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Single-Visit vs Multiple-Visit Root Canal Treatment: What the Evidence Says

For dentists

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Introduction

Root canal treatment can be completed in a single visit, with obturation directly after instrumentation and irrigation, or over two or more visits, with obturation in the final session [PMID 36512807]. The single-visit approach offers fewer appointments and less chair time, but it has long been questioned whether it carries a higher risk of post-operative pain or flare-up [PMID 28148534][PMID 27507626].

For general dentists and endodontists in India, the question is practical: does the number of visits change healing, pain or complications, and how should the decision be made for an individual patient? This article summarises the systematic review evidence, led by the 2022 Cochrane review, and sets out what it means for clinical scheduling.

1. Healing and long-term success

The 2022 Cochrane review. Mergoni and colleagues updated the Cochrane review on single versus multiple visits for people aged over 10 years, including 47 randomised and quasi-randomised studies with 5805 participants and 5693 teeth analysed. Ten studies were judged at low risk of bias, 17 at high risk and 20 at unclear risk. Notably, five studies included in the previous version were excluded because they did not meet the current standard of care, defined as rubber dam isolation and irrigation with sodium hypochlorite [PMID 36512807].

The principal long-term findings were as follows [PMID 36512807].

  • Tooth extraction. Only two studies reported this outcome, with no evidence of a difference (risk ratio 0.46, 95% CI 0.09 to 2.50; 402 teeth; very low certainty).
  • Radiological failure. No evidence of a difference (risk ratio 0.93, 95% CI 0.81 to 1.07; 13 studies, 1505 teeth; moderate certainty).
  • Sinus tract or fistula. No evidence of a difference (risk ratio 1.00, 95% CI 0.24 to 4.28; 5 studies, 650 teeth; very low certainty).

Other syntheses. An overview of eight systematic reviews concluded that single and multiple visits showed similar repair or success rates regardless of the pre-operative condition of the pulp and periapex [PMID 28457639]. A meta-analysis with trial sequential analysis of 29 trials (4341 patients) found no significant difference in the risk of long-term complications (risk ratio 1.00, 95% CI 0.75 to 1.35), but the authors noted that firm evidence for benefit, harm or futility had not been reached [PMID 28148534].

Retreatment. In a randomised trial of 100 asymptomatic single-rooted teeth with periapical lesions undergoing retreatment, success at 24 months did not differ significantly between single-visit and two-visit groups; 88.6% of single-visit teeth and 86.7% of two-visit teeth were classified as healed. Lesion size and the pre-operative length of the root canal filling affected outcome [PMID 35488883].

In our reading, the long-term evidence does not favour either approach, and the factors that determine healing appear to relate more to the tooth and the quality of treatment than to the number of appointments.

2. Post-operative pain

Post-operative pain is the outcome on which the evidence is most nuanced.

  • Pain up to 72 hours. The 2022 Cochrane review found no evidence of a difference in the proportion of participants reporting pain (risk ratio 0.97, 95% CI 0.81 to 1.16; 12 studies, 1329 teeth; low certainty) or in pain intensity [PMID 36512807].
  • Pain within one week. A higher proportion of participants reported pain within one week in single-visit groups (risk ratio 1.55, 95% CI 1.14 to 2.09; 5 studies, 638 teeth; moderate certainty). In subgroup analysis this was higher for single-visit treatment of vital teeth (risk ratio 2.16, 95% CI 1.39 to 3.36; 2 studies, 316 teeth) [PMID 36512807].
  • Analgesic use. No evidence of a difference was found (risk ratio 1.25, 95% CI 0.75 to 2.09; very low certainty), in contrast to the 2016 version of the review [PMID 36512807], which had reported moderate-quality evidence that single-visit patients were more likely to use painkillers (risk ratio 2.35, 95% CI 1.60 to 3.45) [PMID 27905673].

A 2026 umbrella review of 12 systematic reviews found that the higher-confidence reviews did not show a consistent or clinically important difference in post-operative pain between the two approaches, while noting heterogeneity in outcome definitions and overlap of primary studies across reviews [PMID 41856391]. An earlier systematic review of 16 studies reported that the prevalence of post-operative pain ranged from 3% to 58%, and found no compelling evidence of a difference between approaches [PMID 17956561].

In our reading, patients should be told that some discomfort in the first week is possible with either approach, and that this may be somewhat more likely after single-visit treatment of vital teeth.

