Pulp response to thermal tests- Cold and Heat

Both test sensitivity of pulp but a response to cold usually indicates a vital pulp, regardless of
whether that pulp is normal or abnormal. In contrast, an increased response to heat is suggestive of pulpal
or periapical pathology that may require endodontic intervention.

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. This rapid movement of dentinal fluid results in
hydrodynamic forces acting on the A nerve fibres within the pulpdentine complex, leading to a sharp
sensation lasting for the duration of the test. A variety of cold tests may be employed, the major difference
between them is the degree of cold that is applied to the tooth. The most common pulp testing method
employed by practitioners is to seek a response to a cold stimuli. Ideally, cold testing should be used in
conjunction with an electric pulp tester so that the results from one test will verify the findings of the
other test. If a mature, non-traumatized tooth does not respond either to EPT or cold, then the tooth may
be considered non-vital. However, caution should be exercised when testing multi-rooted teeth, as they
may respond positively to cold, even though only one root actually contains vital pulp tissue. The cold
test may be used to differentiate between reversible and irreversible pulpitis. It should be noted, however,
whether stimulus application produces a lingering effect or if the pain subsides immediately on removal
of the stimulus from the tooth. If the patient feels a lingering pain, even after the cold stimulus is
removed, a diagnosis of irreversible pulpitis may be reached. Conversely, if the pain subsides
immediately after stimulus removal, a diagnosis of reversible pulpitis is more likely. The clinician should
also take into consideration other factors such as a history of pain on lying down and the duration of pain.
The diagnosis of reversible/irreversible pulpitis is only a clinical diagnosis and may not correlate with a
histological diagnosis.
A simple means of applying a cold stimulus to a tooth is to wrap a sliver of ice in wet gauze and
place it against the buccal surface, comparing the reaction between the test tooth and a control tooth.
Ethyl chloride may be sprayed onto a cotton pledget, resulting in the formation of ice crystals, prior to
application to the tooth. Dichlorodifluoromethane (DDM) is a compressed refrigerant spray, which can
similarly be sprayed onto a cotton pledget for cold testing. Frozen CO 2 or dry ice can also be used.
When testing with a cold stimulus, one must begin with the most posterior tooth and advance
towards the anterior teeth. Such a sequence will prevent any melted ice water dripping in a posterior
direction which may cause stimulation of other teeth, thereby giving a false response. 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. Cold tests should be applied until the patient definitely responds or
the stimulus has been applied for a maximum of 15s. Overall, cold tests appear to be more reliable than
heat tests. Furthermore, there is a general consensus that the colder the stimulus, the more effective the
assessment of tooth innervation status

Heat test
Heat testing can be undertaken using a stick of heated gutta-percha or hot
water. A gutta-percha stick, preferably base-plate gutta-percha, is heated with a
naked flame or an electric heater until it becomes soft and glistens. It is then
applied to the vaseline-coated surface of the test tooth. It is purported that a tooth

surface temperature as high as 150 C can be achieved with this technique , guttapercha 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 Afibres initially, followed by the
pulpal C fibres. Activation of C fibres may result in a lingering pain, therefore heat
tests should be applied for no more than 5 s. However, inadequate heating of the
gutta-percha stick could result in the stimulus being too weak to elicit a response
from the pulp. The use of hot water, administered through an irrigating syringe
under rubber dam isolation, has also been described as a means of thermal testing.
Frictional heat may be generated by using a rubber cup intended for prophylaxis
(without paste) against the buccal aspect of a tooth . The normal use of thermal
tests on teeth has been shown not to be harmful to healthy pulp tissue .