JOURNAL OF ENDODONTICS Copyright 2002 by The American Association of Endodontists

Printed in U.S.A. VOL. 28, NO. 5, MAY 2002

A Survey of the Incidence of Single-Visit Endodontics

Kyoko Inamoto, DDS, Koko Kojima, DDS, Kumiko Nagamatsu, DDS, Akiko Hamaguchi, DDS, Kazuhiko Nakata, DDS, PhD, and Hiroshi Nakamura, DDS, PhD

This survey was conducted to obtain answers to some basic questions regarding the timing of root canal obturation. A questionnaire was sent via email to 738 randomly chosen United States endodontists listed in the 1998 to 1999 membership roster of the American Association of Endodontists. One hundred fifty-six replies were received. In pulpectomy cases, root canal obturation at the first visit was carried out by 55.8% of the responding endodontists; in infected root canal cases, the percentage was 34.4%. Of the responding endodontists, 34.2% indicated that their patients had experienced some trouble after root canal obturation at the first visit.

15 (endodontist) and who had an e-mail address were considered. The questionnaire was e-mailed in December 1999, with wording briefly explaining the purpose of the study. The questionnaire addressed three basic questions: timing of root canal obturation, root canal medication, and root canal irrigation.

Timing of Root Canal Obturation 1. In pulpectomy cases, how many visits of patients do you think are usually required to carry out root canal obturation? 2. In infected root canal cases, how many visits of patients do you think are usually required to carry out root canal obturation? 3. In pulpectomy cases, how long do you usually take to treat your patients? 4. In infected root canal cases, how long do you usually take to treat your patients? 5. Has there been any trouble with root canal obturation at the first visit? If YES, what kinds of trouble have there been? 6. Could you tell us about important considerations for the timing of root canal obturation (e.g. no symptom)? Root Canal Medication and Temporary Restorative Materials 1. If two, or more than two, visits are normally required to carry out root canal obturation, do you use some medications between appointments? If YES, what kinds of medications do you use? If YES, what kinds of temporary restorative materials do you use? Root Canal Irrigation 1. Do you use some irrigation solution before root canal obturation? If YES, what kind of irrigation solution do you use? RESULTS The number of questionnaires returned by January 20, 2000, was 156. The survey form with frequency and percentage results of the answers to the questions are shown in Table 1.
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Root canal obturation is one of the most important procedures in endodontic therapy, and the timing of root canal obturation, root canal medication, and root canal irrigation is an important consideration. In Japan, endodontic therapy accomplished in a single appointment is not popular. In recent years, one-appointment endodontic therapy has gained increased acceptance as an acceptable treatment for most cases in the United States (1). One-visit endodontic therapy has many advantages (1), e.g. (a) it reduces the number of patient appointments; (b) it eliminates the chance for interappointment microbial contamination; (c) it allows for the immediate use of the canal space for retention of a post. There are, however, a few disadvantages to one-appointment endodontic therapy, and the extent of the practice of one-appointment endodontics and the incidence of flare-ups differ from one report to another (2 8). We have become interested in the timing of root canal obturation. The purpose of this study was to report and discuss the views of endodontists in the United States, based on their responses to a questionnaire related to the timing of various endodontic procedures. MATERIALS AND METHODS A questionnaire was sent to 738 endodontists listed in the Membership Roster of the American Association of Endodontists, 1998 to 1999. Only members with the practice identification code

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Inamoto et al. TABLE 1. Questionnaire with frequency and percentage responses

Journal of Endodontics

I. Timing of root canal obturation Q1. In pulpectomy cases, how many visits of patients do you think are usually required to carry out root canal obturation? (1) First visit:

(2) Second visit:

(3) Third visit or later:

a. 0% b. 25% c. 50% d. 75% e. 100% a. 0% b. 25% c. 50% d. 75% e. 100% a. 0% b. 25% c. 50% d. 75% e. 100%

13 (8.3%) of 156 10 (6.4%) of 156 6 (3.8%) of 156 40 (25.6%) of 156 87 (55.8%)a of 156 87 (55.8%) of 156 41 (26.3%) of 156 12 (7.7%) of 156 7 (4.5%) of 156 9 (5.8%) of 156 146 (93.6%) of 156 7 (4.5%) of 156 1 (0.6%) of 156 1 (0.6%) of 156 1 (0.6%) of 156

Q2. In infected root canal cases, how many visits of patients do you think are usually required to carry out root canal obturation? (1) First visit:

(2) Second visit:

(3) Third visit or later:

a. 0% b. 25% c. 50% d. 75% e. 100% a. 0% b. 25% c. 50% d. 75% e. 100% a. 0% b. 25% c. 50% d. 75% e. 100%

