This document discusses the diagnosis of pulp disease in primary and permanent teeth. It outlines the importance of taking a thorough history and performing a clinical examination for diagnosis. Key aspects of history include assessing the characteristics, duration, intensity and location of any pain. The clinical examination involves visual examination, palpation, percussion, mobility testing, and radiographs. Diagnostic tools also discussed include sensibility tests to check neural response and tests to evaluate pulp vascularity. Recent advances mentioned are digital radiography and tests to objectively measure pulp inflammation. Making an accurate diagnosis is important for establishing the correct treatment plan.

1. DIAGNOSIS OF
PULP
DEPARTENT OF PEDIATRIC & PREVENTIVE DENTISTRY
BDS Fourth Year lecture
Dr. Rishabh Kapoor
Reader (Pediatric and Preventive Dentistry)
29/5/2023

2.  Understand the value of taking history and clinical examination in diagnosis of
pulpal diseases.
 Various traditional and advanced diagnostic aids.
 Special care for pediatric patient.

3. • INTRODUCTION
• PULPAL PHYSIOLOGY
• DISEASES OF PULP
• DIAGNOSIS
 History
 Extra- and Intraoral Examination
 Pain Characteristics
 Sensibility Tests
 Trauma
• RECENT ADVANCES
• EVIDENCE BASED DIAGNOSTIC AIDS
• CONCLUSION
• REFERENCES

4. PULP is a soft tissue of mesenchymal origin residing
within the pulp chamber and root canals of tooth
lined by a layer of highly specialized cells called the
odontoblastic cells.
- Cohen
The pulp – rich vascular connective tissue contained
within a rigid dentinal wall

5. Camp JH. Pediatric Endodontic Treatment.
Cohen S, Burns R. Cohen's pathways of the pulp. Elsevier Health Sciences; St. Louis, Missouri :Mosby, Inc. 2015. p 719-720.
PERMANENT V/S PRIMARY TEETH
COMPARATIVELY
LARGER
COMPARATIVELY
SMALLER
HIGHE
R
LOWER
POROUS AND
MORE
ACCESSORY
CANALS
INTACT AND MORE
ACCESSORY
CANALS
LONGER AND SLENDER
,FLARED AND DIVERGING
SHORTER AND
BULBOUS; STRAIGHT
POOR
GOOD

6. A low compliance
environment.
An ineffective
collateral
circulation.
Resilience of the
connective
tissue.
Perceives all
types of stimuli
as Pain.

7. NEURAL FIBRES IN THE PULP
Superficial in pre-
dentine and pulp
dentine border
Stimulated in
physiological and
reversible
condition
Sharp, Pricking,
unpleasant but
bearable
Low, can be stimulated
without tissue injury
Deep near blood
vessels throughout
pulp.
Throbbing, Aching
Lingering and
extremely unbearable
High; Intense
stimulus as tissue
damage is there
Stimulated in
pathological
condition or when
tissue injury.

8. Sympathetic(ANS)
: control the
contraction of blood
vessels.
Sensory nerves:
maxillary and
mandibular divisions
of trigeminal nerve.

9. Characteristics Aδ Fibers C Fibers
Diameter 2-5μm 0.3-1.2 μm
Conduction velocity
(m/sec)
5-30 0.4-2
Myelination Yes No
Location
Superficial in predentine and pulp
dentine border
Deep near blood vessels
throughout pulp.
Pain Characteristics
Fast and Momentary
Sharp, Pricking, unpleasant but
bearable
Throbbing, Aching and less
bearable; Lingering and
extremely unbearable
Stimulation Threshold
Low, can be stimulated without
tissue injury.
High; Intense stimulus as
tissue damage is there.
Clinical applications
Stimulated in physiological and
reversible condition
Stimulated in pathological
condition or when tissue injury.

10. DISEASE
S
OF
PULP

11. CLASSIFICATION OF DISEASES OF
THE PULP
Grossman L. The Dental Pulp And Periradicular Tissues.Chandra S, Gopikrishna V.,editor. Grossman's Endodontic
Practice-13th ed. Wolters Kluwer.2016 September.p 89-94
Inflammatory diseases of the dental
pulp
• Reversible pulpitis
i. Symptomatic (acute)
ii. Asymptomatic (chronic)
• Irreversible pulpitis
I. Acute
i. Abnormally responsive to cold
ii. Abnormally responsive to heat
II. Chronic
i. Asymptomatic with pulp exposure
ii. Hyperplastic pulpitis
iii. Internal resorption
Pulp
degeneration
Pulp Necrosis
i. Calcific (radiographic diagnosis)
ii. Others

