Diagnosis of The Condition of The Dental Pulp, A Systematic Review PDF

doi:10.1111/j.1365-2591.2012.02016.
Review
Diagnosis of the condition of the dental pulp: a

systematic review
I. A. Meja`re1,2, S. Axelsson2, T. Davidson2,3, F. Frisk4,5, M. Hakeberg6, T. Kvist5, A. Norlund2,

A. Petersson7, I. Portenier8, H. Sandberg9, S. Tranus2 & G. Bergenholtz5
1
Department of Pediatric Dentistry, Faculty of Odontology, Malmo University; 2SBU (Swedish Council on Health Technology
Assessment), Stockholm; 3Center for Medical Technology Assessment, Linkoping University, Linkoping; 4Department of
Endodontology/Periodontology, The Institute for Postgraduate Dental Education, Jonkoping; 5Department of Endodontology,
Institution of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg; 6Department of Behavioral and
Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg; 7Department of
Oral and Maxillofacial Radiology, Faculty of Odontology, Malmo University, Malmo, Sweden; 8Division of Cariology and
Endodontics, School of Dentistry, University of Geneva, Geneva, Switzerland; and 9Karolinska Institutet, Stockholm, Sweden
Abstract
Meja`re IA, Axelsson S, Davidson T, Frisk F, Hakeberg M,
Kvist T, Norlund A, Petersson A, Portenier I, Sandberg
H, Tranus S, Bergenholtz G. Diagnosis of the condition of
the dental pulp: a systematic review. International Endodontic
Journal, 45, 597613, 2012.
The aim of this systematic review was to appraise the

diagnostic accuracy of signs/symptoms and tests used
to determine the condition of the pulp in teeth affected
by deep caries, trauma or other types of injury.
Radiographic methods were not included. The electronic literature search included the databases PubMed,
EMBASE, The Cochrane Central Register of Controlled
Trials and Cochrane Reviews from January 1950 to
June 2011. The complete search strategy is given in an
Appendix S1 (available online as Supporting Information). In addition, hand searches were made. Two
reviewers independently assessed abstracts and full-text
articles. An article was read in full text if at least one of
the two reviewers considered an abstract to be poten-
Introduction
An accurate diagnosis of the condition of the pulp in
teeth compromised by caries, dental procedures or
other forms of injury is crucial for arriving at a proper
Correspondence: Ingegerd Meja`re, SBU, Statens Beredning for
medicinsk Utvardering, PO Box 3657, 103 59 Stockholm,
Sweden (tel.: +46 84123242; e-mail address: mejare@sbu.se).
2012 International Endodontic Journal
tially relevant. Altogether, 155 articles were read in full

text. Of these, 18 studies fulfilled pre-specified inclusion
criteria. The quality of included articles was assessed
using the QUADAS tool. Based on studies of high or
moderate quality, the quality of evidence of each
diagnostic method/test was rated in four levels according to GRADE. No study reached high quality; two were
of moderate quality. The overall evidence was insufficient to assess the value of toothache or abnormal
reaction to heat/cold stimulation for determining the
pulp condition. The same applies to methods for
establishing pulp status, including electric or thermal
pulp testing, or methods for measuring pulpal blood
circulation. In general, there are major shortcomings in
the design, conduct and reporting of studies in this
domain of dental research.
Keywords: accuracy, dental pulp disease, dental
pulp test, diagnosis, sensitivity, specificity.
Received 30 September 2011; accepted 30 December 2011
treatment decision. Important information in this

respect is whether the pulp is vital or necrotic. It is
equally important to be able to determine whether the
pulp is reversibly or irreversibly inflamed, especially in
connection with a carious or traumatic exposure of the
tissue. In other words, can the pulp heal and survive in
a long-term perspective or is it damaged to the extent
that it is not treatable and that root canal treatment is
required?
International Endodontic Journal, 45, 597613, 2012
597
Diagnosis of dental pulp Meja`re et al.
Diagnostic information is gained from the patients

history of pain or discomfort, experience of trauma or
restorative procedures, clinical examinations, results of
clinical tests and radiographic examination of the teeth
and the surrounding tissues. A diagnosis is seldom
based on a single finding, rather on a set of observations. The clinical situation may be so complex that a
proper diagnosis and treatment decision requires a
diagnostic process consisting of several steps.
A variety of methods are used to assess the condition
of injured or diseased dental pulp. Whilst such methods
have been reviewed thoroughly and repeatedly in
many textbooks and narrative reviews, no consensus
has been reached as to which method or combination
of methods will give the most accurate information
(Levin et al. 2009). The aim of this systematic review
was to assess the diagnostic accuracy of contemporary
methods used to assess the condition of the pulp in
injured or diseased teeth. The review does not include
assessments of the accuracy of radiographic methods;
that is presented in a separate article (Petersson et al.
2011). This review is part of a more comprehensive
systematic review published in Swedish by SBU (Swedish Council on Health Technology Assessment) covering methods of diagnosis and treatment in endodontics
(The Swedish Council on Health Technology Assessment (SBU) 2010). SBU is an independent government
agency for the critical evaluation of methods for
preventing, diagnosing and treating health problems.
The following questions were addressed:
How accurate are different diagnostic methods for
determining the condition of exposed vital pulps in
teeth with different types of damage or injury
(caries, trauma, restorative interventions or other
causes)?
Are there clinical or biological markers that can
determine the degree, severity and extent of inflammation of exposed vital pulp?
Are there methods that can predict the outcome of a
treatment that aims at keeping the pulp vital,
healthy and without symptoms?
How accurate are methods used to determine the
sensibility and vitality of dental pulps, including
methods to determine vascular function?
Materials and methods

Literature search and selection of articles
The electronic literature search included the databases
PubMed, EMBASE, The Cochrane Central Register of
598
Controlled Trials and Cochrane Reviews from January

