It is understood that in a non-vital tooth there is an absence of both neural and vascular supplies. However, almost all conventional pulp tests employ assessment of the neural supply.
Endodontic treatment should not be undertaken on the basis of pulpal status alone. The patient's medical history, the overall treatment plan and the periodontal status must also be taken into consideration. There are also contraindications to endodontics. These may be divided into general aspects such as factors in the medical history of relevance, poor access, poor oral hygiene and local factors, for example the tooth being unrestorable, the periodontal support being poor, the presence of advanced resorptive defects and complex root morphology.
In the past, these have been of limited value due to the high incidence of false readings. The latest testers, however, appear to be promising but their use is limited if full coverage restorations are in place. Pulp testers stimulate neural tissue, and there is not necessarily a direct correlation between the existence of nervous tissue and a viable blood flow. Additionally, patients' pain thresholds vary. The actual reading is not important, as it cannot measure any degree of degeneration. However, testing contralateral teeth can give the clinician an indication of pulpal involvement.
Cold is the more useful test as it is safer and uses a constant temperature. The use of a cotton pellet soaked in a volatile liquid (for example ethyl chloride) is a common method, though sticks of ice may also be used. Although heat is not routinely used, it is helpful when the only symptom is that of heat sensitivity and the patient cannot identify the tooth. Heat may be applied with a warm stick of gutta-percha, though care must be taken to lubricate the tooth surface to be tested with petroleum jelly to prevent the hot gutta-percha from sticking to the tooth and possibly causing a thermal injury. Another method of applying heat is to isolate an individual tooth with rubber dam and syringe hot water over the tooth.
The most reliable indication of significant periapical inflammation is that of tenderness to percussion. Periodontal inflammation, which produces milder symptoms, can be identified by finger pressure applied to the tooth in question.
This test has gained popularity in recent years, but is generally more effective in localising affected areas rather than individual teeth.
This method is useful in the diagnosis of vertical crown fractures. Radiography
Radiographic examination is a useful and necessary diagnostic aid. However, it must be remembered that pathology does not result in immediate radiographic changes and periapical changes are not usually seen until the cortical plate within the socket becomes involved (seen radiographically as a loss of definition of the lamina dura). It may be necessary to take more than one radiograph at different angles. Good quality radiographs, a paralleling technique and proper film development are essential for accurate diagnosis.
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