doi:10.1111/iej.

13507

A laboratory study of the accuracy of three

electronic apex locators: influence of embedding
media and radiographic assessment of the
electronic apical limit

~ overo1, L. Piasecki2
M. F. Iparraguirre Nun , A. V. K. Segato1, V. P. D. Westphalen1,
U. X. Silva Neto & E. Carneiro1
1
1
Department of Endodontics, Life Sciences School, Pontifıcia Universidade Cat
olica do Paran
a, Curitiba, Brazil; and
2
Department of Periodontics and Endodontics, University at Buffalo, New York, NY, USA

Abstract radiographs (bucco-lingual and proximal views) were

~ overo MF, Piasecki L, Segato AVK,
Iparraguirre Nun
Westphalen VPD, Silva Neto UX, Carneiro E. A
laboratory study of the accuracy of three electronic apex
locators: influence of embedding media and radiographic
assessment of the electronic apical limit. International
Endodontic Journal.
Aim To evaluate several factors that might interfere
with the use of electronic root canal length measurement
devices (ERCLMDs) in a laboratory setting, including two
different embedding media (alginate and electroconduc-
tive gel), three different types of devices and the radio-
graphic view on the assessment of the electronic
readings.
Methodology Thirty single-rooted extracted human
mandibular premolars were selected. After access and
canal pre-flaring, a size 10 K-file was inserted in the canal
up to the major apical foramen under magnification
(910), and this length was recorded as the actual length
(AL) of the canal. Teeth were mounted on a specific
endodontic training kit platform (ProTrain). Two different
embedding media (electroconductive gel and alginate) and
three different ERCLMDs: Apex ID (SybronEndo, Glendora,
CA, USA), CanalPro Apex Locator (Coltene-Endo, Cuya-
hoga Falls, OH, USA) and the Root ZX II (J. Morita, Tokyo,
Japan), were tested. Following the measurement at the
0.5 mark of each ERCLMD using alginate, two periapical
taken. The difference between the electronic readings and
the AL, as well as the distance from the file tip to the apex
of the roots on the radiographs, was calculated. Data were
analysed statistically (two-way ANOVA, Tukey’s and chi-
squared tests) at 5% significance level.
Results The incidence of over-extended readings was
significantly greater (P < 0.05) when using the Pro-
Train electroconductive gel, except for Root ZX II at the
0.5 mark. Root ZX, CanalPro and Apex ID had similar
accuracy when the 0.0/APEX mark was used to locate
the foramen. For the radiographic method, no difference
was found between the devices or radiographic views.
Conclusion Compared with alginate, the conductive
gel of the ProTrain kit negatively affected most of the
electronic readings. The three evaluated ERCLMDs had
similar accuracy in locating the apical foramen when
using the mark 0.0/APEX and alginate as the embedding
media. Although the ProTrain platform allows radio-
graphs to be exposed in both bucco-lingual and proximal
views, no difference was found between the views when
evaluating the apical limit provided by the 0.5 mark in
mandibular premolars embedded in alginate.
Keywords: embedding media, electronic root canal
length measurement device, endodontics, tooth apex,
working length.
Received 8 October 2020; accepted 4 March 2021

Correspondence: Everdan Carneiro, Life Sciences School, Pontifıcia Universidade Cat

olica do Paran ~o,
a, Imaculada Conceicßa
1155, 80215-901 Curitiba, Brazil (Tel: +55 41 3271-2525; e-mail: everdan.carneiro@pucpr.br).

