ASSESSMENT OF PULP VITALITY

Presented by:Anjali Miglani

(P.G Student)

Department of Conservative Dentistry & Endodontics

INTRODUCTION The assessment of pulp vitality is a crucial diagnostic procedure in the practice of dentistry-Noblett 1996 Most methods rely on stimulation of A-fibers gives no indication of blood flow within the pulp

THE MOST COMMON SYSTEM ASSOCIATED WITH SYMPTOMATIC PULP IN THE PAIN PATHOPHYSIOLOGY OF PAIN
- An unpleasant sensory and emotional experience associated with actual or potential tissue damage defines the physiologic and the physiologic components. - The pain process begins in the periphery, where specialized nerve fibers receive a painful stimulus. These nerve fibers transmit this information to the spinal cord and ultimately to the brain where information is interpreted and recognized as PAIN.

DETECTION OF PAIN
Odontogenic pain transmission is mediated primary by peripheral sensory nerves of the trigeminal nerve. A fibers nerve innervate the dentin (Fibers) Unmyelinated fibers innervate the body of these pulp and its blood vessels

A DELTA FIBERS
Pulpodentinal complex The circumpulpal nerve sends free nerve ending onto and though the odontoblastic cell layer extending upto 200 um into the dentinal tubules while also conducting the odontoblastic cell processes. This intimate association of A Delta fibers with the odonto blastic cell layer and dentin is referred to as the pulpodentinal complex. Disturbances of the pulpodentinal complex in a vital tooth initially affect the low threshold a delta fibers. Drying, probing drying with air and application of hyper osmotic solution to exposed dentin will cause pain. - Movement of fluid in dentinal tubules known as the hydrodynamic theory of dentin sensitivity stimulation the A delta fibers. - Vital pulp responds immediately with symptoms of dentinal pain. - Through a Delta fibers pain is perceived as quick, Sharp, Momentary Pain. - Dessipates quickly upon removal of the stimulus such as drinking cold liquids a probing exposed dentin. - The clinical symptoms of a delta fiber pain signify external disturbance. that the pulpodentinal complex is intact and capable of responding to a

NERVE FIBERS
- Small, - Unmyelinated nerves - High Threshold fibers subadjacent to the A-delta fibers. - Pain associated with C fibers dull, poorly localized

C fibers activated by intense heating or cooling of the tooth crown or mechanical stimulation of the pulp. C fiber pain associated with tissue injury and is modulated by inflammatory mediations. Vascular changes in blood volume blood flow decrease in tissue pressure

CLINICAL SIGNIFICANCE
- When inflammation leads to pulp necrosis, periradicular lesions may develops - Radiograph shows lesion - Vital testing response is seen - Instrumentation of necrotic pulp may also cause pain

REASON C fibers more resistant that A fibers to compromised blood flow and hypoxic conditions Pain associated with a necrotic pulp in due to C fiber stimulation.

CLINICAL FEATURES OF PULPAL PATHOLOGIES

Clinical classification of pulpal disease is based on INFLAMMATION OF THE PULP OR PULPITIS May be Acute on chronic Can be Determined can not be determined partial or total infected or sterile

Chronic inflammation of exposed pulp Due to caries or trauma Acute form runs - a short, painful cause chronic hyperplasic pulpitis.

Chronic form runs

- Symptoms or slightly painful and of longer duration. - Clinical class - Baume found no direct correlation between clinical symptoms and histologic findings. Based on clinical symptoms, he divided disease of pulp into 4 categories 1) The symptom less, vital pulp which has been injured or involved by deep caries, for which pulp capping may be done. 2) Pulps with a history of pain amenable to pharmacotherapy. 3) Pulps indicated for extirpation and immediately root filling. 4) Necrosed pulp accessible to root canal therapy. Garfunkel and associated found a direct correlation between clinical diagnosis and histologic examination in 49% of pulps examined.

HISTOLOGICAL FEATURES
Nature Direct and immune mechanisms - Release of chemical mediators - Increase in vascular permeability of vessels - Benkoryfe around dilated vessels An interesting phenomenon Mast cells (inhabitant of loose fibrous connective tissue)

Rarely seen in heath pulps appears in inflammation. Immune and inflammatory reactions may destroy normal cellular and extracellular components.

A. REVERSIBLE PULPITIS
Clinical Features - Mild to moderate inflammatory condition - Pulp is capable of returning to the uninflamed state following removed of stimuli. - Pain of brief duration subsides as soon as stimulus is removed

Histopathology
- Reparative dentin - Disruption of the Odontoblastic layer - Dilated blood vessels - Extravasation of edema fluid - Pressure of immunologically competent cells.

B. IRREVERSIBLE PULPITIS
It is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic, caused by a noxious stimulus. Acute irreversible pulpitis exhibits pain usually caused by hot or cold stimulus or pain that occurs spontaneously. - Pains persists for several minutes to hours, lingering after removal of the thermal stimulus. - Nerves may occur quickly or the process may require years. - Pulp death occur slowly and without dramatic symptoms.

- Microabssecesses of the pulp begin as tiny zones of necrosis within dense inflammatory all infiltrates comprised principally of acute inflammatory cells. .

Symptoms
- Sudden temperature changes causes pain. - Pressure from packing food into a cavity or suction exerted by tongue or cheek. - Recumbency which results in congestion of the blood vessels of the pulp. - Pain Sharp, piercing or shooting may be intermittent or continuous. - Changes of position, bend over or lying down excerts pains. - In late stage, pain is more severe ,growing throbbing. - Pain increased by heat and sometimes relieved by cold.

