Abstract:

Magnification, caries detection devices, and improved

access to enlarged radiographic images help take the
guesswork out of caries diagnosis. As is true in pulp
testing, no one test is perfect, but clinicians who use a
combination of diagnostic measures and sound clinical
judgment can routinely achieve more accurate
assessments of disease.
In this review article the recent advances in diagnosis of
dental caries, use of digital radiography, newer pulp
vitality testing devices, Magnetic Resonance Imaging and
Cone Beam Volumetric Tomography in dentistry have
been elaborated.
Key words:
Recent advances, dental caries, digital radiography, pulp
vitality.
Introduction:
Diagnosis is the procedure of accepting a patient,
recognizing that he has a problem, determining the cause
of the problem, and developing a treatment plan that will
solve or alleviate the problem.
As noted by McLean, "The diagnosis and treatment of
early dental caries remains an area of controversy and
arouses great emotion among clinicians and
academicians". Pulp vitality test is crucial in monitoring

the state of health of dental pulp, especially after

traumatic injuries. The newer pulp testing devices, detect
the blood supply of the pulp, through light absorption and
reflection, are considered to be more accurate and noninvasive.
Discussion:
Magnification, caries detection devices, and improved
access to enlarged radiographic images help take the
guesswork out of caries diagnosis. As is true in pulp
testing, no one test is perfect, but clinicians who use a
combination of diagnostic measures and sound clinical
judgment can routinely achieve more accurate
assessments of disease.
The following list outlines procedures for achieving an
accurate diagnosis of caries in fissures (modified from
Wilson and McLean):
1. Use magnifying loupes or intraoral camera
magnification.
2. Use excellent lighting (operatory head lamp or fiber
optic).
3. Clean and dry the teeth (ideally with an air abrasion
cleaning device or a water abrasion device such as
Prophy Jet [Dentsply/Caulk, Milford, Delaware, USA] or
Prophy Flex [KaVo, Biberach, Germany]).
4. Use caries indicators and caries detection devices.
Detection of Dental Caries with devices:

1. Laser fluorescence
Quantitative light induced fluorescence: (QLF)
Laser fluorescence and dye-enhanced laser fluorescence
are alternative techniques for caries detection( Fig:1). The
DIAGNOdent (KaVo) is a laser fluorescence
device( Fig:2).7 The device contains a diode laser (such
as those used in computer disc readers) that emits a
pulsed light of one specific wavelength directed onto a
tooth, the light wavelength is consistent until it
encounters a change in tooth structure.
Changes in structure attributable to decay cause the light
to refract (break up) and change color (owing to a loss of
energy, which results in a longer wavelength) (Fig:2b).
This changes the pulse of fluorescent light reflected back
to a sensor. The device translates these changes into a
qualitative reading that is subsequently displayed by the
control unit and interpreted as a numeric value from 1 to
99. When the unit shows a value of less than 30, the
tooth is usually sound. A sound signal can be correlated
to the digital readout. The device is easy to use and is
calibrated to a standard, which allows comparison of
current readings to those of previous or subsequent
patient visits.
Studies showed:
1.Accuracy of DIAGNOdent was significantly better than
that of radiography for occlusal lesions.
2.The device could diagnose pit and fissure lesions with

92% accuracy.
3.DIAGNOdent has higher diagnostic validity than the
ECM for occlusal caries and good in vitro reproducibility of
findings.
2. Electronic Caries Monitor
The electronic caries monitor (ECM) (Lode Diagnostics,
Germany),(Fig:3), measures a tooth's electric resistance
during controlled air drying to determine its mineral
content.
The electric resistance value of any given area of a tooth
depends on the local porosity, the amount of liquid
present, the temperature, the mobility of the liquid, and
the ion concentration of the liquid. To avoid the influence
of surface liquid (saliva), the ECM technique involves
drying the tooth surface using a standardized airflow
procedure. Interpreting the measurements is relatively
complex since there is no standard representing different
levels of caries. Studies suggest that ECM can be an
accurate diagnostic tool for the diagnosis of early,
noncavitated occlusal lesions on posterior teeth.
Detection with chemical dyes
Dyes are a diagnostic aid for detecting caries in
questionable areas (ie, for locating soft dentin that is
presumably infected)9. Fusayama introduced a technique
in 1972 that used a basic fuchsin red stain to aid in
differentiating layers of carious dentin.10,11 Because of
potential carcinogenicity, basic fuchsin was replaced by