1950 to April 2010. A complementary search was
made in June 2011. All languages were accepted,
provided there was an abstract in English. The Mesh
terms were Dental pulp diseases/classification, Dental
pulp diseases/diagnosis, Dental pulp test and Tooth
discoloration. The complete search strategy is given in
the Appendix S1 (available online as Supporting
Information). The electronic searches resulted in
2131 abstracts (Fig. 1). Two reviewers (GB and IM)
read the abstracts independently. An article was read in
full text if at least one of the two reviewers considered
an abstract to be potentially relevant. In addition to the
electronic search, a hand search was made and
references of narrative reviews, text books and articles
in international journals not identified in the main
search were included. The hand search resulted in
another 33 articles. Grey literature was not included.
The pre-specified inclusion/exclusion criteria are given
in Table 1. Altogether, 155 articles were read in full
text and assessed independently by the same two
reviewers. Of the 155 articles, 137 did not fulfil the
inclusion criteria and were excluded from further
analysis. A list of excluded articles with the main
reason for exclusion is given in the Appendix S2
(available online as Supporting Information). The
remaining included articles (n = 18) were assessed
using the QUADAS tool (Whiting et al. 2003).
Data analysis
Measures used to assess diagnostic accuracy
The diagnostic accuracy (validity) of a test (index test)
requires a reference standard (reference test) for comparison. Such a reference standard should reflect the
true condition as closely as possible. For pulp, histological examination has often been used as the reference standard.
The relationship between positive and negative test
results and the presence or absence of diseased pulp can
be expressed as sensitivity and specificity. Sensitivity is
the number of true positive tests divided by the total
number of diseased pulps. Specificity is the number of
true negative tests divided by the total number of
healthy pulps. Other measures are predictive values
and likelihood ratios. The positive predictive value is
the number of true positive tests divided by the total
number of positive tests, and the negative predictive
value is the number of negative tests divided by the
total number of negative tests. Likelihood ratio combines sensitivity and specificity and states how many
Meja`re et al. Diagnosis of dental pulp
Abstracts from electronic search

1. 2009-09-01 (n = 1883)
2. 2010-04-07 (n = 119)
3. 2011-06-28 (n =129)
Excluded abstracts
(not relevant)
n = 2009
Articles in full text
n = 122
Excluded articles (not
relevant or not fulfilling
inclusion criteria)
n = 137
Articles from other sources,

i.e. reference lists
n = 33
Included articles
n = 18
Study quality: High
Study quality: Moderate
Study quality: Low
n=0
n=2
n =16
Figure 1 Flow chart showing the search strategy, excluded and included articles and study quality of included articles.
times more likely particular test results are in patients

with disease than in those without disease. The positive
likelihood ratio = the odds of a positive test result in
patients with disease (sensitivity/1- specificity), and the
negative likelihood ratio = the odds of a negative test
result in patients with disease (1- sensitivity/specificity).
The main outcome measures of this systematic
review were sensitivity and specificity of individual
studies. The intention was to pool sensitivity and
specificity of reasonably homogeneous studies with
high or moderate study quality.
Rating quality of individual studies
Each included study was rated high, moderate or low
quality according to pre-specified criteria given in
Table 2.
Rating evidence across studies
The quality of evidence of the diagnostic accuracy of
each method/test was rated in four levels according to
GRADE (Schunemann et al. 2008, Guyatt et al. 2011):
High (): based on high- or moderate-quality
studies containing no factors that weaken the
overall judgement.
Moderate (s): based on high- or moderatequality studies containing isolated factors that
weaken the overall judgement.
Limited (ss): based on high- or moderatequality studies containing factors that weaken the
overall judgement.
Insufficient (sss): the evidence base is insufficient when scientific evidence is lacking, the quality
of available studies is low or studies of similar
quality are contradictory.
GRADE amounts to asking how much confidence
one can have in a particular estimate of effect. Is it built
on solid ground, or is it likely that new research
findings will change the evidence in the foreseeable
future? The rating starts at high, but confidence in the
evidence may be lowered for several reasons, including
limitations in study design and/or quality, inconsistency or indirectness of results, imprecision of estimates
and probability of publication bias.
Any disagreements about inclusion/exclusion criteria,
rating quality of individual studies or quality of evidence
of test methods were solved by consensus. A flow chart
showing the results of the literature search and the
outcome of the selection procedures is given in Fig. 1.
Results
Eighteen studies were included (Seltzer et al. 1963,
Guthrie et al. 1965, Eidelman et al. 1968, Hasler &
Mitchell 1970, Johnson et al. 1970, Koch & Nyborg
1970, Tyldesley & Mumford 1970, Garfunkel et al.
599
Table 1 Pre-specified inclusion and exclusion criteria

Inclusion criteria
Study design
Population
Index test
Reference test
Outcome measures
Exclusion criteria
Study design
Population
Index test
Reference test
Outcome measures
Cross-sectional, casecontrol, prospective cohort

Patients that can be expected to undergo the examination or the tests in clinical praxis
Clinical signs or symptoms, other clinical information, clinical tests or biological markers
Histological examination of the extracted tooth
Histological examination of extirpated pulp tissue
For deciding pulp vitality: the same criteria as above or inspecting/probing the exposed pulp tissue
Immature teeth: radiographic examination combined with observing continued root development
Prospective study design: symptoms combined with clinical and radiographic information were accepted
Sensitivity, specificity, likelihood ratio, odds ratio (from multivariate analysis), ROC
curves or AUC (area under the curve)
Retrospective
In vitro or animal studies, cracked teeth
Product comparisons, tooth bleaching procedures
Not defined or not acceptable according to inclusion criteria
Other than inclusion criteria. An article was accepted if sensitivity and specificity were not reported,
but contingency tables enabled calculation of these measures
Table 2 Criteria of high, moderate and low study quality, mainly according to QUADAS (Whiting et al. 2003)
High: small risk of bias
Study design either cross-sectional or prospective. A casecontrol design was not accepted,
because it usually overestimates diagnostic accuracy (Lijmer et al. 1999). Particular emphasis was put
on the following items:
Randomly or consecutively selected, adequately described patients involving a representative and
clinically relevant sample (QUADAS items 1, 2)
The index test should not form part of the reference standard (item 7)
The index test and the reference standard should each be interpreted without knowledge of the results
of the other (items 10, 11)
The tests should be described in sufficient detail to permit replication (items 8, 9)
Sample size in subgroups 30
Diagnostic accuracy presented as sensitivity and specificity
Moderate: moderate
risk of bias
A casecontrol design was accepted as well as nonrandom or nonconsecutive enrolment of patients.