© 2021 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 1

Embedding media and radiographic images on AELs Iparraguirre Nun
Introduction
One of the most important factors for the success of
root canal treatment is the establishment of an ade-
quate apical limit for instrumentation and filling of
the root canals (Sj€ogren et al. 1990, Ricucci & Lange-
land 1998). Under- or overestimated working lengths
(WL) might lead, respectively, to inadequate disinfec-
tion or damage to the periapical tissues, thus result-
ing in delayed or unfavourable apical healing
ogren et al. 1990).
(Sj€
Currently, the most common methods for intraoper-
ative determination of WL are radiographic and elec-
tronic (ESE 2006, Martins et al. 2014, Savani et al.
2014) methods. Periapical radiographs are an essen-
tial part of the diagnosis, treatment and follow-up of
endodontic procedures; however, the limitations of
the radiographics for WL determination are mainly
related to its 2-dimensional nature, which might
result in the superimposition of anatomical structures,
distortions and difficulties with landmark identifica-
tion (ElAyouti et al. 2001, Williams et al. 2006,
Vieyra & Acosta 2011). On the other hand, modern
electronic root canal length measurement devices
(ERCLMDs) work based on electrical and physical
principles to detect the apical foramen (AF) and the
apical constriction (AC; Nekoofar et al. 2006). The
use of ERCLMDs is more rapid, simpler, more accurate
and reproducible when compared to the traditional
radiographic method (Fouad & Reid 2000, Cianconi
et al. 2010, Martins et al. 2014); however, the perfor-
mance and consistency of ERCLMDs are affected by
many factors such as obstructions (ElAyouti et al.
2009, Vasconcelos et al. 2016), anatomical complexi-
ties (Piasecki et al. 2016, Shacham et al. 2020) and
the differences in the operating mechanisms between
devices (Piasecki et al. 2018, Connert et al. 2018).
ERCLMDs work by detecting the relation between
impedance values of two or more different electrical
frequencies applied into the root canal system (Nekoo-
far 2005). Current devices measure the physical
effects rather than tissue resistance; thus, it is possible
to be replicated in a laboratory setting by placing the
tooth in a conductive embedding media such as algi-
nate, gelatine or saline to mimic the periapical tissues
(Aurelio et al. 1983, Tinaz et al. 2002, Nekoofar et al.
2006, Baldi et al. 2007). This approach is useful not
only for research investigations, but also for teaching
the electronic method for working length determina-
tion (Aurelio et al. 1983, Tinaz et al. 2002, Chen
2 International Endodontic Journal
~ overo et al.
et al. 2011). However, only a few reports have com-
pared the influence of the conduction media on the
performance of the electronic measurements of WL
(Baldi et al. 2007, Chen et al. 2011, Guerreiro-Tano-
maru et al. 2012). Moreover, for educational pur-
poses, it is important to select an embedding media
that offers the most accurate and reproducible mea-
surements in a laboratory setting, allowing dental
student to experience a simulation that mimics the
clinical scenario with minimal bias from the experi-
mental and educational setting (Tinaz et al. 2002).
The training kit platform ProTrain (Simit Dental
srl, Mantova, Italy) is especially designed for labora-
tory training of endodontic procedures, including WL
determination. It allows electronic and radiographic
methods to be used simultaneously whilst keeping the
tooth in a fixed position (Cianconi et al. 2010, Man-
cini et al. 2011). This kit features an electroconduc-
tive gel (Farmacare Srl, Casale, Italy), recommended
by the manufacturer for use as the embedding media.
Although the electroconductivity of this gel was
reported to be more stable than alginate (Cianconi
et al. 2010), the influence of these two embedding
media on the accuracy of ERCLMDs has not been
compared.
In the light of the many different factors that might
interfere with the use of electronic devices for work-
ing length determination in a laboratory setting, the
present study aimed to assess the following: (i) the
influence of two different embedding media (alginate
and electroconductive gel) on the electronic measure-
ments of the 0.5 and 0.0 marks of three different
brands of ERCLMDs; (ii) the accuracy of 0.0 mark
measurements compared with the position of the api-
cal foramen; and (iii) the influence of the radiographic
view on the assessment of the electronic readings
obtained at the 0.5 mark. The null hypothesis is that
the measurements will not be affected by the tested
variables.
Materials and methods
After approval of the local ethical committee (protocol
number 2.348.485), one hundred and fifty extracted
human mandibular premolar teeth were collected.
The teeth were scanned by means of cone-beam com-
puted tomography (CBCT) using the Scanora 3D
(Soredex, Tuusula, Finland) at 120 kV, 12.5 mA,
field of view (FOV) of 75 9 100 mm and 0.2 mm
voxel. Thirty standardized teeth with Vertucci’s type I
