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ENDODONTICS

Pulp Testing and Apex Locators:

Eliminating the
Guesswork
From Endodontic
Diagnostics
Joseph Chikvashvili, DDS

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Joseph Chikvashvili, DDS
Director of Endodontics, Newark Beth Israel
Medical Center, Newark, New Jersey;
Private Practice specializing in Endodontics,
West Orange, New Jersey
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Pulp Testing and Apex Locators:
Eliminating the Guesswork
From Endodontic Diagnostics
Joseph Chikvashvili, DDS
ABSTRACT
Clinicians must effectively
manage endodontic testing
to better achieve successful
diagnoses of injured teeth.
Taking accurate periapical
radiographs and bitewings is
a critical part of the process.
In addition to radiography,
however, apex locators have
become an instrumental tool
in helping dentists perform
high-quality endodontic care.
Having undergone various
generations of advancements,
these instruments help clinicians
eliminate guesswork in achieving
accurate working lengths when
performing root canal therapies.
LEARNING OBJECTIVES
• Discuss the importance of
taking accurate periapical
radiographs and bitewings
when diagnosing an injured
tooth.
• Describe various methods of
testing that can be performed
to evaluate the health of a
tooth.
• Explain how apex locators
can be effectively used to
determine canal length.
VOLUME 3 • NUMBER 63
PEER-REVIEWED
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A
ccurate, reproducible endodontic testing is essential for
determining the proper diagnosis of an injured tooth.
Several types of tests can be used to help evaluate the vi-
tality of a tooth. Equally important, other tests are also available
that assist dentists in determining the source of a patient’s pain.
However, the starting point should reflect the famous words of
Sir William Osler, MD: “Listen to your patient, he is telling you
the diagnosis.”1
Excellent diagnosis essentially begins with two fundamental
components: a doctor willing to listen to the patient’s chief com-
plaint, and proper diagnostic tools. Among the most important
tools are a precise periapical radiograph (PA) and bitewing (BW).
Although a PA is often enough to provide an accurate portrayal of
the patient’s condition, sometimes it alone does not suffice. Figure
1 through Figure 3 demonstrate a case that illustrates this point
clearly. Despite two acceptable PAs (Figure 1 and Figure 2), it is
difficult to assess the source of the patient’s pain to temperature.
However, the BW radiograph (Figure 3) provides significantly
more clarity than either of the two PAs. The BW depicts local-
ized bone loss (around tooth No. 2), a pulp stone (No. 2), a flat
occlusion, numerous calcified canals, multiple restorations in
tooth No. 30, and gross decay especially on tooth No. 3, which
is the source of the patient’s pain to temperature. In this instance
these images depict how much more useful a BW can be than
just a conventional PA.
EVALUATING THE HEALTH OF A TOOTH
Having established the importance of taking meticulous PAs and
BWs, testing should be done to evaluate the health of a tooth. An
array of tests could be performed, ranging from hot, cold, elec-
tric pulp testing (EPT), percussion, palpation, mobility, probing,
biting, and anesthesia. All of these tests are useful, but depend-
ing on the patient’s chief complaint, some are more valuable
CDEWORLD.COM 3
 than others. Hot and cold testing are generally
considered to be the best for determining the
responsiveness of pulpal, sensory neurons.2

Hot testing can be performed with a heated

gutta-percha or compound stick, friction, or—
the most superior method—isolating the tooth
with rubber dam and rinsing with a syringe
filled with hot water.2 Cold can be tested using
ice, frozen carbon dioxide, or, the most prudent
alternative, a can of cold refrigerant spray, ie,
1,1,1,2 tetrofluoroethane (eg, Frigi-Dent™, Ell-
man International Inc., www.ellman.com).2 The
latter is a simple way to elicit a response. When
using this method, the clinician sprays the re-
1
frigerant spray on a piece of cotton and applies
it to the tooth. In the author’s experience, using
a loosely wound cotton ball held with a college
pliar will produce a more accurate result than
using a cotton tip applicator or a tightly wound
cotton ball.

