single visit endo

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ENDO (Lond Engl) 2009;3(3):215–225

� 215REVIEW

Single-visit endodontic therapy is an old concept in clinical practice. However, the controversy stillexists as to which root canal treatment option is best between single- and multiple-visit endodontictherapies. Initially considered as a radical and substandard procedure, single-visit endodontic thera-py is now being considered as a good alternative to multiple-visit endodontic treatment. This is dueto the introduction of new and improved technologies and materials in endodontics, including sur-gical microscopes, NiTi rotary instrument systems, newer more reliable apex locaters, ultrasonics andnewer obturation systems.This review article highlights the indications, contraindications, advantages, disadvantages, guide-lines and criteria for evaluation of single-visit endodontic therapy. The review also emphasises theevidence-based practice for single-visit endodontic therapy in clinics, based on the available currentliterature on this issue.

Neeraj Malhotra, Kundabala M, Shashirashmi Acharya

Contemporary endodontic approach: single-visit root canal treatment revisited

post-operative pain, retreatment, single-visit endodontic therapy, successKey words

Neeraj Malhotra Department of ConservativeDentistry and Endodontics,Manipal College of DentalSciences, Mangalore, India

Kundabala M Department of ConservativeDentistry and Endodontics,Manipal College of DentalSciences, Mangalore, India

Shashirashmi Acharya Department of ConservativeDentistry and Endodontics,Manipal College of DentalSciences, Manipal, India

Correspondence toDr Neeraj Malhotra Department of ConservativeDentistry and Endodontics,MCODSMangalore - 575001Karnataka, India Tel: (91 0824) 98445 79329 Fax: (91 0824) 2422653Email:[email protected]

� Introduction

Progress in any field can only be achieved by alter-ing and/or rejecting the old beliefs, concepts andattitudes and moving forward. This will then allownew information for the growth and expansion ofa profession to be discovered. Professionals shouldbe eager to re-examine and re-evaluate the pre-existing data to adopt a new treatment protocol forbetter results. However, for health professionals,

this procedure is slower and more difficult to follow.This is due to the risks involved and the un-predictability of success on introduction of a newconcept, method or modality. Similar problems arestill associated with the practice of single-visitendodontic therapy in clinics.

Single-visit endodontic therapy is defined as ‘the conservative non-surgical treatment of anendodontically involved tooth consisting of com-plete biomechanical cleansing, shaping and obtura-

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tion of the root canal system during one visit’1. Withthe advent of new instrumentation techniques,material science and technology, it is no more anorthodox empirical procedure for obturation of rootcanals. However, with the introduction of magnify-ing loupes (Fig 1), surgical microscopes, NiTi rotaryinstrument systems (Fig 2), ultrasonic devices (Fig 3),newer obturation systems (injectable obturationsystem) (Fig 4), it is now considered as an accept-able alternative treatment procedure for endodon-

tic problems. Although a number of clinical researchstudies have shown favourable results with single-visit protocols2,3,4,5, evidence-based studies do reportthat there is a lack of clinical evidence to supportthese 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-visitendodontics. This review article focuses on the avail-able data to determine the success of single-visitendodontic therapy in clinical settings. This will aidin the design of an evidence-based practice and/orapproach to appropriately diagnose those clinicalcases 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

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216 � Malhotra et al Single-visit root canal treatment revisited

Fig 1 Magnifyingloupes.