© 2021 International Endodontic Journal. Published by John Wiley & Sons Ltd
 ~ overo et al. Embedding media and radiographic images on AELs
Iparraguirre Nun
canal configuration, apical curvature less than 10°
and apical diameter up to 0.3 mm were obtained.
The cusps of the teeth were flattened to obtain a
reproducible coronal reference, and conventional
endodontic access was performed. The root canals
were pre-flared using ProTaper SX (Dentsply Sirona,
Ballaigues, Switzerland). Irrigation was performed
using 2.5% sodium hypochlorite and apical patency
confirmed using a size 15 K-file. The actual length
(AL) of the canals was measured by placing the tip of
the size 15 K-file up to the major apical foramen
(MAF) under 910 magnification. The silicone stop
was fixed using cyanoacrylate. Then, the distance
between the file tip and the silicone stop of the file
was measured using a digital calliper to 0.1 mm pre-
cision.
For the electronic measurements, each tooth was
mounted in the ProTrain endodontic training device.
Each tooth was locked and secured by a plastic ring
nut at the level of the CEJ, whilst the root was within
a plastic tube filled with the embedding media. First,
all the electronic measurements were performed using
the ProTrain manufacturer’s eco-electroconductive gel
(Farmacare Srl, Casale, Italy). Then, the root canals
and plastic tubes were washed in running water prior
to performing all electronic measurements using
freshly prepared alginate (Ava Gel; Dentsply Sirona)
as the embedding media.
Three different ERCLMDs were tested in this study:
Apex ID (SybronEndo, Glendora, CA, USA), CanalPro
Apex Locator (Coltene-Endo, Cuyahoga Falls, OH,
USA) and the Root ZX II (J. Morita, Tokyo, Japan).
For each tooth, the order of using the different
ERCLMDs was assigned using an online random num-
ber service (random.org), and the root canals were
irrigated using 2.5% sodium hypochlorite. All elec-
tronic measurements were performed by one operator,
specialist in Endodontics.
The electronic measurements were obtained using
a mounting model as previously described (Piasecki
et al. 2016, Segato et al. 2018). Briefly, the teeth were
embedded in freshly mixed alginate, and the canals
were irrigated with 2.5% sodium hypochlorite. A size
15 K-file connected to a digital calliper with 0.1 mm
precision was positioned at the coronal reference (flat-
tened buccal cusp), and the digital calliper was set to
zero. The file was then inserted into the root canal,
and the ERCLMD was connected to the system by
placing the lip clip in the alginate and the file holder
on the K-file. The file was advanced until the
ERCLMD mark was reached and remained stable for
© 2021 International Endodontic Journal. Published by John Wiley & Sons Ltd
5 s. The distances shown by the digital calliper for
both 0.0 and 0.5 marks of each ERCLMD were
recorded. For both marks, the difference between the
electronic measurements and the actual length
according to the different devices, marks and embed-
ding media was calculated and assigned as negative
or positive for short and long lengths, respectively.
Following the measurements at the 0.5 mark in
alginate media, the file was kept in position, and con-
ventional periapical radiographs (E-Speed, Carestream
Dental, New York, USA) were taken in both bucco-
lingual and proximal views (0.05 s exposure, 70 kV,
7 mA, Heliodent 70; Siemens, Munich, Germany).
The radiographic images were scanned and imported
to ImageJ (National Institutes of Health, Bethesda,
MD, USA) software to measure the distance between
the file tip and the root apex to obtain the radio-
graphic length (RL). Radiographic measurements
within 0.5 and 2 mm short of the radiographic apex
were considered correct (ESE 2006). The radiographic
measurements between bucco-lingual and proximal
views were compared.
Statistical analysis
Data obtained from all measurements were analysed
statistically with the significance set at 0.05 level.
The Kolmogorov–Smirnov test confirmed the normal
distribution. A two-way ANOVA followed by the Tukey
test was used to compare the absolute values of the
mean length differences amongst the variables. The
chi-square test and the Z-test were used to compare
the distribution of the percentages of electronic mea-
surements between devices and embedding media.
Results
Overall, the use of the electroconductive gel nega-
tively affected (P < 0.05) the electronic readings
except for the 0.5 mark of the Root ZX (Table 1). No
difference was found amongst the different brands of
ERCLMDs. Figure 1 shows a subsequent rank analysis
of the measurements obtained at the 0.0 mark in
relation to the position of the apical foramen accord-
ing to the devices and embedding media. The Tukey
HSD test revealed no difference amongst the devices
for the radiographic distances of the electronic mea-
surements obtained at the 0.5 mark in alginate
media.
Similarly, no difference was found when comparing
the distances measured in the bucco-lingual or
International Endodontic Journal 3
 ~ overo et al.
Embedding media and radiographic images on AELs Iparraguirre Nun

