COCHRANE Review
Single Versus Multiple Visits for Endodontic Treatment of
Permanent Teeth: A Cochrane Systematic Review
Lara Figini, DDS,* Giovanni Lodi, DDS, PhD,* Fabio Gorni, MD,† and
Massimo Gagliani, MD*
Abstract
The Cochrane Collaboration promotes evidence-based
healthcare decision making globally through systematic
reviews of the effects of healthcare intervention. The
purpose of this systematic review was to investigate
whether the effectiveness and frequency of short-term
and long-term complications are different when end-
odontic procedure is completed in one or multiple visits.
Randomized and quasi-randomized controlled trials en-
rolling patients undergoing endodontic treatment were
identified by searching biomedical databases and hand-
searching relevant journals. The following outcomes
were considered: tooth extraction as a result of end-
odontic problems and radiologic failure after 1 year,
postoperative discomfort, swelling, analgesic use, or
sinus track. Twelve studies were included in the review.
No detectable difference was found in the effectiveness
of root canal treatment in terms of radiologic success
between single and multiple visits. Neither single-visit
root canal treatment nor multiple-visit root canal treat-
ment can prevent 100% of short-term and long-term
complications. Patients undergoing a single visit might
experience a slightly higher frequency of swelling and
refer significantly more analgesic use. (J Endod 2008;
34:1041–1047)
Key Words
Apical periodontitis, COCHRANE, meta-analysis, multi-
ple visit endodontics treatment, nonsurgical root canal
therapy, one visit endodontics, systematic review
From the *Dipartimento di Medicina, Chirurgia Odontoia-
tria, Università degli Studi di Milano; and †Dental practitioner,
Milan, Italy.
Address requests for reprints to Dr Giovanni Lodi, Univer-
sità degli Studi di Milano, Milano, Italy. E-mail address:
giovanni.lodi@unimi.it.
0099-2399/$0 - see front matter
Copyright © 2008 American Association of Endodontists.
doi:10.1016/j.joen.2008.06.009
JOE — Volume 34, Number 9, September 2008
T his article provides the essence of a Cochrane Review published in the Cochrane
Library, issue 4, October 2007. Cochrane Reviews are regularly updated in response
to comments and criticism and as new evidence emerges. Hence, the Cochrane Library
should be consulted for the most recent version of this systematic review at www.
theCochraneLibrary.com.
Considerable controversy exists over the question of whether it is preferable to
complete endodontic therapy in one or multiple appointments. The factors to be con-
sidered in the choice of the type of treatment are operator ability and clinical experi-
ence, tooth conditions (vital or nonvital tooth, symptomatic or asymptomatic, presence
or absence of swelling), adequate treatment time, patient’s time constraints, medical
history and attitude, as well as anatomic and biologic considerations. The advantages of
doing single-visit endodontics are reduction in patient’s appointments per tooth, which
most would appreciate, reduction of interappointment leakage, immediate use of canal
for retention of posts, particularly in the anterior region (aesthetic consideration),
reduced procedural costs, decreased morbidity from repeat injections and rubber dam
placement. The main objective of an endodontist undertaking a canal treatment proce-
dure is to obtain success in terms of prevention and, when necessary, healing of end-
odontic diseases such as apical periodontitis, while minimizing any discomfort for the
patients.
Endodontic treatment can be followed by “short term” and “long term” compli-
cations. The former includes signs and symptoms of postoperative inflammation of
periradicular tissues, with discomfort being the most common short-term outcome of
root canal treatment (RoCT) procedures (1, 2). Discomfort after an endodontic treat-
ment is thought to be related to a periapical inflammatory response caused by 1 or more
of the following factors: instrumentation, passage of medications or infected debris into
the periapical tissues, damage of vital neural or pulpal tissue, or central sensitization. In
previous studies, postoperative discomfort after nonsurgical RoCT has been reported to
range from approximately 3% to more than 50% (3, 4). Postoperative discomfort can
lead to increased analgesic usage or unscheduled dental visits.