12. 1.
Pulpitis
5. Pulp
necrosis
CLASSIFICATION BY WEINE
2. Hyperalgesia
(reversible
pulpitis)
Hyperaemi
a
3. Painful
pulpitis
Chronic
pulpalgia
Acute
pulpalgia
4. Non-
painful
pulpitis
Chronic
pulpitis (no
caries)
Chronic
ulcerative
pulpitis
Chronic hyperplastic
pulpitis (pulp polyp)
Atrophy
Dystrophic
calcificatio
ns
6. Pulp
degeneratio
n
7. Internal
Resorption

13. Diagnosis is the art and
science of detecting and
distinguishing deviations
from health and the cause
and nature thereof.
-COHEN

14. Accurate diagnosis of the pulp status is an important step to achieve success in
endodontic therapy.
INCORRECT TREATMENT PLAN
Therefore, careful data gathering as well as a planned, methodical, and systematic
approach to this investigatory process is crucial.

15. THE PATIENTS
REASON FOR
SEEKING ADVICE
SYMPTOMS &
HISTORY
OBJECTIVE
CLINICAL TESTS
CO-RELATION OF
OBJECTIVE &
SUBJECTIVE
FINDINGS
DEFINITIVE
DIAGNOSIS PROCESS
OF
DIAGNOSIS

16. OUTLINE OF PULPAL DIAGNOSIS
• History of spontaneous unprovoked pain
• Visual and tactile examination
• Radiographic examination of
a. Peri-radicular and furcation areas
b. Pulp canals
c. Periodontal space
d. Developing succedaneous teeth
• Extra-oral and intra oral examination
• Pain from percussion
• Pain from mastication
• Degree of mobility
• Palpation of surrounding soft tissues
• Size, appearance, and amount of hemorrhage associated with pulp exposure
Mohammad G, Jerin F, Jebin S. Pulpal diagnosis of primary teeth: guidelines for clinical practice. Bangladesh Journal of
Dental Research & Education. 2012;2(2):65-8.

17. Camp JH. Pediatric Endodontic Treatment. Cohen S, Burns R. Cohen's pathways of the pulp. Elsevier Health Sciences; St.
Louis, Missouri :Mosby, Inc. 2015. p 719-720.

18. SYMPTOMS
SUBJECTIVE SYMPTOMS
Experienced and reported to
the clinician by the patient
OBJECTIVE SYMPTOMS
Ascertained by the clinician
through various tests
Ingle’s Endodontics.7th Edition Cohen S, Burns R. Cohen's
Pathways Of The Pulp

19. TYPE OF PAIN
Continuous
Intermittent/Episodic
LOCATION
Diffuse
Localised
INTENSITY
Severe
Mild
DURATION
Protracted
Momentary
Okeson JP. Pain mechanism. Bell's orofacial pains: the clinical management of orofacial pain. Chicago, Ill, USA: Quintessence
Publishing Company; 2005.p 272-73
HISTORY & CHARACTERISTICS OF PAIN

20. Not consistently associated with an external
stimulus, may arise at any time of the day, or
may wake the child from sleep
PROVOKED PAIN
SPONTANEOUS
PAIN
Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:384-92.
Triggered by a thermal or an osmotic
stimulus (e.g., cold drinks, eating candy) and
usually ceases when the stimulus is removed

21. 59
Quality of pain How it feels to patient
Bright
When patient has a stimulating or exciting type of
pain
Dull
When the pain has a depressing effect – patient try
to withdraw from work
Bright and tingling
pain(Pricking)
Mild and stimulating pricking sensation
Itching pain
Superficial discomfort – does not reach pain
threshold
Deep pain Vague, diffuse, febrile, tenderness
Burning pain
When the discomfort has irritating, hot,
raw, caustic quality.
Pulsating or throbbing Increases with each heartbeat.
Spontaneous Pain without any stimulus.

22. BEHAVIOUR OF
pain
Intermittent/Episodic
Pain comes and goes
with pain free
intervals.
Continuous:
If pain free intervals do
not occur.
Duration
Momentary:
If duration is
expressed in
seconds.
Protracted:
If pain is
continuous.
Location
Localized : If patient is able to
define to anatomical location.
Well defined
Diffuse: If Less well defined
and vague.
Okeson JP. Pain mechanism.Bell's orofacial pains: the clinical management of orofacial pain. Chicago, Ill, USA: Quintessence Pub. Co.; 2005.p 272-73

23. Acute Pain:
Short duration.
Chronic Pain:
Long duration which is
lasted longer than 6
months.
Intensity
Mild Pain
Pain described by
patient but
without display of
visible physical
reactions.
Severe Pain
Associated with
significant reactions of
the patient to
provocation of the
painful area.

