Content Server

doi:10.1111/iej.
12410
REVIEW
Master apical file size smaller or larger: a

systematic review of microbial reduction
A. Aminoshariae1 & J. Kulild2

1
Department of Endodontics, Case School of Dental Medicine, Cleveland, OH; and 2Dental School, UMKC, Kansas City, MO, USA
Abstract
Aminoshariae A, Kulild J. Master apical file size
smaller or larger: a systematic review of microbial reduction.
International Endodontic Journal, 48, 10071022, 2015.
The purpose of this systematic review was to

determine, in patients undergoing root canal treatment, whether apical enlargement of canals affected
microbial reduction. A PICO (population, intervention,
comparison and outcome) strategy was developed to
identify previously published studies dealing with apical size of canal and microbial reduction. The MEDLINE, Embase, Cochrane and PubMed databases were
searched. Additionally, the bibliographies of all relevant articles and textbooks were manually searched.
Based on inclusion and exclusion criteria,
two
reviewers independently selected the relevant articles.
Due to the variety of methodologies and different
techniques used to measure outcome for master apical
Introduction
Although it has been reported that it is virtually
impossible to render root canal systems (RCS) of teeth
bacteria-free, (Bystr
om & Sundqvist 1981, rstavik
et al. 1991, Wu & Wesselink 1995, Dalton et al.
1998, Shuping et al. 2000), the primary objective of
root canal treatment (RCT) is to eliminate microorganisms and pathologic debris from the root canal
system (Kakehashi et al. 1969, Sj
ogren et al. 1997)
and to prevent its reinfection (Nair 2004). Gutierrez
Correspondence: Anita Aminoshariae, D.D.S., M.S.,

Diplomate of American Board of Endodontics, 2123 Abington Road A 280, Cleveland, OH 44106, USA (e-mail:
axa53@case.edu).
2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
file enlargement, it was not possible to standardize

the research data and to apply a meta-analysis. Seven
articles were identified that met the inclusion criteria.
Five of the seven articles generally concluded that
canal enlargement reduced bioburden in the root
canal system. Two articles reported no difference in
canals enlarged to size 25 or 40. The results of the
systematic review confirmed that more evidence-based
research in this area is needed. With the limited information currently available, the best current available
clinical evidence suggests that contemporary chemomechanical debridement techniques with canal
enlargement techniques do not eliminate bacteria
during root canal treatment at any size.
Keywords: apical enlargement, apical size, master
apical file, microbial outcome, systematic review.
Received 21 August 2014; accepted 7 November 2014
& Garcia (1968) reported that root canal systems are

often improperly cleaned and shaped, and it has also
been reported that contemporary chemomechanical
debridement techniques do not consistently eliminate
bacteria during RCT (Chrepa et al. 2014).
Bystr
om & Sundqvist (1981) cultured fifteen teeth
with necrotic root canal system after instrumentation
with saline irrigation. They reported a 100- to 1000fold reduction in bacterial counts, yet no teeth cultured
bacteria-free after the first appointment. Chemomechanical preparation with supplemental irrigation
devices promoted higher microbial reduction, but they
did not render the canals bacteria-free (Dalton et al.
1998, Shuping et al. 2000, Sum et al. 2005, Alves
et al. 2011, Paiva et al. 2012, Saini et al. 2013).
In a quest for a perfect solution to eliminate
microbes from the root canal system, some authors
International Endodontic Journal, 48, 10071022, 2015
1007
Apical size and microbial reduction Aminoshariae & Kulild
have suggested that the size of apical preparation

