BASIC RESEARCH – TECHNOLOGY

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

Impact of Contracted Alejandro R. Pe
rez, DDS, MSc,
PhD,* Fla
vio 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,
†
PhD*

ABSTRACT
SIGNIFICANCE
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.)

KEY WORDS
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 Fl
avio
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. T
avora, 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.
com
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
fracture resistance of root canal–treated teeth
and shaping effects of instrumentation have
reported controversial results7–13. A
systematic review of ex vivo studies concluded
that there is no evidence that supports the use
of contracted endodontic cavities over
traditional endodontic cavities for the increase
of fracture resistance in human teeth14. There
is also limited and inconclusive information
about the effects of MIE on root canal
shaping7,8,10. At the time of this writing, no
study has evaluated the impact of contracted
endodontic cavities on root canal disinfection.
Because the elimination of intracanal bacteria
to levels compatible with periradicular tissue
healing is paramount for root canal treatment
success15,16, discussion and acceptance of
MIE approaches should not advance without
knowing if this goal of endodontic treatment
will be substantially impacted.
The purpose of this ex vivo study was to
evaluate the effects of minimally invasive
endodontic approaches on the disinfection
and shaping of oval canals of mandibular
incisors. Bacterial reduction was assessed by
a quantitative real-time polymerase chain
reaction (qPCR) assay, and the shaping effects
were evaluated by micro–computed
tomographic (micro-CT) analysis.
MATERIALS AND METHODS
Specimen Selection and
Preparation
The sample size was calculated using
G*Power 3.1 software (Heinrich Heine
€sseldorf, Germany) with an
Universit€at, Du
alpha-type error of 0.05 and 95% power,
which revealed that at least 22 teeth per group
were required for the bacteriologic analysis
and 12 for the micro-CT analysis. Thirty teeth
were used per group, considering the risk of
losing specimens during the experiment and to
strengthen the statistic analysis. Sixty-two
mandibular incisors with long oval root canals
were selected from a collection of 250 incisors
extracted for reasons not related to this study.
The teeth were anatomically matched in pairs
and randomly assigned to 2 groups. Two teeth
were used as contamination controls. The
study protocol was approved by the
institutional ethics committee (reference
number 1278002).
The inclusion criterion was as follows:
teeth with a single canal that was oval shaped
at 3 mm short of the apex based on
buccolingual and mesiodistal radiographic
projections and further confirmed by micro-CT
imaging. To be considered oval shaped, the
canal had to present a buccolingual distance at
least twice as large as the mesiodistal
2 Vieira et al.
distance17. Moreover, selected teeth had
intact crowns (without caries and restorations),
completely formed roots, and no significant
calcifications or internal resorption defects.
Micro-CT Analyses
Morphometric evaluation of the root canal
was performed using micro-CT imaging. The
SkyScan 1174v2 device (Bruker-microCT,
Kontich, Belgium) was used at an isotropic
resolution of 23.14 mm, 70 kV, and 800 mA.
Scanning was performed by 180 rotation
around the vertical axis with a rotation step
of 1.0 using a 0.5-mm-thick aluminum filter.
The aims of micro-CT scanning were to
evaluate the root canal anatomy for
specimen selection, standardize distribution
between groups by matching the teeth by
volume and anatomic similarities, plan
access cavity preparation, and analyze and
quantify the prepared canal surface areas.
Images of each specimen were
reconstructed with dedicated software
(NRecon v.1.6.3, Bruker-microCT) providing
axial cross sections of the samples. The
images were segmented into CTAn v.1.12
software (Bruker-microCT), and
reconstruction of the 3-dimensional models
was performed using Ctvol v.2.2.1 software
(Bruker-microCT). ImageJ 1.50d software
(National Institutes of Health, Bethesda, MD)
was used to calculate the surface area
(mm2) and volume (mm3) of the canal in the
full canal length (from the working length to
10 mm short) and in the apical segment
(from the working length to 4 mm short).
The same software was used to evaluate the
amount of unprepared root canal surfaces
by calculating the number of static voxels,
which was expressed as a percentage of the
total number of voxels on the canal surface.
Preparation of the Contracted
Access Cavity
Micro-CT images were used to plan the
preparation of the contracted access cavities,
which consisted of a small round cavity as
incisal as possible, conserving hard tissue
structure in the cingulum region. For this, the
micro-CT image of the incisal edge was
superimposed to the image of the pulp
