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Gaya C. S. Vieira, DDS, MSc,*

Impact of Contracted Alejandro R. Pe rez, DDS, MSc,
PhD,* Flavio R. F. Alves, DDS,
Endodontic Cavities on Root MSc, PhD,*†
Jose C. Provenzano, DDS, MSc,
Canal Disinfection and Shaping PhD,* Ibrahimu Mdala, MSc,
PhD,‡ Jose  F. Siqueira, Jr., DDS,
MSc, PhD,*† and
Isabela N. Ro^ças, DDS, MSc,


Introduction: The impact of minimally invasive endodontic procedures on root canal
disinfection has not been determined. This ex vivo study compared root canal disinfection and Preserving hard tissue during
shaping in teeth with contracted or conventional endodontic cavities. Methods: Mandibular root canal treatment is a logical
incisors with oval-shaped canals were selected and anatomically matched based on micro– goal to prevent tooth fracture
computed tomographic (micro-CT) analysis and distributed into 2 groups. Conservative and and loss. In this context,
conventional access cavities were prepared, and the canals were contaminated with a pure preparation of conservative
culture of Enterococcus faecalis for 30 days. Root canal preparation in both groups was endodontic access cavities
performed using the XP-endo Shaper instrument (FKG Dentaire, La Chaux-de-Fonds, has been proposed. Although
Switzerland) and 2.5% sodium hypochlorite irrigation. Intracanal bacteriologic samples were shaping of oval canals with
taken before and after preparation, and DNA was extracted and subjected to quantitative adjustable instruments was not
polymerase chain reaction. Micro-CT scans taken before and after preparation were used for significantly different between
shaping evaluation. Bacteriologic data were analyzed by the Poisson regression model and groups, disinfection was much
the chi-square test with Yates correction. Micro-CT data were analyzed by the Wilcoxon, better in teeth with
Mann-Whitney, and Student t tests with the significance level set at 5%. Results: All initial conventional cavities than in
samples were positive for E. faecalis. After preparation, the number of bacteria-positive teeth with contracted cavities.
samples was significantly higher in the contracted cavity group (25/29, 86%) than in the
conventional cavity group (14/28, 50%) (P , .01). Intergroup quantitative comparison showed
that the reduction in bacterial counts was also significantly higher in the group of conventional
cavities (P , .01). Micro-CT data revealed no significant difference in the amount of unpre-
pared areas between groups. Conclusions: Our findings showed that although shaping
using an adjustable instrument was similar between groups, disinfection was significantly
compromised after root canal preparation of teeth with contracted endodontic
cavities. (J Endod 2020;-:1–7.)

Bacterial reduction; contracted endodontic cavity; endodontic treatment; minimally invasive From the *Department of Endodontics
endodontics; root canal preparation and Dental Research, Iguaçu University
(UNIG), Nova Iguaçu, Rio de Janeiro,
Brazil; †Department of Endodontics,
Because apical periodontitis is an inflammatory disease caused by bacteria that colonize the root canal Grande Rio University (UNIGRANRIO),
system, successful root canal treatment relies on effective infection control1. An initial and very important Duque de Caxias, Rio de Janeiro, Brazil;
and ‡Department of General Practice,
phase of root canal treatment is to prepare a coronal access cavity with adequate design and size to
University of Oslo, Oslo, Norway
permit the detection of all root canal orifices, reducing the risks of missing canals that might jeopardize the
Address requests for reprints to Dr Flavio
treatment outcome2, and enhance the efficacy of root canal instrumentation, eliminating coronal
R. F. Alves, Department of Endodontics
anatomic interferences and preventing intraoperative iatrogenic complications, such as ledge formation and Dental Research, Av Abílio Augusto
and instrument fracture3,4. Tavora, 2134, Nova Iguaçu–RJ, Brazil
Recently, the concept of minimally invasive endodontics (MIE) has been introduced with the main 26260-045.
purpose of promoting minimal change to the dental hard tissues during root canal treatment in order to E-mail address: flavioferreiraalves@gmail.
improve the long-term survival and function of treated teeth5. MIE is a natural derivative of minimally 0099-2399/$ - see front matter
invasive dentistry, which has been claimed to include approaches to prevent or treat disease with as little
Copyright © 2020 American Association
loss of original tissue as possible6. An important aspect of MIE refers to the size and design of endodontic of Endodontists.
access cavities. Contracted cavities have been recommended to preserve hard tissue structure and https://doi.org/10.1016/
reduce the risks of tooth fracture and loss after root canal treatment. Studies evaluating the influence of j.joen.2020.02.002