31 (20.5%) of 151 18 (11.9%) of 151 17 (11.3%) of 151 33 (21.9%) of 151 52 (34.4%) of 151 52 (34.7%) of 150 34 (22.7%) of 150 21 (14.0%) of 150 22 (14.7%) of 150 21 (14.0%) of 150 131 (87.9%) of 149 15 (10.1%) of 149 1 (0.7%) of 149 1 (0.7%) of 149 1 (0.7%) of 149

Q3. In pulpectomy cases, how long do you usually take to treat your patients? This question is only for the subjects who chose (1)e for Q1. (1) Front tooth:

(2) Premolar tooth:

(3) Molar:

a. within 30 minutes b. within 60 minutes c. within 90 minutes d. longer than 90 minutes a. within 30 minutes b. within 60 minutes c. within 90 minutes d. longer than 90 minutes a. within 30 minutes b. within 60 minutes c. within 90 minutes d. longer than 90 minutes

62.2% 37.8% 0% 0% 40.5% 54.1% 5.4% 0% 24.3% 35.1% 35.1% 5.4%

Q4. In infected root canal cases, how long do you usually take to treat your patients? This question is only for the subjects who chose (1)e for Q2. (1) Front tooth:

(2) Premolar tooth:

(3) Molar:

a. within 30 minutes b. within 60 minutes c. within 90 minutes d. longer than 90 minutes a. within 30 minutes b. within 60 minutes c. within 90 minutes d. longer than 90 minutes a. within 30 minutes b. within 60 minutes c. within 90 minutes d. longer than 90 minutes

54.1% 40.5% 2.7% 2.7% 27.0% 59.5% 10.8% 2.7% 8.1% 35.1% 45.9% 10.8%

Vol. 28, No. 5, May 2002 TABLE 1. Continued. Q5. Has there been any trouble with root canal obturation at the first visit? Yes No Others If YES, what kinds of trouble have there been? (Some respondents listed more than one answer.) Pain Flare-ups Swelling Occlusion Discomfort Others Q6. Could you tell us about important considerations for the timing of root canal obturation (e.g. no symptom)? (Some respondents listed more than one answer.)

Single-Visit Endodontics

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52 (34.2%) of 152 94 (61.8%) of 152 6 (3.9%) of 152

21 (40.4%) 16 (30.8%) 12 (23.1%) 6 (11.5%) 4 (7.7%) 13 (25.0%)

Dry canals No symptoms No exudate Clean and shaped canal Sufficient time No swelling No severe pain No sinus tract Others II. Root canal medication Q7. If two or more than two visits of patients are normally required to carry out root canal obturation, do you use some medications between appointments? Yes No If YES, what kinds of medications do you use? (Some respondents listed more than one answer.) Calcium hydroxide Formocresol Cresatin Steroid Camphorated monoparachlorophenol Ladermix Others If YES, what kinds of temporary restorative materials do you use? (Some respondents listed more than one answer.) Cavit Zinc oxide-eugenol-based cement Light-activated particlefilled composite resin Glass-ionomer cement Others III. Root canal irrigation Q8. Do you use some irrigation solution before root canal obturation? Yes/No Yes No If YES, what kind of irrigation solution do you use? (Some respondents listed more than one answer.) Sodium hypochlorite EDTA Water Hydrogen peroxide Others

68 39 39 32 19 11 8 8 16

110 (71.0%) of 155 45 (29.0%) of 155

99 (90.0%) 14 (12.7%) 5 (4.5%) 5 (4.5%) 3 (2.7%) 2 (1.8%) 4 (3.6%)

75 (68.2%) 64 (58.2%) 13 (11.8%) 9 (8.2%) 5 (4.5%)

156 (100%) of 156 0 (0%) of 156

149 (95.5%) of 156 69 (44.2%) of 156 13 (8.3%) of 156 9 (5.8%) of 156 18 (11.5%) of 156

We received a total of 156 responses. But some participants in this study didnt answer all of the question, so for Q2, Q5, Q6, and Q7, the total number was under 156.

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Inamoto et al.