C. CHRONIC HYPERPLASTIC PULPITIS

- Pulp Polyp. Due to extensive carious exposure of young pulp. Rising out of the carious shell of the crown in mushrooms of pulp tissue that is often firm and insensitive to touch. - Low grade, long standing irritation

Histopathology
- covered by Stratified squamous epithelium - Granulation tissue

Symptoms
- Symptoms except during mastication.

D. INTERNAL RESORPTON
- Is idiopathic slow or fast progressive resorptive process in the dentin of the pulp.

HISTOPATHOLOGY
- Results of osteoclastic activity. - Pressure of granulation tissue accounts for profuse bleeding when pulps is removed - Multinucleated giants cells are present

Symptoms
- Asymptomatic - Manifested as reddish area pink spot.

E. NECROSIS
- Death of the pulp. Partial total Can be due to traumatic injury, sequel to inflammation. Lack of collateral circulation and unyielding walls of dentin Insufficient drainage Necrosis Coagulation necrosis liquefaction necrosis

Symptoms
- No painful stimulus. - Dull or opaque appearance of the crown due to back of normal transluscency

Teeth with partial necrosis can respond to thermal changes owing to presence of vital nerve fibers. Clinical Classification of Pulpal and Periapical Disease according to Cohen Clinical classification system was developed. This system was based on the patients symptoms and the results of clinical tests. It was developed to provide basic terms and phrases that clinicians could use to describe the extent of pulpal and periapical disease before selecting a method of treatment. A clinical classification of this sort is not meant to list every possible variation of inflammation, ulceration, proliferation, calcification degeneration of the pulp, or attachment apparatus. Rather its purposes are to suggest in the broadest possible interpretation whether the pulp is either healthy or unhealthy and to help the clinical experience. Pulpal Disease Within Normal Limits A normal pulp is asymptomatic and produces a mild to moderate transient response to thermal and electrical stimuli. When the stimulus is removed the response subsides almost immediately. The tooth and its attachment apparatus do not cause a painful response when per cussed or palpated radiographs reveal a clearly delineated canal that taper smoothly toward the apex. There is no evidence of root resportion, and the lamina dura is intact.

Reversible Pulpitis
The pulp is uninflamed to the extent that thermal stimuli usually cold cause a quick sharp hypersensitive response that subsides as soon as the stimulus is removed. Otherwise the pulp remains asymptomatic. Any irritant that can affect the pulp may cause reversible pulpitis including early caries, periodontal scaling root planning microleakage and unbased restorations.

Reversible pulpitis is not a disease it is a symptom. If the irritant is removed and further insult is prevented by sealing the dentinal tubules communication with the inflamed pulp the pulp will revert to an asymptomatic uninflamed state. Conversely if the irritant remains the symptoms may persist indefinitely or may become more widespread leading to irreversible pulpitis. Reversible pulpitis can be distinguished from a symptomatic irreversible can be distinguished from a symptomatic irreversible pulpitis in two ways. 1. Reversible pulpitis causes a momentary painful response to thermal change that subsides as soon as the stimulus is removes. However symptomatic irreversible pulpits causes a painful response to thermal change the lingers after the stimulus is removed. 2. Reversible pulpitis does not involve a complaint of spontaneous (unprovoked) pain. Symptomatic irreversible pulpitis commonly includes a complaint of spontaneous pain. Therefore the key difference is that reversible pulpitis is reactive it produces a response albeit exaggerated only when stimulated. Irreversible Pupitis Irrreversible pulpitis may be acute subacute or chronic it may be partial it be partial or total infected or sterile. Clinically the acutely inflamed pulp is symptomatic whereas the acutely inflamed pulp is symptomatic whereas the chronically inflamed pulp is asymptomatic in most cases. The apical extent of irreversible pulpitis cannot be determined clinically until the periodontal ligament is affected by the cascade of inflammatory mediators and the tooth becomes sensitive to percussion.3,58 Dynamic changes in the irreversibly inflamed pulp are continual the pulp may move from quiescent chronicity to acute pain within hours.

Asymptomatic Irreversible Pulpitis Although uncommon asymptomatic irreversible pulpitis may be the conversion of symptomatic irreversible pulpits to a quiescent state. Caries and trauma are the most common causes of this condition which can be information gathered from the patients dental history and properly exposed radiographs. Hyperplastic Pulpits A reddish cauliflower like growth of pulp tissue through and around a carious exposure is one variation of asymptomatic irreversible pulpitis. The proliferative active nature of this pulpal reaction sometimes known as a pulp polyp, is attributed to a low grade chronic irritation of the pulp and the generous vascularity characteristically found in young people. Occasionally this condition may cause mild transient pain during mastication. Internal Resorption Internal resorption is a painless condition resulting from the recruitment of blood-borne clastic cells often stimulated by trauma which produces dentin routine radiographic examination. If undetected internal resorption will eventually perforate the root. Before perforation of the crown the resorption can be detected as a pink spot on the site. Only prompt endodontic therapy to eliminate these elastic cells will prevent tooth destruction. Symptomatic Irreversible Pulpitis Symptomatic irreversible pulpitis is characterized by spontaneous )i.e.), intermittent or continous paroxysms of pain. Sudden temperature changes (usually cold) elicit prolonged episodes of pain )i.e., pain that lingers after the thermal stimulus is removed). This pain may be relived in some patients by the application of heat or could. Occasionally patients may report that a postural change (lying down or bending over) induces pain resulting in fitful sleep. Even with the use of