Table 1 Descriptive (mean and SD) difference between the working time. Cianconi et al. (2010) reported that
electronic measurements and the actual length according to over time, the gel was more stable and not influenced
the different devices, marks and embedding media by outside temperature or humidity compared with
Alginate ProTrain Gel the alginate; however, their study did not assess the
effect of this gel compared with other embedding
Mark Device n Mean SD Mean SD
media in the performance of the ERCLMDs. In fact,
a b
APEX/0.0 Root ZX II 30 0.20 0.34 0.49 0.51 two studies that used the ProTrain gel to evaluate
Apex ID 30 0.27a 0.52 0.73b 0.69
ERCLMDs for initial root canal treatment reported a
CanalPro 30 0.11a 0.36 0.50b 0.55
Total 90 0.19a 0.41 0.57b 0.59 tendency to overestimate readings, on average
0.5 Root ZX II 30 0.13a 0.44 0.06a 0.54 +0.3 mm beyond the foramen when using the 0.0 or
Apex ID 30 0.35a 0.47 0.03b 0.49 APEX mark (Cianconi et al. 2010, Mancini et al.
CanalPro 30 0.41a 0.47 0.05b 0.50 2011). For the same parameters, the present results
Total 90 0.29a 0.47 0.01b 0.49
were on average +0.57 mm (0.59), being signifi-
Negative values indicate measurements short of the major cantly different from the use of alginate
apical foramen.
(+0.19 mm  0.41). The same effect was also
Different superscript letters indicate a significant difference
within rows. observed for the measurements obtained at 0.5 mark,
which were overall significantly longer when using
the gel (Table 1). A possible explanation could be the
proximal radiographic views (Table 2). Radiographi- semi-liquid consistency of the tested gel, which may
cally, 51.1% of all measurements obtained at the 0.5 penetrate the apical foramen or generate bubbles that
mark when using alginate as media were considered can prevent the creation of the electrical circuit, giv-
correct because they were within 0.5 to 2 mm short ing unreliable readings. On the other hand, despite its
of the radiographic apex, whilst 48.9% were located firm consistency, alginate remains a gel allowing ions
within 0 to 0.5 mm from the radiographic apex. to circulate and thus promote adequate electrocon-
ductivity (Tinaz et al. 2002, Baldi et al. 2007, Guer-
Discussion reiro-Tanomaru et al. 2012). Present results support
the use of alginate as the embedding material of
Currently, ERCLMDs are considered a reliable method choice for laboratory use of ERCLMDs, since it is a
to determine the apical limit for root canal treatment material commonly used in Dentistry, easy to obtain
procedures (ElAyouti et al. 2009, Vieyra & Acosta and low in cost (Baldi et al. 2007, Chen et al. 2011,
2011, Martins et al. 2014). However, it requires Guerreiro-Tanomaru et al. 2012).
proper conditions to allow the electronic circuit to be The three evaluated ERCLMDs had similar perfor-
completed and detect the root canal impedance. In mance, but the Root ZX II was the only device that
the literature, experimental models and embedding was not significantly affected by the embedding media
media have been used for ex vivo investigations when using the 0.5 mark, corroborating its well-doc-
(Aurelio et al. 1983, Baldi et al. 2007). For educa- umented precision (Piasecki et al. 2016, Vasconcelos
tional purposes, however, it is important also that the et al. 2016, Segato et al. 2018). Previous reports on
laboratory setting allows the simulation of clinical the Apex ID have concluded that its performance was
conditions, such as mounting in phantom heads and comparable to the Root ZX (de Vasconcelos et al.
taking radiographic images, to be readily produced, 2015, Piasecki et al. 2016, Oliveira et al. 2017). In
reliable and accurate (Tinaz et al. 2002, Chen et al. the present study, the 0.0 mark of Apex ID resulted
2011). The null hypothesis was not accepted because in the more extended mean measurements, the great-
a difference was found in the accuracy of ERCLMDs est standard deviation and only 20% of correct mea-
regarding the embedding media. The electroconduc- surements. The performance of CanalPro was similar
tive gel resulted in more cases of overextensions com- to Root ZX II, resulting in the same percentage of cor-
pared with alginate. rect readings; however, little information is available
The electroconductive gel evaluated in this study on the literature regarding this device (Piasecki et al.
(Farmacare Srl) is recommended by the manufacturer 2018).
of the ProTrain platform. This gel is simpler, faster Similar to previous studies (Jung et al. 2011, Segato
and more convenient compared with alginate, since et al. 2018), the major apical foramen was selected as
the latter has to be freshly prepared and has limited the reference to evaluate the accuracy of the

