ENDODONTIC FLARE UPS

INTER-APPOINTMENT
FLARE UPS
Dr. Rohit Bansal

CONTENT
 INTRODUCTION
 CLINICAL CONDITIONSASSOCIATEDWITH
FLARE UP
 AETIOLOGICAL FACTOR
 RISK FACTORS
 PREVENTIVE MEASURES
 MANAGEMENT
 CONCLUSION

 The inter-appointment flare-up is a true
complication characterized by pain or swelling or
both which commences within a few hours or days
after root canal procedures and is of sufficient
severity to require an unscheduled visit for
emergency treatment.
 Studies have reported varying frequency of flare-
ups ranging from 1.4 to 16%
(Morse et al, 1986;Torabinejad et al,1988;
Barnett andTornstad, 1989;Trope,1990;
Walton and Fouad, 1992; Harrington and
Natkin, 1992; Imura and Zuolo, 1995;
Sequiera et al, 2002).

 It is important to know that flare-ups can occur
even in the best of treatments but they usually
happens due to improper treatment or when
insufficient time is allowed for specific
modalities in therapy.
Weine
 American Association of Endodontics (AAE)
defines a Flare-ups as “An acute exacerbation of
periradicular pathosis after initiation or in continuation
of root canal treatment.”

APICAL PERIDONTITIS SECONDARY TO
TREATMENT
 A tooth which was symptomless before the
initiation of endodontic treatment but
becomes sensitive to percussion during the
course of the treatment.
 Causes for this condition most frequently are
over instrumentation or over medication or
forcing debris into the periapical tissues.

INCOMPLETE REMOVAL OF PULP TISSUES
DURING THE
INTIAL APPOINTMENT
 In some instances due to lack of time factor
the endodontic therapy may consist of
incomplete pulpectomy after a diagnosis of
acute or chronic pulpitis.
 This situation generally occurs when the
radicular pulp is already inflamed.

PHOENIX ABSCESS
 It is a condition that occurs in teeth with
necrotic pulps and apical lesions that are
asymptomatic .
 There is a exacerbation of a previously
symptomless periradicular lesion.
 The reason for this phenomenon is thought
to be due to the alteration of the internal
environment of the root canal space during
instrumentation which activates the bacterial
flora.

RECURRENT PERIAPICAL ABSCESS
 It is a 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 recur more
than once,due to micro organism of high
virulence or poor host resistance.

MICROBIAL FACTORS
 Microorganisms in the root canal system take part in
the pathogenesis of asymptomatic apical
periodontitis and together with virulent factors they
are able to enter periradicular tissues.
 Various species microorganisms proliferate in the
apical area of the root canal. Microbial density in 5
mm of the apical root area may reach up to 106
bacteria, with predominating anaerobic
microorganisms.
 Because of its complicated anatomy (accessory
canals, apical deltas) and high bacteria density, the
apical root canal area is said to be “dangerous” for
the pathogenic bacteria, the host and the dentist.

 Local adaptation syndrome
In a case of asymptomatic apical periodontitis
there is a balance between infectious micro
flora and defensive mechanisms of human
immune system in the periodontal tissues.
 During the chemomechanical preparation of the
root canal after extrusion of infected debris from
apical foramen to periradicular tissues, the
inflammation is increased due to imbalance
between microorganisms and human immune
system caused by irritants getting in the apical
periodontal tissues: vessels dilate, their
permeability increases and inflammation cell
chemotaxis begins.

 Its intensity depends on the virulence of
microorganisms and their amount in the
periodontal tissues.
 Specificity in anaerobic infections is low and
numerous combinations of normally low
virulent oral bacterial species have the
capacity to induce an acute infection in the
root canal and periapical tissues.
 The low virulence is compensated by the
increase in numbers by the growth and
multiplication and by the poly-microbial
nature of the primary endodontic infection.

 The concomitant outgrowth of bacteria
through apical foramen into the periradicular
tissues cannot be prevented since the
bacteria are in an active growing phase,
sometimes even stimulated by host factors
such as blood components and serum.
 If the root canal is not adequately chemo-
mechanically prepared and between visits is
not filled in with intracanal medicaments, the
synergistic interaction of microbes in the root
canal changes therefore activating virulence
genes of pathogenic strains and that causes
increased inflammatory response.

