Dental Pulp Diagnostic

Dr. Csaba Dobó Nagy

Department of Oral Diagnostics

Pulp conditions

• normal when there is a response to the stimulus provided be the sensibility test and this response is not pronunced or exaggerated,and it does not linger

• Pulpitis is present when tehere is an exaggerated response that produse pain. Pulpitis can be considered as reversible or irreversible, depending on the severity of pain and whether the pain lingers or not.

• Pulp necrosis: the tooth is pulpless or has had previous root canal therapy

Diagnostic objectives of pulp testing• Assesment of pulp health based on its qualitative

sensory response– Prior to restorative, endodontic and orthodontic

procedures– As a follow-up and for monitoring the pulp after trauma of

the theeth– In different diagnosis, such as excluding periapical

pathosis of pulp origin• Replication of sympthoms and triggers of pain

diagnostic purposes:– To localise the source of pain– As an aid in excluding nonodontogenic orofacial pain

Definition

• Pulp Vitality Testing: Assesment of the pulp’s blood supply

• Pulp Sensibility Testing: assesment of the pulp’s sensory response

• Pulp Sensitivity : condition of th pulp being very responsive to a stimulus

Pulp Testing Techniques/Pulp Senibility Testing

• Thermal Tests– Cold tests:

• Ice• Refrigeant Spray (chlor-etil, dichlor-difluorometane-

DDM, tetrafluoro-etane TFE)• Carbon-dioxide snow

– Heat test• Warm gutta-percha • Touch and heat

• Electric pulp test• Test cavity preparation

Pulp Vitality Testing 3.

Other:• Photoplethysmography : to improve pulse oximetry ,

by adding a light with a shorter wavelength• Spectrophotometry: dual wavelength lights• Transmitted Laser Light (TLL): separated

sending/receiving probes• Transillumination: colour changes that may indicate

pulp pathosis• Ultraviolet light photography: fluoresens patterns• Surface temperature measurment (breathing)

Comparison of pulp testing• Cold tests

– Rate of temperature decrease: CO2 in 5 sec. 2°C, • Heat tests

– melting point of Guttapercha between 78°C -150°C, but 11°C increase cause damage in the pulp

• Electric pulp tests– In recently erupted teeth it takes 5 years myelinated (Aδ)

fibres reach DEJ– Orthodontic movement sensory functions may be disturbed

up to 9 months– 2-6 weeks recovery following trauma– Contamination (ginigva, metal restauration)

Types of Nerve Fibres and their distribution inside the dental pulp

• Dental pulp is a highly innervated tissue that contains sensory trigeminal afferent axons

• N trigeminal sensory nerve fibers– 90% of A fibres are A –delta fibres , which are located at

the pulp-dentin border in the coronal portion of the pulp and concentrated in the pulp horns

– C fibres are located in the core of the pulp and extend into the cell –free zone underneath the odontoblastic layer

• Symphatetic efferent fibres regulate the blood flow

Pulp tests and innervation• Electric current simulates Aδ-fibres, but not the C-fibres,

because their high treshold.• Cold simuli produce stronger response than cold stimuli,

because of the outward flow of fluid.• Repeated application of cold will reduce the displacement of

fluid – less painful.• Aδ-fibres are more affected by the reduction of blood flow

than C-fibres, because they more sensitive to hypoxia.• Uncontrolled heat can injure pulp release mediators that

affect the C-fibres.

Positive/negative hydrostatic pressure

+150 Hgmm-150 Hgmm

Neuro-parakrin inflammation

normal pulp + - -

inflamed pulp ++ - -

Comparison of pulp tests

Etil-chloride

warm guttapercha

Electric test

senzitivity 0,83 0,86 0,72

specificity 0,93 0,41 0,93

Recovery of traumatic teeth function

Test 0. day 28. day 2 month 3 month

pulzus oximetry

100% 100% 100% 100%

Electric test 0 29,4% 82,35% 94,11%

Heat test 0 29,4% 82,35% 94,11%

Faults of electric pulp test

• False-negative• False-pozitive• Localization:

– Incizal third– Molars, premolars neck– EKG gel

Determination of pulp circulation

• Yet no available clinical test• Senzibility tests 84-90% reliable for pulp

vitality.• Fals-pozitive: remaining C-fibres• Fals-negative:

– Calcification– recent trauma– developing tooth

Differentiation of reverzibilis/irreverzibilis pulpitis

Small area dentin-recording

microdialysis

bradikin ↑10x gyulladt pulpában JOE, 2000;26:744

Special clinical cases

• Dentin hypersensitivity• Pulpitis chronica• Pulp-perio

irreversibilis pulpitis?

Pulpitis chronica