Review Article SINGLE-VISIT ENDODONTICS: A REVIEW

Nandakishore K J,* Shija A S,* Vinaychandra R** Abstract

This article presents a review on single-visit endodontics. With the present fast paced life that everyone leads, it is a must for every dentist practicing endodontics to be aware of when, how and with what means to successfully complete root canal treatment in a single-visit. This article will also help dispel some myths regarding single-visit endodontics. With the introduction of newer instruments and techniques, it is much easier today to successfully perform single-visit endodontics. Keywords : Asymptomatic Nonvital Pulps, Periradicular surgery, Acute apical periodontitis, Anatomic anomalies, Chemical debridement * Senior Lecturer, ** Reader, Department of Conservative Dentistry and Endodontics, RajaRajeswari Dental College and Hospital. Bangalore. Correspondence: Nandakishore K J, Senior Lecturer, Department of Conservative Dentistry and Endodontics, RajaRajeswari Dental College and Hospital, Kumbalgodu, Mysore Road, Bangalore - 560074. Email id: dr_nandu1@rediffmail.com

Today knowledge is power. It controls the access to opportunities and advancement. Advancement has occurred in all fields and dentistry is not an exception. Single sitting root canal therapy is an outcome of such newer advancements. One visit endodontics is defined as the conservative non surgical treatment of an endodontically involved tooth consisting of complete biomechanical cleansing, shaping, and obturation of the root canal system during one visit.1 Maximum dentistry in minimum visits has been the rule in modern dental practice. The concept of doing complete endodontic treatment in one visit is not new. It was there from at last 100 Years. Although the concept remained constant, the technique varied. However, only recently the beliefs and attitudes concerning the inclusion of this technique into practice of clinical endodontics appear to be undergoing a process of change, because of expanding favorable clinical experience and an increasing number of favorable clinical research studies, single sitting endodontics has moved away from being an empirical technique. It is now viewed as an acceptable treatment procedure for certain specific endodontic problems.

Guidelines for Single-Visit Endodontics

Success in endodontic therapy is based on: 1. Accurate diagnosis 2. Proper case selection 3. Use of skilled techniques of treatment

Preliminary Considerations
Operator Ability and Clinical Experience It is a technique for experienced practitioners who have made endodontics an integral part of their clinical practices and not for the person who only does an occasional endodontic case. Once endodontics is done routinely and with satisfactory results, the practitioner should make a careful assessment as to how long it takes to thoroughly cleanse, shape, and fill the root canal systems of anterior and posterior teeth, utilizing conventional multivisit procedures. The clinician will then know the time that is necessary to perform a complete treatment on any tooth in the mouth and can schedule his or her one-visit procedures accordingly. Time and Auxiliary Utilization It should be remembered that one-visit endodontics is dependent upon the use of fundamental endodontic operative skills. There are no short cuts, simply the application of these skills in a thoughtful and organized manner. A failure to develop these basic skills to a high degree of competence can only result in a high incidence of broken instruments, ledged canals, perforations, inadequately prepared and incompletely filled root canals.
Clinical criteria It should be remembered that one-visit endodontics is dependent upon the use of fundamental endodontic operative skills. There are no short cuts, simply the application of these skills in a thoughtful and organized manner.

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A failure to develop these basic skills to a high degree of competence can only result in a high incidence of broken instruments, ledged canals, perforations, inadequately prepared and incompletely filled root canals. Systemic Evaluation and Premedication A history of myocardial infarction within the past six months is contraindicated for elective dental treatment. These patients should be treated with a stress reduction protocol which includes short appointments, psychosedation and pain and anxiety control. Patients with a history of rheumatic heart disease should be premeditated with amoxicillin, erythromycin or clindamycin, as per the current American Heart Association Guidelines.

