Single visit endodontics/prosthodontic courses

SINGLE VISIT
ENDODONTICS
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education

• Introduction
• Definition
• History
• Guidelines
-Oliet’s criteria for case selection
• Indications of single – Visit.
• Contra Indications of single – visit
• Advantages of Single – Visit.
• Disadvantages of Single – Visit
• Patient Consent
- Systemic evaluation and
- Premeditation

• Bio-Mechanical Techniques used
- The crown –down pressure less technique (Marshall and
Papin 1980),
-The step down technique (Goerig et al 1982),
-The preflaring technique (Gerstein 1983),
-The double flare technique (Fava 1983) and
-The reverse flaring technique (Weine 1989).
• Use of ultrasonics
• Endox® Endodontic System

• Post-operative pain and Flare-ups
• Success rates and failures
• Survey results
• One vs. Several visits
• Conclusion

Introduction
• Completing the endodontic treatment in a single visit
is an old concept since 100 years. In the recent years
single visit – appointment endodontics has gained
increased acceptance as the best treatment for many
cases. Recent studies have also shown that there is no
difference in quality of treatment, incidence of post-
treatment complications, or success rates between
single-visit and multiple visit root canal treatment.

• Many dentists nowadays are preferring single visit
endodontic treatment because of many advantages.
Perhaps, the most important advantage is the prevention
of root canal contamination and bacterial re-growth that
can occur when the treatment is prolonged over an
extended period.

DEFINITION
• Single visit endodontic therapy is defined as the
conservative ,non surgical treatment of an endodontically
involved tooth consisting of complete biomechanical
preparation and obturation of the root canal system in
one visit.

HISTORY
Historically the single visit procedure can be traced through the
literature for at least 100 yrs .Although the concept remained
constant ,the technique varied.
• Dodge described various techniques for single visit. In early
years pressure anesthesia was followed by root canal
sterilization using hydrogen peroxide and sodium dioxide and
subsequently filled with chlorppercha ,guttapercha and
formapercha.
• In 1901- Trallers used biochloride wash ,hot platinum –wire
sterilization ,and zinc oxide eugenol and xeroform paste fill.

• 1904 –Inglis used cocaine as an anesthetic and potassium
permanganate for the sterilization ,applied rubber dam and then
filled with chlorpercha, sectional guttapercha and Fermapercha.
He excluded all the acute cases and expected absolute
success when directions are followed.
• In the same year (1904) ,Phillips also reported successful
single visit endodontic therapy.
• In 1908, Barns used sulfuric acid for the root canal irrigation
and filled them with chlorpercha, but he excluded the
‘abscessed’ roots from treatment.

• Following world war II there came a resurgence of single
visit endodontics. initially it started with the immediate
root resection i.e apiocectomy, but later some of the
clinicians began to practice single visit endodontics
without periapical surgical procedures (except in
exacerbations when artificial fistulations was employed to
reduce pain and swelling.

Guidelines for single – Visit Endodontics
Success in endodontic therapy is based on –
• Accurate diagnosis
• Proper case selection
• Use of skilled techniques of treatment
These procedures are based upon known biological
principles incorporated into the technique triad, specifically
• Biomechanical preparation of the root canal
• Debridment and disinfection
• Complete obturation of the root canal

• The first and important criteria is that single – visit endodontics
should not be undertaken by inexperienced clinicians. The dentist
must posses a full understanding of endodontic principles and the
ability to exercise these principles fully and efficiently. There can
not be any shortcuts to success. As a guideline, the case should be
one that can be completed within 60 minutes. Treatments that takes
considerably longer time should be done in multiple visits.

