Pulpal Diagnosis in Children

The dictionary defines diagnosis as "the art of identifying a disease from its signs and
symptoms." Although scientific devices can be used to gather some information, diagnosis is still
primarily an art because it is the thoughtful interpretation of the data that leads to a diagnosis.11
To perform successful pulp therapy, it is first necessary to correctly diagnose the affected
tooth or teeth. This diagnosis can often be simple where there is a large carious cavity and there
are healthy, restoration-free adjacent teeth, or it can be extremely complex where the symptoms
are less defined and there have been multiple endodontic procedures on numerous teeth.
Irrespective of the details of the case, the same protocol of examination and testing should be
employed in each instance in order to obtain the most precise response and establish an accurate
diagnosis.12

Diagnostic aids

Conventional Non
methods conventional
methods

Conventional methods
Traditionally dentist has relied mostly on the following methods for diagnosis.

Extra oral Examination

Inflammatory changes originating intra-orally and observable extra-orally may indicate a
serious, spreading problem. The patient must be examined for asymmetries, localized swelling,
changes in color or bruises, abrasions, cuts or scars, and similar signs of disease, trauma, or
previous treatment. Positive findings combined with the chief complaint and information about
past injuries or previous treatments to teeth or jaws will begin to clarify the extent of the patients
problem.13
Intra oral Examination
After a careful external visual examination the clinician should, with the aid of a mouth
mirror and the blunt-ended handle of another instrument, begin an oral examination to look for
abnormalities of both hard and soft tissues. With a head lamp and good magnification the lips,
cheek pouch, tongue, palate, and throat should be briefly examined Using a mouth mirror and an
explorer, and possibly a fiber-optic light source, the dentist carefully and thoroughly examines
the suspected tooth or teeth for caries, defective restorations, discoloration, enamel loss, or
defects that allow direct passage of stimuli to the pulp. During the visual phase of the
examination the clinician should also be checking both the patient's oral hygiene and the integrity
of the dentition.11
Palpation Tests
Palpation tests are performed using firm pressure from an index finger on the buccal and
lingual mucosa in the area of the root apex and then on the gingival margin of each tooth to be
tested. This palpation will help to identify whether there is swelling present at the apex of these
teeth or if there is severe apical inflammation. Palpation testing around the gingival margin will
help to determine whether purulent drainage through the buccal sulcus is present, providing
information about the infection status of the peri-radicular tissues. Identification of sinus tracts
should also be performed at this time. 12
Mobility Test
Mobility test is to determine tooth stability. Buccal to lingual movement of the tooth using a
mirror handle and the index finger, or using the thumb and index finger, can help determine the
amount of tooth mobility. This is rated on a scale of 1 to 3, with a grade 1 representing 1 mm of
buccal to lingual movement, grade 2 representing 2 mm of buccal to lingual movement, and
grade 3 being depressible by greater than 1 mm and with greater than 2 mm of buccal to lingual
movement. If there is grade 2 or 3 mobility, it could be the result of a number of factors,
including trauma, rapid orthodontic movement, root fractures or, most commonly, periodontal
disease. This mobility should significantly improve following endodontic treatment if it is related
to pulpal non-vitality.12
Percussion Test
Percussion is another test used to isolate the causative tooth and helps in determining the peri-
radicular diagnosis. This test is typically performed using the metal handle end of an intra-oral
mirror, and the tooth is gently tapped a few times from the occlusal and then the buccal surface.
The intensity should be minimal but repeated consecutively, with each tapping motion becoming
slightly more pronounced. A painful response confirms the presence of peri-radicular
inflammation, and the intensity of the discomfort can be compared with other teeth by the
increase in severity of the symptoms when the tooth is repeatedly percussed as described. 12
Radiographs
Radiographs are essential aids in endodontic diagnosis. Unfortunately, some clinicians rely
exclusively on radiographs in their attempt to arrive at a diagnosis. This obviously can lead to
