Internattonal Endodonttc Journal (1989) 22, 179-183
A comparison of one versus two appointment endodontic
therapy in teeth with non-vital pulps
L. R. G. FAVA Sao Paulo, Brazil
Summary. A cHnical study using upper central
incisors was carried out to evaluate the incidence
of postoperative pain after root canal preparation
by the double-flared technique. Sixty teeth with
necrotic pulps from 48 patients whose ages ranged
from 12 to 65 years were prepared and filled in
either one or two appointments. No difference was
observed in the incidence of postoperative pain
between the two groups.
Introduction
One-appointment endodontic therapy gained
popularity during World War 11. However,
the philosophy at that time was that periapical
surgery should be performed on all such teeth
because of the limited time for treatment
(Wolch 1975, Calhoun & Landers 1982).
Many authors stated that one-appointment
therapy should be restricted to vital cases (i.e.
pulpal inflammation, traumatic or iatrogenic
pulp exposure during cavity preparation or
when an intentional pulpectomy was per-
formed for prosthetic or periodontal reasons),
teeth with necrotic pulps associated with sinus
tracts or when a surgical procedure would be
performed anyway (Wolch 1975, Soltanoff
1978, Calhoun & Landers 1982).
For cases of pulpal necrosis, Calhoun &
Landers (1982) stated that 'multiple appoint-
ments were necessary for successful treatment
and for minimal periapical inflammation
resulting in less postoperative pain'. On the
other hand, Morse (1974) claimed that 'in
non-vital cases, once the canals are clean,
smooth, tapered and dry and the tooth is
symptomless, then obturation can be done.
This may be the first, second, third or fourth
visit'.
Many authors have already reported their
results on the endodontic treatment of non-
Correspondence: Dr Luiz Roberto G. Fava, Rua da
Consolafao 3527, 01416 Sao Paulo, Brazil.
vital pulps performed in one or more appoint-
ments. Fox et al. (1970) treated 168 non-vital
teeth by a single-visit technique and found
that 130 teeth exhibited no spontaneous pain
and 106 teeth had no pain on biting 1 day after
the treatment. Grassi (1971) evaluated the
incidence of postoperative pain in 30 single-
rooted teeth with necrotic pulps treated in
one or two visits; her results showed a better
performance in the one-visit group. Okuno
et al. (1976) performed one-appointment
treatment in 58 teeth with large radiolucent
areas and reported only nine cases with symp-
toms 1 day after completion of treatment.
Mulhern et al. (1982) treated 60 maxillary
and mandibular single-rooted, symptomless,
necrotic teeth in one or three visits and
reported no significant differences in pain
incidence between the groups. In addition,
Pekruhn (1981) observed no significant differ-
ence in the incidence of postoperative pain
after 24 hours in teeth with non-vital pulps
treated in one or two sittings.
It should be realized that during cleaning
and shaping procedures, dentine chips,
micro-organisms, pulpal remnants, irrigating
solution or necrotic debris may be pushed into
the periapical region causing inflammation
and postoperative pain. Since this extrusion is
a problem common to all root canal prep-
aration techniques, modern procedures have
been advocated to minimize this situation.
These new cervical flaring techniques pro-
pose that the enlargment of the cervical part of
the canal should occur prior to preparation of
the apical portion using Peeso reamers or
Gates Glidden drills in a handpiece (Goerig et
al. 1982, Montgomery 1985).
Fairbourn et al. (1987) described the
following advantages of early cervical flaring:
(i) straighter and more direct access to
the apical region;
(ii) elimination of the cervical constric-
179
180 /.. R. G. Fava
tion, often the narrowest portion of
the canal due to the continuous forma-
tion ofdentine with age;
(iii) deeper penetration of irrigating sol-
utions and easier removal of debris
from the apical part;
(iv) reduced possibility of ledging;
(v) reduced possibility of debris packing;
(vi) reduced possibility of straightening
the apical portion of the canal; and
(vii) the bulk of the canal contents is
removed before apical instrumen-
tation, greatly reducing the number of
contaminants that can be extruded
from the canal.
In 1983, Fava introduced the double-flared
technique as an alternative method for root
canal preparation of non-vital single-rooted
teeth. This technique was designed to improve
the cleanliness of the root canal space before
preparation of the apical third, reducing the
probability of pushing debris towards the
apex. In this technique no drills were used for
canal enlargement. The purpose of this study
was to analyse the incidence of postoperative
pain after the completion of endodontic
treatment performed in one or two visits in
single-rooted teeth with non-vital pulps pre-
pared by this technique.