may be important in achieving that outcome (rstavik et al. 1991, Parris et al. 1994, Wu & Wesselink
1995, Shuping et al. 2000, Card et al. 2002, Rollison
et al. 2002, Saini et al. 2012). Weine (1972) defined
the master apical file (MAF) as enlarging the apical
portion of the root canal system three sizes larger
than where the first file bound. This was accomplished after coronal flaring of the RCS. It is unclear,
however, where this binding occurred (Wu et al.
2002, Jou et al. 2004, Dillon & Amita 2012). A
thorough search of the literature failed to show what
an optimal apical preparation diameter might be
(Baugh & Wallace 2005), and it still remains a subject of uncertainty. Some authors have suggested
creating a larger apical preparation followed by a
1-week dressing of calcium hydroxide (rstavik et al.
1991, McGurkin-Smith et al. 2005, Siqueira et al.
2008). Other authors have suggested enlarging the
apical size to a predetermined size beyond size 35 or
40 (Ram 1977, Salzgeber & Brilliant 1977, Chow
1983, Shuping et al. 2000, Card et al. 2002, Rollison
et al. 2002, Usman et al. 2004, Bierenkrant et al.
2008, Siqueira et al. 2008), whilst others have suggested that enlarging the canal three sizes larger
than the first apical binding file would be adequate
(Tan & Messer 2002, Darda et al. 2009, Saini et al.
2012, Souza et al. 2012). It seems unclear where
this apical binding is taking place as Wu et al.
(2002) reported that the first file to bind in the apical root canal system did not necessarily reflect the
true canal diameter at the proposed working length
because the apical anatomy is often irregularly
shaped and not a round configuration. Therefore,
preparing the apical canal to only three sizes larger
than the first binding file does not ensure removal of
the inner layer of dentine from all apical canal walls
or all infected necrotic pulp tissue (Wu et al. 2002).
Yet some authors have suggested that taper is more
important than final apical size. It was reported that
a taper of 0.10 allowed for minimum instrumentation of the apical canal (Albrecht et al. 2004). In a
recent study, Rocas et al. (2013) reported that in
terms of bacterial reduction, there was no significant
difference between hand files with 0.02 taper nickel
titanium (NiTi) and rotary files with 0.04 taper NiTi
instrumentation. However, they also reported that
rotary instrumentation with 0.04 taper had better
microbial reduction in the same quantitative analysis
by real-time polymerase chain reaction. In that
1008
study, the canals were instrumented to a similar apical diameter. However, Siqueira et al. (1999)
reported that canal preparation to an apical size of
30 with an 0.02 taper was significantly more effective than rotary NiTi GT files with a size 20 tip and
an 0.12 taper in reducing intracanal bacteria. Thus,
it can perhaps be concluded that both taper and
diameter are equally important in chemomechanical
instrumentation of the root canal system in reducing
the bioburden.
To date, only a few studies have addressed the clinical outcome of various master apical file sizes
(MAFSs), and despite conflicting claims, the ideal
MAFS remains a mystery in any individual canal
(Parris et al. 1994, Yared & Bou Dagher 1994b, Card
et al. 2002, McGurkin-Smith et al. 2005, Saini et al.
2012, Souza et al. 2012).
In a previous systematic review (Aminoshariae &
Kulild 2015), the authors reported that there was
only one randomized controlled clinical trial (RCT)
available to indicate that in patients with necrotic
pulps undergoing root canal treatments, enlargement
of the apical diameter resulted in a better healing outcome than smaller diameters.
Despite recent research efforts to study the effect of
master apical size on bacterial reduction, no effort has
been made to evaluate the efficacy of this approach
by means of a systematic review of the literature.
Against this backdrop of current clinical variability
and the concurrent move towards evidence-based
practice, an exhaustive search of the literature failed
to reflect what is the current best available evidence
used when making decisions about the optimal MAF
of individual canals which would result in significant
microbial reduction (Sackett et al. 2007).
The ideal clinical question to be answered in this
context can be framed in terms of a PICO question
(population [P], intervention [I], comparison [C] and
outcome [O]) as follows: in patients with restorable
teeth that have had persistent periapical pathosis
and/or clinical symptoms, is there an optimal apical
enlargement which would result in better microbial
reduction?
Materials and methods

The protocol for this systematic review was developed
following established guidelines (Bader 2004), and a
well-defined review question was developed using the
PICO framework.
Aminoshariae & Kulild Apical size and microbial reduction
Formulating the review question

The following PICO framework was developed for a
systematic review of the existing literature regarding
clinical and/or radiographic outcomes of root canal
treatments. In patients with restorable teeth that have
had persistent periapical pathosis and/or clinical
symptoms, is there an optimal apical enlargement
which would result in better microbial reduction?
Inclusion and exclusion criteria

Inclusion criteria were a modified version of a previous study (Ng et al. 2007). The inclusion criteria for
this review were as follows:
1. In vivo human investigations from peer-reviewed
journals published in English from January 1950
to July 2014 which reported microbial reduction.
2. A comparison between different MAFS.

3. The sample size was identified.
4. The effect of enlargement on microbial reduction
was measured as a primary objective.
5. Quantitative results were reported.
Exclusion criteria consisted of studies that did
not meet the above inclusion criteria, studies that
used predetermined file size with no comparison(s),
laboratory studies, animal studies and studies that
only discussed other antimicrobial protocols
(Table 1).
Search methodology
The MEDLINE, Embase, Cochrane and PubMed databases were searched. Additionally, the bibliographies
of all included articles and textbooks were manually
searched. Based on inclusion and exclusion criteria,
Table 1 Excluded articles with reasons (33 articles)

Studies
Rocas et al. (2013)
Akhlaghi et al. (2014a)
Akhlaghi et al. (2014b)
Cohenca et al. (2013)
Rocas et al. (2013)
Souza et al. (2012)
Saini et al. (2013)
Silva et al. (2013)
Elayouti et al. (2011)
Borges et al. (2011)
Fornari et al. (2010)
Boutsioukis et al. (2010)
Brunson et al. (2010)
Siqueira et al. (2008)
Khademi et al. (2006)
Mickel et al. (2007)
Garcez et al. (2007)
Chen et al. (2006)
Versluis et al. (2006)
Bartha et al. (2006)
Lam et al. (2005)
Tan & Messer (2002)
Coldero et al. (2002)
Rollison et al. (2002)
Siqueira et al. (1999)
gren et al. (1997)
Sjo
Yared & Bou Dagher (1994a,b)
Parris et al. (1994)
de Souza Filho et al. (1987)
m et al. (1987)
Bystro
Benatti et al. (1985)
m & Sundqvist (1981)
Bystro
Kerekes & Tronstad (1979)
Salzgeber & Brilliant (1977)
Strindberg (1956)
Reason for exclusion

