturation monitoring device widely
used in medical practice for recording blood
oxygen saturation levels during the
administration of intravenous anesthesia. It
contributes to the increased safety of general
anesthesia. Pulse oximeter is a standard
equipment in operating rooms and is routinely
being used in other acute care settings,

14
 Samraj RV et al.
including intensive care units, emergency
rooms and endoscopy suites where sedation
and analgesia are provided 8 . Its wide
acceptance in the medical field results from
its ease of application and its capability of
providing vital information about the patient's
status.
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This device is currently under investigation
in dental practice to detect pulpal blood
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circulation by virtue of its non-invasive and
atraumatic nature. Specific objectives were to
develop a design for a. dental sensor (a
modified finger probe) that can be successfully
applied and adapted to the tooth and well suited
to detect pulsatile absorbance.
The principle of this technology is based
on a modification of Beer's law, which relates
the absorption of light, by a solute to its
concentration and optical properties at a given
light wavelength9. It also depends on the
absorbance characteristics of haemoglobin in
the red and infra-red range. In the red region,
oxyhaemoglobin absorbs less light than
deoxyhaemoglobin and vice versa in the infra-
red region. Hence one wavelength was
sensitive to changes in oxygenation and the
second was insensitive to compensate for
changes in tissue thickness, haemoglobin
content and light intensity.
The system consists of a probe containing
a diode that emits light in two wavelengths:
I. Red light of approximately 660 nm
II. Infra-red light of approximately 850 nm
A silicon photo detector diode is placed
on the opposing surfaces of the tooth, which
is connected to a microprocessor.
The probe is placed on the labial surface
of the tooth crown and the sensor on the palatal
surface. Ideal placement of the probe is in the
middle third of the crown. If placed in the
gingival third, disturbances from gingival
circulation or any gingival trauma or bleeding
will interfere with the readings. Incisally, less
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Pulp vitality testing...
of pulp tissue is present for adequate detection
of the pulse.
A number of clinical studies have proved
that the pulse oximetry is an effective and
objective method of evaluating dental pulp
vitality. Though the surrounding insulation of
the enamel and dentine are hindrances to the
detection of a pulse in the pulp, it has proved
to be a successful method in 70% of the clinical
trials and further work is still in progress. It is
also useful in cases of impact injury where the
blood supply remains intact but the nerve
supply is damaged12. Also current results
indicate that pulpal circulation can be detected
by the pulse oximeter independent of gingival
circulation. Signal filtration is now employed to
make it easier to reproduce pulp pulse
readings. Smaller and cheaper commercial
oximeters are now available for routine clinical
use in an average dental office.
Despite its advantages, limitations include
background absorption associated with venous
blood and tissue constituents, which should be
differentiated. In addition to the absorption,
refraction and reflection also occur as in
Penumbra effect, which is seen in patients with
strong tissue pulsations, where some of the
light reaches the photo detector diode without
passing through the tissue bed13. The oxygen
saturation values from the teeth routinely
register lower than the readings from the
patient's finger. This may be due to the
limitations of using a probe designed for other
body parts, not specifically for the anatomy of
a tooth14.
Dual Wavelength
Spectrophotometry
Dual wavelength spectrophotometry
(DWLS) is a method independent of a pulsatile
circulation. The presence of arterioles rather
than arteries in the pulp and its rigid
encapsulation by surrounding dentine and
enamel make it difficult to detect a pulse in the
pulp space. This method measures