several pillows to stabilize themselves at a comfortable postural lives patients ,may continue the experience pain. Generally pain from symptomatic irreversible pulpitis is moderate to severe it can be sharp or dull localized or referred. In most cases radiographs are not useful in diagnosing symptomatic irreversible pulpitis because the inflammation remains confined to the pulp. However radiographs can be helpful in identifying offending teeth (i.e., teeth with deep caries extensive restorations pins evidence of previous pulp capping calicific metamorphosis)2. In the advanced stage of symptomatic irreversible pulpitis thickening of the apical portion of the periodontal ligament may become evident on the radiographs. Symptomatic irreversible pulpitis can be diagnosed through synthesis of the information provided a thorough dental history a complete visual examination properly exposed radiographs and carefully conducted thermal tests. If radiating or referred pain is involved the application of 0.2 ml of intraligamentary anesthesia in the distal sulcus of the correctly identified tooth will immediately stop the pain. EPT is of little value in the diagnosis of symptomatic irreversible pulpitis because the pulp though inflamed is still reversible pulpitis because the pulp though inflamed is still responsive to electrical stimulation. There inflammatory process of symptomatic irreversible pulpitis may become so severe that it will lead to necrosis of the pulp. In the degenerative transition from pulpitis to necrosis the usual symptoms of symptomatic irreversible pulpitis may subside as necrosis occurs.

Necrosis
Necrosis the death of the pulp actually refers to a histologic condition resulting from an untreated irreversible pulpitis a traumatic injury or any event that causes long term interruption of the blood supply to the pulp. Pulp may become liquefied or coagulated. Total necrosis is asymptomatic

before it affects the periodontal ligament because the pulpal nerves are nonfunctional. For this reason there is no response to thermal or EPT. Some crown discoloration may accompany pulp necrosis in anterior teeth but this diagnostic sign is not reliable.27,48 Partial necrosis may be difficult to diagnose because it can produce may be difficult to diagnose because it can produce some of the symptoms associated with irreversible pulpitis. For example a tooth with two or more toot canals could have an inflamed pulp in one canal and a necrotic pulp in the other. The bacterial toxins (and sometimes bacteria) that produced the necrosis in the pulp follow the pulp tissue through the apical foramen to the periodontal ligament resulting in an inflammatory reaction in the periodontium. This inflammation will lead to thickening of the periodontal ligament and manifest itself as tenderness to percussion and chewing.3.58 As these irritants cascade out of the root canal system often periapical disease will occur.5 The difficulty with the use of the term necrosis is that pulp vitality testing has been limited to electrical and thermal stimulation of pulpal nerves. In the case of teeth that have been traumatized9 teeth in a segment of bone that has been surgically repositioned,1 teeth with immature apices, 17,18,31 or teeth that have calcified with age,8 nerve function can be diminished or cease altogether while the pulp retains an intact vasculature. Thus reliance upon EPT and thermal pulp testing can result in the unnecessary removal of healthy denervated pulps. Perhaps the use of more sophisticated testing techniques, such as laser Doppler flowmetry or pulse oximetry will overcome this limitation and provide a clinical test Laser doppler measurements augement clinical observations providing an improved basis for dental treatment plan Assessments of pulpal status in by various AIDS Correction of various methods pulp vitality in different pulpal conditions,

VARIOUS AIDS IN DETECTING THE VITALITY OF THE PULP

Assessment of pulp vitality should be based on blood supply of the pulp. Unfortunately, assessment of the pulpal blood supply remains complicated and there is no practical clinical test to determine this basis aspect of the tooths biology. The clinical condition of the pulp can be evaluated by various methods. 1. History of the patient 2. Thermal test 3. Percussion 4. Palpation 5. Electric pulp test 6. Transillumination 7. Liquid crystal testing. 8. Hughes probeye camera. 9. Occlusal pressure test 10.Anaesthetic test 11.Test cavity 12.Pulse oximetry. 13.Dual Wavelengths spectrophotometry 14.Laser Doppler flowmetry 15.Use of tooth temperature 16.MRI.

1. HISTORY OR THE PATIENT

To know the status of the pulp, patients is chief complaint plays an important role includes symptoms that occur following specific events (eg chewing drinking cold liquids) - Whether pain is of short duration of long duration we can judge condition to be Acute chronic

It patient presents with so symptoms, but gives a part history of pain then we can suspect necrosis of the pulp history should be corroborated with other clinical tools and radiographs.

2. PALPATION
- Uses digital pressure to check tenderness in the cavity covering suspected tooth. Sensitivity indicates inflammation in the periodontal ligaments surrounding affected tooth. We can suspect that inflammation through caries lesion has gone to the PDL if tenderness to palpation occur.

Thermal Pulp Tests:-

One of the

most common

symptoms associated with the symptomatic inflamed pulp is pain elicited by thermal stimulation. Although some patients suffer pain when cold is applied to the tooth but are comfortable with warm substances and others require frequent applications of cold liquid to keep their pain bearable there

