Single Versus Multiple Visits for Endodontic Treatment of Permanent Teeth: A Cochrane Systematic Review

Dipartimento di Medicina, Chirurgia Odontoiatria, Università degli Studi di Milano, Milan, Italy.
Journal of endodontics (Impact Factor: 3.38). 10/2008; 34(9):1041-7. DOI: 10.1016/j.joen.2008.06.009
Source: PubMed
ABSTRACT
The Cochrane Collaboration promotes evidence-based healthcare decision making globally through systematic reviews of the effects of healthcare intervention. The purpose of this systematic review was to investigate whether the effectiveness and frequency of short-term and long-term complications are different when endodontic procedure is completed in one or multiple visits. Randomized and quasi-randomized controlled trials enrolling patients undergoing endodontic treatment were identified by searching biomedical databases and hand-searching relevant journals. The following outcomes were considered: tooth extraction as a result of endodontic problems and radiologic failure after 1 year, postoperative discomfort, swelling, analgesic use, or sinus track. Twelve studies were included in the review. No detectable difference was found in the effectiveness of root canal treatment in terms of radiologic success between single and multiple visits. Neither single-visit root canal treatment nor multiple-visit root canal treatment can prevent 100% of short-term and long-term complications. Patients undergoing a single visit might experience a slightly higher frequency of swelling and refer significantly more analgesic use.

Full-text

Available from: Giovanni Lodi
Single versus multiple visits for endodontic treatment of
permanent teeth (Review)
Figini L, Lodi G, Gorni F, Gagliani M
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 1
http://www.thecochranelibrary.com
1Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 1
T A B L E O F C O N T E N T S
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .
3SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .
4METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .
8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18Table 01. Endodontic r adiological success: from scales to binary outcome . . . . . . . . . . . . . . .
19Table 02. Definition of flare-up in the included studies . . . . . . . . . . . . . . . . . . . . . .
20ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20Comparison 01. Single visit versus multiple visits . . . . . . . . . . . . . . . . . . . . . . . .
20Comparison 02. Sensitivity analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21Analysis 01.01. Comparison 01 Single visit versus multiple visits, Outcome 01 Pain . . . . . . . . . . . .
22Analysis 01.02. Comparison 01 Single visit versus multiple visits, Outcome 02 Painkiller use . . . . . . . . .
23Analysis 01.03. Comparison 01 Single visit versus multiple visits, Outcome 03 Radiological failure . . . . . . .
23Analysis 01.04. Comparison 01 Single visit versus multiple visits, Outcome 04 Swelling . . . . . . . . . .
24Analysis 01.05. Comparison 01 Single visit versus multiple visits, Outcome 05 Subgroup analysis in necrotic teeth .
26Analysis 02.01. Comparison 02 Sensitivity analysis, Outcome 01 Pain . . . . . . . . . . . . . . . .
27Analysis 02.02. Comparison 02 Sensitivity analysis, Outcome 02 Painkiller use . . . . . . . . . . . . .
27Analysis 02.03. Comparison 02 Sensitivity analysis, Outcome 03 Radiological failure . . . . . . . . . . .
28Analysis 02.04. Comparison 02 Sensitivity analysis, Outcome 04 Swelling . . . . . . . . . . . . . . .
28Analysis 02.05. Comparison 02 Sensitivity analysis, Outcome 05 Subgroup analysis in necrotic teeth . . . . . .
iSingle versus multiple vi sits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 2
Single versus multiple visits for endodontic treatment of
permanent teeth (Review)
Figini L, Lodi G, Gorni F, Gagliani M
This record should be cited as:
Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth . Cochrane Database
of Systematic Reviews 2007, Issue 4. Art. No.: CD005296. DOI: 10.1002/14651858.CD005296.pub2.
This version first published online: 17 October 2007 in Issue 4, 2007.
Date of most recent substantive amendment: 21 August 2007
A B S T R A C T
Background
Root canal treatment (RoCT), or endodontic treatment, is a common procedure in dentistry. The main indications for RoCT are
irreversible pulpitis and necrosis of the dental pulp caused by carious processes, tooth cracks or chips, or dental trauma. Successful
RoCT is characterised by an absence of symptoms and clinical signs in teeth without radiographic evidence of periodontal involvement.
The success of RoCT depends on a series of variables related to the preoperative condition of the tooth, as well as the endodontic
procedures.
Objectives
To compare the effectiveness of single- and multiple-visit RoCT, measured as tooth extraction due to endodontic problems and
radiological success.
To assess the difference in short- and long-term complications between single- and multiple-visit RoCT.
Search strategy
The following databases were searched for relevant trials: Cochrane Or al Health Groups Trials Register, CENTRAL, MEDLINE,
and EMBASE. Handsearching was performed for the major oral medicine journals. References of included studies and reviews were
checked. Endodontics experts were contacted through e-mail. No language limitations were imposed. Date of last search was 6th March
2007.
Selection criteria
Randomised and quasi-randomised controlled trials of patients needing RoCT were included. Surgical endodontic treatment was
excluded. The outcomes considered were the number of teeth extracted for endodontic problems; radiological success after at least 1
year, that is, absence of any periapical radiolucency; postoperative pain; painkiller use; swelling; or sinus track formation.
Data coll ection and analysis
Data were collected using a specific extraction form. The validity of included studies was assessed on the basis of allocation concealment,
blindness of the study, and loss of participants. Data were analysed by cal cul ating risk ratios. When valid and relevant data were collected,
a meta-analysis of the data was undertaken.
Main results
Twelve randomised controlled trials were included in the review. Four studies had a low risk of bias, four a moderate risk, and another
four had a high risk of bias. The frequency of radiological success and immediate postoperative pain were not significantly different
between single- and multiple-visit RoCT. Patients undergoing single-visit RoCT reported a higher frequency of painkiller use and
swelling, but the results for swelling were not significantly different between the two groups. We found no study that included tooth
loss and sinus track formation among its primary outcomes.
1Single versus multiple visits for endodontic treatment of permanent teeth (Review)
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Authors conclusions
No difference exists in the effectiveness of RoCT, in terms of radiological success, between single- and multiple-visit RoCT. Most short-
and long-term complications are also similar in terms of frequency, although patients undergoing a single visit may experience a slightly
higher frequency of swelling and are significatively more likely to take painkillers.
P L A I N L A N G U A G E S U M M A R Y
Single versus multiple visits for endodontic treatment of pe r manent teeth
Root canal treatment or endodontic treatment, is a common procedure in dentistry. The main indications for root canal treatment
are irreversible inflammation of the dental pulp (pulpitis) and death of the dental pulp caused by carious processes, tooth cracks or
chips, or dental trauma. Successful root canal treatment is characterised by an absence of symptoms and clinical signs in teeth without
radiographic evidence of periodontal involvement. The success of root canal treatment depends on a series of variables related to the
preoperative condition of the tooth, as well as the endodontic procedures.
No difference exists in the effectiveness of root canal treatment, in terms of radiological success, between single- and multiple-visit root
canal treatment. Most short- and long-term complications are also similar in terms of frequency, although patients undergoing a single
visit may experience a slightly higher frequency of swelling and are significatively more likely to take painkillers.
B A C K G R O U N D
Root canal treatment (RoCT), or endodontic treatment, is a com-
mon procedure in dentistry. The main indications for RoCT are
irreversible pulpitis and necrosis of the dental pulp caused by
carious processes, tooth cracks or chips, or dental trauma. Root
canal treatment is a procedure performed to remove organic tis-
sue, infected debris, and pathogenic bacteria from the root canal
system by means of mechanical instrumentation associated with
copious irrigation with disinfectant agents. After drying, the en-
dodontic space is filled with an intracanal filling usually made
from root canal ce ment and gutta-percha, a rubber-based material.
The placement of a safe coronal seal completes the RoCT pro-
cedure. All these procedures have been summarised by Orstavik
1998; the basic biological rationale for achieving final success of
RoCT consists primarily of eliminating microorganisms from the
entire root canal system. Different therapeutic procedures can be
employed, depending upon the biological condition of the tooth
being treated, its pathological state, clinician expertise, instrument
availability, and patient preference. Successful RoCT is charac-
terised by the absence of symptoms and clinical signs of infection
in a tooth without radiographic evidence of periodontal involve-
ment (Friedman 2002). The success of RoCT depends on a series
of variables related to the preoperative condition of the tooth, as
well as the endodontic procedures.
Root canal treatment can be followed by numerous short- and
long-term complications (Battrum 1996). The former include im-
mediate postoperative inflammation of periradicular tissues asso-
ciated with pain, either spontaneous or provoked. The correla-
tion of postoperative pain with different variables, including the
number of visits needed to complete RoCT, operative procedures,
pulp vitality, and dental anatomy, has been the objective of numer-
ous studies (Albashaireh 1998; DiRenzo 2002; Eleazer PD 1998;
Gambarini 1991; Pekruhn 1981; Roane 1983; Soltanoff 1978).
The main long-term complications include the persistence of in-
flammation and/or fistula or sinus track, pain, and an absence
of radiographic healing. Several studies have investigated the fre-
quency of radiographic healing in teeth with preoperative periapi-
cal pathology and have compared single- and multiple-visit ap-
proaches, employing interappointment medication (Katebzadeh
2000; Peters 2002; Soltanoff 1978; Trope 1999; Weiger 2000).
The results of such investigations have led to conflicting conclu-
sions. Some studies (Fava 1995) have suggested that the use of
different medications in between visits can contribute to the elim-
ination of all bacteria. In contrast, others have emphasised th e
need to seal th e e ndodontic space in a single visit, as temporary
cements are unreliable in maintaining a good coronal seal during
the time between visits. In addition, postoperative complications
have been reported with both methods, varying from 5% (Abbott
2000) to > 20% (Friedman 1995).
The aim of this review was to clarify whether completion of root
canal treatment in a single visit or over a few visits, employing
bacteriostatic or bactericidal medications, makes any difference in
term of efficacy or complications or both.
O B J E C T I V E S
To test the null h ypothesis that no diffe rence exists in effectiveness,
measured as tooth loss and radiological failure, between single-
and multiple-visit root canal treatment (RoCT).
2Single versus multiple visits for endodontic treatment of permanent teeth (Review)
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To test the null hypothesis that no difference exists in short- and
long-term complications between single- and multiple-visit RoCT.
To investigate whether single- and multiple-visit RoCT offer simi-
lar prognosis for pulpitic teeth (vital), necrotic teeth, or previously
treated teeth.
C R I T E R I A F O R C O N S I D E R I N G
S T U D I E S F O R T H I S R E V I E W
Types of studies
Randomised and quasi-randomised (i.e. those using an alternative
assignment based on, for example, birth date) controlled trials
with a minimal follow up of 12 months for evaluation of the final
outcome. The same study designs were considered without any
limitations in the follow-up evaluation of long- and short-term
complications. Split-mouth studies were also considered.
Types of participants
Patients aged > 10 years who underwent root canal treatment. All
subjects had te eth with a completely formed apex and without
internal reabsorption.