 If aseptic rules are not followed during the
endodontic treatment, insufficient patient
mouth hygiene, working without rubber dam
system, uncleaned carious tissue or old non-
hermetic filling and secondary infection in the
root canal can be a cause of post-operation pain
and flare-up.
 Between visits microorganisms can also enter
the root canal through non-hermetic temporary
filling or in case of it falling out. After endodontic
treatment infection might enter through
temporary coronal filling left for longer than two
weeks or through non-hermetic and cracked
permanent coronal restoration.

MECHANICAL FACTOR
 During asymptomatic apical periodontitis
root canal system of the tooth is infected
therefore microorganisms are able to reach
the apical third of the root canal, apical
foramen and apical deltas.
 Chemo-mechanical preparation is one of the
factors causing success of endodontic
treatment.

 During it pieces of debris, necrotic pulp
masses, irrigative solutions and
microorganisms from root canal access apical
periodontal tissues and causes inflammation
and postoperative pain that disturbs healing
of periradicular tissues
 Despite chosen technique, during mechanical
formation of root canal some amount of
infected debris are extruded into the
periodontal tissues

 Studies show that minimal amount of extrusion
of debris through the apical foramen is reached
using crown-down technique with engine-driven
Ni-Ti systems.
 Comparable study performed by Reddy and
Hicks shows that cleaning canals with hand
endodontic instruments using step-back
technique, average amount of extrusion of
debris into the periradicular tissues is 2.58 mg,
while using NiTi rotational mechanical
instruments with crown-down technique it is less
than 0.5 mg.

 While performing the chemomechanical
preparation of root canal, it is essential to
reach the end point of root canal which is the
physiological apex of the root – the
conjunction of cementum and dentine.
 The mechanical irritation of periradicular
tissues is caused by over-instrumentation of
the root canal and filling material extrusion
through the apical foramen.

 One of the iatrogenic factors causing the
flare-up of the endodontic treatment is
incorrectly measured working length of the
root canal (WL).
 WL is a distance between the highest chosen
point of the coronal part of the tooth and the
conjunction of cementum and dentine called
the physiological apex of the root which is the
place where the chemomechanical
preparation and filing of the root canal has to
be finished.

 Langeland estimated that the conjunction of
cementum and dentine in the area of apex is
localized in the distance of 0.5-3 mm from the
visible anatomical apex of the root and
moderately in the distance of 1-2 mm from
the radiological apex of the root.
 The Brunton et al study results show that
when the tip of endodontic instrument
working part is withdrawn 1 mm from the
radiological apex of the root, the
physiological apex of the root is correctly
localized only 16% of cases

 IfWL measured is too long, the apical
constriction in the area of physiological apex of
the root is destroyed, infected debris and filling
material of the canal are extruded to the
periodontal tissues, periodontal tissues is being
mechanically stimulated and exudation and
blood enters the canal, therefore
microorganisms left in the root canal can
multiply and proliferate in the beneficial
conditions.
 IfWL measured is too short, pulp remnants and
bacteria are left in the apical third of the canal
therefore success and prognosis of endodontic
treatment is significantly decreased

Immature Teeth
 The apical constriction is not present when
roots are not fully formed, also it might be
resorbed due to inflammation of periradicular
tissues or iatrogenically destroyed by
incorrectly measured WL, recapitulation and
drainage of apical abscess through the root
canal.

Radiographic Method
 WL measuring by the dental radiograph depends
to the condition of the root and periodontal
tissues.
 According toWeine: -1 mm from the radiological
apex of the root, if no alveolar bone and root
resorption is detected; -1.5 mm from the
radiological apex of the root, if alveolar bone
resorption is detected; -2 mm if alveolar bone
and root resorption is detected.
Apex Locators

CHEMICAL FACTORS
 Irrigation solutions, intracanal medicaments,
root fillings and substances, that are in their
composition , used in endodontic treatment
might be toxin therefore they cause chemical
irritation and post-operation pain and sensitivity
after entering the periradicular tissues.
 Pastes that are used with gutapercha for filling
the root canal have different level of toxicity by
the time they consolidate.
 The more filling from the root canal is extruded
to periodontal tissues, the more intense
inflammatory reaction is.

