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Redefining SingleVisit Endodontic Protocol

Brijesh Tiwari1, Manu Krishnan2, Vimal Arora3

ABSTRACT:

With the advent of new rotary instruments and equipments,

single visit endodontics has spawned considerable interest in

dental practice. However, little consensus exist regarding the

right procedures: canal preparation, irrigation, debridement and

obturation, to be followed for this modality. Here in, we report

a simple protocol for single visit endodontics, adhering to basic

principles of root canal treatment with routinely used

instruments and materials. The case series involved all types

of teeth: upper/lower and single/multi rooted. The high rate of

success with respect to treatment outcome and post operative

pain observed in this series validate our protocol on single visit

endodontics as a reliable, economical and predictable option.

Key words: Single visit endodontics, Crown down method,Lateral condensation

CASE REPORT

doi: 10.5866/2014.621550

1Department of Dental Research and Implantology,Institute of Nuclear Medicine and Allied Sciences(INMAS), Defence Research and DevelopmentOrganization (DRDO), Min of Defence, Govt. of India,Delhi- 542HOD & Classified Specialist (Orthodontics)Dept of Dental Research & ImplantologyInstitute of Nuclear Medicine and Allied Sciences(INMAS), Defence Research and DevelopmentOrganization (DRDO), Timarpur, Delhi-1100543Director General Dental Services &Classified Specialist (Prosthodontics)Army Dental Centre (Research & Referral), Delhi.

Article Info:

Received: January 11, 2014Review Completed: February 12, 2014Accepted: March 12, 2014Available Online: July, 2014 (www.nacd.in)© NAD, 2014 - All rights reserved

Email for correspondence:manukrishnanin@yahoo.co.in

Quick Response Code

INTRODUCTION

Root canal treatment (RCT) or endodontics is awidely sought out therapeutic option in dentistryfor rescuing tooth from pulpal and periapicalpathologies, which otherwise would end up inextractions. However, number of visits indicated forsuccessful RCT continues to be a matter of debateamong clinicians. Though multi visit RCT has beena time tested protocol in endodontics, the single visitversion has recently generated considerable interest,

notwithstanding its reporting even as early as in1880s.1

Multi visit endodontics has provision foraddressing episodes of ‘infective flare ups’ throughintra canal dressings (calcium hydroxide) andantibacterial agents, followed by obturation insubsequent visits.2 The hydroxyl ions from highlyalkaline calcium hydroxide reduce bacterial growthin root canals through lysis of its proteins/toxins andminimize the inflammatory reactions by inhibiting

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interleukins (IL1α), tumor necrosis factor (TNFα)and calcitonin gene related peptides (CGRP).3 Incontrast, single visit endodontics involvesconservative non surgical treatment of anendodontically involved tooth with completebiomechanical cleansing, shaping, and obturation ofthe root canal in one visit. This method does not relyon calcium hydroxide dressings and see no majordifference in the clinical outcome between the two.Moreover, risk for root canal contamination is alsoreported to be high with multi visit.4 Finally; from astatistical perspective; systematic reviews/meta-analysis, too have strong evidences in favour of singlevisit endodontics, in terms of post operative pain andhealing of the periapical lesion.5 Nevertheless; theresurge in single visit RCT and its success rate, tosome extent has been attributed to the advancementsin endodontic armamentarium: surgical microscopes/magnifying loupes, nickel titanium (NiTi) rotaryinstruments, apex locators, better disinfecting andsealing agents/materials, injectable obturationsystems and digital radiography.

In this context, it is imperative to evaluatewhether single visit endodontics can be used as apredictable treatment for upper/lower/single/multirooted teeth without the use of expensive andsophisticated instruments/equipments. This wouldmake available the benefits of single visitendodontics to a larger section of patients ataffordable cost. Here, with a case series involvingall types of teeth, we present a protocol for singlevisit root canal treatment with routinely usedinstruments and methods.

Case report

Thirty patients aged 18-60 yrs and scheduledfor root canal treatment were selected from the dailyOPD for single visit RCT. Those with cellulitis andprofuse discharge from root canals were excluded.