Discussed different tapers with similar apical size2
In vitro1
Laboratory SEM study on debridement1
It is not clear what was the final apical size(s)2,3,4
Discussed different tapers with similar apical size2
Healing outcome1,4
Healing outcome1,4
Enlargement and postoperative pain1,4
Canal enlargement lead to unnecessary removal of dentin1,4
Canal enlargement and apical extrusion1,4
Debridement evaluation1,4
Apical size and irrigation.1,4
Irrigation penetration with apical size was studiedntage1,4
Canals were instrumented to predetermined size2
Apical size and irrigation penetration were studied1,4
Laboratory study1
Laboratory study1
The enlargement of root canal diameter brought on increase of stress of root canal wall1,4
The enlargement of canal brought stress concentrations on roots with round configuration1,4
Apical enlargement using hand instrumentation and light speed and apical preparation1,4
Apical enlargement with LightSpeed did not increase fracture susceptibility1,4
Apical size preparation and debridement1, 4
In vitro study1,4
In vitro study1,4
In vitro study1,4
Predetermined instrumentation to size 402,5
Canal enlargement and extrusion1,4
Remaining tissue, predentin and debris with apical clearing technique were discussed1,4
Animal study1
MAF was not discussed1,4
Animal study1
MAF was not discussed2
Radiographic outcome1,4
The outcome is not in terms of microbial reduction4
Quantitative results were not provided. It was unclear how instrumentation was performed1,3,4,5
1009
Reviewer
Date
Author
Year
Record Number
Yes
1.
Was the assignment to treatment groups truly

random?
2.
Were participants blinded to treatment allocation?
3.
Was allocation to treatment groups concealed from

the allocator?
No
Unclear
4. Were the outcomes of the withdrawn-group

described and included in the analysis?
5. Were those assessing the outcomes blind to the
treatment allocation?
6. Were control and treatment groups comparable at
entry?
7. Were groups treated identically other than for the
named interventions?
8. Were outcomes measured in the same way for all
groups?
9. Were outcomes measured in a reliable way?
10. Was appropriate statistical analysis used?
Overall appraisal:
Christina M. Godfrey and Margaret B. Harrison
Joanna Briggs Institute 2012
Unclear and No: 0

Yes: 1
Figure 1 Joanne Briggs Institute (JBI) critical appraisal.
two reviewers independently selected the relevant

articles.
To answer the clinically relevant question, a fourstep method of evidence-based analysis was applied:
step 1, a search for the clinical evidence regarding
the MAFS in electronic databases, and bibliographies
of all relevant articles and review articles were both
electronically searched and hand-searched; step 2,
appraisal and selection of papers according to study
validity and clinical importance; step 3, collection and
analysis of the published evidence; and step 4, determining the clinical applicability of the results.
Using the PICO formatted question, methodological
MeSH (medical subject heading) terms were generated
to make the search strategy more sensitive for identification of studies. These terms included: apical size,
1010
apical diameter, root preparation, root apex, tooth

apex, determining apical size, master apical size, and
apical canal enlargement and endodontics. Studies that
met the above inclusion criteria underwent critical
analysis.
Extracted data included a description of the materials and methods with a detailed assessment of the size
of the apical enlargement and the outcome variables
used to measure the effectiveness of the apical
enlargement.
Quality assessment of randomized clinical trials and
observational studies was performed using the CONsolidated Standards Of Reporting Trials (CONSORT)
statement criteria (J
uni et al. 2001) and the STROBE
(STrengthening the Reporting of OBservational studies
in Epidemiology) statement criteria (Von Elm et al.
Identification
Records identified through database

searching apical diameter; apical canal
enlargement and endodontics; apical
canal apical size; master apical size;
bacterial reduction (n = 84)
Additional records identified

through other sources
(n = 5)
Eligibility
Screening
Records after duplicates removed

(n = 89)
Records screened
(n = 40)
Records excluded
(n = 49)
Full-text articles assessed

for eligibility
(n = 7)
Full-text articles excluded,

with reasons
(n = 33)
Included
Studies included in
qualitative synthesis
(n = 7)
Studies included in
quantitative synthesis
(meta-analysis)
(n = 0)
Figure 2 Prisma flow diagram.
2007), respectively. The risk of bias for each of the

included studies was reported as low, moderate or
high (Kotsakis et al. 2014). In addition, the methodological quality of the reviews was assessed based on
pre-defined quality assessment by the Joanne Briggs
Institute (JBI) criteria for experimental studies (JBI
2012), Fig. 1.
Results
Due to variety of methodologies and different techniques used to measure outcome for master apical file
enlargement, it was not possible to standardize the
research data and to apply a meta-analysis. Figure 2
details the research strategy.
A total of 40 articles were included in the final
search and 33 articles were excluded for the reasons
given in Table 1.
The final list of articles, generated after electronic
and hand searching, included seven studies that
reported on microbial reduction with apical enlargement. The basic characteristics of the included studies
are presented in Table 2. There were no randomized
controlled clinical studies, and none of the included
studies reported any adverse events associated with

