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. 2025 Jun 20;4:100050. doi: 10.1016/j.jfscie.2025.100050

The future of endodontic diagnosis

A narrative review focusing on biological markers

Marie Mora a,∗, Juan Pacheco-Yanes b, Asgeir Sigurdsson a
PMCID: PMC13229021  PMID: 42238113

Abstract

Objectives

Innovative methods for pulpal diagnosis are becoming increasingly important in endodontics, as traditional diagnostic techniques often lack the precision and reliability needed for confident decision making. Molecular diagnostic approaches, like biomarker analysis and advanced sampling methods, represent a step forward in clinical practice. This narrative review aims to identify key biomarkers associated with pulpal inflammation, compare published cutoff points for these biomarkers, and briefly review molecular methods and sampling techniques.

Search Strategy

This study is a narrative review of literature identified by a web-based search on PubMed. Original scientific articles, such as clinical studies, reviews, and case reports, were included.

Results

Several biomarkers have been associated with pulp inflammation and have been reported as statistically significant, including interleukin 1, 6, and 8; tumor necrosis factor-α; vascular endothelial growth factor; fibrocyte growth factor acidic; and matrix metalloproteinases 8 and 9. Although some cutoff points for these biomarkers have been identified, further research is necessary to refine their clinical applicability. Various sample collection methods, such as gingival crevicular fluid, dentinal fluid, pulpal tissue, and pulpal blood, have been used. Among the analytical techniques, enzyme-linked immunosorbent assay and Luminex protein assays have proven to be the most accurate, sensitive, and specific for evaluating pulpal inflammation.

Key Words: Biomarkers, molecular diagnosis, endodontic diagnosis

Graphical abstract

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Why Is This Important?

Using molecular diagnosis, clinicians can make better-informed decisions, adjust treatments to fit each patient’s needs, and avoid unnecessary procedures. These methods open new opportunities to connect endodontic diagnosis with the growing trend of personalized care in dentistry.

Introduction

One of the main objectives of diagnosis in endodontics is to infer the inflammatory status from the clinical signs and symptoms.1 During the clinical examination, the clinician asks about the patient’s chief concern and history of pain.2 In addition, routine tests, such as cold, hot, and electric pulp tests, are performed to assess the pulpal status. In contrast, percussion, palpation, and biting tests are performed to evaluate the periapical status. However, these tests are not objective, and there are controversies regarding the correlation between the diagnostic tests and the histologic diagnosis.

Some researchers have concluded that there is a poor correlation,3,4 or even no association between the pain’s signs or symptoms and the histologic status of the pulp.5 Other authors concluded that there is a good agreement between the clinical and histologic diagnoses; however, they also noted that a few teeth would still be at risk of being unnecessarily treated.6 To add to the controversy, several studies have shown mixed results on the sensitivity and specificity and how well the sensibility tests can predict which pulps do or do not have the disease.1,7, 8, 9, 10 These studies only evaluated sensitivity and specificity between vital and nonvital teeth, rather than the degree of disease in vital cases (ie, reversible or irreversible pulpitis).

The diagnostic tests’ lack of correlation with histologic diagnosis is due to the tests assessing only the functional neural component of the pulp rather than the degree of inflammation. When the thermal tests are performed, either cold or hot, they activate the hydrodynamic forces within the dentinal tubules, activating the A delta fibers.11 When the electric pulp test is performed, it delivers a low-voltage electric current sufficient to stimulate the sensory fibers at the dentin-pulp zone.12 Other diagnostic methods, such as laser Doppler flowmetry and pulse oximetry, assess the vascular supply rather than the nerve component. However, these methods are challenging to quantify, susceptible to artifacts, and require costly equipment.13, 14, 15, 16, 17

None of the diagnostic tests described above can assess the level of pulpal inflammation. Traditionally, histologic evaluation of pulp tissues has been the only reliable technique for validating the clinically suspected degree of inflammation.4,6 However, histologic examination is only possible after the pulp has been extirpated or after the tooth has been extracted. In addition to being an invasive test, the histologic status cannot quantify inflammation in a manner that correlates with or predicts any clinical outcome. Therefore, further diagnostic tools are needed to confirm the suspected histologic diagnosis.