JOE  Volume -, Number -, - 2020 Impact of Contracted Cavities on Shaping and Disinfection 1
minimally invasive access cavities on the distance17. Moreover, selected teeth had all phases of the root canal treatment.
fracture resistance of root canal–treated teeth intact crowns (without caries and restorations), Minimally invasive access cavities were
and shaping effects of instrumentation have completely formed roots, and no significant prepared under magnification with an
reported controversial results7–13. A calcifications or internal resorption defects. operating microscope (DF Vasconcellos,
systematic review of ex vivo studies concluded Valença, RJ, Brazil) using round 1012 HL burs
that there is no evidence that supports the use Micro-CT Analyses (KG Sorensen, Sa ~o Paulo, SP, Brazil) at high
of contracted endodontic cavities over Morphometric evaluation of the root canal speed.
traditional endodontic cavities for the increase was performed using micro-CT imaging. The In the other group, access cavities were
of fracture resistance in human teeth14. There SkyScan 1174v2 device (Bruker-microCT, prepared following conventional guidelines for
is also limited and inconclusive information Kontich, Belgium) was used at an isotropic size and outline4 using round 1014 HL and
about the effects of MIE on root canal resolution of 23.14 mm, 70 kV, and 800 mA. Endo-Z burs (Dentsply Maillefer, Ballaigues,
shaping7,8,10. At the time of this writing, no Scanning was performed by 180 rotation Switzerland) at high speed under an operating
study has evaluated the impact of contracted around the vertical axis with a rotation step microscope.
endodontic cavities on root canal disinfection. of 1.0 using a 0.5-mm-thick aluminum filter.
Because the elimination of intracanal bacteria The aims of micro-CT scanning were to
to levels compatible with periradicular tissue evaluate the root canal anatomy for Root Canal Contamination
healing is paramount for root canal treatment specimen selection, standardize distribution A hand K-type file size 15 (FKG Dentaire, La
success15,16, discussion and acceptance of between groups by matching the teeth by Chaux-de-Fonds, Switzerland) was placed in
MIE approaches should not advance without volume and anatomic similarities, plan the root canal until its tip was visualized at the
knowing if this goal of endodontic treatment access cavity preparation, and analyze and apical foramen using a stereomicroscope. This
will be substantially impacted. quantify the prepared canal surface areas. measure was recorded as the patency length,
The purpose of this ex vivo study was to Images of each specimen were and all root canals were instrumented up to
evaluate the effects of minimally invasive reconstructed with dedicated software this point with an Mtwo 10/.04 instrument
endodontic approaches on the disinfection (NRecon v.1.6.3, Bruker-microCT) providing (VDW, Munich, Germany) operated in the VDW
and shaping of oval canals of mandibular axial cross sections of the samples. The Silver torque-limited electric motor to
incisors. Bacterial reduction was assessed by images were segmented into CTAn v.1.12 standardize the initial root canal diameter and
a quantitative real-time polymerase chain software (Bruker-microCT), and create room for further canal contamination.
reaction (qPCR) assay, and the shaping effects reconstruction of the 3-dimensional models The smear layer was removed as follows. The
were evaluated by micro–computed was performed using Ctvol v.2.2.1 software canals were filled with 17% EDTA (Merck, Rio
tomographic (micro-CT) analysis. (Bruker-microCT). ImageJ 1.50d software de Janeiro, RJ, Brazil) using a NaviTip 30-G
