SINGLE VISIT VS SINGLE VISIT VS MULTIPLE VISIT MULTIPLE VISIT ENDODONTICSENDODONTICS

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

Some dental schools are currently teaching one sitting Some dental schools are currently teaching one sitting treatment in every case and some are teaching it in treatment in every case and some are teaching it in selected cases.selected cases.

A number of skilled practioners regularly perform therapy in A number of skilled practioners regularly perform therapy in this manner, this manner, European dentistsEuropean dentists use it more frequently then do use it more frequently then do those from those from United States.United States.

Endodontists have been treating patients in one-Endodontists have been treating patients in one-appointment visits for some time. And 86% of the appointment visits for some time. And 86% of the directors of postgtaduate endodontic programs, when directors of postgtaduate endodontic programs, when surveyed, reported that nonsurgical one-visit treatment surveyed, reported that nonsurgical one-visit treatment was part of their program.(was part of their program.(Landers 1980Landers 1980))

When questioned, however, most dentists When questioned, however, most dentists reply that they reserve one-appointment reply that they reserve one-appointment treatment for treatment for vital pulpvital pulp and and immediate immediate periradicular surgery cases.periradicular surgery cases. ( (IngleIngle))

In 1982 only 12.8% of dentists queried thought In 1982 only 12.8% of dentists queried thought necrotic teeth would be successfully treated in necrotic teeth would be successfully treated in one appointment.(one appointment.(CalhounCalhoun))

What has held back one-What has held back one-appointment endodontics? appointment endodontics?

major consideration has been major consideration has been concern concern about about pain and failure.pain and failure.

less evident causes are fear of both less evident causes are fear of both professional rejection of the practiceprofessional rejection of the practice and and justification of multi-appointment feesjustification of multi-appointment fees for one- for one-appointment therapy.appointment therapy.

These hidden reasons are These hidden reasons are gradually fadinggradually fading, , however, as more and more dentists are however, as more and more dentists are practicing and accepting single-visit therapy. practicing and accepting single-visit therapy.

Competition will take care of the fee problem; Competition will take care of the fee problem; more patients will be seen in a shorter time.more patients will be seen in a shorter time.

Postoperative PainPostoperative Pain

The fear that patients will probably develop The fear that patients will probably develop postoperative pain and that the canal has been postoperative pain and that the canal has been irretrievably sealed has probably been the irretrievably sealed has probably been the greatest deterrent to single-visit therapy. greatest deterrent to single-visit therapy.

Yet the literature shows no real difference in Yet the literature shows no real difference in pain experienced by patients treated with pain experienced by patients treated with multiple appointment.multiple appointment.

40 % of the endodontic course directors 40 % of the endodontic course directors surveyed were of the opinion that necrotic surveyed were of the opinion that necrotic cases treated in one visit have more flareups.cases treated in one visit have more flareups.((Calhoun 1982Calhoun 1982))

GalberryGalberry did not find this to be true in did not find this to be true in Louisiana nor did Louisiana nor did Nakamuta Nakamuta andand Nagasawa Nagasawa in in Japan who had only a Japan who had only a 7.5%7.5% pain incidence pain incidence after treating 106 infected cases in single after treating 106 infected cases in single appointments.appointments.

Moreover, the symptoms the patients Moreover, the symptoms the patients experienced were experienced were mild mild and needed no drugs and needed no drugs or emergency treatment.or emergency treatment.

OlietOliet reported that reported that only 3%only 3% of his sample of of his sample of 264 patients receiving single-appointment 264 patients receiving single-appointment treatment had severe pain, Compared with treatment had severe pain, Compared with 2.4% of the 123 patients treated in two visits. 2.4% of the 123 patients treated in two visits.

Wolch'sWolch's records of over 2000 cases treated at records of over 2000 cases treated at a single appointment showed that less than I a single appointment showed that less than I % of patients indicated any severe reaction.% of patients indicated any severe reaction.

PekruhnPekruhn reported no statistically significant reported no statistically significant difference between his two groups. difference between his two groups.

