Endodontic Diagnosis: Pulp Vitality Tests

In this lecture I explain in step-by-step fashion the basics of Endodontic Diagnosis: Pulp Vitality Tests. a photo guide is attached to the guide to aid in better understanding of the topic

1. {f Iraqi Dental Academy

2. Overview

Pulp vitality tests play an important role in

diagnosis of the status of pulp

Pulp tests are usually done before restorative or
endodontic treatment to aid in treatment plan.

Pulp that is vital is indicated for resotrative treatment

Pulp that is non-vital is indicated for endodontic
treatment

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3. Overview

Pulp vitality tests are:

m Cold Test
= Electrical Pulp Test
= Anesthesia Test

= Percussion Test

m Heat Test
m Cavity Test
a Bite Test

= Palpation Test

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4. Cold Test

Start with adjacent tooth first, place an ice stick
on the cervical area of the tooth where enamel is
thin, so that conductivity to pulp is fast

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5. Cold Test

Three conditions exist:

= Patient feel immediate pain, that lasts for 1-3 seconds
after removal of the ice stick., Indicate vital pulp

= Patient feel immediate severe pain, that lasts for
several minutes after removal of the ice. Indicate
irreversibly inflammed pulp

= Patient feels nothing, indicate non-vital pulp

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6. Heat Test

Starting with the adjacent tooth first, place hot
instrument (e.g., burnisher) or hot material (e.g., heated
gutta-percha) over the cervical third of the tooth, so
that conductivity to pulp is fast

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7. Heat Test

Three conditions exist:

= Patient feels immediate pain, that last for 1-3 seconds
after removal of the heated instrument, indicate vital

pulp

= Patient feels immediate severe pain, that Last for
several minutes after removal of the heated instrument,
indicate irreversibily inflammed pulp

= Patient feels nothing, indicate non-vital pulp

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8. Electrical Pulp Testing

Starting with the adjacent tooth first, place one of the
electrodes (black) on patient finger and other electrode
(red) on the tooth to complete the electrical circuit.
then apply little electrical current and increase it slowly

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9. Electrical Pulp Testing

Turn on the device and slowly increase the electircal current

and ask patient to tell you when he fails pain.

Each tooth should be tested 2-3 times and the results are
compared. If the results are not definitive, test the adjacent

tooth and tooth on opposite arch.

If patient feels pain then tooth is vital, if no pain is felt then
tooth is not-vital.
Use another technique in combination with electrical pulp

testing to reach a reliable dignosis

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10. Why we start with adjacent

Tooth First???

To serves as control.

So that to compare it with the questionable
tooth. If both tooth are not responsive to
pulp test it either mean the pulp is not-vital
for both teeth (which is relatively uncommon
unless for trauma) or something wrong with
our testing (which is more likely)

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11. Cavity Test

This method should be used only when all other test
methods provide inconclusive results

The tooth is not anesthetized and tooth is drilled with
round bur with water coolant. The patient is asked if he
feel any pain during drilling. Do not expose the pulp!

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12. Cavity Test

Two conditions exist:
= Patient feel immediate severe pain, Indicate vital pulp

= Patient feel nothing, Indicate non-vital pulp

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13. When patient is not able to specify the site of pain and
when other pulp testing techniques are inconclusive, this
test is used

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14. Anesthesia Test

We anesthetize single tooth at a time, using only
intraligamentary injection.

The most posterior tooth in the suspected quadrant is
anesthetized first. If pain persist, repeat the procedure
to the next tooth mesial to it. It is continued until the
pain disappears.

If source of pain cannot be determined, repeat the same

technique on the opposite arch.

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15. E Bite Tesb

This test helps if patient complains of pain on mastication.

Patient feel pain on biting if pulp necrosis has reached

to PDL space or periapical area, or there is vertical fracture

in the tooth

er

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16. Bite Test

Ask the patient to bite on hard object ( cotton roll,
tooth pick, or tooth slooth) on the suspected
tooth and tooth on the opposite arch.

Patient report pain if there is vertical fracture or
pulp infection has reached PDL space or periapical
area

S| —

Tooth slooth

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17. Bite Test

Vertical Fracture Apical Periodontitis

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18. Percussion Test

Place your finger at the incisal edge / occlusal area of the
tooth and gently press it inward. If patient feel pain, then
periapical area is inflammed. If patient report no pain then
periapical area is healthy. More accurate results can be

obtained from radiograph and combination of other tests

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19. Palpation Test

Use your index finger and place it at the periapical area
of the suspected tooth. The patient will report pain if the
periapical area is infected. No pain if it's intact.

More accurate results can be obtained from radiograph

and combination of other tests

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20. Reliability of Pulp Tests

Pulp test can be a helpful tools for dentist through
diagnostic phase. However, question may be asked. Are

they completely reliable ?

Single pulp test with negative result (non-vitality) is not
that much reliable. Therefore, combination of tests should
be used in order to get an accurate diagnosis.

Add to that, sometimes pulp test tell you that the tooth
is non-vital while the reality is the tooth is vital. This
kind of situation called False Negative result.

And sometimes the test result show that tooth is vital,
while it is not. This situation called False Positive result

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21. Flase Negative Result

Somtimes, pulp test show that tooth is not vital, but the
reality is that tooth is vital
This kind of result occur in some situations like:
m Recently traumatized tooth
= Recently erupted teeth with immature apex
= Patients with high pain threshold
u Calcified canals

# Low battery in electrical pulp tester
a Patient taking pain killers or psychiatric drugs

# One necrotic canal in multi-rooted tooth, while other
canals are vital

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22. Flase Positive Result

Somtimes, pulp test show that tooth is vital, but the
reality is that tooth is not vital
This kind of result occur in some situations like:

= Error in pulp testing, like when ice is melting and
reaching another tooth or gingiva. Or when electrical
current conducting with adjacent tooth and similar
situations

= One vital canal in multi-rooted tooth, while other
canals are necrotic

= In tooth with abscess, there is liquefaction necrosis
in the pulp, which conduct electricity during electrical
pulp testing.

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23. New Technologies in Pulp Testing

More accurate and reliable tests has been developed in
recent years, one of the disadvantages of these techniques
is their cost

= Laser Doppler flowmetry (LDF): It send Laser Light to

the tooth and transmitted beam is recieved by
photodetector.

m Pulp oximetry: It measure the pulse rate of blood in the
tooth and show the result in screen

a Dual wavelength spectrophotometry: This method
measure the oxygen Level in capillaries using lightbeam
and provide results on screen

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24. New Technologies in Pulp Testing

Other new techniques and advances:

* Measurement of temperature of tooth surface
® Transillumination with fiber-optic Light

® Plethysmography

* Detection of interleukin—1 beta

® Xenon—133

* Hughes probeye camera

® Gas desaturation

® Radiolabeled microspheres

® Electromagnetic flowmetry

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25. Summary

= Pulp tests are used during diagnostic phase to detect
the status of the pulp

ı It is recommended to use more than one test and
compare the results to get a definitive diagnosis

= Pulp tests are not 100% accurate. False negative and
false positive result are possible in some cases, as
described previously

= New technologies depend on oxygen Level and pulse
rate of pulp capillaries and other techniques are
invented to provide very accurate results

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26. THANK YOU
+ EB

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