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Endodontic flare-ups: A prospective study

Article  in  Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology · November 2010
DOI: 10.1016/j.tripleo.2010.05.014 · Source: PubMed

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 ARTICLE IN PRESS

Endodontic flare-ups: a prospective study

Vanessa de Oliveira Alves, DDS, São Paulo, Brazil
SÃO PAULO DENTAL ASSOCIATION

The objective of this prospective clinical study was to evaluate the incidence of flare-ups (pain and/or
swelling requiring endodontic interappointment and emergency treatment) and identify the risk factors associated with
their occurrence in patients who received endodontic treatment from June 2006 to June 2007 at the endodontics clinic
of the São Paulo Dental Association (APCD), Jardim Paulista branch, São Paulo, Brazil. The incidence of flare-ups was
1.71% out of 408 teeth that had received endodontic therapy. Statistical analysis using the chi-squared test (P ⬍ .05)
indicated a direct correlation between the flare-up rate and the presence of a periradicular radiolucency. (Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2010;xx:xxx)

Endodontic flare-ups are those occurrences of pain
and/or swelling resulting from a session of endodontic
treatment and requiring an emergency interappointment
and active treatment.1 The rates reported in the litera-
ture range from 1.4% to 16%. This could be attributed
to the fact that each study follows a particular protocol,
thus using different samples and criteria to evaluate the
stage of pain and/or swelling.2-6
Several factors have been studied to elucidate which
factors could be correlated with the occurrence of flare-
ups. These include the number of sessions to complete
the treatment7; intracanal medication used8; host fac-
tors, such as gender, age, and dental group3; presence
of preoperative pain of periapical origin6; pulpal diag-
nosis5; periradicular diagnosis1; type of treatment,
whether initial treatment or retreatment9; presence of
irritants inside the radicular canal system6; apical ex-
trusion of debris; and whether or not apical patency was
maintained during preparation.10
The objective of the present prospective clinical
study was to evaluate the incidence of flare-ups and to
identify the risk factors that may be associated with this
occurrence after initial treatment and retreatment in
patients who were endodontically treated from June
2006 to June 2007 at the endodontics clinic of the São
Paulo Dental Association (APCD), Jardim Paulista
branch, São Paulo, Brazil.
MATERIALS AND METHODS
Data were collected from all patients with endodon-
tic needs, who were seen by students attending the
Endodontics Specialist, São Paulo Dental Association; MSc student,
São Leopoldo Mandic Dental Research Center.
Received for publication Sep 1, 2009; returned for revision May 5,
2010; accepted for publication May 15, 2010.
1079-2104/$ - see front matter
© 2010 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2010.05.014
specialization course in endodontics, during a 13-
month period.
Endodontic treatment was provided to patients under
controlled and standardized conditions and under the
supervision of the attending faculty to ensure quality
and consistency of treatment. All of the students were
fully instructed to administer treatment according to the
principles and philosophy of the specialization pro-
gram.
A total of 266 patients were seen, for a total of 408
treated teeth. All patients were informed of the aims
and design of the study, and written informed consent
was obtained from each of the participants before their
inclusion. Each patient’s record consisted of the fol-
lowing data: pulpal and periradicular diagnosis of the
tooth; presence of preoperative pain; type of medication
used before treatment; type of treatment performed;
number of sessions needed to complete the endodontic
treatment; and whether or not apical patency was main-
tained while preparing the root canal.
Each patient was anesthetized with a local anesthetic.
A rubber dam was placed, and the operative field was
decontaminated with 2.5% sodium hypochlorite (NaOCl).
Conventional straight-line access preparations were
performed. Chemomechanical preparation was performed
in all of the teeth, using a modified crown-down pro-
gressive enlargement technique, with cervical enlarge-
ment by way of Gates-Glidden burs size 070 and 090
(Maillefer, Ballaigues, Switzerland), and files activated
by an endodontic rotary system. An electronic apex
locator (Root ZX; J. Morita, Tokyo, Japan) was used to
determine the working length 1 mm short of the apical
foramen. Apical patency, whenever possible, was con-
firmed with a small file after each larger file was used.
Irrigation was carried out with 1 mL 2.5% sodium
hypochlorite, delivered by a 30-G needle, after apply-
ing each bur and file size. Final irrigation with 17%
ethylenediaminetetra-acetic acid was activated with ul-

