Assessment of pulp vitality: a review - plagiarismtext

Assessment of pulp vitality: a review

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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Introduction Diagnosis in dentistry may be defined as ‘the process whereby the data obtained from questioning, examining and testing are combined by the dentist to identify deviations from the normal’ (Robinson 1963).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Introduction Diagnosis in dentistry may be defined as ‘the process whereby the data obtained from questioning, examining and testing are combined by the dentist to identify deviations from the normal1.	Reference (1) is Robinson, 1963.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Ehrmann (1977) discussed three uses of pulp testing: i. Prior to operative procedures Pulp tests should be carried out on teeth prior to restorative or orthodontic work, even if the teeth are symptomless and the radiographic appearance is normal. It is known that there can be loss of periapical bone associated with a non-vital pulp before it is detectable in a radiograph and Kramer (1954) has shown that acute, severe pulp disturbance can occur without causing pain.	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Ehrmann2 has proposed three key uses of pulp testing in clinical practice: 1) Prior to operative procedures: Pulp testing may be indicated for selected teeth prior to restorative or orthodontic interventions, particularly where pulp health may be in question. The absence of symptoms or radiographic changes alone may not be taken as conclusive evidence of pulp vitality, because pulpal degeneration can occur without accompanying symptoms3.	Reference (2) is Ehrmann, 1977. Reference (3) is Kramer, 1954.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	ii. Diagnosis of pain The origin of most oral pain is pulpal (Ehrmann 1977), but pain localization may be difficult, and may require a full range of tests as well as a careful history and examination. Mumford & Bjorn (1962) and Mumford (1976) acknowledge the value of pulp testing in the diagnosis of pain in the trigeminal area. Duquette & Goebel (1973) illustrated the value of pulp testing in pain diagnosis with three cases where pulpitis simulated the myofascial pain dysfunction syndrome. Harris (1973) showed the use of pulp testing in pin-pointing the tooth responsible for pain referred to an apparently sound tooth in another quadrant. Likewise, normal pulp test results would suggest that nonpulpal pathology is responsible for an undiagnosed pain.	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	2) Diagnosis of pain: The origin of most oral pain is pulpal2, but pain localization may be difficult, and may require a full range of tests as well as a careful history and examination. A number of authors have acknowledged the value of pulp testing in the diagnosis of pain in the trigeminal area4,5. Furthermore, case reports have illustrated the value of pulp testing in identifying pulpal pain from other conditions such as myofascial pain dysfunction syndrome6 and referred pain7. Conversely, a normal response to pulp testing may eliminate the diagnosis of pulpal pathology in oro-facial pain of unknown aetiology.	Reference (2) is Ehrmann, 1977. Reference (4) is Mumford and Bjorn, 1962. Reference (5) is Mumford, 1976. Reference (6) is Duquette and Goebel, 1973. Reference (7) is Harris, 1973.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	iii. Investigation of radiolucent areas Radiolucent areas at the apices of teeth may be the result of periapical extension of pulpal pathology, but may also be due to other pathological processes, or may, in fact, represent normal structures. If pulpal pathology is not responsible for the lesion, the associated teeth would be expected to give a normal vitality test. Periodontal lesions, cysts, fibrous lesions, congenital abnormalities, and even neoplastic processes may all produce periapical radiolucencies similar to those due to pulp degeneration. The mental foramen and the incisive canal are two normal structures which may present as periapical radiolucencies.	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	3) Investigation of radiolucent areas : Radiolucent areas at the apices of teeth may be the result of periapical extension of pulpal pathology, but may also be due to other pathological processes, or may, in fact, represent normal structures. If pulpal pathology is not responsible for the lesion, the associated teeth would be expected to give a normal response to vitality testing. Periodontal lesions, cysts, fibrous lesions, congenital abnormalities, and even neoplastic processes may all produce periapical radiolucencies similar to those associated with pulp degeneration 7,8 . The mental foramen and the incisive canal are two normal structures which may also present as periapical radiolucencies.	The paragraph is exact but for reference 7 & 8 in the imitation, perhaps to make it more legitimate.