Oliet’s criteria for case selection include :
• Positive patients acceptance.
• Sufficient available time to complete the procedure
properly.
• Absence of any acute symptoms requiring drainage via
the canal and of persistent continuous flow of exudates
or blood.
• Absence of anatomical obstacles like
 calcification in the canals, and
 procedural difficulties (ledge formation, blockage,
perforation, inadequate fills)

Indications for single – visit
• Uncomplicated vital or non vital teeth preferably.
• Fractured anterior or bicuspid teeth where esthetics is a
concern and temporary post and crown are required.
• Patients who are physically unable to return for the
completion.
• Patients with heart value damage or prosthetic implants
who require repeated regimens of prophylactic antibiotics .
• Necrotic, uncomplicated teeth with draining sinus tracts .
• Patients who require sedation or operating room
treatment.

Contra – Indications for Single – visit.
• Painful, necrotic tooth with no sinus tract for drainage.
• Teeth with severe anatomic anomalies or cases with procedural
difficulties.
• Asymptomatic nonvital molars within periapical radiolucencies
and no sinus tract.
• Patients who have acute apical periodontitis with severe pain
on percussion.
• Most of the re-treatment cases.

Advantages of single visit.
• It reduces the number of patient’s appointments while
achieving predictably high levels of success and patients
comfort.
• It eliminates the chance for inter appointment microbial
contamination and flare-ups caused by leakage or loss of
the temporary seal.
• For anterior cases it allows immediate use of the canal
space for retention of a post, and construction of an
esthetics temporary crown.

• Allows the practitioner to prepare and fill the canals at
the same appointments without the need for the
clinician’s refamiliarization with the canal anatomy at the
next visit.
• It minimizes fear and anxiety in the apprehensive
patients.
• It eliminates the problem of the patient who does not
return to have their case completed.

Disadvantages of Single – Visit.
• The longer single – visit appointment may be tiring and
uncomfortable for the patient. Some, patients especially
with TMJ disfunction or other impairments may not be
able to keep their mouth opened long enough for a single
– appointment procedure.
• Flare-ups cannot be easily treated by opening the tooth
for drainage.
• if hemorrhage or exudation occurs, it may be difficult to
control that and to complete the case at the same visit,
and if it doesn’t stop after pulp extirpation also, then better
to go for multiple – visit.

• Difficult cases with extremely fine, calcified, multiple
canals may not be treatable in one appointment
without causing under stress for both the patient and
the clinician.
• The clinician may lack the expertise to properly treat a
case in one visit. This could result in failures, flare up
etc.

PATIENT CONSENT
• The patient should accept the proposed single appointment
procedure - desired co-operation.
SYSTEMIC EVALUATION AND PREMEDITATION :
• 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 ,psycosedation and
pain and anxiety control.
• Patients with a history pf Rheumatic heart disease should
be premeditated with amoxicillin ,erythromycin or
clindamycin, as per the current “American heart
association guidelines”

Situations Agent Regimen
Standard
general
prophylaxis
Amoxycillin Adults - 2gm
Children - 50mg/kg orally 1 hour before procedure
Unable to take oral
medications
Ampicillin Adults - 2gm 1M or IV
Children - 50mg / kg 1M or IV
within 30 min before procedure
Allergic to pencillin Clindamycin
or
Cephalexin
or
Cephadroxil
or
Azithromycin
Clarithromycin
Adults 600 mg
Children - 20mglKg orally 1 hr before procedure.
Adults - 2gm
Children - 50 mg/ Kg orally 1 hr before procedure
Adults - 500 mg
Children - 15 mg/kg or orally 1 hr before procedure
Allergic to pencillin
unable to take oral
medications
clindamycin
Or
Cefazolin
Adults - 600 mg
Children - 20 mg /Kg and IV within 30 minutes before
procedure.
Adults - 1 gm
Children - 25 mg/kg 1M or IV within 30min before
procedure.www.indiandentalacademy.com

TECHNIQUES FOR CLEANING AND SHAPING
USED IN SINGLE – VISIT.
• Cleaning and shaping of root canal system is considered
to be most important step for endodontic therapy. The
introduction of canal preparation techniques that focus
on the flaring of the canal walls has significantly
influenced this phase of root canal treatment, however
some disadvantages have also been reported. One of
these is extrusion of material beyond the apical foremen.

