Single-Visit Versus Multiple-Visit Endodontics
Dr. Musikant is a graduate of the University of Pennsylvania School of Dental Medicine. He is a member of the American Academy of Endodontists, the Academy of General Dentistry, and the American Society of Dental Aesthetics, and is a member of the board of the First Madison Group. In addition, he is the President and Co-Director of Dental Research at Essential Dental Systems. He has lectured throughout the world and is the author or co-author of more than 185 published articles.
- To have a better understanding of when a second visit is beneficial to the patient.
- To appreciate that the patient is a unique individual that has as much to say in determining the number of visits as the state of the tooths pulpal anatomy.
- To be better informed regarding the ability of reamers both unrelieved and relieved when attached to a 30º reciprocating handpiece to deliver safe, rapid and effective instrumentation.
My attitude regarding single-visit versus multiple-visit endodontics has changed over the years. When I was younger, I equated my capabilities with speed. I wanted a well-tapered preparation. This was well before the introduction of rotating NiTi, so the tapers we take for granted today were mainly achieved, at least in the coronal half of the root, with various sized Peeso Reamers or Gates-Gliddens. From my first clinical days in dental school, I have always appreciated the advantages of using Reamers, rather than K-files, in shaping canals and negotiating to the apex. Made from stainless steel like K-files, they encountered far less resistance along length in negotiating to the apex and were significantly more flexible than their counterparts. Yet, despite the reduced resistance, all shaping had to be done manually. This made for a slow process, and multiple visits were the norm.
Today, we are able to reduce the time it takes to shape canals, and the spaces are often quite easy to obturate with a gutta-percha point corresponding to that shape, at least in the mesiodistal plane. With reduced time requirements, it is no longer the main determinant in deciding whether treatment should be one visit or longer. Now, that decision is largely a matter of patient management, and how to best serve patients’ conflicting interests. They would like the procedure to be done as quickly as possible, but they also want to be predictably free of pain and free of the underlying infection that probably caused the initial complaint. In all likelihood, if a tooth is inflamed because of a predominantly vital pulp exposure, single-visit endodontics will be successful, leaving the patient feeling quite comfortable in its wake. If the tooth is non-vital with or without a periapical area, I tend to treat it over two visits. I do not automatically cover these patients with antibiotics unless they are in acute distress or have systemic problems that require extra precautions. Here is my thinking:
If I treat the patient in one visit and their pain initially subsides, I may indeed be a hero in their eyes. But there is also the possibility that infected debris beyond the apex will exacerbate an already acute situation or, worse, create a new source of distress in a formerly asymptomatic tooth.(1) Of course, the patient is informed of all the nasty possibilities that they may face. They also know we are open seven days a week, and they get my home phone number for added security. This last feature is not a bother. Calls occur rarely and when they are required I am glad to be available for my patients’ needs. Despite the relative improbability of flare-ups after initial treatment, I believe most patients appreciate the caution that comes with a second visit.
Teeth associated with fistulas are unlikely to flare up, providing an avenue of escape for the purulent discharges, keeping the patient comfortable. In the past, I usually treated these patients in one visit. Today, however, I like to confirm the success of the first treatment by seeing the fistula disappear prior to obturation. Unless there are systemic considerations, I do not provide antibiotic coverage in these situations. In a sense, it would be self-defeating if the fistula were to disappear only to reappear after the course of antibiotics is finished.
There are a host of other reasons single-visit endodontics is not usually performed. Age, for example, may be a deciding factor. It is one thing to perform endodontics on the mandibular first molar of a 25-year-old, quite another to perform the same procedure on an 85-year-old. It is entirely likely that simply finding the canals on an older patient will take far more time. Generally, they lack the mass of soft pulp tissue that covers the canal orifices in younger patients. In many cases, the entire pulp chamber will have been replaced with calcified tissues and the orifices themselves will have receded apically, requiring careful removal of secondary dentin.(2) Cautious care takes time, and the 85-year-old in the chair will not have the stamina of a 25-year-old to sit for the greater time it takes to effectively complete treatment in one visit, be the case vital or non-vital. Adding an extra visit may present a burden for the patient in terms of traveling, but has the benefit of causing less stress while in the chair. This becomes increasingly important with patients of increasingly compromised health. In these situations, especially, I prefer to err on the side of caution.
As you can see, the time requirements are crucial with compromised patients. So whether the procedure is done in one visit or more, it is good to know that, with automated endodontics, we can do a good deal of the shaping in a more efficient manner than before, when the predominant method involved the manual use of K-files alone. Interestingly, the use of rotating NiTi, while generally faster, is associated with the removal of excess coronal dentin as a requirement of crown-down preparations, a technique that avoids engagement along length by widening the more coronal aspects of the canal as greater depth is gained. Alternatively, by using predominantly 02 tapered relieved vertically fluted reamers in a 30° reciprocating hand-piece oscillating at 3000-4000 cycles per minute, we can open the canals routinely to 30° with a maximum taper of 04, if that is even required, eliminating the need for crown-down preparations by shaping the canals within 2-3 minutes after first gaining length and, most importantly, preserving coronal dentin. In this way, we can maintain the integrity of the root while virtually eliminating any chance of instrument separation.
30° reciprocation, oscillating at 3000-4000 cycles per minute, using predominantly 02 tapered relieved reamers, preserves far more dentin, negotiates to the apex with far less resistance and may make the difference between one and two visits, always taking into account the health of the patient and the complexity of the case. Common sense tells us that the teeth of older patients are more susceptible to fracture. Their teeth have undergone a lifetime of function, and therefore are more desiccated than those of younger patients and far more likely to produce micro-cracks when subjected to rotary motions, particularly when curved canals are present. Keeping the tapers minimal and the amplitude of motion confined to 30° minimizes the loss of coronal dentin and avoids the micro-cracks associated with large amplitudes of motion, while extending the canal preparations into the thin buccal and lingual extensions that so often harbor untouched bacteria.
As we can see, so much is interrelated: the health and stamina of the patient, the perception by the patient of what constitutes the best treatment they could have, and the ultimate relationship the patient has with the dentist performing the procedures. We should consider all of these factors carefully when deciding between single-visit and multiple-visit endodontics.References:
1. Madhusudhana K, Mathew VB, Reddy NM. Apical extrusion of debris and irritants using hand and three rotary instrumentation systems — An in vitro study. Contempt Clin Dent. 2010 Oct–Dec; 1(4): 234–236. doi:10.4103/0976-237X.76390.
2. Perlea P, Nistor CC, Iliescu MG, et al. High risk in root canal negociation (sic) in elderly patients: Clinical case series. Int J Med Dent. 2015; 5(1): 52.ADA Recognition Statement
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