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ORIGINAL ARTICLE
Year : 2012  |  Volume : 4  |  Issue : 1  |  Page : 9-17

The effect of variation in inter-appointment time on the incidence of post-operative pain in single-visit versus two visit endodontics: An in vivo study


1 Department of Conservative Dentistry and Endodontics, Pdm. Dr. D.Y. Patil Dental College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
2 College of Dental Sciences and Research Centre, Ghuma, Ahmedabad, Gujarat, India

Date of Web Publication23-Apr-2014

Correspondence Address:
Sumita A Bhagwat
406/27 Siddhachal Phase 5, Near Vasant Vihar High School, Thane West - 400 610, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.131371

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   Abstract 

Aim: This clinical study was conducted to observe and note the effect of variation in inter-appointment time period on the incidence of post-operative pain following single-visit versus two visit endodontics in vital and nonvital teeth with and without periapical radiolucency. Materials and Methods: A total of 80 adult patients requiring root canal therapy in anterior and premolar teeth were selected for this study and divided into four groups. Two sitting root canal treatment was carried out in three groups (Group 1 with inter-appointment time of 72 h, Group 2 with inter-appointment time of 48 h and Group 3 with inter-appointment time of 24 h) and single sitting root canal treatment was carried out in one group (Group 4). The subjects were recalled after 2 weeks and instructed to fill out a series of self-report questionnaires for responses about pain in the interim after 1 day, 2 day, 3 day, 1 week and 2 weeks. Results: Though comparison of pain incidence in different groups was not statistically significant, there was a greater tendency for post obturation pain incidence in teeth treated with single sitting root canal therapy and those with inter appointment period of 72 h. Results obtained were comparable to those obtained by several investigators.

Keywords: Pain after obturation, pain after root canal treatment, post-operative pain in endodontics, single sitting endodontics


How to cite this article:
Bhagwat SA, Patel A, Mandke LP. The effect of variation in inter-appointment time on the incidence of post-operative pain in single-visit versus two visit endodontics: An in vivo study. J Int Clin Dent Res Organ 2012;4:9-17

How to cite this URL:
Bhagwat SA, Patel A, Mandke LP. The effect of variation in inter-appointment time on the incidence of post-operative pain in single-visit versus two visit endodontics: An in vivo study. J Int Clin Dent Res Organ [serial online] 2012 [cited 2019 Jun 24];4:9-17. Available from: http://www.jicdro.org/text.asp?2012/4/1/9/131371


   Introduction Top


Fear of pain is probably the single most important reason why patients are scared of dental treatment and root canal therapy. The promise of "no pain" is often the most chosen protocol when a patient opts for a particular treatment modality. Several factors and variables have been held responsible for greater incidence of post-operative pain since the inception of root canal therapy. The purpose of this study was to observe the effect of variation in inter-appointment time on the incidence of post-operative pain in single-visit versus two visit endodontics in vital and non-vital teeth with and without periapical radiolucency.


   Materials and Methods Top


A total of 80 adult patients, aged between 16 and 65 years, requiring root canal therapy in anterior and single-rooted premolar teeth were selected from Department of Conservative Dentistry and Endodontics, Pad. Dr. Y. Patil Dental College and Hospital, Nerul, Navi Mumbai for this study.

Selection criteria

  1. Asymptomatic vital/non-vital teeth requiring root canal treatment
  2. Teeth with sound periodontal apparatus
  3. Teeth without pus or inflammatory exudate draining through the canal
  4. Teeth without anatomic variations
  5. Patients not on analgesics or sedative medication prior to root canal therapy
  6. Teeth without sinus tract
  7. Teeth without history of trauma
  8. Teeth selected as abutments or to be retained under an overdenture
  9. Teeth with periapical radiolucency not exceeding 3 mm × 3 mm in size.


Patients with any systemic diseases, pregnant patients, immuno-compromised patients, retreatment cases and teeth with calcified canals were not included in the study.

At an initial appointment, subjects were informed about the nature of the study. A thorough clinical examination including vitality testing and case history was taken. A pre-operative radiograph was taken to check the canal, periodontal tissues and presence of periapical radiolucency.

The subjects were divided into four groups based on different obturation timings:

  • Group 1: 20 teeth (two visit with inter-appointment time of 72 h)
  • Group 2: 20 teeth (two visit with inter-appointment time of 48 h)
  • Group 3: 20 teeth (two visit with inter-appointment time of 24 h)
  • Group 4: 20 teeth (single visit).