another dye, acid red 52, which showed equal

effectiveness.
Products based on acid red 52 are marketed by a number
of manufacturers e.g. Caries Detector, Kuraray, Osaka,
Japan. Many clinicians also have had good success with
acid reds 50, 51, 54, and other commercially available
caries detectors. Some caries detection products contain
a red and blue disodium disclosing solution (eg, Cari-DTect, Gresco Products, Stafford, Texas). These products
stain infected caries dark blue to bluish-green. Studies
show dye stains are about 85% effective in detecting all
caries in a tooth. Clinical removal of caries without the aid
of a dye is 70% effective.
How chemical dyes work:
Caries-detecting stains differentiate mineralized from
demineralized dentin in both vital and nonvital teeth.
Outer carious dentin is stainable because the irreversible
breakdown of collagen cross-linking loosens the collagen
fibers. Inner carious dentin and normal dentin are not
stained because their collagen fibers are undisturbed and
dense. In other words, dyes do not stain bacteria but
instead stain the organic matrix of poorly mineralized
dentin.
Technique:
1.The area to be tested is rinsed with water and then
blotted dry (excess water dilutes a stain).
2.The tooth is treated with a 1% acid red 52 solution for

10 seconds
3.The tooth is rinsed with water and suctioned and then
excess water is removed. After rinsing with water for 10
seconds, some tooth structure shows Discoloration
4.Stained decay is removed with a spoon excavator and
evaluated by tactile sensation.
When removing stained caries, it is important to be
conservative near the pulp. Any questionable stained
dentin should be left in place; remineralization will occur
in this area, and the bacterial activity will be arrested
once the tooth is restored.
Detection with transillumination2
Transillumination works best with longer wavelengths of
light in the yellow and orange range, because they have
higher penetration properties. Blue light used for curing is
the least effective, owing to decreased penetration and
increased scattering. Blue light should be avoided, since
it is harmful to the eyes. A major advantage of
transillumination is that the patient can easily see the
problems that the practitioner is addressing. It can be
used as a screening device to determine if a radiograph is
necessary.
Transillumination works best when a small light source is
used in a dark field. The optimal approach is to turn the
operatory light away and use an incandescent yellow-towhite light source about 1-mm wide. The most contrast is
achieved when the light source is placed against the side
of the tooth that has the most enamel and then viewed
from the side of the tooth with the largest mass of

restoration. In anterior teeth, the light source is usually

placed on the facial, and the dentist views from the
lingual. Moving the light back and forth improves the
likelihood of detecting pathology.
Transillumination devices
There are many devices that can transilluminate a tooth.
The standard light for a ear, nose, and throat examination
works well. Some composite curing lamps have filtered
tips that change the wavelength of light to yellow-orange
so the lamp can be used for transillumination. Small light
probes used in electronics (that look like tiny flashlights)
also work well.
An easy-to-use alternative is the fiber optics built into
most delivery systems for lighting handpieces. Fiber
optics yield an intense white light with a small spot-size.
Technique:
Remove the bur from the handpiece and turn the
operatory light away. Then turn on the fiber-optic light
and use the handpiece as a light wand. It is best to place
the light opposite the tooth under inspection. Rotating the
light source in a dark field can reveal carious lesions,
cracks, stains, and retained restorations. Headlamps
should be turned off.
Indications:
1. Proximal caries Transillumination is a good method of
detecting proximal decay in anterior teeth (Fig:6). It is

less effective in detecting decay in premolars and molars.

Transillumination is an excellent adjunct to radiographs.
2. Effective in determining the extent of a lesion.
3. Caries under existing composite When a tooth is filled
with a radiolucent composite, the best and usually the
only method of checking for decay is transillumination.
Discoloration along the dentinenamel junction is usually
decay, whereas uniform discoloration around a
restoration can be simply discoloration in the resin
bonding agent.
Digital imaging fiber-optic transillumination
Principle:
Since a carious lesion has a lowered index of light
transmission, an area of caries appears as a darkened
shadow.
Another option in transillumination, the Digital Imaging
Fiber-Optic Transillumination (DIFOTI) system from
Electro-Optical Sciences Inc. (Irvington, New York) ( Fig:8),
uses white light, a CCD camera, and computer-controlled
image acquisition and analysis to detect caries. The
mouthpiece carries a single fiber-optic illuminator.
Directed toward a smooth surface of a tooth, the light
travels through enamel and dentin and scatters toward
the tooths non illuminated areas. The CCD camera in the
handpiece digitizes the light emerging from the smooth
surface opposite the illuminated surface or the occlusal
surface for real-time display on a computer monitor.
Caries is detected via computer analysis using dedicated

