REVIEW ARTICLE

Thaine Oliveira Lima, DDS,*

lio de Oliveira Rocha, DDS,
Aure A Global Overview of Guided
†
MS, Lucas Menezes dos Anjos,
DDS, MS,† Endodontics: A Bibliometric
nior,
Nailson Silva Meneses Ju
DDS,* Marco Antonio Hungaro Analysis
Duarte, DDS, MS, PhD,*
Murilo Priori Alcalde, DDS, MS,
PhD,* Mariane Cardoso, DDS,
MS, PhD,† and
ABSTRACT
Rodrigo Ricci Vivan, DDS, MS,
Introduction: This review aimed to analyze the trend and main characteristics of articles
PhD*
related to guided endodontics (GE). Methods: The search was conducted in May 2023 on
Web of Science. GE-related articles were included, and conferences were excluded. Three
SIGNIFICANCE
researchers selected the articles and extracted: the number of citations; year and journal;
Guided endodontics has been design and study theme; authorship and institutions; country and continent. Collaborative
a very effective technique in networks were generated in the Visualization of Similarities Viewer software. The relationship
resolving complex cases in between data was determined by Spearman’s correlation. Google Trends was used to
endodontics, bringing greater investigate the global popularity of GE research. Results: The search resulted in 135 articles,
safety, delaying work time, and of which 85 were included. The most cited article totaled 116 citations. The studies were
increasing the predictability of published between 2016 and 2023, most frequently in 2022 (n 5 22). The most prevalent
cases. journal was the Journal of Endodontics (n 5 28). Case report (n 5 38) was the most frequent
study design. The most studied theme was the use of static GE for calcified canals (n 5 27).
Connert T was the author with the highest number of articles (n 5 13). The University of Basel
(n 5 9) stood out. The most prevalent country was Brazil (n 5 13). Europe was the most
frequent continent (n 5 38). Visualization of Similarities Viewer demonstrated an interaction
between authors. There was a moderate positive correlation between citations and the impact
factor (rho 5 .483). According to Google Trends, the United States was the country that most
researched GE. Conclusions: Based on this review, a more significant research interest in
GE was observed in Europe, addressing the application of GE in locating severely calcified
root canals. (J Endod 2024;50:10–16.)

KEY WORDS
Bibliometric analysis; calcified canals; guided endodontics; root canals

An important challenge of endodontic treatment is access to calcified root canals1. Pulp canal
obliteration occurs mainly after traumatic injuries, where approximately 4%–24% of these teeth develop
some degree of obliteration. Also, 7%–27% of traumatized teeth develop pulp necrosis, requiring
endodontic intervention2. Planned and guided access in cases of calcifications can help preserve the
From the *Department of Endodontics, dental structure and avoid accidents such as deviations and perforations, which can result in a better
~o Paulo, Bauru, S~ao Paulo,
University of Sa prognosis3. In this context, guided endodontics (GE), used to access calcified root canals, is
Brazil; and †Department of Dentistry, considered a promising technique that offers highly predictable results, a lower risk of iatrogenesis, and
Federal University of Santa Catarina, a shorter working time4.
Florianopolis, Santa Catarina, Brazil
Krastl et al (2016) conducted the first scientific report on GE in a clinical case report where the
Address requests for reprints to Dr Aurelio authors used this technique to access the calcified pulp chamber of an upper central incisor with apical
de Oliveira Rocha, Postgraduate Program
periodontitis5. According to these authors, the images obtained from cone-beam computed tomography
of Dentistry / Federal University of Santa
Catarina, Campus Universita rio - Bloco H are initially aligned with intraoral scan images. Subsequently, a customized guide will be planned virtually
- Trindade, Florianopolis, Santa Catarina and produced through a 3-dimensional printer, featuring a hole to guide the correct path of the calcified
88040-900, Brazil. channel4,5. Moreover, GE is also indicated for endodontic surgeries in areas of difficult access, removal of
E-mail address: aureliorocha2015@gmail. fiberglass posts, and endodontic access in teeth with developmental anomalies6-8.
com
0099-2399/$ - see front matter
With the advancement of this technique, GE emerged dynamically9,10. Dynamic navigation
integrates spatial positioning technology and cone-beam computed tomography imaging using an
Copyright © 2023 American Association
of Endodontists.
optical tracking system controlled by a computer screen. In real-time, the navigation guides the user to
https://doi.org/10.1016/ drill the desired position according to the previous virtual planning10. However, both techniques have high
j.joen.2023.10.002 success rates10.