4 International Endodontic Journal © 2021 International Endodontic Journal. Published by John Wiley & Sons Ltd

Iparraguirre Nun
Figure 1 Rank analysis of the electronic readings at 0.0/APEX mark in relation to the position of the major apical foramen.
Table 2 Descriptive (mean and SD) radiographic distance of
the 0.5 mark measurements obtained in alginate media,
according to the different devices and radiographic plane
Bucco-lingual
view Proximal view
N Mean SD Mean
Alginate Root ZX II 0.50a 0.32 0.54a
Apex ID 0.56a 0.36 0.68a
CanalPro 0.52a 0.39 0.64a
Negative values indicate measurements short of the radio-
graphic apex.
Different superscript letters indicate a significant difference
within columns.
electronic measurements obtained at the 0.0 mark.
Although the mean measurements were very close to
the major apical foramen, only about 30% of the
measurements were correctly positioned at the most
coronal border of the apical foramen. This low per-
centage is related to the very strict criteria established
for the rank, which considered any difference lower
or higher than 0.1 mm compared with the actual
position of the foramen, respectively, as short or long.
In contrast, most previous studies used a range of
error that varies from 0.5 to 1 mm, thus overesti-
mating the precision of the electronic readings (Jung
et al. 2011, Mancini et al. 2011, Piasecki et al. 2016,
Segato et al. 2018). The present laboratory setting
can be used to show dental students the limitations of
the 0.0 mark: one can carefully remove the tooth
© 2021 International Endodontic Journal. Published by John Wiley & Sons Ltd
~ overo et al. Embedding media and radiographic images on AELs
from the platform and observe under magnification
the position of the tip of the file in relation to the
foramen. Therefore, it is known that the use of 0.0
mark requires adjustments to establish a proper work-
ing length within the root canal (Jung et al. 2011,
SD
Mancini et al. 2011, Piasecki et al. 2016, Connert
et al. 2018).
0.31
On the other hand, the 0.5 mark is meant to locate
0.39
0.44 the apical constriction; thus, it is recommended to be
used for the establishment of the apical limit for
endodontic procedures (Piasecki et al. 2016, Connert
et al. 2018). However, the presence and position of
the apical constriction are highly variable, and can
only be assessed by histological or micro-computed
tomography (micro-CT; Dummer et al. 1984, ElAyouti
et al. 2014, Piasecki et al. 2016, 2018). Although
micro-CT studies have revealed the accuracy of
ERCLMDs in locating the apical constriction (Piasecki
et al. 2016, 2018, Connert et al. 2018), clinically it is
not possible to verify the accuracy of the 0.5 mark;
however, it is a common practice to perform a radio-
graph with the file in position suggested by the
ERCLMDs, aiming to minimize possible errors of the
electronic measurements (Martins et al. 2014, Savani
et al. 2014). Thus, in the present study, the electronic
measurements obtained at the 0.5 mark using algi-
nate were used for a further radiographic evaluation.
The criteria for radiographic determination of WL
consider that the file should be placed 0.5 to 2 mm
short of the radiographic apex of the root (ESE 2006).
In the literature, most studies that evaluated both
International Endodontic Journal 5