algorithms.
The DIFOTI device has been tested by imaging teeth in
vitro. The results suggest it can sensitively detect
proximal, occlusal, and smooth-surface caries.
Detection with digital radiographs
Digital intraoral radiographs have become available to
the profession over the past decade. Several studies have
shown that, theoretically, direct digital radiography
provides a number of advantages when compared with
conventional film. These include contrast and edge
enhancement, image enlargement, lower radiation dose,
image compression, and automated image analysis.
Digital radiology encompasses all the techniques that
produce digital (or computerized) images, as opposed to
conventional radiology that uses x-ray film. Note that
dental radiology is currently limited to radiography, in
other terms to one-shot images. Some technologies
would indeed allow the acquisition of a sequence of
images, or even live x-ray video such as radioscopy or
fluoroscopy used in other medical fields. But dental
applications, which require the practitioner's hands be in
the field of the acquired subject, preclude the use of a
continuous x-ray stream for obvious reasons.
Techniques:
There are three main techniques that are used in intraoral
digital radiology: film scanners, intraoral phosphor plates,

and intraoral digital sensors. Other techniques such as

digital panoramic imaging or x-ray CT-scan are extraoral
techniques available.
Film
Film scanners are not digital radiology devices per se, but
produce digital images from x-ray pictures nonetheless.
They produce a digital image out of an existing film. This
can be done in two different manners: either by taking a
digital photograph (very much like a digital still camera)
of a film or by scanning the film line by line (like a flatbed scanner). In either case, films have to be transilluminated because they do not reflect light as a regular
paper photo.
Intraoral storage phosphor plates17
A phosphor plate reader works very much like a film
scanner, except that the film is replaced by a phosphor
plate. A phosphor plate has the same size of dental film,
but is primarily made of a remanent phosphor layer that
"remembers" the image, hence the name of "storage
plates".
In order to read out the image, phosphor plates need to
be put into a phosphor plate reader. What this device
does is illuminate the plate by a tiny laser beam. When a
portion of the plate is illuminated, it emits light which is
collected by a digital imaging device.
Phosphor plates are often referred to as "multiple-use

films", because their shape looks very much like intraoral

film and therefore do not require any adaptation of the
positioning techniques and can be re-used a number of
times.
The image is captured on a phosphor plate as analog
information and is converted into a digital format when
the plate is processed.(Fig:9) Photostimulable phosphor
radiographic systems were first introduced in 1981 by the
Fuji Corporation (Tokyo, Japan).
Intraoral digital sensors17
A digital intraoral sensor is based on an "imager", or a
silicon chip that permits the acquisition of an image. Such
a chip is constituted of a myriad of pixels, each pixel
capturing a small quantity of light and converting this
light into electricity.
There are several technologies that are used to produce
images. The two major ones are CCD (Charge-Coupled
Device) and CMOS. (Complementary Metal-Oxide
Semiconductor). They both convert photons into
electrons.
The RVG is a digital sensor that allows the doctor to make
intraoral radiographs images without film. The sensor
takes place the conventional dental film to make
periapical, occlusal or bite wing images.
The RVG system is composed of :

1.A very small camera called the sensor that is designed

to catch x-ray images into the patient's month.
2.An acquisition electronic device that can be integrated
to a computer (PCI acquisition board) or external (USB
acquisition device).
3.A software or external Dedicated software is in charge
of displaying the image and providing sophisticated
digital tools.
4.A set of various holders to place the sensor in the
patient month according to different radiological
techniques.
5.A x-ray generator of at least 70Kv (conventional or high
frequency).
6.A timer able to deliver very short x-ray doses (from 0.02
seconds) The timer can be linked to the RVG system or
operated without any link.
7.A computer PC compatible
The timer drives the x-rays generator a very short pulse.
The generator delivers a flash of x-rays.
The x-rays beam cross the object and reach the sensor.
The sensor catches the information immediately and
turns it into electrical signal that is sent to the computer.
The computer converts the information into digital image
and displays it on the monitor. The image is now a simple
computer file that contains a radiological image. Digital
filters and contrast enhancement tools can be used to
lead the doctor in is diagnostic. The image is stored into
the patient file and can be retrieved at any moment.