Implementing a modern diagnostic method, such as molecular diagnosis, could address the subjectivity of the diagnostic tests in endodontics. Molecular diagnosis encompasses techniques that analyze biological markers or molecules, such as genetic material, proteins, or metabolites, to detect and monitor diseases or conditions with high precision.18 According to the Biomarkers Definitions Working Group, a biological marker (biomarker) is “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.”19

Pulp inflammation increases immune cells that produce inflammatory mediators, including proteases, growth factors, chemokines, and cytokines.20 These mediators have the potential to serve as biomarkers for endodontic diagnosis.20 Unlike traditional histologic techniques, a significant advantage of biomarker-based methods in endodontic diagnosis is their potential to collect samples noninvasively from the gingival crevicular fluid (GCF) before dental treatment21, 22, 23 or dentinal fluid (DF) in sound dentin after caries excavation.24 They can also be obtained from pulpal blood during vital pulp therapy (VPT) in a noninvasive manner, or from pulp tissue, although this last method is more invasive and may not be suitable for preserving pulp tissue (Figure).25,26

Figure.

Figure

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Diagrammatic representation of sampling methods for biomarker collection (colored dots). A. Gingival crevicular fluid. B. Dentinal fluid. C. Pulpal blood. Figure created by Jessica Moyano.

Biomarkers reflect the inflammatory status of the pulp and offer a potentially more precise diagnostic tool, particularly in assessing pulp status in teeth undergoing VPT.18 In addition, biomarkers have been investigated for the early detection of various types of root resorption.27, 28, 29 Although correlating inflammatory mediators with pain has garnered attention, it holds limited clinical value, as patients can directly report their pain levels. The true value of biomarker-based diagnostics lies in providing a more objective and accurate assessment, enhancing treatment planning, and ultimately improving patients’ outcomes.30,31 Similar molecular diagnostic methods have been explored in periodontics, including chairside tests for assessing inflammatory mediators, which have shown promise in diagnosing periodontal disease and differentiating its stages.32,33

On the basis of the endodontic literature, our review aimed to identify key biomarkers associated with pulpal inflammation, compare published cutoff points for these biomarkers, and briefly review molecular methods and sampling techniques. In general, we aim to provide an evidence-based summary of molecular diagnosis in endodontics for dental practitioners.

Inflammatory Mediators as Biomarkers for Endodontic Diagnosis

The first step in establishing a molecular diagnosis in endodontics is identifying inflammatory mediators. Because of the complicated nature of pulpal disease, a single mediator is unlikely to provide sufficient information to diagnose pulpitis.18 It is well-accepted that the immune response does not depend on a single mediator but rather on a complex combination of mediators.34 Abd-Elmeguid et al35 have suggested that evaluating a large panel of biomarkers in clinically diagnosed pulpitis would provide a better understanding of what is happening at the molecular level.

Cytokines are proteins secreted by several immune and nonimmune cells. These proteins affect different cell functions, such as proliferation, differentiation, recruitment, and apoptosis.20,36,37 The cytokine family includes interleukins (ILs), monokines, interferons, tumor necrosis factors (TNFs), and chemokines.36 Cytokines are redundant in their activity, meaning different cytokines can stimulate similar functions. They participate in innate and adaptive immune responses37 and can act synergistically or antagonistically.36 In pulpal inflammation, some cytokines were markedly elevated in the inflamed pulp compared with the peripheral blood.38 The following cytokines are the most common in inflamed pulp tissue.

