This action might not be possible to undo. Are you sure you want to continue?
Presented by:Anjali Miglani
Department of Conservative Dentistry & Endodontics
INTRODUCTION The assessment of pulp vitality is a crucial diagnostic procedure in the practice of dentistry-Noblett 1996 Most methods rely on stimulation of A-fibers gives no indication of blood flow within the pulp
THE MOST COMMON SYSTEM ASSOCIATED WITH SYMPTOMATIC PULP IN THE PAIN PATHOPHYSIOLOGY OF PAIN
- An unpleasant sensory and emotional experience associated with actual or potential tissue damage defines the physiologic and the physiologic components. - The pain process begins in the periphery, where specialized nerve fibers receive a painful stimulus. These nerve fibers transmit this information to the spinal cord and ultimately to the brain where information is interpreted and recognized as PAIN.
DETECTION OF PAIN
Odontogenic pain transmission is mediated primary by peripheral sensory nerves of the trigeminal nerve. A fibers nerve – innervate the dentin (Fibers) – Unmyelinated fibers innervate the body of these pulp and its blood vessels
A – DELTA FIBERS
Pulpodentinal complex – The circumpulpal nerve sends free nerve ending onto and though the odontoblastic cell layer extending upto 200 um into the dentinal tubules while also conducting the odontoblastic cell processes. This intimate association of A Delta fibers with the odonto blastic cell layer and dentin is referred to as the pulpodentinal complex. Disturbances of the pulpodentinal complex in a vital tooth initially affect the low threshold a delta fibers. Drying, probing drying with air and application of hyper osmotic solution to exposed dentin will cause pain. - Movement of fluid in dentinal tubules known as the hydrodynamic theory of dentin sensitivity stimulation the A –delta fibers. - Vital pulp responds immediately with symptoms of dentinal pain. - Through a Delta fibers pain is perceived as quick, Sharp, Momentary Pain. - Dessipates quickly upon removal of the stimulus such as drinking cold liquids a probing exposed dentin. - The clinical symptoms of a delta fiber pain signify external disturbance. that the pulpodentinal complex is intact and capable of responding to a
- Small, - Unmyelinated nerves - High Threshold fibers subadjacent to the A-delta fibers. - Pain associated with C fibers dull, poorly localized
When inflammation leads to pulp necrosis.Vital testing – response is seen . periradicular lesions may develops . C fiber pain associated with tissue injury and is modulated by inflammatory mediations. Vascular changes in blood volume blood flow decrease in tissue pressure CLINICAL SIGNIFICANCE . CLINICAL FEATURES OF PULPAL PATHOLOGIES Clinical classification of pulpal disease is based on INFLAMMATION OF THE PULP OR PULPITIS May be Acute on chronic Can be Determined can not be determined partial or total infected or sterile .C fibers activated by intense heating or cooling of the tooth crown or mechanical stimulation of the pulp.Instrumentation of necrotic pulp may also cause pain REASON C fibers more resistant that A fibers to compromised blood flow and hypoxic conditions Pain associated with a necrotic pulp in due to C fiber stimulation.Radiograph shows lesion .
Chronic form runs .Clinical class . he divided disease of pulp into 4 categories 1) The symptom less. for which pulp capping may be done. vital pulp which has been injured or involved by deep caries. Garfunkel and associated found a direct correlation between clinical diagnosis and histologic examination in 49% of pulps examined. painful cause chronic hyperplasic pulpitis.Symptoms or slightly painful and of longer duration. 3) Pulps indicated for extirpation and immediately root filling.Increase in vascular permeability of vessels . Based on clinical symptoms.Chronic inflammation of exposed pulp Due to caries or trauma Acute form runs . 2) Pulps with a history of pain amenable to pharmacotherapy.Benkoryfe around dilated vessels An interesting phenomenon Mast cells (inhabitant of loose fibrous connective tissue) . 4) Necrosed pulp accessible to root canal therapy. .Baume found no direct correlation between clinical symptoms and histologic findings.Release of chemical mediators .a short. HISTOLOGICAL FEATURES Nature – Direct and immune mechanisms .
.Pulp death occur slowly and without dramatic symptoms. A.Rarely seen in heath pulps appears in inflammation. symptomatic or asymptomatic. IRREVERSIBLE PULPITIS It is a persistent inflammatory condition of the pulp. REVERSIBLE PULPITIS Clinical Features .Nerves may occur quickly or the process may require years. caused by a noxious stimulus.Mild to moderate inflammatory condition .Disruption of the Odontoblastic layer . lingering after removal of the thermal stimulus. .Pains persists for several minutes to hours. . B.Dilated blood vessels . Acute irreversible pulpitis exhibits pain usually caused by hot or cold stimulus or pain that occurs spontaneously. .Pulp is capable of returning to the uninflamed state following removed of stimuli. Immune and inflammatory reactions may destroy normal cellular and extracellular components.Extravasation of edema fluid .Pain of brief duration subsides as soon as stimulus is removed Histopathology .Pressure of immunologically competent cells.Reparative dentin . .
Granulation tissue Symptoms .Microabssecesses of the pulp begin as tiny zones of necrosis within dense inflammatory all infiltrates comprised principally of acute inflammatory cells.Low grade.covered by Stratified squamous epithelium . CHRONIC HYPERPLASTIC PULPITIS . long standing irritation Histopathology . . .Sudden temperature changes causes pain. piercing or shooting may be intermittent or continuous. . .Changes of position. .. pain is more severe .Pain – Sharp.Recumbency which results in congestion of the blood vessels of the pulp. .Pain increased by heat and sometimes relieved by cold. .Pulp Polyp. Symptoms . C.Pressure from packing food into a cavity or suction exerted by tongue or cheek. Rising out of the carious shell of the crown in mushrooms of pulp tissue that is often firm and insensitive to touch. . Due to extensive carious exposure of young pulp.Symptoms except during mastication.In late stage.growing throbbing. . bend over or lying down excerts pains.
