considerations and Single Vs Multiple endodontics

1. Single Visit Endodontics
Rajana Raghunath
Post graduate student

2. Contents
 Introduction
 History
 Indications
 Contraindications
 Practice management advantages
 Patient advantages
 Disadvantages

3.  Guidelines for one-appointment endodontics
 Single visit versus multiple visit endodontic treatment for infected root canals
 SVE Vs Multiple Visit Endodontics
 Conclusion
 References

4. Introduction
 Maximum dentistry in minimum visit- rule in modern dentistry
 In recent years, single-appointment endodontics has gained increased acceptance
as the best treatment for many cases.
 Single visit dentistry has been defined as the conservative non surgical treatment
of an endodontically involved tooth, consisting of complete biomechanical
preparation and obturation of the root canal in one visit

5. History
 Completing endodontic treatment in a single visit is an old concept that can be
traced through the literature for at least 100 years.
 Dodge et al described various techniques, which included root canal sterilization by
hydrogen dioxide and sodium dioxide, hot platinum wire sterilization, potassium
permanganate sterilization, or sulfuric acid irrigation. The canals were filled with
chloropercha, formopercha, sectional gutta-percha, or zinc oxide and eugenol
paste

6.  Single-visit endodontics enjoyed a resurgence following World War II. However, it
was generally performed in conjunction with resection of the root apex immediately
after filling the canals. Trephination, or artificial fistulation, was also used in
conjunction with single-visit endodontics, to prevent or alleviate postoperative pain
and swelling.
 In many of the early reports opinions were based on limited clinical observations
and inadequate scientific studies. In 1959, Feranti reported that there was little
difference in postoperative sequelae between single-visit and two-visit root canals.
However, relatively few comprehensive studies of one-visit endodontics were
published until the 1970s.

7.  Over the past decade, nickel titanium rotary instrumentation, more reliable apex
locators, ultrasonics, microscopic endodontics, digital radiography, newer
obturation systems, and biocompatible sealing materials have helped practitioners
perform endodontic procedures more effectively and efficiently than ever before.
 All of these advances increase the incidence of single-visit endodontics in the
dental clinics and the rational for this treatment regime are less stressful and only
one anesthesia is needed, which makes it very well accepted by the patient, less
time-consuming, reduces the risk of inter-appointment contaminations, less
expensive and more productive for the clinician.

8. Indications
oPatients requiring full mouth rehabilitation.
oUncomplicated vital teeth.
oPatients in whom sedation is required.
oFractured anterior or bicuspid teeth where esthetics is the concern.
oTeeth with accidental/mechanical pulp exposure.
oNon vital teeth with sinus tract
oMedically compromised patients who require antibiotic prophylaxsis
oPhysically compromised patients who cannot come to dental clinics frequently

9. oTeeth requiring immediate post placement, where esthetics is the concern.
oTeeth with sub-gingival breakdown, multiple coronal walls missing, where isolation
and sealing is the problem.
oSome of the re-treatment cases
Ahmed F, Thosar N, Baliga MS and Rathi N. Single Visit Endodontic Therapy: A Review. Aust J
Dent.2016; 3(2): 1035.

10. Contraindication
 Patients having severe pain on percussion suffering from acute apical periodontitis.
 Teeth with anatomic anomalies for e.g. calcified and curved canals.
 Acute alveolar abscess cases with pus discharge.
 Patients who are unable to keep mouth open for long duration for e.g. TMJ
disorders.
 Teeth with limited access.

11.  Symptomatic non vital teeth and no sinus tract.
 Asymptomatic non vital teeth with periapical pathology and no sinus tract
 Most retreatments.
 Patients with allergies or previous flare ups
 Hot tooth

12. Practice management advantages
 It reduces the number of patient appointments while achieving predictably high levels
of success and patient comfort.
 it eliminates the chance for interappointment microbial contamination and flare-ups
caused by leakage or loss of the temporary seal. Medico legal risk is reduced: The
likelihood of cross contamination is minimized
 For anterior cases it allows immediate use of the canal space for retention of a post
and construction of an esthetic temporary crown.
 It is the most efficient way of performing endodontic treatment, because it allows the
practitioner to prepare and fill the canals at the same appointment without the need for
the clinician's re familiarization with the canal anatomy at the next visit. Immediate
familiarity with the internal anatomy, canal shape, and contour facilitates obturation and
also less errors in working length

