Accuracy of the American Association of Endodontists diagnostic criteria for assessing pulp health in primary teeth.

OBJECTIVES: There is a lack of studies evaluating the accuracy of the 2009 American Association of Endodontists (AAE) diagnostic criteria for diagnosing pulpal health in primary teeth. This study aimed to estimate and correlate the diagnostic accuracy of clinical diagnosis of reversible and irreversible pulpitis using the 2009 AAE criteria with histological findings in primary teeth. METHODS: Eighty primary teeth that were clinically diagnosed with normal pulp (n = 10), reversible pulpitis (n = 30), irreversible pulpitis (n = 30) and pulp necrosis (n = 10) were collected. The teeth were histo-processed, and pulp tissues were diagnosed histologically as uninflamed pulp, reversible or irreversibly inflamed and necrosis based on previously proposed criteria. RESULTS: The clinical diagnosis of pulp necrosis (sensitivity 70%, specificity 96%) and normal pulp (sensitivity 91%, specificity 100%) matched the histological diagnosis of necrosis and uninflamed pulp in 70% and 100%, respectively. The clinical diagnosis of irreversible pulpitis (sensitivity 64%, specificity 72%) matched the histological diagnosis of irreversible pulp inflammation for 47% of teeth evaluated. For the clinical diagnosis of reversible pulpitis (sensitivity: 65%, specificity: 86%), 80% matched the histological diagnosis of reversible pulp inflammation. Teeth with histologically diagnosed irreversible pulp inflammation were more likely to have lingering (OR 5.08; 95% CI 1.48-17.46, P = 0.010) and nocturnal tooth pain (OR 15.86; 95% CI 1.57-160.47, P = 0.019) when compared to teeth with reversible pulp inflammation. Using the classification and regression tree model, the presence of widened periodontal ligament space and nocturnal tooth pain were useful predictors of irreversible pulp inflammation with an accuracy of 78%. CONCLUSION: The 2009 AAE criteria was acceptable for primary teeth with pulp necrosis and normal pulp but poor for reversible pulpitis and irreversible pulpitis.

Diagnosis and management of transverse root fractures.

BACKGROUND: Root fractures are not a common injury, but a thorough understanding of their etiology, healing responses, diagnosis, management, and prognosis is essential. REVIEW: The prognosis is largely related to the patient's age; degree of displacement, if any, of the coronal fragment; and the location and orientation of the fracture. The more apical the fracture is located, the better the prognosis. Teeth with root fractures located supracrestally may have the worst prognosis, but their management and outcome depend on many factors, with the most influential factor being the ability to restore the tooth because the coronal fragment usually needs to be removed. In contrast, root fractures located in the apical and middle thirds and those subcrestally in the coronal third of the root have a good prognosis and usually require little, if any, treatment apart from immediate repositioning (if the coronal fragment has been displaced) and stabilization. Monitoring of root-fractured teeth over time is essential to determine the healing response and to assess whether the pulp survives or not. In some cases, the pulp in the coronal fragment may necrose and become infected, thus requiring root canal treatment, but this should only be done to the fracture line. Pulp necrosis and infection typically occur within the first 3-4 months if it is a direct result of the trauma. However, pulp necrosis and infection can also occur many years later, in which case it is likely to be a result of bacterial penetration via cracks or breakdown of restorations. CONCLUSION: Overall, root fractures should be managed conservatively unless they are located supracrestally.

Diagnostic accuracy of three placement sites for the cold test in subjects amongst different age groups.