EPT can also be an effective test. However,

responsiveness of the pulp to EPT does not
reflect the histologic health or disease status
of the pulp.3 Rather, a response only denotes
that viable nerve fibers are present in the pulp.
Moreover, the numerical figures associated
2
with EPT readings are less relevant than num-
bers that appear to be outliers.2 EPT can be a
highly useful adjunct for testing a tooth; how-
ever, it, too, has limitations as performing the
test can be difficult or even impossible when
the tooth has a full-coverage restoration.

Percussion and palpation can offer insight

3
Fig 1. Foreshortened PA radiograph. Fig 2. Acceptable PA radiograph.
Fig 3. BW of the same upper right area as shown in Figure 1 and
Figure 2, depicting gross decay not visualized on prior PAs.
into acute pain that is occurring. While per-
cussion alone cannot indicate that a tooth
needs root canal therapy, this type of pain is
often accompanied by an unhealthy, diseased
pulp. Thermal testing must be done in tandem
with this method to ensure that the discomfort
does not stem from some parafunctional habit
(clenching, grinding, etc) or for some other rea-
son (such as placement of a recent restoration).

4 CDEWORLD.COM DECEMBER 2016

A bitestick test can also be helpful in testing to
see what is acute.2 However, the author prefers
to have the patient bite on a smaller saliva ejec-
tor tip.
Mobility can often suggest improper occlu-
sion, parafunctional habits, or possibly puru-
lence underneath an infected tooth. Meanwhile,
probing can provide an effective assessment of
the periodontal health and whether any frac-
tures exist.
It should be noted that not all of these tests
need to be performed for every tooth examined.
However, cold, percussion, mobility, and prob-
ing should be done most frequently, because
they are usually the most reliable and helpful
tests to enable proper diagnosis and restorabil-
ity of the tooth.2 The author performs all four of
these tests on more than 90% of the teeth that
he routinely evaluates.
Some clinicians prefer to assess the source of
the pain by testing the likely tooth in question
first, either by percussion or cold. However, a
different method, which the author prefers, is
to test what appears to be a healthy tooth first.
This provides two primary benefits: it allows
the clinician to ascertain the patient’s baseline
to cold or percussion, and it encourages further
rapport with the patient. Eliciting pain from pa-
tients immediately after meeting and greeting
them is not conducive to developing a relation-
ship of trust with them. If the clinician is a spe-
cialist, some patients may be meeting him or
her for the first time.
Once a proper diagnosis is obtained, and
informed consent is attained and reviewed,
treatment can typically begin. While access is
essential, preservation of the tooth should al-
ways be the highest goal in root canal therapy.
Removing excessive tooth structure to perform
a beautiful root canal will likely lead to the
tooth’s eventual demise.4 Therefore, it is crucial
VOLUME 3 • NUMBER 63
to keep accesses conservative. Unfortunately,
practitioners often master the delicate art of ac-
cess only after they have learned how to prop-
erly perform successful root canal therapy,
which is ironic because access is usually the
first thing a practitioner learns and is how root
canal therapy begins on every tooth.
Figure 4 through Figure 10 depict several
teeth that have conservative accesses while
still allowing the clinician to adequately instru-
ment and clean each tooth to achieve effective
root canal therapy. The success of these cases
still hinges on the proper cleaning and shap-
ing of the root canal system, and while conser-
vative accesses are desirable, too small of an
access can lead to missed canals, poor instru-
mentation, improper cleaning, and, ultimately,
a failed procedure.
LIMITATIONS OF RADIOGRAPHS
Once the access is performed and canals have
been located, the length of the canals need to
be determined. This can be achieved by taking
a working film radiograph or by using an apex
locator. Radiographs have been used for many
years to determine proper length, but this meth-
od is rather arbitrary. An examination into the
research performed by various authors, includ-
ing Kuttler,5 Pineda and Kuttler,6 and Dummer
et al,7 demonstrated that canal length can vary
greatly. One reason is that the anatomy of the
apex changes with age, which is often due to
hard-tissue deposition. Additionally, the apical
foramen (or major foramen) often does not lie
at the anatomical apex of the tooth, and, more-
over, the apical constriction (or minor fora-
men) itself can vary greatly in its appearance.5
For all tooth types, it was determined that the
distance from the apical foramen to the apical
constriction was 0.5 mm in younger individu-
als and 0.8 mm in older adults.6,7 This vari-
ability could be due to many factors, including
caries, apical disease, genetics, etc. However, it
CDEWORLD.COM 5
 illustrates that there is a difference in anatomi- really fostered the common teaching practice of
cal considerations due to the age of the person. determining working length to be approximately
Furthermore, early anatomical studies are what 1 mm short of the anatomical apex.7 While this

