Intra- and Interobserver Agreement during the Assessment of the Different Stages of Root Development Using 4 Radiographic Classifications

Hugo Plascencia, Mariana Díaz, Ronald Ordinola-Zapata, María Eugenia Vázquez-Sánchez, Norberto Juárez-Broon, Aloysia Ruíz-Gutiérrez, Gerardo Gascón, Alvaro Cruz

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2 Scopus citations


Introduction: This study analyzed intra- and interobserver agreements during radiographic assessment of the different stages of root development using the dichotomous, Moorrees, Demirjian, and Cvek classifications, as well as the effect of the observer's level of experience on the result. Methods: Two hundred eighty-five digital periapical radiographs were examined via visual inspection by 3 experienced and 3 nonexperienced observers (n = 6) under strict technological and viewing conditions. After observer calibration, determination of the presence or absence of an open apex and the assignment of a root development stage according to the different subdivisions of the 4 indexes were performed. This evaluation was carried out by each observer in duplicate in the first round (n = 8) and repeated in the second round (n = 8). The 16 examinations performed by each observer (N = 96) were analyzed to determine the percentage of concordance followed by intraobserver, interobserver, and global observer agreement using the kappa coefficient and a weighted kappa. Additionally, to determine the level of concordance between the visual determination of an open or closed apex and the apical foramen width measured in millimeters, a dichotomized kappa coefficient was applied. Results: A good level of global observer agreement was found for the dichotomous, Demirjian, and Cvek classifications. However, a significantly low percentage of total concordance and global observer agreement (6.66% and 0.498, respectively) was obtained using the Moorrees classification, which was more pronounced among nonexperienced observers (0.247). Apical foramen width measurements indicated the presence of 143 roots with an open apex (50.2%) and 142 with a closed apex (49.8%), and the dichotomized kappa coefficient test revealed a good level of agreement during the visual determination of an open or closed apex (range, 0.611–0.636). Conclusions: The classifications of Cvek and Demirjian provided reliable results when determining the different stages of root development. In contrast, the Moorrees classification provided the lowest agreement values, with a significant negative effect among nonexperienced observers. Finally, the visual estimation of the presence (or absence) of an open apex provided a good level of concordance with the radiographic apical foramen width.

Original languageEnglish (US)
Pages (from-to)906-913
Number of pages8
JournalJournal of Endodontics
Issue number6
StatePublished - Jun 2021

Bibliographical note

Funding Information:
The authors thank the 3 second-year students enrolled in the degree in dentistry at the University Center of Health Sciences (CUCS), University of Guadalajara, Guadalajara, Mexico, who participated as nonexperienced observers in this study: Paulina Michelle Suárez-Huizar, Jorge Arturo Peña-Bañuelos, and Roberto Adrián Zamora-Regalado. The authors deny any conflicts of interest related to this study.

Publisher Copyright:
© 2021 American Association of Endodontists


  • Concordance studies
  • interobserver agreement
  • intraobserver agreement
  • open apex
  • stages of root development

PubMed: MeSH publication types

  • Journal Article


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