IL-1

IL-1 is one of the initiators of the cellular immune response. It has been shown that the upregulation of IL-1 in human dental pulp is a strong indicator of pulpal disease.39 Levels of IL-1 family members, such as IL-1α, IL-1β, and IL-1rα, significantly increase in reversible and irreversible pulpitis groups compared with controls, with no significant differences observed between the 2 pulpitis groups. In addition, IL-1 levels were higher in irreversible pulpitis than in reversible pulpitis, without statistically significant differences.35 IL-1β is released primarily by monocytes, macrophages, and nonimmune cells, such as fibroblasts and endothelial cells, during cell injury, infection, bacterial invasion, and inflammation.40 IL-1β may be involved in both the pulpal inflammatory and healing processes40 and could contribute to inflammatory responses in pulpitis by stimulating the expression of vascular cell adhesion molecule 1.41 Furthermore, fibroblasts in diseased pulp produce higher levels of IL-1β than healthy pulp, leading to increased collagen synthesis during the healing phase.42,43

IL-2

IL-2 has been reported to be slightly elevated in pulpal inflammation; however, studies have shown contradictory findings. Kim et al44 reported an increase in T lymphocytes related to bacterial infection and accompanied by an increase in IL-2 concentration. Despite the relatively low concentration of IL-2 in pulpitis, they suggested that these initial changes may lead to progressive pulpal inflammation; however, Hirsch et al26 concluded that IL-2 is unsuitable as a possible biomarker because considerable discrepancies exist between different studies.

IL-6

IL-6 is produced by several immune and nonimmune cells that regulate inflammatory responses.45 Its expression is strongly upregulated in vivo through the activation of toll-like receptor-2 and in vitro by odontoblasts in inflamed pulps invaded by bacteria.46 It increases vascular permeability and might induce edema in the pulp caused by the progressive intradentinal penetration of gram-positive bacteria.46 Elsalhy et al47 and Abd-Elmeguid et al35 found high levels of IL-6 in pulps confirmed to have irreversible pulpitis. These results were confirmed later by Giuroiu et al,48 who analyzed acute and chronic pulpitis and reported that 73.8% of the samples contained cells producing IL-6, significantly higher than in normal pulp tissue.48

IL-8

IL-8 is produced by macrophages, lymphocytes, fibroblasts, and endothelial cells.49 It is possible that bacteria and their by-products in invading caries can stimulate and increase the production of IL-8 by odontoblasts.50,51 Huang et al50 showed that soluble IL-8 protein levels in odontoblasts usually exhibit low levels that substantially increase with the stimulation of the pathogen-associated molecular patterns. They concluded that IL-8 was significantly higher in pulpitis than in normal pulps. This increased IL-8 expression is correlated with increased polymorphonuclear neutrophils (PMNs) within the pulp.50 Because IL-8 induces neutrophil chemotaxis and the release of degradation enzymes, it is often described as the primary regulatory molecule in the acute inflammatory response. Elevated levels may perpetuate and exacerbate inflammation.18 Karapanou et al52 reported similar results, in which IL-8 levels significantly increased in patients with irreversible pulpitis after evaluating GCF. Silva et al53 also concluded that inflamed pulps present higher amounts of IL-1β and IL-8 than healthy pulps.

IL-17

IL-17 is a proinflammatory cytokine secreted by activated cluster of differentiation 4+ helper T cells.54 IL-17 mainly contributes to its positive regulatory role in inflammation through upregulating cytokines and mediating macrophage migration.55 IL-17 acts as an inflammatory mediator in pulpitis.55 Xiong et al56 concluded that IL-17 may participate in the pulp immune response by inducing chemokine production through nuclear factor κB and mitogen-activated protein kinases signaling pathways.