is no particular response to either heat or cold that is unique to a specific pulpal pathologic state56. The only conclusion the clinician may draw when a pulp responds abnormally to thermal stimulation either in an exaggerated manner or not at all is that is not in a state of good health. The rationale for innervation of any bodily structure is to provide a warning of damage that is occurring pain with the application of thermal stimuli is normal and a vital part of the patients protective defense mechanism. The pain is proportionate to the stimulation consequently even teeth with intact enamel will react to extreme cold such a in ice or carbon dioxide snow. When teeth begin to react to stimuli that do not normally produce pain such as tap water the probability is that dentin has been exposed by caries that the tooth structure is fractured or that faulty restoration abrasion or attachment loss caused by periodontal disease exists. Additionally an exaggerated response to thermal stimuli can indicate a lowered threshold to stimulus because of pulpal inflammation (e.g immediately after placement of a restoration). Solution is to address the cause of the dentin sensitivity by occluding the dentinal tubules by placing a temporary sedative restoration such as intermediate restorative material (IRM).In the case of the new restoration the clinician should simply wait to see whether the acute inflammation subsides in a short. When the chief complaint is pain to a thermal stimulus (usually cold) the clinician must distinguish between thermal testing to isolate the offending tooth by reproducing the patients symptoms and attempting to determine whether a suspected tooth has a vital or nonvital pulp. In the former case the patient is complaining of painful pulpal response cold therefore pulpal vitality is not at issue. A graduated method of applying the stimulus is required to avoid causing the triple syringe followed by isolation the tooth under a rubber dam and

bathing it with cold water should elicit the patients symptoms and quickly indicate the offending tooth. In contrast when there is no complaint of cold sensitivity the following methods for using cold to determine pulpal vitality are appropriate. Cold Test: Various methods have been used to apply cold to the teeth for testing. The most commonly used method are ice sticks, various compressed gasses and carbon dioxide snow. Freezing water in the plastic covers from hypodermic needles one is removed from the freezer and held tightly in the clinicians hand for a few minutes. This melts the outside of the stick so that it can be removed from the plastic and held in a 2 x 2 gauze for use. The ice stick applied immediately to the middle third of the facial surface of the crown of the tooth or on any exposed metal surface of crowns and kept in contact for 5 seconds of until the patient begins to feel pain. Ethyl chloride is available as a compressed spray, commonly used in medicine as a skin refrigerant. Its use in pulp testing is no longer recommended because it has been found to be less effective than carbon dioxide snow or dichlorodifluoromethane which is the refrigerant R-12 commercially packaged as a compressed spray (Endo-Ice). It has been replaced by the manufacturer with 1,1,1,2 Tetrafluoroethane, which is the nonchlorofluo-rocarbon refrigerant R-134a, available as Green Endo-Ice. No studies are yet available on the efficacy of this replacement compared with other testing methods. However it also has a low boiling point (15.10F). The material is sprayed liberally onto a cotton pellet or swab, which is then applied immediately to the middle third of the facial surface of the crown of the tooth. The pellet is kept in the contact with the crown for 5 seconds of until the patient begins to feel pain. Carbon dioxide snow formed into sticks is extremely cold. It is the most effective method of eliciting a response in vital teeth. No detrimental effects occurred in vital pulpal tissue and no cracks or surface irregularities

were produced in the enamel of tested teeth.26,43,47 The carbon dioxide is released into a special syringe in which it forms the snow. It is compacted with a plunger and the pellet is expressed onto a 2 x 2 gauze. It is applied immediately to the middle third of the facial surface of the crown of the tooth and kept in contact with the crown for 2 second or until the patient begins to feel pain. Although less convenient than the isolating the teeth individually with a rubber dam and bathing each tooth with ice water from a syringe for 5 secs simultaneously cools all surfaces of the teeth. Heat Test : As with cold testing many methods for heat testing teeth have been suggested. Although all transfer heat to the tooth the methods most commonly used are warm sticks of temporary stopping used are warm sticks of temporary stopping and the hot water bath. Warm sticks of temporary stopping and the hot water bath. Warm sticks of temporary stopping are the most convenient for the clinician but the hot water bath will yield the most accurate patient response. Temporary stopping consists of gutta-percha in 3-inch sticks. To use this technique the teeth to be tested are first protected with a light coating of petrolatum to prevent the warm temporary stopping from sticking to them. The stopping is warmed over a flame until it becomes soft and just begins to glisten (Grossmans method)23 but not so that it slumps and becomes too limp to use. Application to the middle third of the facial surface of the crown usually results in a response in less than 2 seconds. A 5- second application has been found to increase the temperature at the pulpodentinal junction less then 20 C there fore it is unlikely that damage will occur to the pulp47. The tooth is bathed in very warm water from a plastic syringe for 5 seconds or until the patient begins to feel pain. Since the patients chief complaint is pain in response to heat the temperature is gradually increased if no

response is obtained rather than producing unnecessarys pain by beginning with excessively hot liquid. Although the cold and hot water bath methods of thermal testing are time consuming they are clearly superior in their accuracy compared to very warm temporary stopping or ice pencils. The use of water allows allows the entire crown to be immersed not just one section of one surface of the tooth. Even when the tooth has been restored with a full crown (metal or porcelain) sufficient contact is made to allow cooling or warming of the pulp. In addition the cold ant hot water bath methods prevent damage to the tooth caused by excessive temperature change. Responses to Thermal test: The sensory fibers of the pulp transmit only pain whether the pulp has been cooled or heated. There are four possible responses to thermal stimulation: 1. No response 2. mild- to moderate degree of awareness of slight pain that subsides within 1 to 2 seconds after the stimulus has been removed 3. Strong momentary painful response that subsides within 1 to 2 seconds after the stimulus has been removed 4. Moderate to strong painful response that lingers for several seconds or longer after the stimulus has been removed If there is no response to thermal testing a nonvital pulp is often the cause. However no response to thermal testing can also indicate a false negative response because of excessive calcification an immature apex recent trauma or patient premedication. A momentary mild-to-moderate response to thermal change is generally considered within normal limits. A somewhat exaggerated response that subsides quickly is characteristic of reversible pulpitis. A painful response that linger for several minutes after the stimulus

is removed that lingers for several minutes after the stimulus is removed is characteristic of irreversible pulpitis.

