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seminar on pulp vitality test

Pulp vitality test is the one of the diagnosing method in DENTISTRY....this presentation deals about the best methods for diagnosting the vitality of the tooth.

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seminar on pulp vitality test

  3. 3. INTRODUCTION Pulp vitality test is crucial in monitoring the state of health of dental pulp, especially after traumatic injuries. The traditional pulp testing methods such as thermal and electric pulp testing methods depend on the innervation and often yield false positive and negative response. The newer pulp testing devices, some of which are still under development stage, detect the blood supply of the pulp, through light absorption and reflection, are considered to be more accurate and non-invasive). 3
  4. 4. PULP VITALITY TESTS Visual and tactile inspection[2]  Simple clinical test  Examination  Colour - discoloration of tooth associates with necrotic, gangrenous  Pulps internal & external, resorption carious resorption  CONTOUR - fractures  Wear facets  Restorations  CONSISTENSY - relates to presence of caries  External resorption  Internal resorption Percussion 4
  5. 5.  Evaluate status of periodontium surrounding tooth • By using handle of instrument, to determine whether tooth is tender • Vertical percussion - apical periodontitis • Horizontal percussion - chronic periododintis Palpation • Done with fingertip using light pressure to examine tissue consistency & pain response. • Determining -  Whether tissue is fluctuant & enlarged 5
  6. 6.  Intensity & location of pain  Presence & location of adenopathy  Presence of bone crepitus Mobility and depressibility[2]  MOBILITY TEST -to evaluate integrity of attachment apparatus surrounding tooth  Moving tooth laterally in its socket by using fingers or handles of two instruments  DEPRESSIBILITY TEST - moving tooth vertically in its socket endodontic tratment should not be carried out on teeth with third degree mobility Radiography[2] • To use radiographs properly , clinician must have knowledge & skills • To interpret them correctly • Through understanding of normal anatomical structures & changes occur due to aging , trauma , healing • Contain information on presence of caries that may involve pulp or not Radiographs may show number ,course ,length ,& width of root canals 6
  7. 7. • Presence of calcified material in root canal • Internal resorption • External resorption • Calcification or obliteration of pulp cavity • Thickening of periodontal ligament • Nature & extent of periapical &alveolar bone destruction Thermal Pulp Test • Various methods [4] and materials have been used to test the pulp ‘s response to thermal stimuli. • The baseline or normal response to either hot or cold is a patient’s report that a sensation is felt but disappear immediately upon removal of the thermal stimulus . • Heat testing is most useful when a patients complaint is intense dental pain upon contact with any hot liquid or instances where a 7
  8. 8. patients is unable to identify which tooth is sensitive ,a heat test is appropriative. • Starting with the most posterior tooth in that area of the mouth , each tooth is individually isolated with the rubber dam. • An irrigating syringe is filled with a liquid that has a temperature similar to that which would cause the painful sensation. • The liquid is then express from the syringe onto the isolated tooth to determine whether the response is normal or abnormal. • The tooth will exhibit an immediate , intense painful responds to the heat.with the heat testing a delayed response may occur ,so waiting 1o seconds between each heat test will allow sufficient for any onset or 8
  9. 9. symptoms.another metho for heat testing is applie heated gutta – purcha.or compound stick to the surface of the tooth. • If this method is used, a light layer of lubricant should be placed onto the tooth surface prior to applying the heated material to prevent the hot gutta purcha or compound from adhering to the dry tooth surface. • Cold is the primary pulp testing method for many practitioners today. • Cold testing should be used in conjunction with the electric pulp tester so that results from one test will verify the findings of the other test. • It can be accomplished similarly to heat testing by individually isolating teeth with a rubber dam. • Another benefit of this technique for cold testing is that it requires no armamentarium except for a rubber dam. 9
  10. 10. • If a clinician choose to perform this test with sticks of ice , then the use of the rubber dam is recommended because melting ice will run onto adjacent teeth and gingiva, yielding potentially false positive responses. • Frozen carbon dioxide (co2)also known as dry ice or carbon dioxide snow, has been found to very reliable in eliciting a positive response if vital pulp tissue is present in the tooth. Carbon dioxide has also been found to be effective in evaluating the pulp response in teeth with full coverage crowns for which electric pulp testing is not possible. • For testing purposes a solid stick of co2 gas into a specially design plastic cylinder. • The resulting co2 is stick is applied to the facial surface of either natural 10
