TIME IS PRECIOUS!

SO LETS SAVE THE

TOOTH AND THE TIME
TOGETHER.
SINGLE VISIT ENDODONTICS
PRESENTED BY:-DR. PIYUSH
RAUL
GUIDED BY:
DR .VIBHA HEGDE
DR. MRUNALINI VAIDYA
DR. USHAINA FANIBUNDA
DR. ASHWIN JAIN
 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.
 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 Al-Rahab ,Single visit root canal treatment: Review. Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue
 •“Maximum dentistry in minimum visits” has been the rule in modern dental practice

• 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

“MAXIMUM DENTISTRY IN MINIMUM

microbes, all together for the success of endodontic therapy.

VISITS”
• Multiple visit endodontics was an established norm in the field of endodontics,
HAS BEEN THE RULE IN MODERN
but it has certain disadvantages like
DENTAL PRACTICE
- 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-Rahab ,Single visit root canal treatment: Review. Saudi Endodontic Journal • May-Aug 2012 • Vol 2
• Issue
 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 , pg no-
445.

“ The Conservative non-surgical treatment of an endodontically involved tooth

consisting of access opening, complete chemo-mechanical cleaning and shaping
of root canals and obturation of the root canal system during one visit ”

Paul J Ashkenaz ( DCNA vol. 28, 1984 )

 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.
 CONCEPT OF SINGLE VISIT ROOT
CANAL TREATMENT

• This is based on the ENTOMBING

THEORY, in which large number of
microorganisms are removed during
cleaning & shaping and the remaining
bacteria entombed by the root canal
obturation, therefore it will MISS THE
ESSENTIAL ELEMENTS NUTRITION
• AND SPACE TO SURVIVE.
•
In addition, the antimicrobial activity of
the sealer or the ZINC (Zn) IONS OF
GUTTA-PERCHA can kill the residual
bacteria
According to Oliet, the criteria for case selection
are:
Positive acceptance by the patient

Time should be sufficient to complete the procedure properly

Acute symptoms which require drainage through the canal and if it is a continuous flow of exudates or blood.

There should be no anatomic obstacles such as

a) calcified canals

b) Fine tortuous canals

c) Bifurcated or accessory canals

d) Ledge formations

e) Blockages

f) Perforations

g) Inadequate fills
Teeth with pre operative apical periodontitis should not be selected as they will lead to  post operative
problems
 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.

• Medically compromised patients who require antibiotic prophylaxis.

• Physically compromised patients who cannot come to dental clinics

frequently.
Ashkenaz. P.J. One-visit endodontics Dent Clin North Am. Oct;28(4):853-63.1984
• Intentional root canal therapy.

• Patients requiring full mouth rehabilitation.

• Some of the re-treatment cases.

• Accidental/Mechanical pulp exposure.

• Vital pulp exposures because of trauma with symptomatic pulpitis.

• Vital pulp exposure because of caries with symptomatic pulpitis.

• Teeth requiring immediate post placement, where esthetics is the

concern.
Ashkenaz. P.J. One-visit endodontics Dent Clin North Am. Oct;28(4):853-63.1984
 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 frank pus discharge.

• Patients who have acute apical periodontitis with severe pain on

percussion.

• Symptomatic non vital teeth and no sinus tract.

Ashkenaz. P.J. One-visit endodontics Dent Clin North Am. Oct;28(4):853-63.1984

• 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 Dent Clin North Am. Oct;28(4):853-63.1984

 CLINICAL

Advantages
PRACTICE
Patien
MANAGEME
t
NT

Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article Dr. Pradnya V. Bansode1 Dr. Seema D. Pathak2
, Dr. M. B. Wavdhane3, Dr. Shirish Khedgikar4, Dr. Priyanka P. Birage5 IOSRolume 17, Issue 11 Ver. 7 (November. 2018)
 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 inducedSingle-Visit

by leakage of temporary seal.
Versus Multiple-Visit Root Canal Treatment- A Review Article
Dr. Pradnya V. Bansode1 Dr. Seema D. Pathak2 , Dr. M. B. Wavdhane3, Dr. Shirish Khedgikar4, Dr. Priyanka P. Birage5 IOSRolume 17, Issue 11 Ver. 7 (November. 2018
• 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.
 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