Types of intervention
Root canal treatment in single or multiple visits, i.e . two or more
appointments.
No difference in systemic medical treatment (antibiotics, non-
steroidal anti-inflammatories or analgesics) could be present in the
two groups.
Types of outcome measures
The outcome measures for effectiveness were the following.
Tooth extraction due to endodontic problems (binary, yes/no).
Radiological failure after 1 year, i.e. the presence of any periapi-
cal radiolucency (binary, yes/no). ’Additional Table 01’ sum-
marises how we adapted the most common scales of radiologi-
cal success to a binary outcome.
The outcome measures for complications were the following.
Postoperative pain (binary, yes/no).
Swelling (binary, yes/no).
Painkiller use (binary, yes/no).
Sinus track or fistula formation (binary, yes/no).
S E A R C H M E T H O D S F O R
I D E N T I F I C A T I O N O F S T U D I E S
See: Cochrane Oral Health Group methods used in reviews.
The following databases were searched for relevant trials:
Cochrane Oral Health Groups Trials Register (to March 2007)
Cochrane Central Register of Controlled Trials (CENTRAL)
(The Cochrane Library 2007, Issue 1)
MEDLINE (1966 to March 2007)
EMBASE (1974 to March 2007).
Studies to include in the review were searched for in MEDLINE
using the PubMed software and the following search strategy.
The numbers in parentheses indicate the number of records
retrieved in PubMed on 6th March 2007:
#1Search endodontic* (11565)
#2Search root canal therapy (13439)
#3Search dental pulp capping OR pulpectomy OR pulpotomy
(3025)
#4Search endodontic* OR pulpectom OR pulpotom (11565)
#5Search root canal ( therapy OR treat) (11407)
#6Search ( pulp AND cap*) OR ( pul p* AND devitali*) (1104)
#7Search single AND ( visit* OR appointment* OR session*)
(10572)
#8Search multi AND ( visit* OR appointment* OR session*)
(1302)
#9Search ( first OR second OR third) AND (visit* OR
appointment* OR session*) (31650)
#10Search ( 1st OR 2nd OR 3rd) AND (visit* OR appointment*
OR session*) (1751)
#11Search ( one OR two OR th ree) AND (visit* OR
appointment* OR session*) (66975)
#12Search #7 OR #8 OR #9 OR #10 OR #11 (83203)
#13Search #1 OR #2 OR #3 OR #4 OR #5 OR #6 (22020)
#14Search #12 AND #13 (401)
This strategy was adapted for the othe r databases.
The following journals were identified as being important for
conducting manual searches to include in this review, when these
had not already been searched as a part of the Cochrane Journal
Handsearching Programme (check at www.ohg.cochrane.org in
the Journal Handsearching Programme section to know which
journals are handsearched):
Giornale Italiano di Endodonzia, Revue Française de Endodontie,
German Endodontie, Endodontic Practice.
Proceedings from major dental organisations International
Federation on Endodontic Associations (IFEA), European
Society of Endodontology (ESE), Italian Endodontic Society
(SIE), International Association for Dental Research (IADR),
British Endodontics Society, Brazilian Endodontics Society from
1980 to 2004.
Studies in all languages were considered for translation.
All references in the identified papers were checked and the
authors contacted to identify any additional published or
unpublished data.
3Single versus multiple visits for endodontic treatment of permanent teeth (Review)
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M E T H O D S O F T H E R E V I E W
The titles and abstracts (when available) of all reports identified
through the electronic searches were scanned independently by
two review authors (Massimo Gagliani (MG) and Lara Figini
(LF)). For studies appearing to meet the inclusion criteria, or for
which insufficient data were in the title and abstract to make
a clear decision, the full report was obtained. The full reports
obtained from all the el ectronic databases and other methods of
searching were assessed independently by two review authors (MG
and LF) to establish whether the studies met the inclusion criteria.
Any disagreements were resolved by discussion. A third individual
(Giovanni Lodi (GL)) was consulted if unresolved disagreements
occurred.
All studies meeting the inclusion criteria underwent a validity
assessment and data extraction. The validity of the studies was
judged according to the criteria for randomised trial data suggested
by the Cochrane Handbook for Systematic Reviews ofInterventions
4.2.6 (updated September 2006) (Higgins 2006) and Evidence-
Based Medicine: How to practice and teach EBM (Sackett 1997). In
particular, study validity was judged on the basis of the following.
(1) Allocation concealment, recorded as (A) Adequate (criterion
met), (B) Unclear, or (C) Inadequate (criterion unmet), as
described in the Cochrane Handbook for Systematic Reviews of
Interventions 4.2.6.
(2) Participant loss. At least 80% of the patients who entered the
trial were included in the final analysis: (A) Yes (criterion met),
(B) No (criterion unmet), or (C) Unclear.
The global validity of the studies was assessed using the following
three categories.
(1) Low risk of bias: all of the criteria me t.
(2) Moderate risk of bias: not all cases included in categories (1)
or (2).
(3) High risk of bias: one or more criter ia unmet.
The critical appraisal of the studies was carried out by two
review authors (MG and LF) without concealing the names of
authors, institutions, and medical journals. Data about the study,
its eligibility, validity, design, and outcome were recorded by each
review author on a custom-designed form. In case of disagreement,
consensus was sought out through discussion, and a new form was
consequently filled out.
In cases when valid and relevant data were collected, a meta-
analysis of the data was undertaken. For each intervention,
statistical analyses evaluated differences among the outcomes
considered. Dichotomous data were expected for the main
outcome measurements. To compare dichotomous data risk ratio
was employed. A meta-analysis could only be conducted if the
studies were judged sufficiently similar in terms of design, types
of patient, and interventions. In addition, heterogeneity between
trial results was tested using a standard chi-squared test. A standard
result model was used in the statistical analyses.
The patient was the statistical unit. Studies considering the tooth
as the statistical unit were considered in cases where the number
of teeth was not too much larger than the number of patients.
During interpretation of results, it was noted that when data from
teeth were included, the confidence interval is narrower than it
should be.
When raw data were not available, they were obtained by
consulting tables and graphs, or by contacting the authors.
Subgroup analysis was planned to investigate the relevance of
pretreatment conditions (vital teeth versus necrotic pupal teeth),
pretreatment symptoms (symptomatic versus asymptomatic
teeth), pretreatment radiographic periapical appearance (apical
radiolucency versus no apical radiolucency), endodontic
technique, and antimicrobials employed (antimicrobial A versus
antimicrobial B).
A sensitivity analysis was performed, excluding the studies of lower
methodological quality (i.e. studies with an ele vated risk of bias).
D E S C R I P T I O N O F S T U D I E S
Fifty-four potentially e ligible randomised controlled trials were
identified; 41 were excluded (see ’Characteristics of excluded stud-
ies table), and one is awaiting assessment (Papworth B 1998), leav-
ing 12 studies to be included in this review. All studies compared
root canal treatment (RoCT) performed in a single visit to root
canal treatment performed in multiple visits. In the multiple-visit
approach, the majority of authors completed the treatment in two
visits (Al-Negrish 2006; Albashaireh 1998; DiRenzo 2002; Gesi
2006; Ghoddusi 2006; Peters 2002; Trope 1999; Weiger 2000;
Yoldas 2004), while in one study RoCT lasted th ree visits (Mul-
hern 1982). In two studies the number of visits is not specified
(Oginni 2004; Soltanoff 1978). All studies had a two-arm design,
with the exception of two studies with three arms, in which the
authors compared a single visit, multipl e visits without intracanal
medication, and multiple visits with intracanal medication (cal -
cium hydroxide) (Ghoddusi 2006; Trope 1999). In order to in-
clude such data in the meta-analysis we decided to combine the
two multivisit arms, we considered it acceptable as in the same
meta-analysis we pooled data from studies that used or did not use
a dressing.
All studies considered one tooth per patient, with the exception of
Oginni 2004 and Trope 1999. Trope 1999 considered 102 teeth
in 81 patients (61 patients had a single tooth, 18 had two and 2
patients had three teeth). In Oginni 2004 patients requiring root
canal treatment on more than one tooth, underwent consecutive
treatment of each tooth with an interval at least 4 weeks to allow
proper evaluation. There were 283 teeth randomised in 255 pa-
tients. For each study (Oginni 2004; Trope 1999) the analysis was
conducted at the level of the tooth (consideration was given to the
width of the confidence interval).
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Al-Negrish 2006; Ghoddusi 2006; Mulhern 1982; Peters 2002;
Trope 1999; Weiger 2000 included patients with necrotic teeth
only, Yoldas 2004 is th e only one that included only retreatment,
while Gesi 2006 included only patients with vital teeth. Three
studies included both necrotic teeth and vital teeth (Albashaireh
1998; DiRenzo 2002; Oginni 2004), but two of them did not
provide details on the numbers of the two categories (DiRenzo
2002; O ginni 2004). One study did not provide details on the
pretreatment status (Soltanoff 1978).
In the multiple-visit approach, five studies (Albashaireh 1998; Di-
Renzo 2002; Ghoddusi 2006; Mulhern 1982; Trope 1999) did
not use any intracanal medications in the interappointment pe-
riod. In five studies (Al-Negrish 2006; Gesi 2006; Peters 2002;
Weiger 2000; Yoldas 2004), the root canals were medicated with a
calcium hydroxide paste, while two studies did not specify the type
of interappointment medication (Oginni 2004; Soltanoff 1978).
In nine studies, sodium hypochlorite was used as an irrigant (Al-
Negrish 2006; Albashaireh 1998; DiRenzo 2002; Gesi 2006; Mul-
hern 1982; Peters 2002; Trope 1999; Weiger 2000; Yoldas 2004),
and in two studies, saline solution was used as irrigant (Ghoddusi
2006; Soltanoff 1978). In the study of Oginni 2004, the type of
irrigant used was not specified.
We found no study providing information on tooth e xtraction due
to endodontic problems as outcome measure.
Radiological failure was investigated in five studies (Gesi 2006;
Peters 2002; Soltanoff 1978; Trope 1999; Weiger 2000). Methods
adopted to construct scales for radiological success or failure are
shown in ’Additional Table 01.’ Follow up varied from 1 (Trope
1999) to 5 (Weiger 2000) years.
Eight studies investigated postoperative pain (Al-Negrish 2006;
Albashaireh 1998; Gesi 2006; Ghoddusi 2006; Mulhern 1982;
Oginni 2004; Soltanoff 1978; Yoldas 2004). The methods for eval-
uating postoperative pain are summarised in the ’Characteristics
of included studies table. We dichotomised all data into pain or
’no pain values. We considered only pain after canal obturation,
assessing pain incidence in the canal in the immediate postobtu-
ration period (until 72 hours), at 1 week, and at 1 month. We did
not consider pain during the interappointment period in th e mul-
tiple-visit approach, as we could not compare this with a similar
situation in the single-visit approach.
