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Endodontic flare-ups
Introduction
• Pain may occur soon after initiating
endodontic treatment for an asymptomatic
tooth or shortly after the initial emergency
treatment or during the course of treatment.
• Flare-up is described as the
occurrence of pain, swelling or
the combination of these
during the course of root canal
therapy, which results in
unscheduled visits by patient.
American Association of
Endodontics (AAE) defines a
flare-
up “as an acute exacerbation of
periradicular pathosis after
initiation or in continuation of root
canal treatment.”
• Flare-ups may occur with the best of the
therapy, but most flare-ups occur when
improper treatment is rendered or when
insufficient time is allowed for specific
modalities in therapy
ETIOLOGY
The occurrence of flare-ups during the endodontic therapy is a
polyetiologic phenomenon.
• Causative Factors
Comprise mechanical, chemical and/or microbial injury to the pulp or
periapical tissues resulting in the release of myriad of inflammatory
mediators. Pain then occurs due to the direct stimulation of the nerve
fibers by these mediators or edema resulting in an increase in the
hydrostatic pressure with consequent compression of nerve endings
• Causative Factors
A-Mechanical Injury
1- Periapical extrusion of
debris
2-Incomplete removal
of pulp tissue.
3-Overinstrumentation—
most common cause of
mid treatment flare-ups.
B-Chemical Injury
1.
2.
3.
Irrigants
Intracanal medicaments
Overextended filling materials
C-Microbial Induced Injury
• It is considered as the most significant factor in
the flare-up pathogenesis. Microbial factors
may be combined with iatrogenic factors to
cause inter-appointment pain.
•
Contributing Factors for
Flare-ups
• Age ..Patients in the 40–59 years
range have the most flare-ups and
those under the age of 20 have the
least.
• Gender.. females < males .
• Tooth type.. Mandibular teeth
<maxillary teeth
molars < 17 times than other teeth.
• Pulpal &Periradicular status.. vital pulps >necrotic pulp
3.4 % chronic apical periodontitis
4.8% acute apical periodontitis
13.1 % acute apical abscess.
• Pre-operative pain.. 80% of patients who feel tooth pain
before the beginning of the treatment usually feel the pain
after treatment
• Allergies.. higher frequency of inter-appointment pain
• Anxiety.. Anxious patients are likely to have more pain
during the course of the treatment
• Number of Visits .. If proper case selection is not done, more
flare-ups occur after multi-visit approach as compared to
single visit approach to
endodontics.
• Retreatment Cases… Chances of flare-ups are 10 folds
higher in the retreatment cases because of extrusion of infected
debris or solvents into
periapical tissues
Hypothesis for flare ups
• Dr Seltzer discussed a number of hypothesis thought to be
related to the etiology of flareups
 Alteration of the local adaption syndrome .
 Changes in periapical tissue pressure .
 Microbial factors.
 Effects of chemical mediators.
 Changes in cyclic nucleotides.
 Immunological phenomena.
 Various psychological factors
1 - Alteration of local adaptation syndrome
when a new irritant is introduced in a chronically
inflamed tissue, a violent reaction may occur
because of disturbance in local tissue adaptation
to applied irritants.
For example in case of chronic pulpal diseases, the inflammatory lesion
is adapted to irritants but during root canal therapy, a new irritant in
form of medicament get introduced in the lesion leading to flare-up
2- Changes in Periapical Tissue Pressure
Studies have shown that endodontic therapy causes
pressure changes in periapical area in both directions
Teeth with POSITIVE periapical pressure, excessive
exudate creates pain by causing pressure on nerve
endings. Root canals of such teeth when kept open,
exudate comes out but in teeth with NEGATIVE
periapical pressure, microorganisms and altered tissue
proteins gets aspirated into periapical area leading to
increased inflammatory response and pain.
3- Microbial Factors
• Gram-negative anaerobes Produce a variety of enzymes and
release neurotoxic endotoxins. Also they activate the Hageman
factor to release bradykinin, a potent pain mediator.
• Teichoic acid, present in the cell wall and plasma membranes of
many gram positive bacteria is potent immunogen, producing
humoral antibodies IgM, IgG, IgA and releases various chemical,
mediators that cause pain.
Microbial Mechanisms in the Induction of Flare-ups
1- Extrusion of microorganisms and their products result
in flare-ups
2- Incomplete debridement of canal disrupts the
balance between various microbial communities with
in root canal system and favor the overgrowth of
certain species.