Otherwise the same criteria as for high quality. A sample size of 20 in subgroups was accepted
Low: high risk of selection

and/or verification bias
Criteria of moderate quality not met
1973, Dummer et al. 1980, Klausen et al. 1985, Olgart

et al. 1988, Georgopoulou & Kerani 1989, Matsuo
et al. 1996, Evans et al. 1999, Petersson et al. 1999,
Kamburoglu & Paksoy 2005, Gopikrishna et al. 2007,
Weisleder et al. 2009). Their main characteristics and
quality rating are presented in Table 3. None of the
studies satisfied the criteria for high quality, two were
of moderate quality (Hasler & Mitchell 1970, Gopikrishna et al. 2007), and the remaining 16 studies
were of low quality. Owing to the scarcity of studies of
sufficient quality, no meta-analysis was performed.
Based on the two studies of moderate quality, each
investigated test method was rated for the quality of
evidence according to the GRADE approach (Schunemann et al. 2008), Tables 4 and 5. The 18 included
studies can be divided into two categories: those
600
designed to assess the accuracy of signs and symptoms

of the inflammatory status of pulp, and those investigating the accuracy of methods for testing pulp vitality.
Signs and symptoms as indicators of the

inflammatory status of pulp
Of 11 included studies, 10 were of low quality (Seltzer
et al. 1963, Guthrie et al. 1965, Eidelman et al. 1968,
Johnson et al. 1970, Koch & Nyborg 1970, Tyldesley &
Mumford 1970, Dummer et al. 1980, Klausen et al.
1985, Matsuo et al. 1996, Kamburoglu & Paksoy
2005). The study of moderate quality (Hasler &
Mitchell 1970) recorded normal or abnormal responses
to cold, heat, electric pulp test (EPT) and percussion in
47 asymptomatic teeth with deep caries. The findings
were compared with the degree of pulp inflammation as

assessed by histological examination after extraction of
the tooth. There was no obvious association between
any of the test results and the inflammatory condition
of the pulp. Tenderness to percussion occurred in 80%
(37/47) of the teeth without regard to the inflammatory status. All teeth having minimal or no pulp
inflammation responded abnormally to either cold or
heat provocation or both. The range of inflammation
was substantial; 28% (13/47) of the teeth displayed
either moderate or severe pulp inflammation. Thus,
absence of painful symptoms such as toothache did not
exclude the presence of a severe inflammatory involvement of the pulp. The histological examination revealed
that 30% (14/47) of the teeth had carious pulp
exposure (with no dentine separating the pulp from
the caries lesion as measured histologically). Moderate
to severe pulp inflammation was more frequent in these
teeth (71%) compared with teeth without caries
reaching the pulp. The sample is, however, relatively
small, and the results have wide confidence intervals.
Table 4 is based on the results of this study.
The accuracy of isolated clinical symptoms or
combinations of symptoms for differentiating between
pulpitis, apical periodontitis and marginal periodontitis was assessed in 74 patients with acute dental
pain (Klausen et al. 1985). Probing the pulp after
exposure was used as the reference test to distinguish
between vital and nonvital pulps. Bursts of pain
initiated by thermal provocation (cold or heat) were
associated with vital pulp (pulpitis) in >75% of the
teeth. Constant pain combined with a tooth that felt
extruded was associated with pulp necrosis in >80%
of the cases.
Presence of toothache, response to percussion, cold
or heat provocation or EPT were compared with the
histological status of the pulp in 166 teeth extracted
because of caries or other causes (Seltzer et al. 1963).
The relationship between any of the signs and symptoms and the inflammatory condition of the pulp (either
low sensitivity or low specificity) was poor. The study
has methodological shortcomings.
The ability of various clinical signs and symptoms to
predict the outcome of pulp capping was assessed in a
prospective study (Matsuo et al. 1996). The material
comprised 44 permanent teeth with pulp exposure after
excavating deep caries. Pulps with profuse and lingering bleeding had a significantly poorer outcome than
those with modest bleeding or a bleeding of short
duration. Pre-operative pain of minor intensity did not
affect the success rate. The sample is relatively small
with wide confidence intervals, and the study has

methodological shortcomings.
To sum up, there is insufficient evidence to determine
whether the presence, nature and duration of toothache offer accurate information about the extent to
which dental pulp is inflamed. The evidence base is also
insufficient to assess the accuracy of other commonly
used clinical markers of pulp inflammation (Table 4).
Sensibility and vitality testing

Electric pulp testing
One study of moderate quality (Gopikrishna et al. 2007)
examined 80 patients who had a single-rooted tooth
affected by deep caries, indicating irreversible pulpitis,
or in need of endodontic therapy for other reasons.
Using direct visual inspection as the reference test, EPT
correctly identified 71% of the necrotic pulps (sensitivity) and 92% of the vital pulps (specificity). Table 5 is
based on the results of this study. With one exception
(Georgopoulou & Kerani 1989), all included studies on
EPT (Seltzer et al. 1963, Johnson et al. 1970, Dummer
et al. 1980, Olgart et al. 1988, Evans et al. 1999,
Kamburoglu & Paksoy 2005, Weisleder et al. 2009)
had a similar, high specificity (>90%). Sensitivity varied
substantially in all included studies (range = 2187%).
Cold test
In the same sample of 80 patients as described earlier
(Gopikrishna et al. 2007), cold test with tetrafluoroethane correctly identified pulp necrosis in 81% of the
teeth (sensitivity) and vital pulps in 92% (specificity). In
the other included studies (Seltzer et al. 1963, Tyldesley
& Mumford 1970, Garfunkel et al. 1973, Dummer et al.
1980, Olgart et al. 1988, Georgopoulou & Kerani
1989, Evans et al. 1999, Petersson et al. 1999, Kamburoglu & Paksoy 2005, Weisleder et al. 2009), the
specificity of a variety of cold tests ranged from 10 to
98%, whilst sensitivity with one exception reached
>75%.
Heat test
Six studies (Seltzer et al. 1963, Garfunkel et al. 1973,
Dummer et al. 1980, Olgart et al. 1988, Georgopoulou
& Kerani 1989, Petersson et al. 1999), all of low
quality, reported highly variable values of sensitivity
and specificity for thermal provocation by heat.
Combining tests
Two studies examined the accuracy of combining tests
(Seltzer et al. 1963, Weisleder et al. 2009). In one
601
602
Aim
Accuracy of
clinical markers
of saveable/
nonsaveable
pulps, and
vitality tests
Accuracy of
clinical markers
of treatable/
nontreatable
pulps
References
Dummer
et al. (1980)
Eidelman
et al. (1968)
Cross-sectional:
32 primary teeth in children
aged 612 years
Cross-sectional:
75 permanent teeth to be
extracted mainly because
of pain
Study design and

population
characteristics
Reference test
Main results
Study
quality
Markers of pulp status:

Presence/absence of pain
Character of pain
Tenderness at apex
Intraoral swelling
Tenderness to percussion
Hypersensitivity to cold
and heat
Vitality test:
EPT (Scoones Unipolar)
Cold (ethyl chloride)
Heated gutta-percha
Histology of pulp after

extraction:
Classification according
to criteria by Seltzer
et al. (1963)
Dichotomized into:
saveable pulp (chronic
partial pulpitis) (n = 50)
and nonsaveable
pulp (severe
inflammation/necrosis)
(n = 25)
Disease prevalence:
Nonsaveable pulp: 67%
Nonvital pulp: 25%
Loss of sleep because of pain:a

