12 May 2025

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A Diagnostic Insight of Dental Pulp Testing Methods in Pediatric Dentistry

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The accurate diagnosis of pulpal pathology in pediatric dentistry is essential for the success of vital pulp therapy. Pulp testing is often a challenging task due to understanding and cooperation issues of pediatric patients, as well as the particularities of pulpal physiology encountered in primary and immature permanent teeth. Sensibility tests, although still widely used by dental practitioners, are no longer recommended by pediatric specialists mainly due to their subjective nature. Vitality pulp tests have gained popularity in the last decade in light of some encouraging results of clinical studies. However, their use is not a routine practice yet. This paper is a literature review aimed to guide dental practitioners towards selecting the appropriate pulp testing method for their pediatric cases. It provides an overview on a multitude of pulp testing methods and an update in recommendations for primary and immature permanent teeth.

Introduction

Deep dental caries and dental trauma to the primary and immature permanent dentition are frequent occurrences in a pediatric dental practice, and they present a challenge concerning the evaluation of the pulpal status and consequent choice of treatment strategy. In today’s pediatric dentistry, the conservative or minimally invasive dentistry (MID) concept has revolutionized the approach to caries excavation and diagnosis in both primary and permanent teeth. The treatment paradigm has shifted towards techniques aimed at maintaining pulp vitality, allowing the tooth to heal, and for that reason, an accurate diagnosis of the pulp status prior to the treatment is essential.

The accuracy of a pulp diagnosis relies on a combination of data obtained from clinical examination, corroborated with radiographic findings, results of pulp testing, and reported dental history. The diagnostic process is also influenced to some degree by the clinician’s experience in the field. Dental pulp testing is a useful and essential diagnostic aid widely used in endodontics. There are multiple methods of testing the pulp status (Figure 1): either by assessing the neural component of the pulp (triggering a sensory response through mechanical or sensibility tests), or by assessing the vascular component (through vitality tests). The use of sensibility tests in primary and in immature permanent teeth to evaluate pulp status is frequently a challenging task, due to the particularities in the pulp physiology of these teeth and to the fact that the results of the tests are highly subjective, depending on the patient’s cooperation and understanding of the situation, which is particularly difficult in young children. Mechanical tests are equally challenging in children, as any pain stimulation may hinge cooperation for further treatment. Vitality tests, on the other hand, proved to be more reliable, patient-friendly (pain-free), and objective, but they still come with a few drawbacks that have prevented them from being routinely used in pediatric practice.

The ideal technique for the evaluation of the dental pulp status needs to be non-invasive, objective, painless, reliable, reproducible, and standardized. To this list, we can add two more requirements that are essential for pediatric use: easy to employ (a simple technique) and fast. The diagnostic accuracy of a pulp test is measured using a gold or reference standard for comparison. The gold standard is the best available method against which the performances of other diagnostic tests are evaluated, whereas a reference standard does not necessarily identify the target condition with 100% accuracy. In the case of the dental pulp, histological examination has been regarded as the gold standard, whereas direct visualization has been used most often as a reference standard in clinical studies. In clinical day-to-day practice, the results of pulp testing of intact, healthy adjacent and/or contralateral teeth to the ones in question are often used as controls, to observe a baseline normal response. Teeth with evidence of root canal filling are also used as controls to confirm nonvital teeth. Specificity and sensitivity are two parameters used to assess the outcome of a pulp test, showing its intrinsic ability to correctly identify vital pulp and necrotic pulp, respectively. Specificity refers to the percentage of teeth correctly identified as vital, and sensitivity refers to the percentage of teeth correctly identified as nonvital.

Authors: Andreea Igna, Doina Mircioagă, Marius Boariu, Ștefan-Ioan Stratul

Source: https://www.mdpi.com/