3-Coronal leakage leads to Secondary intraradicular infection
4- Alteration of oxidation-reduction potential in the root
canal during treatment may favor the overgrowth of
facultative bacteria that resisted chemomechanical
procedures and lead to flare-ups.
4- Effects of chemical mediators
Cell mediators Like histamine, serotonin, prostaglandins,
platelet activating factors, leukotrienes etc. are capable of
producing severe pain, which are released from cells.
5 -Changes in Cyclic Nucleotides
Increased levels of cAMP inhibits mast cell
degranulation which helps in reducing pain where as
increase in cGMP levels stimulate mast cell
degranulation which results in increase in pain.
Studies have shown that during
flare-up, there is increased
level of cGMP over
cAMP concentrations.
6- Immunological Response
In chronic pulpitis and periapical disease, presence of
macrophages and lymphocytes indicates both cell mediated
and humoral response. Despite of their protective effect, the
immunologic response also contributes to destructive phase
of reaction which can occur, causing perpetuation and
aggravation of inflammatory process.
7- Psychological factors
• Anxiety, fear, psychosis, apprehension
& previous traumatic dental
experience means a lot to dental
patients especially during root canal
procedures
• These anxieties aggravate and
intensify painful episodes
CLINICAL CONDITIONS RELATED
TO FLARE-UP
Flare-ups in endodontics may be grouped as:
1. Interappointment flare-ups.
2. Postobturation flare-ups.
1- Interappointment flare-ups.
1. Apical periodontitis secondary to treatment:
• An asymptomatic tooth become sensitive to percussion.
• Pain may become severe causing a throbbing or gnawing
pain.
Causes:
• Over instrumentation.
• Over medication.
• Forcing debris into periapical tissue.
Confirmatory test:
• Use paper point
• Mark W/L.
• Place the paper point in the canal.
• If over instrumentation has happened by fault, then the paper
point will go beyond the working length without obstruction. On
withdrawal, tip of the point will show a reddish or
brownish color indicating inflamed tissue in the periapical
region and absence of stop in apical preparation.
Management:
• An intracanal corticosteroid-antibiotic
medication is given to the patient for symptomatic
relief. The medication is carried on the paper point and
applied with a pumping action so as to reach the
inflammed periapical tissues.
•
Routine endodontic therapy may be continued after 2
to 5 days after readjusting the working length
2. Incomplete removal of pulp tissue:
•
Sensitivity to hot and cold or pain on percussion is
usually seen.
Confirmatory test:
When paper point is removed, it will display
brownish discoloration and short of the
working length. indicative of
inflamed seeping tissue.
Management:
The working length is re-established and the
remaining pulp tissue is removed.
3. Recrudescence of chronic apical periodontitis:
(phoenix abscess).
•
It is a condition that occurs in teeth with necrotic pulps and
apical lesions that are asymptomatic.
• It occurs due to the alteration of the internal environment of root
canal space during instrumentation which activates the bacterial
flora.
• Mobility, tenderness and swelling are usually the sign and
symptoms.
Management:
The tooth is opened under rubber dam and
allowed to drain. Irrigation with warm sterile saline or water
helps to encourage the drainage.
Drainage is allowed until the exudation ceases or a slight clear
serum drains. The canal is then irrigated with sodium
hypochlorite, dried with paper point; filled with an appropriate
intracanal medicament (calcium hydroxide paste) and sealed
with a dry cotton pellet and a temporary filling.
4. 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 microorganism of high
virulence or it results in resistance.
• Management: The management and
treatment are the same as for phoenix abscess
5- Flare-ups Related to Necrotic Pulp
Teeth with necrotic pulp often develop as acute apical
abscess after the initial appointment. As the lesion, is
confined to bone, there occurs severe pain.
Management: The drainage is established, canal copiously
irrigated, and the tooth sealed after placing an intracanal
medicament of calcium hydroxide. Increasing the
appointment time allows more exposure of the bacteria to
irrigants like hydrogen peroxide and sodium hypochlorite,
thus reducing the chances of flare-ups.
2- Postobturation Flare-ups
Only 1/3 of the endodontic patients experience some pain
after obturation . A mild pain is usually present which may
resolve spontaneously. Patients experiencing preoperative pain
are more likely to suffer from postobturation flare-ups.
Another cause of postobturation flare-ups may be overextended root canal fillings.
Management: Mild to moderate pain may be controlled
with analgesics. For cases with severe pain, retreatment is
indicated.
Management of flare-ups
A -Preventive Management
• Proper diagnosis.
• Long acting local anesthesia.
• Determination of proper working length.
• Complete debridement.
• Occlusal reduction.