designed restoration. In each and every instance treatment can be planned ahead of time and endodontic treatment can be completed in one visit. 4. Vital Pulp Exposures and Symptomatic Pulpitis Teeth containing vital pulp could include teeth with pulp exposures caused by trauma, caries, or mechanical reasons and teeth that exhibit clinical symptoms to heat or cold stimuli but not percussion. In cases of vital pulp, a singlevisit treatment should be used whenever possible. This is based on the fact that the pulp is only superficially infected and the root canal is free of bacteria, provided the aseptic chain is maintained during the intracanal procedures. Therefore, there is no apparent reason not to treat vital pulp in single visit. 5. Asymptomatic Nonvital Pulps This particular indication is probably the most controversial in terms of whether or not a one-visit procedure can be performed without an increased incidence of postoperative pain. Teeth with non vital pulps plus an associated sinus tract appear to be the least likely to cause postoperative discomfort. 6. Patients who are physically unable to return for the completion.

Specific Case Selection

Oliet's Criteria for Case Selection3 1. Positive patient acceptance. 2. Sufficient available time to complete the procedure properly. Absence of any acute symptoms requiring drainage via the 3. canal and of persistent continuous flow of exudate or blood. Absence of anatomical obstacles like calcification in the 4. canals, and procedural difficulties (ledge formation, blockage, perforation, inadequate fills).

Indications 4,5,6
1. Isolation and Sealing Problems There are certain instances when a one-visit procedure can be used to eliminate the potential problem of inter-appointment contamination and/or flare-ups due to leakage or complete loss of the temporary seal. 2. Anterior Esthetic Problems
Cases falling into this category would be maxillary anteriors involved in trauma that have resulted in a horizontal fracture of the crown at the gum line. These cases are probably the most frequently treated in one visit and pose esthetic as well as isolation and sealing problems if treated in the conventional multi-visit manner. At the completion of

7. Patients who require sedation or operating room treatment. 8. Immediate periradicular surgery 9. Dentist skill

Contraindications 7-11
1. 2. 3. 4. 5. 6. 7. 8. 9. Cellulitis Acute apical abscess requiring incision and drainage Severe pain when the tooth is lightly touched A weeping canal that cannot be dried Difficult cases that extend beyond our allotted time and the patient's tolerance Patients with acute apical periodontitis Molars with necrotic pulps and periradicular radiolucencies Symptomatic Root canal retreatment Patients with TMJ disorders and inability to open the mouth

3. Restorative Considerations Cases that fall into this category require endodontics for restorative reasons and not because they have pathologic pulp tissue that must be removed or because of pulp exposures. Examples would include teeth to be used as overdenture abutments, mandibular anteriors to be cut down for full jacket crowns, teeth with severe coronal breakdown that cannot possibly retain a restoration because of the severe loss of tooth structure, and teeth that require preparation that would result in pulp exposure in order to get them into a certain desired alignment for the construction of a specifically

Conditions where multiple visit therapy is preferred over single visit therapy7
1. Asymptomatic nonvital teeth with periapical pathology and no sinus tract 2. Teeth with anatomic anomalies

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3. Infected cases with evidence of apical periodontitis (periapical radiolucency, swelling, exudates). 4. Patients with many allergies or previous flare-ups.

Myth No.1:
Postoperative pain is greater when endodontic therapy is completed in a single visit, especially in nonvital teeth.

Advantages

Fact No.1:
Overwhelming evidence shows that postoperative pain resulting from treatment of vital or nonvital teeth does not differ among patients treated in a single visit or in multiple visits.12

1. It reduces patient appointment visits per tooth while still maintaining a traditionally predictable high level of treatment. 2. It eliminates inter-appointment contamination and flare-ups due to leakage or loss of the temporary seal in severely broken-down teeth. 3. It allows the practitioner to immediately use the canal for retention of a post to construct an esthetic temporary crown in maxillary anterior trauma cases in which the crown has been fractured off to the gum line. 4. It allows the practitioner to fill the canal when he or she is most familiar with the canal anatomy, working length, and position of the apical stop. 5. As the treatment is completed in a single-visit, it allows the dentist to pass on the savings of chair time in the form of a reduction in fee to the patient.

Myth No.2:
There is less healing when endodontic therapy is completed in a single visit, especially in non-vital tooth.