Death of the pulp. . HISTOPATHOLOGY .Pressure of granulation tissue accounts for profuse bleeding when pulps is removed . sequel to inflammation.Results of osteoclastic activity.No painful stimulus.Asymptomatic .Multinucleated giants cells are present Symptoms . Partial total Can be due to traumatic injury. E.Dull or opaque appearance of the crown due to back of normal transluscency . Lack of collateral circulation and unyielding walls of dentin Insufficient drainage Necrosis Coagulation necrosis liquefaction necrosis Symptoms .Manifested as reddish area pink spot.Is idiopathic slow or fast progressive resorptive process in the dentin of the pulp. NECROSIS . INTERNAL RESORPTON .D. .
When the stimulus is removed the response subsides almost immediately. Pulpal Disease Within Normal Limits – A normal pulp is asymptomatic and produces a mild to moderate transient response to thermal and electrical stimuli. periodontal scaling root planning microleakage and unbased restorations. This system was based on the patient’s symptoms and the results of clinical tests. Clinical Classification of Pulpal and Periapical Disease according to Cohen Clinical classification system was developed. .Teeth with partial necrosis can respond to thermal changes owing to presence of vital nerve fibers. There is no evidence of root resportion. calcification degeneration of the pulp. Any irritant that can affect the pulp may cause reversible pulpitis including early caries. The tooth and its attachment apparatus do not cause a painful response when per cussed or palpated radiographs reveal a clearly delineated canal that taper smoothly toward the apex. proliferation. ulceration. Rather its purposes are to suggest in the broadest possible interpretation whether the pulp is either healthy or unhealthy and to help the clinical experience. and the lamina dura is intact. Otherwise the pulp remains asymptomatic. It was developed to provide basic terms and phrases that clinicians could use to describe the extent of pulpal and periapical disease before selecting a method of treatment. A clinical classification of this sort is not meant to list every possible variation of inflammation. Reversible Pulpitis The pulp is uninflamed to the extent that thermal stimuli – usually cold cause a quick sharp hypersensitive response that subsides as soon as the stimulus is removed. or attachment apparatus.
If the irritant is removed and further insult is prevented by sealing the dentinal tubules communication with the inflamed pulp the pulp will revert to an asymptomatic uninflamed state. Symptomatic irreversible pulpitis commonly includes a complaint of spontaneous pain. However symptomatic irreversible pulpits causes a painful response to thermal change the lingers after the stimulus is removed. .3. 2.Reversible pulpitis is not a disease it is a symptom. Clinically the acutely inflamed pulp is symptomatic whereas the acutely inflamed pulp is symptomatic whereas the chronically inflamed pulp is asymptomatic in most cases. Reversible pulpitis causes a momentary painful response to thermal change that subsides as soon as the stimulus is removes. Irreversible Pupitis Irrreversible pulpitis may be acute subacute or chronic it may be partial it be partial or total infected or sterile. Conversely if the irritant remains the symptoms may persist indefinitely or may become more widespread leading to irreversible pulpitis. Therefore the key difference is that reversible pulpitis is reactive it produces a response albeit exaggerated only when stimulated.58 Dynamic changes in the irreversibly inflamed pulp are continual the pulp may move from quiescent chronicity to acute pain within hours. Reversible pulpitis can be distinguished from a symptomatic irreversible can be distinguished from a symptomatic irreversible pulpitis in two ways. The apical extent of irreversible pulpitis cannot be determined clinically until the periodontal ligament is affected by the cascade of inflammatory mediators and the tooth becomes sensitive to percussion. 1. Reversible pulpitis does not involve a complaint of spontaneous (unprovoked) pain.
intermittent or continous paroxysms of pain. Before perforation of the crown the resorption can be detected as a pink spot on the site. Hyperplastic Pulpits A reddish cauliflower like growth of pulp tissue through and around a carious exposure is one variation of asymptomatic irreversible pulpitis. Occasionally patients may report that a postural change (lying down or bending over) induces pain resulting in fitful sleep.e.Asymptomatic Irreversible Pulpitis Although uncommon asymptomatic irreversible pulpitis may be the conversion of symptomatic irreversible pulpits to a quiescent state. Internal Resorption Internal resorption is a painless condition resulting from the recruitment of blood-borne clastic cells often stimulated by trauma which produces dentin routine radiographic examination.). The proliferative active nature of this pulpal reaction sometimes known as a “pulp polyp..” Occasionally this condition may cause mild transient pain during mastication. Even with the use of .” is attributed to a low grade chronic irritation of the pulp and the generous vascularity characteristically found in young people.e. Only prompt endodontic therapy to eliminate these elastic cells will prevent tooth destruction. pain that lingers after the thermal stimulus is removed). Caries and trauma are the most common causes of this condition which can be information gathered from the patient’s dental history and properly exposed radiographs. Symptomatic Irreversible Pulpitis Symptomatic irreversible pulpitis is characterized by spontaneous )i. Sudden temperature changes (usually cold) elicit prolonged episodes of pain )i. This pain may be relived in some patients by the application of heat or could. If undetected internal resorption will eventually perforate the root.
