CONSORT Randomized Clinical Trial
Success Rate of Single- versus Two-visit Root Canal
Treatment of Teeth with Apical Periodontitis:
A Randomized Controlled Trial
Jorge Paredes-Vieyra, PhD, and Francisco Javier Jimenez Enriquez, PhD
Abstract
Introduction: The aim of this study was to evaluate the
outcome of single- versus 2-visit root canal treatment of
teeth with apical periodontitis after a 2-year follow-up
period. Methods: Three hundred maxillary and mandib-
ular nonvital teeth with apical periodontitis were treated
in either a single visit or 2 visits. The main inclusion
criteria were radiographic evidence of apical periodonti-
tis (minimum size $2.0  2.0 mm) and a diagnosis of
pulpal necrosis confirmed by a negative response to
hot and cold tests. Radiographically, all teeth showed
small and irregular periapical radiolucencies before
treatment. The canals were enlarged with Light-
SpeedLSX (Discus Dental, Culver City, CA) root canal
instruments to a final apical preparation size #60 for
anterior and premolar teeth and size #45 to #55 for
molars. The EndoVac negative-pressure irrigation
system (Discus Dental) was used for disinfecting irriga-
tion, and all canals were filled by lateral compaction
of gutta-percha and Sealapex sealer (SybronEndo,
Orange, CA). The healing results were clinically and
radiographically evaluated 2 years postoperatively.
Results: Of the 300 teeth treated, 18 were lost to
follow-up, 9 in the 2-visit group and 9 in the 1-visit
group. Of the 282 teeth studied, the randomization
procedure had allocated 146 teeth to 1-visit treatment
and 136 teeth to 2-visit treatment. Teeth with symptoms
of persisting periapical inflammation were scored as not
healed. Teeth with a reduced periapical rarefaction were
judged as uncertain. Teeth with complete restitution of
the periodontal contours were judged as healed. In the
1-visit group, 141 of 146 teeth (96.57%) were classified
as healed as compared with 121 (88.97%) of 136 teeth
in the 2-visit group. Eleven cases were classified as
uncertain in the 2-visit group (8.08%) compared with
4 (2.73%) in the 1-visit group. Two of 10 teeth in the
2-visit group presented with pain before the 2-year
follow-up and were classified as not healed. The hypoth-
esis tests were conducted at the 0.05 level of signifi-
cance. Statistical analysis of the healing results did not
From the School of Dentistry, Universidad Aut
onoma de Baja California, Tijuana, Baja California, Mexico.
Address requests for reprints to Dr Jorge Paredes-Vieyra, 710E San Ysidro Boulevard, Suite A, San Ysidro, CA 92173. E-mail address: jorgitoparedesvieyra@
hotmail.com
0099-2399/$ - see front matter
Copyright 2012 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.05.021
1164 Paredes-Vieyra and Enriquez
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 subjec-
tive 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
T he goal of endodontic therapy is to prevent or eliminate apical periodontitis by
means of cleaning, shaping, disinfecting, and filling the root canal system. Because
the vast majority of endodontic problems are microbial in origin, their removal is
considered the most important step in root canal therapy (1, 2). Little controversy
exists that teeth diagnosed with irreversible pulpitis should be treated in 1 session.
However, in cases of pulp necrosis with or without periradicular periodontitis, the
literature is more controversial (3). Periradicular periodontitis is an inflammatory
disease process comprising host responses to infection of the root canal system of
the affected tooth (4).
It has been established beyond doubt that apical periodontitis is caused by
bacteria within root canals (5). Logically, the treatment of apical periodontitis
should be the removal of the cause of the disease. The reduction of the microbial
load as well as the disruption of biofilms are achieved by a combination of
mechanical instrumentation, irrigation with tissue-dissolving and microbicidal solu-
tions, and application of antimicrobial medicaments in the root canal between
appointments.
The role of mechanical instrumentation in removing microorganisms from the
root canal system has been investigated in many studies. The majority of studies re-
ported a significant reduction of bacteria with an increase in preparation size and irri-
gation (6). On the other hand, Peters and Wesselink (7) showed that more than 30% of
the root canal walls remained untouched even by modern rotary nickel-titanium instru-
mentation techniques.
Mechanical debridement combined with antibacterial irrigation using 0.5%
sodium hypochlorite can render 40% to 60% of the treated teeth bacteria negative
JOE Volume 38, Number 9, September 2012