  11. 11. tooth structure or crown.several tooth can be tested with single stick. • The tooth should be isolated with a 2*2gauze or co2 will not come into contact with these structures. • The most popular method of testing is with a refrigerant spray. • It is readily available and easy to use,and provides test result that are reproducible, reliable and equivalent to that co2 . • The current product contain 1,1,1,2-tetrafluroethane,which has zero ozone depletion potential and is environmentally safe. • It has temperature -26.2c . • The spray is most effective or testing purpose when it is applied to the tooth on large #2 cotton pellete. 11
  12. 12. • The sprayed cotton pellete should be applied to the midfacial of the Crown. . • The sensitivity which is the ability of a test to identify teeth that are diseased , was 0.83 for cold and 0.86 for heat and 0.72 for the electric test. • This means the cold test correctly identified 83% of the teeth that had anecrotic pulp while heat test where correct 86% of the time and electric pulp test were correct only 72% of the time. 12
  13. 13. REFRIGERATOR SPRAY CONTAINER A COTTON ROLL CAN BE USED TO FORM A LARGE COTTON PELLET Electric Pulp Test • Assessment of the pulp vitality test with is most frequently accomplished[4] by electric pulp testing or cold testing. 13
  14. 14. • The vitality of the pulp is determined by the intactness and health of the the vascular supply, not the status of the pulpal nerve fibres. • Even though advances are being made with regard to determine the vitality of the pulp regard to the blood supply, this technology is not accurate enough to be used on a routine basis in clinical setting • The electric pulp tester has limitations in providing information about the pulp . ELECTRI PULP TESTER WITH PROBE • The response of the pulp to electric testing is not reflecting the histologic health status of the pulp. 14
  15. 15. • A response by the pulp to the electric current only denotes that some viable nerve fibres are present in the pulp and are capable of responding. • The lack of response has been found most frequently when an electric pulp is present. • The electric pulp tester will not work unless the probe can be placed in contact with the natural tooth. • With the advent of universal precautions for infection control, the patient may be required to place a finger on the tester probe to complete the electric circuit for the models, however lip clips are an alternative to having patients hold the tester. • The use of rubber gloves prevents the clinician from completing the circuit. 15
  16. 16. • purpose use of the electric pulp tester requires that the tooth to be evaluated be isolated and dried. • A control tooth of similar tooth type and location in the arch should be tested first in order to establish a base line response and to inform the patients with a normal sensations. • The suspected tooth should be tested at least twice to confirm the results. • The tip of the testing probe that will be placed in contact with the tooth structure must be coated with the water or petroleum based media. • The most commonly used media is toothpaste. • The coated probe tip is placed in the incisal third of buccal or facial area of the tooth to be tested. • once the probe is contact with the tooth the patient is asked to touch the 16
  17. 17. tester probe. • This completes the circuit and initiates the delivery of electric current to the tooth. • The patient is instructed to remove his or her finger from the probe when a tingling or warming sensation is felt in the tooth. • The readings from the pulp tester are recorded and will be evaluated once all the appropriate teeth have been tested and the result obtained from other pulp testing methods. • If a complete coverage crown or extensive restoration is present, a bridging technique can be attempted to deliver current to any exposed natural tooth structure. • The tip of the endodontic explorer is coated with tooth paste or other 17
  18. 18. appropriate media and placed in contact with the natural tooth. • The tip of the electric pulp tester probe is coated with a small amount of tooth paste and placed in contact with the side of the explorer. • However, unlike electric pulp testing, cold testing can reveal the health and integrity of pulp tissue response. • Until such time that testing method used to assess the vascular supply of the pulp become less time consuming and technique sensitive to thermal and electric pulp testing will continue to be the primary methods for determining pulp vitality. PULP NERVE TESTER 18
  19. 19. SPECIAL TEST Bite test • Identifying cracked tooth or fractured cusp[4] . • It also helpful in diagnosing cases where in pulpal pathosis is extended to periradicular region causing apical periodontitis • Tooth slooth & Frac Finder are available devices for bite test • Pain on biting -- apical periodontitis • Pain on release of bite force - cracked tooth 19
  20. 20. To determine which tooth is sensitive to mastication and which part of the tooth is sensitive,having the patients bite on a specialy designed bite stick often helpful. • For the bite test to be meaningful a device should be used that will allow practitioners to apply pressure to individual cusp or areas of tooth. • Variety of devices have been used for the bite test including cotton applicators , tooth picks, orange wood sticks, rubber polishing wheels. • As with all the pulp test, adjacent teeth should be use as controls so that the patient is aware of the normal response to these test. 20