Local anesthesia was administered and root canal treatment was initiated. The tooth was isolated using rubber dam. Caries/defective restoration was removed. Biomechanical preparation was done with step-back technique and obturation with lateral condensation technique as seen in intraoral periapical xrays in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]. [1] Root canal treatment was completed as per obturation schedule of each group. Subjects were recalled after 1 week and instructed to fill out a series of self-report questionnaires [2] in the interim after 24 h, 48 h, 72 h and 1 week. The questionnaires asked for responses about pain, experienced during 1 week.
Figure 1: Group 1 (teeth treated in two visit with inter-appointment time of 72 h): Pre-operative intra oral periapical X-ray

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Figure 2: Group 1: Working length intra oral periapical

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Figure 3: Group 1: Master cone intra oral periapical

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Figure 4: Group 1: Post obturation intra oral periapical

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Figure 5: Group 2 (teeth treated in two visit with inter-appointment time of 48 h): Figure 6: Group 2: Working length intra oral periapical Pre-operative intra oral periapical

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Figure 6: Group 2: Working length intra oral periapical

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Figure 7: Group 2: Master cone intra oral periapical

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Figure 8: Group 2: Post obturation intra oral periapical

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Figure 9: Group 3 (teeth treated in two visit with inter-appointment time of 24 h): Preoperative intra oral periapical

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Figure 10: Group 3: Working length intra oral periapical

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Figure 11: Group 3: Master cone intra oral periapical

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Figure 12: Group 3: Post obturation intra oral periapical

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Figure 13: Group 4 (teeth treated in single visit): Pre-operative intra oral periapical

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Figure 14: Group 4: Working length intra oral periapical

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Figure 15: Group 4: Master cone intra oral periapical

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Figure 16: Group 4: Post obturation intra oral periapical

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Rating for pain

  • 0 - No pain
  • 1 - Mild pain: Any discomfort that did not require medication or emergency treatment, no matter how long it lasted
  • 2 - Moderate pain: Pain requiring medication
  • 3 - Severe pain: Pain that was not relived by medication and required palliative treatment.



   Results Top


All 80 patients were available for follow-up. Post-obturation evaluation was carried out after 24 h, 48 h, 72 h and 1 week and the readings obtained were tabulated for each group [Table 1], [Table 2], [Table 3], [Table 4]. The objective was to test the significance of difference between Group 4 and Group 1, Group 2, Group 3 individually. The test chosen was Mann-Whitney U-test of testing the significance of difference between two independent groups. Intra group comparison was carried out.
Table 1: Incidence of pain in Group 1

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Table 2: Incidence of pain in Group 2

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Table 3: Incidence of pain in Group 3

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Table 4: Incidence of pain in Group 4

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After 24 h obturation, nearly 65% of teeth did not have post-operative pain. Nearly 32.5% teeth had mild pain and 2.5% moderate pain. Severe pain was not reported in any case [Table 5].
Table 5: Incidence of pain in all treated patients 24 h after obturation

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In Group 1 - 60% did not have pain, 40% teeth had mild pain and none had moderate pain.

Group 2 - 70% did not have pain, 30% teeth had mild pain and none had moderate pain.

Group 3 - 65% did not have pain, 35% teeth had mild pain and none had moderate pain.

Group 4 - 65% did not have pain, 25% teeth had mild pain and 10% had moderate pain.

After 48 h obturation, nearly 90% teeth did not have pain. 10% teeth had mild pain and none had moderate pain. Severe pain has not been reported in any of the cases [Table 6].
Table 6: Incidence of pain in all treated patients 48 h after obturation

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In Group 1 - 90% did not have pain, 10% teeth had mild pain and none had moderate pain. 30% teeth showed a reduction in pain, whereas in 10% teeth the pain was not reduced when compared to post-operative pain after 24 h.

In Group 2 - 85% did not have pain, 15% teeth had mild pain and none had moderate pain.

In 15% teeth pain was reduced where as in 15% teeth there was no reduction in pain compared to post-operative pain after 24 h.

In Group 3 - 95% did not have pain, 5% teeth had mild pain.

30% teeth showed a reduction in pain where as 5% teeth showed no reduction in pain compared to post-operative pain after 24 h.

In Group 4 - 90% did not have pain, 10% teeth had mild pain and none had moderate pain.

In 15% teeth pain was reduced where as in 10% teeth there was no reduction in pain compared to post-operative pain after 24 h.

