Effectiveness of Diagnosing Pulpitis: A Systematic Review (International Endodontic Journal PDF)

Received: 20 February 2022 | Accepted: 6 May 2022 DOI: 10.1111/iej.13762 REVIEW ARTICLE Effectiveness of diagnosing pulpitis: A systematic review David Donnermeyer1 | Till Dammaschke1 | Mariusz Lipski2 | Edgar Schäfer3 1 Department of Periodontology and Abstract Operative Dentistry, Westphalian Background: The diagnosis of the status of the inflamed pulp is essential in clinical Wilhelms-University, Münster, Germany diagnosis and treatment provision. There are a limited number of well-designed and 2 Department of Preclinical well-executed clinical trials on the diagnosis of the true status of the pulp. Conservative Dentistry and Preclinical Objectives: Three PICO questions were formulated and agreed a priori by the European Endodontics, Pomeranian Medical University, Szczecin, Poland Society of Endodontology to evaluate the clinical tests for sensibility testing, determina- 3 Central Interdisciplinary Ambulance tion of biomarkers and pulp bleeding with regard to their suitability to correctly diag- in the School of Dentistry, Münster, nose the condition of the pulp tissue for the development of S3-Level guidelines. Germany Methods: A literature search was conducted using PubMed, Clarivate Analytics' Correspondence Web of Science, Scopus, Google Scholar and Cochrane Central Register of Controlled Edgar Schäfer, Central Interdisciplinary Trials from inception to 21 January 2022. Additionally, a hand search was performed, Ambulance, Waldeyerstr. 30, Münster D-48149, Germany. and the contents of the major subject journals were also examined. Eligibility criteria Email: eschaef@uni-muenster.de followed the proposed PICO questions. Two independent reviewers were involved in study selection, data extraction and appraising the included studies; disagreements were resolved by a third reviewer. The risk of bias was assessed by the QUADAS-2 tool for diagnostic accuracy studies, the Newcastle–Ottawa scale for noncompara- tive, nonrandomized studies and the Newcastle–Ottawa Quality Assessment scale adapted for cross-sectional studies. Results: In total, 28 studies out of 29 publications were considered eligible and were included in the review. Twelve studies were identified to investigate the diagnostic accuracy of the pulp vitality. Ten studies fulfilled the criteria to evaluate the diagnos- tic accuracy of the pulpal conditions, while 6 studies investigating the expression of biomarkers were eligible. Three studies addressing the prognostic factors and thera- peutic interventions relating to pulpal status were included. Discussion: The core problem in pulp diagnostics is that a reliable reference standard is lacking under clinical conditions. Based on limited evidence, the most promising cur- rent approach seems to define a combination of different clinical tests and symptoms, probably in future including molecular diagnosis (“diagnostic package”) will be required to ascertain the best possible strategy to clinically diagnose true pulpal conditions. Conclusions: The effectiveness of diagnosing pulpitis is low due to limited scientific evidence regarding the accuracy and reproducibility of diagnostic tests. There is a lack of evidence to determine the true status of the pulp or to identify prognostic indicators allowing for a reliable pre-operative estimation of the outcome of vital pulp treatment. Registration: PROSPERO database (CRD42021265366). This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2022 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd on behalf of British Endodontic Society. 296 | wileyonlinelibrary.com/journal/iej Int Endod J. 2023;56(Suppl. 3):296–325. | 13652591, 2023, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13762 by Cochrane Romania, Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License DONNERMEYER et al. 297 KEYWORDS biomarker, decision-making, dental pulp test, endodontics, pulpal status, pulpotomy I N T RO DU CT ION The presence of microorganisms in the pulp tissue is decisive for whether pulpitis can heal (reversible) or Systematic diagnostics is the key to any endodontic ther- not (irreversible). However, this cannot be readily de- apy. In medicine, however, every diagnostic procedure is termined clinically, as irreversible pulpitis can be clini- associated with some degree of uncertainty. This is true cally asymptomatic in 14% to 60% of cases (Michaelson for endodontic diagnostics due to the lack of objective cri- & Holland, 2002; Seltzer et al., 1963). Thus, in pulpitis, teria for detecting the actual condition of the pulp tissue the histologic