PULP VITALITY TEST
• By Bighnaraj Purohit
Pulp pain (pulpalgia)
Can be classified into 3 types
A- acute
B-chronic
C-hyperactive
Acute pulpalgia
-incipient
-moderate
-advanced(ultimate tooth ache)
Seltzer simplified pulpalgia into
---treatable ( conservative )
---nontreatable (NS RCT indicated).
• To determine status of pulp,we use
various methods of pulp vitality
tests.........
• Where pulp diagnosis indicated
1. Prior to operative procedures – For selected tooth prior to restorative or
orthodontics interventions,where pulp health may be in question...
2. Diagnosis of painthe value of pulp testing in identifying pulpal
pain from other conditions such as
myofascial pain dysfunction syndrome
and referred pain...
3. Investigation of radiolucent area at apices- to
determine Changes in the process of pulp pathology...
MUMFORD AND BJORN SUGGESTIONS___---1
POST TRAUMA ASSESSMENT -important in determining
the treatment needs of teeth involved in
jaw fractures , and those affected by surgical
trauma, such as subapical osteotomy or
vital transplantation procedures.
2
ASSESMENTT OF ANAESTHESIA- Grossman pulp tester to assess, a tooth is
completely Anesthetized,local anesthesia prior to any Operative procedures
3. ASSESMENTT OF WHICH HAVE BEEN PULP CAPPED OR REQUIRED DEEP RESTORATION
IDEAL REQUIREMENTS OF PULP TESTING
•
Simple
•
Standardised
•
Reproducibility
•
Non painful
•
Non injurious
•
Inexpensive
•
accurate
METHODS OF PULP ASSESSMENTS
PULP SENSIBILITY TESTS
PULP VASCULARITY
TESTS
OTHERS
1.
Thermal tests
1. Pulse oxymetry
1. Crown surface temperature Change
2.
EPT
3.
Test cavity preparation
2. Laser doppler flowmetry
4.
2. Thermography
Anaesthesia test
5.
Percussion test
6.
Palpattion test
3. Dual Wavelength
(Spectrophotometry)
THERMAL TEST--The response of the pulp to the heat and cold
is noted.
 The basic princible of the pulp to respond to
pulp stimuli is that the patient report sensation
but disappear immediately.
 Any other type of respond i.e painful
sensation after removable of stimuli,or no
response are considered abnormal.
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• Cold test----
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Commonly used method
for performing this test
as following:
Spraying cold air
directed to the isolated
tooth.
Application of cotton
pellete saturated with
ethyl-chloride.
Spray of ethyl chloride
after isolation the tooth
with rubber dam.(The
ethyl chloride evaporated so
rapidly that it absorbs heat
and thus , cools the tooth).
• This merely identifies presence
of pulp nerve tissues that is
capable of responding to a
change in temperature.
• Other cold test are carried out
with
1. Endo ice(tetrafluroethane)
2. Carbon dioxide snow(dry ice)
3. Freons(dichlorodifluromethane)
Heat test---
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Heated gutta percha sticks is most
commonly used method for heat test.
Tooth is coated with a lubricant such
as petroleum jelly to prevent gutta
percha from adhering to the tooth
surface.
The heated gutta percha is applied
at the junction of cervical and
middle third of the facial surfaces of
tooth and patient response is noted.
• The other methods of heat testing frictional heat produced by rotating polishing rubber disk(burlew rubber wheel) , deliver
warm water from syringe (especially useful of teeth with the porcelain or full coverage restoration),heated ball burnisher etc
• Cold test preferred over warm test because
1. Difficult to perform
2.
Patients are sensitive to heat stimuli
3.
May cause irreversible pulp damage
Electric pulp tester (EPT)
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This test is used for evaluation of condition of
the pulp by electrical excitation of neural
element within the pulp.
The pulp tester is an instrument which uses the
graduation of electrical current to excite a
response from the pulp tissue.
A positive response indicates the vitality of
the pulp, no response indicate pulp necrosis
(The probe can be placed in contact with natural
teeth )
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The electric pulp tester is a battery-operated
instrument, which is connected to a probe that
is applied to the tooth under investigation. It
functions by producing a pulsating electrical
stimulus, the initial intensity of which should
be at a very low value to prevent excessive
stimulation and discomfort.
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The intensity of the electric stimulus is then
increased steadily
at a pre-selected rate, and a note is made
of the read-out on the digital display when
the
patient acknowledges a warm or tingling
sensation.
The read-out simply provides evidence that
the Aδ fibres are sufficiently healthy to
function.
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The tip of testing probe in
contact with the tooth
structure ,coated with water
or petroleum media (tooth
paste ).
