DR ASMA NAWAZ CHANNA FCPS 2 TRAINE

Pulp testing is a useful and essential diagnostic aid in pulp disease and apical periodontitis.(2)

Indications of pulp testing are 1. Assess pulp vitality. 2. Prior to procedure. 3. After trauma. 4. For differential diagnosis.

1.PULP SENSIBILITY TEST:

Assessment of pulp response. thermal and electric test.(1)

2.PULP VITALITY TEST: Assessment of the pulps blood supply 1. Pulp tissue may have have an adequate vascular supply but is not necessarily innervated.
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Is

better measure of true pulp health then sensibility.(1) 1. Laser Doppler flowmetry 2. Pulse oximetry 3. Dual wavelength spectrometry(3)
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Assessment of pulp sensibility using routine methods rely on the stimulation of A nerve fibers and there is no direct indication of the blood flow.
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Two methods are used to stimulate the A nerve fibers 1. Thermal stimulation 2. Electrical stimulation

Pulp sensibility tests are most commonly used clinically, they are not without shortcomings and limitation.(1) They yield false positive and false negative response.(3)

There are two types: Cold test Hot test

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Reponses may be: Sharpe localized pain/tingling sensation for the duration of the applied test and for a few second after a removal of stimulus pulp is healthy(positive response.(2)
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pulp response lasting more than half a minute after the stimulus has been removed is indicating an irreversibly inflamed pulp.(2)

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No

response from the patient to such stimulation is normally indication of a necrotic pulp (negative response.(2)

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It

the primary method for many clinicians today. Cold testing should be used in conjunction with an electric pulp tester so that the results from one test will verify the findings of other test.
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Cold

test technique is especially used for patient present with porcelain jacket crown or porcelain fused to metal.(4) It requires no armamentarium except rubber dam.(4)
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It

help us to distinguish between normal and inflamed pulp(pulpits): 1. A response indicates that nerves are alive .(5) 2. An exaggerated response may indicate an in flamed pulp.(5)
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1.

2.

No response may indicate the coronal pulp is necrotic.(5) A prolong and lingering response after removal of cold stimuli, usually indicates irreversible pulpits.(5)
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1.

2.

False negative response when there are calcified canal. False positive response when cold contact with gingiva.
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Ethyl
Ice

chloride

Ice

cold water Co2 snow Refrigerant spray

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Conventionally made by filling sterilized discarded needles/needle sheath/cartridges with water placing it in freezer.(2,5) rubber dam

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Fig. Tooth isolated with rubber dam and bathed in cold water

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-69F _ 119F.(4) -56C_98C .(4) Frozen CO2,Also known as dry ice or CO2 snow .(4) Found to be reliable in eliciting +ve response if vital pulp present.
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Also

found to be effective in evaluate the pulpal response in teeth with full coverage crown.(4)

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Fig. Plastic cartridge attached to Fig. A stick of dry ice in its applicator on the tooth a cylinder of CO2.

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most

widely used.(4) Result equivalent to CO2.(4) Ethyl chloride. Dichlorodifluoromethane(DDM). (4) Tetrafluoroethane(TFE) or (EndoFrost,Roeko,Langenae,Ger many).(1,4)
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Fig. Iced cotton pellet in tweezers following spraying of Endo-Fro

Fig. A container of compressed refrigerant spray,dichloro-difluoro-methane (EndoFrost, Roeko, Langenau, Germany).

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Temp

of TFE is -26.2C.(4) Always use large#2 cotton pellet.(4) Apply on mid facial area of tooth.

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Most

useful when a patient chief complaint is intense dental pain with hot.(4) start with most posterior tooth.(4) Individual tooth rubber dam isolation indicated.(4)
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Hot

water bath. GP or Compound stick. Dry rubber polishing cup.

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Fig. Tooth isolated with rubber dam and bathed in hot water

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Light

layer of lubricant should be applied.(4) required temp 150C.(4)

Fig. Heated stick of gutta-percha (Obtura) applying 33 heat to a tooth. Pitt and pael

Frictional

heat may generated.(4)

Fig. A rubber cup applied to a tooth to generate frictional heat

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Response indicate some viable nerve fibers are present( positive ).(4) EPT results are most accurate when no response obtain(negative). (4) Only works if probe place on natural tooth structure. (4)

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Isolate

the tooth. Tip of the probe should be coated with conducting medium. Probe placed on incisal 1/3 of facial or buccal surface.
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Fig. An isolated tooth undergoing electric pulp testing. Electrical conducting gel is present between the electrode and the tooth.

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Fig. An isolated tooth undergoing electric pulp testing. A hook on the patients lip completes the circuit. Rubber dam has been used to isolate the tooth from those adjacent.

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Complete

coverage crown. Extensive restoration

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small tip for the electric pulp tester can be used under crown margins.

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PULSE OXIMETRY: PULSE OXIMETRY Studies show blood circulation and not innervations is most accurate determinant in assessing pulp vitality. It is a non invasive oxygen saturation monitor which provides continuous pulse rate reading.
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Records

blood oxygen saturation levels. Inflammation, causes deoxy. of Hb and change in oxygen saturation of the blood.
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Uses

information with known absorption curves for oxygenated & deoxygenated Hb to determine oxygen saturation levels.

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Detects pulpal inflammation, Partial necrosis in teeth that are still vital.

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Measures oxygenation changes in the capillary bed rather than in the supply vessels. DWLS detects the presence or absence of oxygenated blood at 760 nm and 850nm

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DWLS

able to differentiate with reproducible readings between a pulp chamber of a vital and non-vital tooth in vivo. Instrument is small, portable, relatively inexpensive and suitable for use in a private dental office.
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In

young children ,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.

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This

instrument can give readings much before the electrical pulp tester & can show that the pulp is healing.

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non-invasive, electro optical technique. Allows semi-quantitative recording of pulpal blood flow. Measures blood flow in the very small blood vessels of the microvasculature.
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Fig.LDF probe applied to a sectioned tooth showing the passage of light via the enamel prisms and dentinal tubules to the pulp. Fig. LDF probe showing laser light guides

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Fig. The splint in position on the patients Fig. 15. Two probes have been placed in a teeth putty impression splint for accurate location on the teeth while the trace is being recorded.

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Uses

a laser beam of known wavelength directed through crown of tooth to blood vessels within pulp.

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Moving

red blood cells cause frequency of laser beam to be Doppler shifted and some of light to be back scattered out of tooth.

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Moving

red blood cells cause frequency of laser beam to be doppler shifted and some of light to be back scattered out of tooth.

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The

output of which is proportional to the number and velocity of the blood cells.

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The

position of crown of tooth and location of the pulp within tooth cause variation. Antihypertensive medications & nicotine affect blood flow to the pulp. Equipment is expensive.

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1.

2.

3. 4. 5.

Eugene and paul,Dental pulp testing:A Review,International journal of dentistry.volume2009.Artical ID365785,12pages,doi:10.1155/2009/36575 8 Thomas R.PITT FORD AND SHANON PATEL, Technical equipment for assessment of dental pulp status,Endodontic topics 2004 Samraj RV ,Indera R,Srinivasan MR,Kumar A,Resent advances in pulp vitality testing Pop 9th edition Hartys

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Conclusion An accurate assessment of tooth vitality is of paramount importance in clinical practice. Although sensitivity testing is the de facto standard employed by the majority of clinicians, it has acknowledged limitations. Rapid advances in knowledge and applied technology relating to pulpal blood flow may lead the way for a more objective, accurate, and predictable means of pulp vitality assessment

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