Another short-term adverse event is swelling, which could result from an exacer-
bation of a chronic periapical lesion or could occur without a detectable periapical
lesion. Swelling is thought to be dependent on bacterial contamination of the periapical
tissues caused by instrumentation, inadequate canal disinfection, bacterial recontami-
nation of root canal systems as a result of unsatisfactory coronal seal, or host factors.
The main long-term complications include persistence of inflammation and/or sinus
track, discomfort, and radiographic signs of periapical bone resorption.
Our review was conducted to investigate whether completion of RoCT in a single
visit or during multiple visits makes any detectable difference in terms of clinical and
radiologic success and in terms of both short-term and long-term complications.
Material and Methods
Inclusion Criteria and Search Strategy
To be included in the review a study had to be a random or a quasi-random
controlled trial design comparing RoCT in single and multiple visits (ie, 2 or more
appointments) in patients aged ⬎10 years, and no difference in medical treatment (ie,
use of antibiotics, nonsteroidal anti-inflammatory drugs, or analgesics) could be
present in the 2 groups. We considered only permanent single-root and multi-root teeth
Single versus Multiple Visits for Endodontic Treatment of Permanent Teeth 1041
COCHRANE Review
TABLE 1. Endodontic Radiologic Success: Conversion from Continuous to a Binary Outcome Measure
Classification
Trope 1999 (5); Orstavick (6);
Kirkevang (PAI) (7)
Strindberg (8); Gutman (9)
Katebzadeh (10)
Halse and Molven (11)
Peters 2002 (12); Reit and
Gröndahl (13); Kvist (14)
Weiger 2000 (15)
Soltanoff 1978 (16)
Gesi 2006 (17)
PAI, periapical index.
Success (Binary)
PAI score 1 (normal periapical), PAI
score 2 (bone structural change)
Success (normal to slightly thickened
periodontal ligament space ⬍1
mm, elimination of previous
rarefaction, normal lamina dura in
relation to adjacent teeth, no
evidence of resorption)
Healed (normal pattern of
trabecular bone and normal width
of periodontal ligament space)
Healed (normal pattern of
trabecular bone and normal width
of periodontal ligament space)
Success: A (the width and contour of
the periodontal ligament are
normal, or there is a slight
radiolucent zone around apex)
Complete healing (no clinical signs
and symptoms, radiographically a
periodontal ligament space of
normal width)
Healed (radiographically, but criteria
are not specified)
Normal or unclear periapical
condition (widened apical
periodontal space or diffused
lamina dura)
Failure (Binary)
PAI score 3 (structural changes with mineral loss), PAI score 4
(radiolucency with features of exacerbation)
Questionable (increased periodontal ligament space ⬎1 and
⬍2 mm, stationary rarefaction or slight repair evident,
increased lamina dura in relation to adjacent teeth,
evidence of resorption); Failure (increased width of
periodontal ligament space ⬎2 mm, lack of osseous repair
within rarefaction or increased rarefaction, lack of new
lamina dura, presence of osseous rarefactions in
periradicular areas where previously none existed)
Improved (reduction in lesion size); Failed (increased or no
change in the lesion size)
Increased width of the periodontal space, pathologic
findings
Uncertain: B (the radiolucency is clearly decreased, but
additional follow-up is not available); Failure: C (there is
unchanged, increased, or new periradicular radiolucency)
Incomplete healing (no clinical signs and symptoms,
radiographically a reduction of the lesion in size or an
unchanged lesion within an observation time of 4 years);
No healing (clinical signs and symptoms indicating an
acute phase of apical periodontitis and/or radiographically
a persisting lesion after a follow-up time of 4–5 years and/
or a new lesion formed at an initially uninvolved root of a
multi-rooted tooth)
Not healed (radiographically, but criteria are not specified)
Presence of periapical radiolucency when there was a
distinct radiolucent area associated with the apical portion
of the root

with completely formed apices and without internal resorption. Split
mouth studies could also be included.
The following medical databases were searched for relevant trials:
Cochrane Oral Health Group’s Trials Register, Cochrane Central Regis-
ter of Controlled Trials (CENTRAL), MEDLINE 1966 to present, and
EMBASE 1974 to present.
