Jurnal Tentang Tes Vitalitas

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ENDO (Lond Engl) 2008;2(4):259–266

� 259REVIEW

The dental pulp is a fascinating tissue that has always attracted much attention within the dental pro-fession. Pulp vitality testing is crucial in monitoring the state of health of the dental pulp and althoughpulp vitality is just a function of vascular health, traditional methods are based on stimulation of nervefibres and demonstrate further limitations. However, these methods have been unreliable in childrenover the years. The recent advances in pulp vitality testing mean that the pulpal blood flow is as-sessed, which is a true indicator of pulp vitality. This review article discusses the advantages and lim-itations of traditional and recent methods of pulp vitality testing in children. This article is clinically rel-evant, as understanding of both the usefulness and limitations of pulp testing methods is essential foreffective endodontic diagnosis and treatment planning in children.

Gurusamy Kayalvizhi

Reliability of pulp-vitality testing in children: a review

children, neural stimulation, pulpal blood flow, reliability, vitality Key words

Gurusamy KayalvizhiMDS, Senior Lecturer,Department of Pedodonticsand Preventive Dentistry,M.R Ambedkar DentalCollege, Cooke Town,Bangalore, 560005,IndiaEmail:[email protected]

� Introduction

‘This is a big issue about a little tissue and this littletissue has created a big issue’ (Samuel and Bender)1.

The dental pulp is a richly vascularised and innervatedconnective tissue of mesodermal origin contained inthe central cavity of a tooth, delineated by dentine andhaving formative, nutritive, sensory and protectivefunctions. The traditional methods of pulp vitalitytesting rely on neural stimulation, that is, they dependon innervation and stimulation of nerve fibres,whereas recent methods record the pulpal blood flowto assess pulp vitality.

The traditional methods of pulp vitality testing arebased on neural stimulation. Assessing the vitality of

the pulp is a crucial diagnostic procedure in distinguish-ing or identifying disease2, which helps in effectivetreatment planning. This review discusses the reliabilityof traditional and recent advances of pulp vitalitytesting in children, highlighting the advantages andlimitations, with the focus mainly on newer strategies.

� Traditional pulp vitality testingmethods

� Electric pulp testing

Marshall and Woodward3 were the first to use elec-tricity to demonstrate the vitality of teeth in 1896.Electric pulp testers3 (EPT) act directly by stimulating

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sensory nerves in the pulp, thereby measuring theexcitation threshold of these nerves (Fig 1).

EPT is useful when used on elderly patients whoseteeth have a large amount of secondary dentine. EPTcan also be used in post-trauma assessment of toothvitality, provided the tester can be applied to theenamel. EPT requires tooth isolation and may also elicita response from the periodontium. However, it cannotbe used on crowned teeth without cavity preparationor in patients with full orthodontic bands or metallicrestorations, because of the risk of conduction.

� Thermal pulp testing

The first reference to the use of the thermal pulp testwas made by Jack in 18994. These tests involved eitherheating or removing heat from a tooth. Early worksuggested that the response of pulpal nerve fibres isdue to the direct effect of the temperature change onthe pulp, causing expansion and pressure or vaso-motor changes, and, thus, stimulating nerves. Thiswas carried out using heated gutta-percha, ethylchloride, dichlorotetrafluoroethane and dry ice (Fig 2).

Thermal pulp testing can be used on metallic restor-ations and orthodontically banded teeth. It requires notooth isolation and allows full-mouth vitality testing tobe carried out quickly, therefore apparently over-coming the problems related to electrical testing. Dis-advantages of the thermal pulp test are that it may notbe effective for teeth of elderly patients with a largeamount of secondary dentine and is not reliable forteeth restored with full-coverage acrylic or porcelaincrowns. Thermal pulp testing is also not as useful as the

EPT in post-trauma assessments, as thermal tests areunable to determine threshold values.

� Mechanical tests

Mechanical stimulation tests3 include percussion testsas well as probing or blowing air onto exposed dentineand test cavities.

Probing or drying dentine causes pain by initiatinghydrodynamic pressure changes in dentinal tubules,thus affecting the pulp. Therefore, these methods arelimited in their usefulness6. Test cavities are advocatedas the last option when other attempts of sensitivitytesting are uncertain. A sensation of pain when thedentine is pierced is an indication of the presence ofvital pulp. However, this does not imply the absenceof pulpal inflammation and is indicated for use in teeththat are covered with full crowns or if hard tissue hasformed in the pulpal space. However, these tests donot provide reliable results in anxious patients.