Mulhern and PattersonMulhern and Patterson reported no reported no significant difference in the incidence of pain significant difference in the incidence of pain between 30 single rooted teeth with necrotic between 30 single rooted teeth with necrotic pulps treated in one appointment, and 30 pulps treated in one appointment, and 30 similar teeth treated in three appointments. similar teeth treated in three appointments.

More recent reports from Brazil and from the More recent reports from Brazil and from the Netherlands found no difference in the Netherlands found no difference in the incidence of pain between one and two visit incidence of pain between one and two visit cases. cases.

TropeTrope reported no flare ups in one- reported no flare ups in one-appointment cases with no apical lesions. appointment cases with no apical lesions.

One might expect pain from any case as One might expect pain from any case as reported by Harrison from Baylor University. reported by Harrison from Baylor University. Out of 229 patients treated twice, Out of 229 patients treated twice, 55.5% 55.5% had had no inter appointmet pain, 28.8% had slight pain, no inter appointmet pain, 28.8% had slight pain, and 15.7%and 15.7% had moderate to severe pain.had moderate to severe pain.

In light of these studies In light of these studies pain does not appear pain does not appear to be a valid reason to avoid single-to be a valid reason to avoid single-appointment root canal therapy.appointment root canal therapy.

Fear of failureFear of failure

PekruhnPekruhn - failure was higher (15.3%) in teeth - failure was higher (15.3%) in teeth with periradicular lesions that had had no prior with periradicular lesions that had had no prior access openingaccess opening. . If this type of case had been If this type of case had been previously opened, the incidence of failure previously opened, the incidence of failure dropped to 6.5%.dropped to 6.5%.

Symptomatic cases were twice as likely to fail Symptomatic cases were twice as likely to fail as were asymptomatic cases (10.6% vs 5.0%).as were asymptomatic cases (10.6% vs 5.0%).

A Japanese study followed one-visit cases for A Japanese study followed one-visit cases for as long as 40 months and reported an 86% as long as 40 months and reported an 86% success rate. success rate.

Oliet again found no statistical significance Oliet again found no statistical significance between his two groups. between his two groups.

The majority of the postgraduate directors of The majority of the postgraduate directors of endodontics felt that the chance of successful endodontics felt that the chance of successful healing was equal for either type of therapy. healing was equal for either type of therapy.

"In the treatment of any disease, a cure can "In the treatment of any disease, a cure can only be effected if the cause is removed, Since only be effected if the cause is removed, Since endodontic diseases originate from an infected endodontic diseases originate from an infected or affected pulp, it is axiomatic that the root or affected pulp, it is axiomatic that the root canal must be thoroughly and carefully canal must be thoroughly and carefully debrided and obturated." debrided and obturated." (Wolch)(Wolch)

Guidelines for one-appointment Guidelines for one-appointment endodonticsendodontics

One-appointment endodontics should not be One-appointment endodontics should not be undertaken by inexperienced clinicians. undertaken by inexperienced clinicians.

The dentist must possess a full understanding The dentist must possess a full understanding of endodontic principles and the ability to of endodontic principles and the ability to exercise these principles fully and efficiently. exercise these principles fully and efficiently.

There can be no shortcuts to success. There can be no shortcuts to success.

The endodontic competence of the practicing dentist The endodontic competence of the practicing dentist should be the overriding factor in undertaking one-should be the overriding factor in undertaking one-visit treatment.visit treatment.

As a guideline, the case should be one that can As a guideline, the case should be one that can

be completed within 60 minutes.be completed within 60 minutes.

Treatments that take considerably longer should be Treatments that take considerably longer should be done in multiple visits. done in multiple visits.

Oliet's criteria for case selectionOliet's criteria for case selection

positive patient acceptancepositive patient acceptance sufficient available time to complete the procedure properlysufficient available time to complete the procedure properly absence of acute symptoms requiring drainage via the absence of acute symptoms requiring drainage via the

canal and of persistent continuous flow of exudate or bloodcanal and of persistent continuous flow of exudate or blood absence of anatomical obstacles (calcified canals, fine absence of anatomical obstacles (calcified canals, fine

tortuous canals, bifurcated or accessory canals) and tortuous canals, bifurcated or accessory canals) and procedural difficulties (ledge formation, blockage, procedural difficulties (ledge formation, blockage, perforations, inadequate fills).perforations, inadequate fills).

