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Clinical Research

The Precision of Electronic Apex Locators in Working


Length Determination: A Systematic Review and
Meta-analysis of the Literature
Igor Tsesis, DMD,* Tamar Blazer, DMD,†‡ Gil Ben-Izhack,* Silvio Taschieri, MD, DDS,§
Massimo Del Fabbro, BSc, PhD,§ Stefano Corbella, DDS, PhD,§ and Eyal Rosen, DMD*

Abstract
Introduction: This study aimed to evaluate the preci- Key Words
sion of electronic apex locators (EALs) in locating the Apical constriction, electronic apex locators, root canals, working length
apical constriction (AC) during a root canal treatment
compared with a histologic evaluation of the AC as
well as the effects of possible influencing factors by
means of a systematic review of the literature and
R oot canal treatment (RCT) procedures should be confined within the root canal sys-
tem (1). The working length (WL) is defined as the distance between a coronal
reference point and the point at which canal preparation and obturation should termi-
meta-analysis. Methods: A systematic search of the nate (2). Maintaining a correct WL during RCT is expected to positively influence the
literature was performed to identify studies that histo- outcome of RCT (3, 4), and it prevents postoperative pain (5). Thus, the WL should
logically evaluated the precision of EALs in human teeth. be measured as precisely as possible (6).
The identified studies were subject to strict inclusion An idealized anatomy of the main apical opening of the root canal (apical foramen
criteria followed by data extraction and meta-analysis. [AF]) was described as having a minor apical diameter (apical constriction [AC], the
Results: From 247 articles, 10 articles met the inclusion apical portion of the root canal having the narrowest diameter), and from that point the
criteria, with a total of 1105 EAL measurements per- canal gradually widens apically toward the major apical diameter (major foramen
formed by 4 types of EALs: Root ZX (J Morita, Tokyo, [MF], the area of the apical foramen where the walls are farthest apart), taking on a
Japan), Justy II (Hager & Werken GmbH & Co, Duisburg, funnel-shape appearance (2, 7). However, many times, the AF anatomy does not fit
Germany), Endy 5000 (Loser Co, Leverkusen, Germany), into this idealized form (8, 9). Many times, depending on the tooth type (8, 10), the
and Endox (Lysis Co, Milan, Italy). Root ZX, Justy II, AF deviates from the long axis of the tooth (9, 11–13) and may enlarge with the
and Endy 5000 were found to be significantly more ac- patient’s age, tooth adaptation to the functional activity (7, 13, 14), and pathological
curate than Endox in determining the distance between changes (15, 16). In addition, the number of foramina may range from 1 to 16,
the file tip and the apical constriction (P < .05). The whereas the distances between the apical foramina and the anatomic root apex may
longest mean distance was measured by Endox range from 0.20–3.80 mm. These variations in the AF anatomy render clinical
(1.35  0.41 mm), and the shortest mean distance identification of the WL practically impossible (17).
was measured by Justy II (0.25  0.17 mm, P < .05). In addition to this anatomic confusion, there is controversy regarding the favor-
The mean distance measured by Root ZX and Justy II able location of the termination point of the apical preparation. Some authors suggested
in the presence of hydrogen peroxide was shorter the cementodentin junction (CDJ) as the favorable termination point of root canal prep-
compared with the mean distance measured by them aration (11, 12). However, the CDJ is a histologic site that can only be detected
in the presence of sodium hypochlorite (P < .05). The histologically in extracted teeth (6). In addition, the CDJ is highly irregular, and the
pulp status (vital or necrotic) had no significant effect extension of the cementum into the root canal can significantly vary (1, 18).
on the precision of the EALs. Conclusions: The precision The AC was also suggested as the optimal WL because at this point healing is sup-
of electronic working length measurement depends on posed to be optimal, and the wound to the periapical tissues during RCT is expected to
the device used and the type of irrigation and is not be the smallest (1). However, the topography and morphology of the AC is variable, and
influenced by the status of the pulp tissue. (J Endod less than half of the teeth have a ‘‘traditional’’ single AC (19).
2015;-:1–6) Electronic root canal length measuring devices (electronic apex locators [EALs])
offer a means of locating the WL for root canal procedures (6). The reliability of double-
frequency EALs in determining AC is superior to the radiographic method (20).