Percussion only tests if there is significant peri-odontal inflammation in the apical region. However,lack of a positive percussion test does not give assur-ance that inflammation has not extended into theperiapical tissues. Thus, mechanical tests are not veryreliable in assessing pulp vitality.

� Palpation test

Palpation tests are performed by exerting digital press-ure on the tooth and on the soft tissue adjacent to theroot apices. If soreness of mucosa is felt over the root

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260 � Kayalvizhi Reliability of pulp-vitality testing in children

Fig 1 Electric pulp tester.

Fig 2 Thermal pulp testing using warm gutta-percha(courtesy of Edgar Schäfer, Münster, Germany).

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periodontal ligament inflammation of pulpal origin.The palpation test helps in the planning of treatment,but does not assess pulp vitality.

� Anaesthetic test

The anaesthetic test is used in cases where pain isdiffuse, radiating or referred. Injection of a local anaes-thetic should be made in the region of the tooththought to be affected by pulpitis to determine theorigin of the pain. The anaesthetic test is only usefulin cases where pain is present at the time of exami-nation, and this test does not indicate the pathologicalstate of the pulp.

� Ultrasonics

In 1966 Kossoff and Sharpe7 attempted to detectpulpitis using ultrasonics, but were unsuccessful. Theproblem was the availability of information relative tothe acoustic properties of dental hard tissues, mainlybecause of the crudity of instrumentation. Later withan improved instrument, the transmission and reflec-tion of sound from the dentine–enamel junction anddentine–pulp interface were recorded. However, thistool still needs to be further perfected8.

� Ultraviolet light

Foreman9 investigated the usefulness of ultravioletlight as a diagnostic tool in endodontics. Ultravioletfluorescence as a test of vitality, accentuates the colourchanges that occur in a tooth when the pulp is alteredby trauma or inflammation. The loss of ultraviolet fluor-escence in a natural tooth indicates pulpal damage orthe presence of a root canal filling, but the presence ofultraviolet light of normal intensity does not indicate ifthe pulp is vital or non-vital. The ultraviolet lightmethod allows checking of a number of teeth in rapidsuccession. If a tooth is heavily restored or crowned,this may be the only method that can be used to assessthe loss of vitality. The greatest problem with ultravioletlight is the installation of efficient blinds to the surgeryor the availability of a suitably dark room. The time

required for the light source to warm up (3 to 5 min)and the necessity to provide ultraviolet protectivegoggles for patient, operator and dental surgeryassistant must also be taken into account. As anisolated test ultraviolet fluorescence is unreliable. How-ever, when used in conjunction with other vitality testsit may serve as a diagnostic aid.

� Transillumination

Hill9 assessed the usefulness of transillumination forassessing tooth vitality and found that the tooth losesits translucency as the pulp becomes non-vital. It is anindependent and inexpensive technique, but the effectsof large amalgam restorations on translucency aredifficult to assess. Teeth become less translucent as pulpbecomes non-vital and transillumination test resultselicited a positive response in some non-vital teeth.

Although this technique has limitations, it can stillbe considered as a useful adjuvant to conventionalmethods of pulp vitality testing, particularly in assess-ing anterior or posterior teeth with minimal restorations.

� A paradigm shift

Chambers suggested that the technique for evaluationof dental pulp status must be simple, objective, stan-dardised, reproducible, non-painful, non-injurious,accurate, and inexpensive. Unfortunately the trad-itional methods fall short of nearly all of the abovecriteria3.

Pulp testing in children below the age of 10 yearsis unreliable, because children may not co-operate forthe test and the incomplete innervation of newlyerupted teeth may affect the results (as neural sensi-tivity in primary teeth varies according to the stage ofroot development and resorption)11. False positive orfalse negative results may occur if the clinician asks thechild leading questions. In addition, the unpleasantstimuli produced by the tester may affect behaviourmanagement and co-operation in paediatric patients10.Though the use of traditional tests establish an empiri-cal diagnosis, none of these tests are completely reli-able. Recent studies have shown that blood circulationand not root innervation is the most accurate determi-nant in assessing pulp vitality, as it provides an objective

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� 261Kayalvizhi Reliability of pulp-vitality testing in children

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The unpredictability of testing pulp nerve response iswell recognised. When nerve sensations are inhibitedor abolished in the tooth, traditional tests are of littlevalue. However, using methods based upon the pulpalvasculature response is a better option. Thus, thevalidity of childrens’ responses in pulp vitality testinghas been questioned12.

