What are the protocols and procedures for a pulp vitality test?

Protocols and Procedures for Pulp Vitality Testing

Pulp vitality testing is essential for accurate diagnosis of pulpal health, with periapical intraoral radiography being the primary imaging technique for evaluating dento-alveolar modifications following trauma or suspected pulpal pathology. 1

Types of Pulp Tests

Sensibility Tests

These tests evaluate the pulp's neural response rather than its actual vitality:

• Cold Test

  • Most reliable sensibility test with 83% sensitivity and 93% specificity 2
  • Commonly uses refrigerant sprays (carbon dioxide or tetrafluoroethane) applied to the tooth surface 3
  • A positive response indicates neural function but not necessarily vascular health 4

• Heat Test

  • Less reliable than cold tests (86% sensitivity but only 41% specificity) 2
  • Typically uses heated gutta-percha applied to the tooth surface 2
  • More prone to false positives than cold tests 2

• Electric Pulp Testing (EPT)

  • Delivers controlled electric current to stimulate neural response 5
  • 72% sensitivity and 93% specificity 2
  • Requires proper tooth isolation and conductive medium 5

Vitality Tests

These assess pulpal blood flow, which is a more accurate indicator of pulp health:

• Laser Doppler Flowmetry

  • Measures blood flow in the pulp tissue 4
  • More accurate than sensibility tests but less commonly available in clinical practice 5

• Pulse Oximetry

  • Evaluates oxygen saturation in pulpal blood 4
  • Promising but still under investigation for routine clinical use 4

Testing Protocol

1. Patient Positioning and Preparation

   • Explain the procedure to the patient 5
   • Position patient comfortably in dental chair 5
   • Isolate the tooth being tested to prevent false readings 5

2. Test Application Sequence

   • Begin with least invasive tests (cold or EPT) 3
   • Apply tests to adjacent and contralateral teeth for comparison 5
   • Document all responses carefully 5

3. Interpretation of Results

   • 97% of teeth responding positively to all three tests (cold, heat, EPT) contain vital pulps 3
   • 90% of teeth not responding to any test contain necrotic pulps 3
   • For mixed responses, consider additional diagnostic information 3

Follow-up Radiographic Protocols

For teeth that have undergone pulp treatment, follow-up radiographic examinations should be performed at:

• 3 months post-treatment
• 6 months post-treatment
• 1 year post-treatment
• Annually for the next 3 years 1

Common Pitfalls and Limitations

• False Positives

  • May occur in multi-rooted teeth where some canals remain vital 5
  • Patient anxiety can lead to premature responses 5
  • Adjacent vital teeth may transmit sensation 5

• False Negatives

  • Recently traumatized teeth may temporarily lose responsiveness despite being vital 1
  • Calcified canals may prevent neural stimulation 5
  • Teeth with immature roots may have incomplete innervation 5

• Diagnostic Accuracy Concerns

  • A tooth falsely diagnosed as non-vital may undergo unnecessary root canal treatment 4
  • A necrotic pulp misdiagnosed as vital may lead to periapical pathology 4
  • Combined testing (cold test + EPT) provides more accurate diagnosis than any single test 3

Special Considerations

• For teeth with suspected pulpal exposure, immediate referral to a dentist is recommended to preserve pulp vitality 1
• In cases of dental trauma, periapical radiographs with proper paralleling technique are essential for accurate diagnosis 1
• For patients with fistulas, radiographs should be taken with a gutta-percha cone inserted into the fistula tract 1