major errors in diagnosis and treatment. Because the radiograph is a two-dimensional image of a
three-dimensional object, misinterpretation is a constant risk, but with proper angulations of the
cone, accurate flim placement, correct processing of the exposed film, and good illumination
with a magnifying glass, the hazards of misinterpretation can be substantially minimized. The
full benefit of periapical radiographs for diagnostic purposes can be achieved if the technique
described here is employed. After correct film placement, either bisected-angle or long cone
methods are effective for film exposure. It is important to expose two diagnostic films. By
maintaining the same vertical cone angulations and changing the horizontal cone angulations
10 to 15 degrees for the second diagnostic film, the clinician can obtain a three-dimensional
impression of the teeth that will aid in discerning superimposed roots and anatomic landmarks.
The state of pulpal health or pulpal necrosis cannot be determined radiographically; but any of
the following findings should arouse suspicion of degenerative pulp changes: deep carious
lesions, deep and extensive restorations, pulp caps, pulpotomies, pulp stones, extensive canal
calcification, root resorption, radiolucencies at or near the apex, root fractures, thickened
periodontal ligament, and periodontal disease that is radiographically evident.11
Radiographs can be classified into the conventional and advanced techniques. Though,
conventional radiographs like bitewing and intraoral periapical radiograph are most frequently
used for the detection of caries, they may cause overlapping of teeth due to faulty angulations
and may also miss the initial lesion. During the primary dentition, the occlusal surface is most
susceptible to caries attack, but with the eruption of first permanent molars the incidence of
proximal lesions greatly increases. In such situation, bitewing radiographs are absolutely
required to detect proximal lesions in primary molars. The Advanced radiographic techniques
include digital radiography and xeroradiography. Digital radiography-, utilizes very little of the
radiation to which the patient has been exposed and avoids the need for developing
films. Xeroradiography has the advantages of producing less radiation and edge enhancement
along with its wide latitude of exposure.14
Pulp Vitality Tests
The next series of tests are collectively termed pulp vitality tests and are performed in order
to determine the pulpal status. These tests are important, as there has to be irreversible pulpal
inflammation present for peri-radicular inflammation to be initiated by endodontic etiology.
Thermal testing is the most accurate method of testing pulp vitality and is carried out to stimulate
A-delta fibers in the pulp. These fibers are some of the most resistant to degeneration, and the
absence of sensations during testing is a true indicator of irreversible pulp damage, which is the
precursor to pulp necrosis.12
Cold Testing
Cold test is done using refrigerator ice or ethyl chloride (-4 C), frozen CO (carbon dioxide
snow) or a cotton pellet sprayed with difluorodichlormethane. It works on the principle of
hydrodynamic force. Cold test causes contraction of dentinal fluid within the dentinal tubules,
which can cause rapid outward movement of fluid within the tubules. This movement of dentinal
fluid leads to hydrodynamic forces which act on A-delta nerve fibers and is responsible for
sharp pain.15
Testing is carried out using a variety of cold materials, each with varying degrees of coldness.
The material used is selected based on the patients chief complaint. If he or she is complaining
of pain from cold even when breathing in cold air, then it is inhumane to use an Endo Ice spray
that will send his or her pain levels soaring. It is more appropriate to use cold air from the air/
water syringe to directly spray air to the buccal gingival margin of each tooth individually, while
the other teeth are completely shielded using dry gauze. The cold air may not be sufficiently cold
to evoke responses in all teeth that have healthy pulps, but the offending tooth should be easily
detected using this method. This method has numerous limitations and should be used only when
a patient cannot tolerate anything that is remotely cold in his or her mouth. Patients who provide
information that cold drinks or ice stimulates their pain should be tested using ice pencils. These
can be made at little or no cost by freezing water in local anesthetic needle sheaths that have not
been contaminated. 12
In pediatric patients, application of CO2 snow produces a low intrapulpal pressure and is far
more effective and reliable even in immature tooth.14

