doi:10.1111/iej.
12611
REVIEW
Pulp sensibility and vitality tests for diagnosing
pulpal health in permanent teeth: a critical review
R. A. Alghaithy1,2 & A. J. E. Qualtrough2
1
Al Mustashfa Al Am St, Al Andalus, King Fahad Hospital, Jeddah, Saudi Arabia; and 2School of Dentistry, The University of
Manchester, Manchester, UK
Abstract
Alghaithy RA, Qualtrough AJE. Pulp sensibility and
vitality tests for diagnosing pulpal health in permanent teeth:
a critical review. International Endodontic Journal.
The aim of this review was to critically appraise the
literature related to pulp vitality and sensibility testing
in order to determine the diagnostic accuracy of pulp
tests with reference to a gold standard or control
group. Implications of the results for research and
clinical practice are also explored. The MEDLINE
(Ovid), MEDLINE (PubMed), Embase and Cochrane
databases were searched for English-language clinical
trials in humans in which in vivo studies were
designed to evaluate or compare the accuracy of
selected pulp sensibility and pulp vitality tests in
determining the state of pulpal health in permanent
teeth. Studies were included only if the results were
compared to a control group or to a valid gold or
reference standard. Eight studies were identified.
Introduction
Identification of diseases at their earliest stages allows
the clinician to initiate the most conservative manage-
ment techniques and avoid possible complications and
expenses that may arise if a disease is left undiagnosed
and untreated for a longer period. Accurate assessment
of the state of the health of the dental pulp, which is a
key step for the successful diagnosis of oral diseases, is
achieved through a detailed patient history, thorough
Correspondence: Reema A. Alghaithy, King Fahad Hospital,
P.O. Box 55498, Jeddah 21534, Saudi Arabia (Tel.:
00966505682964; e-mail: gh_reema@yahoo.com).
© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
Shortcomings in research design were found to influ-
ence the findings. The limited number of studies
investigating pulp vitality tests was insufficient to
answer the research question. It was concluded from
this critical appraisal of the literature that laser Dop-
pler flowmetry appeared to be the most accurate
method for diagnosing the state of pulpal health and
came closest to serving as a gold standard. Pulp vital-
ity tests proved superior to pulp sensibility tests for
early and accurate assessments of the pulpal health of
traumatized teeth. When accurately used and inter-
preted, pulp sensibility tests provide valuable diagnos-
tic information, particularly when an electric pulp
test is used in combination with either CO2 snow or
Endo-Ice.
Keywords: dental pulp, electric pulp tester, laser
doppler flowmetry, pulse oximetry, thermal pulp test,
tooth pulp.
Received 30 May 2015; accepted 13 January 2016
clinical and radiographic examinations and the use of
special diagnostic tests (Cooley et al. 1984).
Diseases affecting the dental pulp are inflammatory
or infectious in origin. In either case, the microcircu-
lation within the healthy dental pulp initiates an
inflammatory response as part of a complex defensive
mechanism to maintain the integrity and health of
the dental pulp. Thus, it is generally accepted that
assessment of the blood supply within the dental pulp
(pulp vitality) is the earliest indicator and may be the
only available true indicator of the actual state of pul-
pal health (Baumgardner et al. 1996, Trowbridge &
Kim 1998).
International Endodontic Journal 1
 Tests of pulpal health: Review Alghaithy & Qualtrough
Pulp sensibility tests (thermal and electric) have
been used to indirectly determine the state of pulpal
health by assessing the condition of the nerves within
the dental pulp. False-positive and false-negative
responses are commonly encountered with such tests
(Gopikrishna et al. 2009), especially when the exam-
ined teeth are immature (Gopikrishna et al. 2009) or
have undergone injuries that temporarily disable the
sensory nerves (Zadik et al. 1979). In these cases, the