4 5

7 8

9 10

Fig 4. Endodontic therapy on molar with four canals. Fig 5. Same tooth as shown in Figure 4 allows for visualization of tiny access despite
having obturated four canals. Fig 6. Tiny access specifically performed to preserve tooth structure and avoid the rest seat of a maxillary partial
denture. Fig 7. Conservative access does not prevent the “popping” of six or seven lateral canals on this particular molar. Fig 8. Complex four
canals with internal resorption in distal canals. Fig 9. The author’s typical access preparation for a molar tooth endodontically treated.
Fig 10. Despite tiny access, three canals were negotiated in this difficult premolar.

6 CDEWORLD.COM DECEMBER 2016

proved to be a good starting point for properly
finding canal length, today far superior methods
of obtaining accurate lengths exist, due primar-
ily to the innovation of apex locators.8
Radiographs were not without their limi-
tations. They were 2-dimensional while the
images they were capturing were, of course,
3-dimensional. They were technique-sensitive
and open to subjective interpretation. At times,
analyzing them was impaired by existing anat-
omy. Superimposition of the zygomatic arch
could interfere with maxillary first molar api-
ces 20% of the time.9 The zygoma, a torus, or
natural root bifurcation could all contribute to
increasing a clinician’s inaccuracy in locating
the correct working length. Additionally, prior
11
13
Fig 11. Preoperative PA depicting complex root anatomy. Fig 12. Working PA depicting arduous mesial bends and two mesial canals.
Fig 13. Six-year checkup PA. Fig 14. Three-rooted premolar displaying how difficult anatomy can obscure a clinician from visualizing the apex
of the tooth.
VOLUME 3 • NUMBER 63
to digital radiography, radiation was an even
greater concern.
PROGRESSION OF APEX LOCATORS
Using the earlier work of Custer and Suzuki,
Sunada was able to develop a device that used
direct current to measure canal length.10 How-
ever, using direct current led to some instabil-
ity with measurement and elicited more pain
for the patient. Second-generation apex loca-
tors began to use impedance measurements in-
stead of resistance to locate working length. In-
oue developed a change in frequency method,
which allowed for beeping sounds when the
apex was reached. Still, most second-genera-
tion apex locators failed to give accurate read-
ings in both dry and wet canals.11
12
14
CDEWORLD.COM 7
 Third-generation apex locators improved
upon their predecessors by generating multiple
frequencies to determine accurate canal length.
Finally, with Kobayashi’s efforts, erroneous
readings with electrolytes were solved.12 He
used a ratio method that worked based on the
principle that two electrical currents with dif-
ferent sine wave frequencies would have mea-
surable impedances. These impedances could
be measured and compared as a ratio, regard-
less of the type of electrolyte in the canal.12
Yet despite these advances, newer fourth-
generation apex locators still have limita-
tions. Inflammation has been demonstrated to
adversely affect an apex locator’s readings.13
Intact tissue, blood, and exudate can all cause
inaccurate readings by conducting electrical
current. Caries and metal restorations can also
lead to inaccurate readings. Additionally, some
apex locators have demonstrated that they are
more accurate when readings are attempted in
the presence of sodium hypochlorite.13
Dentin debris or lack of patency can also af-
fect an apex locator’s readings. While small
or larger files both can be used to accurately
determine working length, often clinicians will
achieve a better result by using a larger-diam-
eter hand file. Constant recapitulation and ir-
rigation are both necessary to achieve optimal
readings.

15 16

17 18

Fig 15. Molar with significant radiolucencies. Fig 16. Mesial-lingual (ML) length looks to be precise, while distal-lingual (DL) looks to be slightly
long. Fig 17. Mesial-buccal (MB) length appears to be long, and distal-buccal (DB) has a kink likely due to its joining the DL canal just before
the apex. Fig 18. Completed case shows how the lengths were corrected prior to final obturation to achieve an ideal result.

