SINGLE VISIT ENDODONTICS powerpoint presentation

Single visit endodontics, definition, indications, contraindications, advantages, disadvantages

1. SINGLE VISIT ENDODONTICS V.TEJASWINI III MDS

2. contents Introduction Evolution Of Single Visit Endodontics Case Selection for Single Visit Endodontics Indications Contraindications Advantages Disadvantages Myths Adjuncts To Render Efficient And Faster Treatment In Single Visit Endodontics Procedure For Single Visit Endodontics Conclusion 2

3. INTRODUCTION The main objective of endodontic therapy is thorough mechanical and chemical debridement of the entire pulp cavity and its complete obturation with an inert filling material. ENDODONTIC SUCCESS DEPENDS UPON 1. LOCALIZATION OF CANALS 2. PROPER CHEMO MECHANICAL PREPARATION 3. THREE DIMENSIONAL OBTURATION Mothanna Al- Rahabi . Single visit root canal treatment: Review. Saudi Endodontic Journal · May-Aug 2012 · Vol 2 · Issue 2 3

4. To achieve all these goals endodontic therapy used to be performed in multiple visits to cope up with the complete infection and to make the canals free of microbes, all together for the success of endodontic therapy. Multiple visit endodontics was an established norm in the field of endodontics, but it has certain disadvantages like Inter appointment microbial contamination and flare ups, Prolonged time leading to patient fatigue Unable to provide esthetic restorations in time, Discontinued treatment leading to failures Mothanna Al- Rahabi . Single visit root canal treatment: Review. Saudi Endodontic Journal · May-Aug 2012 · Vol 2 · Issue 2 4

5. DEFINITION: Single-visit endodontic therapy is defined as ‘the conservative non-surgical treatment of an endodontically involved tooth consisting of complete biomechanical cleaning, shaping, and obturation of the root canal system during one visit.’ Single-visit endodontics (SVE) applies to cleaning, shaping, and disinfection of a root canal system followed by obturation of the root canal at the same appointment. Nisha Garg Textbook of Endodontics, 3rd Edition 5

6. Richard E. Walton 2012, reported that 78% of respondents preferred 1-visit RCT, 7% preferred 2-visit RCT and 16% would follow their dentist’s recommendation. Although most respondents preferred 1-visit RCT regardless of success rates, many would prefer 2-visit RCT if its success rate were greater than that of 1-visit RCT . 6

7. Evolution of single visit endodontics 7

8. Case selection given by olIets includes Kaur, G., Gupta, A., & Bansal, C. (2021). Single visit endodontics with associated myths: A review. International Journal of Health Sciences, 5(S1), 143–148. 8

9. INDICATIONS Uncomplicated vital tooth Fractured anteriors where aesthetics is the concern Teeth indicated for endodontic surgery Non-vital teeth with sinus tract Physically compromised patients who cannot come to dental clinics frequently Intentional root canal therapy Accidental/mechanical pulp exposure Teeth with subgingival breakdown, multiple coronal walls missing, where isolation and sealing are the problem Vital pulp exposure because of trauma or caries with symptomatic pulpitis Ashkenaz , P.J. One-visit endodontics. Dent Clin North Am. Oct;28(4):853–63, 1984. 9

10. CONTRAINDICATIONS Teeth with anatomic anomalies such as calcified and curved canals Retreatment cases Patients who are unable to keep mouth open for long duration Teeth with limited access Symptomatic non-vital teeth and no sinus tract Asymptomatic non-vital teeth with periapical pathology and no sinus tract Patients having severe pain on percussion suffering from acute apical periodontitis Ashkenaz , P.J. One-visit endodontics. Dent Clin North Am. Oct;28(4):853–63, 1984. 10

11. ADVANTAGES Clinical Advantages – Clinicians have the most intimate awareness of canal morphology, immediately following instrumentation and need not reorient themselves with the peculiarities of particular teeth. No risk of bacterial regrowth and leakage of the temporary seal. No risk of flare-up induced by leakage of temporary seal. Dr. Pradnya V. Baroudi, Dr. Seema D. Pathak, Dr. M. B. Wavdhane , Dr. Shirish Khodkeghar , Dr. Priyanka P. Bargaje . IOSR-JDMS; Volume 17, Issue 11 Ver. 7 (November. 2018) 11

