REVIEW  215

pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
tio
te otn

n
ss e n c e
fo r
Neeraj Malhotra, Kundabala M, Shashirashmi Acharya

Contemporary endodontic approach:

single-visit root canal treatment revisited

Neeraj Malhotra
Department of Conservative
Dentistry and Endodontics,
Manipal College of Dental
Sciences, Mangalore, India

Kundabala M
Department of Conservative
Key words post-operative pain, retreatment, single-visit endodontic therapy, success Dentistry and Endodontics,
Manipal College of Dental
Sciences, Mangalore, India

Shashirashmi Acharya
Department of Conservative
Single-visit endodontic therapy is an old concept in clinical practice. However, the controversy still Dentistry and Endodontics,
Manipal College of Dental
exists as to which root canal treatment option is best between single- and multiple-visit endodontic Sciences, Manipal, India
therapies. Initially considered as a radical and substandard procedure, single-visit endodontic thera-
Correspondence to
py is now being considered as a good alternative to multiple-visit endodontic treatment. This is due Dr Neeraj Malhotra
to the introduction of new and improved technologies and materials in endodontics, including sur- Department of Conservative
Dentistry and Endodontics,
gical microscopes, NiTi rotary instrument systems, newer more reliable apex locaters, ultrasonics and MCODS
Mangalore - 575001
newer obturation systems.
Karnataka, India
This review article highlights the indications, contraindications, advantages, disadvantages, guide- Tel: (91 0824) 98445 79329
Fax: (91 0824) 2422653
lines and criteria for evaluation of single-visit endodontic therapy. The review also emphasises the Email:
evidence-based practice for single-visit endodontic therapy in clinics, based on the available current nmalhotra81@gmail.com

literature on this issue.

 Introduction this procedure is slower and more difficult to follow.

Progress in any field can only be achieved by alter-
ing and/or rejecting the old beliefs, concepts and
attitudes and moving forward. This will then allow
new information for the growth and expansion of
a profession to be discovered. Professionals should
be eager to re-examine and re-evaluate the pre-
existing data to adopt a new treatment protocol for
better results. However, for health professionals,
This is due to the risks involved and the un-
predictability of success on introduction of a new
concept, method or modality. Similar problems are
still associated with the practice of single-visit
endodontic therapy in clinics.
Single-visit endodontic therapy is defined as
‘the conservative non-surgical treatment of an
endodontically involved tooth consisting of com-
plete biomechanical cleansing, shaping and obtura-

ENDO (Lond Engl) 2009;3(3):215–225

216  Malhotra et al Single-visit root canal treatment revisited
pyrig
No Co

ht
t fo
r

by N
Fig 1 Magnifying tic problems. Although a number of clinicalP ub
research

Q ui
loupes. lica
studies have shown favourable results with single- ti
te do report on
ot

tion of the root canal system during one visit’1. With
the advent of new instrumentation techniques,
material science and technology, it is no more an
orthodox empirical procedure for obturation of root
canals. However, with the introduction of magnify-
ing loupes (Fig 1), surgical microscopes, NiTi rotary
instrument systems (Fig 2), ultrasonic devices (Fig 3),
newer obturation systems (injectable obturation
system) (Fig 4), it is now considered as an accept-
able alternative treatment procedure for endodon-
n
visit protocols2,3,4,5, evidence-based studiesss e n c e
fo r
that there is a lack of clinical evidence to support
these results6,7. Thus, it is still a dilemma for the con-
temporary general practitioner as well as the special-
ist as to when and how to proceed with single-visit
endodontics. This review article focuses on the avail-
able data to determine the success of single-visit
endodontic therapy in clinical settings. This will aid
in the design of an evidence-based practice and/or
approach to appropriately diagnose those clinical
cases that are indicated for treatment with single-
visit endodontic therapy.
 Clinical practice of single-visit
endodontics
The exact incidence of single-visit endodontic ther-
apy in clinical practice is not well documented.
According to a study by Landers and Calhoun,
single-visit endodontic therapy was taught in

Fig 2 NiTi rotary

instrument systems:
a) ENDO-mate DT
handpiece (NSK,
Nakanishi, Japan);
b) ProFile (Dentsply
Maillefer, Switerzland);
c) ProTaper (Dentsply
Maillefer, Brazil);
d) EasyRaCe (FKG
Dentaire, Switerzland).

a b

c d

ENDO (Lond Engl) 2009;3(3):215–225

 Malhotra et al Single-visit root canal treatment revisited  217
pyrig
No Co

ht
t fo
r

by N
Fig 3 PUltrasonic
ub hand-

Q ui
lictips
piece (a) and
ati(b).
te ot on

n
ss e n c e
fo r

a b

85.7% of the endodontic programs, and 91.4% of
the directors, faculty and residents of postgraduate
endodontic programs treated some cases in one
visit8. A random poll of 429 endodontists showed
that they would treat 67% of vital cases and only
12.8% of necrotic cases in a single visit9, as they
believed that more pain is experienced in single-visit
endodontic therapy. A survey by Trope and Gross-
man10 of 35 directors of endodontic programs indi-
cated that 54% of the operators completed vital
cases in one appointment, but only 9% would
obturate teeth with necrotic pulps in one visit.
When a peri-apical lesion was present, 70% of the
respondents preferred multiple treatments with an
intracanal medicament. Gatewood et al11 reported
that 35% of 568 diplomats treat teeth with a
normal peri-apex in a single visit, 16% would do so
when apical periodontitis was present and less than
10% of the diplomats would complete a non-vital
case in one visit. A recent survey carried out by