Heat Testing
The application of heat is usually reserved for cases where the patient states that he or she is
experiencing pain with warm substances. The pain in these situations is usually intense and
lingers for a period of time following the intake of the warm substance and its stimulation of the
offending tooth. The application of heat causes expansion of the gases created by necrosis to
invoke significant pain. Pain with heat is typically an indicator of partial pulp necrosis and the
initiation of a pulpal infection in the tooth. When patients are experiencing pain with heat, this
test should be used as one of the final tests, after other testing has been performed and additional
information has been obtained. Even if prior testing provides a definite diagnosis as to the
affected tooth, the heat test should still be performed to reassure the patient and the treating
doctor that the etiology will definitely be managed by endodontic treatment. Application of heat
stimulates a response in the pulp by causing expansion of the fluid inside the dentinal tubules.
This movement will again trigger the A-delta fibers located around the tubules. Once the
symptoms have been reproduced, cold can be quickly reapplied to the tooth using Endo Ice spray
or applying an ice pencil to the buccal surface, and this should again relieve the patients
discomfort.12
In heat test, initially A-delta fibers are stimulated leading to sharp localized pain and with
continuous stimulation, it activates C fibers causing a dull radiating pain. Heat test should not be
done for more than 5 seconds to avoid damage to the pulp. Negative response indicates necrosis
of pulp.15
Pulp testing in children below the age of 10 years is unreliable because children may not
cooperate for the test. They may elicit false positive or false negative results if the dentist asks
the child leading questions and also the unpleasant stimuli produced by the tester may affect
behavior management/cooperative problems with pediatric patients.16 Heat test in pediatric
patients as it might increase the anxiety of the child. Secondly, the heat might damage the pulp,
since pulp horns are highly placed in deciduous teeth and if the child is uncooperative the heat
might cause injury to the soft tissue.14
Responses
There are four possible reactions the patient may have: (1) no response; (2) a mild to
moderate transient thermal pain response; (3) a strong painful response that subsides quickly
after the stimulus is removed from the tooth; and (4) a strong painful response that lingers after
the thermal stimulus is removed. If there is no response, the pulp is either nonvital or possibly
vital but giving a false-negative response because of excessive calcification, an immature apex,
recent trauma, or patient premedication. A moderate transient response is usually considered
normal. A painful response that subsides quickly after the stimulus is removed is characteristic of
reversible pulpitis. Finally, a painful response that lingers after the thermal stimulus is removed
indicates a symptomatic irreversible pulpitis.11
Electric Pulp Test
The final test that is used for pulpal diagnosis is the electric pulp test. Electric Pulp tester,
(hereafter known as EPT), is placed on incisal surface to middle third of anterior tooth and
mesiobuccal edge of lower/upper tooth to determine the lowest response threshold. This test
stimulates A-delta fibers by using electric current at pulp dentin complex on the tooth surface. A
positive result from EPT indicates shift in the dentinal fluid within the tubules causing local
depolarization .15
The patient's response to the electric pulp test does not provide sufficient information for a
diagnosis. The electric pulp test merely suggests whether the pulp is vital or nonvital and does
not provide information regarding the health or integrity of a vital pulp. The electric pulp test
does not provide any information about the vascular supply to the tooth, which is the real
determinant of vitality. Additionally, a number of situations may cause a false-positive or false-
negative response, so using other diagnostic tests is essential before arriving at a final diagnosis.
11