Finally, one should consider recent methods of pulpvitality testing that attempt to measure the pulpalcondition objectively. Taylor13 coined the word ‘physio-metric’ to describe such tests. Some of these methodsattempt to assess the state of pulpal circulation ratherthan the integrity of nervous tissues and, thus, providemore valuable information than conventional tests3.

Pulp vitality is purely a function of vascular health,as blood vessels to the pulp supply and mediate theprocess of acute and chronic inflammation. Thus,newer pulp vitality methods have been developed.These newer pulp-testing devices, which are still underdevelopment, are non-invasive and are considered tobe more accurate. They detect blood supply of thepulp through light absorption and reflection (photo-plethysmography), pulse oximetry and dual wave-length spectrophotometry or the shift in light fre-quency as it is reflected back from a tooth, as in laserDoppler flowmetry (LDF)2.

� Recent advances in pulp vitalitytesting

� Pulp haemogram

It was suggested that taking the first drop of bloodfrom an exposed pulp and subjecting it to a differentialwhite cell count may be useful in diagnosis of pulpalconditions. However, no clear relationship has beenfound2. Though this is a traditional test performed byGuthrie et al14, it is included in this review as it was thepreliminary method assessing pulpal vitality and notsensitivity.

� Pulse oximeter

Matthes is often considered the father of oximetry15.Pulse oximetry directly measures blood saturation levels

by comparing amplitudes of the ratio of transmittedinfrared with red light. This ratio varies with relativefractions of oxygen saturated to unsaturated haemo-globin and is used to calculate oxygen saturation. Thesecharacteristics infer that the pulse oximeter is also cap-able of evaluating the blood vasculature status within atooth and, therefore, the pulp vitality16.

The pulse oximeter is an objective, non-invasivetechnique, requiring no subjective response from thepatient. It is useful in case of intrusion (traumatisedteeth) where the blood supply remains intact, but thenerve supply is damaged.

Limitations of this device include the following:background absorption associated with venousblood and tissue constituents should be differen-tiated; in addition to the absorption, refraction andreflection, penumbra effect also occurs, which is seenin patients with strong tissue pulsations where someof the light reaches the photo detector diode withoutpassing through the tissue bed; the oxygen saturationvalues from the teeth routinely register readings lowerthan that from the patient’s finger (this may be dueto the limitation of using a probe designed for otherbody parts and not specifically for the anatomy of atooth). The pulse oximeter does not detect arterialpulse2.

The process of developing a design for a dentalsensor, which can be successfully adapted to the toothand well suited to detect pulsatile absorbance, is stillunder progress.

� Optical reflection vitalometer

The optical reflection vitalometer (ORV) is based onpulse oximetry, that is, this method is based on opticalreflection absorption, which measures arterial pulse.The difference from conventional pulse oximetry isthat the absorption is measured from reflected lightinstead of transmitted light. This device is still beingresearched17.

� Dual wavelength spectrophotometry

Dual wavelength spectrophotometry (DWLS) is atechnique that was developed by Millikan18 andimproved by Wood and Geraci19. It is a method inde-

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oles rather than arteries in the pulp and its rigid encap-sulation by surrounding dentine and enamel makes itdifficult to detect the pulse in the pulp space. The DWLStechnique uses visible light and measures oxygenationchanges in the capillary bed, rather than in the bloodvessels. The light is filtered to a near infrared range (760to 850nm) and guided to the tooth by fibre optics. Thismeans that added eye protection is unnecessary for thepatient and the operator. This test is non-invasive, doesnot rely on a subjective patient response and, therefore,yields objective results. The DWLS instrument is smalland portable, relatively inexpensive and suitable for usein a private dental office. However, it detects only thepresence of haemoglobin and not the circulation ofblood. Influence of the gingival circulation cannot beruled out and data on how large a mass of pulp tissueis needed for accurate readings to be obtained must bedetermined. Still, in vivo tests of this hypothesis are inprogress20.

