Correlation between Histological Status of the Pulp and Its

Response to Sensibility Tests

Mandana Naseri a, Akbar Khayat b, c, Sara Zamaheni a, Shiva Shojaeian a*

a Department of Endodontics, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran; b Shiraz University Dental School, Shiraz, Iran; c Department
of Endodontic, University of British Columbia, Vancouver, Canada
ARTICLE INFO ABSTRACT
Article Type: Introduction: The purpose of this study was to assess the accuracy of sensibility tests by
Original Article correlating it with histologic pulp condition. Methods and Materials: Assessment of clinical
Received: 12 May 2016 signs and symptoms were performed on 65 permanent teeth that were scheduled to be
Revised: 19 Aug 2016 extracted for periodontal, prosthodontic or orthodontic reasons. The normal pulp and
Accepted: 07 Sep 2016 reversible pulpitis were considered as treatable tooth conditions while irreversible pulpitis and
Doi: 10.22037/iej.2017.04 necrosis were considered as untreatable conditions. The teeth were then extracted and
sectioned for histological analysis of dental pulp. Histologic status and classification
*Corresponding author: Shiva corresponded to the treatable or untreatable pulp condition. Comparisons between histological
Shojaeian, Department of treatable and untreatable pulp condition were performed with chi-square analysis for
Endodontics, Dental School, sensibility test responses. The positive predictive value (PPV), negative predictive value (NPV)
Shahid Beheshti University of and accuracy to detect untreatable from treatable pulp condition were calculated for each test.
Medical Sciences, Tehran, Iran. Results: A significant difference was detected in the normal and a sharp lingered response to
heat and cold tests. There was significant difference in the negative response to EPT between
Tel:+98-915 5191031 histological groups. The kappa agreement coefficient between clinical and histological
E-mail: [email protected] diagnosis of pulp condition was about 0.843 (P<0.001). The accuracy of cold and heat tests and
EPT to detect treatable pulp or untreatable pulp states were 78, 74 and 62%, respectively. The
sensibility tests diagnosed untreatable pulpitis with a higher probability (NPV=63%-67% -54%,
PPV=83%-91% -95% for heat, cold and EPT, respectively). Conclusion: Sensibility test results
were more likely to diagnose pulpal disease or untreatable pulp conditions. However, to
increase the diagnostic accuracy patient history, clinical signs and symptoms and also
radiographic findings in conjunction with sensibility tests must be used. The result of this small
study demonstrated a good agreement between clinical and histological pulp diagnosis.
Keywords: Clinical Diagnosis; Histologic; Pulp Tests

Introduction necrosis of dental pulp and more importantly reversible or

irreversible nature of pulpitis are determined based on patient’s
ariogenic bacteria are the most common causes of pulpitis. clinical signs and symptoms, sensibility tests including thermal
C However, the degree of pulp inflammation cannot be
determined based on the size of carious lesion [1, 2]. Histological
and electrical pulp tests (EPT) and radiographic assessment;
however clinical diagnosis is challenging when results of
reactions within the pulp including various immunity and sensibility test are inconsistent with subjective findings [4]. A
inflammatory responses are triggered in dental pulp and may review of the literature shows that a few studies have assessed the
even occur due to initial caries limited to enamel and according accuracy of clinical methods in diagnosis of pulp conditions [5].
to caries extension [3]. Although it has been demonstrated that using a combination of
Accurate diagnosis of pulp conditions is critical for proper diagnostic tests improves accurate diagnosis, sufficient evidence is
treatment planning. The clinicians, based on their clinical lacking on the accuracy of diagnostic pulp tests or clinical signs
diagnosis, decide on selection of a conservative restorative and symptoms to identify pulp conditions [5, 6]. With recent
treatment, vital pulp therapy or root canal therapy. Vitality or advances in vital pulp therapy for treatment of pulpitis and