12. The small chance of a life-threatening reaction is reduced by not repeating procedure such as local anaesthetic injection. For patients at risk of contracting bacterial endocarditis, the American Heart Association (AHA) recommends completing as many procedures as possible during the antibiotic course. Patient's pre-appointment anxiety and post operative discomfort are limited to one episode. 12

13. PATIENT ADVANTAGES Patient convenience – Patient does not have to endure the discomfort of repetitive local anesthesia, treatment procedure and no additional appointments. Patient comfort – because of reduced number of visits and injections. Reduced intra appointment pain – Mostly the mid treatment flare ups are caused by leakage of the temporary cements. 13

14. Restorative considerations – In single visit endodontics, immediate placement of coronal restoration (post and core placements) ensure effective coronal seal and esthetics. Economics – Extra cost of multiple visits, use of fewer materials and comparatively less chair side time all increase the economics to both patient as well as doctor. Minimises the fear and anxiety 14

15. DISADVANTAGES Single-Visit Versus Multiple-Visit Root Canal Treatment: A Review ArticleDr . Pradnya V. Bonde | Dr. Seema D. Pathak | Dr. M.B. Wadkar | Dr. Darsh Khokhani | Dr. Priyanka Bangad | Dr. Josna C. Nair | December 2019 No easy access to the apical canal if there is a flare-up. Clinician fatigue with extended one-appointment operating time. Patient fatigue - The longer single appointment may be tiring and uncomfortable for the patient. Flare-ups cannot easily be treated by opening the tooth for drainage. 15

16. If hemorrhage or exudation occurs, it may be difficult to control. Difficult cases with extremely fine, calcified, multiple canals may not be treatable in one appointment without causing undue 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-ups, and legal repercussions. 16

17. MYTHS 17

18. Myth No.1: Postoperative pain is greater when endodontic therapy is completed in a single visit, especially in nonvital teeth. 18

19. Bayaram Incea , 2009 stated that the prevalence of postoperative pain did not differ between vital and non-vital teeth. The majority of patients in either group reported no or only mild pain. Ashish Patil 2006 reported that the incidence of pain after endodontic treatment being performed in one visit or two visits is not significantly different experienced by patients 48hours after treatment in both groups. Eur J Dent .2009 Oct;3(4):273-9 JCDR. 2016 May;10(5):ZC09 19

20. Myth No.2;There is less healing when endodontic therapy is completed in a single visit, especially in non-vital tooth. 20

21. Dorasanı et al. 2013 reported that both single-visit and multiple-visit treated teeth showed favorable healing at 12 months without any significant differences. C.Sathron 2005, stated that single-visit root canal treatment appeared to be slightly more effective than multiple visit. J Conserv Dent. 2013 Nov;16(6):484-8. Int Endod J. 2005 Jun;38(6):347-55 21

22. Myth No.3:Post operative flare up is greater when endodontic therapy is completed in a single visit. 22

23. Postoperative pain and swelling are together described as flare-ups, which is possibly one of the most concerning issues that dentists performing single-visit therapy need to deal with. Trope stated that Teeth without apical periodontitis did not flare up and be treated in a single visit. Teeth with apical periodontitis but no previous root treatment can be treated in a single visit, with a low probability of flare-ups. Teeth with apical periodontitis which need retreatment the flare-up rate was highest and single visit treatment would be inadvisable. 23

24. According to the findings of his study: Teeth without apical periodontitis did not flare-up and may be treated in a single visit; Teeth with apical periodontitis but no previous root treatment can be treated in a single visit, with a low probability of a flare-ups. (1.4 per cent) Teeth with apical periodontitis which need retreatment the flare-up rate was highest and single-visit root treatment would be inadvisable . (13.6 per cent). 24

25. Krishna prasad et al in 2013 , stated that ,little or no significant difference occurred between single visit versus multi visit endodontic therapy. 25