� Laser doppler flowmetry

Gazelius et al21 first reported the ability of LDF tomeasure pulpal blood flow in humans anddistinguished between vital and non-vital teeth. LaterOlgart et al22 and Wilder-Smith23 considered it as a‘gold standard’ in determining pulpal blood flow. LDFis a non-invasive, electro-optical technique, whichallows the semi-quantitative recording of pulpal bloodflow. This technique measures blood flow in very smallblood vessels of the microvasculature. It depends onthe ‘Doppler principle’, which uses a beam of infrared(780 to 820nm) or near infrared light (632.8nm) thatis directed into tissue by optical fibres, and the enamelprisms and dentine tubules guide this light to the pulp.As light enters the tissue, it is scattered by moving redblood cells and stationary tissue cells. Photons whichinteract with moving red blood cells are scattered andfrequency is shifted according to the ‘Dopplerprinciple’. Photons that interact with the stationarytissue cells are scattered, but not ‘Doppler shifted’. Aportion of light is returned to the photo detector anda signal is produced24. Currently available flowmetersdisplay the signal on the screen, from which theclinician can interpret if the pulp is alive and healthy,or dead25.

LDF fulfils most of the requirements as an idealpulp tester. It has an immediate clinical application inthe assessment of vascular status of the pulp in pri-mary teeth26 and it yields definitive results in recentlytraumatised or immature teeth. If a two channelinstrument with a dual probe set up is used, data canbe collected on two teeth simultaneously, so that thetest tooth can be compared with an adjacent andcontralateral tooth27.

Limitations of using LDF are that it is too expensiveand time consuming. The sensor should be motionlessand in constant contact with the tooth for accuratereadings, otherwise structures other than blood cellsgenerate ‘Doppler shifts’ (this means a custom-fabricated jig e.g. mouth guard is required). Specificversions of the LDF for routine dental use are not yetavailable11. The LDF is unable to quantify bloodvolume directly and is adversely affected by move-ment and saliva contamination. Medications such asnicotine and those used in cardiovascular diseases (e.g.anti-hypertensives) may affect blood flow to the pulp,thus invalidating laser Doppler results28. It has alsobeen found that blood pigments within a discolouredtooth crown can also interfere with laser lighttransmission29.

Thus, this technique is useful in young childrenwhose responses are unreliable, and the non-invasivenature helps promote patient co-operation andacceptance.

� Transmitted laser light

Transmitted laser light30 is similar to LDF, but LDF alsorecords signals from non-pulpal origin. To overcomethis disadvantage of LDF, in 1997 Sasano et al31 testedpulpal blood flow using the same method as LDF, butinstead used transmitted laser light, rather than back-scattered light that is normally used in LDF.

Conventional LDF probes comprise two glassgraded index optical fibres, one transmitting and onereceiving, with a core diameter of 100μm. Whenusing transmitted laser light, a single probe is used,one fibre of which acts as the transmitter on the labialside of the tooth, the other held on the palatal sideas the receiver.

An advantage of transmitted laser light over LDFare that the blood flow signals do not include flow of

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changes were greater and could be easily monitoredwith less noise.

The limitations are that it is still not possible to testin situ because of the position of the splint and the sizeof oral opening. At present, this device can only beusedfor anterior teeth. With further development ofthe device, it may be used for posterior teeth and forteeth from elderly persons with narrow pulp cham-bers, so that the photons can penetrate deeper andstraight towards the receiving fibre.

� Temperature measurement

Diagnosing tooth vitality by temperature measure-ment can provide valuable information on the integrityof the underlying pulp. Howell et al30 used liquidcholesteric crystals and Fanibunda32 used a thermistorunit to measure crown surface temperature and timetemperature graphs to differentiate vital and non-vitalteeth. Vital teeth showed a rise in temperature,whereas non-vital teeth did not show any increase intemperature. Little research has been done using thistechnique2.

� Computerised infrared thermographicimaging

Computerised infrared thermographic imaging (TI) isanother non-invasive method. To date, only one studyby Pogrel et al33 has reported the use of TI to measurehuman tooth surface temperature. Hughes ProBeye4300 thermal video system was used, as it detectstemperature changes as small as 0.10°C, hence as it isa highly sensitive technique it was used to measurepulp vitality. If it is to be used as a research tool, theoperating environment must be carefully controlled toeliminate any thermal influences, to ensure consistentdata collection and to validate the methodology. Thismethod requires a high level of patient co-operation(it takes 40 minutes) and steady head position must bemaintained for 3 min for two recording sequences. Atpresent this method is under investigation for its suit-ability to assess pulp vitality in human teeth. Furtherresearch has been carried out with the sole aim of in-creasing the detectable difference between vital and

non-vital teeth, so that a method of temperaturemeasurement may be evolved which is of diagnosticsignificance under routine clinical conditions34,35.