Low
Se (nonsaveable) = 0.74, Sp = 0.74
Presence of pain:
Se (nonsaveable pulp) = 0.88, Sp =
0.60
Tenderness to percussion:
Hypersensitivity to heat:
Se (nonsaveable) = 0.18, Sp = 0.92)
Hypersensitivity to cold:
EPT:
Se (nonvital) = 0.21, Sp = 1.0
Cold test:
Se (nonvital) = 0.68, Sp = 0.70
Heat test:
Se (nonvital) = 0.95, Sp = 0.41
Low
Correct classification of
Presence/absence, nature,
extraction:
histological diagnoses from all
duration and quality of
Classification according to
clinical markers:a 18 : 32 = 56%
pain
criteria by Seltzer et al. (1963) Combining clinical symptoms
(dull pain, pain upon percussion,
Pulp exposed during
Dichotomized into: treatable
pulp exposure, radiographic evidence
excavation
pulp (chronic partial pulpitis):
of deep caries, widened periodontal
n = 10 and nontreatable pulp
Hypersensitivity to heat and (severe inflammation/necrosis): membrane):
Se (nontreatable pulp) = 0.91,
cold (pain continued after
n = 22
Sp = 0.40
stimulus removal)
Disease prevalence:
Radiographic findings
Nontreatable pulps: 69%
Vitality tests:
EPT, cold, heat
Index test
Table 3 Main characteristics, results and quality rating of the 18 included studies on pulp diagnosis
Accuracy of
clinical markers
of pulp status
Garfunkel et al.
(1973)
Cross-sectional:
132 teeth with painful pulp
conditions in need of
endodontic therapy
Exclusion criteria: Teeth with
radiographic signs of apical
periodontitis, incomplete case
history, technical difficulties
(n = 23)
Cross-sectional:
Sample 1: 67 teeth in 55 patients
aged 835 years. Anterior teeth
subjected to dental trauma with
at least two signs of pulp
necrosis (loss of pulp
sensitivity, discoloration,
radiographic signs of
pathology)
Sample 2: 77 noninjured intact
teeth from the same or other
patients
Study design and

population
characteristics
Accuracy of pulp Cross-sectional:

vitality test
Patients scheduled for
methods
endodontic treatment
168 patients (one tooth per
patient) aged 1178 years
Accuracy of
clinical markers
of pulp vitality
Evans et al.
(1999)
Georgopoulou &
Kerani (1989)
Aim
References
Table 3 (Continued).

History of pain
Presence of sinus tract
Coronal discoloration
Apical radiolucency
Inflammatory external
root resorption
Vitality test:
1. Laser Doppler
flowmetry (LDF)
2. EPT (Analytic Technology)
3. Cold (ethyl chloride)
Character of pain
Percussion tenderness
Cold test
Heat test
Character of pulp bleeding
Vitality tests:
EPT
Heated gutta-percha
Vitality test:
EPT
Cold (ice)
Heated gutta-percha
Index test
Histology of extirpated pulp

Classification:
Acute pulpitis (n = 35)
Chronic pulpitis (n = 27)
Chronic pulpitis with partial
necrosis (n = 39)
Total necrosis (n = 8)
Disease prevalence:
Pulpitis = 57%
Partial or total necrosis = 43%
Visual examination after pulp
exposure
Classification:
Vital (n = 100)
Necrotic (n = 68)
Disease prevalence:
Necrotic pulp: 40%

exposure
Classification:
Whole pulp necrotic (n = 60)
Coronal pulp necrotic (n = 7)
Disease prevalence:
(Sample 1)Total pulp necrosis:
90%
Coronal pulp necrotic: 100%
Reference test
EPT:
Se = 0.94, Sp = 0.73
Cold:
Se = 1.0, Sp = 0.62
Heat:
Se = 1.0, Sp = 0.66
Clinical and histological diagnoses

correlated ina
54 of 109 cases = 50%
Cold:
Se (total necrosis) = 0.75, Sp = 0.57
Heat:
Se (total necrosis) = 0.63, Sp = 0.61
LDF with flux values at <7.0 and

amplitude values at <1.6:
Se = 1.0, Sp = 1.0
Cold:
Se = 0.92, Sp = 0.89
EPT:
Se = 0.87, Sp = 0.96
Discoloration:
Se = 0.49, Sp = 0.97
Main results
Low
Low
Low
Study
quality
603
604
Aim
Study design and

population
characteristics
Gopikrishna et al. Accuracy of pulp Cross-sectional:

(2007)
vitality test
80 patients with one
methods
single-rooted incisor, canine
or pre-molar requiring
endodontic therapy because
of either deep caries or
prosthodontics
Control: Contra-lateral
sound tooth
Guthrie et al.
Accuracy of
Cross-sectional:
(1965)
biological and
44 primary and nine permanent
clinical markers teeth in 27 children aged 4
of pulp
11 years with carious pulp
inflammation
exposure and bleeding pulp
(coronal versus upon caries excavation
total pulpitis)
Controls: 14 primary and
permanent teeth with normal
pulps

Vitality test:
Blood oxygen saturation
level by pulse oximeter
monitor. Value <75%
= nonvital
EPT (Parker vitality tester)
Cold (tetrafluoroethane)
Index test
Reference test

exposure (test sample only)
Classification:
Bleeding (vital) (n = 38)
No bleeding (necrotic) (n = 42)
Disease prevalence:
No bleeding (necrotic) 53%
Controls subjected to EPT and
cold test only
White blood cell count
extraction
(haemogram). Rise in
Classification:
neutrophils or
Coronal (inflammation
lymphocytes (10% =
restricted
elevated count) compared to pulp chamber) (n = 28)
with peripheral counts
Total (inflammation extending
(finger punch). Character of into root canals) (n = 25)
bleeding at exposure site Disease prevalence:
History of pain
Total pulpitis: 47%
EPT
Hypersensitivity to ice, warm
gutta-percha
Percussion test
Tooth mobility test
Hasler & Mitchell Accuracy of
Cross-sectional:
(1970)
clinical markers 47 patients age 1356 years
EPT
extraction
as indicators of (mean 28 years).One tooth per Cold (ethyl chloride,
Classification:
pulp status in
patient
ice) Heated gutta-percha
No or minimal pulpitis (n = 34)
asymptomatic
Control: Adjacent or
Percussion test
Moderate/severe pulpitis
teeth with
contra-lateral sound tooth
(n = 13)
extensive caries
Disease prevalence:
and suspected
Moderate/severe pulpitis: 28%
pulpitis
References
Abnormal reaction to heat:a

