Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2011 38; 340347

Comparison of the reliability of laser Doppler owmetry, pulse oximetry and electric pulp tester in assessing the pulp vitality of human teeth
H. KARAYILMAZ & Z. KIRZIOGLU
Isparta, Turkiye Faculty of Dentistry, Department of Pedodontics, Suleyman Demirel University,

This study was designed to evaluate and compare the reliability of laser Doppler owmetry (LDF), pulse oximetry (PO) and electric pulp tester (EPT) for assessing the pulpal status as a vitality test method by calculating their sensitivity, specicity and predictive values. Data were collected from 59 pairs of maxillary anterior teeth (38 pairs of central, 21 pairs of lateral incisors) in 51 patients (range 1218 years, mean age 146 173 years, 28 women, 23 men). The teeth with complete endodontic llings constituted the study group, and the healthy, contralateral teeth of the same patients were constituted the control group. The calculated sensitivity was 0915 for the EPT and 0813 for the
SUMMARY

PO. And the specicity of EPT was 0881 and PO was 0949. The difference between the LDF values obtained from the study, and control group was statistically signicant (P = 00001). The ndings of this study indicated that LDF can reliably discriminate the vitality of the teeth with a sensitivity and specicity of 10 for this sample. Laser Doppler owmetry was found to be a more reliable and effective method than PO and EPT of assessing the pulpal status of human teeth. KEYWORDS: laser Doppler owmetry, pulse oximetry, pulp vitality testing, pulpal blood ow Accepted for publication 26 August 2010

Introduction
The vitality assessment of teeth is a critical diagnostic procedure in the practice of dentistry. But it is complicated by the fact that the dental pulp is enclosed within calcied tissue. As the pulp tissue cannot be directly inspected, the dentist has to use indirect methods (1). However, the most widely used traditional pulp vitality test methods, such as electric pulp testers (EPT) and thermal stimulus, determine only the pulp sensitivity to the stimuli used but given no direct indication of blood ow within the pulp. Consequently, false-positive or false-negative responses can be obtained from traumatically injured teeth or from immature teeth (2, 3). Furthermore, each of these subjective methods is depends on the patients perceived response to a stimulus, as well as the dentists interpretation of that response (4). Also, these methods have a potential to produce an unpleasant and occasionally painful
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sensations. Thus, the reliability of these methods can vary, and they are of limited use with children (5). Therefore, new, improved diagnostic methods are needed to assist in the diagnosis of teeth with pulpal pathosis and consequently to aid in their correct treatment. Pulse oximetry (PO) and laser Doppler owmetry (LDF) are non-invasive methods for assessing blood ow in microvascular systems, which have been recently introduced as a new method to diagnose pulp vitality in human teeth.

The PO measurement technique Pulse oximetry is a relatively recent advancement in non-invasive monitoring of oxygen saturation (SaO2) of the blood and pulse rate of the patient. It is effectively and routinely used in medical applications through the use of nger, toe, ear and foot probes. Its wide acceptance in the medical eld results from its ease of application
doi: 10.1111/j.1365-2842.2010.02160.x

