SEMINAR ON

Single Visit V/S Multiple

Visits
Root Canal Treatment

Submitted by
Dr. Ramesh Panchal
M.D.S IInd Year

Deptt. Of Conservative
Dentistry and Endoodntics

CONTENTS
1.

Introduction

2.

History

3.

Indications

4.

Contraindication

5.

Advantages

6.

Disadvantages

7.

Microbiological bases: can maximal outcome be achieved in one visit

8.

Comparison with multiple visit endodontics

9.

Success versus failure

10.

Conclusion

11.

References

INTRODUCTION
The objective of endodontic therapy is restoration of the treated tooth to its
proper form and function in the masticatory apparatus, in a healthy state.
Endodontics has been termed a science as well as an art because inspite of all
the factual scientific foundation on which current endodontics is based,
completing an ideal endodontic job is an art in itself. The evolution of endodontics
journey can be outlined in 5 periods:Prescience

: 1776-1826

Age of Discovery

: 1826

The Dark Age

: 1876-1926

The Renaissance

: 1926-1976

Innovation Era

: 1977 onwards

The golden period of endodontics is the Renaissance which established it

as a science and therapy. It was in the renaissance era that Sargenti first reintroduced the concept of single visit endodontics. By single visit endodontics we
mean the initiation and completion of endodontic treatment in one appointment.
Since its inception, Single visit endodontics has been surrounded by controversy.
In 1982, a survey revealed that 87% of endodontists did not believe that most
necrosed teeth could be treated successfully in one visit. In addition,, the majority
thought that performing treatment in this fashion would cause more post
operative pain and failure than if performed in post operative pain and failure
than if performed in multiple appointments. However, in the innovation era the
single visit endodontic therapy concept is almost globally being accepted by all
schools of thought. This can be attributed to the breathtaking advancements
happening in endodontic therapy at a very rapid pace. Improved visibility is now
available with the advent of the endomicroscope. Newer, better and more reliable
apex locators are challenging the need for radiographs.

Improved and better forms of instruments and BMP are being cheered out and
obturation technique are becoming simpler, easier and faster. The net resultant is
simplification of endodontic therapy with higher success rates.
This seminar is an attempt to discuss the status of single visit endodontics in the
present scenario.

History:
The single visit procedure can be traced through the literature for at least
100 years. Although the concept remained, constant, the techniques varied. In
the early years, pressure anesthesia was followed by root canal sterilization
using hydrogen dioxide and sodium dioxide. Root canals were filled with
chloropercha, gutta-percha, and formapercha. In 1901, Trallero used a bichloride
was, hot platinum-wire sterilization, and zinc oxide-eugenol and xeroform paste
fill. Inglis, in 1904, anesthetized with cocaine, applied the rubber dam, "sterilized"
with potassium permanganate, and filled with chloropercha, sectional guttapercha, or formapercha; he excluded all "acute cases" and expected "absolute
success when directions are followed. In same year, Philips reported that teeth
he treated were "in perfect condition after three years," color as when alive," and
no abscess in a thousand. In 1908, Barnes irrigated root canals with sulfuric acid
and filled them with chlorepercha, but he excluded "abscessed root" from
treatment.
In the middle of the twentieth century came a resurgence of single-visit
endodontics. Initially, it started with the immediate root resection, that is,
endodontic treatment including apicoectomy in a single visit, but some clinicians
began to practice single-visit endodontics without periapical surgical procedures.
In 1955, Lorinczy-Landgraf and Polocz reported that 10% of 1200
gangrenous teeth, treated in single visits, caused moderate to severe post-

operative pain, with 3% requiring trephination. Two years later, these

investigators reported 82% healing. In 1959 Feranti compared post-operative
sequalae following single visit and 2-visit procedures and found little different.

INDICATIONS
(i)

Single visit treatment can be done in vital cases (i.e.) pulpal inflammation,
traumatic or iatrogenic pulp exposure during cavity preparation.

(ii)

Cases where an intentional pulpectomy is to be performed for prosthetic or

periodontal reasons can be obturated in single visit.

