Medical

Communication

Biosci. Biotech. Res. Comm. 10(1): 178-183 (2017)

Comparative evaluation of pulpal vitality test accuracy

in different groups of teeth

Elnaz Mousavi

*, Narges Simdar

, Sara Mehri

, Maryam Ghamari

and Sepideh Arab

Assistant Professor, Department of Endodontics, Faculty of Dentistry, Guilan University of Medical Science,

Rasht, Iran

Dentist

Assistant Professor, Department of Endodontics, Faculty of Dentistry, Ghazvin University of Medical

Science, Ghazvin, Iran

Assistant Professor, Department of Orthodontic, Faculty of Dentistry, Tehran University of Medical Science,

Tehran, Iran

ABSTRACT

The vitality pulp tests are necessary for diagnosis of pulpal disease and differentiation between endodontic and non-

endodontic disease. Thermal and electrical tests are conventional method for evaluation pulp vitality. The aim of the

present study was to evaluate the accuracy of thermal and electrical tests to register pulp vitality in different group

of teeth. 184 teeth (81 male, 103 female) with unknown pulpal status that need endodontic treatment were examined.

After complete isolation, the thermal and electrical tests were performed. The cold, heat and electrical tests were done.

The interval between tests was conducted after 2 minutes. Based on information obtained the sensitivity, speci city,

accuracy, positive and negative predictive value were calculated. In total, 78 teeth with necrotic pulp and 106 teeth

with vital pulp were tested. The gold standard was established by direct pulp inspection of 184 teeth with endodontic

treatment. Based on information obtained the accuracy of cold test in anterior teeth was 78/8%, in premolar teeth

was 81.8% and in molar teeth was 80.5%. The accuracy of heat test in anterior teeth was 82.6%, in premolar teeth

was 78.1% and in molar teeth was 72.7%. The accuracy of electric pulp test in anterior teeth was 71.1%, in premolar

teeth was 74.5% and in molar teeth was71.4%. In anterior teeth the heat test has more accuracy than the other one.

In premolar and molar teeth the cold test has more accuracy than other test.

KEY WORDS: DENTAL PULP TESTS, DIAGNOSIS

178

ARTICLE INFORMATION:

*Corresponding Author: elnaz32@gmail.com

Received 12

Jan, 2017

Accepted after revision 27

March, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

Elnaz Mousavi et al.

INTRODUCTION

Diagnosis in dentistry may be de ned as ‘the process

whereby the data obtained from questioning, examin-

ing and testing are combined by the dentist to identify

deviations from the normal. The diagnosis of dental pulp

status should be seen as a synthesis of history, clinical

examination, special tests, and radiological examination,

and not as the outcome of any one speci c test. Vitality

testing is an important aid in the diagnosis of pulp dis-

ease and apical periodontitis (Gopikrishna et al. 2009).

The complex anatomical structure and inaccessibility of

the dental pulp to clinical tests makes an accurate diag-

nosis of the health of the dental pulp often dif cult and

challenging to the dentist. The physical con nement of

the dental pulp, with its rich sensory nerve innervations

and microcirculatory components make the dental pulp

a unique tissue (Samuel et al. 2014).

Conventional pulp tests such as electric pulp tests and

thermal tests measure the neural component of the pulp

and are now considered as pulp sensibility tests (Lin et

al. 2008). Studies have shown that blood circulation, and

not the nerve innervation, is the accurate determinant of

the pulp vitality as it provides an objective differentia-

tion between vital and non-vital pulp (Yu and Abbott,

2007). Hence, pulpal circulation is the true determinant

of pulp vitality. The nerve  bers of the pulp may be

resistant to necrosis than the vascular tissue and may be

reactive long after the surrounding tissues have degen-

erated (Gopikrishna et al. 2007).The conventional tests

are subjective and depend upon the patient’s perceived

response to the stimulus as well as the dentist’s interpre-

tation of that response. Pulp sensibility tests have limi-

tations, and false responses can occur (Bender, 2000).