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	In addition to the above-mentioned uses, Mumford & Bjorn (1962) mention three further uses.: iv. Post-trauma assessment Vitality testing forms an important part of the examination and follow-up of traumatized teeth. However, the validity of test results is controversial and will be discussed fully in a later section. Vitality testing is also important in determining the treatment needs of teeth involved in jaw fractures (Roed-Petersen & Andreasen 1970), and those affected by surgical trauma, such as subapical osteotomy (Johnson & Hinds 1969) or vital transplantation procedures (Urbanska & Mumford 1980). v. Assessment of anaesthesia Pulp testers have been used to assess whether a tooth is completely anaesthetized following an injection of local anaesthetic prior to operative procedures (Grossman 1978). This seems unnecessary, however, as the mechanical stimulation of the procedure will assess the anaesthesia in any case. Mumford & Bjorn (1962) noted that this use has also been applied in studies to compare or evaluate analgesic drugs. vi. Assessment of teeth which have been pulp-capped, or which have required deep restorations (Mumford & Bjorn 1962).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	In addition to the mentioned uses, Mumford and Bjorn 4 suggest three further uses for pulp testing: 1) Post-trauma assessment : Vitality testing forms an important part of the examination and review of traumatized teeth. However, the validity of test results is controversial and will be discussed fully in a later section. Vitality testing is also important in determining the treatment needs of teeth involved in jaw fractures9, and those affected by surgical trauma, such as subapical osteotomy10 or vital transplantation procedures 11. 2) Assessment of anaesthesia : Grossman advocated the use of pulp testers to assess whether a tooth is completely anaesthetized following injection of local anaesthetic prior to operative procedures 12 . This would, however, seem unnecessary in normal clinical practice. It has also been suggested that pulp testing may be a useful adjunct in experimental studies which specifically seek to evaluate the effectiveness of different analgesic drugs 4 . 3)Assessment of teeth which have been pulp capped or required deep restoration :	Reference (4) is Mumford and Bjorn, 1962. Reference (9) is Roed-Petersen and Andreasen, 1970. Reference (10) is Johnson and Hinds, 1969. Reference (11) is Urbanska and Mumford, 1980. Reference (12) is Grossman, 1978. Reference (4) is Mumford and Bjorn, 1962.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	LACK OF OBJECTIVITY Ingle & Beveridge (1976) have suggested that the response of a patient to the pulp testing procedure may be considered objective, but in view of the very subjective nature of pain, this suggestion seems unreasonably optimistic. Several other authors have noted the problem of subjectivity (Degering 1962, Mumford 1976, Ehrmann 1977, Stark et al.1977).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	OBJECTIVITY Ingle and Beveridge79 have proposed that patient responses to pulp testing procedures may be considered objective. Many other authors, however, would disagree due to the subjective nature of pain.2,5,80,81	Reference ( 2, 5, 80, 81) are as follows; Ehrmann, 1977 Mumford, 1976 Degering, 1962 Stark, 1977, which is the same as what is cited in the original source.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Thus any attempts to correlate intensity of response with pulpal condition have the problem of subjectivity in addition to those problems already discussed.	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Thus, any attempts to correlate intensity of response with pulpal condition are complicated by this issue of subjectivity.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	The use of a ‘control’ tooth on the opposite side of the mouth has been employed in an attempt to remove the factor of subjectivity of an individual’s response, and despite the support of Chilton & Fertig (1 972), this has several criticisms. Firstly, Seltzer et al. (1963) note that there is no way of knowing whether the ‘control’ tooth itself is normal without extracting it and observing it histologically, and secondly, Mumford (1976) reminds us that, since response intensity does not represent pathological state, comparative testing contributes no further information.	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	The use of a ‘control’ tooth, on the opposite side of the mouth, has been proposed to remove subjectivity from an individual’s response82. This, approach, however, is still open to criticism as there is no way of knowing whether the ‘control’ tooth itself is normal35. Furthermore, Mumford5 reminds us that, as response intensity does not represent pathological state, comparative testing contributes little further information.	Reference (82) is Chilton & Fertig, 1972. Reference (35) is Seltzer et al, 1963. Reference (5) is Mumford, 1976. Compare the above the references in both the original and imitation, including the wordings, comma, apostrophe, etc.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Lack of reproducibility Reiss & Furedi (1933) and Schaffer (1958) have stated that patients respond differently to pulp tests   on different days, and at different hours of the same day.	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Reproducibility Reiss and Furedi83, and Schaffer84 have reported that patients respond differently to pulp tests on different days, and at different hours of the same day.	The identical reference is quite obvious.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Grossman (1 978) notes that the result of the electric pulp test depends on the state of mind of the patient, and thus is a changeable factor. The lack of intrinsic accuracy of several types of commercial electrical pulp testers has been described (Matthews & Searle 1974, Cooley & Robison 1980).