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SINGLE VS.

MULTIPLE VISITS FOR


ENDODONTIC TREATMENT OF
PERMANENT TEETH
Dominique Abela
Outline
Clinical scenario and question
Background and evidence selected
PICO
Methods- selection criteria
Data analysis and results
Strengths and weaknesses
Implications

Clinical scenario
RFA: 35 yr old female presents for endodontic
treatment on her upper right first molar
(previously extirpated pulp) due to caries which lead
to chronic apical periodontitis.
DRN 0879867
Medical history: NAD
Dent History: full dentition with previous orthodontic
treatment. No other restorations or periodontal
disease.
Clinical Question
Patient wanted to know
is there a difference in
single vs. multiple visit
endodontics.
Background
Endodontics/ RCT is a procedure in which organic tissue,
infected debris and pathogenic bacteria are removed from the
root canal system
mechanical and chemical means
root canal is then filled with a rubber based material
this can be performed in single or multiple visits.
Best Evidence
This is a question of therapy therefore best
level of evidence
1a) Systematic review of randomised control
trials
1b) Individual randomised control trials (with
narrow confidence intervals)
PICO
P- non-vital permanent teeth due to caries
I- single visit
C- multiple visits
O- absence of symptoms and clinical signs with
radiographic evidence of periapical healing.
The search

Evidence Chosen
Single vs. multiple visits for endodontic
treatment of permanent teeth. Figini L et al
Cochrane Database of Systematic Reviews
issue 2, 2009.
Methods
Objective- to compare single vs. multiple
RCT measuring tooth extraction and
radiological success in the long and short
term.
Search strategy- central, medline and
EMBASE, endodontists were contacted and
no language limitations imposed.
Selection criteria
randomised and quasi- randomised control trails were
included
surgical endodontics excluded
patients > 10 yrs who underwent RCT with closed apex
and no internal root resorption
outcomes considered; teeth extracted due to failed
endodontics, radiological success at least 1 yr later,
absence of periapical radiolucency, post- op pain with
pain killer use and swelling or sinus tract formation.
No difference could exist in systemic medications
between the two groups (e.g. NSAIDs, antibiotics,
analgesics)
Data analysis
validity was based on allocation
concealment, blindness and loss of
participants. Data analysed using
quantitative meta-analysis and
comparison made by employing risk
ratios.

Results
12 RCTs were included.
No significant difference in single vs. multiple visits
for radiological success and post- operative pain
Patients undergoing single visit RCT reported higher
frequency of pain killer use and swelling, but results
for swelling were not significantly different between
the two groups.
No study included tooth loss or sinus tract formation.
Significant Results: Forest Plot
Results Summary
Outcome No. Of
Studies
No. Of
Participants
RR (CI)
Post-op pain (72h) 6 1047 0.99 (0.83 to 1.18)
Pain at 1 week 5 936 1.07 (0.72 to 1.57)
Pain at 1 month 2 Analysis not possible
Painkiller use 3 559 *2.42 (1.62 to 3.62)
Radiological failure 5 657 0.85 ( 0.59 to 1.23)
Swelling 3 192 1.40 (0.67 to 2.93)
Strengths of the study
Systematic review of all published randomized control
trials (level 1a evidence).
12 RCT fitted the inclusion criteria.
Good inclusion criteria.
Plain language summary included.
Recently published (2009) thus most recent evidence
included.
Participant loss was 20%
All RCT used lateral condensation obturation technique.
Trial data was homogenous
All confidence intervals were small.

Weaknesses of the study
Bias: high in 4 RCT, medium in 4 RCT and low in 4RCT.
Medium risk of bias: allocation concealment was not
described.
High risk of bias: randomization was inadequate (3 RCT) or
not explained satisfactorily (1 RCT).
Authors assessing studies to be included were not blinded
to publication name and authors.
The types of cases (complex vs easy) was not described.
Use of Rubber Dam. (4 RCT used RD, 8 RCT did not).
Treatment medicaments in multiple visit group varied and
was not mentioned in some RCTs.

Weaknesses of the study
Irrigants varied (saline in 2 RCT, NaOCl in 10RCT).
Type of sealer not consistant. (1RCT ZOE,

2RCT
Roth 801, 2RCT AH26, Pulp canal sealer 1RCT,
Tubi seal 1RCT, Ostebys 1RCT, Seal apex 2RCT,
unknown in 2RCT).
Use of magnification. (Mentioned in 2 RCT, not
mentioned in 10RCT)
Instrumentation varied (rotary + hand instruments
2RCT, unknown or not mentioned satisfactorily
5RCT, hand 5RCT).

Weaknesses of the study
Instrumentation technique varied (Crown down
1RCT, step back 4RCT, double flare 1RCT,
unknown 6RCT).
Operator and level of experience varies.
Time between visits in multiple visit group varied.
Radiographic assessment only 1yr. Optimum is 4yr.
Thus lack of long term follow-up.
Data group as dichotomous.

Implications
The effectiveness of single-visit and multiple-visit endodontic
treatment is not substantially different.
Patients undergoing single-visit Endodontic treatment may
experience a higher frequency of pain killer use and are more likely to
take analgesics.
It would be more helpful for clinician if researchers include tooth loss
as a primary outcome.
Because of the increasing popularity and use of rotary
instrumentation, a well designed RCT comparing single vs multiple
visit endodontic treatment would be an important contribution.
Reduced time spent in the chair thus reduced disruption to patient.
Cost- vs cost of pain??
Reduction in use of materials.

Acknowledegments
Librarian
Patient
Thank you all for listening.

Questions?????