Pulp and Periradicular Testing

Injuries to Permanent Dentition Symposium

Pulp and Periradicular TestingLinda Gibson Levin, DDS, PhD

Abstract
Pulp and periradicular testing is crucial to the initialtrauma evaluation and to subsequent monitoring ofthe traumatized teeth and supporting structures. Anaccurate diagnosis serves as the basis for therapeuticintervention and helps to ensure that destruction ofthe dental structures will be minimized and functionwill be regained. The purpose of this review is to presentthe current best evidence for accurate diagnostic testingof the pulp and periapex of traumatized teeth. Five data-bases were searched for literature pertaining to pulpaltesting and trauma. Widely recognized textbooks werealso consulted. Currently used pulp vitality testing isconstrained by its subjective character and by the factthat it is a measure of neuronal status and not truepulpal viability. Tests that measure tissue perfusionmore accurately reflect pulpal vitality, but they are notavailable commercially. This review discusses the spec-ificity, sensitivity, and accuracy of commonly used tests,with emphasis on the applicability of certain tests tospecific patient presentations in trauma. Factors thatinfluence test selection are discussed, and specificrecommendations are made on the basis of bestevidence. Although differences exist between thevarious studies as to the accuracy of commonly usedpulpal and periradicular tests, most of these haveacceptable predictive value. Pulpal and periradiculartests in the trauma patient should be used in conjunctionwith clinical and radiographic observations to arrive ata diagnosis and treatment plan. (J Endod2013;39:S13–S19)
Key WordsDental trauma, electric pulp test, laser Doppler flowme-try, pulse oximetry, sensitivity testing, thermal tests,vitality tests

From the University of North Carolina School of Dentistry,Chapel Hill, North Carolina.

This article is being published concurrently in PediatricDentistry 2013;35(2). The articles are identical. Either citationcan be used when citing this article.

Address requests for reprints to Dr Linda Gibson Levin,3624 Shannon Road, Suite 106, Durham, NC 27707. E-mailaddress: [email protected]/$ - see front matter

Copyrightª 2013 American Academy of Pediatric Dentistryand American Association of Endodontists.http://dx.doi.org/10.1016/j.joen.2012.11.047

JOE — Volume 39, Number 3S, March 2013

A proper diagnosis is the basis for any successful treatment in dentistry. This is partic-ularly important in the treatment of traumatic injuries to the dentition in which

proper assessment of the conditions of the affected tissues can limit the invasivenessof therapy or substantiate an aggressive approach to treatment to limit further destruc-tion of biological structures.

A variety of diagnostic tests are used in endodontics to assess pulpal and peri-radicular health. These tests vary in their sensitivity, specificity, and predictive values.Sensitivity is defined as the ability of a test or technique to identify teeth that arediseased. Specificity is defined as the ability of a test to identify healthy teeth. Thepredictive value is an attempt to relate sensitivity and specificity in such a manneras to make a correct diagnosis of the teeth evaluated (1). A positive predictive valueexpresses the probability that a positive test really represents a diseased tooth, anda negative predictive value expresses the probability that a tooth with a negativeresponse is actually free from disease. The accuracy of a given test is the overall agree-ment between that diagnostic test and a gold standard (2). In overall health care,accuracy has been classically defined as the extent or frequency in which a testcorrectly classifies a patient (3). Numerous investigators have looked at the accuracyand predictability of pulpal/periradicular testing, and the results of these studies havebeen applied to clinical practice (2, 4, 5). A recent systematic review of the diagnosticaccuracy of tests used to determine pulpal status concluded that no studiesreached high quality (6). A number of studies have provided ‘‘best evidence’’ forthe use of existing tests. Selected best evidence data for pulpal vitality tests are shownin Table 1.

A review of diagnostic testing shows that most of the currently used tests aresubjective in nature. That subjectivity is both patient and operator dependent. Dataobtained from thermal and electrical tests are dependent on the patient’s subjectiveperception and description of a response to the applied stimulus. The applicationof a testing stimulus by the operator is dependent on the length of time it is applied,where and how it is placed on the tooth, as well as the physical character of the stim-ulus (degree of heat, cold, pressure, etc) (1). Such subjectivity limits the predictivevalue of a test particularly in the trauma patient where damage to the periodontiumand psychological factors interfere with the perception of any stimulus. It is for thisreason that tests that evaluate the pulpal tissue directly have become a focus of interestin the field of trauma. These tests bypass patient perception and directly gauge thecondition of the pulp. They offer a significant advantage over conventional pulpaltesting, which has been documented to have a poor correlation with the histologicstatus of the tissue tested (7, 8). Presently these modalities are not readilyavailable to the clinician. A meaningful and clinically cogent discussion thereforeshould focus on those tests presently used in everyday dental practice. Thepurpose of this review is to discuss currently used pulpal and periradicular tests inthe traumatized tooth and to show their role in case management. This will includea discussion of experimental diagnostic technologies, but only from a theoreticalperspective.