26. Myth No.4: Canals are cleansed if an antibacterial medicament such as Ca(OH)2 'is left in the tooth. 26

27. Ghoddusi .2006 have reported that the clinical outcome of multiple-visit endodontic treatment was better for teeth treated with the intracanal calcium hydroxide than for those with root canals left empty. Despite the high alkalinity antibacterial properties of calcium hydroxide, some bacteria species, such as E. faecalis and Candida albicans, have been found to be resistant to it. Ghoddusi J, Jafari M, Zarrabi MH, Birjandi H. Flare-ups: incidence and severity after using calcium hydroxide as intracanal dressing. NY State Dent J. 2006;72(4):24-28 27

28. Complete elimination of bacteria is not strictly necessary, and maximum reduction of bacteria and effective canal filling may be sufficient in terms of healing, rather than complete eradication. Moreover, the tooth may also be susceptible to reinfection through the temporary filling and dressing. Gesi et al 2006, stated that with proper use of aseptic operating procedures, proper instrumentation, and filling, an inter-appointment dressing with calcium hydroxide does not seem to influence outcome. Gesi L, Hülsmann M, Warfvinge J, Bergenholtz G. Incidence of periapical lesions and clinical symptoms after pulpectomy - A clinical and radiographic evaluation of 1- versus 2-session treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod . 2006;101:379-88. 28

29. Myth No.5: Multiple-visit endodontics is safer than single-visit endodontics, and multiple visits mean more careful treatment. 29

30. For patients at the risk of contracting bacterial endocarditis AHA recommends as many procedures as possible during antibiotic prophylaxis. The small chance of a toxic reaction from medication (analgesics, antibiotics, or anesthetic) is reduced by not using them repeatedly (at multiple appointments) an by using a smaller dose (enough for one appointment) Multiple visit treatment is more likely to cause clinicians to forget important aspects of canal morphology and landmark. Clinicians are encouraged to develop three dimensional mental images of canals during instrumentation. It is difficult to remember three dimensional images between appointments that are week apart. 30

31. 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. 31

32. Aside from cost, there are two other major barriers to patients visiting the dentist: FEAR OF PAIN Time Required Completing root canal therapy in one appointment limits fear of pain to one incident and decreases the time required (the number of appointments and total treatment time). Patients are more likely to accept single-visit treatment . 32

33. Myth No.7: After obturation, treating a flare-up is complicated; therefore, treatment should not be completed at the first appointment. 33

34. Fear of a post obturation flare-up prevents clinicians from performing single-visit endodontics, but such flare-ups generally are less common than inter appointment flare-ups. 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. 34

35. Adjuncts To Render Efficient And Faster Treatment In Single Visit Endodontics 35

36. 36

37. Pain Control It relaxes the patient and saves time. It is preferable to use a long acting local anaesthetic agent. It also helps to control post operative pain. Sometimes supplemental anaesthesia is indicated along with the standard injection. These includes 1. Local Infiltration 2. Intrapulpal injection 3. Intra osseous injection . 37

38. Masoud Parvizi et al. 2012 stated that Patients who received bupivacaine as the anesthetic agent for single-visit endodontic treatment of irreversible pulpitis in mandibular molars had significantly less early postoperative pain and used fewer analgesics than those who had lidocaine as the anesthetic . Effect of Bupivacaine on Postoperative Pain after Inferior Alveolar Nerve Block Anesthesia for Single-visit Root Canal Treatment in Teeth with Irreversible Pulpitis. JOE - Volume 38, Number 8, August 2012 Digital Technologies In Local Anesthesia Electronic Dental Anaesthesia  Wand 38

39. ISOLATION USE OF RUBBER DAM IS MANDATORY The patient is protected from aspiration of instruments, tooth debris, medications, and irrigating solutions. Soft tissues are retracted and protected. A surgically operating field is isolated from saliva, blood, and other tissue fluids. Visibility is improved. Efficiency is increased. 39

40. Plastic rubber dam frames are recommended for endodontic procedures. Ex- Young's Rubber Dam frame (plastic type), The star visi frame The Nygard Ostby (N-0) frame . New to endodontics is a specially designed foldable plastic frame The disposable handidam rubber dam system also provides a radio-lucent plastic frame. The quick dam is another disposable single-isolation device with a flexible outer ring, eliminating the need for an additional frame. 40