microcirculatory components of the dental pulp may
still be normal (Bhaskar & Rappaport 1973).
Tests of pulp vitality have been introduced in dental
practice. Laser Doppler flowmetry (LDF) and pulse
oximetry (PO) are reportedly able to assess blood flow
within the dental pulp directly. Despite being a better
indicator of the state of a tooth’s pulpal health that
can overcome most problems associated with pulp
sensibility tests, vitality tests may fail to reflect the
true state of health of the dental pulp in clinical situa-
tions where the dental pulp is diseased, but maintains
a viable blood supply; that is, when blood flow can be
detected positively. Vitality tests are not limitation-
free, and their use is complicated and requires strict
adherence to optimum application techniques, which
make the benefits of using these tests in daily practice
questionable.
This review aims to critically appraise the literature
related to the diagnostic accuracy of the most widely
used pulp sensibility and pulp vitality tests for deter-
mining the pulpal health of permanent teeth in
humans. Also, it attempts to assess the quality of evi-
dence and to explore the implications of these findings
for clinical practice and future research planning.
Review
Methodology
The MEDLINE (Ovid), MEDLINE (PubMed), Embase
and Cochrane databases were last searched in
November 2014 using six keywords (dental pulp,
tooth pulp, electric pulp test, thermal pulp test, laser
Doppler flowmetry and pulse oximetry) and combina-
tions of controlled vocabulary (MeSH) (‘dental pulp
AND sensibility test OR vitality test OR electric pulp
test OR thermal pulp test OR laser Doppler flowmetry
OR pulse oximetry’, and ‘tooth pulp AND sensibility
test OR vitality test OR electric pulp test OR thermal
pulp test OR laser Doppler flowmetry OR pulse oxime-
try’) to identify published English-language in vivo
diagnostic clinical trials conducted to evaluate the
2 International Endodontic Journal
accuracy of pulp sensibility and pulp vitality tests in
human teeth.
After excluding duplicates, 201 articles were identi-
fied. Of these, 161 were excluded at the title and
abstract screening stage. The abstracts, and when
needed, full texts of the remaining 40 articles were
reviewed by two independent examiners to identify
those meeting the inclusion criteria (Table 1). Eight
studies matched the inclusion criteria (Fig. 1;
Table 2).
The quality of papers meeting the inclusion criteria
was assessed using the methodology checklist for
studies of diagnostic accuracy. The methodology
checklist is based on the QUADAS (Quality Assess-
ment of Diagnostic Accuracy Studies) tool (Whiting
et al. 2004).
Population
Ideally, the population included in a study investigat-
ing diagnostic accuracy should be representative. In
other words, it should demonstrate a range of disease
severity similar to that seen in practice. Amongst the
studies appraised, three using a cohort design (Peters-
son et al. 1999, Gopikrishna et al. 2007, Weisleder
et al. 2009) met this criterion. A case–control study
by Peters et al. (1994) examined the complete denti-
tion of patients referred for endodontic evaluation and
treatment. The wide variation in pulp status and
crown conditions also constituted a representative
population.
In one cohort study (Kamburo
glu & Paksoy 2005),
teeth with caries were considered to need root canal
treatment (RCT), implying that the dental pulps of
these teeth were diagnosed as nonvital or diseased.
The comparison of these teeth to intact teeth as
healthy controls suggests a biased spectrum.
Table 1 Inclusion criteria for the literature review
Population Permanent teeth of humans
Diagnostic Pulp sensibility tests (electric
tests and thermal)
Pulp vitality tests (laser Doppler
flowmetry and pulse oximetry)
Comparisons Results achieved by the tests under
investigation must be compared to those
achieved by testing control teeth or
using a gold or reference standard
Outcome Sensitivity and specificity values of the
diagnostic tests
© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd

