BASIC RESEARCH – TECHNOLOGY

Nelly Abdelsalam, BDS, MSc,

Impact of Apical Patency on PhD, and Nasr Hashem, BDS,
MSc, PhD
Accuracy of Electronic Apex
Locators: In Vitro Study

ABSTRACT
SIGNIFICANCE
Introduction: This study aimed to investigate the importance of apical patency and its
influence on the accuracy of 2 apex locators (Root ZX and Raypex 6). Methods: We Patency file could enhance the
determined the actual working length under dental operating microscope at !25 accuracy of the investigated
magnification in 43 extracted human mandibular molars with completely formed roots and EALs. Dentaport Root ZX was
patent apical foramen. Readings of the 2 apex locators were then compared with the actual more sensitive to apical
microscopic working length. Thereafter, we established apical blockage at the apical foramen; foramen blockage than
files were introduced to the same previous length determined by each apex locator before Raypex 6.
blockage. Variation in the readings of apex locators after blockage was compared with original
readings before blockage to determine the measurement error. Results: Friedman’s test
showed no statistically significant difference between the 2 apex locators before blockage
(P . .05; effect size 5 0.013). Within the margin of accuracy 61, both Root ZX and Raypex 6
revealed the same percentage of accuracy, 96.7%. After blockage, both apex locators
revealed a statistically significant difference in median measurement error compared with the
measurements before blockage (P , .05; effect size 5 0.305). Root ZX showed a higher
median measurement error (.–1 mm and 0.01–0.5 mm) than Raypex 6.
Conclusions: Apical foramen blockage has a negative influence on the accuracy of apex
locators that was more pronounced in Root ZX than Raypex 6. (J Endod 2020;-:1–6.)

KEY WORDS
Apex locator’s accuracy; apical foramen blockage; apical patency; Raypex 6, Root ZX

Successful root canal treatment depends on shaping of the whole length of the root canal space for
meticulous cleaning and disinfection, followed by 3-dimensional obturation. This necessitates accurate
determination of the apical constriction. The apical constriction, which is described as the minor apical
diameter, is the point beyond which the periodontal tissues exist1. Thus, maximizing the outcome of root
canal treatment is closely related to limiting all the instruments, antimicrobial agents, and filling materials to
the confines of the root canal system at the apical constriction2.
Electronic apex locator (EAL) has become an essential tool for working length determination
because it overcomes the drawbacks of the 2-dimensional technique sensitive periapical radiography3.
There has been a series of generations since the first launching of apex locator, which relied on
direct electrical current and resistance. All the recent generations rely on alternating current of more than
one frequency and on impedance rather than resistance4.
The main concept of all of these generations is electrical conductivity between the attached file clip
From the Department of Endodontics,
and the lip clip where the root dentin acts as an insulator and the periodontal ligament is the conductor.
Faculty of Dentistry, Suez Canal
The electrical circuit is closed when the current passes through periodontal ligament to the oral mucosa University, Ismailia, Egypt
and then to the lip clip5.
Address requests for reprints to Dr Nelly
Blockage of the apical foramen occurs during cleaning and shaping if irrigation and recapitulation Abdelsalam, Department of Endodontics,
were not applied. Blockage could be detected in a file that stops short of the working length with a tactile Faculty of Dentistry, Suez Canal
tacky feeling6, or it might go undetected if limited to the apical foramen with denial of the patency file7. University, 4.5 Km Ring Road, Ismailia,
Apical patency is defined as a technique where the apical portion of the canal is maintained free of debris Egypt 41522.
E-mail address: nellyendo@gmail.com
by recapitulation with a small file through the apical foramen8. Apical blockage may act as a major 0099-2399/$ - see front matter
contributing factor linked to failure of root canal treatment due to contamination of this apical plug with
Copyright © 2020 American Association
microorganisms from infected root canal. of Endodontists.
The aim of the present study was to shed light on the importance of apical patency and its influence https://doi.org/10.1016/
on the accuracy of 2 apex locators (Root ZX and Raypex 6). j.joen.2020.01.010