8 CDEWORLD.COM DECEMBER 2016

OVERCOMING PITFALLS
There are ways, of course, to eliminate some
of these pitfalls. Clinicians should bear in mind
that as a tooth is shaped, especially through
use of rotary instruments, canal length will get
shorter.14 Therefore, rechecking one’s measure-
ments is usually beneficial. Apical debris is a
major hindrance to achieving both accurate
readings and overall clinical success. Thus, re-
moval of debris via recapitulation and active
irrigation is often necessary. If an amalgam
restoration is interfering with the readings, it
should be removed entirely if possible. If it is
not feasible to do so, the file should be held
away from the amalgam until an accurate read-
ing can be achieved. Some burs come with
plastic sleeves that can also be placed over a
file so that the metal restoration does not con-
tact the hand file itself. Similarly, this can also
be achieved by coating the coronal aspect of a
file, even with nail polish.
If the desired reading cannot be attained us-
ing a small file, the clinician can increase the file
size by one or two sizes. It should be noted that
readings are effectively attained when the canal,
not the chamber, is wet. If a reading seems to
be obviously inaccurate, other methods of deter-
mining working length should be used.
Other means for locating working length
include use of radiographs or paper points.
Although radiographic evaluation can be sub-
jective, paper point confirmation can be very
helpful. If a paper point is consistently “wet” at
19 mm, then that is likely the proper working
length. If a working length radiograph is taken
and the file looks significantly short, it may be
due to a lateral canal, resorbed apex, or some
other anatomical anomaly.
WORKING WITH BOTH APEX LOCATORS
AND RADIOGRAPHS
The question remains: how often should clini-
cians use apex locators, and are they really nec-
VOLUME 3 • NUMBER 63
essary? Because studies have shown them to
be up to 96% accurate,8 it stands to reason that
they could be used in every case possible. In
some instances, the apex cannot even be seen
radiographically. In these cases, using an apex
locator is imperative to finding the true work-
ing length of the canals. Figure 10 and Figure
11 through Figure 14 demonstrate two such
cases; they likely would not have been suc-
cessfully completed without the use of an apex
locator. Even the final PA (Figure 14) does not
clearly depict where the canals end.
Working films or radiographs, however,
should not be completely eliminated from the
clinician’s armamentarium. While practitioners
may legally only be required to depict a preop-
erative and postoperative radiograph, from an
endodontic point of view at least one working
radiograph should always be taken. This does
not mean that a master file radiograph has to
be taken; however, it is prudent to take one in
cases in which the anatomy is challenging, and
the author recommends always taking a master
cone radiograph (Figure 11 through Figure 14).
The master cone PA is the last indicator cli-
nicians have in assessing whether or not their
working lengths were truly accurate. This ra-
diograph is crucial in affording the practitioner
the opportunity to make adjustments to prop-
erly complete the procedure to the desirable
lengths. An example is presented in Figure 15
through Figure 18. Figure 16 and Figure 17
show a master cone PA that demonstrates two
of four canals to proper length. After adjust-
ing the length of the other two master cones,
the clinician was able to correct the lengths to
produce a more appropriate result, as seen in
Figure 18.
Having the opportunity to make adjustments
prior to completing treatment should not be mere-
ly an option; rather, it is imperative to enable the
clinician to perform the best possible endodontic
CDEWORLD.COM 9
 therapy for the patient. In a discipline where 1
mm can determine success or failure, this cannot
be overemphasized.
CONCLUSION
It is crucial for clinicians to learn how to man-
age endodontic tests to better achieve successful
diagnoses and, ultimately, offer optimal treat-
ment to patients. Apex locators have become
instrumental in helping dentists perform high-
quality endodontic care by eliminating guess-
work in achieving accurate working lengths.
Nevertheless, practitioners should always use
supplementary methods, such as radiographic
analysis of master cone PAs or paper point in-
spection, to confirm working lengths.
REFERENCES
1. Sir William Osler & His Inspirational Words. The Os-
ler Symposia website. http://www.oslersymposia.org/
about-Sir-William-Osler.html. Accessed December 8,
2016.
2. Cohen S, Burns R. Pathways of the Pulp. 8th ed. Phil-
adelphia, PA: Mosby; 2002.
3. Seltzer S. Endodontology: Biologic Considerations in
Endodontic Procedures. 2nd ed. Philadelphia, PA: Lea
& Febiger; 1988.
4. Larson TD, Douglas WH, Geistfeld RE. Effect of
prepared cavities on the strength of teeth. Oper Dent.
1981;6(1);2-5.
5. Kuttler Y. Microscopic investigation of root apexes. J
Am Dent Assoc. 1955;50(5):544-552.
10 CDEWORLD.COM
6. Pineda F, Kuttler Y. Mesiodistal and buccolingual
roentgenographic investigation of 7,275 root canals.
Oral Surg Oral Med Oral Pathol. 1972;33(1):101-110.
7. Dummer PM, McGinn JH, Rees DG. The position and
topography of the apical canal constriction and apical fo-
ramen. Int Endod J. 1984;17(4):192-198.
8. Shabahang S, Goon WW, Gluskin AH. An in vivo
evaluation of Root ZX electronic apex locator. J Endod.
1996;22(11):616-618.
9. Tamse A, Kaffe I, Fishel D. Zygomatic arch interfer-
ence with correct radiographic diagnosis in maxillary
molar endodontics. Oral Surg Oral Med Oral Pathol.
1980;50(6):563-566.
10. Sunada I. New method for measuring the length of
the root canal. J Dent Res. 1962;41(2):375-387.
11. Inoue N. An audiometric method for determining the
length of root canals. J Can Dent Assoc. 1973;39(9):630-
636.
12. Kobayashi C, Okiji T, Kawashima N, et al. A basic
study on the electronic root canal length measurement:
Part 3. Newly designed electronic root canal length
measuring device using division method. Jpn J Conserv
Dent. 1991;34:1442-1448.
13. Meares WA, Steiman HR. The influence of sodium
hypochlorite irrigation on the accuracy of the Root ZX
electronic apex locator. J Endod. 2002;28(8):595-598.
14. Khurana P, Nainan MT, Sodhi KK, Padda BK.
Change of working length in curved molar root canals
after preparation with different rotary nickel-titanium in-
struments. J Conserv Dent. 2011;14(3):264-268.
DECEMBER 2016
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Eliminating the Guesswork