13.  The number of teeth that patients are willing to save may increase because they do
not have to return as often .
 Prosthetic work can begin without delay.
 Single appointment treatment limits schedule interruption to replace lost or broken
temporary restorations.
 Materials needed for separate visits (disposable bibs, suction tips, anaesthetic and
irrigation needles and rubber dams) are saved

15.  Time is saved: There is no need to neither reappoint patient nor reconfirm
appointments; no need to greet patients, update medical history nor anaesthetize
more than once; no need to customize instruments for patients, place rubber dam,
remove temporary restorations, nor relearn patient’s canal morphology etc.

16. Patients advantages
 Patient comfort – as the number of visits are reduced.
 Patient convenience – Patient does not have to endure the discomfort of repetitive
pricking of local anesthesia and no additional appointments.
 Economics – Extra cost of multiple visits, use of comparatively less chair side time,
fewer materials all increase the economics to both patient as well as doctor.
 Restorative considerations – In single visit endodontics, immediate placement of
coronal restoration (post and core placements) ensure effective coronal seal and
esthetics.
 Reduced intra appointment pain: Mid treatment flare ups which are usually caused by
leakage of the temporary cements which would be reduced in single visit endodontic
cases.

17. Disadvantages
 The longer single appointment may be tiring and uncomfortable for the patient.
Some patients, especially those with temporomandibular dysfunction or other
impairments, may not be able to keep their mouth opened long enough for a one-
appointment procedure.
 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.

18.  No opportunity to place an intracanal disinfectant (other than allowing NaOCl to
disinfect during treatment)
 Clinician fatigue with extended one-appointment operating time
 The clinician may lack the expertise to properly treat a case in one visit. This could
result in failures, flare-ups, and legal repercussions.

19. 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.
 As a guideline, the case should be completed within 60 minutes.
 Treatments that take considerably longer should be done in multiple visits.
 Vital teeth are better candidate for SVE as there are less chances of flare ups

20. Oliet's criteria for case selection
Oliet's criteria for case selection include
1. Positive patient acceptance,
2. Sufficient available time to complete the procedure properly,
3. Absence of acute symptoms requiring drainage via the canal and of persistent
continuous flow of exudate or blood, and
4. Absence of anatomical obstacles (calcified canals, fine tortuous canals,
bifurcated or accessory canals) and procedural difficulties (ledge formation,
blockage, perforations, inadequate fills).
Oliet S: Single-visit endodontics: a clinical study, J Endod 9:147,1983.

21. Pain control
 It is preferable to use a long acting local anesthetic agent such as bupivacaine or
etidocaine.
 It also helps to control post-operative pain as compared to short acting local anesthetic
like lignocaine.
 Pariorokhet al has stated that patients who receive bupivacaine as the anesthetic
agent in mandibular molars for single-visit endodontic treatment of irreversible pulpitis
as compared to those who had lidocaine as the local anesthetic has significantly less
early postoperative pain and also used fewer analgesics.
 For better success rate of the anesthetic efficacy use of 4% articane can be
incorporated as compared to traditional use of lignocaine as observed by Roberston

22.  Sometimes supplemental anesthesia is indicated along with the standard injection.
 These include:
i. Intra-pulpal injections
ii. Intra-osseous injection
iii. Periodontal ligament injection

23. Digital Technologies In Local Anesthesia
 Electronic Dental Anesthesia
 Wand (Computer -controlled local anesthetic delivery system)
 1.8ml injection - 36-160 sec

24. Isolation
 The use of the rubber dam is mandatory in root canal treatment because of its
following advantages:
1. Patient is protected from aspiration of instruments, tooth debris, medicaments
and irrigating solutions.
2. Soft tissues are retracted and protected.
3. A surgically operating field is isolated from saliva, blood and other tissue fluids. It
also reduces the risk of cross contamination of the root canal system with the
spread of infectious agents.
4. Visibility is improved. It provides a dry field and reduces mirror fogging.
5. Efficiency is increased.