It consist of A metal hook or clip is placed on the patients lip, and a probe tip covered in a
conducting medium such as toothpaste is applied to the middle third of the tooth surface.
Whenever possible, the probe should not contact the surface of a restoration. A pulsating electric
stimulus is created, beginning at a very low value and gradually increasing in intensity. When
patients experience a pulsing, tingling or vibrating sensation, they are instructed to indicate their
response to the stimulus.12
Electric pulp testing has shown to be unreliable or rather non effective in deciduous teeth and
immature permanent teeth because the relationship between odontoblasts and nerve fibers of the
pulp has yet to develop. Failure of immature teeth to respond to the electric pulp testing may be
caused by the lack of development of Raschkow plexus in the region of pulp dentin border.
Another reason for the unreliability of electric pulp test in deciduous teeth is that the nerve fibers
are the last to develop and first to degenerate in these teeth.14
As the pulp is in a state of shock following trauma, pulp tests may not give reliable results
immediately following traumatic injury. 16This temporary loss of response is caused by injury,
inflammation, pressure, or tension to apical nerve fibers. It may take 8 weeks, or longer, before a
normal pulpal response can be elicited. 17 It has been observed that there is superior ability of
blood vessels to withstand trauma compared with the nerves. Thus it is recommended that in
traumatized teeth endodontic therapy should be delayed, considering the affected pulp tissue to
be vital.16

Validity of Sensitivity Tests

The validity of any diagnostic test is best described by its sensitivity & specificity, whereas its
clinical usefulness is described by its positive predictive value & negative predictive value.

Sensitivity: It is the proportion of cases identified correctly by means of the diagnostic test.
Specificity: It is the proportion of non cases identified correctly by means of the diagnostic test.
Positive Predictive Value (PPV): It is the proportion of positive test results that are cases.
Negative Predictive Value (NPV): It is the proportion of negative test results that are noncases.18
Comparison among Sensitivity [Thermal, Cold and Electrical] Tests 18
Cold test Heat test EPT
Type of response
Probability of Non 89% 48% 88%
sensitive reaction
representing necrotic
pulp

Probability of 90% 83% 84%

Sensitivity reaction
representing vital
pulp
Sensitivity 0.83 0.86 0.72
Specificity 0.93 0.41 0.93
PPV 0.89 0.48 0.88
NPV 0.90 0.83 0.84
Accuracy 0.86 0.71 0.81

Cavity Test
Cavity test refers to access, without anesthesia, to a cavity preparation in a tooth that is
suspected to be necrotic.12This test is often a last resort in testing for pulp vitality. It is important
to explain the procedure to the patient because it must be done without anesthesia. Make a
preparation through the enamel or the existing restoration until the dentin is reached. If the pulp
is vital, the heat from the bur will probably generate a response from the patient; however, it may
not necessarily be an accurate indication of the degree of pulpal inflammation. As with other
tests, the cavity test must be used in conjunction with the history and other testing procedures
and not used as the sole determinant.11

Local anesthetic test

 When dental symptoms are poorly localized or referred, an accurate diagnosis is extremely
difficult. Sometimes, patients may not even able to specify whether the symptoms are from the
maxillary or mandibular arch. In such cases, and where pulp testing has proved inconclusive, an
anesthetic test may be helpful. The technique is as follows: using either infiltration or an
intraligamentary injection, the most posterior tooth in the area suspected of causing the pain is
anaesthetized. If pain persists once the tooth has been fully anaesthetized, the tooth immediately
mesial to it is then anaesthetized, and so on, until the pain disappears. If the source of the pain
cannot be even localized to the upper or lower jaw, an inferior alveolar nerve block injection is
given; cessation of pain indicates involvement of a mandibular tooth.17

Non conventional Methods

Current conventional methods of vitality test rely on stimulation of A-delta nerve fibers and
give no direct indication of blood flow in the pulp. They have potential to produce an unpleasant
and painful sensation. In addition, they are dependent of patients response to stimulus. This is
very crucial in case of children where childrens response to stimulus may not be reliable.
Recently, new devices have been introduced which measure pulp vitality based on blood
circulation in pulp. They are still under scientific research, but showing promising results.15
Pulse Oximetry
Pulse Oximetry has been the most commonly used technique for the measurement of oxygen
saturation in medicine because of its ease and affordability. Pulse Oximetry uses red and infrared
wavelengths in order to transilluminate a tissue and detects absorbance peaks due to pulsatile
19
circulation and uses this information to calculate the pulse rate and oxygen saturation. The
principle is based on a modification of Beer Lamberts 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 hemoglobin in the red and infra-red range. In the red region,
oxyhemoglobin absorbs less light than deoxyhemoglobin and vice versa in the infrared region. 20
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

