Endodontic Topics 2004, 7, 2–13 Copyright r Blackwell Munksgaard

Printed in Denmark. All rights reserved ENDODONTIC TOPICS 2004

Technical equipment for

assessment of dental pulp status
THOMAS R. PITT FORD & SHANON PATEL

Assessment of dental pulp status is normally undertaken using thermal or electrical tests that indicate the
functioning of Ad nerve fibers. The tests are quick and usually reliable, although nothing is absolute. Newer tests
have involved assessment of blood flow, and of these laser Doppler flowmetry has been the most widely used and
beneficial to patients particularly after traumatic injury. The high cost of flowmeters and the time-consuming
procedure have limited uptake.

The diagnosis of dental pulp status should be seen as a Sensitivity testing

synthesis of history, clinical examination, special tests,
Currently, the most widely used vitality testers assess
and radiological examination, and not as the out-
the integrity of the Ad nerve fibers in the dentine–pulp
come of one specific test. Too often dentists base
complex by briefly applying the stimulus to the outer
treatment decisions on limited information that may be
surface of the tooth. If the Ad nerve fibers are
contradictory; this is not in the best interests of
successfully stimulated, the patient will respond by
patients.
acknowledging a brief sharp sensation/tingling from
Vitality testing is an important aid in the diagnosis of
the tooth. The test indicates that the nerve fibers are
pulp disease and apical periodontitis. If the pulp is
functioning but does not give any indication of blood
deemed to be unhealthy as a result of the diagnostic
flow in the pulp, or whether it is partially damaged. If
synthesis, then endodontic treatment is indicated. In
there is no blood flow in the pulp, it will rapidly become
particular, pulp vitality testing should be carried out on
anoxic and the Ad fibers will cease to function.
traumatized teeth over an extended period to monitor
However, there are instances, for example, after
their vitality following the traumatic incident, as teeth
trauma, where there is blood flow in the pulp but the
which may initially not respond to testing may well do
Ad nerve fibers are not functioning.
so after a period of months (1, 2). It is important to
assess pulp vitality prior to undertaking extensive tooth
preparation in order to improve the prognosis of the
Thermal testing
restoration (3). It is also desirable to confirm periodi-
cally continued pulp vitality in teeth that have under- Thermal testing relies upon applying heat or cold to a
gone pulp preservation procedures or have had localized part of the tooth to stimulate Ad nerve fibers
extensive restorations (4). within the dental pulp. When the test is applied to a
As the dental pulp is enclosed in an opaque tooth, the healthy pulp it results in a sharp localized pain/tingling
assessment of pulp vitality is undertaken by: looking for sensation for the duration of the applied test and for a
clinical or radiological evidence of pulp necrosis or few seconds after removal of the stimulus (positive
apical periodontitis; investigating nerve conduction; or response). A pulp response lasting more than half a
examining blood flow. Diagnosis must not be made on minute after the stimulus has been removed is
the strength of one piece of evidence, but from all the frequently interpreted as indicating an irreversibly
evidence derived from the history and the examination. inflamed pulp. No response from the patient to such

2
 Assessment of dental pulp status

stimulation is normally regarded as an indication of a

necrotic pulp (negative response). The outcome of
such testing is never absolutely certain, and that is why
diagnosis must not rely on a single test.

Cold tests
It is believed that cold thermal testing causes contrac-
tion of the dentinal fluid within the dentinal tubules;
this results in rapid outward flow of fluid within the
patent tubules (5, 6). The rapid movement of dentinal
fluid results in ‘hydrodynamic forces’ acting on the Ad
nerve mechanoreceptors within the pulp–dentine
complex leading to a sharp sensation lasting for the
duration of the thermal test (7).
Currently, there are several different cold tests that
may be applied to teeth, the major difference between
them being the degree of cold. Ice sticks can be made in
the dental surgery by freezing water in local anesthetic
needle sheaths, which have not been contaminated or
have been adequately disinfected. When required, they
may be taken out of the freezer and briefly run under
the tap to melt the surface thus allowing the ice stick to
be removed from the plastic sheath. One half of the ice Fig. 1. A container of compressed refrigerant spray,
stick is then wrapped with gauze to act as a handle; the dichloro-difluoro-methane (Endo-Frost, Roeko, Langenau,
other end may then be applied to the tooth under Germany).
investigation.
Ethyl chloride (boiling point 41C) may be sprayed
on to a cotton pledget resulting in the formation of ice
crystals; it is then applied to the tooth. Dichloro-
difluoro-methane (DDM) (boiling point 501C) is a
compressed refrigerant spray (Fig. 1), which can simi-
larly be sprayed on to a cotton pledget and applied to
the tooth under investigation (Fig. 2). More recently,
ozone friendly non-chlorofluorocarbon sprays have
been introduced in certain countries (8).
Another effective cold test is carbon dioxide (CO2)
snow (boiling point 721C). The CO2 gas is released
from a gas cylinder into a plastic plunger mechanism
(Fig. 3) and compressed to produce a stick of CO2. By
using a special applicator it may then be applied to the
tooth under investigation (Fig. 4). This investigation is Fig. 2. Iced cotton pellet in tweezers following spraying
especially effective when attempting to assess teeth that of Endo-Frost.
have been restored with full coverage metal restorations
(9). Concerns regarding possible damage to enamel this may be due to their greater rate of temperature
and healthy pulps of teeth from the extreme cold of this reduction (12).
test appear to be unfounded (10). The colder tests Ice-cold water is another useful and inexpensive test.
(DDM and CO2 snow) appear to be the more reliable The tooth under investigation is isolated with rubber
than ethyl chloride (8, 11) in stimulating vital teeth; dam and then bathed with water from a syringe (Fig. 5).