Fig 4 Obturating sys-

tems:
a) Obtura II gun and
pellets (Obtura
Corporation, Missouri,
USA);
b) ProTaper F2 gutta-
percha points (Dentsply
Maillefer, Brazil);
c) Thermafil cones
(Dentsply/Tulsa Dental
Products, Oklahoma,
USA);
d)GuttaFlow capsules
(Colténe/Whaledent,
a b Langenau, Germany).

c d

ENDO (Lond Engl) 2009;3(3):215–225

218  Malhotra et al Single-visit root canal treatment revisited
Fig 5 Radiographs
showing the treatment
of a vital molar (46)
tooth using single-visit
endodontic therapy:
a) preoperative radi-
ograph;
b) post-operative radi-
ograph.
a b
Inamoto et al12, that included 738 randomly chosen
endodontists of the American Association of
Endodontists, indicated that 87 out of 156 (55.8%)
endodontists performed root canal obturation
during a first visit in pulpectomy cases and 52 out
of 151 (34.4%) endodontists performed single-visit
treatment in infected root canal cases.
The difference in incidence could be due to
variability in the level of understanding and knowl-
edge of the individual operators and the variability
in the diagnosis made for individual cases. The
tooth type, time available, clinician’s skills and
anatomical or periodontal complications are
among the determining factors. Also, multiple-visit
endodontic therapy is usually the preferred treat-
ment option by clinicians.
 Indications
Teeth indicated to be treated in a single visit are
discussed below13.
 Vital teeth
Teeth having pulp exposures caused by trauma,
caries, or mechanical reasons, without any symp-
toms (tender on percussion) or peri-apical
changes, are the ideal candidates for single-visit
endodontic therapy (Fig 5). It has the following
advantages:
• pulp extirpation is easier and fast (vital pulp)
• no recall appointments so time is saved
• an inter-appointment intracanal medicament is
not required
ENDO (Lond Engl) 2009;3(3):215–225
pyrig
No Co
ht
t fo
rP
by N
ub
Q ui
lica
tio
te ot n
n
ss e n c e
fo r
• chances of flare-up are less likely as a temporary
inter-appointment restoration is not required.
 Cases where a temporary seal cannot be
provided between appointments
Usually in vital teeth with subgingival breakdown,
teeth with multiple missing coronal walls, and teeth
having full coverage restorations with decayed mar-
gins, the extent of lost tooth structure is quite
extensive. This makes it extremely difficult and
time-consuming to secure well fitting temporary
restorations on teeth.
 Fractured anterior or premolar teeth
These teeth are present in the aesthetic zone of the
mouth. Fracture of these teeth is thus of aesthetic
concern to the patient and a temporary restoration
(temporary post and crown) is often required. Ante-
rior tooth fractures approximating the gingival line
without apparent pulp exposure and any clinical
symptoms (tenderness on percussion) can be treated
with single-visit endodontic therapy. Following the
treatment, an aesthetic anterior temporary crown
can be rapidly placed and easily retained by a tem-
porary post secured in the root canal of the tooth.
 Cases requiring endodontic therapy
for restorative reasons
These include teeth that serve as overdenture abut-
ments, mandibular anterior teeth requiring full jacket
crowns and teeth with severe coronal breakdown
(severe attrition) that require a restoration (whose