25. Magnification light
 Use of high quality magnification in dentistry improves both the quality and speed
of treatment, hence suitable for single visit endodontics.
 Santos AcciolyLins C, et al. gave a systemic review on operating microscope
stating that use of operating microscope provide a marked significant improvement
in vision of operative field thereby offering better quality jobs and a higher success
rate

26. Bio-Mechanical Techniques used
 Instead of preparing the root canal in an apical – cervical direction (flared
preparation, step-back preparation, canal funneling, telescopic preparation), newer
technique have been designed to avoid problems such as apical extrusion of
debris . These technique are called cervical or coronal flaring techniques, in which
the root canal is prepared in cervical apical direction.

27.  Especially in cases of non-vital pulps, this extrusion may cause of flare up with
subsequent discomfort and swelling for the patient.
 Moreover Holland et al., (1980) have demonstrated that the healing process may
be impaired when infected dentin chips are carried to the apical area and lie
between the filling material and the periapical tissues. These findings, together with
the reports have told us that debris extrusion during instrumentation, have led to
the adoption of another approach in canal preparation.

28.  The crown –down pressure less technique (Marshall and Papin 1980),
 The step down technique (Goerig et al 1982),
 The preflaring technique (Gerstein 1983),
 The double flare technique (Fava 1983)
 Use of ultrasonics
 Endox® Endodontic System

29. Crown down technique

30.  Work hardening of titanium instruments – M wire technology (vortex, vortex blue)
 R phase – twisted files
 Controlled memory – Hy flex
 Rotation reciprocation – wave one
 Newer instruments – shorter shank , smaller head hand piece

31. Self Adjusting File
 Compressible leaflets that expand inside root canal, and oscillate in a vertical
manner to prepare canal
 Irrigation with attached tube
 Used – oval irregular canal
 Limitations – decrease apical preparation irrigation

32.  Single-visit root canal treatment was performed with ProTaper™ S1-S2-F1-F2 and
WaveOne™
 Pain curves demonstrated a more favourable time-trend in the rotary group
 Difficulty in eating, in performing daily activities, in sleeping and in social relations,
was more evident in the reciprocating group.
 Patients' perception of the impact of treatment was more favourable in the rotary
group.
Pasqualini et al. Postoperative quality of life following single‐visit root canal treatment performed by rotary
or reciprocating instrumentation: a randomized clinical trial. IEJ, 2015

33.  Endox is an innovative method for the treatment of bacterial infections of the root
canal.
 initially locate the apex of the root canal system (endometrial) and subsequently the
pulp tissue vaporization with reduction of bacterial content of the canal system, by
increasing temperature, after high frequency current (600 kHz) for one tenth of a
second.
 It has a fine surgical steel needle that is used as an active electrode, introduced into
the open root canal and a neutral electrode that is held in the patient's hand. Then a
discharge of high frequency alternating current (HFAC) is applied.
 The passage of this electromagnetic field, when carried out under specific conditions of
impedance, produces a sterilization of the root canal similar to that observed with
standard methods using chemicals, with beneficial effects for inside and outside the
tooth

34.  The Endox endodontic system should not be used on patients with pacemakers,
contact lenses (in which case they should be removed) and cellular phones should
be turned off to avoid interference.
 There are three different needles, a black one, longer and larger diameter, for
molars (30 mm long/0.20mm diameter), a shorter red one with a slightly smaller
diameter (24mm/0.15) and a Teflon covered green needle to be used exclusively
for apical measurements in cases of teeth with necrotic pulp

35.  Acc to a study done by Mammani et al, it was found out that Endox method was
reasonably effective in the elimination of Enterococcus faecalis from infected single
rooted canals.
Mammani et al. Efficacy of Endox Endodontic System in eradication of Enterococcus
faecalis from Infected Pulp in Duhok, Kurdistan, Iraq. Rawal Med J 2010;35

36. Irrigation
Manual Machine
Syringe Rotary brushes
Brushes (endo brush) Continuous irrigation during
Manual agitation rotary (quantec)
Sonic irrigation
Rispy
Endoactivator
Ultrasonic
Pressure activation device

37. Sonic Endo activator
 Portable hand piece 2000-10000 cycles / min
 Vibrating tip - up down vertical strokes
 Hydrodynamic phenomenon
 Remove debris, smear layer, biofilm

