Flare ups described as occurrence of pain, swelling or combination of both during the course of root canal therapy which result in unscheduled visit by the patient
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Mid treatment flare ups in endodontic
1. Mid treatment
Flare ups in endodontic
Done by:-
Dr. Sarah Abd Al-Salam
Supervise by:-
Dr. Sawsen Al-Rubaie
2. Contents
Flare ups definition
Predisposing factors
The etiology
Clinical condition of the flare ups
The hypothesis or microbiology of flare ups
Diagnosis and management
Precaution to prevent flare ups
3. Flare ups in endodontics
Flare ups is described as the occurrence of severe pain
,swelling or the combination of these during the course of root
canal therapy which result in unscheduled visit by patient
4. Pain may occur soon after intiating endodontic treatment for
an asymptomatic tooth or shortly after the initial emergency
treatment or during the course of treatment
5. Flare ups may even occur with the best of therapy but these
flare up usually due to improper treatment or when
insufficient time is allowed for specific modalities in therapy
11. Microbial causes
Microorganisms are the major causative agents of acute periradicular
inflammation regardless of whether it develop preoperatively or
postoperatively
There are some special circumstance in which microorganisms can
cause flare ups
Apical extrusion of infected debries
Change in endodontic microbial
Secondary intraradicular infection
Increase of the oxidation reduction potential
17. Clinical condition of flare up
Apical periodontitis secondary to treatment
Causes for this condition are:-
Over instrumentation or over medication or forcing
debries into periapical tissue
18. Balance between the microbial aggression and host
defence of the periradicular tissue is disrupted
Host will mobilize an acute inflammation to re establish
the equilibrium
Apical foramen enlargement increase influx of exudate and
blood in the root canal
20. Incomplete removal of pulp tissue during the initial
appointment
In some instances due to the lack of time factor the endodontic therapy
may consist of incomplete inflamed pulp tissue after a diagnosis of
acute or chronic pulpities
21. Recrudescence of chronic apical periodontitis
(Phoenix Abscess)
Is the condition that occur in the teeth with necrotic pulp
and apical lesions that are symptomless
22. The reason for this phenomena is thought to be due to the alteration
of the internal environment of root canal space during instrumentation
which activate the bacterial flora
Mobility, tenderness and swelling are usually the sign and symptoms
found in phoenix abscess
23. Recurrent periapical abscess :- It is the condition where a
tooth with an acute periapical abscess is relieved by emergency
treatment after which the acute symptoms return
In some cases , the abscess may recurrent more than once due to
microorganism of high virulence or poor host resistence
24. The hypothesis
There are a numbers of hypothesis thought to be related to the etiology
of flareups
Alteration of local adaptation syndrome
Change in the periapical tissue pressure
Microbial factors
Effects of chemical mediators
Changes in cyclic nucleotides
Immunological phenomena
Various psychological factors
25. Alteration of local adaptation syndrome
New irritant Inflamed tissue
Violent reaction may occur due to disturbance in local tissue
adaptation to the applied irritants
26. Change in periapical tissue pressure
Teeth with increased periapical pressure
Excessive exudate Pressure on nerve ending
Pain
Teeth with less periapical periapical pressure
Microorganism and other irritant get aspirated into periapical
tissue pain
27. Microbial factors
Anaerobic in root canal produce enzymes, endotoxin and other
irritant
Persistence of periapical lesions
28. Effect of chemical mediators
Cell mediators ( Histamine, Serotonin, Prostaglandins,
Platelat activating factors and lysosome)
Plasma mediators ( Hageman factor
Bradykinin and activating clotting cascade )
Neotrophils products ( Collagenase, peroxidase, amylase,
lipase and other lytic enzymes cause sever pain)
New irritant
29. Change in cyclic nucleotide
In flare up Increase in the level of GMP over AMP
concentration
Pain
31. Psychological factor
Anxiety , apprehension , fear and previous history of dental
experience appear to play an important role in mid treatment flare ups
32. Diagnosis and management
Establishing the cause of flare up is an important step towards
management of mid treatment pain
It is necessary to warn the patient that he or she may experience
slight pain after the appointment
33. Previously vital pulp with complete
debridement
In these conditions, chances of flare ups
are less
Only patient reassurance and the
prescription of mild to moderate analgesics
There is no need of reopening and placing
and placing corticosteroid
34. Previously vital pulp with incomplete
debridement
Here pulp remnants considered to be a major
irritant, causing pain
WL should be rechecked
Canal cleaned with copious irrigation of NaHcl
Dry cotton pellet is placed + TF
Mild analgesic is prescribed
Relieve tooth from occlusion
35. Previously necrotic pulp without swelling
The best method of managing the necrotic pulp:-
Establish the accurate WL
Complete instrumentation of root canal
Irrigation with copious amount of NaHcl
If there is drainage from the canal , after drying
the canal CaOH dressing is placed and the access
is sealed
Prescribe analgesics and antibiotics
36. Previously necrotic pulp with swelling
These cases are best managed by incision and drainage
Canal should be opened , debrided and gently irrigated with NaHcl
Ca(OH)2 should be placed and closed
45. Precautions to be taken to prevent
flare ups
Proper diagnosis of the
case
Determination of correct
WL
Complete extirpation
of the vital pulp
46. Complete chemo
mechanical
procedures in one visit Selection of
instrumentation
technique that extrude
less amount of debries
Placement of intracanal
medicaments between
appointment in the
treatment of infected
case
49. Conclusion
The occurrence of mild pain and discomfort is common even if the
treatment rendered is of highest standard . But still psychological
preparation , complete cleaning and shaping of root canal system , use
of long acting anesthetic and analgesics decrease the incidence of inter
appointment flare ups in mild to moderate levels