Joypex

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Joypex

  1. 1. Evaluation of the multifrequency electronic apex locator Joypex 5 in primary teeth E. J. N. L. Silva, D. R. Herrera, E. J. Souza-Júnior & T. P. Rosa European Archives of Paediatric Dentistry ISSN 1818-6300 Eur Arch Paediatr Dent DOI 10.1007/s40368-013-0065-0 1 23
  2. 2. Your article is protected by copyright and all rights are held exclusively by European Academy of Paediatric Dentistry. This eoffprint is for personal use only and shall not be self-archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23
  3. 3. Author's personal copy Eur Arch Paediatr Dent DOI 10.1007/s40368-013-0065-0 ORIGINAL SCIENTIFIC ARTICLE Evaluation of the multifrequency electronic apex locator Joypex 5 in primary teeth ´ E. J. N. L. Silva • D. R. Herrera • E. J. Souza-Junior T. P. Rosa • Received: 16 February 2013 / Accepted: 19 June 2013 Ó European Academy of Paediatric Dentistry 2013 Abstract Aim To evaluate ex vivo the accuracy of the multifrequency electronic apex locator (EAL) Joypex 5 in primary molars. Methods Fourteen primary molars were selected for a total of 25 root canals. Working length measurements were performed by direct observation (DO), using a 15 K-file into the root canal until its tip was visible at the apical foramen and electronically using the EALs Joypex 5. Data were analysed statistically using the intraclass correlation coefficient (ICC). To assess whether a significant difference in accuracy of the electronic apex locator existed, the Student’s t test was performed at 5 % significance. Results No statistical difference was observed between the direct observation and the EAL measurement (p 0.05). The ICC confirmed the agreement of different methods to measure canal length. The R2 coefficient was close to 1, denoting a strong agreement between measures obtained with Joypex 5 and DO. Conclusion The multifrequency EALs Joypex 5 showed adequate accuracy in the root length determination of primary teeth. E. J. N. L. Silva Endodontics Department, Grande Rio UniversityUNIGRANRIO, Rio de Janeiro, Brazil E. J. N. L. Silva (&) Rua Herotides de Oliveira, ´ ´ 61/902, Icaraı, Niteroi, RJ CEP 24230-230, Brazil e-mail: nogueiraemmanuel@hotmail.com ´ D. R. Herrera Á E. J. Souza-Junior Á T. P. Rosa Endodontics Department, Piracicaba Dentistry School, Campinas State University-UNICAMP, Campinas, Brazil Keywords Endodontics Á Electronic apex locator Á Primary teeth Introduction Pulpectomies are indicated in cases of irreversible pulpitis, necrosis or infections in primary teeth with at least 2/3 of intact roots. The determination and maintenance of the working length (WL) is an important step in root canal treatment, ensuring an efficient chemo-mechanical preparation and a hermetic sealing of the root canal system (Ricucci 1998). It is especially critical in primary teeth, since over-instrumentation and over-filling of a primary tooth can damage the permanent tooth germ and underinstrumentation and underfilling, on the other hand, is also a risk factor that accounts for persistence of apical infection (Kielbassa et al. 2003; Angwaravong and Panitvisai 2009; Leonardo et al. 2009). The most widely used method for the measurement of working length for primary teeth is the use of conventional and digital radiography. Several studies have demonstrated the limitations of radiographs that include inconsistent working length determination due to image distortion, superposition of roots and adjacent anatomical structures (e.g. permanent tooth germ), radiation exposure and patient management (Katz et al. 1996; ElAyouti et al. 2001). The advent of electronic apex locators (EALs) provides an additional feature to the endodontic arsenal for determining the correct odontometry. The latest generation of EALs operates by measuring changes in impedance (alternating current). For this, two or more different frequencies are used and processed using different mathematical algorithms (Nekoofar et al. 2006). Many studies report a high efficacy achieved by new generations of electronic apex 123