(National Institutes of Health, Bethesda, MD) needle (Ultradent, South Jordan, UT); the teeth
was used to calculate the surface area were completely immersed in the same
(mm2) and volume (mm3) of the canal in the solution and then subjected to ultrasonic
Specimen Selection and full canal length (from the working length to agitation for 3 minutes. Next, the same
Preparation 10 mm short) and in the apical segment approaches were performed in sequence
The sample size was calculated using (from the working length to 4 mm short). using distilled water, 2.5% sodium
G*Power 3.1 software (Heinrich Heine The same software was used to evaluate the hypochlorite (NaOCl), and 10% sodium
€sseldorf, Germany) with an
Universit€at, Du amount of unprepared root canal surfaces thiosulfate (Merck).
alpha-type error of 0.05 and 95% power, by calculating the number of static voxels, The canals were washed with distilled
which revealed that at least 22 teeth per group which was expressed as a percentage of the water and then filled with trypticase soy broth
were required for the bacteriologic analysis total number of voxels on the canal surface. (Difco, Detroit, MI). The teeth were completely
and 12 for the micro-CT analysis. Thirty teeth immersed in the same broth within
were used per group, considering the risk of microcentrifuge tubes and centrifuged twice at
losing specimens during the experiment and to Preparation of the Contracted 10,000 rpm for 2 minutes in order to release
strengthen the statistic analysis. Sixty-two Access Cavity entrapped air and allow penetration of
mandibular incisors with long oval root canals Micro-CT images were used to plan the the culture medium into root canal
were selected from a collection of 250 incisors preparation of the contracted access cavities, irregularities. The specimens were sterilized
extracted for reasons not related to this study. which consisted of a small round cavity as in an autoclave.
The teeth were anatomically matched in pairs incisal as possible, conserving hard tissue Enterococcus faecalis strain ATCC
and randomly assigned to 2 groups. Two teeth structure in the cingulum region. For this, the 29212 (American Type Culture Collection,
were used as contamination controls. The micro-CT image of the incisal edge was Manassas, VA) was used for canal
study protocol was approved by the superimposed to the image of the pulp contamination. A freshly grown overnight
institutional ethics committee (reference chamber, and the distance from the latter to culture of this bacterial strain was used to
number 1278002). the mesial and distal aspects was measured inoculate the medium containing the teeth. The
The inclusion criterion was as follows: using ImageJ 1.50d. These measures were specimens were incubated for 30 days at 37 C
teeth with a single canal that was oval shaped transferred to the incisal edge of the tooth under gentle shaking, and the culture medium
at 3 mm short of the apex based on specimen with the aid of a digital caliper was replenished every week by a fresh one.
buccolingual and mesiodistal radiographic (Stainless Hardened; TooXem, Nivelles, Two teeth were fixed in 10% buffered formalin
projections and further confirmed by micro-CT Belgium) and marked with a fine-tip pilot pen. and processed for evaluation by scanning
imaging. To be considered oval shaped, the To make handling easier, teeth were mounted electron microscopy to confirm bacterial
canal had to present a buccolingual distance at vertically up to the cervical region with the root colonization and biofilm formation on the canal
least twice as large as the mesiodistal wrapped in moistened gauze in a bench vise in walls as described previously18.