(iii)

Teeth with necrotic pulps associated with sinus tracts or when a surgical
procedure would be performed anyway can be considered for single visit.

(iv)

In non vital cases, once the canals are clean, smooth, tapered and dry,
and if the tooth is symptomless then it can be obturated in single visit.

(v)

Positive patient acceptance of the proposed single visit procedure

(informed consent)

(vi)

Sufficient treatment time available to properly complete the procedure.

(vii)

The patients should be in good general health.

CONTRAINDICATIONS
i)

Exclusion of any tooth with acute symptoms where drainage via the root
canal was established, as well as those teeth with a persistent, continuous
flow of exudate.

ii)

Exclusion of any tooth which could not be completed within available time
because of anatomical difficulties (calcified canals, fine tortuous canals,

bifurcated canals, additional canals) or procedural difficulties (leadge

formation, blockage, perforation, inadequate filling.)
iii)

Tooth should not be treated in single visit if there is possible increased

stress on temporomandibular joint musculature.

iv)

If in any case it is discovered during the treatment that much over

instrumentation has occurred by error, the tooth should not be completed
in one appointment.

ADVANTAGES
There are numerous advantages to completing root canal therapy in one
appointment rather then practicing multiple visit endodontics (Wahl MJ, 2000):(i)

The clinician has the most intimate awareness of the canal anatomy
immediately following instrumentation.

(ii)

There is no risk of losing important landmarks.

(iii)

The canal is never cleaner than immediately after proper instrumentation.

(iv)

There is no risk of flare-up induced by leakage of the temporary seal

(because obturation has been completed)

(v)

Teeth are ready sooner for final restoration, diminishing the risk of a
fracture necessitating extraction.

(vi)

Patients pre-appointment anxiety and post-operative discomfort are limited

to one episode.

(vii)

Time is saved for the patient and for the practitioner since the treatment is
completed in one visit.

(viii) Further more dentists need not be concerned with the problem of coronal
leakage, loss of temporary seal or any problem that can and does occur
between visits.
(ix)

It allows restoring esthetics expeditiously in a traumatically damaged

crown of a tooth.

(x)

Another advantage lies in completing an endodontic procedure in a single

visit when it is performed with the patient under general anesthesia in the
office or hospital environment.

PERCEIVED DISADVANTAGES (Oliet, 1983):(i)

Clinician fatigue with extended one-appointment operating time.

(ii)

Patient fatigue and discomfort with extended operating time.

(iii)

No opportunity to place an intra canal disinfectant.

(iv)

No easy access to the apical canal if there is a flare-up.

(v)

It does not allow culturing to check effectiveness of the biochemical

preparation.

(vi)

Single visit procedure eliminates the ability to apply tincture of time to

reevaluate tissue responses following treatment procedures.

MICROBIOLOGICAL BASIS: CAN MAXIMAL OUTCOME BE ACHIEVED IN

ONE VISIT?
Endodontics is the prevention or elimination of pulp space infection and
associated inflammatory sequelae. Microorganisms cause virtually all pathosis of
the pulp and periradicular tissues. The logical goal of treatment of the disease
has been to eliminate or substantially reduce the rnicrobial population within the

root canal system and to prevent reinfection by a tight seal of the root canal
space.

Mechanisms of bacterial action in endodontic infections

Root canal bacteria cause apical periodontitis by a mechanism of growth
and multiplication. This releases variety of substances (breakdown products of
intra and extracellular origin, enzymes, cell wall material, etc.) into the periapicai
tissue compartment. The best studied of these substances are bacterial
endotoxin .(IPS) from the cell wall of gram negative organisms. Schein & Schilder
(1975) found that the pulps of teeth with apical periodontitis harbored high levels
of IPS,' and speculated that may be mechanism by which bacteria produce the
apical lesion. Dahlen & Bergenhoitz (1980) confirmed a strong association
between IPS levels and the prevalence of Gram negative bacteria in infected
pulp necroses. Endodontic procedures and their effectiveness
The essential role of bacteria in the initiation, propagation and persistence
of apical penoddontitis has been established. Endodontic therapy is aimed at the
elimination of bacteria from the infected root canal and at the prevention of
reinfection. This is accomplished by a thorough "chemo-mechanical cleaning of
the root canal followed by a complete filling of the canal space. Cleaning,
shaping and irrigation greatly reduce the cultivable bacteria. However, a number
of studies thorough cleaning, shaping, and irrigating with antisftptir.fi after one
visit. Antimicrobial agents are recommended for intracanal antisepsis