Six studies investigated the incidence of swelling or flare-up or
both (Al-Negrish 2006; DiRenzo 2002; Ghoddusi 2006; Mulh-
ern 1982; Oginni 2004; Yoldas 2004). The definitions of flare-up
can vary (see ’Additional Table 02’). Only DiRenzo 2002; Mulh-
ern 1982 and Ghoddusi 2006 clearly defined flare-up as swelling.
Therefore, we considered only studies clearly indicating swelling
as an outcome. We considered swel ling incidence in the operative
and postoperative periods.
Three studies examined the need for patients to take analgesics to
relieve pain (Mulhern 1982; Soltanoff 1978; Yoldas 2004).
We found no studies providing information on fistula or sinus
track formation as outcome measure.
All the studies were performed in university clinics or h ospitals,
with the exception of Gesi 2006, which was undertaken in private
practice. In all studies, the treatment was conducted by expert en-
dodontists, except for DiRenzo 2002 and Mulhern 1982, in which
the treatment was performed by postgraduate students, and f or
Ghoddusi 2006, in which the operators were general practitioners.
Oginni 2004; Soltanoff 1978; Trope 1999 and Yoldas 2004 did
not provide details about the operators.
M E T H O D O L O G I C A L Q U A L I T Y
On the basis of the criteria used in the critical appraisal, four stud-
ies were shown to have a low risk of bias (DiRenzo 2002; Gesi
2006; Trope 1999; Weiger 2000). Four studies were judged as
having a moderate risk of bias (Ghoddusi 2006; Mulhern 1982;
Oginni 2004; Soltanoff 1978), and in these studies, the allocation
concealment was not described. The remaining studies (Al-Negr-
ish 2006; Albashaireh 1998; Peters 2002; Yoldas 2004) were con-
sidered as posing a high risk of bias. In three of these (Al-Negrish
2006; Albashaireh 1998; Peters 2002), the randomisation was in-
adequate for alternative assignment (randomly and consecutively,
quasi-random method), and in Yoldas 2004, the randomisation
was not explained in a satisfactory way. In all the included studies,
> 80% of the patients who enrolled were included in the final
analysis.
R E S U L T S
No study reported tooth extraction due to endodontic problems
or fistula or sinus track formation.
Pain (Comparison 01 Outcome 01)
Postoperative pain (up to 72 hours)
Results from six studies (Al-Negrish 2006; Albashaireh 1998;
Ghoddusi 2006; Mulhern 1982; Oginni 2004; Soltanoff 1978)
that included 1047 patients were available for the analysis of pain
incidence 72 hours after canal obturation. Between-study hetero-
geneity was assessed using the standard chi-squared (chi
2
) test and
I-squared (I
2)
test. The studies were homogeneous (chi
2
8.68; de-
grees of freedom (df) 5; P = 0.12; I
2
42.4%), and a meta-analysis
was performed on the combined data. Incidence of postoperative
pain at 72 hours was similar in the two groups (risk ratio (RR) 0.99
(95% confidence interval (CI) 0.83 to 1.18)). Sensitivity analy-
ses performed on four studies (Ghoddusi 2006; Mulhern 1982;
Oginni 2004; Soltanoff 1978) corroborated the previous result.
Pain at 1 week
Results from five studies (Al-Negrish 2006; Gesi 2006; Mulher n
1982; Oginni 2004; Soltanoff 1978) that included 936 patients
were available for analysis of pain at 1 week. The studies were
homogeneous (chi
2
3.73; df 4; P = 0.44; I
2
0%), allowing data
5Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 7
pooling. One-week postoperative pain was less common follow-
ing multiple-visit root canal treatment (RoCT) compared to sin-
gle-visit treatment, but the difference was not statistically signif-
icant (RR 1.07 (95% CI 0.72 to 1.57)). Sensitivity analyses per-
formed on four studies (Gesi 2006; Mulhern 1982; Oginni 2004;
Soltanoff 1978) corroborated this result (RR 1.17 (95% CI 0.78
to 1.76)).
Pain at 1 month
Only two studies reported pain 1 month after canal obturation
(Albashaireh 1998; Oginni 2004). In both studies, no patient had
persistent pain at 1 month. Thus, a meta-analysis of th e studies
was not possible.
Results from Yoldas 2004 were excluded from pain meta-analysis
because the pain data were not divided according to time of onset.
Single- and multiple-visit RoCT showed no significant difference
in incidence of pain (RR 1.88 (95% CI 0.87 to 4.07)). The inci-
dence of pain was greatest during the first 48 hours after obtura-
tion, and th en decreased steadily in the subsequent 7 days. Of the
227 patients enrolled in the study, 68 had symptomatic and 159
had asymptomatic teeth. When data were analysed to consider the
presence of symptoms before RoCT, postoperative pain was found
significantly more often in patients with symptomatic teeth.
Painkiller use (Comparison 01 Outcome 02)
Results from three studies (Mulhern 1982; Soltanoff 1978; Yoldas
2004), including 559 patients, were available for the analyses. In
all three studies use of painkillers afte r canal obturation was more
common among patients undergoing the single-visit approach.
Studies were homogeneous (chi
2
1.31; df 2; P = 0.52; I
2
0%).
Meta-analysis showed that use of painkillers was significantly more
common in patients undergoing single-visit RoCT (RR 2.42 (95%
CI 1.62 to 3.62)). This was confirmed also by sensitivity analysis
(RR 2.36 (95% CI 1.51 to 3.66)) including two studies (Mulhern
1982; Soltanoff 1978).
Gesi 2006; Ghoddusi 2006 and Mulhern 1982 reported pain in-
cidence in the interappointment period of the multiple-visit pro-
cedure, such data are not included in the meta-analysis, as they
cannot be compared with a similar outcome of the single-visit ap-
proach.
Radiological failure (Comparison 01 Outcome 03)
Results from five studies (Gesi 2006; Peters 2002; Soltanoff 1978;
Trope 1999; Weiger 2000) that included 657 patients were avail-
able for the meta-analysis. The radiological failure rate was based
on binary data, that is, radiological healing versus lack of such
healing; scores including more than two values were dichotomised
according to the methods indicated in ’Additional Table 01. The
studies included were homogeneous (chi
2
3.41; df 4; P = 0.49;
I
2
0%), and f ollowing data pooling, single-visit RoCT appeared to
be slightly more effective than multiple-visit RoCT, alth ough the
difference was not statistically significant (RR 0.85 (95% CI 0.59
to 1.23)). These results were corroborated by sensitivity analyses
performed in the four studies (RR 0.88 (95% CI 0.60 to 1.30)).
Swelling (Comparison 01 Outcome 04)
We could not compare all the studies reporting flare-up (see ’Ad-
ditional Table 02’) because they did not provide a comparable
definition of flare-up. Many studies included both swelling and
severe pain in the definition of flare-up, so it was not possible to
discriminate these data. Only three studies considered flare-up as
swelling (DiRenzo 2002; Ghoddusi 2006; Mulhern 1982); these
included 192 patients, and data were available for analysis. The
studies were homogeneous (chi
2
1.67; df 2; P = 0.43; I
2
0%), and
swelling appeared to be less common with multiple-visit RoCT
than with single-visit RoCT, but the difference was not statistically
significant (RR 1.40 (95% CI 0.67 to 2.93)).
Subgroup analysis in necrotic teeth
We repeated the analysis, dividing the studies according to pre-
treatment status. We found seven studies (Al-Negrish 2006; Ghod-
dusi 2006; Mulhern 1982; Peters 2002; Trope 1999; Weiger 2000;
Yoldas 2004) that included only necrotic teeth and one study that
included only vital tee th (Gesi 2006). In addition, it was possi-
ble to extract data regarding vital teeth from another study (Al-
bashaireh 1998). Data pooling was possible only for studies in-
cluding necrotic teeth, as those with vital teeth had non-compa-
rable outcomes. Incidence of pain remained non-significantly dif-
ferent when necrotic tee th were considered, although it was less
common with the single-visit approach. Radiological failure was
less common after a single visit and the result was close to statistical
significativity (RR 0.62 (95% CI 0.37 to 1.02)). The results for
swelling and any complications were not affected by this subgroup
analysis.
There were insufficient data to undertake subgroup analyses on
other predefined criteria.
D I S C U S S I O N
The main objective for an endodontist undertaking root canal
treatment (RoCT) is to be successful in terms of preventing, and
when necessary, healing endodontic diseases, such as apical peri-
odontitis, and avoiding patient discomfort in the process if pos-
sible. The basic biological rationale for achieving ultimate suc-
cess with RoCT consists primarily of eliminating microorganisms
from the entire root canal system and creating an environment
that is most favorable for healing. Several studies have shown that
it is very difficult to achieve a bacteria-free root canal system, even
after adequate cleaning, shaping, and irrigation (Bystrom 1981;
Orstavik 1991; Sjogren 1997). Two approaches have been pro-
posed to solve this problem. In one case, residual bacteria are
eliminated or prevented from repopulating the root canal system
by introducing an interappointment dressing into the root canal,
generally falling into the following categories: phenolic deriva-
tives (eugenol, camphorated para-monochlorophenol, camphor-
ated phenol, metacresyl acetate, beechwood creosote), aldehydes
(formocresol), halides (iodine-potassium iodide), calcium hydrox-
6Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 8
ide, antibiotics, and various other combinations. The most pop-
ular intracanal medication currently in use is calcium hydroxide.
Some studies (Kvist 2004; Orstavik 1991; Reit 1988) have shown
that calcium hydroxide fails to produce sterile root canals and even
allows regrowth in some cases. However, even a negative culture
before obturation gives no guarantee of healing in all cases (Sjo-
gren 1997; Trope 1999; Weiger 2000). The second approach is
aimed at eliminating the remaining bacteria or rendering them
harmless by entombing them by complete and three-dimensional
obturation, finishing the treatment in one visit, to deprive the mi-
croorganisms of nutrition and the space required to survive and
multiply (Oliet 1983; Soltanoff 1978; Weiger 2000). The antimi-
crobial activity of the seal er or the zinc (Zn) ions of gutta-percha
can kill the residual bacteria (Moorer 1982; Siqueira 2000).
Endodontic success indicators can be short or long term. The
short-term indicators concern the absence of any postoperative
discomfort, the most important short-term outcome of RoCT.
Pain perception is highly subjective and modulated by multiple
physical and psychological factors, and the measurement of pain
is fraught with hazards and opportunities for errors. The level of
discomfort must be rated in categories arranged in advance and ex-
actly described (slight pain: the tooth involved was slightly painful
for a time, regardless of duration, but no need existed to take
analgesics). This is stated in Al-Negrish 2006; Albashaireh 1998;
Oginni 2004 and Yoldas 2004, who gave accurate criteria for the
categories of patient pain; however, it was not given by Mulhern
1982 and Soltanoff 1978, who were more imprecise in their defi-
nition of different pain categories. For this reason, we considered
only two categories (pain and no pain), and we did not consider
pain intensity because it is too subjective. According to our review,
the incidence of postobturation pain is similar with single- and
multiple-visit RoCT, although painkiller use is significantly less in
patients undergoing multiple-visit RoCT. It is possible that in the
single-visit approach the working time is longer, causing a more
severe acute inflammatory response in the interappointment pe-
riod. Another factor could be the beneficial effect of the intracanal
medication in the between-visit interval.