Periradicular Testing of the Traumatized DentitionImmediately after trauma the purpose of periradicular testing is primarily to assess

the degree of injury to the tooth and periodontium. It is expected that the traumatizedtooth will be sensitive to manipulation initially. The persistence or recurrence of sensi-tivity in the posttrauma period can indicate pathology and direct further treatment of thedental structures involved (9). The primary tests for evaluating the periradicular tissuesafter trauma include mobility, percussion, and palpation testing.

Pulpal and Periradicular Testing S13

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http://dx.doi.org/10.1016/j.joen.2012.11.047

TABLE 1. Sensitivity and Specificity of Various Vitality Tests on Mature Permanent Teeth Taken from Recent Studies by Using a Clinical Gold Standard (2, 18, 45)

Clinical presentation Cold test Heat test EPT LDF Pulse oximetry

Sensitivity 0.81–0.92 0.86 0.71–0.87 1.0 1.0Specificity 0.89–0.93 0.41 0.71–0.87 1.0 0.95Accuracy (%) 97* — 97.7 96.3 —

*CO2 ice pencil.


Mobility TestingTooth mobility is an important indicator of how severely the tooth

has been dislodged from its normal position in the tooth socket. Thedegree of mobility is directly proportional to the physical stretchingor tearing of the vasculature of the pulp. Likewise, a lack of physiologicalmobility can indicate intrusion in one or more dimensions, resulting incrushing injuries to the vasculature (9). Recovery appears to be relatedto the amount of force the tooth sustains as well as the maturationlevel of the apex. The former may be gauged by the degree of toothdisplacement, and the latter is apparent with proper radiographs andpatient age (10).

The mobility of several teeth in unison is indicative of an alveolarfracture. Tooth vitality within the segment may be unaltered, but stabi-lization of the broken segment is necessary, and it influences the splint-ing time (11). Tooth mobility can also indicate an unfavorable type andlocation of horizontal root fracture. Transverse root fractures in thecervical area of the tooth are associated with higher mobility of thecoronal segment and a higher rate of healing complications (12).Mobility at the time of luxation injury does not appear to have a signif-icant effect on prognosis (13).

Percussion TestingSensitivity to percussion is an indication of mechanical allodynia,

which is defined as a reduction in the mechanical pain threshold. It isa reflection of inflammation of the periodontal ligament, and as a clinicaltest it shows a high sensitivity for detecting periradicular pain (14, 15).The technique for percussion testing is variable. The most typicalmethod is to use a gloved finger or the blunt end of a dentalinstrument to percuss teeth in the quadrant of interest anda contralateral tooth. This method, however, is not quantitative. Theuse of bite force transducers and digital force transducers have beenshown to be reliable instruments for quantitatively measuringmechanical allodynia in the teeth of patients, but these devices arenot widely clinically available (14, 15).

The results of percussion testing in the traumatized dentitioncan have different implications depending on the length of timesince the injury. Percussion sensitivity immediately after traumareflects inflammation of the attachment apparatus as a result ofthe trauma and is a result of tissue damage. Percussion sensitivityat follow-up visits can indicate infection or an undetected alveolarfracture. It has been reported that sensitivity to percussion afterluxation injuries is the only sign significantly related to pulpnecrosis (16).

In addition to the subjective response of the patient to percussionof a traumatized tooth, the clinician’s perception of the tone of percus-sion is significant. A high-pitched or metallic percussion tone imme-diately after injury can indicate that the injured tooth is locked inbone as in a lateral or intrusive luxation injury. Andreasen et al(11) discuss in depth the art of auscultation of the tooth duringpercussion. They note that if a tooth is lodged in the socket, the per-cussing of the tooth will not be felt by the examiner’s finger on thelingual. After the initial healing of a trauma, high-pitched or metallictone is indicative of ankylosis.