ELECTRIC PULP TESTS: The electric pulp tester (EPT) uses

electric excitation to stimulate the A sensory fibers within the pulp. A positive response to electric pulp testing does not provide any information about the health or integrity of the pulp it simply indicates that there are vital sensory fibers present within the pulp.58 Often irreversibly inflamed pulp is responsive to EPT because it still contains vital function nerve fibers that can produce a toothache. The EPT provides only a responsive or nonresponsive result that correlates in many cases with vital or nonvital pulpal status. Therefore attempting to interpret the numerical values produced by the EPT is not recommended. The electric pulp test fails to provide any information about the vascular supply to the pulp which is the true determinant of pulp vitality. As a result teeth that temporarily or permanently lose their sensory function (e.g., teeth damaged by trauma or teeth that have undergone orthognathic surgery) will be nonresponsive to EPT. However they will have intact vasculature.9 Seltzer et al reported that 28% of teeth necrotic pulps tested positive to EPT, and more that half of those with [partially necrotic pulps were responsive. When a patients reports sensation in a tooth with a necrotic pulp, it is termed a false positive response. Circumstances that can cause false positive response to electric pulp testing include patients anxiety, saliva conducting the stimulus to the gingiva, metallic restorations conducting the stimulus to the adjacent teeth, and liquefactive necrosis conducting the stimulus to the attachment apparatus. A false negative response means that although the pulp is vital, the patient dose not indicate that any sensation is felt in the tooth. This situation can be

produced by premedication with drug or alcohol, immature teeth, trauma, poor contact with the tooth, inadequate media, partial necrosis with vital pulp remaining in the apical portion of the root, and individual patients with atrophied pulps or high pain thresholds. Therefore, it is essential that multiple tests be performed before a final diagnosis is made. EPT is an imperfect, though useful, way to determine the pulpal status of a tooth. In the case of a periapical radiolucency, EPT will help the clinician determine whether the pulp is vital. When used thermal and periodontal testing the EPT can help differentiate pulpal disease from periodontal disease or nonodontogenic causes.

LASER DOPPLER FLOWMETRY. EPT uses electric current to

stimulate the A nociceptors in the pulp. When these fibers are intact stimulation results in a painful sensation and the pulp is said to be vital. However, intact nerve functioning is not essential for pulp vitality. Teeth that have experienced recent trauma or are in a portion of jaw that has under gone orthognathic surgery can lose sensibility while retaining an intact blood supply and vital pulp. Investigators found that 21% of teeth in patients that tested nonresponsive to electrical stimulation after having undergone Le Fort operations had intact blood supplied when tested with laser Doppler flowmetry. With EPT only, the pulps would have been considered necrotic, and endodontic therapy would have been needlessly undertaken. Laser Doppler flowmetry uses a laser beam of known wavelength that is directed through the crown of the tooth to the blood vessels within the pulp. Moving red blood cells cause the frequency of the laser beam to be Doppler shifted ands some of the light to the back scattered out of the tooth. This reflected light is detected by a photocells on the tooth surface, the output of which is proportional to the number and velocity of the blood cells.

Laser Doppler flowmetry is complicated by the fact that the laser beam must interact with moving cells within the pulpal vasculature. To avoid artifactual responses, a custom fabricated. Jig (i.e., mouth guard) is needed to hold the sensor motionless and maintain its contact with the tooth. The position on the crown of the tooth and the location of the pulp within the tooth cause variations in pulpal blood flow measurements. Additionally differences in sensor output and inadequate calibrations by the manufacturer may mandate the use of multiple probes for accurate assessment and antihypertensive medications and nicotine may affect blood flow to the pulp, producing inaccurate results. Finally, the equipment still is too expensive for the average dental office. Current limitations aside, laser Doppler flowmetry promises an objective measurements of pulpal vitality and health. When equipment costs decrease and clinical applications improves, this technology could be used for patients who cannot communicate effectively or whose responses may not be reliable (e.g. young children). Because this testing modality produces no noxious stimuli, apprehensive or distressed patients may accept it more readily than current methods.

PULSE OXIMETRY
Another optical diagnostic method currently under investigation is the adaption of pulse oximetry to the diagnosis of pulpal vitality. Pulse oximetry is a widely used technique for recording blood oxygen saturation levels during the administration of intravenous anesthesia. Increased acidity and metabolic rate produced by inflammation cause deoxygenation of hemoglobin and change the oxygen saturation of the blood. A pulse oximeter uses a probe for oxygen saturation of the blood. A pulse oximeter uses a probe containing a diode that emits light in two wavelengths (1) red light of approximately 660 mm and (2) infrared light or approximately 850

nm. This light is received by a photodetector diode, connected to a microprocessor. The device compares the ratio of the amplitude of the transmitted infrared with red light. It uses this information together with known absorption curves for oxygenated and deoxygenated hemoglobin, to determine the oxygen saturation levels. By monitoring changes in oxygen saturation, pulse oximetry may be able to detect pulpal inflammation or partial necrosis in teeth that are still vital. Several investigators have successfully used modified finger probes or adapted the instruments to teeth to demonstrate the reliability of the system in the diagnosis of pulp vitality. Other investigators indicate that the use of reflected light may be preferable to transmitted light and that different or multiple wavelengths may be required to improve the sensitivity of the technique. Pulse oximeters measure the arterial oxygen saturation of hemoglobin, the technology involved is complicated but there are two basic physical principles, first the absorption of light at two different wavelengths by haemoglobin differs depending on the degree of oxygenation of haemoglobin second the light signal following transmission through the tissues has a pulsatile component ,resulting from the changing volume of arterial blood with each pulse beat .this can be distinguished by the microprocessor from the non-pulsatile component resulting from venous ,capillary and tissue light absorption the function of a pulse oximeters is affected by many variable ,including :ambient light ,shivering abnormal haemoglobin pulse rate and rhythm ;vasoconstriction and cardiac function a pulse oximeter gives no indication of a patient , ventilation ,only of their oxygenation ,and thus can give a false sense of security if supplemental oxygen is being given ,in addition ,there may be a delay between the occurrence of a potentially hypoxic event

such as respiratory obstruction and a pulse oximeter detecting low oxygen saturation however ,oximetry is a useful non-invasive monitor of a patient ,s cardio-respiratory system which has undoubted improved patient safety in many circumstances Pulse Oximeters are now the standard part of preoperative monitoring which give the Operator a non