10 Lima et al. JOE  Volume 50, Number 1, January 2024

 Bibliometric analysis helps map necessary. Disagreements were resolved by necessary. Two conference documents were
cumulative scientific knowledge and consensus with a fourth researcher (R.V.). excluded from these articles and 48 were
evolutionary nuances on a given subject, excluded because they did not address the
making sense of large volumes of rigorously Data Extraction from Selected proposed objective (Fig. 1). Thus, 85 articles
unstructured data11. Bibliometric analysis can Studies were included in this bibliometric analysis
help researchers identify research trends and The following bibliometric data were extracted (Supplementary Table 1).
build solid grounds for the advancement of a from each article: number of citations, year of
field in a significant way, allowing researchers to publication, journal, impact factor (IF) (2021) Citation Analysis
obtain an overview, identify knowledge gaps, (Journal Citation Reports from Clarivate Selected articles received a total of 1262
and indicate new research ideas12. Bibliometric Analytics), study design, theme, country and citations in WoS-CC. Of these, 728
studies have been conducted in several fields of continent, institution (based on the affiliation of represented self-citations. Written by Krastl
dentistry12-14. In endodontics, important topics the corresponding author), authors, and et al, with 116 citations, the most cited article in
such as pulp regeneration, endodontic keywords. Study designs were classified into WoS-CC was “Guided Endodontics: a novel
microscopy, endodontic microbiology, systematic reviews, literature reviews, case treatment approach for teeth with pulp canal
photodynamic therapy in endodontics, and reports, case series, laboratory, and calcification and apical pathology,” published
minimally invasive access cavities were observational studies. Considering the theme in Dental Traumatology. According to
addressed in bibliometric analyses15-19. addressed in the studies, the studies were Spearman’s correlation, a moderate positive
However, to the best of our knowledge, no grouped according to the most prevalent correlation was observed between the number
bibliometric analysis on GE has been published. themes, namely: application of GE to calcified of citations and the journal’s IF (rho 5 .483)
Thus, as it is a recent technique with canals, application of GE in parendodontic and a strong negative correlation between the
many publications, conducting a bibliometric surgery, application of GE to remove fiberglass number of citations and year of publication
analysis on GE is crucial to map existing posts, GE for minimally invasive access, and (rho 5 2.760).
concepts, point out the lines of research used scientific status of GE. The topics covered in a
in its investigation, outline the scientific profile, single study were classified as “other.” The
Year of Publication
and encourage new studies. Thus, this study extracted data were transferred to Microsoft
The oldest article was published in June 2016,
aimed to analyze the characteristics of Excel 2010 (Microsoft, Redmond, WA) for
entitled “Guided Endodontics: a novel
published articles on GE. categorization. The global popularity of the
treatment approach for teeth with pulp canal
“guided endodontics” search query through
calcification and apical pathology,” published
METHODOLOGY Google Trends was also investigated.
in Dental Traumatology by Krastl et al.
Sources of Information and Search Published in May 2023, the most recent article
Data Analysis was: “Effectiveness of guided endodontics in
Strategy The graphical representation of the existing
An electronic search was conducted on May locating calcified root canals: a systematic
bibliometric networks was made using the review,” authored by Pena-Bengoa et al,
25, 2023, in the Web of Science Core
Visualization of Similarities Viewer software published in Clinical Oral Investigations. The
Collection database (https://www.
(version 1.6.17.0, Netherlands), allowing the highest number of articles (n 5 22) was
webofscience.com). For article selection, the
identification of connections between authors published in 2022. The description of the
following search strategy was applied: [TS5
and keywords. In the analysis of networks, the number of publications and citations each year
(“Guided Endodontics” OR “Endodontic
terms corresponding to the largest foci and can be seen in Figure 2.
Guide” OR “Guided Endodontic Surgery” OR
sources showed a higher occurrence. On the
(“Guided Endodontics” AND “Pulp Canal
other hand, the lower the focus or source, the
Calcification”) OR (“Guided Endodontics” AND Journals and Impact Factor
lower the occurrence of the associated term.
“Cone-Beam Computed Tomography”) OR The main journals and respective IFs in which
The lines that interconnect the terms
(“Cone-Beam Computed Tomography” AND the articles on GE were published are in
demonstrate the collaboration between them.
“Dynamic Navigation”))]. To delimit the search Table 1. The Journal of Endodontics (JOE)
Spearman’s correlation was applied to
strategy, Medical Subject Headings were (n 5 28) was the journal that most published
determine whether there was a correlation
considered, as well as synonyms and relevant studies related to GE, followed by the
between the number of citations, the year of
terms on GE reported in articles addressing International Endodontic Journal (IEJ) (n 5 10)
publication, and the journal’s IF. Before the
this topic. No filters were applied to allow a and the Australian Endodontic Journal (n 5 5).
analysis, the Kolmogorov-Smirnov test was
comprehensive search. According to the Journal Citation Reports, the
used to verify the normality of the data
journals with the highest IFs in 2021 linked to
distribution—due to the nonnormal
Eligibility Criteria this study were: the IEJ (IF 5.165) with 10
distribution, the Spearman correlation
Studies in which GE was investigated, articles, Journal of Dentistry (IF 4.991) with 1
coefficient test was used. Data analysis was
described, or mentioned were included in this article, and Journal of Clinical Medicine with 2
performed using the statistical software SPSS
bibliometric analysis. There was no year or articles (IF 4.964).
for Windows (SPSS, version 24.0; IBM,
language restriction. Publications that were not Armonk, NY).
related to the use of GE, as well as conference Study Design and Themes
articles, were excluded. Most articles were case reports (n 5 38),
RESULTS followed by laboratory studies (n 5 29),
Selection Process Search Results literature review (n 5 8), systematic review
The articles were selected by 3 independent The primary search resulted in 135 (n 5 6), observational studies (n 5 2), and case
researchers (T.O.L., L.M.A., and A.O.R.) after documents. To select the articles, title, series (n 5 2) (Fig. 1). The studies addressed
reading the title, abstract, and/or full text when abstract, and/or full text was read when the following themes: application of GE to