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Reproducibility of pulp testing is therefore an area for concern and may relate to the variable state of mind of the patient12 as well as the lack of intrinsic accuracy of several types of commercial electrical pulp testers51,73.	The meaning is the same. Reference (12) is Grossman, 1978. Reference (51) is Cooley & Robinson, 1980. Reference (73) is Matthews et al, 1974.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Lack of correlation with the histological condition of the pulp As Seltzer et al. (1963) and Dummer et al. (1980) point out, conservative procedures on teeth, aimed at preserving the pulp vitality, can only be effective if the status of the pulp is accurately assessed. However, with present vitality tests, we are very limited in the ability to do this. Seltzer et al. (1963) describe a ‘sense of inadequacy, often bordering on frustration’ accompanying attempts to predict the pathological state of the pulp. Many studies have confirmed the lack of correlation between various pulp testing methods and the histological condition of the pulp (Raper 1921, Mumford & Bjorn 1962, Reynolds 1966, Mumford 1967, 1976, Barker & Ehrmann 1969, Lundy & Stanley 1969, Matthews et al. 1974b, Ehrmann 1977, Marshall 1979, Dummer et al. 1980). What then, one may ask, does pulp testing contribute to oral diagnosis? Despite the lack of correlation between test threshold and the specific histological state of the pulp, it has been found that there is a statistically significant relationship between absence of a response to the pulp test (or perhaps a very high reading in the case of electric pulp testers) and the presence of a totally necrotic pulp (Seltzer et al. 1963, Lundy & Stanley 1969, Seltzer & Bender 1975, Marshall 1979). The old view that a lowered threshold to pulp testing indicates hyperaemia or acute pulpitis and an increased threshold indicates chronic pulpitis should be discarded (Kaletsky & Furedi 1935). It must also be remembered that there is a poor correlation between symptoms and pulpal histopathology (Tyldesley & Mumford 1970, Garfunkel et al. 1973, Dummer et al. 1980),	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Correlation with pulp histopathology Conservative procedures, aimed at preserving pulp vitality, can only be effective if the status of the pulp is accurately assessed35,59. Responses to vitality testing, however, correlate poorly with histological findings. Seltzer et al.35 described a ‘sense of inadequacy, often bordering on frustration’ accompanying attempts to predict the pathological state of the pulp. Numerous studies have confirmed the lack of correlation between various pulp testing methods and the actual histological condition of the pulp2,39,59,70–74. Despite the acknowledged lack of correlation between test threshold and the specific histological state of the pulp, it has been found that there is a statistically significant relationship between the absence of a response to pulp testing and the presence of a completely necrotic pulp35,39,74,75. The traditional view that a lowered threshold to pulp testing indicates hyperaemia or acute pulpitis, and an increased threshold indicates chronic pulpitis is questionable76. It must also be remembered that there is a poor correlation between symptoms and pulpal histopathology77,78.	Reference (35) is Seltzer et al, 1963. Reference (59) is Dummer et al, 1980. Reference (2) is Ehrmann EH, 1977. Reference  (39) is Lundy and Stanley, 1969. Reference (59) is Dummer et al, 1980. Reference (70) is Reynolds RL, 1966. Reference (71) is Mumford JM, 1967. Reference (72) is Barker & Ehrmann 1969. Reference (73) is Matthews et al, 1974. Reference (74) is Marshall FJ, 1979. Reference (75) is Seltzer and Bender, 1975. Reference (76) is Kaletsky and Furedi, 1935. Reference (77) is Tyldesley & Mumford, 1970. Reference (78) is Garfunkel et al, 1973.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Effect of trauma Several authors have commented on the unreliable response of a tooth to a pulp test following trauma (Kaletsky & Furedi 1935, Teitler et al. 1972, Barkin 1973, Bhaskar & Rappaport 1973, Ehrmann 1977, Zadik et al. 1979).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Effect of trauma Several authors have highlighted the unpredictable response of a tooth to pulp testing following trauma59,76,103,104.	Reference (59) is Reference (76) is Kaletsky & Furedi, 1935. Reference (103) is Teitler et al,. 1972. Reference (104) is Zadik et al, 1979.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Multi-roo ted teeth Grossman (1978) has noted the problems of assessing the vitality of multi-rooted teeth when the pulp is vital in one root canal but not in another.	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Multi-rooted teeth Grossman12 has noted the problems of assessing the vitality of multi-rooted teeth when the pulp is vital in one root canal but not in another.	Reference (12) is Grossmann, 1978.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Effect of periodontal disease Rubach & Mitchell (1965) and Reynolds (1966) found no increase in pulpal stimulus threshold with periodontal disease, or with bone loss (Rubach & Mitchell 1965).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Effect of periodontal disease There are conflicting reports as to the effect of periodontal disease on pulp testing responses. No increase in pulpal stimulus threshold has been reported in the presence of periodontal disease or bone loss70,94,98.	