From Endodontic Diagnostics
Joseph Chikvashvili, DDS

1. Excellent diagnosis begins with two fundamental 6. With whose efforts were erroneous apex locator readings with
components: a doctor willing to listen to the patient’s chief electrolytes solved?
complaint, and: A. Kobayashi
A. access to good research. B. Kuttler
B. paper points. C. Sunada
C. proper diagnostic tools. D. None of the above
D. irrigation instrumentation.
7. Some apex locators are more accurate when readings are
2. Which testing is/are generally considered to be the best for attempted in the presence of:
determining the responsiveness of pulpal, sensory neurons? A. metal restorations.
A. Hot and cold B. sodium hypochlorite.
B. Electric pulp testing (EPT) C. blood.
C. Percussion and palpation D. dentin debris.
D. Anesthesia
8. When locating working length, in addition to radiographic
3. While access is essential, what should always be the highest evaluation, confirmation with which of the following can be
goal in root canal therapy? very helpful?
A. Preservation of the tooth A. EPT
B. Finding all canals B. Heated gutta-percha
C. Cleaning all canals C. Paper point
D. Ensuring the root canal appears properly on a radiograph D. Frozen carbon dioxide

4. Canal length can vary greatly because the anatomy of the 9. Studies have shown apex locators to be:
apex: A. less than 36% accurate.
A. never changes. B. up to 56% accurate.
B. changes with age. C. up to 76% accurate.
C. is unaffected by hard-tissue deposition. D. up to 96% accurate.
D. changes based on a person’s parafunctional habits.
10. The last indicator clinicians have in assessing whether or
5. When evaluating a radiograph, which of the following could not their working lengths were truly accurate is:
interfere with a clinician’s view and contribute to inaccuracy A. a master file radiograph.
in locating the working length? B. the master cone PA.
A. Zygoma C. the BW radiograph.
B. Torus D. a fourth-generation apex locator.
C. Root bifurcation
D. All of the above

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