After written informed consent, patients weregiven appropriate local anaesthesia with 2%lignocaine and 1:80,000 adrenaline, (LignospanSpecial, Septodont Inc, Delaware, USA) followed byrubber dam (Dentsply, Addlestone, UK) application.Coronal access to pulp chamber was made by ISO Ø016 round diamond bur and cavity enlargement byEndo-Z bur (Dentsply Maillefer, Switzerland).‘Crown down’ technique was used for canalpreparation using ProTaper NiTi (Dentsply,Maillefer, Switzerland) and ISO K# stainless steelfiles (Mani, Tochigi, Japan). After irrigation andscouting with ISO K#10 files (Mani, Tochigi, Japan)canal enlargement was sequentially done by

ProTaper SX, S1 and S2 files till ISO K#15 file. Atthis point, working length was determined byperiapical radiograph. Finally ProTaper finishingfile F1 was used after which apical canal width wasrefined with an ISO #20 file. If it was snugly fittingto the apex, preparation was assumed to becomplete; otherwise instrumentation was continuedtill finishing file F2. Removal of smear layer wasdone with ‘Glyde’ (Dentsply, Addlestone, UK), a rootcanal conditioner consisting of ethylene-diamine-tetra-acetic acid (EDTA) and carbamide peroxide ina water soluble base. After each file, canal wasirrigated with 5.2% sodium hypochlorite andrecapitulated with ISO size #10 file. For oval and‘C’ shaped canals, pre-curved stainless steel ISO fileswere used. Lastly, irrigation was completed with 2%chlorhexidine. Canal was then dried by ProTaperpaper points and obturated with ProTaper guttapercha and AH Plus sealer (Dentsply, Addlestone,UK) by ‘lateral condensation’ method. Access cavitywas filled with light cure composite, Ceram X duo(Dentsply, Konstanz, Germany). Occlusal reductionwas done in cases of tender teeth. Patients weregiven antibiotics/non steroidal anti inflammatorydrugs and were followed up to 2-5 months.Conventional instruments and materials used forthe cases are shown in Figure 1. Representativecases of single visit RCT are shown in Figures 2-6.

Discussion

Single visit endodontics has several advantages:few appointments, no repeat anaesthesia/rubberdam application, less microbial contamination andimmediate restoration. Further, here the clinicianneed not remember the canal for next sitting. It isgenerally indicated for (1) vital pulp exposures incaries/trauma, (2) mutilated crowns, (3) abutmentsand (4) medically compromised/non ambulatorypatients who cannot afford multi visits. Conversely,it is not indicated for unduly curved/calcified canals,perforations/ledges/broken instruments, previouslyattempted/failed cases and in cellulitis/abscesses. Itmay also be not feasible for child patients and thosewith temporomandibular/neuromuscular disorders.Preferably, it is better to keep duration of single visitendodontics to 40-45 minutes. These tenets have beenwell laid down in Oliet’s criteria for single visit RCT.6

Clinical expertise and selection of appropriatetools/technique is important in single visit RCT.Central to it is achieving a straight line access toroot apex and meticulous debridement/disinfection/shaping of the canal prior to root filling. Complexityof tooth anatomy is to be rightly judged while

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Fig. 5: Pre-intra and post-operative periapicalradiographs of upper premolars (a) first and (b) second

Fig. 6: Pre-intra and post-operative periapicalradiographs of upper molars (a) first (b) second and (c) third

Fig. 1: Instruments and materials for single visitendodontics

Fig. 2: Pre-intra and post-operative periapicalradiographs of lower (a) incisors and (b) premolars

Fig. 3: Pre-intra and post-operative periapicalradiographs of lower molars (a) first, (b) second and (c) third

Fig. 4: Pre-intra and post-operative periapicalradiographs of upper (a) incisor and (b) canine