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

• Instead of preparing the root canal in an apical –
cervical direction (flared preparation, step-back
preparation, canal funneling, telescopic preparation),
newer technique have been designed to avoid problems
encountered in this approach. These technique are
called cervical or coronal flaring techniques, in which the
root canal is prepared in cervical apical direction.

• Some of the techniques involved are
• The crown –down pressure less technique (Marshall and
Papin 1980),
• The step down technique (Goerig et al 1982),
• The preflaring technique (Gerstein 1983),
• The double flare technique (Fava 1983)
• and The reverse flaring technique (Weine 1989).
These technique were designed following a series of findings that
established the basic principles which are as follows.

– Removal of dentin interferences at the canal orifice
and cervical third, resulting in more direct access to
the middle and apical thirds.
– Neutralization and removal of pulp contents from the
cervical third before the preparation of middle and
apical thirds.

– Establishment of an adequate coronal escape route in
the initial phase of the treatment. This decreases the
apically directed hydrostatic pressure generated by
the up and down movements of the file in the wet
canal. It also decreases the probability of carrying
pulpal debris beyond the apical foramen.
– Deeper penetration of the irrigant needle, which
permits the irrigant solution to go further into the root
canal and reach the middle and apical thirds in the
initial phase of the treatment.

CROWN DOWN PRESSURE LESS TECHNIQUE
(MARSHALL &PAPIN 1980)
• Gates glidden drills and larger size files are used in the
coronal 2/3rd
of the canal.
• progressively smaller K –type files in clockwise rotation without
apical pressure, are used in sequences until a satisfactory
apical preparation is obtained.
• The purpose of this technique is to minimize or eliminate the
amount of necrotic debris that could be extruded through the
apical foramen during instrumentation. This helps in preventing
post – treatment discomfort incomplete cleansing and difficulty
in achieving a biocompatible seal at the apical constriction.

STEP DOWN TECHNIQUE (George et al 1982)
• Combination of crown down and step back technique .
• Coronal enlargement of the curved canal prior to the
apical enlargement.
• Done by using a file placed approximately 2/3rd
of the way
down the curved canal and then filing laterally at the
length using only filling action with H files from No 15
through No 25 .
• Next gates Glidden (#2 & #3) are used to widen the
coronal portion of the preparation.
• Working length is established and apical portion is
enlarged to size no 25.

DOUBLE – FLARE TECHNIQUE
According to Fava (1983), the double flare technique
has three phases. In the first one, a cervical – apical
flaring was performed according to the basic
principles.
• In second phase : This was characterized by
development of apical matrix. After reaching the
correct length, two or three instruments were used in
sequential order to prepare the space where the
master cone would be adjusted and placed in the
filling procedures.
INT – ENDO. J. 1998

• The third phase was performed in the apical - cervical
direction (flared – preparation) to achieve enhancement of
canal shape and cleanliness.
MODIFIED DOUBLE FLARE TECHNIQUE( Fava,1991)
• The modification for this technique was done by
elimination of third phase, for the following reasons.
– It was believed that flaring would be achieved during the
first and second phases.
– Elimination of the third phase makes the procedure less time
consuming.
– Elimination of the third phase will decrease the possibility of
the tooth by excessive dentin removal.
– This technique saves lot of operating time also.