preparation would result in pulp exposure) to obtain
a desired alignment for the designed restoration.
 Medically compromised and
disabled patients
Physically disabled patients who cannot return for
recall appointments, patients who require sedation
and/or operating room treatment and patients
with heart valve damage or prosthetic implants
that require repeated regimens of prophylactic
antibiotics, should be considered for single-visit
endodontic therapy.
 Contraindications
Multiple-visit endodontic therapy is usually advo-
cated due to ease of opening up a tooth for relief
of pain in case of an exacerbation and to avoid mul-
tiplication of facultative anaerobes14.
 Anatomical anomalies or procedural
difficulties
A variety of anatomical problems such as receding
pulp chambers, calcified canals, severely curved
canals, bifurcated canals and dilacerations or pro-
cedural errors including broken instruments, per-
forations and ledge formation, make it virtually
impossible at times to perform endodontic therapy
in one visit.
 Physical or mental disabilities
Patients who suffer from diseases of the muscle tis-
sues, such as muscular dystrophy, temporomandibu-
lar joint disorders, mental illness such as attention-
deficit disorder or any other neuromuscular disorder
may require longer appointments for their treatment.
Long appointments may be extremely taxing to both
the patient and the practitioner.
 Non-vital teeth with or without apical
periodontitis and re-treatment cases
This particular condition is probably the most con-
troversial in terms of whether or not a single-visit
Malhotra et al Single-visit root canal treatment revisited  219
pyrig
No Co
ht
t fo
rP
by N
endodontic therapy procedure can be performed ub
Q ui
lica
with clinical success in such cases. Pekruhn 15
tio
observed more failures in teeth involved with peri- tes
n ot
n
se nc e
fo r
apical extension of pulpal disease and that sympto-
matic cases were twice as likely to fail compared
with asymptomatic cases (10.6% versus 5.0%).
The highest failure rate (16.6%) was seen in
endodontic re-treatment cases.
Inter-visit use of an antimicrobial dressing (cal-
cium hydroxide, Ca(OH)2), is considered to be an
essential factor in eradicating all infection from the
root canals. According to Waltimo et al16, an inter-
appointment dressing of Ca(OH)2 can reduce the
number of bacteria within a week. Also, more reports
on high failures rates have been reported in teeth
with apical periodontitis treated with single visit
endodontics. Sjögren et al17 investigated the influ-
ence of infection at the time of root filling on the out-
come of endodontic treatment of teeth with apical
periodontitis. They concluded that complete elimi-
nation of bacteria is not possible in a single visit,
because it is not possible to eradicate all infection
from the root canal without the support of an inter-
appointment antimicrobial dressing. In a follow-up
study, Delano et al18 treated teeth with apical peri-
odontitis, with and without Ca(OH)2, in one or two
visits. The Ca(OH)2 group showed the greatest
improvement in peri-apical index (PAI) score, fol-
lowed by the single-visit group (74% versus 64%).
They concluded that the additional disinfecting
action of Ca(OH)2 may increase healing rates by
10%, which is clinically important. Also, the majority
of the flare-ups happen in teeth with signs of apical
periodontitis requiring retreatment. In another 52
week comparative study in North Carolina, the
researchers concluded that Ca(OH)2 disinfection
before obturation of infected root canals results in
significantly less peri-apical inflammation than obtu-
ration alone. Also, a two-visit root canal treatment is
more effective at completely eliminating pain of pre-
viously symptomatic teeth. Microorganisms are
essentially the main aetiological agents of primary
apical periodontitis and post-treatment apical peri-
odontitis. The intracanal flora of an infected root
canal is an immobilised biofilm on the dentinal sur-
face in an organised, multi-species, micro-ecosystem
that cannot be eradicated by host defences or
chemotherapy alone. Nair et al19 observed that com-
ENDO (Lond Engl) 2009;3(3):215–225
220  Malhotra et al Single-visit root canal treatment revisited
plete elimination of microorganisms, which existed
primarily as biofilms, is not practically possible by any
of the contemporary root canal treatments, particu-
larly with the single-visit treatment. Also, it has been
shown that the amount of of Enterococcus faecalis
inside the root canals can be reduced, but cannot be
eliminated completely either by single or multiple
visits20.
On the contrary, a few recent studies have advo-
cated the treatment of teeth with apical periodonti-
tis in a single visit. Kvist et al21 observed no statisti-
cally significant differences between the groups of
teeth with apical periodontitis treated with either
single-visit or multi-visit treatment regimens. A
recent study reviewed the effectiveness of single-
versus multiple-visit endodontic treatment of teeth
with apical periodontitis22. Of all the studies
analysed, only three studies met the inclusion crite-
ria for a meta-analysis. However, the sample size of
these studies was unjustifiably small and, thus, was
not sufficient enough to make a clinical decision. The
meta-analysis also showed no statistically significant
difference in the healing rate of the two treatment
regimens. Hence, the evidence failed to demon-
strate a difference between the two treatment reg-
imens in cases of apical periodontitis. Other reasons
that may favour the use of single-visit root canal
therapy in apical periodontitis cases are as follows.
Short intra-appointment application of a bacte-
ricidal dressing does not satisfactorily reduce the
number of root canal microbes. With respect to
clinical outcomes, no additional benefit is provided
by the use of an inter-appointment antibacterial
dressing such as Ca(OH)2 4,22,23.
Introduction of many current techniques and
systems has made it possible to perform endodon-
tic therapy more efficiently and effectively in a
single visit. All of these recent developments help
the operator to complete the root canal therapy in
a single visit with the utmost clinical precision.
It is much easier and faster to identify and detect
the canal orifices, accessory canals, hidden canals,
obstructions and pulpal calcifications with the use
of magnifying loupes (Fig 1) and microscopes,
reducing the chances of perforation.
The use of NiTi hand and rotary systems such as
the ProTaper® (Dentsply Maillefer, Ballaigues,
Switzerland) and ProFile® series (Dentsply Maillefer)
ENDO (Lond Engl) 2009;3(3):215–225
pyrig
No Co
ht
t fo
rP
by N
ub of
(Fig 2) requires less clinical time (fewer number
Q ui
lica
files) and is much easier (pre-determined sequence ti
te and shap- on
ot
n
of set files) when completing the cleaning ss e n c e
fo r
ing of root canals. These instruments are also con-
sidered to be superior and predictable in shaping
and cleaning root canals24,25. Apex locaters help in
confirming the radiographic working length to
reduce the chances of procedural errors.
Newer obturation systems like Greater Taper
cones (SybronEndo, Orange, CA. USA), Thermafil®
system (Dentsply/Tulsa Dental Products, Oklahoma,
USA), ProTaper gutta-percha cones (Dentsply
Maillefer), Obtura II (Obtura Corporation, Missouri,
USA), and more recently the GuttaFlow® system
(Roeko Coltène/Whaledent, Langenau, Germany)
(Fig 4), aid in obturating the root canals more easily
and conveniently and require less chairside time.
The introduction of better disinfecting systems
like ultrasonics26 (Fig 3), photo-activated disinfec-
tion (PAD)27 and better irrigants (like MTAD) that
have equivalent or improved anti-microbial efficacy
against E. faecalis compared with previously used
irrigants28,29.
So far there is paucity of research-based data
available to support the efficacy of current materi-
als and techniques in single-visit endodontic ther-
apy. More evidence-based studies have to be pub-
lished to advocate single-visit endodontic therapy in
apical periodontitis cases13. Until then it is better to
use an intracanal medicament, such as Ca(OH)2,
within a multiple-visit regimen for treatment of
teeth with apical periodontitis. In addition, if pus
and inflammatory exudate develop peri-apically,
and complete endodontic treatment has already
been performed, then trephination or an incision
and drainage are the only procedures available to
obtain relief in such cases. Thus, in the contempo-
rary clinical practice it is advised to treat teeth with
apical periodontitis in multiple visits.
 Advantages of single-visit
endodontic therapy
• Number of patient appointments is reduced,
leading to increased level of patient comfort.
• The chances of inter-appointment microbial con-
tamination and associated flare-ups caused by
 Malhotra et al Single-visit root canal treatment revisited  221
pyrig
No Co