Advantages:
The RVG uses at the mean time the most standard
principle of the conventional radiology and the most
advanced digital and electronic tools that allow:
1. The total suppression of the film, which is replaced by
the intraoral sensor. Consequently that eliminates :
1.1 the film processing drawbacks (chemical liquids to be
changed from time to time, loss of time while waiting the
radio to be ready) that cause breaks during the operating
act.
1.2 image distortions due to film bending.
1.3 the dark room and bulky processing machine.
2. Getting an instant X-ray image that provides to the
doctor accurate clinical information for his diagnostic
3. Up to 90% X-ray doses reduction compared to standard
film. Only a few tenth of seconds are necessary to take an
x-ray image.
4. Unparalleled diagnostic capabilities thanks to: 4.1 the
high resolution of the image (over 20 line pairs per mm)
which is the only condition for the image to contain
accurate clinical details.
4.2 the display of the image in scale one to the monitor.

4.3 a wide scale of grey shades contained into the image.

A human eye is able to see a maximum of +/-60 different
greys, whereas the sensor catches up to 4096. The digital
tools will adapt this too large grey shade scale to the
human eye capabilities. The doctor has several
investigation levels according to what he is wishing to
observe. Still the image remains with the full original
information to operate various investigations when
required.
4.4 the ultimate imaging filter, sharpness filter, preprogrammed modes (Endo, Paro, Dentine to Enamel
Junction) and high light tool. These filters and tools will
enhance the global or local contrast of the image in order
to focus the diagnostic on a particular part of the image.
4.5 a measurement tool that allow the doctor to know the
length of a canal, a bone crest The accuracy and
reliability of the measurement depends on the positioning
technique in use as well as the calibration of the
measurement tool. So far, the most accurate
measurements are only available with scanner images.
4.6 the display of several image at once on the screen
allows instant comparison.
5. An improved communication between the doctor and
the patient thanks to clear images easy to show and to
explain.
6. A tremendous booster for the dental practices fame
additionally to a improved working comfort, and time

savings.
Digital Subtraction Radiography
For years dentistry has dealt with the problem of no
quantitative measures to determine the success of a
particular treatment. When evaluating bone height,
changes can be masked by disparities in projection
geometry. Digital subtraction radiography is a technique
that allows us to determine quantitative changes in
radiographs. The premise is quite simple. A radiographic
image is generated before a particular treatment is
performed. At some time after the treatment, another
image is generated. The two images are digitized and
compared on a pixel-by-pixel basis. The resultant image
shows only the changes that have occurred and
subtracts those components of the image that are
unchanged.
DICOM Standard
Medical imaging has dealt with many of the issues that
confront digital dental imaging. Medical radiologists found
that many of their imaging systems could not
communicate with each other. Most manufacturers had
their own proprietary software and file types that were
not compatible with those of other manufacturers. This
led to the development of the DICOM Standard. DICOM
stands for Digital Imaging and Communications in
Medicine. The current version is 3.0. The DICOM 3.0
standard addresses the need for standardized formats so
digital information can be transferred to remote sites as

well as local work stations. Dentistry is beginning to

recognize the DICOM 3.0 standard.
Extraoral Imaging
Extraoral digital imaging can be accomplished utilizing
direct or indirect digital imaging systems. There are
several panoramic systems available that use either
linear array CCD or PSP plate sensors. The cost of the
sensor, the time needed to capture the image data, and
file size are all considerations that must be evaluated
when considering a digital panoramic system. In either
case, the method is similar to conventional panoramic
radiography, but the receptor, processing, display, and
storage differ from film-based imaging. Both film-based
and digital formats produce comparable images with
spatial resolution of 4 lp/mm.
Disadvantages of digital radiography
1.
2.
3.
4.
5.
6.

Cost of devices.
Cost of converting previous records to digital
Thickness of the sensor
Rigidity of the sensor
Loss or breakage of sensors.
Lack of universal use of digital radiography.