  21. 21. • The small cupped out areas on the instruments is placed in contact with the cusp to be tested. • The patient is then asked to apply biting pressure with opposing teeth to the flat surface on the opposing side of the device. • The biting pressure should be applied slowly until full closure is achieved. • The firm pressure should be applied for few seconds, the patient is then asked to release the pressure quickly. • Each individual pressure on a tooth can be tested in a like manner. • The practitioner should note if the pain is elicited during the pressure phase or upon quick release of pressure. 21
  22. 22. • A common finding is with fractured cusp or cracked tooth is frequent presence pain upon release of biting pressure Staining and transillumination • Inorder to determine the presence of crack in the surface of the tooth,the application of a stain to the area is often of great assistants[4] . • Shining a bright light on the surface of the tooth is also very helpful. Selective anaesthesia • When symtops are non localised or reffered,the diagnosed may be very challenging[4] . 22
  23. 23. • Sometimes the patients may not even able to specify whether the symptoms are emanating from the maxillary or mandibular arch. • This test is restricted to the patient who are in pain at the time of the test when the usual tests have failed to identify the tooth • The objective is to anesthetize one tooth at a time until the pain. disappears and is localized to a specific tooth TECHNIQUE • Using either infiltration or intraligament injection, inject the most posterior tooth in the area suspected of being the cause of pain[2] 23
  24. 24. • If the pain persist anesthetize the next tooth mesial to it and continue to do so until the pain disappears • If the pain cannot be identified as from maxillary or mandibular origin ,an inferior alveolar block is given • Cessation of pain naturally indicates involment of mandibular tooth ADVANTAGE • This test is obviously a last resort and has an advantage over the ‘test cavity’ during which iatrogenic damage is possible[2] Test cavity • This method is used only when all other test methods are deamed impossible or the result of the other test are inconclusive [2] . 24
  25. 25. • This test allows one to determine the pulp vitality • It is performed when other methods of diagnosis have failed • The test cavity is made by drilling through the enamel-dentin junction of an un-anesthetized tooth • The drilling should be done at slow speed and without a water coolant • Sensitivity or the pain felt by the patient is an indication of pulp vitality • No endodontic treatment is indicated • Sedative cement is then placed in the cavity ,search for source of pain continues • If no pain is felt -cavity preparation may be continued until 25
  26. 26. the pulp chamber is reached ,If pulp is completely necrotic- endodontic treatment can be continued RECENT PULP VITALITY ASSESSMEMT • The two technologies which are being developed and which could potentially prove to be an effective and objective vitality assessment tools are follows Laser Doppler flowmetry • Laser Doppler flowmetry is a method used to assess blood flow in micro vascular system[3,4] . • Attempts are being made to adapt this technology to assess pulpal blood flow. • A diode is used to project a infrared light beam through the crown and pulp chamber of a toot. • The Doppler principle states that the light beam will be frequency- 26
  27. 27. shifted by moving red blood cells but will remain un-shifted as it passes through static tissue. • .This technique is accurate ,reliable en reproducible method of assessing pulpal blood flow. • Even with this positive findings ,the technology is not advanced enough for this method to be used on a routine basis in a dental practice. • If technology can be developed whereby the testing with the LDF can be accomplished in minutes ,it will likely replace the thermal and electric pulp testing methods Pulp oximetry • Another non-invasive method[4,5] that has been investigated as a method to determine pulpal blood flow uses a pulse oximeter ,which is designed to measure the oxygen concentration of the blood and the pulse rate. • It works on the principle that two wavelengths of light transmitted by a photoelectric diode detect oxygenated and deoxygenated haemoglobin as they pass through a body part to a receptor. • The diffrences between the light emitted and the light received is calculated by a microprocessor to provide the pulse rate and oxygen concentrations in the blood. 27
  28. 28. • Attempts to use the pulse oximeter to diagnose pulp vitality have met mixed results . • The device used for pulp testing are too cumbersome and complicated to be used on a basis in a dental practice. 28
  29. 29. Meanism of dental pulp oximeter: (a).light emitting diode emitting red light at 660nm.(b).light – emitting diode emitting infra red light at .940nm.(c)photo etector.(d)pulse oimeter monitor.(e)pulse oimeter sensor.(f).custom made pulse oximeter sensor holder.HbO2 ,oxygenated haemoglobin.HbR,deoxygenated haemoglobin ;SpO2, oxygen saturation of arterial blood. 29
  30. 30. DISEASES OF PULP 1.Inflammatory diseases of dental pulp (a)Reversible pulpitis (i)Symptomatic(acute) (ii)Asymptomatic(chronic) (b)Irriversible pulpitis (i)Syptomati(acute)  Abnormally response to cold  Abnormally response to heat (ii)Asymptomatic (chronic)  Hyperplastic pulpitis  Internal resorption 30