Reference (70) is Reynolds, 1966. Reference (94) is Ruback and Mitchell, 1965.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Bender & Seltzer, however, produced a very comprehensive paper in 1972 which examined the effect of periodontal disease on the pulp and they stated that ‘there was . . . strong inferential evidence that teeth with periodontal disease produce a high incidence of degeneration and inflammation of the pulp.’	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Bender and Seltzer99, however, produced a very comprehensive paper in 1972 which examined the effect of periodontal disease on the pulp. They stated that there was strong inferential evidence that teeth with periodontal disease may have associated pulpal inflammation and degeneration.	Reference (99) is Bender and Seltzer, 1972.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Age influence Except for newly erupted teeth, age of the patient from 10 to 73 years appears to have no effect on pain perception threshold of the pulpal nerves (Mumford 1963, Rubach & Mitchell 1965, Harkins & Chapman 1976, 1977).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Age influence With the exception of newly erupted teeth, the age of the patient (10–73 years) appears to have no effect on thresholds to pulp testing93-96.	Reference (93-96) are as follows: Mumford, 1963; Rubach & Mitchell, 1965; Harkins & Chapman, 1976; Harkins & Chapman 1977.
	The lack of age effect is somewhat surprising in view of the findings of Bernick (1967b) and Bernick & Nedelman (1975) who noted that with increasing age, there was calcification of nerves in the pulp, with a decrease in the number of nerve branches in the coronal pulp.		This would seem surprising in view of histological findings of pulpal nerve calcification and decreased neural density with increased age97,98.	Reference (97-98) as follows: Note: Bernick 1967b is wrongly printed. Bernick, 1976b; Bernick and Nedelman, 1975.
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Chamber IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod Dent 1982;15:1-5.	Sex influence Several authors have found no definite differences in pain perception threshold due to sex of the patient (Schumacher et at. 1940, Mumford 1965, 1976, Elomaa 1968, Nordenram 1970).	Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.	Gender There is no evidence for a difference in perception threshold to pulp testing according to the gender of the patient100–102.	Reference (100-102)  as follows: Mumford, 1965. Schumacher et al, 1940. Elomaa, 1968.

Which is original? Pitt Ford TR and Patel S. Technical equipment for assessment of dental pulp status. Endod Top 2004;7:2-13. OR Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.

Pitt Ford TR et al, 2004, page 3	Gopikrishna V et al, page 3	Remark
The diagnosis of dental pulp status should be seen as a synthesis of history, clinical examination, special tests, and radiological examination, and not as the outcome of one specific test. Too often dentists base treatment decisions on limited information that may be contradictory; this is not in the best interests of patients. Vitality testing is an important aid in the diagnosis of pulp disease and apical periodontitis. If the pulp is deemed to be unhealthy as a result of the diagnostic synthesis, then endodontic treatment is indicated.	The diagnosis of dental pulp status should be seen as a synthesis of history, clinical examination, special tests, and radiological examination, and not as the outcome of any one specific test. Vitality testing is an important aid in the diagnosis of pulp disease and apical periodontitis. If the pulp is deemed to be severely compromised as a result of the diagnostic testing, then endodontic treatment, or indeed extraction, may be indicated.	Note: Lack of citation in the latter as in the former.
Pitt Ford TR et al, page 3	Gopikrishna V et al, page 5	Remark
Sensitivity testing Currently, the most widely used vitality testers assess the integrity of the Ad nerve fibers in the dentine–pulp complex by briefly applying the stimulus to the outer surface of the tooth. If the Ad nerve fibers are successfully stimulated, the patient will respond by acknowledging a brief sharp sensation/tingling from the tooth. The test indicates that the nerve fibers are functioning but does not give any indication of blood flow in the pulp, or whether it is partially damaged. If there is no blood flow in the pulp, it will rapidly become anoxic and the Ad fibers will cease to function. However, there are instances, for example, after trauma, where there is blood flow in the pulp but the Ad nerve fibers are not functioning.	Sensitivity testing Currently, the most widely used vitality testers assess the integrity of the A δ nerve fibers in the dentine–pulp complex by briefly applying a stimulus to the outer surface of the tooth. If the Aδ nerve fibres are successfully stimulated, the patient will respond by acknowledging a short, sharp sensation/tingling from the tooth. A positive response indicates that the nerve fibres are functioning (to some degree), but does not give any indication of pulpal blood flow. If there is no vascular supply to the pulp, it will rapidly become anoxic and the A δ fibres will cease to function. It should be noted, however, that there may be instances, such as following trauma, where there is a blood flow to the pulp, but the A δ nerve fibres are not functioning.	Note: missing citations as in the original.