TNF-α

TNF-α is secreted by several immune cells,57 and it stimulates acute-phase inflammatory proteins and induces inflammatory cytokine production.58 The highest concentrations of TNF-α have been detected in symptomatic irreversible pulpitis; however, its concentration decreases as symptomatic irreversible pulpitis progresses.58 Pezelj-Ribaric et al58 speculated that the decrease in TNF-α concentration may represent a late phase of irreversible inflammation, progressing toward pulp necrosis.58 Zanini et al18 reported similar findings, concluding that irreversible pulpitis shows increased TNF-α expression, which may inhibit pulp repair and induce apoptosis.

Vascular endothelial growth factor-α

Vascular endothelial growth factor (VEGF)-α is a glycoprotein that can increase vascular proliferation and blood vessel permeability. It initially helps repair by encouraging cell chemotaxis to the inflamed site.59

Fibroblast growth factor acidic

Fibroblast growth factor acidic (FGFa) is secreted by fibroblasts with mitogenic potential because it allows the differentiation of pulp stem cells into fibroblasts and the proliferation of endothelial cells in affected areas.60 Jeanneau et al61 reported the importance of VEGF-α and FGFa in the pulp repair process, showing that 6 hours after damage, the expression of both growth factors could be seen in the first inflammation repair reactions.

Matrix metalloproteinases

Matrix metalloproteinases (MMPs) are endopeptidases responsible for degrading structural extracellular matrix (ECM) proteins.62 MMPs alter cellular adhesive properties to aid cellular migration through the ECM. MMPs modulate inflammation by regulating the bioavailability and activity of cytokines, chemokines, and growth factors as well as the integrity of physical tissue barriers. These events can contribute to the chronic cycle of inflammation.37 The following are the most common MMPs found in pulp inflammation.

Collagenases

Collagenase 1 (MMP-1), collagenase 2 (MMP-8), and collagenase 3 (MMP-13) break down fibrillar collagens of types I, II, and III, which are resistant to proteolysis by most proteinases. MMP-1 has not been found in inflamed pulp tissue,63 although it was correlated with dental pain to cold.38 MMP-8 is mainly synthesized by neutrophils and stored in their intracellular granules.64 It has been identified in inflamed pulp and periapical tissue in cases of pulpal necrosis and has been shown to participate in ECM degradation.65 MMP-8 was highly correlated with reports of the worst dental pain ever and dental pain associated with cold stimuli, but showed a weaker correlation with the duration (lingering) of pain to cold.38

Gelatinases

Gelatinases A (MMP-2) and gelatinases B (MMP-9) were initially named for their ability to break down denatured collagen (gelatin).64 MMP-2 is primarily secreted by fibroblastlike cells and macrophages.55 It has been strongly correlated with dental pain to cold38; however, its levels are lower in inflamed pulps than in healthy pulps, making its role in inflamed pulp tissue unlikely.63 In contrast, MMP-9 is secreted primarily by PMNs.64 Its levels in inflamed pulps were significantly higher than those in normal pulps63 and were highly correlated with the duration (lingering) of dental pain to cold.38 Because of its primary role in degrading gelatin, MMP-9 is often considered a biomarker of pulp tissue breakdown.63 Mente et al66 assessed the relationship between different degrees of inflammation in pulp tissue and MMP-9 levels in pulpal blood. They concluded that MMP-9 levels could be a useful ancillary diagnostic tool for distinguishing stages of pulp tissue inflammation.66 In addition, several authors have shown that this enzyme can significantly predict the outcome of VPT.67, 68, 69 Periodontal studies of MMP levels, particularly MMP-9 in the GCF, further support the potential role of MMPs in pulpal disease.70, 71, 72, 73

Tissue inhibitors of metalloproteinases

Tissue inhibitors of metalloproteinases (TIMPs) regulate and inhibit the proteolytic activity of MMPs after their activation.64 MMPs and TIMPs partially regulate pulp tissue destruction.62 The TIMP family comprises 4 members (TIMP-1, -2, -3, -4). TIMP-1 prevents uncontrolled ECM turnover caused by elevated MMP-9 levels.74 This specific down-regulating function of TIMP-1 may explain its delayed expression compared with MMP-9, making it a less sensitive protein biomarker in the early stages of pulpal inflammation.66,74