Studies to include in the review were searched for in MEDLINE by
using the PUBMED software and a formal search strategy that was ap-
proved by the Trials Search Co-ordinator of the Cochrane Oral Health
Group. This strategy was adapted for the other databases.
The additional following journals, not currently indexed in
PUBMED, were identified as being important to be hand-searched from
1980 –2004 for this review (see www.ohg.cochrane.org in the Journal
Handsearching Programme section): Giornale Italiano di Endodon-
zia, Revue Française de Endodontie, German Endodontie, Endodon-
tic Practice.
We also searched the proceedings from major dental organiza-
tions such as International Federation of Endodontic Associations, Eu-
ropean Society of Endodontology, Società Italiana di Endodonzia, Inter-
national Association for Dental Research, British Endodontics Society,
and Brazilian Endodontics Society.
Studies in all languages were considered for translation.
The full reports obtained from all the electronic and other meth-
ods of searching were assessed independently by 2 reviewers to estab-
lish whether the studies met the inclusion criteria. Any disagreements
were resolved by discussion. A third individual was to be consulted if
there were unresolved disagreement.
Outcomes
The main outcomes considered were tooth extraction caused by
endodontic problems (binary, yes/no) and radiologic failure after 1
year, ie, the presence or absence of any periapical radiolucency (scored
as a binary [yes/no] outcome). Table 1 summarizes how the most
common scales of radiologic success can be converted to a binary
outcome.
One of the outcome measures for complications was postoperative
discomfort (binary, yes/no). We considered only discomfort after canal
obturation, assessing pain incidence in the canal during the immediate
postobturation period (until 72 hours), at 1 week, and at 1 month. We
did not consider discomfort during the interappointment period in the
multiple-visit approach, because we could not compare this with a
similar situation in the single-visit approach. The other outcome mea-
sures for complications were swelling (binary, yes/no), analgesic use
(binary, yes/no), and sinus track formation or resolution after treat-
ment (binary, yes/no).
Critical Appraisal
All studies meeting the inclusion criteria underwent a validity as-
sessment based on (1) concealment of treatment allocation (ie, blind-
ing) and (2) loss of participants over time.
The global validity of the studies was assessed by using the follow-
ing 3 categories: (1) low risk of bias: all of the criteria met; (2) mod-
erate risk of bias: all cases not included in categories (1) or (3); and
(3) high risk of bias: one or more criteria unmet.

1042 Figini et al. JOE — Volume 34, Number 9, September 2008


Statistical Analysis
Dichotomous data were expected for the main outcome measure-
ments. To compare dichotomous data, a calculation of the risk ratio was
used. A meta-analysis could only be conducted if the studies were
judged sufficiently similar in terms of design, types of patients, and
interventions. In addition, heterogeneity between trial results was tested
by using a standard ␹2 test. A standard result model was used in the
statistical analyses.
The patient was the statistical unit. Studies considering the tooth as
a statistical unit were considered only if the number of teeth was exces-
sively larger than the number of patients. The reason for selecting the
patient as the statistical unit is that when interpreting study results, the
confidence intervals are narrower if data are generated from multiple
teeth within one patient, possibly overestimating the real effect. Thus,
having the patient as the statistical unit results in a more relevant con-
fidence interval for clinical interpretations.
The meta-analysis was only conducted if the studies were judged
sufficiently similar in terms of design, types of patient, and interventions.
When raw data were not available, they were obtained by consult-
ing tables and graphs or by contacting the authors.
Subgroup analyses were planned to investigate the relevance of
pretreatment conditions (teeth with vital versus necrotic pulps), pre-
treatment symptoms (symptomatic versus asymptomatic teeth), pre-
treatment status of periradicular findings (apical radiolucency versus
no apical radiolucency), endodontic technique, and antimicrobials
used.
A sensitivity analysis was performed, excluding the studies of lower
methodologic quality (ie, studies with an elevated risk of bias).
