Clinical Research

The Precision of Electronic Apex Locators in Working

Length Determination: A Systematic Review and
Meta-analysis of the Literature
Igor Tsesis, DMD,* Tamar Blazer, DMD,†‡ Gil Ben-Izhack,* Silvio Taschieri, MD, DDS,§
Massimo Del Fabbro, BSc, PhD,§ Stefano Corbella, DDS, PhD,§ and Eyal Rosen, DMD*

Abstract
Introduction: This study aimed to evaluate the preci-
sion of electronic apex locators (EALs) in locating the
apical constriction (AC) during a root canal treatment
compared with a histologic evaluation of the AC as
well as the effects of possible influencing factors by
means of a systematic review of the literature and
meta-analysis. Methods: A systematic search of the
literature was performed to identify studies that histo-
logically evaluated the precision of EALs in human teeth.
The identified studies were subject to strict inclusion
criteria followed by data extraction and meta-analysis.
Results: From 247 articles, 10 articles met the inclusion
criteria, with a total of 1105 EAL measurements per-
formed by 4 types of EALs: Root ZX (J Morita, Tokyo,
Japan), Justy II (Hager & Werken GmbH & Co, Duisburg,
Germany), Endy 5000 (Loser Co, Leverkusen, Germany),
and Endox (Lysis Co, Milan, Italy). Root ZX, Justy II,
and Endy 5000 were found to be significantly more ac-
curate than Endox in determining the distance between
the file tip and the apical constriction (P < .05). The
longest mean distance was measured by Endox
(1.35  0.41 mm), and the shortest mean distance
was measured by Justy II (0.25  0.17 mm, P < .05).
The mean distance measured by Root ZX and Justy II
in the presence of hydrogen peroxide was shorter
compared with the mean distance measured by them
in the presence of sodium hypochlorite (P < .05). The
pulp status (vital or necrotic) had no significant effect
on the precision of the EALs. Conclusions: The precision
of electronic working length measurement depends on
the device used and the type of irrigation and is not
influenced by the status of the pulp tissue. (J Endod
2015;-:1–6)
Key Words
Apical constriction, electronic apex locators, root canals, working length
R oot canal treatment (RCT) procedures should be confined within the root canal sys-
tem (1). The working length (WL) is defined as the distance between a coronal
reference point and the point at which canal preparation and obturation should termi-
nate (2). Maintaining a correct WL during RCT is expected to positively influence the
outcome of RCT (3, 4), and it prevents postoperative pain (5). Thus, the WL should
be measured as precisely as possible (6).
An idealized anatomy of the main apical opening of the root canal (apical foramen
[AF]) was described as having a minor apical diameter (apical constriction [AC], the
apical portion of the root canal having the narrowest diameter), and from that point the
canal gradually widens apically toward the major apical diameter (major foramen
[MF], the area of the apical foramen where the walls are farthest apart), taking on a
funnel-shape appearance (2, 7). However, many times, the AF anatomy does not fit
into this idealized form (8, 9). Many times, depending on the tooth type (8, 10), the
AF deviates from the long axis of the tooth (9, 11–13) and may enlarge with the
patient’s age, tooth adaptation to the functional activity (7, 13, 14), and pathological
changes (15, 16). In addition, the number of foramina may range from 1 to 16,
whereas the distances between the apical foramina and the anatomic root apex may
range from 0.20–3.80 mm. These variations in the AF anatomy render clinical
identification of the WL practically impossible (17).
In addition to this anatomic confusion, there is controversy regarding the favor-
able location of the termination point of the apical preparation. Some authors suggested
the cementodentin junction (CDJ) as the favorable termination point of root canal prep-
aration (11, 12). However, the CDJ is a histologic site that can only be detected
histologically in extracted teeth (6). In addition, the CDJ is highly irregular, and the
extension of the cementum into the root canal can significantly vary (1, 18).
The AC was also suggested as the optimal WL because at this point healing is sup-
posed to be optimal, and the wound to the periapical tissues during RCT is expected to
be the smallest (1). However, the topography and morphology of the AC is variable, and
less than half of the teeth have a ‘‘traditional’’ single AC (19).
Electronic root canal length measuring devices (electronic apex locators [EALs])
offer a means of locating the WL for root canal procedures (6). The reliability of double-
frequency EALs in determining AC is superior to the radiographic method (20).