Se (moderate/severe pulpitis) = 0.54,
Sp = 0.21
Abnormal reaction to cold:
Sp = 0.12
Abnormal reaction to percussion:
Sp = 0.21
Pulp exposed by caries:
Sp = 0.88
Pulse oximetry:
Se = 1.0, Sp = 0.95
PPV = 0.95, NPV = 1.0
Cold:
Se = 0.81, Sp = 0.92
PPV = 0.92, NPV = 0.81
EPT:
Se = 0.71, Sp = 0.92
PPV = 0.91, NPV = 0.74
Hemogram:a
Se (total pulpitis) = 0.36, Sp = 0.64
Profuse bleeding:
History of spontaneous pain:
Main results
Moderate
Low
Moderate
Study
quality
Aim
Accuracy of
clinical markers
of pulp status
and EPT in
diagnosis of
pulp
hyperaemia,
irreversible
pulpitis,
pulp necrosis
Accuracy of
clinical markers
of vital and
necrotic pulp
Significance of
clinical markers
in differential
diagnosis of
pulpitis, apical
periodontitis
(AP), marginal
periodontitis
(MP)
References
Johnson et al.
(1970)
Kamburoglu &
Paksoy (2005)
Klausen et al.
(1985)

extraction
Classification:
Hyperaemic stage (no
inflammatory cell infiltrates)
Irreversible cellular
inflammation or necrosis
Disease prevalence:
Hyperaemia: 31%
Severe inflammation: 10%
Necrosis: 7%
Visual inspection of exposed
pulp
Classification:
Bleeding (n = 50)
No bleeding (necrotic) (n = 43)
Disease prevalence:
Necrotic pulp: 46%

Hypersensitivity to heat
(heated gutta-percha) and
cold (ethyl chloride)
Vitality test:
EPT (Burton vitalometer)

History of pain
Caries removal without
anaesthesia
Sensibility to probing
exposed pulp
Percussion test
Radiographic examination
Vitality test:
EPT (Parker electronics)
Cold (butan-propan gas)
Reference test
Index test
Significant correlation of hyperaemia
with sensitivity to heata
Cold:
Se (irreversible inflammation) = 0.35,
Sp = 0.49
Heat:
Se (irreversible inflammation) = 0.59,
Sp = 0.39
EPT:
Se (pulp necrosis) = 0.57, Sp = 0.99
Main results
Sensibility to probing:
Se (necrotic) = 1.0, Sp = 0.76
Sensibility on caries removal:
EPT
Se (necrotic) = 0.84, Sp = 0.96
Cold:
Se (necrotic) = 0.93, Sp = 0.98
Percussion:
Se (necrotic) = 0.19, Sp = 0.81
Widened lamina dura:
Cross-sectional:
Visual examination and
Combined signs and symptoms,
74 patients with acute dental
Ability to point out tooth
probing of exposed pulp
that is, constant pain, tenderness
pain
Interference with sleep
Classification:
to temperature changes, tooth feels
Exclusion criterion: Patients with Constant pain
vital or necrotic pulp
extruded, impaired mouth opening,
dubious or mixed diagnosis
Tenderness to temperature radiography: normal or apical
tenderness to palpation in apical
changes and chewing
rarefaction, marginal bone loss. region and mobility discriminated
Tooth feels extruded
Marginal periodontium: normal between diagnoses in 82% of the
Impaired mouth opening. or deepened pocket
cases
Reddening of the apical oral Disease prevalence:
No or limited differential diagnostic
mucosa
1. Pulpitis 38%
value of pain to sweet and sour,
Tenderness at apex,
2. AP 41%
character or duration of pain, fever,
percussion, digital pressure 3. MP 12%
colour of tooth, tenderness to
Tooth mobility
4. Pulpo-periodontitis 9%
percussion, swelling of regional
Swollen regional lymph
(excluded from analysis)
lymph node, patient ability to point
nodes
out tooth
Cross-sectional:
93 teeth in 97 patients aged
1565 years (mean 33 years) in
need of endodontic therapy
because of caries
Comparison group: Adjacent or
contra-lateral sound teeth
(n = 49)
Cross-sectional:
706 extracted teeth in 94
consecutive patients because
of full-mouth extraction or be
cause of caries, tooth ache,
marginal periodontitis, and
prosthodontics
361 teeth pulp vitality tested
Study design and

population
characteristics
Low
Low
Low
Study
quality
605
606
Olgart et al.
(1988)
Matsuo et al.
(1996)
Accuracy of
Cross-sectional:
clinical markers 48 painful primary lower molars Frequency and duration of
of pulp status in
tooth ache
deciduous teeth
Character of bleeding at pulp
with deep caries
exposure
Thermal sensitivity
and pressure
Gingival swelling and fistula
Significance of
Prospective cohort:
clinical markers 44 teeth in 38 patients
History of pain
(age 2069 years) with
Heat, cold and
as predictors of
carious exposure and
percussion test
the outcome of
pulp capping
without extensive pain
Colour, hardness of dentin
Exclusion criteria:
surrounding pulp exposure
Severe damage to the pulp
Pulp exposure size
during caries excavation
Bleeding character
(n = 3)
Vitality tests:
EPT (Dentotest)
Cold (ethyl chloride,
temporary stopping)
Percussion
Accuracy of Laser Cross-sectional/longitudinal
Doppler
study
Vitality test:
flowmetry (LDF) Sample 1: 33 teeth in 25
Laser Doppler flowmetry
in diagnosis of
patients aged 720 years with
pulp vitality in
1 year history of injury from
traumatized
trauma scheduled for
young
endodontic
permanent
treatment
anterior teeth
Control: 33 noninjured teeth
Sample 2: 20 teeth in 18 patients
aged 716 years subjected to
moderate trauma and initially
nonsensitive to EPT
Koch & Nyborg

(1970)
Index test
Aim
Study design and

population
characteristics
References
Low
Overall success rate:a 8083%

Character of bleeding the only
significant predictor
Se (conspicuous bleeding not
arresting at 30 s past
exposure) = 0.50, Sp = 0.86
Low
Low
Study
quality
Clinical assessments correlated with

histological classification in 88%
of the casesa
Main results
Visual examination and