3
Pitt Ford & Patel
Fig. 3. Plastic cartridge attached to a cylinder of CO2.
Fig. 4. A stick of dry ice in its applicator on the tooth.
Fig. 5. Tooth isolated with rubber dam and bathed in
cold water.
The advantages of this cold test are that the entire tooth
is cooled down and teeth restored with full coverage
metal restorations may be evaluated, thus resulting in a
4
very clear response from the patient (8). Cold tests
should be applied until the patient definitely responds
to the stimulus or for a maximum of 15 s, whichever
comes first (12).
Cold tests have appeared to be more reliable than
heat tests (3, 13). There is a general consensus that the
colder the stimulus, the more effective the investigation
is in assessing the status of the nerve supply within the
tooth (8, 9, 12, 14).
Heat tests
A gutta-percha stick may be heated with a naked flame
or an electric heater until it becomes soft and glistens
(15) and applied to the Vaseline-coated surface of the
tooth under investigation (Fig. 6). It has been believed
that a tooth-surface temperature as high as 1501C
could be achieved with this technique (16); gutta-
percha softens at 651C and may be heated in delivery
devices up to 2001C. This test may be difficult to use on
posterior teeth because of limited access (3). The
disadvantage of using heated gutta-percha is that
prolonged heating could result in pulp damage (17).
Prolonged heat application will result in bi-phasic
stimulation of initially Ad fibers and then C fibers
within the pulp (18) resulting in a lingering pain;
therefore, heat tests should be applied for no more than
5 s. Inadequate heating of the gutta-percha stick could
result in the stimulus being too weak to elicit a response
from the pulp (19).
The tooth under investigation may be isolated with
rubber dam and submerged with hot water from a
syringe (20); this is not only the most effective method
of testing the entire crown instead of just one aspect but
Fig. 6. Heated stick of gutta-percha (Obtura) applying
heat to a tooth.