Fact No.2:
Comparative studies have produced no statistical difference between healing of vital and nonvital teeth treated in single or in multiple visit.12

Myth No.3:
Post operative swelling is greater when endodontic therapy is completed in a single visit.

Disadvantages

1,4,9

Fact No.3:
Trope defined flare-up as "intolerable pain and/or swelling". Using a similar definition, Walton and Found studied data from 946 patients' visits for treatment of vital and nonvital teeth, and found no significant difference in flare-ups between single-and multiple-visit endodontics (no inter-appointment medicaments were used). 12

1. For those practitioners who culture the root canal microflora, this check on the effectiveness of their biomechanical preparation would be missing from the treatment regimen. 2. Clinician fatigue with extended one-appointment operating time 3. Patient fatigue and discomfort with extended operating time. 4. No opportunity to place an intracanal disinfectant (other than allowing NaOCl to disinfect during treatment). 5. Inability to control exudate may prevent completion of the procedure.

Myth No.4:
Canals are cleansed if an antibacterial medicament such as Ca(OH)2 is left in the root canal and a later appointment is given for permanent root canal filling.

Myths Associated With Single-Visit Endodontics

12

Fact No.4:
Prolonging treatment to multiple appointment, leads to bacterial regrowth in canals, with or without most inter-appointment medicaments, including Cresantine, phenols, and polyantibiotics. On the Other hand, if multiple appointments are necessary, Ca(OH)2 has been shown to be an effective inter-appointment antibacterial medicament.12

For many years, dentists have practiced single-visit endodontics (initiating and completing root canal treatment in one appointment) on vital and nonvital teeth. However, a significant number of clinicians do not perform single visit treatment for various misconceptions. There are three major reasons that patients once refused endodontic treatment and often chose tooth extraction instead: cost, fear of pain, and time. These are three reasons to perform single-appointment treatment. For single-visit procedures, less time and materials are required. With so many advantages and few disadvantages, why don't more clinicians practice single-appointment endodontics? Reasons include widespread belief in myths associated with such treatment.

Myth No.5:
Multiple-visit endodontics is safer than single-visit endodontics, and multiple visits mean more careful treatment.

Fact No.5:
Goerig and Neaverth summed it up best: Recent studies have shown no difference in the quality of treatment, incidence of post treatment complications, or success rate when comparing single-visit with multiple-visit root canal treatment.12

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Myth No.6:
Patients do not mind multiple appointments and are likely to object to the fee if the procedure is completed in a single visit

Fact No.6:
Aside from cost, there are two other major barriers to patients visiting the dentist: fear of pain and time required. Completing root canal therapy in one appointment limits fear of pain to one incidence and decreases the time required (the number of appointments and total treatment time). Patients are more likely to, accept single-visit treatment. Dentists may think that single-visit endodontics should cost less than multiple-visit endodontics; on the contrary, patients may pay a premium for more efficient treatment. Nonstop flights often cost more than indirect flights and overnight mail costs more than regular delivery. We live in a fast-paced society. Patients want efficient, high-quality care, and usually are willing to pay a reasonable fee for it.12