JOE  Volume -, Number -, - 2020 Impact of Apical Patency on Accuracy of EALs 1

METHODS
Teeth Selection and Preparation
Forty-three extracted human mandibular
molars with completely formed roots, 2
separate mesial canals and foramina (Vertucci
type IV), and a single distal canal were included
in the study. Teeth were collected and
subjected to 5.25% sodium hypochlorite
(NaOCl) for disinfection and then stored in
normal saline (0.9% NaCl) until used.
Examination of root surfaces and apical regions
was done under a dental operating microscope
(Labomed; Labo America, Fremont, CA) at !
25 magnification to detect possible fractures
and to determine the apex maturity. Teeth with
open apices, fractures, and resorption were
excluded from the study. Three samples were
discarded from this study during specimen
preparation and evaluation; one was because
of fractured K-file #10 inside the canal, and the
other two teeth were calcified.
Actual Working Length
Determination (Microscopic
Working Length Measurement)
All the samples (30 experimental and 10
negative control) were decoronated at the level
of cementoenamel junction with diamond
disks (Kerr Dental, Orange, CA). Patency was
confirmed by using #10 K-file (MicroMega,
Besancon, France), and then the canals were
irrigated by 5 mL 2.5% NaOCl. Thirty
experimental samples were sequentially
numbered from 1 up to 30, and the remaining
10 samples were considered as negative
control. K-file #10 was advanced inside the
root canal until it became visible at the apical
foramen (Flushed) under a dental operating
microscope at !25 magnification. The file was
withdrawn, then the length was measured by
using a triangular architect’s scale ruler, and
the readings were recorded to the nearest
0.01 mm. Each measurement was repeated 3
times, and the mean of the obtained length
was considered as the representative
measurement of that sample. We subtracted
0.5 mm from this measurement and then
recorded it as actual working length (AWL).
Electronic Working Length
Determination
We used a plastic mold of 15 ! 10 ! 5 mm,
and then we packed adequate amount of
alginate (Cavex Holland, Haarlem,
Netherlands) within the molds in which the
roots were embedded, leaving nearly 5 mm of
the root surface exposed9.
Both apex locators were calibrated to
ensure proper function before measurements.
During electronic measurement, the lip clip
was inserted into the alginate during setting. All
2 Abdelsalam and Hashem
the electronic measurements were performed
within a period of 2 hours.
Dentaport Root ZX (Morita Co, Tokyo,
Japan) and Raypex 6 (VDW, Munich, Germany)
were used in accordance with manufacturers’
recommendations. For Dentaport Root ZX, we
inserted #10 K-file with silicone stopper inside
the canal until the apex reading was reached.
The file was then withdrawn to the green
flashing bar (05) on display. For Raypex 6, the
file was progressed inside the root canal until the
first red bar was seen on the screen, and it was
then withdrawn until all flashing green bars had
been reached. The extent of penetration inside
the root canal of each sample was measured
with each EAL and compared with the AWL.
Measurements of Working Length
after Canal Blockage
Canal blockage was intentionally induced in the
experimental samples (n 5 30) by filing the
cervical dentin with Hedstrom stainless steel files
(MicroMega) to create dentinal mud or plug. This
dentinal plug was then forced to the apical
foramen of the root canal until the loss of canal
patency was verified10, where #10-K file could
reach the previously recorded length but could
not go beyond this length. During electronic
measurement #10 K-file was inserted to the
same previously recorded length for both apex
locators, and then new readings were recorded.
Values were admitted as creditable if the reading
remained stable for at least 5 seconds.
Discrepancies in reading before and after
blockage of each individual EAL were
calculated. Positive difference meant that the
measured length after blockage was longer than
that before blockage, whereas negative
measurements indicated shorter length, and 0.0
meant coincident measurements. In negative
control samples (n 5 10), a tiny increment of
packable composite (Herculite XRV Ultra; Kerr,
Bolzano, Italy) was forced with small hand
plugger to block the apical 2 mm of the root
canal and then cured for 1 minute. A #10 K-file
was inserted to the level of the blockage to
check the display of each apex locator.
Numerical data were nonparametric
when explored for normality by checking the
distribution of data and Kolmogorov-Smirnov
test. Wilcoxon signed-rank test was used to
compare between the 2 apex locators.
Qualitative data were presented as frequencies
and percentages. Friedman’s test was used to
compare between the 2 apex locators.
RESULTS
Measurement Error of the 2 Apex
Locators:
Either before or after blockage, statistical
analysis showed that Root ZX (P value , .05)
had higher median error than Raypex 6 (P
value , .001) (Fig. 1). In regard to the effect of
blockage within each group, each group
showed a statistically significant increase in
median measurement error after blockage for
Root ZX (P value , .05; effect size 5 0.612)
and Raypex 6 (P value , .05; effect
size 5 0.382).
Control Group
Negative control samples failed to record any
readings with both apex locators. Therefore,
these samples were excluded from statistical
analysis.
Distribution of Working Length
before or after Blockage
Before blockage, Friedman’s test showed no
statistically significant difference between the 2
apex locators (P value . .05; effect
size 5 0.013) (Table 1). Within the margin of
accuracy 61, both Root ZX and Raypex 6
revealed the same percentage of accuracy,
96.7%; however, considering the margin of
accuracy 60.5, Root ZX recorded 60%,
whereas Raypex 6 registered 53.3%. This
difference was not statistically significant.
There was a statistically significant
difference in median error measured by the 2
apex locators before and after blockage (P
value , .05; effect size 5 0.305). Root ZX
showed higher median measurement error
within the range of .–1 mm and 0.01–0.5 mm
than Raypex 6. However, Raypex 6 showed
higher median measurement error in the range
of –1 to –0.51 mm and –0.5 to –0.01 mm than
Root ZX. There was no statistically significant
difference between the working lengths
measured before and after blockage by both
apex locators at distances 0 and 0.5 to 1 mm,
recording the same percentage of error (6.7%).
DISCUSSION
Apex locators are considered the most reliable
tool for working length determination; thus the
ideal parameters for their accuracy must be
addressed. In the present study the actual
length was determined with the dental
operating microscope (!25) because
periapical radiograph is not an accurate tool for
locating the working length, especially if the
apical foramen opens laterally11.
Teeth were mounted in alginate to act
as a conducting medium for the electric circuit
between the file clip inside the root canals and
the lip clip attached to the alginate, because it
is considered the ideal medium for in vitro
testing of EALs12,13.
Regarding the accuracy of Root ZX and
Raypex 6 before blockage, both had an
accuracy of 96.7%, considering the deviation
JOE  Volume -, Number -, - 2020
FIGURE 1 – Box plot representing median and range values for measurement errors of the 2 apex locators. Asterisks represent outliers.