chamber, and the distance from the latter to
the mesial and distal aspects was measured
using ImageJ 1.50d. These measures were
transferred to the incisal edge of the tooth
specimen with the aid of a digital caliper
(Stainless Hardened; TooXem, Nivelles,
Belgium) and marked with a fine-tip pilot pen.
To make handling easier, teeth were mounted
vertically up to the cervical region with the root
wrapped in moistened gauze in a bench vise in
all phases of the root canal treatment.
Minimally invasive access cavities were
prepared under magnification with an
operating microscope (DF Vasconcellos,
Valença, RJ, Brazil) using round 1012 HL burs
(KG Sorensen, Sa ~o Paulo, SP, Brazil) at high
speed.
In the other group, access cavities were
prepared following conventional guidelines for
size and outline4 using round 1014 HL and
Endo-Z burs (Dentsply Maillefer, Ballaigues,
Switzerland) at high speed under an operating
microscope.
Root Canal Contamination
A hand K-type file size 15 (FKG Dentaire, La
Chaux-de-Fonds, Switzerland) was placed in
the root canal until its tip was visualized at the
apical foramen using a stereomicroscope. This
measure was recorded as the patency length,
and all root canals were instrumented up to
this point with an Mtwo 10/.04 instrument
(VDW, Munich, Germany) operated in the VDW
Silver torque-limited electric motor to
standardize the initial root canal diameter and
create room for further canal contamination.
The smear layer was removed as follows. The
canals were filled with 17% EDTA (Merck, Rio
de Janeiro, RJ, Brazil) using a NaviTip 30-G
needle (Ultradent, South Jordan, UT); the teeth
were completely immersed in the same
solution and then subjected to ultrasonic
agitation for 3 minutes. Next, the same
approaches were performed in sequence
using distilled water, 2.5% sodium
hypochlorite (NaOCl), and 10% sodium
thiosulfate (Merck).
The canals were washed with distilled
water and then filled with trypticase soy broth
(Difco, Detroit, MI). The teeth were completely
immersed in the same broth within
microcentrifuge tubes and centrifuged twice at
10,000 rpm for 2 minutes in order to release
entrapped air and allow penetration of
the culture medium into root canal
irregularities. The specimens were sterilized
in an autoclave.
Enterococcus faecalis strain ATCC
29212 (American Type Culture Collection,
Manassas, VA) was used for canal
contamination. A freshly grown overnight
culture of this bacterial strain was used to
inoculate the medium containing the teeth. The
specimens were incubated for 30 days at 37 C
under gentle shaking, and the culture medium
was replenished every week by a fresh one.
Two teeth were fixed in 10% buffered formalin
and processed for evaluation by scanning
electron microscopy to confirm bacterial
colonization and biofilm formation on the canal
walls as described previously18.
JOE  Volume -, Number -, - 2020
Bacteriologic Sample Taking
Procedures
The apical foramina of all of the teeth were
sealed with Topdam material (FGM, Joinville,
SC, Brazil) to prevent leakage of bacteria
through the apical foramen and to create a
closed-end system that simulates the vapor
lock effect. Before chemomechanical
preparation, the tooth crown, including the
pulp chamber walls, and the external surface
of the root were cleaned with 3% hydrogen
peroxide and disinfected with 2.5% NaOCl.
The latter was then inactivated with 10%
sodium thiosulfate. This procedure was
performed with sterile cotton swabs and sterile
paper points moistened with the solutions. A
sterility control sample (negative control) was
taken from the internal surfaces of the access
cavity using sterile paper points, which were
placed in Tris-EDTA buffer (10 mmol/L Tris-HCl
and 1 mmol/L EDTA, pH 5 7.6) and later
processed and analyzed the same way as
described for the root canal samples (see
later).
Intracanal bacteriologic samples were
taken before (S1) and after root canal
preparation (S2). The root canal was initially
rinsed with 1 mL sterile 0.85% saline solution to
remove unattached bacterial cells, and an initial
sample was taken by the sequential use of 3–5
paper points placed 1 mm short of the patency
length. This measure was defined as the
working length (WL). Each paper point was left
in the canal for 1 minute, removed, and placed
in flasks containing 1 mL Tris-EDTA buffer.
Samples were immediately frozen at 220 C
until DNA extraction and qPCR analysis.
Chemomechanical Preparation
All the procedures were performed by the
same operator, an experienced endodontist
blinded to the internal anatomy as revealed by
micro-CT imaging. The teeth were distributed
into 2 groups of 30 each, one with contracted
access cavities and the other with conventional
ones.
Preparation was performed the same
way in all canals from the 2 groups using the
XP-endo Shaper instrument (FKG Dentaire).
Initially, the canal was irrigated with 2 mL NaOCl
for 30 seconds, and a glide path to the WL was
established using a hand K-type file size 15.
