DRJ_632_12R11

Dental Research Journal

1 1
2 2
3 3
4 Original Article 4
5 5
6 A comparative evaluation of working length with digital radiography 6
7 7
8
and third generation apex locator (ProPex) in the presence of various 8
9 intracanal irrigants: An in vivo/ex vivo study 9
10 10
11 AQ1 Irfana Khursheed1, Ruchika Bansal2, Tajinder Bansal3, Harkanwal Preet Singh4, Madhulika Yadav5, Jetender Reddy6 11
12 12
Departments of Conservative Dentistry, Private Practitioner, Srinagar, 2Departments of Conservative Dentistry, 3Oral Medicine and Radiology,
1

13 Oral Pathology and Microbiology, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, 5Department of Pedodontics and Preventive
4 13
14 Dentistry, Faculty of Dental Sciences, King George’s Medical, University, Lucknow, Uttar Pradesh, India., 6Department of Oral Medicine and 14
15 Radiology, Sri Venkata Sai Institute of Dental Sciences, Hyderabad, India 15
16 16
17 17
18 ABSTRACT 18
19 Background: Accurate working length determination is a pre-requisite for a successful endodontic 19
20 treatment. Even with improved systems of working length measurement, different readings may be 20
21 recorded in different electrolytes present in the canal.The purpose of this in vivo/ex vivo comparative 21
22 study was to determine the accuracy in measuring the working length of root canal using Direct 22
23 Digital Radiographic Method (Radiovisiography or RVG) and ProPex electronic apex locator in the 23
24 presence of three different irrigating solutions: 0.9% normal saline, 2% chlorhexidine, 3% NaOCl 24
25 solutions. 25
26 Materials and Methods: Forty single-rooted human teeth scheduled for extraction with mature 26
27 apices were selected for this study. Measurements were performed by using RVG and ProPex in the 27
28 presence of irrigating solutions.After extraction of the teeth, light microscope was used to confirm 28
29 visually the relationship of the tip of the endodontic file to the apical foramen, and actual lengths 29
30 were determined by reducing 0.5 mm from this length. The statistical analysis was performed by 30
31 Received: January 2013 one-way ANOVA test and Tukey-HSD post hoc procedure. P < 0.05 was considered as significant. 31
32 Accepted: April 2013 Results: No significant difference was found between overall mean electronic working length 32
33 and digital radiographic length; however, prediction error (P < 0.05) was significant with respect 33
Address for correspondence:
34 Dr. Harkanwal Preet Singh, to different irrigants. Among the irrigating solutions, chlorhexidine gluconate had the smallest 34
35 Department of Oral distance to the actual lengths, whereas NaOCl had the greatest. 35
36 Pathology and Microbiology, Conclusion: Electronic apex locator ProPex yielded best result in the presence of chlorhexidine, 36
37 Swami Devi Dyal Hospital 37
and Dental College,
whereas the largest error was demonstrated with NaOCl indicating that higher electroconductive
38 Panchkula, Haryana, India. irrigating solutions affect the precision of multi-frequency apex locators. 38
39 E-mail: hkps0320 39
40 @yahoo.com Key Words: Apex locators, digital radiography, irrigation solutions, working length 40
41 41
42 42
43 43
44 INTRODUCTION Traditional methods for estimating working length 44
45 include radiography, anatomical averages and 45
46 Precise working length measurement is a pre- knowledge of anatomy, tactile sensation, and 46
47 requisite for a successful endodontic treatment.[1,2] moisture on a paper point. All of these methods have 47
48 limitations and do not allow precise localization of 48
49 apical constriction.[3] In recent years to overcome 49
Access this article online
50 50
the limitations offered by traditional methods, new
51 51
52 techniques have been introduced, which include 52
53 digital radiography and apex locators. Thus, in 53
Website: http//:drj.mui.ac.ir
54 addition to radiographic measurements, electronic 54
55 root canal working length determination and digital 55
56 radiology has become increasingly important.[2] The 56

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 Khursheed, et al.: Irrigant solutions and apex locator

