This document discusses a case of interappointment flare up in an 18-year-old female patient. It summarizes the patient's history, clinical examination findings, diagnosis of pulp necrosis with symptomatic apical periodontitis in tooth #11, and proposed root canal treatment. The discussion section then covers potential predisposing factors for flare ups like pre-existing periapical pathology, hyperocclusion, vital vs. nonvital pulps, challenges in retreatment cases, issues with working length determination and obturation. It emphasizes the importance for clinicians to understand flare up etiologies and prevention strategies.

1. CASE DISCUSSION – Interappointment
flare up
By
Dr M. Abbas Ansari
MDS 2nd Year
Dept Of Conservative Dentistry & Endodontics
PRESENTATION DATE – 10-07-2020

2. CASE RECORDS
DEMOGRAPHIC DATA
 OPD NUMBER:
 NAME: shabana
 AGE/GENDER: 18 YEARS / FEMALE
 OCCUPATION: student
 ADDRESS: MORADABAD

3. CHIEF COMPLAINT
 Patient complains of pain in her upper front tooth region while biting since 2 months
HISTORY OF PRESENT ILLNESS
 Patient was apparently asymptomatic 2 months back and later developed pain in her upper
front tooth region while biting. The pain is dull, moderate in intensity that induces on biting
aur pressing the tooth with finger and relieves itself after few minutes. She also reported that
she had a trauma in her upper front tooth region 1 year back.
MEDICAL HISTORY
 There was no significant medical history.
DENTAL HISTORY
 No dental history

4.  EXTRAORALEXAMINATION
 VISUAL INSPECTION
1. Examination of Head -Symmetrical
2. Examination of Skin- No abnormality detected
3. Examination of Neck Swelling - No
abnormality detected
4. Examination of the Jaws Symmetry – Bilateral
synchronous movement with no clicking and
popping sound.
 PALPATION
1. Bidigital / Bimanual: No abnormality detected.
 GENERALPHYSICALEXAMINATION
 GAIT : No abnormality detected. POSTURE : Erect BUILT : Mesomorphic
 FACIAL SYMMETRY : Bilaterally symmetrical FACIAL DIVERGENCE : Straight


5. Hard Tissue Examination
 VISUAL INSPECTION
 No. of teeth present : 7654321 1234567
7654321 1234567
 Stains/Calculus : ++/+
PERCUSSION TEST : With instrument
 Vertical Percussion: Positive i.r.t. 11
 Lateral percussion: Negative i.r.t. 11
 INTRAORAL EXAMINATION
Soft tissue examination
VISUAL INSPECTION
 Tongue
 Cheek
 Gingiva
 Frenum NAD
 Lips
 Labial And Buccal Mucosa
 Palate
PALPATION No abnormality detected


6.  PROVISIONAL DIAGNOSIS
 Elles class II fracture irt 11 Elles class I fracture irt 21
 Symptomatic apical periodontitis irt 11
 VITALITY TEST
Cold Test – No response irt 11, normal response response in 21
ELECTRIC PULP TEST : No response i.r.t. 11, positive response in 21
RADIOGRAPHIC EXAMINATION
 Radiolucency seen at the apical portion of root of 11
 Widening of periodontal ligament irt 11
 Disruption of lamina dura irt 11
 FINAL DIAGNOSIS
Pulp necrosis with symptomatic apical periodontitis irt 11.
 Elles Class I fracture irt 21
 TREATMENT PLAN
Root canal treatment i.r.t. 11
Composite restoration irt .21

7. Preoperative
Access Opening and
WL determination

8. Master cone Obturation

9. Discussion
 A flare-up is an acute exacerbation of an asymptomatic pulp/ or periapical
pathosis after the initiation or continuation of root canal.
 While some flare-ups have an iatrogenic component, others do not.
 Severe pain and swelling associated with flare-ups represent the clinical
manifestation of complex pathologic changes occurring at a cellular level.