BACKGROUND: The cold test is a specific test of pulp sensitivity and is part of the endodontic diagnosis. The aim of this study was to identify the diagnostic accuracy including sensitivity, specificity, accuracy, positive predictive value and negative predictive value in three sites for the cold test in teeth with a need for endodontic treatment within different age groups from both genders. METHODS: A cross-sectional study was performed, evaluating 425 subjects. Two hundred and fifty-eight subjects from both genders from the ages of 17-27, 28-39, 40-50, and 51-65 years-old participated in the study. The cold test studied was 1, 1, 1, 2-tetrafluoroethane, and the gold standard was established through direct pulp inspection. The sites evaluated in the study were: The sites evaluated in the study were: a) the middle third of the buccal surface; b) the cervical third of the buccal surface, and c) the middle third of the lingual surface. RESULTS: The highest diagnosted accuracy was observed on the middle third buccal surface with an accuracy of = 0.97, a sensitivity of = 1.00, a specificity of 0.95, a predictive value of = 0.95 and a negative predictive value of = 1.00. This was in the female group aged from 40 to 50 years old. CONCLUSION: The tables of this study can be used as an auxiliary for pulp sensitivity tests.

The diagnostic accuracy of laser Doppler flowmetry in assessing pulp blood flow in permanent teeth: A systematic review.

BACKGROUND/AIM: Pulp necrosis is a frequent complication following dental trauma. The diagnosis of the state of the dental pulp can be challenging as most commonly used diagnostic tools are subjective and rely on a response from the patient, potentially making their use unreliable, especially in the child population. The aim of the study was to systematically review the evidence on the use of laser Doppler flowmetry in the assessment of the pulp status of permanent teeth compared to other sensibility and/or vitality tests. METHODS: A systematic literature search, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, www.clinicaltrials.gov and www.controlled-trials.com, in addition to citation and manual reference list searches, was conducted up to 15th January 2018. A risk of bias assessment was performed using the quality assessment for diagnostic accuracy studies tool (QUADAS-2) with all steps performed independently by two reviewers. RESULTS: Four studies with a high risk of bias were included in the final analysis. Laser Doppler flowmetry was reported to be more accurate in differentiating between teeth with normal pulps and pulp necrosis with a sensitivity of (81.8%-100%) and specificity of 100% in comparison to other vitality tests such as pulp oximetry (sensitivity = 81.3%, specificity = 94.9%) and sensibility tests such as electric pulp testing (sensitivity = 63.3%-91.5%, specificity = 88%-100%). CONCLUSION: Despite the higher reported sensitivity and specificity of laser Doppler flowmetry in assessing pulp blood flow, these data are based on studies with a high level of bias and serious shortfalls in study designs. More research is needed to study the effect of different laser Doppler flowmetry's parameters on its diagnostic accuracy and the true cut-off ratios over which a tooth could be diagnosed as having a normal pulp.

Analysis of the characteristics of cracked teeth and evaluation of pulp status according to periodontal probing depth.

BACKGROUND: The purpose of this study was to analyze the characteristics of cracked teeth and to evaluate pulp status according to periodontal probing depth (PPD). METHODS: A total of 182 cracked teeth were included. The location and type of the cracked teeth, age and gender of the patients, restoration type, pulp status, PPD, and radiographic findings were analyzed. RESULTS: Mandibular second molars (25.3%) were the most frequently involved teeth, followed by mandibular first molars (22.5%), maxillary first molars (22.0%), and maxillary second molars (17.6%). The patient age was most frequently 50-59 years. Cracks occurred mainly in nonbonded restorations, such as gold (26.9%), and were usually found in intact teeth (37.9%). A total of 103 teeth (56.6%) had an initial PPD of less than 3 mm, while 40 (22.0%) had a PPD of 4-6 mm, and 39 (21.4%) had PPD of 7 mm or more. A total of 33 cracked teeth (18.1%) were diagnosed with pulp necrosis, 40 (22.0%) with irreversible pulpitis, and 97 (53.3%) with reversible pulpitis. The incidence of pulp necrosis was 31.8% among cracked teeth with a PPD of 4-6 mm, and 28.6% among those with a PPD of 7 mm or more. CONCLUSIONS: Cracks occurred mainly in molar teeth, and were commonly found in intact teeth with no restoration. Patients with cracked teeth were most frequently aged 50-59 years. Cracked teeth showing a PPD of more than 4 mm were more likely to show pulp necrosis.

Effect of maintaining apical patency on endodontic pain in posterior teeth with pulp necrosis and apical periodontitis: a randomized controlled trial.