Fig. 7. A rubber cup applied to a tooth to generate fric-
tional heat.
also allows rapid heating of the tooth. Frictional heat
may be generated by using a rubber cup intended for
prophylaxis (without paste) against the buccal aspect of
a tooth (Fig. 7) (20, 21). The normal use of thermal
tests on teeth has been shown not to be harmful to
healthy pulp tissue (10, 22).
Electric pulp testing
The objective of electric pulp testing is to stimulate
intact Ad nerves in the pulp–dentine complex by
applying an electric current on the tooth surface. A
positive result from electric pulp testing is a result of an
ionic shift in the dentinal fluid within the tubules
causing local depolarization and subsequent generation
of an action potential from the intact nerve (23).
The electric pulp tester consists of a battery-operated
unit, which is connected to a probe that is applied to the
tooth under investigation. The electrical circuit is
completed by the patient holding the rear end of the
handle of the probe (Fig. 8), or by placing a hook over
the patient’s lower lip (Fig. 9). Two widely used pulp
testers are the Analytic Technology pulp tester and the
Vitality Scanner (Analytic Sybron Dental Specialities,
Orange, CA, USA). Electric pulp testers function by
producing a pulsating electrical stimulus, the intensity
of which automatically begins from a very low value to
Assessment of dental pulp status
Fig. 8. An isolated tooth undergoing electric pulp
testing. Electrical conducting gel is present between the
electrode and the tooth.
Fig. 9. An isolated tooth undergoing electric pulp
testing. A hook on the patient’s lip completes the
circuit. Rubber dam has been used to isolate the tooth
from those adjacent.
prevent unnecessarily excessive stimulation and dis-
comfort. The intensity of the electrical stimulus steadily
increases at a preselected rate; a note is made of the
reading on the digital display when the patient
acknowledges a warm or tingling sensation. The output
characteristics of this unit have been investigated (24).
The rate of voltage increase was also found to vary
depending on the device used. A further investigation
concluded that there was no consistency in threshold
excitation values for healthy teeth (25). The readout is
not a quantitative measurement of the health of the
pulp, and therefore does not indicate to what extent the
pulp is healthy/unhealthy; a response only implies that
the Ad fibers are sufficiently healthy to function.
5
Pitt Ford & Patel
Fig. 10. A small tip for the electric pulp tester can be used
under crown margins.
The electric pulp tester is technique sensitive (26,
27). The tooth to be assessed should be sufficiently dry
to prevent electrical conduction to adjacent teeth, or to
the periodontium although the current is unlikely to be
sufficient (24). A conducting medium should be
applied to the electrode to ensure maximum current
passes from the electrode to the tooth surface (27). It is
important to make sure that the electrode lies flat
against the surface of the tooth (therefore maximising
electrode contact area) as this also reduces the response
threshold value (27). Cellulose strips or rubber dam
strips may be used interproximally to prevent electrical
conduction to adjacent teeth (Fig. 9). Direct contact
with tooth tissue is required, and this may be a problem
with extensively restored teeth (9). However, a small tip
is available that may be used instead of the standard
electrode tip; this allows tooth contact below a crown
margin where there is slight gingival recession (Fig.
10). The threshold excitation value is influenced by the
position of the electrode on the tooth; for example, the
lowest threshold for response and therefore most
desirable area of assessment in incisor teeth is at the
incisal edge, where the enamel is thinnest or absent
(28). The tester should be applied on the tooth surface
adjacent to a pulp horn, that is, the region of highest
nerve density within the pulp (29–31); this is the
incisal-third of anterior teeth and the mid-third of
posterior teeth. The threshold for response may be
influenced by the thickness of the enamel and dentine
overlying the pulp (18, 32); therefore, it has been
considered that the response threshold in healthy teeth
may be lowest in incisors, slightly greater in premolars
and greatest in molar teeth. However, in one study
using two pulp testers, the threshold was lower in
premolars than incisors (25). Signs of tooth surface loss
6
may result in a lowering of the response threshold due
to increased exposure of dentine (28). Multi-rooted
teeth which give a negative result on one aspect may be
tested on the opposite surface to ensure that as much of
the pulp as possible has been stimulated.
General considerations of sensitivity tests
The patient should be advised of the purpose of the test,
what to expect, and also reassured that the aim of the test
is not to elicit an unpleasant response. A vital
contralateral tooth should be tested prior to assessing
the tooth under investigation. First, this allows the
patient to learn what to expect with the test, and
secondly gives the clinician an idea of the duration of the
thermal test and also the patient’s response. To improve
objectivity the tests should be repeated after a recovery
period of 1 min, unless too much discomfort has been
caused. The teeth on either side of the tooth being
assessed should also be tested as this will aid in diagnosis.
A large clinical study assessed by thermal and electric
pulp testing 166 teeth, which were subsequently
extracted and examined histologically (21). Although
it was concluded that there was a poor overall
correlation between clinical signs and the pathological
state of the pulp, there did appear to be a relationship
between a negative response to electric pulp tester and
total pulp necrosis. A similar investigation (33) that
assessed 75 teeth also found no relationship between
the condition of the pulp from the clinical examination
and investigation using the same complex histological
classification (seven pulp state categories). However,
when the data from this investigation were examined at
a broader level, a correlation was apparent between
total necrosis and a negative response to thermal
testing. With both investigations there is no mention
of how soon after the clinical examination the teeth
were extracted. In one investigation (33) only step-
serial histological sections were examined; thus, poten-
tially useful information may not have been evaluated.
A retrospective evaluation was carried out on the
results of five studies in which teeth had been clinically
assessed, extracted and examined histologically (34). It
was concluded that the results of diagnostic investiga-
tions were more likely to be correct in cases of disease-
free teeth rather than in teeth with pulp disease.
Responses from thermal and electric pulp testing are
not quantitative and therefore do not give information
on how healthy or to what degree the pulp is inflamed.