From the *Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel; †Department of End-
odontics and Dental Traumatology, Graduate School of Dentistry, Rambam Health CareCampus, Haifa, Israel; ‡Universit
a degli Studi di Milano, Department of Biomed-
ical, Surgical and Dental Sciences, Research Centre in Oral Health, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; and §Department of Biomedical, Surgical and Dental
Sciences, Universit
a degli Studidi Milano, IRCCS Istituto Ortopedico Galeazzi, Dental Clinic, Milan, Italy.
Address requests for reprints to Dr Igor Tsesis, Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel
Aviv, Israel. E-mail address: dr.tsesis@gmail.com
0099-2399/$ - see front matter
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.08.012

JOE — Volume -, Number -, - 2015 Electronic Apex Locators and Working Length Determination 1
Clinical Research
TABLE 1. Criteria for Inclusion of Studies in the Systematic Review
1 Fully developed human permanent teeth,
nonendodontically treated
2 Ex vivo/in vitro studies
3 Histologic evaluation of the actual location of the AC
4 Presents detailed data regarding the measured distance
between the file tip used for the EAL measurement
and the actual location of the AC
5 Manual evaluation of WL with multiple frequency EALs
AC, apical constriction; EAL, electronic apex locator; WL, working length.
Evidence-based dentistry is an approach to oral health care that
integrates the best available clinical evidence to support a practitioner’s
clinical expertise for each patient’s treatment needs and preferences
(21–23). Numerous studies were published on the precision of EALs
in WL determination (24–32). These studies have significant
variability in their study designs and terminology used regarding the
apical foramen anatomy, and their results are confusing and
imprecise (24–32). Thus, a systematic review and analysis of the
available literature according to evidence-based dentistry principles
and strict inclusion criteria regarding the precision of EALs in WL deter-
mination is of utmost importance (21, 23, 33).
The aim of this study was to evaluate the precision of EALs in
locating the AC as well as the effects of possible influencing factors by
means of a systematic review of the literature and meta-analysis.
Materials and Methods
Criteria for Considering Studies
for the Systematic Review
This systematic review included studies that reported the precision
of EALs in locating the AC in primary RCT of human teeth compared with
a histologic evaluation of the AC. The inclusion and exclusion criteria
are presented in Tables 1 and 2, respectively.
Search Methods for the Identification of Studies
The search covered all articles published in dental journals from
1966 to January 2014. The following electronic databases were
searched: MEDLINE using PubMed search engine (http://www.ncbi.
nlm.nih.gov/sites/pubmed), Embase (http://www.embase.com), Sco-
pus (http://www.scopus.com), and Cochrane Central Register of
Controlled Trials (http://www.cochrane.org).
TABLE 2. Criteria for Exclusion of Studies in the Systematic Review
1 Teeth not fully developed/open apex
2 Deciduous, resorbed, perforated, resected teeth
3 Root canal treated teeth
4 Technique excluded: observation of file through
the apex
5 Case reports (less than 10 cases), reviews, or studies
irrelevant to the topic of the present study
6 No histologic evaluation of apical anatomy
7 Studies in which the distance of file tip used for
the EAL measurement to the AC is not specified
or given as a range
8 Working length determination during a rotary
file preparation
9 Not a multiple frequencies EAL
10 Identifications of landmarks other than the
constriction/minor foramen.
AC, apical constriction; EAL, electronic apex locator.
2 Tsesis et al.
The following key words were used for an initial search through
MEDLINE: ‘‘apex locator’’ with the application of the following limits:
‘‘humans’’ and ‘‘English language.’’ Additional searches were then per-
formed through Embase, Scopus, and Cochrane databases using the
same key words and search limits.
Related articles and the reference lists of the literature reviews that
were retrieved by the MEDLINE search engine were manually checked
for possible further eligible articles.
Data Collection and Analysis
Selection of Studies. The articles were initially evaluated for rele-
vance based on their titles and abstracts by 2 reviewers independently
(T.B., G.B.-I.). Possibly eligible studies were subject to a full-text eval-
uation. The full text of the relevant studies was obtained and reviewed
for suitability based on the inclusion and exclusion criteria described
previously. Cases of disagreement were discussed together until agree-
ment was reached. The identified suitable articles were subject to data
extraction, assessment of the methodological quality, and data synthesis
and analysis.
Data Extraction. Data were extracted by 2 reviewers independently
(E.R, I.T). Cases of disagreement were subject to joint evaluation by the
reviewers until agreement was reached. The authors’ names and the
date of publication were recorded for each study.
The following variables were recorded: the distance between the
file tip during the EAL measurement and the actual AC location as deter-
mined histologically, the type of teeth tested (single-rooted vs multi-
rooted), the type of EAL (Root ZX [J Morita, Tokyo, Japan], Justy II
[Hager & Werken GmbH & Co, Duisburg, Germany], Endy 5000 [Loser
Co, Leverkusen, Germany], or Endox [Lysis Co, Milan, Italy]), status of
the pulp (vital or necrotic), and whether an irrigant was used during
measurement and its type (sodium hypochlorite [NaOCl] or hydrogen
peroxide [H2O2]).
Methodological Quality Assessment. The methodological
quality of the selected studies was evaluated independently and in par-
allel by 2 reviewers (T.B. and G.I.) based on the following methodolog-
ical parameters (34):
1. Type of study: Ex vivo studies (the electronic measurement was
performed on extracted teeth) versus in vivo studies (electronic
measurement was performed in vivo and then the teeth were ex-
tracted with the endodontic file fixed in the canal and were evaluated
histologically).
2. Random sequence generation: The method used to generate the
allocation sequence is sufficiently detailed to allow an assessment
of whether it should produce comparable groups.
3. Allocation concealment: The method used to conceal the alloca-
tion sequence is sufficiently detailed to determine whether interven-
tion allocations could have been foreseen in advance of, or during,
enrollment.
4. Blinding of outcome assessment: Measures used, if any, to blind
the investigator from knowledge of intervention received.
5. Selection bias: Clear definition of selection criteria.
6. Sample size: Studies testing 30 roots or less were considered at high
risk of bias, whereas studies that presented with more than 30 roots
were considered at low risk of bias.
7. Attrition bias: Incomplete outcome data presented, including attri-
tion and exclusions from the analysis.
All these parameters were assessed as adequate, unclear, or inad-
equate. To summarize the validity of studies, they were grouped into the
following categories (34):
JOE — Volume -, Number -, - 2015