� Photoplethysmography (optical detection of blood flow)

Photoplethysmography has been suggested as a po-tential non-invasive method to detect vascularisationof the dental pulp. Recent optical techniques demon-strate distinct, reproducible intensity changes due toblood volume within the pulp chamber. Experi-mentally it has been applied to the pulp in cats, dogsand adult humans1. Diaz-Arnold et al35 investigatedthe influence of blood concentration, blood flow rateand pulp chamber size on the intensity time profile.They suggested that photoplethysmography meas-urements may be sensitive to the amount of blood inthe pulp chamber, as it reflects the pulsatile-relatedexpansion and contraction of capillaries within thepulp tissue.

The equipment and techniques used are shown inFig 3. The system includes a 5mmx3mmx1mm lightemitting diode (LED) powered by a 3V battery as thelight source, with a peak output of 576nm, with a36nm bandwidth at half the peak intensity. A siliconphotodiode detector with a special range of 400 to1100nm is used in a photovoltaic mode that requires noexternal power supply. The detector output is interfaceddirectly to an 8088-based computer. Polyethylenetubing is sealed into the coronal access and connectedto syringe infusion pump. The pump is capable of pro-ducing desired flow rate solutions lengthwise throughthe tooth. The LED and detector are positioned on

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Fig 3 Schematic drawing illustrating the principle of photo-plethysmography (LED, light emitting diode).

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optical carrier and on holders in an optical rail.As the number of blood cells increase, nearly all

light passing through the pulp chamber is scattered by1:1 solution/maximum limiting apparent absorbance.As the relative blood concentration increases, less lightis detected because more incident light is scattered bythe larger number of blood cells in the optical path.Due to the smaller size of the pulp chamber, a signifi-cant fraction of the detected light passes through thetooth, but bypasses the pulp chamber and, therefore,is not scattered by the blood cells. This non-pulpal lightprovides a constant background intensity that isindependent of the relative concentration of bloodcells in the pulp tissue. As the number of blood cellsincreases, nearly all light passing through the pulpchamber is scattered, thereby resulting in a maximumlimiting apparent absorbance. The concept of meas-urement is to pass a selected band of light through thetooth, while continuously monitoring the intensity ofthe transmitted light.

The advantages of the equipment used in thismethod is that signal contamination derived fromperiodontal blood flow does not occur. It has less signalnoise (periodontal ligament blood flow) comparedwith LDF, due to the pathway of transmitted light. Thismethod is still under research.

� Conclusions

The dental pulp is a vital connective tissue consistingof blood vessels and nerves. Pulp vitality is a functionof vascular health and pulp vitality testing, although isonly one facet of a proper endodontic diagnosis, is anintegral part. Routine methods of pulp vitality testingthat have been followed over the years rely on stimu-lation of ��-nerve fibres and give no direct indicationof blood flow within the pulp tissue. These testingmethods have the potential to produce an unpleasantsensation and inaccurate results. In addition, each is asubjective test that depends on patient’s perceivedresponse to a stimulus as well as the clinician’s inter-pretation of that response. Thus, its reliability inchildren is still questionable.

Recording the pulpal blood flow would be an objec-tive assessment of the status of the pulpal blood circu-lation and a true indicator of pulp vitality. Optical

devices that exploit the various absorbance propertiesof different substances within the dental pulp are beingstudied to determine pulsation and blood volume. Theyoffer the advantages of being objective, non-invasiveand atraumatic, resulting in greater patient acceptanceand co-operation. Currently, the significance and reli-ability of these methods are being studied. It is hopedthat with further research these new technologies willbe able to provide reliable results in children.

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Pulp: Quintessence Publishing, London, 2002.2. Samraj RV, Indira R, Srinivasan MR, Kumar A. Recent

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3. Chambers IG. The role and methods of pulp testing in oraldiagnosis: a review. Int Endod J 1982;15:1-5.

4. Reynolds RL. The determination of pulp vitality by means ofthermal and electrical stimuli. Oral Surg Oral Med Oral Pathol1966;22:231-240.

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10. Hill CM. The efficacy of transillumination in vitality tests. IntEndod J 1986;19:198-201.

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18. Millikan GA. The oxymeter, an instrument for measuringcontinuously the oxygen saturation of arterial blood in man.Rev Sci Instrum 1942;13:434-439.

19. Wood WH, Geraci JE. Photoelectric determination of arterialsaturation in man. J Lab Clin Med 1949:34;387-401.

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Jurnal Tentang Tes Vitalitas

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