canal enlargement.
Table 3 details the primary outcome in each study
as the effect of apical enlargement on the microbial
load in the canal system, and this was measured
using microbiological sampling methods and analyses.
Table 4 details the potential for the prognostic factors for the included studies.
Four of seven articles (rstavik et al. 1991, Dalton
et al. 1998, Shuping et al. 2000, McGurkin-Smith
et al. 2005) suggested that apical enlargement significantly reduced the microbial load in canals. One
article reported a trend towards significant reduction
in bioburden with a MAFS above 60 (Card et al.
2002). However, the difference between Profile 0.04
Series 29 (Tulsa Dental Products, Tulsa, OK, USA)
(S2) and LightSpeed rotary instruments (LightSpeed
Technology Inc., San Antonio, Texas, USA) that
enlarged canals two sizes larger than (S2) was not
significant (P = 0.0617).
Finally, two articles reported no difference in bacterial reduction with canal enlargement between sizes
25 and 40 (Yared & Bou Dagher 1994a,b, Nair et al.
2005).
1011
1012
Chapel Hill, NC
Zurich,
Switzerland
Chapel Hill, NC
Chapel Hill, NC
Chapel Hill, NC
Nair et al. (2005)
Card et al. (2002)
Shuping et al.
(2000)
Dalton et al.
(1998)
State, Country
McGurkin-Smith
et al. (2005)
Study
Supported in part
by grant from
American
Association of
Endodontists
Foundation
NA
Funded in part by
grant from
Steven Senia,
LightSpeed Tech
NA
NA
Funding source
Study design
Clinical study (Two exp groups and

four interventions). Five teeth
served as negative controls
Clinical study (one exp group and

five interventions). Five teeth
Clinical study (two exp groups using

necrotic pulps of M roots of
mandibular 1st molars. MB canals
instrumented using SS hand files
to 0.25 & ML canals with NiTi to
0.40). Apical of D root of foue
mandibular 1st molars with
necrotic pulps & apical
periodontitis used as positive
controls, apical of three clinically
healthy mandibular 1st bicuspid
roots served as negative controls
Clinical study (one exp group and
three interventions). Five teeth
Clinical study (1 exp group and

three interventions: S1, S2, SC)
Table 2 Summary of the main characteristics of studies included
Yes
NA
NA
NA
NA
Random
allocation
Apical
periodontitis &
necrotic pulps
Apical
periodontitis &
necrotic pulps
Apical
periodontitis &
necrotic pulps
Apical
periodontitis &
necrotic pulps
Apical
periodontitis &
necrotic pulps
Population
characteristics
48
42
40
16
31
N
(sample
size)
Bacterial sampling performed upon

access & after each of two
consecutive instrumentations. First
instrumentation used 0.04 taper
ProFile rotary files & 1% NaOCl
irrigation. Second used LightSpeed
files and 1% NaOCl irrigation for
further enlargement of apical
Canals sampled before treatment,
during & after instrumentation, &
after treatment with Ca(OH)2, &
samples incubated anaerobically
for 7 days at 37 C. Bacteria from
each sample quantified & log10
values used for calculations &
comparisons
Canals sampled before, during, &
after instrumentation. Samples
incubated anaerobically for 7 days
at 37 C, colony-forming unit
numbers calculated, & log
transformation performed to
normalize counts
Bacterial samples taken upon access

(S1), after instrumentation and
strict irrigation protocol (S2), &
following >1 week of Ca(OH)2 (SC)
After treatment, apical portion of
root of each tooth was surgically
removed. Specimens fixed,
decalcified, subdivided in
horizontal plane, embedded in
plastic, processed and evaluated by
correlative light and transmission
electron microscopy for presence
of microorganisms
Microbiological sampling method
Beirut, Lebanon
Haslum, Norway
rstavik et al.
(1991)
State, Country
Yared & Bou

Dagher (1994a,b)
Study
Table 2 (Continued)
NA
NA
Funding source
Clinical Study (two exp groups and

three interventions)
Clinical study (two exp groups and

three interventions)
Study design
NA
NA
Random
allocation
Apical
periodontitis and
necrotic pulps
Apical
periodontitis &
necrotic pulps
Population
characteristics
23
60
N
(sample
size)
60 single-rooted teeth used. Half