CAN BACTERIA FREE CANALS BE OBTAINED IN SINGLE VISIT OR

MULTIPLE VISITS?
BACTERIAL ELIMINATION BY MECHANICAL INSTRUMENTATION ALONE
Mechanical instrumentation is a primary means of bacterial reduction in
endodontic treatment Bystrom & Sundqvist (1981) tested instrumentation with

saline irrigation in the reduction of intracanal bacterial counts. Fifteen singlerooted teeth with necrotic pulps and periapical esions were instrumented for up to
five appointments. While mechanical instrumentation reduced the number of
bacterial counts 100-1000-fold, no teeth cultured bacteria-free after the first
appointment. The bacterial remaining in the canals multiplied between
appointments, and they were not possible to consistently remove even after
multiple treatment episodes. This study indicates that significant reduction occurs
due to the instrumentation of infected root canals. According to Moller (1966) an
additional effect may have been attained using saline as an irrigant, which is
mildly antibacterial anaerobic flora might have been exposed to oxygen from the
instrumentation and irrigation procedures, which may have contributed further to
reduce bacterial counts.

BACTERIAL ELIMINATION BY MECHANICAL INSTRUMENTATION AND

CHEMICAL DISINFECTION BY IRRIGATION
While the use of irrigants in conjunction with mechanical instrumentation is
important to loosen and help remove debris and bacteria, it has been considered
critical that the irrigating solution provides antibacterial effects. There are several
presumed important purposes of such a property. One is to enhance bacterial
killing overall. Another is to provide disinfection in areas of the canal that are
inaccessible to mechanical cleansing, Active irrigants may also dissolve
remaining tissue or products of bacteria.
The ideal irrigant would readily dissolve, and detoxify all bacterial
substances within the canal and dentinal tubules, all without risking appreciate
host tissue damage.
Shaping et al (2000) evaluated the extent of bacterial reduction with nickeltitanium rotary instrumentation and 1.25% NaOCI irrigation. Also, the additional
antibacterial effect of Ca(OH)2 for > week was tested. After instrumentation with
NaOCI solution, 61.9% of canals were rendered bacteria-free. The placement of

Ca(OH)2 for at least 1 week rendered 92.5% of the canals bacteria free. This
was the significant reduction as compared with NaOCI irrigation alone.
Bystrom & Sundavist (1983) compared the antibacterial properties of 0.5%
NaOCI and sterile saline irrigants in infected root _canals. NaOCI irrigation plus
mechanical instrumentation rendered 33% of the canals bacterial-free after the
first appointment.
Nair P.N.R. (2005) assessed the in vivo intracana! microbial status of
apical root canal system of mesial roots of human mandibular first molars with
primary periodontitis immediately after one - visit endodontic treatment, teeth
were irrigated with 5.25% NaOCI during the instrumentation procedures, rinsed
with 10 ml of 17% EDTA, and obturated with gutta-percha and ZOE cement.
Thereafter, (he apical portion of the root of each tooth was removed by flap
surgery. Fourteen of the 16 endodontically treated teeth revealed residual
intracanal infection after instrumentation, antimicrobial irrigation and obturation.
The microbes were located in inaccessible recesses and diverticula of
instrumented main canals, the intracanal isthmus, and accessory canals; mostly
as biofilms.
Although irrigation with NaOCI provides a number of features attractive to
root canal therapy, it appears that it is not possible to attain complete bacterial
elimination by this adjunctive measure. This^means that if one-step endodont/cs
is practiced in infected cases, a substantial number of root canals will still harbor
bacteria.
Peters L.B. et al (1995) addressed the question of the relevance and
consequences of bacteria remaining in the tubules of root dentin after cleaning
and shaping of the root canal. They concluded that:
There is not enough evidence to support the clinical application of special
measures to eradicate the bacteria left in the dentinal tubules