Review manager 4.2 and RevMan Analyses 1.0.5 statistical soft-
ware were used for the calculation and generation of graphs.
Characteristics of the Included Studies
Fifty-four potentially eligible randomized controlled trials were
identified, but only 12 met the criteria and were included in this review.
All studies compared RoCT performed in a single visit with that per-
formed in multiple visits. In the multiple-visit approach, the majority of
authors completed the treatment in 2 visits (5, 12, 15, 17–22), whereas
in one study, RoCT was completed in 3 visits (23). In 2 studies, the
number of visits was not specified (16, 24). All studies had a 2-arm
design, with the exception of 2 studies with 3 arms, in which the authors
compared a single visit, multiple visits without intracanal medication,
and multiple visits with intracanal medication (calcium hydroxide) (5,
21). All of the studies only enrolled subjects with teeth with a completely
formed apex and without internal resorption. The main characteristics
of the included studies are summarized in Table 2.
On the basis of the criteria used in the critical appraisal, 4 studies
were shown to have a low risk of bias (5, 15, 17, 20), four were judged
as having a moderate risk of bias (16, 21, 23, 24), and the remaining
studies (12, 15, 18, 19) were considered as posing a high risk of bias.
All the studies were performed in university clinics or hospitals,
with the exception of one study (17), which was undertaken in a private
practice setting.
Results
Tooth Extraction
We found no study investigating tooth extraction caused by end-
odontic problems.
Radiologic Outcome
Results from 5 studies (5, 12, 15–17) including 657 patients were
available for the meta-analysis (Fig. 1). Single-visit RoCT appeared to be
JOE — Volume 34, Number 9, September 2008
COCHRANE Review
slightly more effective (15%) than multiple-visit RoCT for radiographic
resolution of apical periodontitis, although the difference was not sta-
tistically significant (relative risk [RR], 0.85; 95% confidence interval
(CI), 0.59 –1.23).
Postoperative Discomfort
Immediate Discomfort (up to 72 Hours)
Results from 6 studies (16, 18, 19, 21, 23, 24) including 1047
patients were available for the analysis of discomfort incidence 72 hours
after canal obturation. The incidence of postoperative discomfort at
72 hours showed no difference between the 2 groups (RR, 0.99;
95% CI, 0.83–1.18).
Discomfort at 1 Week
Results from 5 studies (16, 17, 19, 23, 24) including 936 patients
were available for analysis of discomfort at 1 week. One-week postop-
erative discomfort was less common after multiple-visit RoCT compared
with single-visit treatment, but the difference was not statistically signif-
icant (RR, 1.07; 95% CI, 0.72–1.57).
Discomfort at 1 Month
Only 2 studies reported discomfort 1 month after canal obturation
(18, 24). In both studies, no patient had persistent discomfort at 1
month. Thus, a meta-analysis of the studies was not possible.
Results from one study (22) were excluded from discomfort meta-
analysis because the discomfort data were not divided according to time
of onset. In this study single-visit and multiple-visit RoCT showed no
significant difference in incidence of discomfort (RR, 1.88; 95% CI,
0.87– 4.07). The incidence of discomfort was greatest during the first
48 hours after obturation and then decreased steadily during the sub-
sequent 7 days. When data were analyzed on the basis of the presence of
symptoms before RoCT, postoperative discomfort was found signifi-
cantly more often in patients with symptomatic teeth.
Postoperative Swelling/Flareup
We could not compare all the studies reporting flareup because
they did not provide a comparable definition of flareup. Many studies
included both swelling and severe pain in the definition of flareup, so it
was not possible to discriminate these data. Only 3 studies considered
flareup as swelling (20, 21); these included 192 patients, and data were
available for analysis. Swelling appeared to be less common with mul-
tiple-visit RoCT than with single-visit RoCT, but the difference was not
statistically significant (RR, 1.40; 95% CI, 0.67–2.93).