Fig 2 NiTi rotary instrument systems: a) ENDO-mate DThandpiece (NSK,Nakanishi, Japan); b) ProFile (DentsplyMaillefer, Switerzland);c) ProTaper (DentsplyMaillefer, Brazil); d) EasyRaCe (FKGDentaire, Switerzland).

a b

c d

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85.7% of the endodontic programs, and 91.4% ofthe directors, faculty and residents of postgraduateendodontic programs treated some cases in onevisit8. A random poll of 429 endodontists showedthat they would treat 67% of vital cases and only12.8% of necrotic cases in a single visit9, as theybelieved that more pain is experienced in single-visitendodontic 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% wouldobturate teeth with necrotic pulps in one visit.When a peri-apical lesion was present, 70% of therespondents preferred multiple treatments with anintracanal medicament. Gatewood et al11 reportedthat 35% of 568 diplomats treat teeth with anormal peri-apex in a single visit, 16% would do sowhen apical periodontitis was present and less than10% of the diplomats would complete a non-vitalcase in one visit. A recent survey carried out by

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� 217Malhotra et al Single-visit root canal treatment revisited

a b

a b

c d

Fig 3 Ultrasonic hand-piece (a) and tips (b).

Fig 4 Obturating sys-tems: a) Obtura II gun andpellets (ObturaCorporation, Missouri,USA); b) ProTaper F2 gutta-percha points (DentsplyMaillefer, Brazil);c) Thermafil cones(Dentsply/Tulsa DentalProducts, Oklahoma,USA);d)GuttaFlow capsules(Colténe/Whaledent,Langenau, Germany).

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Inamoto et al12, that included 738 randomly chosenendodontists of the American Association ofEndodontists, indicated that 87 out of 156 (55.8%)endodontists performed root canal obturationduring a first visit in pulpectomy cases and 52 outof 151 (34.4%) endodontists performed single-visittreatment in infected root canal cases.

The difference in incidence could be due tovariability in the level of understanding and knowl-edge of the individual operators and the variabilityin the diagnosis made for individual cases. Thetooth type, time available, clinician’s skills andanatomical or periodontal complications areamong the determining factors. Also, multiple-visitendodontic 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-apicalchanges, are the ideal candidates for single-visitendodontic therapy (Fig 5). It has the followingadvantages:• pulp extirpation is easier and fast (vital pulp)• no recall appointments so time is saved• an inter-appointment intracanal medicament is

not required

• chances of flare-up are less likely as a temporaryinter-appointment restoration is not required.

� Cases where a temporary seal cannot beprovided between appointments

Usually in vital teeth with subgingival breakdown,teeth with multiple missing coronal walls, and teethhaving full coverage restorations with decayed mar-gins, the extent of lost tooth structure is quiteextensive. This makes it extremely difficult andtime-consuming to secure well fitting temporaryrestorations on teeth.

� Fractured anterior or premolar teeth These teeth are present in the aesthetic zone of themouth. Fracture of these teeth is thus of aestheticconcern to the patient and a temporary restoration(temporary post and crown) is often required. Ante-rior tooth fractures approximating the gingival linewithout apparent pulp exposure and any clinicalsymptoms (tenderness on percussion) can be treatedwith single-visit endodontic therapy. Following thetreatment, an aesthetic anterior temporary crowncan 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 jacketcrowns and teeth with severe coronal breakdown(severe attrition) that require a restoration (whose

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a b

Fig 5 Radiographsshowing the treatmentof a vital molar (46)tooth using single-visitendodontic therapy: a) preoperative radi-ograph; b) post-operative radi-ograph.

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preparation would result in pulp exposure) to obtaina desired alignment for the designed restoration.

� Medically compromised and disabled patients

Physically disabled patients who cannot return forrecall appointments, patients who require sedationand/or operating room treatment and patientswith heart valve damage or prosthetic implantsthat require repeated regimens of prophylacticantibiotics, should be considered for single-visitendodontic therapy.

� Contraindications

Multiple-visit endodontic therapy is usually advo-cated due to ease of opening up a tooth for reliefof 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 recedingpulp chambers, calcified canals, severely curvedcanals, bifurcated canals and dilacerations or pro-cedural errors including broken instruments, per-forations and ledge formation, make it virtuallyimpossible at times to perform endodontic therapyin 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 disordermay require longer appointments for their treatment.Long appointments may be extremely taxing to boththe patient and the practitioner.