EPT is of little value in the diagnosis of symptomatic irreversible pulpitis because the pulp though inflamed is still reversible pulpitis because the pulp though inflamed is still responsive to electrical stimulation.may continue the experience pain. However radiographs can be helpful in identifying offending teeth (i. In most cases radiographs are not useful in diagnosing symptomatic irreversible pulpitis because the inflammation remains confined to the pulp. There inflammatory process of symptomatic irreversible pulpitis may become so severe that it will lead to necrosis of the pulp. Necrosis Necrosis the death of the pulp actually refers to a histologic condition resulting from an untreated irreversible pulpitis a traumatic injury or any event that causes long –term interruption of the blood supply to the pulp.. Pulp may become liquefied or coagulated. In the advanced stage of symptomatic irreversible pulpitis thickening of the apical portion of the periodontal ligament may become evident on the radiographs. Generally pain from symptomatic irreversible pulpitis is moderate to severe it can be sharp or dull localized or referred. teeth with deep caries extensive restorations pins evidence of previous pulp capping calicific metamorphosis)2. Symptomatic irreversible pulpitis can be diagnosed through synthesis of the information provided a thorough dental history a complete visual examination properly exposed radiographs and carefully conducted thermal tests.2 ml of intraligamentary anesthesia in the distal sulcus of the correctly identified tooth will immediately stop the pain. If radiating or referred pain is involved the application of 0. Total necrosis is asymptomatic . In the degenerative transition from pulpitis to necrosis the usual symptoms of symptomatic irreversible pulpitis may subside as necrosis occurs.e.several pillows to stabilize themselves at a comfortable postural lives patients .
Thus reliance upon EPT and thermal pulp testing can result in the unnecessary removal of healthy denervated pulps. Perhaps the use of more sophisticated testing techniques.5 The difficulty with the use of the term “necrosis” is that pulp vitality testing has been limited to electrical and thermal stimulation of pulpal nerves.31 or teeth that have calcified with age. Some crown discoloration may accompany pulp necrosis in anterior teeth but this diagnostic sign is not reliable.58 As these irritants cascade out of the root canal system often periapical disease will occur.3. For this reason there is no response to thermal or EPT. The bacterial toxins (and sometimes bacteria) that produced the necrosis in the pulp follow the pulp tissue through the apical foramen to the periodontal ligament resulting in an inflammatory reaction in the periodontium.18. such as laser Doppler flowmetry or pulse oximetry will overcome this limitation and provide a clinical test Laser doppler measurements augement clinical observations providing an improved basis for dental treatment plan Assessments of pulpal status in by various AIDS Correction of various methods pulp vitality in different pulpal conditions.before it affects the periodontal ligament because the pulpal nerves are nonfunctional. 17.1 teeth with immature apices. This inflammation will lead to thickening of the periodontal ligament and manifest itself as tenderness to percussion and chewing. .27. In the case of teeth that have been traumatized9 teeth in a segment of bone that has been surgically repositioned. For example a tooth with two or more toot canals could have an inflamed pulp in one canal and a necrotic pulp in the other.48 Partial necrosis may be difficult to diagnose because it can produce may be difficult to diagnose because it can produce some of the symptoms associated with irreversible pulpitis.8 nerve function can be diminished or cease altogether while the pulp retains an intact vasculature.
VARIOUS AIDS IN DETECTING THE VITALITY OF THE PULP Assessment of pulp vitality should be based on blood supply of the pulp.Pulse oximetry. Hughes probeye camera. assessment of the pulpal blood supply remains complicated and there is no practical clinical test to determine this basis aspect of the tooth’s biology.Laser Doppler flowmetry 15. 13. The clinical condition of the pulp can be evaluated by various methods. Thermal test 3. History of the patient 2.Test cavity 12. Percussion 4. Transillumination 7. 9. 8.Use of tooth temperature 16. Electric pulp test 6.MRI.Dual Wavelengths spectrophotometry 14. Unfortunately. Occlusal pressure test 10. 1. .Anaesthetic test 11. Liquid crystal testing. Palpation 5.
but gives a part history of pain then we can suspect necrosis of the pulp history should be corroborated with other clinical tools and radiographs. PALPATION .Uses digital pressure to check tenderness in the cavity covering suspected tooth. 2. patients is chief complaint plays an important role includes symptoms that occur following specific events (eg chewing drinking cold liquids) .Whether pain is of short duration of long duration we can judge condition to be Acute chronic It patient presents with so symptoms. Thermal Pulp Tests:- One of the most common symptoms associated with the symptomatic inflamed pulp is pain elicited by thermal stimulation. Sensitivity indicates inflammation in the periodontal ligaments surrounding affected tooth. HISTORY OR THE PATIENT To know the status of the pulp. Although some patients suffer pain when cold is applied to the tooth but are comfortable with warm substances and others require frequent applications of cold liquid to keep their pain bearable there . We can suspect that inflammation through caries lesion has gone to the PDL if tenderness to palpation occur.1.