oxygenation changes in the capillary bed rather
than in the supply vessels and hence does not
depend on a pulsatile blood flow. Pulse
oximetry is a method based on DWLS.
DWLS detects the presence or absence
of oxygenated blood at 760 nm and 850nm.
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The blood volume or concentration channel
(760 nm plus 850 nm) is arranged to respond
linearly to the increase in light absorption. The
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oxygenation channel (760 nm minus 850 nm)
senses the oxygenated blood because of the
greater absorption at 850 nm as compared to
760 nm. In vivo and in vitro studies were
conducted to differentiate between pulp
chambers that were empty, filled with
oxygenated blood or fixed pulp tissue. DWLS
was able to differentiate with reproducible
readings between a pulp chamber of a vital
and non-vital tooth in vivo.
In young children, in cases of avulsed and
replanted teeth with open apices, the blood
supply is regained within the first 20 days after
replantation but nerve supply lags behind15.
Repeated spectrophotometric readings taken
at the start of the replantation and continuing
upto 40 days later revealed an increase in blood
oxygenation levels indicating a healing process
and that the pulp of the avulsed tooth was
recovering. Hence endodontic treatment need
not be undertaken.
Even though the instrument was not
specifically designed for dental use, it was easy
to use and can be developed as a pulp tester.
A major advantage is that it uses visible light
that is filtered and guided to the tooth by
fibreoptics. Thus unlike Laser light, added eye
protection is unnecessary for the patient and
the operator.
Still in vivo tests of this hypothesis are in
progress. Influence of the gingival circulation
cannot be ruled out and data on how large a
mass of pulp tissue is needed for accurate
readings must be determined. The test is non-
invasive and yields objective results. The
16
Endodontology, Vol. 15, 2003
instrument is small, portable, relatively
inexpensive and should be suitable for use in
a private dental office.
Laser doppler flowmetry
Laser Doppler Flowmetry (LDF) is a non-
invasive, electro optical technique, which
allows the semi-quantitative recording of pulpal
blood flow16. The Laser Doppler technique
measures blood flow in the very small blood
vessels of the microvasculature.
The technique depends on the Doppler
principle whereby light from a laser diode
incident on the tissue is scattered by moving
RBC's and as a consequence, the frequency
broadened.
The frequency broadened light, together
with laser light scattered from static tissue is
photo detected and the resulting photocurrent
processed to provide a blood flow
measurement. The Doppler shifted laser light,
back- scattered out of the tooth is detected by
a photocell on the tooth surface. The output is
proportionate to the number and velocity of the
blood cells.
Over the past decade LDF technology has
been used experimentally to monitor blood flow
in the pulps of both, the animals and the
humans17,18. LDF has been shown to be
valuable in monitoring revascularization of
immature incisors following severe dental
trauma. During follow-up examination the
traumatized tooth was unresponsive to
traditional vitality testing during the first 6
months. However LDF indicated that
revascularization had occurred much sooner19.
The primary issues in pulp-vitality testing
as follows:
• A non-vital post-traumatized incisor has a
better long-term prognosis if root canal
therapy is completed before the necrotic
pulp gets infected.
• The best outcome for the post-traumatized
 Samraj RV et al.
immature incisor is for it to revascularize
and continue normal root development,
including increased root wall thickness,
which is not possible to assess with
conventional electrical and thermal
testing20.
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• Watching and hoping for revascularization
using sensitivity testing may lead to
infection in the post-trauma observation
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period.
Studies were carried out to compare LDF
with conventional pulp tests, EPT (electric pulp
testing) and thermal tests, in children with
certain dental injuries. At the initial assessment
at presentation, all tests had poor sensitivity
and specificity; however at 3, 6, and 12 months,
LDF was significantly better than the other
tests21. There was no difference between tests
at the later time periods, 18 months and 2
years. It was concluded that LDF identified
more vital and non-vital teeth correctly at earlier
time periods following injury than conventional
tests.
The limitations of this method include a too
expensive device for use in a dental office. The
sensor should be maintained motionless and
in constant contact with the tooth for accurate
readings. Also the laser beam must interact
with the moving cells within the pulpal
vasculature. However, it is useful in young
children whose responses are unreliable and
its non-invasive nature helps to promote patient
co-operation and acceptance.
Other Testing Modalities
The concept of diagnosing tooth vitality by
temperature measurement can provide
valuable information on the integrity of the
underlying pulp. Howell et al used liquid
cholesteric crystals and found that non-vital
teeth have lower temperature than vital teeth22.
Fanibund in 1985 concluded from a
laboratory study that it is possible to
differentiate by means of crown surface
17
Pulp vitality testing...
temperature, distinct differences in vital and
nonvital teeth. He used a Thermistor unit
consisting of 2 matched thermistors connected
back to back, one measuring the surface
temperature of the crown (measuring
thermistor) while the other acting as a
reference thermistor23. The tooth to be tested
was dried with gauze and the thermistor unit
was positioned so that the measuring
thermistor contacted the center of the buccal
surface of the crown. The reference thermistor
was suspended in air, close to it, but not
touching either the measuring thermistor or the
enamel surface.
An equilibrium was next achieved between
the temperatures of the thermistors, the crown
surface and the immediate environment by
holding the measuring unit in the described
position until a steady state was established
for at least 20 seconds22. Stimulation of the
crown surface was carried out by means of a
rubber-polishing cup fitted to a dental contra-
angle handpiece. The recordings were.
continued for a period of time following the
stimulation period. It was found that a difference
was obtained between the critical period for
vital and non-vital teeth and the difference
corresponded with a specific temperature
change.
The feasibility of temperature
measurement as a diagnostic procedure in
human teeth was again demonstrated in 1986
by Fanibunda in another clinical study, using
the time-temperature relationship method.
Graphs were constructed from temperature
readings of teeth at 15 seconds intervals. At
the end of the cooling period, vital teeth
illustrated a rise in temperature and following
this a steady state was reached. Non-vital
teeth, at the end of the cooling period did not
show any rise in temperature before it reached
a steady state. The temperature remained at a
steady level or decreased further. Information
in respect of tooth vitality can be gained from
the time-temperature relationship method.

Recently, computerised infrared
thermographic imaging (TI)24,25 for human
teeth is under investigation to assess pulp
vitality.
Further research is being undertaken with
the sole aim of increasing the detectable
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difference between vital and non-vital teeth, so
that a method of temperature measurement
may be evolved which is of diagnostic
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significance under routine clinical conditions.
Conclusion
The unreliability of testing tooth pulp nerve
response is well documented. When nervous
sensations are inhibited or abolished in the
tooth, for example following trauma, tooth
transplantation procedures or during a general
anaesthetic, conventional tests are of little
value. However, a method based on the
vascular response of the pilip need not be
restricted under such conditions. Recording the
pulpal blood flow would be an objective
assessment of the status of the pulpal blood
circulation, a true indicator of pulp vitality.
Optical devices that exploit the various
absorbance properties of different substances
within the dental pulp are being studied to
determine pulsation and blood volume. They
offer the advantages of being objective, non-
invasive and atraumatic testing modalities,
which result in greater patient acceptance and
co-operation. Currently, the significance and
reliability of these methods are being studied.
It is hoped that newer technology will enable a
more thorough study of the pulpal vasculature
and define its role in pulp vitality testing.
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