Problems with current devices/assessing
pulp status
At present the techniques that are commonly used in
everyday practice (i.e. thermal and electric pulp testing)
assess whether the nerve supply within the tooth is
intact. A positive result confirms that the Ad nerves in
this region of the pulp chamber are responsive; the
inference is that this can be interpreted as there being
an intact blood supply within the tooth. However, the
only true means of assessing the health of the pulp is to
determine that there is a normal flow of blood within
the tooth (Table 1).
Thermal tests are highly subjective as they are wholly
dependent on the patient’s response to testing. There is
no accurate or objective method of assessing how
responsive the tooth under investigation is to testing,
nor of comparing with a previous measurement. In
contrast, electric pulp testers have numerical digital
displays, which allow the operator to note down the
reading, and compare with a previous reading.
False-positive results (i.e. non-vital teeth
responding positively to testing)
These are summarized in Table 2. Because sensitivity
tests are reliant on the patient’s response, a premature
response or even a false-positive response may occur in
anxious or young patients who are expecting to feel an
unpleasant sensation (27, 28). It has been suggested
that localized breakdown products in one part of the
root canal system may be able to conduct the electric
current from an electric pulp tester to viable nerve
tissue in adjacent areas thereby resulting in a false-
positive result (33). Contact with metal restorations
may possibly result in conduction of the current to the
Table 1. Ideal features of a pulp vitality tester
Assesses pulp blood flow
Objective measurements
Free from error
Effective for heavily restored teeth
Effective when the pulp size is reduced
Quick and easy to use
Inexpensive
Assessment of dental pulp status
Table 2. False responses from pulp testing
False positives
 Anxious patients
 Liquefaction necrosis
 Contact with metal restorations
 Vital tissue still present in partially necrotic root canal
system
False negatives
 Incomplete root development
 Recently traumatized teeth
 Sclerosed canals
 Recent orthodontic activation
 Patients with psychotic disorders
periodontium, giving a false-vital response (14); the
same may occur with inadequately dried teeth prior to
testing (14, 35). Multi-rooted teeth pose an additional
problem because the pulp in the tooth under investiga-
tion may be partially necrotic; therefore, part of the root
canal system may still possess relatively healthy pulp
tissue (36). There has been a report of three previously
root-treated maxillary molars, which responded posi-
tively to testing, and on root canal retreating the teeth
untreated second mesio-buccal canals were identified
(36); it was concluded that viable tissue in the second
mesio-buccal canal resulted in the positive response.
False-negative results (i.e. vital teeth
responding negatively to testing)
These are also summarized in Table 2. Teeth with
incomplete root development may have a higher
threshold to testing; thus, a stronger stimulation may
be needed to elicit a response compared with teeth with
complete root development (37). This is because teeth
erupt and become functional before the completion of
neural development (38, 39). In these situations cold
testing with DDM or CO2 snow appears to be more
reliable than electric pulp testing (12, 37). It has also
been suggested that cold tests may not be reliable in
teeth with obliteration of the coronal pulp as the
excessive dentine may act as an insulator to cold tests
(40). Traumatized teeth may not initially respond to
7
Pitt Ford & Patel
thermal and/or electric pulp testing or only respond
weakly (28). It has been postulated that non-responsive
recently traumatized immature teeth do not respond to
sensitivity testing because the nerves have been
ruptured (41). However, the pulps of the teeth may
still be vital as their blood vessels may remain intact or
have revascularized. Therefore, traumatized teeth
should always be carefully monitored at periodic
intervals as their pulps may revascularize and their
nerve fibers regain function. The vitality of teeth after
the activation of fixed orthodontic appliances has been
assessed by thermal and electric pulp testing for up to 2
months afterwards (42). A lack of response was found
to the electric pulp tester for up to 2 months after
activation of the appliances; however, thermal testing
appeared more reliable. This may be due to a reduction
in blood flow and possible anoxia of the Ad nerves (43).
Patients with psychotic disorders may not respond to
pulp testing (27). It has been reported that individuals
who are under the influence of sedative drugs/alcohol
may either not respond or respond to stronger
stimulation due to their increased threshold to nerve
excitation (44).
Physiometric testing
Crown surface temperature/heat
registration
The evaluation of tooth-surface temperature as a means
of assessing the vitality of teeth has been reported.
Cholesteric liquid crystals, which exhibit different
colors when heated, have been used in one study to
determine pulp vitality (45). It was based on the
principle that teeth with an intact pulp blood supply
(vital/healthy pulp status) had a warmer tooth-surface
temperature compared with teeth that had no blood
supply.
Surface temperature of teeth has been measured over
a period of time at 15-s intervals using an electric
thermometer attached to a surface probe, which was
placed in contact with the tooth (46, 47). These studies
showed that after teeth were cooled, there was only a
rise in the temperature of vital teeth.
Thermographic imaging has been used to show that
when teeth have been cooled, non-vital teeth were
slower to rewarm than vital teeth (48). Further work in
this area has resulted in the development of an index to
8
allow for future comparison of thermographic imaging
with laser Doppler flowmetry (LDF) in order to
determine pulp blood flow (49). A disadvantage of
this technique is that teeth must be isolated with rubber
dam, after which a period of acclimatization is necessary
prior to imaging (50). The technique is complex and
also requires the subjects to be rested for 1 h prior to
testing (50).
Photoplethysmography
The detection of blood flow within the pulp by passing
light through the tooth has been reported (51).
Hemoglobin absorbs certain wavelengths of light,
while the remaining light passes through the tooth
and is detected by a receptor. Photoplethysmography
has been compared with LDF in experiments on skin,
and found to be of similar value (52). The technique
has not been successfully developed further for dental
application apart from one recent investigation (53).
LDF
LDF is a non-invasive method of assessing and
measuring the blood flow of pulp tissue (54). Laser
light is directed onto the tooth under investigation by
securing a fiber-optic probe against the tooth surface.
The laser light from the probe (Fig. 11) passes along
the enamel prisms to the enamel–dentine junction and
the S-shaped dentinal tubules, which act as light guides,
to the pulp (Fig. 12) (55, 56). Light absorbed by red
blood cells in the capillary plexus is scattered and
undergoes a shift in frequency according to the
Doppler principle; light absorbed by stationary objects
does not undergo a shift in frequency. A signal is
produced which measures the flux of the blood cells
(number of red blood cells times mean velocity). The
proportion of Doppler-shifted light is detected by a
photodetector. The detected signal is weak and there-
fore highly amplified; a mathematical calculation using
Fourier analysis can be used to gain more meaningful
information (57). A trace of signals from vital and non-
vital teeth is shown in Fig. 13. Fourier analysis of the
traces has revealed a heart beat frequency in the vital
tooth, but not in the non-vital tooth (Fig. 14), and is
therefore an effective discriminator.
This technique is more objective and reliable than
sensitivity testing in assessing and following up the pulp
status of traumatized teeth (1, 54, 58, 59). It is usually