� Non-vital teeth with or without apicalperiodontitis and re-treatment cases

This particular condition is probably the most con-troversial in terms of whether or not a single-visit

endodontic therapy procedure can be performedwith clinical success in such cases. Pekruhn15

observed more failures in teeth involved with peri-apical extension of pulpal disease and that sympto-matic cases were twice as likely to fail comparedwith asymptomatic cases (10.6% versus 5.0%).The highest failure rate (16.6%) was seen inendodontic re-treatment cases.

Inter-visit use of an antimicrobial dressing (cal-cium hydroxide, Ca(OH)2), is considered to be anessential factor in eradicating all infection from theroot canals. According to Waltimo et al16, an inter-appointment dressing of Ca(OH)2 can reduce thenumber of bacteria within a week. Also, more reportson high failures rates have been reported in teethwith apical periodontitis treated with single visitendodontics. 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 apicalperiodontitis. They concluded that complete elimi-nation of bacteria is not possible in a single visit,because it is not possible to eradicate all infectionfrom the root canal without the support of an inter-appointment antimicrobial dressing. In a follow-upstudy, Delano et al18 treated teeth with apical peri-odontitis, with and without Ca(OH)2, in one or twovisits. The Ca(OH)2 group showed the greatestimprovement in peri-apical index (PAI) score, fol-lowed by the single-visit group (74% versus 64%).They concluded that the additional disinfectingaction of Ca(OH)2 may increase healing rates by10%, which is clinically important. Also, the majorityof the flare-ups happen in teeth with signs of apicalperiodontitis requiring retreatment. In another 52week comparative study in North Carolina, theresearchers concluded that Ca(OH)2 disinfectionbefore obturation of infected root canals results insignificantly less peri-apical inflammation than obtu-ration alone. Also, a two-visit root canal treatment ismore effective at completely eliminating pain of pre-viously symptomatic teeth. Microorganisms areessentially the main aetiological agents of primaryapical periodontitis and post-treatment apical peri-odontitis. The intracanal flora of an infected rootcanal is an immobilised biofilm on the dentinal sur-face in an organised, multi-species, micro-ecosystemthat cannot be eradicated by host defences orchemotherapy alone. Nair et al19 observed that com-

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plete elimination of microorganisms, which existedprimarily as biofilms, is not practically possible by anyof the contemporary root canal treatments, particu-larly with the single-visit treatment. Also, it has beenshown that the amount of of Enterococcus faecalisinside the root canals can be reduced, but cannot beeliminated completely either by single or multiplevisits20.

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 ofteeth with apical periodontitis treated with eithersingle-visit or multi-visit treatment regimens. Arecent study reviewed the effectiveness of single-versus multiple-visit endodontic treatment of teethwith apical periodontitis22. Of all the studiesanalysed, only three studies met the inclusion crite-ria for a meta-analysis. However, the sample size ofthese studies was unjustifiably small and, thus, wasnot sufficient enough to make a clinical decision. Themeta-analysis also showed no statistically significantdifference in the healing rate of the two treatmentregimens. Hence, the evidence failed to demon-strate a difference between the two treatment reg-imens in cases of apical periodontitis. Other reasonsthat may favour the use of single-visit root canaltherapy in apical periodontitis cases are as follows.

Short intra-appointment application of a bacte-ricidal dressing does not satisfactorily reduce thenumber of root canal microbes. With respect toclinical outcomes, no additional benefit is providedby the use of an inter-appointment antibacterialdressing such as Ca(OH)2 4,22,23.

Introduction of many current techniques andsystems has made it possible to perform endodon-tic therapy more efficiently and effectively in asingle visit. All of these recent developments helpthe operator to complete the root canal therapy ina single visit with the utmost clinical precision.

It is much easier and faster to identify and detectthe canal orifices, accessory canals, hidden canals,obstructions and pulpal calcifications with the useof magnifying loupes (Fig 1) and microscopes,reducing the chances of perforation.

