Single Visit vs multiple visit Endodontics.pptx

Should root canal treatment (RCT) be done in a single visit or multiple visits? What are the indications and contraindications for single-visit and multiple-visit RCT?

1. Arjeet Ghosh SINGLE VISIT ENDODONTICS MULTIP LE VISIT ENDODONTICS

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

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. • In other words, Endodontic success depends upon - Localization Of Canals - Proper Shaping And Cleaning Of Root Canal System, - 3 D Obturation Of Canal System. Mothanna AI Rahab. Single visit root canal treatment: Review Saudi Endodontic Journal, May-Aug 2012 , Vol 2

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 AI Rahab. Single visit root canal treatment: Review Saudi Endodontic Journal, May-Aug 2012 , Vol 2

5. DEFINITION Single visit endodontic therapy can be defined as a conservative, non surgical treatment of an endodontically involved tooth consists of complete biomechanical preparation and obturation of the root canal system in single visit. Textbook of endodontics, first edition, Mithra N. Hegde, pa no- 445 .

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

7. Evolution Of Single Visit Endodontics Dodge JS. 1880s Concept of a single-visit root canal treatment Ferranti 1950s Use of diathermy for pulpal disinfection and hydrogen peroxide for irrigation Tosti 1970 Clinical study using a single-visit approach. Rudner and oliet 1983 Described a concept and clinical technique for treating teeth in a single visit. Ashkenaz. P.J. 1984 Defined and enumerated the indications and contraindications for single visit endodontics.

8. Case selection as given by Oliet includes Text book of endodontics, Nisha Grag , 3rd edition

9. Indications • Uncomplicated vital teeth . • Fractured anteriors or bicuspid teeth where aesthetics is the concern. • Teeth indicated for endodontic surgery. • Non vital teeth with sinus tract . Patients who require sedation every time. • Medically compromised patients who require antibiotic prophylaxis . • Physically compromised patients who cannot come to dental clinics frequently. Ashkenaz, P J. “One-visit endodontics.”  Dental clinics of North America  28 4 (1984): 853-63 .

10. Intentional root canal therapy. Patients requiring full mouth rehabilitation. Accidental/Mechanical pulp exposure . Vital pulp exposures because of trauma with symptomatic pulpitis. Vital pulp exposure because of caries with symptomatic pulpitis. Ashkenaz, P J. “One-visit endodontics.”  Dental clinics of North America  28 4 (1984): 853-63 .

11. Contraindications Teeth with anatomic anomalies such as calcified and curved canals . Asymptomatic non vital teeth with periapical pathology and no sinus tract . Acute alveolar abscess cases with pus discharge . Patients who have acute apical periodontitis with severe pain on percussion . Ashkenaz, P J. “One-visit endodontics.”  Dental clinics of North America  28 4 (1984): 853-63 .

12. • Most of the re-treatment cases. • Patients with allergies or previous flare ups. • Teeth with limited access . • Patients who are unable to keep mouth open for long duration such as TMJ disorders . Ashkenaz, P J. “One-visit endodontics.”  Dental clinics of North America  28 4 (1984): 853-63 .

13. 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 . Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V, Volume 17, Issue 11 Ver. 7 (November. 2018), PP 70-74.

14. • 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 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. Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V, Volume 17, Issue 11 Ver. 7 (November. 2018), PP 70-74.

15. Practice management advantages: • Prosthetic work can begin without delay . • The risk of cancelled appointments is reduced . The number of teeth that patients are willing to save may increase . • Same patients will pay a premium to save time . Materials needed for separate visits (disposable bibs, suction tips, anaesthetic and irrigation needles and rubber dams) are saved. Time is saved : There is no need to reappoint patient nor reconfirm appointments. Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V, Volume 17, Issue 11 Ver. 7 (November. 2018), PP 70-74.

16. Patients 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. Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V, Volume 17, Issue 11 Ver. 7 (November. 2018), PP 70-74.

17. • 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. Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V, Volume 17, Issue 11 Ver. 7 (November. 2018), PP 70-74.

18. Disadvantages 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 • 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. Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V, Volume 17, Issue 11 Ver. 7 (November. 2018), PP 70-74.

