Dr. Mayuresh Shintre

1. GOOD MORNING

2. PULP
VITALITY
TEST
DR. MAYURESH SUHAS SHINTRE.
FIRST YEAR MDS

3. CONTENTS
 INTRODUCTION
 DEFINITIONS
 PULP NEUROPHYSIOLOGY
 CLASSIFICATION OF PULP TESTING
 PULP SENSITIVITY TEST
 PULP VITALITY TEST
 CONCLUSION
 REFFERENCES

4.  Vitality tests are performed to help with the diagnosis of
the condition of the pulp. Traditionally, these tests have
been called “vitality” tests but this is an incorrect term to
use.
 The use of this incorrect term over many years has resulted
in many clinicians mis-diagnosing the pulp condition and
not understanding the test process. The nature of the tests
and the information they provide should be understood by
clinicians so they can be applied correctly.
INTRODUCTION

5. “Sensitivity” is defined as “the ability to respond to a stimulus”
whereas “vitality” is defined as “the capacity to live, grow, or
develop.”
In dental settings, “vitality” is taken to imply that there is a
viable blood supply to the pulp.

6. The ideal pulp test should provide a
 Simple
 Objective
 Standardized
 Reproducible
 Non-painful
 Non-injurious
 Accurate
 Inexpensive way of assessing the condition of the
pulp tissue.

7. DEFINITIONS
 PULP SENSITIVITY TEST:
A diagnostic procedure to determine pulpal status ; can
be performed with electrical , mechanical or thermal
methodologies to assess the pulp’s response to stimuli.
 PULP VITALITY TEST:
A diagnostic procedure to determine pulpal status by
the assessment of blood supply to the tooth.

8. PULP NEUROPHYSIOLOGY
 The sensory neurons of the pulp are located in the
trigeminal ganglion.
 The majority of the nerve bundles reach the coronal
dentin where they fan out to form the nerve plexus
of Raschkow.
 they anastomose and terminate as free nerve
endings that synapse onto and into the odontoblast
cell layer and the odontoblastic cell processes.
 The 2 types of sensory nerve fibres in the pulp are
myelinated A fibres (A-delta and A-beta fibres) and
unmyelinated C fibres.

9.  Ninety percent of the A fibres are A-delta fibres, which
are mainly located at the pulp–dentin border in the
coronal portion of the pulp and concentrated in the
pulp horns.
 The C fibres are located in the core of the pulp, or the
pulp proper, and extend into the cell-free zone
underneath the odontoblastic layer.
 The A-delta fibres have a small diameter and therefore
a slower conduction velocity than other types of A
fibres, but are faster than C fibres.
 The A fibres transmit pain directly to the thalamus,
generating a fast, sharp pain that is easily localized.

10.  The C fibres are influenced by many modulating
interneurons before reaching the thalamus,
resulting in a slow pain, which is characterized as
dull and aching.
 Heat or cold stimuli cause fluid movement
through the dentinal tubules, resulting in a
painful sensation in a tooth.
 The rapid temperature change that causes a
sudden fluid flow within the tubules and rapid
fluid movement excites the A-delta fibres.
 The C fibres elicit a response to a gradual
temperature change.

11. USES OF PULP TESTING
• It is done before carrying out restorative or orthodontic
treatment so as to know status of the tooth/teeth even if teeth
are asymptomatic and with normal radiographic appearance.
• To confirm whether radiolucent area present at apical part of
tooth is because of:
– Pulpal origin
– Other pathological reasons
– Or it is a normal anatomic structure

12. • To diagnose oral pain whether it is of pulpal or
periodontal
origin or because of other reason.
• To assess vitality of traumatized teeth
• To check the status of tooth especially which has past
history of pulp capping or deep restoration.