IEJ Iranian Endodontic Journal 2017;12(1): 20-24

21 Naseri et al.

preservation of pulp vitality, it is extremely important to The normal pulp and reversible pulpitis were considered as
accurately diagnose the pulpal conditions and know how well the treatable conditions that lead to conservative treatment if
clinical diagnosis correlates with the actual pulp state[7]. needed while the irreversible pulpitis and pulp necrosis were
The purpose of this clinical/histological study was to assess considered as untreatable condition which required root canal
the accuracy of sensibility tests and the correlation between the therapy and extirpation of the pulp.
results of sensibility tests and histologic pulp condition.
Histological processing
After performing clinical examinations, the teeth were extracted
Materials and Methods gently, under local anesthesia. Immediately after extraction, the
apical one-third of the roots were cut by a high speed handpiece
This study was approved in the Ethics Committee of Shahid and #169 plain tapered carbide fissure bur (SWS, Switzerland)
Beheshti University, Tehran, Iran. Sixty-five permanent incisors under water spray for better penetration of fixative according to
and premolars that were scheduled for extraction due to Seltzer and Dummer [9, 10].
periodontal disease, prosthodontic or orthodontic purposes, etc. The teeth were immersed in 10% formalin solution at 4°C for
at Oral and Maxillofacial Surgery of Dental School of Shahid 3 days. Next, the specimens were stored in 10% formic acid for 12
Beheshti Medical University, Iran, were evaluated in this study. days for hard tissue demineralization. The solution was stirred 3
All teeth had mature apices and were collected from patients times a day and exchanged daily. In order to ensure
aged between 20 to 55 years old. Clinical data were collected in demineralization, radiography was taken and compared with the
predesigned questionnaires, including patient̕ s information, control radiograph of the intact tooth. The teeth were then rinsed
tooth number, medical and dental history, characteristics of under running water, dehydrated in ascending grades of ethanol,
pain, intra- and extra-oral examinations, sensibility tests and cleared in xylene (Merck, Darmstadt, Germany) and double
clinical diagnosis of pulp disease. The patients were excluded if embedded in paraffin blocks. Paraffin blocks were then
they received analgesic drugs before the examination. longitudinally and serially sectioned into 8 μm thick slices. Of each
All the clinical examinations were accomplished by a single 3 sections, one was chosen and stained with Hematoxylin and
examiner. Heat and cold tests were performed using a hot gutta- Eosin for histological analysis. To assess the penetration depth of
percha stick (GC Corporation, Tokyo, Japan) and an Endo-ice bacteria into dentin, some of the specimens were Gram stained.
(Hygenic Corp., Akron, OH, USA) sprayed onto a cotton pellet, At least two calibrated investigators evaluated the specimens
respectively. Two teeth were tested as controls before the under light microscope. Pulp reaction to stimuli was evaluated
experimental one to observe a baseline normal response. All the teeth in different areas of the coronal and radicular pulp tissue to
were isolated with cotton rolls and dried thoroughly before testing. locate the area with the most severe inflammatory reaction and
The testing site was confined to the middle of the buccal surface for contained the carious lesion. Changes in the odontoblastic layer,
10 sec. In case of no response after one min, the tests were repeated at vascular alterations, type and extent of inflammatory cells,
the cervical, and occlusal thirds to ensure no response to the stimuli. presence of abscess, necrosis or calcification, and internal
Severity, quality and duration of pulpal response to sensibility tests resorption were all evaluated in histopathological sections and
were recorded as normal or uncomfortable pain, sharp or dull and the type of pulp disease were determined according to Seltzer’s
short or lingering, respectively. classification [10]:
Electrical pulp testing (EPT) was carried out on both, Intact un-inflamed pulp (IUP): No significant changes are seen
experimental and control teeth using an electric pulp tester in cells and pulp vessels and the odontoblastic layer is intact.
(Parkell, Edgewood, NY, USA) according to the manufacturer’s Hyperemic pulpitis (HP): Dilated blood vessels and blood
instructions. Toothpaste was the conducting medium and the congestion are apparent. There is some slight changes in the
probe was placed on intact tooth structure [7]. A response before odontoblastic layer of some specimens but no sign of
an 80 reading was recorded as positive. The diagnosis of pulp inflammatory cells exists.
diseases was made based on the following classification [8]: Transient pulpitis (TP): Chronic inflammatory cells, mainly
normal pulp had no symptom and showed normal responses to lymphocytes, macrophages and plasma cells, are scattered in the
clinical testing. The pulp responded to sensibility tests as mild pulp tissue and more commonly in the coronal pulp, but
transient sensation that did not cause patient distress. Reversible inflammatory exudate has yet to be formed.
pulpitis produced a rapid and sharp response. The stimulation Retrogressive pulp (RP): The pulp tissue is atrophic, number
was uncomfortable to the patient but quickly reversed after and size of pulp cells such as odontoblasts and fibroblasts have
removal the irritation. There were no significant radiographic decreased. Number of collagen fibers has been visibly increased
changes in the periapical region of the suspected tooth and the and deposition of reparative dentin can be seen in some areas.
experienced pain was not spontaneous. Irreversible pulpitis Chronic inflammatory cells are not prominent in this group.
produced a sharp or dull pain that continued after the Chronic partial pulpitis (CPP): Chronic inflammatory exudate
elimination of stimulant and caused lingered pain. The pain of the pulp is locally seen. Inflammation is limited to a small area
might be spontaneous or referral and awakened patients during in the coronal section and has not yet extended to the radicular
the night. Necrotic pulp gives no response to sensibility tests. pulp. Irregular arrangement of odontoblasts and disseminated or