Incidence of short-term swell ing (another sign of infectious com-
plication) was lower with the multiple -visit approach. Note that
in the three studies considering this outcome (DiRenzo 2002;
Ghoddusi 2006; Mulhern 1982), all teeth undergoing RoCT had
necrotic pulp. DiRenzo 2002 and Mulhern 1982 gave conflict-
ing results for the incidence of swelling; both used 2.5% sodium
hypochlorite as an irrigant, and no intracanal interappointment
medication with the multiple-visit approach, closing the empty
canals only with a sterile dry cotton pellet and a temporary restora-
tion for 1 week. In any case, th e incidence of swelling in these two
studies was very small (two episodes in Mulhern 1982 and only
one in DiRenzo 2002). The Ghoddusi 2006 study is of particu-
lar interest. In fact, when no interappointment canal medication
was employed, the incidence of swelling was very similar in the
two groups, while when calcium hydroxide was left in the canals
between visits, the multiple-visit treatment performed much bet-
ter. Such a difference may have occurred because normal saline
solution was used as the sole irrigant during RoCT. Thus, with
the single-visit approach, nothing with any antibacterial activity
was included in the RoCT. While with the multiple -visit treat-
ment empl oying interappointment medication, antibacterial ac-
tivity was provided by calcium hydroxide.
Long-term success is based mainly on the healing of periapical
lesions whenever present, and the prevention of new lesions. The
healing rate can be established by radiographic interpretation, a
method very dependent on human visual perception. Trope 1999
was the only study that performed an extensive calibration of the
evaluators (nine observers: four graduate oral and maxillofacial ra-
diology residents, two graduate endodontic residents, one oral epi-
demiologist, one general dentist, and one experienced endodon-
tist, all blinded to the treatment groups and aims of the study).
In Weiger 2000 the radiographs were judged by both dentists in-
volved in the study in a blinded manner. Pe ters 2002 reported
that three e xperienced endodontists who had not been involved in
the treatment or follow up were asked to analyse the radiographs.
Radiological success was more common in the single-visit group,
although the result did not reach statistical significance. It became
significant, however, when only necrotic teeth were considered;
therefore, intracanal interappointment medication may be unnec-
essary when the operator, during a single visit, carefully cleans the
canals with an adequate irrigant. It is accepted that multiple visits
are appropriate for symptomatic teeth with long-standing chronic
periapical lesions, and for those undergoing retreatment, based on
the rationale that placing an interim dressing of an iodine-calcium
hydroxide combination is known to be effective against Strepto-
coccus faecalis, an organism commonly found in failed cases. Un-
fortunately, we could not investigate this question in this review
because only one study (Yoldas 2004) considered retreatment, and
it had a high risk of bias.
Thus, the effectiveness of single- and multiple-visit root canal
treatment is not substantially different. Most short- and long-term
complications are similar in terms of frequency, although patients
undergoing single-visit RoCT may experience a higher frequency
of swelling and are more likely to take analgesics. Our results with
healing reveal that single-visit RoCT appears to be slightly more
effective than multiple-visit RoCT, without the difference reach-
ing statistical significance, and very similar results were obtained
by another systematic review (Sathorn 2005).
A U T H O R S C O N C L U S I O N S
Implications for practice
There is no evidence to suggest th at one treatment regimen (single -
visit or multiple-visit root canal treatment) is better than the other.
Neither can prevent 100% of short- and long-term complications.
7Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 9
It is likely that the benefit of a single-visit treatment, in terms of
time and convenience, for both patient and dentist, has the cost of a
higher frequency of late postoperative pain (and as a consequence,
painkiller use) and swelling.
Implications for research
Because of th e increasing use of rotary nickel-titanium (NiTi) in-
struments, a well designed randomised controlled trial compar-
ing single-visit and multiple-visit root canal treatment, both per-
formed with such instruments, would be an important contribu-
tion.
It would be very helpful for clinicians that researchers include in
their studies tooth loss as primary outcome, even reporting if none
occur.
P O T E N T I A L C O N F L I C T O F
I N T E R E S T
None know.
A C K N O W L E D G E M E N T S
The review authors wish to thank Emma Tavender, Luisa Fer-
nandez, Sylvia Bickley and Marco Esposito for their support. Dr
Cristina Frezzini for her help in retrieving papers. All the re-
searchers of the cited studies who have provided some of the data
useful in the review and the referees for their precious suggestions.
A special thanks to Silvia Motta for translation from Russian lan-
guage and to Hu Luca for translation from Chinese.
S O U R C E S O F S U P P O R T
External sources of support
No sources of support supplied
Internal sources of support
No sources of support supplied
R E F E R E N C E S
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DiRenzo 2002 {published data only}
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teach EBM. Churchill Livingstone, 1997:79–156.
Sathorn 2005
Sathorn C, Parashos P, Messer HH. Effectiveness of s ingle- versus
multiple-visit endodontic treatment of teeth with apical periodonti-
tis: a systematic review and meta-analysis. International Endodontic
Journal 2005;38(6):347–55.
Siqueira 2000
Siqueira JF, Favieri A, Gahyva SM, Moraes SR, Lima KC, Lopes HP.
Antimicrobial activity and fl ow rate of newer and established root
canal sealers. Journal of Endodontics 2000;26(5):274–7.
T A B L E S
Characteristics of included studies
Study Al-Negrish 2006
Methods Quasi-randomised parallel-group, clinical trial; high risk of bias. 93.3% of patients who entered the study
were included in the final analysis.
Participants 120 participants (66 female and 54 males) aged 15-45 years. 8 patients (6 females and 2 males, 6 from Group
1 and 2 from Group 2) were excluded from the analysis of the results as they failed to attend postoperative
visits.
Inclusion criteria: patients with asymptomatic necrotic central incisor teeth. Exclusion criteria: any evidence
of periapical radiolucent lesion, teeth tender to touch, with intracanal calcification or incompletely formed
apices, retreatments, teeth with pulpal sensitivity and vitality. Diagnostic criteria for pulpally or periapical
disease: Rx signs, pulp testing, presence or absence of haemorrhage upon access opening.
11Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 13
Characteristics of included studies (Continued )
Interventions Single visit (Group 1) or multiple visits (Group 2). Rubber dam isolation. Use of magnification loupes not
specified. Canal shaping: step-back technique with conventional K files and gates. Irrigation: 2.5% sodium
hypochlorite. Working length determined by Rx, obturation with gutta-percha and a zinc oxide eugenol
sealer (Tubliseal, Kerr) in lateral condensation. In the Group 2 the number or visits were 2 (the second
appointment 7 days later), the canals were medicated for 7 days with a calcium hydroxide paste with a dry
sterile cotton pledget and a temporary filling restoration.
Outcomes Pain (after 2-day postobturation period, and after 7-day postobturation period) was reported as: 1 no pain,
2 slight pain, 3 moderate pain, 4 severe pain. We considered only 2 categories: No pain and pain (slight,
moderate and severe pain).
Flare-up: percentage of patients experiencing moderate to severe pain evaluated after 2 and 7 days (see
’Additional Table 02’).
Notes
Allocation concealment C Inadequate
Study Albashaireh 1998
Methods Quasi-randomised parallel-group, clinical trial; high risk of bias. 97% of patients who entered the study were
included in the final analysis.
Participants 300 participants, 291 were included in the final analysis. Sex not reported, age range from 15 to 65. All
patients referred to the Conservation Unit (Jordan University of Science and Technology) for conventional
endodontic treatment during the period of the investigation (30 days), were included in the study. Exclusion
criteria: teeth tender to touch, with extensive intracanal calcification and incompletely formed apices.
Diagnostic criteria for pulpal or periapical disease: pulpal vitality and sensitivity (pulp-testing and direct
presence or absence of haemorrhage), presence of periapical radiolucency in periapical radiographs.
Interventions Single visit (Group 1) or multiple visits (Group 2). 1 operator. Rubber dam isolation, use of magnification
loupes and working length not reported.
Canal shaping with step-back technique, obturation with gutta-percha and a calcium h ydroxide-based root
canal sealer (Sealapex) with lateral condensation technique. Irrigation with 2.6% sodium hypochlorite solu-
tion. In Group 2 no medicament was placed, but a dry sterile cotton pledget sealed in pulp chamber with a
temporary filling restoration.
Outcomes Pain (incidence and degree of pain at the 1st, and 30th postobturation day) was reported as: 1 no pain,
2 slight pain, 3 moderate pain, 4 severe pain. We considered only 2 categories: no pain and pain (slight,
moderate and severe pain).
Notes
Allocation concealment C Inadequate
Study DiRenzo 2002
Methods Randomised, parallel-group, clinical trial. Low risk of bias. 90% of patients who entered the study were
included in the final analysis.
Participants 80 participants, 72 were included in the final analysis. Sex and ethnic group not reported. Age of patients:
over 18 years old. Inclusion criteria: mature vital and non-vital permanent maxillary and mandibular molars.
Exclusion criteria: pregnancy, use of antibiotics or corticosteroids at the time of treatment, immunocompro-
mised states, subjects under 18 years old. Diagnostic criteria for pulpal or periapical disease not specified.
Interventions Single visit (Group 1) or multiple visits (Group 2). 2 operators (postgraduate students). Rubber dam isolation.
Use of magnification loupes not specified. Canal shaping with hand files and NiTi rotary files. Irrigation with
2.5% Na0Cl. Working length deter mined by an electronic apex locator and 2 or more angled radiographs.
Obturation with gutta-percha and Roth 811 sealer in lateral condensation. In the Group 2 the treatment
were done in 2 visits, and th e teeth in the interappointment period were closed with a sterile dry cotton pellet
and Cavit temporary restorative cement.
12Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 14
Characteristics of included studies (Continued )
Outcomes Pain: a modified VAS was used to measure pain at 6, 12, 24, 48 hours after the first appointment. Flare-up
(as swelling that needs antibiotics and narcotic analgesics) (see ’Additional Table 02’).
Notes We were not able to extract th e dichotomous data from the tables that reported VAS pain measurements. We
sent an e-mail to authors to ask for these data. No answer obtained so we considered only result in flare-up.
Allocation concealment A Adequate
Study Gesi 2006
Methods Randomised, clinical trial, low risk of bias. 100% of patients who entered the study were included in the final
analysis of the outcome ’pain.’ 71.8% of patients who entered the study were included in the final analysis
of the outcome ’healing at 3 years f ollow up.