Pitt Ford TR et al, page 3	Gopikrishna V et al, page 5	Remark
Cold tests It is believed that cold thermal testing causes contraction of the dentinal fluid within the dentinal tubules; this results in rapid outward flow of fluid within the patent tubules (5, 6). The rapid movement of dentinal fluid results in ‘hydrodynamic forces’ acting on the Ad nerve mechanoreceptors within the pulp–dentine complex leading to a sharp sensation lasting for the duration of the thermal test (7).	Cold tests Cold thermal testing causes contraction of the dentinal fluid within the dentinal tubules, resulting in a rapid outward flow of fluid within the patent tubules 25,26. This rapid movement of dentinal fluid results in ‘hydrodynamic forces’ acting on the Aδ nerve fibres within the pulp–dentine complex, leading to a sharp sensation lasting for the duration of the thermal test 27. .	Reference 25-27  is the same as 5-7.
Pitt Ford TR et al, page 3	Gopikrishna V et al, page 6	Remark
Ice-cold water is another useful and inexpensive test. The tooth under investigation is isolated with rubber dam and then bathed with water from a syringe (Fig. 5). The advantages of this cold test are that the entire tooth is cooled down and teeth restored with full coverage metal restorations may be evaluated, thus resulting in a very clear response from the patient (8). Cold tests should be applied until the patient definitely responds to the stimulus or for a maximum of 15 s, whichever comes first (12). Cold tests have appeared to be more reliable than heat tests (3, 13). There is a general consensus that the colder the stimulus, the more effective the investigation is in assessing the status of the nerve supply within the tooth (8, 9, 12, 14).	Ice-cold water is another useful and inexpensive test. The tooth under investigation should be isolated with rubber dam and then bathed with water from a syringe 29. Cold tests should be applied until the patient definitely responds or the stimulus has been applied for a maximum of 15 s 34. Overall, cold tests appear to be more reliable than heat tests 2,35. Furthermore, there is a general consensus that the colder the stimulus, the more effective the assessment of tooth innervation status 29,30,34.	Reference 29 is the same as 8. Reference 34 is the same as 12.
Pitt Ford TR et al, page 4	Gopikrishna V et al, page 6	Remark
It has been believed that a tooth-surface temperature as high as 150°C could be achieved with this technique (16); gutta-percha softens at 65°C and may be heated in delivery devices up to 200°C. This test may be difficult to use on posterior teeth because of limited access (3). The disadvantage of using heated gutta-percha is that prolonged heating could result in pulp damage (17). Prolonged heat application will result in bi-phasic stimulation of initially Aδ fibers and then C fibers within the pulp (18) resulting in a lingering pain; therefore, heat tests should be applied for no more than 5s. Inadequate heating of the gutta-percha stick could result in the stimulus being too weak to elicit a response from the pulp (19).	It is purported that a tooth surface temperature as high as 150°C can be achieved with this technique 37: gutta-percha softens at 65°C and may be heated in delivery devices up to 200°C. This test may be difficult to use on posterior teeth because of limited access. A further disadvantage is that excessive heating may result in pulp damage 38. Prolonged heat application will result in bi-phasic stimulation of Aδ fibres initially, followed by the pulpal C fibres 18. Activation of C fibres may result in a lingering pain, therefore heat tests should be applied for no more than 5s. However, inadequate heating of the gutta-percha stick could result in the stimulus being too weak to elicit a response from the pulp 39.	Reference 37 is same as 16. Reference 3 in the original is missing in the copied version. Reference 38 is the same as 17. Reference 18 is same in both. Reference 39 is same as 19.