AIM: To evaluate the association between apical patency and post-operative pain in posterior teeth with pulp necrosis and apical periodontitis. METHODOLOGY: Sixty-eight patients requiring primary root canal treatment in mandibular first molars with necrotic pulps and apical periodontitis were included. The patients were randomly allocated to one of two groups: patency (n = 34) and nonpatency (n = 34). After administering local anaesthesia, root canal preparation was completed using ProTaper rotary instruments. A size 10 K-file was used as a patency file and carried 1 mm beyond the working length (WL) between each instrument change in the patency group, while it was carried up to WL in the nonpatency group. Patients were asked to record their pain experience on a pain chart daily for 7 days. Three patients (two in the patency group, one in the nonpatency group) did not return with completed pain charts on the subsequent visit, resulting in a total of 65 patients for the final analysis (patency, n = 32; nonpatency, n = 33). Data was analysed using Chi Square test, t-test, Mann-Whitney test and Wilcoxon Signed Ranks test. RESULTS: Overall, 43% of the patients experienced post-operative pain. The patency group had less incidence of pain (34%) as compared to the nonpatency group (52%), but the difference was not significant (P = 0.163). CONCLUSION: Maintenance of apical patency during chemomechanical preparation had no significant influence on post-operative pain in posterior teeth with necrotic pulps and apical periodontitis.

Pulse oximetry: a useful test for evaluating pulp vitality in traumatized teeth.

BACKGROUND AND AIM: Subjective pulp tests are not trustworthy, particularly in traumatized teeth, and may lead to inaccurate diagnosis. The use of an objective test such as pulse oximetry (PO) could be a more reliable method to properly evaluate pulp status in this condition. The aim of this study was to analyze the effectiveness of PO in determining pulp vitality in traumatized teeth based on oxygen saturation measurements (%SpO2 ). SUBJECTS AND METHODS: Fifty-nine permanent teeth that had undergone lateral luxation, and which were unresponsive to a cold spray test and were free from signs of necrosis, were selected and tested with PO at 7, 30 and 60 days after trauma. RESULTS: Fifty-nine teeth were tested. At 7 days after trauma, 8 teeth had low rates of oxygenation, compared to 10 at 30 and 60 days. Low rates were defined as a saturation reading ≤77%SpO2 . These teeth were assigned to the pulp necrosis (PN) group. The other 49 teeth were either considered to have healthy pulps (HP) (saturation ≥90%SpO2 ) or were assigned to a pulpitis (PP) group (saturation ≥78 to ≤89%SpO2 ). The 10 non-responsive teeth were followed up for 1 year and all exhibited indications for endodontic treatment. The other 49 teeth (HP or PP) began to show positive responses to the cold spray (after 3-9 months of follow up). No significant differences (P < 0.05) were detected between the three periods analyzed, but %SpO2 rates were significantly different (P < 0.01) between the groups (HP vs PP, HP vs PN and PP vs PN). CONCLUSIONS: PO can be extremely useful for the assessment of dental pulp status in traumatized teeth, particularly when these teeth do not show signs of PN and do not respond to cold tests.

Laser-induced fluorescence in the diagnosis of pulp exposure and the influence of residual dentin thickness: An in vivo study.

PURPOSE: To clinically (a) determine whether laser-induced fluorescence (LIF) was able to assess pulp tissue health or disease in situations of pulp exposure; (b) evaluate the influence of different pulp tissue conditions upon LIF through dentin thicknesses of ≤1 mm; and (c) explore possible differences between the diagnostic performance of quantitative (q) and qualitative (ql) LIF. METHODS: 98 healthy subjects were scheduled for the treatment of caries. Three groups were established according to pulp tissue condition: Group A (n=30 teeth) (deep caries with healthy pulp tissue); Group B (n=30 teeth) (pulp necrosis); and Group C (n=30 teeth) (irreversible symptomatic acute pulpitis). The carious lesions were eliminated, and q and ql LIF measurements were made at two levels: measurement in dentin at < 1 mm from the pulp (A-D); and direct pulp exposure measurement (A-LP). In healthy pulp tissue at level A-LP, eight teeth with accidental pulp exposure were used. The Kruskal-Wallis test was used to evaluate the statistical significance of the differences in LIF readings among the three groups. The diagnostic performance of q and ql LIF in application to pulp tissue health or disease was assessed by calculating the sensitivity and specificity of the two tests at level A-LP. RESULTS: A significant correlation was observed between acute pulpitis and an increase in the q LIF values at level A-D (P= 0.004), but with no correlation to healthy pulp. Quantitative and qualitative LIF may be useful in diagnosing pulp tissue health or disease in situations of pulp exposure (A-LP).