Biomarker Concentrations and Cutoff Points for Pulpal Diagnosis

The second step in establishing a molecular diagnostic approach in endodontics involves determining cutoff points or thresholds for biomarkers.18 Several studies have found an increase in the levels of some biomarkers, but only a few articles have studied the cutoff points between normal pulp, reversible pulpitis, and irreversible pulpitis. Diagnostic terms, such as reversible pulpitis and symptomatic or asymptomatic irreversible pulpitis, are primarily based on clinical signs and symptoms, rather than histologic assessment of the pulp or the definitive predictability of whether the condition is truly reversible or irreversible.

For normal pulp, inflammatory mediators are scarce because of the low number of immune cells. The healthy dental pulp contains only some leukocytes that can respond to the local environment.75 Enzymatic analysis revealed that leukocytes represent approximately 1% of the total cell population in nonerupted human third molars.76 Nawal et al25 reported that IL-8 and TNF-α concentrations were below the detection limit (29 pg/mL and 8 pg/mL, respectively) in healthy pulp, consistent with findings from another study in which TNF-α levels were undetected in normal pulp.35 Similar results were reported in a different study, in which IL-8 was undetectable in healthy pulpal blood samples.47 TNF-α was detected at concentrations as low as 0.038 through 0.212 pg mg−1 of total protein using a high-sensitivity enzyme-linked immunosorbent assay (ELISA) test.47 When TNF-α levels in normal pulps were compared with those in asymptomatic caries exposure (0.089-24.45 pg mg−1) and irreversible pulpitis (0.065-8.811 pg mg−1), significantly higher levels were observed in both conditions compared with normal pulps, with no significant difference between caries exposure and irreversible pulpitis.47

Reversible pulpitis is associated with a moderate increase in inflammatory cells, leading to higher levels of inflammatory mediators than normal pulp.35,53 Histologic characteristics of reversible pulpitis include atrophic pulp (less cellular than the healthy pulp with fewer fibroblasts and increased collagen) or coronal chronic inflammation (characterized by lymphocytes and plasma cells concentrated beneath the deepest areas of caries). Coagulation or liquefaction necrosis and bacteria are absent.6 Therefore, elevated levels of some inflammatory mediators are indicative of reversible pulpitis.

Biomarkers such as VEGF, PDGF, and FGFa show increased levels in reversible pulpitis. This increment is positively correlated with the expression of osteocalcin and negatively correlated to molecules like IL-1, frequently expressed in deep caries lesions. This negative correlation persists as pulpal inflammation progresses to irreversible pulpitis.35 Regarding cutoff points for reversible pulpitis, Nawal et al25 reported median IL-8 levels of 259.8 pg/mL (187.5-310 pg/mL) and TNF-α levels of 75.4 pg/mL (62.7-95.8 pg/mL).

Irreversible pulpitis is histologically characterized by at least 1 area of the pulp tissue that manifests with liquefaction or coagulation necrosis surrounded by masses of live and dead PMNs.6 Leukocyte numbers significantly increase when pathogens invade the pulp, leading neutrophils to release MMPs, recruit additional immune cells, and generate reactive oxygen intermediates.77 Gradual tissue necrosis begins with the formation of microabscesses, whereas chronic inflammatory cells form a dense halo around the central zones of the abscess.6 Adjacent to the halo, pulp tissue may remain in a state of reversible inflammation or even may remain in a normal histological state. This observation underpins the biological principle underlying VPT, as it shows that pulp tissue near the halo retains its healing potential or remains unaffected.78 The marked increase in inflammatory cells also correlates with elevated concentration of inflammatory mediators.21