A silicon photo detector diode is placed on the opposing surfaces of the tooth, which is
connected to a microprocessor. 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.
18

Limitations:
1) Measures low oxygen level from teeth.
2) Probe designed do not match the anatomy of tooth.15
Laser Doppler Flowmetry
The technique depends on the Doppler principle whereby light from a laser diode incident on
the tissue is scattered by moving RBCs and as a consequence, the frequency is broadened. The
frequency broadened light, together with laser light scattered is photo detected and the resulting
photocurrent processed to provide a blood flow measurement. LDF is an optical measuring
method that enables the number and velocity of particles conveyed by a fluid flow to be
measured. The particles (120 m) must be big enough to scatter sufficient light for signal
detection but small enough to follow the flow faithfully. The original technique used a light beam
from a heliumneon (HeNe) laser emitting at 632.8 nm. Other wavelengths of semi-conductor
laser have also been used: 780 nm and 780820 nm. Laser light is transmitted to the dental pulp
by means of a fibre optic probe placed against the tooth surface. Two equal-intensity beams (split
from a single beam) intersect across the target area. The scattered light beams from moving red
blood cells are frequency-shifted whilst those from the static tissue remain unshifted in
frequency. The unshifted light is returned by an afferent fibre within the same probe to photo
detectors in the flow meter and the signal is produced. The LDF output signal or Flux can be
simplified as a function of the product of red blood cells concentration as well as their mean
velocity. It should be emphasized that the optical properties of a tooth change when the pulp
becomes necrotic and this can produce changes in the LDF signal that are not due to differences
in blood flow. In fact, as red blood cells represent the vast majority of moving objects within the
tooth measurement of the Doppler-shifted backscattered light serves as an index of PBF. LDF
evaluates dynamic changes in blood flow by detecting blood cell movement in a small volume of
tissue (about 1 mm3).20

Limitations:
The limitations of this method include a too expensive device for use in a dental office . It is
technique-sensitive: its readings are affected by the movement of the patient, a non fixed probe
or a mobile tooth. It takes about an hour to produce recordings, making it impractical for dental
practices. The technique yields false-positive results when used for endodontically treated teeth
and when the gingival blood flow is measured. Moreover, intracoronal and extra coronal
scattering of the laser beam calls for special precautions such as covering the gingiva and the
crown of the tooth.18

Comparison among Sensitivity Vs Vitality Tests

 Pulse oximeter gave constant positive vitality reading compared to thermal & EPT methods
and considered more reliable compared to EPT & cold test.18

Type of response EPT Pulse oximeter LDF

Sensitivity 0.915 0.813 1.0
Specificity 0.881 0.949 1.0
PPV 0.885 0.941 Accurate
NPV 0.912 0.835 Accurate

