JOURNAL OF ENDODONTICS Printed in U.S.A.

Copyright © 2002 by The American Association of Endodontists VOL. 28, NO. 7, JULY 2002

Comparison of Carbon Dioxide versus Refrigerant

Spray to Determine Pulpal Responsiveness

Vincent R. Jones, DDS, Eric M. Rivera, DDS, MS, and Richard E. Walton, DMD, MS

There is little evidence for which cold delivery probe, a 5-s application of CO2 dry ice resulted in a statistically
method is most accurate in determining pulp re- greater temperature decrease than ethyl chloride or frozen water in
sponsiveness. This study compared carbon diox- both noncarious and crowned teeth (5). Therefore, both CO2 dry
ide dry ice sticks (CO2) versus refrigerant spray ice and RS seem to be a reliable source for cold testing, although
there are no conclusive data as to differences between the two
(RS) to generate a patient response from different
methods.
types of teeth restored to varying degrees. Fifteen
Usage tests of carbon dioxide dry ice (CO2) and refrigerant
human patients were selected. In each quadrant, spray (RS) on patients have been with application on nonrestored
three teeth were identified and the restoration type premolars only (6); no usage tests have compared CO2 dry ice with
recorded. Blindfolded patients were randomly RS among different tooth groups with a range of restorations in the
tested with either CO2 or RS in a crossover design same patient.
at two different sessions. Responsiveness was re- The objective of our study was to compare the effectiveness of
corded as yes/no and the interval (in seconds) from CO2 dry ice versus RS in eliciting a response in human patients. To
application to response was determined. Results be examined were (a) response time, (b) different tooth groups, and
showed that (a) CO2 and RS were equivalent in (c) whether and how the teeth were restored, which ranged from
producing a pulpal response regardless of tooth none to full coverage. The hypothesis was that CO2 dry ice was
and presence of restoration, and (b) CO2 took sig- more likely than RS to consistently and rapidly generate a patient
nificantly (p < 0.05) longer to evoke a response response across different tooth types (such as anteriors, premolars,
and molars) and restorations of varying degrees.
than RS using paired t tests. In conclusion, RS and
CO2 were equivalent in determining pulpal respon-
siveness, but the elicited response from RS was
MATERIALS AND METHODS
faster.
Fifteen of the staff and students of the University of Iowa
College of Dentistry were selected. Informed consent was obtained
in accordance with established guidelines. The subjects consisted
Pulpal vitality tests that are quick and dependable for most teeth, of eight males and seven females from 28 to 56 yr old. One
no matter the location or type of restoration, need to be identified. anterior, one premolar, and one molar tooth from each quadrant
Cold tests have proven useful in their ability to elicit a response and the contralateral tooth (when suitable) were selected for test-
from pulpal nerves. Several methods are available: carbon dioxide ing. Teeth excluded were those that exhibited greater than class I
dry ice (CO2), dichlorodifluoromethane refrigerant spray (RS), mobility and greater than 3-mm probing depths. There were no
ethyl chloride, frozen water as an ice stick, or ice water. exclusions, therefore a total of 12 teeth were tested per subject.
CO2 dry ice was first introduced into dentistry in 1936 by Back Presence or absence of restoration was also recorded. Negative
(1), whose apparatus was modified by Obwegeser and Steinhauser controls were endodontically treated teeth.
(2) to collect CO2 dry ice in a thin Plexiglas tube (3). As used Carbon dioxide sticks were prepared using the Union Broach
clinically, CO2 dry ice produces a low reading of ⫺56°C (⫺69°F) Corporation Odontotest plastic cylinder (York, PA), which pro-
(4), which is generally effective for decreasing intrapulpal temper- duces a CO2 dry ice stick 3.5 mm in diameter. Refrigerant spray
ature (5, 6), which elicits a painful response. Hygenic Endo-Ice® Green (1,1,1,2-Tetrafluoroethane) (Whale-
Other means of delivering low temperatures to teeth are avail- dent, Mahwah, NJ) was applied for 3 s by #2 large cotton pellets.
able; these are of varying effectiveness. In usage tests on patients, The study was conducted as a blinded, crossover study with
CO2 dry ice and RS were found to be more effective than ethyl each subject serving as his or her own control. The subjects were
chloride and ice in producing a positive response (6). Comparisons blindfolded with an opaque face shield. One quadrant at a time was
of pulpal diagnosis determined with ethyl chloride or ice testing isolated with gauze and dried. For each patient a RS test and CO2
procedures versus subsequent histological findings in the pulp are test were always prepared for each tooth to keep the agent being
unreliable (7). In extracted teeth measured by a needle thermistor used blinded to the subject. However, only one test was performed

531
532 Jones et al. Journal of Endodontics

FIG 2. Number of responses plotted according to responses to CO2

FIG 1. Number of teeth plotted against yes or no responses to CO2 or RS within defined time intervals (1–5 s, 6 –10 s, 11–15 s) by tooth
or RS and grouped according to tooth types (anterior, premolar, or type (anterior, premolar, or molar). As demonstrated, most teeth,
molar). As shown, both test methods were very predictable in pro- regardless of the test method, responded within 5 s.
ducing a response, particularly in anterior teeth.