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PalpationPalpation of the alveolus can indicate the presence of an alveolar

fracture as well as the direction and degree of a luxation injury in theperitrauma period. It can also indicate if a luxation has been appropri-ately reduced. A comparison to contralateral tissues can aid in thedetermination of altered anatomy or soft tissue swelling as well. Atthe follow-up visits palpation sensitivity can indicate that pulp necrosisand infection have ensued, and the infection has eroded through thecortical plate. This finding is confirmed with vitality testing and radio-graphic evaluations. Last, persistent palpation sensitivity can indicatethat osseous healing from an (undiagnosed) alveolar fracture has notresolved.

Existing tests for evaluating the periradicular tissues after traumahave not been systematically evaluated for sensitivity, specificity, andpredictive value. In routine endodontic evaluation that uses traditionaltechniques, they do not appear to consistently differentiate betweenpulpal and periodontal diseases (1). In the trauma patient they can yieldvaluable information regarding the tissues involved, the extent ofinvolvement, and responses to healing.

Pulpal Testing of the Traumatized DentitionNumerous studies have been designed to study the accuracy of

pulp vitality testing. Although their results are of interest, their applica-bility to the traumatized tooth must be cautiously interpreted. The trau-matized tooth often suffers from paresthesia as a result of the injury, andthis altered neurologic response can take up to 9months to resolve (13,17–19). Andreasen et al (11) and Skieller (20), citing classic literature,report that immediately after trauma, up to one-half of all luxationinjuries will have no response to sensibility testing. Despite the lackof neurologic response to testing, studies with laser Doppler flowmetry(LDF) and pulse oximetry consistently show signs of pulpal blood flowin the absence of a response to thermal or electric testing after trauma(18, 21). The converse is also true; teeth that respond to vitality testingimmediately after trauma may subsequently undergo pulpal necrosis. Itis for this reason that conventional vitality testing is considered only inconcert with other findings and ‘‘prior probabilities,’’ particularly in theimmediate posttrauma period.

The most significant predictors of continued pulpal vitality aftertrauma are the type of injury and the developmental status of the tooth(13) (Figs. 1 and 2). In mature permanent teeth after luxation injuriesand certain types of fractures, a continued negative response to vitalitytests after 3 months is considered a strong indication of pulp necrosis(22). Because of the revascularization abilities of the pulp in a toothwith an open apex (>1.0 mm), cautious continued monitoring isadvocated (22, 23).

Baseline vitality testing should be conducted at the earliest possibletime. Although optimal, this may not be at the initial trauma treatmentwhere the patient has sustained considerable physical and psycholog-ical trauma. Vitality testing should be completed for all teeth in themaxillary and mandibular field of trauma. Although this is mostcommonly the anterior region, this may not always be the case. Alltesting results should be recorded and repeated at 2, 4, and 6–8 weeksand then 6 and 12 months. Follow-up after that depends on the type of


Figure 1. Reliability of pulp testing in teeth with closed apices versus thosewith open apices as reported by Fuss et al (4).


injury (22). The most commonly used vitality tests are thermal and elec-trical. LDF, pulse oximetry, dual-wavelength spectrophotometry, andthermography all show great promise but are not widely available tothe clinician. Routine pulp vitality tests have traditionally been usedwith the trauma patient. The accuracy and applicability of conventionalvitality tests vary depending on the type of injury and the age of thepatient (4, 24).

Electric Pulp TestingThe electric pulp tester (EPT) has been available for many years

for pulpal sensitivity testing. Its accuracy has been debated largelybecause of its high rate of false positives (25). EPT indicates the pres-ence of functional neurons but does not indicate pulpal health (26, 27).It functions by using a low-grade current to stimulate the peripherallysituated myelinated Ad nerve fibers in the dentin-pulp complex. Cen-trally located, pulpal C fibers do not react because their firing thresholdis higher and requires a much stronger electrical current (28). Adnerve fibers are particularly vulnerable to trauma where a compromisein blood flow is the principal cause of pulpal demise. This is because theAd nerve fibers are the most sensitive to oxygen deprivation and willcease to function before pulp necrosis ensues. The clinical implicationis that the EPT may not elicit a response despite a vital pulp in trauma-tized teeth. Likewise, in the immature permanent tooth the develop-mental ingress of Ad fibers in the periphery of the pulp tissue isrelatively late and can result in a higher rate of false-negative responses

Figure 2. Percent pulpal necrosis during 10-year period in teeth with imma-ture apices versus those with mature apices (16).


(5, 24, 29, 30). For this reason it is not the vitality test of choice forimmature traumatized teeth (4).

