SINGLE VISIT ENDODONTICS

CONTENTS
Introduction History Preliminary considerations
Operator ability and clinical experience Time and auxillary utilization Clinical techniques

Criteria for case selection Indications and Contraindications Advantages and Disadvantages

The advances which have favored single visit endodontics

Digital radiography Microscopes Electronic apex locators Ni-Ti rotary instrumentation & crown down technique Concept of working width Newer obturation systems

Conclusion

Single Visit Endodontics is defined as the conservative non surgical treatment of an endodontically involved tooth consisting of complete biomechanical cleansing, shaping, and obturation of the root canal system during one visit. Paul J. Ashkenaz

New technology and research is helping clinicians avoid multiple visits and long, drawn out endodontic treatment. There is widespread acceptance of singlevisit endodontics for vital cases and the trend for Nonvital Single Visits is becoming more widely accepted.

Historically, root canal treatment was performed in multiple visits primarily to ensure sterility of the root canal system prior to obturation. Culturing techniques were used to determine the nature of the root canal flora immediately upon entry to the canal, during therapy and prior to obturation. Later a wide variety of antimicrobial agents were introduced to eliminate microbes present in the root canal system. In addition to killing bacteria, these agents, primarily phenolic compounds, were also highly irritating to the periradicular tissues.

Overzealous use of these medicaments led to a multitude of post operative problems that were inappropriate and excessive use of antibiotics to control the so called infection. Ultimately, the deleterious effects of these medicaments were identified and their routine clinical case was discontinued. This led to one of the two courses of treatment: Either treat the root canal in one visit or Seek an intracanal medicament that does not injure the periradicular tissues.

PRELIMINARY CONSIDERATIONS

Operator Ability and Clinical Experience:

Highest level of Endodontic Competence required. Technique for experienced practitioners who have made endodontics an integral part of their clinical practices and not for the person who only does an occasional endodontic case. The clinician must gauge the time that is necessary to perform a complete treatment on any tooth in the mouth and can schedule his or her one-visit procedures accordingly.

Time and Auxiliary Utilization

In order to accomplish a one-visit procedure successfully, a realistic treatment time must be set aside based on both the clinician's ability and the difficulty of the case. However, as a RULE OF THUMB, the overwhelming majority of cases should be able to be completed within 30 to 45 minutes The ability to complete treatment within this time frame is dependent upon the clinician's ability to organize and have ready for immediate use, an efficient endodontic delivery system .

Allows for the rapid and efficient delivery of the various endodontic procedures such as isolation, access, biomechanical preparation, and obturation of the root canal system. At the heart of this delivery system is the well-trained dental assistant. For it is the assistant that not only prepares the tray set-ups, but also aids in placement of the rubber dam, passes the intracanal enlarging and filling instruments and materials, and aids in temporization. This enables the dentist to make more efficient use of his or her time.

Clinical Techniques
One-visit endodontics is dependent upon the use of fundamental endodontic operative skills. There are no short cuts, simply the application of these skills in a thoughtful and organized manner. A failure to develop these basic skills to a high degree of competence can only result in a high incidence of broken instruments, ledged canals, perforations, inadequately prepared and incompletely filled root canals. Errors in fundamental skills lead to failures of iatrogenic origin in any clinical situation. Once these preliminary criteria have been met, specific clinical cases can be selected on which to perform a one-visit procedure.

Oliets criteria for case selection

Positive patients acceptance. Sufficient available time to complete the procedure properly. Absence of any acute symptoms requiring drainage via the canal and of persistent continuous flow of exudates or blood. Absence of anatomical obstacles like calcification in the canals, and procedural difficulties (ledge formation, blockage, perforation, inadequate fills)

INDICATIONS

Vital Pulp Exposures and Symptomatic Pulpitis

Teeth with pulp exposures caused by trauma, caries, or mechanical reasons and teeth that exhibit clinical symptoms to heat or cold stimuli but not percussion. Briefly in cases of vital pulp, a single visit treatment should be used whenever possible. This is based on the fact that the pulp is only superficially infected and the root canal is free of bacteria, provided the aseptic chain is maintained during the intracanal procedures. Therefore, there is no apparent reason not to treat vital pulp in single visit

Restorative Considerations
Teeth requiring endodontics for restorative reasons and not because they have pathologic pulp tissue that must be removed or because of pulp exposures. In each and every instance, because treatment can be planned for ahead of time, completion of endodontics in one visit can be readily accomplished.