• Medicolegal risk is reduced: AHA gudelines are

followed, the likelihood of cross contamination is
minimized and invasive procedures are fewer.
 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.
•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

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,

 DISADVANTAGES
• 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

Single-Visit Versus Multiple-Visit Root Canal Treatment- A Review Article

Dr. Pradnya V. Bansode1 Dr. Seema D. Pathak2 , Dr. M. B. Wavdhane3, Dr. Shirish Khedgikar4, Dr. Priyanka P. Birage5 IOSRolume 17, Issue 11 Ver. 7 (November. 2018
• 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.
 Myth No. 1

Post operative pain is greater when

endodontic therapy is completed in a single visit,
especially in non vital teeth.
 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>.01).
Bayram Incea, Ertugrul Ercan Incidence of Postoperative Pain after Single- and Multi-Visit
Endodontic Treatment in Teeth with Vital and Non-Vital Pulp . Eur J of dentistry October 2009 -
Vol.3

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

C. Keskin, E.O. Demiryurek and T. Ozyurek, 2015. Postoperative Pain after Single-Versus-Multiple Visit
Root Canal Treatment in Teeth with Vital or Non-Vital Pulps in a Turkish Population. Asian Journal of
Scientific Research, 8: 413-420.
 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.

Avinash A. Patil1 , Sonal B. Joshi Incidence of Postoperative Pain after Single Visit and Two Visit Root Canal Therapy: A Randomized Controlled Trial. Journal of
Clinical and Diagnostic Research. 2016 May, Vol-10(5): ZC09-ZC12
 Myth No-2

There is less healing when endodontic therapy

is completed in a single visit, especially in
non vital teeth.
• 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.

C. Sathorn et al, Effectiveness of single- versus multiple-visit endodontic treatment of teeth with apical
periodontitis: a systematic review and meta-analysis, International Endodontic Journal, 38, 347–355,
2005

• 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 1-visit and
2-visit root canal treatment
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;38(9):
• Dorasani et al, 2013 reported that Both single-visit and multiple-visit-treated teeth
healed
satisfactorily with no significant differences

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.
Jorge Paredes Vieyra, Fabian Ocampo Acosta, Seidi Karin Nevarez Osuna (2018).
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
 MYTH
NO- 3

Post operative swelling is greater when endodontic

therapy is completed in a single visit.
• 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 " .

According to the findings of his study:

(i)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),
 ENDODONTOLOGY Volume: 25 Issue Dec 2013

Krishna prasad et al in 2013, stated that ,little or no significant difference

occurred between single visit versus multi visit endodontic therapy.
 Jorge Paredes Vieyra1 *, Fabian Ocampo Acosta2 and Seidi Karin Nevarez Osuna. Volume 4 • Issue 2 • 2018

• There was a significant difference regarding the occurrence of flare-

ups when comparing treatment cases with retreatment cases (p=
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
 MYTH
NO- 4

Canals are cleaned better ,if an

antibacterial medicament such as Ca(OH)2
'is left in the tooth.
• 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.
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;72(4):24–28

• 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.
• 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 1- versus 2-
session treatment. Oral Surg Oral Med Oral Pathol Oral RadiolEndod. 2006;101:379–88.
 MYTH
NO- 5

Multiple-visit endodontics is safer than single-

visit endodontics, and multiple visits mean
more careful treatment.
• 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 )
and 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.
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, A.W., Tsang, C.S., Zhang, S. et al. Treatment outcomes of single-visit versus multiple-visit non-surgical endodontic therapy: a
randomised clinical trial. BMC Oral Health 15, 162 (2015) doi:10.1186/s12903-015-0148-x
 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.
• 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.

 MYTH
NO- 7

After obturation, treating a flare-up is

complicated; therefore, treatment should not be
completed at the first appointment.
• Fear of a post obturation flare-up prevents clinicians from performing single-
visit endodontics, but such flareups 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.
 ADJUNCTS TO RENDER
EFFICIENT AND FASTER
TREATMENT IN SINGLE VISIT
ENDODONTICS:
 Pain control

Isolation
Use of irrigants

Light and Access cavity

magnification preparation
 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.
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

Digital Technologies In Local

Anesthesia

 Electronic Dental Anaesthesia

 Wand
 ISOLATION
The use of the rubber dam is mandatory in single visit root canal treatment.