JOE  Volume 50, Number 1, January 2024 Bibliometric Analysis on Guided Endodontics 11
 institutions with the highest number of
publications. The first three positions belong to
the University of Basel with 9 articles, the
Federal University of Minas Gerais with 6
articles, and the University of Maryland with 5
articles.

Contributing Authors
A total of 317 authors contributed to the
articles on GE. Table 3 shows the authors with
the highest number of publications. With 13
articles, Connert T was the author with the
most publications, followed by Krastl G with 12
articles, and Weiger with 11 articles. The
frequency (3 or more occurrences) with which
they appear and the co-authorship relationship
between them is represented in
Supplementary Figure 1.

Keywords
A total of 294 keywords were identified. The
most prevalent was “guided endodontics” (58
occurrences), followed by “accuracy” (33
FIGURE 1 – Flowchart of the study selection protocol.
occurrences), and “access cavity preparation”
(30 occurrences). Figure 4 shows the most
calcified canals (n 5 41), application of GE in with 13 articles, the United States with 12
prevalent keywords (4 or more occurrences)
parendodontic surgery (n 5 10), application of articles, Switzerland with 9 articles, India with 6
and their collaborative relationships.
GE to remove fiberglass posts (n 5 4), GE for articles, and Germany with 5 articles. Among
Based on Google Trends data, the
minimally invasive access (n 5 18), scientific the continents with the most articles (Fig. 3),
popularity of “guided endodontics” research
status of GE (n 5 6), and others (n 5 6). Europe (n 5 38) stands out, followed by Latin
has remained constant over the past 5 years.
America (n 5 16) and Asia (n 5 16).
However, only the United States showed
Countries and Continents research interest. The most common related
A total of 21 countries contributed to the GE- Institutions research topics included “local guide,” “tooth,”
related articles. Considering the number of A total of 52 institutions contributed to the “surgery,” and “dental implant.” Users
publications by country, the top 5 were: Brazil articles related to GE. Table 2 shows the searching for “guided endodontics” also

FIGURE 2 – Distribution of the number of publications over the years.