Conversely, the EPT has been shown to be superior to cold testing inolder teeth or teeth that have undergone pulp canal obliteration/miner-alization because it does not rely on dentinal fluid flow to elicit a pulpalresponse. Studies have shown that that with age, the dentinal tubulesdecrease in size, and the amount of dentin fluid is reduced, making teethless sensitive to thermal changes (31, 32). The same changes could beexpected in the younger traumatized tooth that has undergone pulp canalmineralization. Thus, in the assessment of an ‘‘old’’ trauma wherethere has been pulp canal mineralization, the EPT may be the mostaccurate test for pulp vitality (4, 33, 34). It is noted that pulp canalmineralization results in higher threshold readings with EPT inposttrauma observation periods greater than 5 years (35).

Consistent with other vitality tests, EPT is technique sensitive. Toothisolation, probe placement, and conduction medium have been shownto have an impact on accuracy (21). Moisture on the tooth surface andcontacting metallic restorations can conduct current to adjacent teethor the gingiva, giving a false-positive reading (36). An interproximalinsulating material or even rubber dam placement can facilitate properisolation and minimize this. Probe placement for the EPT has beendebated. From a theoretical perspective, the placement of the probeshould be where the maximum concentration of Ad nerve fibers exists,and the overlying enamel and dentin thickness is minimal (21, 37). Thisallows a summation effect where the maximum number of nerveterminals is stimulated by the current (28). In the young tooth thiswould be a pulp horn (38–40). In the older tooth it may be closerto the cervical one-third of the crown. This optimal position also variesdepending on the type of tooth tested; for anterior teeth the area of highneural density would be the incisal edge, and for posterior teeth it wouldbe the middle third (21, 40). Conduction medium is necessary forproper probe contact with the tooth surface. One study concludedthat K-Y lubricating gel (Johnson & Johnson, New Brunswick, NJ)and Crest baking soda and peroxide toothpaste (Procter & Gamble,Cincinnati, OH) provided the optimal conduction for EPT (41).Previous studies had indicated no difference in conduction media(42, 43). Last, EPT cannot be used on teeth where there is noexposed natural tooth surface.

In the majority of studies the specificity of EPT is consistently high.The sensitivity is more variable. EPT has a lower dependability for de-tecting a necrotic pulp, but the ability to confirm vitality is the sameas that of the cold test (2, 44, 45). The accuracy of the EPT is highestwhere there is no response to the current at any level. Stated anotherway, a negative response to EPT has a high positive predictive value(5, 7, 18). Information obtained from EPT indicates the presence orabsence of vitality, but it gives no information on the health status ofthe pulp. An EPT reading cannot differentiate between reversible orirreversible pulpitis.

Thermal Sensitivity TestsThere are several techniques for thermal testing of the traumatized

tooth. Unlike the EPT, thermal tests work by stimulating expansion orcontraction of dentinal fluid within the patent tubules, resulting in a rapidfluid movement. This movement of dentinal fluid results in the stimula-tion of Ad fibers in the pulp/dentin complex (37). Of the thermal tests,cold testing is the most commonly performed. The most popular modesof cold application are CO2 pencil, refrigerant spray, and ice. The phys-ical properties of each cold stimulus are different as are their respectiveaccuracies in controlled clinical trials (45, 46).

Pencils made of compacted carbon dioxide crystals havea temperature of –69�C, but when used clinically, they can only


Figure 3. Selection of commonly used vitality tests with highest accuracy is influenced by maturation level of the tooth and presence of pulp canal mineralization.The flow chart suggests a selection process that is based on best evidence.


achieve a temperature of –56�C (47). Even though CO2 has anextremely low temperature, it has been shown that vitality testingwith CO2 snow is safe for the pulp tissue and enamel (48). Further-more, it has been shown to be one of the most accurate and reliablevitality tests (45).

Despite the effectiveness of CO2 pencils, the necessity for theacquisition, maintenance, and storage of a cumbersome CO2 tankmakes it impractical for many dental offices. A more convenient yeteffective cold test was introduced by the adaptation of refrigerant sprayfor pulp testing (49). Original formulations of the spray weredichlorotetrafluoromethane (DDM) and had a temperature of–50�C. Environmental concerns resulted in a reformulation of thesprays to allow zero ozone depletion. The currently available onesare 1,1,1,2-tetrafluoroethane (TFE). TFE has a temperature of–26.2�C and is most effective when applied to the tooth by saturatinga #2 cotton pellet and placing it on the midfacial aspect of the tooth orcrown (50). Comparisons between refrigerant sprays and CO2 ice haveshown them to be equivalent to each other in their accuracy and equiv-alent to or superior to EPT (4).