The use of NiTi hand and rotary systems such asthe ProTaper® (Dentsply Maillefer, Ballaigues,Switzerland) and ProFile® series (Dentsply Maillefer)

(Fig 2) requires less clinical time (fewer number offiles) and is much easier (pre-determined sequenceof set files) when completing the cleaning and shap-ing of root canals. These instruments are also con-sidered to be superior and predictable in shapingand cleaning root canals24,25. Apex locaters help inconfirming the radiographic working length toreduce the chances of procedural errors.

Newer obturation systems like Greater Tapercones (SybronEndo, Orange, CA. USA), Thermafil®

system (Dentsply/Tulsa Dental Products, Oklahoma,USA), ProTaper gutta-percha cones (DentsplyMaillefer), 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 easilyand conveniently and require less chairside time.

The introduction of better disinfecting systemslike ultrasonics26 (Fig 3), photo-activated disinfec-tion (PAD)27 and better irrigants (like MTAD) thathave equivalent or improved anti-microbial efficacyagainst E. faecalis compared with previously usedirrigants28,29.

So far there is paucity of research-based dataavailable 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 inapical periodontitis cases13. Until then it is better touse an intracanal medicament, such as Ca(OH)2,within a multiple-visit regimen for treatment ofteeth with apical periodontitis. In addition, if pusand inflammatory exudate develop peri-apically,and complete endodontic treatment has alreadybeen performed, then trephination or an incisionand drainage are the only procedures available toobtain relief in such cases. Thus, in the contempo-rary clinical practice it is advised to treat teeth withapical 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

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leakage or loss of the temporary seal are reduced.• 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 anduncomfortable to some patients, especiallythose 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 unduestress for both the patient and the clinician.

• Expertise is required by the clinician to effi-ciently and properly treat a case in a singlevisit.

� Guidelines

Single-visit endodontics should only be performedafter a full understanding of endodontic principlesand the ability to exercise these principles effi-ciently. The operating clinician should have all theclinical skills required to complete the treatment ina given time-frame. As a guideline, the caseshould 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. Theseinclude:• 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 oraccessory canals) and procedural difficulties(ledge formation, blockage, perforations, inad-equate fills).

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Fig 6 Diagrammaticrepresentation of com-parison parameters: incidence of post-operative pain andflare-ups, and successversus failure rates. The“?” for success versusfailure rates indicatethat there is no differ-ence in success rate (orfailure rate) betweensingle- and multiple-visit endodontic thera-pies and the ‘x’ for in-cidence of post-opera-tive pain indicates thatit is not a valid compar-ison parameter be-tween single- and mul-tiple-visit endodontictherapies.

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� Single-visit versus multiple-visitroot canal treatment

The two basic parameters used for the comparisonof single-visit and multiple-visit endodontic therapyare (Fig 6):• incidence of post-operative pain and flare-ups• success versus failure rates.

� Post-operative pain

Fear of post-operative pain following treatment isthe biggest factor in avoiding single-visit endodon-tic therapy. A large number of studies and researchhave been carried out to compare the incidence ofpost-operative pain in single- versus multi-visitendodontic therapy.

Fox et al32 treated 291 teeth in single visits andreported severe pain within 24 hours in only 7% ofcases. They found that 90% of the teeth were freeof spontaneous pain after 24 hours, whereas 82%had little or no pain on percussion. Rudner andOliet33 observed that if an accurate diagnosis,proper case selection and skill in technique are used,the incidence of post-operative pain and healingremained 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-operativepain was associated with treatment of anteriorteeth. In a long-term study, Oliet31 observed nostatistically significant difference between the twotreatment groups in relation to post-operativepain and swelling. Similarly, no significant differ-ence existed between the groups when comparedby tooth morphology (anterior teeth, premolarsand molars), gender, diagnosis (vital pulps versusnecrotic pulps) and filling terminus (filling short orwithin 0.5 mm of the radiographic apex). Roaneand colleagues35 viewed the post-operative painexperience of patients treated in a single visit andmulti-visit approach. Their results indicated that ahigher frequency of post-operative pain was asso-ciated with a multi-visit treatment in both vital andnon-vital cases. This may be attributed to themicroleakage caused by temporary restorations in between the appointments. According to