Additionally an exaggerated response to thermal stimuli can indicate a lowered threshold to stimulus because of pulpal inflammation (e. A graduated method of applying the stimulus is required to avoid causing the triple syringe followed by isolation the tooth under a rubber dam and . The only conclusion the clinician may draw when a pulp responds abnormally to thermal stimulation either in an exaggerated manner or not at all is that is not in a state of good health. The pain is proportionate to the stimulation consequently even teeth with intact enamel will react to extreme cold such a in ice or carbon dioxide snow.g immediately after placement of a restoration). When teeth begin to react to stimuli that do not normally produce pain such as tap water the probability is that dentin has been exposed by caries that the tooth structure is fractured or that faulty restoration abrasion or attachment loss caused by periodontal disease exists. In the former case the patient is complaining of painful pulpal response cold therefore pulpal vitality is not at issue. Solution is to address the cause of the dentin sensitivity by occluding the dentinal tubules by placing a temporary sedative restoration such as intermediate restorative material (IRM). When the chief complaint is pain to a thermal stimulus (usually cold) the clinician must distinguish between thermal testing to isolate the offending tooth by reproducing the patient’s symptoms and attempting to determine whether a suspected tooth has a vital or nonvital pulp.is no particular response to either heat or cold that is unique to a specific pulpal pathologic state56. The rationale for innervation of any bodily structure is to provide a warning of damage that is occurring pain with the application of thermal stimuli is normal and a vital part of the patient’s protective defense mechanism.In the case of the new restoration the clinician should simply wait to see whether the acute inflammation subsides in a short.
This melts the outside of the stick so that it can be removed from the plastic and held in a 2” x 2” gauze for use. which is then applied immediately to the middle third of the facial surface of the crown of the tooth. It has been replaced by the manufacturer with 1. The most commonly used method are ice sticks. No studies are yet available on the efficacy of this replacement compared with other testing methods. The ice stick applied immediately to the middle third of the facial surface of the crown of the tooth or on any exposed metal surface of crowns and kept in contact for 5 seconds of until the patient begins to feel pain.1. The pellet is kept in the contact with the crown for 5 seconds of until the patient begins to feel pain. Freezing water in the plastic covers from hypodermic needles one is removed from the freezer and held tightly in the clinician’s hand for a few minutes. which is the nonchlorofluo-rocarbon refrigerant R-134a. Carbon dioxide snow formed into sticks is extremely cold. Its use in pulp testing is no longer recommended because it has been found to be less effective than carbon dioxide snow or dichlorodifluoromethane which is the refrigerant R-12 commercially packaged as a compressed spray (Endo-Ice). No detrimental effects occurred in vital pulpal tissue and no cracks or surface irregularities . However it also has a low boiling point (15. Cold Test: Various methods have been used to apply cold to the teeth for testing.2 Tetrafluoroethane. commonly used in medicine as a skin refrigerant. Ethyl chloride is available as a compressed spray. It is the most effective method of eliciting a response in vital teeth.1. various compressed gasses and carbon dioxide snow. In contrast when there is no complaint of cold sensitivity the following methods for using cold to determine pulpal vitality are appropriate.bathing it with cold water should elicit the patient’s symptoms and quickly indicate the offending tooth. available as Green Endo-Ice.10F). The material is sprayed liberally onto a cotton pellet or swab.
The tooth is bathed in very warm water from a plastic syringe for 5 seconds or until the patient begins to feel pain. To use this technique the teeth to be tested are first protected with a light coating of petrolatum to prevent the warm temporary stopping from sticking to them. The stopping is warmed over a flame until it becomes soft and just begins to glisten (Grossman’s method)23 but not so that it slumps and becomes too limp to use.47 The carbon dioxide is released into a special syringe in which it forms the “snow”. Warm sticks of temporary stopping and the hot water bath.43. Since the patient’s chief complaint is pain in response to heat the temperature is gradually increased if no . Although less convenient than the isolating the teeth individually with a rubber dam and bathing each tooth with ice water from a syringe for 5 secs simultaneously cools all surfaces of the teeth. Although all transfer heat to the tooth the methods most commonly used are warm sticks of temporary stopping used are warm sticks of temporary stopping and the hot water bath. It is applied immediately to the middle third of the facial surface of the crown of the tooth and kept in contact with the crown for 2 second or until the patient begins to feel pain.26.second application has been found to increase the temperature at the pulpodentinal junction less then 20 C there fore it is unlikely that damage will occur to the pulp47. Temporary stopping consists of gutta-percha in 3-inch sticks. Warm sticks of temporary stopping are the most convenient for the clinician but the hot water bath will yield the most accurate patient response. A 5. It is compacted with a plunger and the pellet is expressed onto a 2” x 2” gauze. Application to the middle third of the facial surface of the crown usually results in a response in less than 2 seconds. Heat Test : As with cold testing many methods for heat testing teeth have been suggested.were produced in the enamel of tested teeth.
Even when the tooth has been restored with a full crown (metal or porcelain) sufficient contact is made to allow cooling or warming of the pulp. No response 2. In addition the cold ant hot water bath methods prevent damage to the tooth caused by excessive temperature change. There are four possible responses to thermal stimulation: 1. However no response to thermal testing can also indicate a false negative response because of excessive calcification an immature apex recent trauma or patient premedication. The use of water allows allows the entire crown to be immersed not just one section of one surface of the tooth. A painful response that linger for several minutes after the stimulus . Strong momentary painful response that subsides within 1 to 2 seconds after the stimulus has been removed 4. A momentary mild-to-moderate response to thermal change is generally considered within normal limits.to – moderate degree of awareness of slight pain that subsides within 1 to 2 seconds after the stimulus has been removed 3. A somewhat exaggerated response that subsides quickly is characteristic of reversible pulpitis.response is obtained rather than producing unnecessary’s pain by beginning with excessively hot liquid. mild. Moderate –to strong painful response that lingers for several seconds or longer after the stimulus has been removed If there is no response to thermal testing a nonvital pulp is often the cause. Responses to Thermal test: The sensory fibers of the pulp transmit only pain whether the pulp has been cooled or heated. Although the cold and hot water bath methods of thermal testing are time consuming they are clearly superior in their accuracy compared to very warm temporary stopping or ice pencils.
