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show any significant difference between the groups (P = .05). Conclusions: Several
factors play an important role in the decision-making process of 1- versus 2-visit
endodontics. Among these are objective factors like preoperative diagnosis, the ability
to obtain infection control, root canal anatomy, procedural complications, and subjective factors like patients signs and symptoms. This study provided evidence that with
a treatment protocol with instrumentation to predefined larger apical instrumentation
sizes and irrigation with a negative apical pressure system can lead to healing in cases
of apical periodontitis, which is a significant finding compared with more dated studies
that showed average healing of apical periodontitis cases. With the given sample size,
there was no statistically significant difference between the 2 treatment modalities. (J
Endod 2012;38:11641169)
Key Words
1 visit, 2 visits, pain, periapical lesion, success and failure rate
From the School of Dentistry, Universidad Autonoma de Baja California, Tijuana, Baja California, Mexico.
Address requests for reprints to Dr Jorge Paredes-Vieyra, 710E San Ysidro Boulevard, Suite A, San Ysidro, CA 92173. E-mail address: jorgitoparedesvieyra@
hotmail.com
0099-2399/$ - see front matter
Copyright 2012 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.05.021
1164
Clinical Procedures
All treatment sessions were approximately 50 minutes in length to
allow for acceptable time for the completion of treatment for 1 or 2
visits. All treatment was performed by the author. After local anesthesia
by 2% lidocaine with 1:100,000 epinephrine (Scandonest, Saint Maur
des Fosses, France) and rubber dam isolation, the tooth was disinfected
with 5.25% NaOCl (Ultra Bleach, Bentonville, AR). All caries were
removed and endodontic access cavities made with sterile high-speed
carbide #331 (SS White, Lakewood, NJ) and Zekrya Endo burs (Dentsply-Maillefer, Ballaigues, Switzerland).
The working length was established with the Root ZX Electronic
Apex Locator (J Morita, Irvine, CA) and confirmed radiographically.
The canals were negotiated and enlarged with hand instruments
(Flex-R Files; Moyco/Union Broach, York, PA) until reaching an ISO
#20 at the working length. The coronal portions of the canals were
flared with sizes 2 to 3 Gates Glidden burs (Dentsply Maillefer,
Mandibular
n = 300 (%)
34 (11.33)
17 (5.66)
51 (17.00)
77 (25.66)
179 (59.66)
21 (7.0)
12 (4.0)
29 (9.66)
59 (19.66)
121 (40.33)
1 visit
(n = 155) (%)
1-visit
follow-up
(n = 146) (%)
2 visits
(n = 145) (%)
2-visit
follow-up
(n = 136) (%)
28 (18.06)
18 (11.61)
45 (29.03)
64 (41.22)
155 (100)
26 (17.80)
16 (10.95)
42 (28.76)
62 (42.46)
146 (100)
27 (18.62)
11 (7.58)
35 (24.13)
72 (49.65)
145 (100)
25 (18.38)
9 (6.61)
33 (24.26)
69 (50.73)
136 (100)
1165
Mandibular
n = 300 (%)
23 (7.66)
156 (52.0)
179 (59.66)
17 (5.66)
104 (34.66)
121 (40.33)
1 visit
(n = 155) (%)
1-visit
follow-up
(n = 146) (%)
2 visits
(n = 145) (%)
2-visit
follow-up
(n = 136) (%)
30 (19.35)
125 (80.64)
155 (100)
2 (1.36)
144 (98.63)
146 (100)
10 (6.89) 2 (1.47)
135 (93.10)
145 (100)
2 (1.47)
134 (98.52)
136 (100)
a buildup restoration was placed by using the same etching technique and Fuji IX.
For the 2-visit group, the canals were dried and calcium hydroxide
powder (Roth, International Ltd, Chicago, IL) was placed with an
amalgam carrier and condensed with a size 9 posterior Schilder plugger
(Dentsply Maillefer). The access cavities (occlusal/palatal surface)
were sealed with Cavit (3M ESPE, AG Seefeld, Germany), and the quality
of the calcium hydroxide powder filling was checked radiographically
with posttreatment radiographs.
Patients in the 2-visit group were scheduled for a second appointment to complete root canal therapy at least 1 week after the initial
appointment. At the second appointment, the calcium hydroxide was
removed with hand instruments, and copious irrigation with 5.25%
sodium hypochlorite followed by 2.5 mL 17% EDTA and a final rinse
of 5.0 mL 5.25% sodium hypochlorite using the EndoVac irrigation
system was performed.
For complete removal of the calcium hydroxide, the canals were
dried with sterile paper points, and obturation was performed with
the same technique described for the 1-visit group and posttreatment
Lost to follow-up:
Lost to follow-up:
Analysed (n=146)
Analysed (n=136)
None excluded
None excluded
1166
2-Year Follow-up
The healing results were clinically and radiographically evaluated
2 years postoperatively. (Supplemental CONSORT flow chart is available
at www.jendodon.com.) All radiographic films obtained preoperatively
and at follow-up were coded blind and organized in a random order.
Two precalibrate endodontist examiners (author not included) independently evaluated all radiographs under moderate illumination at
a light table using a 2 magnifying viewer equipped with a masking
frame the same size as the dental film. Before evaluation of the study
images, each examiner graded a series of 15 radiographic images not
associated with the study sample and representing a wide range of periapical bone densities.
To minimize the false-positive diagnoses, observers used a strict
definition of periapical disease (20). In case of disagreement, a joint
re-evaluation was performed until a consensus was reached on all
images. The consensus score for each image was considered the true
score and was used for statistical analysis. Follow-up radiographs
were made with the individual custom index and recorded exposure
settings. All radiographs were obtained by using the same digital
imaging system (Schick Technologies Inc, Long Island City, NY).