12 Lima et al. JOE  Volume 50, Number 1, January 2024

TABLE 1 - Journals That Published the Most on Guided Endodontics pioneers in the published works on GE, it is
very common for the other authors to use them
Source title Number of papers Impact factor to discuss the emergence and description of
Journal of Endodontics 28 4.422 the technique, which may explain the high rate
International Endodontics Journal 10 5.165 of citations, making them classics for this
Australian Endodontics Journal 5 1.179 theme. An article must have at least 100
BMC Oral Health 3 3.747 citations to be considered a classic in a
International Journal of Computerized 3 2.923 research area14.
Dentistry The most prevalent theme addressed
Giornale Italiano di Endodonzia 3 0.14
the use of static navigation for calcified
Journal of Clinical Medicine 2 4.964
channels. Not surprisingly, it was the subject of
International Journal of Environmental 2 4.614
Research and Public Health study of the first articles since pulp calcification
Journal of Prosthetic Dentistry 2 4.148 was the reason why it promoted the
Clinical Oral Investigations 2 3.607 emergence and development of this
Journal of Esthetic and Restorative 2 3.040 technique3. Thus, the emphasis on this theme
Dentistry may be associated with the greater indication
Journal of Visualized Experiments 2 1.424 for this technique since, according to the
literature, using a guide in locating a severely
calcified channel allows a result with greater
search for related queries. The most popular research on GE. The University of Basel was predictability and presents less risk of
search queries were “local guide program” and the institution with the highest number of iatrogenic damage6. The year 2022 presented
“periodontics.” articles published in the area, and the most the highest number of publications on GE. This
prevalent keyword was “guided endodontics.” may demonstrate the increased interest in this
The most cited article was “Guided line of research, which may also be associated
DISCUSSION Endodontics: a novel treatment approach for with the incorporation of digital flow in the
This is the first bibliometric study on GE, teeth with pulp canal calcification and apical clinical routine of endodontists since this
generating valuable information about current pathology” by Krastl et al Coincidentally, this technology can be used in different stages of
lines of research and future perspectives. The was the first article published on GE in 2016, endodontic treatment, presenting greater
oldest article was published 7 years ago, in followed by “Guided endodontics: accuracy of comfort to the patient, being a safe and
2016. The JOE was the journal that presented a novel method for guided access cavity clinically applicable technique6,9, thus making
the most articles on the subject. The most preparation and root canal location,” published GE increasingly implemented by clinicians and
found study design were case reports, and by Zehnder et al, also in 2016, and it is the studied by researchers. These data
Brazil was the country that contributed most to second most cited study. As they were corroborate the result of Google Trends, which

FIGURE 3 – Worldwide distribution of the origin of publications on guided endodontics.