-invasive indication of the patient ,s cardio respiratory status .having been successfully used in intensive care the recovery room and during anaesthesia they have been introduced in other areas of medicine such as general wards apparently without staff undergoing What dose a pulse oximeter measure ? 1 the oxygen saturation of haemoglobin in arterial blood which is a measure of the average amount of oxygen bound to each haemoglobin molecule ,the percentage saturation is given as a digital readout together with an audible signal varying in pitch depending on the oxygen saturation Principles of modern pulse oximetry oxygen is carried in the bloodstream mainly bound to haemoglobin .one molecule of haemoglobin can carry up to four molecules of oxygen ,which is then 100%saturated with oxygen .the average percentage saturation of a population of haemoglobin molecules in a blood sample is the oxygen saturation of the blood ,In addition ,a very small quantity of oxygen is carried dissolved in the blood ,which can become important if the haemoglobin levels are extremely low .the however ,is not measured by pulse oximetry a pulse oximeter consist of a peripheral probe, together with a microprocessor unit, displaying a wave from, the oxygen saturation and

the pulse rate. Most oximeters also have an audible pulse tone, the pitch of which is proportional to the oxygen saturation useful when one can not see the oximeter display. The probe is placed on a peripheral part of the body such as a digit, ear lobe or the nose. Within the probe are two light emitting diodes (LEDs) one in the visible red spectrum (660nm) and the other in the infrared spectrum (940nm). The beams of light pass through the tissue to a photodetector. During passage through the tissue, some light is absorbed by blood and soft tissue depending on the concentration of haemoglobin. The amount of light absorption at each light free frequency depends on the degree of oxygenation of haemoglobin within the tissue. The microprocessor can select out the absorbance of the pulsatile fraction of blood, i.e. that due to arterial blood, from consists absorbance due to non pulsatile venous or capillary blood and other tissue pigment. Several recent advances in microprocessor technology have reduced the effect of interference on pulse oximeter function. Time division multiplexing, whereby the LEDs are cycled, red on then infrared on, then both off many times per second, helps to eliminate background noise. Quadrate division multiplexing is a further then recombined in phase later. In this way, an artifact due to motion or electromagnetic interference may be phase later. In this way, an artifact due to motion or electromagnetic interference may be eliminated since in will not be in the same phase of the two LED signal once they are recombined. Saturation values are averaged out over 5 to 20 second. The pulse rate is also calculated from the number of LED cycles between successive pulsatile signals and averages out over a similar variable period of time, depending on the particular monitor. From the proportions of light absorbed at each light frequency, the microprocessor calculates the ratio of two. Within the oximeter memory is a series of oxygen saturation values obtained from experiments

performed in which human volunteers were given increasingly hypoxic mixtures of gases to breath. The microprocessor compares the ratio of absorption at the two light wavelengths measured with these stored values, and then display the oxygen saturation digitally as a percentages and audibly as a tone of varying pitch. Practical tips to the successful use of pulse oximetry. Plug the pulse oximeter in to an electrical socket, if available to recharge the batteries. Turn the pulse oximeter on the wait for it to go through its calibration and check tests. ] Selects the probe you require with particular attention to correct sizing where it is going to go. The light should be clean (remove nail varnish). Position the probe on the chosen digit, avoiding excess force. Allow several seconds for the pulse oximeter to detect the pulse and calculate the oxygen saturation. Look for a displayed waveform. Without this, any reading is meaningless. Read off the displayed oxygen saturation and pulse rate. Be cautious interpreting figures where there has been an instantaneous change in saturation for example 99% falling suddenly to 85%. This is physiologically not possible. Is in doubt, rely on your clinically judgement, rather than the value the machine gives.

Pulse oximetery is a simple non invasive method of monitoring the percentage of haemoglogin (Hb) which is saturated with oxygen. The pulse oximeter consists of a probe attached to the patient finger or ear lobe which is linked to a computerized unit. The unit displays the percentage of Hb saturated with oxygen together with an audible single for each pulse beat, a calculated hart rate and in some models, a graphical display of the blood flow past the probe. A audible alarms which can be programmed by the user are provided. How does an oximeter work? A source of light originates from the probe at two wavelengths (650nm and 805nm). The light is partly absorbed by

haemoglobin, by amounts which differ depending on whether it is saturated or desaturated with oxygen. By calculating the absorption at the two wavelengths the processor can compute the proportion of haemoglobin which is oxygenated. The oximeter is dependent on a pulsatile flow and produce a graph of the quality of flow. The computer within the oximeter is capable of distinguishing pulsatile flow from other more static signals (such as tissue or venous signals) to display only the arterial flow. Calibration and Performance. Oximeters are calibrated during manufacture and automatically check their internal circuits when they are turned on. They are accurate in the range of oxygen saturations of 70 to 100% (/-2%), but less accurate under 70%. The pitch of the audible pulse signal falls with reducing values of saturation. The size of the pulse wave (related to flow) is displayed graphically.

