Clinical Diagnosis, Pulp Vitality Testing, and Treatment Planning
A disciplined diagnostic sequence
History first: character, duration, provocation (thermal, biting, spontaneous), and whether pain outlasts the stimulus. Then extraoral and intraoral examination, palpation, percussion, periodontal probing, mobility and occlusal tests, followed by pulp sensibility testing on the suspect tooth and a control. Radiographs are adjuncts: they show anatomy and periapical change but never pulp status.
Sensibility, not vitality
Cold (refrigerant spray) and electric pulp testing stimulate A-delta fibres; a response means the nerve supply is excitable, not that blood flow is intact. A tooth can be sensibility-positive with a compromised blood supply, and a multirooted tooth with one necrotic canal may still respond. EPT is unreliable through full-coverage restorations, in recently traumatised teeth (transient neuropraxia) and in immature teeth with open apices. Cold is generally the more useful first test; EPT helps when cold is equivocal.
Traps
- Equating 'no response' with necrosis: calcific metamorphosis, luxation injury and poor contact all produce false negatives.
- Using percussion to diagnose pulpitis: percussion tests the periapex, not the pulp.
- Missing a cracked tooth: use magnification, transillumination, bite tests with a cotton roll, and selective loading of individual cusps.
- Failing to test adjacent and contralateral teeth; referred pain from a mandibular molar to the ear is common.
Rule of thumb: two concordant findings (for example, a lingering cold response plus tenderness to percussion on a deeply carious tooth) justify a treatment decision; a single equivocal test does not.