Analgesic Use
Results from 3 studies (16, 22) including 559 patients were avail-
able for analysis (Fig. 2). In all 3 studies, analgesic use after canal
obturation was more common among patients treated at a single visit. A
meta-analysis showed that analgesic use was significantly more com-
mon in patients undergoing single-visit RoCT (RR, 2.42; 95% CI, 1.62–
3.62).
Three studies (17, 21, 23) reported discomfort during the intera-
ppointment period of the multi-visit approach. However, such data were
not included in the meta-analysis, because they could not be compared
with a similar outcome in the single-visit approach.
Sinus Track Formation
We found no studies investigating fistula or sinus track formation.
Single versus Multiple Visits for Endodontic Treatment of Permanent Teeth 1043
COCHRANE Review
TABLE 2. Characteristics of Included Studies
Study (Including First Teeth and Pretreatment Risk of
Participants Intervention
Author) Status Bias

Al-Negrish 2006 (19) 120 participants (1 tooth Asymptomatic central Single visit or multiple visits. Rubber dam isolation. Canal shaping: step-back technique High
each), 112 included in incisors with pulpal with conventional K files and Gates. Irrigation: 2.5% sodium hypochlorite. Working
the final analysis. necrosis length was determined by x-ray, obturation with gutta-percha and a zinc oxide–
eugenol sealer (Tubliseal; Kerr, Orange, CA) in lateral condensation. In the multiple-
visit group the number of visits was 2 (the second appointment 7 days later); the
canals were medicated for 7 days with a calcium hydroxide paste with a dry sterile
cotton pledget and a temporary filling restoration.
Albashaireh 1998 300 participants (1 tooth Teeth with vital and Single visit or multiple visits. Single operator. Canal shaping with step-back technique, High
(18) each), 291 included in nonvital pulps obturation with gutta-percha and a calcium hydroxide–based root canal sealer
the final analysis. (Sealapex; Sybron Endo, Orange, CA) with lateral condensation technique. Irrigation
with 2.6% sodium hypochlorite solution. In the multiple-visit group no medicament
was placed, but a dry sterile cotton pledget was sealed in pulp chamber with a
temporary filling restoration.
DiRenzo 2002 (20) 80 participants (1 tooth Permanent maxillary and Single visit or multiple visits. Two operators (postgraduate students). Rubber dam Low
each), 72 included in mandibular molars isolation. Canal shaping with hand files and NiTi rotary files. Irrigation with 2.5%
the final analysis. with vital and nonvital NaOCl. Working length was determined by an electronic apex locator and 2 or more
pulps angled radiographs. Obturation with gutta-percha and Roth 811 sealer in lateral
condensation. In the multiple-visit group patients underwent 2 visits, and the teeth
in the interappointment period were closed with a sterile dry cotton pellet and
Cavit temporary restorative cement.
Gesi 2006 (17) 256 participants (1 tooth Teeth with vital pulps, Single visit or multiple visits. Single operator. Rubber dam. Canal shaping: hand Low
each), 244 included in bleeding on access of instrumentation with Flexofiles (Dentsply Maillefer, Tulsa, OK) by using balanced
the final analysis. the pulpal chamber force technique and crown-down technique. Irrigation: 3% sodium hypochlorite.
Working length was established by x-ray. Obturation with gutta-percha and pulp
canal sealer (Kerr) with lateral condensation. In the multiple-visit group the patients
underwent 2 visits. In the interappointment period calcium hydroxide was used as
intracanal medication and Coltosol (Coltene Whaledent, Langenau, Germany) as
temporary cement.
Ghoddusi 2006 (21) 69 participants (1 tooth Teeth with necrotic pulps Single visit or multiple visits. Rubber dam. Irrigation with saline solution. Working Moderate
each), 60 included in length was evaluated by x-ray, obturation with gutta-percha in lateral
the final analysis. condensation. In the multiple-visit group the patients underwent 2 visits; after the
first appointment the canal was left empty, and the access cavities were sealed with
sterilized cotton pellets and at least 3 mm of temporary filling material (Coltosol).
Treatment was completed after 1 week.