Pitt Ford TR et al, page 5	Gopikrishna V et al, page 6-7	Remark
Electric pulp testing The objective of electric pulp testing is to stimulate intact Aδ nerves in the pulp–dentine complex by applying an electric current on the tooth surface. A positive result from electric pulp testing is a result of an ionic shift in the dentinal fluid within the tubules causing local depolarization and subsequent generation of an action potential from the intact nerve (23). The electric pulp tester consists of a battery-operated unit, which is connected to a probe that is applied to the tooth under investigation. The electrical circuit is completed by the patient holding the rear end of the handle of the probe (Fig. 8), or by placing a hook over the patient's lower lip (Fig. 9). Two widely used pulp testers are the Analytic Technology pulp tester and the Vitality Scanner (Analytic Sybron Dental Specialities, Orange, CA, USA). Electric pulp testers function by producing a pulsating electrical stimulus, the intensity of which automatically begins from a very low value to prevent unnecessarily excessive stimulation and discomfort. The intensity of the electrical stimulus steadily increases at a preselected rate; a note is made of the reading on the digital display when the patient acknowledges a warm or tingling sensation. The output characteristics of this unit have been investigated (24). The rate of voltage increase was also found to vary depending on the device used. A further investigation concluded that there was no consistency in threshold excitation values for healthy teeth (25). The readout is not a quantitative measurement of the health of the pulp, and therefore does not indicate to what extent the pulp is healthy/unhealthy; a response only implies that the Aδ fibers are sufficiently healthy to function.	Electric pulp test The objective of EPT is to stimulate intact Aδ nerves in the pulp–dentine complex by applying an electric current on the tooth surface. A positive result stems from an ionic shift in the dentinal fluid within the tubules causing local depolarization and subsequent generation of an action potential from intact Aδ nerves 43. The electric pulp tester is a battery-operated instrument, which is connected to a probe that is applied to the tooth under investigation. It functions by producing a pulsating electrical stimulus, the initial intensity of which should be at a very low value to prevent excessive stimulation and discomfort. The intensity of the electric stimulus is then increased steadily at a pre-selected rate, and a note is made of the read-out on the digital display when the patient acknowledges a warm or tingling sensation. The read-out is not a quantitative measurement of pulp health, but simply provides evidence that the Aδ fibres are sufficiently healthy to function 44,45. .	Reference 43 is same as 23.
Pitt Ford TR et al, page 6	Gopikrishna V et al, 7	Remark
The threshold excitation value is influenced by the position of the electrode on the tooth; for example, the lowest threshold for response and therefore most desirable area of assessment in incisor teeth is at the incisal edge, where the enamel is thinnest or absent (28). The tester should be applied on the tooth surface adjacent to a pulp horn, that is, the region of highest nerve density within the pulp (29–31); this is the incisal-third of anterior teeth and the mid-third of posterior teeth. The threshold for response may be influenced by the thickness of the enamel and dentine overlying the pulp (18, 32); therefore, it has been considered that the response threshold in healthy teeth may be lowest in incisors, slightly greater in premolars and greatest in molar teeth.	Therefore, the most desirable area of assessment in incisor teeth is at the incisal edge, where the enamel is thinnest or absent. The tester should be applied on the tooth surface adjacent to a pulp horn, as this receives the highest nerve density within the pulp16,22,56. This position equates to the incisal third region of anterior teeth and the mid-third region of posterior teeth. The threshold for response may be influenced by the thickness of the enamel and dentine overlying the pulp18,57. Thus, the response threshold for healthy teeth may be lowest in incisors, slightly greater in premolars, and greatest in molar teeth.	Reference 16, 22, 56 is the same as
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False-positive results (i.e. non-vital teeth responding positively to testing) These are summarized in Table 2. Because sensitivity tests are reliant on the patient’s response, a premature response or even a false-positive response may occur in anxious or young patients who are expecting to feel an unpleasant sensation (27, 28).  It has been suggested that localized breakdown products in one part of the root canal system may be able to conduct the electric current from an electric pulp tester to viable nerve tissue in adjacent areas thereby resulting in a false positive result (33). Contact with metal restorations may possibly result in conduction of the current to the periodontium, giving a false-vital response (14); the same may occur with inadequately dried teeth prior to testing (14, 35).	A false positive response is where a non-vital tooth appears to respond positively to testing. This may occur in anxious or young patients who may report a premature response because they are anticipating an unpleasant sensation23,51.   Necrotic breakdown products in one part of a root canal system can conduct electric currents to viable nerve tissue in adjacent areas, thereby resulting in a false positive result59. Contact with metal restorations may also result in conduction of the current to the periodontium, giving a false vital response; the same may occur with inadequately dried teeth60.	Reference 23, 51 are same as 27, 28.