The rubber dam is used in endodontics because it ensures the following:

1. Patient is protected from aspiration of instruments, tooth debris,

medicaments and irrigating solutions.

2. A surgically clean operating field is isolated from saliva, hemorrhage

and other tissue fluids.

3. Soft tissues are retracted and protected.

4. Visibility is improved.
• 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.
 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..
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.
• 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.
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.
 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.
• Surgical loupes, endodontic endoscopes, and DOM are
some of the commercially available instruments that
can help the clinician accomplish these goals.

• Adding a headlight to the system of surgical telescopes

significantly enhances both depth of field and
magnified resolution, greatly increasing visual activity.

• The head light provides line of straight lumination,

which is shadow less and avoids multiple adjustments
to the traditional overhead dental operating light.
• 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.
 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
 TECHNIQUES FOR CLEANING AND
SHAPING USED IN SINGLE VISIT
ENDODONTICS
• Cleaning and shaping of root canal system is considered to be most important
step for endodontic therapy.

• The introduction of canal preparation techniques that focus on the flaring of

the canal walls has significantly influenced this phase of root canal treatment,
however some disadvantages have also been reported. One of these is
extrusion of material beyond the apical foramen.

IEJ 1995, 28, 103-7

 TECHNIQUES FOR CLEANING AND SHAPING USED IN SINGLE VISIT
Newer techniques have been designed to avoid problems encountered traditional approach. These technique are called cervical or coronal flaring
CROWN DOWN
PRESSURE LESS
(MARSHALL AND
PAPIN1980)
Gates glidden drills and larger
size files are used in the coronal
2/3rd of the canal.
progressively smaller K –type
files in clockwise rotation
without apical pressure.
The purpose of this technique is
to minimize or eliminate the
amount of necrotic debris that
could be extruded through the
apical foramen during
instrumentation.
techniques, in which the root canal is prepared in cervical apical direction.
STEP DOWN
TECHNIQUE
(GEORGE ET AL
1982)
Combination of crown down and
step back technique .
Coronal enlargement of the
curved canal prior to the apical
enlargement.
file placed approximately 2/3rd of
the way down the curved canal and
then filing laterally at the length using
only filling action with H files from
No 15 through No 25 .
Next gates Glidden (#2 & #3) are
used to widen the coronal portion of
the preparation.
Working length is established and
apical portion is enlarged to size no
25.
DOUBLE – FLARE
TECHNIQUE FAVA
(1983)
a cervical – apical flaring
This was characterized by
development of apical matrix.
After reaching the correct length,
two or three instruments were
used in sequential order to prepare
the space where the master cone
would be adjusted and placed in
the filling procedures
REVERSE FLARING
TECHNIQUE (WEINE 1989)
• Utilizes the flaring technique
long before the completion of
the apical portion of the
preparation
• The dentist minimally enlarges
the apical portion and then
widens the coronal portion
prior to completing the apical
portion
• May be achieved by a
rotary instrument or by
hand instruments.
• Very useful in curved canals and
seems to simplify and lessen the
time required
 Biomechanical preparation

• Better instrumentation with rotary instruments.

Sufficiently enlarge the canal.
Irrigant reaching the apical third is more.
Corresponding tapered obturating cones.
• In terms of bacterial numbers , instrumentation even without
disinfectant reduces the volume of microbial flora more than
90%.

• As the size of file used in the apical third increases, there is a

significant reduction in the number of remaining bacteria.

Essential endodontology , Orstavik, 2nd ed, Pg 352

“Bacterial reduction with NiTi rotary instrumentation” - Dalton et al
1998

• Evaluated the antimicrobial effect of mechanical instrumentation

without the addition of anti-bacterial irrigant.

• Increased instrumentation reduced the remaining bacteria

significantly

• In MB canal of mandibular molar – size 25 – 20% canals free of

bacteria
• Size 35 – 60% free of bacteria
• Another important finding – no difference of remaining
bacteria whether the instrumentation was performed with
stainless steel or NiTi files if the apical instrumentation sizes
were similar.