Mulhern 1982 (23) 60 participants (1 tooth Asymptomatic teeth with Single visit or multiple visits. Two operators (graduate endodontic students). Rubber Moderate
each), all included in pulpal necrosis dam. Irrigation: 2.5% sodium hypochlorite. Working length was not reported.
the final analysis. Obturation with lateral condensation was performed with gutta-percha and Kerr
Tubliseal. In the multiple-visit group the patients underwent 3 visits. In the
interappointment period no medication was used; only a dry pledget of cotton with
a double cement system of Cavit G and zinc oxyphosphate cement in the coronal
access cavity was used.
Oginni 2004 (24) 255 participants and 283 Teeth with vital and Single visit or multiple visits. The root canals were obturated with multiple gutta- Moderate
teeth, 222 teeth nonvital pulps percha cones and a zinc oxide–eugenol based sealer by using the lateral
included in the final condensation technique. Medication and number of visits in the multiple-visit
analysis. treatment were not reported.
Peters 2002 (12) 39 participants (1 tooth Asymptomatic teeth with Single visit or multiple visits. One operator (endodontist). Rubber dam and High
each), 38 included in radiographic evidence magnification loupes. Canal shaping: hand instrumentation by double flare
the final analysis. of periapical bone loss technique. Irrigation: 2% sodium hypochlorite. Working length was evaluated by
x-ray and electronic apex locator. Obturation: gutta-percha and AH 26 sealer in
lateral condensation. In the multiple-visit group the patients underwent 2 visits (the
second appointment 4 weeks later). In this group in the interappointment period
the canals were dressed with a thick mix of calcium hydroxide in sterile saline, and
the cavity access was filled with 2 layers of Cavit and a glass ionomer restoration.
Soltanoff 1978 (16) 330 participants (1 tooth Unspecified Single visit or multiple visits. In multiple visits the medication and the total number of Moderate
each), 281 included in visits were not specified. In both groups sterile saline solution was used as irrigation;
the final analysis. the canals were filled with gutta-percha cones and Ostby’s Kloroperka as the
cementing medium for lateral condensation.
Trope 1999 (5) 81 participants and 102 Radiographic evidence of Single visit or multiple visits. One operator. Rubber dam isolation. Irrigation with 2.5% Low
teeth periapical bone loss NaOCl. Working length was evaluated by x-ray; obturation with gutta-percha and
on a single-rooted Roth 801 sealer in lateral condensation. In the multiple-visit group the
tooth or on 1 root instrumentation was completed at the first appointment, the canal was left empty,
with a single canal in and the treatment was completed after 1 week.
a multi-rooted tooth.
Weiger 2000 (15) 73 participants (1 tooth Teeth with pulpal Single visit or multiple visits. Two operators. Use of rubber dam. Canal shaping: K-files Low
each), 67 included in necrosis and with and Gates Glidden used in step-back technique. Irrigation: 1% sodium hypochlorite.
the final analysis. radiographic evidence Working length was determined by x-ray. Obturation: gutta-percha with Sealapex
of periapical bone loss in lateral condensation. In the multiple-visit group the patients underwent 2 visits,
and the medication used was calcium hydroxide mixed with sterile physiologic
saline, which was left in the canals for 7–47 days. The cavity access was filled by a
temporary cement.
Yoldas 2004 (22) 227 participants (1 tooth Inadequate root canal Single visit or multiple visits. Three operators. Canal shaping with Gates Glidden, hand High
each), 218 included in treatment files NiTi rotary instruments with step-back technique. Irrigation: 2.5% NaOCl.
the final analysis. Working length was determined by apexes locator and periapical radiograph.
Obturation: gutta-percha and AH 26 sealer with lateral condensation. In the
multiple-visit group the patients underwent 2 visits, and the canals in the
interappointment period were medicated with calcium hydroxide chlorhexidine
paste and closed with a sterile dry cotton pellet and a temporary restorative
material (Cavit) for 7 days.

1044 Figini et al. JOE — Volume 34, Number 9, September 2008


Figure 1. Radiologic outcome in single-visit and multiple-visit groups.