Indication Indication

Uncomplicated vital teeth.Uncomplicated vital teeth.

Fractured anterior or bicuspid teeth where esthetics Fractured anterior or bicuspid teeth where esthetics is a concern and a temporary post and crown are is a concern and a temporary post and crown are required.required.

Patients who are physically unable to return for the Patients who are physically unable to return for the completion.completion.

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

Necrotic, uncomplicated teeth with draining sinus Necrotic, uncomplicated teeth with draining sinus tracts.tracts.

Patients who require sedation or operating room Patients who require sedation or operating room treatment.treatment.

Contrandication Contrandication

Painful, necrotic tooth with no sinus tract for Painful, necrotic tooth with no sinus tract for drainage.drainage.

Teeth with severe anatomic anomalies or cases Teeth with severe anatomic anomalies or cases fraught with procedural difficulties.fraught with procedural difficulties.

Asymptomatic nonvital molars with periapical Asymptomatic nonvital molars with periapical radiolucencies and no sinus tract.radiolucencies and no sinus tract.

Patients who have acute apical periodontitis Patients who have acute apical periodontitis with severe pain on percussion.with severe pain on percussion.

Most retreatments.Most retreatments.

Advantages of one appointment Advantages of one appointment therapytherapy

Patient convenience – no additional appointment.Patient convenience – no additional appointment.

Immediate familiarity with the internal anatomy, canal Immediate familiarity with the internal anatomy, canal shape, and contour facilitates obturation.shape, and contour facilitates obturation.

No risk of bacterial leakage beyond a temporary coronal No risk of bacterial leakage beyond a temporary coronal seal between appointments.seal between appointments.

Reduction of clinic time.Reduction of clinic time.

It minimizes fear and anxiety in the apprehensive It minimizes fear and anxiety in the apprehensive patient .Few patients ever request to have root canal patient .Few patients ever request to have root canal treatment completed in several appointments.treatment completed in several appointments.

It eliminates the problem of the patient who does not It eliminates the problem of the patient who does not return to have his case completed.return to have his case completed.

For anterior cases it allows immediate use of the For anterior cases it allows immediate use of the canal space for retention of a post and construction of canal space for retention of a post and construction of an esthetic temporary crown.an esthetic temporary crown.

Disadvantages Disadvantages

The longer single appointment may be tiring and The longer single appointment may be tiring and uncomfortable for the patient.( patients, especially uncomfortable for the patient.( patients, especially those with temporomandibular dysfunction or other those with temporomandibular dysfunction or other impairments )impairments )

Flare-ups cannot easily be treated by opening the Flare-ups cannot easily be treated by opening the tooth for drainage.tooth for drainage.

If hemorrhaging or exudation occurs, it may be If hemorrhaging or exudation occurs, it may be difficult to control that and to complete the case at the difficult to control that and to complete the case at the same visit.same visit.

Difficult cases with extremely fine, calcified, multiple Difficult cases with extremely fine, calcified, multiple canals may not be treatable in one appointment canals may not be treatable in one appointment without causing undue stress for both the patient and without causing undue stress for both the patient and the clinician.the clinician.

The clinician may lack the expertise to properly treat The clinician may lack the expertise to properly treat a case in one visit. This could result in failures, flare-a case in one visit. This could result in failures, flare-ups, and legal repercussions.ups, and legal repercussions.

Careful case selection and proper and thorough Careful case selection and proper and thorough adherence to standard endodontic principles, with no adherence to standard endodontic principles, with no shortcuts, should result in successful one-shortcuts, should result in successful one-appointment endodontics. appointment endodontics.

Practitioners should attempt one-visit root canal Practitioners should attempt one-visit root canal treatment only after making an honest assessment of treatment only after making an honest assessment of their endodontic skills, training, and ability.their endodontic skills, training, and ability.

