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  • 1. Dental Pulp status PARAS ANGRISH DEPT OF PEDODONTICS AND PREVENTIVE DENTISTRY
  • 2. – INTRODUCTION – DIAGNOSTIC OBJECTIVES – PULP VITALITY TESTS – THERMAL TESTING – ELECTRICAL TEST – SPECIAL TESTS – BITE TEST – STAINING AND TRANSILLUMINATION – SELECTIVE ANAESTHESIA – TEST CAVITY – LASER DOPPLER FLOW METRY – PULSE OXIMETRY – NEWER TECHNIQUES – DISEASES OF PULP – CONCLUSION – REFERENCES
  • 3. INTRODUCTION Dental pulp tests are investigations that provide valuable diagnostics and rx planning information to the dental clinician. If pathosis is present, pulp testing combined with information taken from the history, examination and other investigations such as radiographs leads to diagnosis of underlying disease which can be used relatively easily. From the late 1970’s until 90’s, application of pulp tests in different areas of clinical dentistry were met with varying degree of success. This could be interpreted that, to date the notion of ideal diagnostic test is still to be realized. From a technical prespective, all current Pulpal tests have shortcomings interms of accuracy, reliability and reproducibility in a given diagnostic challenge. In addition the correct application of pulp test in the appropirate clinical situations.
  • 4. Diagnostic objective of pulp testing As an investigation , pulp testing can have several aims 1. Assessment of pulp health based on qualitative sensory response. This is commonly done: -prior to restorative , endodontic, and orthodontic procedure -as a follow up and monitoring the pulp after trauma to the teeth. -in differential diagnosis such as excluding periapical pathosis of pulp origin.
  • 5. • The most accurate way of evaluating the pulp status is by examination of histological sections of the tissue specimen involved to assess the extend of inflammation or presence of necrosis as a mean of gauging pulp health. Unfortunately in the clinical scenario. These are both impractical and not feasible;hence clinicians must use investigations such as pulp tests to provide additional diagnostic information. PULP VITALITY TESTING, PULP SENSIBILTY TESTING AND PULP SENSTIVITY Pulp vitality testing- Assessment of pulp’s blood supply Pulp tissue may have an adequate vascular supply, but is not necessarily innervated. Hence, most of the current pulp testing modalities do not directly assess the pulp vascularity. Examlpe is tooth with fresh trauma can have no response to cold for a period of time stimulus following injury., newly errupted tooth,
  • 6. • PULP SENSIBILITY TEST: Assessment of the pulp sensory response • Sensibility test is defined as a ability to respond to stimulus, and hence this is a accurate and appropriate term for typical and common clinical pulp tests such as thermal and electrical tests given that they do not detect or measure the blood supply of the dental pulp. • PULP SENSITIVITY: Condition of pulp being very responsive to a stimulus. • Thermal and electrical pulp tests are not sensitivity tests though they can be used as sensitivity tests when attempting diagnosis a tooth with pulpitis since such teeth are more responsive than others
  • 7. Pulp testing techniques and effectivenessSensibility testing: Thermal Pulp Test •Various methods[4] and materials have been used to test the pulp ‘s response to thermal stimuli. •The baseline or normal response to either hot or cold is a patient’s report that a sensation is felt but disappear immediately upon removal of the thermal stimulus . •Heat testing is most useful when a patients complaint is intense dental pain upon contact with any hot liquid or food.in instances where a patients is unable to identify which tooth is sensitive ,a heat test is appropriative. •Starting with the most posterior tooth in that area of the mouth , each tooth is individually isolated with the rubber dam. •An irrigating syringe is filled with a liquid that has a temperature similar to that which would cause the painful sensation.42 C •The liquid is then express from the syringe onto the isolated tooth to determine whether the response is normal or abnormal.