19. Myth No. 1 Post operative pain is greater when endodontic therapy is completed in a single visit, especially in non vital teeth

20. Bayram Incea , 2009 stated that Postoperative pain occurred in 107 (69.9%) and 106 (69.3%) teeth in the single- and multi-visit treatment groups, respectively. There was no significant difference in postoperative pain between the two groups (P>.OI). Ince B, Ercan E, Dalli M, Dulgergil CT, Zorba YO, Colak H. Incidence of postoperative pain after single- and multi-visit endodontic treatment in teeth with vital and non-vital pulp. Eur J Dent. 2009 Oct;3(4):273-9. Keskin C, Özdemir Ö, Uzun İ, Güler B. Effect of intracanal cryotherapy on pain after single-visit root canal treatment. Aust Endod J. 2017 Aug;43(2):83-88. C. Keskin , 2015 reported that there was no difference in the incidence and intensity of postoperative pain whether treatment was completed in a single- or multiple-visits in teeth with vital or non-vital pulps.

21. Ashish patil , 2016 reported that incidence of pain after endodontic treatment being performed in one-visit or two-visits is not significantly different experienced by the patients 48 hours after treatment in both the groups. Patil AA, Joshi SB, Bhagwat SV, Patil SA. Incidence of Postoperative Pain after Single Visit and Two Visit Root Canal Therapy: A Randomized Controlled Trial. J Clin Diagn Res. 2016 May;10(5):ZC09-12.

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

23. In a systematic review done by C. Sathorn, 2005 found that single-visit root canal treatment appeared to be slightly more effective than multiple visit, i.e. a 6.3% higher healing rate. Paredes- Vieyra J , 2012 stated that meticulously instrumented single visit root canal treatment can be as successful as a 2-visit treatment and found that there was no significant difference in radiographic evidence of periapical healing between I-visit and 2-visit root canal treatment. C. Sathom et al. Effectiveness of single versus multiple visit endodontic treatment of teeth with apical periodontitis: a systematic review and International Endodontic Journal, 38, 347-355, 2005 Paredes- Vieyra J, Enriquez FJ. Success rate of single- versus two-visit root canal treatment of teeth with apical periodontitis: a randomized controlled trial. J Endod . 2012 Sep;38(9):1164-9.

24. Dorasani et al , 2013 reported that Both single-visit and multiple-visit-treated teeth healed satisfactorily with no significant differences. Dorasani G, Madhusudhana K, Chinni SK. Clinical and radiographic evaluation of single-visit and multi-visit endodontic treatment of teeth with periapical pathology: An in vivo study. J Conserv Dent. 2013 Nov;16(6):484-8. Vieyra , Jorge Paredes, Fabian Paredes Ocampo, Acosta and Seidi Karin Nevarez Osuna. “Incidence of Flare-Ups and Apical Healing after Single-Visit or Two Visits Treatment of Teeth with Necrotic Pulp and Apical Periodontitis after a Two-Year Control Period. A Randomized Clinical Trial.” (2018). Fabian Ocampo Acosta et al , 2018 stated that there was no significant difference in radiographic evidence of periapical healing between single-visit and two visits root canal treatment.

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

26. Postoperative pain or swelling are collectively described as flare-up , which is probably one of the most concerning issues that dentists practicing single-visit treatment mostly deal with. Trope defined flare up as "intolerable pain and/or swelling " .

27. According to the findings of his study: Teeth without apical periodontitis did not flare-up and may be treated in a single visit; (ii) 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) (iii) 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 ),

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

29. There was a significant difference regarding the occurrence of flare- ups when comparing treatment cases with retreatment cases 0.05). Moderate pain occurred in 5% of the treatment cases 16.67% of the retreatment cases. This study gave evidence that a meticulously instrumentation and irrigation performed in a single-visit root canal treatment can be as successful as a two visits treatment.

30. Myth No- 4 Canals are cleaned better, if an antibacterial medicament such as Ca(OH)2 is left in the tooth.

31. 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, Javidi M, Zarrabi MH, Bagheri H. Flare-ups incidence and severity after using calcium hydroxide as intracanal dressing. N Y State Dent J. 2006 Jun-Jul;72(4):24-8.

