In vivo accuracy of conventional and digital radiographic methods in confirming root canal working length determination by Root ZX

Evaluation of the Accuracy of Electronic Apex Locators in Modern Endodontics: An Umbrella Review

Background and Objectives: To achieve success in endodontic treatment, it is essential to properly perform the steps of shaping, cleansing and obturation. Determining the working length of the canal is, therefore, a process that must be precise and accurate. Electronic apex locators are a useful tool for the clinician to best perform this step of endodontic treatment. Materials and Methods: The purpose of the following umbrella review is to evaluate, through data in the literature, the degree of accuracy of apex locators. Results: Seven systematic reviews were included in the following umbrella review. Five compare the accuracy of apex locators versus radiographic techniques, two compare different types of electronic apex locators, and two analyze the determination of working length in primary teeth. Conclusions: From the results obtained from the following umbrella review, albeit at low levels of evidence, the methods for determining working length using electronic apex locators and other methods, particularly using radiographic evaluation, are equally valid.

Efficacy of electronic apex locators in comparison with intraoral radiographs in working length determination- a systematic review and meta-analysis

BACKGROUND

Successful endodontic treatment needs accurate determination of working length (WL). Electronic apex locators (EALs) were presented as an alternative to radiographic methods; and since then, they have evolved and gained popularity in the determination of WL. However, there is insufficient evidence on the post-operative pain, adequacy, and accuracy of EALs in determining WL.

OBJECTIVE

The systematic review and meta-analysis aims to gather evidence regarding the effectiveness of EALs for WL determination when compared to different imaging techniques along with postoperative pain associated with WL determination, the number of radiographs taken during the procedure, the time taken, and the adverse effects.

METHODS

For the review, clinical studies with cross-over and parallel-arm randomized controlled trials (RCTs) were searched in seven electronic databases, followed by cross-referencing of the selected studies and related research synthesis. Risk of bias (RoB) assessment was carried out with Cochrane's RoB tool and a random-effects model was used. The meta-analysis was performed with the RevMan software 5.4.1.

RESULTS

Eleven eligible RCTs were incorporated into the review and eight RCTs into the meta-analysis, of which five had high RoB and the remaining six had unclear RoB. Following meta-analysis, no significant difference in postoperative pain was found among the EAL and radiograph groups (SMD 0.00, CI .29 to .28, 354 participants; P value = 0.98). Radiograph group showed better WL accuracy (SMD 0.55, CI .11 to .99, 254 participants; P value = 0.02), while the EAL group had 10% better WL adequacy (RR 1.10, CI 1.03-1.18, 573 participants; P value = 0.006).

CONCLUSION

We found very low-certainty evidence to support the efficacy of different types of EAL compared to radiography for the outcomes tested. We were unable to reach any conclusions about the superiority of any type of EAL. Well-planned RCTs need to be conducted by standardizing the outcomes and outcome measurement methods.

The Effect of Different Image Processing Techniques on the Measurement Accuracy of Endodontics File Length

Statement of the Problem

Different software capabilities have been used in digital systems to increase the diagnostic quality of radiographic projections. Considering the availability of different enhancement techniques, it is necessary to determine the suitability of each technique for various diagnostic cases. There is controversy between studies over the effect of different digital enhancement techniques on the accuracy of file length measurements in endodontics.

Purpose

The present in vitro study aimed to determine the effect of the software capabilities on the diagnostic accuracy to determine endodontic file lengths in photostimulable phosphor (PSP) radiographs.

Materials and Method

In the present in vitro study, standard access cavities were prepared in 44 extracted human single-rooted permanent teeth. An endodontic file was placed in each root canal. PSP sensors were used for digital imaging using the parallel technique. All the images were reviewed on a same monitor; once normally with no software enhancement and once using software manipulations including pseudo-color, sharpness, emboss, and edge enhancement. The distance from the file tip to the rubber stop was measured on the images by an electronic ruler.

Results

Significantly, all of the image enhancement techniques presented shorter measurements comparing to the actual length. The results revealed the significant accuracy of the measured error in the pseudo-color enhancement technique compared to other techniques.

Conclusion

The results revealed significant differences between the initial measurements (the gold standard) and those made on the manipulated radiographs. In all cases, the measurements were significantly lower than the real values. Therefore, none of these digital enhancement techniques can increase the accuracy of file length measurements significantly. However, manipulation with the pseudo-color option resulted in fewer errors compared to other options and the normal images. Hence, for precise measurements of the endodontic file lengths, pseudo-color processing algorithm can be suggested when using PSP sensors.

Clinical accuracy and precision of 3 multi-frequency electronic apex locators assessed through micro-CT imaging

INTRODUCTION

This study aimed to compare the in vivo accuracy and precision of 3 electronic apex locators (EALs) in determining the position of the major foramen using micro-computed tomographic (micro-CT) technology.