3. Flare-up and swelling

The evidence on flare-up is inconsistent and of low certainty. Schwendicke and Göstemeyer found a significantly higher risk of flare-up after single-visit treatment (risk ratio 2.13, 95% CI 1.16 to 3.89; 8 studies, 1110 teeth), but graded this evidence as very weak, and suggested that multiple-visit treatment might be preferred for certain teeth, such as those with periapical lesions [PMID 28148534]. The 2022 Cochrane review, by contrast, found no evidence of a difference in swelling or flare-up incidence (risk ratio 0.56, 95% CI 0.16 to 1.92; 6 studies, 605 teeth; very low certainty) [PMID 36512807].

4. Teeth with apical periodontitis and the role of calcium hydroxide

Multiple-visit treatment typically involves an inter-appointment dressing, most commonly calcium hydroxide. A systematic review of treatment for apical periodontitis found moderate certainty that single-visit treatment was associated with better radiographic evidence of a normal periodontal ligament space, under strict criteria, than multiple-visit treatment with calcium hydroxide (risk ratio 1.10, 95% CI 1.03 to 1.19), and concluded that the use of calcium hydroxide for apical periodontitis may not be beneficial [PMID 35579074]. The overview of systematic reviews similarly reported a slight positive trend favouring a single session in the apical periodontitis subgroup [PMID 28457639].

In our reading, these findings sit uneasily with the suggestion that multiple visits might be preferred for teeth with periapical lesions [PMID 28148534]. The evidence therefore does not support a fixed rule for such teeth, and clinical judgement remains central.

5. Cost and scheduling

A model-based cost-effectiveness analysis from a German health-care perspective found that, for non-vital molars without periapical lesions, single-visit treatment was minimally less costly and slightly more effective in terms of tooth retention time, whereas in single-rooted teeth multiple-visit treatment was less costly and more effective. The authors concluded that the overall difference seems limited, and that practical aspects of scheduling and the preferences of patients and dentists should be considered [PMID 27507626]. The costs in this model are based on German fee catalogues and are not directly transferable to Indian practice.

A practical checklist for dentists

The following checklist is our interpretation of the evidence above. It is not a protocol tested in the studies cited and does not replace clinical judgement.

  • Apply the current standard of care, including rubber dam isolation and sodium hypochlorite irrigation, whichever approach is chosen [PMID 36512807].
  • Present single-visit and multiple-visit treatment as equally effective for long-term healing [PMID 36512807][PMID 28457639].
  • Inform patients that pain within the first week is possible with either approach, and may be more likely after single-visit treatment of vital teeth [PMID 36512807].
  • Do not assume that a calcium hydroxide dressing improves outcomes in apical periodontitis [PMID 35579074].
  • Consider case complexity, infection control, patient preference and logistics when choosing the number of visits [PMID 41856391][PMID 27507626].
  • For retreatment, record lesion size and the length of the existing root filling, which affected outcome in a randomised trial [PMID 35488883].
  • Review healing radiographically at follow-up of at least one year, the time frame used for radiological outcomes in the Cochrane review [PMID 36512807].

How D4dent can support endodontic practice

For multiple-visit cases, D4dent's appointments workspace supports online booking and email/SMS reminders, which can help patients return for the obturation visit. In our reading, a short teleconsultation in the first week can be a convenient way to address post-operative discomfort before deciding whether the patient needs to be seen. Within the doctor workspace, the LA dose calculator supports local anaesthetic dosing, AI diagnostics can serve as a second reader for radiographs alongside the clinician's own assessment, and lab orders help coordinate the definitive restoration with a dental laboratory. Dentists can also consult the clinical resources and discuss difficult cases in the dentist community. More about the doctor workspace is available on the D4dent for dentists page.

Frequently asked questions

Is single-visit root canal treatment as successful as multiple-visit treatment?

Current evidence shows no difference in long-term success. The 2022 Cochrane review of 47 studies found no evidence of a difference in radiological failure between single-visit and multiple-visit root canal treatment (risk ratio 0.93, 95% CI 0.81 to 1.07; 13 studies, 1505 teeth; moderate-certainty evidence), and concluded that neither regimen is more effective than the other.

Does single-visit root canal treatment cause more pain?

