FLARE-UP IN

ENDODONTICS
Word document

Dr. Anamika Thakur
7/5/2014




Flare ups in endodontics
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INTRODUCTION
Flareup 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 patients 1
.Pain may occur soon after initiating endodontic treatment for an asymptomatic tooth or
shortly after the initial emergency treatment or during the course of the treatment.It is
suggested that the incidence of interappointment emergency associated with endodontic
therapy was 4.2% and unrelated to patients sex , age or the tooth location by Mor C et al 2 .
Flareups may occur with the best of the therapy, but most flareups occur when improper
treatment is rendered or when insufficient time is allowed for specific modalities in therapy
according to Franklin S Weine 3 . Acute periapical inflammation is the most common cause
of mid treatment pain and swelling. Mid treatment emergencies are related to irritants left
within root canal system, iatrogenic factors under the control of the operator and host
factors 4 The occurrence of mild pain is relatively common following root canal therapy,it
should be expected and anticipated by patients. However a flareup with severe pain and
swelling is a rare occurrence ranging from 1.4% -16% 5.
The use of prophylactic antibiotics in endodontic dentistry has been guided by the
recommendations set forth by the American Heart Association (AHA). In general, the use of
prophylaxis is indicated for immunosupressed patients or individuals susceptible to cardiac
infection such as endocarditis (Mata et al., 1985). In effect, this recommendation of
antibiotic prophylaxis is meant to prevent the onset of dental infection that might spread
systemically. Research has also been conducted concerning the efficacy of antibiotics in
treating asymptomatic teeth with pulpal necrosis and periapical pathosis (Abbott et al.,
1988). While the use of systematic antibiotics alone to treat periapical abscess has been
suggested ineffective (Grad, 1997), the use of antibiotics to prevent infection related post-
operative pain and swelling is still contentious. Flare-up is a term commonly used to describe
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the characteristic symptoms of pain and swelling that may arise following endodontic
treatment. However, amongst the dental community a great deal of variation exists in both
the definition of flare-up and the best treatment solution to prevent its occurrence. Due to
these differences and the lack of a definitive guideline, this report sets out to use an
evidence-based approach to evaluate the available literature and answer the following
question: should antibiotics be used to prevent flare-up after endodontic treatment of
asymptomatic teeth with pulpal necrosis and periapical pathosis. This paper summarizes the
strongest sources of evidence regarding this issue.
Definition of flare-up
Utilization of different definitions of flare-up by different studies renders it difficult
to compare results concerning the efficacy of antibiotics at reducing flare-up. For instance,
Pickenpaugh et al. (2001) defined flare-up as moderate-to-severe postoperative pain or
moderate to severe swelling that began 12 to 48 hours after treatment and lasted at least 48
hours. In essence, a flare-up could consist of pain alone in the absence of swelling or vice
versa, but the symptom needed to persist for at least two days. Walton et al. (1993) chose
flare-up to describe severe pain and/or swelling requiring an unscheduled visit. In this case,
an unscheduled visit was necessary for a flare-up occurrence but the duration of the pain or
swelling was not considered.
Perhaps most problematic is that the Temple University research team uses the control
group from Mata et al. (1985) which uses pain and/or swelling that necessitated an
unscheduled emergency visit as the definition of flare-up, whereas their subsequent studies
adopted swelling and pain combined or swelling alone that necessitate unscheduled
emergency appointments to define a flare-up. In their first definition, swelling is sufficient
but not necessary for a flare-up but their latter definition requires the presence the swelling.
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It is our opinion that the placebo group from Mata et al. (1985) is not an appropriate control
for Abbott et al. (1988), Morse et al. (1987) and Morse et al.
CLINICAL CONDITIONS
Common clinical conditions associated with flareups are - 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 thatare 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 6 . 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.
ETIOLOGY
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 .
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_ Microbial factors.
_ Effects of chemical mediators.
_ Changes in cyclic nucleotides.
_ Immunological phenomena.
_ Various psychological factors.
Alteration in local adaptation syndrome explained by Selye is one of the most
accepted theory explaining flareups in symptomless tooth. He showed that there is a local
tissue adaptation to applied irritants .Chronic inflammation persists if irritant is not
removed. However when a new irritant is introduced to the inflamed tissue, a violent
reaction may occur. When endodontic therapy is performed new irritants in the form of
medicaments, irrigating solutions, chemically altered tissue proteins or debris may be
introduced into the periapical lesion leading to liquefaction necrosis indicative of alteration
of local adaptation syndrome7. During over instrumentation, due to lack of apical stop and
extrusion of a large amount of infected debris can result in severe periradicular injury,
causing a flareup . Microbial factors play an important role in endodontic flareups.Apical
extrusion of contaminated debris to the periapical tissues is one of the principle cause of
post operative pain. Studies of microbial flora of the root canal shows the presence of a
considerable variety of microorganisms. According to Sundquist most strains found in the
root canals with necrotic pulp are obligately anaerobic microorganisms 7 These organisms
can produce enzymes which are collagenolytic and fibrolytic.They also produce endotoxin
which in turn activates Hageman factor, which leads to production of bradykinin a potent
pain mediator.Chemical mediators which are activated during inflammation ,such as
histamine, serotonin ,prostaglandin, platelet activating factor, leukotrienes etc are all
capable of producing pain.
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DIAGNOSIS AND MANAGEMENT
Establishing the cause, the flare-up is an important step towards management of
mid treatment pain. It is necessary to forewarn the patient that he may experience slight
pain after the appointment and advise an over-the-counter analgesic. When patient
experience moderate to severe pain after the first appointment, the clinician must review
the diagnosis to ensure the tooth under treatment has been identified correctly as the
source of pain. If so the periapical and pulpal status have to be reviewed to determine
whether the patient has a inflammatory condition or acute infection 1.
Pain associated with instrumentation-
It can manifest as Acute periapical periodontitis or as Phoenix abscess. Acute
periapical peridontitis occurs due to overinstrumentation ,extrusion of canal contents
through the apex ,leaving the tooth in traumatic occlusion or placing too much of intracanal
medicament 6 . Absence of an apical stop and presence of blood in the apical portion of the
root canal usually indicates overinstrumentation 4.
Treatment constitutes of
Reopening the tooth,
irrigation with a combination of irrigants such as sodium hypochlorite and
chlorhexidine ,
placement of a suitable intercanal medicament and
Relieving the tooth from occlusion.
Cohen advocated relieving occlusion prior to root canal therapy to prevent post-
operative pain 9.
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Antibiotics and analgesics can be prescribed.
Pain subsequent to vital pulp extirpation-
Mid treatment pain following complete removal of vital pulp is uncommon .When pain is
intense it
indicates incomplete removal of vital pulp tissue from the root canal and if the
tooth becomes tender, the inflammation process has involved the periapical tissues
Treatment
Consist of reestablishing the working length,
complete removal of the remaining vital pulp tissue and
relieving the tooth from occlusion.
Pain associated with pulpal necrosis-
Studies suggest that the incidence of flare-ups is higher with necrotic pulp tooth than in vital
tooth (7.17%).
The best method of managing the necrotic pulp is to
Establish accurate working length of tooth and
Complete instrumentation of root canal in the first appointment.
Removal of debris from the canal should be the goal.
When there is a flare-up the tooth should be
reopened ,
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Observe for the presence of pus.
If there is pus in the canal without soft tissue swelling it indicates an acute abscess
in early stages ,
In such cases pain is more severe.
If only pain is present copious irrigation should be used and all debris is
removed.
An intracanal medicament is placed and resealed.
If pain is present along with swelling then
Drainage should be established either through the apex of the tooth or
the soft tissue.
Antibiotics and analgesics such as NSAIDS are prescribed.
The use of antibiotics alone without establishing drainage is not
considered appropriate.
The concept of leaving the canal open for drainage is controversial .Seltzer
and Weine dont advocate it, since exposure to oral flora serves no useful
purpose and may actually cause subsequent flare-ups when additional
treatment is undertaken.
PREVENTION OF FLAREUPS -
Flare ups cause a dilemma to the clinician 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 clinician can
prevent flare-ups in most instances.
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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 chlorhexidine.
Avoid filing too close to the radiographic apex.
Preform apical trephination only if necessary.
Reduce tooth from occlusion especially if apex is severely violated by over
instrumentation.
Placement of intracanal medicaments.
Prescription of mild analgesics and antibiotics whenever condition warrants it .