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making the treatment plan and this would decidefor either single or multi visit RCT. ‘Crown down’and ‘step back’ techniques are two methods in rootcanal preparation based on direction ofinstrumentation; the former starts from the coronalpart of the canal towards the apical area where asthe latter is in the reverse direction.1 NiTi rotaryinstruments in a crown down approach for canalpreparation were used in these patients whichensured a flared preparation with small apicalenlargement. NiTi files are cited to produce wellshaped canals with few iatrogenic problems thanstainless steel versions and to have lesspostoperative pain, due to its file design and thecrown down modality.7 The hybrid method; acombination of two, was effective in cases withextremely curved canals. Electronic apex locators,based on the principles of resistance, impedance andfrequency are a recent innovation in determiningthe working length to an accuracy of 0.5mm.Similarly, ultrasonics in combination with irrigantsis another fresh addition for canal debridement.However, neither apex locators nor ultrasonics wereused; instead, worked with hand instruments andtwo reagents: sodium hypochlorite andchlorhexidine gluconate. Sodium hypochlorite (2.5%)with its ability to liberate free chlorine hasantimicrobial as well as solvent action on root canaldebris through protein breakdown. Alternatively,chlorhexidine (2%) has a broader and sustainedaction on microbes than sodium hypochlorite. Rootcanal instrumentation results in a smear layerwhich is an organic/inorganic mix of dentinalshavings and necrotic debris of pulp/microorganisms. Removal of this layer is essentialsince it acts as a nidus for microbes and tends toalter dentinal tubule surface, which in turnjeopardizes the innate adaptation of obturationmaterials to dentine.8 So, adequate care was takento eliminate the smear layer with ‘Glyde,’ an EDTAcontaining canal lubricant.

Obturation of the canals was done by lateralcondensation method, where a wedge shapedspreader was pressed to move the gutta perchalaterally.9 This type of condensation goes well witha canal ared from apex to coronal direction asprepared by crown down method in this series. Guttapercha condensation done in the same sitting deprivesmicrobes of essential nutrients. Also, the zinc ionsliberated from it has antibacterial action. As rootcanal sealant, ‘AH Plus’ a thermoplastic ‘epoxide-amine’ paste was used. Another material which iswidely used is mineral trioxide aggregate (MTA),

which contains tricalcium-silicate, aluminate, oxides,and bismuth oxide. It has a high alkaline pH (12.5)like calcium hydroxide which makes it antibacterial.8

Yet, the multiple utilities of AH Plus: highbiocompatibility, dimensional stability, antibacterialand self adhesive properties were more appealing andwas found to be very effective.

Post operative pain is an important issue insingle visit endodontics. In our 30 cases, only threewere tender on percussion after obturation, whichbecame asymptomatic in the next 24-48hrs. This washigher than the results discussed in a recentreview.10 Success rate of 100% noticed in our serieswas also higher than those reported in anotherreview.11 This was because cases with cellulitis anddraining canals were avoided and meticulousstandards were maintained throughout all the cases.

Conclusion

A simple and reliable protocol for single visitRCT is presented. The case series highlighted theimportance of clinical judgment and correctdiagnosis for pursuing this type of endodontics. Italso proved that costly and advanced equipments/instruments need not be a restraining factor for thisversatile treatment, which can resolve the morbidityassociated with tooth pulp exposures. Successfulresults from all types of teeth proved that the protocolcan be a viable guide line for single visit endodontics.

References1. Mohammadi Z, Farhad A, Tabrizizadeh M. One visit versus

multiple visit endodontic therapy - a review. Int Dent J 2006;56: 289-93.

2. Weiger R, Rosendahl R, Lost C. Influence of calciumhydroxide intracanal dressings on the prognosis of teethwith endodontically induced periapical lesions. Int EndodJ 2000; 33: 219-226.

3. Law A, Messer H. An evidence based analysis of theantibacterial effectiveness of intracanal medicaments. JEndod 2004; 30:689-694.

4. Ashkenaz PJ. One visit endodontics. Dent Clin NorthAmerica 1984; 28:853-863.

5. Sathorn C, Parashos P, Messer HH. Effectiveness of singleversus multiple visit endodontic treatment of teeth withapical periodontitis: a systematic review and meta analysisInt Endod J. 2005; 38: 347-355.

6. Oliet S. Single visit endodontics: A clinical study. J Endod1983; 9:147-152.

7. Glickman G. 21st century endodontics. J Am Dent Assoc2000; 131: 39-46.

8. Zehnder M. Root canal irrigants. J Endod 2006; 32:389-398.9. Lee M, Winkler J, Hartwell G, Stewart J, Caine R. Current

trends in endodontic practice. J Endod 2009; 35:35-39.10. Al-Rahabi M, Abdulkhayum AM. Single visit root canal

treatment: Review. Saudi Endod J 2012; 2:80-84.11. Spanberg LSW, Haapasalo M. Rationale and efficacy of root

canal medicaments and root filling materials with emphasison treatment outcome. Endod Topics 2002; 2:35-58.

Redefining Single Visit Endodontic Protocol Brijesh Tiwari, et, al.

Indian J Dent Adv 2014; 6(2): 1550-1553