Fig. 11. A LDF probe showing laser light guides.
used when available evidence is contradictory. Several
reports have found earlier positive responses with LDF
when compared with sensitivity testing in traumatized
teeth (2, 60, 61), therefore avoiding unnecessary
invasive treatment. In addition, LDF offers the
advantage of storing data, allowing initial baseline
measurements to be compared objectively with sub-
sequent LDF measurements (61). There has been little
use of LDF on decayed or heavily restored teeth (62).
Unfortunately there are some drawbacks to LDF.
The device is technique sensitive and requires prepara-
tion of a putty splint to hold the probes (Figs 15 and
16), and a patient who is relaxed and not anxious. It is
necessary to ensure that the reflected signal only comes
from the pulp; this may be readily achieved with an
opaque putty splint (63) or by isolating the teeth with
rubber dam (64). In the case of following up teeth that
have had traumatic injuries, reusing the putty splint
ensures that the probe is reapplied to the same site and
therefore to the same part of the pulp unless growth
Assessment of dental pulp status
Fig. 12. A LDF probe applied to a sectioned tooth
showing the passage of light via the enamel prisms and
dentinal tubules to the pulp.
Fig. 13. A LDF trace showing signals from two teeth; the
upper is from a vital tooth while the lower is from a non-
vital tooth.
prevents repositioning of the splint. The available LDF
equipment has primarily been developed for medical
use (Fig. 17) and is expensive. It is probably for
this reason that LDF has generally not been used
as a routine special investigation in dental practice.
It has been used to observe the effects of local
anesthetic solutions on pulp blood flow during
anesthesia (63, 65).
Pulse oximetry
Pulse oximetry is a non-invasive technique to measure
oxygen saturation levels within the blood of patients
9
Pitt Ford & Patel
Fig. 14. Fourier analysis of the LDF traces reveals the
vital tooth to have a heart beat frequency (lower) while
there is no such frequency peak for the non-vital tooth
(upper).
Fig. 15. Two probes have been placed in a putty
impression splint for accurate location on the teeth
while the trace is being recorded.
Fig. 16. The splint in position on the patient’s teeth.
10
Fig. 17. A laser Doppler flowmeter (Moor Instruments,
Axminster, UK).
under general anesthesia or sedation; this device has
been modified to investigate its suitability for assessing
pulp vitality (66, 67). A modified probe has been fitted
over the tooth, and diodes emit two wavelengths of
light (infra-red and red) that are intended to pass
through the tooth and are then detected by a
photodetector diode. The oxygenation saturation of
the pulp blood supply is calculated from the ratio of
absorption of the oxygenated and deoxygenated blood
(68). One early investigation assessing the possible use
of pulse oximetry for pulp vitality testing produced
disappointing results (67); this was probably because
the equipment being used was not designed, nor
suitably adapted, for teeth. In addition, light has been
shown not to pass straight through the tooth, but is
directed along dentinal tubules (56). More recent
investigation has concluded that pulse oximetry has
potential for assessing pulp vitality in immature per-
manent teeth (66) and perhaps traumatized teeth (69).
Future developments
For many teeth pulp testing can easily be undertaken
using current thermal or electrical tests, be they
modern refrigerants or electric pulp testers. For a
minority of teeth, these tests are inconclusive and
something better is needed. LDF is the most promising
alternative as it measures blood flow rather than nerve
conduction, and produces data that can be re-examined
at a later time. However, in heavily decayed teeth the
pulp has a much smaller volume than in a young sound
tooth (70); in short all tests are struggling under such
adverse conditions and this is an area for further