Several biomarkers, such as IL-6, IL-8, IL-10, TNF-α, and interferon-γ, increase in irreversible pulpitis compared with normal pulp, and the ratios of IL-8/IL-10 and IL-6/IL-10 could be considered potential markers for pulpal inflammation in patients exposed to caries.47 In addition, the results of a systematic review suggest that the gene and protein expression of IL-8, TNF-α, MMP-9, and receptor for advanced glycation end products increase inside pulp clinically diagnosed with symptomatic irreversible pulpitis.18 Another study reported contradictory results.79 They found no significant differences in IL-1α, IL-18, and TNF-α concentration between inflamed and normal pulps. However, the mean levels of these cytokines were higher in the inflamed group than in the normal group.79

Brizuela et al80 evaluated the cutoff point for irreversible pulpitis and found that IL-1α, VEGF-α, and FGFa showed significantly higher levels in irreversible pulpitis than in reversible pulpitis (P < .05). In addition, combining FGFa, IL-1α, IL-6, and TIMP-1 resulted in an area under the receiver operating characteristic curve of 0.92 (95% CI, 0.84 to 0.99) for distinguishing irreversible from reversible pulpitis, with a significant difference compared with the FGFa receiver operating characteristic curve alone (P = .0231).80 In another study, Nawal et al25 reported cutoff concentrations for IL-8 and TNF-α at 404.4 and 130.68 pg/mL, respectively, using Youden index. IL-8 showed high sensitivity (95.5%) and specificity (99.76%) for differentiating reversible from irreversible pulpitis. The sensitivity and specificity of TNF-α showed lower sensitivity (59.1%) but high specificity (92.1%) when distinguishing between reversible and irreversible pulpitis.25

Although previous studies reported high sensitivity and specificity for certain biomarkers, a systematic review and meta-analysis found that IL-8 and IL-6 showed diagnostic accuracy with high sensitivity, specificity, and diagnostic odds ratio for distinguishing healthy pulps from irreversible pulpitis.81 However, none of the biomarkers tested showed a high diagnostic odds ratio and the ability to differentiate between reversible and irreversible pulpitis reliably.81 Further research is needed to establish definitive biomarker cutoff points.

Advances in Molecular Methods for Pulpal Diagnosis

The third step in establishing a molecular diagnosis in endodontics involves outlining existing clinical tools to detect biomarkers. Analytical methods for assessing pulp tissue include reverse transcription polymerase chain reaction and microarray analysis, which both measure gene expression; multiplex assay, which can detect multiple genes, proteins, or enzymes; western blotting, radioimmunoassay, and immunohistochemistry, which analyze proteins or hormones; ELISA, which determines proteins, antibodies, or antigens; zymography, which detects enzymes; flow cytometry, which analyzes cells, proteins or cellular markers; limbus amoebocyte assay, which detects toxins such as endotoxins; and specific enzyme assays, which assess proteins, antibodies, or enzymes. In addition, substrates other than pulp tissue, such as serum, GCF, and DF, can be analyzed using radioimmunoassay, ELISA, or specific enzyme assays.21

Protein expression evaluation is considered the most appropriate method for assessing pulpal inflammation clinically.18 Among immunoassay techniques, ELISA appears to be the most accurate, sensitive, and specific test for measuring inflammatory mediators in the pulp tissue.18 However, ELISA assays require a relatively large sample size to analyze multiple proteins, which is often impractical for pulp tissue, especially when preserving a portion of the pulp is necessary. The Luminex protein assay system offers an alternative by enabling the simultaneous evaluation of multiple proteins.38

Although traditional molecular diagnostic methods are not typically executable chairside, advancements such as biosensors and rapid immunoassays show promise for integrating molecular diagnostics directly into clinical settings.30 However, further research and development are needed to make these methods more practical and available for routine endodontic therapy.18

Several sampling methods have been used in research, including pulp tissue, pulpal blood, DF, and GCF. Although pulp tissue could be a suitable sample for pulpal diagnosis, it presents several challenges. The procedure is invasive, and no conservative therapy can be performed once the pulp is entirely removed. In addition, loss or damage during removal may result in undetectable biomarker levels.26 Noninvasive alternatives, such as DF or GCF, offer the advantage of preserving pulp vitality. However, they may require further validation to match the diagnostic accuracy of pulp tissue.