10. Predisposing Conditions
 When symptomatic pretreatment patients have been included in a study , predisposing
conditions include periapical abscess, acute apical periodontitis, pre-operative pain, and
swelling.
 Studies have found that the lowest incidence of flare-ups occurred in patients without
periapical pathosis and when a sinus tract is present.
 In some studies results indicated that the most important factor in predicting the
incidence of post-endodontic pain is the absence of occlusal contacts. It was predicted
that the patient with the highest probability of developing post-endodontic pain had
previously experienced pain in a molar with prior endodontic treatment, no apical
radiolucency and occlusal contacts
 The major causative factor has been described as microbial in origin.
 There are additional factors that may also predispose a patient to pain. They include
genetics, gender, and anxiety.

11. Hyper Occlusion
 A number of clinical studies have evaluated the pain preventive value of occlusal adjustment.
 A research hypothesized that there may be specific pre-operative conditions that are statistically significant
indicators for occlusal reduction following instrumentation. Among the conditions evaluated was the presence or
absence of pulp vitality, pre-operative pain, and percussion sensitivity, presence of a periapical radiolucency, a
stoma, swelling, and a history of bruxism.
 In a study of 117 patients, approximately twice as many patients (80%) with a diagnosis of irreversible pulpitis,
who underwent occlusal reduction, reported no post-treatment pain when compared to control subjects with no
occlusal reduction.
 Research Findings
 Occlusal reduction was found to result in the prevention of post operative pain when any or all of the following
indicators were present:
 • Sensitivity to percussion
 • Vital Tooth
 • History of pain
 • Absence of a periapical radiographic lesion.

12. Vital and Nonvital Pulps
 A clinician may categorize flare-ups as occurring in vital or nonvital cases.
 The vital case can be defined as a case in which the pulp is still capable of conducting an
impulse to higher centers. Vital tooth may contain areas of acute inflammation, chronic
inflammation, and necrotic tissue in a dynamic mix. while treating a vital case, it is
necessary to completely extirpate well-innervated tissue without shredding it or
instrumenting through the apical foramina, causing additional inflammation to periapical
tissues.
 The nonvital pulp poses a different problem. If we consider the vital case to be primarily a
challenge of managing inflamed tissue, the nonvital case represents a challenge of
managing infected tissue. Thus it poses a microbial challenge. The dentist must avoid
pushing microbes and necrotic tissue debris through and beyond the apical foramen into the
periapical tissues. The resulting inflammatory/immune response is the basic cause of the
swelling and pain associated with nonvital case flare-up.

13. Retreatment Cases
 In retreatment teeth with apical periodontitis. It can be hypothesized that
retreatment cases are often technically difficult to treat, and there is a
tendency to push remnants of gutta-percha, solvents, and other debris into
the periapical tissues. Microbes may also be pushed apically during the
retreatment process. Extrusion of infected debris or solvents into the
periapical tissues during preparation of the canals is allegedly one of the
principal causes of postoperative pain.
 Retreatment cases are usually associated with a persistent or secondary root
canal infection by therapy-resistant microorganisms that may be more
difficult to eradicate when compared to primary infections.

14. Working Length
 Inaccurate working length or inadvertent over- or under-instrumentation can result
in negative outcomes for the patient. Over-instrumentation may force infected
debris into the periapical tissues eliciting a severe inflammatory response and pain.
 Under-instrumentation will leave microorganisms in close proximity to the apical
foramina where they or their virulence factors can gain access to the periapical
tissues.

15. Obturation
 Overfilling can cause postoperative pain particularly when a substantial
amount of filling material extrudes through the apical foramen. Gross
overfilling involves the introduction of excess sealer into the periapical
tissues causing tissue damage and inflammation.
 In order to avoid increased postoperative pain, patients who present for
obturation but have significant acute apical periodontitis should have the
procedure postponed until the tooth is more comfortable.

16. conclusion
Even though it has been demonstrated that a flare-up has no significant
influence on the outcome of endodontic treatment, its occurrence is
extremely undesirable for both the patient and the clinician, and can
undermine clinician–patient relationships. Therefore, it is necessary for a
clinician to have a good understanding and experience about the etiologies
and management startegies in an attempt to prevent the development of
interappointment flare-up.

17. THANK YOU