SINGLE VISIT VS

MULTIPLE VISIT
ENDODONTICS
 In the past few years, many operators have claimed
high rates of success with one sitting endodontic
therapy, particularly when their patients come from
great distance and would be considerably
inconvenienced by return trips.

Some dental schools are currently teaching one sitting

treatment in every case and some are teaching it in
selected cases.
 A number of skilled practioners regularly perform therapy in
this manner, European dentists use it more frequently then do
those from United States.

Endodontists have been treating patients in one-

appointment visits for some time. And 86% of the
directors of postgtaduate endodontic programs, when
surveyed, reported that nonsurgical one-visit treatment
was part of their program.(Landers 1980)
 When questioned, however, most dentists
reply that they reserve one-appointment
treatment for vital pulp and immediate
periradicular surgery cases. (Ingle)

In 1982 only 12.8% of dentists queried thought

necrotic teeth would be successfully treated in
one appointment.(Calhoun)
What has held back one-
appointment endodontics?
major consideration has been concern about
pain and failure.

less evident causes are fear of both

professional rejection of the practice and
justification of multi-appointment fees for one-
appointment therapy.
 These hidden reasons are gradually fading,
however, as more and more dentists are
practicing and accepting single-visit therapy.

Competition will take care of the fee problem;

more patients will be seen in a shorter time.
Postoperative Pain

The fear that patients will probably develop

postoperative pain and that the canal has been
irretrievably sealed has probably been the
greatest deterrent to single-visit therapy.

Yet the literature shows no real difference in

pain experienced by patients treated with
multiple appointment.
 40 % of the endodontic course directors
surveyed were of the opinion that necrotic
cases treated in one visit have more
flareups.(Calhoun 1982)
 Galberry did not find this to be true in
Louisiana nor did Nakamuta and Nagasawa in
Japan who had only a 7.5% pain incidence
after treating 106 infected cases in single
appointments.

Moreover, the symptoms the patients

experienced were mild and needed no drugs or
emergency treatment.
 Oliet reported that only 3% of his sample of
264 patients receiving single-appointment
treatment had severe pain, Compared with
2.4% of the 123 patients treated in two visits.
 Wolch's records of over 2000 cases treated at
a single appointment showed that less than I %
of patients indicated any severe reaction.

Pekruhn reported no statistically significant

difference between his two groups.
 Mulhern and Patterson 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 appointments.
 More recent reports from Brazil and from the
Netherlands found no difference in the
incidence of pain between one and twovisit
cases.

Trope reported no flare ups in one-

appointment cases with no apical lesions.
 One might expect pain from any case as
reported by Harrison from Baylor University.
Out of 229 patients treated twice, 55.5% had
no interappointmet pain, 28.8% had slight pain,
and 15.7% had moderate to severe pain.
 In light of these studies pain does not appear
to be a valid reason to avoid single-
appointment root canal therapy.
Fear of failure
Pekruhn - failure was higher (15.3%) in teeth
with periradicular lesions that had had no prior
access opening. If this type of case had been
previously opened, the incidence of failure
dropped to 6.5%.

Symptomatic cases were twice as likely to fail as

were asymptomatic cases (10.6% vs 5.0%).
 A Japanese study followed one-visit cases for
as long as 40 months and reported an 86%
success rate.

Oliet again found no statistical significance

between his two groups.
 The majority of the postgraduate directors of
endodontics felt that the chance of successful
healing was equal for either type of therapy.
 "In the treatment of any disease, a cure can
only be effected if the cause is removed, Since
endodontic diseases originate from an infected
or affected pulp, it is axiomatic that the root
canal must be thoroughly and carefully
debrided and obturated." (Wolch)
Guidelines for one-appointment
endodontics

One-appointment endodontics should not be

undertaken by inexperienced clinicians.
The dentist must possess a full understanding
of endodontic principles and the ability to
exercise these principles fully and efficiently.
There can be no shortcuts to success.
 The endodontic competence of the practicing dentist
should be the overriding factor in undertaking one-
visit treatment.

As a guideline, the case should be one that can

be completed within 60 minutes.

Treatments that take considerably longer should be

done in multiple visits.
Oliet's criteria for case selection

positive patient acceptance

sufficient available time to complete the procedure
properly
absence of acute symptoms requiring drainage via the
canal and of persistent continuous flow of exudate or
blood
absence of anatomical obstacles (calcified canals, fine
tortuous canals, bifurcated or accessory canals) and
procedural difficulties (ledge formation, blockage,
perforations, inadequate fills).
Indication

Uncomplicated vital teeth.

Fractured anterior or bicuspid teeth where esthetics

is a concern and a temporary post and crown are
required.

Patients who are physically unable to return for the

completion.
 Patients with heart valve damage or prosthetic
implants who require repeated regimens of
prophylactic antibiotics.

Necrotic, uncomplicated teeth with draining sinus

tracts.

Patients who require sedation or operating room

treatment.
Contrandication

Painful, necrotic tooth with no sinus tract for

drainage.

Teeth with severe anatomic anomalies or cases

fraught with procedural difficulties.

Asymptomatic nonvital molars with periapical

radiolucencies and no sinus tract.
 Patients who have acute apical periodontitis
with severe pain on percussion.

Most retreatments.
Advantages of one appointment
therapy
Patient convenience no additional appointment.

Immediate familiarity with the internal anatomy, canal

shape, and contour facilitates obturation.

No risk of bacterial leakage beyond a temporary coronal

seal between appointments.