The XP-endo Shaper instrument was operated
in the VDW Silver motor at 800 rpm and 1 Ncm
for 10 seconds with in-and-out motions and an
amplitude of 3–4 mm up to the WL. The
instrument was removed from the canal and
cleaned with a sterile gauze, and irrigation was
performed with 2 mL NaOCl for 30 seconds. A
hand K-type file size 15 was used to check and
maintain the patency of the root canal any time
JOE  Volume -, Number -, - 2020
the XP-endo Shaper instrument was
withdrawn. Next, the XP-endo Shaper
instrument was used twice as described (a total
of 3 cycles of 10 seconds each at the WL). After
the last cycle, the canal was irrigated with 2 mL
NaOCl for 30 seconds, 5 mL 17% EDTA for 30
seconds, and 2 mL NaOCl for 30 seconds. A
final irrigation with 1 mL 10% sodium thiosulfate
for 1 minute was performed for NaOCl
inactivation, and the S2 bacteriologic sample
was taken as outlined earlier. A new micro-CT
scan was performed (scan 2).
Each instrument was used to prepare 3
root canals. NaviTip needles (30-G) were used
for all irrigation procedures. Needles were
placed at 3 mm short of the WL. The irrigation
needle was coupled to the Vatea irrigation
pump (ReDentNOVA, Ra’anana, Israel) for
control of the irrigant flow. In both groups, the
total volume of irrigant used per canal was 10
mL 2.5% NaOCl and 5 mL 17% EDTA.
All procedures were conducted under
strict aseptic conditions inside an ultraviolet
sterilizer cabinet with the internal temperature
condition kept at 37 C by a heater (800-
Heater; PlasLabs, Lansing, MI). All irrigants
were also preheated in a water bath at 37 C.
Molecular Microbiology Analysis
The QIAamp DNA Mini Kit (Qiagen, Valencia,
CA) was used for DNA extraction from the
bacteriologic samples (sterility control, S1, and
S2) according to the protocol recommended
by the manufacturer. The total E. faecalis levels
were quantified in a 16S ribosomal RNA gene-
based qPCR assay using a specific primer pair
for this species19. The qPCR assay was
conducted using Power SYBR Green PCR
Master Mix (Thermo Fisher Scientific, Foster
City, CA) on an ABI 7500 Real-time PCR
instrument (Thermo Fisher Scientific) in a total
reaction volume of 20 mL containing each
primer in a concentration of 0.5 mmol/L and 2
mL of the DNA extract from each sample. The
qPCR reaction was as described previously20.
Briefly, the temperature cycling conditions
included an initial step at 95 C for 10 minutes
followed by 40 cycles of 95 C for 1 minute,
60 C for 1 minute, and 72 C for 1 minute. The
accumulation of polymerase chain reaction
products was measured at each cycle.
Negative controls containing no template DNA
were subjected to the same procedures.
Evaluations were performed in triplicate for the
samples, standards, and controls. Melting
curve analysis of polymerase chain reaction
products was performed after amplification to
confirm the method’s specificity. Data
acquisition and analysis were performed using
ABI 7500 software v2.0.4 (Applied
Biosystems, Foster City, CA). E. faecalis
Impact of Contracted Cavities on Shaping and Disinfection
counts were inferred based on a standard
curve constructed using DNA extracts from
known concentrations of E. faecalis ATCC
29212, which were 10-fold diluted from 107 to
102 cells in Tris-EDTA buffer and used for
curve construction.
Statistical Analysis
Bacteriologic samples were taken from the 2
groups at 2 time points. Multilevel Poisson
regression models were fitted to bacterial count
data to account for the overdispersion in data
and the fact that these data were clustered at
the individual level. Incidence rate ratios were
obtained from the models and described the
intragroup and intergroup changes in bacterial
counts after treatment. Analyses were
performed in StataSE 15 software (StataCorp,
Station College, TX). Data on bacterial
presence/absence after treatment were
compared using the chi-square test with Yates
correction using STATISTICA v8.0 software
(StatSoft, Tulsa, OK).
For micro-CT analysis of the unprepared
surface areas, normality of the quantitative
variables was verified through the
Kolmogorov-Smirnov test and graphic
analysis. For intra- and intergroup
comparisons related to the total root canal
length (10 mm), the Student t test was applied
to data from root canal volume and surface
(initial and final) as well as the amount of
unprepared areas. When the apical 4-mm
segment of the canal was evaluated
separately, the nonparametric Mann-Whitney
test was used for intergroup analyses and the
Wilcoxon test for intragroup analyses. SPSS
software (Statistical Package for Social
Sciences 21.0; IBM Corp, Armonk, NY) was
used for analysis of micro-CT data with the
significance level set at 5%.
RESULTS
Disinfection Results
Three teeth were excluded from the study
because they fractured during sterilization in
the autoclave (2 teeth) or had a positive result
for the sterility control (1 tooth). All sterility
control samples for the other teeth were