METHODS

After access preparation of 23 necrotic or vital teeth from 5 patients, canals were negotiated and hand files were used to determine the position of the foramen with 3 EALs: Propex Pixi, Woodpex III and Root ZX II. After fixing the silicon stop to the file, teeth were extracted and scanned in a micro-CT device with and without the instrument inserted into the canal. Datasets were co-registered, and the accuracy and precision of the EALs were determined at a tolerance level of ± 0.5 mm by measuring the distance from the tip of the instruments to a tangential line crossing the margins of the foramen. Statistical comparisons were performed using Friedman with post hoc Related Samples Sign and Spearman tests (α = 5%).

RESULTS

A significant difference was detected comparing the accuracy of Root ZX II (100%), Woodpex III (86.96%) and Propex Pixi (52.17%) (P < .05). There was a lack of significance in the relationship between the pulp status and the accuracy of tested EALs (P > .05). Propex Pixi was significantly less precise than Root ZX II (P < .05), while no difference was found between Woodpex III to either Root ZX II or Propex Pixi (P > .05).

CONCLUSIONS

EALs presented similar precision, but Woodpex III and Root ZX II showed better accuracy to determine the position of the apical foramen than Propex Pixi.

Improvements in image quality after optimization in digital intraoral radiographs

BACKGROUND

Digital intraoral radiographic exposures are optimized largely on the basis of subjective assessment of diagnostic image quality. This study presents an objective approach to optimize radiographic exposure settings for digital intraoral radiographic systems.

METHODS

Seven size 2 digital intraoral systems were assessed for image quality and determination of optimal exposure following the protocol specified in American National Standard Institute/American Dental Association Standard No. 1094: Quality Assurance for Digital Intra-Oral Radiographic Systems. A ProX radiograph unit (Planmeca) at 63 kVp and 6 mA was used to obtain radiographs of the Dental Digital Quality Assurance phantom. ImageJ software (National Institutes of Health) was used to quantify dynamic range and spatial resolution, and contrast perceptibility was evaluated visually. Optimal exposure is the setting with the maximal contrast perceptibility and spatial resolution while displaying the full dynamic range. After image optimization, a custom phantom consisting of an endodontically prepared tooth was imaged to evaluate the file position relative to the apex for each system. Differences in distances between file position relative to the root apex at the optimal exposure as well as 1 increment above and below were measured.

RESULTS

Radiographic images obtained at the optimal exposure yielded better visualization and more accurate measurements of the file tip relative to the apex.

CONCLUSIONS

Optimizing radiographic exposures improves image quality and accuracy in clinical decisions.

PRACTICAL IMPLICATIONS

Improvement in image quality and better accuracy in actual distance of the endodontic file to the radiographic apex coupled with complete cleaning, shaping, and obturation of the canal should lead to better endodontic treatment outcomes.

Micro-CT study of the in vivo accuracy of a wireless electronic apex locator

INTRODUCTION

This study aimed to compare the in vivo accuracy of Wirele-X and RootZX II electronic apex locators (EALs) in determining the position of the major foramen using micro-CT as analytical tool.

METHODS

Eleven vital teeth from 5 patients planned for extraction were used. After conventional access cavity preparation, root canals were flared and negotiated up to the apical third with sizes 08 and 10 K-files followed by irrigation with 2.5% NaOCl. K-type files were used to determine the working length of the selected canals using Root ZX II and Wirele-X apex locators until their numeric displays read '0.0'. After fixing the silicon stop to the file, teeth were extracted and imaged in a micro-CT device using a double-scan protocol. Image stacks, with and without the file in the root canal, were then co-registered and the measurement error calculated as the absolute difference between the tip of the file and the major foramen. Positive and negative values were recorded when the file tip was detected beyond or short the major foramen, respectively. Accuracy was determined on stable measurements within ± 0.5 mm when the file tip did not extend beyond the major foramen. The Chi-square test was applied to compare the ability of the EALs to detect the position of the major foramen, while T test for dependent variables was used to verify differences in the two measurements obtained in each tooth. Significance level was set at 5%.

RESULTS

Within a tolerance level of ± 0.5 mm, no significant differences were observed between the tested EALs regarding the absolute distance values (p=0.82) or in their ability to detect the position of the major foramen (Χ²=0.2588; p=0.6109). The accuracy of the Root ZX II and the Wirele-X apex locators within ± 0.5 mm were 81.8% and 90.9%, respectively.

CONCLUSIONS

Root ZX II and Wirele-X performed similarly regarding the in vivo detection of the major foramen. Using strict criteria, the accuracy of the Root ZX II and the Wirele-X apex locators were 81.8% and 90.9%, respectively.

Comparison of Tentative Radiographic Working Length with and without grid Versus Electronic Apex Locator

The apical termination of obturation is the most important factor influencing the success of root canal treatment (RCT). Working length (WL) is the key element in achieving this.

AIM

The aim of this study is to compare and evaluate the preoperative estimated WL with conventional radiograph and with grid radiograph, with reference to electronic apex locator (EAL) in single-rooted teeth.

SETTINGS AND DESIGN

Thirty permanent anterior teeth with complete root formation indicated for RCT were included in this study.

MATERIALS AND METHODS

Conventional radiograph (Group 1) and conventional radiograph with external grid (Group 2) were made before access opening. WL with EAL (Group 3) was determined after access opening.