1 electronic method eliminates many of the problems anesthesia with rubber dam isolation. The incisal 1
2 associated with radiographic methods. It is more edges were flattened to establish a level surface to 2
3 accurate, easy and fast, with no requirements serve as a stable and reproducible reference for all 3
4 of X-ray exposures.[3,4] However, it requires measurements. The root canal orifices were widened 4
5 5
special devices, and the accuracy is influenced and coronal preflaring was carried out with Gate-
6 6
7
by electrical condition of the canal. The presence Glidden drills no 2-3 (Dentsply, Maillefer Chemin 7
8 of tissue and conductive irrigants in the canal can du Verger 3, Ballaigues [VD], Switzerland). Samples 8
9 change the electrical characteristics and lead to were divided into 3 equal groups according to the 9
10 measurement error. The most recent generation of method of working length evaluation, containing 10
11 dual frequency apex locators have attempted to 40 teeth each. For Group-I working length was 11
12 minimize this problem.[5] Similarly, digital radiology determined by electronic apex locator (ProPex) 12
13 that generates images by means of an X-ray sensor (Dentsply, Maillefer, DENTSPLY New Zealand) in 13
14 instead of conventional film had many advantages the presence of three irrigation solutions. 14
15 15
over conventional radiographs. They are: Speed
16 Three equal groups were made according to the 16
of image acquisition, reduced patient irradiation,
17 method of working length evaluation, containing forty 17
18 the possibility of editing the image, and a quality 18
teeth each. The working length of all 40 teeth was
19 of detail similar to that afforded by conventional 19
determined using three different systems.
20 radiology.[6,7] 20
21 Group 1: Electronic Working Length method (ProPex) 21
In view of the possible variation between the
22 22
radiographic and anatomic apex with various Group 2: Digital Radiographic Method (RVG)
23 23
24 techniques that have been employed to determine Group 3: Actual working length (AWL) under light 24
25 working length, along with the improvements in microscope ×10 25
26 electronic apex locators an in vivo study has been 26
27 conducted. Even with these improved systems, Group 1 was further divided into 3 equal subgroups 27
28 measurements may exhibit different readings containing 40 teeth each depending upon the irrigation 28
29 according to the type of electrolytes present in the solution used. 29
30 canal. 30
31
The first measurement was taken with ProPex apex 31
32 The purpose of this in vivo/ex vivo comparative study locator in the presence of 0.9% normal saline. The 32
33 was to evaluate the diagnostic efficacy of an electronic canals of 40 single rooted teeth were irrigated with 33
34 system (ProPex) in the presence of three irrigants for 0.9% normal saline, the lip-clip electrode was applied 34
35 the determination of working length of root canal, in to the patient’s lower lip. No. 15 stainless steel k-file 35
36 comparison with direct digital radiographic method was taken and the unit’s cable was clipped to its 36
37 metal shank. The ProPex apex locator was turned on 37
(RVG).
38 and the file was advanced apically into the canal, and 38
39 39
MATERIALS AND METHODS when the file reached 2-3 mm to the apex, 2 horizontal
40 40
41
arrows appeared on the screen. The file progressed 41
42 Ethical clearance from institution was taken before until “0.5” appeared on the screen, suggesting that the 42
43 the commencement of study. Forty human single tip of the file was at the middle of apical zone (apical 43
44 rooted vital teeth scheduled for extraction for constriction). The rubber stop on the file was set to the 44
45 periodontal or prosthetic reasons with mature apices reference point. If the measurement remained constant 45
46 were selected for the study. Teeth with open apices, for 5 s, the file was withdrawn carefully and the 46
47 calcification in the pulp chamber or root canal, grossly distance between the rubber stop and the tip of the file 47
48 resorbed apex, retreatment cases, and any abnormal was measured with a digital caliper (INSIZE, Mumbai, 48
49 49
canal configuration were excluded from the study. India) to the accuracy of 0.01 mm and recorded as
50 50
51 Detailed history and thorough clinical examination EWL1 measurement. Then, two more measurements 51
52 was done. Patients with heart pacemakers or with were taken after irrigating the canals with 3% NaOCl 52
53 contributory medical history were excluded from and 2% chlorhexidine gluconate solutions and recorded 53
54 the study. Informed written consent was obtained as EWL2 and EWL3 measurements. Between each 54
55 from each patient before treatment. Access opening measurement, the canal was irrigated with distilled 55
56 of forty single rooted teeth was made under local water and dried with paper points. 56

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 Khursheed, et al.: Irrigant solutions and apex locator