IEJ Iranian Endodontic Journal 2017;12(1): 20-24

 Histological status of the pulp and its response to sensibility tests 22

local vacuolization are seen. Congestion of local blood vessels is histological patterns of the pulp were seen in teeth that gave
evident. In most specimens, calcification is seen in different forms. similar responses to tests (Figure 1).
In some specimens, small abscesses are seen in the pulp beneath Chi-square test; with Bonferroni correction, detected a
the carious lesion with necrosis. significant difference in the normal (P<0.001) and a sharp
Chronic total pulpitis (CTP): The inflammation is similar to the lingered (P=0.04) response to heat test between two histological
previous group but with greater extent of involvement. The entire treatable and untreatable groups.
pulp chamber and radicular pulp are also involved. Coronally, an A significant difference was detected in normal (P<0.001)
area of liquefaction or coagulation necrosis was always discerned. and sharp linger (P=0.004) responses to cold test with a
The remainder of the pulp contained granulation tissue. marginally significant difference for no responses (P=0.064)
Partial necrosis (PN): No vital or cellular tissue is seen in the between two histological treatable and untreatable groups.
coronal section adjacent to the carious lesion. Severe There was significant difference in the negative response to EPT
inflammation and abundant infiltration of inflammatory cells are between treatable and untreatable histological groups but the
seen in radicular pulp. Bacteria have direct access to pulpal space. positive response to EPT was not significantly different between
Total necrosis (TN): In the entire pulp, no sign of odontoblasts is two histological groups.
seen. Blood vessels have been completely destructed and The AC, PPV, and NPV for thermal tests and EPT results to
inflammatory cells are being disintegrated. detect treatable or untreatable pulp conditions were calculated
Although different pathological conditions may be and are summarized in Table 2.
simultaneously observed in dental pulp tissue, one specific state is The kappa agreement coefficient between clinical and
often dominant; which was considered as the final diagnosis. In histological diagnosis of pulp condition was about 0.843 which
Seltzer’s classification, IUP, HP, TP, AP, CPP (without necrosis) was significant (P<0.001). A significant difference were detected
correspond to treatable pulp condition and CPP (with necrosis), in normal, irreversible and necrosis (P<0.001) diagnosis
CTP , PN, TN correspond to untreatable pulp condition [11]. between two histological groups (Table 3).
Statistical comparisons between histological treatable and
untreatable pulp condition were performed with chi-square Discussion
analysis for sensibility test responses and Kappa agreement
between histological and clinical diagnosis was calculated. The In the current study, we investigated the correlation of pulp
positive predictive value (PPV) (True Positive/True response to sensibility tests and histologic pulp condition.
Positive+False Positive), negative predictive value (NPV) Analysis of thermal test results revealed that the lingering sharp or
(True Negative/True Negative+False Negative) and accuracy no response to cold test was significantly correlated with
(AC) (True Positive+True Negative/Total) to detect untreatable pulpal conditions, including irreversible pulpitis and
untreatable from treatable pulp condition were calculated for necrosis. However, short sharp pulpal response to cold test, which
each test. is a sign of reversible pulpitis, was not significantly related to a
histological diagnosis as in several cases, the pulpitis was deemed
Results untreatable. Cold test had a higher likelihood to diagnose pulpal
disease or untreatable pulp conditions (PPV=91%>NPV=67%).
Table 1 shows the distribution of histological pulp conditions as Lingering sharp response to heat test had a significant correlation
well as their correlation with the type of pulp responses to with untreatable pulp condition. But, short sharp or no response
sensibility tests. None of the sensibility test results was correlated did not have a significant correlation with histological diagnosis.
with a specific histological pattern of dental pulp. Different Thus, the heat test also diagnosed