• It is the final shape of the instrumented canal rather than the

tools used to obtain it that matters.

NiTi rotary:
Faster
Crown down – less apical extrusion of debris
Better taper – more irrigant
 USE OF IRRIGANTS
• The concept of single visit root canal treatment 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.
Shuping G, Ørstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using Nickel-titanium rotary instrumentation and various medications. J Endod 2000;26:751-5
• 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.
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, EDTAC 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.
• 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”.
• It cannot dissolve inorganic dentin particles and thus prevent the formation of a smear
layer
during instrumentation

• Demineralizing agents such as ethylenediamine tetraacetic acid (EDTA) and citric acid
have
therefore been recommended as adjuvants in root canal therapy.

• These are highly biocompatible and are commonly used in personal care products.

• Although citric acid appears to be slightly more potent at similar concentration than
EDTA, both agents show high efficiency in removing the smear layer.
 INTRACANAL MEDICAMENTS

“Effects of dentin on the antimicrobial properties

of endodontic medicaments”
Markus Haapasalo, Wei Qian, et al
- JOE- vol 33, no 8, August 2007

Buffering capacity of dentin resulting in inactivation of

medicaments.

Dentin has the capacity to buffer both acids and alkalis due to
large quantities of carbonates and it resists a change in pH
 Buffering capacity of dentin

It has been reported that dentine has buffering ability because of the presence of
proton donors, such as H2PO4, H2CO3, and HCO3, in the hydrated layer of
hydroxyapatite, which furnish additional protons to keep the pH unchanged

(Wang & Hume 1988, Nerwich et al. 1993)

 • Another factor can also help to explain the inefficacy of calcium hydroxide in
disinfecting dentinal tubules.

• The arrangement of the bacterial cells colonizing the root canal walls can reduce the
antibacterial effects of calcium hydroxide, since the cells located at the periphery of
colonies can protect those located more deeply inside the tubules
(Siqueira et al. 1996a, Siqueira & Uzeda 1996)

• Bacteria colonizing necrotic tissue in ramifications, isthmuses and irregularities are

also, probably, protected from the action of calcium hydroxide, due to pH
neutralization.
• Inherent difficulties of inserting calcium hydroxide into the apical third of the root
canal

• Anatomical characteristics of the apical third, where the dentine tubules are smaller
and less frequent make the diffusion of hydroxyl ions more difficult. For these
reasons bacterial growth in that region between treatment visits may have occurred

• Poor diffusion of hydroxyl ions into infected-dentine and the buffering capacity of
dentine can limit the raise of pH - reasons why hydroxide pastes are ineffective
against E. faecalis
 PROCEDURAL SEQUENCE OF SINGLE
VISIT ROOT CANAL TREATMENT

Access
Radiographic opening Proper
Case selection Obturation
examination Cleaning & restoration
shaping
 • To illustrate the modern endodontic procedural sequence for
single visit endodontics, the sequence follows:

1. The diagnosis indicates that endodontic treatment is needed and

the
tooth is anesthetized.

2. Following placement of the rubber dam, access is made.

3. Using the microscope at low to mid magnification, the pulp

chamber is thoroughly prepared using a Buc tip size 2 for
inspection.

4. Under high magnification (16–24), the floor of the chamber

is
examined for additional canals because more than 50% of
• 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 onehalf 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
• 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

• This master cone, coated with root canal cement, is inserted into the canal,
and the coronal part of the point is seared 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 seared 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.
 INT J DENT ORAL HEALTH 2(9), 2016

• 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
 VOL. 12, NO. 2, FEBRUARY
1988

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%.

• No significant difference was found between the tooth groups;

however, significant differences were found among the problem code
groups (teeth with pulpal pathosis, teeth with periapical extension of
pulpal disease, endodontic retreatments, and intentional
devitalization cases).

• Also, the incidence of failure was higher in those teeth with periapical
extension of pulpal disease which had no prior access opening.
 JOE — Volume 45, Number 2, February 2019

Chung et al 2019, reported that among patients with intellectual and

cognitive disabilities, the periapical health of endodontically treated
teeth was maintained throughout the observation period ( 56 months).