negative, and all S1 samples from these same
teeth were positive for E. faecalis. The number
of specimens with positive results for bacteria
in S2 were 25 of 29 (86%) in the group with
contracted endodontic cavities and 14 of 28
(50%) in the group with conventional cavities
(P , .01).
Intragroup quantitative analysis showed
a significant mean S1 to S2 bacterial reduction
of 98% and 99% in the groups of contracted
and conventional cavities, respectively (P ,
.01) (Table 1). There were no significant
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
time as the bacteriologic samples (ie, before
preparation [scan 1] and after XP-endo
Shaper instrumentation, 30/.04 [scan 2]).
After preparation with the XP-endo Shaper in
both groups, no statistically significant
difference was observed, suggesting that the
access cavity size did not influence canal
shaping when this adjustable instrument was
used. These findings are in agreement with
studies using other instruments8,10.
Nevertheless, it has been shown that
minimally invasive access cavities in
mandibular molars may compromise the
shaping performance of conventional
instruments in the preparation of distal
canals7. The difference in results may have
been caused by the type of instruments and
the teeth evaluated. In addition, the
bacteriologic results of the present study
indicated enhanced bacterial elimination in
teeth with conventional access preparations.
Therefore, although the type of endodontic
cavity did not influence the amount of walls
prepared by the XP-endo Shaper instrument,
bacterial reduction was significantly affected.
The contracted endodontic access
cavity was performed in the incisal area of the
teeth following the recommendations of
JOE  Volume -, Number -, - 2020
Bo
veda and Kishen28 to conserve the cingulum
dentin and the largest amount of dentin as
possible. The XP-endo Shaper was used for
canal preparation in all groups because it is 1 of
the recently introduced instruments that can
adjust itself to the original root canal anatomy
and does not require transforming a nonround
canal into a round one. This instrument was
designed to improve shaping, cleaning, and
disinfection because of its snake shape and
ability to expand and contract inside the root
canal at body temperature26,29. Because the
XP-endo Shaper instrument was designed to
touch more walls than conventional
instruments without excessively removing
dentin structure, it might be indicated for
minimally invasive treatments.
In this study, the specimens were
matched in pairs on the basis of the anatomic
configuration and the total volume of the root
canal as assessed by micro-CT imaging. The
absence of significant statistical differences
regarding the volume and initial surface area of
the root canals between groups showed that
the sample was homogeneous, eliminating
potential anatomic biases that might interfere
with the results.
One of the limitations of this study was
that bacteriologic sampling was performed
Impact of Contracted Cavities on Shaping and Disinfection
with paper points. This approach only permits
evaluation of the bacteriologic conditions in the
main canal and cannot determine the exact
location of the residual bacteria30,31.
Cryopulverization of root specimens has been
proposed to overcome these limitations, but
because of its destructive nature, it cannot be
used for longitudinal analyses of samples taken
at different time points32,33.
In conclusion, findings from the present
study showed that disinfection was
significantly compromised after root canal
preparation of teeth with contracted
endodontic cavities. Because healing of apical
periodontitis is reliant on effective infection
control15,16, excessive dentin preservation has
the potential to negatively affect the treatment
outcome of infected teeth.
ACKNOWLEDGMENTS
Supported by grants from Fundaça ~o Carlos
Chagas Filho de Amparo a  Pesquisa do
Estado do Rio de Janeiro and Conselho
Nacional de Desenvolvimento Científico e
Tecnolo
gico, Brazilian Governmental
Institutions.
The authors deny any conflicts of
interest related to this study.
5
REFERENCES
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
2016;42:1779–83.

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
2019;45:813–7.
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,
Sjo
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
2010;36:1860–5.

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

20. ^ças IN, Siqueira JF Jr. Characterization of microbiota of root canal-treated teeth with
Ro
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
2012;45:871–7.
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
2018;44:1173–8.

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. Bo
veda 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
2019;52:709–15.
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
2009;35:486–92.

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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