Table 1.The correlation of pulp responses to sensibility tests with histological pulp conditions
Cold Heat EPT
Histological diagnosis Sharp pain Sharp pain N (%)
Normal Dull - Normal Dull - + -
Short Lingering Short Lingering
Normal 5 1 - - 1 5 1 - - 1 7 - 7 (10%)
Hyperemia 2 1 - - 1 1 - - 1 3 - 3 (4.6%)
Transitional 5 1 - - 1 5 1 1 6 1 7 (10.8)
Retrogressive 2 - - - - 2 - - - - 2 -- 2 (3.1%)
CPP without necrosis 2 3 - - 1 2 2 - 2 6 - 6 (9.2%)
CPP with necrosis 1 - 4 - - 1 3 - 1 5 - 5 (7.7%)
CTP - 4 1 - 1 1 2 2 - 1 6 - 6 (9.2%)
Partial necrosis - 3 3 - 4 - 3 4 - 3 6 4 10 (15.4%)
Total necrosis 1 2 5 - 11 1 3 3 - 12 3 16 19 (29%)
Treatable 16 6 - - 3 15 4 1 - 5 24 1 25 (38.5%
Untreatable 2 9 13 - 16 2 9 12 - 17 20 20 40 (61.5%)

IEJ Iranian Endodontic Journal 2017;12(1): 20-24

23 Naseri et al.

untreatable pulpitis with a higher probability (PPV=83%, This study demonstrated a good agreement between clinical
NPV=63%). No response to EPT indicated untreatable pulpal and histological pulp diagnoses. However, this correlation is not
condition but positive response to EPT could not differentiate too accurate. In particular, no significant association was found
treatable from untreatable pulpitis. between the clinical and histological diagnoses of reversible
Previous studies have evaluated the predictive value and pulpitis. Some cases of clinical diagnosis of reversible pulpitis
accuracy of sensibility tests for identifying pulp vitality or necrosis. existed that were histologically diagnosed as untreatable pulpitis.
A cold test has often shown accuracy over 90% [12-14]. The Dental pulps were histologically analyzed as the reference test to
accuracy of a heat test and EPT was reported 86% and 76%, assess the real pulp condition. We used human teeth scheduled for
respectively [13, 14]. But, this study analyzed sensibility test results extraction due to different purposes, so having all pulpal
to differentiate between the treatable and untreatable pulp which conditions from normal to necrotic ones to reduce a risk of
help clinician to make a decision for selection of a conservative spectrum bias [20]. Teeth serial sections were made in such way
treatment or extirpation of pulp tissue and root canal treatment. that they all contained the carious lesion. This allowed assessment
Hyman et al. [15], in a retrospective study showed that diagnostic of the entire pulp tissue related to the carious site. Yet, preparation
tests were much poorer as positive predictors of disease than as of specimens, histological interpretation of pulp status and
negative predictors and there have been cases with normal distinction of different pulp conditions are all challenging. The
histological condition that were diagnosed as pulpitis by other limitation of this study was that it was not possible to
diagnostic tests. Cisneros-Cabello [16] found a significant but low diagnose asymptomatic irreversible pulp condition clinically
correlation between painful response to thermal stimuli and because we were not ethically allowed to perform clinical
histological pattern of dental pulp and concluded that pain on procedures including caries removal. Also, radiographic findings
thermal stimuli, particularly cold, should not be used as a reliable were not used to diagnose pulp condition. Asymptomatic
reference for diagnosis and treatment planning. irreversible cases usually have no clinical symptoms and respond