Sample 1 (pulp necrosis):a
Se (necrosis) = 0.88, Sp = 1.0
probing pulp exposure
Sample 2: LDF indicated recovering
Classification:
blood circulation in luxated teeth
Vital (n = 37)
before regaining response to EPT in
Necrotic (n = 16)
16/20 teeth 3 weeks28 months after
Disease prevalence: (controls
traumatic injury
excluded):
Necrotic pulp (no bleeding): 70%

extraction
Classification:
Inflammation restricted to
coronal pulp (n = 28)
Inflammation of one or more
radicular pulps (total pulpitis)
(n = 20)
Disease prevalence:
Total pulpitis: 42%
Success of treatment (pulp
capping)
Criteria:
No clinical signs or symptoms
of irreversible pulpitis,
tooth sensitive to EPT
Follow-up: 12 months
Reference test
Aim
Accuracy of pulp
vitality test
methods
Correlation of
clinical markers
of pulp status
and tests with
histological
status of pulp
References
Petersson et al.
(1999)
Seltzer et al.
(1963)
Cross-sectional
Sample 1:
59 teeth in 56 patients
(2179 years) scheduled for
endodontic treatment.
Sample 2: (controls): 16
teeth in nine
dental students with intact
teeth
Cross-sectional:
166 teeth scheduled for
extraction because of tooth
ache, orthodontic, periodontal
or prosthetic reasons
Study design and

population
characteristics
Histology of pulp
after extraction
Classification:
a. Intact uninflamed (n = 23)
b. Atrophic (n = 40)
c. Intact with scattered
inflammatory cells (n = 19)
d. Chronic partial pulpitis with
partial necrosis (n = 24)
e. Chronic total pulpitis with
partial necrosis (n = 14)
f. Chronic total pulpitis (n = 22)
g. Total necrosis (n = 22)
Dichotomized in
ad = nonsuppurative (n = 106)
and
eg = suppurative (n = 60)
Disease prevalence:
Total pulpitis/necrosis
(eg): 35%
Visual inspection after pulp

exposure. (not sample 2)
Classification:
Vital (bleeding pulp) (n = 46)
Nonvital (no bleeding) (n = 29)
Disease prevalence: (sample 2
included):
Nonvital pulp: 38%

Vitality test:
EPT(Analytic Technology)
Heated gutta-percha

Presence and character of
pain
Sensibility to percussion
Radiographic signs.
Abnormal reaction to heat
or cold
EPT
Vitality test:
Pain (presence /absence)
Percussion
EPT (Burton vitalometer)
Cold (ice or ethyl chloride)
Heated gutta-percha or ball
burnisher
Heat and cold
combined
Reference test
Index test
Localized pulpitis (ad) versus total

pulpitis or necrosis (eg):a
Pain:
Abnormal reaction to heat: Se (total
pulpitis) = 0.31, Sp = 0.84
Abnormal reaction to cold:
Sensibility to percussion:
Vital versus necrotic pulp:
Pain (presence/absence):
Se (necrotic) = 0.36, Sp = 0.46
EPT:
Se (necrotic) = 0.72, Sp = 0.92
Response to cold:
Se (necrotic) = 0.89, Sp = 0.24
Response to heat:
Se (necrotic) = 0.94, Sp = 0.29
Response to heat and cold: Se
(necrotic) = 0.78, Sp = 0.86
EPT:
Se (nonvital) = 0.72, Sp = 0.90
Cold:
Se (nonvital) = 0.83, Sp = 0.90
Heat:
Se (nonvital) = 0.86, Sp = 0.57
Main results
Low
Low
Study
quality
607
608
Visual inspection after pulp

exposure
Classification:
Vital (bleeding) (n = 64)
Necrotic (no bleeding,
bleeding
in apical part only) (n = 86)
Disease prevalence:
Necrotic pulp: 57%

extraction
Classification:
a. Normal/hyperaemic (n = 16)
b. Acute localized pulpitis
(n = 25)
c. Acute generalized and or
chronic pulpitis (n = 69)
d. Degeneration or necrosis
(n = 32)
Disease prevalence:
Localized pulpitis: 18%
Generalized pulpitis: 49%
Degenerated/
necrotic pulp: 23%

Character of pain
Heat, cold and percussion
test
Vitality test:
Cold
Heat
Percussion

Vitality test:
EPT (Analytic Technology)
Cold (carbon dioxide,
Endo-ice)
Reference test
Index test
Se, sensitivity; Sp, specificity; EPT, electric pulp testing.

Sensitivity and specificity calculated by us from contingency tables reported in the original article.
Cross-sectional:
150 patients (1876 years)
undergoing endodontic
treatment. One tooth per
patient
Weisleder et al.
(2009)
Diagnostic
accuracy of EPT
and two cold
tests, separately
and combined as
indicators of
pulp vitality
Cross-sectional:
142 teeth scheduled for
extraction because of
toothache
Aim
Study design and

population
characteristics
Tyldesley &
Accuracy of
Mumford (1970) clinical markers
as indicators of
pulp status
References
Study
quality
Low
Localized (ab) versus generalized
pulpitis/necrosis(cd):a
Mild versus severe pain:
Se (cd) = 0.68, Sp = 0.41
Intermittent versus constant pain:
Se (cd) = 0.37, Sp = 0.61
Cold:
Se (cd) = 0.92, Sp = 0.12
Heat:
Se (cd) = 0.92, Sp = 0.02
Percussion:
Se (cd) = 0.16, Sp = 0.93
Vital(ac) versus necrotic(d):
Cold:
Se (necrotic) = 0.94, Sp = 0.10
Heat:
Se (necrotic) = 0.89, Sp = 0.05
Percussion:
Se (necrotic) = 0.28, Sp = 0.89
EPT:
Low
Se (necrotic) = 0.75, Sp = 0. 92
Cold:
Endo-ice: Se (necrotic) = 0.92, Sp = 0.76
Carbon dioxide: Se (necrotic) = 0.89,
Sp = 0.76
All three test combined:
Se (necrotic) = 0.96, Sp = 0.92
Main results
Table 4 Quality of evidence of the diagnostic accuracy of abnormal reaction to heat, cold, percussion test and discontinuity of
dentin floor over the pulp for determining the status of vital pulp (no/minimal versus moderate/severe inflammation) in teeth with
deep caries. Data from Hasler & Mitchell (1970)
Test method
Sample size
(no of studies)
Sensitivity
(95% CI)
Specificity
(95% CI)
Quality of
evidence
Heat
47 (1)
54 (29;77)
21 (10;37)
sss
(insufficient)
Cold
47 (1)
85 (58;96)
12 (5;27)
sss
(insufficient)
Percussion
47 (1)
77 (50;92)
21 (10;37)
sss
(insufficient)
Pulp exposed by caries