Materials and methods
Sixty maxillary central incisors with necrotic
pulps in 48 male and female patients with ages
ranging from 12 to 65 years were treated by the
double-flared technique (Fava 1983).
In this technique a coronal access was made
and the root canal was initially flooded with 1
per cent sodium hypochlorite. A small instru-
ment (size 15 or 20) was introduced into the
root canal to dislodge and neutralize its
contents. When this instrument had approxi-
mately reached the middle third, a radiograph
was taken and an estimated working length
calculated. With larger instruments (size 80-
50) the root canal was filed in its cervical and
middle thirds, the diameter of the instrument
being decreased at the same time, so that
the root canal length was increased by I mm.
Thus, the preparation advanced apicaily in
1 mm steps using progressively smaller instru-
ments. Once two-thirds had been cleaned and
was free of pulp contents, a small instrument
(size 15 or 20) was placed to the estimated
working length and a second radiograph taken
to confirm it. After this, the same procedure
was used to clean the apical third. Preparation
was then completed by the flared technique.
During the procedure copious and frequent
irrigation was carried out after each instru-
ment.
The status of the pulp was determined from
the history related by the patient, routine
clinical tests such as oral examination, nega-
tive responses to thermal tests, positive re-
sponses to palpation and percussion tests, and
examination of the initial radiograph.
To eliminate variables in this study, all
clinical procedures were undertaken by the
author in his private practice and were based
upon the following:
(i) the patient would accept the proposed
one- or two-appointment procedure
and agree with the criteria for post-
operative pain evaluation;
(ii) the tooth had a non-vital pulp which
was not causing spontaneous symp-
toms;
(iii) only maxillary central incisors were
selected for this study because they had
almost straight roots; and
(iv) the patients were in good general
health.
Half of the selected teeth were treated in one
sitting. The two-visit group was treated as fol-
lows. In the first visit the tooth was isolated,
opened, biomechanically prepared using K-
files', dried, dressed with camphorated
monochlorphenol and sealed. At the second
appointment, generally 7 days after the first
one, the tooth was isolated, opened, irrigated,
dried andfilledw ith laterally condensed gutta-
percha cones and a zinc oxide-eugenol based
root canal sealer (Kerr pulp canal sealer)'.
In the course of this study no surgical inter-
vention, such as fistulation or apicectomy, was
performed at any stage. The criteria for evalu-
ation of postoperative pain were arbitrary. All
patients were called 48 hours after completion
of treatment and were asked to report all post-
operative reactions. If the patient did not
require an analgesic and reported none or
minimal discomfort that disappeared within
'Kerr/Sybron, Romulus, Michigan, SA.
 Therapy in one or ttpo visits 181
Table I. The incidence of postoperative pain within 48 hours of
treatment when using the one or two visit technique

Pain
Treatment None to slight Moderate Severe Total

One visit 29 1 0 30
Two visits 30 0 0 30
Total 59 1 0 60

48 hours, it was classified as none to slight Table II. The incidence of pain following percus-
postoperative pain. If the patient reported sion testing 1 week after treatment by the one or two
tolerable discomfort with slight tenderness on visit technique
biting that required an analgesic such as
aspirin, it was classified as moderate post- Treatment Pain No pain Total
operative pain. If the patient reported
continuous pain with extreme sensitivity on One visit 1 29 30
biting that required a strong analgesic, the Two visits 0 30 30
postoperative pain was classified as severe. Total 1 59 60
A final postoperative clinical evaluation was
performed 1 week after completion of treat-
ment; this consisted of assessing the status of
the periapical region by routine percussion
and palpation tests. At the same time the Table III. The incidence of pain following pal-
patients were asked to report any other pation testing 1 week after treatment by the one or
reactions that they had felt during the second two visit technique
to the seventh day after treatment.