APPLICATIONS
Tooth pulp vitality Testing Tubules within the dentin act as light guides and direct light incident on the tooth surface into the pulp. This in highly vascular tissue and because of its position within a rigid structure, the vessel compliance is vary limited. Cardiac cycle blood pulsation in the supplying artery are transmitted to the pulp capillaries as pulsations in blood velocity. These pulsation are apparent on Doppler monitor traces of vital teeth and are absent from non vital teeth. The mean blood flux level in healthy teeth is much higher than for non vital teeth. However in vital teeth with impaired blood supply the flux level can be low and the presence of pulsation is the only indication of vitality.

RADIOGRAPHIC INTERPRETATION
Only films of the highest quality should be accepted; any time or money saved by not taking questionable films would be forfeited by one

misdiagnosis. Clinicians should strive to limit their patients exposure to radiation and maximize their skills and the skills of staff members to achieve this end. However because the benefits or radiographs outweigh the risks, diagnostic quality radiographs should be obtained even at the expense of repeated image Once high quality radiographs are obtained, the next step is to view them properly. They found that a diagnosis based on the continuity and shape of the lamina dura and the width and shape of the periodontal ligament space was the most accurate in identifying teeth with nonvital pulps. In addition to inspecting the lamina dura and periodontal ligament space, the clinician should consider whether the bony architecture is within normal limits or whether there is evidence of demineralization. The clinician should be also consider whether the root canal system is within normal limits, whether it appears to be resorbing or calcifying and what anatomic landmarks could be expected in the area. A sound, correct examination protocol includes a careful investigation of each of these considerations. In addition to periapical films in the posterior region, it is helpful to prepare bite wing films. Early caries, the depth of existing restorations, pulp caps, and pulpotomies or dens invaginatus can be identified in bite wing films. Deep caries or extensive restorations increase the likelihood of pulpal involvement. A necrotic pulp will not cause radiographic changes until the enzymes produced by the inflammatory process have begun to demineralize the cortical plate. For this reason, significant medullary bone destruction may occur before any radiographic sings begin to appear. Toxins and other irritants may exit through a lateral canal, causing periradicular (rather than periapical) demineralization. Conversely, a lateral canal in a tooth affected by periodontal disease can become a portal of entry for harmful toxins.

Pulp stones and canal calcifications do not necessarily have pathologic origin; they can be the result of normal aging of the pulp. These calcification were not correlated with the severity of periodontal disease, did not produce higher EPT responses and were not related to age. In traumatized teeth with pulp obliteration studied between 7 and 22 years posttrauma, 51% had a normal response to EPT. Another 40% did not respond but were clinically and radiographically normal. The investigations calculated the average rate of pulp survival for 20 years at 84%. Consequently, in the pulp stones or canal calcification should not be interpreted as a pulpal disorder that requires endodontic therapy. However, internal resorption (occasionally seen after trauma) is an indication for endodontic therapy. The inflamed pulp recruits clastic cells, which asymptomatically resorb the radicular dentin from the blood vascular system. In this case the pulp must be removed as soon as possible to eliminate these cells and avoid a pathologic perforation of the root. Recognizing the presence of immature apices allows the clinician to anticipate erroneous responses to thermal and electric pulp tests. If the canal appears blurred when compared with the irregular demineralized radiolucency surrounding the root, lingual development grooves would be suggested. In a few cases root fractures may cause pulp degeneration. Only a horizontal root fracture will be identifiable in the early stage and then only if the fracture line is within 15 degree of the central radiographic beam. In the case of a suggested horizontal fracture, two additional radiographs should be produced from angles 30 degrees. Vertical and oblique root fractures will eventually cause demineralization and a resultant diffuse radiolucency adjacent to the fracture.

SPECIAL TESTS
Crown Removal Many times a patient will describe symptoms of irreversible pulpitis, but the suspected tooth is completely hidden from view clinically and radiographically by a prosthetic crown. Although thermal and EPT may be possible, if there are intact nerve fibers in the pulp, the results may be difficult to differentiate from normal. In this case it is often necessary to complete the examination by carefully removing the crown to inspect the tooth underneath. Many times leakage from sub gingival margins that were impossible to adequately explore clinically has resulted in a carious exposure of the pulp. Removal of the prosthetic crown not only conforms the diagnosis it also allows the clinician to assess the restorability of the tooth.

SELECTIVE ANESTHESIA TEST

Test Cavity Occasionally the clinical will encounter a tooth that exhibits mixed responses to pulp testing (e.g. it fails to respond to cold, but it does respond to EPT). Is this an example of a false positive response to EPT caused by gingival conduction. The most accurate technique to discover whether a pulp is vital is to begin to make a preparations in a concealed area of the tooth without anesthetizing the patient, who has been adequately approved of what to expect and how to respond if discomfort is felt, when the dentinoenamel junction (DEJ) is passed, or as the pulp is approached the patient should feel pain if the pulp is vital. Once a vital response is elicited, the cavity preparation should caesed and the tooth should be restored. If no response is evoked access preparation may continue and endodontic therapy completed. Although the damage can be repaired, this not a reversible procedure. Therefore, it should be reserved for cases when it is impossible to arrive at a pulpal diagnosis in another way.