2 Vieira et al. JOE  Volume -, Number -, - 2020

Bacteriologic Sample Taking the XP-endo Shaper instrument was counts were inferred based on a standard
Procedures withdrawn. Next, the XP-endo Shaper curve constructed using DNA extracts from
The apical foramina of all of the teeth were instrument was used twice as described (a total known concentrations of E. faecalis ATCC
sealed with Topdam material (FGM, Joinville, of 3 cycles of 10 seconds each at the WL). After 29212, which were 10-fold diluted from 107 to
SC, Brazil) to prevent leakage of bacteria the last cycle, the canal was irrigated with 2 mL 102 cells in Tris-EDTA buffer and used for
through the apical foramen and to create a NaOCl for 30 seconds, 5 mL 17% EDTA for 30 curve construction.
closed-end system that simulates the vapor seconds, and 2 mL NaOCl for 30 seconds. A
lock effect. Before chemomechanical final irrigation with 1 mL 10% sodium thiosulfate Statistical Analysis
preparation, the tooth crown, including the for 1 minute was performed for NaOCl Bacteriologic samples were taken from the 2
pulp chamber walls, and the external surface inactivation, and the S2 bacteriologic sample groups at 2 time points. Multilevel Poisson
of the root were cleaned with 3% hydrogen was taken as outlined earlier. A new micro-CT regression models were fitted to bacterial count
peroxide and disinfected with 2.5% NaOCl. scan was performed (scan 2). data to account for the overdispersion in data
The latter was then inactivated with 10% Each instrument was used to prepare 3 and the fact that these data were clustered at
sodium thiosulfate. This procedure was root canals. NaviTip needles (30-G) were used the individual level. Incidence rate ratios were
performed with sterile cotton swabs and sterile for all irrigation procedures. Needles were obtained from the models and described the
paper points moistened with the solutions. A placed at 3 mm short of the WL. The irrigation intragroup and intergroup changes in bacterial
sterility control sample (negative control) was needle was coupled to the Vatea irrigation counts after treatment. Analyses were
taken from the internal surfaces of the access pump (ReDentNOVA, Ra’anana, Israel) for performed in StataSE 15 software (StataCorp,
cavity using sterile paper points, which were control of the irrigant flow. In both groups, the Station College, TX). Data on bacterial
placed in Tris-EDTA buffer (10 mmol/L Tris-HCl total volume of irrigant used per canal was 10 presence/absence after treatment were
and 1 mmol/L EDTA, pH 5 7.6) and later mL 2.5% NaOCl and 5 mL 17% EDTA. compared using the chi-square test with Yates
processed and analyzed the same way as All procedures were conducted under correction using STATISTICA v8.0 software
described for the root canal samples (see strict aseptic conditions inside an ultraviolet (StatSoft, Tulsa, OK).
later). sterilizer cabinet with the internal temperature For micro-CT analysis of the unprepared
Intracanal bacteriologic samples were condition kept at 37 C by a heater (800- surface areas, normality of the quantitative
taken before (S1) and after root canal Heater; PlasLabs, Lansing, MI). All irrigants variables was verified through the
preparation (S2). The root canal was initially were also preheated in a water bath at 37 C. Kolmogorov-Smirnov test and graphic
rinsed with 1 mL sterile 0.85% saline solution to analysis. For intra- and intergroup
remove unattached bacterial cells, and an initial comparisons related to the total root canal
sample was taken by the sequential use of 3–5 Molecular Microbiology Analysis length (10 mm), the Student t test was applied
paper points placed 1 mm short of the patency The QIAamp DNA Mini Kit (Qiagen, Valencia, to data from root canal volume and surface