(discontinuity of dentin
floor over the pulp).
47 (1)
77 (50;92)
88 (73;95)
sss
(insufficient)
Rating according to
Study design/quality,
indirectness, consistency,
precision, publication bias
Study design/quality
Precision 1
One study 1
Precision 1
One study 1
Precision 1
One study 1
Precision 1
One study 1
Table 5 Quality of evidence of the diagnostic accuracy of electric stimulation, pulse oximetry and cold test for determining pulp
vitality. Data from Gopikrishna et al. (2007)
Test method
Sample size
(no of studies)
Sensitivity
(95% CI)
Specificity
(95% CI)
Quality of
evidence
Electric stimulation
80 (1)
71 (56;83)
92 (79;97)
sss
(insufficient)
Pulse oximetry
80 (1)
100 (91;100)
95 (83;99)
sss
(insufficient)
Cold
80 (1)
81 (67;90)
92 (79;97)
sss
(insufficient)
study (Seltzer et al. 1963), combining cold and heat

tests increased specificity compared with the results of
each test separately, whilst sensitivity decreased. In
the other study (Weisleder et al. 2009), the combination of cold tests (carbon dioxide and Endo-ice) and
EPT improved the ability to correctly identify necrotic
pulps (sensitivity = 96%) and vital pulps (specificity = 92%). Both studies have methodological shortcomings.
Assessment of blood flow
Two studies (Olgart et al. 1988, Evans et al. 1999)
reported high sensitivity and specificity for laser Doppler flowmetry (88100% and 100%, respectively). The
reference tests were visual inspection of the pulp in
connection with subsequent endodontic therapy or
Rating according to:

Study design/quality,
indirectness, consistency precision,
publication bias
Study design/quality 1
Indirectness 1
One study 1
Indirectness 1
One study 1
Indirectness 1
One study 1
conventional pulp vitality tests (cold, heat and EPT).

Both studies suffer from methodological shortcomings.
A study of moderate quality (Gopikrishna et al. 2007)
compared pulse oximetry with direct inspection of the
pulp (reference test). All non-vital pulps were correctly
identified (sensitivity = 100%) and almost all vital
pulps (specificity = 95%).
Other clinical markers
Only one study reported on the accuracy of sensibility to
probing exposed dentin or a radiographically observed
widened periodontal membrane for differentiating between vital and necrotic pulps (Kamburoglu & Paksoy
2005). Both tests yielded perfect sensitivity and relatively high specificity (7680%). The study has, however, several methodological shortcomings.
609
To conclude, there is insufficient evidence to determine the diagnostic accuracy of tests used to assess
pulp vitality (Table 5).
Biological markers as indicators of pulps

inflammatory status
Whilst numerous efforts have been made to link biological
markers of inflammation, including inflammatory mediators, to the inflammatory status of pulp, only one study
satisfied the inclusion criteria (Guthrie et al. 1965). In this
study, blood samples were taken from pulp exposures
induced by caries or other injuries. The samples were
analysed with regard to white blood cell counts. The cell
counts correlated poorly with the extent of pulp inflammation as assessed by histology after tooth extraction
(sensitivity = 36% and specificity = 64%). Hence, there is
no scientific basis on which to assess the diagnostic value
of biological markers to determine the condition of pulp in
terms of reversible and irreversible pulpitis.
Discussion
The literature targeting the problem field addressed in
this systematic review is extensive. However, most of
the publications consist of narrative overviews describing methods, techniques and materials for the clinical
evaluation of the condition of pulp. In contrast, only a
few studies were designed for assessing the accuracy of
tests or methods. No systematic review that has
critically evaluated the scientific literature corresponding to the research questions could be identified. It is
worth noting that most of the included studies in the
current review are out of date and relatively few have
assessed novel test methods in a clinical context.
A conceivable explanation for the lack of highquality studies could be the difficulty in obtaining a
good reference test. Dental pulp tissue is normally not
available for direct inspection or for microscopic or
other examinations, especially if the tooth is healthy
and in no need of endodontic treatment or extraction.
Formerly, such teeth were frequently available as they
were extracted if decayed by caries rather than being
treated endodontically. Healthy teeth were also often
sacrificed for prosthodontic reasons. Today, access to
such teeth is highly limited. Another explanation for
the lack of studies of good quality may be that crosssectional data have traditionally been regarded as the
only means, whilst the benefit of a prospective study
design has not been considered. Only one of the
included studies used this design (Matsuo et al. 1996).
610
Inflammatory mediator substances identified in pulps

exposed by caries or other injuries, for example,
prostaglandins (Cohen et al. 1985, Waterhouse et al.
2002), superoxide dismutase (Tulunoglu et al. 1998),
TNF-alfa (Pezelj-Ribaric et al. 2002), substance P
(Bowles et al. 2003) and MMPs (Zehnder et al. 2011),
may indicate pulp status and have the potential to
predict the outcome of treatment intended to maintain
an exposed pulp vital and asymptomatic, for example,
pulp capping or pulpotomy. Although markers of this
nature have been correlated with clinical symptoms,
no study satisfying the inclusion criteria could be
identified.
It must be recognized that the natural history of a
caries-induced pulpitis is not well delineated and
knowledge concerning the healing potential of injured
pulp is restricted. Considering that infection is often the
cause of inflammation, any inflamed pulp should be
able to heal if the source of infection is eliminated, as is
often the case in other body organs/systems. Thus,
caries-induced pulpitis ought to be reversible and the
pulp able to heal if caries is removed. An important prerequisite is, however, that infectious elements have not
established themselves permanently in the pulp chamber. No study of sufficient quality could be identified
that assessed the relationship between markers of pulp
infection and the outcome of conservative treatment
(aimed at preserving pulp exposed by caries or other
forms of injury).
Quite a few studies assessed the accuracy of methods
for testing pulp vitality; tests that initiate pain response
to thermal or electric provocation have attracted most
attention. Intact, healthy teeth are often used as the
reference test without examining the true status of
these pulps (other than a positive response to thermal
and/or electric testing). This limits the value of such
studies in that overall diagnostic studies using a case
control design overestimate test accuracy (Knottnerus
1995, Rutjes et al. 2006). Furthermore, the prevalence
of pulps with severe inflammation and/or necrosis is
relatively high in most of the studies because the
samples often consist of referred patients or teeth
scheduled for endodontic treatment or extraction.
Results based on such samples have an inherent risk
of so-called spectrum bias, implying that the study
population may not represent patients who would be
exposed to the test in daily clinical practice. Vitality
testing may also already have been performed before
referral. The effect of this is that the value of the test is
partly used-up, a phenomenon sometimes called
work-up bias (Begg 1987, Panzer et al. 1987). The
implication is that both sensitivity and specificity may