24.  Mild to moderate inflammatory condition of the pulp
caused by noxious stimuli in which the pulp is
capable of returning to the uninflammed state
following removal of the stimuli.
 Sharp pain lasting for a
moment (Short duration).
 It is more often brought
on by cold, cold air,
sweet, sour than hot food
or beverages.
 Goes away once stimuli
is removed (Subsides)
 Does not occur
spontaneously and does
not continue when the
cause has been removed.
 It is localised by stimulus.
Radiographically : Normal on R/L
examination.

25. ⦿Persistent inflammatory condition of the pulp, symptomatic or
asymptomatic, caused by a noxious stimulus.
⦿ Acute irreversible pulpitis exhibits pain usually caused by hot
or cold stimulus, or pain that occurs spontaneously.
⦿ The pain persists for several minutes to hours,
lingering after removal of the thermal stimulus
• The severe dull aching, piercing,
shooting pain often continues when
the cause has been removed, and it
may come and go spontaneously,
without apparent cause.
• The patient may describe the pain
on bending or lying down.
• It is intolerable, diffused and
referred pain.
• In later
throbbing.
stages boring,
patients often
remain awake at night.
Radiographically : R/L involving enamel,
dentin and pulp.

26.  Chronic hyperplastic pulpitis or "pulp polyp" is a
productive pulpal inflammation due to an extensive
carious exposure of a young pulp.
 This disorder is characterized by the development of
granulation tissue, covered at times with epithelium
and resulting from long-standing, low-grade irritation.
• Symptomless except during
mastication, when pressure of
the food bolus may cause
discomfort.
• The appearance of the
polypoid tissue.
Radiographically : Large open cavities
with direct access to the pulp chamber.

27.  Necrosis is death of the pulp. It may be partial or total.
 Necrosis, although a sequel to inflammation, can also
occur following a traumatic injury in which the pulp is
destroyed before an inflammatory reaction takes place.
 Ischemic infarction can develop - dry gangrenous
necrotic pulp.
• No painful symptoms.
• Discoloration of the tooth is
the first indication that the
pulp is dead.
• Dull greyish discoloration
Radiographically : large cavity or filling, an open approach
to the root canal, and a thickening of the periodontal ligament.
Asymptomatic. Necrotic pulp does not respond to cold, the
electric pulp test, or the test cavity.

28. PULP STONES
 Pulp stones are formed within the coronal portions of
the pulp and may arise as a part of age-related or local
pathologic changes.
• No painful symptoms.
• Radiographic finding.
Radiographically : Diffused or discrete radio-opacity may
be seen in the pulp chamber and occasionally in the canals.
Clinically: entire or partial obliteration of the pulp
chamber may be noticed

29. ANSWER:
In primary teeth,
1. Furcation area is more porous
2. More accessory canals are
located in the furcal area
3. Short cervical trunk
4. Long flared roots
5. Ribbon Shaped canals
6. Thin tortuous pulp filament
WHY IS IT THAT
IN PRIMARY
MOLAR,
RADIOLUCENCY IS
SEEN IN
FURCATION AREA
RATHER THAN
APICAL REGION?

30. WHY ARE CHILDREN
NOT GOOD
HISTORIANS?
 Age and behaviour can compromise reliability of pain.
 More anxious & fearful
 Reluctance towards the treatment – Gives false negative history (to avoid treatment)
 Neural innervation - Both primary and immature permanent teeth are not fully innervated
with alpha myelinated axons, the neural components which are responsible for the pulpal
pain response.
Camp JH. Pediatric Endodontic Treatment. Cohen S, Burns R. Cohen's pathways of the pulp. Elsevier Health Sciences; St.
Louis, Missouri :Mosby, Inc. 2015. p 719-720.

31. DIAGNOSTIC TOOLS
SIMPLE
CHEAP
RELIABLE
VISUAL–TACTILE EXAMINATION
Use of a mirror and blunt probe is
the most common method of
diagnosing tooth decay.
LESION
SEVERITY LESION
ACTIVITY
Braga MM, Mendes FM, Ekstrand KR. Detection activity assessment and diagnosis of dental caries lesions. Dental Clinics.

32. LESION SEVERITY
CAST INDEX
SYSTEM
LESION ACTIVITY
Braga MM, Mendes FM, Ekstrand KR. Detection activity assessment and diagnosis of dental caries lesions. Dental Clinics.