  • 8. •The tooth will exhibit an immediate , intense painful responds to the Heat with the heat testing a delayed response may occur ,so waiting 1o seconds between each heat test will allow sufficient for any onset or symptoms ,another method for heat testing is applied heated gutta – purcha or compound stick to the surface of the tooth. •If this method is used, a light layer of lubricant should be placed onto the tooth surface prior to applying the heated material to prevent the hot gutta purcha 78 C TO 150 C By ZACH ET AL or compound from adhering to the dry tooth surface. •Cold is the primary pulp testing method for many practitioners today. •Cold testing should be used in conjunction with the electric pulp tester so that results from one test will verify the findings of the other test. • It can be accomplished similarly to heat testing by individually teeth with a rubber dam.Dachi n associate recommended use of ¼” ice cone Placed against the tooth for 5 sec to quantify cold test. -Max of 15 sec can be used for detection of pulpal vitality
  • 9. •Another benefit of this technique for cold testing is that it requires no armamentarium except for a rubber dam. •If a clinician choose to perform this test with sticks of ice , then the use of the rubber dam is recommended because melting ice will run onto adjacent teeth and gingiva, yielding potentially false positive responses. •Frozen carbon dioxide (co2)also known as dry ice or carbon dioxide snow, has been found to very reliable in eliciting a positive response if vital pulp tissue is present in the tooth by EHRMANN. Carbon dioxide has also been found to be effective in evaluating the pulp response in teeth with full coverage crowns for which electric pulp testing is not possible. In contrast, Fulling and Andreasen61 found that thermal testing with carbon dioxide snow gave consistently positive responses irrespective of the stage of dental development. •For testing purposes a solid stick of co2 gas into a specially design plastic cylinder.
  • 10. Cold tests: Is believed that cold testing cause contraction of dentinal fluids, this results in outward flow of fluids with in patent tubules. This rapid flow results in hydrodynamic forces acting on A delta fibers in dentino pulpal complex leading to sharp sensation for few seconds in sound tooth. • Refrigeant Spray , dichlor-difluoromethane-DDM, O C • Ethyl chloride- -41 C • Carbon-dioxide snow -72 C • Recently ozone free non fluorocarbons sprays • TETRA FLUORO ETHANE- 30 C
  • 11. •The resulting co2 is stick is applied to the facial surface of either natural tooth structure or crown.several tooth can be tested with single stick. •The tooth should be isolated with a 2*2gauze or cotton.so co2 will not come into contact with these structures. •The most popular method of testing is with a refrigerant spray. •It is readily available and easy to use,and provides test result that are reproducible, reliable and equivalent to that co2 .(ODONTOTEST) •The current product contain 1,1,1,2-tetrafluroethane,which has zero ozone depletion potential and is environmentally safe. •It has temperature -26.2c . •The spray is most effective or testing purpose when it is applied to the tooth on large #2 cotton pellete. •The sprayed cotton pellete should be applied to the midfacial of the Crown. . •The sensitivity which is the ability of a test to identify teeth that are diseased , was 0.83 for cold and 0.86 for heat and 0.72 for the electric test. •This means the cold test correctly identified 83% of the teeth that had A necrotic pulp while heat test where correct 86% of the time and electric pulp test were correct only 72% of the time.
  • 12. REFRIGERATOR SPRAY CONTAINER A COTTON ROLL CAN BE USED TO FORM A LARGE COTTON PELLET
  • 13. Electric Pulp Test •Assessment of the pulp vitality test is most frequently accomplished[4] by electric pulp testing or cold testing. •The vitality of the pulp is determined by the intactness and health of the the vascular supply, not the status of the pulpal nerve fibres. •Even though advances are being made with regard to determine the vitality of the pulp regard to the blood supply, this technology is not accurate enough to be used on a routine basis in clinical setting •The electric pulp tester has limitations in providing information about the pulp. . ELECTRI PULP TESTER WITH PROBE
  • 14. •The response of the pulp to electric testing is not reflecting the histologic health status of the pulp. •A response by the pulp to the electric current only denotes that some viable nerve fibres are present in the pulp and are capable of responding. •The lack of response has been found most frequently when an electric pulp is present. •The electric pulp tester will not work unless the probe can be placed in contact with the natural tooth. •With the advent of universal precautions for infection control, the patient may be required to place a finger on the tester probe to complete the electric circuit for the models, however lip clips are an alternative to having patients hold the tester. •The use of rubber gloves prevents the clinician from completing the circuit. •proper use of the electric pulp tester requires that the tooth to be evaluated be isolated and dried. •A control tooth of similar tooth type and location in the arch should be tested first in order to establish a base line response and to inform the patients with a normal sensations. •The suspected tooth should be tested at least twice to confirm the results.