research. The cost of laser Doppler flowmeters is high,
because they are overspecified for pulp testing;
commercial development of a more appropriate flow-
meter would be welcomed.
Conclusion
The diagnosis of the state of the dental pulp is
frequently given insufficient attention by many den-
tists, and where doubt exists root canal treatment is too
often performed, even though it is a costly procedure,
and may reduce the prognosis for the restored tooth.
The profession needs to re-evaluate its attitude to
diagnosis of pulpal and periapical conditions for the
benefit of patients.
References
1. Olgart L, Gazelius B, Lindh-Strömberg U. Laser
Doppler flowmetry in assessing vitality in luxated
permanent teeth. Int Endod J 1988: 21: 300–306.
2. Odor TM, Pitt-Ford TR, McDonald F. Use of laser
Doppler flowmetry for pulp testing – preliminary
findings (Abstract). Int Endod J 1998: 31: 207.
3. Ehrmann EH. Pulp testers and pulp testing with
particular reference to the use of dry ice. Aust Dent J
1977: 22: 272–279.
4. Cvek M. A clinical report on partial pulpotomy and
capping with calcium hydroxide in permanent incisors
with complicated crown fracture. J Endod 1978: 4: 232–
237.
5. Brännström M. A hydrodynamic mechanism in the
transmission of pain-producing stimuli in dentine. In:
Anderson DJ, ed. Sensory Mechanisms in Dentine.
Oxford: Pergamon Press, 1963.
6. Brännström M. The hydrodynamic theory of dentinal
pain: sensation in preparations, caries and dentinal crack
syndrome. J Endod 1986: 12: 453–457.
7. Trowbridge HO, Franks M, Korostoff E, Emling R.
Sensory response to thermal stimulation in human teeth.
J Endod 1980: 6: 405–412.
8. Cohen S, Burns RC. Pathways of the Pulp, 8th edn. St.
Louis, MI, USA: Mosby, 2002, 14, 521.
9. Trope M, Sigurdsson A. Clinical manifestations and
diagnosis. In: Ørstavik D, Pitt Ford TR, eds. Essential
Endodontology: Prevention and Treatment of Apical Pe-
riodontitis. Oxford: Blackwell Science, 1998: 157–178.
10. Ingram TA, Peters DD. Evaluation of the effects of
carbon dioxide used as a pulpal test. Part 2. In vivo effect
on canine enamel and pulpal tissues. J Endod 1983: 9:
296–303.
11. Augsburger RA, Peters DD. In vitro effects of ice, skin
refrigerant, and CO2 snow on intrapulpal temperature.
J Endod 1981: 7: 110–116.
Assessment of dental pulp status
12. Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S.
Assessment of reliability of electrical and thermal pulp
testing agents. J Endod 1986: 12: 301–305.
13. Seltzer S, Bender IB, Ziontz M. The dynamics of pulpal
inflammation: correlation between diagnostic data and
actual histological findings in the pulp. Oral Surg Oral
Med Oral Pathol 1963: 16: 973–977.
14. Chambers IG. The role and methods of pulp test-
ing in oral diagnosis: a review. Int Endod J 1982: 15:
1–5.
15. Grossman LI. Clinical diagnostic methods. In: Endodon-
tic Practice, 10th edn. Philadelphia: Lea and Febiger,
1981: 17–22.
16. Rowe AHR, Pitt Ford TR. The assessment of pulpal
vitality. Int Endod J 1990: 23: 77–83.
17. Mumford JM. Evaluation of gutta percha and ethyl chlo-
ride in pulp-testing. Brit Dent J 1964: 116: 338–343.
18. Närhi MVO. The characteristics of intradental sensory
units and their responses to stimulation. J Dent Res
1985: 64(Special issue): 564–571.
19. Lundy T, Stanley HR. Correlation of pulpal histopathol-
ogy and clinical symptoms in human teeth subjected to
experimental irritation. Oral Surg Oral Med Oral Pathol
1969: 27: 187–201.
20. Pitt Ford TR, Rhodes JS, Pitt Ford H. Endodontics.
Problem-Solving in Clinical Practice. London: Martin-
Dunitz, 2002: 12.
21. Walton RE, Torabinejad M. Diagnosis and treatment
planning. In: Walton RE, Torabinejad M. Principles and
Practice of Endodontics, 3rd edn. Pennsylvania: WB