of 61 from the actual length (minor apical
diameter) as acceptable. This is comparable
with Sto€ber et al14 reporting 100% accuracy
for Root ZX and Raypex 5 with the margin 61
and Aguiar et al15 recording 100% accuracy
for Root ZX, whereas Teslnik et al16 showed
that Root ZX had an accuracy of 89.9% with
the margin of 61. However, the accuracy
decreased significantly when considering the
deviation of 60.5 from the actual length as the
acceptable margin of accuracy, where Root ZX
and Raypex 6 recorded 60% and 53.3%,
respectively. The percentage of accuracy
within the range of 60.5 mm was in agreement
with da Silva and Alves Flavio17 (62.5%
accuracy for Root ZX), Aguiar et al (68.8%
accuracy for Root ZX), and Gurel et al18, who
reported 53.58% accuracy for Raypex 6. The
current results were inconsistent with Guise
et al19 reporting the accuracy of Root ZX to be
97.5% within 60.5 mm; discrepancies could
be due to the different methodology because
the apical foramen (apex) was the measuring
point rather than the apical constriction (0.5).
Apical canal blockage arises from
packing of the dentin chips in the apical part of
the canal during root canal preparation,
accompanied with inadequate irrigation and
failure to establish apical patency. Persistent
apical periodontitis arises from residual or
secondary infection during primary root canal
treatment. Microorganisms responsible for this
infection most often reside in the most apical
part of the root canal, with unrestrained access
to the periapical tissue20. Thus, management
of failed cases is always directed toward