Participants 256 participants, 244 were included in the final analysis. 141 females, 115 mal es. Range age and ethnic group
not reported. Inclusion criteria: patients with teeth with painful and non-painful vital pulp, with bleeding
upon access of the pulpal chamber. Exclusion criteria: patients with physical or mental disability, patients
that took pain me dications or in treatment with antibiotics for systemic or local infection. Diagnostic criteria
for pulpal or periapical disease: vitality testing and thermal and mechanical stimulation.
Interventions Single visit (Group 1) or multiple visits (Group 2). Single operator. Rubber dam. Use of magnification loupes
not specified. Canal shaping: hand instrumentation with flexo-files using balanced force technique and crow-
down technique. Irrigation: 3% sodium hy pochlorite. Working length established by Rx. Obturation with
gutta-percha and pulp canal sealer (Kerr) with l ater al condensation. In the multiple approach the patients
underwent 2 visits. In the interappointment period calcium hydroxide was employed as intracanal medication
and Coltosol as temporary cement.
Outcomes Pain: valuated at 1 week after canal obturation by clinical examination and by a verbal rating scale to assess
pain experience. Patients with multivisit treatments were asked to evaluate their pain after 1 week for each
visit. We considered pain-related data only after canal obturation. A verbal rating scale (VRS) graded 0-3 was
used. Patients were asked to indicate 0 for no, 1 for mild, 2 for moderate and 3 for severe pain. Teeth were
also tapped for percussion sensitivity. We considered only 2 categories: pain (mild, moderate, severe) and no
pain.
Healing: (follow up until 3 years): 2 endodontists, well experienced in radiographic assessment of endodontic
treatments, neither of whom was the operator and both masked to the assigned treatment group, carried out
the analysis of the radiographs. Parameters were presence or absence of periapical radiolucency (radiographic
lesion) (see ’Additional Table 01’). In 2-or multirooted te eth, the tooth was classified according to the
diagnosis of the worst root.
Notes
Allocation concealment A Adequate
Study Ghoddusi 2006
Methods Randomised, parallel-group, clinical tr ial; moderate risk of bias. 85% of patients who entered the study were
included in the final analysis.
Participants 69 patients e nrolled, 60 were included in the final analysis. Of these subjects 2 were excluded because they
did not pursue the treatment, 3 because of overfilling and 4 because of positive cavity test. 39 females and 30
males. Not spe cified age range and ethnic group. Inclusion criteria: patients with pulpally necrotised teeth
referred to the Endodontics Department of Mashad Dental School. Exclusion criteria: patients taking some
medication for systemic conditions. Diagnostic criteria for pulpal or periapical disease: ther mal and electrical
pulp test, pulp cavity test (direct presence or absence of haemorrhage), presence of periapical radiolucency
in periapical radiographs.
Interventions Single visit (Group 1) or multiple visits without any dressing (Group 2). Rubber dam isolation used. Use
of magnification loupes and canal shaping not specified in a satisfactory way. Irrigation with saline solution.
Working length e valuated by Rx, obturation with gutta-pecha in lateral condensation. In the Group 2 after
13Single versus multiple visits for endodontic treatment of permanent teeth (Review)
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Page 15
Characteristics of included studies (Continued )
the first appointment, the canal was left empty and the access cavities were sealed with sterilised cotton pel lets
and at least 3 mm of temporary fil ling material (Coltosol), the treatment was completed after 1 week.
Outcomes Pain (incidence and degree of pain in the immediate canal postobturation until 72 hours) was reported as:
1 no pain, 2 mild pain, 3 moderate pain, 4 severe pain. We considered only 2 categories: no pain, and pain
(mild, moderate and severe pain).
Flare-up (swelling).
Notes
Allocation concealment B Unclear
Study Mulhern 1982
Methods Randomised, clinical trial, moderate risk of bias. 100% of patients who entered the study were included in
the final analysis.
Participants 60 participants, all of the m were included in the final analysis: 31 females, 29 males. Range age from 13 to 75
years. Ethnic group reported: 1 Asian, 42 Whites and 17 Blacks. Inclusion criteria: non-surgical endodontic
treatment of asymptomatic mature single-rooted teeth with necrotic pulps. Exclusion criteria: patients with
severe medical conditions, using corticosteroids or anti-inflammatory drugs and/or recent or active antibiotics
therapy. Diagnostic criteria for pulpal or periapical disease: Rx and vitality test.
Interventions Single visit (Group 1) or multiple visits (Group 2). 2 operators (graduate endodontic students). Rubber
dam. Use of magnification l oupes and canal shaping not detailed. Irrigation: 2.5% sodium hypochlorite.
Working length not reported. Obturation with lateral condensation was performed using gutta-percha and
Kerr tubliseal. In the multiple approach the patients underwent 3 visits. In the interappointment period
no medication was used, only a dry pledget of cotton with a double cement system of Cavit G and zinc
oxyphosphate cement in the coronal access cavity was employed.
Outcomes Pain: valuated at 48 hours after treatment (by a questionnaire) and at 1 week (clinical examination). Patients
with multivisit treatment were asked to complete a questionnaire for each visit. Painkiller use. Flare-up
(swelling) (see ’Additional Table 02’).
Notes
Allocation concealment B Unclear
Study Oginni 2004
Methods Randomised, clinical trial, moderate risk of bias. 85.86% of patients who entered the study were included
in the final analysis about pain and flare-up in the 1st day; 80.21% of patients who entered the study were
included in the final analysis about pain and flare-up in the 7th day; 78.4% of patients who entered the study
were included in the final analysis at 30th day.
Participants 255 patients and 283 tee th were enrolled, 222 teeth were included in the final analysis about pain and flare-
up. For patients with more than 1 tooth requiring treatment, the treatment of each tooth was separated by
a period of at least 4 weeks. Sex, range or mean age, not reported. Inclusion criteria: all patients referred
to the department of Restorative Dentistry for root canal therapy. Patients that did not turn up after the
first appointment (incomplete treatment) were excluded from the study. Diagnostic criteria for pulpal or
periapical disease: the pulp vitality was determined by an electric pulp tester in combination with the presence
of pulpal haemorrhage.
Interventions Single visit (Group 1) or multiple visits (Group 2). Rubber dam isolation, use of magnification loupes,
canal shaping, irrigation, working length not reporte d. The root canals were obturated with multiple gutta-
percha cones and a zinc oxide-eugenol based se aler, using the lateral condensation technique. Medication
and number of visits in the multiple-visit treatment not reported.
Outcomes Pain (incidence and degree of pain) at the 1st, 7th and 30th days postobturation. Pain was recorded as none,
slight, or moderate\severe. We considered only 2 categories: pain (slight and moderate\severe), and no pain.
14Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 16
Characteristics of included studies (Continued )
Flare-up was defined as either patient’s reporting pain not controlled with over-the-counter medication or
increasing swelling or both (see ’Additional Table 02’).
Notes
Allocation concealment B Unclear
Study Peters 2002
Methods Quasi-randomised, clinical trial; high risk of bias. 97.44% of patients who entered the study were included
in the final analysis.
Participants 39 participants, 38 were included in the final analysis. 19 females and 20 males, the mean age was 40 years
and the range was from 19 to 86 years. Ethnic groups not specified. 1 patient lost (in the Group 2) because his
series of radiographs for imperfections of radiographic technique was excluded. Inclusion criteria: root with
1 canal, teeth asymptomatic that did not respond to sensitivity testing and never had endodontic treatment,
root th at showed radiographic evidence of pe riapical bone loss. Exclusion criteria: maxillary molars, patients
< 19 and > 86 years old. Diagnostic criteria for pulpal or periapical disease: Rx evaluated with PAI score,
sensitivity testing.
Interventions Single visit (Group 1) or multiple visits (Group 2). 1 operator (endodontist). Use of rubber dam isolation
and magnification loupes. Canal shaping: hand instrumentation by double flare technique. Irrigation: 2%
sodium hypochlorite. Working length evaluated by Rx and el ectronic apex locator. Obturation: gutta-percha
and AH 26 sealer in lateral condensation. In the Group 2 the number of visits were 2 (the second appointment
4 weeks later). In this group in th e interappointment period the canals were dressed with a thick mix of
calcium hydroxide in sterile saline and the cavity access filled with 2 layers of Cavit and a glass ionomer
restoration.
Outcomes Healing (follow up 4.5 years). Routine evaluation during follow up: 3, 12, 24 months to 4.5 years. The
authors evaluated the treatment outcome as: score A (success: the width and contour of the periodontal
ligament is normal, or there is a slight radiolucent zone around excess filling material); score B (uncertain:
the radiolucency is clearly decreased but additional f ollow up is not available); score C (failure: there is an
unchanged, increased or new periradicular radiolucency). We considered only 2 categories: success (score A)
and failure (score B and C) (see Additional Table 01).
Notes
Allocation concealment C Inadequate
Study Soltanoff 1978
Methods Randomised, parallel-group,clinical trial; moderate risk of bias. 85.1% of patients who entered the study
were included in th e final analysis about pain and use of painkillers, 80.6% of patients who entered the study
were included in the final analysis about healing. Study duration: 20 years.
Participants 330 participants, 281 were included in the final analysis about pain. Sex, range or mean age, ethnic group not
reported. Inclusion and exclusion criteria not reported. Diagnostic criteria for pulpally or periapical disease
not specified.
Interventions Single visit (Group 1) or multiple visits (Group 2). Rubber dam, use of magnification loupes, working length
not reported. In multiple visits the medication and the total number of visits were not specified. In both
groups sterile saline solution was used as irrigation, the canals were filled with gutta-percha cones and Ostbys
Kloroperka as the cementing medium for lateral condensation.
Outcomes Pain (incidence, severity and duration: less than 1 day, 1 to 3 days, 4 to 7 days, more than 1 week). Pain was
categorised as: no pain, mild pain, moderate pain, severe pain. We considered only 2 categories: no pain and
pain (mild, moderate,s evere pain). Healing (observed radiographically in periods ranging from 6 months to
2 years postoperatively). The criteria for success or failure were: healed (success) and non-healed (failure).
Notes
Allocation concealment B Unclear
15Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 17
Characteristics of included studies (Continued )
Study Trope 1999
Methods Randomised, parall el-group, clinical trial; low risk of bias. 100% of patients who entered the study were
included in the final analysis. Study duration: 1 year.
Participants 81 participants with 102 teeth (61 patients had a single teeth to treat, 18 had 2, 2 had 3). 54 females and 27
males had a mean age of 44.6 years, with a range of 19 to 79. Inclusion criteria: presence of radiographically
demonstrable apical periodontitis on a single-rooted tooth or on 1 root with a single canal in a multirooted
tooth. Exclusion criteria: patients with diagnosis of diabetes, HIV infection or other immunocompromising
disease, patients < 16 or > 80 years old and teeth with 2/3 of the root canal treated before enrolment.