The pulpal blood sample can be ideal for qualitative and quantitative biomarker analysis,25 but its main disadvantage is its invasiveness, which can only be performed on pulp-exposed teeth. In addition, most of the values collected from blood samples show lower values than those from pulp tissue.26 Several methods have been used to collect pulpal blood. Mente et al66 collected pulpal blood samples using heparinized microcapillary tubes and concluded that this was a reliable method of collecting blood volume. Nawal et al25 collected pulpal blood using a micropipette to ensure precise and standard blood volume. Nakanishi et al79 used absorbent pellets that were easy to handle when approaching the exposed pulp. They quantified the sampled blood by measuring the pellets’ increased weight and quantitatively analyzing the inflammatory markers.

DF is a pulpal interstitial fluid composed of serum proteins and immunoglobulins with a protein concentration about one-fifth of plasma,80 which can be collected from cut dentin surfaces.24,82,83 Its composition is mediated by odontoblasts in normal conditions and by pulpal capillaries under inflammation.84 According to Maita et al,24 DF could be used as a diagnostic test for pulp disease and may serve as a liquid biopsy medium to assess the degree of inflammation. In addition, Pashley et al85 concluded that the collection and analysis of DF looks promising as a noninvasive method of determining the state of the underlying pulp. However, 1 limitation of this method is that DF will only move across dentin if there is a positive hydrostatic pulpal tissue pressure providing a driving force for fluid filtration, and this applies even if the remaining dentin is thin, free of smear layer, and highly permeable.85

Different methods for collecting the DF have been explored. Brizuela et al80 successfully used a polyvinylidene fluoride filter membrane (Durapore, Millipore) for a 2-minute collection, with samples stored at −80 °C. Zehnder et al86 compared cellulose and polyvinylidene fluoride membranes. They found that cellulose membranes with smaller pore sizes retained significantly more protein, whereas those with larger pores absorbed more water. For optimal DF collection, a 2-sampling procedure per tooth is recommended, with membranes left in place for 1 through 2 minutes,86 and the smear layer removed before to enhance fluid conductance.85

GCF is an exudate from the gingival crevice that contains several host factors, including antibodies, bacterial antigens, proteins, and cytokines.23 GCF analyses may be promising because of the ease of application. It may be possible to assess the dynamics of apical periodontitis using GCF.22 However, it is essential to consider that the detection of pulpal biomarkers in GCF is affected by the need for these molecules to reach the periodontal ligament and, ultimately, the gingival crevice in sufficient concentrations. It is difficult to distinguish on a molecular level between marginal and apical periodontal inflammation. When sampling from the GCF for pulpal diagnostics, this potential drawback could be overcome by creating healthy periodontal conditions, averaging out several sites on 1 or multiple teeth, combining clinical and radiographic observations, or defining a specific pattern of metabolites relevant to the pulp and not the periodontium.21

Conclusions

There is a growing need for innovative methods of pulpal diagnosis in endodontics. Molecular diagnostic techniques hold considerable promise, offering the potential for more precise diagnoses. These advanced methods can enhance clinical decision making, enabling dentists to tailor treatments more effectively to meet individual patient needs. By improving accuracy, molecular methods can also reduce unnecessary root canal overtreatment, leading to more efficient and patient-centered care. In addition, these techniques offer the potential for more accurate diagnoses and aid in understanding the biological processes involved in pulpal inflammation.

Disclosures

None of the authors reported any disclosures.

Footnotes

This study was supported by the Department of Endodontics, College of Dentistry, New York University.

The authors thank the Clinical and Translational Science Institute at New York University Langone Health and graphic designer Jessica Moyano for their collaboration.

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