STATISTICAL ANALYSIS

The statistical package for the social sciences (SPSS) version 16.0 (SPSS Inc., Chicago, IL, USA) was used to compare the WLs of three groups, and the statistical significance was considered to be P ≤ 0.05. ANOVA, post hoc test were made to measure the intergroup comparison, and Pearson correlation values were obtained.

RESULTS AND CONCLUSION

The results of the study showed a higher correlation between grid WL and apex locator WL than conventional WL and apex locator WL. Preoperative metrics with radiographic grid along with the apex locator is a better measuring tool compared to the conventional radiographic WL in a single-rooted tooth.

Comparison of four electronic root canal length measurement devices

OBJECTIVE

The objective of this study is to evaluate the performance of four electronic root canal length measurement devices (ERCLMDs) [Root ZX, Raypex 6, ProPex II, and VDW Gold with ERCLMD] in wet and dry root canals with different major foramen diameters, in association with three file positions within the final 1 mm of canals.

MATERIALS AND METHODS

Fifty roots were divided into five groups that were instrumented apically to the terminus diameter using K-files 15, 20, 30, 40, and 60. ERCLMD measurements were made when the file tip was at major foramen, 0.5 mm and 1.0 mm short of the foramen, when the apex touched to the surface of saline or was immersed 3 mm into saline, and when the canal was dry or was irrigated with saline. The differences between the electronic lengths and the actual lengths were calculated. The data were analyzed using the three-, two-, and one-way ANOVA and the LSD test (p < .05).

RESULTS

Overall, the four ERCLMDs demonstrated 12.8% unstable and beyond the foramen measurements (11.3%). About 85% of the beyond the foramen measurements had foramen diameters 0.40 and 0.60. ERCLMD comparisons related to the file positions in the foramen diameters showed significant differences between ERCLMDs in each foramen diameter (p < .05).

CONCLUSIONS

All ERCLMDs provided highly accurate measurements within the final 1 mm of the foramen. Wet or dry canals and apex conditions did not adversely affect the accuracy of the ERCLMDs' readings. ProPex II located the file positions in the teeth with different foramen diameters more accurately than the other ERCLMDs.

Clinical efficacy of electronic apex locators: systematic review

INTRODUCTION

Apical constriction has been proposed as the most appropriate apical limit for the endodontic working length. Despite being the most used, some limitations are attributed to the radiographic method of working length determination. It lacks precision because it is based on the average position of the apical constriction. The electronic apex locators have been presented as an alternative to the odontometry performed by radiography. These devices detect the transition of the pulp to the periodontal tissue, which is anatomically very close to the apical constriction and may perform with improved accuracy.

METHODS

A systematic review was performed to compare the radiographic and electronic methods. Clinical studies that compared both methods were searched for on 7 electronic databases, a manual search was performed on the bibliography of articles collected on the electronic databases, and the authors were contacted to ask for references of more research not detected on the electronic and manual search.

RESULTS

Twenty-one articles were selected. The majority were comparative or evaluation studies, and very few clinical studies comparing both methods are available. Several methodological limitations are present on the collected articles and debated in this review.

CONCLUSIONS

Although the available scientific evidence base is short and at considerable risk of bias, it is still possible to conclude that the apical locator reduces the patient radiation exposure and also that the electronic method may perform better on the working length determination. At least one radiographic control should be performed to detect possible errors of the electronic devices.

Accuracy of five electronic foramen locators with different operating systems: an ex vivo study

OBJECTIVE

The aim of this study was to evaluate, ex vivo, the precision of five electronic root canal length measurement devices (ERCLMDs) with different operating systems: the Root ZX, Mini Apex Locator, Propex II, iPex, and RomiApex A-15, and the possible influence of the positioning of the instrument tips short of the apical foramen.

MATERIAL AND METHODS

Forty-two mandibular bicuspids had their real canal lengths (RL) previously determined. Electronic measurements were performed 1.0 mm short of the apical foramen (-1.0), followed by measurements at the apical foramen (0.0). The data resulting from the comparison of the ERCLMD measurements and the RL were evaluated by the Wilcoxon and Friedman tests at a significance level of 5%.

RESULTS

Considering the measurements performed at 0.0 and -1.0, the precision rates for the ERCLMDs were: 73.5% and 47.1% (Root ZX), 73.5% and 55.9% (Mini Apex Locator), 67.6% and 41.1% (Propex II), 61.7% and 44.1% (iPex), and 79.4% and 44.1% (RomiApex A-15), respectively, considering ±0.5 mm of tolerance. Regarding the mean discrepancies, no differences were observed at 0.0; however, in the measurements at -1.0, the iPex, a multi-frequency ERCLMD, had significantly more discrepant readings short of the apical foramen than the other devices, except for the Propex II, which had intermediate results. When the ERCLMDs measurements at -1.0 were compared with those at 0.0, the Propex II, iPex and RomiApex A-15 presented significantly higher discrepancies in their readings.

CONCLUSIONS

Under the conditions of the present study, all the ERCLMDs provided acceptable measurements at the 0.0 position. However, at the -1.0 position, the ERCLMDs had a lower precision, with statistically significant differences for the Propex II, iPex, and RomiApex A-15.