it is termed a false positive response. When a patients reports sensation in a tooth with a necrotic pulp. metallic restorations conducting the stimulus to the adjacent teeth. Circumstances that can cause false positive response to electric pulp testing include patients anxiety. As a result teeth that temporarily or permanently lose their sensory function (e. The electric pulp test fails to provide any information about the vascular supply to the pulp which is the true determinant of pulp vitality. A false negative response means that although the pulp is vital.58 Often irreversibly inflamed pulp is responsive to EPT because it still contains vital function nerve fibers that can produce a toothache. saliva conducting the stimulus to the gingiva.9 Seltzer et al reported that 28% of teeth necrotic pulps tested positive to EPT. Therefore attempting to interpret the numerical values produced by the EPT is not recommended.g. and more that half of those with [partially necrotic pulps were responsive. teeth damaged by trauma or teeth that have undergone orthognathic surgery) will be nonresponsive to EPT. A positive response to electric pulp testing 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. the patient dose not indicate that any sensation is felt in the tooth. ELECTRIC PULP TESTS: The electric pulp tester (EPT) uses electric excitation to stimulate the A sensory fibers within the pulp. However they will have intact vasculature. This situation can be . and liquefactive necrosis conducting the stimulus to the attachment apparatus. The EPT provides only a responsive or nonresponsive result that correlates in many cases with vital or nonvital pulpal status..is removed that lingers for several minutes after the stimulus is removed is characteristic of irreversible pulpitis.
produced by premedication with drug or alcohol. partial necrosis with vital pulp remaining in the apical portion of the root. Laser Doppler flowmetry uses a laser beam of known wavelength that is directed through the crown of the tooth to the blood vessels within the pulp. Teeth that have experienced recent trauma or are in a portion of jaw that has under gone orthognathic surgery can lose sensibility while retaining an intact blood supply and vital pulp. EPT uses electric current to stimulate the A nociceptors in the pulp. inadequate media. . though useful. and endodontic therapy would have been needlessly undertaken. and individual patients with atrophied pulps or high pain thresholds. the output of which is proportional to the number and velocity of the blood cells. way to determine the pulpal status of a tooth. it is essential that multiple tests be performed before a final diagnosis is made. However. immature teeth. EPT is an imperfect. trauma. EPT will help the clinician determine whether the pulp is vital. In the case of a periapical radiolucency. LASER DOPPLER FLOWMETRY. With EPT only. the pulps would have been considered necrotic. When these fibers are intact stimulation results in a painful sensation and the pulp is said to be vital. Moving red blood cells cause the frequency of the laser beam to be Doppler shifted ands some of the light to the back scattered out of the tooth. poor contact with the tooth. Therefore. This reflected light is detected by a photocells on the tooth surface. When used thermal and periodontal testing the EPT can help differentiate pulpal disease from periodontal disease or nonodontogenic causes. intact nerve functioning is not essential for pulp vitality. Investigators found that 21% of teeth in patients that tested nonresponsive to electrical stimulation after having undergone Le Fort operations had intact blood supplied when tested with laser Doppler flowmetry.
A pulse oximeter uses a probe for oxygen saturation of the blood.e.Laser Doppler flowmetry is complicated by the fact that the laser beam must interact with moving cells within the pulpal vasculature.. apprehensive or distressed patients may accept it more readily than current methods. When equipment costs decrease and clinical applications improves. Current limitations aside. Jig (i. Additionally differences in sensor output and inadequate calibrations by the manufacturer may mandate the use of multiple probes for accurate assessment and antihypertensive medications and nicotine may affect blood flow to the pulp. To avoid artifactual responses. Pulse oximetry is a widely used technique for recording blood oxygen saturation levels during the administration of intravenous anesthesia. young children). Increased acidity and metabolic rate produced by inflammation cause deoxygenation of hemoglobin and change the oxygen saturation of the blood. Finally. this technology could be used for patients who cannot communicate effectively or whose responses may not be reliable (e. A pulse oximeter uses a probe containing a diode that emits light in two wavelengths (1) red light of approximately 660 mm and (2) infrared light or approximately 850 . mouth guard) is needed to hold the sensor motionless and maintain its contact with the tooth. The position on the crown of the tooth and the location of the pulp within the tooth cause variations in pulpal blood flow measurements. a custom fabricated. producing inaccurate results. Because this testing modality produces no noxious stimuli. PULSE OXIMETRY – Another optical diagnostic method currently under investigation is the adaption of pulse oximetry to the diagnosis of pulpal vitality. the equipment still is too expensive for the average dental office. laser Doppler flowmetry promises an objective measurements of pulpal vitality and health.g.
to determine the oxygen saturation levels.including :ambient light .there may be a delay between the occurrence of a potentially hypoxic event . Several investigators have successfully used modified finger probes or adapted the instruments to teeth to demonstrate the reliability of the system in the diagnosis of pulp vitality. This light is received by a photodetector diode. It uses this information together with known absorption curves for oxygenated and deoxygenated hemoglobin. Pulse oximeters measure the arterial oxygen saturation of hemoglobin. ventilation .shivering abnormal haemoglobin pulse rate and rhythm . connected to a microprocessor. pulse oximetry may be able to detect pulpal inflammation or partial necrosis in teeth that are still vital.only of their oxygenation .nm. the technology involved is complicated but there are two basic physical principles.vasoconstriction and cardiac function a pulse oximeter gives no indication of a patient . first the absorption of light at two different wavelengths by haemoglobin differs depending on the degree of oxygenation of haemoglobin second the light signal following transmission through the tissues has a pulsatile component .resulting from the changing volume of arterial blood with each pulse beat .capillary and tissue light absorption the function of a pulse oximeters is affected by many variable .and thus can give a false sense of security if supplemental oxygen is being given .this can be distinguished by the microprocessor from the non-pulsatile component resulting from venous . Other investigators indicate that the use of reflected light may be preferable to transmitted light and that different or multiple wavelengths may be required to improve the sensitivity of the technique. By monitoring changes in oxygen saturation.in addition . The device compares the ratio of the amplitude of the transmitted infrared with red light.