Saunders, 2001: 49–70.
22. Rickoff B, Trowbridge H, Baker J, Fuss Z, Bender IB.
Effects of thermal vitality tests on human dental pulp. J
Endod 1988: 14: 482–485.
23. Pantera EA, Anderson RW, Pantera CT. Reliability of
electric pulp testing after pulpal testing with dichlorodi-
fluormethane. J Endod 1993: 19: 312–314.
24. Dummer PMH, Tanner M, McCarthy JP. A laboratory
study of four electric pulp testers. Int Endod J 1986: 19:
161–171.
25. Dummer PMH, Tanner M. The response of caries-free,
unfilled teeth to electrical excitation: a comparison of two
new pulp testers. Int Endod J 1986: 19: 172–177.
26. Millard HD. Electric pulp testers. Council on Dental
Materials and Devices. J Am Dent Assoc 1973: 86: 872–
873.
27. Cooley RL, Robison SF. Variables associated with electric
pulp testing. Oral Surg Oral Med Oral Pathol 1980: 50:
66–73.
28. Bender IB, Landau MA, Fonsecca S, Trowbridge HO.
The optimum placement-site of the electrode in electric
pulp testing of the 12 anterior teeth. J Am Dent Assoc
1989: 118: 305–310.
29. Lilja J. Innervation of different parts of the predentin and
dentin in young human premolars. Acta Odontol Scand
1979: 37: 339–346.
30. Byers MR, Dong WK. Autoradiographic location of
sensory nerve endings in dentin of monkey teeth. Anat
Rec 1983: 205: 441–454.
11
Pitt Ford & Patel
31. Byers MR. Dental sensory receptors. Int Rev Neurobiol
1984: 25: 39–94.
32. Rubach WC, Mitchell DF. Periodontal disease, age, and
pulp status. Oral Surg Oral Med Oral Pathol 1965: 19:
482–493.
33. Dummer PMH, Hicks R, Huws D. Clinical signs
and symptoms in pulp disease. Int Endod J 1980: 13:
27–35.
34. Hyman JJ, Cohen ME. The predictive value of endo-
dontic diagnostic tests. Oral Surg Oral Med Oral Pathol
1984: 58: 343–346.
35. Stock CJR. Patient assessment. In: Stock CJR, Gulabi-
vala K, Walker RT, Goodman JR, eds. Endodontics, 2nd
edn. London: Mosby-Wolfe, 1995.
36. Peters DD, Baumgartner JC, Lorton L. Adult pulpal
diagnosis. 1. Evaluation of the positive and negative
responses to cold and electrical pulp tests. J Endod 1994:
20: 506–511.
37. Fulling HJ, Andreasen JO. Influence of maturation
status and tooth type of permanent teeth upon electro-
metric and thermal pulp testing. Scand J Dent Res 1976:
84: 286–290.
38. Johnsen DC. Innervation of teeth: qualitative, quantita-
tive and developmental assessment. J Dent Res 1985:
64(Special issue): 555–563.
39. Fernhead RW. The histological demonstration of nerve
fibres in human dentine. In: Anderson DJ, ed. Sensory
Mechanisms in Dentine. Oxford: Pergamon Press, 1963:
15–26.
40. Bellizzi R, Hartwell GR, Ingle JI, Goerig AC, Nearerth
EJ, Marshall FJ, Krasny RM, Frank AL, Gaum C. Dia-
gnostic procedures. In: Ingle JI, Bakland LK, eds. Endo-
dontics, 4th edn. Malvern: Williams and Wilkins, 1994.
41. Bhaskar SN, Rappaport HM. Dental vitality tests and
pulp status. J Am Dent Assoc 1973: 86: 409–411.
42. Hall CJ, Freer TJ. The effects of early orthodontic force
application on pulp test responses. Aust Dent J 1998: 43:
359–361.
43. McDonald F, Pitt Ford TR. Blood flow changes in
permanent maxillary canines during retraction. Eur J
Orthod 1994: 16: 1–9.
44. Degering CI. Physiological evaluation of dental-pulp
testing methods. J Dent Res 1962: 41: 695–700.
45. Howell RM, Duell RC, Mullaney TP. The determination
of pulp vitality by thermographic means using cholesteric
liquid crystals. A preliminary study. Oral Surg Oral Med
Oral Pathol 1970: 29: 763–768.
46. Fanibunda KB. The feasibility of temperature measure-
ment as a diagnostic procedure in human teeth. J Dent
1986: 14: 126–129.
47. Fanibunda KB. Diagnosis of tooth vitality by crown
surface temperature measurement: a clinical evaluation.
J Dent 1986: 14: 160–164.
