Evaluating the cold sensibility test as a predictor of inferior alveolar nerve block success in mandibular molars with symptomatic irreversible pulpitis: a systematic review and meta-analysis

Achieving pulpal anesthesia in mandibular molars with symptomatic irreversible pulpitis (SIP) is challenging, with inferior alveolar nerve block (IANB) often showing high failure rates. The cold sensibility test has been proposed to evaluate anesthetic success. This systematic review and meta-analysis assessed its diagnostic accuracy in predicting IANB outcomes in SIP. Following PRISMA guidelines, PubMed, Embase, Web of Science, and Scopus were searched to August 2025. Studies on cold test accuracy in IANB for SIP were included. Outcomes were sensitivity and specificity. Risk of bias was assessed with QUADAS-2. Eligible studies were clinical investigations studies which comparing cold test outcomes with the definitive reference standard, patient pain during access cavity preparation or pulpal extirpation. Data extraction and quality appraisal were performed independently by two reviewers. Only studies which providing sufficient data to calculate sensitivity and specificity were retained for quantitative synthesis. Four studies met inclusion criteria. Pooled sensitivity was 0.68 (95% CI: 0.43–0.86; I²=84.4%), specificity 0.97 (95% CI: 0.91–0.99; I²=0%). Diagnostic odds ratio was 69.74, AUC 0.715. The post-anesthetic cold sensibility test showed high specificity but only moderate sensitivity for predicting inferior alveolar nerve block failure in mandibular molars with symptomatic irreversible pulpitis. A positive cold response is clinically useful for ruling in likely anesthetic failure, whereas a negative response does not reliably exclude the possibility of pain during access cavity preparation or pulpal extirpation.