 Further research is necessary to answer the question that is whether

bacteria survive in dentinal tubules, and if they survive do they grow to
sufficient pathologically significant numbers ?
Failure of root canal therapy appears to be unrelated to the relatively small
number of bacterial left in the dentinal tubules after proper root canal
preparation and obturation. Rather, partly or improperly filled canals give
way to regrowth or reinfection leading to failure.

COMPARISON WITH MULTIPLE VISIT ENDODONTICS

The main reasons for not completing the root canal treatment in single visit
are related to pain, flare-ups and the remaining microorganisms.
1.

Pain: The fear that patient will probably develop post operative 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

patient

treated

with

multiple

appointments. Another reason for not treating the teeth in single visit is of
having more flare ups especially in necrotic cases.
2.

Flare-ups: A flare up may be defined as the occurrence of severe pain

and / or swelling following an endodontic treatment appointment, requiring
an unscheduled visit and active treatment. Flare-up is a well known
complication that disturbs both patients and dentists. Eleazer (1998) have
found that obturation of root canals in single visit is associated with fewer
flare-ups. After obturation, the highest degree of pain occurs in the first 24
hours, and it diminishes substantially thereafter.

3.

Bacterial elimination: Endodontic therapy is aimed at the elimination of

bacteria from the infected root canal and at the prevention of reinfection. In
clinical practice the remaining bacteria can be prevented from repopulating

the root canal space by enclosing an interappointment dressing like

calcium hydroxide in the canal. Some authors consider therefore a multivisit root canal treatment mandatory in case of root canal infection. Another
approach has been to allow the remaining microorganisms no nutrition or
room to multiply by direct and complete filling of the prepared and
disinfected root canal space, as practiced in single-visit endodontics. In
orthograde surgical endodontics, the canal is clean and obturated in one
visit, neglecting the remaining microorganisms. Independent of the use of
and type of interappointment dressing, 70-95% success rates are claimed
with multi-visit endodontic treatment, as well as with single visit endodontic
treatment and with orthodograde surgical endodontic treatment.

Single visit endodontics

Time

Multiple visit endodontics

Though it takes more time It takes more time in toto

during one appointment
but limits fear of pain to
one

incidence

and

decreases the total time

required to complete the
treatment
Canal

Clinician has the most There

anatomy

intimate

awareness

canal anatomy during one

awareness

is

risk

of

loosing

of important landmarks

visit
Inter-

No

option

appointment

placing

medicament

appointment

for
inter-

Medicament
placed
appointment

can

be

between
for

medicament

antisepsis

Studies have shown

that

number

of

Microorganisms

can

survive the effects of

bacterial

cells

chemomechanical

remaining

after

preparation. In certain

instrumentation and

cases, microorganisms

irrigation

with

can survive even in a

NaOCl is very low

well filled root canal,

and

obturation

acquiring nutrients and

the

canal

of

space

reaching

sufficient

blocks the nutrient

number to perpetuate a

supply and hence

periradicular lesion. To

bacterial potential to

eradicate

these

multiply is reduced

remaining

bacteria

inter-appointment
antimicrobial

dressing

is necessary
Flare ups

No risk of flare-up

Increased

risk

of

due to leakage of

bacteria entering the

the temporary seal

root canal through a

Various

authors

found no significant
difference in flareups between single
and

multiple

visit

endodontics Roane
(1983),

temporary

barrier

between the visits.