Journal of Endodontics

In pulpectomy cases, root canal obturation during a first visit was carried out by 87 (55.8%) of the 156 endodontists who responded to this question (Q1); in infected root canal cases, the number was 52 (34.4%) out of 151 endodontists (Q2). In pulpectomy cases, all the respondents accomplished one-visit treatment of a front tooth within 60 min. For one-visit treatment of molars, 35.1% of the respondents needed from 60 to 90 min of treatment time, and 5.4% needed more than 90 min (Q3). In infected root canal cases, 94.6% of the respondents accomplished one-visit treatment of a front tooth by 60 min. For molars, 45.9% of the respondents needed from 60 to 90 min, and 10.8% needed more than 90 min; thus, more than half of the respondents required over 60 min to accomplish a one-visit treatment of a molar (Q4). Fifty-two (34.2%) of the 152 endodontists indicated that their patients had experienced some trouble, such as pain, flare-ups, swelling, discomfort, etc. after root canal obturation at the first visit (Q5). In multiple visit cases, 90% of the respondents used mainly calcium hydroxide as a root canal medication. Cavit was used as a temporary sealant by 68.2% and zinc-oxide-eugenol cement was used by 58.2% (Q7). An irrigation solution before root canal obturation was used by all 156 of the respondents. One hundred forty-nine (95.5%) of the 156 endodontists used mainly sodium hypochlorite as a root canal irrigant, 69 (44.2%) used EDTA, and 13 (8.3%) used water (Q8). DISCUSSION One-visit endodontic therapy has many advantages for the dentist and patient. Some studies have been published about the extent of the practice of one-appointment endodontics. Calhoun and Landers (2) questioned 429 endodontists who were randomly selected and found that 90% of them treated certain types of cases in one appointment; 67.1% would treat vital teeth in one appointment, whereas only 16.8% would treat necrotic cases in one appointment. Gatewood et al. (3) questioned 568 diplomats and found that 34.7% of the respondents completed treatment in one visit for teeth with a normal periapex, whereas only 16.2% did so if apical periodontitis were present. The results of our survey showed that 87 (55.8%) of the 156 responding endodontists completed treatment in one visit in pulpectomy cases; and in infected root canal cases, the number was 52 (34.8%). The results of our survey are higher than the finding of Gatewood et al. (3). The reasons for the differences may relate to the fact that they investigated only the treatment of endodontic emergencies in one visit. So, the real number of endodontic cases treated in one visit is probably higher. Comparing single- and multiple-visit procedures, the question of the incidence of postoperative pain and flare-ups has been posed. Severe pain after endodontic therapy is a significant problem. Our survey showed that 34.2% of responding endodontists experienced postobturation troubles, such as pain, flare-ups, etc. Different studies report various incidences of postoperative pain and flare-ups, due to differences in the criteria used in these studies (4 7). Walton and Fouad (4) treated 946 patients and then examined the correlating factors that cause a flare-up after root canal treatment. They reported that there was no correlation between patient demographics or systemic conditions, number of appoint-

ments, treatment procedures, or taking antibiotics. Jurcak et al. (5) performed one-visit endodontics on 167 patients. All cases were performed in one visit regardless of the presence of pain, swelling, sinus tracts, or radiographic lesions. They reported that one-visit endodontic therapy was no more uncomfortable and as equally successful as multiple-visit therapy. Similarly, other studies (6, 7) reported little or no difference in the incidence of posttreatment complications between single and multiple appointments. The study by Oliet (6) indicated that one-appointment endodontic postoperative sequelae and healing did not differ significantly when compared with two-visit endodontics. Fava (7) reported that no difference was observed in the incidence of postoperative pain between one and two appointments. Pekruhn (8) reported that the incidence of failure after one-appointment endodontics was higher in those teeth with periapical extension of pulpal disease. To achieve success with one-appointment therapy, careful case selection is needed, and the dentist must have a full understanding of the techniques of endodontics. The dentists undertaking one-appointment endodontic therapy should act according to the guidelines for one-appointment endodontics (1). Regarding medication, Itoh et al. (9) reported that of the 85 endodontists in the United States in their study, calcium hydroxide was used at least some of the time by 78 (91.7%) of them. The results of our survey are similar to theirs. This study indicated that sodium hypochlorite is the most widely used irrigant in endodontics (10). Cavit and zinc-oxide-eugenol cement, as sealing agents for inter-treatment dressings, were mainly used by our respondents. Weine (10) recommended Cavit as the first choice and zinc-oxideeugenol cement as the second. Our survey agrees with his opinion. The results of this survey should be useful to provide good information for general dental clinicians and the endodontic education of undergraduate students and postgraduate students.
Drs. Inamoto, Kojima, Nagamatsu, Hamaguchi, Nakata, and Nakamura are affiliated with the Department of Endodontics, School of Dentistry, Aichi Gakuin University, Chikusa-ku, Nagoya, Japan. Address requests for reprints to Kyoko Inamoto, Departments of Endodontics, School of Dentistry, Aichi Gakuin University, 2-11 Suemori-dori, Chikusa-ku, Nagoya 464-8651, Japan.

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