Identification
Records identified through database
searching after duplicates removed
(n = 201)
Screening
Records screened
(n = 201)
Full-text articles assessed
Eligibility
for eligibility
(n = 40)
Studies included in
Included
qualitative synthesis
(n = 8)
Figure 1 PRISMA 2009 Flow Diagram.
The remaining cohort study (Evans et al. 1999)
and two case–control studies (Fuss et al. 1986, Karay-
ilmaz & Kirzio
glu 2011) compared teeth with vital
pulps with teeth with nonvital pulps based on clinical
and radiographic assessments. These studies therefore
failed to fulfil the prerequisite of a representative
population.
Gold or reference standards
The gold standard is the best available method
against which the performances of other diagnostic
(index) tests are evaluated. Unlike the gold standard,
a reference standard does not necessarily identify the
target condition with 100% accuracy.
The current gold standard for determining the
actual state of pulpal health is histological examina-
tion of the dental pulp. The implementation of such a
gold standard requires the extraction of the tooth
shortly after the use of the diagnostic tests and is
thus impossible in the majority of cases where
© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
Alghaithy & Qualtrough Tests of pulpal health: Review
Records excluded
(n =161)
Full-text articles excluded,
with reasons
(n = 32)
sacrificing the tooth is not clinically indicated.
Instead, less invasive reference standards, such as
direct inspection of the dental pulp, may be used for
comparison.
Of the selected studies, five (Evans et al. 1999,
Petersson et al. 1999, Kamburo
glu & Paksoy 2005,
Gopikrishna et al. 2007, Weisleder et al. 2009) used
direct inspection of the dental pulp as a reference
standard for verifying the actual state of the pulpal
health of the teeth. Despite the invasive nature of
direct pulp inspection, it is an objective and valid
method for diagnosing the state of pulpal health of
teeth when properly interpreted (Sigurdsson 2008,
Levin et al. 2009).
The improper use of a gold or reference standard in
diagnostic accuracy studies may produce different
forms of bias. Partial verification, incorporation and
disease progression biases were encountered in two
studies. In the first (Evans et al. 1999), only teeth
diagnosed as having nonvital dental pulps based on
at least two clinical signs of pulp necrosis (one of
International Endodontic Journal 3
 Tests of pulpal health: Review Alghaithy & Qualtrough

