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Dent 423; Diagnostic Tests I

Aceil Al-Khatib DDS, MS, Diplomat ABOM

Routine Dental Tests

Vitality tests:
Thermal: cold and heat Electrical Cutting an access cavity without anaesthesia

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Vitality Tests
Provide an adjunct to determining the state of pulp Results must be interpreted with caution False positive and false negative results are common

Vitality tests
Surrounding and contralateral teeth should also be tested Test should begin on a normal tooth Stimuli should be applied to normal enamel of the crown of the tooth Better results if more than one test is used ( heat and cold, or cold and electrical tests)

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Uses Of Vitality Testing In Clinical Practice

Prior to operative procedures Diagnosis of pain Investigation of radiolucent areas Post-trauma assessment Assessment of anaesthesia Assessment of teeth which have been pulp capped or required deep restoration

Thermal Vitality Tests

A temperature in the range of 20-50 C does not elicit pain from healthy teeth Teeth with inflamed pulps (pulpitis) react with severe pain on temperature stimulation within 20-50

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Cold Test
Involves using a refrigerant, such as endo-ice, ethyl chloride spray The middle third of the clinical crown for posterior teeth and the border between the coronal and middle thirds of the clinical crown for anterior teeth

How to Apply the Cold Test

Hold a cotton pellet in tweezers Spray Ethyl chloride or endo ice until crystals form Apply the icy pellet to the facial surface of the tooth Leave the chilled cotton pellet on the tooth for at least 10 seconds before deciding on the response

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The Heat Test

Apply to the vaseline-coated surface of the test tooth Use a ball of softened gutta percha on the tip of a plastic instrument (gutta-percha softens at 65 C) Place the gutta percha onto the tooth the same way you would the ice Wait approximately 5 seconds Compare the results from other tested teeth

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A rubber cup applied to a tooth to generate frictional heat

The use of hot water, administered through an irrigating syringe under rubber dam isolation

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Disadvantages
May be difficult to use on posterior teeth because of limited access Excessive heating may result in pulp damage May result in a lingering pain, therefore heat tests should be applied for no more than 5 seconds Inadequate heating of the gutta-percha stick could result in the stimulus being too weak to elicit a response from the pulp

Electric Pulp Test (EPT)

EPT is technique-sensitive The tooth must be clean and dry The anatomic location should have no restoration, orthodontic band or brackets, or arch wire An adequate medium ( gel, toothpaste)should be applied having contact between the tooth probe and tooth for a completed electrical circuit

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How To Conduct The EPT

Before beginning, provide the patient with specific instructions to raise a hand or arm when a sensation occurs Clean , dry and isolate the tooth Use a small amount of toothpaste on the metal tip of the probe Place the tip on the middle of the facial surfaces of the tooth

How To Conduct The EPT; Contd

Do not place the probe on a restorative material (metal, composite, ceramic) or touch gingival tissues The probe should not touch lips or cheeks Have the patient touch the handle of the device with a finger ( in order to ground the unit to complete the electric circuit) Start by pressing and holding the start button

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How To Conduct The EPT; Contd

Gradually increase the voltage until a response is elicited When the patient indicates a response, release the start button The reading will be fixed on the display for some time after the button is released A response to the maximum reading (e.g. reading of 64 is usually indicative that the pulp of the tooth being tested is nonvital)

Between 0-40, the patient feels ache; vital pulp Between 4080,with abovementioned reaction, partially vital pulp 80, no mentioned reaction, non-vital pulp

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Electrical conducting gel is present between the electrode and the tooth

A hook on the patients lip completes the circuit

Electric Pulp Test (EPT)

This test should be used when the hot and cold tests fail to give clear information on the state of vitality of the tooth Results must be compared with the response from other teeth The most desirable area of assessment is at the incisal edge of incisor teeth, and the midthird region of posterior teeth (on the tip of the mesiobuccal cusp on molars )

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False Positives From EPT Testing

Anxious patients Liquefaction necrosis Contact with metal restorations Vital tissue still present in partially necrotic root canal system

False Negatives From EPT Testing

Incomplete root development Recently traumatized teeth Sclerosed canals Recent orthodontic activation Patients with psychotic disorders

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Interpretation Of The Results Of Vitality Tests; Positive ( Normal)

The test tooth responds in a similar way and to a similar level of stimulation to the other healthy teeth. This result suggests that the pulp is vital

Interpretation Of An Exaggerated (prolonged) Response

The test tooth responds more severely than and to a lower level of stimulation to the other healthy teeth. Pain lasts for more than some 15 seconds ( minutes, hours) after removal of the stimulus The response to heat & electrical stimulation may be greater than to cold. Cold may reduce the pain

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Interpretation Of An Exaggerated (prolonged) Response

Irreversible pulpitis Chronic pulpitis; if gradual reaction to heat, but not to cold or electrical stimulation leads to an exaggerated response

Interpretation Of Negative Response

The test tooth does not respond to stimulation but healthy teeth do The result suggests:
Non- vital pulp Root canals are sclerosed

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False Positive
The test unhealthy tooth responds normally; Occur in anxious or young patients Contact with metal restorations (electric test) Inadequately dried teeth ( electric test) Multi rooted teeth with one vital root canal pulp In a root canal filled with pus or gas In a patient with low pain threshold

False Negative
Teeth with restorations ( heat and cold test) Teeth with secondary dentine Nerve supply to the pulp is damaged (e.g. trauma) In a patient with a high pain threshold Faulty technique or equipment

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Inconclusive Result
All teeth give similar responses: conflictive results If the results of two tests are inconclusive add a third test Consider cutting a diagnostic access cavity without local anaesthesia

Diagnostic Cavity Preparation

Is the most reliable vitality test This test may serve as a last resort in testing for pulp vitality Is made by drilling through the enamel dentine junction of an unanaesthetized tooth with good isolation If the patient feels pain once the bur contacts the sound dentin, the procedure is terminated and cavity is restored

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Local Anaesthetic Test

When dental symptoms are poorly localized or referred, an accurate diagnosis is extremely difcult Using either inltration or an intraligamentary injection, the most posterior tooth in the area suspected of causing the pain is anaesthetized If pain persists, the tooth immediately mesial to it is then anaesthetized, and so on, until the pain disappears

Assessment Of Pulpal Vascularity

Crown surface temperature Laser Doppler owmetry: a non-invasive , painless technique with direct and objective registrations, but has limitations : environmental and technique-related factors. Nonpulpal signals, principally from periodontal blood flow, may contaminate the signal Pulse oximetry: measure oxygen saturation levels

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Laser Doppler Flowmetry (LDF)

A LDF probe applied to a sectioned tooth showing the passage of light via the enamel prisms and dentinal tubules to the pulp

A LDF trace showing signals from two teeth; the upper is from a vital tooth while the lower is from a nonvital tooth

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