findings do not infrequently deviate from (Schäfer et al., 2019). Despite this, the correct diagnosis the clinical picture. Hence, in 15.6% of cases, the clini- of the pulp condition plays an important role in the clin- cal and histological diagnoses do not coincide (Ricucci ical success of endodontic therapy. Therefore, it is neces- et al., 2014). Other histological examinations could even sary to assess the possible degree of inflammation and/ detect a discrepancy between clinical and histological or infection of the pulp tissue (Bogen et al., 2021; Ricucci findings in 60% to 80% of the cases, i.e., the pulpal alter- et al., 2014). ations were clinically underestimated (“hypodiagnosis”) If odontogenic pain originates from a tooth with a (Barańska-Gachowska et al., 1969; Barańska-Gachowska vital pulp, a distinction is made between reversible and & Waszkiewicz-Gołoś, 1969). Moreover, pain does not cor- irreversible pulpitis. By definition, reversible pulpitis is a relate with the extent of inflammation, is always subjective clinical diagnosis based on subjective and objective find- and cannot be detected histologically (Lin et al., 2020). It ings indicating that the inflammation of the pulp should should also be noted that clinical symptoms are not indic- subside and the tissue return to normal, whereas irrevers- ative of tissue regenerative capacity (Ricucci et al., 2014). ible pulpitis is defined as a clinical diagnosis indicating In addition to the pain history and sensibility tests, the that the vital but inflamed pulp cannot heal (AAE, 2020). bleeding after pulp exposure should also be examined. While measures to maintain the vitality of the pulp are The extent of pulp bleeding could be considered a more indicated in the case of reversible pulpitis, the diagnosis reliable diagnostic method than sensibility testing and of irreversible pulpitis often leads to pulpectomy and initi- pain symptoms. If the pulp tissue is free of inflamma- ation of root canal treatment (Schäfer et al., 2019). tion or if only superficial inflammation has occurred as Recently, an attempt was therefore made to establish a result of the caries, the pulp bleeding is weak. If, on the an extended diagnostic scheme (Wolters et al., 2017). other hand, microorganisms or bacterial toxins have al- According to this, a distinction can be made between ready penetrated the pulp and the inflammatory reaction initial, mild, moderate, and severe pulpitis. Treatment extends deeper into the tissue, the pulp bleeding is more options for initial and mild pulpitis are indirect or direct severe. The extent of bleeding may therefore reflect the de- pulp capping; for moderate pulpitis, partial or full pulpo- gree of pulp inflammation. Prolonged or severe bleeding tomy. In contrast, for severe pulpitis, full pulpotomy is in- is indicative of irreversible pulpitis. Therefore, pulp tissue dicated, or in case of persisting pulp haemorrhage, vital with severe or persistent bleeding has a significantly worse extirpation (Wolters et al., 2017). Thus, the suggested new chance of healing (Christensen, 1998; Kang et al., 2017; classification may lead to more frequent preservation of Langeland, 1981; Matsuo et al., 1996). However, it must pulp vitality as it seems to be of benefit in cases in which be emphasized that scientific evidence as to the prolonged vital pulp treatment (VPT) is considered to be a treatment bleeding time, above which the pulp must be consid- option (Richert et al., 2022). ered unsuitable for vital pulp treatment is still lacking Clinically, reversible pulpitis is a pain linked to a stimu- (Christensen, 1998; Kang et al., 2017; Langeland, 1981; lus. The painful tooth can be localized by the patient, and Matsuo et al., 1996). the sensibility test is positive (Seltzer et al., 1963). In con- In summary, the treatment of pulpitis (vital pulp treat- trast, in irreversible pulpitis, one finds irritation-sustained ment versus root canal treatment) depends on the extent pain or even spontaneous pain, pain on heat, with the culprit of the bacterial infection, which unfortunately cannot be tooth not clearly locatable by the patient. The sensibility test accurately determined clinically. There is no good cor- is positive, which makes diagnosis difficult for the dentist. relation between the clinical symptoms and the actual Histologically, there are signs of inflammation with polymor- histological findings of the pulp. However, there is a good phonuclear neutrophilic granulocytes, microabscesses, and correlation between the depth of carious bacterial pene- even partial necrosis caused by bacteria that have already in- tration in the