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Summary of Evidence
Pain and swelling are complications that are often encountered following
endodontic treatment of asymptomatic teeth with pulpal necrosis and associated periapical
radiolucent lesion (PN/PL) (Mata et al., 1985). In general, the term flare-up is used to
describe moderate to severe pain and/or moderate to severe swelling that usually begins
12-48 hours after treatment, lasts at least 48 hours, and requires unscheduled emergency
appointments (Abbott et al., 1988). Unfortunately, studies testing the efficacy of antibiotics
to prevent pain and swelling often adopt different definitions of flare-up that ultimately
render cross study comparisons difficult. Comparison of research evidence is also
problematic due to differences between studies with respect to patient population, surgical
procedures, post-operative analgesic use, and data collection. Moreover, the studies under
examination use patient reports and questionnaires to obtain data on postoperative pain
and swelling. Pain is a subjective perception that is difficult to quantify let alone compare
between different individuals and as such is a problematic marker for detecting flare-up.
Mata et al. (1985) suggests that many factors may be etiologically involved in the production
of pain and swelling following endodontic therapy. For instance, entrance of oxygen into
the root canal during access may induce facultative aerobic bacteria to proliferate and
produce inflammatory agents. Instrumentation and the air syringe can force bacteria into
the canal and perhaps through the apical foramen. The use of local anesthetic or
instrumentation might act as local irritants that cause an inflammatory response. Thus,
there are many possible factors that might contribute to a flare-up.
Regardless, the efficacious use of antibiotics necessitates bacterial involvement in the flare-
up mechanism, otherwise antibiotic treatment is unwarranted and unjustified.

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CONCLUSION
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 flare-ups is an
essential part of the overall endodontic treatment .















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REFERENCES -
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2. Mor C, Rotstein I, Friedman S.Incidence of interappointment emergency associated with
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3. Franklein S.Weine .Endodontic Therapy Fifth Edition,Mosby;203-237.
4. Mahmoud Torabinejad , Richard E. Walton, Managing endodontic emergencies.JADA.
1999; 122:99 103.
5. Jose F.Siqueira,Isabela N.Rocas,Amauri Favieri,Andreia G .Machado, Sergio M. Gahyva,
Julio C.M.Oliveira. Incidence of post operative pain after intracanal procedures based on an
antimicrobial strategy. J Endod.2002;28:457-460.
6. P.Carrotte.Endodontic Part 3. Treatment of endodontic emergenies. BDJ .2004 ;197:299-
305.
7. Samuel Seltzer, Irving J. Naidorf . Flareups in endodontics.1 Etiological factors.
J Endod .2004;30:476-481.
8. Samuel Seltzer, Irving J. Naidorf . Flareups in endodontics. II. Therapeutic Measures.
J Endod. 2004;30:482-488
9. Shephen Cohen.Pathways of the pulp. Mosby; 6th edition 1997:44-46.
10. Tayfun Alacam ,Ali Cemal Tinaz .Interappointent emergencies in teeth with necrotic
pulps. J Endodon 2002;28:375-377.