13. CLASSIFICATION OF PULP
TESTING
PULP SENSITIVITY TEST
(a) Thermal tests
(i) Heat test
(ii) Cold test
(b) Electric pulp test (EPT)
(c) Anesthetic test
(d) Test cavity
(e) Bite Test

14. 2. PULP VASCULARITY / VITALITY TESTS
(a) Pulse oximetry
(b) Laser Doppler flowmetry
(c) Others
(i) Dual-wavelength spectrophotometry
(ii) Thermography
(iii) Crown surface temperature
(iv) Transmitted light photoplethysmography

15. PULP SENSITIVITY TEST
In general, pulp sensitivity tests are used to:
 Assess the health status of the pulp:
◊ Prior to restorative, endodontic, orthodontic, periodontal
or surgical procedures,
 To Locate and diagnose a tooth with pulpitis (reversible or
irreversible) when the history suggests such a condition
exists:
◊ In such a situation, the pulp sensitivity tests can
reproduce the pulpitis pain (especially when associated with
cold stimuli)

16. ◊ These tests can also be used to differentiate between
reversible and irreversible pulpitis by observing the
patient’s response to the test stimulus.
• Locate and diagnose a tooth that has a necrotic pulp
or one that has become pulpless and infected where the
history suggests such a condition exists.
•Sensory stimuli, such as heat, cold or an electrical
current, are applied to the tooth in order to stimulate
the nocireceptors within the pulp..

18. THERMAL TEST
 The principle of using these tests is to apply the THERMAL
stimulus to the enamel of the tooth.
 The nerve fibres within the pulp will feel this change in
temperature either they are functioning normally or if
they are inflamed.
 In the inflamed situation (i.e., pulpitis), the sensation will
be greater and typically reproduces the pain that the
patient has been experiencing.

19. COLD TEST
1. DRY ICE -(The dry ice is formed in a device known as
the Odontotest The temperature of the dry ice is
approximately −78°C
2. ICE STICKS
3. REFRIGERANT (COLD) SPRAYS ( ETHYL CHLPRIDE)
4. DICHLORODIFLUOROMETHANE (FREON)
5. 1, 1, 1, 2-TETRAFLUOROETHANE (Endo Ice)

21. HEAT TEST
 Various methods have been proposed for heat testing— these
include the use of a
1. Heated ball burnisher,
2. a rotating rubber polishing cup,
3. a heated gutta-percha stick,
4. an electronic device (e.g., System B; Sybron Endo,
Orange, CA, USA), or
5. the application of hot water.
6. Nd:YAG Laser

23. The preferred temperature for heat test is 150°F
(65.5°C)
The patient may respond to heat or cold test in
following possible ways:
• Mild, transitory response to stimulus shows
normal pulp
• Absence of response in combination with other
tests indicates pulp necrosis.
• An exaggerated and lingering response indicates
irreversible pulpitis.

24. But there are certain conditions which can give FALSE
NEGATIVE
response, i.e. the tooth show no response but the pulp
could be possibly vital.
These conditions can be:
• Recently erupted teeth with immature apex
• Recent trauma

25. • Excessive calcifications may also interfere
with the nerve conduction.
• Patients on premedication with analgesics or
tranquilizers may not respond normally.

26. ELECTRIC PULP TESTING
The objective is to stimulate a pulpal response by
subjecting the tooth to an increasing degree of electric
current.
A positive response is an indication of vitality and helps in
determining the normality or abnormality of that pulp.
No response to the electrical stimulus can be an indication
of pulp necrosis.

28. Location of probe tip: The placement of the tester is
critical to ensure accurate response from the tooth.
–– Anterior teeth incisal third
–– Posterior teeth mid-third of the mesiobuccal cusp of
molars and buccal cusp of premolars

29. Clinical Interpretations of Pulpal Response to EPT
1. Normal response: A positive response is a response that
occurs at the same neural excitation threshold as the control
tooth.
2. Negative response: This denotes a nonvital tooth. which
fails to respond even when the tester is set to the highest
electrical excitation value.
3. Early response: This denotes a diseased state of pulp as the
tooth responds to a threshold which is less than that of
the control tooth.

