Diagnostic Accuracy of 5 Dental Pulp Tests: A Systematic Review and Meta-analysis.

INTRODUCTION: The aim of this systematic review was to investigate and compare the diagnostic accuracy including sensitivity, specificity, adjusted accuracy, adjusted positive predictive value (PPV), and adjusted negative predictive value (NPV) of cold pulp testing (CPT), heat pulp testing (HPT), electric pulp testing (EPT), laser Doppler flowmetry (LDF), and pulse oximetry (PO). METHODS: Three electronic databases were searched from January 1964 to December 2016. True-positive, false-positive, true-negative, and false-negative values were extracted from data in each study. Sensitivity, specificity, adjusted accuracy, adjusted PPV, and adjusted NPV were calculated from those values, if not presented. A random effects model was used to calculate pooled estimates of sensitivity, specificity, adjusted accuracy, adjusted PPV, and adjusted NPV. RESULTS: A total of 125 articles were identified, and 28 studies were included for the final review. The pooled estimates of sensitivity for CPT, EPT, HPT, LDF, and PO were 0.87, 0.72, 0.78, 0.98, and 0.97, respectively. Those of specificity were 0.84, 0.93, 0.67, 0.95, and 0.95, respectively. Those of adjusted accuracy were 0.84, 0.82, 0.72, 0.97, and 0.97, respectively. For adjusted PPV, they were 0.81, 0.89, 0.62, 0.94, and 0.94, respectively, and for adjusted NPV, they were 0.87, 0.80, 0.79, 1.00, and 0.99, respectively. CONCLUSIONS: LDF and PO were the most accurate diagnostic methods, and HPT was the least accurate diagnostic method. EPT showed high accuracy when testing vital teeth (specificity = 0.93) but low accuracy when assessing nonvital teeth (sensitivity = 0.72). CPT had moderate accuracy when evaluating vital (specificity = 0.84) and nonvital (sensitivity = 0.87) teeth.

Validity of Preoperative Clinical Findings to Identify Dental Pulp Status: A National Dental Practice-Based Research Network Study.

INTRODUCTION: Endodontic diagnostic tests are often used clinically to assess pulp status as a basis for the diagnosis and determination of whether root canal treatment (RCT) is indicated. Response to cold and pain on percussion are 2 common tests, yet their validity in identifying nonvital pulp in regular dental practice has not been reported. METHODS: We assessed the validity of cold and percussion tests to identify nonvital pulp in teeth requiring RCT in a dental practice setting performed by 46 general dentists and 16 endodontists in the National Dental Practice-Based Research Network. The influence of patient-, tooth-, and dentist-related characteristics was investigated. Observed bleeding from the pulp chamber was the clinical reference. Sensitivity (SN), specificity (SP), overall test accuracy (TA), positive (PPV) and negative (NPV) predictive values, and likelihood and diagnostic odds ratios (LR+, LR-, dORs) were calculated for each single test and the combined cold and percussion tests. RESULTS: Seven hundred eight patient teeth were included. Cold test showed high validity to identify a nonvital pulp status (SN = 89%, SP = 80%, TA = 84%, PPV = 81%, NPV = 88%, LR+ = 4.35, LR- = 0.14, dOR = 31.4), whereas pain on percussion had lower validity (SN = 72%, SP = 41%, TA = 56%, PPV = 54%, NPV = 60%, LR+ = 1.22, LR- = 0.69, dOR = 1.78). Combining the 2 tests did not increase validity, whereas preoperative pain, medication intake, patient age and sex, and dentist training level affected test validity significantly. CONCLUSIONS: In regular dental practice, the cold test exhibits higher validity to discriminate between vital and nonvital pulp than the tooth percussion test.

Evaluation of dental pulp sensibility tests in a clinical setting.

INTRODUCTION: The goal of this project was to evaluate the performance of dental pulp sensibility testing with Endo Ice (1,1,1,2-tetrafluoroethane) and an electric pulp tester (EPT) and to determine the effect of several variables on the reliability of these tests. METHODS: Data were collected from 656 patients seen in the University of Iowa College of Dentistry Endodontic graduate clinic. The results of pulpal sensibility tests, along with the tooth number, age, sex, number of restored surfaces, presence or absence of clinical or radiographic caries, and reported recent use of analgesic medications, were recorded. The presence of vital tissue within the pulp chamber was used to verify the diagnosis. RESULTS: The Endo Ice results showed accuracy, 0.904; sensitivity, 0.916; specificity, 0.896; positive predictive value, 0.862; and negative predictive value, 0.937. The EPT results showed accuracy, 0.75; sensitivity, 0.84; specificity, 0.74; positive predictive value, 0.58; and negative predictive value, 0.90. Patients aged 21-50 years exhibited a more accurate response to cold testing (P = .0043). Vital teeth with caries responded more accurately to cold testing (P = .0077). There was no statistically significant difference noted with any other variable examined. CONCLUSION: Pulpal sensibility testing with Endo Ice and EPT are accurate and reliable methods of determining pulpal vitality. Patients aged 21-50 exhibited a more accurate response to cold. Sex, tooth type, number of restored surfaces, presence of caries, and recent analgesic use did not significantly alter the results of pulpal sensibility testing in this study.

Comparison of heat-testing methodology.