ht
t fo
r

by N
Fig 6 PDiagrammatic
ub

Q ui
licaof com-
representation
tio
parison parameters:
te of post- n
ot

n
incidence
c eand
ss e npain
fo r
operative
flare-ups, and success
versus failure rates. The
“?” for success versus
failure rates indicate
that there is no differ-
ence in success rate (or
failure rate) between
single- and multiple-
visit endodontic thera-
pies and the ‘x’ for in-
cidence of post-opera-
tive pain indicates that
it is not a valid compar-
ison parameter be-
tween single- and mul-
tiple-visit endodontic
therapies.

leakage or loss of the temporary seal are reduced.  Guidelines

• An immediate aesthetic replacement can be
given for anterior teeth.
• No need for refamiliarisation with the canal
anatomy at the recall appointment.
• The therapy is cost-effective as there is reduc-
tion in clinic time.
• Patients’ pre-appointment anxiety, apprehen-
sion during the appointment and post-opera-
tive discomfort are minimised.
 Disadvantages of single-visit
endodontic therapy
• A single long appointment can be tiring and
uncomfortable to some patients, especially
those with temporomandibular dysfunction.
• It is difficult to manage flare-up cases.
• If haemorrhaging or exudation occurs, it may
be difficult to control and complete the treat-
ment at the same visit.
• Treatment of difficult cases of extremely fine,
calcified, multiple canals may cause undue
stress for both the patient and the clinician.
• Expertise is required by the clinician to effi-
ciently and properly treat a case in a single
visit.
Single-visit endodontics should only be performed
after a full understanding of endodontic principles
and the ability to exercise these principles effi-
ciently. The operating clinician should have all the
clinical skills required to complete the treatment in
a given time-frame. As a guideline, the case
should be one that can be completed within
60 minutes30. Oliet has proposed certain criteria
(Oliet’s criteria) for appropriate selection of
cases for single-visit endodontic therapy31. These
include:
• positive patient acceptance of single-visit
endodontic therapy
• sufficient available time to complete the proce-
dure properly
• absence of acute symptoms such as pain,
swelling and drainage via root canals
• absence of anatomical obstacles (calcified
canals, fine tortuous canals, bifurcated or
accessory canals) and procedural difficulties
(ledge formation, blockage, perforations, inad-
equate fills).