length. This measure was defined as the CA) was used for DNA extraction from the (initial and final) as well as the amount of
working length (WL). Each paper point was left bacteriologic samples (sterility control, S1, and unprepared areas. When the apical 4-mm
in the canal for 1 minute, removed, and placed S2) according to the protocol recommended segment of the canal was evaluated
in flasks containing 1 mL Tris-EDTA buffer. by the manufacturer. The total E. faecalis levels separately, the nonparametric Mann-Whitney
Samples were immediately frozen at 220 C were quantified in a 16S ribosomal RNA gene- test was used for intergroup analyses and the
until DNA extraction and qPCR analysis. based qPCR assay using a specific primer pair Wilcoxon test for intragroup analyses. SPSS
for this species19. The qPCR assay was software (Statistical Package for Social
conducted using Power SYBR Green PCR Sciences 21.0; IBM Corp, Armonk, NY) was
Chemomechanical Preparation Master Mix (Thermo Fisher Scientific, Foster used for analysis of micro-CT data with the
All the procedures were performed by the City, CA) on an ABI 7500 Real-time PCR significance level set at 5%.
same operator, an experienced endodontist instrument (Thermo Fisher Scientific) in a total
blinded to the internal anatomy as revealed by reaction volume of 20 mL containing each
micro-CT imaging. The teeth were distributed primer in a concentration of 0.5 mmol/L and 2
into 2 groups of 30 each, one with contracted mL of the DNA extract from each sample. The Disinfection Results
access cavities and the other with conventional qPCR reaction was as described previously20. Three teeth were excluded from the study
ones. Briefly, the temperature cycling conditions because they fractured during sterilization in
Preparation was performed the same included an initial step at 95 C for 10 minutes the autoclave (2 teeth) or had a positive result
way in all canals from the 2 groups using the followed by 40 cycles of 95 C for 1 minute, for the sterility control (1 tooth). All sterility
XP-endo Shaper instrument (FKG Dentaire). 60 C for 1 minute, and 72 C for 1 minute. The control samples for the other teeth were
Initially, the canal was irrigated with 2 mL NaOCl accumulation of polymerase chain reaction negative, and all S1 samples from these same
for 30 seconds, and a glide path to the WL was products was measured at each cycle. teeth were positive for E. faecalis. The number
established using a hand K-type file size 15. Negative controls containing no template DNA of specimens with positive results for bacteria
The XP-endo Shaper instrument was operated were subjected to the same procedures. in S2 were 25 of 29 (86%) in the group with
in the VDW Silver motor at 800 rpm and 1 Ncm Evaluations were performed in triplicate for the contracted endodontic cavities and 14 of 28
for 10 seconds with in-and-out motions and an samples, standards, and controls. Melting (50%) in the group with conventional cavities
amplitude of 3–4 mm up to the WL. The curve analysis of polymerase chain reaction (P , .01).
instrument was removed from the canal and products was performed after amplification to Intragroup quantitative analysis showed
cleaned with a sterile gauze, and irrigation was confirm the method’s specificity. Data a significant mean S1 to S2 bacterial reduction
performed with 2 mL NaOCl for 30 seconds. A acquisition and analysis were performed using of 98% and 99% in the groups of contracted
hand K-type file size 15 was used to check and ABI 7500 software v2.0.4 (Applied and conventional cavities, respectively (P ,
maintain the patency of the root canal any time Biosystems, Foster City, CA). E. faecalis .01) (Table 1). There were no significant