predictable root canal shaping. The rotary technique is less fatiguing for the practitioner and NiTi decreases postoperative pain for the patient, most likely due to a combination of file design and a crown-down modality. Eg: Pro Taper Files, Light Speed, Greater Taper Files, Hero shaper, Profile, K3, Race Because rotary systems reduce treatment time, single visits are now within the reach of most practitioners. However, speed alone does not justify single-visits. It is meticulous canal cleaning and disinfection that does. 2. Microscopes The introduction of the microscope to the field of endodontics has provided the clinician an opportunity to observe areas of interest at high magnification under constant illumination. The use of this device during root canal treatment can assist the clinician in locating and negotiating calcified canals, and performing surgical and nonsurgical root canal treatments. 3. Chemical debridement 14-19 While it can reduce the bacterial count significantly, mechanical debridement does not disinfect the root canal system completely. Thus, a root canal irrigant is needed to aid in the debridement of the canals. Sodium hypochlorite (NaOCl) is the most commonly used root canal irrigant. However, NaOCl has some major shortcomings, including its inability to remove the smear layer and to kill all bacteria present in infected root canals. Chlorhexidine, an antimicrobial agent with strong affinity to dental hard tissues is used as an irrigating solution because it would be retained and would contribute to the maintenance of a bacteria free root canal for some time after completed endodontic therapy. Smear layer removal is best achieved by irrigating the canal system with NaOCl throughout the chemo mechanical preparation procedure to prevent accumulation of debris on the canal walls and to flush out the canal system. A final rinse with 17.5% ethylene diamine tetra-acetic acid (EDTA) is recommended for removal of the inorganic component. Recently, a mixture of a tetracycline isomer, an acid and a detergent known as MTAD has been introduced as a final rinse for disinfection of the root canal system. This irrigant is able to remove the smear layer safely, and it is a more effective disinfectant than NaOCl even against resistant bacteria such as E. faecalis.

Myth No.7:
After obturation, treating a flare-up is complicated; therefore, treatment should not be completed at the first appointment.

Fact No.7:
Fear of a post-obturation flare-up prevents clinicians from performing single-visit endodontics, but such flare-ups generally are less common than inter-appointmentflare-ups. The flare-up rate associated with single-visit endodontics is the same as that associated with multivisit endodontics. Flare-ups after single-visit treatment are treated exactly the same way as post-obturation flare-ups after multi-visit treatment. Most flare-ups can be treated with occlusal reduction, analgesics, and antibiotics. In the unusual event that a problem continues, apical trephination (fistulization) can be performed. If the canals are cleaned and filled properly, a need to remove filling material is rare. Whether obturation is performed in a single visit or after multiple visits, removal of gutta-percha (if necessary) usually is straight forward.12

Single Visit Endodontic Therapy And Recent Advances

Over the past decade, nickel titanium rotary instrumentation, microscopic endodontics, digital radiography, a plethora of obturation systems, and biocompatible sealing materials have helped practitioners perform endodontic procedures more effectively and efficiently than ever before. This is not implying that endodontic treatment has become easier; however, better tools and technology have made it more predictable and challenge us to take on a wider variety of complex cases. 1. Nickel Titanium rotary instrument & crown down technique13 The introduction of nickel titanium, or NiTi, rotary instrumentation has made endodontics easier and faster than hand instrumentation, resulting in consistent and

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4. Electronic apex locators The task of determining canal length has moved into a new and more precise era with the rapid evolution of electronic devices that measure the length of the root canal. Research and clinical experience support the claim that apex locators can assist accurately in determining canal length in the majority of cases. Electronic apex locators work on the principles of resistance, impedance and frequency. Recent apex locators (Root ZX, AFA, Justy, Endex- Plus) have been reported to be accurate to within 0.5 mm in >90% of cases. They reduce not just the radiation dosage, but are also helpful in quick determination of working length. 5. Obturation systems Successful single-visit treatment depends on effective mechanical debridement, chemical disinfection, and proper sealing of the canal system. Obturation can only be as good as the instrumentation, since filling material cannot occupy the same space as the debris left by poor instrumentation. Researchers have attributed failure of root canal therapy largely to incomplete obturation of the root canal system. Injectable thermoplasticized techniques have been found to be not just time saving, but they also produce dense, well obturated root canal systems. Eg: Obtura II, Thermafil, One Step Obturators, E and Q System. 6. Digital Radiography It is a computerized imaging system that uses an electronic sensor instead of an X-ray film. They are helpful in achieving a successful single-visit endodontic therapy by the following means, 1. 2. 3. 4. Yielding sharp, clear images Using 70% less radiation than conventional X-ray film Image appearing rapidly on a computer screen It is quick and has the added ability to zoom in on a specific area on the radiograph. 5. The resolution and diagnostic quality is excellent, storage is easy and there are no developing or processing errors. 7. Ultrasonics Recent studies have shown ultrasonics to be superior in debriding the root canal system when compared with hand instruments. The irrigating solution used with ultrasonics was sodium hypochlorite 2.5%. The ultrasonics used with small file held free of the canal walls, warms the solution in the canal and

resonant vibrations cause movement of aqueous irrigants; an effect called Acoustic microstreaming. According to many studies, the use of ultrasonics will result in few cases of post operative pain compared to the cases done with hand-instrumentation.