1 For group II working length determination was carried length showed no statistically significant difference 1
2 out by digital radiography (RVG) (Progeny, Vision DX between groups (P = 0.73). Intergroup statistical 2
3 Progeny Dental, Lincolnshire, IL USA). A file with a analysis showed a statistically significant difference 3
4 length 1 mm less (safety factor) than the tooth length (P < 0.003) between three electronic working length 4
5 as noted from the pre-operative radiograph was kept in 5
measurements (Normal saline group, Chlorhexidine
6 6
the root canal. After placing the instrument in the canal, group and NaOCl group). Cross tabulation of
7 7
8 working length was determined by radiovisiograph using coincidence of AWL method with electronic and 8
9 extension cone paralleling technique. On the digital image digital radiography working length method was carried 9
10 the difference between the end of the instrument and the out. The electronic working length measurement in 10
11 end of the root was measured. This amount was added to the presence of chlorhexidine irrigant (Subgroup-Ib) 11
12 the original measured length. If the exploring instrument is giving the highest proportion of exact coincidence 12
13 had gone beyond the apex then the amount gone beyond (42.50%) followed by digital radiographic working 13
14 was subtracted from the original measured length. From 14
length method (Group II) (7.50%) and the lowest
15 this adjusted length of tooth 1 mm was subtracted to 15
16
by electronic working length measurement in the 16
confirm with the cementodentinal junction. This value presence of NaOCl (Subgroup-Ic) (0.00%). The
17 17
was registered as RVG working length (RWL). proportion of exact coincidence in electronic working
18 18
19 After that teeth were extracted carefully and stored length method is significantly higher than digital 19
20 in 5.25% of NaOCl solution to remove remaining radiographic working length method. The results were 20
21 tissues from the external root surface. Then, a size 15 statistically significant (P < 0.05). 21
22 k-file was inserted into the canal to measure actual 22
23 DISCUSSION 23
length for group III under ×10 magnification in a light
24 24
25
microscope (Olympus, BX45 Melville, NY-Olympus 25
America). From this length, 0.5 mm was deducted to Establishment of correct working length is an
26 26
27 obtain the proposed AWL [Figure 1]. important stage in root canal treatment because 27
28 sufficient evidence suggests that instrumentation 28
The difference between RVG measurements, ProPex
29 either beyond or too short of apex can adversely affect 29
measurements and the actual canal length was
30 the success.[8] Various schools of thought exist for 30
calculated for each tooth and the mean values were
31 the termination of root canal working length. Kuttler 31
32 calculated for each group. The statistical analysis was 32
(1955) stated that the cementodentinal junction lies
33 carried out by one-way ANOVA test and Tukey-HSD 33
0.507 mm short of the apical foramen in persons
34 post hoc procedure. Proportion of exact coincidence 34
18-25 years of age and 0.784 mm short in persons
35 with AWL method for various other methods was 35
55 years of age and older.[9] This natural constriction,
36 compared by Chi-square test. In the present study, 36
where the dentin meets cementum, appears to be
37 P ≤ 0.05 was considered as the level of significance. 37
38 the ideal location for development of an apical 38
39 RESULTS seat for the root filling material.[10] Over the years 39
40 radiography and electronic apex locators have been 40
41 Comparison of three methods Group I (EWL), used for determining the working length. Although 41
42 conventional radiography is the most commonly 42
Group II (RWL), Group III AWL with respect to
43 used diagnostic aid in endodontics, but radiation 43
44 44
hazard concerns, time taking chemical processing
45 45
46 and observer’s bias in radiographic interpretation puts 46
47 digital radiography in the front seat.[7] Current progress 47
48 in the field of dental radiology is being channeled 48
49 toward reducing exposure time and obtaining greater 49
50 image definition.[11] 50
51 51
52 Different studies that have compared electronic 52
53 working length and digital radiography[12-14] 53
54 considered the reliability of the former technique 54
55 Figure 1: Determination of actual length under ×10 in a light in measuring working length to be equal or even 55
56 microscope superior to that of RVG. In the present study, results 56

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1 of direct digital radiographic evaluation of working measurements of the ProPex were more precise in the 1
2 length showed overall accuracy of 62.50% under presence of chlorhexidine. Presence of NaOCl solution 2
3 which 7.50% showed exact coincidence with AWL, in the canal almost inhibited its working capability, 3
4 55% showed acceptable coincidence and 18% showed indicating that when the canals are filled with strong 4
5 5
non-acceptable coincidence. Martínez-Lozano et al.,[6] electrolytes, the results of ProPex were negatively
6 6
7 showed accuracy of 61.4% by digital radiological affected; most of the measurements were short of AWL. 7
8 method (RVG system) as compared to apex locator 8
9 (Apit EM-S3), which showed accuracy of 67.8%. The CONCLUSION 9
10 results of evaluation of working length showed no 10
11 statistical difference (P > 0.5) between the techniques The performance of the direct digital radiography 11
12 investigated. Similarly, in the present study, no (RVG) was similar to that of electronic apex locator 12
13 statistically significant difference was found between ProPex in the presence of irrigating solutions in 13
14 the techniques investigated (P > 0.5). terms of their capacity to diagnose working length. 14
15 No statistically significant difference was noted 15
16 The effect of irrigation solutions on working length in prediction error (P > 0.05). Among irrigating 16
17 determination was also evaluated. Early generation solutions, electronic apex locator ProPex yielded
17
18 electronic apex locators were often inaccurate in the 18
19 best result of 92.50% close to accepted AWL in the 19
presence of conductive fluids. However, manufacturer presence of chlorhexidine, whereas the largest error
20 20
claims that ProPex locates the foramen under any was demonstrated with NaOCl showing accuracy of
21 21
22
canal condition (wet, dry, sodium hypochlorite etc.) 50%. A higher prediction error was apparent for more 22
23 as a result of its multi-frequency technology. Although conductive solutions (P < 0.5); thus, indicating that 23
24 frequency-dependent electronic apex locators enhance higher electroconductive irrigating solutions affect the 24
25 the measurement accuracy, there is still concern as precision of multi-frequency apex locators. 25
26 to whether high electroconductive irrigants such as 26
27 blood, saline, a local anesthetic solution, and irrigant 27
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2011;11:38-43. Source of Support: Nil. Conflict of Interest: None declared.
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