 Some researches show that flare-ups are often
after endodontic retreatment of teeth filled with
resorcinol – formaldehyde resin.
 Pastes containing formaldehyde are cytotoxic,
can cause necrosis after contacting live tissue
and extruded into apical periodontal tissues
initiate inflammation which causes pain and
swelling.
 If formaldehyde is exuded as by-product during
consolidation, periodontal tissues are damaged
temporarily, though it is insoluble and might be
only surgically eliminated.

DEMOGRAPHIC FACTOR
Studies on evaluating the probability and intensity of the pain
occurring after treatment show that patient is not a
significant factor in development of the fl are-up
ElMubarak et al show opposing results, assessing that post-
operative pain was more common among younger patients
(18-33 years old).
Flareup and post-operative sensitivity rarely occur in older
patients due to the narrowing of the diameter of the root
canal therefore less debris is extruded below the apex of
the root and decreased blood flow in the alveolar bone
resulting in weaker inflammatory response.

 It is established that post-operative pain is
more common among women than men
comparing the sexual influence to the
development of the fl are-up.
 Pain threshold and toleration depend on
sexual hormones and their proportion during
different stages of menstrual cycle.

GENERAL HEALTH STATUS
 Flare rate after endodontic treatment procedures is
low in patients using systemic steroids as treatment
for systemic diseases.
 Steroids suppress the acute inflammatory response
during the chemomechanical preparation of the root
canal when mechanical, chemical and/ or microbial
factors irritate the apical periodontal tissue.
 Torabinejad et al points that patients tendency to
allergies is associated with development of a flare-
up after endodontical treatment, howeverWolton
and Fouad study disproves this hypothesis.

PULPAL AND PERIRADICULAR HEALTH
 Results of the studies defining the connection
between the frequency of flare-up after
endodontic treatment, pain intensity and
condition of the pulp (viable or necrotic) are
controversial.
 It is established that 47-60% of patients
having asymptomatic necrotic pulp
experience pain defined from medium to
acute during the first 24 hours after
endodontic treatment.

 Bone destruction which is visible in dental
radiograph is said to be a risk factor of post-
operative pain and flare-up.
 Chance of a flare is 9.64 times higher when
the bone destruction is detected.
 The connection between size of the bone
destruction area and post-operative pain was
defined by Genet et al: bone destruction of 5
mm and more is said to increase the
probability of pain occurring

CLINICAL SYMPTOMS
 The next factor determining the post-operative
pain is clinical symptoms that were before the
treatment such as tooth pain when biting,
chewing or by itself and sensitivity to percussion.
 80% of patients who feel tooth pain before the
beginning of the treatment usually feel the pain
and after it.
 Pain enhances the stress level in the body and
effects immune function in a negative way
therefore increasing the probability of a fl are-
up.

TOOTH CONCERNED
 Glennon et al study results show that
temporary pain is felt 1.7 times more often
when the canals of the molar teeth are
treated compared to other teeth types.
 Higher frequency of pain in the lateral teeth
type is determined by the complicated
complex anatomy of the root canals and
chemomechanical preparation.

SINGLE VS MULTIPLE VISIT RCT
 Primary endodontic treatment when the pulp is viable or endodontic
retreatment when there are no visible clinical symptoms related to the
changes in periradicular tissues, chemomechanical preparation and
filling of the root canal is done by one visit.
 If the pulp is necrotic and there are radiological changes in periradicular
tissues, endodontic treatment is done by two visits: during the first visit
the root canal is prepared chemomechanically, filled with intracanal
medicaments for maximal root canal disinfection and the crown is
hermetically sealed with temporary filling while during the second visit
the filling of the root canal is performed.
 Studies show that there is no direct link between manifestation of the
post-operative pain and amount of the visits during the endodontic
treatment. However some studies show controversial results, i.e. that
pain is more common after one visit endodontic treatment.
 Yold et al study summarizes that fl are-up rate is 4,9 times higher after
one visit endodontic retreatment compared to retreatment by two –
visits.