Efficiency and Reliability of Thermal and Electrical Tests to Evaluate Pulp Status in Primary Teeth with Assessment of Anxiety Levels in Children.

OBJECTIVE: Assessing the pulp status plays a vital role in diagnosis and treatment planning in dentistry especially in children, who may not be able to verbalize their dental symptoms. Pulp sensibility test is used as a valuable investigation to evaluate the state of pulp. The aim of this study is to assess the efficiency and reliability of thermal and electrical pulp tests in primary teeth and to rule out the anxiety level involved in each tests. STUDY DESIGN: 30 children aged between 6 to 8 years with carious primary molar teeth in need of conservative pulp therapy were included in this study. 3 tests at random were employed on each tooth which includes cold, heat, electrical pulp test. The sensitivity, specificity, positive predictive value and negative predictive value were evaluated based on the clinical visual examination on access opening and the accuracy for each test was calculated. The Facial Image Scale (FIS) was used to assess the state of dental anxiety in children due to these pulp sensibility tests. RESULTS: The highest accuracy rate was calculated for EPT (0.814) followed by cold test (0.777) and heat test (0.759). CONCLUSION: No significant association was found between the accuracy of all the three tests. (P value > 0.05). Cold test is the most reliable test due to its simplicity and ease to perform. (FIS -1.53).

Electrical Pulp Testing: Sources of Error.

INTRODUCTION: Accurate identification and assessment of an inflamed or necrotic tooth is essentialfor endodontic treatment. The purpose of this research was to investigate possible sources of error associated with the use of the electric pulp tester (EPT). METHODS: Forty-six intact teeth (23 tooth pairs) in 22 patients were evaluated in vivo. For the tooth pairs, one tooth had to have been previously endodontically treated and restored with a class II amalgam restoration. The restoration was required to have proximal contact with a class II amalgam of another vital posterior tooth. EPT was performed on pulpless and vital teeth for experimental groups (enamel, restoration, contacting, or isolated). RESULTS: The highest rate of false positive responses (82%) was found in the pulpless restored contacting group, suggesting that EPT impulses are able to travel through proximal metallic contacts and stimulate teeth distant from the EPT probe. All vital tooth groups had a high rate of positive responses with no significant diferences. CONCLUSIONS: If a tested tooth contains an interproximal restoration contacting adjacent restorations or the gingival, the teeth must be isolated (rubber dam) and the EPT probe should be placed in a region suspected to have uninterrupted tubule paths to the pulp.

Diagnosis of the condition of the dental pulp: a systematic review.

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 potentially 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.

Transient discoloration of the coronal fragment in intra-alveolar root fractures.

BACKGROUND: Root fractures are a relatively rare type of injury with frequencies of 0.5-7% of traumatized permanent teeth. It is well known that teeth with intra-alveolar root fractures have a good prognosis. The pulp remains vital in about 80% of these teeth. If pulp necrosis develops, this normally only occurs in the coronal fragment. Although several studies on intra-alveolar root fractures have been published during the last decades, none have mentioned that transient discoloration can occur. The aim of our study was to study the frequency and prognosis for intra-alveolar root fractures with discoloration. MATERIAL AND METHODS: The material consisted of 42 permanent incisors from 21 boys and 18 girls aged 7-19 years (mean = 12.7, median 12.0). In two girls and one boy, two incisors exhibited concurrent intra-alveolar root fractured. The follow-up period ranged from 1 to 9 years. The colour changes were determined at each control by transillumination of the clinical crown from the facial and palatal surfaces. Electrometric sensibility was evaluated and compared to the values of adjacent teeth using an electric pulp tester. At the final clinical and radiographic control, the type of healing was registered. RESULTS: Discoloration was found in nine teeth. The root development was completed in all these teeth. The discoloration disappeared within 4 weeks to 6 months in eight teeth. The sensibility, which was lost at the injury, followed the changes in discoloration, and all teeth had regained normal sensibility when the discoloration had disappeared. Only one tooth, which showed a greyish hue, developed pulp necrosis. CONCLUSION: Transient discoloration in intra-alveolar fractures is relatively common and is indicative of a good prognosis for healing.