32. 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 A. Hakeberg M. Warfvinge J. Bergenholtz G. Incidence of periapical lesions and clinical symptoms after pulpectomy - A clinical and radiographic evaluation of I- versus 2-session treatment Oral Surg Oral Med Otal Pathol Oral RadiolEndod .. 2006; 101: 379-388

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

34. 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 .

35. Amy Wai-Yee Wong 2015 Summed it up best. “Recent studies have shown that the success rate and prevalence of postoperative pain of single-visit or multiple-visit treatment had no significant difference. The chairside time for single-visit treatment was shorter than multiple-visit treatment.” Wong AW, Tsang CS, Zhang S, Li KY, Zhang C, Chu CH. Treatment outcomes of single-visit versus multiple-visit non-surgical endodontic therapy: a randomised clinical trial. BMC Oral Health. 2015 Dec 19;15:162.

36. 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.

37. 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.

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

39. 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 These includes: 1. Local Infiltration 2. Intrapulpal injection 3. Intra osseous injection.

40. Masoud Parirokh 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 for Inferior Alveolar Nerve Block Anesthesia after Single-visit Root Canal Treatment in Teeth with Irreversible Pulpitis. JOE — Volume 38, Number 8. August 2012

41. Isolation The use of the rubber dam is mandatory in root canal treatment. The rubber dam is used in endodontics because it ensures the following: Patient is protected from aspiration of instruments, tooth debris, medicaments and irrigating solutions. A surgically clean operating field is isolated from saliva, hemorrhage and other tissue fluids. Soft tissues are retracted and protected. Visibility is improved.

42. 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. A. NO. 2 bur - anterior and premolar teeth and a No.4 should be used in molar teeth. B. Once the roof is perforated, A round bur, a tapered fissure bur or a safety tip diamond or carbide bur is used C. Tapered, Flame shaped and round ended tapered diamonds are excellent for endodontic access.

43. Light And Magnification The use of high quality magnification in dentistry improves both the quality and speed of treatment, hence suitable for single visit endodontics. Magnification and illumination are particularly important in single visit root canal therapy ,especially for - Determining the location of canals, Negotiating constricted, - Curved and calcified canals, - Debriding and removing tissue and - Calcifications from the pulp chamber.

44. Surgical loupes, endodontic endoscopes, and DOM are some of the commercially available instruments that can help the clinician accomplish these goals. The head light provides line of straight lumination , which is shadow less and avoids multiple adjustments to the traditional overhead dental operating light.

45. Use Of Irrigation The concept of single visit root canal treatment is based on the entombing theory, which the large number of microorganisms removed during cleaning and shaping and the remaining bacteria entombed by the root canal obturation, will therefore miss essential elements to survive and space. 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. Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod . 2000 Dec;26(12):751-5 .

46. 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 ℃ significantly increases the rate of effectiveness of tissue dissolution.

47. Procedural Sequence Of Single. Visit Root Canal Treatment Text book of endodontics, Nisha Grag , 3 rd edition

48. • The incidence of mishaps was 7% in teeth treated in a single visit , and the incidence increased significantly to 16.2% and 28.3% for teeth treated in two and three visits, respectively. • Single-visit treatment was significantly correlated with fewer mishaps

49. Richard B , 1988 evaluated the incidence of failure following single-visit endodontic therapy and reported that the endodontic failure rate was found to be 5.2%. Also, the incidence of failure was higher in those teeth with periapical extension of pulpal disease which had no prior access opening.

50. Conclusion The aim of endodontic therapy to achieve resolution of disease means elimination of the etiology (the bacteria). Therefore everytime we get free microorganism canals. The canals with vital pulps can be regarded as free of bacteria at the initiation of treatment. In teeth with necrotic pulp and apical periodontitis and with complex anatomy of the teeth and root canals creates an environment that is a challenge to the complete cleansing in SVE. Therefore MVE may be more effective to achieve more bacteria negative canals. Regardless of number of sessions, an effective bacteriological control is mandatory.