33. RADIOGRAPHIC EXAMINATION
Obtain a high-quality bitewing /periapical
radiograph. Interradicular radiolucencies, a common
finding in primary teeth with pulpal pathosis
The integrity of the lamina dura of the affected tooth
should be compared with that of adjacent or
contralateral teeth
Camp JH. Pediatric Endodontic Treatment.
Cohen S, Burns R. Cohen's pathways of the pulp. Elsevier Health Sciences; St. Louis, Missouri :Mosby, Inc. 2015. p 719-720.
CONVENTIONA
L

34. Gopakumar R, Gopakumar M. Diagnostic aids in pediatric dentistry. International journal of clinical pediatric dentistry. 2011
ADVANCED
RADIOGRAPHIC
TECHNIQUES
 Less radiation
 Edge enhancement along with its wide
latitude of exposure
 Avoids the need for developing films
DIGITAL RADIOGRAPHY AND
XERORADIOGRAPHY

35. CLINICAL EXAMINATION
Camp JH. Pediatric Endodontic Treatment. Cohen S, Burns R. Cohen's pathways of the pulp. Elsevier Health Sciences; St.
Louis, Missouri :Mosby, Inc. 2015. p 719-720.

36. Ingle’s Endodontics.7th Edition Cohen S, Burns R. Cohen's
PALPATION, PERCUSSION, AND
MOBILITY
• Fluctuation, felt by palpating a swollen mucobuccal fold, may be the expression of an acute
dentoalveolar abscess that may not be visualized yet externally.
• Bone destruction associated with a chronic dentoalveolar abscess may also be detected by
palpation
• Teeth with varying degrees of pulpal inflammation
may have very little mobility
• Active physiologic root resorption or pathologic in
primary teeth
Percussion test cannot be performed with instruments used in pediatric
patients
1. Children are more fearful and anxious
2. Root resorption

37. DEPRESSIBILITY
Greater the movement, poorer the prognosis.
In primary teeth –
mobility is not
graded if it is
physiological,
graded if is
pathological

38. RESTORATIVE DIAGNOSIS
SIZE
COLOUR &
AMOUNT Presence of excessive or deep purple
hemorrhage from an exposed or
amputated pulp is evidence of
extensive inflammation in both
primary and young permanent teeth
Purulent exudate
Camp JH. Pediatric Endodontic Treatment. Cohen S, Burns R. Cohen's pathways of the pulp. Elsevier Health Sciences; St.
Louis, Missouri :Mosby, Inc. 2015. p 719-720.
IRREVERSIBLE PULPITIS OR PULPAL
NECROSIS

39. ASSESSMENT OF PULP VITALITY
NEURAL
SENSIBILITY
TESTS
PULP
VASCULARITY
TESTS
RECENT
TECHNOLOGIES
1. Thermal tests
• Heat testing
• Cold testing
2. Electric pulp tester
(EPT)
3. Anesthetic test
4. Test cavity
1. Laser Doppler
Flowmetry
2. Pulse oximetry
1. Dual-wavelength
spectrophotometer
2. Thermography
3. Crown surface temperature
4. Transmitted light
photoplethysmography
Camp JH. Pediatric Endodontic Treatment. Cohen S, Burns R. Cohen's pathways of the pulp. Elsevier Health Sciences; St.
Louis, Missouri :Mosby, Inc. 2015. p 719-720.

40. HEAT TEST
VAN HASSEL’S THEORY
Ingle’s Endodontics.7th Edition
Cohen S, Burns R. Cohen's Pathways Of The Pulp

41. Ingle’s Endodontics.7th Edition Cohen S, Burns R. Cohen's
Pathways Of The Pulp
COLD TEST
BRANNSTROM’S THEORY
Cold test can be used to differentiate between reversible and
irreversible pulpitis.
In irreversible pulpitis, patients complain of increased pain
secondary to heat test, while in such a situation the gets relieved on
application of cold

42. ELECTRIC PULP TEST
EPTs assess
integrity of A-δ
fibres
C fibres do not
respond to the EPTs
(more current needed)
OBJECTIVE
To stimulate a pulpal response by
subjecting the tooth to an increasing
degree of electric current.
Ingle’s Endodontics.7th Edition
Cohen S, Burns R. Cohen's Pathways Of The Pulp
A positive response to EPT is due
to ionic shift in dentinal fluid
within DT inducing action
potential with rapid hopping action
at nodes in A-δ fibres

43. FALSE NEGATIVE
RESPONSE
• Multirooted teeth in which the pulp is vital in one or
more canals
• Failure to isolate/dry teeth properly
• Electrodes contact gingiva
• Teeth with extensive restorations / pulp
protecting base
• Recently traumatized /newly erupted teeth with
incomplete root formation
• Sedative medication
• High pain threshold
FALSE POSITIVE
RESPONSE
Ingle’s Endodontics.7th Edition
Cohen S, Burns R. Cohen's Pathways Of The Pulp