JOE  Volume -, Number -, - 2020 Impact of Contracted Cavities on Shaping and Disinfection 3
TABLE 1 - Molecular Microbiological Data on Intracanal Bacterial Counts before (S1) and after Preparation with the XP- unprepared wall surfaces (shaping) in oval-
endo Shaper (S2) in Teeth with Contracted or Conventional Endodontic Cavities shaped canals of mandibular incisors
compared with conventional cavities. Shaping
S1–S2 reduction and disinfection were evaluated by means of
Groups S1 S2 IRR* (95% CI) micro-CT and qPCR analyses, respectively.
The results revealed that although root canal
Contracted endodontic cavities 0.02 (0.02–0.03)
shaping was not significantly affected,
Mean 3.86E104 8.75E102
Median 2.27E104 7.74E102 intracanal disinfection was compromised in the
Range 2.16E103–2.16E105 0–3.37E103 group with conservative endodontic cavities.
Conventional endodontic cavities 0.01 (0.01–0.01) Intragroup quantitative analyses
Mean 3.24E104 2.51E102 evaluating root canal disinfection showed that
Median 1.24E104 5.74E101 both treatment protocols promoted a highly
Range 1.09E103–2.92E105 0–2.26E103 significant intracanal bacterial reduction. These
findings confirm the essential role played by
CI, confidence interval; IRR, incidence rate ratio.
*If IRR ,1, then a reduction in bacterial counts is observed; if it is .1, then an increase in bacterial counts is observed. chemomechanical procedures in disinfecting
When the IRR 5 1, then there is no change in bacterial counts. root canals21–23. However, many canals still
had detectable bacteria after preparation.
differences in S1 counts between groups (P . showing that sample distribution between These residual bacteria may have occurred in
.05). Intergroup quantitative comparisons of groups was homogeneous. Intragroup analysis unprepared areas, including recesses of oval
S2 samples showed that bacterial counts in revealed statistically significant differences in canals24,25. Because residual bacteria can put
the group of conventional cavities were 82% volume and surface area after canal preparation the treatment outcome at risk15,16, there is a
lower than in the contracted cavity group (P , with the XP-endo Shaper (P , .05). Intergroup need for developing strategies to improve
.01) (Table 1). comparison showed no significant difference in disinfection during or after chemomechanical
the amount of unprepared areas between the preparation of oval and irregular canals.
contracted and conventional endodontic cavity Intergroup comparisons of S2 samples
Shaping Results showed that treatment using conventional
groups in both the full canal length and the
Table 2 depicts the mean, median, and range
apical 4 mm (Fig. 1A–D). access cavities promoted a highly significantly
values for volume and surface area of the full
better disinfection than the group with minimally
canal length (10 mm) and the apical portion
invasive access cavities. This was observed for
(4 mm) of the oval root canals before and after
DISCUSSION both the reduction in bacterial counts and the
preparation with the XP-endo Shaper in both
number of cases negative for bacterial
groups evaluated. No statistically significant This ex vivo study evaluated the impact of
presence. Microbiological studies have been
differences were observed in the initial volume contracted endodontic cavities on the bacterial
regarded as a surrogate end point for outcome
and surface area of the root canals (P . .05), reduction (disinfection) and the amount of
studies, and a recent study reported better
prognosis when the results of qPCR were
TABLE 2 - Micro–computed Tomographic Analyses after Root Canal Enlargement with the XP-endo Shaper in Teeth negative for bacterial presence or resulted in low
with Contracted or Conventional Endodontic Cavities bacterial counts at the time of filling16. The
present findings indicate that the size and
Contracted endodontic Conventional design of the access cavity may influence root
Data cavities endodontic cavities canal disinfection. The contracted cavity may
Total length (10 mm) have interfered with the performance of the XP-
Volume (mm3) endo Shaper instrument. This instrument works
Initial 7.1 (6.8, 4.8–9.5) 7.1 (6.4; 3.5–12.8) in a serpentine motion to touch more areas,
After XP-endo Shaper 11.3 (11.2, 7.5–13.9) 12.7(12.4, 8.4–19.6) which may conceivably improve detachment of
D% after XP-endo Shaper 60.7 (57.7, 25.9–99.4) 88.9 (78.8, 43.0–260.1) bacterial biofilms from the canal walls26.
Surface area (mm2) Conservative access cavities have been shown
Initial 51.5 (51.8, 37.9–71.9) 51.3 (50.4, 34.7–74.3) to negatively affect the angle of entry of the
After XP-endo Shaper 63.2 (61.5, 46.7–81.7) 68.0 (66.2, 50.0–92.7) instrument in the canal27 and may have
D% after XP-endo Shaper 23.7 (21.7, 5.5–51.8) 32.3 (27.9, 15.8–76.6)
restricted the movement of XP-endo Shaper.
Unprepared area (%)
After XP-endo Shaper 38.6 34.2 However, because micro-CT imaging disclosed
Apical portion (4 mm) no significant differences in the amount of
Volume (mm3) unprepared areas between groups, it is also
Initial 1.4 (1.4, 0.8–4.4) 1.5 (1.4, 0.7–2.6) possible that better flushing of the irrigant
After XP-endo Shaper 2.3 (2.5, 1.2–8.9) 2.6 (2.7, 1.2–4.4) develops in teeth with conventional access
D% after XP-endo Shaper 78.6 (83.6, 23.7–128.4) 79.3 (70.4, 32.5–165.8) preparations. The possibility also exists that the
Surface area (mm2) XP-endo Shaper instrument may have touched
Initial 16.2 (15.3, 11.1–36.9) 16.5 (15.3, 9.2–24.1) more walls in the conventional cavity group
After XP-endo Shaper 20.6 (20.6, 14.3–51.6) 21.0 (20.8; 13.7–29.3) without necessarily enlarging the canal (and
D% after XP-endo Shaper 27.2 (28.7, 5.8–44.7) 29.1 (26.1, 10.8–62.5)
consequently not being shown in micro-CT
Unprepared area (%)
After XP-endo Shaper 45.2 43.0 imaging). This may have been sufficient to
detach biofilms and improve bacterial reduction.
Data for the total root canal length (10 mm) and the apical segment (4 mm) expressed as mean (median, range). These speculations need to be clarified.

