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.

Prevalence of Vertical Root Fractures in a University Endodontics Program versus a Private Endodontics Office.

Introduction: Vertical root fractures (VRFs) typically have a poor prognosis with an extraction or occasionally root amputation as the preferred treatment. VRFs have been considered an epidemic, motivating changes in the access openings, as well as in the preparation and disinfection protocols of endodontic treatment. Hence, we aimed to evaluate the prevalence of VRFs by tracking cases in both a University Endodontic Program (UEP) and a private endodontics practice (PP). We also evaluated changes in prevalence during COVID-19 along with the alterations in the frequency of cases diagnosed by clinical and radiographic signs which were later confirmed by direct visualization compared to those in which the suspicion was based on clinical and radiographic signs alone. Methods and Materials: This retrospective study looked at the prevalence of VRF in patient records at UEP and a PP. Data for the pre-COVID-19 and COVID-19 time periods were extracted from patient records and referral letters then compared. Data for suspected and confirmed prevalence were compared. Results: The UEP group included 21,156 patients while the PP group comprised 7,209 patients. The prevalence of VRFs in the former cohort was 1.80%, while 2.62% of the latter cohort exhibited VRFs with a combined total of 2.01%. The combined total prevalence of VRFs pre-COVID-19 was 1.72%, increasing from 2.1% to 3.82% during COVID-19 (p < 0.0001). The same applied to suspected cases for both clinical settings. The increase in confirmed cases between the two periods was statistically significant for the UEP group (p=0.0202) but it was insignificant for the PP group (p=0.0721). Conclusion: The combined prevalence for VRFs was 2.01% for all years denying the claim that VRF is a pandemic phenomenon. COVID-19 period saw almost a double increase in the prevalence of VRF compared to pre-COVID-19 era. This was consequently associated with a significant increase in the number of suspected VRF cases.

Accuracy of Root ZX Electronic Apex Locator in Relation to Two Different Employment Protocols: An In Vitro Study.

Objective The aim of this study is to determine the apical level of the root canal, whether it is the apical foramen or a level coronal to it, that Root ZX (J. Morita Co., Kyoto, Japan) targets and to identify its employment protocol that provides better accuracy. Methods Actual lengths (ALs) of 75 extracted single-rooted teeth were obtained by inserting a K-file size 8 until its tip was in level with the most coronal border of the apical foramen. Reference length (RL) was calculated by deducting 0.5 mm from AL. Roots were placed in porous sponge block soaked with Ringer's solution, and canals were irrigated with 2 mL of 5% sodium hypochlorite. The blinded operator used Root ZX to measure lengths with K-file size 8. In the first tested employment protocol, the file was advanced to the "APEX mark" of the digital display, and the length was obtained. The second employment protocol followed the manufacturer's recommendations by inserting the file until the "APEX mark" followed by its withdrawal to the "0.5 mark." Stability of the digital meter for 5 seconds was mandatory before recording the lengths. All measurements were repeated one week later and then both measurements were averaged to represent "APEX mark" and "0.5 mark," respectively. Data were analyzed using t-test, with significance set at 0.05. Results Regardless of the employment protocol, most registered lengths were longer than targeted. The mean "APEX mark" was significantly longer than the mean AL (P=0.000), and the mean "0.5 mark" was significantly longer than the mean RL (P=0.000). Although the mean "0.5 mark" was longer than the mean AL, the difference was not significant (P=0.07). Conclusion The apical level of the root canal targeted by the Root ZX was the apical foramen. The most accurate employment protocol to achieve that is to use the Root ZX according to the manufacturer's recommendations.

Influence of Hand File Size on the Accuracy of Root ZX and iPex Electronic Apex Locators: An In Vitro Study.

OBJECTIVE: To investigate the effect of the hand file size on the accuracy of Root ZX (J. Morita Co., Kyoto, Japan) and iPex (NSK, Tochigi, Japan). METHODS: Seventy-five single-rooted teeth were decoronated, and canals were coronally flared with Gates Glidden burs sizes 4, 3, and 2. Actual canal length was determined by averaging two readings obtained by inserting K-file size 8 until its tip was apparent at the most coronal border of the apical foramen. The reference length was actual length-0.5 mm. The blinded operator utilized Root ZX and iPex following the manufacturer's recommendations. Teeth were placed in sponge blocks soaked with Ringer's solution. Canals were irrigated with 5% sodium hypochlorite. K-file size 8 was attached to the lip clip and introduced until the APEX/0.0 mark, then withdrawn to the 0.5 mark. A stable meter gauge for five seconds indicated an acceptable reading. Readings with sizes 10 and 15 were obtained afterward. All measurements were done twice, then averaged. Data analysis was done using ANOVA and a posthoc Bonferroni test with the significance level set at P<0.05. RESULTS: For Root ZX, the mean length with size 8 was not significantly different from the mean reference length (P=0.205). The same was found for its mean length at size 10 (P=0.093). However, the mean Root ZX length with size 15 was significantly shorter than the mean reference length (P=0.019). Mean iPex lengths with sizes 8, 10, and 15 were all significantly shorter than the mean reference length (P=0.038, 0.006, and 0.02, respectively). CONCLUSION: The size of the hand file affected the precision of Root ZX and iPex.