COMPARISON OF THE RELIABILITY OF LDF, PO AND EPT

and its capability of providing vital information about the patients status (6, 7). The principles of PO are based on a modication of Beers law and the absorbance characteristics of haemoglobin in the red and infrared range. The PO probe consists from a photo-detector and two light-emitting diodes (LED). One of the LED transmits red light (640 nm), and the other transmits infrared light (960 nm) to the vascular tissue. Oxygenated and deoxygenated haemoglobin absorbs different amount of red and infrared light. The pulsate change in the blood volume causes periodic changes in the amount of red and infrared light absorbed by the vascular tissue before reaching the photo-detector, and PO uses this information to calculate the pulse rate and SaO2 (57). The LDF measurement technique Laser Doppler owmetry is non-invasive electro-optical technique, which has been shown to have potential as a method of assessing the vitality of teeth by detecting the presence or absence of a pulpal blood ow (PBF) (8, 9). The LDF technique utilises a beam of infrared (780 820 nm) or near infrared (6328 nm) light that is directed to the tissue by optical bres within a special designed probe. Monochromatic laser light is transmitted through the crown of the tooth to the dental pulp via the probe, and it is scattered by moving red blood cells and stationary tissue cells. Photons which are reected from the moving red blood cells are scattered and frequency shifted according to the Doppler principle. Photons that interact with stationary tissue cells are scattered but not Doppler shifted. The proportion of shifted to unshifted light within the reected light gives a semi-quantitative measurement of blood ow through the tissue and recorded as a voltage output from the LDF (811). The measured voltage was linearly related to the PBF and expressed in arbitrary perfusion units (PU) (1 PU = 10 mV) in accordance with general consensus (European Laser Doppler Users Groups, 1992) (814). This study was designed to evaluate and compare the reliability of LDF, PO and EPT for assessing the pulpal status as a vitality test method by calculating their sensitivity, specicity, and predictive values. of Pedodontics, Suleyman Demirel University, Faculty of Dentistry. The participants selected for the study had one or two endodontically treated (at least 1 year before) maxillary incisor teeth; the contralateral of the same teeth was healthy. Also, the participants were non-smokers and had no history of systemic vascular or cardiovascular disease or any evidence of hypertension, and none of them were taking any medication. The research ethical committee of Suleyman Demirel Uni versity, Faculty of Medicine, approved the study (09.03.2006-02 17). The experimental purpose and methodology were explained to the patients or their parents carers, and an informed consent was obtained. Data were collected from 59 pairs of maxillary anterior teeth (38 pairs of central, 21 pairs of lateral incisors) in 51 patients (range 1218 years, mean age 146 173 years, 28 women, 23 men) (Fig. 1). The teeth with complete endodontic llings constituted the study group, and the healthy, contralateral teeth of the same patients were constituted the control group. A full history was taken, and clinical and radiographical examinations of patients were carried out by the same examiner in accordance with normal clinical practice. All the teeth selected for the study had clinically intact crowns or small restorations, which were located in areas away from cervical region, where the vitality tests were performed. Sample criteria required teeth to be free of caries, developmental defects, discolouration or root resorption. Patients were warned to abstain from hot or cold foods and beverages for at least 2 h before attending. All measurements were performed in a temperature-controlled room (24 1C) using the same unit and in keeping the same position. The patients rested for 10 min in the unit before the measurements.

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Materials and methods

The study sample was constituted from the archives of the patients who were attending to the Department
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Fig. 1. The distribution of 51 participants according to age and gender.

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The PO apparatus A commercially available Life Scope I, Multiparameter Bedside Monitor (Model BSM-2301K*) and a modied infant probe were used to record SaO2 levels. Special probe holders designed taking into consideration the morphology of the maxillary incisors to hold the modied probe on the tooth. Stainless steel clips and rubber dam clamps were used as the base for the holders. The tapes enclosing the LEDs and photodetector of the infant probe were removed and attached to the holder in parallel to each other (Figs 2 and 3).

The PO measurement procedures The probe was positioned on the cervical region of the crown of the tooth using probe holder. So that light would travel from the facial to the palatinal side through the middle of the crown. Pulse oximetry values were recorded after 45 s of monitoring each of the teeth. If there was no response at the end of the measurement period, the PO values of the tooth were recorded as negative (Fig. 4).

The LDF apparatus The PBF of the teeth was measured by a commercially available LDF device (BLF21A; wavelength 780 nm) and a custom made (ext. diam.; 15 mm, two bre in 02 mm diam., centres 05 mm apart) dental probe in this study (Figs 5 and 6).

The LDF measurement procedure Silicon-impression-based personal splints were prepared to ensure accurate and reproducible positioning of the probe on the tooth for each of the participants. On the labial side of the splints, holes 2 mm above the gingival margins were drilled to insert and to x the probe. The probe was held perpendicular to the surface of the crown 2 mm from the gingival margin using these splints. Evaluation took 45 s for each tooth, and data were collected by a PC connected to the LDF device while maintaining a real-time display on the monitor. The 20 s of the data, which was optimum part of the measurement, were selected for the study by a special software package (Windaq ver. 2.36), and the average

Fig. 2. The appearance of modied infant probe.

Fig. 4. The placement the modied infant probe with probe holder on the tooth and the measurement procedure. Fig. 3. The appearance of special designed probe holder.

*Nihon Kohden Corp., Tokyo, Japan.

Transonic Systems Inc., Ithaca, NY, USA. DATAQ Instruments Inc., Akron, OH, USA. 2010 Blackwell Publishing Ltd

COMPARISON OF THE RELIABILITY OF LDF, PO AND EPT

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Fig. 5. The appearance of commercially available laser Doppler owmetry.

Fig. 6. The appearance of device and a custom made dental probe used in this study.

PBF of the teeth was calculated in PU by the same software (Figs 7 and 8).

