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 Table of Contents  
Year : 2019  |  Volume : 31  |  Issue : 1  |  Page : 21-24

Evaluation of a new means of pulpal diagnosis through a prospective study of 133 cases

Department of Dental Medicine, Faculty of Dentistry, Sahloul Hospital, Sousse; Laboratory of Research in Oral Healh and Maxillo Facial Rehabilitation (LR12ES11); Faculty of Dental Medicine, University of Monastir, Monastir, Tunisia

Date of Web Publication19-Jun-2019

Correspondence Address:
Dr. Walid Lejri
Department of Dental Medicine, Faculty of Dentistry, Sahloul Hospital, Sousse; Laboratory of Research in Oral Healh and Maxillo Facial Rehabilitation (LR12ES11), Monastir; Faculty of Dental Medicine, University of Monastir, Monastir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/endo.endo_47_18

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Introduction: The most accurate method for evaluation of pulpal status is histological examination. Unfortunately, it is clinically inapplicable. The goal of our work is to focus on in situ observation, which is proven to be a historically reliable and clinically applicable means.
Materials and Methods: This is a 22-month prospective cross-sectional epidemiological study of 133 cases. For each case, the initial pulpal diagnosis is confronted with the in situ observation. The initial pulpal diagnosis is either retained or corrected according to the in situ observation.
Results: The Chi-squared test gave a value of P < 0.005; no correlation is observed between the initial pulpal diagnosis and the final diagnosis (After the in situ observation).
Conclusion: Histologically, when the pulp is irritated, a vascular reaction is observed. This reaction will influence the color and the flow of pulp blood. This blood changes can be detected with the naked eye which led us to propose a classification of the different in situ observations to refine the initial pulp diagnosis.

Keywords: Blood color, blood flow, in situ diagnosis, pulp diagnosis

How to cite this article:
Lejri W, Douki N, Kallel I. Evaluation of a new means of pulpal diagnosis through a prospective study of 133 cases. Endodontology 2019;31:21-4

How to cite this URL:
Lejri W, Douki N, Kallel I. Evaluation of a new means of pulpal diagnosis through a prospective study of 133 cases. Endodontology [serial online] 2019 [cited 2022 Nov 30];31:21-4. Available from: https://www.endodontologyonweb.org/text.asp?2019/31/1/21/260527

  Introduction Top

Regenerative approaches to dental pulp have long been adopted with pulp capping, using materials such as calcium hydroxide[1] and the Cvek partial pulpotomy technique.[2] Like all disciplines, endodontics is punctuated by fashion effects. Among these effects, some are ephemeral, others settle in time, and pulpotomy should be reconsidered as a viable permanent treatment approach for permanent teeth as well as for primary teeth. The literature is enriched with articles about vital pulp therapy (VPT) as an alternative to traditional root canal treatment for teeth, diagnosed with irreversible symptomatic pulpitis with a success rate higher than conventional treatment over a period of 5 years.

The success of the VPT depends on the diagnostic criteria established for assessing the pulp status. An accurate diagnosis of the inflammatory state of the pulp is critical to choose a correct treatment strategy.[3],[4]

The most accurate method for assessment of pulpal status still the histological examination by which the extent of inflammation or presence of necrosis is observed.[5] However, it is difficult, if not impossible, to clinically determine it.

In cases of irreversible pulpitis, the pulp becomes inflamed to a varying degree, but it is not possible to precisely establish the level of inflammation on the basis of indirect diagnostic methods.[6]

It should be known that in our practice the tests used to diagnosis a pulpal status (thermal or electrical tests) give us a subjective idea and are dependent on the pain's perception by the patient. On the other hand, vitality tests such as laser Doppler flowmetry and oximetry give an objective idea but remain clinically inapplicable.

Following the answers obtained, the clinician will establish a pulpal diagnosis. In the literature, the diagnosis obtained is qualified by indirect or provisional.

In light of these recent data, it is necessary to develop a diagnostic means that is histologically reliable and clinically applicable.