38. PIPS
(Photon Induce Photo Acoustic Streaming)
 Er.Yag laser
 PIPS in coronal 3rd
 Photo acoustic shock waves
 6ml of 5 % NaOCl

39.  Bacteria are known to penetrate depth of 600 to 10000 micro meters whereas the
irrigant can penetrate a depth of around 100 micrometer.
 Laser has been used lately for better disinfecting of the root canal and it gives
access to the deeper area of dentinal tubules of around 1000 micrometer.
 Thus laser improves the overall disinfection of the root canals thereby improving
the treatment outcome.
 As per Preethee, et al., use of LASER (908 nm diode) in conjunction with
conventional chemo-mechanical techniques significantly eliminate E. Faecalis in
apical third of root dentin.

40. Single Visit Endodontic Therapy: Acceptance
 The main concern among dentist - association of its post-operative pain and the
regular failure of the treatment outcome previously observed.
 Unfortunately, there is a widely held but anecdotal opinion that current
chemomechanical cleaning techniques are superior, predictably removing the
entire bacterial flora. If this is so, single-visit treatment of necrotic pulp cases would
definitely be indicated.
 Although single appointments would be very appropriate in cases with vital pulps,
on the other hand, for teeth with necrotic pulps and periapical periodontitis, and for
failed cases requiring retreatment, there may be a risk of lower success rates in the
long term.

41. Success rates
 Prognostic studies of one-appointment root canal treatment are less numerous
than pain studies, but most also indicate that there is no substantial difference in
the success rate of one and two-visit cases
 Ashkenaz claimed that one appointment root canals succeeded 97% of the time,
but he did not evaluate multiple visits.
 Rudner and Oliet compared one-visit to multiple-visit treatments and found that
both healed with a frequency of about 88% to 90%.
 Southard and Rooney described total healing of ail recalled cases when one
appointment endodontics was combined with incision and drainage and antibiotic
therapy.

42.  Pekruhn, in a study of 1140 single-visit cases, found a failure rate of only 5.2%. He
noted that teeth teeth with periradicular lesions that had had no prior access
opening showed three times the number of failures as those that had been
previously opened. This was especially true of teeth involved with periapical
extension of pulpal disease. There was also a higher incidence of failure in teeth
being retreated.
 Stamos and colleagues described two cases in which total healing occurred
following one-visit treatments in which combined hand instrumentation and
ultrasonic technique were utilized.

43.  Vera et al stated that the 2-visit protocol by using an interappointment medication
with calcium hydroxide resulted in improved microbiological status of the root canal
system when compared with the 1- visit protocol. Residual bacteria were more
frequent and abundant in ramifications, isthmuses, and dentinal tubules when root
canals were treated without an interappointment medication. Apical ramifications
and isthmuses were never completely filled. The use of an antibacterial
interappointment agent is necessary to maximize bacterial reduction before filling.
Vera J, Siqueira JF, Ricucci D, Loghin S, Fernández N, Flores B, Cruz AG. One-versus two-visit
endodontic treatment of teeth with apical periodontitis: a histobacteriologic study. J End. 2012 Aug
31;38(8):1040-52.

45. Healing rate of single visit versus multiple visit
endodontic treatment for infected root canals
 Analyzing the healed and non-healed outcome is the commonest way of
comparing both the treatment modality.
 Short or long term follow-up of both size of the lesion as well as the bone
radiograph is the most commonly used technique to evaluate the process of
healing, usually based on PAI score developed by Orstavik, et al.
 Yingying in a systemic review states that healing rate for infected tooth is similar
for single visit as compared to multiple visits root canal treatment.

46. Post operative 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 appointments
 There is that feeling in single visit management the chances of flare ups are more.
 The fear that patients will probably develop post-operative pain and that the canal has
been irretrievably sealed has probably been the greatest discouragement to single
visit therapy.
 Yingying in a systemic review has quoted that patients experience less frequency of
short-term post-obturation pain after single-visit than those having multiple-visit root
canal treatment.
Su Y, Wang C, Ye L. Healing Rate and Post-obturation Pain of Single- versus Multiple-visit Endodontic
Treatment for Infected Root Canals: A Systematic Review. J Endod. 2011; 37: 125-132.