  • 15. •The tip of the testing probe that will be placed in contact with the tooth structure must be coated with the electric conducting based media. • The most commonly used media is toothpaste. •The coated probe tip is placed in the incisal third of buccal or facial area of the tooth to be tested. •once the probe is contact with the tooth the patient is asked to touch the tester probe. •This completes the circuit and initiates the delivery of electric current to the tooth. •The patient is instructed to remove his or her finger from the probe when a tingling or warming sensation is felt in the tooth. •The readings from the pulp tester are recorded and will be evaluated once all the appropriate teeth have been tested and the result obtained from other pulp testing methods.. •The tip of the endodontic explorer is coated with tooth paste or other appropriate media and placed in contact with the natural tooth.
  • 16. •The tip of the electric pulp tester probe is coated with a small amount of tooth paste and placed in contact with the side of the explorer. •However, unlike electric pulp testing, cold testing can reveal the health and integrity of pulp tissue response. •Until such time that testing method used to assess the vascular supply of the pulp become less time consuming and technique sensitive to thermal and electric pulp testing will continue to be the primary methods for determining pulp vitality. PULP NERVE TESTER
  • 17. Bite test •Identifying cracked tooth or fractured cusp[4]. •It also helpful in diagnosing cases where in pulpal pathosis is extended to periradicular region causing apical periodontitis •Tooth slooth & Frac Finder are available devices for bite test •Pain on biting -- apical periodontitis •Pain on release of bite force - cracked tooth To determine which tooth is sensitive to mastication and which part of the tooth is sensitive,having the patients bite on a specialy designed bite stick often helpful.
  • 18. •For the bite test to be meaningful a device should be used that will allow practitioners to apply pressure to individual cusp or areas of tooth. •Variety of devices have been used for the bite test including cotton applicators , tooth picks, orange wood sticks, rubber polishing wheels. • As with all the pulp test, adjacent teeth should be use as controls so that the patient is aware of the normal response to these test. •The small cupped out areas on the instruments is placed in contact with the cusp to be tested. •The patient is then asked to apply biting pressure with opposing teeth to the flat surface on the opposing side of the device. •The biting pressure should be applied slowly until full closure is achieved. •The firm pressure should be applied for few seconds, the patient is then asked to release the pressure quickly. •Each individual pressure on a tooth can be tested in a like manner. •The practitioner should note if the pain is elicited during the pressure phase or upon quick release of pressure. •A common finding is with fractured cusp or cracked tooth is frequent presence pain upon release of biting pressure.
  • 19. Staining and transillumination •In order to determine the presence of crack in the surface of the tooth, the application of a stain to the area is often of great assistants[4]. •Shining a bright light on the surface of the tooth is also very helpful. Selective anaesthesia •When symptoms are non localized or refered, the diagnosed may be very challenging[4]. •Sometimes the patients may not even able to specify whether the symptoms are emanating from the maxillary or mandibular arch. •This test is restricted to the patient who are in pain at the time of the test when the usual tests have failed to identify the tooth •The objective is to anesthetize one tooth at a time until the pain. disappears and is localized to a specific tooth TECHNIQUE •Using either infiltration or intraligament injection, inject the most posterior tooth in the area suspected of being the cause of pain[2]
  • 20. •If the pain persist anesthetize the next tooth mesial to it and continue to do so until the pain disappears •If the pain cannot be identified as from maxillary or mandibular origin ,an inferior alveolar block is given •Cessation of pain naturally indicates involvement of mandibular tooth ADVANTAGE •This test is obviously a last resort and has an advantage over the ‘test cavity’ during which iatrogenic damage is possible[2]
  • 21. Test cavity •This method is used only when all other test methods are deamed impossible or the result of the other test are inconclusive [2]. •This test allows one to determine the pulp vitality •It is performed when other methods of diagnosis have failed •The test cavity is made by drilling through the enamel-dentin junction of an un-anesthetized tooth •The drilling should be done at slow speed and without a water coolant •Sensitivity or the pain felt by the patient is an indication of pulp vitality •No endodontic treatment is indicated •Sedative cement is then placed in the cavity ,search for source of pain continues •If no pain is felt -cavity preparation may be continued until the pulp chamber is reached ,If pulp is completely necrotic- endodontic treatment can be continued.