Albashaireh (1998)
observed that there
is

an

incidence
after

increased
of

pain

multi-visit

treatment
Healing

Various studies have shown that healing is the same for

prognosis

single and multiple visit regardless of pulp vitality

Is one visit treatment more successful than two visit

Edward M (1976) found mild increase in pain after instrumentation and
obturation in one visit. Soltanoff (1978) compared the effect of treating teeth
endodontically in either a single visit or in multiple visits. They found no
significant difference between the healing capabilities of teeth treated either in a
single visit or in multiple visits. There was no difference in the healing of teeth
either overfilled or underfilled using either the one-visit or multi-visit procedure.
Significantly more postoperative pain occurred after the single visit procedure
than with the multiple-visit procedure.
Landers RR et al (1980) conducted a questionnaire survey in the United
States concerning one-appointment endodontic therapy. The 70% of the
responses indicated that a large percentage of these programs are teaching and
practicing one-appointment therapy. Most respondents are of the opinion that
little difference exists between one and multiple appointment therapy with respect
to postoperative flare-ups, chance of successful healing and acceptance by
patients.

Pekruhn (1981) conducted a clinical investigation to compare the

incidence and severity of postoperative pain in single-visit and multiple-visit
conventional endodontic therapy. Although the single-visit patients seemed to
experience more discomfort than did the multiple-visit patients after the first
postobturation day, the difference were not statistically significant. When the total
numbers of pain days were considered, there was no significant difference
between the two groups. Thus, single-visit endodontic therapy appears at least
equal in desirability to multiple-visit therapy from the point of view of painfulness
to the patient.
Oliet S 1983 compared single-visit and two visit and two-visit endodontic
procedures. Under controlled circumstances including accurate diagnosis, proper
case

selection

and

skilled

treatment

technique,

single-visit

treatment

postoperative sequelae and healing did not differ significantly when compared
with two-visit procedures.
Wahl MJ (1996) reviewed the literature concerning single and multiple-visit
endodontics and found single visit endodontic therapy to be a safe alternative to
multi-visit treatment for most vital and non-vital teeth.
Kvist T. et al (2004) compared the microbiological outcome of a one-visit
treatment regime, including a 10 min. intraappointment dressing with 5% iodinepotassium-iodide, after removal of the smear layer, with a standard two-visit
procedure, including an interappointment dressing with calcium hydroxide. They
found no statistically significant difference between two groups and concluded
that from a microbiological point of view treatment of teeth with apical
periodontitis performed in two appointments was not more effective than the
investigated one-visit procedures.
Sathorn C et al (2006) presented a systemic review and metaanalysis to
answer: does single-visit root canal treatment without calcium hydroxide
dressing, compared to multiple-visit treatment with calcium hydroxide dressing

for 1 week or more, result in a lower healing rate (as measured by clinical and
radiographic interpretation). The included studies were randomized controlled
clinical trials (RCTs) comparing healing rate of single- and multiple-visit root
canal treatment in humans. They concluded based on the current best available
evidence, single-visit root canal treatment appeared to be slightly more effective
than multiple visit, i.e. 6.3% higher healing rate. However, the difference in
healing rate between these two treatment regimens was not statistically
significant.

SUCCESS VERSUS FAILURE

Measures to be employed to improve success
1.

Greater care should be taken in case selection by being aware of the case
that would be an obvious failure.

2.

One should maintain an organized approach by being certain of instrument

position and procedure before progressing.

3.

Access cavity preparation can be improved by modifications of the coronal

preparation and the radicular preparation, which can be improved by a
more thorough canal debridement, cleaning and shaping.

4.

Exact length of tooth to the foramen should be determined and be

operated only to the apical stop about 0.5 to 1.0 mm from the external
orifice of the foramen.

5.

Curved sharp instruments should be used in curved canals and the curved
instruments should be cleaned and reshaped each time it is used.

Susan E et al (2002) reviewed various other factors that have a strong

influence on outcome of endodontic treatment:
1.

Preoperative status of root canal.

2.

Presence of periapical lesion.

3.

Culture result before obturation.

4.

Previous root canal treatment.

5.

Presence of unfilled canal.

6.

Incomplete root canal preparation and filling.

7.

Vertical root fractures.

8.

External root resorption.

9.

The apical extent of root filling.

10.

The presence of an adequate coronal restoration.