The EPT measurement procedures A conventional EPT (Pulptester, Model PT-20) was used for EPT, and the response was recorded as positive if the teeth tested showed any response on the aforementioned scale or negative if there was no response.
Fig. 7. Silicon-impression-based personal splints were used to ensure accurate and reproducible positioning of the probe on the tooth.

Other measurements The following measurements were performed to examine the effects of the values obtained from the teeth by PO and LDF:

1 The systemic SaO2 level and pulse rate of the patients were measured by PO device from the index nger using a nger probe. 2 Systolic and diastolic arterial blood pressures were also measured and recorded. Statistical analyses (paired t test, MannWhitney U, Pearsons correlation) were performed using SPSS (Ver. 13.0) at P < 005 signicance level. Also the sensitivity,

Parkell Inc., Edgewood, NY, USA.

SPSS Inc., Chicago, IL, USA.

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H. KARAYILMAZ & Z. KIRZIOGLU

Fig. 8. The display of the waveform that synchronised with heart beat.

specicity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

Results
Electric pulp tester identied 5 of the 59 teeth with complete endodontic llings as vital, while 54 as nonvital. In control group consisted from the healthy, contralateral tooth of the same patient, 52 teeth were identied as vital and 7 as non-vital with EPT.

The 59 tooth with complete endodontic llings, 11 teeth gave positive response, whereas 48 teeth responded negatively to the PO. But in the control group, 56 gave a positive response, whereas three responded negatively. The average PO and LDF values obtained from the healthy, contralateral teeth and teeth with complete endodontic llings have been summarised in Table 1. In general, it was determined that approximately a 1 10 ratio between the PBF values measured by LDF

Table 1. The distribution of laser Doppler owmetry (LDF) and pulse oximetry (PO) values obtained from healthy, contralateral teeth and teeth with complete endodontic llings Central incisors n Min. Max. Mean s.d. Lateral incisors n Min. Max. Mean s.d. Total n Min. Max. Mean s.d.

Healthy, contralateral teeth LDF (PU) 38 584 1817 1043 PO (%) 38 81 93 8632 Teeth with complete endodontic llings LDF (PU) 38 013 221 099 PO (%) 38 00 79 175 PU, perfusion unit.

325 333 054 3186

21 21 21 21

623 80 08 00

1811 92 235 76

1211 371 8747 306 129 066 695 2197

59 59 59 59

584 80 013 00

1817 93 235 79

1102 348 8671 326 109 060 1374 2899

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COMPARISON OF THE RELIABILITY OF LDF, PO AND EPT

from the tooth with complete endodontic llings and the healthy contralateral tooth of the same patient. The difference between the study and the control group was statistically signicant (P = 00001). Thereupon, it was deduced that LDF can successfully differentiate the vitality of the teeth inspected in the study. On the basis of these ndings, the sensitivity, specicity and predictive values were calculated for each of the method. The sensitivity and the specicity of EPT were 0915 and 0881, respectively. But for the PO, the sensitivity was 0813 and the specicity was 0949. The calculated PPV and NPV for EPT were 0885 and 0912, respectively. For the PO, the PPV was 0941 and the NPV was 0835. Under the ndings from vitality assessment using LDF in this study would give LDF a sensitivity and specicity of 10 in discrimination between teeth with complete endodontic llings and healthy, contralateral tooth of the patients. In addition to these ndings, statistically signicant positive correlations were observed between the LDF values obtained from the study and the control group (r = 059, P = 00001) and between PO and LDF values obtained from healthy, contralateral teeth (r = 032 P = 0016). Although the PO values obtained from the healthy, contralateral teeth were showed a positive correlations only with pulse rate (r = 028 P = 0034) of the patients, the LDF values were showed statistically signicant correlations with the systemic SaO2 levels (r = 034 P = 0009) and pulse rate (r = 030 P = 0019) of the patients. The gender and arterial blood pressures of the patients were not signicant. Negative predictive value is the probability that a person with a negative test result is actually free of disease (15). This study was designed to evaluate and compare the reliability of EPT, PO and LDF as a vitality test method by calculating their sensitivity, specicity and predictive values. To our knowledge, this is the rst study evaluating and comparing the reliability of EPT, PO and LDF together in same study as a vitality test method. The calculated sensitivity and specicity of PO and EPT in our study denoted that 91% of the teeth with complete endodontic llings were identied as nonvital by EPT, while 81% of these teeth were identied as non-vital by PO. Likewise, 88% of the healthy contralateral teeth were identied as vital by EPT, while 95% of these teeth were identied as vital by PO. Thus, the calculated PPV and NPV denoted that there was a probability of 88% that no sensitive reaction represented a root-canal lled tooth, and a there was a probability of 91% that sensitive reaction represented a healthy, vital tooth when EPT was used. Likewise, the probability that no sensitive reaction represented a root-canal lled tooth was 94%, while the probability that a sensitive reaction represented a healthy, vital tooth was 83% with PO. These results imply that the ability of PO in determining the vitality of healthy teeth was found better than EPT, but PO was found insufcient in determining the vitality of teeth with complete endodontic llings. The reasons for this could be that the scattering of the light (transmitted from PO) from the composite restorations of the root-canal-treated teeth to the adjacent tissues (gingiva, etc.) and the physical limitations of PO. Therefore, the efcacy of PO in teeth with composite restorations that located in cervical region of the tooth caused suspicion. Although some of the studies had shown the effectiveness and accuracy of PO in determining the PBF (5, 1620), a few studies reported that the overall accuracy of the commercially available PO instruments was disappointing and, in its present form, was not considered to have predictable diagnostic value in determining the PBF of the teeth (2123). Recently, Gopikrishna et al. (19) evaluated the efcacy of PO in comparison with the conventional pulp vitality tests. They were reported that the sensitivity and the specicity of PO were 100 and 095, respectively. Although specicity of PO reported in both of