prepared to size 25 file and other
half to size 40 file. Root canals
dressed with Ca(OH)2 for 1 week.
Sample 1 collected from
uninstrumented canal, & Sample 2
collected after cleaning and
shaping & final irrigation with 1%
NaOCl. Canals dried and filled with
aqueous Ca(OH)2, & after 1 week,
post-Ca(OH)2 dressing sample
(Sample 3) taken from canals
Samples subjected to standardized
2-appt regimen of extensive apical
reaming in the absence of
antimicrobial agents & 1-week
dressing with Ca(OH)2.
Bacteriological samples taken from
root canal at the start, & apical
samples at the end of each sitting:
uninstrumented canals (sample I),
files 2025 used with saline as
irrigant (sample R1). Working
length not discussed. Canals
increased in size until dry white
dentin visible with size 3580. Four
to 5 mm of tip of last two sizes of
reamers cut-off (sample D1 and
D2). Canals were with Ca(OH)2 &
sealed for 1 week. At 2nd apt,
Sample R2 taken. Canals enlarged
2 ISO sizes following largest
reamer used at first sitting. Tips of
these two reamers cut-off for
bacteriological testing (D3 and D4)
Microbiological sampling method
1013
1014
Nair et al. (2005)
McGurkin-Smith
et al. (2005)
Study
Canal instrumented to a SS
15 to 20 file & placed
within 1 mm of estimated
working length. Apical
flutes cut-off & placed into
liquid dental transport
media (LDT). Canals
instrumented with
predetermined final Profile
GT file size and 5.25%
NaOCl. Hand file two sizes
larger than last GT file
placed and irrigated with
EDTA and 5.25% NaOCl
(S2). Ca(OH)2 placed for
1 week, canal then irrigated
with saline and final
sample (SC) taken. Canals
further instrumented to
larger apical diameter and
obturated, but no further
samples taken
MB roots of mandibular 1st
molars instrumented to
size 25 and ML roots
instrumented to size 40.
Irrigation with 5.25%
NaOCl and 17% EDTA.
After obturation, apical
portion of the root of each
tooth surgically removed.
Specimens fixed,
decalcified, subdivided in
horizontal plane,
embedded in plastic,
processed and evaluated
by correlative light and
transmission electron
microscopy
Interventions
Primary outcomes
Table III in article by Nair

et al. details no differences
in microbial reduction
between the two canals. 14
of the 16 root canals
revealed residual intracanal
infection after
instrumentation,
antimicrobial irrigation &
obturation. Microbes
located in inaccessible
recesses & diverticula of
main canals, intercanal
isthmus & accessory
canals, mostly biofilms
GT protocol significantly
reduced bacteria in canals
but failed to render canal
bacteria-free in more than
half of cases. Ca(OH)2
significantly further
reduced bacteria. Master
apical file (MAF) size not
identified
Table 3 Summary of the results of the studies included
Not Available
At S1, 93.55% harboured

bacteria. At S2, 52.72% of
the cases sampled bacteria.
At SC, 14% of the cases
cultured bacteria.
McNemar test showed
significant reduction
(P < 0.0009) in bacteria
between S1 and S2. This
was also true between S2
and SC (P < 0.0019)
Results of intragroup
comparison
Not Available
jdNA
Results of intergroup
comparison
Adverse effects
Not Available
None reported
Risk of bias
Low
Moderate
Shuping et al.
(2000)
Card et al. (2002)
Study
Table 3 (Continued)
Sample 1: size 1020 to

within 1 mm of estimated
WL. Working length
established within 1 mm of
apex. Sample 2: canals
instrumented to
predetermined size.
Mandibular M canals
instrumented to 0.465 mm
and single-rooted teeth
instrumented to 0.599 mm.
Dilacerated molars were
instrumented to 0.36. S3:
final instrumentation
performed with
LightSpeed. Molar sizes
ranged from 0.565 to
0.65 mm and bicuspid/
cuspid canals ranged from
0.8 to 1.0. Irrigation with
1% NaOCl
Sample 1: initial, preinstrumentation sample.
Sample 2: sample after
initial instrumentation to
working length with size
0.2160.360 mm depending
on canal. Sample 3: sample
during instrumentation and
irrigation with 1.25%
NaOCl with size larger than
at S2 ranging from 0.279 to
0.465 mm. Sample 4:
sample after final
instrumentation. Canals
instrumented to
predetermined size one
size larger than size
instrumented at S3 (0.360
Interventions
NaOCl irrigation with rotary

instrumentation is
important step in reduction
of bacteria during
endodontic treatment
specifically after S3 (0.279
0.465)
100% of cuspid/bicuspid
canals and 81.5% of molar
canals rendered bacteriafree after first
instrumentation
Primary outcomes
Statistically significant
decrease in bacteria from
S1 to S4. Statistically
significant decrease in
bacteria between S4 & S5
Significant difference
between S1 and S3, and S1
and S2. However, no
statistically significant
difference between S2 and
S3. Although authors
concluded that a high
percentage of the infected
root canals from
mandibular cuspids,
bicuspids and molar mesial
roots will no longer
harbour cultivatable
bacteria when
instrumented to sizes
above 60, their statistical
analysis (the difference
between S2 and S3) did
not show that P = 0.0617
comparison
Compared the results with

previous study (Dalton
et al. 1998): Only after S3
were bacteria reduced in
the NaOCl study compared
with saline study. Addition
of irrigating with NaOCl
resulted in better
antibacterial effect when
instrumentation exceeded
size 3035
Not Available
comparison
Not Available
Not Available
Adverse effects
Low
Moderate
Risk of bias
1015
1016
rstavik et al.
(1991)
Yared & Bou