Common ice pencils, which are made by filling spent anestheticcarpules with water, have been widely used for cold testing; however,they are consistently shown to be less accurate than either CO2pencils or spray refrigerant (4, 45). This could be attributed to thefact that frozen water is not as cold as CO2 snow or DDM/TFE. Itcould also be due to the difficulty of confining the cold stimulus tothe target tooth because cold water from the melting stick can flowonto adjacent teeth, confounding interpretation of the patient’sresponse.

Heat testing is another form of thermal testing. It is often used inroutine endodontic evaluations when the patient’s chief complaint ispain to hot food/liquids. It is not typically performed as an initial eval-uation in the traumatized tooth; however, it may be indicated if a reportof heat sensitivity develops subsequently. A heat stimulus can be appliedto a tooth by using a variety of techniques. These include heated gutta-percha stopping, hot water, and frictional heat by using a rubber cup or

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application of a heated instrument. In current practice the use ofa controlled heat source or hot water are the most commonly used me-thods. Both of these have the advantage of controlling the temperature,which is important because excessive heating can damage thepulp (51).

The accuracy of heat testing has been shown to be low when simplyevaluating vitality. Petersson et al (2) showed that the lack of sensationto heat was not a reliable indicator of pulp necrosis. Likewise, a positiveresponse to heat was more accurate but still less reliable than thatachieved with cold or EPT.

Unlike the electric pulp test, thermal testing can be used to evaluatethe health of the pulp. The character of the response has been shown tocorrelate with the potential for healing or necrosis (52). In the moni-toring of traumatic injuries, distinguishing between reversible or irre-versible pulpitis may result in a less invasive therapy or a moreaggressive one that prevents infection, a known stimulator of inflamma-tory root resorption (53).

Factors That Affect Patient Responseto Sensitivity Testing

Numerous factors have been identified as having an impacton vitality testing results. Immediately after trauma, teeth areoften unresponsive to testing. This is due to neuronal degenera-tion that is characterized by intramyelin edema, axonal swelling,and a partial loss of the myelin sheath (54). Concurrent dentaltreatment such as orthodontics can alter the response to EPT byincreasing the threshold of response (55). This has been attrib-uted to a change in tissue respiration and blood flow that canaffect vulnerable Ad nerve fibers (56). Medications, alcoholuse, and psychological disorders have also been shown todecrease the response to EPT (57). Psychological factors suchas fear of pain can influence the patient’s perception of a stim-ulus or even motivate a false response in an attempt to avoidpain.



Experimental Vitality TestsVitality Tests That Measure Blood Flow

Conventional vitality tests assess the integrity of the neuronalsupply of the pulp, yet vascular supply is the most accurate determinantof pulpal vitality (58). An understanding of this has stimulated interest indiagnostic modalities that focus on blood supply rather than innerva-tion. LDF and pulse oximetry are noninvasive technologies that directlyevaluate blood flow in the target tissue. Both have been investigated asdiagnostic tools to assess pulp vitality, and both offer great potential (59,60). Despite this, there are practical limitations that must be overcomebefore either test becomes part of the routine pulpal assessment aftertrauma.

Laser Doppler Flowmetry. Soft tissue perfusion injuries and digitreplants have been monitored with LDF for years (61). Adaptation ofthis technology to teeth has posed more of a challenge and has so farprecluded a commercially available device. Numerous investigatorshave evaluated the efficacy of LDF for determining pulpal blood flowin a laboratory setting or isolated patient trials (19, 62, 63, 64, 65).The findings of these studies consistently support the accuracy of LDFin determining pulpal vitality.

LDF works by measuring the number and velocity of particles inthe microcirculation. It does this by emitting an infrared light beamfrom a laser diode that is deflected by moving red blood cells but notstationary ones. This deflection is called a Doppler shift, and it is re-corded by a photodetector in the flowmeter that interprets the interfer-ence pattern by using an algorithm. The result is a semiquantitativeassessment of blood flow termed the flux signal that is expressed asthe number of moving erythrocytes per second multiplied by theirmean velocities (66). As with all vitality testing, control readings fromuninvolved healthy teeth are required to interpret readings.