TABLE 1 - Descriptive Statistics and Results of Friedman’s Test for the Comparison between Distributions of Distances from Real Working Length

Root ZX (N 5 30) Raypex 6 (N 5 30)

Blockage Distance (mm) n (%) n (%) P value Effect size (w)
Before blockage .–1 1 (3.3) 1 (3.3) .532 .013
–1 to –0.51 9 (30) 10 (33.3)
–0.5 to –0.01 8 (26.7) 9 (30)
0.00 7 (23.3) 0 (0)
0.01–0.5 3 (10) 7 (23.3)
0.51–1 2 (6.7) 3 (10)
After blockage .–1 20 (66.7) 0 (0) .002* .305
–1 to –0.51 1 (3.3) 16 (53.3)
–0.5 to –0.01 3 (10) 9 (30)
0.00 3 (10) 3 (10)
0.01–0.5 1 (3.3) 0 (0)
0.51–1 2 (6.7) 2 (6.7)

*Significant at P , .05.

JOE  Volume -, Number -, - 2020 Impact of Apical Patency on Accuracy of EALs 3

eradication of these bacteria to the frontline of
infection21; this could be ensured by
establishing apical patency, which in turn
improves the outcome and success rate of
root canal treatment22. The role of apical
patency is more appreciated in symptomatic
apical periodontitis, where maintaining apical
patency allows for the escape of inflammatory
exudates from the periapex, subsequently
relieves the pain resulting from the apical
pressure, and provides a favorable condition
for the host defense mechanism to start repair
at the confined area of periapex23. This
resembles apical drainage in acute apical
abscess, with the difference that the apical
foramen is slightly enlarged to facilitate the
drainage of pus through the root canal24.
From the biological point of view, it
seems that apical patency has no rule in cases
of vital pulp; however, from the technical point
of view, maintaining apical patency is important
to avoid the consequences of loss of working
length and apical transportation of curved
canals25, thereby affecting the outcome of root
canal treatment.
On the other hand, the claim that apical
patency results in extrusion of debris into the
periapical tissue, with the ensuing flare-up or
infection in case of necrotic pulp with
contaminated debris26,27, might be accepted if
a large file closely fitted to the apical size was
used. However, a small patency file #10 would
not push the debris but rather pierces the
accumulated debris to loosen it and facilitates
its removal with the aid of irrigants28.
Furthermore, apical patency prevents the
formation of vapor lock and enhances the
penetration of irrigant into the apical 2 mm of
the canal29.
The diameter of the tip of patency file
#10 is 100 mm less than the needles used in
acupuncture (300–400 mm), so irritation or
inflammation to the normal periapical tissue
expressed by postoperative pain should not be
expected. This was confirmed in previous
studies demonstrating that apical patency
either decreases the incidence of
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The inaccurate readings in the presence
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Hypothetically, if the apical foramen becomes
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2 mm with the composite resin.
It should be emphasized that
maintaining the apical foramen patent does not
imply overinstrumentation or overfilling
because cleaning, shaping, and obturation
should be limited to the apical constriction,
albeit accurate determination of the apical
constriction is done by the apex locator in a
patent foramen as demonstrated in the
present study.
CONCLUSION
On the basis of the results of this study, it can
be concluded that root canal blockage has a
negative influence on the accuracy of apex
locators that was more pronounced in Root ZX
than Raypex 6. Foraminal patency could be
considered as a prerequisite for a reliable
working length determination with apex
locators.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.
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