Table 2 Studies included in the critical appraisal

Authors and year of publication Title of the article

Fuss et al. 1986,
Peters et al. 1994,
Evans et al. 1999,
Petersson et al. 1999,
Kamburog
lu & Paksoy 2005,
Gopikrishna et al. 2007,
Weisleder et al. 2009,
Karayilmaz & Kirziog
lu 2011
Assessment of reliability of electrical and thermal pulp testing agents.
Adult pulpal diagnosis. I. evaluation of the positive and negative responses to cold
and electrical pulp tests.
A comparison of laser Doppler flowmetry with other methods of assessing the vitality of
traumatized anterior teeth.
Evaluation of the ability of thermal and electrical tests to register pulp vitality.
The usefulness of standard endodontic diagnostic tests in
establishing pulpal status.
Evaluation of the efficacy of a new custom-made pulse oximeter dental probe in
comparison with electrical and thermal tests for assessing pulp vitality.
The validity of pulp testing: a clinical study.
Comparison of the reliability of laser Doppler flowmetry, pulse oximetry, and electric pulp
tester in assessing the pulp vitality of human teeth.

which could have been a negative response to pulp
sensibility tests) had their true pulp status verified
using the reference standard. In the second (Kam-
buro
glu & Paksoy 2005), the reference standard was
used solely to confirm the state of pulpal health of
carious teeth requiring root canal treatment. The
remaining studies (Petersson et al. 1999, Gopikrishna
et al. 2007, Weisleder et al. 2009) were free from the
aforementioned biases, as the pulp status of the entire
sample of teeth were verified using the reference stan-
dard directly after conclusion of the index tests and
regardless of the results of these tests.
In contrast, two studies (Fuss et al. 1986, Karayil-
maz & Kirzio
glu 2011) were case–control clinical tri-
als in which teeth with vital pulps were compared
to teeth with nonvital pulps by clinical and radio-
graphic assessments. This study design is widely
used because of its simplicity and potential to deter-
mine the sensitivity and specificity of the index tests
in the absence of a perfect reference standard or
when the use of a reference standard would be con-
sidered destructive. Unfortunately, spectrum bias is
the major pitfall of this study design. However, a
study of the same design (Peters et al. 1994) exam-
ined the full dentition of patients referred for
endodontic evaluation and treatment. In this particu-
lar instance, the anticipated variability in tooth
condition overcame the major downside of the
case–control study design.
Investigators and blinding
Under ideal circumstances, investigators who carry
out the index tests or the gold or reference standard
must be unaware of the actual state of the pulpal
heath of the teeth to be examined, and to the results
achieved by each other. In other words, total blinding
is required to eliminate the possibility of a review bias
arising within a study.
Information concerning the blinding of investiga-
tors was missing in five studies (Fuss et al. 1986,
Peters et al. 1994, Evans et al. 1999, Kamburo
glu &
Paksoy 2005, Karayilmaz & Kirzio
glu 2011). A
review bias could be expected with certainty in one
study (Kamburo
glu & Paksoy 2005) in which carious
teeth were compared with those with intact crowns.
The opposite is true in the study by Peters et al.
(1994), as it is unlikely that two operators examining
the full dentitions of 60 patients would be able to
remember the predetermined state of pulpal health of
each tooth.
A key advantage of directly inspecting the dental
pulp as the reference standard is its objectivity, which
is further emphasized by establishing clear and easily
applied guidelines for interpreting test results. Thus,
blinding is not required for significance when such a
standard is to be implemented.
Assessed outcomes
The selected studies either reported values for sensitiv-
ity (identification of cases positive for the disease) and
specificity (identification of cases free from the disease)
or presented sufficient data to enable calculations of
sensitivity and specificity (Table 3). In the study by
Weisleder et al. (2009), the authors defined sensitivity
and specificity opposite to the definitions used in the
other studies. Therefore, the sensitivity and specificity
values reported by this study were transposed for the
sake of comparison.

4 International Endodontic Journal © 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Table 3 Sensitivity and specificity values of pulp tests in the selected studies

Sensitivity Specificity

Authors and Laser Electric Heated Laser Electric Heated

Study year of Doppler Pulse pulp CO2 Endo- Ethyl Ice gutta- Doppler Pulse pulp Endo- Ethyl Ice gutta-
design publication flowmetry oximetry tester snow Ice chloride sticks Coolan percha flowmetry oximetry tester CO2 snow Ice chloride sticks Coolan percha

Cohort Petersson – – 0.72 – – 0.83 – – 0.86 – – 0.93 – – 0.93 – – 0.41

et al. (1999)
Evans et al. 1 – 0.87 – – 0.92 – – – 1 – 0.96 – – 0.89 – – –
(1999)
Kamburo
glu – – 0.83 – – – – 0.93 – – – 0.96 – – – – 0.98 –
& Paksoy
(2005)
Gopikrishna – 1 0.71 – 0.81 – – – – – 0.95 0.92 – 0.92 – – – –
et al.
(2007)

© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
Weisleder et – – 0.75 0.89 0.92 – – – – – – 0.92 0.76 0.76 – – – –
al. (2009)a
Case– Fuss et al. – – 1 0.98 0.98 0.53 0.31 – – – – 1 1 1 1 1 – –
control (1986)
(adult)b
Fuss et al. – – 0.79 0.98 1.0 0.43 0.47 – – – – 1 1 1 1 1 – –
(1986)
(youth)b
Peters et – – 0.67 0.94 – – – – – – – 0.997 0.95 – – – – –
al. (1994)b
Karayilmaz 1 0.81 0.92 – – – – – – 1 0.95 0.88 – – – – – –
&
Kirziog
lu
(2011)

a
Sensitivity and specificity values given by the authors were reversed.
b
Sensitivity and specificity values were calculated from data reported by the study.
Alghaithy & Qualtrough Tests of pulpal health: Review