Albashaireh and Alnegrish2 a significantly higherincidence of post-obturation pain was found in themultiple-visit group (38%) than in the single-visitgroup (27%) within 24 h of obturation. Also,teeth that had non-vital pulp prior to treatmentwere associated with a significantly greater inci-dence of post-obturative pain. Wolch36 observedthat out of 2000 patients, less than 1% had anyform of severe reaction following single-visitendodontic therapy. Nakamuta and Nagasawa37

reported a pain incidence of 7.5% after treating106 infected cases in single appointments. Mulh-ern et al38 reported no significant difference in theincidence of pain between 30 single-rooted teethwith necrotic pulps treated in one appointmentand 30 similar teeth treated in three appoint-ments. A recent study by Al-Negrish and Habah-beh3 observed no statistically significant differencebetween both groups, in the incidence and degreeof postoperative pain in asymptomatic non-vitalmaxillary central incisors. Also, strong evidenceindicating 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 offlare-ups in single- and multiple-visit endodontictherapy. Some studies have concluded that eitherthere is no difference in the incidence of flare-upsbetween 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 literatureshowed that there is no significant differencebetween the two treatment protocols as far as inci-dence of post-operative pain is considered, there isa 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, subjectivenature of the pain interpretation and evaluation,and pre-operative symptoms of patients (withor without preoperative pain)

• the definition of flare-up is reported to be differ-ent by different authors

• anxiety regarding the procedure can alter theincidence of reported pain experience.

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Therefore, on the basis of available data, the inci-dence of post-operative pain cannot be used as abasic parameter for the comparison between single-and multiple-visit endodontic therapies (Fig 6).

� Success versus failure rates

Long-term success of any treatment is dependenton various criteria, including case selection, treat-ment procedures and protocols, time managementand sufficient duration of recall appointments. Mostof the studies in the literature indicate that there isminor or no substantial difference in the successrates of single- and multiple-visit endodontic ther-apy. Jurcak et al42 reported 89% success rate follow-ing single-visit endodontic therapy. DespiteSoltanoff’s43 report of considerably more pain inassociation with single-visit endodontic treatment,he found that both techniques provided successrates exceeding 85%. Rudner and Oliet33 comparedsingle-visit with multiple-visit endodontic therapyand found that both healed with a frequency ofabout 88% to 90%. Oliet31 evaluated 153 singlevisits and 185 multiple-visit cases 18 months post-operatively and found a failure rate of 11% in bothcategories. He also found no significant differenceswhen tooth groups and pulp vitality status werecompared. Ashkenaz44 found a failure rate of 3%after 1 year in 101 single-canal, vital teeth that weretreated in one visit. Pekruhn39, in a study of 1140single-visit cases, found a failure rate of only 5.2%.Weiger et al4 observed that the success rate after 5years, 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 casestreated in one visit and 71% of the cases treated intwo visits. Waltimo et al45 found no remarkable dif-ferences between the two treatment groups (singlevisit 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 singlevisits using peri-apically extruded endomethasonepaste showed consistently successful results withradiographic peri-apical healing on follow-up. A ret-rospective study by Field et al47 concluded that nostatistically significant differences were observed

between the two treatment protocols based ongender, age, arch or provider. However, they pro-posed that anterior teeth were more successful thanposterior teeth. This was in accordance with thefindings of Rudner and Oliet33. This is most likely dueto the anatomical complexities of posterior teeth.Location and preparation of the fourth canal in max-illary first molars (second canal in the mesiobuccalroot) may take considerable time.