4 Vieira et al. JOE  Volume -, Number -, - 2020

FIGURE 1 – Representative 3-dimensional models of mandibular incisors with contracted and conventional access cavities. (A and B ) Scans were taken before (green) and after root
canal preparation (red) with the XP-endo Shaper. Areas in green in (B and C ) superimposed images correspond to unprepared areas. (D ) Representative 3-dimensional models of the
access cavities.

Micro-CT scans were taken the same Bo veda and Kishen28 to conserve the cingulum with paper points. This approach only permits
time as the bacteriologic samples (ie, before dentin and the largest amount of dentin as evaluation of the bacteriologic conditions in the
preparation [scan 1] and after XP-endo possible. The XP-endo Shaper was used for main canal and cannot determine the exact
Shaper instrumentation, 30/.04 [scan 2]). canal preparation in all groups because it is 1 of location of the residual bacteria30,31.
After preparation with the XP-endo Shaper in the recently introduced instruments that can Cryopulverization of root specimens has been
both groups, no statistically significant adjust itself to the original root canal anatomy proposed to overcome these limitations, but
difference was observed, suggesting that the and does not require transforming a nonround because of its destructive nature, it cannot be
access cavity size did not influence canal canal into a round one. This instrument was used for longitudinal analyses of samples taken
shaping when this adjustable instrument was designed to improve shaping, cleaning, and at different time points32,33.
used. These findings are in agreement with disinfection because of its snake shape and In conclusion, findings from the present
studies using other instruments8,10. ability to expand and contract inside the root study showed that disinfection was
Nevertheless, it has been shown that canal at body temperature26,29. Because the significantly compromised after root canal
minimally invasive access cavities in XP-endo Shaper instrument was designed to preparation of teeth with contracted
mandibular molars may compromise the touch more walls than conventional endodontic cavities. Because healing of apical
shaping performance of conventional instruments without excessively removing periodontitis is reliant on effective infection
instruments in the preparation of distal dentin structure, it might be indicated for control15,16, excessive dentin preservation has
canals7. The difference in results may have minimally invasive treatments. the potential to negatively affect the treatment
been caused by the type of instruments and In this study, the specimens were outcome of infected teeth.
the teeth evaluated. In addition, the matched in pairs on the basis of the anatomic
bacteriologic results of the present study configuration and the total volume of the root
indicated enhanced bacterial elimination in canal as assessed by micro-CT imaging. The
teeth with conventional access preparations. absence of significant statistical differences Supported by grants from Fundaça ~o Carlos
Therefore, although the type of endodontic regarding the volume and initial surface area of Chagas Filho de Amparo a  Pesquisa do
cavity did not influence the amount of walls the root canals between groups showed that Estado do Rio de Janeiro and Conselho
prepared by the XP-endo Shaper instrument, the sample was homogeneous, eliminating Nacional de Desenvolvimento Científico e
bacterial reduction was significantly affected. potential anatomic biases that might interfere Tecnolo gico, Brazilian Governmental
The contracted endodontic access with the results. Institutions.
cavity was performed in the incisal area of the One of the limitations of this study was The authors deny any conflicts of
teeth following the recommendations of that bacteriologic sampling was performed interest related to this study.

JOE  Volume -, Number -, - 2020 Impact of Contracted Cavities on Shaping and Disinfection 5
1. ^ças IN. Clinical implications and microbiology of bacterial persistence after
Siqueira JF Jr, Ro
treatment procedures. J Endod 2008;34:1291–1301.e3.

2. Costa F, Pacheco-Yanes J, Siqueira JF Jr, et al. Association between missed canals and apical
periodontitis. Int Endod J 2019;52:400–6.

3. Christie WH, Thompson GK. The importance of endodontic access in locating maxillary and
mandibular molar canals. J Can Dent Assoc 1994;60:527–36.
4. Weine FS. Endodontic Therapy. 5th ed. St Louis, MO: Mosby; 1996.

5. Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent
Clin North Am 2010;54:249–73.
6. Ericson D. What is minimally invasive dentistry? Oral Health Prev Dent 2004;2(Suppl 1):287–92.

7. Krishan R, Paque F, Ossareh A, et al. Impacts of conservative endodontic cavity on root canal
instrumentation efficacy and resistance to fracture assessed in incisors, premolars, and molars. J
Endod 2014;40:1160–6.

8. Moore B, Verdelis K, Kishen A, et al. Impacts of contracted endodontic cavities on

instrumentation efficacy and biomechanical responses in maxillary molars. J Endod

9. Plotino G, Grande NM, Isufi A, et al. Fracture strength of endodontically treated teeth with
different access cavity designs. J Endod 2017;43:995–1000.
10. Rover G, Belladonna FG, Bortoluzzi EA, et al. Influence of access cavity design on root canal
detection, instrumentation efficacy, and fracture resistance assessed in maxillary molars. J
Endod 2017;43:1657–62.
11. € u
Ozy €
€rek T, Ulker €rek EO, Yilmaz F. The effects of endodontic access cavity
O, Demiryu
preparation design on the fracture strength of endodontically treated teeth: traditional versus
conservative preparation. J Endod 2018;44:800–5.
12. Abou-Elnaga MY, Alkhawas MA, Kim HC, Refai AS. Effect of truss access and artificial truss
restoration on the fracture resistance of endodontically treated mandibular first molars. J Endod
13. Corsentino G, Pedulla E, Castelli L, et al. Influence of access cavity preparation and remaining
tooth substance on fracture strength of endodontically treated teeth. J Endod 2018;44:1416–21.