  • 22. Problems with current devices/assessing pulp status At present the techniques that are commonly used in everyday practice (i.e. thermal and electric pulp testing) assess whether the nerve supply within the tooth is intact. A positive result confirms that the Ad nerves in this region of the pulp chamber are responsive; the inference is that this can be interpreted as there being an intact blood supply within the tooth. However, the only true means of assessing the health of the pulp is to determine that there is a normal flow of blood within the tooth .Thermal tests are highly subjective as they are wholly dependent on the patient’s response to testing. There is no accurate or objective method of assessing how responsive the tooth under investigation is to testing, nor of comparing with a previous measurement. In contrast, electric pulp testers have numerical digital displays, which allow the operator to note down the reading, and compare with a previous reading.
  • 23. False responses from pulp testing False positives Anxious patients Liquefaction necrosis Contact with metal restorations Vital tissue still present in partially necrotic root canal system False negatives Incomplete root development Recently traumatized teeth Sclerosed canals Recent orthodontic activation Patients with psychotic disorders Ideal features of a pulp vitality tester -Assesses pulp blood flow -Objective measurements -Free from error -Effective for heavily restored teeth -Effective when the pulp size is reduced -Quick and easy to use Inexpensive
  • 24. RECENT PULP VITALITY ASSESSMEMT Physiometric testing Crown surface temperature/heat registration The evaluation of tooth-surface temperature as a means of assessing the vitality of teeth has been reported. Cholesteric liquid crystals, which exhibit different colors when heated, have been used in one study to determine pulp vitality . It was based on the principle that teeth with an intact pulp blood supply (vital/healthy pulp status) had a warmer tooth-surface temperature compared with teeth that had no blood supply. Surface temperature of teeth has been measured over a period of time at 15-s intervals using an electric thermometer attached to a surface probe, which was placed in contact with the tooth .These studies showed that after teeth were cooled, there was only a rise in the temperature of vital teeth. Photoplethysmography The detection of blood flow within the pulp by passing light through the tooth has been reported . Hemoglobin absorbs certain wavelengths of light, while the remaining light passes through the tooth and is detected by a receptor. Photoplethysmography has been compared with LDF in experiments on skin, and found to be of similar value . The technique has not been successfully developed further for dental application apart from one recent investigation .
  • 25. LDF 1st in dentistry by GAZELIUS ET AL IN 1986 LDF is a non-invasive method of assessing and measuring the blood flow of pulp tissue. Laser light wavelengths 633 and 780 nm is directed onto the tooth under investigation by securing a fiber-optic probe against the tooth surface. The laser light from the probe passes along the enamel prisms to the enamel–dentine junction and theS-shaped dentinal tubules, which act as light guides, to the pulp .Light absorbed by red blood cells in the capillary plexus is scattered and undergoes a shift in frequency according to the Doppler principle; light absorbed by stationary objects does not undergo a shift in frequency. A signal is produced which measures the flux of the blood cells (number of red blood cells times mean velocity). The proportion of Doppler-shifted light is detected by a photodetector. The detected signal is weak and there- fore highly amplified; a mathematical calculation using Fourier analysis can be used to gain more meaningful information. A trace of signals from vital and non- vital teeth. Fourier analysis of the traces has revealed a heart beat frequency in the vital tooth, but not in the non-vital tooth and is therefore an effective discriminator. •.This technique is accurate ,reliable and reproducible method of assessing pulpal blood flow. • Even with this positive findings ,the technology is not advanced enough for this method to be used on a routine basis in a dental practice. • If technology can be developed whereby the testing with the LDF can be accomplished in minutes ,it will likely replace the thermal and electric pulp testing methods
  • 26. A LDF probe showing laser light guides. A LDF probe applied to a sectioned tooth showing the passage of light via the enamel prisms and dentinal tubules to the pulp. A LDF trace showing signals from two teeth; the upper is from a vital tooth while the lower is from a non- vital tooth.
  • 27. A study by MIWA ETAL suggested that the transmitted light technique can Detect pulpal blood flow in young permanent teeth and is thus applicable assess Pulp vitality. Pulp oximetry •Another non-invasive method[4,5] that has been investigated as a method to determine pulpal blood flow uses a pulse oximeter ,which is designed to measure the oxygen concentration of the blood and the pulse rate. •It works on the principle that two wavelengths 660 nm and 940 nm.of light transmitted by a he ne source and photoelectric diode detect oxygenated and deoxygenated haemoglobin as they pass through a body part to a receptor. •The diffrences between the light emitted and the light received is calculated by a microprocessor to provide the pulse rate and oxygen concentrations in the blood. •Attempts to use the pulse oximeter to diagnose pulp vitality have met mixed results . •The device used for pulp testing are too cumbersome and complicated to be used on a basis in a dental practice.