Pulp vitality testing

Pulp vitality test is crucial in monitoring the state of
health of dental pulp, especially after traumatic injuries.
The traditional pulp testing methods such as thermal and

electric pulp testing methods depend on the innervation

and often yield false positive and negative response. The
newer pulp testing devices, detect the blood supply of the
pulp, through light absorption and reflection, are
considered to be more accurate and non-invasive.
Pulse Oximetry
The pulse oximeter is a non-invasive oxygen saturation
monitoring device widely used in medical practice for
recording blood oxygen saturation levels during the
administration of intravenous anesthesia. It contributes to
the increased safety of general anesthesia.
The principle of this technology is based on a
modification of Beer's law, which relates the absorption of
light, by a solute to its concentration and optical
properties at a given light wavelength24. It also depends
on the absorbance characteristics of haemoglobin in the
red and infra-red range. In the red region,
oxyhaemoglobin absorbs less light than
deoxyhaemoglobin and vice versa in the infrared region.
Hence one wavelength was sensitive to changes in
oxygenation and the second was insensitive to
compensate for changes in tissue thickness, haemoglobin
content and light intensity. The system consists of a
probe containing a diode that emits light in two
wavelengths: I. Red light of approximately 660 nm II.
Infra-red light of approximately 850 nm A silicon photo
detector diode is placed on the opposing surfaces of the
tooth, which is connected to a microprocessor. The probe
is placed on the labial surface of the tooth crown and the

sensor on the palatal surface. Ideal placement of the

probe is in the middle third of the crown. If placed in the
gingival third, disturbances from gingival circulation or
any gingival trauma or bleeding will interfere with the
readings.
Laser doppler flowmetry
Laser Doppler Flowmetry (LDF) is a noninvasive, electro
optical technique, which allows the semi-quantitative
recording of pulpal blood flow.
The Laser Doppler technique measures blood flow in the
very small blood vessels of the microvasculature. The
technique depends on the Doppler principle whereby light
from a laser diode incident on the tissue is scattered by
moving RBC's and as a consequence, the frequency
broadened. The frequency broadened light, together with
laser light scattered from static tissue is photo detected
and the resulting photocurrent processed to provide a
blood flow measurement. The Doppler shifted laser light,
back- scattered out of the tooth is detected by a photocell
on the tooth surface. The output is proportionate to the
number and velocity of the blood cells.
Over the past decade LDF technology has been used
experimentally to monitor blood flow in the pulps of both,
the animals and the humans.
Dual Wavelength Spectrophotometry
Dual wavelength spectrophotometry (DWLS) is a method

independent of a pulsatile circulation. The presence of

arterioles rather than arteries in the pulp and its rigid
encapsulation by surrounding dentine and enamel make
it difficult to detect a pulse in the pulp space. This
method measures oxygenation changes in the capillary
bed rather than in the supply vessels and hence does not
depend on a pulsatile blood flow. Pulse oximetry is a
method based on DWLS.
DWLS was able to differentiate with reproducible readings
between a pulp chamber of a vital and non-vital tooth in
vivo. Still in vivo tests of this hypothesis are in progress.
Influence of the gingival circulation cannot be ruled out
and data on how large a mass of pulp tissue is needed for
accurate readings must be determined. The test is
noninvasive and yields objective results. The instrument
is small, portable, relatively inexpensive and should be
suitable for use in a private dental office.
Other Testing Modalities
The concept of diagnosing tooth vitality by temperature
measurement can provide valuable information on the
integrity of the underlying pulp. Howell et al used liquid
cholesteric crystals and found that non-vital teeth have
lower temperature than vital teeth.
Magnetic resonance imaging (MRI): has shown definite
potential as a future replacement for CT imaging, with the
obvious advantage that it delivers no ionizing radiation.
Cone Beam Volumetric Tomography

CBVT is a new technology that allows patients to have the

accuracy of CT imaging without the high exposure to
radiation and the high cost. The exposure varies from 20150 microseverts , a fraction of conventional CT scanning.
Instead of taking "axial-slices" of the patient, volumetric
tomography takes multiple images for 14-20 seconds
during a single partial rotation around the patients head.
Conclusion
Hidden caries is now a historic phrase. Mirror and probe
Examination is only 25 percent accurate in detecting
early occlusal caries. The use of caries detection dye and
laser caries diagnosis raises diagnostic accuracy beyond
90 percent.
Early and accurate diagnosis of occlusal caries enables
successful prevention and minimal intervention
restorative techniques, ending the common evolution
from occlusal restorations through to cusp restorations,
crowns, and endodontics.
Digital radiography delivers diagnostic, archiving and cost
control capabilities absolutely unobtainable using film.
Digital Radiography systems help more dentists achieve
superior imaging results
REFRENCES
1. Endodontics. John. L Ingle. Fifth Edition

