MANAGEMENT OF
MID-TREATMENT
ENDODONTICS
FLARE-UPS
MID-TREATMENT FLARE UPS
Complication characterized by pain, swelling or combination of
both, which commences within a few hours or days following root
canal procedures
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.
The occurrence of mild pain and discomfort following endodontic
treatment is common even when the treatment has followed
acceptable standards, and this should be expected and anticipated by
the patients.
However, an inter-appointment flare has been demonstrated to be an
unusual occurrence with frequencies ranging from 1.4% -16%.
According to Weine most flare-ups occur when improper treatment
is rendered or when insufficient time is allowed for specific
modalities.
CLINICAL CONDITIONS RELATED TO MID-
TREATMENT FLARE UPS
1. Apical Periodontitis secondary to treatment
Tooth becomes sensitive to percussion - throbbing or gnawing pain
Causes: over instrumentation or
forcing debris into periapical tissue
Confirmatory test :
On a sterile paper point, mark the working length. Then place it into the
canal. If over instrumentation has happened, paper point will go beyond
working length without obstruction. On withdrawal, tip of the point will
show reddish or brownish colour indicating inflammed tissue in the
periapical region
2. Incomplete Removal of Pulp Tissue
Sensitivity to hot and cold or pain on percussion
Confirmatory Test: Place a sterile paper point into the canal short of
the working length. When removed, it will display a brownish
discoloration indicating inflamed seeping tissue
3. Recurrent Periapical Abscess
Abscess may recur more than once due to high virulence of
microorganism or poor host resistance
4. Recrudescence of Chronic Apical Periodontitis (Phoenix Abscess)
Alteration in the internal environment of the root canal space during
instrumentation activates the bacterial flora.
Mobility, tenderness and swelling are seen.
ETIOLOGY OF MID-TREATMENT FLARE UPS
1. Alteration in Local Adaptation Syndrome
When new irritants in the form of medicaments, irrigating solutions
or debris is introduced to the inflamed tissue, a violent reaction may
occur due to disturbance is local tissue adaptation.
2. Apical extrusion of infected debris
It can lead to transient disruption in balance between microbial
aggression and host defense in such a way that host will mobilize an
acute inflammation to re-establish the balance.
It is one of the principle causes of pain.
3. Secondary intra radicular infections
It is caused by microbes not present in primary infection.
Enter through root canal in between appointments via leaking
temporary restorations, fractured tooth or when the tooth is left open
for drainage.
4. Presence of pathogenic bacteria
The bacterial species can be associated with symptomatic
periradicular lesions.
Include Porphyromonas endodontalis, Porphyromonas gingivalis,
and Prevotella species.
5. Increase of the oxidation - Reduction potential
A form of environmental change induced by endodontic intervention -
entrance of oxygen in the root canal.
Can alter the oxidation - reduction potential (Eh) in the root canal and
an acute exacerbation can occur. This theory is based on the fact that
the increase in Eh would induce microbial growth pattern to change
from anaerobic to aerobic. Energy yield of facultative anaerobe is
more marked in the presence of oxygen than under anaerobic
condition and a faster growth rate is expected with consequent
overgrowth of facultative anaerobic bacteria. This theory is
considered speculative and there is no scientific evidence indicating it
is valid.
CAUSES OF MID-TREATMENT PAIN
The origin of mid-treatment endodontic flare-up is due to various
factors such as mechanical, chemical and microbial.
Regardless of the type of factor, the flare-up depends on the
extent of peri-radicular tissue injury, its severity and intensity of
inflammatory response.
Mechanical and chemical injuries are often associated with
iatrogenic factors.
Microbial injury is arguable and also the most common cause of
inter-appointment pain.
MICROBIAL CAUSES
Predominantly anaerobic microorganism proliferate in the apical
area of the root canal.
Apical root canal area is said to be “dangerous” for pathogenic
bacteria due to it’s complicated anatomy (accessory canals, apical
deltas) and high bacteria dentsity.
When there’s extrusion of infected debris from the apical foramen
to the periradicular tissue, inflammation increases.
Vessels dilation, permeability increases and inflammation cell
chemotaxis begin
Intensity depends on virulence and amount of microorganism in the
periodontal tissue
When tooth is sensitive to percussion, predominant strains of
microorganisms are Parvimonas micra, Eubacterium, Porphyromonas
([Link], [Link]) and Prevotella.
If the root canal is not adequately chemomechanically prepared and
between visits is not filled with intracanal medicaments, interaction of
microbes in the root canal occur.
Between visits microorganisms can also enter the root canal through
non-hermetic temporary filling or in case of it falling out.
MECHANICAL FACTORS
During mechanical preparation of the root canal, some amount of
debris, necrotic pulp masses, irrigative solutions can enter the
periradicular area through apical foramen.
Incorrectly measured working length of the root canal.
If working length measured too long, the apical constriction in the
area of physiological apex of the root is destroyed.
If working length measured is too short, pulp remnants and bacteria
are left in the apical third. Success and prognosis of the treatment
will be significantly decreased.
RECAPTULATION
Recapitulation is being done by inserting flexible k-file (#6, #8, #
10) which enters the canal deeper than the measured working
length
Advantage – avoiding obstruction of the apex and improve access
of irrigation solution in the apical third of root canal.
Disadvantage – Mechanical irritation of the periodontal tissue and
extrusion of debris into apical periodontal tissues.
CHEMICAL FACTORS
Irrigating solutions, intracanal medicaments, root canal filling
substances might be toxin therefore causing chemical irritation.