False-negative results (i.e. vital teeth responding negatively to testing) These are also summarized in Table 2. Teeth with incomplete root development may have a higher threshold to testing; thus, a stronger stimulation may be needed to elicit a response compared with teeth with complete root development (37). This is because teeth erupt and become functional before the completion of neural development (38, 39). In these situations cold testing with DDM or CO2 snow appears to be more reliable than electric pulp testing (12, 37).	A false negative result means that a vital tooth has not responded positively to testing. This may be seen in teeth with incomplete root development, which have a higher threshold to testing, and require a stronger stimulation than normal to elicit a response61. This is because teeth erupt and become functional before completion of neural development62,63. In these conditions, cold testing has proved more reliable than EPT34,61.	Reference 62, 63 are same as 38, 39.
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It has been postulated that non-responsive recently traumatized immature teeth do not respond to sensitivity testing because the nerves have been ruptured (41). However, the pulps of the teeth may still be vital as their blood vessels may remain intact or have revascularized. Therefore, traumatized teeth should always be carefully monitored at periodic intervals as their pulps may revascularize and their nerve fibers regain function.	Following injury, traumatized teeth may not respond to thermal or EPT due to nerve rupture64. The pulps of these teeth, however, may still be vital as their blood vessels remain intact or have revascularized. Therefore, traumatized teeth should always be carefully monitored at periodic intervals as their nerve fibres may subsequently regain function.
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Patients with psychotic disorders may not respond to pulp testing (27). It has been reported that individuals who are under the influence of sedative drugs/alcohol may either not respond or respond to stronger stimulation due to their increased threshold to nerve excitation (44).	Patients with psychotic disorders may not respond to pulp testing51. It has also been reported that individuals who are under the influence of sedative drugs/alcohol may either not respond or respond to stronger stimulation due to their increased threshold to nerve excitation67.	Reference 51 is same as 27.

Which is original? Lin J and Chandler NP. Electric pulp testing: a review. Int Endod J 2008;41:365-374. OR Gopikrishna V et al. Assessment of pulp vitality: a review. Int J Paed Dent 2009;19:3-15.

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In the pulp chamber coronal nerve bundles diverge and branch out towards the pulpo-dentine border (Dahl & Mjo¨r 1973, Gunji 1982). Nerve divergence continues until each bundle looses its integrity and smaller fibre groups travel towards the dentine. This route is relatively straight until the nerve fibres form a loop resulting in a mesh that is termed the plexus of Rashkow. The density of this nerve plexus is well developed in the peripheral pulp along the lateral wall of coronal and cervical dentine and along the occlusal wall of the pulp chamber. The nerve fibres emerge from their myelin sheaths and branch repeatedly to form the subodontoblastic plexus. Finally, the terminal axons exit from their Schwann cell investiture and pass between the odontoblasts as free nerve endings (Byers & Na¨rhi 2002).	It is important to have an understanding of pulpal innervation characteristics in order to appreciate the rationale for, and mechanisms involved in, tests of pulpal sensitivity. Within the coronal pulp, nerve bundles diverge and branch out towards the pulpo-dentine border, and emerge from their myelin sheaths 13–15. Nerve divergence continues until each bundle looses its integrity and smaller fibre group stravel towards the dentine. This course is relatively straight until the nerve fibres form a loop and a resultant mesh termed the nerve plexus of Rashkow. Terminal axons exit from their Schwann cell investiture and pass between the odontoblasts as free nerve endings 15. This nerve plexus is most well developed in the peripheral pulp along the lateral wall of coronal and cervical dentine, and along the occlusal aspect of the pulp chamber.	Reference 13-15 is R13-Dahl E, Mjor IA, 1973. R14-Gunji T, 1982. R15-Byers MR, Narhi MO, 2002.