30. 5. False positive response:
(a) When gangrenous necrotic pulp is present in a root
canal
(b) Multirooted teeth in which the pulp is partially necrotic,
with some nerve fibers still vital in one or more of the
root canals
4. Delayed response: This also denotes a diseased state
of the pulp wherein the tooth responds at a significantly
higher electrical excitation level than compared to the
control tooth

31. 6. False negative response:
(a) Extensive calcification in the pulp tissue or
dentin
(b) In a tooth with increased reparative dentin
and a diminishing pulp cavity
(c) Fibrotic pulp
(d) Teeth with extensive restorations and a pulp
protecting base
(e) Recently traumatized teeth
(f) Recently erupted teeth with incomplete root
formation
(g) Sedative medication taken by patient
(h) Patients with an unusually high pain threshold

32. ANESTHETIC TEST
This test is restricted to patients 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.

33. The technique is as follows:
 using either infiltration or the intraligament
injection, inject the most posterior tooth in the
area suspected of being the cause of pain.
 If pain persists when the tooth has been fully
anesthetized, 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
(mandibular block) is given.
 Cessation of pain naturally indicates involvement
of a mandibular tooth.

34. TEST CAVITY
 This test allows one to determine 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 unanesthetized tooth.
 The drilling should be done at high speed and with a
water coolant.

35. BITE TEST
This test helps in identifying a cracked or fractured
tooth. This is done if patient complains of pain on
mastication.
Tooth is sensitive to biting if pulpal necrosis has extended
to the periodontal ligament space or if a crack is present
in a tooth.

36. Bite test
Pain present on biting—apical
periodontitis
Pain present on release of biting
force—cracked tooth.

37. PULP VITALITY TEST
1. Laser doppler flowmetry
2. Pulse oximetry
3. Crown surface temperature
4. Transillumination with fiber optic light
5. Photoplethysmography
6. Dual wavelength Spectrometry
7. Ultraviolet light photography
8. Transmitted laser light
9. Detection of interleukins
10. 133 Xenon Isotope

38. LASER DOPPLER FLOWMETRY
The laser Doppler flowmetry technique was
developed by Tenland in 1982 later by Holloway.
This electro-optical technique uses a laser
source that is aimed at the pulp, and the laser light
travels to the pulp using the dentinal tubules as
guides.

39. The backscattered reflected light from circulating blood
cells is Doppler-shifted and has a different frequency to
the static surrounding tissues . The total backscattered
light is processed to produce an output signal .
Red blood cells represents the majority of moving
objects within the tooth, measurements of Doppler
shifted back scattered light may be interpreted as
an index of pulpal blood flow.

41. The signal is commonly recorded as
the concentration and velocity
(FLUX) of cells using an arbitrary
term “PERFUSION UNITS” (PU) ,
where 2.5 volts of blood flow is
equivalent to 250 PU .
In order to record the Doppler shift of
the blood cells, both the probe and
tooth need to be completely still.
Hence, a stabilising splint made of
polyvinyl siloxane (PVS) or acrylic is
usually used.

42. LDF probe
The end of the LDF probe which
contacts the tooth contains both
sending and receiving optic fibres,
Calibration of the probes is
important to ensure accurate
readings.
 The larger the optical fibre
separation distance on the probes, the
higher the signal output as a larger
surface area is covered,and also
potentially a higher chance of blood
flow signal contamination from non-
pulp sources.
To date, 0.5mm or 0.25mm
separation distances seem to be
preferred in experiments.

43.  Advantages of laser Doppler flowmetry
• An objective test
• Accurate to check vitality
 Disadvantages of laser Doppler flowmetry
• Cannot be used in patients who cannot refrain from
moving or if tooth to be tested cannot be stabilized
• Medications used in cardiovascular diseases can affect
the blood flow to pulp
• Requires higher technical skills to achieve
• Expensive

44. PULSE OXIMETRY
The pulse oximeter is a non-invasive oxygen saturation
monitoring device widely used in medical practice for recording
blood oxygen saturation levels during the administration of
intravenous anesthesia.

45. PRINCIPLE
The principle of this technology is based on a modification of
Beer's law, which relates the absorption of light, by a solute
to its concentration and optical properties at a given light
wavelength.
It also depends on the absorbance characteristics of
haemoglobin in the red and infra-red range.
In the red region, oxyhaemoglobin absorbs less light than
deoxyhaemoglobin and vice versa in the infrared region.
Hence one wavelength was sensitive to changes in oxygenation
and the second was insensitive to compensate for changes in
tissue thickness, haemoglobin content and light intensity.