Figure 1. A flowchart of the systematic review process.
1. Low risk of bias (ie, studies that met at least 4 of the quality criteria)
2. High risk of bias (ie, studies that met no more than 3 quality
criteria)
In cases in which there was a discrepancy between the 2 reviewers,
a third reviewer was consulted (I.T.) until consensus was achieved. The
authors of the identified articles were contacted when needed for clar-
ifications or providing missing information.
Statistical Analysis
Statistical analysis was performed by using SPSS version 21 (IBM
SPSS Statistics for Windows; IBM Corp, Armonk, NY). Analysis of vari-
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Random sequence generaƟon
AllocaƟon concealment
Blinding of outcome assessment
Clear definiƟon of selecƟon criteria
Sample size
AƩriƟon bias: complete outcome assessment
Type of study according to clinical relevance
low level of bias high level of bias
Figure 2. A risk of bias graph. Each risk of bias item is presented as a percentage across all included studies (n = 10).
JOE — Volume -, Number -, - 2015
Clinical Research
TABLE 3. Precision of Electronic Apex Locators
Mean distance between
Number of the tip of the file and the
EAL type measurements apical constriction (mm)
Root ZX 412 0.32  0.25a
Justy II 331 0.25  0.17b
Endy 5000 202 0.56  0.47c
Endox 160 1.36  0.41d
Statistically significant differences (P < .05) were found between a and d, b and d, and c and d.
ance or Kruskal-Wallis tests with multiple comparisons were used to
evaluate the differences between EALs.
Linear regression was done to assess the effects of several indepen-
dent parameters (type of device and type of irrigant) on the EAL’s mea-
surement precision. P < .05 was considered significant.
Results
The results of the electronic databases search and the manual
search are shown in Figure 1 (45).
Methodological Quality Assessment
From the included studies: 3 studies were considered to have a low
risk of bias (35, 36, 44), and 7 studies were considered to have a high
risk of bias (37–43) (Fig. 2).
The included studies reported a total of 1105 EAL measurements
performed by 4 types of EALs: 412 measurements (37.28%) by Root ZX,
331 measurements (29.95%) by Justy II, 202 measurements (18.28%)
by Endy 5000, and 160 (14.4%) measurements by Endox (Table 3).
The mean distance between the file tip and the AC measured by
Endox was significantly longer than by any other EAL type (P < .05).
For Root ZX and Justy II, the mean distance measured in the presence
of hydrogen peroxide solution was significantly shorter compared with
the measurements in the presence of NaOCl (P < .05), whereas no data
were available for the use of Endy 5000 and Endox in the presence of
NaOCl in the analyzed studies (Table 4).
The status of the pulp was available for only 194 (17.55%) of all
included measurements. One hundred thirty-three of these (68.55%)
were performed in roots having a vital pulp, whereas 61 measurements
(31.44%) were performed in nonvital teeth (Table 5). The distance
Electronic Apex Locators and Working Length Determination 3
Clinical Research
TABLE 4. Precision of Electronic Apex Locators According to the Type of Irrigant
Type of irrigant
NaOCl H2O2 Total
Root ZX Precision* (mm) 0.43  0.24 0.19  0.186 0.32  0.25
No. of measurements 252 160 412
Justy II Precision* (mm) 0.42  0.03 0.19  0.15† 0.25  0.17
No. of measurements 120 211 331
Endy 5000 Precision* (mm) NA 0.56  0.47 0.56  0.47
No. of measurements NA 202 202
Endox Precision* (mm) NA 1.36  0.41 1.36  0.41
No. of measurements NA 160 160
H2O2, hydrogen peroxide; NA, not applicable; NaOCl, sodium hypochlorite.
*Precision = Mean distance  standard deviation (in millimeters) of the file tip to the apical constriction for each of the EALs.
†
P < .05 in comparison with the other irrigant (same EAL type).