5 International Endodontic Journal

 Tests of pulpal health: Review Alghaithy & Qualtrough
Discussion
The number of studies matching the inclusion criteria
did not provide a sufficient foundation to evaluate the
clinical performance of pulp vitality tests, which were
rarely compared within the studies. The exclusion of
unpublished studies and those not written in English
could be a limitation of this critical appraisal. Varia-
tions in sensitivity and specificity reported by the
studies are understandable, given that shortcomings
in the designs and conduction of diagnostic accuracy
studies predispose them to different forms of bias.
Studies in which the spectrum of selected patients
was found to be biased (Fuss et al. 1986, Evans et al.
1999, Kamburo
glu & Paksoy 2005, Karayilmaz &
Kirzio
glu 2011) reported sensitivity and specificity
values that were remarkably higher than those in
studies in which the sample of patients was represen-
tative of the range of patients commonly seen in den-
tal practice (Peters et al. 1994, Petersson et al.1999,
Gopikrishna et al. 2007, Weisleder et al. 2009). Spec-
trum bias was proven to overinflate the sensitivity,
specificity and diagnostic accuracy of the index tests
(Rutjes et al. 2005). Identifying cases with disease
extremes can be compared to discriminating between
black and white objects and is always less challenging
than judging borderline conditions. A closer look at
studies with cohort designs (Table 3) reveals that
with the exception of two studies, the reported sensi-
tivities were comparable. The exceptionally high sen-
sitivity values in the studies by Evans et al. (1999)
and Kamburo
glu & Paksoy (2005) can be attributed
to the incorporation, partial verification, disease pro-
gression and review biases identified.
LDF was found to be highly reliable in assessing
the pulpal health of teeth, as it maintained a sensitiv-
ity and specificity equal to one and fulfilled the pre-
requisites of a gold standard in two studies (Evans
et al. 1999, Karayilmaz & Kirzio
glu 2011). Interest-
ingly, the teeth investigated varied in stage of devel-
opment, history of trauma, state of pulpal health and
the presence or absence of minimal restoration in an
attempt to determine whether LDF would succeed in
clinical circumstances in which other tests failed or
exhibited low accuracy. The results of LDF seem
promising, but should be regarded with care as they
originated from somewhat biased studies.
The results obtained using PO were inconsistent
with regard to the sensitivity values. Karayilmaz &
Kirzio
glu (2011) proposed that composite restorations
in the access cavities of root filled teeth might have
6 International Endodontic Journal
scattered the light directed to them by the pulse
oximeter to the surrounding gingival tissues, yielding
a greater number of false-positive responses. The sen-
sitivity of their study (0.81) was lower than that
(1.0) of a study by Gopikrishna et al. (2007), in
which the teeth examined were not accessed for RCT,
and therefore were probably not restored in the cervi-
cal palatal region. Both studies reported a specificity
of 0.95, which is disappointing when the technical
difficulties and expenses of this technique are
considered.
The electric pulp test (EPT) was found to be more
reliable in detecting teeth with healthy than with dis-
eased pulp tissues (Fuss et al. 1986, Peters et al.
1994, Evans et al. 1999, Petersson et al. 1999, Kam-
buro
glu & Paksoy 2005, Gopikrishna et al. 2007,
Weisleder et al. 2009). The opposite was reported by
Karayilmaz & Kirzio
glu (2011). This contradictory
finding may have been caused by not excluding teeth
with a history of trauma, resulting in false-negative
responses. The same study reported a lower specificity
for the EPT than the remaining studies. The study
does not include a detailed description of the methods
used for electric pulp testing. It is possible that a fail-
ure to establish adequate isolation using a rubber
dam or celluloid strips during pulp testing may have
resulted in false-positive responses. These responses
could be elicited through stimulation of the adjacent
teeth or periodontium with the electric current (N€ arhi
et al. 1979, Cooley et al. 1984, Myers 1998). Peters
et al. (1994) reported a sensitivity of 0.67 for the
EPT, the lowest value amongst the remaining studies.
The low sensitivity could have been caused by the
heavily restored and crowned teeth in the study; these
teeth are known to transmit electric current to adja-
cent teeth and gingiva if not isolated.
Amongst the cold-testing agents, CO2 snow and
Endo-Ice (Coltene Group, Altst€ atten, Switzerland) were
found to be almost equally predictable for determining
pulpal health (Fuss et al. 1986, Weisleder et al.
2009). When compared within a single study, both
agents were diagnostically superior to ethyl chloride
and ice sticks in detecting teeth with diseased pulp tis-
sue (Fuss et al. 1986), presumably because of the
large differences in temperature reduction induced by
each on the tooth surface (Pitt Ford & Patel 2004).
However, the same study reported no difference in
the ability of the four agents to perfectly detect teeth
with healthy pulp tissues, as all of them produced a
specificity equal to one. CO2 snow and Endo-Ice were
found to be significantly more reliable than the EPT
© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd

in assessing the pulpal health of immature teeth (Fuss
et al. 1986). The increased excitation thresholds of
immature teeth to EPT (Fulling & Andreasen 1976,
Grossman 1978) were linked to the progressive devel-
opment of nerve terminals, which is not fully com-
plete until 4 to 5 years following eruption and
function of a tooth (Bernick 1964). However, the
same concept should apply to CO2 snow and Endo-
Ice, as each of these diagnostic tools operates by elicit-
ing a response from viable pulpal nerves.
Ideally, a method for testing pulp health should be
simple, objective, valid, reliable, reproducible, inexpen-
sive and not painful or injurious (Chambers 1982).
An advantage of LDF is that it is objective and not
painful. In LDF, a readable computerized record that
describes the pulp condition can be saved for future
comparison. Furthermore, its ability to directly assess
the presence or absence of blood flow within the den-
tal pulp favours its use in practice.
LDF accurately assessed the pulpal health of teeth
following traumatic injuries. The introduction of such
a technique in the field of dental traumatology started
a new era, as there was finally a procedure that was
preferable to the ‘wait and see’ policy (Roeykens et al.
2002). ‘Wait and see’ was devised to compensate for
the nerve disruption phenomenon, which is known to
occur following dental injuries and may last for up to
6 months (Zadik et al. 1979), rendering pulp sensibil-
ity tests useless. Therefore, it has been advocated that
RCT should not be initiated until at least one addi-
tional sign of pulp necrosis has developed, such as a
sinus tract, crown discoloration or periradicular radi-
olucency (Bhaskar & Rappaport 1973). Others have
suggested that the ‘wait and see’ policy may result in
catastrophic consequences, including external root
resorption (Tronstad 1988) or tooth discoloration.
Bleaching of discoloured teeth in the presence of a
history of trauma has been found to be associated
with a higher incidence of cervical root resorption
(Heithersay 1999a,b). Furthermore, the success of
RCT is significantly reduced in the presence of peri-
radicular lesions (Ørstavik et al. 2004). However, the
pulp tissues in immature teeth may revascularize after
necrosis caused by traumatic incidents (Kling et al.
1986, Cvek et al. 1990). When such a possibility
exists, it seems likely that it is worth the wait, espe-
cially in young patients for whom the cessation of
root development following RCT jeopardizes the long-
term restorability of the tooth and complicates the
treatment plan.
© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd
Alghaithy & Qualtrough Tests of pulpal health: Review
A diagnosis should never be established on the sole
basis of results obtained using pulp tests. Such tests
serve at best as valuable adjuncts to treatment deci-
sions based on the history and clinical and radio-
graphic assessments. None of the critically appraised
studies investigated whether a decision based on the
evaluation of all diagnostic aspects contributed to the
accuracy of the results. Weisleder et al. (2009)
showed that using the EPT along with CO2 snow or
Endo-Ice was more accurate than when the tech-
niques were used alone in assessing the pulpal health
of teeth.
Conclusions
Accurate assessment of the state of health of the den-
tal pulp is challenging. In the context of the critically
appraised studies, LDF appeared to be remarkably
promising and was the test that came closest to serv-
ing as the exclusive gold standard. Assessment of the
state of pulpal health using pulp sensibility tests,
although subject to error, can provide valuable diag-
nostic information in the hands of an experienced
clinician. Understanding the limitations of such meth-
ods, together with using precise application tech-
niques, contributes significantly to the accuracy of
the results. The use of LDF is advocated for clinical
situations in which pulp sensibility tests are expected
to be unreliable, particularly following traumatic
dental injuries.
Conflict of interest statement
The authors have stated explicitly that there is no
conflict of interest in connection with this article.
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