Diagnostic Accuracy of Cold, Heat, and Electric Pulp Tests: An In Vivo Study

This is a prospective, in vivo, observational diagnostic accuracy study conducted at the Endodontics Clinic of Istanbul University Faculty of Dentistry. The protocol was approved by the Ethical Committee of Istanbul University Faculty of Dentistry (Ref. 2024/48 Rev-2) and registered in the Turkish Medicines and Medical Devices Agency (Protocol No. 2023/38). The study was performed in accordance with the Declaration of Helsinki, and written informed consent was obtained prior to study procedures. Before study initiation, the research team was trained and calibrated for the testing protocol and data collection.

Eligible adult participants presenting with at least one tooth indicated for root canal treatment were recruited during routine clinical care. One tooth per participant was included. Eligibility criteria and exclusions were defined a priori and are described in the Eligibility module.

Index Tests (Pulp Sensibility Tests) All index tests were performed by a single operator who was blinded to the participants' clinical signs/symptoms, dental history, and radiographic findings. Participants were instructed to raise their hand immediately when they perceived pain, discomfort, or tingling.

To establish an individual baseline response, testing was first performed on an asymptomatic, functional contralateral tooth without prior endodontic treatment; if unavailable, an adjacent tooth meeting these criteria was used. The study (index) tooth was tested last. Teeth were isolated with cotton rolls and dried with an air syringe before each test. Tests were applied to standardized anatomical sites (incisors/canines: middle third of buccal surface; premolars: occlusal third; molars: mesiobuccal cusp tip area or the closest available site). Responses were recorded dichotomously as "response present" or "response absent" (response time and intensity were not measured). The three tests were performed in the following order, with a 5-minute interval between tests to minimize carryover effects:

Cold test: Refrigerant spray containing propane-butane (Endo-Frost; Roeko, Coltene Whaledent, Germany) was applied to a size 2 cotton pellet. Once frosting was visible, the pellet was placed on the standardized site for up to 15 seconds or until the participant responded.