between the file tip and the AC in vital versus necrotic teeth did not differ
significantly for any of the electronic devices tested (Table 5).
Discussion
The present study undertook an exhaustive literature search using
various electronic search engines and manual searches to identify
studies dealing with the precision of electronic WL measurement during
primary root canal treatment of human teeth. The gold standard was
defined as the histologic evaluation of the minor foramen. To overcome
heterogeneity of data, strict inclusion and exclusion criteria were
applied to the studies. Ten studies (35–44) were identified as
eligible for the systematic review.
In the present review, the methodological quality of the included
studies was appraised and was described as the risk of bias (34) in each
of the studies. A bias is a systematic error, or deviation from the truth, in
results or inferences, and it may lead to a false estimation of the inter-
vention effect (34). Meta-analysis of results from studies of variable val-
idities may result in false conclusions, whereas differences in risks of
bias can help explain variations in the results of the studies included
in a systematic review (34). Thus, it is important to assess the risk of
bias in all studies in a review (34).
The precision of EALs has many shortcomings, and it has been
challenged in some articles (46). Hoer and Attin (44) and H€or et al
(47) reported that the use of an EAL did not result in precise
determination of the AC, but the authors presented the AC as an area
located somewhere coronal to the minor apical foramen, which is
not in correspondence to the current definitions of apical anatomy (2).
The WL termination point should reflect the anatomic area be-
tween the AC and the MF. This is an acceptable termination point to
complete the endodontic procedures (1, 48, 49). Any EAL device that
indicates measurements falling between the AC and the MF may be
acceptable for clinical use (50–52).
Early-generation EALs were often inaccurate in the presence of
conductive fluids. However, manufacturers claim that Root ZX and Justy
II locate the foramen under any canal condition (wet, dry, NaOCl, and so
on) using their multifrequency technology. Despite this, several studies
have warned that a high electroconductive solution might affect the ac-
curacy (eg, NaOCl). Kobayashi (53) and Fan et al (54) reported that the
electroconductive solutions present inside the canal greatly reduce the
impedance and therefore resulted in tendency toward shorter measure-
ments, whereas longer measurements were detected in the lower elec-
troconductive solution. This is in agreement with other studies in which
the accuracy of different brands of apex locators were evaluated in the
presence of different irrigants, and a greater deviation from the actual
WL was obtained with NaOCl (55, 56). Nevertheless, none of these
studies compared the electronic measurements with the histologic
AC, and, therefore, they are of limited value. We found that for Root
ZX and Justy II, the mean distance to the histologic constriction
(representing the precision of measurement) was significantly
shorter in the presence of H2O2 compared with the presence of
NaOCl. H2O2 was recommended in the past as an endodontic irrigant
in combination with NaOCl to enhance the efficacy of irrigation. It is
also used for decontamination of the tooth before commencing root
canal treatment (57). H2O2 is a far less conductive solution than NaOCl,
which explains the reason for more accurate measurements in its
presence.
Regarding the status of the pulp and its relation to the precision of
EAL measurement, few publications are available in the literature, with
conflicting data (37, 39, 58–60). Some of these studies plead that a
canal with a vital pulp may have different impedance than a canal
with a necrotic pulp because of the destruction of the periodontal