Interventions Single visit (Group 1) or multiple visits without any dressing (Group 2). 1 operator, 9 observers (4 graduate
oral and maxillofacial radiology residents, 2 graduate endodontic residents, 1 oral epidemiologist, 1 general
dentist, 1 experienced endodontist) to evaluated radiographs using the PAI scoring system. Rubber dam
isolation used. Use of magnification loupes and canal shaping not specified in a satisfactory way. Irrigation
with 2.5% Na0Cl. Working length evaluated by Rx, obturation with gutta-pecha and Roth 801 sealer in
lateral condensation. In the Group 2 the instrumentation was completed at the first appointment, the canal
was left empty, the treatment was completed after 1 week.
Outcomes Healing (follow up 52 weeks). The criteria for success or failure were the following: success (PAI 1 or 2),
failure (PAI 3, 4, 5) (see ’Additional Table 01’).
Notes
Allocation concealment A Adequate
Study Weiger 2000
Methods Randomised, parallel-group, clinical trial; low risk of bias. 91.7% of patients who entered the study were
included in the final analysis. Study duration: 5 years.
Participants 73 recruited participants: 6 lost (5 did not return at recall appointments, 1 deceased). 67 entered in the
final analysis (37 females and 30 males). Mean age 38 years (range: 11-84). Inclusion criteria: teeth with
periapical lesion radiographically demonstrated and where the vitality test was negative; in each patients only
1 tooth was sele cted. Exclusion criteria: te eth having pockets communicated with the lesion, teeth treated
previously, patients that h ad taken antibiotics 4 weeks prior to the treatment. Diagnostic criteria for pulpally
or periapical disease: Rx and vitality test.
Interventions Single visit (Group 1) or multiple visits (Group 2). 2 operators (experienced endodontists). Use of rubber
dam isolation. Use of magnification loupes not reported. Canal shaping: K- files and Gates Glidden used in
step-back technique. Irrigation: 1% sodium hypochl orite. Working length determined by Rx. Obturation:
gutta-percha with sealapex in lateral condensation. In the Group 2 the number of visits was 2 and the
medication used was calcium hydroxide mixed with sterile physiological saline, that was left in the canals for
7-47 days.The cavity access was filled by a temporary cement.
Outcomes Healing: (follow up 5 years). The criteria for success or failure were the following in the paper: complete
healing, incomplete healing, no healing. The radiographs were judged by both dentists involved in the study
by using a magnifying glass and a light box. The operators did not know whether the tooth belonged to
the 1-visit or the 2-visit group. In case of disagreement a joint decision was made. We considered only 2
categories: success (complete h ealing) and failure (incomplete healing and no healing) (see ’Additional Table
01’).
Notes
Allocation concealment A Adequate
Study Yoldas 2004
Methods Randomised, parall el group, clinical trial; high risk of bias. 96% of patients who entered the study were
included in the final analysis.
16Single versus multiple visits for endodontic treatment of permanent teeth (Review)
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Page 18
Participants 227 participants, 218 were included in the final analysis. Sex and ethnic group not reported. Age over 18 years
old. Inclusion criteria: teeth with inadequate root canal filling. Exclusion criteria: patients with complicating
systemic disease, severe pain or acute apical abscess or both, under 18 years of age, use of antibiotics or
corticosteroids, multiple teeth requiring retreatment, root canals that could not be treated well with initial
root canal treatment. Diagnostic criteria for pulpal or periapical disease: valutation of periapical status with
Rx evaluated by 1 author according to PAI.
Interventions Single visit (Group 1) or multiple visits (Group 2). 3 operators. Use of rubber dam and magnification
loupes not specified. Canal shaping with Gates Glidden, hand files NiTi rotary instruments with step-back
technique. Irrigation: 2.5% Na0Cl. Working length: determined by apexes locator and periapical radiograph.
Obturation: gutta-percha and AH 26 sealer with later al condensation. In the Group 2 the patients underwent
2 visits and the canals in the interappointment period were medicated with calcium hydroxide chlorhexidine
paste and closed with a sterile dry cotton pellet and a temporary restorative material (Cavit) for 7 days.
Outcomes Pain (1 week after initial appointment the patients were recalled and asked about the occurrence of postop-
erative pain): the level of discomfort was rated as foll ows: no pain, mil d pain, moderate pain, severe pain.
We considered only 2 categories: no pain, pain (mild, moderate, severe). Flare-up: patients with severe post-
operative pain or occurrence of swelling or both (see ’Additional Table 02’). Painkiller use.
Notes
Allocation concealment C Inadequate
Na0Cl = sodium hypochlorite
NiTi = nickel titanium
PAI = periapical index
VAS - visual analogue scale
Characteristics of excluded studies
Study Reason for exclusion
De Rossi A 2005 Animal study.
Eleazer PD 1998 This is a retrospective study.
Farzaneh 2004 The study was not randomised or quasi-randomised.
Fava 1989 This study was not randomised or quasi-randomised.
Fava 1994 This study design was unclear. We sent an e-mail to authors asking for more details about their randomisation
method but we did not consider the answer satisfactory to consider the paper randomised or quasi- randomised.
Ferranti 1959 This study is not randomised or quasi-randomised.
Fox 1970 This is a retrospective study.
Friedman 1995 This study is not randomised or quasi-randomised.
Goreva 2004 This study is not randomised or quasi-randomised.
Hargreaves 2006 This is a review.
He 2004 This study is not randomised or quasi-randomised.
Holland 2003 Animal study.
Imura 1995 This study is not randomised or quasi-randomised.
Inamoto 2002 This study considers only single visit.
Kane 1999 This study considers only single visit.
Kane 2000 This study considers only single visit.
Kenrick 2000 It is a comment.
Kvist 2004 This study considers only single visit.
17Single versus multiple visits for endodontic treatment of permanent teeth (Review)
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Page 19
Characteristics of excluded studies (Continued )
Lagarde 1975 This is a retrospective sudy.
Landers 1980 This study considers only single visit.
Lipton 1982 It is a review.
Morse 1987 This study considers only single visit.
Ng 2004 The study was not randomised or quasi-randomised.
O’Keefe 1976 This study is not randomised or quasi-randomised.
Oliet 1983 This study is not randomised or quasi-randomised.
Pekruhn 1981 This study is not randomised or quasi-randomised.
Pekruhn 1986 This study is not randomised or quasi-randomised.
Peters 2002bis This study considers only the microbiological aspects.
Roane 1983 This study is not randomised or quasi-randomised.
Rudner 1981 This study is not randomised or quasi-randomised.
Siqueira 2003 It is a review.
Sjogren 1997 This study considers only single visit and it is not randomised or quasi-randomised.
Soares 2001 This study considers only single visit.
Southard 1984 This study considers only single visit.
Spangberg 2001 This study is a lette r.
Trusewicz 2005 This study considers only the microbiological aspects.
Waltimo 2005 The study does not include any of the outcomes considered in the review.
Walton 1992 This study is not randomised or quasi-randomised.
Weine 1997 This study is a comment.
Whitaker 2002 This study is a comment.
Yamada 1992 This study considers only single visit.
A D D I T I O N A L T A B L E S
Table 01. Endodontic radiological success: from scales to bina ry outcome
Classification Success (binary) Failure (binary)
Trope 1999; Orstavick; Kirkevang (PAI) PAI score 1 (normal periapical), PAI score 2
(bone structural changes)
PAI score 3 (structural changes with
mineral loss), PAI score 4 (radiolucency),
PAI score 5 (radiolucency with features of
exacerbation)
Strindberg; Gutmann Success (normal to slightly thickened
periodontal ligament space < 1 mm,
elimination of previous rarefaction, normal
lamina dura in relation to adjacent teeth, no
evidence of resorption)
Questionable (increased periodontal
ligament space > 1 mm and < 2 mm,
stationary rarefaction or sligth repair
evident, increased lamina dura in relation
to adjacent teeth, evidence of resorption);
Failure (increased width of periodontal
ligament space > 2 mm, lack of osseous
repair within rarefaction or increased
18Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 20
Table 01. Endodontic radiological success: from scales to bina ry outcome (Continued )
Classification Success (binary) Failure (binary)
rarefaction, lack of new lamina dura,
presence of osseous r arefactions in
periradicular areas where previously none
existed)
Katebzadeh Healed (normal pattern of trabecular bone
and normal width of periodontal ligament
space)
Improved (reduction in lesion size); Failed
(increased or no change in the lesion size)
Halse & Molven Healed (normal pattern of trabecular bone
and normal width of periodontal ligament
space)
Increased width of the periodontal space,
pathological findings
Peters 2002; Reit & Grandhal; Kvist Success (A) the width and contour of the
periodontal l igament is normal, or there is a
slight radiolucent zone around apical
Uncertain (B) the radiolucency is clearly
decreased but additional follow up is not
available; Failure (C) there is an unchanged,
increased or new periradicular radiolucency
Weiger 2000 Complete healing: no clinical signs and
symptoms, radiographically a periodontal
ligament space of normal width
Incomplete h ealing: no clinical signs and
symptoms, radiographically a reduction
of the lesion in size or an unchanged
lesion within an observation time of
4 years. No healing: clinical signs and
symptoms indicating an acute ph ase of
apical periotontitis and\or radiographically
a persisting lesion after a follow-up time of
4-5 years and\or a new lesion formed at an
initially uninvolved root of a multirooted
tooth.
Soltanoff 1978 Healed ( by Rx but the criteria not specified
in a satisfactory way)
Not h ealed ( by Rx but the cr iter ia not
specified in a satisfactory way)
Gesi 2006 Normal periapical condition or unclear
apical condition (widened apical
periodontal space or diffused lamina dura)
Presence of periapical radiolucency when
there was a distinct radiolucent area
associated with the apical portion of the
root
Table 02. Definition of flare-up in the included studies
Authors Definition
Al-Negrish 2006 Percentage of patients experiencing moderate to severe pain. Moderate pain: the tooth involved caused discomfort
and/or pain wich was either tolerable or was rended tolerable by analgesics. Severe pain: the pain caused by the
treated tooth disturbed normal activity or sleep and analgesics had little or no effect
DiRenzo 2002 Swelling that needs antibiotics and narcotic analgesics
Mulhern 1982 Swelling
Oginni 2004 Either patient’s report of pain not controlled with over-the-counter medication and or increasing swelling
Yoldas 2004 Patients with severe postoperative pain and/or occurrence of swelling
19Single versus multiple visits for endodontic treatment of permanent teeth (Review)
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Page 21
Table 02. Definition of flare-up in the included studies (Continued )
Authors Definition
Ghoddusi 2006 Swelling
A N A L Y S E S
Comparison 01. Single visit versus multiple visits
Outcome title
No. of
studies
No. of
participants
Statistical method Effect size
01 Pain Relative Risk (Fixed) 95% CI Subtotals only
02 Painkiller use Relative Risk (Fixed) 95% CI Subtotals only
03 Radiological failure Relative Risk (Fixed) 95% CI Subtotals only
04 Swelling Relative Risk (Fixed) 95% CI Subtotals only
05 Subgroup analysis in necrotic
teeth
Relative Risk (Fixed) 95% CI Subtotals only
Comparison 02. Sensitivity analysis
Outcome title
No. of
studies
No. of
participants
Statistical method Effect size
01 Pain Relative Risk (Fixed) 95% CI Subtotals only
02 Painkiller use Relative Risk (Fixed) 95% CI Subtotals only
03 Radiological failure Relative Risk (Fixed) 95% CI Subtotals only
04 Swelling Relative Risk (Fixed) 95% CI Subtotals only
05 Subgroup analysis in necrotic
teeth
Relative Risk (Fixed) 95% CI Subtotals only
C O V E R S H E E T
Title Single versus multiple visits for endodontic treatment of pe r manent teeth
Authors Figini L, Lodi G, Gorni F, Gagliani M
Contribution of author(s) Lara Figini: main review author, participation in all phases of the review’s preparation.