51. references Mothanna AI Rahab. Single visit root canal treatment: Review Saudi Endodontic Journal, May-Aug 2012 , Vol 2. Textbook of endodontics, first edition, Mithra N. Hegde, pa no- 445. Vela KC, Walton RE, Trope M, Windschitl P, Caplan DJ. Patient preferences regarding 1-visit versus 2-visit root canal therapy. J Endod . 2012 Oct;38(10):1322-5. Ashkenaz, P J. “One-visit endodontics.” Dental clinics of North America 28 4 (1984): 853-63 . Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V, Volume 17, Issue 11 Ver. 7 (November. 2018), PP 70-74. Ince B, Ercan E, Dalli M, Dulgergil CT, Zorba YO, Colak H. Incidence of postoperative pain after single- and multi-visit endodontic treatment in teeth with vital and non-vital pulp. Eur J Dent. 2009 Oct;3(4):273-9.

52. Keskin C, Özdemir Ö, Uzun İ, Güler B. Effect of intracanal cryotherapy on pain after single-visit root canal treatment. Aust Endod J. 2017 Aug;43(2):83-88. Patil AA, Joshi SB, Bhagwat SV, Patil SA. Incidence of Postoperative Pain after Single Visit and Two Visit Root Canal Therapy: A Randomized Controlled Trial. J Clin Diagn Res. 2016 May;10(5):ZC09-12. C. Sathom et al. Effectiveness of single versus multiple visit endodontic treatment of teeth with apical periodontitis: a systematic review and International Endodontic Journal, 38, 347-355, 2005 Paredes- Vieyra J, Enriquez FJ. Success rate of single- versus two-visit root canal treatment of teeth with apical periodontitis: a randomized controlled trial. J Endod . 2012 Sep;38(9):1164-9. Dorasani G, Madhusudhana K, Chinni SK. Clinical and radiographic evaluation of single-visit and multi-visit endodontic treatment of teeth with periapical pathology: An in vivo study. J Conserv Dent. 2013 Nov;16(6):484-8. Vieyra , Jorge Paredes, Fabian Paredes Ocampo, Acosta and Seidi Karin Nevarez Osuna. “Incidence of Flare-Ups and Apical Healing after Single-Visit or Two Visits Treatment of Teeth with Necrotic Pulp and Apical Periodontitis after a Two-Year Control Period. A Randomized Clinical Trial.” (2018).

53. Trope M. Flare-up rate of single-visit endodontics. Int Endod J. 1991 Jan;24(1):24-6. Prasada , Lashkari. (2013). A comparative study of flare-ups in nonvital molars in single-visit versus multi-visit endodontic treatment. endodontology. 25. Vieyra , Jorge Paredes, Fabian Paredes Ocampo, Acosta and Seidi Karin Nevarez Osuna. “Incidence of Flare-Ups and Apical Healing after Single-Visit or Two Visits Treatment of Teeth with Necrotic Pulp and Apical Periodontitis after a Two-Year Control Period. A Randomized Clinical Trial.” (2018). Ghoddusi J, Javidi M, Zarrabi MH, Bagheri H. Flare-ups incidence and severity after using calcium hydroxide as intracanal dressing. N Y State Dent J. 2006 Jun-Jul;72(4):24-8. Gesi A. Hakeberg M. Warfvinge J. Bergenholtz G. Incidence of periapical lesions and clinical symptoms after pulpectomy - A clinical and radiographic evaluation of I- versus 2-session treatment Oral Surg Oral Med Otal Pathol Oral RadiolEndod .. 2006; 101: 379-388 Wong AW, Tsang CS, Zhang S, Li KY, Zhang C, Chu CH. Treatment outcomes of single-visit versus multiple-visit non-surgical endodontic therapy: a randomised clinical trial. BMC Oral Health. 2015 Dec 19;15:162.

54. Effect of Bupivacaine on Postoperative Pain for Inferior Alveolar Nerve Block Anesthesia after Single-visit Root Canal Treatment in Teeth with Irreversible Pulpitis. JOE — Volume 38, Number 8. August 2012 Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod . 2000 Dec;26(12):751-5. Text book of endodontics, Nisha Grag , 3rd edition Alsulaimani , Reem & Al- Manei , Kholod & Ababtain , Razan & Binrabba , Reem & Ashri , Nahid. (2016). The Correlation between Endodontic Mishaps and Single-Visit Treatment in King Saud University. International Journal of Dentistry and Oral Health. Pekruhn RB. The incidence of failure following single-visit endodontic therapy. J Endod . 1986 Feb;12(2):68-72.