From the *Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel; †Department of End-
odontics and Dental Traumatology, Graduate School of Dentistry, Rambam Health CareCampus, Haifa, Israel; ‡Universita degli Studi di Milano, Department of Biomed-
ical, Surgical and Dental Sciences, Research Centre in Oral Health, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; and §Department of Biomedical, Surgical and Dental
Sciences, Universita degli Studidi Milano, IRCCS Istituto Ortopedico Galeazzi, Dental Clinic, Milan, Italy.
Address requests for reprints to Dr Igor Tsesis, Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel
Aviv, Israel. E-mail address: dr.tsesis@gmail.com
0099-2399/$ - see front matter
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.08.012

JOE — Volume -, Number -, - 2015 Electronic Apex Locators and Working Length Determination 1
Clinical Research
TABLE 1. Criteria for Inclusion of Studies in the Systematic Review The following key words were used for an initial search through
1 Fully developed human permanent teeth, MEDLINE: ‘‘apex locator’’ with the application of the following limits:
nonendodontically treated ‘‘humans’’ and ‘‘English language.’’ Additional searches were then per-
2 Ex vivo/in vitro studies formed through Embase, Scopus, and Cochrane databases using the
3 Histologic evaluation of the actual location of the AC same key words and search limits.
4 Presents detailed data regarding the measured distance
between the file tip used for the EAL measurement
Related articles and the reference lists of the literature reviews that
and the actual location of the AC were retrieved by the MEDLINE search engine were manually checked
5 Manual evaluation of WL with multiple frequency EALs for possible further eligible articles.
AC, apical constriction; EAL, electronic apex locator; WL, working length.

Data Collection and Analysis


Evidence-based dentistry is an approach to oral health care that Selection of Studies. The articles were initially evaluated for rele-
integrates the best available clinical evidence to support a practitioner’s vance based on their titles and abstracts by 2 reviewers independently
clinical expertise for each patient’s treatment needs and preferences (T.B., G.B.-I.). Possibly eligible studies were subject to a full-text eval-
(21–23). Numerous studies were published on the precision of EALs uation. The full text of the relevant studies was obtained and reviewed
in WL determination (24–32). These studies have significant for suitability based on the inclusion and exclusion criteria described
variability in their study designs and terminology used regarding the previously. Cases of disagreement were discussed together until agree-
apical foramen anatomy, and their results are confusing and ment was reached. The identified suitable articles were subject to data
imprecise (24–32). Thus, a systematic review and analysis of the extraction, assessment of the methodological quality, and data synthesis
available literature according to evidence-based dentistry principles and analysis.
and strict inclusion criteria regarding the precision of EALs in WL deter- Data Extraction. Data were extracted by 2 reviewers independently
mination is of utmost importance (21, 23, 33). (E.R, I.T). Cases of disagreement were subject to joint evaluation by the
The aim of this study was to evaluate the precision of EALs in reviewers until agreement was reached. The authors’ names and the
locating the AC as well as the effects of possible influencing factors by date of publication were recorded for each study.
means of a systematic review of the literature and meta-analysis. The following variables were recorded: the distance between the
file tip during the EAL measurement and the actual AC location as deter-
mined histologically, the type of teeth tested (single-rooted vs multi-
Materials and Methods rooted), the type of EAL (Root ZX [J Morita, Tokyo, Japan], Justy II
Criteria for Considering Studies [Hager & Werken GmbH & Co, Duisburg, Germany], Endy 5000 [Loser
for the Systematic Review Co, Leverkusen, Germany], or Endox [Lysis Co, Milan, Italy]), status of
This systematic review included studies that reported the precision the pulp (vital or necrotic), and whether an irrigant was used during
of EALs in locating the AC in primary RCT of human teeth compared with measurement and its type (sodium hypochlorite [NaOCl] or hydrogen
a histologic evaluation of the AC. The inclusion and exclusion criteria peroxide [H2O2]).
are presented in Tables 1 and 2, respectively. Methodological Quality Assessment. The methodological
quality of the selected studies was evaluated independently and in par-
allel by 2 reviewers (T.B. and G.I.) based on the following methodolog-
Search Methods for the Identification of Studies ical parameters (34):
The search covered all articles published in dental journals from
1966 to January 2014. The following electronic databases were 1. Type of study: Ex vivo studies (the electronic measurement was
searched: MEDLINE using PubMed search engine (http://www.ncbi. performed on extracted teeth) versus in vivo studies (electronic
nlm.nih.gov/sites/pubmed), Embase (http://www.embase.com), Sco- measurement was performed in vivo and then the teeth were ex-
pus (http://www.scopus.com), and Cochrane Central Register of tracted with the endodontic file fixed in the canal and were evaluated
Controlled Trials (http://www.cochrane.org). histologically).
2. Random sequence generation: The method used to generate the
allocation sequence is sufficiently detailed to allow an assessment
of whether it should produce comparable groups.
TABLE 2. Criteria for Exclusion of Studies in the Systematic Review 3. Allocation concealment: The method used to conceal the alloca-
1 Teeth not fully developed/open apex tion sequence is sufficiently detailed to determine whether interven-
2 Deciduous, resorbed, perforated, resected teeth
3 Root canal treated teeth
tion allocations could have been foreseen in advance of, or during,
4 Technique excluded: observation of file through enrollment.
the apex 4. Blinding of outcome assessment: Measures used, if any, to blind
5 Case reports (less than 10 cases), reviews, or studies the investigator from knowledge of intervention received.
irrelevant to the topic of the present study 5. Selection bias: Clear definition of selection criteria.
6 No histologic evaluation of apical anatomy
7 Studies in which the distance of file tip used for 6. Sample size: Studies testing 30 roots or less were considered at high
the EAL measurement to the AC is not specified risk of bias, whereas studies that presented with more than 30 roots
or given as a range were considered at low risk of bias.
8 Working length determination during a rotary 7. Attrition bias: Incomplete outcome data presented, including attri-
file preparation
tion and exclusions from the analysis.
9 Not a multiple frequencies EAL
10 Identifications of landmarks other than the All these parameters were assessed as adequate, unclear, or inad-
constriction/minor foramen.
equate. To summarize the validity of studies, they were grouped into the
AC, apical constriction; EAL, electronic apex locator. following categories (34):