DISCUSSION
per tooth per session for all teeth under investigation. At the next
session (2–7 days later), a RS test and CO2 test were prepared for Interestingly, as to predictability of response, both cold testing
each tooth but by crossover, that is, the opposite test was per- methods were equally effective. This was contrary to the hypoth-
formed. One investigator performed these tests for a maximum of esis that CO2 dry ice would be more effective. Obviously, the
15 s application as determined by stopwatch. Sessions were con- refrigerant spray on a cotton pellet delivered a substantial amount
ducted at a minimum of 2 days apart. of cold to generate a response. The amount of cold per surface area
CO2 testing was by placing the tip of the ice stick on the of a #2 cotton pellet versus a 3.5-mm ice stick may be a factor,
midfacial surface of the tooth (8, 9). RS testing was by spraying because it was observed that the cotton pellet expanded once
refrigerant on a #2 cotton pellet from a distance of 5.0 mm for a saturated.
period of 3 s, thus saturating the pellet (8). Excess was shaken off Several investigators (6, 11, 12) have studied the diagnostic
and after crystals appeared on the surface, and the pellet was placed usefulness of common pulp tests in terms of their ability to register
on the midfacial surface. Responses were scored as responsive or responsiveness. In general, these tests were able to adequately
nonresponsive. Responses were scored as nonresponsive when 15 s identify persons who were likely to be free of disease. In contrast,
or more elapsed before the subject raised their hand (6, 10). The the studies were substantially less effective in identifying teeth that
time before response was also scored as to the number of seconds were disease-positive, as confirmed on the basis of histological
elapsed before the subject raised their hand. examination (13). However, in the case of thermal pulp tests that
A response was recorded as yes or no. The elapsed time before create cold, such easily performed diagnostic procedures are quite
response was recorded in seconds for each of the 12 teeth in each reliable (6, 11, 12). For example, with the ethyl chloride cold test,
subject for both the RS test and CO2 test. Statistical analyses were the probability of a nonresponse accurately representing a necrotic
performed to test for correlation and significance with Stata 5.0 pulp was 89%; the probability of a positive response accurately
(College Station, TX) and SAS (Cary, NC) statistical software. The representing a vital pulp was 90% (12).
results of the clinical tests were compared and analyzed in relation We utilized a commercial dental product of refrigerant spray in
to overall ability as well as speed of producing a response amongst a manner advocated by Jones (8). RS has been reformulated to
different tooth types with or without restorations. Paired t tests contain 1,1,1,2-tetrafluoroethane instead of dichlorodifluorometh-
were used with a significance level of p ⬍ 0.05. ane, as reported (5, 6, 8, 9), presumably for environmental reasons.
According to the manufacturer (Hygenic Corporation, Akron, OH),
the new formula has a low liquid temperature of ⫺26.2°C, is
RESULTS environmentally safe, and has zero ozone depletion potential. RS
was effective in decreasing intrapulpal temperature by a range of
Overall, CO2 dry ice and RS were equivalent in producing a 35.0°C to 45.0°C, and the spray technique was slightly more
response, regardless of the tooth group (Fig. 1) or restoration effective than the dip technique (8).
category. RS was usually faster than CO2 dry ice in eliciting a We found, in contrast to the hypothesis, that RS was more likely
pulpal response (Fig. 2). Paired t tests that compared RS and CO2 to produce a response and likely to produce it in a shorter time than
indicated an overall longer time to respond for CO2 (p ⬍ 0.0001) CO2 dry ice. This was true no matter whether restored or which
(Table 1). This speed of response by RS was true for all three tooth tooth group. Figure 2 shows that most responses to CO2 or RS
groups. Table 2 demonstrates that the absence or presence of occur in 1–5 s. If it took longer than 1 to 5 s, then it was only the
restorations had no major effect on the response time differences CO2 that took longer (nearly all RS tests responded within 1–5 s).
between CO2 and RS. Table 1 presents the mean time to respond Interestingly, a subjective observation was that subjects generally
in seconds ⫾ SD. had a more intense reaction to RS than CO2. This increased cold
Vol. 28, No. 7, July 2002 Responsiveness of CO2 versus Refrigerant Spray 533

TABLE 1. Mean time until response in seconds ⴞ SD

Mean
CO2 RS p value*
difference
All teeth 3.88 ⫾ 3.81 2.17 ⫾ 2.80 1.71 ⫾ 2.78 p ⬍ 0.0001
Anteriors 2.48 ⫾ 2.43 1.67 ⫾ 1.94 0.82 ⫾ 1.84 p ⫽ 0.0011
Premolars 4.08 ⫾ 3.86 2.18 ⫾ 2.74 1.90 ⫾ 2.74 p ⬍ 0.0001
Molars 5.08 ⫾ 4.55 2.67 ⫾ 3.47 2.42 ⫾ 3.34 p ⬍ 0.0001
* Significant (p ⬍ 0.01).

TABLE 2. Restored versus nonrestored: mean difference The authors greatly appreciate the assistance of Ms. Jane Jakobsen,
CO2–RS in seconds (with SD) Xian-Jin Xie, and Dr. Suhaila Shariff in the preparation and evaluation of the
statistical analyses.
Restored (sec ⫾ SD) Nonrestored (sec ⫾ SD)
Dr. Jones was an endodontic resident, University of Iowa College of
Anteriors 2.63 ⫾ 4.10 4.00 ⫾ 5.23 Dentistry and is currently affiliated with the United States Navy, NAVDENCEN
Premolars 5.13 ⫾ 6.56 4.00 ⫾ 2.89 NW, Bremerton, WA. Dr. Rivera is the department head, and Dr. Walton is
professor, University of Iowa College of Dentistry, Department of Endodon-
Molars 6.25 ⫾ 6.23 5.00 ⫾ 3.11 tics, Iowa City, IA. Address requests for reprints to Eric M. Rivera, DDS, MS,
Department of Endodontics DSB #S-435, University of Iowa College of Den-
tistry, Iowa City, IA 52242-1001.
reaction may have been due to the volume of agent retained on a
#2 large cotton pellet or to the volume of RS that remained on the
tooth surface after removal of the cotton pellet. As indicated by
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