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Discussion
The perfect diagnostic test would always be positive in the presence of disease and negative in the absence of disease. The extent to which a test correctly classies patients denes its accuracy. The concepts of sensitivity, specicity, PPV and NPV have been developed to characterise test accuracy and to compute the benets of test usage (15). Sensitivity denotes the ability of a test to detect disease in patients who actually have the disease. Conversely, specicity describes the ability of a test to detect the absence of disease. The ideal pulp test method would have sensitivity and specicity of 10. The PPV is the probability that a positive test result actually represents a disease-positive person.
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the studies was similar, the sensitivity of PO reported in our study groups was low. It was considered that the disagreements arise from the differences in study groups selected and the methods preferred for the studies. Single-rooted incisors requiring endodontic therapy were selected for their study, but the teeth with complete endodontic llings constituted the study group and the healthy, contralateral teeth of the same patients constituted the control group in our study. In view of these results, it was determined that LDF can reliably discriminate between vital and non-vital dental pulps of maxillary anterior teeth with a sensitivity and specicity of 10 for this sample, and LDF was found to be a more reliable method than PO and EPT. There were a number of studies in the literature that have proved these results (8, 1014, 2426). Of these studies, Evans et al. (12) reported in accordance with our results, the sensitivity and specicity of LDF were 10 in their study. Using LDF as a vitality test method, it appeared that we could diagnose pulpal necrosis more accurately than with conventional test methods. This may lead to less pain and discomfort for the patient, less cost and earlier treatment. However, despite its advantages, LDF still has a number of specically technical limitations (27, 28). These include, motion artefact noise, multiple Doppler shifting, variations in instrument and probe specications, lack of quantitative units and knowledge of depth of measurements, lack of the knowledge of normal PBF values of the healthy teeth, environmental effects to the measurements and high costs of the instrument.