2. Harry F. Albers. Tooth-Colored Restoratives. Principles

and Techniques. Ninth Edition.
3. Wilson AD, McLean JW. Treatment of early carious
lesions. In: Glass-ionomer cement. Chicago:
Quintessence, 1988:17995.
4. Shi XQ, Welander U, Angmar-Mansson B. Occlusal
caries detection with KaVo DIAGNOdent and radiography:
an in vitro comparison. Caries Res 2000;34:1518.
5. Ross G. Caries diagnosis with the DIAGNOdent laser: a
users product evaluation. Ont Dent 1999;76:214.
6. Lussi A, Imwinkelried S, Pitts N, et al. Performance and
reproducibility of a laser fluorescence system for
detection of occlusal caries in vitro. Caries Res
1999;33:2616.
7. Eggertsson H, Analoui M, van der Veen M, et al.
Detection of early interproximal caries in vitro using laser
fluorescence, dye-enhanced laser fluorescence and direct
visual examination. Caries Res 1999;33:22733.
8. Ashley PF, Blinkhorn AS, Davies RM. Occlusal caries
diagnosis: an in vitro histological validation of the
Electronic Caries Monitor (ECM) and other methods. J
Dent 1998;26:838.
9. List G, Lommel TJ, Tilk MA, Murdoch HG. The use of a
dye in caries identification.

Quintessence Int 1987;18:3435. 10. Fusayama T. Two

layers of carious dentin: diagnosis and treatment. Oper
Dent 1979;4:6370.
11. Kuboki Y, Liu CF, Fusayama T. Mechanism of
differential staining in carious dentin. J Dent Res
1983;62:7134.
12. Fusayama T. Clinical guide for removing caries using a
caries-detecting solution. Quintessence Int 1989;19:397
401.
13. Styner D, Kuyinu E, Turner G. Addressing the caries
dilemma: detection and intervention with a disclosing
agent. Gen Dent 1996;44:4469.
14. Boston DW, Graver HT. Histological study of an acid
red caries-disclosing dye. Oper Dent 1989;14:18692.
15. Boston DW, Graver HT. Histobacteriological analysis of
acid red dye-stainable dentin found beneath intact
amalgam restorations. Oper Dent 1994;19:659.
16. Schneiderman A, Elbaum M, Shultz T, et al.
Assessment of dental caries with digital imaging fiberoptic transillumination (DIFOTI): in vitro study. Caries Res
1997;31:10310.
17. www.wgreen.com.au. William Green Dental
Equipment.

18. Parks ET, Williamson GF. Digital Radiography: An

Overview. J Contemp Dent Pract 2002 November;
(3)4:023-039.
19. Borg E, Attaelmanam A, Grndahl H-G. Image plate
systems differ in physical performance. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2000 Jan;89(1):11824.
20. Farman AG, Farman TT. Extraoral and Panoramic
Systems. In: Miles D, editor. Applications of Dental
Imaging Modalities in Dentistry. Dent Clin North Am. 2000
Apr;44(2):257-72, v-vi. Review.
21. Gordon JC. Why switch to digital radiography? J Am
Dent Assoc;135(10):1437-1439.
22. Samraj RV ,Indira R, Srinivasan MR, Kumar A. Recent
advances in pulp vitality testing. Endodontology,
2003;15:14-19
23. Severinghans JW and Kelleher JF. Recent
developments in pulse oximetry. Anesthesiology 1992;76:
1918-38.
24. Weddington T, Alexander CM and Gross JB. Principles
of pulse oximetry. Anesthesia Equipment Manual
1997:147-55.
25. Andreasan FM, Yu Z, Thomsen B and Andreasan
P.Occurrence of pulp canal obliteration after luxation
injuries in the permanent dentition. Endod. Dent.

Traumatol. 1987;3: 103-15.

26. Evans D, Reid J, Strang R and Stirrups D. A
comparison of laser Doppler flowmetry with other
methods of assessing the vitality of traumatized anterior
teeth. (Abstract) Endod. Dent. Traumatol. 1999; 15: 28490.
27. Gazelius B, Olgart L, Edwall B and Edwall L.
Noninvasive recording of blood flow in human dental
pulp. Endod. Dent. Traumatol. 1986; 2: 219-21.
28. Olgart L, Gazelius B and Lindh-Stromberg U. Laser
Doppler flowmetry in assessing vitality in luxated
permanent teeth. Int. Endod.1988; 21: 300-6.
29. Fanibunda KB. The feasibility of temperature
measurement as a diagnostic procedure in human teeth.
J. Dent. 1986; 14; 126-9.
30. www.dentalhealth.com.