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Two types of sensory fibres are present in the pulp, the myelinated (A fibres) and unmyelinated C fibres. The A fibres predominantly innervate the dentine and are grouped according to their diameter and conduction velocities into Ab and Ad fibres. The Ab fibres may be more sensitive to stimulation than the Ad fibres, but functionally these fibres are grouped together. Approximately 90% of A fibres are Ad fibres. The C fibres innervate the body of the pulp. The Ad fibres have lower electrical thresholds than the C fibres and respond to a number of stimuli which do not activate C fibres (Olgart 1974). Ad fibres mediate acute, sharp pain and are excited by hydromechanical events in dentinal tubules such as drilling or air-drying (Byers 1984). Pulpal Ab- and Ad- fibres respond to drilling and dentine probing and probably belong to the same functional group (Na¨rhi 1985, 1990). Ad fibres may act as mechanoreceptors that trigger withdrawal reflexes so that potentially damaging forces may be avoided (Dong et al. 1985, Olgart et al. 1988, Byers & Na¨rhi 1999). The C fibres mediate a dull, burning and poorly located pain and are activated only by stimuli reaching the pulp proper (Na¨rhi 1985, Markowitz & Kim 1990). C fibres have a high threshold and can be activated by intense heating or cooling of the tooth crown. Once activated, the pain initiated by C fibres can radiate in the face and jaws. C fibre pain is associated  with tissue injury and is modulated by inflammatory mediators, vascular changes in blood volume and flow, and increases in pressure (Na¨rhi 1990). As the intensity of the stimulus increases, more sensory nerves are activated and this results in a progressive increase in the sensory response. The response to a given stimulus will be greatest where neural density is the highest. Key factors in pulp testing are the thickness of the enamel and dentine and the number of nerve fibres in the underlying pulp. Lilja (1980) found that the highest concentration of neural elements was in the pulp horn region. A progressive decrease in the number of nerve fibres in the cervical and radicular areas was observed. Similar findings were reported by Byers & Dong (1983). Presumably the direction of the dentinal tubules is also important in establishing pulp test responses in various parts of the tooth crown. The dentinal tubules run an almost straight course from the incisal edge of anterior teeth to the pulp horn. Elsewhere in teeth the course of tubules is somewhat curved and resembles an ‘S’ shape. Because it is principally the fluid in the tubules that conducts electrical impulses from the pulp tester electrode to the pulp, the shorter the distance between the electrode and the pulp, the lower the resistance to the flow of current (Bender et al. 1989).	Two types of sensory fibres are present in the pulp: the myelinated (A fibres) and unmyelinated C fibres. The A fibres predominantly innervate the dentine and are sub grouped according to their diameter and conduction velocities into A β and A δ fibres. The A β fibres may be more sensitive to stimulation than the A δ fibres, but functionally these fibres are grouped together. Approximately 90% of A fibres are A δ fibres. The C fibres innervate the body of the pulp. The Aδ fibres have lower electrical thresholds than the C fibres, and respond to a number of stimuli which do not activate C fibres16. Aδ fibres mediate acute, pain and are excited by hydromechanical events in dentinal tubules such as drilling or air-drying17. The C fibres mediate a dull, burning, and poorly located pain, and are activated only by stimuli reaching the pulp proper 18,19. C fibres have a high threshold and can be activated by intense heating or cooling of the tooth crown. Once activated, the pain initiated by C fibres can radiate throughout the face and jaws. C fibre pain is associated with tissue injury and is modulated by inflammatory mediators, vascular changes in blood volume and flow, and increases in pressure 20.  As the intensity of the stimulus increases, more sensory nerves are activated, and this results in a progressive increase in the sensory response. The response to a given stimulus will be greatest where neural density is the highest. Key variables known to affect the response to pulp testing are the thickness of the enamel and dentine, and the number of nerve fibres in the underlying pulp. Lilja 21 found that the highest concentration of neural elements was in the pulp horn region. A progressive decrease in the number of nerve fibres in the cervical and radicular areas was observed. Similar findings were reported by Byers and Dong 22. Presumably, the direction of the dentinal tubules is also important in establishing pulp test responses in various parts of the tooth crown. The dentinal tubules run an almost straight course from the incisal edge of anterior teeth to the pulp horn. In multi-cuspal teeth, the course of tubules is somewhat curved and resembles an ‘S’ shape. Because it is principally the fluid in the tubules that conducts electrical impulses from the pulp tester electrode to the pulp, the shorter the distance between the electrode and the pulp, the lower the resistance to the flow of current 23. .	Reference 16 is Olgart L, 1974. Reference 17 is Byers MR, 1984. Reference 18 is Narhi MVO, 1985. Reference 19 is Markowitz K, Kim S, 1990. Note: the reference number 19 and 20 was wrongly cited as the authors were confused in copying. Reference 20 is Narhi MVO, 1990. Reference 21 is Lilja J, 1980. Reference 22 is Byers MR, Dong WK, 1983. Reference 23 is Bender et al, 1989.