 Studies show that there is no direct link between
manifestation of the post-operative pain and
amount of the visits during the endodontic
treatment.
 However some studies show controversial
results, i.e. that pain is more common after one
visit endodontic treatment.
 Yold et al study summarizes that fl are-up rate is
4.9 times higher after one visit endodontic
retreatment compared to retreatment by two –
visits.

INTRA-CANAL MEDICAMENT
 Antimicrobial intracanal medicaments are
essential when controlling the endodontic
infection due to the insufficient amount of
microorganisms that are eliminated during the
chemomechanical preparation of the root canal.
 Harrison et al studies shows contrary that
antimicrobial intracanal medicaments reduce
postoperative pain caused by microorganisms
that are left in the root canal and secondary
infection.

 Flare ups causes a dilemma to the clinican
when it is difficult for the patient to
comprehend that they enter the office pain
free, but experience a sustained increase or
severe pain during or after treatment.
 Certain precaution that are taken by a
clinican can prevent flare-ups in most
instances.

PRECAUTIONS
 Proper diagnosis-
Identify the correct tooth causing pain. Ascertain
whether tooth is vital or non vital. Identify if tooth
is associated with periapical lesion.
 Determine correct working length.-
Radiographs.
Apex locaters
 Complete extirpation of vital pulp.
 Irrigation -
Preferably with combination of irrigants
such as sodium hypochlorite and
chlorohexedine.

 Avoid filing too close to the radiographic apex.
 Perform apical trephination only if necessary.
 Reduce tooth from occlusion especially if apex is
severely violated by overinstrumentation.
 Placement of intracanal medicaments.
 Prescription of mild analgesics and antibiotics
whenever condition warrants it .

PRE-MEDICATION OF ROOT CANAL
 Medication of pulp chamber & root canal has
been tried to reduce flare ups due to forcing of
infected debris to periradicular area in Ist
appointment before instrumentation.
 But Pearson et al (20) found out no significant
difference in acute exacerbation episodes in
premedicated root canals prior to
instrumentation in comparison to completely
instrumented canals without any premedication.

ESTABLISHING A DRAINAGE
 Inflammatory edema results due to chemical
mediators whereas suppuration is caused by
infections.
 Drainage relieves pain and swelling dramatically in
suppuration cases, by removing intracanal dressing
and keeping the access cavity open.
 Sometimes discharge does not drain, in those cases
,soft tissue incision in the most dependent part of
swelling is advocated.
 After cessation of discharging exudate, the access
cavity should be temporarily closed again, since it
does not serve any purpose to leave root canal open
to oral microbial flora.

RELIEF OF OCCLUSION
 Cohen suggested occlusal relief prior to
endododontic therapy whereas Ingle,Weine
and Grossman are of the opinion that
occlusion should be relieved prior to root
canal treatment in teeth which are painful to
start with.
 Dorn et al advocated reduction of occlusion
whenever the painful symptoms appear.

INTRACANAL MEDICAMENT
 Most of the intracanal medicaments like
calcium hydroxide formocresol, eugenol,
camphorated monochlorophenol and iodine
potassium iodide have been studied.
 None appeared to be particularly effective,
nor was there any significant relationship
between inter-appointment pain and the
type of therapy used.

IRRIGATION SOLUTION
 Harrison et al found out that patients whose
canals were not irrigated or irrigated with normal
saline experienced more pain in comparison to
those patients whose canals were irrigated with
5% sodium hypochlorite and 3% hydrogen
peroxide or even 0.5% sodium hypochlorite
alone, provided irrigating solution was not
pushed to periapical region.
 However pain of endodontic origin is
multifactorial and cannot be attributed to
irrigant alone.

CORTICOSTEROIDS
 Moskow et al. have reported that corticosteroids
placed in root canal control pain successfully.
 The anti-inflammatory activity of corticosteroids
is based partly due to reduction of lysosomal
release and partly due to inhibition of free
arachidonic acid release from the phospholipids
of cell membrane.
 The main disadvantage of using corticosteroids
in endodontic therapy is their interference with
phagocytosis and protein synthesis leading to
rampant infection & repair impairment.

 Systemic corticosteroids reduce pain &
swelling in cases of single sitting flare ups.
 It was demonstrated by Marshall and Walton
in their study by administering 4mg
dexamethasone intramuscularly which
significantly reduced pain & swelling within 4
hrs after single sitting endodontic therapy.