e1
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Table I. Occurrence of flare-ups according to age Table III. Occurrence of flare-ups according to arch/
group dental group
Flare-ups Flare-ups
Age, y No. of teeth n % Dental group No. of teeth n %
⬍21 45 0 0 Maxillary*
21-30 94 2 2.12 Anterior 84 0 0
31-40 115 2 1.73 Premolar 72 3 4.16
41-50 93 2 2.15 Molar 80 1 1.25
51-60 44 1 2.27 Mandibular†
⬎60 17 0 0 Anterior 28 0 0
Premolar 33 0 0
P ⫽ .9284 (not statistically significant at ␣ ⫽ .05).
Molar 111 3 2.70
*P ⫽ .1235 (not statistically significant at ␣ ⫽ .05).
Table II. Occurrence of flare-ups according to gender †P ⫽ .4322 (not statistically significant at ␣ ⫽ .05).
Flare-ups
Gender No. of teeth n %
Male 144 3 2.08
Table IV. Occurrence of flare-ups according to pre-
Female 264 4 1.51 treatment medication
Flare-ups
P ⫽ .6728 (not statistically significant at ␣ ⫽ .05).
Pretreatment medication No. of teeth n %
No medication 327 5 1.52
Analgesics/antiinflammatories/ 81 2 2.46
antibiotics
trasound for 1 minute in each canal to improve the
efficacy of the smear layer removal procedure. P ⫽ .5597 (not statistically significant at ␣ ⫽ .05).
In retreatment cases, root canal preparations were
completed after removal of the previous root canal
filling with Gates-Glidden burs and hand files as de-
scribed above. RESULTS
Most treatments were completed in a single visit. Four hundred eight teeth were included in the study.
However, additional sessions were required in the event Seven of these required emergency treatment, thus
of an abscess, when there was lack of time, when the yielding a flare-up rate of 1.71%. There were no statis-
patient felt tired, or in cases of greater complexity. tically significant differences in the incidence of flare-
Under these circumstances, a nonsetting calcium hy- ups regarding the following factors: age (Table I); T1
droxide powder (Fórmula e Ação, São Paulo, SP, Bra- gender (Table II); maxillary versus mandibular teeth T2
zil) mixed with a sterile saline solution was used to fill (Table III); intake of medication preoperatively (Table T3
the canals, and a temporary seal was placed using Cavit IV); performance of initial treatment or retreatment T4, AQ: 1
(Espe-Premier, Norriston, PA, USA). (Table V); number of visits to complete the treatment T5
At the end of each appointment, the attending dentist (Table VI); or whether apical patency was maintained T6
instructed the patient on how to proceed by saying: (Table VII). T7
“Expect the tooth to be sore for 1 or 2 days. Over-the- Although the analysis of the pulpal diagnosis factor
counter medication should be enough to take care of revealed 6 cases of flare-up in teeth with nonvital pulps,
this initial soreness. However, should the pain persist, this factor did not influence the incidence of flare-ups
or particularly if it seems to be getting worse, please significantly (Table VIII). However, the periradicular T8
call me. Also call if you notice continuous swelling. If status was correlated positively with the occurrence of
you have any other questions or problems, be sure to flare-ups. In this group, the occurrence of a periradicu-
contact me.” lar radiolucent alteration was responsible for 3.04% of
In the cases where there was pain and/or swelling, an the emergencies, representing a statistically significant
emergency interappointment was arranged. Appropri- increase compared with teeth showing normal radio-
ate treatment, consisting of further canal instrumenta- graphic appearance in the periapical region (Table IX). T9
tion, was performed. These cases were classified as
positive occurrences of flare-up. DISCUSSION
The flare-up rates were registered and expressed as This study revealed a low incidence of flare-ups
percentages, and then compared through the chi- during endodontic treatment (1.71%). These results are
squared test (P ⬍ .05) using StatXact software (Cytel similar to those obtained by Imura and Zuolo,5 Trope,12
Software Corp., Cambridge, MA, USA). and Siqueira et al.,6 who used the following criterion
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Table V. Occurrence of flare-ups according to treat- Table VIII. Occurrence of flare-ups according to pul-
ment modality pal diagnosis
Flare-ups Flare-ups
Treatment
modality No. of teeth n % Diagnosis No. of teeth n %
Initial treatment 283 3 1.06 Normal 77 0 0
Retreatment 125 4 3.20 Pulpal inflammation 83 1 1.20
Pulp with no vitality 248 6 2.41
P ⫽ .1249 (not statistically significant at ␣ ⫽ .05).
P ⫽ .3327 (not statistically significant at ␣ ⫽ .05).

Table VI. Occurrence of flare-ups according to no. of

appointments Table IX. Occurrence of flare-ups according to perira-
Flare-ups dicular diagnosis
Flare-ups
Sessions No. of teeth n %
Single 240 2 0.83 Diagnosis No. of teeth n %
Multiple 168 5 2.97 Normal appearance 244 2 0.81
Presence of lesion 164 5 3.04
P ⫽ .1009 (not statistically significant at ␣ ⫽ .05).
P ⬍ .0001 (statistically significant at P ⬍ .01).