s cardio –respiratory status .which can become important if the haemoglobin levels are extremely low .such as respiratory obstruction and a pulse oximeter detecting low oxygen saturation however .one molecule of haemoglobin can carry up to four molecules of oxygen .is not measured by pulse oximetry a pulse oximeter consist of a peripheral probe. displaying a wave from. the oxygen saturation and .the however .oximetry is a useful non-invasive monitor of a patient .which is then 100%saturated with oxygen .In addition .having been successfully used in intensive care the recovery room and during anaesthesia they have been introduced in other areas of medicine such as general wards apparently without staff undergoing What dose a pulse oximeter measure ? 1 the oxygen saturation of haemoglobin in arterial blood –which is a measure of the average amount of oxygen bound to each haemoglobin molecule .the average percentage saturation of a population of haemoglobin molecules in a blood sample is the oxygen saturation of the blood .a very small quantity of oxygen is carried dissolved in the blood .s cardio-respiratory system which has undoubted improved patient safety in many circumstances Pulse Oximeters are now the standard part of preoperative monitoring which give the Operator a non -invasive indication of the patient .the percentage saturation is given as a digital readout together with an audible signal varying in pitch depending on the oxygen saturation Principles of modern pulse oximetry • oxygen is carried in the bloodstream mainly bound to haemoglobin . together with a microprocessor unit.
In this way. then both off many times per second. Quadrate division multiplexing is a further then recombined in phase later. an artifact due to motion or electromagnetic interference may be phase later.the pulse rate.e. The beams of light pass through the tissue to a photodetector. Most oximeters also have an audible pulse tone. the pitch of which is proportional to the oxygen saturation – useful when one can not see the oximeter display. Within the probe are two light emitting diodes (LED’s) one in the visible red spectrum (660nm) and the other in the infrared spectrum (940nm). ear lobe or the nose. from consists absorbance due to non pulsatile venous or capillary blood and other tissue pigment. Within the oximeter memory is a series of oxygen saturation values obtained from experiments . red on then infrared on. In this way. Time division multiplexing. The pulse rate is also calculated from the number of LED cycles between successive pulsatile signals and averages out over a similar variable period of time. The amount of light absorption at each light free frequency depends on the degree of oxygenation of haemoglobin within the tissue. During passage through the tissue. The probe is placed on a peripheral part of the body such as a digit. whereby the LED’s are cycled. Saturation values are averaged out over 5 to 20 second. the microprocessor calculates the ratio of two. an artifact due to motion or electromagnetic interference may be eliminated since in will not be in the same phase of the two LED signal once they are recombined. depending on the particular monitor. From the proportions of light absorbed at each light frequency. Several recent advances in microprocessor technology have reduced the effect of interference on pulse oximeter function. i. some light is absorbed by blood and soft tissue depending on the concentration of haemoglobin. The microprocessor can select out the absorbance of the pulsatile fraction of blood. that due to arterial blood. helps to eliminate background noise.
The light should be clean (remove nail varnish). How does an oximeter work? A source of light originates from the probe at two wavelengths (650nm and 805nm). rely on your clinically judgement. a graphical display of the blood flow past the probe. • Be cautious interpreting figures where there has been an instantaneous change in saturation – for example 99% falling suddenly to 85%. The microprocessor compares the ratio of absorption at the two light wavelengths measured with these stored values.performed in which human volunteers were given increasingly hypoxic mixtures of gases to breath. • Position the probe on the chosen digit. • Allow several seconds for the pulse oximeter to detect the pulse and calculate the oxygen saturation. avoiding excess force. • Is in doubt. ] • Selects the probe you require with particular attention to correct sizing where it is going to go. • Read off the displayed oxygen saturation and pulse rate. • Look for a displayed waveform. if available to recharge the batteries. Without this. Pulse oximetery is a simple non invasive method of monitoring the percentage of haemoglogin (Hb) which is saturated with oxygen. rather than the value the machine gives. and then display the oxygen saturation digitally as a percentages and audibly as a tone of varying pitch. Practical tips to the successful use of pulse oximetry. A audible alarms which can be programmed by the user are provided. This is physiologically not possible. • Plug the pulse oximeter in to an electrical socket. The pulse oximeter consists of a probe attached to the patient finger or ear lobe which is linked to a computerized unit. a calculated hart rate and in some models. The unit displays the percentage of Hb saturated with oxygen together with an audible single for each pulse beat. any reading is meaningless. • Turn the pulse oximeter on the wait for it to go through its calibration and check tests. The light is partly absorbed by .