CONCLUSION
A generation ago, dentists were taught to culture canals before obturating them and the idea of single-visit endodontics was unheard of. Multiple medicaments and intracanal antibiotics were the generally accepted standard of care. Presently, singlevisit endodontics is widely accepted and practiced. In the present times, everyone leads a fast-paced life. No patient would like to come to a clinic several times to get a single tooth root canal treated. A quick, efficient and well done root canal therapy in a single appointment will be well appreciated. It is advantageous to both the patient and dentist in many ways. Single-visit endodontics can be practiced by a dentist who is well versed with root canal therapy, provided the dentist is fully aware of the indications and contraindications of single-visit endodontic therapy. It is important to note that there is no short cut to success; single-visit endodontics does not mean skipping of any step, rather all the steps must be systematically performed to achieve a successful outcome. To conclude, one must bear in mind that irrespective of the number of visits, a good quality of endodontic treatment must be provided.

References
1. Ashkenaz PJ. One-visit endodontics. Dent Clin North Am 1984;28(4):853-63. 2. Damle SF, Kakade A, Bhavsar JP. Endodontic treatment of primary molars: A comparison of single and multiple visit techniques. J Ind Dent Assoc 1995;66(2):18-22. 3. Oliet S. Single-visit endodontics: A clinical study. J Endod 1983;9:147-52. 4. Ingle JI, Bakland LK. Modern endodontic therapy, In: Ingle JI, editor. Endodontics. Hamilton Ontario, Canada: Elsevier; 2002. P. 15-20. 5. Grossman LI, Oliet S, Del Rio CE. Single visit endodontics. In: Grossman LI, editor. Endodontic practice. Philadelphia, PA. USA:Lea & Febiger;1988.P.349-50. 6. Mohammadi Z, Farhad A, M Tabrizizadeh. One visit versus multiple visit endodontic therapy A Review, Int Dent J 2006;56:289-93. 7. Munce R, Teplitsky P. Point of care, J Can Dent Assoc 2005;71(1):46-51. 8. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth: A Cochrane review. J Endod 2008;34(9):1041-47.

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9. JD Regan and JL Gutmann. Preparation of the root canal system. In : Pittford, editor. Hartys Endodontics in Clinical Practice, Edinburgh:Wright;2004;P.90-94. 10. Behrend GD, Cutler CW, Gutmann JL. An in-vitro study of smear layer removal and microbial leakage along root-canal fillings. Int Endod J 1996;29:99107. 11. Bender IB. Factors influencing the radiographic appearance of bony lesions. J Endod 1997;23(1):514. 12. Wahl M J. Myths of single visit endodontics. General dentistry 1996;44(2):126-29. 13. Glickman G. 21st century endodontics. J Am Dent Assoc 2000;131:39-46. 14. Zehnder M. Root canal irrigants. J Endod 2006;32(5):389-98. 15. Torabinejad M, Ung B, Kettering JD. In-vitro bacterial penetration of coronally sealed endodontically treated teeth. J Endod 1990;12:56669. 16. rstavik D et al. Effects of apical reaming and calcium hydroxide dressing on bacterial infection during treatment of apical periodontitis. Int Endod J 1991;24(1):1-7. 17. Trope M, Delano EO, Orstavik D. Endodontic treatment of teeth with apical periodontitis: Single vs. Multivisit treatment. J Endod 1999;25(5):345-50. 18. Shahrokh Shabahang. Chemical Debridement. J Am Dent Assoc 2005;136(1):41-52. 19. Spanberg LSW & Haapasalo M. Rationale and efficacy of root canal medicaments and root filling materials with emphasis on treatment outcome. Endod Topics 2002;2:35-58.

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