JOE  Volume 50, Number 1, January 2024 Bibliometric Analysis on Guided Endodontics 13
TABLE 2 - Main Institutions Associated with Guided Endodontics Research public and private sectors for dental research
in this country.
Institution Country Number of papers Europe stands out among the
University of Basel Switzerland 9 continents with more articles, a result often
Federal University of Minas Gerais Brazil 6 found in other bibliometric studies12,13. A fact
University of Maryland United States 5 that may contribute to this result in this study
University Leuven Belgium 4 on GE is that University Basel is in Europe,
University of Wu€rzburg Germany 4 which ranked first among the institutions that
Goias Federal University Brazil 3 contributed to the articles evaluated on the
University of London United Kingdom 2
theme. Oceania published only 3 articles, and
University of Copenhagen Denmark 2
Africa did not publish any articles on GE.
Griffith University Australia 2
Virginia Commonwealth University United States 2 Therefore, there is a need to introduce this
Bharati Vidyapeeth Deemed University India 2 technique in clinical practice and scientific
University of Coimbra Portugal 2 research on these continents.
Connert T was the author with the highest
number of publications, followed by Krastl G and
has exhibited the constant popularity of randomized clinical trials and, consequently, Weiger R. Together, who published nine studies
“guided endodontics” research in recent years. systematic reviews that are still underexplored and are the pioneers to publish on this topic and
The JOE was the journal that most in this theme15. initially describe the technique. Thus, they are
published studies related to GE, followed by Based on dental evidence, randomized responsible for the first five most cited articles of
the IEJ. Both are considered the leading controlled trials are considered the gold this bibliometric analysis. The articles published
journals as to aspects of research and clinical standard for clinical decision-making and have by them were mainly case reports and laboratory
practice in endodontics, and their important the highest level of scientific evidence20-22. studies describing the use of this technique for
IFs also indicate the great resource and quality Thus, randomized, well-designed clinical trials calcified root canals.
of information these journals offer to are encouraged, showing their results and A strong point observed in this study is
researchers and clinicians interested in this follow-ups. Perhaps this gap in the literature is that it did not use filters with limitations of
area15. The critical influence of these journals justified by the difficulty in standardizing these years, citations, or language. This allowed a
on endodontic practice justifies the patients with exact indications for undergoing broad and complete analysis of all documents
prominence of both in this bibliometric review. the technique. An alternative to circumvent the with this theme published until the search date.
Case reports on GE had a significant difficulty in obtaining a significant sample is to As most studies require reading results from
number of publications. The case reports conduct multicenter clinical studies. previous research, this bibliometric study has
evaluate the results and describe the GE Brazil stood out as the country with the limitations that should be considered, such as
technique in clinical practice. This fact can be most published works on GE, being the most using a single database to extract the selected
justified due to this being a recent technique, fruitful in another bibliometric study16. This articles. However, this is the most prestigious
making it challenging to conduct well-designed highlight may be associated with the important database for bibliometric surveys25,26.
randomized clinical studies, which require a performance of the Federal University of Minas This bibliometric review demonstrated
longer clinical time to be carried out and follow- Gerais, which ranked second among the the current state and trend of research related
up. Furthermore, the difficulty in standardizing institutions that research the most on the topic. to GE, observing that, at the moment, there is
and assembling a significant sample of According to Vitali et al23, despite having gaps greater research interest in Europe. However,
patients with pulp calcification may explain the in professional networks and limited access to Brazil is the prominent country with the most
large number of clinical cases on GE. information, Brazil is still among the most cited articles on the topic, followed by the United
Understandably, the laboratory study was the countries in dental research due to the States. There is a growing line of published
second most found study design, which is commitment of professionals and government studies on GE over the years, demonstrating
extremely important to outline the degree of funding. The United States was the second progress in the research interest in this field.
safety of application of the technique in country with the highest number of published Much of the work was published in the JOE.
patients, in addition to providing preliminary studies, which also stood out in several other Most of them were clinical case reports
data on which subsequent studies with greater bibliometric studies15,23,24. This is likely due to addressing the application of GE in locating
evidence can be designed, such as the existence of institutes that actively fund the severely calcified root canals. No randomized
clinical studies on GE were found, which may
TABLE 3 - Authors with More Publications on Guided Endodontics be an important line of future research. Also,
conducting studies on this theme on the
Authors Number of papers Number of citations African continent is suggested.
Connert T 13 479
Krastl G 12 479
Weiger R 11 461
CREDIT AUTHORSHIP
Kuhl S 8 452 CONTRIBUTION STATEMENT
Machado VC 8 120 Thaine Oliveira Lima: Conceptualization,
Krug R 5 98
Funding acquisition, Formal analysis, Data
Torres A 5 77
curation, Writing – original draft, Final approval.
Mostoufi B 5 61
Price JB 5 61 Aure lio de Oliveira Rocha:
Leontiev W 5 25 Conceptualization, Funding acquisition,
Formal analysis, Data curation, Writing –

14 Lima et al. JOE  Volume 50, Number 1, January 2024

FIGURE 4 – Frequency and interaction of the main keywords associated with the study. Minimum number of keywords: 4 studies. In the largest points and with highlighted font are the
keywords that appeared more often; on the other hand, the words that appear less often are associated with the smallest points and written with a smaller font. The lines joining these
points indicate the relationship and use of these words in the same studies.

original draft, Final approval. Lucas Menezes curation, Writing – review & editing, Final ACKNOWLEDGMENTS
dos Anjos: Conceptualization, Funding approval. Murilo Priori Alcalde:
acquisition, Formal analysis, Data curation, Conceptualization, Formal analysis, Data This study was financed in part by the
Writing – original draft, Final approval. Nailson curation. Mariane Cardoso: Coordenaç~ao de Aperfeiçoamento de Pessoal
Silva Meneses Ju  nior: Funding acquisition, Conceptualization, Formal analysis, Data de Nivel Superior–Brazil (CAPES), grant
Writing – original draft, Final approval. Marco curation. Rodrigo Ricci Vivan: number 001.
Antonio Hungaro Duarte: Conceptualization, Formal analysis, Data The authors deny any conflicts of
Conceptualization, Formal analysis, Data curation. interest related to this study.

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