47.  Roane and his associates found that treatment completed in multiple visits had a
two to one higher frequency of pain when compared to those completed in one
visit.
 Trope reported no flare ups in one appointment cases with no apical lesions.
However retreatment of the failed cases with apical periodontitis did made the
difference.
Roane JB, Dryden JA, Grimes EW. Incidence of postoperative pain after single and multiple-visit endodontic
procedures. Oral Surg Oral Med Oral Pathol. 1983; 55: 68-72.
Trope M. Flare-up rate of single visit endodontics. Int. Endo J. 1991; 24: 24-27

48.  Morse and co-workers, in an exhaustive series of clinical studies covering a period
of 24 years investigated factors that could reduce the incidence of flare-ups and of
pain and swelling not associated with flare-up. They concluded that one-
appointment endodontics combined with prophylactic administration of antibiotics
(penicillin V or erythromycin) and intentional over instrumentation of the root canal
into the approximate center of the bony lesion reduced the prevalence of flare-ups
from about 20% to 1.5%.
 One study suggests that single-visit endodontic treatment of posterior teeth seems
to produce more postoperative discomfort.
Roane JB, Dryden JA, and Grimes EW: Incidence of post-operative pain after
single- and multiple-visit endodontic procedures, Oral Surg 55:68, 1983.

49.  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 2,000 cases treated at a single appointment showed that
less than 1% of patients indicated any severe reaction.
 Mulhern et al. 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

50.  Re-treatment of failed cases with apical periodontitis made the difference, however.
These cases suffered a 13.6% flare-up rate
 In light of these studies, pain does not appear to be a valid reason to avoid single-
appointment root canal therapy.

51.  A study conducted in our college came to a conclusion that little or no significant
difference occurred between single visit versus multi visit endodontic therapy, and
which is in accordance with several investigators.

52.  A study conducted in Nigerian teaching hospital revealed higher incidences of
post-obturation pain and flare-ups following the single visit procedures
 The incidence of flare-up is minimal when teeth are treated in one visit. Absence of
a periapical lesion in necrotic teeth is a significant risk factor for flare-ups.
Oginni et al, Endodontic flare-ups: comparison of incidence between single and multiple visit procedures in
patients attending a Nigerian teaching hospital. BMC Oral Health 2004;4:4
Onay et al. The evaluation of endodontic flare-ups and their relationship to various risk factors. BMC
Oral Health2015;15:142

53. Conclusion
 With the advent of technological advancement and emergence of new gadgets,
evidence based dentistry and more scientific deliberations and the concept of
maximum dentistry in minimum visits led to a resurgent impetus towards laying
down of various protocols to enable dentists to venture into single visit endodontics
with reasonable level of outcome.
 Single visit root canal treatment versus the multiple visit root canal treatment has
been the subject of a long standing debate within the dental community, when the
clinicians are faced with choices of which treatment should be offered to patients,
the central issues that should be considered are effectiveness, complication, cost
and probably patient /operator satisfaction

54.  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.

55. References
 Pathways of Pulp- Cohen
 Ingles Endodontics
 Grossmans Endodontic Practice
 Textbook of Endodontics – Nisha Garg
 Roane JB, Dryden JA, Grimes EW. Incidence of postoperative pain after single and
multiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol. 1983; 55:
68-72.
 Trope M. Flare-up rate of single visit endodontics. Int. Endo J. 1991; 24: 24-27
 Su Y, Wang C, Ye L. Healing Rate and Post-obturation Pain of Single- versus
Multiple-visit Endodontic Treatment for Infected Root Canals: A Systematic Review.
J Endod. 2011; 37: 125-132.

56.  Vera J, Siqueira JF, Ricucci D, Loghin S, Fernández N, Flores B, Cruz AG. One-
versus two-visit endodontic treatment of teeth with apical periodontitis: a
histobacteriologic study. J End. 2012 Aug 31;38(8):1040-52
 Mammani et al. Efficacy of Endox Endodontic System in eradication of
Enterococcus faecalis from Infected Pulp in Duhok, Kurdistan, Iraq. Rawal Med J
2010;35
 Pasqualini et al. Postoperative quality of life following single‐visit root canal
treatment performed by rotary or reciprocating instrumentation: a randomized
clinical trial. IEJ, 2015
 Oliet S: Single-visit endodontics: a clinical study, J Endod 9:147,1983

57. Thankyou