46. The system consists of a probe containing a diode
that emits light in two wavelengths:
I. Red light of approximately 660 nm
II. Infra-red light of approximately 850 nm
A silicon photo detector diode is placed on the
opposing surfaces of the tooth, which is connected
to a microprocessor.

47. The probe is placed on the labial
surface of the tooth crown and the
sensor on the palatal surface.
Ideal placement of the probe is in the
middle third of the crown.
PULSE OXIMETRY PROBE

48.  Maxillary and mandibular healthy molars pulps
presented a mean of SaO2 of 85.09%.
 Maxillary molars showed 83.59%, with significant
difference between the first (85.76%) and second
(81.87%).
 In mandibular was detected the mean of SaO2 of
86.89%, with significant difference between the first
(85.58%) and seconds (88.15%).

49.  Advantages of pulp oximetry
• Effective and objective method to evaluate pulp
vitality
• Useful in cases of traumatic injuries where the blood
supply remains intact but nerve supply is damaged
• Pulpal circulation can be detected independent of
gingival circulation
• Easy to reproduce pulp pulse readings
• Smaller and cheaper pulp oximeters are now
available.

50. Limitations
 Background absorption associated with venous
blood
 In addition to the absorption,refraction and
reflection also occur as in Penumbra effect, which
is seen in patients with strong tissue pulsations,
where some of the light reaches the photo
detector diode without passing through the tissue
bed.

51. CROWN TEMPERATURE ASSESSMENT
Temperature measurement, as a diagnostic
procedure for human teeth, has been described
with the use of thermistors,infrared
thermography, and liquid crystals.

52. Liquid crystals
Cholesteric liquid crystals, which exhibit different
colours when heated, employed to determine pulp vitality.
The underlying principle was that teeth with an intact pulp
blood supply (vital/ healthy pulp tissue) had a warmer
tooth surface temperature compared with teeth that had
no blood supply.

53. Surface temperature of teeth has also been measured over
a period of time at 15 s intervals using an electric
thermometer attached to a surface probe, placed in
contact with the tooth.
These studies showed that, only vital teeth showed a
subsequent rise in surface temperature.
ELECTRIC THERMOMETER

54. Thermographic imaging is a non-invasive and highly accurate
method of measuring the body’s surface temperature.
It has been used to demonstrate that nonvital teeth were
slower to rewarm than vital teeth.
The disadvantage of using this technique is that the teeth
must be isolated with rubber dam, after which a period of
acclimatization is necessary prior to imaging.
The technique is complex and requires the subjects to be at
rest for 1 hr prior to testing
THERMOGRAPHIC IMAGING

56. TRANSILLUMINATION WITH
FIBER OPTIC LIGHT
 Fiber optics (optical fiber) refers to flexible, thin
cylindrical fibers of high-optical-quality glass or plastic.
 The theory of fiber optics is based on a single optical fiber
that consists of glass or plastic material with an outer
cladding of a lower index of refraction material.
 Since the fiber core has a higher refractive index, light
rays are reflected back into the core.

57. • This phenomenon is based on Snell’s Law and is
called Total Internal Reflection (TIR).
• Individual fibers are grouped together to form a
fiber optic bundle.
• These fibers can be as small as 0.01 mm in diameter
for glass and 0.1 mm for plastic

58.  The colors seen with pulpitis are due to trauma to
blood vessels within the center of the tooth, which
results in leakage of red blood cells outside of pulp
vasculature.
 The breakdown products of hemoglobin from lysed red
blood cells travel from the pulp into dentinal tubules to
just beneath the enamel, imparting discoloration of
the crown.
 Over time the discoloration progresses to a gray,
brown, or tan color.

59.  Transillumination describes the
use of a bright light that is placed
behind the tooth to observe how
light travels through the tooth.
 Normally a tooth should be
translucent and light up like a
lantern when transilluminated.
 If intrinsic discoloration is
present, light will not transmit.
 The vital tooth lets light pass
through the tooth very readily,
whereas the dead tooth appears
more opaque when comparing to
contralateral vital teeth in the
mouth.