(8, 9). In addition to mechanical debridement and antibacterial
irrigation, dressing the canal with calcium hydroxide has been shown
to increase the percentage of bacteria-negative teeth to around 70%
(10). Single-visit root canal treatment has become common practice
and offers several advantages such as a reduced flare-up rate (11,
12), a reduced number of appointments, a reduced risk of
interappointment flare-up, and a reduced cost.
It is understood that single-visit treatments are based on the clin-
ical opinion that additional treatments would not improve the quality of
care (13). On the other hand, bacterial eradication cannot be predict-
ably maximized without calcium hydroxide dressing between appoint-
ments (14, 15). However, even though an interappointment dressing
with calcium hydroxide reduces the bacterial count, it does not
ensure total eradication of canal microorganisms (10). The issue
remains controversial because opinions vary greatly as to the relative
risks and benefits of single- versus multiple-visit root canal treatment
of asymptomatic teeth with apical periodontitis.
The purpose of this randomized controlled trial was to compare
the outcome of 1- versus 2-visit root canal treatment of teeth with apical
periodontitis after a 2-year healing period. We hypothesized that
necrotic teeth with apical periodontitis treated in 2 appointments with
calcium hydroxide as an intracanal medication would show superior
healing at 2 years when compared with teeth treated in 1 appointment.
Materials and Methods
This study took place at the University Autonomous of Baja Califor-
nia, School of Dentistry, Tijuana, Mexico. The subjects review
committee approved the study, and all participants were treated in
accordance with the Helsinki Declaration (www.cirp.org/library/
ethics/helsinki). The study was developed between February 2009
and December 2011.
The main inclusion criteria were radiographic evidence of apical
periodontitis (minimum size $2.0  2.0 mm) and a diagnosis of
pulpal necrosis confirmed by negative response to hot and cold tests.
Thermal pulp testing was performed by the author (J.P.-V.), and radio-
graphic interpretation was verified by 2 certified endodontists. Patient
selection was based on the following criteria:
1. The aims and requirements of the study were freely accepted.
2. Treatment was limited to patients in good health.
3. All teeth had nonvital pulps and apical periodontitis with or without
a sinus tract.
4. A negative response to hot and cold pulp sensitivity tests.
5. The presence of enough coronal tooth structure for rubber dam
isolation.
6. No prior endodontic treatment on the involved tooth.
7. No analgesics or antibiotics were used before the clinical proce-
dures began.
Exclusion criteria included the following:
1. Patients who did not meet inclusion requirements.
2. Patients who did not provide authorization for participation. flared with sizes 2 to 3 Gates Glidden burs (Dentsply Maillefer,
TABLE 1. Distribution of Teeth by Randomization Factors (tooth group)
Maxillary Mandibular
1 visit
Tooth group n = 300 (%) (n = 155) (%)
Incisor 34 (11.33) 21 (7.0) 28 (18.06)
Canines 17 (5.66) 12 (4.0) 18 (11.61)
Premolar 51 (17.00) 29 (9.66) 45 (29.03)
Molar 77 (25.66) 59 (19.66) 64 (41.22)
Total 179 (59.66) 121 (40.33) 155 (100)
JOE Volume 38, Number 9, September 2012
CONSORT Randomized Clinical Trial
3. Patients who were younger than 16 years of age.
4. Patients who were pregnant.
5. Patients who had a positive history of antibiotic use within the past
month.
6. Patients who were diabetic.
7. Patients whose tooth had been previously accessed or endodonti-
cally treated.
Once eligibility was confirmed, the study was explained to the
patient by the authors, and the patient was invited to participate. A finan-
cial incentive was offered for patients to return for follow-up clinical and
radiographic examination. After explaining the clinical procedures and
risks and clarifying all questions raised, each patient signed a written
informed consent form, and the patient was randomly assigned to either
the 1-visit or 2-visit group by using a block of random numbers gener-
ated by 1 of the investigators.
Randomization was performed before the clinical examination
using the minimization method described by Pocock (16). Two
randomization factors were considered: tooth group and pain as a clin-
ical symptom (Tables 1 and 2). The sample size was determined with
the method described by Walters (17). The minimum sample size
per group was determined to be 145 on the basis of power P < .05,
and the minimum clinically significant mean difference between groups
was set at 0.5 units (standard deviation 1.0 unit) using the periapical
index scale described by Orstavik et al (18).
Two hundred eighty-seven of 295 patients (149 women and 138
men) 18 to 60 years of age (mean = 55 years) with 300 eligible teeth
consented to participate in the study. Twenty-one patients contributed
more than 1 tooth. The study layout is shown in Figure 1.
A medical history was obtained, and a clinical examination was
performed. All teeth were asymptomatic with a diagnosis of pulp
necrosis determined by hot and cold sensitivity tests and radiographi-
cally all showed a small and irregular radiolucency at the apex. Peri-
odontal probing revealed no increased probing depth around any of
the teeth. All of the clinical procedures were performed by the author.
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 Foss
es, 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 (Dents-
ply-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
1-visit 2-visit
follow-up 2 visits follow-up
(n = 146) (%) (n = 145) (%) (n = 136) (%)
26 (17.80) 27 (18.62) 25 (18.38)
16 (10.95) 11 (7.58) 9 (6.61)
42 (28.76) 35 (24.13) 33 (24.26)
62 (42.46) 72 (49.65) 69 (50.73)
146 (100) 145 (100) 136 (100)
1- versus 2-visit Root Canal Treatment of Apical Periodontitis 1165
CONSORT Randomized Clinical Trial
TABLE 2. Distribution of Teeth by Randomization Factors (pain)
Maxillary Mandibular 1-visit 2-visit
1 visit follow-up 2 visits follow-up
Tooth group n = 300 (%) (n = 155) (%) (n = 146) (%) (n = 145) (%) (n = 136) (%)
With pain 23 (7.66) 17 (5.66) 30 (19.35) 2 (1.36) 10 (6.89) 2 (1.47) 2 (1.47)
Without Pain 156 (52.0) 104 (34.66) 125 (80.64) 144 (98.63) 135 (93.10) 134 (98.52)
Total 179 (59.66) 121 (40.33) 155 (100) 146 (100) 145 (100) 136 (100)