Cardiac cycle blood pulsation in the supplying artery are transmitted to the pulp capillaries as pulsations in blood velocity. However in vital teeth with impaired blood supply the flux level can be low and the presence of pulsation is the only indication of vitality. The mean blood flux level in healthy teeth is much higher than for non vital teeth. but less accurate under 70%. Oximeters are calibrated during manufacture and automatically check their internal circuits when they are turned on. The computer within the oximeter is capable of distinguishing pulsatile flow from other more static signals (such as tissue or venous signals) to display only the arterial flow. RADIOGRAPHIC INTERPRETATION Only films of the highest quality should be accepted. These pulsation are apparent on Doppler monitor traces of vital teeth and are absent from non vital teeth. the vessel compliance is vary limited. The pitch of the audible pulse signal falls with reducing values of saturation. Calibration and Performance. They are accurate in the range of oxygen saturations of 70 to 100% (/-2%). The oximeter is dependent on a pulsatile flow and produce a graph of the quality of flow. By calculating the absorption at the two wavelengths the processor can compute the proportion of haemoglobin which is oxygenated. The size of the pulse wave (related to flow) is displayed graphically. any time or money saved by not taking questionable films would be forfeited by one . by amounts which differ depending on whether it is saturated or desaturated with oxygen.haemoglobin. APPLICATIONS Tooth pulp vitality Testing Tubules within the dentin act as light guides and direct light incident on the tooth surface into the pulp. This in highly vascular tissue and because of its position within a rigid structure.
diagnostic quality radiographs should be obtained even at the expense of repeated image Once high quality radiographs are obtained. causing periradicular (rather than periapical) demineralization. They found that a diagnosis based on the continuity and shape of the lamina dura and the width and shape of the periodontal ligament space was the most accurate in identifying teeth with nonvital pulps. A sound. Early caries. the depth of existing restorations. The clinician should be also consider whether the root canal system is within normal limits. the clinician should consider whether the bony architecture is within normal limits or whether there is evidence of demineralization. . In addition to inspecting the lamina dura and periodontal ligament space. Deep caries or extensive restorations increase the likelihood of pulpal involvement. In addition to periapical films in the posterior region. For this reason. Toxins and other irritants may exit through a lateral canal. a lateral canal in a tooth affected by periodontal disease can become a portal of entry for harmful toxins. the next step is to view them properly. significant medullary bone destruction may occur before any radiographic sings begin to appear. and pulpotomies or dens invaginatus can be identified in bite wing films. whether it appears to be resorbing or calcifying and what anatomic landmarks could be expected in the area. Conversely. pulp caps. correct examination protocol includes a careful investigation of each of these considerations. Clinicians should strive to limit their patients exposure to radiation and maximize their skills and the skills of staff members to achieve this end.misdiagnosis. A necrotic pulp will not cause radiographic changes until the enzymes produced by the inflammatory process have begun to demineralize the cortical plate. it is helpful to prepare bite wing films. However because the benefits or radiographs outweigh the risks.
Vertical and oblique root fractures will eventually cause demineralization and a resultant diffuse radiolucency adjacent to the fracture. If the canal appears blurred when compared with the irregular demineralized radiolucency surrounding the root. The inflamed pulp recruits clastic cells. lingual development grooves would be suggested. These calcification were not correlated with the severity of periodontal disease. Only a horizontal root fracture will be identifiable in the early stage and then only if the fracture line is within 15 degree of the central radiographic beam. internal resorption (occasionally seen after trauma) is an indication for endodontic therapy. in the pulp stones or canal calcification should not be interpreted as a pulpal disorder that requires endodontic therapy. Recognizing the presence of immature apices allows the clinician to anticipate erroneous responses to thermal and electric pulp tests. In traumatized teeth with pulp obliteration studied between 7 and 22 years posttrauma. Consequently. In the case of a suggested horizontal fracture. However. The investigations calculated the average rate of pulp survival for 20 years at 84%. In this case the pulp must be removed as soon as possible to eliminate these cells and avoid a pathologic perforation of the root. 51% had a normal response to EPT. they can be the result of normal aging of the pulp. did not produce higher EPT responses and were not related to age.Pulp stones and canal calcifications do not necessarily have pathologic origin. two additional radiographs should be produced from angles 30 degrees. In a few cases root fractures may cause pulp degeneration. which asymptomatically resorb the radicular dentin from the blood vascular system. Another 40% did not respond but were clinically and radiographically normal. .
this not a reversible procedure. In this case it is often necessary to complete the examination by carefully removing the crown to inspect the tooth underneath. when the dentinoenamel junction (DEJ) is passed. the results may be difficult to differentiate from normal. Many times leakage from sub gingival margins that were impossible to adequately explore clinically has resulted in a carious exposure of the pulp. or as the pulp is approached the patient should feel pain if the pulp is vital. who has been adequately approved of what to expect and how to respond if discomfort is felt. Is this an example of a false positive response to EPT caused by gingival conduction. . it should be reserved for cases when it is impossible to arrive at a pulpal diagnosis in another way. The most accurate technique to discover whether a pulp is vital is to begin to make a preparations in a concealed area of the tooth without anesthetizing the patient.g. if there are intact nerve fibers in the pulp. the cavity preparation should caesed and the tooth should be restored. but it does respond to EPT). Once a vital response is elicited. SELECTIVE ANESTHESIA TEST Test Cavity – Occasionally the clinical will encounter a tooth that exhibits mixed responses to pulp testing (e. Although thermal and EPT may be possible.SPECIAL TESTS Crown Removal – Many times a patient will describe symptoms of irreversible pulpitis. it fails to respond to cold. Removal of the prosthetic crown not only conforms the diagnosis it also allows the clinician to assess the restorability of the tooth. Therefore. Although the damage can be repaired. but the suspected tooth is completely hidden from view clinically and radiographically by a prosthetic crown. If no response is evoked access preparation may continue and endodontic therapy completed.