  31. 31. 2.Pulp regeneration (a)Calcific (b)Others 3.Necrosis Reversible pulpitis • Reversible pulpitis[2,4] is a mild to moderate inflammatory condition of the pulp caused by the noxious stimuli in which the pulp caused by capable of returning to the uninflamed state following removal of the stimuli. • Symptomatic reversible pulpitis is characterised by sharp pain lasting for a moment,and generally disappears when the stimulus is removed • Cold , sweet, or sour usually causes it • Pain may become chronic. • The pulp may recover completely or the pain may last longer each time and intervals of relief may become shorter ,until the pulp finally succumbs 31
  32. 32. • The pulp is sensitive to temperature changes,particularly cold,application of cold is an excellent method of locating and diagnosing the involved tooth. • A tooth with reversible pulpitis reacts normally to percussion,palpation and mobility. • Thermal test are useful in locating the affected tooth if unknown. • The electric pulp test, using less current than on a control tooth, is an excellent corroborating test. Irreversible pulpitis • Irreversible pulpitis[2,4] is a persistant inflammatory condition of the pulp, symptomatic or asymptomatic caused by a noxious stimulus. • A tooth with symptomatic irreversible pulpitis exhibit intermittent or spontaneous pain,whereby rapid exposure to dramatic temperature changes (especially to cold stimuli) will elicit heightened and prolonge episodes of pain even after the source of the pain is removed. • The pain may be sharp or dull localised or referred. • In the early stages the thermal test may elicit pain that persists after removal of the thermal stimulus. 32
  33. 33. • In the late stages when the pulp is exposed ,it may respond normally to the thermal stimulus. • The electric pulp test induces a response with a marked variation in current form of normal. • Result of examination for mobility and perussion and palpation tests are negative. Chronic Hyperplasic Pulpitis • Chronic hyperplastic pulpitis[2,4] or ”pulp polyp” is a productive pulpal inflammation due to an extensive carious of a young pulp • Slow , progressive carious exposure of the pulp is the cause. • Mechanical irritation from chewing and bacterial infection often provide the stimulus. • The tooth may respond feebly or not at all to the thermal test,unless one use extreme cold, as from an methyl chloride spray. • More current than normal may be required to elicit a response by means of the electric pulp tester. 33
  34. 34. Internal resorption • Internal resorption[2,4] is an idiopathic slow or fast progressive resorptive process occurring in the dentin of the pulp chamber or root canals of the teeth • The cause of internal resorption is not known,but such patients often have a history of trauma • Internal resorption in the root of a tooth is asymptomatic. • In the crown of the tooth ,internal resorption may be manifested as a reddish area called”pink spot”. • Resorptive defect is more extensive in pulpal wall than on the root surface. • The defect is usually is recognised by means of a radiograph. Necrosis of pulp • Necrosis is death of the pulp[2] . • It may be partial or total ,depending on whether part or the entire pulp is removed. • It can be caused by any noxious insult to the pulp ,such as bacteria, trauma ,and chemical irritation. 34
  35. 35. • A normal tooth with a necrotic pulp cause no painful symptoms. • The presence of necrotic pulp may be discovered only by chance because such tooth is asymptomatic ,and the and the radiograph is non diagnostic. • The teeth with partial necrosis can respond to thermal changes ,owing to the presence of vital nerve fibers passing through the adjacent inflamed tissue. • Tooth with necrotic pulp does not respond to cold ,the electric pulp test ,or the test cavity 35
  36. 36. Possible Diagnoses, based on patient responses to thermal stimuli. 36 Pulpal Diagnosis Response to cold or heat Normal Patient reports a thermal sensation and stops feeling it when the stimulus is removed Reversible pulpitis Thermal sensation causes discomfort/pain and the magnitude of response is different from adjacent and/or contralateral teeth;sensation may linger briefly Symptomatic irreversible pulpitis After thermal stimulus is applied, patient reports pain/discomfort is more pronounced than on adjacent teeth and/or contralateral tooth;sensation lingers Asymptomatic irreversible pulpitis Same response as normal or reversible pulpitis, except the patient has a history of pulpal inflammation such as caries, carious exposure, or trauma Necrosis Patient reports feeling no sensation when thermal stimulus is applied for more than 10 seconds
  37. 37. CONCLUSION The most common methods to assess pulp vitality are based on sensitivity assessment of the neural tissues of the pulp. These methods include thermal and electric pulp tests. Vitaliyt can only be assessed when assessment of vascular and blood supply to the tooth can be done. The above mentioned technologies have been proved to be a great help to test the vitality and for further diagnosis and treatment. 37
  38. 38. References 1. Eugene Chen and Paul V. Abbott Review Article Dental Pulp Testing Page 2-4 2. Grossman Text of Grossman’s Endodonti practice 12th edition Page no 84-75 3. Samraj RV Recent advances in pulp vitality testing Page no 3 4. Stephen cohen Kenneth M. Hargreaves Text book of Pathways of the pulp 9th edition. Page 16-20 5. Velayutham Gopikrishna Article on Evaluation of Efficacy of a New Custom-Made Pulse Oximeter Page 1-2 38
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