Subgroup Analysis of Teeth with a Preoperative Diagnosis
of Pulpal Necrosis
We repeated the analysis, dividing the patient outcomes according
to pretreatment status. Seven studies (5, 12, 15, 19, 21–23) included
only teeth with pulpal necrosis, and one study included only teeth with
vital pulpal diagnosis (17). In addition, it was possible to extract data
regarding outcomes of teeth with vital pulps from another study (18).
Data pooling was possible only for studies including necrotic pulpal
tissues, because those with vital pulps had noncomparable outcomes.
Thus, the following conclusions relate only to teeth with a diagnosis of
pulpal necrosis. The incidence of discomfort was not significantly dif-
ferent for single- versus multiple-appointment RoCT, although there was
a trend for lower discomfort incidence in the single-visit approach. The
postoperative radiographic outcome was 38% better in the single-visit
group as compared with the multiple-appointment group, although this
difference did not reach statistical significance (RR, 0.62; 95% CI,
0.37–1.02).
Sensitivity Analyses
All the results of the meta-analysis reported were corroborated by
sensitivity analyses performed excluding studies with high risk of bias.
Discussion
The main objective for RoCT is to prevent or heal endodontic
diseases such as apical periodontitis and to minimize patient discom-
Figure 2. Use of painkiller in single-visit and multiple-visit groups.
JOE — Volume 34, Number 9, September 2008
COCHRANE Review
fort. The basic biologic rationale for achieving ultimate success with
RoCT consists primarily of eliminating microorganisms from the entire
root canal system and creating an environment that is most favorable for
healing. Several studies have shown that it is very difficult to achieve a
bacteria-free root canal system, even after adequate cleaning, shaping,
and irrigation (25–27). Two approaches have been proposed to solve
this problem. In one case, residual bacteria are eliminated or prevented
from repopulating the root canal system by introducing an interappoint-
ment dressing into the root canal, generally falling into the following
categories: phenolic derivatives (eugenol, camphorated paramono-
chlorophenol, camphorated phenol, metacresol acetate, beechwood
creosote), aldehydes (formocresol), halides (iodine–potassium io-
dide), calcium hydroxide, antibiotics, and various other combinations.
The most popular intracanal medication currently in use is calcium
hydroxide. Some studies (26, 28, 29) have shown that calcium hydrox-
ide fails to produce sterile root canals and even allows regrowth in some
cases. However, even a negative culture before obturation gives no
guarantee of healing in all cases (5, 15, 27). The second approach is
aimed at eliminating the remaining bacteria or rendering them harm-
less by entombing them by complete and 3-dimensional obturation,
finishing the treatment in one visit, to deprive the microorganisms of
nutrition and the space required to survive and multiply (15, 16, 30).
The antimicrobial activity of the sealer or the zinc (Zn) ions of gutta-
percha can kill the residual bacteria (31, 32).
Single versus Multiple Visits for Endodontic Treatment of Permanent Teeth 1045
COCHRANE Review
The introduction of new technologies for nonsurgical RoCT and
the increasing use of rotary nickel-titanium (NiTi) instruments might
lead clinicians to prefer single-visit treatment, a decision that reduces
operator working time and simplifies treatment scheduling. However, a
critical question emerges: does completion of RoCT in a single visit or
during a few visits make any difference in terms of clinical and radio-
logic outcomes or complications?
Discomfort is the main short-term complication of RoCT. Unfor-
tunately, 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 (18, 19, 22, 24), who provided
accurate criteria to categorize patient’s pain, but not by others (16, 23),
who were more imprecise in their definition of different discomfort
categories. For this reason we considered only 2 levels for a discomfort
outcome (discomfort and no discomfort), and we did not include dis-
comfort intensity among our outcomes. According to the results of our
review, the incidence of postobturation discomfort is similar with the 2
approaches, although analgesic usage is significantly less common in
patients undergoing multiple-visit RoCT. It is possible that during the
single visit, the working time is longer, causing a more severe inflam-
matory response, manifested as pain during the interappointment pe-
riod. Intracanal medicament might also affect discomfort onset during
the between-visit interval. The incidence of short-term swelling was
more common in the single-visit group, possibly confirming a differ-
ence in postoperative inflammation. Note that in the 3 studies consid-
ering this outcome (20, 21, 23), all teeth undergoing RoCT had necrotic
pulps (20, 23) and were treated similarly (2.5% sodium hypochlorite
as irrigant and no canal interappointment medicament), but the results
were inconsistent, although the incidence of swelling was very small in
both studies. The study by Ghoddusi et al. (21) is of particular interest.