Dagher (1994a,b)
Dalton et al.
(1998)
Study
Table 3 (Continued)
0.600 mm). S5: after

1 week of medication with
Ca(OH)2
Sample 1: size 1520 K-file
used to determine working
length & minimally disrupt
canal contents. S2: sample
after initial instrumentation
to working length with size
0.2160.360 mm depending
on canal. Sample 3:
intermediate sample during
instrumentation &
irrigation with saline with
size larger than at S2
ranging from 0.279 to
0.465 mm. Sample 4:
sample after final
instrumentation. Canals
instrumented to one size
larger than size
instrumented at S3, 0.360
0.600 mm
Sample 1: uninstrumented
canal. Sample 2: Irrigation
with 1% NaOCl. Group A
instrumented to size 25
and Group B instrumented
to size 40. Sample 3: after
1 week of Ca(OH)2
Sample I: uninstrumented
root canal. Sample R1:
reamers up to size 2025
used with saline as
irrigation. D1 and D2:
further instrumentation of
apical part with reamers of
increasing sizes performed
until white dentin visible.
Interventions
There was no statistically

significant difference
between the size 25 and 40
groups regarding Sample 2
and Sample 3
Instrumentation to larger
size files more efficiently
reduced bacterial flora
(Table I in rstavik et al.
1991). Less quantifiable
growth of bacteria from D4
to D3, from D3 to R2, from
R2 to D2, from D2 to D1,
from D1 to R1 & from R1
Instrumentation to larger
size files more efficiently
reduced bacterial flora
(Table I in rstavik et al.
1991). All root canals but
one showed growth at start
of treatment. Dentin
samples positive in 14 of
23 teeth at end of first
All mean bacterial samples

(S2, S3 and S4)
significantly lower than S1
means, regardless of file
type. No statistically
significant difference
detected between S2 and
S3 means (P = 0.07).
Statistically significant
reduction detected
between S2 and S4 means
(P = 0.0006) & between S3
and S4 means (P = 0.01)
comparison
No statistically significant
difference between size 25
and 40 file groups after
instrumentation & after 1week Ca(OH)2
Similar and uniform

reduction with progressive
filing, regardless of
technique (P < 0.0001). No
detectable difference in
CFU after NiTi rotary or SS
hand instrumentation
(P = 0.42). Neither
technique could predictably
render canals free of
bacteria
Primary outcomes
Not Available
Not Available
Extensive apical reaming

and 1-week of Ca(OH)2
reduced bacterial growth.
Canals initially
instrumented to reamer
sizes 35 or 40 tended to
harbour bacteria more
frequently and in greater
mean numbers than canals
Not Available
Adverse effects
Not Available
Not Available
comparison
Low
Low
Low
Risk of bias
which had been

instrumented to greater
than size 40 at the first
appointment (Fig. 2
published in rstavik et al.
1991). The difference at the
second appointment in
bacterial reduction was not
significant. (P = 0.06). Two
roots with evidence of
infection in dentin at 2nd
appt both instrumented to
size 40
appt. Eight of 23 canals
had detectable growth at
start of 2nd appointment,
but in sufficient numbers
for quantification in only
one root canal. Subsequent
dentin samples negative at
2nd appointment
Size of final reamer ranged
from 35 to 80. Four to
5 mm of the tips of last
two sizes of reamers cutoff for Samples D1 and D2.
R2: After a week of Ca
(OH)2, medicament
removed by alternate
rinsing with saline & 0.5%
citric acid. D3 and D4:
canals reinstrumented with
reamers of next two sizes
following largest reamer
used at first sitting
to I within an individual
root canal system
Primary outcomes
Interventions
Study
Table 3 (Continued)
comparison
comparison
Adverse effects
Risk of bias
Discussion
The results of this systematic review confirm that

more evidence-based research in this area is needed
and that there have been no randomized controlled
clinical trials in this area. With the limited information currently available, the best current available
clinical evidence suggests that contemporary chemomechanical debridement techniques with canal
enlargement techniques do not eliminate bacteria
during root canal treatment. However, the reported
investigators in the current systematic review may be
divided into three schools of thought: (1) the investigators who suggested apical enlargement significantly
reduced microbial flora (rstavik et al. 1991, Dalton
et al. 1998, Shuping et al. 2000, McGurkin-Smith
et al. 2005); (2) the investigators who reported that
there was a tendency towards more microbial reduction beyond size 60 MAFS (Card et al. 2002); and (3)
the investigators who suggested apical enlargement
had no significant effect in microbial reduction (Yared
& Bou Dagher 1994a,b, Nair et al. 2005).It is interesting to note that the group of investigators who
reported that apical enlargement significantly reduced
microbial reduction used 1 week of Ca(OH)2 dressing
in addition to apical enlargement (rstavik et al.
1991, Dalton et al. 1998, Shuping et al. 2000,
McGurkin-Smith et al. 2005). Thus, it cannot be irrefutably concluded that enlargement of the canals was
the sole reason, and there was a decrease in bacteria
between the samples.
Card et al. (2002) enlarged the canals to size 60 as
the MAFS and sampled the canals for microbes before
using Ca(OH)2 medication. They reported that there
was a tendency towards more microbial reduction
beyond size 60 MAFS, although there was no significant difference (P = 0.0617). Card et al. (2002)
reported that the difference between S2 (Profile sample) and S3 (LightSpeed) that progressively increased
the canal two sizes larger than S2 (from 0.360.465
to 0.5750.65) was not significant (P = 0.0617).
The investigators who reported that enlargement of
apical preparations had no influence on bacterial
reduction compared MAFS 25 or MAFS 40 (Yared &
Bou Dagher 1994a,b, Nair et al. 2005). Direct comparisons cannot be made because of differences in
methodologies used in the individual investigations,
use of 1% NaOCl (Yared & Bou Dagher 1994a,b) and
5% NaOCl (Nair et al. 2005) and one visit (Nair et al.
2005) versus two visits with Ca(OH)2 medication
(Yared & Bou Dagher 1994a,b). However, both
1017
1018