dentine and the histological response of the vaded the pulp cavity (Bogen et al., 2021; Ricucci et al., 2014). pulp to caries (Lin et al., 2020). The most reliable way to | 13652591, 2023, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13762 by Cochrane Romania, Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 298 DIAGNOSIS OF PULPITIS diagnose the condition of the pulp is after exposure to this Review question and eligibility criteria tissue. If there is severe bleeding from the pulp or if se- rous, purulent or bloody exudate even emerges, this indi- The study was conducted to answer the following PICO cates an invasion of microorganisms and bacterial toxins questions: into the pulp tissue and thus dissents against the attempt to maintain vitality. The same is true if necrotic pulp tis- 1. In patients suspected of pulpitis with no pain (P) sue is identified without haemorrhage (Bogen et al., 2021; what is the effectiveness of pre- or intraoperative Dammaschke et al., 2019). diagnosis of the pulpal condition in respect to if it Recently, pulpotomies have come into focus as a possible to maintain pulp vitality by means of clinical treatment option for permanent, mature teeth diag- findings such as symptoms, depth of caries lesion, nosed with irreversible pulpitis (Bogen et al., 2021; pulp exposure, bleeding or any other method and Krastl et al., 2021). Therefore, it is important to critically evaluation of the presence of inflammatory mediators question previous methods and the effectiveness of di- (biomarkers) (I) in comparison to follow-up results in agnosing pulpitis. terms of (i) pulp survival, when teeth with suspicion Inflammatory processes in the dental pulp result in of pulpitis were treated with any type of vital pulp vascular (e.g. vasodilatation) and cellular changes (e.g. in- therapy, (ii) histological evaluation of the pulp tissue creased numbers of immune cells) (Richert et al., 2022). after extraction and (iii) quantification of inflammatory Even before activation of the cellular immune response, mediators (e.g. interleukin-8, matrix metalloproteinase the molecular immune response releases inflammatory 9, tumour necrosis factor-α) obtained from dentinal mediators, such as cytokines (IL-1, IL-2, IL-6, IL-8, TNF-β fluid or pulp tissue of teeth suspected of pulpitis in and others) (Rechenberg et al., 2016; Zanini et al., 2017). comparison of teeth with normal (healthy) pulp tissue These molecules expressed in the early stage of pulp in- (C) regarding sensitivity and specificity of pre- or in- flammation may conduce as markers for the diagnosis traoperative diagnosis of the level of pulp inflammation of inflammatory changes within the pulp tissue (Hirsch compared with levels of inflammatory mediators and/ et al., 2017; Rechenberg et al., 2016). Recent studies in- or histological findings (O). dicate that increased levels of biomarkers, obtained from 2. In patients suspected of pulpitis with nonspontaneous dentinal fluid, pulpal blood, gingival crevicular fluid and pain (P) what is the effectiveness of pre- or intraopera- periapical fluid, are correlated with different stages of pulp tive diagnosis of the pulpal condition in respect to if inflammation (Hirsch et al., 2017; Rechenberg et al., 2016; it possible to maintain pulp vitality by means of clini- Zanini et al., 2017). Thus, molecular-based diagnosis may cal findings such as symptoms, depth of caries lesion, have the potential to improve the clinical diagnosis of true pulp exposure, bleeding or any other method includ- pulpal conditions (Zanini et al., 2017). ing the evaluation of the presence of inflammatory The aim of this systematic review is therefore to evalu- mediators (biomarkers) (I) in comparison to follow-up ate the clinical tests for sensibility testing, determination results in terms of pulp survival, when teeth with suspi- of biomarkers and pulp bleeding with regard to their suit- cion of pulpitis were treated with any type of vital pulp ability to correctly diagnose the condition of the pulp tis- treatment and histological evaluation after extraction, sue. Traumatized and deciduous teeth were not included quantification of inflammatory mediators (e.g. inter- in this systematic review. leukin-8, matrix metalloproteinase 9, tumour necrosis factor-α) obtained from dentinal fluid, pulpal blood or pulp tissue of teeth with normal (healthy) pulp tissue M ET H O D (C) regarding sensitivity and specificity of pre- or intra- operative diagnosis of the pulpal condition compared Protocol and registration with follow-up results, in terms of pulp survival, where teeth with caries are treated with any type of vital