Technical Details The technique requires probe stability relative to the tooth. A dental putty splint with a small hole drilled at the tooth position of interest, provides mechanical stability for the probe. This technique has the advantage of enabling reproducibility of prove position at successive visit for chronic monitoring. 2) The splint also prevents backscattered light scattering off other tissue and eliminates contamination of the laser Doppler signal by these source. Laser Doppler sampling should be atleast 10 samples per second (10Hz) and the integrated time should be set at 0.1 sec so that the cardiac pulse wave can be observed. A record duration of at least 30 seconds is recommended so that vasomotion features of vitality can also be assessed. Comparison of a flux trace measured from the contra-lateral healthy tooth often aids diagnosis of vitality. Signal processing technique now enable diagnosis with a sensitivity and specificity better than 90%. that reliably indicates pulpal necrosis

MAGNETIC RESONANCE IMAGING

Recently MRI has been tried out a diagnostic tool in endodontics Magnetic fields and radiographic waves are used to generate high quality crosssectional images of the body. It works on electro magnetic energy (X-rays involves ionization). It can distinguish blood vessel and nerves from surrounding tissues. However this needs large equipment. This high electromagnetic waves which are needed have not been approved off for use in scanners. In future MRI offers evaluation of odontogenic problems. CONTRAINDICATIED in patients with cardiac pace makers metallic restorations orthodontic appliances and aneurysms.

It can be divided into few simple stages1. 2. 3. 4. 5. The patient is placed in a magnetic field and essentially becomes a magnet. A radio wave is sent in The radiowave is turned off. The patient emits signal The signal is received and used for reconstruction of the picture.

Application MRI tried as for diagnosing pulp vitality By use of contrast medium VITAL TEETH shows dye contrast NONVITAL TEETH shows no dye contrast.

HUGHES PROBEYE CAMERA

It is used to assess the vitality of the pulp. It measure temperature changes as small as 0.10C TRANS ILLUMINATION WITH FIBER OPTIC LIGHT Light is passed through a finely drawn glass or plastic fibres across the tooth by a process known as Total Internal Reflection. A pulp less tooth is not noticeably discolored may show a gross difference in translucency when a shadow produced on a mirror is compared to that of adjacent vital tooth

XENON -133
This was introduced by Ronni. It was used to check the status of pulpal blood circulation. It is a radioactive substance and pulpal circulating is checked by wash out of Xenon-133.

DUAL WAVELENGTH SPECTROPHOTOMETRY

This was developed by Chance. This technique measures the

oxygenation change of blood. This identifies the teeth with pulp chamber that are either empty filled with fixed pulp tissue or filled with oxygenated blood. Wavelength of 760 nm and 850 nm were used. independent of a pulsatile circulation presence of arterioles rather than arteries in the pulp and rigid encapsulation make it difficult to detect pulse in the pulp space. PRINCIPLE :This method measures oxygenation changes in capillary bed rather than in supply vessels hence does not depend on pulsatile blood flow. In young children ,in cases of avulsed and replanted teeth with open apices the blood supply is regained within first 20 days after replantation but nerve supply lags behind Spectrophotometric readings taken at start of replantation and continuing up to 40 days revealed an increase in blood oxygenation levels

indicating healing process

LIQUID CRYSTAL TESTING

Cholesterol liquid crystals are used to show temperature difference between teeth. Vital pulp may be hotter or show a higher temperature than the necrotic pulp (cooler) IL-1 (A lymphocyte activating factor) is responsible for osteoclast activation which results in bone resorption which is often a feature of inflammatory response. The presence of IL-1 is examined by an Immunosorbent Assay) PLETHEYSMOGRAPHY It is a method in assessing the changes in volume and has been applied to the investigation of arterial disease because the volume of the limb or organ exhibits transient changes over the cardiac cycle. Plethysmography in limb or organ exhibits transient changes over the cardiac cycle. Plethyusmography in limb or digit can be performed using air filled cuffs or mercury in rubber strain gauges. As the pressure pulse passed through the limb segment, a wave form is recorded which related closely to that obtained by intraarterial cannulation. The same principle can be used to assess the vitality of the pulp. Presence or absence of a wave form can indicate the statue of the tooth pulp. Of all the diagnostic aids - Radiovisiography has gained popularity and also Laser Doppler flowmetry, which has come into clinical use, but its usage is limited due to the cost factor. As we near the end of this discussion. We hope that it is possible in the near future to have a host of tests, which will enable an endodontist to assess the blood flow of the pulp and to make an accurate diagnosis, which will help in devising proper treatment plan and increase the long-term success of endodontic treatment. ELISA (Enzyme linked

An evaluation of the use of tooth temperature to assess human pulp vitality Thermographic imaging (TI) has also been used to measure tooth surface temperature (Egg et al 1975. Pogrel et al 1989 kells et al. 2000 a,b) The work of Pogrel el at (1989) supported the finding so Fanlbunda (1986b) that. after cooling vital teeth would rewarm more quickly than nonvital teeth. They also noted a disruptive effect of mouth air Currents. and advocated the isolation of the teeth by rubber dam to exclude this effect. Kells et al. (2000a,b) isolated the eight. most anterior upper teeth in' human subjects with heavy black rubber, dam and measured tooth surface temperature using TI. They established that following isolation it took about 15 min for tooth temperature to stabilize. Despite isolation from respiratory air currents from both the mouth and the nose they noted a significant cooling effect by room air currents. Thermographic imaging is accurate allows comparison of different areas of a tooth. and is entirely noninvasive. However it requires, considerable technical expertise and demands rigorous standardization of the experimental environment. Similarly 1n LDF it is valuable, as an experimental tool but has limited prospect of becoming a common clinical investigation in the near future.

CONCLUSION
Status of the pulp should always be collaborated with two or more test .no one test should be considered final.