• Single-visit endodontic treatment under GA is applicable, especially

when a diseased tooth needs to be retained as a strategic priority
Conclusion:
Single-visit nonsurgical endodontic retreatment presented fewer incidences of
postoperative pain in comparison with 2-visit nonsurgical endodontic
retreatment based on assessments ranging from 1 day to 1 month.
87
 TAKE HOME POINTS

In AN INFECTED VITAL PULP due to a caries exposure the

infection is normally found only at the wound surface, where it
has resulted in a LOCALIZED INFLAMMATORY RESPONSE.

This means that more apically, and in particular in the most

apical portion of the tissue, bacterial organisms are usually
not present.
THE AIM OF ROOT CANAL TREATMENT IN THIS CASE IS
TO MAINTAIN STERILE APICAL CONDITIONS in order to
optimize the healing potential.
 In teeth with NECROTIC PULP,
APICAL PERIODONTITIS an
APICAL INFLAMMATORY LESION
is developed and the aim of root
canal treatment in this is to
eliminate the microorganisms from
the canal to promote HEALING OF
APICAL PERIODONTITIS.
CONCLUSION
 With the advent of technological advancement and emergence of new gadgets,
evidence based dentistry and more scientific deliberations and the concept of
maximum dentistry in minimum visits led to a resurgent impetus towards
laying down of various protocols to enable dentists to venture into single visit
endodontics with reasonable level of outcome.

 Single visit root canal treatment versus the multiple visit root canal
treatment has been the subject of a long standing debate within the dental
community, when the clinicians are faced with choices of which treatment
should be offered to patients, the central issues that should be considered are
effectiveness, complication, cost and probably patient /operator satisfaction
 Careful case selection and proper and thorough
adherence to standard endodontic principles, with no
shortcuts, should result in successful one-appointment
endodontics. Practitioners should attempt one-visit root
canal treatment only after making an honest assessment
of their endodontic skills, training, and ability
 REFERENCES
• Pathways of pulp. Cohen 6th edition

• Endodontic Therapy: Franklin Weine 6 th edition

• Ingle 6th edition

• Textbook of Endodontics: Mithra Hegde

• Textbook of Endodontics: Anil Kohli

• Soltanoff W. A comparative study of the single-visit and the multiple-visit endodontic procedure. J Endod 1978;4:278–81.

• Calhoun RL, Landers RR. One-appointment endodontic therapy: A nationwide survey of endodontists. J Endod
1982;8:35–40.

• Mulhern JM, Patterson SS, Newton CW, Ringel AM. Incidence of postoperative pain after one-appointment endodontic
treatment of asymptomatic pulpal necrosis in single-rooted teeth. J Endod 1982;8:370–5.

• Oliet S. Single-visit endodontics: a clinical study. J Endod 1983;9:147–52.

• Roane JB, Dryden JA, Grimes EW. Incidence of postoperative pain after single- and multiple-visit
endodontic procedures. Oral Surg Oral Med Oral Pathol 1983;55:68–72.
• Southard DW, Rooney TP. Effective one-visit therapy for the acute periapical abscess. J Endod 1984;10:580–3
• Ashkenaz PJ. One-visit endodontics. Dent Clin N Am 1984;28:853–63.
• Sjogren U, Figdor D, Persson S, Sundqist G. Influence of infection at the time of root filling on the outcome
of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997;30:297–306.
• Eleazer PD, Eleazer KR. Flare-up rate in pulpally necrotic molars in one-visit versus two-visit endodontic
treatment. J Endod 1998;24:614–6.
• Katebzadeh N, Hupp J, Trope M. Histological periapical repair after obturation of infected root canals in
dogs. J Endod 1999;25:364–8.
• Hepsenoglu YE, Eyuboglu TF, Özcan M. Postoperative pain intensity after single-versus two-visit
nonsurgical endodontic retreatment: a randomized clinical trial. Journal of Endodontics. 2018 Sep
1;44(9):1339-46.
• Bhargava R, Bhargava R, Ranjan V. Conceptual facts and myths of single visit endodontics–A review.
International Journal of Oral Health Sciences and Advances. 2013;1(1):35-42.