change if the test is carried out on another spectrum of
patients not exposed to such a prior selection process
(Sackett & Haynes 2002). It follows that a careful
description of the patient spectrum and how they are
selected is crucial to enable proper assumptions about
whether or not it is acceptable to generalize the results.
Laser Doppler flowmetry was introduced more than
20 years ago and has been proposed as an alternative
means of assessing pulp vitality. Yet, clinical applicability has still not been ascertained. The method is also
expensive and requires technique-sensitive equipment.
A study examining the feasibility of the method in
clinical practice observed variable and uncertain results
when the test conditions were not highly standardized
(Roy et al. 2008). Another limitation is that the method
is useful only in teeth with a pulp chamber positioned
well above the gingival margin. Pulse oximetry is based
on a simpler and less costly technology. Whilst
promising, this method is also limited to teeth with
pulp tissue well within the crown portion of the tooth.
In general, there were major shortcomings in the
design, conduct and reporting of studies. The extent to
which they satisfied important quality criteria is
illustrated in Fig. 2. The population was inadequately
described in nearly all, and only one study used
consecutively chosen patients. The use of nonconsec-
utive patients tends to overestimate the accuracy of a

diagnostic method (Lijmer et al. 1999, Rutjes et al.
2006). In half of the studies, the index tests and
reference tests were insufficiently described. Few studies
had two independent assessors of the reference test,
which introduces an obvious risk for a biased assessment of the pulps condition. Another serious shortcoming is that it was usually not possible to discern
whether the reference test was interpreted independently and without knowledge of the results of the
index test. If the assessors interpret the reference test
knowing the results of the index test, there will be an
increased risk of overestimating test accuracy (Lijmer
et al. 1999). Precision (e.g. confidence intervals) of
point estimates was not reported in any of the studies.
In summary, there is a great need for improvement
in the design, conduct and reporting of studies on
diagnostic methods in endodontics. Tools for guiding
the performance of such studies can be found in
Standards for Reporting of Diagnostic Accuracy (Bossuyt et al. 2003), which corresponds to the Consort
Statement for randomised clinical studies (Moher et al.
2001).
This systematic review has revealed critical gaps in
knowledge concerning the effect of diagnostic tests
commonly used to determine the condition of pulp.
Thus, available research provides limited information
Yes
Unclear
No
100
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% %
Representative patient spectrum
Population adequately described
Reference test classifies the target condition correctly
Time interval between index- and reference test adequate
Reference test applied on all or on a randomized sample of patients
The same reference test irrespective of results of index test
Index test adequately described
Reference test adequately described
Index test interpreted without knowledge of results of reference test
Reference test interpreted without knowledge of results of index test
Uninterpretable test results reported
At least two independent examiners of reference test
Reliability concerning reference test reported

Precision of test results reported
Figure 2 Reporting of 14 quality criteria, modified after QUADAS (Whiting et al. 2003), of the 18 included studies regarding
accuracy of pulp diagnosis. Percentage distribution of yes/unclear/no of each criterion.
611
about what distinguishes a treatable from a nontreatable pulpal inflammation in teeth subjected to deep
caries, trauma or other injury. Future research should
focus on exploring methods that can disclose whether a
vital but injured pulp can be maintained, or whether it
should be removed and replaced with a root filling.
Furthermore, the long-term benefit to the patient,
which is the ultimate goal of any diagnostic procedure,
should be evaluated.
Conclusion
The scientific evidence is insufficient (sss) to assess
the accuracy of the following clinical signs, symptoms
or tests used to determine the condition of pulp:
hypersensibility to heat, response to cold, electric
stimulation or tenderness to percussion in asymptomatic teeth with deep caries lesions,
presence, character or duration of pain and
in terms of reversible/irreversible pulp inflammation.
The evidence base is also insufficient (sss) to assess
the accuracy of the following:
combining tests to determine the condition of pulp,
electrical or thermal pulp testing or methods for
measuring pulpal blood circulation to determine
whether the pulp is vital or nonvital and
biological markers of pulp inflammation, infection
or other tissue damage for predicting the outcome of
treatment intended to maintain an exposed pulp
vital and asymptomatic.
Conflict of interest
There were no conflicts of interest.
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Supporting information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1. Search terms for diagnosing the
condition of dental pulp in three databases: PUBMED
(NLM), EMBASE.COM (ELSEVIER) and COCHRANE
CENTRAL REGISTRY OF CONTROLLED TRIALS (WILEY).
Appendix S2. Excluded articles.
Please note: Wiley-Blackwell are not responsible for
the content or functionality of any supporting materials
supplied by the authors. Any queries (other than
missing material) should be directed to the corresponding author for the article.
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doi:10.1111/j.1365-2591.2012.02016.

Diagnosis of the condition of the dental pulp: a

I. A. Meja`re1,2, S. Axelsson2, T. Davidson2,3, F. Frisk4,5, M. Hakeberg6, T. Kvist5, A. Norlund2,

The aim of this systematic review was to appraise the

2012 International Endodontic Journal

tially relevant. Altogether, 155 articles were read in full

treatment decision. Important information in this

International Endodontic Journal, 45, 597613, 2012

Diagnosis of dental pulp Meja`re et al.

Diagnostic information is gained from the patients

Materials and methods

International Endodontic Journal, 45, 597613, 2012

Controlled Trials and Cochrane Reviews from January

2012 International Endodontic Journal

Meja`re et al. Diagnosis of dental pulp

Abstracts from electronic search

Articles from other sources,

Study quality: High

Study quality: Moderate

Study quality: Low

times more likely particular test results are in patients

2012 International Endodontic Journal

International Endodontic Journal, 45, 597613, 2012

Diagnosis of dental pulp Meja`re et al.

Table 1 Pre-specified inclusion and exclusion criteria

Cross-sectional, casecontrol, prospective cohort

A casecontrol design was accepted as well as nonrandom or nonconsecutive enrolment of patients.

Low: high risk of selection

Criteria of moderate quality not met

1973, Dummer et al. 1980, Klausen et al. 1985, Olgart

International Endodontic Journal, 45, 597613, 2012

designed to assess the accuracy of signs and symptoms

Signs and symptoms as indicators of the

2012 International Endodontic Journal

Meja`re et al. Diagnosis of dental pulp

were compared with the degree of pulp inflammation as

2012 International Endodontic Journal

with wide confidence intervals, and the study has

Sensibility and vitality testing

International Endodontic Journal, 45, 597613, 2012

International Endodontic Journal, 45, 597613, 2012

Study design and

Markers of pulp status:

Histology of pulp after

Loss of sleep because of pain:a

Diagnosis of dental pulp Meja`re et al.

2012 International Endodontic Journal

2012 International Endodontic Journal

Study design and

Accuracy of pulp Cross-sectional:

Markers of pulp status:

Histology of extirpated pulp

Visual examination after pulp

Clinical and histological diagnoses

LDF with flux values at <7.0 and

Meja`re et al. Diagnosis of dental pulp

International Endodontic Journal, 45, 597613, 2012

Study design and

Gopikrishna et al. Accuracy of pulp Cross-sectional:

Markers of pulp status:

Visual examination after pulp

International Endodontic Journal, 45, 597613, 2012

Abnormal reaction to heat:a