References
1. Rowe AHR, Pitt Ford TR. The assessment of pulp vitality. Int Endod J. 1990;23:7783. 2. Bhaskar SN, Rappaport HM. Dental vitality tests and pulp status. J Am Dent Assoc. 1973;86:409411. 3. Klein H. Pulp response to electrical pulp stimulator in the developing permanent dentition. J Dent Child. 1978;45: 199202. 4. Ehrmann EH. Pulp testers and pulp testing with particular reference to the use of dry ice. Aust Dent J. 1977;22: 272279. 5. Goho C. Pulse oximetry evaluation of vitality in primary and immature permanent teeth. Pediatr Dent. 1999;21: 125127. 6. Samraj RV, Indira R, Srinivasan MR, Kumar A. Recent advances in pulp vitality testing. Endodontology. 2003;15:1419. 7. Jafarzadeh H, Rosenberg PA. Pulse oximetry: review of a potential aid in endodontic diagnosis. J Endod. 2009;35: 329333. 8. Wilder-Smith PE. A new method for the non-invasive measurement of pulpal blood ow. Int Endod J. 1988; 21:307312. 9. Jafarzadeh H. Laser Doppler owmetry in endodontics: a review. Int Endod J. 2009;42:476490. 10. Ramsay DS, Artun J, Martinen SS. Reliability of pulpal blood ow measurements utilizing laser Doppler owmetry. J Dent Res. 1991;70:14271430. 11. Gazelius B, Olgart L, Edwall B. Restored vitality in luxated teeth assessed by laser Doppler owmeter. Endod Dent Traumatol. 1988;4:265268. 12. Evans D, Reid J, Strang R, Stirrups D. A comparison of laser Doppler owmetry with other methods of assessing the vitality of traumatized anterior teeth. Endod Dent Traumatol. 1999;15:284290. 13. Ingooolfsson AR, Tronstad L, Hersh EV, Riva CE. Efcacy of laser Doppler owmetry in determining pulp vitality. Endod Dent Traumatol. 1994;10:8387. 14. Ingooolfsson AR, Tronstad L, Riva CE. Reliability of laser Doppler owmetry in testing vitality of human teeth. Endod Dent Traumatol. 1994;10:185187. 15. Weinstein MC, Fineberg HV. The use of diagnostic information to revise probabilities. In: Weinstein MC, Fineberg HV, eds. Clinical decision analysis. Philadelphia, PA: WB Saunders, 1980:75130. 16. Radhakrishnan S, Munshi AK, Hedge AM. Pulse oximetry: a diagnostic instrument in pulpal vitality testing. J Clin Pediatr Dent. 2002;26:141145. 17. Gopikrishna V, Kandaswamy D, Gupta T. Assessment of the efcacy of an indigenously developed pulse oximeter dental sensor holder for pulp vitality testing. Indian J Dent Res. 2006;17:111113. 18. Gopikrishna V, Tinagupta K, Kandaswamy D. Comparison of electrical, thermal, and pulse oximetry methods for assessing pulp vitality in recently traumatized teeth. J Endod. 2007;33:531535.

Conclusion
Laser Doppler owmetry was found to be a more reliable and effective method than PO and EPT for assessing the pulpal status of human teeth especially in paediatric patients where patient co-operation and incomplete pulp innervations reduce the effectiveness and reliability of conventional test methods. However, the improvement of the LDF method and apparatus with further researches is indicated to become a valuable clinical diagnostic tool in practice of dentistry.

Acknowledgment
This study was supported by the scientic research grant given by Suleyman Demirel University (SDUBAP, 1212-D-05).

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19. Gopikrishna V, Tinagupta K, Kandaswamy D. Evaluation of efcacy of a new custom-made pulse oximeter dental probe in comparison with the electrical, and thermal, tests for assessing pulp vitality. J Endod. 2007;33:411414. 20. Calil E, Caldeira CL, Gavini G, Lemos EM. Determination of pulp vitality in vivo with pulse oximetry. Int Endod J. 2008;41:741746. 21. Kahan RS, Gulabivala K, Snook M, Setchell DJ. Evaluation of a pulse oximeter and customized probe for pulp vitality testing. J Endod. 1996;22:105109. 22. Schnettler JM, Wallace JA. Pulse oximetry as a diagnostic tool of pulpal vitality. J Endod. 1991;17:448490. 23. Schmitt JM, Webber RL, Walker EC. Optical determination of dental pulp vitality. IEEE Trans Biomed Eng. 1991;38: 346352. 24. Gazelius B, Olgart L, Edwall B, Edwall L. Non-invasive recording of blood ow in human dental pulp. Endod Dent Traumatol. 1986;2:219221. 25. Fratkin DR, Kenny DJ, Johnston DH. Evaluation of a laser Doppler owmeter to assess blood ow in human primary incisor teeth. Pediatr Dent. 1999;21:5356. 26. Ingooolfsson AR, Tronstad L, Hersh EV, Riva CE. Effect of probe design on the suitability of laser Doppler owmetry in vitality testing of human teeth. Endod Dent Traumatol. 1993;9:6570. 27. Polat S, Er K, Akpnar KE, Polat NT. The sources of laser Doppler blood-ow signals recorded from vital and root canal treated teeth. Arch Oral Biol. 2004;49:5357. 28. Leahy MJ, de Mul FF, Nilsson GE, Maniewski R. Principles and practice of the laser-Doppler perfussion technique. Technol Health Care. 1999;7:143162.
Correspondence: Dr Huseyin Karayilmaz, Suleyman Demirel Univers i itesi, Dis Hekimlig Fakultesi, Pedodonti Anabilim Dal, Cunur Kampusu, Isparta, Turkiye. E-mail: dthkarayilmaz@yahoo.com

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