one appointment filling?

[organic]

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HI dear friends, here is a little story

my friend, according to his description, had caries on his right upper molar (my guess is first Molar). He went to see his dentist and was told that he needed a crown and possible a root canal treatment. After the first appointment which seemed to involve caries removal and initial crown prep, the tooth started to hurt spontaneously. The symptoms were like acute pulpitis. My friend went to an endodontist and had the root canal done. What bothered me was, his endodontist finished his painful 4 canal molar in one appointment, within 1 1/2 hours ( no microscope used)filled the canales and finished the treatment. I have never heard an one appointment filling with a 4 canal molar, not to mention that it was in pain. I usually perform one appointment filling if the tooth is fresh ( for prosthetic reason )or have one or 2 canals. Am I missing something here? Is there any evidence to back up this molar one appointment filling?

my friend seems very proud of this dentist's " high speed " treatment. Have you ever heard from your patients or friends saying that some dentist is a " great dentist" because he is very fast...

organic
😕

 

[Big_Poppa DDS]

one appointment molar endos are quite common. Its better to get the tooth sealed as soon as possible.

 

[DrJeff]

Reguardless of the number of canals in a tooth, 1 visit start to finish endo is basically the standard of care now in this rotary endo world that we're in. Probably 95%+ of all the endo that I do nowadays is 1 visit, the only exceptions are when I absolutely can't get the canals dry after instrumenation prior to obturation. My local endodontist also has told me anecdotally that the greatest amount of post visit pain that he encounters with his patients is in the mutliple visit cases. His rationale being that 1 visit instrumentation/obturation will do a better job of eliminating the peri-apical bacteria between the pH of the sealer and the heat of the warm gutta percha immediately after the sterilization of the canal via sodium hypochlorite irrigation. In a mutli visit case, even with interim canal medication with IKI/CaOH/ and/or formocreosol bacterial proliferation leading to apical "flare ups" are more likely to occur than with 1 visit, open, disinfect/seal endos. Plus, if you're able via the extra speed of rotary instrumentation perform most endos in 1 visit, your overhead goes down (less supplies setting up once verses twice) and happier patients who can come in in pain and leave about 1 hour later and be down with it. That's the type of word of mouth advertising that goes a long way.

As for the endodontist not using a microscope, many of them won't use them all the time, especially if the canals are "wide open". Additionally if this tooth was prepped for a crown already there wasn't alot of coronal tooth structure to hinder vision. It's a win, win, win situation that is far from uncommon/abnormal by todays standards

 

[organic]

Dr Jeff, I really appreciate your input, it is really interesting to see other dentists' opinions.

I agree with you about all the benefits of single appointment filling ( especially that patients would be happy!) , and even in the textbook, there is no evidence of single appointment filling having more flare-ups than mutiple appointment treatments.

But I used to have lots of patients who were referred to hospital for re-treatment after one appoitment treatment failure. The case selection is very critical, I am not sure if it is correct to say that 95% of patients would be suitable for one appointment treatment. The rationale of providing better sealing with GP is of no doubt, but I also think if a dentist follows all standard procedure, use rubber dam, avoid contamination and provides good inter- appointment temporary sealing, there wouldn't be bacteria re--entry into apex. On the other hand, we all know that we can't really " sterilize" the canals, but control the bacteria to a lower amount so that body immunity would fight back. During root canal treatment, a dentist can't tell if he/she really " cleans well enough" the canals, but by other signs ( exudate...etc. ).
If the canals look good, we apply some medication and seal well, the next time( not too long inter- appointment time) , if the patient feels nothing, wouldn't it be safer to seal the tooth by then? my point is more toward the fact that once the canals are sealed with GP, it'd be very a lot more troublesome to remove GP and and re-treat the tooth. THe second appointment will also allow the dentist to observe the patient if he has some apical periodontitis ( pain on biting..etc.) ...

The other thing that surprised me was, the endodontist of my friend didn't use rotary instruments ....I do know that it is common not to use microscope, in our hospital, we used it for broken instruments, calficied canals or severely curved canals...

Dr. Jeff, so what happens if a patient , after one appointment filling, comes back in pain ? do you remove the GP right away?
( sorry I have limited knowlege regarding to warm GP technique..)