In fact, when no interappointment canal medication was used, the in-
cidence of swelling was very similar in the 2 groups, whereas when
calcium hydroxide was left in the canals between visits, the multiple-visit
treatment performed much better. Such a difference might have oc-
curred because normal saline solution was used as the sole irrigant
during RoCT. Thus, with the single-visit approach, no antibacterial sub-
stance was used in the RoCT. In contrast, the multiple-visit treatment
used an interappointment medication, with antibacterial activity pro-
vided by the administration of calcium hydroxide.
Long-term healing in these studies was based mainly on the radio-
graphic appearance of a periapical lesion, whenever present, and the
prevention of new lesions. It should be noted that this outcome measure
is only one of several outcomes typically used to judge postoperative
healing (ie, radiographic, clinical, and subjective measures). The judg-
ment of resolution of periradicular lesions can be established by radio-
graphic examination, a method very dependent on the investigator’s
visual perception. The study by Trope et al. (5) was the only one
performing an extensive calibration of the evaluators, whereas in the
study by Weiger et al. (15) the radiographs were judged by both
dentists involved in the study in a blinded manner. Peters and Wesselink
(12) reported that 3 experienced endodontists who had not been in-
volved in the treatment or follow-up were asked to analyze the radio-
graphs. The pooled results showed that radiologic success was more
frequent in the single-visit group compared with the multiple-visit
group, although the difference was not statistically significant. There-
fore, the use of an interappointment intracanal medication might be
unnecessary when the operator, during a single visit, carefully debrides
the canals, uses an adequate antimicrobial irrigant, and accomplishes
an effective obturation of the root canal system. It is accepted that multiple
visits are indicated for symptomatic teeth with long-standing chronic peri-
apical lesions and for those undergoing retreatment, on the basis of the
1046 Figini et al.
rationale that an interim dressing of an iodine– calcium hydroxide combi-
nation is effective against Enterococcus faecalis, an organism commonly
found in failed cases. Unfortunately, we could not properly verify this hy-
pothesis in the present review because only one study (22) considered
retreatment, and it was affected by a high risk of bias.
Thus, the effectiveness of single-visit and multiple-visit RoCT is not
substantially different. Most short-term and long-term complications
are similar in terms of frequency, although patients undergoing single-
visit RoCT might experience a higher frequency of swelling and are more
likely to take analgesics. Our results with a radiographic assessment of
healing revealed that single-visit RoCT appears to be slightly more ef-
fective than multiple-visit RoCT, without the difference reaching statis-
tical significance, and very similar results were obtained by another
systematic review (33).
Since the publication of this review in the Cochrane Library, 2
research studies comparing single and multiple RoCTs have been pub-
lished (34, 35), These 2 randomized controlled trials compared radio-
graphic evidence of periapical healing after RoCT of necrotic teeth com-
pleted in 1 visit or 2 visits. The authors’ conclusions were consistent with
those of the present review, because no statistically significant differ-
ences in healing between the 2 groups were shown. The results of these
2 studies will be included in the next update of this systematic review,
which is planned for 2009.
Acknowledgments
We wish to thank Emma Tavender, Luisa Fernandez, Sylvia
Bickley, and Marco Esposito for their support, Dr Cristina Frezzini
for her help in retrieving papers, all the researchers of the cited
studies who have provided some of the data useful in the review, and
the referees for their valuable suggestions. A special thanks to Silvia
Motta for translation from Russian language and to Hu Luca for
translation from Chinese. The authors thank the Cochrane Library
for providing permission to summarize this COCHRANE review.
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