Thermal tests followed by EPT are the most commonly used normally to sensibility tests but deep caries would result in
techniques for the assessment of pulp conditions [17]. However, exposure following caries removal.
these tests, known as the sensibility tests, only assess the response In recent years, small number of studies have assessed the
of nerve fibers in dental pulp and since the nervous tissue is highly accuracy of clinical diagnosis and their correlation with the
resistant to inflammation, the nerve fibers may still remain active histological pulp status. Some studies have found no clear
after the degeneration of pulp tissue. Therefore, these tests cannot correlation between clinical symptoms and pulp responses to
accurately indicate pulp vitality or presence of adequate blood sensibility tests with the histological pattern of dental pulp [9, 10,
supply [18]. Subjectivity and difficult interpretation are another 21, 22]. Other studies have found partial correlation between
drawbacks of sensibility pulp tests. Yet, a more precise clinical sign and symptom with histological findings [16, 23]. A
interpretation may be possibly obtained via a comparison with the recent study demonstrated a good agreement between clinical and
response of a control tooth [17]. Basically, the clinician make a histologic diagnosis of pulp condition, especially for cases with
clinical diagnosis of pulp condition based on patient’s clinical normal pulp and reversible pulpitis [24]. Our results are
signs and symptoms, pulp sensibility tests and radiographic somewhat consistent with their observation. However, this study
examination. However, no accurate method has been described found significant correlation between clinical and histologic
for definite diagnosis of pulp conditions [5]. Accuracy of diagnosis of normal pulp, irreversible pulpitis and also necrotic
diagnostic tests indicates the level of agreement between the test pulp. This inconsistency may be due to the different histologic
results and the reference test and Predictive Value is often criteria. Histologic pulp classification used in both studies has
calculated for diagnostic tests to assess the likelihood of a correct been related to early 70s [10]. It seems necessary to reevaluate
diagnosis. PPV is the probability that a positive test result actually histologic pulp classification according to the new knowledge in
represents a disease-positive person. NPV is the probability that a pulp healing potential and regeneration in future studies.
person with a negative test result is actually free of disease. In conclusion, sensibility tests had a higher likelihood to
However, this value depends on the prevalence of disease and diagnose pulpal disease or untreatable pulp conditions. To
changes with the prevalence rate [15, 19]. increase the diagnostic accuracy, patient history, clinical signs and
symptoms and also radiographic findings in conjunction with
Table 2.The accuracy, positive predictive value (PPV), and negative
Table 3.The correlation of clinical and histological diagnosis of
predictive value (NPV) for thermal tests and EPT
pulp condition
Sensibility tests (%) Reversible Irreversible Number
Cold Heat EPT Diagnosis Normal Necrosis
pulpitis pulpitis of teeth
PPV 91 83 95 Treatable 1 7 0 - 25
NPV 67 63 54 Untreatable 2 3 20 15 40
Accuracy 78 74 62 Total 20 10 20 15 65