REVERSE FLARING TECHNIQUE (WEINE 1989)
• Utilizes the flaring technique long before the completion
of the apical portion of the preparation
• The dentist minimally enlarges the apical portion and
then widens the coronal portion prior to completing the
apical portion
• May be achieved by a rotary instrument or by hand
instruments.
• Very useful in curved canals and seems to simplify and
lessen the time required

PREFLARING TECHNIQUE (Gerstein et al 1982)
• similar to reverse flaring technique

USE OF ULTRASONICS IN SINGLE – VISIT
• Ultrasonics is relatively new in our endodontic armentarium,
yet a multiplicity of uses have already been described.
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%.
J. Of endodontics : 1987

• 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 streaming.
ACOUSTIC STREAMINGwww.indiandentalacademy.com

• After completion of a single visit procedure also some
pulp tissue still remains in the root canal, if hand
instrumentation has been done, but by ultrasonics
debridement in combination with 2.5% NaoCl, significant
clean canals are observed (SEM studies done). The
smear layer was greatly reduced in ultrasonic
instrumentation.
Apical third of root canal.

• According to many studies (J. of Ends 1983) the use of
ultrasonics will result in few cases of post operative pain
compared to the cases done with hand – instrumentation.
Obturation of the lateral canals in the apical third
after using ultrasonics

Endox® Endodontic System
• Endox® Endodontic System establishes a new way to
do endodontic therapy.
• Instead of removing the pulp tissue (eradicate) and then
remove the dentine infested by bacteria, the apical
measurement by means of a needle, is inserted in the
radicular canal where a high frequency impulse is
applied for 1/10th of a second.
• The brief increase in temperature should produce the
vaporization of pulp tissue therefore creating a reduction
of bacteria in the radicular canal.
C. Haffner, C. Benz e,R. Hickel,
Munich Germany

• The transmission of the temperature was principally in
function of the quality of the substance around the tooth
(conductive gel).
• The application of high frequency current showed 99.9%
reduction in bacteria
Graphic : Increase in temperature in the
apex and periapical area during the
aplication of high frequancywww.indiandentalacademy.com

REM (magnified 4800 times) shows that even
dentinal tubule openings are left with no residue
tissue.

• Effective vaporization of the tissue was seen only in
cases where the needle was able to be inserted to the
apex.
DRAW BACKS
CONTRAINDICATIONS
• Patients with pace-marker
•contact lenses, which must be removed before “sitting in the
chair” The fact of removing the contact lenses is due to some of
them containing carbon and could produce adherences, without
great consequence

POST OPERATIVE PAIN AND FLARE UP IN
SINGLE VISIT ENDODONTICS
• There is a ‘myth’ that single visit endodontic treatment
causes more post operative discomfort and flare up
rates to the patients. Most studies show that single visit
root canal procedures produce no more pain than
multiple visit ones.
• In 1970, Fox and co-workers have found that only
7% single visit cases reported of severe pain in 24
hours. They found that 90% of the teeth were free of
spontaneous pain after 24 hours.

• Wolch in 1970 treated 500 non vital cases in single visit
and he found severe pain in only 5% of patients. Many
more studies have shown the success of single visit which
is comparable to multiple visit treatment.
• ‘Morese’ defines “Flare - up” as swelling and pain
combined or swelling above that necessitates unscheduled
emergency appointments .
• ‘Wolton’ defines “Flare-up” within a few hours to a few days
after a root canal treatment procedure, a patient has either
pain or swelling or combination of both.

The factors that can reduce the incidence of flare-ups, pain
and swelling are
– Single visit treatment should be combined with
prophylactic antibiotics (Penicillin V or erythromycin).
– Intentional over instrumentation of root into the
approximate center of the bony lesion reduces the
prevalence of flare ups from about 20% to 1.5%.
J. of Endodontics : 1980

• These techniques should be followed for all single visit
appointment non vital cases without sinus tracts.
• Moderate over instrumentation past the apex of non vital
cases has long been thought, to increase the likelihood
for drainage and relief of pressure.
• However, over instrumentation for vital cases should be
avoided because it crushes tissues and produces pain
and inflammation.

• According to the findings of Trope (Int-Endo J. 1991)
– Teeth without apical periodontitis did not flare up and
may be treated in a single visit.
– Teeth with apical periodontitis but no previous root
canal treatment can be treated in single visit, with a
low probability of a flare-up occurring.
– In teeth with apical periodontitis which need
retreatment, the flare up rate was highest and single –
visit root canal treatment would be inadvisable.