Ballaigues, Switzerland). Canals were then irrigated with 2.0 mL 5.25%
sodium hypochlorite. LightSpeedLSX rotary instruments (Discus
Dental, Culver City, CA) were used to complete the canal preparation
to a size #60 for the anteriors and premolars and to a size #45 to
#55 for molars. RC prep (Premier Dental Product Co, King of Prussia,
PA) was used as a lubricant.
After completion of canal instrumentation, all canals were irri-
gated with 2.5 mL 17% EDTA (Roth International Ltd, Chicago, IL)
for 30 seconds followed by a final irrigation with 5.0 mL 5.25% sodium
hypochlorite using the EndoVac irrigation system (Discus Dental, Culver
City, CA). The EndoVac system is able to apply the irrigant to the working
length and evacuate it using apical negative pressure. The negative
pressure avoids forcing the irrigant beyond the apex into the periapical
tissues (19).
For the 1-visit group, the canals were dried with sterile paper
points and obturated at the same appointment by using lateral
condensation of gutta-percha and Sealapex sealer (SybronEndo,
Orange, CA). Access cavities of anterior teeth were etched and
restored with Fuji IX (GC Corp, Tokyo, Japan). For posterior teeth,
a buildup restoration was placed by using the same etching tech-
nique 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 appoint-
ment 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

Assessed for eligibility (n=295 patients)

Excluded (n=8 patients)

Randomized (n=300 teeth)

Allocated to one visit Allocated to two visit

Regime (n=155 teeth) Regime (n=145 teeth)

Lost to follow-up: Lost to follow-up:

Failed to contact (n=9) Failed to contact (n=9)

Failed to attend (n=9) Failed to attend (n= 9)

Analysed (n=146) Analysed (n=136)

None excluded None excluded

Figure 1. The CONSORT flowchart for this study.