NSAIDS
 Non-narcotic analgesics like aspirin is good
for mild to moderate pain whereas narcotic
analgesics like pentazocine, codeine,
morphine are potent to control severe pain.
 Non -steroidal anti-inflammatory drugs
(NSAID) like ibuprofen, fenoprofen, naproxen
etc are potent antiinflammatory agents and
are helpful in reduction of swelling & pain.

SYSTEMIC ANTIBIOTICS
 Antibiotics are widely used locally and
systemically in endodontic cases, but their role in
pain reduction is limited.
 However systemic antibiotics have a definite role
in situations where patient exhibits cellulitis,
malaise, fever and toxemia. An appropriate
antibiotic to control root canal infections should
depend upon culture sensitivity testing.
 There are no specific studies regarding
antibiotics role in reducing or eliminating pain in
acute exacerbations during endodontic therapy.

PATIENT COUNSELLING
 Detailing the complete procedure, expected
benefits and possible pain responses of root
canal treatment to the patient, will help to
reduce the patient’s anxiety, apprehension &
tension because one prefers to know what will
happen if he or she undergoes particular
procedure.
 Postoperative instructions like proper scheduling
of medicines , application of ice, following the
appropriate regimen of taking medicines etc will
elevate the patient’s pain threshold.

 The occurrence of mild pain and discomfort
following endodontic treatment is common
even when the treatment rendered is of the
highest standard.
 It is the duty of the clinican to explain it to the
patient.
 Prompt and effective treatment of flareups is
an essential part of the overall endodontic
treatment .

CLASSIFICATION OF ENDODONTIC
EMERGENCY
PreTreatment Endodontic Emergencies:
 1. Dentin Hypersensitivity
 2. Pain of Pulpal Origin:
 Reversible Pulpitis
 Irreversible Pulpitis
 3. AcuteApical Periodontitis
 4. Acute Periapical Abscess
 5.Traumatic Injury: Ellis Fractures
 6. CrackedTooth Syndrome

Intra Appointment or UnderTreatment:
 1. Mid treatment Flare ups
 2. Exposure of pulp
 3. Fracture ofTooth
 4. Recently placed restoration –Trauma form
Occlusion due to high points
 5. Periodontal treatment

Post EndodonticTreatment:
 1. Over Instrumentation while doing BMP
 2. Overextended filling during Obturation
 3. Under filling during obturation
 4. Root Fracture
 5. High points during Restoration

DENTINAL HYPERSENSITIVITY
 The presence of short and sharp pain
occurring in presence of external stimulus
thermal, chemical or tactile.
 This can be caused due to exposure of the
dentinal tubules during endodontic
procedure on the adjacent tooth
 It should be treated by identifying the
location and by using Desensitizer over the
tooth surface affected.

Cracked Tooth Syndrome
 The presence of fracture lines not deep but which involve
the enamel and dentin causing pain in the pulp and
periodontal involvement.
 This can be caused by biting on any hard substance or in
presence of any para functional habits in case ofTrauma.
 The patient is asked to bite on any substance and if patient
complains of Pain during release of pressure it is a classic
sign of cracked tooth syndrome.
 Immediate relief will be by de occluding the tooth and
permanent solution can be by Endodontic treatment or
Extraction based on the involvement of Fracture line.

ACUTE PERIAPICAL ABSCESS
 The presence of an abscess in the apical
portion of the tooth caused due to the
inflammation of the periodontal ligament
resulting from pulpal infection orTrauma to
the affected tooth.
 The treatment plan should be incision and
drainage of the abscess to give immediate
relief and Endodontic treatment.

Tissue or Air Emphysema
 It is the collection of Gas in theTissue Spaces
or the facial planes which is seen during
Periapical surgery or Endodontic therapy
where Air is forced towards the tissue either
with an Air-rotor or the Air pump.

Hyper Occlusion or High
Point
 Presence of excess restoration in between
appointments can also lead to severe pain in
less than 2 hours of the restoration which
should be trimmed and high points removed
to relieve the patient.

ENDODONTIC FLARE UPS

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