72 h after obturation 98.75% teeth were reported free of pain. 1.25% teeth had mild pain and none had moderate pain [Table 7].
Table 7: Incidence of pain in all treated patients 72 h after obturation

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In Group 1 - All teeth reported having no pain. 40% teeth had a reduction in pain as compared to post-operative pain after 24 h.

In Group 2 - All teeth reported having no pain. 30% teeth had a reduction in pain as compared to post-operative pain after 24 h.

In Group 3 - 95% did not have pain, 5% had mild pain. 30% teeth showed a reduction in pain whereas 5% teeth did not show any decrease in pain compared to post-operative pain after 24 h.

In Group 4 - All teeth reported having no pain. 25% teeth had a reduction in pain as compared to post-operative pain after 24 h.

1 week post-obturation 98.75% teeth were free of pain and 1.25% had mild pain (1 in Group 3) [Table 8].
Table 8: Incidence of pain in all treated patients 1 week after obturation

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In Group 1 - All teeth were free of pain. 40% teeth showed a reduction in pain compared to post-operative pain after 24 h.

In Group 2 - None of the teeth had pain.

In Group 3 - 95% did not have pain, 5% had mild pain. 5% did not show any reduction in pain whereas 30% teeth the pain was reduced to score 0 as compared to post-operative pain after 24 h.

In Group 4 - None of the teeth had pain.

There was no difference with regard to pain among both the sexes.

Statistical analysis

The test chosen was Mann-Whitney U test of testing the significance of difference between two independent groups.

Comparison of Group 1 and Group 4

Null hypothesis: There is no significant difference between Group 4 and Group 1.

Alternative hypothesis: There is a significant difference between Group 4 and Group 1.



Interpretations

  1. The P value for pain after 24 h is 0.949 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.
  2. The P value for pain after 48 h is 1.0 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.
  3. The P value for pain after 72 h is 1.0 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.
  4. The P value for pain after 1 week is 1.0 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.


Comparison of Group 2 and Group 4

Null hypothesis: There is no significant difference between Group 4 and Group 2.

Alternative hypothesis: There is a significant difference between Group 4 and Group 2.



Interpretations

  1. The P value for pain after 24 h is 0.598 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.
  2. The P value for pain after 48 h is 0.637 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.
  3. The P value for pain after 72 h is 1.0 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.
  4. The P value for pain after 1 week is 1.0 which is greater than that of 0.05. Thus we accept the null hypothesis of no difference.


Comparison of Group 3 and Group 4

Null hypothesis: There is no significant difference between Group 4 and Group 3.

Alternative hypothesis: There is a significant difference between Group 4 and Group 3.



Interpretations

  1. The P value for pain after 24 h is 0.821 which is greater than that of 0.05. Thus we accept null hypothesis of no difference.
  2. The P value for pain after 48 h is 0.553 which is greater than that of 0.05. Thus we accept null hypothesis of no difference.
  3. The P value for pain after 72 h is 0.317 which is greater than that of 0.05. Thus we accept null hypothesis of no difference.
  4. The P value for pain after 1 week is 0.317 which is greater than that of 0.05. Thus we accept null hypothesis of no difference.



   Discussion Top


Root canal treatment can be done either in multiple visits or one visit. Considerable controversy exists in clinical opinion regarding difference in quality of treatment, incidence of post-treatment complications and success rates between single visit and multiple visit root canal treatment. To date, the evidence for recommending either one or multiple visit endodontics is not consistent. One of the major advantages with the multiple visit root canal therapy is an opportunity to place an intra-canal disinfectant. The fear that patients will probably develop post-operative pain and that the canal has been irretrievably sealed has probably been the greatest deterrent to single visit therapy.

The incidence of post-operative pain is one of the major concerns when evaluating endodontic treatment alternatives. Availability of better techniques, better understanding of internal tooth anatomy, evolution of instruments and materials has changed the way of treating routine cases to diminish post-operative pain. Because of the subjective nature of the pain experience, the interpretation and evaluation of patients will show wide variations. Such factors as positive pre and post-operative suggestions concerning a procedure may influence patients to report a lower incidence of pain than if there had been no such suggestions. Stressful situations unrelated to treatment may reduce the patient's tolerance for discomfort and result in an increase in the reported incidence of significant pain. Anxiety and ignorance of the procedure and its squeal can alter the incidence of reported pain experience. Because of the variables introduced as a result of the psychological interactions with the pain experience, in our study it was decided to allow the patients to discriminate between four levels of intensity of pain.