Electric pulp tests are known to be unreliable in imma-

ture teeth and in teeth undergoing orthodontic move-

ment (Myers, 1998). Furthermore, false responses are

known to occur when the electric current is conducted

to adjacent periodontal tissues, adjacent teeth and even

to remnant in amed pulp tissue with liquefactive pulp

necrosis. In traumatized teeth, Electric pulp tests are less

reliable than cold tests It is also reported pulpal sensibil-

ity testing with Endo Ice and pulp tester are more accu-

rate and reliable methods of determining pulpal vitality,

(Chen et al. 2011 and Jespersen et al. 2014).

Cold tests are known to elicit false-negative responses

in elderly patients because of the amount of thermal

insulation provided by secondary dentin (Emshoff et al.

2004). Commonly available agents for cold tests are CO

snow, ice, and refrigerant sprays (eg, tetra uoroethane,

butane, propane, isobutane, dicholoro uoromethane

and ethyl chloride). Cold tests and electric pulp tests are

pulp sensibility tests that have been established as use-

ful aids in the assessment of pulp status despite being

subjective and patient-dependent (Emshoff et al. 2004).

Nonetheless, the lack of pulp sensibility is often associ-

ated with advanced pulp necrosis (Chen et al. 2011).

Currently, there is no reliable and acceptable pulp

testing method for the pediatric age-group. The aim of

the current study was to determine sensitivity and speci-

 city of cold, heat and electric test on pulpal vitality

tests in different dental type.

MATERIAL AND METHODS

PATIENTS

A total 184 teeth (81 male, 103 female) with unknown

pulpal referred to Endodontic Department of dental clinic

of international branch of Guilan University of Medical

Sciences during 2015 were examined. Patients aged 12-81

(mean 37.94 years old). They informed about the study

and signed the form. The inclusion criteria were not suf-

fering systemic disease or administration of NSAID drugs.

STUDY PROTOCOL

Then peri-apical radiography was done on teeth and

those with calci cation and decay without pulp invasion

were included into as case group. The next tooth in the

same arc with no calci cation or decay kept as control.

At  rst, primary diagnosis was done in all pulp based

on observation followed by observation. After complete

isolation, the thermal and electrical tests were performed

in case and control teeth. The cold test by ethyl chol-

oride and heat test by gutta percha and electrical test

with electrical pulp tester (Parkel/USA) were done. Two

minutes interval between tests was conducted. The pain

response of the patients was recorded as normal, high

and highest (+, ++ and +++). Based on information

obtained the sensitivity, speci city, accuracy, positive

and negative predictive value were calculated for each

method in different groups of teeth.

STATISTICAL ANALYSIS

The obtained data was analyzed using SPSS ver. 21

using One Way ANOVA. For treatments showing a main

effect by ANOVA, means were compared using chi squar

test. P<0.05 was considered as signi cant differences

between treatments.

RESULTS

The results of the accuracy of thermal and electrical tests

to register pulp vitality in different group of teeth are

presented in  gures 1-14. A total 184 teeth (81 male,

103 female) with unknown pulpal status that need endo-

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS EVALUATION OF PULPAL VITALITY TESTS ACCURACY IN DIFFERENT GROUPS OF TEETH 179

Elnaz Mousavi et al.

FIGURE 1. the sensitivity of the tests for determine pulp

vitality in teeth

FIGURE 2. the Speci city of the tests for determine

pulp vitality in teeth

FIGURE 3. the sensitivity of the tests for determine

pulp vitality in anterior teeth

dontic treatment were examined. In total, 78 teeth with

necrotic pulp and 106 teeth with vital pulp were tested.

As seen in  gure 1, the heat test had the highest sensi-

tivity (87.2%) compared to the other tests for determine

pulp vitality in teeth.