• Oliet, 1970 (J. of Oral Surgery)
Found that 90% of success was achieved in single – visit
treated teeth. This was comparable to multiple visit
treated teeth. He found that overfilling of the root canals
of teeth treated in a single – visit resulted in moderate to
severe pain in 255 of cases, younger patients aged 10
to 39 years, had significantly more pain than older
patients .

SUCCESS RATES AND FAILURE OF
SINGLE VISIT
• Prognostic studies have shown that there is no
substantial difference in the success rate of single and
multiple appointment cases. Alkenaz claimed that
single appointment root canals succeeded 97% of time
comparable to multiple visit.

• Pekruhum in a study J. of Endodontics 1986 found a
failure of only 5.2% in single-visit cases. He noted that
teeth not previously opened showed three times the
number of failures as those that had been previously
opened. This was especially true of teeth involved with
periapical extension of pulpal disease. The success is
more in the cases where combination of hand
instrumentation and ultra sonic techniques are utilized .

• Determination of success or failure has been based
primarily on radiographic interpretation. But, there are
many shortcomings of utilizing the radiographs as the sole
means to determine success and failure. To avoid
failures, in this study the patients who were treated for
single visit were given Anti-inflammatory and Anti-biotics
J. of Endodontics : 1983.
.

SURVEY RESULTS
• After the survey, it was found that single visit
endodontics was taught in 85.7% of dental schools. In
1982, it was found that 675 would treat vital cases in
single visit where as only 12.8% dentists will treat necrotic
cases.
• In 1990 Survey of 568 dentists, reported that 35%
would complete cases in one visit for teeth will normal
periapex whereas only 16% would do so when apical
periodontitis was present. Fewer than 10% of the dentists
would complete a non vital cases in single visit.
• But, the trend is changing now as many endodontist
prefer single visit endodontics treatment for patients
keeping the indications of single visit in mind.

ONE VS. SEVERAL VISITS
In recent years, a most heated discussion has emerged
as to the need for more than one treatment session in
endodontics. Traditionally, treatment has been divided
into two or more appointments before the placement of a
permanent filling, allowing the clinician to enhance root
canal disinfection, to increase patient comfort, and to
observe the progress of healing (Trope and Bergenholtz,
2002). Unfortunately, the arguments for the number of
patient visits are often unclear.

When one carefully considers the case selection criteria
from advocates of one-visit treatments, it becomes clear
that there are many exclusion criteria which are not
articulated in the debate.
• Ashkenaz (1984) suggested that multi-rooted teeth should be excluded .
• Pekruhn (1986) limited the inclusion criteria to "teeth in my practice,
which could be conveniently treated in a single visit".
• Roane et al. (1983) stated that decisions on the use of single- or
multiple-visit treatment were based solely on the time available for
treatment.

• This type of case selection does not lend itself to
scientific scrutiny and should, of course, not serve as a
basis for a treatment strategy. As in all branches of
medicine, the choice among endodontic treatment
approaches should be based on a proper diagnosis.

• Primary focus of the endodontic procedure is to prevent
microbial infection of the root canal space. Appropriate
procedures to be applied in this respect are well
established.
• Pulp extirpation and the placement of wound dressing—
the root-filling implant—are best completed in a one-
treatment visit if aseptic conditions are to maintained.
Consequently, endodontic treatment of the vital pulp is a
perfect one-visit case. If the surgical procedure is carefully
carried out and is truly aseptic, a successful outcome
should be expected in nearly100% of the cases.

• When the pulp tissue deteriorates to necrosis, the common
diagnosis is necrotic pulp and, later, pulp necrosis with
apical periodontitis.
• Another important treatment situation is the presence of a
failing, previously root-filled tooth, where apical
periodontitis has emerged or prevailed.
There are many other more rare pathological conditions
that can be confused with endodontic disease processes,
but the few listed here include the overwhelming number of
lesions that occur in general practice.