In this study, post-operative pain has been arbitrarily classified. [2] Teeth without any discomfort were classified as no pain. Teeth with minimal discomfort that did not require medication were grouped under mild pain. Teeth with noticeable pain requiring medication were grouped as moderate pain. Intolerable pain that was not relieved by medication and required emergency treatment was grouped as severe pain. The teeth were further grouped as having significant pain and not significant pain.

Not significant pain = No to mild pain.

Significant pain = Moderate to severe pain.

In our study, the incidence of pain and its severity after obturation showed no significant difference when Group 4 was compared to Group 1, Group 2 and Group 3. The present study can be compared with various studies reported in the literature, which used similar method of evaluation.

Fox et al. [3] treated 291 teeth with one visit complete endodontic therapy. They reported that 90% of teeth treated in single visit had little or no spontaneous pain at the end of 1 day and 99% had no spontaneous pain at the end of 1 week and remaining 1% had slight pain.

Soltanoff [4] treated 88 teeth in single visit and 193 in multiple visit and reported that in single visit cases, 40 had no pain whereas out of 48 patients, 31 had only mild pain, 14 had moderate pain, and three had severe pain. In multiple visit procedure, 47 had mild pain, 25 had moderate pain and two had severe pain.

Oliet [5] treated 264 teeth in single visit therapy and found 10.6% incidence of pain following obturation after 24 h and no pain at all after 1 week. His classification was on the reaction of various degrees of mild, moderate and severe pain experienced.

Roane et al. [6] conducted a study of 359, forming a data pool of 250 treatments completed in a single visit and 109 completed in multiple visits. In this study, treatments were performed in teeth of which 153 had vital pulps and 206 had non-vital canal. Out of 250 cases, 15.2% had post-operative pain after single visit endodontics as compared with 31.2% of multiple visit cases.

Mulhern et al. [7] treated 66 patients aged 13 to 75 years, with approximately equal distribution according to gender. 8 patients experienced pain in the single-visit treatment and 12 in the multi-visit treatment. There was no significant difference in the occurrence of pain between the one-appointment and multi-appointment treatment groups.

Pekruhn [8] studied 51 cases and reported 41.2% pain on percussion of the single visit group and in 29.4% of the multiple-visit group. Palpation pain also was a significant finding, present in 33.3% of the single visit group and 25.4% of the multiple visit groups on the 1 st day post-obturation, 19.6% in single visit and 11.8% in multiple visit after 7 days.

In their exhaustive review, Su et al. [9] found that on the basis of current studies, the healing rate of single- and multiple-visit root canal treatment is similar for infected teeth. Patients experience less frequency of short-term post-obturation pain after single-visit than those having multiple-visit root canal treatment.

Some of the authors have correlated the post treatment pain with many variables such as age of the patient, gender, different arch and tooth groups, pulp/periradicular diagnosis and presence of pre-operative signs and symptoms, systemic conditions etc. Apart from these variables, pain in endodontic procedures is related to the presence or absence of inflammation. The potential for increased degree of inflammation is obviously greater when the entire endodontic procedure is performed in one visit. It is reasonable to assume that if severe inflammation exists before treatment, there would be a tendency to expect a distinct increase in post-operative pain after single visit procedure rather than if two or more visits were used. On the other hand, if the tooth is reasonably comfortable before treatment, the chances are that no great discomfort would result either from single or multiple visit procedure. [10]

In vital teeth, severing the dental pulp from the surrounding periodontal tissues will cause an inflammatory response and an open, unfilled canal will allow inflammatory fluids to accumulate and thus dissipate inflammatory pressures. This argument, however, would seem to be invalidated by the fact that when the root canal spaces are prepared, most dentists intentionally terminate the preparation short of the apical canal terminus, thus blocking the apical foramen with dentinal debris. [8]

Some authors believe that in non-vital teeth, intra-canal organisms may inadvertently be forced beyond the cemento-dentinal junction with resulting infection, swelling and pain. Only those teeth with active fistulas were considered candidates for single visit endodontic therapy, simply because they possess a clear anatomical, albeit pathologic, channel through which inflammatory pressure can be released. [8]

With the precise radiographic control and thorough canal debridement techniques, many dentists believe that the damage to the periapical tissues can be minimized, thus greatly reducing the meta-endodontic inflammatory response and consequent discomfort.

On the contrary Mulhern et al. [7] reported that patients who required antibiotics and two patients with detectable swelling in their study were from the group in which one visit endodontic therapy was done and thus supports the hypothesis that post-operative inflammation is more severe in one visit endodontics than multiple visit therapy.