ENDO (Lond Engl) 2009;3(3):215–225

222  Malhotra et al Single-visit root canal treatment revisited
 Single-visit versus multiple-visit
root canal treatment
The two basic parameters used for the comparison
of single-visit and multiple-visit endodontic therapy
are (Fig 6):
• incidence of post-operative pain and flare-ups
• success versus failure rates.
 Post-operative pain
Fear of post-operative pain following treatment is
the biggest factor in avoiding single-visit endodon-
tic therapy. A large number of studies and research
have been carried out to compare the incidence of
post-operative pain in single- versus multi-visit
endodontic therapy.
Fox et al32 treated 291 teeth in single visits and
reported severe pain within 24 hours in only 7% of
cases. They found that 90% of the teeth were free
of spontaneous pain after 24 hours, whereas 82%
had little or no pain on percussion. Rudner and
Oliet33 observed that if an accurate diagnosis,
proper case selection and skill in technique are used,
the incidence of post-operative pain and healing
remained the same in both the treatment groups.
O’Keefe34 found no significant differences in
the post-operative pain experienced by patients
following single- or multiple-visit treatment proce-
dures. However, lower incidence of post-operative
pain was associated with treatment of anterior
teeth. In a long-term study, Oliet31 observed no
statistically significant difference between the two
treatment groups in relation to post-operative
pain and swelling. Similarly, no significant differ-
ence existed between the groups when compared
by tooth morphology (anterior teeth, premolars
and molars), gender, diagnosis (vital pulps versus
necrotic pulps) and filling terminus (filling short or
within 0.5 mm of the radiographic apex). Roane
and colleagues35 viewed the post-operative pain
experience of patients treated in a single visit and
multi-visit approach. Their results indicated that a
higher frequency of post-operative pain was asso-
ciated with a multi-visit treatment in both vital and
non-vital cases. This may be attributed to the
microleakage caused by temporary restorations
in between the appointments. According to
ENDO (Lond Engl) 2009;3(3):215–225
pyrig
No Co
ht
t fo
rP
by N
Albashaireh and Alnegrish2 a significantly uhigher
bli
Q ui
cat
incidence of post-obturation pain was found in the i
tesingle-visit on
ot
n
multiple-visit group (38%) than in the ss e n c e
fo r
group (27%) within 24 h of obturation. Also,
teeth that had non-vital pulp prior to treatment
were associated with a significantly greater inci-
dence of post-obturative pain. Wolch36 observed
that out of 2000 patients, less than 1% had any
form of severe reaction following single-visit
endodontic therapy. Nakamuta and Nagasawa37
reported a pain incidence of 7.5% after treating
106 infected cases in single appointments. Mulh-
ern et al38 reported no significant difference in the
incidence of pain between 30 single-rooted teeth
with necrotic pulps treated in one appointment
and 30 similar teeth treated in three appoint-
ments. A recent study by Al-Negrish and Habah-
beh3 observed no statistically significant difference
between both groups, in the incidence and degree
of postoperative pain in asymptomatic non-vital
maxillary central incisors. Also, strong evidence
indicating a difference in prevalence of post-
operative pain/flare-up among the two treatment
protocols (single- or multiple-visit root canal treat-
ment) is lacking in cases of peri-apical periodonti-
tis6. Few studies have evaluated the incidence of
flare-ups in single- and multiple-visit endodontic
therapy. Some studies have concluded that either
there is no difference in the incidence of flare-ups
between the two treatment protocols or the inci-
dence of flare-ups is higher in the case of multi-
ple-visit endodontic therapy39,40,41.
Although a number of studies in the literature
showed that there is no significant difference
between the two treatment protocols as far as inci-
dence of post-operative pain is considered, there is
a lack of evidence-based data to reinforce this6,7.
This can be attributed to following reasons:
• the difference in inclusion criteria (vital versus
non-vital), variability in sample size, subjective
nature of the pain interpretation and evaluation,
and pre-operative symptoms of patients (with
or without preoperative pain)
• the definition of flare-up is reported to be differ-
ent by different authors
• anxiety regarding the procedure can alter the
incidence of reported pain experience.