41. ACCESS CAVITY PREPARATION Before access cavity preparation, Caries typically is removed early, before the pulp chamber is entered. The roof of the pulp chamber is best perforated with a round bur. No 2 bur - anterior and premolar teeth and a No.4 should be used in molar teeth. Once the roof is perforated, A round bur, a tapered fissure bur or a safety tip diamond or carbide bur is used. Tapered, Flame shaped and round ended tapered diamonds are excellent for endodontic access.. 41

42. An uncovering receded or calcified root canal orifice is a challenge. Use of low - speed smaller burs. These burs have an extra long, flexible shaft that allows in visualization by the operator as the bur advances into the deeper portions of the access preparation. Extended shank round burs, such as the Mueller bur( Brasseler , Savannah, GA) are very useful for this purpose. To identify canal orifices and to determine canal angulation DG-16 endodontic explorer and CK-17 endodontic explorer can be used. 42

43. Once the orifices have been located, they should be flared or enlarged and blended into the axial walls of the access cavity. This process permits the intracanal instruments used during shaping and cleaning to enter the canal(s) easily and effortlessly. Gates-Glidden burs can be used for this purpose, starting with smaller sizes and progressing to the larger sizes. More recently, #.12 tapered or Sx rotary endodontic files have been used for the flaring and blending procedure. 43

44. Ultrasonic unit and Tips An Ultrasonic unit and tips specifically designed for endodontic procedures can be valuable aids in the preparation of access cavities and locating canal orifices. Ultrasonic systems provide excellent visibility compared with conventional handpiece heads, which typically obstruct vision. 44

45. LIGHT AND MAGNIFICATION Use of high-quality magnification improves both the quality and speed of treatment, hence suitable for single-visit endodontics. Magnification and illumination are important in endodontics, especially for: Determining the location of canals Curved and calcified canals Debriding and removing tissues and Calcification from the pulp chamber 45

46. Dental operating microscope (DOM) is an important aid in locating root canals, which was introduced into endodontics to provide enhanced lighting and visibility. Numerous studies have shown that it significantly improves the practitioners ability to locate and negotiate canals. For example, the number of second mesiobuccal (MB-2) canals identified in maxillary molars increased from 51% with the naked eye to 82% with the microscope. 46

47. FIBRE-OPTIC ENDOSCOPE A recent addition to the field of visualization is a fibre -optic endoscope designed for intra oral use. The Orascope uses a fiber optic probe, xenon light source and a medical grade video monitor to provide a magnified image of the operating field 47

48. USE OF IRRIGANTS The concept of single visit root irrigant is based on the entombing theory. Although instrumentation of the root canal is the primary method of canal debridement, irrigation is a critical adjunct. Especially in case of single visit endodontics, irrigation plays a critical role as there is no scope of taking advantage of intracanal medicaments. Irrigation serves as a physical flush to remove smear layer, debris as well as serving as a bactericidal agent, tissue solvent and lubricant. 48

49. Of all the currently used substances, sodium hypochlorite appears to be the most ideal. NaOCl is effective against endodontic microorganisms, including those difficult to eradicate from root canals such as Enterococcus, Actinomyces and Candida organisms. NaOCl solutions are used in concentrations ranging from 0.5% to 5.25%. Studies have shown that in warming NaOCl to approximately 60°C (140°F) significantly increases the rate of effectiveness of tissue dissolution . 49

50. Sodium hypochlorite in combinations- There is increasing evidence that the efficacy of NaOCl , as an antibacterial agent is increased when it is used in combination with other solutions such as calcium hydroxide, EDTA or Chlorhexidine. With Chlorhexidine- Kuruvilla and Kamath 1998 in a study combined alternate use of NaOCl and Chlorhexidine gluconate irrigants and results indicate a greater reduction of microbial flora (84.6%) when compared with the individual use of sodium hypochlorite (59.4%) or chlorhexidine gluconate (70%) alone. 50

51. With EDTA- Goldman et al showed that the smear layer is not removed by NaOCl irrigation alone but it is removed with EDTA. Ultrasonic activation of sodium hypochlorite has also been advocated, as this would "accelerate chemical reactions, create cavitational effects, and achieve a superior cleansing action". 51