  4. 4. Author's personal copy Eur Arch Paediatr Dent locators, even in adverse situations like the presence of irrigating solutions, blood, and the existence of large foramens as in primary teeth (Kielbassa et al. 2003; Angwaravong and Panitvisai 2009; Leonardo et al. 2008; Leonardo et al. 2009; Beltrame et al. 2011). Recently, a new EAL has been introduced (Joypex 5, Denjoy Dental Corporation, Changsha City, China). This EAL adopts multiple frequencies and according to the manufacturer it works more accurately than others EALs in dry or wet canals (www.denjoy.cn). Although a recent study demonstrated that this EAL is accurate in determining the working length in permanent teeth (Soares et al. 2013), little is known about the efficiency and accuracy of this EAL in primary tooth. Therefore, the aim of this study was to evaluate the accuracy of the EALs Joypex 5 in primary molar teeth. The null hypothesis was that there was no significant difference in the direct and EAL measurement. Materials and methods Tooth selection and preparation Fourteen primary molars were selected for a total of 25 root canals. Tooth extraction was necessary as a result of one of the following reasons: prolonged retention (no spontaneous exfoliation), orthodontic purposes or no possibility of restoration after caries excavation. All selected teeth did not show resorption more than 1/3rd the root length. Teeth were stored in saline solution until use. Preliminary radiographs were taken after extraction to evaluate root canal anatomy, identify the radiographic apex and exclude teeth with calcification, whose main canal was not visible radiographically. The roots were numbered and stored in sterile saline until use. After endodontic access cavity preparation, a K-file (Dentsply Maillefer, Ballaigues, Switzerland) with diameter compatible with that of the canal diameter was passively introduced up to the apical foramen or the most coronal limit of root resorption to verify canal patency. No root canal preparation was performed. Direct measurement For direct measurement of working length, a reference point was first marked at the most coronal portion of the tooth crown using a fine paint marker. Then, a 15 K-file (Dentsply Maillefer, Ballaigues, Switzerland) with a silicon stop was passively introduced into the root canal until its tip was visible at the apical foramen under a stereomicroscope at 948 magnification. After this, the file was 123 withdrawn until its tip lay tangential to the apical foramen. The silicon stop was tangentially positioned to the occlusal reference edge, which was recorded previously, and the file was then removed. The distance between the file tip and silicon stop was measured using a digital calliper with 0.01-mm resolution. Each procedure was repeated three times, and the average was calculated and computed. Electronic determination of working length The electronic working length determination was undertaken using the Joypex 5 (DenjoyÒ, China). The teeth were embedded in a plastic device containing 0.9 % saline. Cotton pellets were used to remove excess saline from the pulp chamber. The labial clip was inserted into the saline solution, and a 15 K-file was adapted to the file holder. The file holder was always positioned between the handle of the file and the silicon stop. The file was introduced slowly into the root canal until the EAL displayed the ‘0.0’ mark. The silicon stop was shifted to the occlusal reference edge, which was recorded previously, and the file was then removed. The distance between file tip and silicon stop was measured using a digital caliper with 0.01-mm resolution. Each procedure was repeated three times, and the average was calculated and computed. Statistical analysis The measurements (in mm) of direct and electronic determination of the working length were made by an experienced examiner, and were recorded in specific charts for further comparison of the methods. Data were analysed statistically using the intraclass correlation coefficient (ICC). Mean and standard deviations of direct and electronic means were also calculated. To assess whether a significant difference in accuracy of the electronic apex locator existed, the Student’s t test was performed at 5 % significance, using version 17 SPSS (Chicago, IL, USA). Results Figure 1 compares graphically the actual and electronic working length measurements and shows a high intraclass correlation (ICC = 0.98) between the direct and electronic methods. Table 1 shows the difference between the WL values by direct measurement and EAL measurement. In 19.2 % of the canals a full precision (difference of 0.0 mm) was observed and, only in two cases, a difference[1.0 mm was verified.