pulp This systematic review was developed, conducted and treatment and the level of pulp inflammation com- reported following the Preferred Reporting Items for pared with levels of inflammatory mediators and/or Systematic Reviews and Meta-Analyses (PRISMA) guide- histological findings (O). lines (Page et al., 2021) (Table S1) and relevant recom- 3. In patients suspected of pulpitis with spontaneous mendations (Nagendrababu et al., 2020). The review pain (P) what is the effectiveness of the diagnosis of protocol was established before the initiation of the re- the tooth as vital and being the cause of the pain by search and registered in the International Prospective any method including the presence of inflammatory Register of Systematic Reviews (PROSPERO) database mediators (biomarkers) (I) in comparison to the ocular (CRD42021265366). inspection of pulp tissue status after exposure (e.g. pulp | 13652591, 2023, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13762 by Cochrane Romania, Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License DONNERMEYER et al. 299 bleeding, pus, necrotic tissue), the histological evalua- change of outcome or diagnostic decision-making are tion after extraction and relieve of pain as a result of an not the primary outcome but could also be included operative procedure in the tooth (excavation, medica- (sensitivity/specificity would be calculated wherever tion, pulpotomy, pulpectomy) including quantification possible). of inflammatory mediators (e.g. interleukin-8, matrix metalloproteinase 9, tumour necrosis factor-α) obtained Human experimental studies (Randomized Controlled from dentinal fluid, pulpal blood or pulp tissue of teeth Trials [RCTs], Comparative Clinical trials [CCTs]— suspected of pulpitis with spontaneous pain in com- nonrandomized). To ensure that all relevant clinical in- parison to teeth with normal (healthy) pulp tissue (C) formation, often not tested in experimental studies, was in terms of sensitivity and specificity of pre-operative captured, longitudinal observational studies (retrospec- diagnosis of pulpitis compared with evaluation of pulp tive and prospective comparative cohort and case-control condition after pulp exposure or histological examina- studies) were also included. tion, or relieve of pain after an operative procedure (O). 1. Main outcome(s): A combination of outcomes meas- ures was investigated for diagnostic accuracy with Inclusion criteria data used to calculate the pooled sensitivity, specificity, diagnostic odds ratio, positive predictive value (PPV) Based on the three PICO questions the inclusion can be and the negative predictive value (NPV) as probabilities summarized as: for a correct test result and, if possible and indicated, a receiver-operating characteristic (ROC) analysis. 1. Participants/population: The general population with permanent teeth suspected of pulpitis. For comparative studies and diagnostic nonrandom- 2. Intervention(s): ized and randomized clinical trials designed to combine Any noninvasive method able to diagnose pulpitis in diagnostic tests and therapeutic interventions, the out- permanent teeth, comes of treatment were the primary measures. Clinical findings and character of symptoms (non- Additional outcome(s): Pulp survival when teeth with spontaneous or spontaneous pain) or any other clas- caries were treated with any type of vital pulp treatment, sification of symptoms, depth of caries lesion, pulp or relief of pain after operative procedures. exposure, pulp bleeding or any other method includ- ing any pre- or intraoperative biomarker that allows 1. Duration of data collection: A minimum of one year pre- or intraoperative diagnosis of the described pul- and a maximum of as long as possible for all treat- pal condition with (i) respect to level (severity/de- ment outcome measures. No specification in diagnostic gree) of pulpal inflammation or (ii) respect to if it is accuracy measures. possible to maintain pulp vitality, Any method including the presence of inflamma- tory mediators (biomarkers) that allow to diagnose whether the pulp of the tooth is vital and the cause Exclusion criteria of the pain. 3. Comparator(s)/control: comparative studies that allow 1. Studies published in languages other than English (for answering the abovementioned review question will be the purpose of standardization, in the development included. of the European Society of Endodontology S3-level 4. Study design: Diagnostic accuracy studies examining clinical practice guidelines, it was decided to exclude the accuracy of the method in detecting pulp vitality, non-English papers). level of pulpal