2 Tsesis et al. JOE — Volume -, Number -, - 2015


Clinical Research
TABLE 3. Precision of Electronic Apex Locators
Mean distance between
Number of the tip of the file and the
EAL type measurements apical constriction (mm)
Root ZX 412 0.32  0.25a
Justy II 331 0.25  0.17b
Endy 5000 202 0.56  0.47c
Endox 160 1.36  0.41d

Statistically significant differences (P < .05) were found between a and d, b and d, and c and d.

ance or Kruskal-Wallis tests with multiple comparisons were used to


evaluate the differences between EALs.
Linear regression was done to assess the effects of several indepen-
dent parameters (type of device and type of irrigant) on the EAL’s mea-
surement precision. P < .05 was considered significant.

Results
The results of the electronic databases search and the manual
search are shown in Figure 1 (45).

Methodological Quality Assessment


From the included studies: 3 studies were considered to have a low
risk of bias (35, 36, 44), and 7 studies were considered to have a high
risk of bias (37–43) (Fig. 2).
Figure 1. A flowchart of the systematic review process. The included studies reported a total of 1105 EAL measurements
performed by 4 types of EALs: 412 measurements (37.28%) by Root ZX,
331 measurements (29.95%) by Justy II, 202 measurements (18.28%)
1. Low risk of bias (ie, studies that met at least 4 of the quality criteria) by Endy 5000, and 160 (14.4%) measurements by Endox (Table 3).
2. High risk of bias (ie, studies that met no more than 3 quality The mean distance between the file tip and the AC measured by
criteria) Endox was significantly longer than by any other EAL type (P < .05).
For Root ZX and Justy II, the mean distance measured in the presence
In cases in which there was a discrepancy between the 2 reviewers,
of hydrogen peroxide solution was significantly shorter compared with
a third reviewer was consulted (I.T.) until consensus was achieved. The
the measurements in the presence of NaOCl (P < .05), whereas no data
authors of the identified articles were contacted when needed for clar-
were available for the use of Endy 5000 and Endox in the presence of
ifications or providing missing information.
NaOCl in the analyzed studies (Table 4).
The status of the pulp was available for only 194 (17.55%) of all
Statistical Analysis included measurements. One hundred thirty-three of these (68.55%)
Statistical analysis was performed by using SPSS version 21 (IBM were performed in roots having a vital pulp, whereas 61 measurements
SPSS Statistics for Windows; IBM Corp, Armonk, NY). Analysis of vari- (31.44%) were performed in nonvital teeth (Table 5). The distance

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Random sequence generaƟon


AllocaƟon concealment
Blinding of outcome assessment
Clear definiƟon of selecƟon criteria
Sample size
AƩriƟon bias: complete outcome assessment
Type of study according to clinical relevance

low level of bias high level of bias

Figure 2. A risk of bias graph. Each risk of bias item is presented as a percentage across all included studies (n = 10).