  5. 5. Author's personal copy Eur Arch Paediatr Dent Fig. 1 Direct measurements and electronic measurements in the primary molar teeth. The intraclass correlation represents the intersection of the two measurements that is indicated on the axes X (direct measurement) and Y (electronic measurement). The dots that coincide with the line represent that the two measurements had the same values Discussion Root length determination is a crucial factor for a successful root canal treatment, especially in primary teeth because of the unpredictable root anatomy (Fuks and Eidelman 1991). Radiography as a method of determining the working length has numerous shortcoming in which it depends on the child’s co-operation, as well as the operator’s proficiency. In addition, minor degrees of resorption may not be visible, and overlapped by adjacent anatomical structures that could obscure the clarity of the image (Kielbassa et al. 2003). Another problem associated with intra-oral periapical radiographs is the positioning of the film inside the child’s mouth. Furthermore, radiographic assessment is difficult, particularly in cases where the physiological resorption in primary teeth occurs on buccal or lingual aspects of the root. Recently, electronic methods for determining the root canal length, in both permanent and primary teeth, have gained popularity amongst dentists because of the hazards of radiation, the technical problems associated with radiographic techniques and to avoid overinstrumentation beyond the root canal terminus (Fuks and Eidelman 1991; ElAyouti et al. 2001; Brunton et al. 2002; Schaeffer et al. 2005). Several studies have reported the accuracy of EALs in determining the WL, validating its clinical use as a simple and effective alternative and optimising endodontic therapy (Kielbassa et al. 2003; Leonardo et al. 2008; Angwaravong and Panitvisai 2009; Leonardo et al. 2009; de Vardasca Oliveira et al. 2010; Beltrame et al. 2011]. Recently, the Joypex 5 was launched and according to the manufacturer (www.denjoy.cn) it has an advanced electronic T-surge circuit and uses multiple frequencies alternating current rather than the dual frequency alternating current incorporated in the Root ZX II (Nekoofar et al. 2006; Soares et al. 2013). Moreover, in the Joypex 5, the calculations of the position of the file tip are based on measurements of root mean square values of the signal, which expresses the energy of the measured signal and is more immune to various noises or signal distortions than the other parameters of the signal, such as amplitude or the different phases used in other devices (Majeed and Subhi 2011). According to the manufacturer, these combinations can increase the measurement accuracy and the reliability of the device (www.denjoy.cn). The apical endpoint of root canals in primary teeth is often uncertain as they do not always have a well-defined apical constriction and physiological and pathological resorptions occur (Azar and Mokhtare 2011; Ruschel et al. 2011). Owing to those inherent problems when using EALs, many authors consider it acceptable for the measurement to be ±0.5 mm between the working length obtained directly and that obtained electronically (Angwaravong and Panitvisai 2009; Leonardo et al. 2008; Leonardo et al. 2009), whereas others have quoted a difference of ±1 mm (Kielbassa et al. 2003; Mello-Moura et al. 2010). In the present study, the accuracy of the EAL was assessed by taking into account both differences (±0.5 mm and ±1 mm). The null hypothesis of the present study was upheld because no significant difference was observed in the direct and EAL measurements. This result confirms the efficacy of this device to determine the WL. In 23 of 25 measurements, the difference between direct and EAL measurement was lower than ±1.0 mm. In addition, only two cases showed a greater difference than 1.0 mm, demonstrating high efficacy of the Joypex 5 for determining WL. In this study, it was also possible to observe an almost perfect correlation (ICC = 0.98) between the results of this EAL with those of the direct method. In the same way, previous reports using different EALs found high correlations in primary teeth (Tosun et al. 2008; Nelson-Filho et al. 2011; Saritha et al. 2012). The results obtained for Joypex 5 in a previous study in permanent teeth (ElAyouti et al. 2001) and those obtained in this study Table 1 Difference distribution (in mm) of WL by direct measurement and EAL measurement Difference -1.50 1.00 0.50 0 0.50 1.00 1.50 Direct 9 EAL 2 (8.00 %) 2 (8.00 %) 6 (24.00 %) 5 (20.00 %) 7 (28.00 %) 3 (12.00 %) 0 (0.00 %) Positive values represent a higher direct observation measurement and negative values represent a higher EALs measurement 123