When planning endodontic treatment, direct observation of the pulp at the root canal entrances (color of pulpal bleeding/pulpal bleeding flow) can be valuable to our diagnosis.

We named this observation “In situ observation.” The questions that arise are:

  • Can this “in situ observation” be used to refine our diagnosis
  • Is there a correlation between the initial diagnosis and the final diagnosis with the in situ observation?

We will, therefore, try to answer these questions through a prospective study.

  Materials and Methods Top

This study looked at patients who had either symptomatic or asymptomatic irreversible pulpitis, uncomplicated pulpal necrosis, or reversible pulpitis treated for prosthetic aims. The complete treatment, from the access cavity to the coronary obturation was performed in the Dental Department of EPS Sahloul during the years 2015 and 2016. All endodontic treatments were performed under a rubber dam. A total of 200 files were studied, and only 133 files were selected. We exclude from the sample: teeth presenting necrosis with periapical complication, teeth already obturated, teeth being treated and teeth with indication of extraction.


The ideal is to work with the electrical test but lack of means we opted for the cold test. Each tooth was isolated with a cotton roll. A “frosted” cotton pellet was applied to the buccal surface of the tested teeth. The radiological examination was carried out with the aim of deepening the initial diagnosis. The information collected allowed us to make an initial clinical diagnosis (indirect) according to the classification of the American Association of Endodontists (AAE) (Reversible/Irreversible Pulpitis symptomatic/irreversible asymptomatic/pulpal necrosis). All teeth were anesthetized either by local infiltration with a medical anesthetic supplemented with 1: 1,00,000 epinephrine, or by infiltration of the inferior alveolar nerve block with the same anesthetic without epinephrine. The carious tissue was removed completely, and the tooth was restored with glass ionomer cement as a preendodontic reconstitution. Once the rubber-dam is placed on the tooth and access cavity is made, the coronal pulp is removed gently with hand instruments or a round bur. The root canal entries are localized with a No. 6 probe. Observations of color and blood flow have been noted. The initial pulpal diagnosis is either retained or corrected according to the in situ observation. Finally, shaping and canal filling were performed. In this study, we don't perform VPT, only traditional endodontic treatment was done. We only focus on the in situ observation.

The data collection was done by the interns within the EPS Sahloul dentistry department. To minimize the risk of error, the data collected were all verified by the same operator. For each file, the data collected were relevant to:

  • The initial pulp diagnosis
  • The in situ pulpal diagnosis.

    • Reversible Pulpitis: Bright red blood with bleeding that stops after 5 min
    • Irreversible symptomatic pulpitis: Very abundant cherry red blood ironless
    • Irreversible asymptomatic pulpitis: Red blood scarce cherry and/or white fibrous pulp appearance
    • Pulp necrosis without periapical complication: Depulpless canal
    • Partial necrosis: depulpless canal/bleeding canal for the same tooth.

Statistical analysis

Statistical analysis was set up using SPSS IBM Corp. IBM SPSS Stastictics for windows, version 23,0 (Armonk, NY: IBM Corp). For the analytical study, we used the Chi-squared test to look for a possible association between clinical diagnosis and in situ observation. The level of statistical significance has been set at 5% (P < 0.05).

  Results Top

We hypothesized that there is no difference between the initial direct clinical diagnosis and the final diagnosis based on in situ observation. The Chi-squared test gave a value P < 0.005. The null hypothesis has been rejected, and the alternative hypothesis was retained. There is no correlation between the initial diagnosis and the final diagnosis. Based on the classification of the AAE, the 133 cases were distributed according to [Table 1].
Table 1: Distribution of cases following the initial diagnosis

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After the in situ observation, the final diagnosis was established and we got these results [Table 2].
Table 2: Distribution of cases following the final diagnosis

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  Discussion Top

Cariogenic bacteria are the most common cause of pulpitis. However, the size of the carious lesion is not the only determinant of the degree of pulp inflammation.[7],[8] Pulp histological reactions, including the various immune and inflammatory responses, are triggered in the pulp and may even occur following initial caries limited to enamel.[9]