Treatment Pain No pain Total
Results One visit 1 29 30
The results showed no difference in pain Two visits 0 30 30
incidence between the two groups. In the one- Total 1 59 60
appointment group only one patient reported
moderate pain within the 48-hour period. All
the others reported none to slight post-
operative pain (Table I). and palpation tests after 7 days. The few
The clinical evaluation performed 1 week patients who had felt slight postoperative
after completion of endodontic treatment also discomfort during the first 48 hours reported
showed no difference between the two groups. that it disappeared by day 7, and generally by
In this evaluation, only one patient reported the third or fourth day after treatment in both
tenderness to percussion and palpation tests, the one- or two-visit groups.
and it was the same patient who had reported
moderate pain during the first 48 hours after Discussion
treatment (Tables II and III). The results of this clinical study did not
When asked to report any reactions during indicate a difference in the incidence of post-
the 2-7-day period, only one patient reported operative pain in maxillary central incisors
continuous tenderness on biting and the need with non-vital pulps that were biomechani-
to use analgesics. This was the same patient cally double-flared and filled in one or two
who had reported moderate pain in the first visits. The low incidence of pain is in agree-
period (48 hours) and tenderness to percussion ment with the findings of Clem (1970) and
182 L. R. G. Fava
Roane et al. (1983). Clem (1970) found that
'maxillary anterior teeth and premolars were
involved with significantly less increased post-
treatment pain than other teeth, while Roane
et al. (1983) reported postoperative pain in
only 9 per cent of maxillary anterior teeth.
Many authors have compared the incidence
of postoperative pain in teeth with necrotic
pulps that were endodontically treated in
either one or several visits, and showed
good results in the one-appointment group
(Lorinczy-Landgraf & Palocz 1955, Ferranti
1959,Foxf/a/. 1970, Grassi 1971, Okuno f/a/.
1976, Pekruhn 1981, Mulhern et al. 1982).
These results agree with those of the present
study.
The style of the instrument seems to be an
important factor in obtaining good results.
Tbe use of K-files was based upon Chapman's
findings (1971); he showed that both reaming
and filing were able to transmit contaminated
material through the apical foramen, but this
occurred less frequently with a file. According
to Heuer (1976), K-files from sizes 35 to 140
are manufactured with a triangular cross-
section, and Holland et al. (1976) demon-
strated that K-files with a triangular cross-
section were the best instrument for cutting
dentine in a wet environment. The use of large
K-files in the initial phase of the double-
flared technique is supported by these studies.
In view of the findings by Shovelton (1964)
on the distribution of micro-organisms within
the dentine of infected root canals, it appears
that the use of triangular K-files with large
diameters in the initial phase of the double-
flared technique will remove micro-organisms
more efficiently than a step-back tecbnique,
thus decreasing the chance of carrying them to
the periapical tissues and causing an exacer-
bation.
Another factor to be considered is the extru-
sion of material beyond the apical foramen.
Some studies in vitro have shown that extru-
sion during root canal enlargement occurs
because the endodontic instrument in the root
canal acts like a piston in a cylinder (Vande
Visse & Brilliant 1975, Hession 1977). To
avoid this phenomenon, Hession (1977) pos-
tulated that an early flaring of canal walls
would decrease the potential for a positive
hydrostatic pressure being directed apicaily by
establishing an adequate coronal escape. This
early flaring was developed in the initial phase
of the double-flared technique by the use of
large diameter K-files. To corroborate this,
two recent studies must be cited. Fairbourn et
ul. (1987) compared four instrumentation
techniques tn vitro and collected and weighed
the amount of root canal debris extruded.
Based on analysis of variance, the techniques
were ranked from lowest to highest in the
following sequence:
(i) sonic technique;
(ii) cervical flaring technique;
(iii) ultrasonic technique; and
(iv) step-back technique.
In the same year, Ruiz-Hubard et al. (1987)
compared the step-back technique with the
crown-down pressureless technique for the
amount of debris pusbed tbrough the apical
foramen in both straight and curved simulated
root canals. Their results showed that neither
technique was totally effective in preventing
the extrusion of debris in either canal shape,
but they found that significantly more material
was forced towards the apex when the step-
back technique was used. Based on the above
studies and that double-flaring is a cervical
flaring tecbnique, it may be proposed that its
modus operandi reduces the chance of pushing
debris into the periapical tissues.
Moreover, if infected dentine chips are
carried apicaily and accumulate between the
filling material and periapical tissues the
healing process may be impaired, as was
demonstrated by Holland et al. (1980).
Therefore, the early flaring developed during
the initial phase of the double-flared tech-
nique facilitates both the introduction of
the irrigating needle and the flushing of the
irrigant near the apex which may also help to
remove the infected dentine chips.
Conclusion
In this clinical study 60 maxillary central inci-
sors with necrotic pulps were endodontically
treated by the double-flared technique of root
canal preparation. There was no difference in
the incidence of postoperative pain between
teeth treated in one or two visits.
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