Preoperative and Intraoperative Molecular Pulpal Diagnostics: Practical and Biological Considerations

BACKGROUND: Obtaining an accurate preoperative diagnosis ascertaining the level of pulpal inflammation is fundamental to selecting subsequent endodontic care. Conventional diagnostic methods, including thermal and electric pulp testing, percussion and radiographic assessment, rely largely on subjective patient responses and indirect indicators of pulpal health, resulting only in limited discrimination between pulp necrosis and vitality. These limitations often hinder reliable differentiation between levels of pulpitis such as reversible and irreversible pulpitis, which may result in either under-treatment or over-treatment. Advances in the understanding of pulpal pathophysiology and the success of vital pulp treatment techniques have highlighted the need for objective, accurate, biologically relevant, molecular-based point-of-care diagnostic approaches. OBJECTIVES: This narrative review aimed to synthesise current evidence on the biological basis of pulpal inflammation, critically evaluate the limitations of conventional diagnostic methods, while exploring the potential role of molecular biomarkers and preoperatively/intraoperatively sourced biological fluids in the objective assessment of pulpitis. METHODS: A comprehensive literature search was conducted using PubMed/MEDLINE, Scopus and Web of Science databases. Relevant peer-reviewed original research articles, narrative and systematic reviews and experimental and clinical studies related to pulpitis, caries-induced pulpal inflammation, diagnostic methods, biomarkers and biological fluids were included. The selected literature was qualitatively synthesised to identify prevailing themes. RESULTS: The findings indicate that pulpitis is characterised by complex immune and vascular responses that are inadequately captured by traditional diagnostic tests. Biomarkers associated with inflammatory activity, tissue breakdown and immune regulation potentially offer objective measures of disease presence, severity and progression. Among preoperative biological fluids, gingival crevicular fluid (GCF) demonstrates superior site-specificity and biological relevance compared with saliva and systemic blood, despite limitations related to sample volume and standardisation. In addition, intraoperative biological sources such as dentinal fluid and pulpal blood provide direct, site-specific information reflective of the pulpal microenvironment, with potential to enhance diagnostic accuracy during clinical treatments. CONCLUSION: GCF-based molecular diagnostics are biologically plausible tools to assist preoperative diagnosis having shown encouraging preliminary findings for objective pulpal assessment. However, their clinical utility requires validation through prospective biomarker-outcome studies, standardised diagnostic thresholds and strong analytical validation before considering routine endodontic application.