Thanks for sharing your clinical experience, you do remind me of many other points I nelected....

organic

 

[Big_Poppa DDS]

initial pain is from inflammation
pain a few days later may be due to infection

 

[organic]

I am not sure what you meant

"inflammation " should be tissue reaction ( though the reaction is actually inflammatory reaction....)

" infection" .... if you have a very well sealed and clean canal, where from ...?

the question I had about post treatment pain, I certainly didn't mean the kind of pain that is like tissue reaction.....

 

[DrJeff]

Originally posted by organic
Dr Jeff, I really appreciate your input, it is really interesting to see other dentists' opinions.

I agree with you about all the benefits of single appointment filling ( especially that patients would be happy!) , and even in the textbook, there is no evidence of single appointment filling having more flare-ups than mutiple appointment treatments.

But I used to have lots of patients who were referred to hospital for re-treatment after one appoitment treatment failure. The case selection is very critical, I am not sure if it is correct to say that 95% of patients would be suitable for one appointment treatment. The rationale of providing better sealing with GP is of no doubt, but I also think if a dentist follows all standard procedure, use rubber dam, avoid contamination and provides good inter- appointment temporary sealing, there wouldn't be bacteria re--entry into apex. On the other hand, we all know that we can't really " sterilize" the canals, but control the bacteria to a lower amount so that body immunity would fight back. During root canal treatment, a dentist can't tell if he/she really " cleans well enough" the canals, but by other signs ( exudate...etc. ).
If the canals look good, we apply some medication and seal well, the next time( not too long inter- appointment time) , if the patient feels nothing, wouldn't it be safer to seal the tooth by then? my point is more toward the fact that once the canals are sealed with GP, it'd be very a lot more troublesome to remove GP and and re-treat the tooth. THe second appointment will also allow the dentist to observe the patient if he has some apical periodontitis ( pain on biting..etc.) ...

The other thing that surprised me was, the endodontist of my friend didn't use rotary instruments ....I do know that it is common not to use microscope, in our hospital, we used it for broken instruments, calficied canals or severely curved canals...

Dr. Jeff, so what happens if a patient , after one appointment filling, comes back in pain ? do you remove the GP right away?
( sorry I have limited knowlege regarding to warm GP technique..)

Thanks for sharing your clinical experience, you do remind me of many other points I nelected....

organic

I did some looking and some asking about the "immediate" retreatment need after obturation secondary to residual infection. My own experience since I really entered the "1 visit endo world" a little over 5 years ago has consisted of the following. A total of 450 teeth endodontically treated (based on looking back through my practice management software). Going off of memory I'd say that of those 450 teeth, all but 20 to 30 were done in 1 visit (inability to obtain a dry canal after instrumentation being the most common reason for not completing treatment in 1 visit), and 1 tooth that took me 3 visits to complete (this 1 I remember very vividly for the trouble it gave me 😡 ) Of the 425 teeth or so that I completed in 1 visit, I've had 2 immediate flare ups, one that was successfully managed with antibiotics(asymptomatic and radiographic apical healing after 3 tears), and the other I had to remove the gutta percha and re-instrument and obturate (palatal canal of #2).

I had lunch yesterday with my local endodontist and I posed the same scenario/question to him, and he had similiar flare up rates to what I was finding in my own practice.

Basically then with the clinical success rates that I'm seeing, and also hearing from my local endodontist there really isn't any disadvantage to obturating during the first visit as long as you can successfully clean the canals during instrumentation. If anything with such a high success rate in 1 visit,by bringing the patient back with a few weeks after the first visit just to obturate has the major drawback for you as the business person owner of increasing your overhead. Your using more supplies in 2 visits, and occupying more chairtime which could be used to see other paying patients. Additionally while many patients will appreciate your care for their wellbeing by waiting to obturate, many of them won't appreciate having to comeback and receive another injection and wear the rubber dam for another period of time. Remember afterall happy patients will teel there friends that you're the greatest and then the friends will consider becoming a patient of yours. This is especially true now of 1 visit endo patients, since many folks that may have had an endo in the past recquired multiple visits, they are really amaze when its done in 1 visit in about an hour.

 

[organic]

Dr Jeff

you have given me a totally different point of view regarding to one appointment filling, a very good one! I have to agree with you for all the benefits.

thanks