IEJ Iranian Endodontic Journal 2017;12(1): 20-24

 Histological status of the pulp and its response to sensibility tests 24

7. Mickel AK LK, Chogle S. Electric pulp tester conductance through

various interface media. J Endod. 2006;32:1178-80.
8. Cohen S, Burns R. Pathway of the pulp, Mosby: St. Louis, Baltimore,
Boston.3.
9. Dummer PM, Hicks R, Huws D. Clinical signs and symptoms in pulp
disease. Int Endod J. 1980;13(1):27-35.
10. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation:
correlations between diagnostic data and actual histologic findings in
the pulp. Oral Surg Oral Med Oral Pathol. 1963;16:846-71 contd.
11. IB SSB. Histologic classification of pulp diseases.
12. Chen E, Abbott PV. Evaluation of accuracy, reliability, and repeatability
of five dental pulp tests. J Endod. 2011;37(12):1619-23.
13. Jespersen JJ, Hellstein J, Williamson A, Johnson WT, Qian F.
Evaluation of dental pulp sensibility tests in a clinical setting. J Endod.
2014;40(3):351-4.
14. Villa-Chavez CE, Patino-Marin N, Loyola-Rodriguez JP, Zavala-
Alonso NV, Martinez-Castanon GA, Medina-Solis CE. Predictive
Figure 1. Different histological patterns of the pulp in teeth with similar values of thermal and electrical dental pulp tests: a clinical study. J
response to sensibility tests. A) Transient pulpitis and B) Retrogressive Endod. 2013;39(8):965-9.
pulp in teeth response normal to termal test. [D, Dentin. P, Pulp. Od, 15. Hyman JJ, Cohen ME. The predictive value of endodontic diagnostic
Odontoblast layer. (magnification 100×)]; C) Chronic total pulpitis and tests. Oral Surg Oral Med Oral Pathol. 1984;58(3):343-6.
D) Partial necrosis in teeth response normal to cold test. [AB, Abscess. 16. Cisneros-Cabello R, Segura-Egea JJ. Relationship of patient complaints
RD, Reparative Dentin. C, root canal. Pch, Pulp chamber. INF, and signs to histopathologic diagnosis of pulpal condition. Aust Endod
Inflamation. BV, Blood Vessle (magnification 100×)] J. 2005;31(1):24-7.
17. Jafarzadeh H, Abbott PV. Review of pulp sensibility tests. Part I: general
sensibility tests must be used. Recently, using biological markers information and thermal tests. Int Endod J. 2010;43(9):738-62.
of inflammation has also been suggested for the assessment of 18. Radhakrishnan S, Munshi AK, Hegde AM. Pulse oximetry: a diagnostic
pulp conditions in terms of reversibility or irreversibility of instrument in pulpal vitality testing. J Clin Pediatr Dent.
2002;26(2):141-5.
inflammation [25-27]. However, the diagnostic value of this
19. Mejàre I, Bergenholtz G, Petersson K, Tranæus S. Estimates of
method has yet to be identified. Confirming a reliable standard sensitivity and specificity of electric pulp testing depend on pulp disease
objective and non-invasive method for accurate assessment of spectrum: a modelling study. International endodontic journal.
pulp conditions needs further investigation in future studies. 2015;48(1):74-8.
20. Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ, Prins MH, van der
Acknowledgment Meulen JH, Bossuyt PM. Empirical evidence of design-related bias in
studies of diagnostic tests. Jama. 1999;282(11):1061-6.
21. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation:
In the memory of late Dr. Alexanian, oral and maxillofacial correlations between diagnostic data and actual histologic findings in
biologist and histologist, for his appreciable assistance in the pulp. Oral Surg Oral Med Oral Pathol. 1963;16:969-77.
histologic preparation of samples. 22. Garcia Aranda R. Correlation between clinical diagnosis and
histopathological diagnosis in pulp pathology. Pract Odontol.
Conflict of Interest: ‘None declared’. 1990;11(3):43-6.
23. Garfunkel A, Sela J, Ulmansky M. Dental pulp pathosis.
Clinicopathologic correlations based on 109 cases. Oral Surg Oral Med
References Oral Pathol. 1973;35(1):110-7.
24. Ricucci D, Loghin S, Siqueira JF, Jr. Correlation between clinical and
1. Trowbridge HO. Pathogenesis of pulpitis resulting from dental caries. J histologic pulp diagnoses. J Endod. 2014;40(12):1932-9.
Endod. 1981;7(2):52-60. 25. Zehnder M, Wegehaupt FJ, Attin T. A first study on the usefulness of
2. Reeves R, Stanley HR. The relationship of bacterial penetration and matrix metalloproteinase 9 from dentinal fluid to indicate pulp
pulpal pathosis in carious teeth. Oral Surg Oral Med Oral Pathol. inflammation. J Endod. 2011;37(1):17-20.
1966;22(1):59-65. 26. Rauschenberger CR, McClanahan SB, Pederson ED, Turner DW,
3. Martin FE. Carious pulpitis: microbiological and histopathological Kaminski EJ. Comparison of human polymorphonuclear neutrophil
considerations. Aust Endod J. 2003;29(3):134-7. elastase, polymorphonuclear neutrophil cathepsin-G, and alpha 2-
4. Sigurdsson A. Pulpal diagnosis. Endodontic Topics. 2003;5(1):12-25. macroglobulin levels in healthy and inflamed dental pulps. J Endod.
5. Mejare IA, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, 1994;20(11):546-50.
Norlund A, Petersson A, Portenier I, Sandberg H, Tranaeus S, 27. Elsalhy M, Azizieh F, Raghupathy R. Cytokines as diagnostic markers
Bergenholtz G. Diagnosis of the condition of the dental pulp: a of pulpal inflammation. Int Endod J. 2013;46(6):573-80.
systematic review. Int Endod J. 2012;45(7):597-613.
6. Weisleder R, Yamauchi S, Caplan DJ, Trope M, Teixeira FB. The Please cite this paper as: Naseri M, Khayat A, Zamaheni S, Shojaeian S.
validity of pulp testing: a clinical study. J Am Dent Assoc. Correlation between Histological Status of the Pulp and Its Response to
2009;140(8):1013-7. Sensibility Tests. Iran Endod J. 2017;12(1): 20-4 Doi: 10.22037/iej.2017.04.

IEJ Iranian Endodontic Journal 2017;12(1): 20-24