COMPARISON OF ONE VERSUS MULTIVISIT COMPARISON OF ONE VERSUS MULTIVISIT ENDODONTIC TREATMENTENDODONTIC TREATMENT

Single-appointment root canal therapy has become a Single-appointment root canal therapy has become a common practice. common practice.

If the pulp is necrotic and the canal is filled at the first If the pulp is necrotic and the canal is filled at the first appointment, facultative anaerobes may multiply in appointment, facultative anaerobes may multiply in the new environment and cause exacerbation.i.e the new environment and cause exacerbation.i.e no no easy access to apical canal if there is a flare upeasy access to apical canal if there is a flare up..

An ability to relieve pain quickly and efficiently is the An ability to relieve pain quickly and efficiently is the major reason for not completing endodontic therapy major reason for not completing endodontic therapy in one sitting.in one sitting.

There is no opportunity to place intracanal There is no opportunity to place intracanal disinfectant (other than allowingdisinfectant (other than allowing NaOCl NaOCl to disinfect to disinfect during the treatment).during the treatment).

TEETH THAT SHOULD NOT BE COMPLETED IN ONE TEETH THAT SHOULD NOT BE COMPLETED IN ONE APPOINTMENTAPPOINTMENT

Many studies on canal configuration of maxillary Many studies on canal configuration of maxillary molars indicate that molars indicate that four canalsfour canals are present more are present more often than three canals.often than three canals.

Location and preparation of the fourth canal (Location and preparation of the fourth canal (second second canal in the mesiobuccal rootcanal in the mesiobuccal root) may take considerable ) may take considerable time and must not be rushed, particularly when the time and must not be rushed, particularly when the pulp was involved in an acute pulpitis and pulp was involved in an acute pulpitis and concomitant bleeding is present.concomitant bleeding is present.

Time necessary to locate the additional canal, Time necessary to locate the additional canal, which is quite posterior in the arch, the patient must which is quite posterior in the arch, the patient must keep open widely for a significant time which is keep open widely for a significant time which is uncomfortable.uncomfortable.

Mandibular first molar often has four canals (usually Mandibular first molar often has four canals (usually the the mesiolingual canalmesiolingual canal) too, although not as ) too, although not as frequently as the maxillary molars.frequently as the maxillary molars.

The second condition for which multiple The second condition for which multiple appointments involves the treatment of a patient appointments involves the treatment of a patient who suffers from who suffers from physical and/or mental conditionphysical and/or mental condition that makes longer appointments extremely taxing to that makes longer appointments extremely taxing to both the patient and the practioner.both the patient and the practioner.

This problem may be due to diseases of the muscle This problem may be due to diseases of the muscle tissues such as tissues such as muscular dystrophy or mental muscular dystrophy or mental diseasedisease including including attention deficit disorder.attention deficit disorder.

If it is discovered during the preparation that much If it is discovered during the preparation that much over instrumentationover instrumentation has occurred by error the tooth has occurred by error the tooth should not be completed in one appointment.should not be completed in one appointment.

Case selection is quiet important to rule out with Case selection is quiet important to rule out with preoperative apical periodontitispreoperative apical periodontitis because they are because they are more prone to postoperative problems.more prone to postoperative problems.

Anterior teethAnterior teeth which are easier to radiograph offer a which are easier to radiograph offer a better chance for one visit success than do molar better chance for one visit success than do molar teeth.teeth.

One step treatment is less expensive very well One step treatment is less expensive very well accepted by patients and has been shown to result in a accepted by patients and has been shown to result in a lower flare up rate according to:lower flare up rate according to:

Trope M.Flare up rate of single visit endodontics J Trope M.Flare up rate of single visit endodontics J endo 1991;24:24-7endo 1991;24:24-7

Jureak et alJureak et al 19931993 performed one-visit endodontics on 167 performed one-visit endodontics on 167 patients regardless of pain, swelling,sinus tract, or patients regardless of pain, swelling,sinus tract, or radiogarphic lesions. They reported that one visit was radiogarphic lesions. They reported that one visit was no more uncomfortable than multiple visit and showed no more uncomfortable than multiple visit and showed same success rate.same success rate.