JOE — Volume -, Number -, - 2015 Electronic Apex Locators and Working Length Determination 3
Clinical Research
TABLE 4. Precision of Electronic Apex Locators According to the Type of Irrigant
Type of irrigant
NaOCl H2O2 Total
Root ZX Precision* (mm) 0.43  0.24 0.19  0.186 0.32  0.25
No. of measurements 252 160 412
Justy II Precision* (mm) 0.42  0.03 0.19  0.15† 0.25  0.17
No. of measurements 120 211 331
Endy 5000 Precision* (mm) NA 0.56  0.47 0.56  0.47
No. of measurements NA 202 202
Endox Precision* (mm) NA 1.36  0.41 1.36  0.41
No. of measurements NA 160 160
H2O2, hydrogen peroxide; NA, not applicable; NaOCl, sodium hypochlorite.
*Precision = Mean distance  standard deviation (in millimeters) of the file tip to the apical constriction for each of the EALs.

P < .05 in comparison with the other irrigant (same EAL type).

between the file tip and the AC in vital versus necrotic teeth did not differ indicates measurements falling between the AC and the MF may be
significantly for any of the electronic devices tested (Table 5). acceptable for clinical use (50–52).
Early-generation EALs were often inaccurate in the presence of
conductive fluids. However, manufacturers claim that Root ZX and Justy
Discussion II locate the foramen under any canal condition (wet, dry, NaOCl, and so
The present study undertook an exhaustive literature search using on) using their multifrequency technology. Despite this, several studies
various electronic search engines and manual searches to identify have warned that a high electroconductive solution might affect the ac-
studies dealing with the precision of electronic WL measurement during curacy (eg, NaOCl). Kobayashi (53) and Fan et al (54) reported that the
primary root canal treatment of human teeth. The gold standard was electroconductive solutions present inside the canal greatly reduce the
defined as the histologic evaluation of the minor foramen. To overcome impedance and therefore resulted in tendency toward shorter measure-
heterogeneity of data, strict inclusion and exclusion criteria were ments, whereas longer measurements were detected in the lower elec-
applied to the studies. Ten studies (35–44) were identified as troconductive solution. This is in agreement with other studies in which
eligible for the systematic review. the accuracy of different brands of apex locators were evaluated in the
In the present review, the methodological quality of the included presence of different irrigants, and a greater deviation from the actual
studies was appraised and was described as the risk of bias (34) in each WL was obtained with NaOCl (55, 56). Nevertheless, none of these
of the studies. A bias is a systematic error, or deviation from the truth, in studies compared the electronic measurements with the histologic
results or inferences, and it may lead to a false estimation of the inter- AC, and, therefore, they are of limited value. We found that for Root
vention effect (34). Meta-analysis of results from studies of variable val- ZX and Justy II, the mean distance to the histologic constriction
idities may result in false conclusions, whereas differences in risks of (representing the precision of measurement) was significantly
bias can help explain variations in the results of the studies included shorter in the presence of H2O2 compared with the presence of
in a systematic review (34). Thus, it is important to assess the risk of NaOCl. H2O2 was recommended in the past as an endodontic irrigant
bias in all studies in a review (34). in combination with NaOCl to enhance the efficacy of irrigation. It is
The precision of EALs has many shortcomings, and it has been also used for decontamination of the tooth before commencing root
challenged in some articles (46). Hoer and Attin (44) and H€or et al canal treatment (57). H2O2 is a far less conductive solution than NaOCl,
(47) reported that the use of an EAL did not result in precise which explains the reason for more accurate measurements in its
determination of the AC, but the authors presented the AC as an area presence.
located somewhere coronal to the minor apical foramen, which is Regarding the status of the pulp and its relation to the precision of
not in correspondence to the current definitions of apical anatomy (2). EAL measurement, few publications are available in the literature, with
The WL termination point should reflect the anatomic area be- conflicting data (37, 39, 58–60). Some of these studies plead that a
tween the AC and the MF. This is an acceptable termination point to canal with a vital pulp may have different impedance than a canal
complete the endodontic procedures (1, 48, 49). Any EAL device that with a necrotic pulp because of the destruction of the periodontal

TABLE 5. Precision of Electronic Apex Locators According to Pulp Status


Pulp tissue status
Vital pulp Necrotic pulp Total
Root ZX Precision* (mm) 0.31  0.13 0.26  0.36 0.28  0.22
No. of measurements 46 28 74
Justy II Precision* (mm) 00 0.4 0.2  0.28
No. of measurements 29 11 40
Endy 5000 Precision* (mm) 1.2 0 0.6  0.85
No. of measurements 29 11 40
Endox Precision* (mm) 1.4 1.1 1.25  0.21
No. of measurements 29 11 40
*Precision = mean distance  standard deviation (in millimeters) of the file tip to the apical constriction for each of the EALs.

4 Tsesis et al. JOE — Volume -, Number -, - 2015


Clinical Research
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6 Tsesis et al. JOE — Volume -, Number -, - 2015

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