TABLE 5. Precision of Electronic Apex Locators According to Pulp Status

Pulp tissue status
Vital pulp Necrotic pulp Total
Root ZX Precision* (mm) 0.31  0.13 0.26  0.36 0.28  0.22
No. of measurements 46 28 74
Justy II Precision* (mm) 00 0.4 0.2  0.28
No. of measurements 29 11 40
Endy 5000 Precision* (mm) 1.2 0 0.6  0.85
No. of measurements 29 11 40
Endox Precision* (mm) 1.4 1.1 1.25  0.21
No. of measurements 29 11 40
*Precision = mean distance  standard deviation (in millimeters) of the file tip to the apical constriction for each of the EALs.

4 Tsesis et al. JOE — Volume -, Number -, - 2015


ligament associated with a periapical lesion. Therefore, one would
expect that the precision and/or consistency of the EALs in necrotic
cases would differ from vital cases (37, 58).
Nevertheless, only 2 of the previously mentioned studies
compared the electronic measurement with the AC. Dunlap et al
(37) found no difference between Root ZX measurements in vital
versus necrotic teeth. On the other hand, Haffner et al (39) found
statistically significant differences between electronic measurements
of vital and necrotic teeth for Root ZX and Endy. However, no differ-
ences were found for Justy II and Endox. The current systematic re-
view, which analyzed these studies together, found no significant
difference between vital and necrotic teeth in the precision of WL
measurements for any of the EALs.
Root ZX, Justy II, and Endy 5000 were found to be significantly
more accurate than Endox in determining the distance to the AC. How-
ever, there were no significant differences between Root ZX and Justy II,
Root ZX and Endy 5000, or Justy II and Endy 5000. These findings are in
agreement with the work of Lucena-Martın et al (24), who also found no
difference between Root ZX and Justy II.
The data presented in the evaluated studies support the use of
apex locators for WL measurements, as do the latest studies published
(63, 64). However, the clinical implications of the differences in WL
measurement between the apex locators reported in the present
investigation are still unclear (50–52, 61, 62).
Conclusions
The precision of electronic WL measurement depends on the de-
vice used and the type of irrigation and is not influenced by the status of
the pulp tissue (vital or necrotic).
Root ZX, Justy II, and Endy 5000 are significantly more precise
than Endox. The precision of Root ZX and Justy II improves in the pres-
ence of H2O2in comparison with the presence of NaOCl.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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JOE — Volume -, Number -, - 2015