Giovanni Lodi: contributor in all phases of the reviews preparation, articles retrieval, data
collection, interpretation of results.
Massimo Gagliani: group co-ordinator, articles retrieval, data collection, interpretation of
results.
Fabio Gorni: prospective handsearching, interpretation of results.
Issue protocol first published 2005/2
Review first published 2007/4
Date of most recent amendment 22 August 2007
Date of most recent
SUBSTANTIVE amendment
21 August 2007
What’s New Information not supplied by author
Date new studies sought but
none found
Information not supplied by author
20Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 22
Date new studies found but not
yet included/excluded
Information not supplied by author
Date new studies found and
included/excluded
Information not supplied by author
Date authors’ conclusions
section amended
Information not supplied by author
Contact address Dr Lara Figini
Piazzale Aquileia 6
Milan
20144
ITALY
E-mail: lara.figini@libero.it
Tel: +39 02 4801 8847
Fax: +39 02 4801 8847
DOI 10.1002/14651858.CD005296.pub2
Cochrane Library number CD005296
Editorial group Cochrane Oral Health Group
Editorial group code HM-ORAL
G R A P H S A N D O T H E R T A B L E S
Analysis 01.01. Comparison 01 Single visit versus multiple visits, Outcome 01 Pain
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 01 Single visit versus multiple visits
Outcome: 01 Pain
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Pain in the immediate postoperative (until 72 hours postobturation)
Al-Negrish 2006 8/54 14/58
8.5 0.61 [ 0.28, 1.35 ]
Albashaireh 1998 39/142 56/149
34.2 0.73 [ 0.52, 1.02 ]
Ghoddusi 2006 8/20 10/40
4.2 1.60 [ 0.75, 3.42 ]
Mulhern 1982 7/30 6/30
3.8 1.17 [ 0.44, 3.06 ]
Oginni 2004 58/107 61/136
33.7 1.21 [ 0.94, 1.56 ]
Soltanoff 1978 20/88 40/193
15.7 1.10 [ 0.68, 1.76 ]
Subtotal (95% CI) 441 606
100.0 0.99 [ 0.83, 1.18 ]
Total events: 140 (Single visit), 187 (Multiple visits)
Test for heterogeneity chi-square=8.68 df=5 p=0.12 I² =42.4%
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits (Continued . . . )
21Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 23
(. . . Continued)
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
Test for overall effect z=0.09 p=0.9
02 Pain at 1 week
Al-Negrish 2006 2/54 6/58
13.4 0.36 [ 0.08, 1.70 ]
Gesi 2006 16/130 18/126
42.2 0.86 [ 0.46, 1.61 ]
Mulhern 1982 3/30 2/30
4.6 1.50 [ 0.27, 8.34 ]
Oginni 2004 17/104 14/123
29.6 1.44 [ 0.74, 2.77 ]
Soltanoff 1978 5/88 7/193
10.1 1.57 [ 0.51, 4.80 ]
Subtotal (95% CI) 406 530
100.0 1.07 [ 0.72, 1.57 ]
Total events: 43 (Single visit), 47 (Multiple visits)
Test for heterogeneity chi-square=3.73 df=4 p=0.44 I² =0.0%
Test for overall effect z=0.32 p=0.7
03 Pain at 1 month
x Albashaireh 1998 0/142 0/149 0.0 Not estimable
x Oginni 2004 0/102 0/120 0.0 Not estimable
Subtotal (95% CI) 244 269 0.0 Not estimable
Total events: 0 (Single visit), 0 (Multiple visits)
Test for heterogeneity: not applicable
Test for overall effect: not applicable
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
Analysis 01.02. C omparison 01 Single visit versus multiple visits, Outcome 02 Painkiller use
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 01 Single visit versus multiple visits
Outcome: 02 Painkiller use
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Painkillers
Mulhern 1982 5/30 4/30
16.1 1.25 [ 0.37, 4.21 ]
Soltanoff 1978 29/88 24/193
60.4 2.65 [ 1.64, 4.28 ]
Yoldas 2004 15/106 6/112
23.5 2.64 [ 1.06, 6.55 ]
Subtotal (95% CI) 224 335
100.0 2.42 [ 1.62, 3.62 ]
Total events: 49 (Single visit), 34 (Multiple visits)
Test for heterogeneity chi-square=1.31 df=2 p=0.52 I² =0.0%
Test for overall effect z=4.33 p=0.00002
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
22Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 24
Analysis 01.03. Comparison 01 Single visit versus multiple visits, Outcome 03 Radiological failure
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 01 Single visit versus multiple visits
Outcome: 03 Radiological failure
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Radiological failure versus radiological success
Gesi 2006 6/84 6/100
11.0 1.19 [ 0.40, 3.55 ]
Peters 2002 4/21 5/17
11.1 0.65 [ 0.21, 2.04 ]
Soltanoff 1978 12/80 22/186
26.6 1.27 [ 0.66, 2.44 ]
Trope 1999 9/45 18/57
31.9 0.63 [ 0.32, 1.27 ]
Weiger 2000 6/36 9/31
19.4 0.57 [ 0.23, 1.43 ]
Subtotal (95% CI) 266 391
100.0 0.85 [ 0.59, 1.23 ]
Total events: 37 (Single visit), 60 (Multiple visits)
Test for heterogeneity chi-square=3.41 df=4 p=0.49 I² =0.0%
Test for overall effect z=0.84 p=0.4
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
Analysis 01.04. Comparison 01 Single visit versus multiple visits, Outcome 04 Swelling
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 01 Single visit versus multiple visits
Outcome: 04 Swelling
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Swelling
DiRenzo 2002 0/39 1/33
18.5 0.28 [ 0.01, 6.73 ]
Ghoddusi 2006 7/20 10/40
75.9 1.40 [ 0.63, 3.13 ]
Mulhern 1982 2/30 0/30
5.7 5.00 [ 0.25, 99.95 ]
Subtotal (95% CI) 89 103
100.0 1.40 [ 0.67, 2.93 ]
Total events: 9 (Single visit), 11 (Multiple visits)
Test for heterogeneity chi-square=1.67 df=2 p=0.43 I² =0.0%
Test for overall effect z=0.89 p=0.4
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
23Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 25
Analysis 01.05. C omparison 01 Single visit versus multiple visits, Outcome 05 Subgroup analysis in necrotic
teeth
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 01 Single visit versus multiple visits
Outcome: 05 Subgroup analysis in necrotic teeth
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Pain in the immediate postoperative (until 72 hours postobturation) in necrotic teeth
Al-Negrish 2006 8/54 14/58
17.2 0.61 [ 0.28, 1.35 ]
Albashaireh 1998 33/102 55/113
66.6 0.66 [ 0.47, 0.93 ]
Ghoddusi 2006 8/20 10/40
8.5 1.60 [ 0.75, 3.42 ]
Mulhern 1982 7/30 6/30
7.7 1.17 [ 0.44, 3.06 ]
Subtotal (95% CI) 206 241
100.0 0.77 [ 0.59, 1.02 ]
Total events: 56 (Single visit), 85 (Multiple visits)
Test for heterogeneity chi-square=5.32 df=3 p=0.15 I² =43.6%
Test for overall effect z=1.83 p=0.07
02 Pain at 1 week in necrotic teeth
Al-Negrish 2006 2/54 6/58
74.3 0.36 [ 0.08, 1.70 ]
Mulhern 1982 3/30 2/30
25.7 1.50 [ 0.27, 8.34 ]
Subtotal (95% CI) 84 88
100.0 0.65 [ 0.22, 1.93 ]
Total events: 5 (Single visit), 8 (Multiple visits)
Test for heterogeneity chi-square=1.48 df=1 p=0.22 I² =32.2%
Test for overall effect z=0.77 p=0.4
03 Painkiller in necrotic teeth
Mulhern 1982 5/30 4/30
40.7 1.25 [ 0.37, 4.21 ]
Yoldas 2004 15/106 6/112
59.3 2.64 [ 1.06, 6.55 ]
Subtotal (95% CI) 136 142
100.0 2.08 [ 1.01, 4.26 ]
Total events: 20 (Single visit), 10 (Multiple visits)
Test for heterogeneity chi-square=0.94 df=1 p=0.33 I² =0.0%
Test for overall effect z=1.99 p=0.05
04 Radiological failure versus radiological success in necrotic teeth
Peters 2002 4/21 5/17
17.8 0.65 [ 0.21, 2.04 ]
Trope 1999 9/45 18/57
51.1 0.63 [ 0.32, 1.27 ]
Weiger 2000 6/36 9/31
31.1 0.57 [ 0.23, 1.43 ]
Subtotal (95% CI) 102 105
100.0 0.62 [ 0.37, 1.02 ]
Total events: 19 (Single visit), 32 (Multiple visits)
Test for heterogeneity chi-square=0.04 df=2 p=0.98 I² =0.0%
Test for overall effect z=1.89 p=0.06
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits (Continued . . . )
24Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 26
(. . . Continued)
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
05 Swelling in necrotic teeth
Ghoddusi 2006 7/20 10/40
93.0 1.40 [ 0.63, 3.13 ]
Mulhern 1982 2/30 0/30
7.0 5.00 [ 0.25, 99.95 ]
Subtotal (95% CI) 50 70
100.0 1.65 [ 0.76, 3.59 ]
Total events: 9 (Single visit), 10 (Multiple visits)
Test for heterogeneity chi-square=0.69 df=1 p=0.41 I² =0.0%
Test for overall effect z=1.26 p=0.2
06 Any complications in necrotic teeth
Albashaireh 1998 33/102 55/113
54.8 0.66 [ 0.47, 0.93 ]
Mulhern 1982 8/30 12/30
12.6 0.67 [ 0.32, 1.39 ]
Peters 2002 4/21 5/17
5.8 0.65 [ 0.21, 2.04 ]
Trope 1999 9/45 18/57
16.7 0.63 [ 0.32, 1.27 ]
Weiger 2000 6/36 9/31
10.2 0.57 [ 0.23, 1.43 ]
Subtotal (95% CI) 234 248
100.0 0.65 [ 0.50, 0.85 ]
Total events: 60 (Single visit), 99 (Multiple visits)
Test for heterogeneity chi-square=0.10 df=4 p=1.00 I² =0.0%
Test for overall effect z=3.21 p=0.001
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
25Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 27
Analysis 02.01. Comparison 02 Sensitivity analysis, Outcome 01 Pain
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 02 Sensitivity analysis
Outcome: 01 Pain
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Pain in the immediate postoperative (until 72 hours postobturation)
Ghoddusi 2006 8/20 10/40
7.3 1.60 [ 0.75, 3.42 ]
Mulhern 1982 7/30 6/30
6.6 1.17 [ 0.44, 3.06 ]
Oginni 2004 58/107 61/136
58.7 1.21 [ 0.94, 1.56 ]
Soltanoff 1978 20/88 40/193
27.4 1.10 [ 0.68, 1.76 ]
Subtotal (95% CI) 245 399
100.0 1.20 [ 0.97, 1.49 ]
Total events: 93 (Single visit), 117 (Multiple visits)
Test for heterogeneity chi-square=0.69 df=3 p=0.87 I² =0.0%
Test for overall effect z=1.70 p=0.09
02 Pain at 1 week
