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Inconclusive evidence to support either single or multiple-visit endodontic treatment to minimize pain and flare-ups

Analia Veitz-Keenan DDS .


Systematic Review Conclusion

The evidence is inconclusive for determining if a single 1 visit or multiple visits will reduce postoperative pain and associated flare-ups after endodontic treatment.

Critical Summary Assessment

Pooled evidence from mostly prospective and retrospective cohort studies finds not clear support for either treatment modalities.

Evidence Quality Rating

Limited Evidence

Structured Abstract

Clinical Questions:

The systematic review addresses two clinical questions: in patients undergoing root canal therapy, is a single or multiple visit approach better in reducing 1) post-operative pain and 2) post-operative flare-ups.

Review Methods:

The authors conducted a search of 3 major databases, conference reports and theses to find all clinical studies regardless of research design. All languages were accepted for the review. Of the 220 studies identified in the search, 200 were excluded because they did not answer the clinical question. The 20 remaining studies were analyzed for inclusion. There were 13 studies included, plus 3 additional studies identified from the reference lists, for a total of 16 included studies. Two reviewers independently extracted the data. Heterogeneity among the studies prevented a meta-analysis.

Main Results:

Four of the 16 studies examined flare-ups as an outcome. One study found no significant difference between treatment approaches. One study found that a single visit significantly reduced flare-ups, and 2 others found that multiple visits significantly reduced flare-ups. Twelve studies examined differences in postoperative pain. All but 2 of these studies found no significant difference between single and multiple visits, with the 2 remaining studies favoring different approaches. There was substantial variation across the studies in terms of proportion of patients reporting pain and flare-ups. Study protocols for measuring pain varied widely, as did the specific treatment protocols.


Based on the available evidence, it is not possible to conclude if treatment in a single visit is better than multi-visit treatment. Additional randomized control trials are needed to facilitate comparison across studies and application to specific types of patients.

Source of Funding:

Not Reported


Importance and Context:

The choice between a single or multiple visit depends on many factors including the status of pre-operative infection and the patient's overall health in terms of the host response. Should the practitioner determine after conducting a clinical assessment that a single visit treatment presents a viable option, the issue remains whether or not treatment in single or multiple visits will have a greater potential of reducing post operative discomfort. This systematic review attempted to analyze which of these treatment approaches reduced post-op pain and flare-ups.

Strengths and Weaknesses of the Systematic Review:

A broad search strategy was used and is presented in the review. The selected studies answered the proposed clinical question, which was clearly formulated in a PICO format. Inclusion and exclusion criteria were straightforward and logical. Although the methods of the included studies are explained, there is no formal assessment of study quality to evaluate the likelihood of bias.

Strengths and Weaknesses of the Evidence:

The evidence comes from 16 studies; 6 studies were randomized controlled trials; 7 were prospective cohort studies, 2 were retrospective cohort studies and 1 was a cohort study. The majority of data was provided by weak studies. The heterogeneity of the studies was extensive, and differences in methods to assess pain precluded pooling of the data. An important feature of this systematic review was the author’s mention of the periapical status of the teeth and the presence or absence of lesions as it relates to the decision about performing endodontic treatment in single or multiple visits. Most studies did not analyze teeth with or without periapical pathology separately. They also did not describe preoperative pain, which along with periapical pathology can indicate the increased risk of flare-ups.

Implications for Dental Practice:

Reducing the possibility of pain and flare-ups after endodontic treatment is always a goal for patients and practitioners. Presently there is no strong evidence that a single visit or a multiple-visit treatment approach reduces pain and flare-ups.

Critical Summary Publication Date:


These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association © 2018