1166 Paredes-Vieyra and Enriquez JOE Volume 38, Number 9, September 2012

radiographs taken. All teeth were restored with a Fuji IX buildup. After
the completion of treatment, patients were instructed to return to their
referring dentist for definitive restoration as soon as possible.
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) inde-
pendently 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 peri-
apical 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 periap-
ical radiolucencies that remained unchanged or increased in size.
Teeth with a reduced periapical rarefaction were judged as uncer-
tain. 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 find-
ings 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 eval-
uation of the study images, each examiner graded a series of 12 radio-
graphic 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 Description of radiographic findings
1 Normal periapical structures
2 Small changes in bone structures (PAI #2)
3 Changes in bone structures (PAI $3)
4 Periodontitis with well- defined radiolucent area
5 Severe periodontitis
JOE Volume 38, Number 9, September 2012
CONSORT Randomized Clinical Trial
Results
Randomization allocated 155 teeth to 1-visit and 145 teeth to 2-
visit treatment. Eighteen teeth, 9 in the 1-visit group and 9 in the 2-
visit 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%) expe-
rienced 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 clas-
sified 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 pe-
riodontitis 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 treat-
ment. However, because radiographic images of periapical bone lesions
range from impossible or difficult to see to being easily seen, false-
positives were minimized in this study because periapical radiolu-
cencies 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 corrob-
orates 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 treat-
ment (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 treat-
ment without such pain may result in failure. Glennon et al (30) and
Ng et al (31) reported that discomfort was the most common short-
term 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) (%) Total
Healed 141 (96.57) 121 (88.97) 262 (92.90)
Uncertain healing 4 (2.73) 11 (8.08) 15 (5.31)
Not healed 1 (0.68) 4 (2.94) 5 (1.77)
Total 146 136 282
P = .05. The chi-square test was used to test trends in the contingency table.
1- versus 2-visit Root Canal Treatment of Apical Periodontitis 1167
CONSORT Randomized Clinical Trial
not just on their effectiveness or biological consequences but also on the
minimization of patients discomfort.
Although successfully eliminating bacteria from the root canal
system remains the most important therapeutic goal in endodontics
(32), there is no consensus as to the most effective clinical approach.
Our results agree with Sjogren et al (33) and Doyle et al (34), who
found that the prognosis for complete healing of endodontically treated
teeth with the pretreatment diagnosis of apical periodontitis is approx-
imately 10% to 15% lower than for teeth without apical periodontitis.
Discomfort is the main short-term complication of root canal
treatment. Unfortunately, the measurement of discomfort is fraught
with hazards and opportunities for errors. It is necessary to rate the level
of discomfort in categories arranged in advance and exactly described
by authors. This was accomplished by some investigators. Yoldas et al
(35) provided accurate criteria to categorize patients pain.
Most studies on single-visit endodontics have focused on postop-
erative pain and flare-up (28, 36, 37) despite the fact that pain has been
shown to have no effect on long-term healing success (25, 33). It is
known that results can be influenced by uncontrolled variables such
as metabolic diseases and bad habits such as smoking, which have
shown poorer treatment outcomes (34).
In our study, significantly less postoperative pain was observed
in the single-visit root canal treatment in anterior teeth. This is very close
to the findings of Eleazer and Eleazer (38), who reported fewer flare-
ups for the single-visit group (3.0%) compared with the multiple-visit
group (8.0%).
Historically, several treatments and interappointment dressings
were used for infected teeth, but over the years the number of sessions
has been reduced (36). A 2-visit model using an interappointment
dressing with calcium hydroxide has been proposed as a standard
(39). The expectation that teeth treated in 2 visits with an interappoint-
ment dressing of calcium hydroxide paste would result in improved heal-
ing when compared with 1-visit root canal therapy was not supported by
our results. Our results agree with Roane et al (40) and Fava (37), who
included nonvital teeth with the presence or absence of symptoms.
The quest for an effective, scientifically supported, 1-visit proce-