Ultrasound Doppler or Color Power Doppler

Color Power Doppler flowmetry allows the presence and direction of the blood flow within
the tissue of interest to be observed. The intensity of the Doppler signal is represented by
changes in real time on a graph (Doppler) and is also shown in the form of color spots on the
gray scale image (color). Positive Doppler shifts are caused by the blood moving toward the
transducer and are represented in red, whereas negative Doppler shifts are caused by blood
moving in the opposite direction and are represented in blue. Power Doppler is associated with
color Doppler to improve its sensitivity. It is based on the integrated power spectrum and can
disclose the minor vessels. In a recent evaluation of the device the origin of the signals could also
be differentiated with the aid of different Doppler graphic waveforms and sounds in vital teeth
vs. nonvital teeth. In vital teeth US Doppler reveals a pulsating waveform and sound
characteristic whereas root canal filled teeth shows linear nonplused waveform without pulsating
sound. The intravenous injection of contrast media is said to further increase the echogenicity of
the area of interest.19
Photoplethyesmography
This is an optical measurement technique that can be used to detect blood volume changes in
the microvascular bed of tissue. The basic form of PPG technology requires only a few
opto-electronic components: a light source to illuminate the tissue (e.g., skin or tooth) and a
photo detector to measure the small variations in light intensity associated with changes in
perfusion in the catchment (study) volume. PPG has been compared with LDF in experiments on
skin and was found to be of similar value. PPG has been applied in many different clinical
settings, including clinical physiological monitoring, vascular assessment and autonomic
function. It is proposed that circulatory changes in human dental pulp can also be investigated
with the PPG technique. Hemoglobin absorbs certain wavelengths of light, while the remaining
light passes through the tooth and is detected by a receptor. The heart rate variability is composed
of low- and high frequency fluctuations, which are mediated by the sympathetic and the
parasympathetic nervous systems. The baseline and the amplitude of the PPG signal also show
fluctuations in the same frequencies. PPG assessments of dental pulp tissue viability have
demonstrated pulsatile waveforms synchronous with a finger PPG reference in healthy subjects
and the loss of pulsatility in patients with nonvital dental pulp. There was a significant negative
correlation between the tooth PPG signal and subject age in those with healthy teeth.19
Tooth temperature
The concept of diagnosing tooth vitality by temperature measurement can provide valuable
information about the integrity of the underlying pulp. Body temperature is related to the oxygen
consumption of an organism. Due to differences in the blood supply and the rate of blood flow,
different parts of the body show different thermal patterns. The feasibility of temperature
measurement as a diagnostic procedure in human teeth was demonstrated by Fanibunda in 1985
by a laboratory study. He claimed that it is possible to test whether the tooth was vital by means
of Crown Surface Temperature. In 1986, these results were published by him in a clinical study,
using the Time-Temperature Relationship method.19
Cholesteric liquid crystals
Cholesteric crystals are a type of liquid crystal, i.e. ordered fluids, with a helical structure
ordered along the long axis known as chiral- nematic liquid crystals. Due to their fluidity these
are easily influenced by temperature or pressure. The pitch of the very structure of the crystal
varies when the pressure or temperature are altered thus changing their color heated i.e. they are
thermo chromic. These were used in a study by Howell et al. [ in Lexington 1970. They found
that nonvital teeth have lower temperature than vital teeth. They experimented various liquid
crystals until they arrived at a combination that would indicate temperatures in 30 to 40C
range. They used cholesteric compounds that were in a 10% solution in a chlorinated
hydrocarbon solvent. When applied to the tooth surface, the crystals went through color changes
that were compared with adjacent or contralateral-teeth. Their usage in detecting pulp vitality is
based on the principle that the teeth in intact pulp blood supply have a higher tooth surface
temperature compared with teeth that had no blood supply.19
Dual-wavelength Spectrophotometry
Dual-wavelength spectrophotometry (DWS), which is done with a noninvasive portable
instrument, can be used to test pulpal blood flow. Oximetry by spectrophotometer determines the
level of oxygen saturation in the pulpal blood supply with a dual-wavelength light source (760
and 850 nm). This instrument may be useful for determining pulp necrosis and the inflammatory
status of the pulp. Nissan and others did an in vitro study to determine the feasibility of using
DWS to identify teeth with pulp chambers that are either rempty, filled with fixed pulp tissue or
filled with oxygenated blood. Their findings indicated that continuous-wave spectrophotometry
may be a useful method for testing pulp.21

REFERANCE
11. Cohens pathways of the pulp. Stephen Cohen, Richard c. Burns. Sixth edition
12. Manish Garala, 2010
13. Ingle. Fifth Edition
14. Gopakumar R, 2011
15. Diwanji Amish.
16. Gurusamy Kayalvizhi1, 2009
17. Velayutham Gopikrishna, 2011
18. Arun A, 2013
19. Shashi Prabha Tyagi, 2012
20. Dakshita Joy Vaghela, 2011
21. Ashraf Abd-Elmeguid, 2009