Embedding media and radiographic images on AELs Iparraguirre Nun
radiographic and electronic methods reported a better
performance of ERCLMDs (ElAyouti et al. 2002,
Vieyra & Acosta 2011); similarly, in the present
study, the mean radiographic measurements tended
to underestimate the position of the file in relation to
the foramen (Williams et al. 2006, Mancini et al.
2011). Only half of the electronic measurements were
considered correct in the radiographic evaluation. It
should be noted that in a pre-clinical laboratory set-
ting, it is not desirable to use destructive methods to
locate the apical constriction to evaluate the accuracy
of the 0.5 mark since the teeth should be used for the
competition of the endodontic procedures. However,
performing both electronic and radiographic working
length determination on extracted teeth is helpful for
a dental student understand the correlation and limi-
tations of both methods.
The ProTrain platform allowed radiographs to be
exposed immediately after the electronic measure-
ments without the need of moving the tooth or file;
the radiographs were taken in both bucco-lingual and
proximal directions using a parallel technique and
keeping a constant source–object–film distance (Cian-
coni et al. 2010, Mancini et al. 2011). Similar to pre-
vious reports, no difference was found when
comparing the measurements obtained in the bucco-
lingual and proximal radiographs (Cianconi et al.
2010, Mancini et al. 2011). The present results sug-
gest that for mandibular premolars, it is not necessary
to take radiographs in different views for the purpose
of verifying the electronic apical limit. However, when
reading a WL radiograph, rather than just measuring
the distance from the file tip to the apex, the clinician
should consider many factors such as the morphology
and shape of the roots, the trajectory of the canal,
possibility of bifurcations and lateral foramen, pres-
ence of resorption, distortions, superimposition and
other limitations of both electronic and radiographic
methods (Fouad & Reid 2000, ElAyouti et al. 2001,
Williams et al. 2006, Mancini et al. 2011).
Conclusions
Within the limitations of this laboratory study using
extracted premolar teeth, the conductive gel of the
ProTrain kit negatively affected most of the electronic
readings, leading to higher incidence of overexten-
sions. The three evaluated ERCLMDs presented similar
accuracy when alginate was used as embedding
media, precisely locating the apical foramen in 30%
of the cases. No difference was found when
6 International Endodontic Journal
~ overo et al.
comparing the distances measured in the bucco-lin-
gual and proximal radiographic views of the apical
limit provided by the 0.5 mark in mandibular premo-
lars.
Conflict of interest
The authors have stated explicitly that there are no
conflicts of interest in connection with this article.
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