dure for nonvital teeth has been approached mainly by excluding an in-
terappointment antibacterial canal dressing and including a short-time
intraappointment dressing instead. Studies by Trope et al (22, 41) and
Weiger et al (23) used the former approach or the 1-visit treatment, and
the meta-analysis could not show any statistically significant difference
in the healing rate compared with the 2-visit alternative.
Mechanical instrumentation facilitates the removal of infected
dentin. However, the apical portion of the root canal is especially diffi-
cult to clean with root canal instruments because of its complicated
anatomy of apical deltas and narrow isthmuses (42). Disinfection
depends on chemicals and effective irrigation. The ability of an irrigant
to reach the most apical part of a canal depends on canal anatomy, the
size of canal enlargement, the delivery system, and the depth of needle
penetration.
Traditionally, the tip of an irrigating needle is placed 2 to 3 mm
short of the apical end of the canal, and the irrigant is passively ex-
pressed. If the needle is placed too close to the apical foramen or the
irrigant is forcibly expressed, the chance of extrusion increases (43,
44). Hulsmann and Hahn (6) found that extruding NaOCl resulted in
severe periapical tissue damage and postoperative pain. In this study,
we used the EndoVac (Discus Dental), a negative-pressure irrigation
technique developed to avoid those adverse effects even when the nee-
dle was placed as far apically as the working length. Nielsen and Baum-
gartner (19) showed that there are significant differences in the
cleaning effect at the apical 1-mm level using the EndoVac technique
in comparison to a conventional positive-pressure technique. When
1168 Paredes-Vieyra and Enriquez
all these materials are removed, the probability of periapical healing
increases over time.
The reduction of situations like apical extrusion of infected debris
and changes in the root canal microbiota and/or in environmental
conditions caused by incomplete chemomechanical preparation (12)
can avoid pain as was seen in the present study. This is very close
with the findings of Eleazer and Eleazer (38), who reported less pain
associated with flare-ups for the single-visit group (3.0%) than for
the multiple-visit group (8.0%).
Our results agree with Peters and Wesselink (7) and Weiger et al
(23) in all the clinical considerations of the root canal treatment but not
in a long period of time to evaluate them. Two years is a practical stand-
point considering the difficulty controlling patient dropouts over time.
Longer observation periods might be ideal. Evidence of periapical
changes in bone density associated with healing should be apparent
at 12 to 18 months.
The probability that teeth treated in 2 visits with an interappoint-
ment dressing of calcium hydroxide would result in improved healing
when compared with 1-visit root canal therapy was not supported by
our results. We also did not attempt to balance the number of multi-
rooted teeth in each group although multi-rooted teeth with apical pe-
riodontitis have a lower possibility of complete healing when compared
with single-rooted teeth (45).
Calcium hydroxide was used in the study because of its antibacterial
activity, antifungal activity, effect on bacterial biofilms, synergism between
calcium hydroxide and other agents, effects on the properties of dentine,
the diffusion of hydroxyl ions through dentine, and toxicity (46). Calcium
hydroxide was used in its basic form (ie, white odorless powder and
chemically classified as a strong base powder without any vehicle).
Because of the high pH of pure CH, a superficial layer of necrosis
occurs in the pulp to a depth of up to 2 mm (47). Beyond this layer, only
a mild inflammatory response is seen and, provided the operating field
is kept free from bacteria when the material was placed, hard tissue may
be formed (48). However, commercial products containing calcium
hydroxide may not have such an alkaline pH. Figini et al (49) reported
2 randomized controlled trials comparing the radiographic evidence of
periapical healing after root canal treatment of necrotic teeth completed
in 1 visit or 2 visits. They reported no statistically significant differences
in healing between the 2 groups, which is in accordance with the
present study. We intend to perform follow-up radiographic and clinical
evaluation on patients in this study at 36 and 48 months to see periapical
changes.
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 preoper-
ative 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 review-
ing this article.
The authors deny any conflicts of interest related to this study.
JOE Volume 38, Number 9, September 2012

Supplementary Material
Supplementary material associated with this article can be
found in the online version at www.jendodon.com (http://dx.doi.
org/10.1016/j.joen.2012.05.021).
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