Prevalence of Intimate Partner Violence and Endodontic Treatment Needs: Pilot Study.

Objective: The aim of this study was to assess the prevalence and potential association between intimate partner violence (IPV) with traumatic dental injuries (TDIs) and the subsequent need for root canal treatment (RCT). Methods: A total of 100 subjects with TDIs presented at emergency or postgraduate restorative clinics at University Dental Hospital, King Abdulaziz University, Jeddah, Saudi Arabia post-TDI. All study subjects completed the Hurt-Insult-Threaten-Scream (HITS) domestic violence screening tool and were clinically and radiographically examined to determine the type of TDI they suffered along with the pulp and periapical status of affected teeth. Demographic data were also recorded. Based on the findings, management included regular follow-up, splinting, reattachment of broken tooth part, vital pulp therapy and/or RCT as seen appropriate. Results: Mean age of participants was 28.4±5.7 years. Prevalence of IPV among subjects presented with TDIs was 18%. Most of the IPV victims held a bachelor's degree (67%) and were unemployed (61%). Most of TDI cases were crown fracture (84%) followed by luxation and avulsion (10% and 6%, respectively). Among all TDI cases, 73% required RCT. Crown fracture was the most prevalent TDI among IPV victims followed by luxation and avulsion with prevalence of 56%, 33%, and 11%, respectively. Out of a total of 73 patients requiring RCT, nine were IPV victims (12.3%) which indicated that one of each eight TDI cases requiring RCT might be a potential IPV victim. Half of the IPV victims required RCT to manage their TDIs. Conclusion: Prevalence of IPV among TDIs was 18%. IPV screening should be included as routine assessment part for TDIs. Identification of IPV victims could be difficult, however, employment status, type of TDI, and RCT needs were suggested as potential predictors of positive IPV cases.

A Prospective Study of Long-Term Regenerative Endodontics Outcomes of Necrotic Immature Permanent Teeth: An 8-Year Follow-Up.

For the management of necrotic immature teeth, regenerative endodontics offers the advantage of further root lengthening, thickening of dentin wall, and apical closure. This prospective study aimed to evaluate the long-term outcome of regenerative endodontics in immature necrotic permanent teeth. A total of 23 immature roots were medicated by triple antibiotic paste. After 21 days, bleeding was induced by over-instrumentation, and then mineral trioxide aggregate and coronal restoration were applied. Patients were scheduled for clinical and radiographic follow-up for 8 years. The radiographic changes of root dimensions were assessed using the ImageJ Plugin and statistically analyzed by Kruskal-Wallis test at a 95% confidence level. For qualitative evaluation, images were overlapped and analyzed using Photoshop software. All teeth were asymptomatic one month after the treatment. All teeth (n = 18) with preoperative periapical radiolucency showed complete resolution within 6-9 months. Recall rate at two, three, and eight years was 69.6%, 56.5%, and 34.8%, respectively. Continuous root development with a significant increase in root length and thickening of dentin wall accompanied by a significant decrease in apical canal diameter was seen at the end of the observation period (p < 0.001). In conclusion, the long-term outcome of regenerative endodontics revealed successful clinical and radiographic results with appropriate case selection.

Physicochemical Properties of Two Generations of MTA-Based Root Canal Sealers.

This study evaluated the physicochemical properties and the effect of solubility on the surface morphology and composition of the root canal sealers MTA-Bioseal, MTA-Fillapex, and Adseal. Discs (n = 10) of freshly mixed sealer were prepared and then analyzed by Fourier transform infrared (FTIR) spectroscopy and scanning electron microscopy/energy-dispersive X-ray spectroscopy (SEM/EDX). The discs were immersed for 1, 7, 14, and 28 days in deionized water. The solubility %; pH change of the solution; and released calcium, phosphate, and silicon were measured for each period. The flowability and film thickness were also evaluated. Changes in the surface morphology and composition after 28 days of immersion were evaluated by SEM/EDX. The data were statistically analyzed by one-way ANOVA at p < 0.05. The FTIR and EDX results revealed similar compositions of MTA-Bioseal and MTA-Fillapex, but with different concentrations. The two MTA-based sealers had higher solution alkalinity (pH > 10) than Adseal (pH ≈ 8.5). MTA-Fillapex exhibited the highest solubility % and the largest calcium and silicon ion release. MTA-Bioseal had the highest phosphate ion release. After 28 days, the sealer surfaces showed large micropores, with larger pores in MTA-Fillapex. Adseal had an intermediate flowability but exhibited the greatest film thickness. Finally, the highest solubility and largest amount of silicon release was exhibited by MTA-Fillapex, which might predispose it to the development of large micropores, compromising the apical seal of obturation.