A review of the questions and needs in endodontic diagnosis.

The current diversity of opinions in endodontic diagnosis has been a source of interest and academic debate by clinicians and researchers. Currently, no single pulp testing technique can reliably diagnose all pulpal conditions neither it has been proven to be superior in all aspects. Despite improvements of various aspects of this process, there are no historically dramatic changes, or consensus for pulpal status in health or disease in addition to a lack of relative systematic reviews. In this review, the past, present and future most debated and critically questioned issues of endodontic diagnosis are discussed. The aim of this review is to provide insights in future diagnostic modalities and areas for further study in endodontic practice pertinent to diagnosis.

[The prevalance of herpesviruses in human apical periodontitis samples]. / Herpeszvírusok elofordulása humán periodontitis apicalis mintákban.

Apical periodontitis is primarily initiated by the endodonto-patogen bacteria spreading from the inflamed or necrotic pulp tissues to the periapical area. Nevertheless, findings within the past years have established a pathogenic role of human herpesviruses such as Epstein-Barr virus (EBV) and human cytomegalovirus (HCMV) in periapical inflammations. The authors analysed the prevalence, activity and disease association of EBV, HCMV and human herpesvirus 6 (HHV-6) in 40 apical periodontitis samples and 40 healthy pulp controls. Based on the viral DNA results, EBV (29/40) was the most frequent herpesvirus in apical periodontitis, followed by HHV-6 (8/40) and HCMV (4/40). According to the mRNA results approximately two-third of the EBV DNA-positive lesions had active EBV infections. However, the HHV-6 and the HCMV infections seemed to be of latent state. Our findings suggest that EBV and HHV-GB infections primarily occurred in large sized and symptomatic periapical lesions. The co-occurrence of large lesion size and active EBV infection was strongly associated (OR = 8.80) with the symptomatic manifestation of apical periodontitis.

Proliferation of rat molar pulp cells after direct pulp capping with dentine adhesive and calcium hydroxide.

The aim was to evaluate the proliferation of pulp cells 1, 3 and 7 days after direct pulp capping with the dentine adhesive Gluma Comfort Bond (GCB) and to compare it with calcium hydroxide (Ca(OH)(2)). An occlusal cavity was prepared in 72 molar teeth of 36 Wistar rats. Then GCB or Ca(OH)(2) was placed on the exposed pulp. All cavities were restored with composite. After 1, 3 and 7 days, the animals were sacrificed. One hour prior sacrification, 5-bromo-2'-desoxyuridine (BrdU) was injected into the intraperitoneal cavity for immunohistological analysis of 18 animals. BrdU was incorporated into the DNA to tag proliferating cells using an antibody staining. Three animals served as controls and were not further treated. The number of the tagged cells was statistically analysed by comparing the results of the three groups. In 18 rats, routine histological analysis was performed in order to evaluate the pulp tissue for bacterial infection, inflammatory cells and necrosis. The marked cells were identified as fibroblasts, endothelial cells (after 1, 3 and 7 days) and Höhl cells (after 7 days). One day after capping, significantly more cells were stained in the GCB than in the Ca(OH)(2) group (p < 0.05). After 3 days, significantly more cells were stained in the GCB than in the Ca(OH)(2) and the control group (p < 0.016). Direct contact of GCB with pulp tissue leads to an increased formation of granulation tissue (fibroblasts, endothelial cells) because of an inflammatory reaction. This may be explained by missing antibacterial effect and foreign body reactions. Also, GCB may have a negative effect on Höhl cells.

