SINGLE VS. MULTIPLE VISITS FOR ENDODONTIC TREATMENT OF

PERMANENT TEETH

Dominique Abela

Outline

Clinical scenario and question Background and evidence selected PICO Methods- selection criteria Data analysis and results Strengths and weaknesses Implications

Clinical scenario

RFA: 35 yr old female presents for endodontic treatment on her upper right first molar

(previously extirpated pulp) due to caries which lead to chronic apical periodontitis.

DRN 0879867 Medical history: NAD Dent History: full dentition with previous orthodontic

treatment. No other restorations or periodontal disease.

Clinical Question

Patient wanted to know is there a difference in single vs. multiple visit endodontics.

Background

Endodontics/ RCT is a procedure in which organic tissue, infected debris and pathogenic bacteria are removed from the root canal system

mechanical and chemical means root canal is then filled with a rubber based material this can be performed in single or multiple visits.

Best Evidence

This is a question of therapy therefore best level of evidence

1a) Systematic review of randomised control trials

1b) Individual randomised control trials (with narrow confidence intervals)

PICO

P- non-vital permanent teeth due to caries

I- single visit

C- multiple visits

O- absence of symptoms and clinical signs with radiographic evidence of periapical healing.

The search…

Evidence Chosen

Single vs. multiple visits for endodontic treatment of permanent teeth. Figini L et al Cochrane Database of Systematic Reviews issue 2, 2009.

Methods

Objective- to compare single vs. multiple RCT measuring tooth extraction and radiological success in the long and short term.

Search strategy- central, medline and EMBASE, endodontists were contacted and no language limitations imposed.

Selection criteria

randomised and quasi- randomised control trails were included

surgical endodontics excluded patients > 10 yrs who underwent RCT with closed apex

and no internal root resorption outcomes considered; teeth extracted due to failed

endodontics, radiological success at least 1 yr later, absence of periapical radiolucency, post- op pain with pain killer use and swelling or sinus tract formation.

No difference could exist in systemic medications between the two groups (e.g. NSAIDs, antibiotics, analgesics)

Data analysis

validity was based on allocation concealment, blindness and loss of participants. Data analysed using quantitative meta-analysis and comparison made by employing risk ratios.

Results

12 RCTs were included. No significant difference in single vs. multiple visits

for radiological success and post- operative pain Patients undergoing single visit RCT reported higher

frequency of pain killer use and swelling, but results for swelling were not significantly different between the two groups.

No study included tooth loss or sinus tract formation.

Significant Results: Forest Plot

Results Summary

Outcome No. Of Studies

No. Of Participants

RR (CI)

Post-op pain (72h) 6 1047 0.99 (0.83 to 1.18)

Pain at 1 week 5 936 1.07 (0.72 to 1.57)

Pain at 1 month 2 Analysis not possible

Painkiller use 3 559 *2.42 (1.62 to 3.62)

Radiological failure 5 657 0.85 ( 0.59 to 1.23)

Swelling 3 192 1.40 (0.67 to 2.93)

Strengths of the study

Systematic review of all published randomized control trials (level 1a evidence).

12 RCT fitted the inclusion criteria. Good inclusion criteria. Plain language summary included. Recently published (2009) thus most recent evidence

included. Participant loss was ˂20% All RCT used lateral condensation obturation technique. Trial data was homogenous All confidence intervals were small.

Weaknesses of the study

Bias: high in 4 RCT, medium in 4 RCT and low in 4RCT. Medium risk of bias: allocation concealment was not

described. High risk of bias: randomization was inadequate (3 RCT) or

not explained satisfactorily (1 RCT). Authors assessing studies to be included were not blinded

to publication name and authors. The types of cases (complex vs easy) was not described. Use of Rubber Dam. (4 RCT used RD, 8 RCT did not). Treatment medicaments in multiple visit group varied and

was not mentioned in some RCTs.

Weaknesses of the study

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

Roth 801, 2RCT AH26, Pulp canal sealer 1RCT, Tubi seal 1RCT, Ostebys 1RCT, Seal apex 2RCT, unknown in 2RCT).

Use of magnification. (Mentioned in 2 RCT, not mentioned in 10RCT)

Instrumentation varied (rotary + hand instruments 2RCT, unknown or not mentioned satisfactorily 5RCT, hand 5RCT).

Weaknesses of the study

Instrumentation technique varied (Crown down 1RCT, step back 4RCT, double flare 1RCT, unknown 6RCT).

Operator and level of experience varies. Time between visits in multiple visit group varied. Radiographic assessment only 1yr. Optimum is 4yr.

Thus lack of long term follow-up. Data group as dichotomous.

Implications

The effectiveness of single-visit and multiple-visit endodontic treatment is not substantially different.

Patients undergoing single-visit Endodontic treatment may experience a higher frequency of pain killer use and are more likely to take analgesics.

It would be more helpful for clinician if researchers include tooth loss as a primary outcome.

Because of the increasing popularity and use of rotary instrumentation, a well designed RCT comparing single vs multiple visit endodontic treatment would be an important contribution.

Reduced time spent in the chair thus reduced disruption to patient. Cost- vs cost of pain?? Reduction in use of materials.

Acknowledegments

Librarian Patient Thank you all for listening.

Questions?????