The coating probe placed on
incisal third of buccal or
facial area of tested tooth .
Reiss and furedi stated
“dentist should not be
interested in just the condition
of the nerve in the pulp.But in
the condition of the PULP
itself.
Palpation Test
•
Palpate the gum just above and surroundings of
the painful tooth with your finger tip.
- Normal: no pain, no swollen
- Abnormal: pain, slightly tender or
swelling.
Percussion Test
•
Tap lightly the surface of the tooth with a
handle of an instrument.
- Normal Limits: no pain
- Slightly inflammated: mild pain
- Inflammated: severe and prolonged
pain
Test cavity preparation
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This test may serve as a last resort in testing
for pulp vitality. It is only considered when
the results of all other tests have proved
inconclusive
drilling through the enamel–dentine junction
of an un anaesthetized tooth with good
isolation. This may be achieved under
rubber dam with a small round diamond bur
in a high-speed hand piece with adequate
coolant.
ANAESTHESIA TEST--In special clinical situations, the use of intraligamentary
anesthesia is an effective diagnostic tool. For example, If
the patient continues to have vague, diffuse, strong pain,
and prior testing has been inconclusive
 patients may not even able to specify whether the
symptoms are from the maxillary or mandibular arch
• Local anesthesia is administrated.
• Help in finding maxillary and mandibular arch
pain...
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Recent advancements....
Pulse Oximetry
 Dual Wavelength (Spectrophotometry)
 Laser doppler flowmetry
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Laser doppler flowmetry...
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Laser Doppler Flowmetry (LDF) is a
noninvasive,
electro
optical
technique, measures blood flow in
the very small blood vessels of the
microvasculature .
The technique depends on the
Doppler principle whereby light
from a laser diode incident on the
tissue is scattered by moving RBC's
and as a consequence, the
frequency broadened.
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The frequency broadened light,
together with laser light scattered
from static tissue is photo detected
and the resulting photocurrent
processed to provide a blood flow
measurement. The Doppler shifted
laser light, back- scattered out of
the tooth is detected by a
photocell on the tooth surface. The
output is proportionate to the
number and velocity of the blood
cells.
Pulse oxymetry....
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Another non invasive method, that has
been investigated as a method to
determined pulpal blood flow uses a
pulse oximeter, which is designed to
measure the oxygen concentration of
blood and pulse rate .
It work on the principle that two wave
length of the light
transmitted by
photoelectric
diode
detected
oxygenated
and
deoxygenated
hemoglobin as they pass through a
body part to a receptor.
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The difference between light emitted
and light received is calculated by
microprocessor to provide the pulse
rate and oxygen concentration in the
blood .
The system consists of a probe
containing a diode that emits light in
two wavelengths:
Red light of approximately 660 nm
Infra-red light of approximately 850
nm
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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 .
Dual wavelength spectrophotometer.....
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Dual wavelength spectrophotometry
(DWLS) is a method independent of a
pulsatile circulation.
The presence of arterioles rather than
arteries in the pulp and its rigid
encapsulation by surrounding dentine
and enamel make it difficult to detect
a pulse in the pulp space. This method
measures oxygenation changes in the
capillary bed rather than in the supply
vessels and hence does not depend on
a pulsatile blood flow.
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DWLS detects the presence or
absence of oxygenated blood at
760 nm and 850nm.
senses the oxygenated blood
because of the greater absorption
at 850 nm as compared to 760 nm.
DWLS was able to differentiate with
reproducible readings between a
pulp chamber of a vital and nonvital tooth
Measurement of tooth surface
temperature....
• By Fanibunda
• He used two
thermistors that were
connected
backtoback.One of
the
thermistors (measurin
g thermistor) touche
d the enamel surface
while the
other (reference
thermistor) was held
• Cholesteric liquid crystals
• Baltzer- termed “liquid crystals”
• A group of cholesteric Esters have unique
property to change in temperature
• Exhibit different colours at different “mesophase”
• Howell used cholesteric compound in 10%
chlorinated hydrocarbon solution.
• Thermistors---
• Banes and Hamond÷in-vitro
• Stoops and Scott÷ in-vivo
Electronic Thermography
Unit contains1. Infrared sensor
2. Control unit
3. Thermal image computer
4. Software
5. Color monitor
6. Printer
• Hughes probeye 4300 thermal video system –can detect 0.1 °c temperature Change....
teeth were cooled by air spray to approximately 22°C and then
allowed to re-warm to their original resting Temperature around 29°c.
• Normal PULP need only 5s to return to normal incase of non vital PULP it is more
than 15 sec
Adjunct tests....
Conclusion