Anterior Esthetic Problems Maxillary anteriors involved in trauma that have resulted in a horizontal fracture of the crown at the gum line, pose esthetic as well as isolation and sealing problems if treated in the conventional multivisit manner Isolation and sealing problems Teeth with subgingival breakdown, teeth with multiple coronal walls missing, and teeth with full coverage that have decay below the margins of their finished restorations would all fall into this category

A one-visit treatment solves these problems because at the completion of treatment, an esthetic anterior temporary crown can be placed rapidly and retained.

However, a one-visit treatment SHOULD NOT be done if the tooth in question presents with anyone or a combination of the following conditions: The presence of a non vital pulp open to the oral cavity The presence of periapical symptoms The presence of alveolar damage

CONTRAINDICATIONS There are NO ABSOLUTE CONTRAINDICATIONS as such , except following;

Cellulitis Acute apical abscess requiring incision and drainage Severe pain when the tooth is lightly touched A weeping canal that cannot be dried Difficult cases that extend beyond our allotted time and the patients tolerance Patients with acute apical periodontitis Molars with necrotic pulps and periradicular radiolucencies Root canal Retreatment

CONDITIONS WHERE MULTIPLE VISIT THERAPY IS PREFERRED OVER SINGLE VISIT THERAPY Multiple appointment therapy should be considered in the following situations:
Asymptomatic nonvital teeth with periapical pathology and no sinus tract Teeth with anatomic anomalies Infected cases with evidence of apical periodontitis (periapical radiolucency, swelling, exudates). Patients with many allergies or previous flare-ups.

ADVANTAGES
Reduces patient appointment visits per tooth It eliminates interappointment contamination and flare ups due to leakage or loss of the temporary seal in severely broken-down teeth. It allows the practitioner to fill the canal when he or she is most familiar with the canal anatomy, working length, and position of the apical stop. It allows the practitioner to immediately use the canal for retention of a post to construct an esthetic temporary in maxillary anterior trauma cases in which the crown has been fractured off to the gum line

EFFICIENCY: The dentist does not have to re-familiarize himself or herself to the patients particular anatomy or landmarks. CONVENIENCE: The patient does not have to endure the discomfort of repetitive local anesthesia, treatment procedures and postoperative recovery. ECONOMICS: Shorter chair time and fewer materials increase the dentists profitability. The patient misses less work and incurs fewer extra costs, such as travel and parking. PATIENT MANAGEMENT: Most patients prefer to have their treatment completed as quickly as possible, and apprehensive patients derive special benefits from single-visit treatment. In some cases, health considerations favour single appointments (e.g., when prophylactic antibiotics or sedation is required) RESTORATIVE CONSIDERATIONS: Prompt completion of endodontic treatment may be required to allow immediate placement of a coronal restoration (immediate postcore placement contributes to the success of treatment by ensuring an effective coronal seal).

DISADVANTAGES
1. 2.

Patient fatigue and discomfort with extended operating time Clinician fatigue with extended one-appointment operating time Flare-ups cannot be easily treated by opening the tooth for drainage. Inability to control exudates may prevent completion of the Procedure. Difficult cases with extremely fine, calcified, multiple canals may not be treatable in one appointment without causing under stress for both the patient and the clinician.

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RECENT ADVANCES FAVOURING SINGLE VISIT ENDODONTICS

Over the past decade, Nickel Titanium Rotary Instrumentation, Microscopic Endodontics, Digital Radiography, A Plethora Of Obturation Systems, And Biocompatible Sealing Materials have helped practitioners perform endodontic procedures more effectively and efficiently than ever before. This is not implying that endodontic treatment has become easier; however, better tools and technology have made it more predictable and challenge us to take on a wider variety of complex cases and complete it succesfully.