0
0
1
0
0
Card et al. (2002)
Shuping et al. (2000)
Dalton et al. (1998)
Yared & Bou Dagher (1994a,b)
rstavik et al. (1991)
Size 40: Log10
JBI 2
log10 4.1
log10 ~2.6
Log10 4.8
~6.8
log10 ~2.0
JBI 3
~6.9
log10 3.02
Size 25: Log10
Log10 4.60
JBI 4
Log10 4.8
Log10 ~6.8
Log10 4.60
Log10 5.5
log10 3.5
log10 ~0.5
size
Canal
35
25
3560
35<
3659
25
4590
preferred
JBI 5
log10 2.22
log10 1.27
S1S3 P < 0.0001)
log10 4.03
S1S2, P < 0.0001)

Log10 5.5
was significant
6.0 9 107NA (only it
canals=8 specimens
Microbes in ML=MB
was significant
6.0 9 107NA (only it
NA
1.01 9 1078.25 9 101
(initial to finalc)
(initial-larger sizeb)
1.01 9 1076.60 9 106
Microbial reduction
Microbial reduction
NA, not available.

a
JBI Critical Appraisal for Experimental Studies and questions as presented in Fig. 1.
b
Larger size.
c
Final sampling after chemomechanical debridement.
Nair et al. (2005)
JBI 1
reamers
and tips of cut
Sterile paper points
23
60
examination
Histological
Methodology
McGurkin-Smith et al. (2005)
Experiment
et al. (1991)
rstavik
(1994a,b)
Yared & Bou Dagher
(1998)
Dalton et al.
48
42
Shuping
et al. (2000)
40
16
31
size (N)
Sample
Card et al. (2002)
et al. (2005)
Nair
Smith et al. (2005)
McGurkin-
Authors
Clinical study
Table 4 Profile of outcome data by potential prognostic factors by the included studies
JBI 6
NA
NA
NA
NA
NA
NA
NA
Patency
JBI 7
Saline, Ca(OH)2
1% NaOCl, Ca(OH)2
Saline, Ca(OH)2
1.25% NaOCl
1% NaOCl, Ca(OH)2
17% EDTA.
5.25% NaOCl and
and Ca(OH)2
5.25% NaOCl, EDTA
Irrigation
Taper
0.02
0.02
JBI 8
0.02, 0.04
0.04
0.04
0.02
0.080.12
Canal
of the
NA
JBI 9
was placed)
specified how far it
30-gauge needle (not
it was placed)
(not specified how far
30-Gauge Maxi Probe
how far it was placed)
needle (not specified
28-Gauge Double D
far as possible
needle and placed as
28-Gauge Double D
NA
how far it was placed)
needle (not specified
28-Gauge Double D
Delivery device
NA
NA
JBI 10
2 mL of sterile saline
NA
NA
EDTA; 10 mL
specified, but 17%
NaOCl was not
NA
Amount of
solution (mL)
JBI
Total
scorea
investigators reported that the entire bioburden could