The primary outcome measure for this study was classified by
using a modification of the Strindberg study (21) used for radiographic
healing assessment. Teeth with symptoms of persisting periapical
inflammation were scored as not healed as were the cases with periapical radiolucencies that remained unchanged or increased in size.
Teeth with a reduced periapical rarefaction were judged as uncertain. Teeth with complete restitution of the periodontal contours were
judged as healed. In teeth with more than 1 root, the least favorable
outcome was recorded.
The periapical index was used as a scoring system to evaluate
radiographic healing (18) as shown in Table 3. Secondary outcome
measures were the presence of clinical symptoms or abnormal findings at 2 years (ie, spontaneous pain, presence of sinus tract,
swelling, mobility, periodontal probing depths greater than baseline
measurements, or sensitivity to percussion or palpation) as shown in
Table 2.
Radiographic images were coded and stored and evaluated
blindly and independently by 2 experienced endodontists. Before evaluation of the study images, each examiner graded a series of 12 radiographic images not associated with the study sample and representing
a wide range of periapical bone densities. The examiners then met as
a group and reviewed all scores to improve calibration and interrater
agreement. Consensus was reached on images that were not formerly
scored the same by all examiners. A chi-square test was used to test
trends in contingency tables using SPSS v. 19 for Windows (SPSS Inc,
Chicago, IL). The hypothesis tests were conducted at the 0.05 level of
significance.
TABLE. 3. Evaluation of Radiographic Findings According to Periapical
Index (PAI)
PAI score
1
2
3
4
5
Results
Randomization allocated 155 teeth to 1-visit and 145 teeth to 2visit treatment. Eighteen teeth, 9 in the 1-visit group and 9 in the 2visit group, were lost to follow-up, leaving a total of 282 teeth that
were evaluated at the 2-year follow-up period (146 teeth in the 1-visit
group and 136 in the 2-visit group, Table 1). Two cases (1.36%) experienced postoperative pain in the 1-visit group and 2 cases (1.47%) in
the 2-visit group (Fig. 1 and Table 2).
At the end of the study, 141 of the 146 teeth (96.57%) in the 1-visit
group and 121 (88.97%) of the 136 teeth in the 2-visit group were classified as healed (Table 4). Eleven cases were classified as uncertain in
the 2-visit group (8.08%) compared with 4 (2.73%) in the 1-visit
group. Two of the 10 teeth in the 2-visit group (Table 2) that showed
clinical symptoms (pain) before the 2-year follow-up were classified
as not healed (Table 4). One patient (2-visit group) presented with
persistent draining sinus tracts at 24 months (both had sinus tracts
present at the initial treatment appointment) as seen in Table 1. The
statistical analysis of the healing results did not show any significant
difference between the groups (P = .05).
Discussion
The purpose of this randomized study was to compare the
outcome of 1- versus 2-visit root canal treatment of teeth with apical periodontitis after a 2-year healing period. Clinical outcome studies take
a long time to monitor, demand substantial economic resources, and
run the risk of losing patients at follow-ups. A determination of healed,
not healed, or uncertain was made radiographically 2 years after treatment. However, because radiographic images of periapical bone lesions
range from impossible or difficult to see to being easily seen, falsepositives were minimized in this study because periapical radiolucencies were recorded only when absolutely certain.
No statistically significant difference in success rates (healed
lesion) was observed between the 1- and 2-visit groups, which corroborates the results of previous studies (7, 22, 23). Published studies
including this one have failed to show any statistically significant
difference in the outcome between 1-visit and 2-visit root canal treatment (2426). Other studies have compared the healing rate after
1-visit and 2-visit root canal therapy although the criteria for endodontic
success were often poorly defined and varied across the studies (7, 9,
27, 28).
The success and failure of endodontic treatment are determined
by long-term results and not the presence or absence of short-term
postoperative pain. Our results agree with Mattscheck et al (29), who
found that root canal treatments with postoperative pain occurring
shortly after treatment can result in long-term success, whereas treatment without such pain may result in failure. Glennon et al (30) and
Ng et al (31) reported that discomfort was the most common shortterm outcome of root canal treatment procedures. Patients with
single-visit follow-up experienced postoperative pain less frequently
(1.35%) than those with multiple-visit root canal treatment (2%).
The adoption of clinical procedures in endodontic therapy depends
TABLE 4. Distribution of Teeth According to Outcome Classification
1 visit
2 visits
(n = 146) (%) (n = 136) (%)
Healed
Uncertain healing
Not healed
Total
141 (96.57)
4 (2.73)
1 (0.68)
146
121 (88.97)
11 (8.08)
4 (2.94)
136
Total
262 (92.90)
15 (5.31)
5 (1.77)
282
P = .05. The chi-square test was used to test trends in the contingency table.
1167
Conclusion
Endodontic treatment tries to eradicate microorganisms from
the root canal system to promote periapical healing. Several factors
play an important role in the decision-making process of 1- versus
2-visit endodontics. Among these are objective factors like preoperative diagnosis, the ability to obtain infection control, root canal
anatomy, procedural complications, and subjective factors like
patients signs and symptoms. This study provided evidence that
a meticulously instrumented 1-visit root canal treatment can be as
successful as a 2-visit treatment. There was no significant difference
in radiographic evidence of periapical healing between 1-visit and
2-visit root canal treatment.
Acknowledgments
The authors thank Dr E. Steve Senia, Dr Michael H
ulsmann,
and Dr Elizeu Alvaro Pascon for their valuable assistance in reviewing this article.
The authors deny any conflicts of interest related to this study.
JOE Volume 38, Number 9, September 2012
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