DIGITAL RADIOGRAPHY
Computerized imaging system that uses an electronic sensor instead of X-ray film Is a type of digital radiology Yields sharp clear images

Uses 70% less radiation than conventional X-ray film

No hazardous chemicalsenvironmentally friendly Image appears rapidly on a computer screen It is quick and has the added ability to zoom in on a specific area on the the radiograph. The resolution and diagnostic quality is excellent , storage is easy and there are no developing or processing errors.

MICROSCOPES

Ease of observing areas of interest at high magnification under constant illumination. The use of this device during root canal treatment can assist the clinician in locating and negotiating calcified canals, and performing surgical and nonsurgical root canal treatments Endoscopes, orascopes and magnifying loupes with or without a supplemental light source are also useful tools to enhance visualization of the operative field.

Endoscopes, orascopes and magnifying loupes with or without a supplemental light source are also useful tools to enhance visualization of the operative field. Has made the task of identifying canals faster and more efficient.

Electronic Apex Locators

The task of determining canal length has moved into a new and more precise era with the rapid evolution of electronic devices that measure the length of the root canal Assist accurately in determining canal length in the majority of cases in a much shorter time

Recent apex locators (ROOT ZX, JUSTY, ENDEXPLUS) have been reported to be accurate to within 0.5 mm in >90% of cases .

A combination of Apex locator and Endodontic handpiece Tri Auto ZX. (Third generation apex locator)

USE OF ULTRASONICS IN SINGLE VISIT

Ultrasonics is relatively new in our endodontic armentarium Recent studies have shown ultrasonics to be superior in debriding the root canal system when compared with hand instruments. The ultrasonics used with small file held free of the canal walls, warms the solution in the canal and resonant vibrations cause movement of aqueous irrigants an effect called Acoustic streaming

CONCEPT OF WORKING WIDTH:

Traditional .02 tapered hand files and rotaries with greater tapers are of little value for accurate determination of the correct W.W. Tapered instruments cut canal walls in several places simultaneously and it is not clear what is happening apically. The correct WW correlates closely to the largest diameter of the original size in the apical third.

Working Width is as important as determining the working length. If the apical portion of the canal is large before instrumentation, the WW should be large after instrumentation, and same applies for small canals. An undersized WW, even with a correct WL , compromises cleanliness. An oversized WW compromises root strength.

OBTURATION: NEW DELIVERY SYSTEMS

Successful single-visit treatment depends on effective mechanical debridement, chemical disinfection, and proper sealing of the canal system. Obturation can only be as good as the instrumentation, since filling material cannot occupy the same space as the debris left by poor instrumentation There are TWO BASIC METHODS of root canal obturation, with a number of permutations to these techniques The Lateral Condensation Technique requires lateral compaction of cold gutta-percha points to fill the space Warm gutta-percha techniques, also called vertical compaction techniques, use warm gutta-percha that is made plastic and compacted apically.

OBTURA II

Viscosity of softened gutta purcha can be controlled High temperature not detrimental to periodontal ligament Allows continuous heat Better adaptation and effective in obturation of accessory canal

Thermafil (Dentsply Tulsa Dental, Tulsa, Okla.)

Solid-core carriers Plastic carrier with a groove to provide back flow of guttapercha Space for carrier retrieval if re-treatment necessary. Verifiers available in Ni-Ti can be heat sterilized for reuse. Verifiers with flutes for minor apical shaping Used in curved canals Less time (17 seconds)

ONE STEP OBTURATORS

Compatible with all rotary and non rotary instruments. No handle. No cutting shaft to remove handle. Better accessibility. Preset to working length each time.

E and Q System
Easy and Quick system for obturation . It has a Automatic heat carrier Gutta percha gun Is used during vertical compaction, heat softened gutta percha injection or combination of both techniques.

When does Single Visit Therapy turns into Multiple Visit Endodontics ?
Factors related to tooth being operated on Calcified canals which take time to negotiate Excessive uncontrolled bleeding Canal blockage due to foreign bodies, glass beads, old restorations Perforations Instrument separation Weeping canals b) Other factors - Patient going in syncope. - Lack of skill of practitioner to manage the case in less time. - Patient fatigue.

Conclusion
Single Visit Endodontics has been proved to be an effective treatment modality, when compared to multiple visit endodontics, it is more beneficial to patients and dentists in many ways. The requirement is to select the case properly and to acquire the required skill for getting the better results from the procedure.