not be removed by contemporary instruments and
irrigation alone.
As detailed in Table 4, size alone is only one
parameter in RCT. However, as reported in this current systematic review, size is a viable factor. Other
factors to consider would be the antimicrobial solution
(Shuping et al. 2000), delivery system (Kahn et al.
1995), canal configuration (isthmus, curvature, etc.)
(Card et al. 2002), intracanal medicament (rstavik
et al. 1991), apical patency (Vera et al. 2011), taper
(Albrecht et al. 2004) and microbial root canal sampling technique (Sathorn et al. 2007). The included
articles all used either paper points for sampling technique or histological analysis. It is suggested that
future studies on this topic should be consistent in
their methodologies and report: the file sizes, the type
(s) of teeth used and if there are various types of teeth
how the MAF was determined and adapted to the
morphology of that particular root, irrigation solution
used, size and type(s) of needle and how far the needle
penetrated the canal, the volume of irrigation solution
used in the various groups (preferably this should be
equal in the experimental versus the control group,
giving all details of the bacterial sampling technique).
Soaking up sampling fluid from the root canal with
paper points for PCR or culturing is equally susceptible to contamination, and to date, the current molecular-based methods are still under continuous
improvement (Sathorn et al. 2007).
Despite much interest and research in this area, a
recommended MAFS remains a controversial topic.
The articles published in the era before NiTi rotary
instrumentation advocated a higher healing rate
where the MAFS was kept as small as possible
(Strindberg 1956, Kerekes & Tronstad 1979). The
concept of minimally invasive procedures has been a
subject of interest with some authors reporting transportation and perforations with aggressive apical
instrumentation (Wu et al. 2000), and others who
reported that enlargement of the apical root canal
system did not ensure removal of the inner layer of
dentine from all apical root canal walls or all infected
necrotic pulp tissue (Wu et al. 2002).
There is a legitimate concern regarding the potential fracturing of teeth instrumented to sizes above 40
(Bier et al. 2009). The question remaining is how
large is large enough to significantly reduce bioburden within the RCS to allow for healing to occur in
an immunologically competent patient? The answer
may be that because the adequate removal of bacteria
is not predictable using current techniques as evidenced by the inadequate results from all the reported
investigations to eliminate microbes, the reliance on
medications and chemomechanical debridement
becomes more critical.
A Cochrane systematic review (Figini et al. 2008)
and a systematic review with meta-analysis (Sathorn
et al. 2005) have reported that there is no significant
differences in healing outcomes comparing single or
multiple visits. Also, it has been shown that it is virtually impossible to render canals bacteria-free, (Bystr
om & Sundqvist 1981, Wu & Wesselink 1995,
Dalton et al. 1998, Shuping et al. 2000). Thus, the
importance of stringent application of all chemomechanical measures to treat teeth with infected canals,
to decrease the bioburden and to reduce the microbial
load to the lowest possible level cannot be discarded.
In a future investigation, the authors in this current investigation are planning a critical review to
explore what might be an optimal size of canal to
allow for maximum efficiency of irrigants and/or irrigant delivery systems to allow maximum cleaning
and debridement.
Conclusion
The results of this systematic review confirm that
more evidence-based research in this area is needed.
There were no randomized controlled trials available,
and thus, the results of this systematic review should
be interpreted with caution. Five of the seven articles
concluded that canal enlargement reduced bioburden
in the root canal system. Two articles reported no difference in canals enlarged to either size 25 MAFS or
40 MAFS. With the limited information currently
available, the best current available clinical evidence
suggests that contemporary chemomechanical
debridement techniques with canal enlargement techniques do not eliminate bacteria during root canal
treatment at any size.
Conflict of interests
The authors deny any conflict of interests.
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doi:10.1111/iej.

Master apical file size smaller or larger: a

A. Aminoshariae1 & J. Kulild2

The purpose of this systematic review was to

Correspondence: Anita Aminoshariae, D.D.S., M.S.,

file enlargement, it was not possible to standardize

& Garcia (1968) reported that root canal systems are

International Endodontic Journal, 48, 10071022, 2015

Apical size and microbial reduction Aminoshariae & Kulild

have suggested that the size of apical preparation

International Endodontic Journal, 48, 10071022, 2015

Materials and methods

Aminoshariae & Kulild Apical size and microbial reduction

Formulating the review question

Inclusion and exclusion criteria

2. A comparison between different MAFS.

Table 1 Excluded articles with reasons (33 articles)

Reason for exclusion

International Endodontic Journal, 48, 10071022, 2015

Apical size and microbial reduction Aminoshariae & Kulild

Was the assignment to treatment groups truly

Were participants blinded to treatment allocation?

Was allocation to treatment groups concealed from

4. Were the outcomes of the withdrawn-group

Unclear and No: 0

Figure 1 Joanne Briggs Institute (JBI) critical appraisal.

two reviewers independently selected the relevant

International Endodontic Journal, 48, 10071022, 2015

apical diameter, root preparation, root apex, tooth

Aminoshariae & Kulild Apical size and microbial reduction

Records identified through database

Additional records identified

Records after duplicates removed

Full-text articles assessed

Full-text articles excluded,

Figure 2 Prisma flow diagram.

2007), respectively. The risk of bias for each of the

studies reported any adverse events associated with

International Endodontic Journal, 48, 10071022, 2015

Nair et al. (2005)

Card et al. (2002)

International Endodontic Journal, 48, 10071022, 2015

Clinical study (Two exp groups and

Clinical study (one exp group and

Clinical study (two exp groups using

Clinical study (1 exp group and

Table 2 Summary of the main characteristics of studies included

Bacterial sampling performed upon

Bacterial samples taken upon access

Microbiological sampling method

Apical size and microbial reduction Aminoshariae & Kulild

Yared & Bou

Clinical Study (two exp groups and

Clinical study (two exp groups and

60 single-rooted teeth used. Half

Microbiological sampling method

Aminoshariae & Kulild Apical size and microbial reduction

International Endodontic Journal, 48, 10071022, 2015

International Endodontic Journal, 48, 10071022, 2015

Nair et al. (2005)

Table III in article by Nair

Table 3 Summary of the results of the studies included

At S1, 93.55% harboured