• From a pathological point of view, pulp necrosis and its
sequelae are very different from the diseases of the vital
pulp. They are almost all infectious. It is therefore
reasonable to believe that teeth with necrotic infected pulp
tissue should require a different treatment regimen than
teeth with vital pulp.

• The proper control of root canal infections by biologically
compatible means has pre-occupied the endodontic
research profession for many years .
• It has been estimated that the pulpal space may harbor
from 107 to 108 bacterial cells (Byström and Sundqvist,
1983; Sjögren et al., 1991).
• The use of saline as an irrigant in combination with
mechanical instrumentation may reduce this number
1000-fold, but it will not predictably eliminate all the
organisms.

• The use of an antimicrobial agent, such as sodium
hypochlorite, will further reduce the bacterial number—in
some cases, to such an extent that cultivable bacteria
are not recovered.
• There is no evidence yet available that instrumentation
and antimicrobial irrigation can predictably reduce the
bacterial count to zero during a single treatment session
(Byström and Sundqvist, 1983, 1985; Byström et al.,
1985; Sjögren et al.,1997; Cvek et al., 1976a,b; Shuping
et al., 2000; Sundqvist et al.,1998).

• When the presently available best regimens of treating
infected root canals are used, about one-third remain
infected after one treatment. The number of remaining
bacterial cells is then often small, in the range of 102 to
104 cells (Sjögren et al.,1991, 1997; Dalton et al., 1998;
Shuping et al., 2000).
• Despite these small numbers, the effect on outcome can
be significant (Sjögren et al., 1997).

• There are conflicting opinions, however, regarding the
need for a complete disinfection of the pulpal space before
the root filling is placed.
• Peters and Wesselink (2002) found no difference in
treatment outcome when root canals were filled, despite
the presence of residual microbes.
• Weiger et al. (2000), in a randomized clinical trial,
observed no difference in outcome between teeth treated
in one session and teeth filled after calcium hydroxide
medication. They concluded, "One-visit root canal
treatment is an acceptable alternative to two-visit treatment
for pulpless teeth associated with an endodontically
induced lesion."

• Other clinical studies suggest that the rate of successful
treatment outcome will decrease if the treatment is
concluded with a root filling before the root canal is free
of micro-organisms. Such data are available from both
prospective (Sjögrenet al., 1997) and retrospective
studies (Engström et al., 1964;Heling and Shapira,
1978).

It is presently unknown if the numbers or types of micro-
organisms remaining at the time of root filling may
modify this conclusion. Therefore, if root canal
disinfection remains the goal, the treatment of a tooth
with an infected necrotic pulp may require at least a two-
visit procedure.

CONCLUSION
• “Maximum dentistry in minimum visits” has been the
rule in modern dental practice.
• The success of endodontic therapy is dependent upon
meticulous attention and detail .a one visit root canal
treatment is attractive to a patient because it saves time
ad probably reduces cost.

• Careful cases selection and proper and thorough
adherence to standard endodontic principles, with no
shortcuts, should results in successful single-visit
treatment. Only skilled and experienced operators
should perform this treatment keeping in mind the mind
as the major factor.
• Wolch said that : “In the treatment of any disease, a
cure can only be effected if the cause is removed”. Since
endodontic diseases originates from an infected or
affected pulp, it is mandatory that the root canal must be
thoroughly and carefully debrided and obturated. This is
fairly done by single visit endodontic treatment.

Single visit endodontics/prosthodontic courses

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Single visit endodontics/prosthodontic courses

Similar to Single visit endodontics/prosthodontic courses (20)

More from Indian dental academy

More from Indian dental academy (20)

Recently uploaded

Recently uploaded (20)

Single visit endodontics/prosthodontic courses