The Gold Standard Is Broken: Too Many Visits for a Simple Infection—A Unified Endodontic-Prosthetic Workflow for Saving Severely Infected Teeth

The Gold Standard Is Broken: Too Many Visits for a Simple Infection—A Unified Endodontic-Prosthetic Workflow for Saving Severely Infected Teeth

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Imagine a surgeon scheduling four separate operations to remove an infected appendix. It sounds absurd, doesn’t it? Yet in dentistry, we’ve normalized requiring patients to endure four visits to nurse an infected tooth back to health—from endodontics to crown placement. In 2025, we have the tools, knowledge, and skills to do better. Shouldn’t we aim to restore teeth to full function in one or two visits, total? Let’s rethink how we serve our patients and modernize our approach to care. The profession—and our patients—deserve no less.

Why does it take so many visits to nurse a tooth back to health:

1. "I just don’t know if it’s ready," thought the general dentist, hesitating before committing to the final restoration.

For decades, practitioners have relied on subjective healing assessments—gauging progress based on intuition rather than objective, real-time confirmation of success. This ingrained hesitation has perpetuated the multi-visit model, prioritizing caution over efficiency. But in 2025, when diagnostic tools, imaging, and evidence-based protocols provide instant feedback, why does this uncertainty persist?

The future of endodontics and prosthodontics isn’t about waiting—it's about precision, predictability, and trusting modern workflows to guide decision-making.

The endodontic science is highly predictable. An endodontist can tell you at the time of the treatment whether to restore immediately or not — and the answer is almost always proceed immediately.

2. Fabricating the final restoration was once the bottleneck in nursing an endodontically compromised tooth. Now, digital prosthodontics delivers not only immediate restorations but also precision perfected—because one visit should mean excellence, not just speed.

Even with the best digital tools, same-day restorations demand precision, coordination, and a seamless workflow.

Unlike traditional analog workflows—where multiple visits, interim restorations, and drawn-out lab processes are expected—modern digital prosthodontics promises same-day final restorations. But here’s the reality: without a well-rehearsed, calibrated workflow or a dedicated team, achieving high-quality, same-day prostheses can be a logistical challenge rather than an efficiency breakthrough.

This is why many practitioners still lean on the traditional multi-visit model—not because it’s superior, but because it’s familiar. Yet, the best practices of 2025 demand more. With optimized systems, streamlined collaboration, and mastery of digital workflows, a single-visit approach is not just possible—it should be the standard.

So, are we holding on to outdated workflows because they work? Or because we haven’t taken the steps to make the modern approach work for us?

The question is no longer if we can—it’s whether we’re ready to embrace the new standard.

3- Diagnosis isn’t just the first step in a single-visit workflow—it’s the defining moment where precision meets clinical mastery. The ability to plan and execute seamlessly in one visit doesn’t depend on speed, but on expertise that transforms complexity into predictability. When done right, a well-structured diagnosis doesn’t just guide execution—it eliminates inefficiencies, streamlining every step from access to final restoration, allowing superior quality without compromise.

Comprehensive Workflow for One-Visit Endodontic and Prosthetic Treatment

Diagnosis and Pre-Treatment Planning

Great dentistry isn’t just about treating disease—it’s about designing success before the first bur ever touches the tooth. The moment a clinician diagnoses the need for endodontic intervention, the final restoration must already be envisioned. This isn’t just a detail—it dictates the entire approach to tooth preparation, from endodontic access design to core buildup and final prosthesis placement. Proper treatment planning at this stage introduces efficiency, eliminates redundant steps, and ensures that every aspect of both endodontics and prosthodontics is carried out in an optimized sequence—transforming what was once a fragmented, multi-visit process into a seamless, single-session restoration.

Tooth Preparation and Endodontic Access

Tooth preparation isn’t just about shaping a surface—it’s about setting the stage for a biologically sound and structurally optimized restoration. Every step should serve a dual purpose: preserving tooth structure while ensuring procedural efficiency. The difference between caries removal, access opening, and final prosthetic restoration becomes nearly indistinguishable when viewed through the lens of minimally invasive dentistry (MID). When executed with precision, these steps seamlessly integrate into a single, well-coordinated process—maximizing efficiency without sacrificing integrity.

Case Illustrations: When Biology Dictates the Workflow in Endodontic and Prosthetic Integration

Modern endodontic workflows aren’t about choosing between single-visit and multi-visit models—they’re about sequencing treatment with clinical precision. Biological factors dictate whether we pause treatment—not hesitation or uncertainty. The key is eliminating inefficiencies while ensuring every procedural step aligns with optimized healing and restoration.

Endodontic Management of a Disrupted Biologic Barrier:

When Infection Extends Beyond the Pulpal Space While single-visit workflows maximize efficiency, certain cases require a multi-visit approach dictated by biological constraints, not indecision. For instance, a retreatment case involving a preexisting post in a tooth with a suppurative acute apical abscess demands a two-visit approach to balance predictability with biological healing dynamics.