As observed in  gure 2, primary test (96.2%) and cold

test (91.5%) had the highest accuracy of the tests for

determine pulp compared to the other tests, respectively.

FIGURE 4. the Speci city of the tests for determine

pulp vitality in anterior teeth

FIGURE 5. the sensitivity of the tests for determine

pulp vitality in pre-molar teeth

FIGURE 6. the Speci city of the tests for determine pulp

vitality in pre-molar teeth

Among the various tests, the heat test had highest

sensitivity (96.7%) for determine pulp vitality in anterior

teeth ( gure 3).

Furthermore, the heat test had lowest Speci city

(63.3%) of the tests for determine pulp vitality in ante-

rior teeth ( gure 4).

The results of the sensitivity of the tests for determine

pulp vitality in pre-molar teeth is presented in  gure 5.

As seen, heat test (95.5%) and electric test (90.9%) had

180 EVALUATION OF PULPAL VITALITY TESTS ACCURACY IN DIFFERENT GROUPS OF TEETH BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Elnaz Mousavi et al.

FIGURE 7. the sensitivity of the tests for determine

pulp vitality in molar teeth

FIGURE 8. the Speci city of the tests for determine

pulp vitality in molar teeth

FIGURE 10. the Speci city of the tests to determine

pulp vitality in various teeth

FIGURE 12. the Speci city of the tests to determine

pulp vitality in patients based on the gender

FIGURE 9. the sensitivity of the tests to determine pulp

vitality in various teeth

the highest sensitivity of the tests for determine pulp

vitality in pre-molar teeth, respectively.

Also, the heat test had lowest Speci city (66.7%) for

determine pulp vitality in pre-molar teeth ( gure 6).

As seen in  gure 7, for the sensitivity of the tests for

determine pulp vitality in molar teeth, the electric test

was highest (80.8%) compared to the other tests.

FIGURE 11. the sensitivity of the tests to determine

pulp vitality in patients based on the gender

According to the  gure 8, primary test (98%) and cold

test (94.1%) had higher Speci city of the tests for deter-

mine pulp vitality in molar teeth

The sensitivity of the tests to determine pulp vital-

ity in various teeth is shown in  gure 9. As observed

heat test had better sensitivity for anterior, pre-molar

and total teeth while electric test had higher sensitivity

for molar ( gure 9).

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS EVALUATION OF PULPAL VITALITY TESTS ACCURACY IN DIFFERENT GROUPS OF TEETH 181

Elnaz Mousavi et al.

FIGURE 13. the sensitivity of the tests to determine

pulp vitality in patients based on the age

FIGURE 14. the Speci city of the tests to determine

pulp vitality in patients based on the age

Based on the results of the  gure 10, primary test and

cold test had highest Speci city to determine pulp vital-

ity in various teeth compared to the other tests.

The heat and electric tests had highest sensitiv-

ity to determine pulp vitality in both men and women

( gure 11).

Interestingly, the cold test had highest Speci city to

determine pulp vitality in both gender ( gure 12).

As seen in  gure 13, cold and heat tests had similar

sensitivity to determine pulp vitality in patients aged

<40 years old while only heat test had higher sensitivity

to determine pulp vitality in patients aged >40.

Furthermore, cold test had higher Speci city to deter-

mine pulp vitality in patents based on their age ( gure 14).

DISCUSSION

The key to developing a treatment plan for oral reha-

bilitation is a correct diagnosis, and in endodontic treat-

ment, it is important to identify the status of the pulp

tissues. To determine the sensitivity of the pulpal nerves,

dentists use thermal and electrical tests (Newton et al.

2009). The ideal test should be easy to use, fast, inexpen-

sive, noninvasive, painless, reproducible, and accurate

(Jafarzadeh and Abbott, 2010). Sensitivity, speci city,

and positive and negative predictive values were previ-

ously developed to characterize the accuracy of given

tests (Dastmalchi et al. 2012).