  6. 6. Author's personal copy Eur Arch Paediatr Dent for primary teeth indicate its usefulness, and because of the low cost of this device compared with traditional EALs. Previous reports showed that the presence of root resorption did not interfere with the accuracy of EALs; therefore, this variable was not tested in the present study (Kielbassa et al. 2003; Mello-Moura et al. 2010; Tosun et al. 2008; Nelson-Filho et al. 2011; Saritha et al. 2012). Conclusion The result of this study supports the use of Joypex 5 to determine root length in primary teeth that require pulpectomy. The use of the electronic apex locator is quick, comfortable, accurate, safe, painless, and does not involve unnecessary radiation. References Angwaravong O, Panitvisai P. Accuracy of an electronic apex locator in primary teeth with root resorption. Int Endod J. 2009;42: 115–21. Azar MR, Mokhtare M. Rotary Mtwo system versus manual K-file instruments: efficacy in preparing primary and permanent molar root canals. Indian J Dent Res. 2011;22:363. Beltrame AP, Triches TC, Sartori N, Bolan M. Electronic determination of root canal working length in primary molar teeth: na in vivo and ex vivo study. Int Endod J. 2011;44:402–6. Brunton PA, Abdeen D, MacFarlane TV. The effect of an apex locator on exposure to radiation during endodontic therapy. J Endod. 2002;28:524–6. de Vardasca Oliveira PT, Chita JJ, Silva PG, De Vicente FS, Pereira KF. Accuracy of two apex locators made in China compared to Root ZX II. Pesq Bras Odontoped Clin Integr. 2010;10:83–8. ElAyouti A, Weiger R, Lost C. Frequency of overinstrumentation with an acceptable radiographic working length. J Endod. 2001; 27:49–52. Fuks AB, Eidelman E. Pulp therapy in the primary dentition. Cur Opin Dent. 1991;1:556–63. 123 Katz A, Mass E, Kaufman AY. Electronic apex locator: a useful tool for root canal treatment in the primary dentition. J Dent Child. 1996;63:414–7. Kielbassa AM, Muller U, Munz I, Monting JS. Clinical evaluation of the measuring accuracy of Root ZX in primary teeth. O Surg O Med O Pathol O Radiol Endod. 2003;95:94–100. Leonardo MR, Silva LA, Nelson-Filho P, Silva RA, Raffaini MS. Ex vivo evaluation of the accuracy of two electronic apex locators during root canal length determination in primary teeth. Int Endod J. 2008;41:317–21. Leonardo MR, da Silva LA, Nelson-Filho P, da Silva RA, Lucisano MP. Ex vivo accuracy of an apex locator using digital signal processing in primary teeth. Ped Dent. 2009;31:320–2. Majeed MA, Subhi AG. Assessment of the accuracy of a fifth generation apex locator (in vitro study). J Bagh Col Dent. 2011;23:12–7. Mello-Moura ACV, Moura-Netto C, Araki AT, Guedes-Pinto AC, Mendes FM. Ex vivo performance of five methods for root canal length determination in primary anterior teeth. Int Endod J. 2010;43:142–7. Nekoofar MH, Ghandi MM, Hayes SJ, Dummer PM. The fundamental operating principles of electronic root canal length measurement devices. Int Endod J. 2006;39:595–609. ´ Nelson-Filho P, Romualdo PC, Bonifacio KC, Leonardo MR, Silva RA, Silva LA. Accuracy of the iPex multi-frequency electronic apex locator in primary molars: an ex vivo study. Int Endod J. 2011;44:303–6. Ricucci D. Apical limit of root canal instrumentation and obturation. Part 1. Int Endod J. 1998;31:384–93. Ruschel HC, Ligocki GD, Flaminghi DL, Fossati AC. Microstructure of mineralized tissues in human primary teeth. J Clin Pediatr Dent. 2011;35:295–300. Saritha S, Uloopi KS, Vinay C. Chandra Sekhar R, Rao VV. Clinical evaluation of Root ZX II electronic apex locator in primary teeth. Eur Arch Paediatr Dent. 2012;13:32–5. Schaeffer MA, White RR, Walton RE. Determining the optimal obturation length: a meta-analysis of literature. J Endod. 2005; 31:271–4. Soares RM, Silva EJ, Herrera DR, Krebs RL, Coutinho-Filho TS. Evaluation of Joypex 5 and Root ZX II: an in vivo and ex vivo study. Int Endod J. 2013 [Epud ahead of print]. Tosun G, Erdemir A, Eldeniz AU, Sermet U, Sener Y. Accuracy of two electronic apex locators in primary teeth with and without apical resorption: a laboratory study. Int Endod J. 2008;41: 436–41.

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