Reduction of clinic time.

 It minimizes fear and anxiety in the apprehensive
patient .Few patients ever request to have root canal
treatment completed in several appointments.
It eliminates the problem of the patient who does not
return to have his case completed.
For anterior cases it allows immediate use of the
canal space for retention of a post and construction of
an esthetic temporary crown.
Disadvantages
The longer single appointment may be tiring and
uncomfortable for the patient.( patients, especially
those with temporomandibular dysfunction or other
impairments )
Flare-ups cannot easily be treated by opening the
tooth for drainage.
If hemorrhaging or exudation occurs, it may be
difficult to control that and to complete the case at the
same visit.
 Difficult cases with extremely fine, calcified, multiple
canals may not be treatable in one appointment
without causing undue stress for both the patient and
the clinician.

The clinician may lack the expertise to properly treat

a case in one visit. This could result in failures, flare-
ups, and legal repercussions.
 Careful case selection and proper and thorough
adherence to standard endodontic principles, with no
shortcuts, should result in successful one-
appointment endodontics.

Practitioners should attempt one-visit root canal

treatment only after making an honest assessment of
their endodontic skills, training, and ability.
COMPARISON OF ONE VERSUS MULTIVISIT
ENDODONTIC TREATMENT
 Single-appointment root canal therapy has become a
common practice.
If the pulp is necrotic and the canal is filled at the first
appointment, facultative anaerobes may multiply in
the new environment and cause exacerbation.i.e no
easy access to apical canal if there is a flare up.
 An ability to relieve pain quickly and efficiently is the
major reason for not completing endodontic therapy
in one sitting.

There is no opportunity to place intracanal

disinfectant (other than allowing NaOCl to disinfect
during the treatment).
TEETH THAT SHOULD NOT BE COMPLETED IN ONE
APPOINTMENT

Many studies on canal configuration of maxillary

molars indicate that four canals are present more
often than three canals.

Location and preparation of the fourth canal (second

canal in the mesiobuccal root) may take considerable
time and must not be rushed, particularly when the
pulp was involved in an acute pulpitis and
concomitant bleeding is present.
 Time necessary to locate the additional canal,
which is quite posterior in the arch, the patient must
keep open widely for a significant time which is
uncomfortable.

Mandibular first molar often has four canals (usually

the mesiolingual canal) too, although not as
frequently as the maxillary molars.
 The second condition for which multiple
appointments involves the treatment of a patient
who suffers from physical and/or mental condition
that makes longer appointments extremely taxing to
both the patient and the practioner.

This problem may be due to diseases of the muscle

tissues such as muscular dystrophy or mental
disease including attention deficit disorder.
 If it is discovered during the preparation that much
over instrumentation has occurred by error the tooth
should not be completed in one appointment.
Case selection is quiet important to rule out with
preoperative apical periodontitis because they are
more prone to postoperative problems.
Anterior teeth which are easier to radiograph offer a
better chance for one visit success than do molar
teeth.
 One step treatment is less expensive very well
accepted by patients and has been shown to result in a
lower flare up rate according to:
Trope M.Flare up rate of single visit endodontics J
endo 1991;24:24-7

Jureak et al 1993 performed one-visit endodontics on 167

patients regardless of pain, swelling,sinus tract, or
radiogarphic lesions. They reported that one visit was
no more uncomfortable than multiple visit and showed
same success rate.
 Oliet et al and Fava et al 1989 reported little or no
differenec in the post treatment complications
between single and multiple visit.
Pekrunh RB et al1986 reported that the incidence
of failure after one appointment endodontics was
higher in those teeth with periapical extension of
pulpal disease.
 In more recent times, and in marked contrast to these
positive reports, Sjogren and his associates (1997) in
Sweden sounded a word of caution. At a single
appointment, they cleaned and obturated 55 single-
rooted teeth with apical periodontitis. All of the teeth
were initially infected. After cleaning and irrigating with
sodium hypochlorite and just before obturation, they
cultured the canals. Using advanced anaerobic
bacteriologic techniques, they found that 22 (40%) of the
55 canals tested positive and the other 33 (60%) tested
negative
 Periapical healing was then followed for 5 years.
Complete periapical healing occurred in 94% of the 33
cases that yielded negative cultures! But in those 22
cases in which the canals tested positive prior to root
canal filling, the success rate of healing had fallen to
just 68%, a statistically significant difference.
In other words, if a canal is still infected before filling at
a single dental appointment, there may be a 26%
greater chance of failure than if the canal is free of
bacteria.
 Their conclusions emphasized the importance
of eliminating bacteria from the canal system
before obturation and that this objective could
not be achieved reliably without an effective
intracanal medicament.
 Kyoko Inamoto et al 2002 reported that in a survey
conducted among 738 United States endodontists
55.8% carried out single visit endodontics and 34.2%
indicated that their patients had experienced some
trouble after root canal obturation at first visit.
 The original investigators in this field, Fox et al.,
Wolch, Soltanoff, and Ether et al.(1981), were
convinced that single visit root canal therapy could be
just as successful as multiple-visit therapy. None,
however, treated the acutely infected or abscess
case with a single visit.
 Walton and Fouad et al1992 treated 946 patients and
then examined the correlating factors that cause flare up
after root canal treatment.
They reported that the cause of flare up after root canal
treatment had no correlation between patients
demographics or systemic conditions, number of
appointments, treatment procedures or taking
antibiotics.
THANK YOU

If the patients tooth is worth saving it is also

worth returning for second appointment.