48. Pogrel MA, Yen CK, Taylor RC. Studies in tooth crown
temperature gradients with the use of infrared thermo-
graphy. Oral Surg Oral Med Oral Pathol 1989: 67: 583–
587.
49. Kells BE, Kennedy JG, Biagioni PA, Lamey PJ.
Computerized infrared thermographic imaging and
12
pulpal blood flow: part 1. A protocol for thermal
imaging of human teeth. Int Endod J 2000: 33:
442–447.
50. Kells BE, Kennedy JG, Biagioni PA, Lamey PJ.
Computerized infrared thermographic imaging and
pulpal blood flow: part 2. Rewarming of healthy human
teeth following a controlled cold stimulus. Int Endod J
2000: 33: 448–462.
51. Daley J, Boyd E, Cooper J, O’Driscoll P. Optical
assessment of dental pulp vitality. J Biomed Eng 1988:
10: 146–148.
52. Lindberg LG, Tamura T, Oberg PA. Photoplethysmo-
graphy. Part 1. Comparison with laser Doppler flowme-
try. Med Biol Eng Comput 1991: 29: 40–47.
53. Miwa Z, Ikawa M, Iijima H, Saito M, Takagi Y. Pulpal
blood flow in vital and nonvital young permanent teeth
measured by transmitted-light photoplethysmography: a
pilot study. Pediatr Dent 2002: 24: 594–598.
54. Gazelius B, Olgart L, Edwall B, Edwall L. Non-invasive
recording of blood flow in human dental pulp. Endod
Dent Traumatol 1986: 2: 219–221.
55. Odor TM, Watson TF, Pitt Ford TR, McDonald F.
Pattern of transmission of laser light in teeth. Int Endod J
1996: 29: 228–234.
56. Odor TM, Chandler NP, Watson TF, Pitt Ford TR,
McDonald F. Laser light transmission in teeth: a study of
the patterns in different species. Int Endod J 1999: 32:
296–302.
57. Odor TM, Pitt Ford TR, McDonald F. Effect of
wavelength and bandwidth on the clinical reliability of
laser Doppler recordings. Endod Dent Traumatol 1996:
12: 9–15.
58. Mesaros SV, Trope M. Revascularization of traumatized
teeth assessed by laser Doppler flowmetry: case report.
Endod Dent Traumatol 1997: 13: 24–30.
59. Roeykens H, Van Maele G, Martens L, De Moor R. A
two-probe laser Doppler flowmetry assessment as an
exclusive diagnostic device in a long-term follow-up of
traumatised teeth: a case report. Dent Traumatol 2002:
18: 86–91.
60. Roeykens H, Van Maele G, De Moor R, Martens L.
Reliability of laser Doppler flowmetry in a 2-probe
assessment of pulpal blood flow. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1999: 87: 742–
748.
61. Lee JY, Yanpiset K, Sigurdsson A, Vann WF. Laser
Doppler flowmetry for monitoring traumatized teeth.
Dent Traumatol 2001: 17: 231–235.
62. Wilder-Smith PE. A new method for the non-invasive
measurement of pulpal blood flow. Int Endod J 1988:
21: 307–312.
63. Odor TM, Pitt Ford TR, McDonald F. The effect
of inferior alveolar nerve block anaesthesia on the
lower teeth. Endod Dent Traumatol 1994: 10: 144–
148.
64. Soo-ampon S, Vongsavan N, Soo-ampon M, Chuckpai-
wong S, Matthews B. The sources of laser Doppler
blood-flow signals recorded from human teeth. Arch
Oral Biol 2003: 48: 353–360.

65. Pitt Ford TR, Seare MA, McDonald F. Action of
adrenaline on the effect of dental local anaesthetic
solutions. Endod Dent Traumatol 1993: 9: 31–35.
66. Goho C. Pulse oximetry evaluation of vitality in primary
and immature permanent teeth. Pediatr Dent 1999: 21:
125–127.
67. Kahan RS, Gulabivala K, Snook M, Setchell DJ.
Evaluation of a pulse oximeter and customized probe
for pulp vitality testing. J Endod 1996: 22: 105–109.
Assessment of dental pulp status
68. Schnettler JM, Wallace JA. Pulse oximetry as a diag-
nostic tool of pulpal vitality. J Endod 1991: 17: 488–
490.
69. Radhakrishnan S, Munshi AK, Hegde AM. Pulse
oximetry: a diagnostic instrument in pulpal vitality
testing. J Clin Pediatr Dent 2002: 26: 141–145.
70. Chandler NP, Pitt Ford TR, Monteith BD. Coronal pulp
size in molars: a study of bitewing radiographs. Int Endod
J 2003: 36: 757–763.
13