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Interference of apex locator,
pulp tester and diathermy on
pacemaker function.
Narayanan Sriman, Prabhakar V., Bhuvaneswaran J.S., Subha N.
J Conserv Dent 2015;1:15-19www.indiandentalacademy.com

There are about 3 million people worldwide
with cardiac pacemakers and each year
about 600000 pacemakers are implanted.
In India an average of 20,000 patients get
pacemaker implants every year.

Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental courses

Traditionally electronic apex locators (EALs)
and electronic pulp testers (EPTs) are not
recommended for use in patients with
implanted cardiac pacemakers (ICPs) due to
possibility of electrical interference in patients
with ICP.

Pacemakers manufactured before 1975 used discrete
electronic components encapsulated in a clear epoxy
case, this casing was not effective in shielding the
cardiac pacemaker from electromagnetic
interference.

• Temporarily cause reversion of an ICP to an asynchronous
pacing mode.
• The signal may inappropriately reprogram the cardiac
device.
• Travel down the lead wires to the heart and induce
ventricular or atrial fibrillation.
• Hence EALs and EPTs were not recommended in patients
with ICPs.

MATERIALS AND METHODS
 Root ZX (J. Morita Co., Tustin, CA, U.S.A.),
 Propex (Dentsply),
 Mini Apex locator (SybronEndo, Anaheim, CA, USA),
 Parkell pulp vitality tester (Farmingdale, NY, USA),
 Diathermy (Neomed 250 B).
 A medtronic kappa KVDD901 pacemaker.
Pace monitoring was carried out with a Medtronic
carelink/vitataron programmer.

APEX LOCATOR
Determine the position of the apical foramen
The apex of the root has a specific resistance to
electrical current, and this is measured using a pair
of electrodes typically hooked into the lip and
attached to an endodontic file.
Reduces the number of radiograph

Composition of composite
APEX
LOCATOR
RESISTANCE
BASED
IMPEDANCE
BASED
MULTIPLE
FREQUENCY
TWO
SEPARATE
FREQUENCY
MEASURES
CAPACITANCE
AND
RESISTANCE
ADAPTIVE
GENERATIONS OF APEX LOCATOR

FIRST GENERATION
Also known as the resistance based
Measures the opposition to the flow of direct current or resistance.
Found to be unreliable, with many reading significantly shorter or
longer than accepted working length.
Also known as impedance based.
Measure the opposition to the flow of alternating current or
impedance.
Suffered similar problems of incorrect reading .
SECOND GENERATION

THIRD GENERATION
Similar to second generation
Uses multiple frequency with high processor
If apical constriction is absent or the canal has an open apex, the
accuracy of these devices has been shown to diminish
FOURTH GENERATION
Similar to third generation.
Uses two frequency of 400 HZ and 8 Khz
Low accuracy on working on wet canals

FIFTH GENERATION
It measures the capacitance and resistance of the circuit separately.
Root canal length varies with the pulp and periapical condition.
Low accuracy working on dry canal
SIXTH GENERATION
Also known as adaptive apex locator.
Overcome the disadvantage of both 4th and 5th generation.
It defines humidity of the canal and immediately adapts to dry and
wet canals.

Root ZX Propex

Mini Apex locator

Electric pulp tester
Diagnostic aid,
More accurate,
Uses nerve stimulation,
Due to increase degree of electric current,
Positive response indicated pulp vitality,
No indication indicate pulp necrosis.

FALSE POSITIVE
MOIST GANGRENOUS PULP
MULTIROOTED TOOTH WITH PARTIALLY NECROSED
CALCIFICATION
EXTENSIVE RESTORATION AND PULP PROTECTING BASE
RECENTLY ERUPTED WITH INCOMPLETE ROOT
FORMATION
SEDATIVE
PATIENT HAVING HIGH PAIN THRESHOLD
FALSE NEGATIVE

Control abnormal heart rhythms.
Electrical pulses to prompt the
heart to beat at a normal rate.
 Pacemakers are used to treat
arrhythmias.
Arrhythmias are problems with the
rate or rhythm of the heartbeat.
Medtronic kappa KVDD901 pacemaker

Stimulation protocol
Directly connected the pacemaker lead, EAL/EPT with the
pacemaker programmer
With the telemetry wand , the surface and intracardiac
electrocardiogram were continuously printed during testing,

It consisted of ten phases . Each lasting for 30
secs.

The pacemaker exhibited a normal pacing pattern
during 30 seconds before each trial (phase I) which was
considered as baseline reading.
The telemetric recordings of the pacemakers with
all of the dental devices were recorded and evaluated
RESULTS

Heuristic evaluation
Heuristic evaluation, a
usability inspection
method commonly used
for software usability
evaluation, modified and
extended for medical
devices.

DISCUSSION
Safe dental treatment requires elimination of
electrical interferences that could affect the cardiac
health of patient with implanted cardiac pacemakers.
Medtronic pacemakers have been shown to be more
reliable than other models.
Cardiac pacemaker interference is not a time dependent
phenomenon.

The results obtained (Phases 2, 3, 4, 5, 6, 7) by evaluating
three apex locators (Root Zx, Propex, Sybron Endo Mini)
showed that they do not cause any interference with the
pacemaker function.
A given stimulus either does or does not inhibit normal
pacing.
Therefore, a testing interval of 25-30 seconds was
deemed satisfactory for the purposes of this study.

Findings with electric pulp tester (Phases 8, 9, 10)
showed
varying degree of background noise, however normal
pacing was not affected, and no change in pacing interval
was noted. Pacing interval remained constant and there
was no interference produced and it can be suggested that
this device is probably safe to use in the dental office

Diathermyh not absolutely contraindicated, it generates
high intensity conducted interference which has been
shown to be capable of interfering with pacing systems.
If sufficient energy is coupled into the pacing system
from diathermy apparatus the myocardium may be burnt or
ventricular fibrillation initiated. The pacing system itself
may
also be damaged

There are no strict guidelines covering the use of
electrical devices on pacemaker patients. Most electrical
equipment can be used safely.
Following factors in favor of its use are
•EALs is confined to the head region,
•Roughly 10-12 inches from the heart,
•Does not cross the chest.
• The titanium or stainless steel case of the pacemaker
will serve as an EMI shield.

These factors may depend on the specific pacemaker
placed and if the patient is totally pacemaker dependent.
We should also make sure that all electronic equipment
used during the procedure is properly grounded and not
placed in close proximity to the pacemaker leads.

From the results of the present in-vitro study, it may be
concluded,
1. The tested EPL Root ZX (J Morita Corp., Japan), Propex
(Dentsply Maillefer, Ballaigues, Switzerland), Sybron
Endo mini (SybronEndo, Anaheim, CA, USA) do not
interfere with cardiac pacemaker function.
CONCLUSION

2. The tested EPT, Parkell pulp vitality tester
(Farmingdale, NY, USA) does not interfere with
cardiac pacemaker function.
3. The use of Diathermy (Neomed 250 B) interfered
with the normal pacing, leading to complete inhibition
of the pacing system.

THANK YOU

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