inflammation and pulpal condition with 2. Letters, commentaries, editorials, case reports, case se- respect to whether it is possible to maintain pulpal vi- ries, reviews tality and cause of tooth pain in permanent teeth in 3. Registered clinical trials without results. humans. The study must have a gold standard refer- 4. Laboratory or animal studies. ence, for example, histologic examination or pulpal examination (in vivo). Articles in which the primary objective was to evaluate the accuracy (sensitivity and Information sources and search strategy specificity) of any type of diagnostic tool, the radio- graphic technique included, in humans were selected. The literature search was performed between October Diagnostic studies based on the ability of diagnosing 1st and 19th 2021. The search process was conducted | 13652591, 2023, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13762 by Cochrane Romania, Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 300 DIAGNOSIS OF PULPITIS in accordance with PRISMA-S guidelines (Rethlefsen were also examined. Furthermore, Google Scholar was et al., 2021). Conducted searches were rerun during the explored by keyword search (Table S2) without any re- final drafting of the paper on 21 January 2022, indicat- strictions. Finally, to ensure the reliability of the data col- ing no new relevant trials had been published after the lected and the inclusion of the relevant studies that may conclusion of the literature search. The following elec- not have been identified through database and grey litera- tronic databases were searched without the date or ture searches, snowballing and screening of the reference status of the publication restrictions: PubMed (includ- lists of included trials and relevant previously published ing MEDLINE), Clarivate Analytics' Web of Science, reviews were also performed (Figure 1). Electronic data- Scopus, and Cochrane Central Register of Controlled bases' search results were exported automatically from Trials (CENTRAL) [Cochrane Library] (Table S2). The their sources and imported into Mendeley for duplicate search strategy was collectively developed by the review removal and further investigation. team (D.D., E.S.), based on preliminary searches of the specified databases to evaluate various information re- trieval strategies to cover all research questions and to Selection process identify relevant controlled vocabulary (Medical Subject Headings–MeSH, https://www.ncbi.nlm.nih.gov/mesh) The screening and selection of studies for this systematic and the most common free keywords and synonyms for review were completed in two phases using Mendeley. the main concepts of interest (diagnosis of pulpitis, diag- Two reviewers (D.D. and E.S.) independently per- nostic accuracy of pulp testing). Table S2 shows complete formed the initial screening of titles and abstracts from search strategies, including used index and free keywords, the search results adopting the study inclusion criteria. Boolean operators (AND, OR) according to the searched Articles that did not meet the eligibility criteria were ex- database. Using the Peer Review of Electronic Search cluded and full texts of initially selected papers were ob- Strategies (PRESS) guideline (McGowan et al., 2016), the tained for further evaluation. In the second stage of the electronic literature search strategies were peer-reviewed study selection, two independent reviewers (D.D. and (T.D.) and feedback was incorporated in the definitive E.S.) critically evaluated full texts of studies identified database search. Additionally, the contents of the major as possibly being relevant in the initial screening stage. subject journals (International Endodontic Journal, The obtained suggestions of eligible studies were com- Journal of Endodontics, Journal of Dental Research, pared, and any disagreements were resolved following Journal of Dentistry, and Clinical Oral Investigations) discussion (Figure 1). Identification of studies via databases and registers Identification of studies via other methods Records removed before screening: Identification Duplicate records removed (n = Records identified from: Records identified from*: 946) Websites (n = 0) Databases (n = 7756) Records removed for language Organisations (n = 0) Registers (n = 265) other than English (n = 656) Citation searching (n = 20) Records found as ineligible by title screening (n = 5681) Records screened Records excluded (n = 738) (n = 667) Reports sought for retrieval Reports not retrieved Reports sought for retrieval Reports not retrieved (n = 71) (n = 0) (n = 20) (n = 0) Screening Reports excluded: Reports assessed for