• Placement of intracanal medicament in case of multi-visit root
canal treatment.
• Medications.
• Closed dressing.
• Behavioral management.
1- Proper Diagnosis
Before initiating endodontic therapy, proper diagnosis of the
condition should be made so as to prevent incorrect treatment that
may lead to pain, swelling or both to the patient.
2- Long Acting Local Anesthetics
Long acting anesthetics, e.g. bupivacaine, provide increased period
of analgesia for up to 8-10 hours during the immediate
postoperative period.
3- Determination of the Proper Working Length
Inaccurate measurement of WL may lead to under or
overinstrumentation and extrusion of debris, irrigants, medicaments
or filling materials beyond the apex.
4- Complete Debridement
Thorough cleaning and shaping of the root canal system may
decrease the incidence of flare-ups. Maintenance of apical
patency and crown-down preparation technique are two
important factors in the management of flare-ups
5- Occlusal Reduction
It is a valuable pain preventive strategy in appropriate cases.
The relief of pain provided by occlusal reduction is due
to the reduction of mechanical stimulation of sensitized
nociceptors.
6- Placement of Intracanal Medicament in Multi-visit
RCT
Calcium hydroxide serves the following purposes:
• Antimicrobial action:. The antimicrobial effect of calcium hydroxide
remains in the canal for one week.
• It obliterates the root canal space which minimizes the ingress of tissue
exudates, a potential source of nourishment of remaining bacteria.
• Extrusion of calcium hydroxide periapically reduces inflammatory reaction
by reducing substrate adherence capacity of macrophages.
• Calcium hydroxide has soft tissue dissolving property because of its high pH.
Its denaturing effect on the necrotic tissue, allows sodium hypochlorite to dissolve
remaining tissue more easily.
7- Medications
• Systemic antibiotics:. Antibiotics should be recommended only
in cases of medically compromised patients at high risk levels and in cases
of spreading infection that indicates failure of local host responses to
control bacterial irritants.
The commonly prescribed antibiotics include penicillin, erythromycin or
cephalosporin. Metronidazole, tinidazole, ornidazole and clindamycin are
also used because of their efficacy against anaerobic bacteria.
• Analgesics: (NSAIDs)and acetaminophen are the most commonly
used drugs to reduce pain. Treatment with an NSAID before a procedure
has shown to reduce postoperative pain. Most commonly used drugs
include ibuprofen, diclofenac sodium and ketorolac.
8- Closed Dressing
Leaving a tooth open for drainage is contraindicated as it can
cause contaminations from the oral cavity and lead to flareups.
Drainage should be allowed under the rubber dam, and
the tooth closed immediately after the treatment to prevent
secondary infections.
9- Behavioral Management
Providing information about the procedure in an important
step in reducing patient anxiety
B- Management of flare-ups
• Drainage through coronal access opening.
• Incision and drainage.
• Proper instrumentation.
• Trephination.
• Intracanal medicaments.
• Analgesics and antibiotics (when indicated
B- Definitive Treatment
1- Drainage through the Coronal Access Opening
The first step in relieving the pain is to establish drainage through the root
canal, when it has not been obturated or poorly obturated. Sometimes
apical trephination may be needed to establish drainage.
2- Incision and Drainage
Occasionally more than one abscess is present in relation to the tooth. One
communicates with the apex, while other is present in the vestibule. As they
do not communicate with one another, flare-up can be best managed
through a combination of canal instrumentation and incision and drainage
3- Proper Instrumentation
Under profound local anesthesia, working length should
be re-established, apical patency obtained and
thorough chemomechanical preparation is done.
4- Trephination
When drainage through the canal is not possible,
surgical trephination can be used as a palliative
measure. However, it is not the first line of treatment
because of the additional trauma, invasiveness and
questionable beneficial result.
5- Intracanal Medicaments
Use of corticosteroid-antibiotic combination as an
intracanal medicament has been recommended to
reduce pain, especially in cases of over
instrumentation.
6- Analgesics and Antibiotics
For most of the patients, NSAIDs are sufficient to
control pain. However, if the pain cannot be
controlled with NSAIDs, opoid analgesics can be
used to supplement with NSAIDs.
Antibiotics are prescribed for the treatment of flareups only when indicated as discussed before. Use of
antihistaminics for treatment of flare-ups has also
been suggested.
CONCLUSION
• The development of flare-up after the endodontic
treatment appointment is an extremely undesirable
problem.
• Despite judicious and careful treatment procedures,
severe pain, swelling or both may occur.
• The clinician should employ proper measures and follow
appropriate guidelines
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