The first visit must incorporate:

? Endodontic disassembly, ensuring complete removal of previous restorations and post systems.

? Interim PMMA endo crown fabrication with a radicular component on the intaglio surface, which serves two purposes:

o Sealing calcium hydroxide in the radicular canal system to facilitate controlled antimicrobial action.

o Providing a highly polished interface that promotes gingival contouring and soft tissue healing for optimal emergence profile.

? Post preparation, performed in synchronization with the digital workflow for the final restoration.

A major advantage of this workflow is digital adaptability. The endo crown digital design from the previous step can be seamlessly modified into a cast post design if needed. Clear PMMA cast posts, milled or printed chairside, serve as a pattern for lost-wax fabrication in lithium disilicate or gold—processed by a specialized laboratory within 24–48 hours.

At the second endodontic visit, after obturation, the cast post and final restoration are placed sequentially while the tooth remains isolated under rubber dam, eliminating inefficiencies and ensuring precision-driven prosthetic integration. In select cases, rather than proceeding with a cast post or core buildup, an endo crown may serve as the definitive restoration, simplifying the procedure while preserving biomechanical integrity.

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Preserving Pulpal Vitality: Early Intervention Before Infection Breaches the Dentin-Pulp Complex

Conversely, in a case of carious pulp exposure with a vital pulp diagnosis, the treatment philosophy shifts entirely. Here, margins and access openings are prepared simultaneously, ensuring no wasted time between procedural phases. While the final prosthesis is being fabricated, vital pulp therapy continues under controlled conditions. Once the pulp dressing is placed, the ceramic restoration is bonded under rubber dam isolation—preserving aseptic conditions and biological integrity.

This isn’t just about efficiency—it’s about establishing a new gold standard in restorative care.

Endo-crowns

Endo-crowns, in particular, offer advantages in such workflows by maximizing the internal ferrule effect while reducing chair time traditionally allocated for core buildup. With a precise understanding of dental materials, shade matching, and modern adhesive protocols, clinicians can successfully achieve aesthetic and functional restorations while maintaining the maximum amount of natural tooth structure, even when crown margins are placed in the middle or coronal third of a natural posterior tooth, optimal results can still be achieved. The design gives us the advantage of not needing to remove extra enamel or tooth structure to obtain ferrule if we can achieve it internally. While we have made great strides in developing dental materials that yield better in vitro results, we still have a long way to go to match the health benefits of natural tissue against natural tissue.

If crown lengthening is necessary, it should be performed after full tooth preparation to ensure adequate restorative space while maintaining the biologic width. The consolidated sequence of endodontic access, core preparation, crown preparation, and any necessary crown lengthening represents a critical stage in this workflow. This step, integrating endodontic access, core buildup, and crown preparation into a seamless workflow, could be referred to as 'Comprehensive Structural Preparation' for clarity.

Scanning and Digital Prosthetic Fabrication

Once tooth 'Comprehensive Structural Preparation' is complete, the next step is scanning for the final restoration using digital intraoral imaging. This can be performed with rubber dam in place and with the undercuts blocked in vivo using a temporary material such as Cavit, or digitally adjusted ex vivo.

While the in-office digital lab fabricates the prosthesis, the intraradicular treatment commences. Depending on the chosen prosthetic workflow, the final digital restoration can be fabricated through additive (printed) or subtractive (milled or ground) techniques. The fabrication time varies based on the material:

PMMA and Resin restorations may be completed in as little as 15 minutes.

Fully stained, glazed, and crystalized ceramic restorations, or sintered zirconia restoration, may require up to 1 hour.

By the time root canal instrumentation is completed, the final restoration should be ready for fit and cementation. In some instances, a second clear PMMA crown can be fabricated immediately and be sent to an outside lab for pressed or cast restorations, such as gold restorations or unique shades of lithium disilicate restorations that are not available in standard in-office CAD block shades

Precision Fitting and Cementation Under Aseptic Conditions

Once a clinician overcomes the learning curve of digital restorative workflows, endodontists—particularly those working under high magnification with a surgical microscope—can achieve an extremely precise fit under rubber dam isolation without additional occlusal checks or radiographs. Although this concept may be controversial, it is well-documented that an overwhelming number of experienced endodontists reach a level of mastery where they can execute endodontic procedures with extreme accuracy, requiring only preoperative and postoperative radiographs for verification.

Prosthetic restorations, particularly single-tooth crowns, are far more predictable than endodontic treatment when performed with surgical microscopy and a well-calibrated digital armamentarium. With this precision, the transition from obturation to final prosthesis placement is seamless, as the resin cements used for crown cementation serve as the final seal for the pulp chamber.

Immediate Function and Patient-Centered Outcomes

Anecdotally, patients report immediate post-treatment function, with the majority able to chew and resume normal occlusal loading the same day or within 24-48 hours in cases where preoperative pain was present. By reducing the number of appointments and consolidating treatment into a single session, patients experience improved comfort, efficiency, and long-term satisfaction—hallmarks of modern patient-centered dentistry

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