Endodontic diagnostic terminology update.

Determination of the etiology of the patient's chief complaint and a correct diagnosis are paramount prior to a recommendation of endodontic therapy. Reproduction of the patient's chief complaint is critical. If the chief complaint cannot be reproduced, consider consultation with or referral to an endodontist or orofacial pain specialist. The diagnostic terminology presented in this update provides for a more accurate description and communication of the health or pathological conditions of both pulpal and apical tissues. This information is summarized in Table I.

Review of pulp sensibility tests. Part II: electric pulp tests and test cavities.

The electric pulp test (EPT) is one type of pulp sensibility test that can be used as an aid in the diagnosis of the status of the dental pulp. However, like thermal pulp sensibility tests, it does not provide any direct information about the vitality (blood supply) of the pulp or whether the pulp is necrotic. The relevant literature on pulp sensibility tests in the context of endodontics up to January 2009 was reviewed using PubMed and MEDLINE database searches. This search identified articles published between November 1964 and January 2009 in all languages. The EPT is technique sensitive, and false responses may occur. Various factors can affect the test results, and therefore it is important that dental practitioners understand the nature of these tests and how to interpret them. Test cavities have been suggested as another method for assessing the pulp status; however, the use of this technique needs careful consideration because of its invasive and irreversible nature. In addition, it is unlikely to be useful in apprehensive patients and should not be required because it provides no further information beyond what thermal and electric pulp sensibility tests provide - that is, whether the pulp is able to respond to a stimulus. A review of the literature and a discussion of the important points regarding these two tests are presented.

Apexogenesis after initial root canal treatment of an immature maxillary incisor - a case report.

AIM: To present a case where a traumatized, immature tooth still showed capacity for continued root development and apexogenesis after root canal treatment was initiated based on an inaccurate pulpal diagnosis. SUMMARY: Traumatic dental injuries may result in endodontic complications. Treatment strategies for traumatized, immature teeth should aim at preserving pulp vitality to ensure further root development and tooth maturation. A 9-year-old boy, who had suffered a concussion injury to the maxillary anterior teeth, was referred after endodontic treatment was initiated in tooth 21 one week earlier. The tooth had incomplete root length, thin dentinal walls and a wide open apex. The pulp chamber had been accessed, and the pulp canal instrumented to size 100. According to the referral, bleeding from the root made it difficult to fill the root canal with calcium hydroxide. No radiographic signs of apical breakdown were recorded. Based on radiographic and clinical findings, a conservative treatment approach was followed to allow continued root development. Follow-up with radiographic examination every 3rd month was performed for 15 months. Continued root formation with apical closure was recorded. In the cervical area, a hard tissue barrier developed, which was sealed with white mineral trioxide aggregate (MTA). Bonded composite was used to seal the access cavity. At the final 2 years follow-up, the tooth showed further root development and was free from symptoms.

Association of crown discoloration and pulp status in traumatized primary teeth.

The aim of the present study was to determine the association of tooth discoloration in traumatized primary teeth with clinical and radiographic signs of pulp necrosis, and pulp status at the time of endodontic access. Clinical and radiographic data from dental reports of the 47 patient charts of the Trauma Patient Care Program were used totaling 55 teeth that underwent endodontic treatment following the protocol of the Federal University of Santa Catarina (Brazil). The following data were collected: gender, age of child at time of trauma; crown discoloration; abscess and/or fistula; periapical bone rarefaction and/or pathological root resorption; and pulp status at the time of endodontic access. The Chi-square test and logistic regression were used in the statistical analysis. The associations between crown discoloration and gender, age, tooth, type of trauma, clinical alteration, and radiographic alteration were not statistically significant. There was a significant association between crown discoloration and pulp necrosis at the time of endodontic access (χ(2) = 7.672; P < 0.05). Traumatized primary teeth with crown discoloration had a fivefold greater likelihood of exhibiting pulp necrosis than teeth without crown discoloration (95% CI: 1.5-17.1). Thus, a significant association was found between crown discoloration and pulp necrosis in traumatized primary teeth.