Table VII. Occurrence of flare-ups according to apical

patency procedure
Flare-ups
Patency No. of teeth n %
Positive 315 5 1.58
Negative 93 2 2.15
P ⫽ .7132 (not statistically significant at ␣ ⫽ .05).
for flare-ups: the occurrence of severe spontaneous pain
and/or swelling after an intracanal intervention, requir-
ing an emergency interappointment and active treat-
ment. The low incidence of flare-ups reinforces the fact
that canal therapy may be considered to be a routine
dental treatment as long as biologic principles are ob-
served and scientifically based contemporary tech-
niques are used.
Analysis regarding the influence of a patient’s age
and gender, as well as of the tooth and arch under
consideration, did not show statistically significant dif-
ferences in the flare-up rates. These results corroborate
the findings of other authors.5,12 Conversely, a retro-
spective study carried out by Torabinejad et al.3 found
a positive correlation between flare-up rates and age,
gender, and dental arch.
The initial diagnosis is an important factor when
evaluating painful exacerbations after an endodontic
intervention. In the present study, there was a statisti-
cally significant difference in the occurrence of flare-
ups in cases presenting with periradicular radiolucen-
cies. An increased incidence of pain in these teeth may
be explained by the presence of bacteria and their
by-products within the root canals. Iqbal et al.13 con-
cluded that the incidence of flare-ups was low and that
the presence of a periapical lesion was the most
important factor for its occurrence during root canal
treatment.
Siqueira9 reported that causes of flare-ups comprise
both mechanical and chemical factors, and/or microbial
injuries to the pulp, as well as extrusion of contami-
nated debris into the periradicular tissues. A study
carried out by Izu et al.14 demonstrated that contami-
nated patency files can potentially contaminate the peri-
apical tissues.
This considered, the clinician should be aware of the
risks of using large instruments for maintaining pa-
tency. This procedure may result in severe periradicular
injury, lead to the lack of an apical stop, and extrude a
large amount of infected debris, which predispose to
postoperative discomfort and/or jeopardize the out-
come of the endodontic therapy.15
In the present study, the procedure of maintaining
apical patency did not correlate with the incidence of
flare-ups, a result similar to that obtained by Tor-
abinejad et al.3 Both our study and that of Torabinejad
et al. used the crown-down technique, which produces
less apically extruded debris, as previously reported by
Al Omari and Dummer16 and Favieri et al.11
The results of the present study demonstrated that
teeth with pain and/or swelling of periradicular origin
did not present any statistically significant difference
regarding flare-up rates. Torabinejad et al.,3 however,
reported that patients with pain and/or swelling before
treatment were more prone to flare-ups than those with
no preoperative complaints.
In the present study, there was no statistically signif-
icant correlation between the use of preoperative med-
ication and flare-up rates, corroborating the findings of
Walton and Fouad.1
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e4 de Oliveira Alves
Analysis of the type of treatment performed–whether
initial treatment or retreatment–showed no statistically
significant difference regarding the incidence of flare-
ups. This was consistent with the study carried out by
Siqueira et al.,6 who considered apically extruded mi-
croorganisms and the incomplete chemical-mechanical
preparation of the apical part of the root canal as the
main causes of flare-ups.
In the present prospective study, there was no statis-
tically significant difference between the incidence of
flare-ups and the number of sessions. Studies compar-
ing single and multiple sessions, such as those carried
out by Fox et al.,17 Al-Negrish and Habahbeh,18 and
Figini et al.,20 did not find any difference regarding the
incidence of postoperative pain whether in 1- or 2-visit
endodontic treatments. Nevertheless, studies by Yodas
et al.,8 Oginni and Iudoye,19 and Ghoddusi et al.21
obtained contrary results, reporting an increase in the
incidence of postendodontic pain in single-session pro-
cedures. Sathorn et al.22 reviewed the evidence regard-
ing postoperative pain/flare-ups and concluded that
there was no evidence to show a significant difference
in the prevalence of postoperative pain/flare-ups after
either single- or multiple-visit root canal treatment. The
low incidence of flare-ups in the present study may
be attributed to the use of an atraumatic crown-down
preparation technique and to compliance with bio-
logic principles; these factors could be even more
relevant than the number of treatment sessions for
successful completion.
Based on the results obtained in this study, it should
be borne in mind that flare-ups often occur when treat-
ing teeth with evidence of periradicular radiolucency.
In such cases, the appropriate technique should be
chosen to reduce the amount of debris extruded api-
cally.
Although psychosocial and cultural factors were not
the object of our study, the self-reported preappoint-
ment pain level of study patients has been associated
with a greater likelihood of flare-ups. Law et al.23
reported that the most successful psychosocial factors
in predicting flare-ups were: 1) the highest level of
distress in the 6 hours before the appointment; and
2) the desire to control the anticipated unpleasantness
associated with the treatment. The reasons for the dif-
ferences cannot be readily explained but could relate to
different patient populations, varying treatment modal-
ities, and other methods of assessment.23
Fear of dentists and dental procedures, anxiety, ap-
prehension, and many other psychologic factors also
may influence the patient’s pain perception and reaction
thresholds.24 Previous traumatic dental experiences ap-
pear to be significant factors in the production of anx-
iety and apprehension in dental patients.25 Furthermore,
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Month 2010
pain perception is a highly subjective and variable
experience modulated by multiple physical and psycho-
logic factors, and pain reporting is influenced by factors
other than the experimental procedure.26
Further research analyzing possible relationships be-
tween cultural and other subjective factors on one hand,
and more objective factors on the other, such as those
investigated in our study, may shed light on alternative
strategies to deal with flare-ups.
The author is grateful to Professors Mario Luis Zuolo and
José Eduardo de Mello Junior for their extremely valuable
guidance throughout the research and development of this
prospective clinical study.
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