There is no basis to the common belief that extending treatment procedures over additional appointments will reduce the periapical trauma and help to prevent the flare ups. Each visit represents an entry, regardless of whether obturation or instrumentation is accomplished and may produce an incidence of pain; therefore multiple visits introduce more opportunity for the patient to experience pain than single visit procedures.

It should be realized that during cleaning and shaping procedures, dentine chips, microorganisms, pulp remnants, irrigating solution or necrotic debris may be pushed into the periapical region causing inflammation and post-operative pain. Since this extrusion is a common problem to all root canal preparation techniques, modern procedures have been advocated to minimize this situation. [11]

One fact not mentioned in the literature is how much tissue remains in the root canal after completion of a single visit procedure. Removal of the vital tissue from the canal is very difficult in the best of circumstances not to mention when time is a factor. Small tissue tags are left behind in the root canal even after instrumentation is completed. Irrigation serves as a physical flush to remove debris as well as serving bactericidal agent, tissue solvent and lubricant. 2.5% sodium hypochlorite used in our study also helps to dissolve vital and non-vital tissue. Thus, the use of sodium hypochlorite in our study along with mechanical instrumentation greatly helped to reduce the amount of tissue and debris in root canal and thus reducing the post-operative pain.

Oliet [5] found increased pain in younger age group (10-39) however did not find any significant difference between sexes. Mulhern et al. [7] and Fox et al. [3] reported more pain associated with female patients. In the present study, pain was found not to be related to age or sex. With the present knowledge and favorable clinical findings, single visit therapy has a definite place in the field of endodontics, but careful case selection and host immune response still play a major role in incidence of post-operative pain.


   Conclusion Top


  1. There is no statistical difference between incidence of pain in single and two visit (with varied time gaps between appointments) root canal treatment in vital and non-vital teeth with and without periapical radiolucency.
  2. There is no significant difference in the pain experienced by the patients 72 h after treatment in both the one visit and two visit groups. After 24 h and 48 h of obturation, pain was significantly higher in two visit groups compared to 72 h and 1 week.
  3. There was no significant difference in the pain on vertical percussion experienced by patient after 1 week of treatment between both the one visit and two visit groups.


 
   References Top

1.Ingle J, Bakland L. Endodontics. 5 th ed. India: B. C. Decker, Elsevier; 2003.  Back to cited text no. 1
    
2.Wang C, Xu P, Ren L, Dong G, Ye L. Comparison of post-obturation pain experience following one-visit and two-visit root canal treatment on teeth with vital pulps: A randomized controlled trial. Int Endod J 2010;43:692-7.  Back to cited text no. 2
    
3.Fox J, Atkinson JS, Dinin AP, Greenfield E, Hechtman E, Reeman CA, et al. Incidence of pain following one-visit endodontic treatment. Oral Surg Oral Med Oral Pathol 1970;30:123-30.  Back to cited text no. 3
[PUBMED]    
4.Soltanoff W. A comparative study of the single-visit and the multiple-visit edodontic procedure. J Endod 1978;4:278-81.  Back to cited text no. 4
[PUBMED]    
5.Oliet S. Single-visit endodontics: A clinical study. J Endod 1983;9:147-52.  Back to cited text no. 5
[PUBMED]    
6.Roane JB, Dryden JA, Grimes EW. Incidence of postoperative pain after single- and multiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol 1983;55:68-72.  Back to cited text no. 6
[PUBMED]    
7.Mulhern JM, Patterson SS, Newton CW, Ringel AM. Incidence of postoperative pain after one-appointment endodontic treatment of asymptomatic pulpal necross in single-rooted teeth. J Endod 1982;8:370-5.  Back to cited text no. 7
[PUBMED]    
8.Pekruhn RB. Single-visit endodontic therapy: A preliminary clinical study. J Am Dent Assoc 1981;103:875-7.  Back to cited text no. 8
[PUBMED]    
9.Su Y, Wang C, Ye L. Healing rate and post-obturation pain of single- versus multiple-visit endodontic treatment for infected root canals: A systematic review. J Endod 2011;37:125-32.  Back to cited text no. 9
    
10.Pekruhn RB. The incidence of failure following single-visit endodontic therapy. J Endod 1986;12:68-72.  Back to cited text no. 10
[PUBMED]    
11.Bender IB, Seltzer S, Turkenkopf S. To culture or not to culture? Oral Surg Oral Med Oral Pathol 1964;18:527-40.  Back to cited text no. 11
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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