60. PHOTOPLETHYSMOGRAPHY
 Photoplethysmography is a reliable method for depicting
changes in tissue opacity.
 Applied on teeth, it facilitates the recording of pulsatile
variations in the blood circulation of the dental pulp.
 The photoplethysmograph consisted of a light source
and photoconductive cell (Clairex 707, 5 mm.2 sensitive
area), mounted on two blocks of acrylic resin, connected
by springs.

61.  The changes in blood flow and volume is the reason for
the change of opacity.
 The recordings read by the plethysmography in a tooth
is mainly because of the light transmission and can be
affected by level of blood oxygen.
 In the encapsulated dental pulp, the amount of blood
passing from the tooth artery to the pulp capillaries
would be determined by the arterial transmural
pressure.

63. DUAL WAVELENGTH
SPECTROPHOTOMETRY
 The continuous dual wavelength spectrophotometer
used in this study produces light at two wavelengths only
760 nm and 850 nm.
 When the light absorption at 760 nm is subtracted from
that at 850 nm, the difference represents the net
absaorption as a result of a change in oxygenation.

64. In case of avulsed and replanted teeth with open
apices where the blood supply is regained within first
20
days but the nerve supply lags behind. Repeated
readings
for 40 days in such teeth reveal the healing process.
• It uses visible light which is filtered and guided to
the tooth by fiberoptics, unlike laser light where eye
protection is necessary for patient and the operator.
• Noninvasive test.
• An objective test.
ADVANTAGES

65.  Cytokines are generally excellent markers of inflammation.
Cytokines, which are polypeptides secreted by leucocytes and
other cells, act as modulators of immune and inflammatory
responses and can be divided into inflammatory and anti-
inflammatory cytokines.
 Inflammatory cytokines include interleukin (IL)-2, IL-6, IL-8,
interferon (IFN)-c and tumour necrosis factor (TNF)-a, while
anti-inflammatory cytokines include IL-4, IL-10 and IL-13.
 Inflammatory cytokines mediate and enhance inflammation,
while anti-inflammatory cytokines generally suppress
inflammation.
 Cytokines are the guiding factors of inflammation and its
progression to tissue necrosis .
DETECTION OF INTERLEUKINS

68. 133 XENON ISOTOPE
 133 Xenon Isotope Radioactive materials for measurement of
pulpal blood circulation were previously used in the radio-
labelled microsphere injection method.
 A method utilizing a radiation probe with 133 xenon
radioisotope to differentiate between vital and pulpless teeth
on the basis of blood supply has been found effective.
 However, the use of radioactive materials is expensive,
restricted on humans, and requires special licencing
requirements.

69.  The radioisotope 133 xenon in saline injeeted into the
periodontium would enter the blood eirculalion ofthe pulp
and be pieked up by means o( a radiation probe placed in
contact with the crown of the tooth.
 The maxillary incisors of a young dog were prepared so that
there were 3 pairs of teeth with 1 vital and 1 pulpless tooth in
each pair.
 The tooth to be tested was injected with 0.2 mCi xenon in
saline by a buccal intraligament injection.
 A lead shield was placed over the tooth and radiation counts
taken every 10 seconds for 15 minutes, using a small cadmium
telluride radiation probe.
 Radiation counts were detected from both vital and pulpless
teeth.

70.  Pulpless teeth had relatively constant counts for the
duration of the experiment (200-300).
 In vital teeth the initial counts were much higher
(718—981).
 A gradual decrease occurred with time and at 6 min
the counts ofthe vital teeth were similar to those
ofthe pulpless teeth and remained so for the rest
ofthe experiment.

71. CONCLUSION
Accurate assessment of pulp vitality is important
part of clinical practice.
Although sensitivity testing is commonly employed
by all the clinician but it has limitation.
New advances and applied technology relating
pulpal blood flow lead to more objective,
predictable and accurate result about pulp vitality.
As blood circulation within the pulp gives the
accurate information about pulp vitality.

72. REFERENCE
 Grossman’s Endodontic Practice
 Ingle’s endodontics
 Cohen pathway of pulp
 Dental pulp neurophysiology: Part 1. Clinical and
diagnostic implications (Article in Journal (Canadian
Dental Association) · March 2009)
 Recent Advances in Endodontics Exploring the Trends in
Diagnosis (International Journal of Innovative Science
and Research Technology ISSN No:-2456-2165)