Therefore, on the basis of available data, the inci-
dence of post-operative pain cannot be used as a
basic parameter for the comparison between single-
and multiple-visit endodontic therapies (Fig 6).
 Success versus failure rates
Long-term success of any treatment is dependent
on various criteria, including case selection, treat-
ment procedures and protocols, time management
and sufficient duration of recall appointments. Most
of the studies in the literature indicate that there is
minor or no substantial difference in the success
rates of single- and multiple-visit endodontic ther-
apy. Jurcak et al42 reported 89% success rate follow-
ing single-visit endodontic therapy. Despite
Soltanoff’s43 report of considerably more pain in
association with single-visit endodontic treatment,
he found that both techniques provided success
rates exceeding 85%. Rudner and Oliet33 compared
single-visit with multiple-visit endodontic therapy
and found that both healed with a frequency of
about 88% to 90%. Oliet31 evaluated 153 single
visits and 185 multiple-visit cases 18 months post-
operatively and found a failure rate of 11% in both
categories. He also found no significant differences
when tooth groups and pulp vitality status were
compared. Ashkenaz44 found a failure rate of 3%
after 1 year in 101 single-canal, vital teeth that were
treated in one visit. Pekruhn39, in a study of 1140
single-visit cases, found a failure rate of only 5.2%.
Weiger et al4 observed that the success rate after 5
years, in single-visit and two-visit root canal treat-
ments with Ca(OH)2 was 92 and 93%, respectively.
According to Peters and Wesselink,5 complete radi-
ographic healing was observed in 81% of the cases
treated in one visit and 71% of the cases treated in
two visits. Waltimo et al45 found no remarkable dif-
ferences between the two treatment groups (single
visit versus multiple visits) following chemomechan-
ical preparation of the root canals with NaOCl inter-
appointment medication with Ca(OH)2. Boggia46
observed that non-vital teeth filled during single
visits using peri-apically extruded endomethasone
paste showed consistently successful results with
radiographic peri-apical healing on follow-up. A ret-
rospective study by Field et al47 concluded that no
statistically significant differences were observed
Malhotra et al Single-visit root canal treatment revisited  223
pyrig
No Co
ht
t fo
rP
by N
between the two treatment protocols based on ub
Q ui
lica
gender, age, arch or provider. However, they pro- tio
posed that anterior teeth were more successful than tes
n ot
n
se nc e
fo r
posterior teeth. This was in accordance with the
findings of Rudner and Oliet33. This is most likely due
to the anatomical complexities of posterior teeth.
Location and preparation of the fourth canal in max-
illary first molars (second canal in the mesiobuccal
root) may take considerable time.
On the contrary, Silveira et al48 observed that a
two-visit treatment using Ca(OH)2/camphormono-
chlorphenol based inter-appointment intracanal
medicament offered a high success rate compared
to one-visit treatment. Similarly, a comparable per-
centage of radiographic healing was seen in both
the treatment protocols but the Ca(OH)2 group
(multiple-visit) showed fewer failed and more
improved cases49.
The difference in the percentage of success
and/or failure rates in different studies and differ-
ence in opinion among the researchers regarding
this issue can be attributed to the following reasons:
• the original investigators in their research did not
treat acutely infected or abscess teeth in a single
visit32,36,43
• shortage of good unbiased studies that can aid
clinical decision making for an evidence-based
practice
• due to the difference in the definition of success
as proposed by different authors, the success of
an endodontic treatment is often poorly
defined. This can alter the overall result of each
study. It is also dependent on other variables
such as, the skill of operators, appropriate diag-
nosis, proper case selection, reviewing radi-
ographs and cases, the techniques and materi-
als used, and the time frame of the treatment.
Thus, the present literature review suggests that
there is no difference in success rate between
single- and multiple-visit endodontic therapies
(Fig 6). However, an appropriate case selection
and clinical diagnosis are essential before opting
for single-visit endodontic therapy as the treat-
ment option for a particular patient and tooth. For
this the following should be considered for an evi-
dence-based practice of single-visit endodontic