INTRODUCTION: Patients with irreversible pulpitis occasionally present with a chief complaint of sensitivity to heat. To appropriately diagnose the offending tooth, a variety of techniques have been developed to reproduce this chief complaint. Such techniques cause temperature increases that are potentially damaging to the pulp. Newer electronic instruments control the temperature of a heat-testing tip that is placed directly against a tooth. The aim of this study was to determine which method produced the most consistent and safe temperature increase within the pulp. This consistency facilitates the clinician's ability to differentiate between a normal pulp and irreversible pulpitis. METHODS: Four operators applied the following methods to each of 4 extracted maxillary premolars (for a total of 16 trials per method): heated gutta-percha, heated ball burnisher, hot water, and a System B unit or Elements unit with a heat-testing tip. Each test was performed for 60 seconds, and the temperatures were recorded via a thermocouple in the pulp chamber. Analysis of the data was performed by using the intraclass correlation coefficient. RESULTS: The least consistent warming was found with hot water. The heat-testing tip also demonstrated greater consistency between operators compared with the other methods. Hot water and the heated ball burnisher caused temperature increases high enough to damage pulp tissue. CONCLUSIONS: The Elements unit with a heat-testing tip provides the most consistent warming of the dental pulp.

Evaluation of accuracy, reliability, and repeatability of five dental pulp tests.

INTRODUCTION: The aim of this study was to compare the clinical accuracy, reliability, and repeatability of laser Doppler flowmetry (LDF), an electric pulp test (EPT), and various thermal pulp sensibility tests. METHODS: Pulp tests were done on 121 teeth in 20 subjects by using LDF, EPT, and thermal pulp testing (CO(2), Endo Frost [EF], Ice) during 2 or 3 test sessions with at least 1-week intervals. The order of testing was reversed on the second visit. A laser Doppler flowmeter was used to measure mean pulp blood flow (Flux) calibrated against a brownian motion medium and zeroed against a static reflector. The laser source was 780 nm, with 0.5-mm fiber separation in the probe, 3.1 kHz as the primary bandwidth for filter set to 0.1-second time output constant. Customized polyvinylsiloxane splints were fabricated for each participant, and a minimum of 90-second recording time was used for each tooth. Raw data were analyzed by using repeated measure analysis of variance, pairwise comparisons, and interclass correlations (ICC). RESULTS: The accuracy of EPT, CO(2), and LDF tests was 97.7%, 97.0%, and 96.3%, respectively, without significant differences (P > .3). Accuracy of EF and Ice was 90.7% and 84.8%, respectively. EPT (P = .015) and CO(2) (P = .022) were significantly more accurate than EF. LDF was more accurate than EF, but this was not statistically significant (P = .063). Ice was significantly less accurate than EPT (P = .004), CO(2) (P = .005), LDF (P = .006), and EF (P = .019). With the exception of Ice (effect of visit: F(2,38) = 5.67, mean squared error = 0.01, P = .007, η(2)(p) = 0.23), all tests were reliable. Ice (ICC = 0.677) and LDF (ICC = 0.654) were the most repeatable of the tests, whereas EPT (ICC = 0.434) and CO(2) (ICC = 0.432) were less repeatable. CONCLUSIONS: CO(2), EPT, and LDF were reliable and the most accurate tests, but CO(2) and EPT were less repeatable yet less time-consuming than LDF. EF was reliable but not as accurate as EPT and CO(2) and less repeatable than Ice and LDF. Ice was the most repeatable but the least accurate and least reliable test.

Identify and determine the metrics, hierarchy, and predictive value of all the parameters and/or methods used during endodontic diagnosis.

A Consensus Conference on Terminology was convened by the American Association of Endodontists in Chicago on Oct 3, 2008 to review solicited papers on focused questions. This paper addressed the question: Identify and determine the metrics, hierarchy, and predictive value of all the parameters and/or methods used during endodontic diagnosis. The best available clinical evidence was used to determine the sensitivity, specificity, and predictive value of pulpal and periapical testing methods and imaging technologies. Diagnosis of dental pulp diseases suffers from operator's inability to test/image that tissue directly due to its location within dentin. In general, current pulp tests are more valid in determining teeth that are free of disease, but less effective in identifying teeth with pulp disease. Radiographic imaging is probably the most commonly used diagnostic tool to determine the status of root-supporting tissue, although interpretation of structural changes in the periradicular tissues is still considered unreliable.

The validity of pulp testing: a clinical study.

OBJECTIVE: In this article, the authors report on an in vivo study in which they assessed the validity of two commonly used cold pulp tests (carbon dioxide [CO(2)]and 1,1,1,2-tetrafluoroethane) and an electrical pulp tester (EPT) in determining pulp vitality by using direct inspection of the pulp as the reference standard. METHODS: One hundred fifty patients undergoing endodontic therapy at the University of North Carolina School of Dentistry (Chapel Hill) undergraduate clinic participated in this study. Before routine endodontic treatment, the authors classified participants by means of EPT, CO(2) and tetrafluoroethane as having either vital or necrotic pulps. Students recorded true pulpal status (vital/necrotic) by observing blood within the pulp chamber after an access cavity was made. The authors calculated the sensitivity, specificity and positive and negative predictive values of each test and the test combinations to describe their validity and clinical usefulness. RESULTS: Ninety-seven percent of teeth responding positively to all three tests contained vital pulps, whereas 90 percent of the teeth that failed to respond to any of the tests contained necrotic pulps. Ten percent of the teeth not responding to any of the tests contained vital pulps. For all other combinations of test results, 54 percent of teeth contained vital pulps, and 46 percent contained necrotic pulps. CONCLUSIONS: These findings support the use of either of the cold tests and the EPT for diagnosis of pulpal status. CLINICAL IMPLICATIONS: Cold test and EPT used in conjunction resulted in a more accurate method for diagnostic testing.

[The reliability of electrical and thermal pulp tests. A clinical study]. / Klinikostatistike melete tes axiopistias ton dokimasion zotikotetas tou polphou.

A clinical study was conducted to assess the reliability of electrical and thermal pulp tests and to correlate the results with the true pulp status, as this was proved after the access opening, as well as to determine which clinical factors might be associated with the tests reliability. The results showed that pulp tests are reliable in a high grade and that there is no significant difference in their reliability.