44. CHILD’S PERCEPTION ON PULP
TESTING
1. Nerve fibers are limited to odontoblastic zone
or pre-dentin in primary teeth.
2. Crowding of dentinal tubules is less at the
pre-dentin so giving straight shape
3. Density of the nerve innervation is less .
4. Both primary and immature permanent
teeth are not fully innervated with alpha
myelinated axons
Okeson JP. Bell's orofacial pains: the clinical management of orofacial pain. Chicago, Ill, USA: Quintessence
Publishing Company; 2005.p 261

45. Ingle’s Endodontics.7th Edition Cohen S, Burns R.
ANESTHETIC TEST TEST CAVITY
The suspected tooth should be
anesthetized and, if the diagnosis is
correct, the referred pain should
disappear
If pulp is vital, the heat from bur will
probably generate a response , no
endodontic treatment

46. DIAGNOSTIC FACTORS
REVERSIBLE
PULPITIS
IRREVERSIBLE
PULPITIS
PULPAL NECROSIS
Increased mobility NO YES YES
Tenderness on percussion NO YES OFTEN
Sensitivity YES YES UNLIKELY
Radiographic or pathologic
changes (thickened
periodontal ligament space,
or radicular disease)
NO OFTEN YES
Excessive bleeding at the
pulp stumps
NO OFTEN NO
Toothache
Sometimes
upon
stimulation
YES OFTEN
Sinus NO NO POSSIBLE
SWELLING NO POSSIBLE POSSIBLE
Mohammad G, Jerin F, Jebin S. Pulpal diagnosis of primary teeth: guidelines for clinical practice. Bangladesh Journal of Dental Research &

47. https://www.youtube.com/watch?v=iHrwgKxDuPE
VIDEO LINK

48. CONCLUSION
Diagnosis of pulpal condition is very much important in the
determination of most appropriate treatment for primary
tooth. For proper pulpal diagnosis, thorough history, clinical
and radiographic examinations should be done.

49. Textbook of Pedodontics; Shobha Tandon, 3rd edition, vol 1.
Comprehensive Pediatric Dentistry; 2nd edition; Nikhil Marwah;
Oral and Maxillofacial Pathology, 4th Edition; Brad W. Neville

50. REFERENCES
• Weine F . 6th ed. 2003.Endodontic therapy. Mosby publications
• Ingle et al.7th ed. 2008. Endodontics.BC Decker Inc
• Cohen’s Pathways of the Pulp- 10th edn.
• Grossman.13th ed.2015.Endodontic practice. Wolters kluver
• American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent
teeth. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2020:384-92.
• McDonald RE, Avery DR. Treatment of deep caries, vital pulp exposure, and pulpless teeth in
children. In: McDonald RE, Avery DR, eds. Dentistry for the child and adolescent. 7th ed. St Louis,
MO: Mosby, 1999.
• Pinkham JR. Diagnosis. In: Pinkham JR, ed. Pediatric dentistry: infancy through adolescence.
Philadelphia: WB Saunders, 1988.
• Gopakumar R, Gopakumar M. Diagnostic aids in pediatric dentistry. International Journal Of
Clinical Pediatric Dentistry. 2011 Jan;4(1):1
• Mohammad G, Jerin F, Jebin S. Pulpal diagnosis of primary teeth: guidelines for clinical practice.

51. 1. EXPLAIN VARIOUS TYPES OF DIAGNOSTIC METHODS FOR PULPAL
DISEASES
2. HOW DO YOU CLINICALLY DIFFERENCIATE BETWEEN REVERSIBLE AND
IRREVERSIBLE PULPITIS?
3. WHY ELECTRIC PULP TESTING IS UNRELIEBLE IN CHILDREN?

52.  Enumerate various pulpal diagnostic methods
 Enumerate differences between Reversible and Irreversible Pulpitis

53. 1. WHICH TYPE OF PULPITIS PRESENT WITH SPONTANEOUS PAIN
a. ASYMPTOMATIC IRREV PULPITIS b. REVERSIBLE
PULPITIS
c. SYMPTOMATIC IRREV PULPITIS d. PULPAL NECROSIS
2. PULP SENSIBILITY TESTING
a. THERMAL TEST b. THERMOMETER
c. PULP OXIMETRY d. LASER DOPPLER
3. REVERSIBLE PULPITIS has
a. PROVOKED PAIN
b. UNPROVOKED PAIN
4. NIGHT PAIN IS ASSOCIATED WITH IREVERSIBLE PULPITIS
a. YES b. NO