A major drawback for LDF in the determination of pulpal vitality isbackground interference from the surrounding tissues. In some studiesit was found that a major portion of the signal detected from teeth camefrom the periodontium (67, 68, 69). Some of the background can bereduced by using a probe and holder that better adapts to thetooth surface and by tooth isolation with a rubber dam or othernonconducting material. Another approach is to increase theintensity of the detection beam by using high-powered transmitted laserlight. This appears to reduce background noise, while increasing thesensitivity to pulpal blood flow in thicker teeth (70). Probe placementand angulation of the beam are additional factors that influence theaccuracy of LDF readings for teeth (71, 72).

Experimental data suggest that LDF is well suited for the determi-nation of pulp vitality and offers great promise for the evaluation of trau-matized teeth. It does not appear to be useful in differentiating a normalfrom an inflamed pulp because of the nonlinear relationship betweensignal output and blood flow rate in small volumes (73). Clinical studiesevaluating accuracy show that LDF has superlative specificity and sensi-tivity when compared with conventional vitality tests (46).

A variety of LDF units have been tested on teeth through the years.The use of laser diodes that emit a longer wavelength of light proved topenetrate enamel and dentin better (74). More recently, ultrasoundDoppler imaging has been evaluated for its use in determining pulpvitality (75).

Pulse Oximetry. Whereas LDF measures the actual flow of bloodthrough the vasculature, pulse oximetry measures the oxygen satura-tion of arterial blood in a tissue. It has been used in the medical fieldfor several decades and only recently has found applicability in theevaluation of tooth vitality. Pulse oximetry detects the amount ofoxygenated blood in circulation by registering the differential lightabsorption of oxygenated hemoglobin versus deoxygenated


hemoglobin and calculating the O2 saturation. Initial studies evaluatingthe applicability of the pulse oximeter to vitality testing have beenfraught with the frustration of accommodating the instrument to thesize and shape of teeth, while maintaining the relationship betweenthe photoreceptor and light-emitting diode sensor. In recent yearsprogress has been made with prototypes of pulse oximeters suitablefor dental use (76).

Studies examining the applicability of pulse oximetry to vitalitytesting have been promising. A comparison of readings froma custom-made pulse oximeter and conventional vitality tests per-formed on teeth slated for endodontic treatment revealed the pulseoximeter was more reliable than the EPT, heat, and cold test (76).The sensitivity and specificity of pulse oximetry were superior to alltests. The gold standard for the study was confirmation of pulpal statuson endodontic access (Table 1). These findings have exciting implica-tions for the development of a unit that could be available in a routineclinical setting.

Dual-Wavelength Spectrophotometry. Dual-wavelength spec-trophotometry can also be used to measure oxygen saturation in thepulpal blood supply. Animal studies have shown that dual-wavelengthspectrophotometry can differentiate between a necrotic pulp spaceand one filled with oxygenated blood (77). A commercially availableunit suitable for dental use is not available.

Thermography. A relationship between surface temperature andtooth vitality has been shown (78). The vital tooth derives its tempera-ture externally from the periodontium and the oral environment andinternally from the pulpal circulation and metabolism. The nonvitaltooth has only an external source of heat, so surface temperature isa function of heat conductance (79). Theoretically, this should allowdifferentiation between the vital and nonvital pulps either by differencesin baseline temperature or by the speed of rewarming after cooling.Although a simple concept, actual measurement is fraught with con-founding variables. A diagnostic temperature differential has beeninvestigated by the use of thermocouples, infrared thermometers, mini-ature thermometers, thermistors, infrared thermography, and chole-steric liquid crystals (80). It holds promise as a noninvasive vitalitytest, but as yet, there are no commercially available devices.

ConclusionsIn summary, a variety of periradicular and pulp vitality tests exist to

evaluate and monitor the trauma patient. Presently, commonly availablepulp vitality tests all depend on the presence of intact nerve endings.Their selection and interpretation are highly dependent on severalpredictive factors or prior/pretest probability such as the age of thepatient, the time since the initial trauma, the type of trauma sustained,the degree of root-end development, and the presence of pulp canalmineralization (Fig. 3). Taken in concert with the radiographic andclinical findings, they provide a basis for therapies designed to preservethe dentition. Klausen et al (15) reported that the cumulative data fromthe patient examination and testing were accurate predictors of diseasethat led to an accurate pulpal diagnosis in 82% of cases. Newer methodsof testing pulpal vitality promise to increase our diagnostic accuracy inthe trauma patient to even higher levels.

AcknowledgmentsThe author denies any conflicts of interest related to this study.

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Pulp and Periradicular Testing