52. Procedure sequence For Single Visit Endodontics 52

53. To illustrate the modern endodontic procedural sequence for single visit endodontics, an itemized sequence follows: The diagnosis indicates that endodontic treatment is needed and the tooth is anesthetized. Following placement of the rubber dam, access is made. Using the microscope at low to mid magnification, the pulp chamber is thoroughly prepared using a Bur tip size 2 for inspection. Under high magnification (16-24), the floor of the chamber is examined for additional canals because more than 50% of molar teeth have a fourth canal. 53

54. After the canal entrance is identified, the microscope is not needed until a later stage. The apex is negotiated with a size 10 K file and is then enlarged with size 15 or 20 files. Gates-Glidden burs are used in reverse order to enlarge the coronal one half or two thirds using the crown down technique. During this enlargement, it is important to use irrigants (2.5%-5% sodium hypochlorite and 17% EDTA solution) to penetrate deep into the canals. 54

55. An apex locator is used to determine the canal length at this stage. Crown down pressureless technique is used for shaping and cleaning with rotary and hand instrumentation combined. The microscope is used to check the preparation and to check again for an additional canal or canals. A master gutta percha cone is selected; the canal length and solid "tug back" is assured. 55

56. This master cone, coated with root canal cement, is inserted into the canal, and the coronal part of the point is scared off using system B. The gutta percha in the apical 3 to 4 mm is packed with S- Kondensers . The Obtura gutta percha compactor with an appropriate tip is inserted into the canal up to where the master gutta percha was scared off. The thermoplasticized gutta percha fills the canal as the tip is slowly withdrawn. The microscope is used again for a final check. Finally, the canal is sealed with temporary cement. 56

57. SUCCESS VERSUS FAILURE RATE Endodontic success indicators can be evaluated as short-term or long-term outcomes. Short-term indicators concern the absence of any postoperative discomfort. Long-term success - dependent on various criteria, including case selection, treatment procedures, and obturation. Time interval, and recall interval are also important. Medical duration of recall plays an important role. The literature indicates that there is minor or no substantial difference in the success rates of single- and multiple-visit endodontic therapy. An appropriate case selection and clinical diagnosis are essential. 57

58. CONCLUSION With the advent of technological advancement and the emergence of new devices, evidence-based dentistry, and more scientific deliberations the concept of maximum dentistry in minimum visits led to the popularity of various protocols to enable dentists to venture into single visit endodontics with reasonable level of outcome. Practitioners should attempt single-visit root canal treatment only after making an honest assessment of their endodontic skills, training, and ability. The success rate and the amount of post-operative complications depend on the selection criteria and the patient's conditions. They depend on the skill set of the clinician and the preparation techniques. 58

59. REFERENCES Mothanna Al- Rahabi . Single visit root canal treatment: Review. Saudi Endodontic Journal · May-Aug 2012 · Vol 2 · Issue 2. Ashkenaz , P.J. One-visit endodontics. Dent Clin North Am. Oct;28(4):853–63, 1984. Kaur, G., Gupta, A., & Bansal, C. (2021). Single visit endodontics with associated myths: A review. International Journal of Health Sciences, 5(S1), 143–148. Dr. Pradnya V. Baroudi, Dr. Seema D. Pathak, Dr. M. B. Wavdhane , Dr. Shirish Khodkeghar , Dr. Priyanka P. Bargaje . IOSR-JDMS; Volume 17, Issue 11 Ver. 7 (November. 2018). Single-Visit Versus Multiple-Visit Root Canal Treatment: A Review ArticleDr . Pradnya V. Bonde | Dr. Seema D. Pathak | Dr. M.B. Wadkar | Dr. Darsh Khokhani | Dr. Priyanka Bangad | Dr. Josna C. Nair | December 2019. Ghoddusi J, Jafari M, Zarrabi MH, Birjandi H. Flare-ups: incidence and severity after using calcium hydroxide as intracanal dressing. NY State Dent J. 2006;72(4):24-28. Gesi L, Hülsmann M, Warfvinge J, Bergenholtz G. Incidence of periapical lesions and clinical symptoms after pulpectomy - A clinical and radiographic evaluation of 1- versus 2-session treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod . 2006;101:379-88. 59