An accurate pulp diagnosis is essential for adequate treatment. Clinicians, based on their clinical diagnosis, decide on the selection of conservative treatment (VPT) or a radical treatment and therefore endodontic treatment. Vitality or necrosis of the pulp and more importantly, the nature of inflammation (reversible or irreversible), are determined indirectly depending on the clinical signs and symptoms of the patient, responses to sensitivity tests, including thermal and electrical tests (EPT) and radiological evaluation. However, clinical diagnosis is difficult when sensitivity test results are inconsistent with subjective results[10] and can lead to the wrong diagnosis and then wrong therapeutic. Our study confirms this clinical ambiguity. Effectively, out of 73 cases of asymptomatic irreversible pulpitis, only 35 cases were diagnosed correctly, of 25 cases of reversible pulpitis, 7 cases were diagnosed as total necrosis and finally, of 34 cases of symptomatic irreversible pulpitis, 6 cases were diagnosed with partial necrosis.

An increasing number of evidence from recent studies has revealed that permanent teeth with irreversible pulpitis contain multipotent stem cells[11] with immense potential for tissue regeneration and can be successfully treated with VPT.[12]

From a histological point of view, such an inflamed pulp is vital, if the circulating blood flow is sufficient, this pulp can heal if appropriate treatment is performed.

Recent reports have revealed the success of VPT in exposed pulps with signs/symptoms of irreversible pulpitis.

The success of the VPT as a biological treatment is based on the healing potential of the so-called “irreversibly inflamed” root pulp and on the biocompatibility of pulp capping materials.[13]

Given the limit of the reliability and reproducibility of the pulp tests mentioned above, we were interested in a means of direct observation of the pulp state (observation of color and blood flow).

In fact, the color of the blood is affected by the level of hemoglobin (Hb) and the oxygen saturation of the Hb molecules in the red blood cells.[14] The arterial and capillary blood (rich in oxygen) is bright red because the oxygen gives a strong red color to the Hb, in the contrary venous blood (low oxygen content) has a darker shade of red.[15] On the light of this information, in 2016 a study looked for[16] a correlation between blood color and pulp state at the primary teeth using a device that determines the color of the blood. The results show that a significant association between the two exists and that the difference in blood color is detectable by the naked eye. Hence, the darker the blood is, the sooner the inflammation is close to necrosis. Other studies[17],[18],[19] reinforce this idea, in particular, the study of Setzer et al. In 2012,[20] Seltzer compared the oxygen saturation of the thumb with that of the pulp with different pulpo-pathologies using oximetry. He found that the oxygen saturation in reversible pulpites is higher than the irreversible pulpites. On the other hand, the oxygen saturation in reversible pulpites is lower then healthy pulps. It is deduced that for pulpites the blood is rich in oxygen but remains poor in oxygen compared to healthy pulps.

About the blood flow, and histologically, during pulpal inflammation, a vascular reaction is observed following the release of neuropeptides. In symptomatic (acute) irreversible pulpitis, the number of congested neocapillaries increases, as does capillary permeability, with the result that intra-tissue accumulation of inflammatory exudate occurs. For asymptomatic irreversible pulpitis (chronic), collagen apposition forms a halo to encircle the abscess zones. These areas of abcedations eventually ulcerate, especially during penetrating caries. In the vicinity of this fibrous zone, there is an area which is poor in vascularization or even avascular.[21] From these biological and histological ascertainment, it has been thought that blood flow and color of blood can give us information on the degree of inflammation.

In the light of this informations, we establish an in situ classification for the different pulp state described by the AAE [Table 3].
Table 3: The in situ classification