Signal processing technique now enable diagnosis with a sensitivity and specificity better than 90%. This high electromagnetic waves which are needed have not been approved off for use in scanners. It can distinguish blood vessel and nerves from surrounding tissues. CONTRAINDICATIED in patients with cardiac pace makers metallic restorations orthodontic appliances and aneurysms.Technical Details The technique requires probe stability relative to the tooth. A dental putty splint with a small hole drilled at the tooth position of interest. provides mechanical stability for the probe. Laser Doppler sampling should be atleast 10 samples per second (10Hz) and the integrated time should be set at 0. In future MRI offers evaluation of odontogenic problems. Comparison of a flux trace measured from the contra-lateral healthy tooth often aids diagnosis of vitality. that reliably indicates pulpal necrosis MAGNETIC RESONANCE IMAGING Recently MRI has been tried out a diagnostic tool in endodontics Magnetic fields and radiographic waves are used to generate high quality crosssectional images of the body. This technique has the advantage of enabling reproducibility of prove position at successive visit for chronic monitoring.1 sec so that the cardiac pulse wave can be observed. A record duration of at least 30 seconds is recommended so that vasomotion features of vitality can also be assessed. . 2) The splint also prevents backscattered light scattering off other tissue and eliminates contamination of the laser Doppler signal by these source. It works on electro magnetic energy (X-rays involves ionization). However this needs large equipment.
It can be divided into few simple stages1. Application MRI tried as for diagnosing pulp vitality By use of contrast medium VITAL TEETH shows dye contrast NONVITAL TEETH shows no dye contrast.10C TRANS ILLUMINATION WITH FIBER OPTIC LIGHT Light is passed through a finely drawn glass or plastic fibres across the tooth by a process known as Total Internal Reflection. The patient is placed in a magnetic field and essentially becomes a magnet. The patient emits signal The signal is received and used for reconstruction of the picture. HUGHES PROBEYE CAMERA It is used to assess the vitality of the pulp. 3. 2. It was used to check the status of pulpal blood circulation. It measure temperature changes as small as 0. It is a radioactive substance and pulpal circulating is checked by wash out of Xenon-133. A radio wave is sent in The radiowave is turned off. A pulp less tooth is not noticeably discolored may show a gross difference in translucency when a shadow produced on a mirror is compared to that of adjacent vital tooth XENON -133 This was introduced by Ronni. . 4. 5.
Wavelength of 760 nm and 850 nm were used. – PRINCIPLE :This method measures oxygenation changes in capillary bed rather than in supply vessels hence does not depend on pulsatile blood flow. – independent of a pulsatile circulation – presence of arterioles rather than arteries in the pulp and rigid encapsulation make it difficult to detect pulse in the pulp space.in cases of avulsed and replanted teeth with open apices the blood supply is regained within first 20 days after replantation but nerve supply lags behind • Spectrophotometric readings taken at start of replantation and continuing up to 40 days revealed an increase in blood oxygenation levels indicating healing process LIQUID CRYSTAL TESTING . This identifies the teeth with pulp chamber that are either empty filled with fixed pulp tissue or filled with oxygenated blood.DUAL WAVELENGTH SPECTROPHOTOMETRY This was developed by ‘Chance’. • In young children . This technique measures the oxygenation change of blood.
We hope that it is possible in the near future to have a host of tests. As we near the end of this discussion. The presence of IL-1 is examined by an Immunosorbent Assay) PLETHEYSMOGRAPHY It is a method in assessing the changes in volume and has been applied to the investigation of arterial disease because the volume of the limb or organ exhibits transient changes over the cardiac cycle. Of all the diagnostic aids .Cholesterol liquid crystals are used to show temperature difference between teeth. Vital pulp may be hotter or show a higher temperature than the necrotic pulp (cooler) IL-1 (A lymphocyte activating factor) is responsible for osteoclast activation which results in bone resorption which is often a feature of inflammatory response. which has come into clinical use. which will help in devising proper treatment plan and increase the long-term success of endodontic treatment. a wave form is recorded which related closely to that obtained by intra–arterial cannulation. which will enable an endodontist to assess the blood flow of the pulp and to make an accurate diagnosis. ELISA (Enzyme linked . As the pressure pulse passed through the limb segment. but its usage is limited due to the cost factor.Radiovisiography has gained popularity and also Laser Doppler flowmetry. Plethysmography in limb or organ exhibits transient changes over the cardiac cycle. Plethyusmography in limb or digit can be performed using air filled cuffs or mercury in rubber strain gauges. Presence or absence of a wave form can indicate the statue of the tooth pulp. The same principle can be used to assess the vitality of the pulp.
b) isolated the eight. after cooling vital teeth would rewarm more quickly than nonvital teeth. Thermographic imaging is accurate allows comparison of different areas of a tooth. Kells et al. 2000 a. They established that following isolation it took about 15 min for tooth temperature to stabilize. Despite isolation from respiratory air currents from both the mouth and the nose they noted a significant cooling effect by room air currents.no one test should be considered final. They also noted a disruptive effect of mouth air Currents.b) The work of Pogrel el at (1989) supported the finding so Fanlbunda (1986b) that. (2000a.An evaluation of the use of tooth temperature to assess human pulp vitality Thermographic imaging (TI) has also been used to measure tooth surface temperature (Egg et al 1975. considerable technical expertise and demands rigorous standardization of the experimental environment. and advocated the isolation of the teeth by rubber dam to exclude this effect. . dam and measured tooth surface temperature using TI. most anterior upper teeth in' human subjects with heavy black rubber. CONCLUSION Status of the pulp should always be collaborated with two or more test . Similarly 1n LDF it is valuable. as an experimental tool but has limited prospect of becoming a common clinical investigation in the near future. and is entirely noninvasive. However it requires. Pogrel et al 1989 kells et al.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.