14. Silva E, Rover G, Belladonna FG, et al. Impact of contracted endodontic cavities on fracture
resistance of endodontically treated teeth: a systematic review of in vitro studies. Clin Oral
Investig 2018;22:109–18.

15. €gren U. Success and Failure in Endodontics [Odontological Dissertation no. 60]. Umea,
Sweden: University of Umea; 1996.
16. Zandi H, Petronijevic N, Mdala I, et al. Outcome of endodontic retreatment using 2 root canal
irrigants and influence of infection on healing as determined by a molecular method: a
randomized clinical trial. J Endod 2019;45:1089–1098.e5.
17. Jou YT, Karabucak B, Levin J, Liu D. Endodontic working width: current concepts and
techniques. Dent Clin North Am 2004;48:323–35.
18. Siqueira JF Jr, Alves FR, Almeida BM, et al. Ability of chemomechanical preparation with either
rotary instruments or self-adjusting file to disinfect oval-shaped root canals. J Endod

19. ^ças IN, Siqueira JF Jr, Santos KR. Association of Enterococcus faecalis with different forms of
periradicular diseases. J Endod 2004;30:315–20.

20. ^ças IN, Siqueira JF Jr. Characterization of microbiota of root canal-treated teeth with
posttreatment disease. J Clin Microbiol 2012;50:1721–4.
21. Alves FR, Ro ^ças IN, Almeida BM, et al. Quantitative molecular and culture analyses of bacterial
elimination in oval-shaped root canals by a single-file instrumentation technique. Int Endod J
22. Neves MA, Ro ^ças IN, Siqueira JF Jr. Clinical antibacterial effectiveness of the self-adjusting file
system. Int Endod J 2014;47:356–65.

23. Neves MA, Provenzano JC, Ro ^ças IN, Siqueira JF Jr. Clinical antibacterial effectiveness of root
canal preparation with reciprocating single-instrument or continuously rotating multi-instrument
systems. J Endod 2016;42:25–9.

6 Vieira et al. JOE  Volume -, Number -, - 2020

24. Siqueira JF Jr, Ro^ças ID, Marceliano-Alves MF, et al. Unprepared root canal surface areas:
causes, clinical implications, and therapeutic strategies. Braz Oral Res 2018;32:e65.

25. Lacerda M, Marceliano-Alves MF, P erez AR, et al. Cleaning and shaping oval canals with 3
instrumentation systems: a correlative micro-computed tomographic and histologic study. J
Endod 2017;43:1878–84.

26. Alves FR, Paiva PL, Marceliano-Alves MF, et al. Bacteria and hard tissue debris extrusion and
intracanal bacterial reduction promoted by XP-endo Shaper and Reciproc instruments. J Endod

27. Eaton JA, Clement DJ, Lloyd A, Marchesan MA. Micro-computed tomographic evaluation of the
influence of root canal system landmarks on access outline forms and canal curvatures in
mandibular molars. J Endod 2015;41:1888–91.

28. Boveda C, Kishen A. Contracted endodontic cavities: the foundation for less invasive alternatives
in the management of apical periodontitis. Endod Topics 2015;33:169–86.
29. Machado AG, Guilherme BPS, Provenzano JC, et al. Effects of preparation with the Self-Adjusting
File, TRUShape and XP-endo Shaper systems, and a supplementary step with XP-endo Finisher
R on filling material removal during retreatment of mandibular molar canals. Int Endod J
30. Sathorn C, Parashos P, Messer HH. How useful is root canal culturing in predicting treatment
outcome? J Endod 2007;33:220–5.
31. Siqueira JF Jr, Antunes HS, Ro^ças IN, et al. Microbiome in the apical root canal system of teeth
with post-treatment apical periodontitis. PLoS One 2016;11:e0162887.

32. Alves FR, Siqueira JF Jr, Carmo FL, et al. Bacterial community profiling of cryogenically ground
samples from the apical and coronal root segments of teeth with apical periodontitis. J Endod

33. Alves FR, Andrade-Junior CV, Marceliano-Alves MF, et al. Adjunctive steps for disinfection of the
mandibular molar root canal system: a correlative bacteriologic, micro-computed tomography,
and cryopulverization approach. J Endod 2016;42:1667–72.

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