Gesi 2006 16/130 18/126
48.8 0.86 [ 0.46, 1.61 ]
Mulhern 1982 3/30 2/30
5.3 1.50 [ 0.27, 8.34 ]
Oginni 2004 17/104 14/123
34.2 1.44 [ 0.74, 2.77 ]
Soltanoff 1978 5/88 7/193
11.7 1.57 [ 0.51, 4.80 ]
Subtotal (95% CI) 352 472
100.0 1.17 [ 0.78, 1.76 ]
Total events: 41 (Single visit), 41 (Multiple visits)
Test for heterogeneity chi-square=1.63 df=3 p=0.65 I² =0.0%
Test for overall effect z=0.78 p=0.4
03 Pain at 1 month
x Oginni 2004 0/102 0/120 0.0 Not estimable
Subtotal (95% CI) 102 120 0.0 Not estimable
Total events: 0 (Single visit), 0 (Multiple visits)
Test for heterogeneity: not applicable
Test for overall effect: not applicable
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
26Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 28
Analysis 02.02. Comparison 02 Sensitivity analysis, Outcome 02 Painkiller use
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 02 Sensitivity analysis
Outcome: 02 Painkiller use
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Painkillers
Mulhern 1982 5/30 4/30
21.0 1.25 [ 0.37, 4.21 ]
Soltanoff 1978 29/88 24/193
79.0 2.65 [ 1.64, 4.28 ]
Subtotal (95% CI) 118 223
100.0 2.36 [ 1.51, 3.66 ]
Total events: 34 (Single visit), 28 (Multiple visits)
Test for heterogeneity chi-square=1.28 df=1 p=0.26 I² =21.9%
Test for overall effect z=3.80 p=0.0001
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
Analysis 02.03. Comparison 02 Sensitivity analysis, Outcome 03 Radiological fa ilure
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 02 Sensitivity analysis
Outcome: 03 Radiological failure
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Radiological failure versus radiological success
Gesi 2006 6/84 6/100
12.4 1.19 [ 0.40, 3.55 ]
Soltanoff 1978 12/80 22/186
29.9 1.27 [ 0.66, 2.44 ]
Trope 1999 9/45 18/57
35.9 0.63 [ 0.32, 1.27 ]
Weiger 2000 6/36 9/31
21.8 0.57 [ 0.23, 1.43 ]
Subtotal (95% CI) 245 374
100.0 0.88 [ 0.60, 1.30 ]
Total events: 33 (Single visit), 55 (Multiple visits)
Test for heterogeneity chi-square=3.19 df=3 p=0.36 I² =5.9%
Test for overall effect z=0.65 p=0.5
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
27Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 29
Analysis 02.04. C omparison 02 Sensitivity analysis, Outcome 04 Swelling
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 02 Sensitivity analysis
Outcome: 04 Swelling
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Swelling
DiRenzo 2002 0/39 1/33
18.5 0.28 [ 0.01, 6.73 ]
Ghoddusi 2006 7/20 10/40
75.9 1.40 [ 0.63, 3.13 ]
Mulhern 1982 2/30 0/30
5.7 5.00 [ 0.25, 99.95 ]
Subtotal (95% CI) 89 103
100.0 1.40 [ 0.67, 2.93 ]
Total events: 9 (Single visit), 11 (Multiple visits)
Test for heterogeneity chi-square=1.67 df=2 p=0.43 I² =0.0%
Test for overall effect z=0.89 p=0.4
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
Analysis 02.05. Comparison 02 Sensitivity analysis, Outcome 05 Subgroup analysis in necrotic teeth
Review: Single versus multiple visits for endodontic treatment of permanent teeth
Comparison: 02 Sensitivity analysis
Outcome: 05 Subgroup analysis in necrotic teeth
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
01 Pain in the immediate postoperative (until 72 hours postobturation) in necrotic teeth
Ghoddusi 2006 8/20 10/40
52.6 1.60 [ 0.75, 3.42 ]
Mulhern 1982 7/30 6/30
47.4 1.17 [ 0.44, 3.06 ]
Subtotal (95% CI) 50 70
100.0 1.39 [ 0.77, 2.54 ]
Total events: 15 (Single visit), 16 (Multiple visits)
Test for heterogeneity chi-square=0.26 df=1 p=0.61 I² =0.0%
Test for overall effect z=1.09 p=0.3
02 Pain at 1 week in necrotic teeth
Mulhern 1982 3/30 2/30
100.0 1.50 [ 0.27, 8.34 ]
Subtotal (95% CI) 30 30
100.0 1.50 [ 0.27, 8.34 ]
Total events: 3 (Single visit), 2 (Multiple visits)
Test for heterogeneity: not applicable
Test for overall effect z=0.46 p=0.6
03 Painkiller in necrotic teeth
Mulhern 1982 5/30 4/30
100.0 1.25 [ 0.37, 4.21 ]
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits (Continued . . . )
28Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 30
(. . . Continued)
Study Single visit Multiple visits Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
Subtotal (95% CI) 30 30 100.0 1.25 [ 0.37, 4.21 ]
Total events: 5 (Single visit), 4 (Multiple visits)
Test for heterogeneity: not applicable
Test for overall effect z=0.36 p=0.7
04 Radiological failure versus radiological success in necrotic teeth
Trope 1999 9/45 18/57
62.2 0.63 [ 0.32, 1.27 ]
Weiger 2000 6/36 9/31
37.8 0.57 [ 0.23, 1.43 ]
Subtotal (95% CI) 81 88
100.0 0.61 [ 0.35, 1.06 ]
Total events: 15 (Single visit), 27 (Multiple visits)
Test for heterogeneity chi-square=0.03 df=1 p=0.87 I² =0.0%
Test for overall effect z=1.74 p=0.08
05 Swelling in necrotic teeth
Ghoddusi 2006 7/20 10/40
93.0 1.40 [ 0.63, 3.13 ]
Mulhern 1982 2/30 0/30
7.0 5.00 [ 0.25, 99.95 ]
Subtotal (95% CI) 50 70
100.0 1.65 [ 0.76, 3.59 ]
Total events: 9 (Single visit), 10 (Multiple visits)
Test for heterogeneity chi-square=0.69 df=1 p=0.41 I² =0.0%
Test for overall effect z=1.26 p=0.2
06 Any complications in necrotic teeth
Mulhern 1982 8/30 12/30
32.0 0.67 [ 0.32, 1.39 ]
Trope 1999 9/45 18/57
42.3 0.63 [ 0.32, 1.27 ]
Weiger 2000 6/36 9/31
25.8 0.57 [ 0.23, 1.43 ]
Subtotal (95% CI) 111 118
100.0 0.63 [ 0.40, 0.98 ]
Total events: 23 (Single visit), 39 (Multiple visits)
Test for heterogeneity chi-square=0.06 df=2 p=0.97 I² =0.0%
Test for overall effect z=2.05 p=0.04
0.1 0.2 0.5 1 2 5 10
Single visit Multiple visits
29Single versus multiple visits for endodontic treatment of permanent teeth (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Page 31
  • Source
    • "A B http://scidoc.org/IJDOS.php of a satisfactory coronal restoration were implemented in this case. Moreover, the successful outcome seen in the current case report is in line with previous studies indicating high success rates of single visit treatment9101112. "
    Preview · Article · Nov 2015
    • "However, a systematic review reported a slightly higher frequency of pain and analgesic use in patients who had undergone single-visit treatment (Figini et al. 2008). This outcome was related to the immediate filling of the root canal system and the prolonged working time of a singlevisit approach (Figini et al. 2008, Pak & White 2011). Another recent study reported data in the 72 h that followed two appointments of root canal treatment (Nekoofar et al. 2015): a significantly higher pain experience and analgesics consumption in patients treated with reciprocating instruments were found. "
    [Show abstract] [Hide abstract] ABSTRACT: Aim: To compare the impact of rotary and reciprocating instrumentation on post-operative quality of life (POQoL) after single visit primary root canal treatment. Methodology: A randomized controlled clinical trial was designed and carried out in a University endodontic practice in northern Italy. Healthy subjects with asymptomatic irreversible pulpitis, symptomatic irreversible pulpitis or pulp necrosis with or without apical periodontitis (symptomatic or asymptomatic), scheduled for primary root canal treatment were enrolled. Single-visit root canal treatment was performed with ProTaper(™) S1-S2-F1-F2 (rotary group, N=23) and WaveOne(™) Primary (reciprocating group, N=24). Irrigation was performed with 5% NaOCl and 10% EDTA. Root canal filling was performed with the continuous wave technique and ZOE sealer. POQoL indicators were evaluated for 7 days post-treatment. The variation of each indicator over time was compared using ANOVA for repeated measures (P < 0.05). The impact of each variable on POQoL was analyzed with a multivariate logistic regression model (P < 0.05). Results: Pain curves demonstrated a more favorable time-trend in the rotary group (mean, P = 0.077; maximum, P = 0.015). Difficulty in eating (P = 0.017), in performing daily activities (P = 0.023), in sleeping (P = 0.021), in social relations (P = 0.077), were more evident in the reciprocating group. Patients' perception of the impact of treatment on POQoL was more favorable in the rotary group (P = 0.006). Multi-rooted tooth type and pre-existing peri-radicular inflammation were associated with a decrease in POQoL. Conclusion: Reciprocating instrumentation affected POQoL to a greater extent than rotary instrumentation. This article is protected by copyright. All rights reserved.
    No preview · Article · Oct 2015 · International Endodontic Journal
  • Source
    • "The antimicrobial effect of calcium hydroxide as an intra-canal medicament is well known, particularly in cases of infection associated with periapical lesion (Mohammadi and Dummer, 2011). However, studies have shown that one-visit root canal treatment can create favorable environmental conditions for periapical repair similar to the two-visit therapy when calcium hydroxide was used as antimicrobial dressing (Weiger et al., 2000; Figini et al., 2008). The findings of this report support this as total healing occurred after a single visit root canal treatment despite the presence of a large periapical lesion. "
    Preview · Article · Apr 2015
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