therapy.50
ENDO (Lond Engl) 2009;3(3):215–225
224  Malhotra et al Single-visit root canal treatment revisited
 Operator ability and clinical experience
Single-visit root canal treatment is a procedure to be
performed only by experienced practitioners who
use it on routine basis. It is not indicated for the
operators who mainly practise general dentistry and
also perform endodontic cases, but not on regular
basis. It is only after years of experience that a
practitioner can attain the precision of operative
skills to perform endodontics in a single visit. Once
endodontics is done routinely, a practitioner can
better assess the time required to thoroughly
cleanse, shape and fill the root canal systems of
anterior and posterior teeth.
 Time and auxiliary utilisation
A practical time limit for the endodontic treatment
has to be decided, taking into consideration the
clinician’s operative skill and the difficulty of the
case. As per the guidelines for single-visit
endodontic therapy, the majority of cases should
be completed within 45 to 60 minutes. This is
dependent on the clinician’s ability to organise and
use an efficient endodontic delivery system for
various endodontic procedures such as isolation,
access, biomechanical preparation and obturation.
A well-trained and efficient dental assistant could
help in achieving this objective. The dental assis-
tant aids in preparation of tray, placement of the
rubber dam, passing of instruments and materials
during treatment procedure, radiographs, tempo-
risation, cleaning of instruments and sterilisation.
 Clinical techniques
Fundamental knowledge of basic operative skills
and a high degree of competence in these skills can
reduce the incidence of broken instruments, ledged
canals, perforations, and inadequately prepared
and incompletely filled root canals. This would nec-
essarily result in a higher than normal success rate.
Thus, failure of an endodontic procedure is due to
the failure of a practitioner to develop skills manda-
tory to perform single-visit root canal treatment in
clinics.
ENDO (Lond Engl) 2009;3(3):215–225
pyrig
No Co
ht
t fo
rP
by N
 Conclusion ub
Q ui
lica
ti
tethe follow- on ot
n
In summary, this literature review draws ss e n c e fo r
ing conclusions regarding single-visit endodontic
therapy.
• Incidence of post-operative pain is not a valid
comparison criterion between single- and mul-
tiple-visit endodontic therapies.
• Emphasis should be given to more prospective,
well-controlled clinical trials to design evidence-
based single-visit endodontic therapy for cases
with apical periodontitis.
• The literature so far does not support a valid
reason to claim that the success rate of the
multiple-visit is better than single-visit endo-
dontic therapy and vice-versa.
• The choice of treatment between single- and
multiple-visit root canal treatment should be
made, taking into the consideration the indi-
viduality of a case and the operator’s skill. But
in cases where the required operator skills are
lacking, diagnosis is doubtful and the progno-
sis is unpredictable for a single-visit endodon-
tic therapy, multiple-visit treatment should be
preferred and performed.
 References
1. Ashkenaz PJ. One-visit endodontics. Dent Clin North Am
1984;28:853-863.
2. Albashaireh ZS, Alnegrish AS. Postobturation pain after sin-
gle- and multiple-visit endodontic therapy. A prospective
study. J Dent 1998;26:227-232.
3. Al-Negrish AR, Habahbeh R. Flare up rate related to root
canal treatment of asymptomatic pulpally necrotic central
incisor teeth in patients attending a military hospital. J Dent
2006;34:635-640.
4. Weiger R, Rosendahl R, Löst C. Influence of calcium hy-
droxide intracanal dressings on the prognosis of teeth with
endodontically induced periapical lesions. Int Endod J 2000;
33:219-226.
5. Peters LB, Wesselink PR. Periapical healing of endodontical-
ly treated teeth in one and two visits obturated in the pres-
ence or absence of detectable microorganisms. Int Endod J
2002;35:660-667.
6. Sathorn C, Parashos P, Messer H. The prevalence of post-
operative pain and flare-up in single- and multiple-visit en-
dodontic treatment: a systematic review. Int Endod J
2008;41:91-99.
7. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple
visits for endodontic treatment of permanent teeth.
Cochrane Database Syst Rev 2007 Oct 17;(4):CD005296.
8. Landers RR, Calhoun RL. One-appointment endodontic
therapy: an opinion survey. J Endod 1980;6:799-801.
9. Calhoun RL, Landers RR. One-appointment endodontic
therapy: a nationwide survey of endodontists. J Endod
1982;8:35-40.