eligibility Study in deciduous teeth (n = 3) Reports assessed for eligibility Reports excluded: (n = 71) Study in traumatized teeth (n = 2) (n = 20) No gold standard reference No further investigation of clinical (n = 16) diagnostics (n = 4) Diagnosis of the pulp not No details of clinical investigations documented (n = 14) reported (n = 22) No gold standard reference (n = 28) Studies included in review Included (n = 28) Reports of included studies (n = 29) *Detailed numbers of records identified from each database or register is given in Suppl. Table S1. FIGURE 1 PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases, registers and other sources. | 13652591, 2023, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13762 by Cochrane Romania, Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License DONNERMEYER et al. 301 Data collection and data items the included studies were homogeneous in nature, a quantitative meta-analysis would be considered. The data extraction was performed by two independent re- viewers (T.D. and E.S.). They independently performed du- plicate data extraction using a pre-established and piloted RESULTS spreadsheet. In case of incomplete or missing data, the au- thors of the papers were contacted for clarification. In case Literature search process and study of nonagreement, the disagreement was resolved by discuss- selection ing with a third reviewer (D.D). In the case of studies with more than two arms and/or multiple papers reporting on the Detailed information on the literature search sequence is same study, only the relevant data of interest was extracted. given in the PRISMA flowchart (Figure 1). Initial searches re- The following details were included in the spreadsheet vealed 8021 hits across all the databases. The language of the for each study included in the final review: name and identified papers was limited to records written in English country of the first author, year published, name of the and duplicates were removed, leaving 6419 papers for title journal, type of study design, total number of participants, screening. Ineligible manuscripts were removed after title age distribution, outcome measures employed, index tests screening and 738 manuscripts were subjected to abstract and reference tests. All extracted data were stored in tables. screening. Following these steps, another 667 papers were The inter-reviewer reliability (percentage of agreement excluded based on their title and abstract. Seventy one papers and kappa correlation coefficient) of the full-text analysis were sought for retrieval in full text. Another 44 records were was calculated and reported. excluded due to the nonexistence of comparison to a gold standard reference, not reporting details of the clinical inves- tigation, studying traumatized teeth, or studying deciduous Study risk of bias assessment teeth (Table S3). Twenty studies eligible for screening were found through citation mining, relevant journals screening The risk of bias was assessed by two independent re- and following expert suggestions. Of these, 3 reports result- viewers (D.D. & E.S.). In case of disagreement, a third ing in two studies were included. In total, 28 studies out of 29 review was consulted for resolution (T.D.). Critical ap- publications were included in the review. praisal of the included studies was performed using the During the eligibility assessment of the full-text reports, QUADAS-2 tool for diagnostic accuracy studies (Whiting a high inter-reviewer reliability was achieved. The review- et al., 2011). Four domains (patient selection, index test, ers agreed on 93% of the manuscripts. Kappa correlation reference standard, and flow and timing) were assessed coefficient for inter-reviewer reliability was 0.850 indicat- in terms of risk of bias. The first three domains were ing almost perfect agreement between the reviewers. also evaluated with regard to concerns regarding appli- cability. Studies that were judged as “low” on all seven domains received an overall judgement of “low risk of Characteristics of the included studies bias” or “low concern regarding applicability.” Studies judged as “high” or “unclear” on one or more domains Diagnostic accuracy—Assessment of were classified as “at risk of bias” or as having “concerns pulp vitality regarding applicability.” Quality assessment of noncomparative, nonrandom- Only studies providing sensibility and specificity values of ized studies was performed using the Newcastle–Ottawa the different clinical tests to assess pulp vitality or those scale and for the included studies on biomarkers, the allowing to calculate these values were included in