Oliet et al and Fava et alOliet et al and Fava et al 1989 1989 reported little or no reported little or no differenec in the post treatment complications differenec in the post treatment complications between single and multiple visit.between single and multiple visit.

Pekrunh RBPekrunh RB et al1986 et al1986 reported that the incidence reported that the incidence of failure after one appointment endodontics was of failure after one appointment endodontics was higher in those teeth with periapical extension of higher in those teeth with periapical extension of pulpal disease.pulpal disease.

In more recent times, and in marked contrast to these In more recent times, and in marked contrast to these positive reports, positive reports, Sjogren and his associates (1997) in Sjogren and his associates (1997) in SwedenSweden sounded a word of caution. At a single sounded a word of caution. At a single appointment, they cleaned and obturated 55 single appointment, they cleaned and obturated 55 single rooted teeth with apical periodontitis. All of the teeth rooted teeth with apical periodontitis. All of the teeth were initially infected. After cleaning and irrigating with were initially infected. After cleaning and irrigating with sodium hypochlorite and just before obturation, they sodium hypochlorite and just before obturation, they cultured the canals. Using advanced anaerobic cultured the canals. Using advanced anaerobic bacteriologic techniques, they found that 22 (40%) of the bacteriologic techniques, they found that 22 (40%) of the 55 canals tested positive and the other 33 (60%) tested 55 canals tested positive and the other 33 (60%) tested negativenegative

Periapical healing was then followed for 5 years. Periapical healing was then followed for 5 years. Complete periapical healing occurred in 94% of the 33 Complete periapical healing occurred in 94% of the 33 cases that yielded negative cultures! But in those 22 cases that yielded negative cultures! But in those 22 cases in which the canals tested positive prior to root cases in which the canals tested positive prior to root canal filling, “the success rate of healing had fallen to canal filling, “the success rate of healing had fallen to just 68%”, a statistically significant difference. just 68%”, a statistically significant difference.

In other words, In other words, if a canal is still infected before filling at if a canal is still infected before filling at a single dental appointment, there may be a 26% a single dental appointment, there may be a 26% greater chance of failure than if the canal is free of greater chance of failure than if the canal is free of bacteria. bacteria.

Their conclusions emphasized the importance Their conclusions emphasized the importance of of eliminating bacteria from the canal system eliminating bacteria from the canal system before obturationbefore obturation and that this objective could and that this objective could not be achieved reliably without an effective not be achieved reliably without an effective intracanal medicament. intracanal medicament.

Kyoko Inamoto et al 2002Kyoko Inamoto et al 2002 reported that in a survey reported that in a survey conducted among 738 United States endodontists conducted among 738 United States endodontists 55.8% carried out single visit endodontics and 34.2% 55.8% carried out single visit endodontics and 34.2% indicated that their patients had experienced some indicated that their patients had experienced some trouble after root canal obturation at first visit.trouble after root canal obturation at first visit.

The original investigators in this fieldThe original investigators in this field, Fox, Fox et al., et al., Wolch, Soltanoff, and Ether et al.(1981),Wolch, Soltanoff, and Ether et al.(1981), were were convinced that single visit root canal therapy could be convinced that single visit root canal therapy could be just as successful as multiple-visit therapy. None, just as successful as multiple-visit therapy. None, however, treated the acutely infected or abscess however, treated the acutely infected or abscess case with a single visit.case with a single visit.

Walton and Fouad et al1992Walton and Fouad et al1992 treated 946 patients and treated 946 patients and then examined the correlating factors that cause flare up then examined the correlating factors that cause flare up after root canal treatment.after root canal treatment.

They reported that the cause of flare up after root canal They reported that the cause of flare up after root canal treatment had no correlation between patients treatment had no correlation between patients demographics or systemic conditions, number of demographics or systemic conditions, number of appointments, treatment procedures or taking appointments, treatment procedures or taking antibiotics.antibiotics.

THANK YOUTHANK YOU

If the patients tooth is worth saving it is also If the patients tooth is worth saving it is also worth returning for second appointment.worth returning for second appointment.