Oliet (1983) found no statistical significance between one visit and multiple
visit groups. The majority of the postgraduate directors of endodontics felt that
the chance of successful healing was equal for either type of therapy. The
original investigators in the field, Fox (1970), Wolch, Soltanofft (1978), and
Ether et al (1970), Lorinczy Landgraf and Palocz(1955), Kitagawa (1969)
were convinced that single-visit root canal therapy could be just as successful as
multiple-visit therapy. None, however, treated the acutely infected or abscess
case with a single visit.
Ashkenaze PJ (1984) presented a review article and found no increase in
post operative pain in single visit treatment and high level of success with single
visit treatment and stated that single visit eliminates inter-appointment
contamination potential.

Denny W. S et al (1984) treated nineteen patients with acute periapical

abscess using a single-visit endodontic protocol. At the 1-yr recall appointment,
11 of the original 19 patients returned. All were asymptomatic and showed
radiographic evidence of reduction in lesion size.
Pekruhn (1986) has published a definitive evaluation of single visit
endodontics. From the clinics of the Arabian-American Oil Company, he reported
a 1-year recall of 925 root filled teeth of 1140 possible cases. His failure rate
was 5.2% very comparable to many multiple-visit studies. Pekruhn was surprised
to learn that his rate of failure was higher (15.3%) in teeth with periradicular
lesion that had no prior access opening. If this type of case had been previously
opened, the incidence of failure dropped to 6.5%, the highest failure rate (16.6%)
in endodontic re-treatment cases. Symptomatic cases were twice as likely to fail
as were asymptomatic cases (10.6% versus 5%).

CONCLUSION
Completing orthograde endodontic therapy in a single visit appears to be
increasing in popularity. In the modern era, researches do support the concept of
single visit endodontics. Single visit endodontics has many advantages for the
dentist and the patient. Perhaps the most important advantage is prevention of
the root canal contamination or bacterial regrowth that can occur when the
treatment is prolonged over.
With so many advantages and few disadvantages why dont more
clinicians practice single appointment endodontics? It is generally believed that
post-operative pain is greater when endodontic treatment is completed in a single
visit. An over whelming number of studies show that post operative pain resulting
from treatment of nonvital teeth does not differ among patients treated in a
single-visit or in multiple-visit.

Aside from the cost factor, there are two major barriers to patients visiting
the dentist that is the fear of pain and time required. Completing root canal
therapy in one appointment limits fear of pain to one incident and decreases the
total time required to complete the treatment. The dentist feels that inspite of
increased exertion, due to the single appointment he will have to charge the
patient less money. The patient also thinks that since treatment involves only one
visit, dentist should charge less money.
One cannot overemphasize that single visit endodontics cannot be
justified, nor advocate such treatment, in a condition where canal cleaning is
compromised. Nevertheless it becomes obligatory to consider single-visit root
canal treatment as an option supported by science. In conclusion, single-visit
endodontics when compared to multiple-visit therapy, is more beneficial to
patient and dentist in many ways.

BIBLIOGRAPHY
1.

Ingle: Endodontics 4th Edition

2.

Grossman: Endodontic Practice 11th Edition

3.

Weine: Endodontic Therapy 6th Edition

4.

Oliet. Single visit endodontics JOE 1983; 9: 147-152

5.

Ashkenaz P.J. one-visit endodontics. Dent Clin North Am Oct. 1984; 28

(4): 853-63.

6.

Fava L.R.G. A comparison of one versus two appointment endodontic

therapy in teeth with no-vital pulp. Int Endod J (1989) 22; 179-183.

7.

Perkruhn R.B. The incidence of failure following single visit endodontic

therapy. J of Endodon Feb 1986 ; 12 (2): 68-72.

8.

Roane J.B., Dryden J.A., Grimes E.W. incidence of postoperative pain

after single and multiple visit endodontic procedures. Oral Surg Oral Med
Oral Pathol Jan, 1983; 55 (1): 68-72.

9.

Trope M. Flare-up rate of single visit endodontics. Int Endod J 1991; 24:
24-27.

10.

Wahl M.J. Myths of single visit endodontics. Gen. Dent March April,
1996; 44 (2): 126-31