  • 28. Meanism of dental pulp oximeter: (a).light emitting diode emitting red light at 660nm.(b).light – emitting diode emitting infra red light at .940nm.(c)photo etector.(d)pulse oximeter monitor.(e)pulse oximeter sensor.(f).custom made pulse oximeter sensor holder.HbO2 ,oxygenated haemoglobin.HbR,deoxygenated haemoglobin ;SpO2, oxygen saturation of arterial blood.
  • 29. SPECTROPHOTOMETRY -Use dual wavelength light in an effort to asertain the content of closed chamber like pulp, has been tested with optimist. Only initial experimental results r obtained. TRANSMITTED LASER LIGHT -Experimental variation of LDF, aimed to eliminate non pulpal signals. No better results were found. TRANSILLUMINATION -Utilize strong light source which identifies color changes that may indicate pulp changes. Not useful in posterior teeth n teeth with restorations. Use as an adjunct to conventional technique. ULTRAVIOLET LIGHT PHOTOGRAPHY -Examine different fluorescence pattern allows additional contrast of otherwise difficult to observe in visible light. This also an adjunct to conventional tests.
  • 30. VARIOUS CONDITIONS AND PULPAL RESPONSE TO TESTS Reversible pulpitis / Pulpal hyperemia •Reversible pulpitis[2,4] is a mild to moderate inflammatory condition of the pulp caused by the noxious stimuli in which the pulp caused by capable of returning to the uninflamed state following removal of the stimuli. •Symptomatic reversible pulpitis is characterised by sharp pain lasting for a moment,and generally disappears when the stimulus is removed •Cold , sweet, or sour usually causes it •Pain may become chronic. •The pulp may recover completely or the pain may last longer each time and intervals of relief may become shorter ,until the pulp finally succumbs •The pulp is sensitive to temperature changes, particularly cold, application of cold is an excellent method of locating and diagnosing the involved tooth. •A tooth with reversible pulpitis reacts normally to percussion, palpation and mobility. •Thermal test are useful in locating the affected tooth if unknown. •The electric pulp test, using less current than on a control tooth, is an excellent corroborating test.
  • 31. Irreversible pulpitis •Irreversible pulpitis[2,4] is a persistant inflammatory condition of the pulp, symptomatic or asymptomatic caused by a noxious stimulus. •A tooth with symptomatic irreversible pulpitis exhibit intermittent or spontaneous pain, whereby rapid exposure to dramatic temperature changes (especially to cold stimuli) will elicit heightened and prolong episodes of pain even after the source of the pain is removed. •The pain may be sharp or dull localised or referred. •In the early stages the thermal test may elicit pain that persists after removal of the thermal stimulus. •In the late stages when the pulp is exposed ,it may respond normally to the thermal stimulus. •The electric pulp test induces a response with a marked variation in current form of normal. •Result of examination for mobility and perussion and palpation tests are negative.
  • 32. Chronic Hyperplasic Pulpitis •Chronic hyperplastic pulpitis[2,4] or ”pulp polyp” is a productive pulpal inflammation due to an extensive carious of a young pulp •Slow , progressive carious exposure of the pulp is the cause. •Mechanical irritation from chewing and bacterial infection often provide the stimulus. •The tooth may respond feebly or not at all to the thermal test, unless one use extreme cold, as from an methyl chloride spray. •More current than normal may be required to elicit a response by means of the electric pulp tester.
  • 33. Internal resorption •Internal resorption[2,4] is an idiopathic slow or fast progressive resorptive process occurring in the dentin of the pulp chamber or root canals of the teeth •The cause of internal resorption is not known,but such patients often have a history of trauma. •Internal resorption in the root of a tooth is asymptomatic. •In the crown of the tooth ,internal resorption may be manifested as a reddish area called”pink spot”. •Resorptive defect is more extensive in pulpal wall than on the root surface. •The defect is usually is recognised by means of a radiograph.