On the contrary, Silveira et al48 observed that atwo-visit treatment using Ca(OH)2/camphormono-chlorphenol based inter-appointment intracanalmedicament offered a high success rate comparedto one-visit treatment. Similarly, a comparable per-centage of radiographic healing was seen in boththe treatment protocols but the Ca(OH)2 group(multiple-visit) showed fewer failed and moreimproved cases49.

The difference in the percentage of successand/or failure rates in different studies and differ-ence in opinion among the researchers regardingthis issue can be attributed to the following reasons:• the original investigators in their research did not

treat acutely infected or abscess teeth in a singlevisit32,36,43

• shortage of good unbiased studies that can aidclinical decision making for an evidence-basedpractice

• due to the difference in the definition of successas proposed by different authors, the success ofan endodontic treatment is often poorlydefined. This can alter the overall result of eachstudy. It is also dependent on other variablessuch 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 thatthere is no difference in success rate betweensingle- and multiple-visit endodontic therapies(Fig 6). However, an appropriate case selectionand clinical diagnosis are essential before optingfor single-visit endodontic therapy as the treat-ment option for a particular patient and tooth. Forthis the following should be considered for an evi-dence-based practice of single-visit endodontictherapy.50

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� Operator ability and clinical experience

Single-visit root canal treatment is a procedure to beperformed only by experienced practitioners whouse it on routine basis. It is not indicated for theoperators who mainly practise general dentistry andalso perform endodontic cases, but not on regularbasis. It is only after years of experience that a practitioner can attain the precision of operativeskills to perform endodontics in a single visit. Onceendodontics is done routinely, a practitioner canbetter assess the time required to thoroughlycleanse, shape and fill the root canal systems ofanterior and posterior teeth.

� Time and auxiliary utilisation

A practical time limit for the endodontic treatmenthas to be decided, taking into consideration theclinician’s operative skill and the difficulty of thecase. As per the guidelines for single-visitendodontic therapy, the majority of cases shouldbe completed within 45 to 60 minutes. This isdependent on the clinician’s ability to organise anduse an efficient endodontic delivery system forvarious endodontic procedures such as isolation,access, biomechanical preparation and obturation.A well-trained and efficient dental assistant couldhelp in achieving this objective. The dental assis-tant aids in preparation of tray, placement of therubber dam, passing of instruments and materialsduring treatment procedure, radiographs, tempo-risation, cleaning of instruments and sterilisation.

� Clinical techniques

Fundamental knowledge of basic operative skillsand a high degree of competence in these skills canreduce the incidence of broken instruments, ledgedcanals, perforations, and inadequately preparedand incompletely filled root canals. This would nec-essarily result in a higher than normal success rate.Thus, failure of an endodontic procedure is due tothe failure of a practitioner to develop skills manda-tory to perform single-visit root canal treatment inclinics.

� Conclusion

In summary, this literature review draws the follow-ing conclusions regarding single-visit endodontictherapy.• 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 caseswith apical periodontitis.

• The literature so far does not support a validreason to claim that the success rate of themultiple-visit is better than single-visit endo-dontic therapy and vice-versa.

• The choice of treatment between single- andmultiple-visit root canal treatment should bemade, taking into the consideration the indi-viduality of a case and the operator’s skill. Butin cases where the required operator skills arelacking, diagnosis is doubtful and the progno-sis is unpredictable for a single-visit endodon-tic therapy, multiple-visit treatment should bepreferred and performed.

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4. Weiger R, Rosendahl R, Löst C. Influence of calcium hy-droxide intracanal dressings on the prognosis of teeth withendodontically 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 J2002;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 J2008;41:91-99.

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8. Landers RR, Calhoun RL. One-appointment endodontictherapy: an opinion survey. J Endod 1980;6:799-801.

9. Calhoun RL, Landers RR. One-appointment endodontictherapy: a nationwide survey of endodontists. J Endod1982;8:35-40.

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