Click here to view

  Conclusion Top

Some authors describe this new philosophy of the least invasive in the endodontic field by Endolight. This philosophy encompasses both the pulp regeneration technic and the so-called conservative endodontic treatment. We believe that these evolutions, may change the way in which canal treatments will be performed in the future. It will be possible to treat each root canal in a different way depending on the pulpal state of the latter.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Karapanou V, Kempuraj D, Theoharides TC. Interleukin-8 is increased in gingival crevicular fluid from patients with acute pulpitis. J Endod 2008;34:148-51.  Back to cited text no. 1
Setzer FC, Kataoka SH, Natrielli F, Gondim-Junior E, Caldeira CL. Clinical diagnosis of pulp inflammation based on pulp oxygenation rates measured by pulse oximetry. J Endod 2012;38:880-3.  Back to cited text no. 2
Seltzer S, Bender IB, Turkenkopf S. Factors affecting successful repair after root canal therapy. J Am Dent Assoc 1963;67:651-62.  Back to cited text no. 3
Aminabadi NA, Huang B, Samiei M, Agheli S, Jamali Z, Shirazi S, et al. Arandomized trial using 3mixtatin compared to MTA in primary molars with inflammatory root resorption: A novel endodontic biomaterial. J Clin Pediatr Dent 2016;40:95-102.  Back to cited text no. 4
García Aranda R. Correlation between clinical diagnosis and histopathological diagnosis in pulp pathology. Pract Odontol 1990;11:43-6.  Back to cited text no. 5
Bjørndal L. Indirect pulp therapy and stepwise excavation. Pediatr Dent 2008;30:225-9.  Back to cited text no. 6
Reynolds RL. The determination of pulp vitality by means of thermal and electrical stimuli. Oral Surg Oral Med Oral Pathol 1966;22:231-40.  Back to cited text no. 7
Närhi MV. The characteristics of intradental sensory units and their responses to stimulation. J Dent Res 1985;64:564-71.  Back to cited text no. 8
Kahan RS, Gulabivala K, Snook M, Setchell DJ. Evaluation of a pulse oximeter and customized probe for pulp vitality testing. J Endod 1996;22:105-9.  Back to cited text no. 9
Kokkas AB, Goulas A, Varsamidis K, Mirtsou V, Tziafas D. Irreversible but not reversible pulpitis is associated with up-regulation of tumour necrosis factor-alpha gene expression in human pulp. Int Endod J 2007;40:198-203.  Back to cited text no. 10
Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and histologic pulp diagnoses. J Endod 2014;40:1932-9.  Back to cited text no. 11
Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A systematic review. J Endod 2011;37:581-7.  Back to cited text no. 12
Asgary S, Eghbal MJ. Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis using biomaterials: A multi-center randomized controlled trial. Acta Odontol Scand 2013;71:130-6.  Back to cited text no. 13
Radhakrishnan S, Munshi AK, Hegde AM. Pulse oximetry: A diagnostic instrument in pulpal vitality testing. J Clin Pediatr Dent 2002;26:141-5.  Back to cited text no. 14
Goga R, Chandler NP, Oginni AO. Pulp stones: A review. Int Endod J 2008;41:457-68.  Back to cited text no. 15
Aminabadi NA, Parto M, Emamverdizadeh P, Jamali Z, Shirazi S. Pulp bleeding color is an indicator of clinical and histohematologic status of primary teeth. Clin Oral Investig 2017;21:1831-41.  Back to cited text no. 16
Hall JE. Guyton and Hall Textbook of Medical Physiology. Philadelphia: Elsevier Health Sciences; 2015.  Back to cited text no. 17
Martin FE. Carious pulpitis: Microbiological and histopathological considerations. Aust Endod J 2003;29:134-7.  Back to cited text no. 18
Mickel AK, Lindquist KA, Chogle S, Jones JJ, Curd F. Electric pulp tester conductance through various interface media. J Endod 2006;32:1178-80.  Back to cited text no. 19
Pezelj-Ribaric S, Anic I, Brekalo I, Miletic I, Hasan M, Simunovic-Soskic M, et al. Detection of tumor necrosis factor alpha in normal and inflamed human dental pulps. Arch Med Res 2002;33:482-4.  Back to cited text no. 20
Rechenberg DK, Bostanci N, Zehnder M, Belibasakis GN. Periapical fluid RANKL and IL-8 are differentially regulated in pulpitis and apical periodontitis. Cytokine 2014;69:116-9.  Back to cited text no. 21


  [Table 1], [Table 2], [Table 3]

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