  • 34. Necrosis of pulp •Necrosis is death of the pulp[2]. •It may be partial or total, depending on whether part or the entire pulp is removed. •It can be caused by any noxious insult to the pulp , such as bacteria, trauma ,and chemical irritation. •A normal tooth with a nerotic pulp cause no painful symptoms. •The presence of necrotic pulp may be discovered only by chance because such tooth is asymptomatic ,and the and the radiograph is non diagnostic. •The teeth with partial necrosis can respond to thermal changes ,owing to the presence of vital nerve fibers passing through the adjacent inflamed tissue. Tooth with necrotic pulp does not respond to cold ,the electric pulp test ,or the test cavity
  • 35. Normal Patient reports a thermal sensation and stops feeling it when the stimulus is removed Reversible pulpitis Thermal sensation causes discomfort/pain and the magnitude of response is different from adjacent and/or contralateral teeth;sensation may linger briefly Symptomatic irreversible pulpitis After thermal stimulus is applied, patient reports pain/discomfort is more pronounced than on adjacent teeth and/or contralateral tooth;sensation lingers Asymptomatic irreversible pulpitis Same response as normal or reversible pulpitis, except the patient has a history of pulpal inflammation such as caries, carious exposure, or trauma Necrosis Patient reports feeling no sensation when thermal stimulus is applied for more than 15 seconds in case of cold test n more than 5 sec in case of hot test. Possible Diagnoses, based on patient responses to thermal stimuli.
  • 36. Types of Nerve Fibres and their distribution inside the dental pulp • Dental pulp is a highly innervated tissue that contains sensory trigeminal afferent axons • N trigeminal sensory nerve fibers – 90% of A fibres are A –delta fibres , which are located at the pulp-dentin border in the coronal portion of the pulp and concentrated in the pulp horns – C fibres are located in the core of the pulp and extend into the cell –free zone underneath the odontoblastic layer • Sympathetic efferent fibres regulate the blood flow
  • 37. Pulp tests and innervation • Electric current simulates Aδ-fibres, but not the C-fibres, because their high threshold. • Cold stimuli produce stronger response than hot stimuli, because of the outward flow of fluid. • Repeated application of cold will reduce the displacement of fluid – less painful. • Aδ-fibres are more affected by the reduction of blood flow than C-fibres, because they more sensitive to hypoxia. • Uncontrolled heat can injure pulp release mediators that affect the C-fibres.
  • 38. Positive/negative hydrostatic pressure +150 Hgmm -150 Hgmm
  • 39. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the cold test, electric test, and pulse oximeter test. Test Sensitivity Specificity PPV NPV Cold 0.81 0.92 0.92 0.81 Electrical 0.71 0.92 0.91 0.74 Pulse oximeter 1.00 0.95 0.95 1.0 Journal compilation © 2008 BSPD, IAPD and Blackwell Publishing Lt
  • 40. Comparison of pulp tests Ethyl- chloride warm guttapercha Electric test sensitivity 0,83 0,86 0,72 specificity 0,93 0,41 0,93
  • 41. Recovery of traumatic teeth function Test 0. day 28. day 2 month 3 month pulse oximetry 100% 100% 100% 100% Electric test 0 29.4% 82,35% 94,11% Heat test 0 29,4% 82,35% 94,11%
  • 42. Differentiation of reversible/irreverisible pulpitis
  • 43. Conclusion The diagnosis of the state of the dental pulp is frequently given insufficient attention by many den- tists, and where doubt exists root canal treatment is too often performed, even though it is a costly procedure, and may reduce the prognosis for the restored tooth. The profession needs to re-evaluate its attitude to diagnosis of pulpal and periapical conditions for the benefits of patients. Attempts at measuring the pulpal blood flow clinically have mixed success, with LDF being one of the popular technique applied in dental traumatology. Currently, no vitality test have been proven to be superior in all aspects compared to pulp sensibility test. Further research is going on to improve all aspects of diagnostic pulp tests.
  • 44. References 1. Eugene Chen and Paul V. Abbott Review Article Dental Pulp Testing Page 2-4 2. Grossman Text of Grossman’s Endodonti practice 12th edition Page no 84-75 3. Samraj RV Recent advances in pulp vitality testing Page no 3 4. Stephen cohen Kenneth M. Hargreaves Text book of Pathways of the pulp 9th edition. Page 16-20 5. Velayutham Gopikrishna Article on Evaluation of Efficacy of a New Custom-Made Pulse Oximeter Page 1-2

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