10. Trope M, Grossman LI. Root canal culturing survey: single-
visit endodontics. J Endod 1985;11:511-513.
11. Gatewood RS, Himel VT, Dorn SO. Treatment of the endo-
dontic emergency: a decade later. J Endod 1990;16:284-291.
12. Inamoto K, Kojima K, Nagamatsu K, Hamaguchi A, Nakata
K, Nakamura H. A survey of the incidence of single-visit en-
dodontics. J Endod 2002;28:371-374.
13. Yazd ZM, Isfahan AF, Yazd MT. One-visit versus multiple-
visit endodontic therapy- a review. Int Dent J 2006;56:
289-293.
14. Weine FS. Endodontic timetables. In: Weine FS (eds).
Endodontic therapy. St. Louis, Missouri: Mosby, 2004:
822-834.
15. Pekruhn RB. The incidence of failure following single-visit
endodontic therapy. J Endod 1986;12:68-72.
16. Waltimo TM, Boiesen J, Eriksen HM, Ørstavik D. Clinical
performance of 3 endodontic sealers. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2001;92:89-92.
17. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of
infection at the time of root filling on the outcome of en-
dodontic treatment of teeth with apical periodontitis. Int
Endod J 1997;30:297-306.
18. Delano EO, Ludlow J B, Ørstavik D, Tyndall D, Trope M.
Comparison between PAI and quantitative digital radi-
ographic assessment of apical healing after endodontic
treatment. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2001;92:108-115.
19. Nair P, Henry S, Cano V, Vera J. Microbial status of apical
root canal system of human mandibular first molars with
primary apical periodontitis after “one-visit” endodontic
treatment. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2005;99:231-252.
20. Vivacqua-Gomes N, Gurgel-Filho ED, Gomes BPFA, Ferraz
CCR, Zaia AA, Souza-Filho FJ. Recovery of Enterococcus
faecalis after single- or multiple-visit root canal treatments
carried out in infected teeth ex vivo. Int Endod J
2005;38:697-704.
21. Kvist T, Molander A, Dahlén G, Reit C. Microbiological eval-
uation of one- and two-visit endodontic treatment of teeth
with apical periodontitis: a randomized, clinical trial. J
Endod 2004;30:572-576.
22. Sathorn C, Parashos P, Messer HH. Effectiveness of single-
versus multiple-visit endodontic treatment of teeth with
apical periodontitis: a systematic review and meta-analysis.
Int Endod J 2005;38:347-355.
23. Trope M, Delano E O, Ørstavik D. Endodontic treatment of
teeth with apical periodontitis: single vs. multivisit treat-
ment. J Endod 1999;25:345-350.
24. Bergmans L, Cleynenbreugel J V, Wevers M, Lambrechts P.
Mechanical root canal preparation with NiTi rotary instru-
ments: Rationale, performance and safety. Am J Dent
2001;14:324-333.
25. Laaya Safi L, Khojastehpour L, Azar MR, Layeghnejad AH.
A comparative study on rotary Mtwo versus passive step
back of hand K-file in preparation of extracted curved root
canals. Int Endod J 2008;3:24-28.
26. Al-Madi EM, Balto HA. The effect of intermittent passive
ultrasonic irrigation and rotary instruments on microbial
colonies of infected root canals. Saudi Dent J 2008;20:
10-16.
27. Bonsor SJ, Nichol R, Reid TM, Pearson GJ. An alternative
regimen for root canal disinfection. Br Dent J 2006;
201:101-105;discussion 98.
28. Krause TA, Liewehr FR, Chin-Lo Hahn CL. The antimicrobial
effect of MTAD, sodium hypochlorite, doxycycline, and cit-
ric acid on Enterococcus faecalis. J Endod 2007;33:28 –30.
Malhotra et al Single-visit root canal treatment revisited  225
pyrig
No Co
ht
t fo
rP
by N
29. Portenier I, Waltimo T, Ørstavik D, Haapasalo M. Killing of ub
Q ui
Enterococcus faecalis by MTAD and chlorhexidine diglu- lica
conate with or without cetrimide in the presence or absence tio
of dentine powder or BSA. J Endod 2006;32:138–141. te not
n
30. Dorn SO, Gartner AH. Case selection and treatment plan- ss e n c e
fo r
ning. In: Cohen S, Burns RC (eds). Pathways of the pulp. St.
Louis, Missouri: Mosby, 1994:60-76.
31. Oliet S. Single-visit endodontics: a clinical study. J Endod
1983;9:147-152.
32. Fox J, Atkinson JS, Dinin AP, Greenfield E, Hechtman E,
Reeman CA et al. Incidence of pain following one-visit en-
dodontic treatment. Oral Surg Oral Med Oral Pathol
1970;30:123-130.
33. Rudner WL, Oliet S. Single-visit endodontics: a concept and
a clinical study. Compend Contin Educ Dent 1981;2:63-68.
34. O’Keefe, EM. Pain in endodontic therapy: preliminary
study. J Endod. 1976;2:315-319.
35. Roane JB, Dryden JA, Grimes EW. Incidence of post-opera-
tive pain after single- and multiple-visit endodontic proce-
dures. Oral Surg Oral Med Oral Pathol 1983;55:68-72.
36. Wolch I. The one-appointment endodontic technique. J
Can Dent Assoc 1975;41:613.
37. Ingle J I, Bakland LK, Beveridge EE. Modern endodontic
therapy. In: Ingle J I, Bakland LK (eds). Endodontics.
Canada: Decker, Inc., 2002:1-24.
38. Mulhern JM, Patterson SS, Newton CW, Ringel AM.
Incidence of post-operative pain after one-appointment en-
dodontic treatment of asymptomatic pulpal necroses in sin-
gle-rooted teeth. J Endod 1982;8:370-375.
39. Pekruhn RB. Single-visit endodontic therapy: a preliminary
clinical study. J Am Dent Assoc 1981;103:875-877.
40. Imura N, Zuolo ML. Factors associated with endodontic flare-
ups: a prospective study. Int Endod J 1995;28:261-265.
41. Eleazer PD, Eleazer KR. Flare-up rate in pulpally necrotic
molars in one-visit versus two-visit endodontic treatment. J
Endod 1998;24:614-616.
42. Jurcak JJ, Bellizzi R, Loushine RJ. Successful single-visit en-
dodontics during Operation Desert Shield. J Endod
1993;19:412-413.
43. Soltanoff W. A comparative study of the single-visit and the
multiple-visit endodontic procedure. J Endod 1978;4:
278-281.
44. Ashkenaz PJ. One-visit endodontics—a preliminary report.
Dent Surv 1979;55:62-67.
45. Waltimo T, Trope M, Haapasalo M, Ørstavik D. Clinical ef-
ficacy of treatment procedures in endodontic infection con-
trol and one year follow-up of periapical healing. J Endod
2005;31:863-866.
46. Boggia R. A single-visit treatment of septic root canals us-
ing periapically extruded endomethasone. Br Dent J
1983;155:300-305.
47. Field JW, Gutmann JL, Solomon ES, Rakusin H. A clinical
radiographic retrospective assessment of the success rate of
single-visit root canal treatment. Int Endod J 2004;37:
70-82.
48. Silveira AM, Lopes HP, Siqueira JF Jr, Macedo SB, Consolaro
A. Periradicular repair after two-visit endodontic treatment
using two different intracanal medications compared to
single-visit endodontic treatment. Braz Dent J 2007;18:
299-304.
49. Katebzadeh N, Sigurdsson A, Trope M. Radiographic eval-
uation of periapical healing after obturation of infected root
canals: an in vivo study. Int Endod J 2000;33:60-66.
50. Spangberg LS. Evidence-based endodontics: the one-visit
treatment idea. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2001;91:617-618.
ENDO (Lond Engl) 2009;3(3):215–225
Copyright of Endodontic Practice Today is the property of Quintessence Publishing Company Inc. and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.