POSTOPERATIVE FLARE-UP

AND SWELLING
(management of abscess and
cellulitis)

PREPARED BY:
Dr ATIKA HASHMI
HOUSE OFFICIER

OBJECTIVE:

Introduction.
Causes.
Risk factors.
Symptoms.
Management.
Prevention.
Conclusion.
References.

FLARE-UP:
It can defined as pain and/or swelling
of the facial soft tissues and the oral
mucosa in the area of endo-donticaly
treated tooth that occur within the few
hours (12-48 hours) or a few days following
the root canal treatment.

Causes Of Endodontic Flare-up:

Chemical
Microbial
factors
Mechanical factors
factors

1.MICROBIAL CAUSES:

extrusion
of debris
Secondary Incomplet
intra
e
radicular instrumen
infection
tation

2.MECHANICAL FACTORS:

Over instrumentation .
Extrusion of filling materials.
Incorrect working length .
Inadequate removal of pulpal tissue.

3.CHEMICAL FACTORS:
Apical extrusion of intra-canal
medicaments.
Extrusion of irrigating solution .
Over extended Root fillings.

Predisposing
factors
Age
Allergies.
Preoperativ
e pain
Tooth
type

Treatmen
t
Procedur
es.
Gender

pulpal
status

Predisposing factors
Flare-up rarely occur in older patients due to
the narrowing of the diameter of the root
canal and decreased blood flow in the
alveolar bone resulting in weaker
inflammatory response.
Post-operative pain is more common among
women than men .

 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 Tx.
Bone destruction which is visible in dental
radiograph is said to be a risk factor of flareup .
80% of patients who feel tooth pain before
the beginning of the treatment usually feel
the pain after treatment .

 The flare-up rate is 4-9 times higher after

one visit endodontic retreatment compared
to retreatment by
two visits.
Incomplete debridement , over
instrumentation

MAGEMENT OF FLARE-UP:
1. Reassurance of patient.
2. Complete debridement of canal system.
3. Incision and drainage.
-To evacuate of pus, microorganisms, and toxic
products from the peri -radicular tissues.
-It releases the peri radicular tissue pressure and
provides significant pain relief.

4. Ca (OH)2 therapy.
5. Intra-canal medicaments:
Clinical studies have demonstrated that post-treatment pain is neither
prevented nor relieved by medicaments such as formocresol , camphorated
paramonochloro-phenol , eugenol , iodine , potassium iodide.
The use of steroids, nonsteriodal anti-inflammatory drugs (NSAIDs), or a
corticosteroidantibiotic has been shown to reduce post-treatment pain.

6. Relief of occlusion.
7. use of irrigating solution.
8. Re-instrumentation.

PREVENTION:
1. Selection of instrumentation techniques.
2. Copious irrigation enhanced removal of
pulpal debris.
3. Completion of procedures in a single visit.
4. Use of intra canal medicaments.
5. Not leaving teeth open for drainage.
6. Maintaining the asepsis during procedure.

DENTAL ABSCESS:
A dental abscess is an loacalized infection of the
mouth, face, jaw, or throat that begins as a tooth
infection.
The original cause may be from a ;

Deep cavity.
Periodontal (gum) disease.
A cracked tooth.
Trauma or sometimes even due to recent dental
procedures such as extractions and implants.

SIGN AND SYMPTOMS:

Pain on chewing .
Red, swollen gums .
A bad, salty taste in the mouth.
Swelling in the jaw or face.
A red, swollen bump in mouth that
have blood or pus oozing from it.

 A tooth that is very tender or sore to

touch.
Nausea ,Vomiting .
Fever , Chills.
Difficulty in swallowing , opening the
mouth, or
breathing.

MANAGEMENT:
1. Patient counseling and reassurance is
done.
2. Give antibiotics.
3. Make a hole in the tooth to drain the pus
and relieve the pain.
4. Do a root canal to remove the infected
pulp.

5. Remove the tooth. This may be needed if

you don't want a root canal, or if you have
one and it doesn't work.

To reduce pain and swelling:

Put an ice pack wrapped in a towel against
the cheek.
Pain killer , including acetaminophen or
ibuprofen .
Do not smoke or use any kind of tobacco .

COMPLICATION OF ABSCESS:

Osteomyelitis of the mandible.

Maxillary sinusitis and orbital abscess.
Ludwigs angina.
Cavernous sinus thrombosis .
Persistent pyrexia of unknown origin.
Septicaemia .
Pulmonary abscess.
Brain abscess.
Mediastinal abscess and pneumonia

MANAGEMENT OF CELLULITIS:

Reassurance and counseling of patient.

Incision and drainage.
Acetaminophen, ibuprofen
Antibiotics.

CONCLUSION
Flare-ups are an undesirable occurrence in the course
of endodontic treatment that causes distress to
both the patient and operator.
Flare-up rate after endodontic treatment is 1.4-16% .
Clinicians should employ appropriate measures in an
attempt to prevent the occurrence of flare-ups and
should be able to treat the flare-up efficiently , when
they do occur.

REFERENCES:

1.Iqbal M, Kurtz E, KoH M, Incidence and factors related to flare-ups in a graduate endodontic programme International
Endodontic Journal, (42), 2009, 99-104.
2.Morse DR, Koren LZ, Esposito JV, Goldberg JM, Belot RM, Sinai IH et al, Asymptomatic teeth with necrotic pulps and
associated periapical radioluscencies: relationship of flare-ups to endodontic instrumentation, antibiotic usage and stress in
three
different time periods, International journal of Psychosomatic research, (33), 1986, 5-87.
3. Sathorn C, Parashos P, Messer H, The prevalence of post-operative pain and flare-up in single- and multiple- visit
endodontic
treatment : A systematic review, Internayional Endodontic Journal, (41), 2008, 91-99.
4. Dean Baugh, James Wallace, The role of apical instrumentation in root canal treatment: A review of the literature, Journal
of
Endodontology, 31(5), 2005, 333-340.
5. J.F.Siqueira Jr, Aetiology of root canal treatment failure: why well-treated teeth can fail, International endodontic journal,
(34),
2001, 1-10.
6. Lin LM, Pascon EA, Skribner J, Gaengler P, Langeland K. 1991, Clinical, radiographic and histopathological study of
endodontic
treatment failures, Oral surg oral medicine oral pathology oral radiology and endodontics, (71), 603-611.
7. Siqueira JF Jr, Uzeda M, Fonseca MEL. 1996, Scanning electron microscopic evaluation of in vitro dentinal tubules
penetration by
selected anaerobic bacteria, Journal of Endodontology, (22), 308-10.
8. Atlas RM, Principles of microbiology. 2nd edition, 1977, Dubuque, IA, USA, WCB Publishers.
9. Fabricius L, Dahlen G, Ohman AE, Moller AJR, predominant indigenous oral bacteria isolated from infected root canals
after
varied times of closure, Scandinavian journal of dental research, (90), 1982, 134-144.
10. J.F.Siqueira Jr, microbial causes of endodontic flare-ups, International endodontic journal, (36), 2003, 453-463
11. Sundqvist G, Ecology of the root canal flora, Journal of endodontics,(18), 1982, 427-430.
12. Siqueira JF Jr, Lima KC, Staphylococcus epidermidis and Staphylococcus xylosus in a secondary root canal inf