The sensitivity value indicates the ability of a test

to identify teeth that are diseased. The speci city value

tests the ability of a procedure to identify teeth without

disease (Chen and Abbott, 2011). Therefore, it is impor-

tant to determine the positive and negative predictive

values to identify the probability of a correct diagno-

sis with thermal and electrical pulp tests (Saeed et al.

2011). As seen in this study the accuracy of heat test in

anterior teeth was 82.6%, in premolar teeth was 74.5%

and in molar teeth was 72.7%. The accuracy of electric

pulp test in anterior teeth was 71.1%, in premolar teeth

was 78.1% and in molar teeth was71.4%. The accuracy

of cold test in anterior teeth was 78/8%, in premolar

teeth was 81.8% and in molar teeth was 80.5%. Evalua-

tion of pulp vitality is an important diagnostic aspect of

treating traumatized teeth. The methods currently used

are thermal and electrical stimulation. However, thermal

and electric testing has limitations in providing accu-

rate diagnosis (Goho et al. 1999). Several studies have

compared different tests to assess sensitivity, but none

of them calculated the positive and negative predictive

values (Newton et al. 2009; Setzer et al. 2012).

In this study, anterior teeth the heat test had more

accuracy than the other one. Studies have shown that

cold testing and electric pulp testing are equally reliable

for over 80% of cases in the diagnosis of vital and non-

vital pulps (Weisleder et al. 2009). However, this evidence

does not con rm the validity of the test in the assess-

ment of the pulpal condition. This appears currently to

be a signi cant limitation in the diagnosis of diseases

of the pulp (Mejàre et al. 2012) attempts to correlate the

actual threshold value evoked by electric pulp testing

with the condition of pulp remain to be elucidated. Pulp

nerve  bers are more resistant to necrosis than vascular

tissue, and thermal or electric testing of only pulp neural

response may also result in false positive results if only

the pulp vasculature is damaged (Goho et al. 1999).

In the current study, premolar and molar teeth the

cold test has more accuracy than other tests. It is reported

that pulpal sensibility testing with Endo Ice and pulp

tests are accurate and reliable methods of determining

pulpal vitality (Jespersen et al. 2014).

Patients aged 21–50 exhibited a more accurate

response to cold. Sex, tooth type, number of restored

surfaces, presence of caries, and recent analgesic use did

not signi cantly alter the results of pulpal sensibility

testing in this study. Previous studies have demonstrated

no gender related differences in perception threshold

(Lin et al. 2007; Jespersen et al. 2014) and our  ndings

was similar to the previous reports. Peterson et al. (1998)

182 EVALUATION OF PULPAL VITALITY TESTS ACCURACY IN DIFFERENT GROUPS OF TEETH BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Elnaz Mousavi et al.

on the ability of thermal and electrical tests to register

pulp vitality reported the sensitivity, speci city, positive

predictive value and negative predictive value were cal-

culated for each method. The sensitivity was 0.83 for the

cold test, 0.86 for the heat test and 0.72 for the electrical

test. The speci city was 0.93 for the cold test, 0.41 for

the heat test and 0.93 for the electrical test. The positive

predictive value was 0.89 for the cold test, 0.48 for the

heat test and 0.88 for the electrical test, and the negative

predictive value was 0.90 for the cold test, 0.83 for the

heat test and 0.84 for the electrical test. This indicated

that the probability of a non-sensitive reaction repre-

senting a necrotic pulp was 89% with the cold test, 48%

with the heat test and 88% with the electrical test. It also

indicated that the probability of a sensitive reaction rep-

resenting a vital pulp was 90% with the cold test, 83%

with the heat test and 84% with the electrical test.

CONCLUSION

In a diagnostic test (cold, heat, and electrical), it is nec-

essary to know the probability that the test will provide

the correct diagnosis. In anterior teeth the heat test has

more accuracy than other one. In premolar and molar

teeth the cold test has more accuracy than other tests.

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