Overextended filling materials also represent chemical irritation to
the periradicular tissues.
OTHER FACTORS
Age of patient
In a large retrospective study done : 40-59 year had the most flare-
ups ; < 20 years of age had the least.
Gender of patient
In most studies, women have reported more severe levels of pain,
more frequent pain, and pain of longer duration.
Systemic conditions
Study found a highly significant association between flare-ups and
the presence of allergies to various substances and the frequency of
inter-appointment pain.
It was suggested that this could be due to an immediate
hypersensitivity reaction occurring in the periapical tissues.
Anatomic location
In a retrospective study done, mandibular teeth were associated with
more inter-appointment emergencies
Mandibular premolars followed by mandibular incisors were the
most problematic teeth after cleaning and shaping.
Anxiety
An anxious pt with the previous dental pain
The slightest pressure on the tooth can be interpreted as pain.
Preoperative history of the tooth
Studies shown statistically higher incidence of flare-ups in patients
taking analgesics and anti-inflammatory drugs.
Pulpal or periapical status
A prospective study found that teeth with vital pulps resulted
relatively few flare-ups.
In contrast, pulp necrosis higher incidence.
Eg : Periapical diagnosis of acute apical abscess has higher incidence
of flare-up when compared with less symptomatic/ less severe apical
pathosis.
Number of treatment visits
Less post-operative pain in single visit approach than multi-visit
approach.
Retreatment cases
Studies found an extremely high incidence of flare-ups in re-treatment
teeth with apical periodontitis.
Tendency to push remnants of gutta percha, solvents, and other debris
into periapical tissues.
Persistent or secondary root canal infection more difficult.
Obturation
Overfilling can cause post-operative pain.
Excess sealer into periapical tissue cause tissue damage and
inflammation.
STRATEGIES TO PREVENT FLARE UPS
1. Anxiety reduction
2. Behavioral intervention
High levels of stress and anxiety decreases speed of wound healing.
Studies shown that intake of analgesics improve treatment
compliance, reduces postoperative pain intensity and accelerates
recovery.
Providing information about the procedure is important.
3. Occlusal reduction
4. Crown down technique
minimal amount of extrusion of debris through apical foramen.
PHARMACOLOGICAL STRATEGIES TO PREVENT
FLARE UPS
Antibiotics
An evidence-based review determined that use of systemic
antibiotics for prevention of post-treatment endodontic pain should
be discouraged.
Not recommended for healthy pt with localized endodontic
infections.
Only considered if there is a spreading infection/compromised
defense mechanisms.
NSAIDS and acetaminophen
Effective for managing pulpal and periapical pain.
Pretreatment - effective for reducing postoperative pain.
In irreversible pulpitis – reduce inflammatory mediators prostaglandin
E2 (PGE2).
Patient should take the medication just prior to or immediately after
treatment.
Combination of ibuprofen and acetaminophen has additive analgesia.
Long-acting local anesthetics
Increase period of post-treatment analgesia beyond usual duration of
anesthesia.
May provide analgesia for up to 8-10 hours following block
injections and may reduce pain even 48 hours later.
Example: Bupivacaine
MANAGEMENT OF MID-TREATMENT FLARE UPS
Hargreaves and Seltzer – ‘3D’ approach
Definitive
Diagnosis Drugs
treatment
DIAGNOSIS
Obtaining a thorough understanding of the patient’s chief complaint
– pain history.
Clinical examination
Clinical test
Re-instrumentation
Drainage will reduce localized tissue pressure and pain will be
relieved
Weine advocated enlarging the apical constriction to at least size
#25 to allow for drainage through tooth
Cortical trephination
Surgical perforation of the alveolar bone - release accumulated
periradicular tissue exudate
Incision & Drainage
In cases of acute exacerbation of chronic periradicular lesion or
post treatment endodontic abcess
To facilitate the evacuation of pus, microorganisms and toxic
products from periradicular tissue
In teeth where endodontic treatment has not yet been completed, it
is advisable to re-enter the root canal system to eliminate the
etiological factors.
Intracanal medicaments
intracanal steroids, NSAIDS, or a corticosteroid-antibiotic compound
Rogers et al. – demonstrated both dexamethasone and ketorolac
placed in root canals of vital teeth after pulpectomy shows statistically
significant pain relief.
Occlusal reduction
Sensitivity to biting and chewing might be due to increase levels of
inflammatory mediators that stimulate periradicular nociceptors.
In teeth with pain upon biting, occlusal reduction is effective in
reducing post-operative pain.
DRUGS
Antibiotics
Prescribed to reduce the inflammatory process.
Non-narcotic analgesics
Non-narcotic analgesics, NSAIDS, acetaminophen have effectively
been used to treat endodontic pain.
NSAIDS (Ibuprofen 400mg, ketoprofen 50mg)
Sensitivity to NSAIDS, acetaminophen is considered.
REFERENCES
Jayakodi, Harikaran et al. “Clinical and Pharmacological Management of
Endodontic Flare-Up.” Journal of Pharmacy & Bioallied Sciences [Link] 2
(2012): S294–S298. PMC. Web.
Singhal G.D et al. ““MID TREATMENT FLARE-UPS IN ENDODONTICS : A
NIGHTMARE FOR CLINICIANS”. Dept of Conservative Dentistry&
Endodontics, Shree Bankey Bihari Dental College, Ghaziabad.(U.P) (2010).
Cohen S. Pathways of the pulp. Mosby;6th edition 1997:44-46.
Garg N. Textbook of Endodontics. 2007: 305-307
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