this re- Newcastle–Ottawa Quality Assessment scale adapted for view. Moreover, all included studies must possess a gold cross-sectional studies was used. Very good studies were standard allowing for the direct conclusion of the pulp sta- those with 9–10 points, good studies with 7–8 points, mod- tus (Tables 1 and S3). This was ensured in most studies erate studies with 5–6 points and unsatisfactory studies by visual inspection of bleeding within the pulp chamber with 0 to 4 points (Herzog et al., 2013). and/or all root canals or of necrotic tissue after an access cavity was created. In two studies the reference was the histological examination of the pulp tissue after tooth ex- Data synthesis method traction (Dummer et al., 1980; Seltzer et al., 1963). Thus, all teeth included in this review were either scheduled for All data relating to the diagnostic accuracy of pulpitis root canal treatment or extraction after conclusion of the were analysed qualitatively and quantitatively and a nar- diagnostic tests. Included studies were limited to perma- rative synthesis of the included studies was achieved. If nent teeth and studies evaluating pulp vitality after any | 13652591, 2023, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13762 by Cochrane Romania, Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 302 DIAGNOSIS OF PULPITIS T A B L E 1 Characteristics and results of the included studies on diagnostic accuracy regarding pulp vitality assessment with quality assessment of individual studies Number of Gender Studies teeth Age (years) M:F Study design Reference standard Seltzer et al. (1963) 166 NS NS Cross-sectional Histology of pulp after Inclusion criteria: extraction Teeth to be extracted due to pain, Graduation: prosthodontic, orthodontic or Intact uninflamed (n = 23) periodontal reasons Different stages of pulpitis Exclusion criteria: NS (n = 121) (see Table 3) Type of teeth included: NS Necrosis (n = 22) Control: NS Disease prevalence: Necrosis 13% Dummer et al. (1980) 75 NS NS Cross-sectional Histology of pulp after Teeth to be extracted because of pain extraction Control: Contralateral tooth Graduation: Saveable pulp (n = 50) Nonsaveable pulp (n = 25) Disease prevalence: Nonvital pulp 25% Nonsaveable pulp 67% Petersson et al. (1999) 59 + 21–79 36:20 Cross-sectional Visual inspection of pulp 16 (control) Group A: tissue (not group B) Patients scheduled for RCT (n = 59 Bleeding n = 30 teeth) Necrotic n = 29 Group B: Disease prevalence Dental students with intact teeth as (group B included) control (n = 16 teeth) Nonvital pulp 38% Type of teeth included: Maxillary and mandibular anterior, premolar, molar teeth Kamburoglu and 142 15–65 44:53 Cross-sectional Visual inspection of Paksoy (2005) Mean: Control: pulp tissue 33.29 ± 12.6 Contralateral or adjacent intact teeth Bleeding n = 50 (n = 49) Necrotic n = 43 Exclusion criteria: Disease prevalence Teeth having periodontal disease, Nonvital pulp 46% restoration, previous history of injury; patients with hypertension, cardiac pacemakers, routinely receiving analgesics or antidepressants Type of teeth included: Maxillary and mandibular anterior, premolar, molar teeth Gopikrishna 80 NS NS Cross-sectional Visual inspection of et al. (2007) Control: Contralateral intact tooth pulp tissue Inclusion criteria: Bleeding n = 38 Teeth requiring RCT because of deep Necrotic n = 42 caries or prosthodontics Disease prevalence Type of teeth included: Nonvital pulp 46% Single-rooted incisors, canines, Controls: only cold premolars test and EPT | 13652591, 2023, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13762 by Cochrane Romania, Wiley Online Library on [09/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License DONNERMEYER et al. 303 Index test Accuracy Sensitivity Specificity PPV NPV DOR Study quality a a Cold (ethyl chloride) NS 0.89 0.24 NS NS 2.56 Unsatisfactory Heat (gutta-percha; ball NS 0.94a 0.29a NS NS 6.40 burnisher) EPT NS 0.72a 0.92a NS NS 29.56 Comb cold & heat NS 0.78 0.86 NS NS 21.75 Cold (ethyl chloride) NS 0.68a 0.70a NS NS 49.59 Unsatisfactory a a Heat (gutta-percha) NS 0.95 0.41 NS NS 13.20 a EPT NS 0.21 1 NS NS # Cold (ethyl chloride) 0.86 0.83 0.93 0.89 0.90 64.92 Unsatisfactory Heat (gutta-percha) 0.71 0.86 0.41 0.48 0.83 4.27 EPT 0.81 0.72 0.93 0.88 0.84 341.95 Cold (propane-butane mixture) 0.95 0.93 0.98 0.97 0.94 664.29 Unsatisfactory EPT 0.90 0.83 0.96 0.94 0.87 117.08 Cold (TFE) 0.86 0.81 0.82 0.92 0.81 19.42 Moderate EPT 0.81 0.71 0.92 0.91 0.74 28.17 PO (

Effectiveness of Diagnosing Pulpitis: A Systematic Review (International Endodontic Journal PDF)

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