Pain in the first 72 hours did not differ between approaches in the 2022 Cochrane review. However, there was moderate-certainty evidence that a higher proportion of patients reported pain within one week after single-visit treatment (risk ratio 1.55, 95% CI 1.14 to 2.09). A 2026 umbrella review of 12 systematic reviews concluded that post-operative pain outcomes are broadly similar after the two approaches.

Are flare-ups more common after single-visit treatment?

The evidence is inconsistent. A 2017 meta-analysis found a higher risk of flare-up after single-visit treatment (risk ratio 2.13) but graded this evidence as very weak, whereas the 2022 Cochrane review found no evidence of a difference in swelling or flare-up, with very low certainty.

Is a calcium hydroxide dressing between visits necessary for apical periodontitis?

A systematic review in teeth with apical periodontitis found moderate certainty that single-visit treatment was associated with better radiographic evidence of a normal periodontal ligament space than multiple-visit treatment with calcium hydroxide, and the authors suggested that calcium hydroxide may not be beneficial for this condition.

How should a dentist decide between one and two visits?

The reviews do not identify a clearly superior approach, so the decision rests on clinical judgement. A 2026 umbrella review suggested that the choice can be guided by case complexity, infection control, patient preference and logistics. A cost-effectiveness model found limited overall differences between approaches and recommended that scheduling and the preferences of patients and dentists be considered.

Limitations to keep in mind

Most trials in the 2022 Cochrane review were at high or unclear risk of bias, and several outcomes were supported by low or very low certainty evidence [PMID 36512807]. Trial sequential analysis indicated that firm conclusions had not been reached for any outcome [PMID 28148534]. Pain outcomes were defined and measured inconsistently across reviews, and the same primary studies appear in many reviews [PMID 41856391][PMID 17956561]. The retreatment trial was conducted in asymptomatic single-rooted teeth by one operator [PMID 35488883], and the cost-effectiveness model used German costs [PMID 27507626]. None of the reviews was specific to India. Figures are taken from published abstracts; readers should consult the full texts before citing specific values.

Conclusion

The best available evidence shows no difference in long-term success between single-visit and multiple-visit root canal treatment [PMID 36512807][PMID 28457639]. Pain within the first week appears somewhat more frequent after single-visit treatment, particularly in vital teeth, although pain in the first 72 hours and analgesic use do not differ [PMID 36512807]. The evidence on flare-up is inconsistent [PMID 28148534][PMID 36512807], and calcium hydroxide dressings may not add benefit in apical periodontitis [PMID 35579074]. In our reading, the number of visits is best decided case by case, on the basis of the tooth, the patient's preferences and practical scheduling, with the quality of treatment, rather than the number of appointments, as the main priority.

More in this series

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References

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  2. Manfredi M, Figini L, Gagliani M, Lodi G. Single versus multiple visits for endodontic treatment of permanent teeth. Cochrane Database Syst Rev. 2016 Dec 1;12(12):CD005296. PMID: 27905673
  3. Schwendicke F, Göstemeyer G. Single-visit or multiple-visit root canal treatment: systematic review, meta-analysis and trial sequential analysis. BMJ Open. 2017 Feb 1;7(2):e013115. PMID: 28148534
  4. Gupta R, Abraham D, Ahmad L, Puri A. Single-visit versus multiple-visit root canal therapy: Post-endodontic pain outcomes from an umbrella review. J Dent. 2026 Jun;169:106637. PMID: 41856391
  5. Rossi-Fedele G, Rödig T. Effectiveness of root canal irrigation and dressing for the treatment of apical periodontitis: A systematic review and meta-analysis of clinical trials. Int Endod J. 2023 Oct;56 Suppl 3:422-435. PMID: 35579074
  6. Moreira MS, Anuar ASN, Tedesco TK, Dos Santos M, Morimoto S. Endodontic Treatment in Single and Multiple Visits: An Overview of Systematic Reviews. J Endod. 2017 Jun;43(6):864-870. PMID: 28457639
  7. Sathorn C, Parashos P, Messer H. The prevalence of postoperative pain and flare-up in single- and multiple-visit endodontic treatment: a systematic review. Int Endod J. 2008 Feb;41(2):91-9. PMID: 17956561
  8. Karaoğlan F, Miçooğulları Kurt S, Çalışkan MK. Outcome of single- versus two-visit root canal retreatment in teeth with periapical lesions: A randomized clinical trial. Int Endod J. 2022 Aug;55(8):833-843. PMID: 35488883
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