Chapter

g.

Endodortictmergenetes and

Therapeutics 159

Causatfive Factot's
assess causality when reviewing the literature on flare-ups; however, certain risk factors have emerged. These factors generally can be categorized as related to the patient (including pulpal and periapical diagnosis) or to treatment procedures. Patient factors include gender (more flare-ups are reportdd to occur in females; however, this may represent a greater tendency for females to seek medical care for painful symptomstr) and preoperative diagnosis. Flare-ups are quite uncommon in teeth with vital pulps.1,61 More often, flareups occur in teeth with necrotic pulps and especially in those with a periapical diagnosis of symptomatic apical periodontitis or acute apical abscess.l'7,5e,61 The presence of a periradicular radiolucency has also been shown to be a risk factor.t'se,62'63 However, it is clear that the patient who experiences a flare-up is more likely to have presented with significant preoperative pain and/or swelling.sT

It is difficu$- to

the clock for the first ?4 to 48 horrrs postoperarively. Although this will reduce p,ostoperative symproms, it is uncertain whefher this will reduce the inciclence of
flare-ups.

Diagnosfis
The same basic procedure is followed as outlined earlier in this chapter for pret{eatment emergencies, although with modifications. The problem has been diagnosed initially, so the operator has an advantage. I{owever, a stepby-step approach to diagnose the existing condition reduces confusiorr and error; most importantly, it calms a patient who has been shaken by the episode of pain or swelling. After the underlying compllcations are identified, treatment is initiated.

lfreatment of
Reassurance

Filane.ups

potential to create flare-ups. Although it would seem intuitive that certain procedures, such as overinstrumentation, pushing debris out the apex, or completing the endodontic therapy in one visit, may increase the incidence of flare-ups, no definitive treatment risk factors
have been identified.si

Treatment factors have also been examined for the

(the "Big R") is the most important aspect of treatment The patient is generally frightene<i and

upset and may even assume that exbaction is necessary. The explanation is that the flare-up is neither unusual nor irrevocable and will be managed. Next in importance is restoring th patient's comfort and breaking the pain cycle. For extended anesthesia and analgesia,

administration of bupivacaine hydrochloride

is

recommended.6s il/ffe\/etn Eaoin

Interappointment emergencies axe divided into

patients with an initial diagnosis of a vital or a necrotic pulp and with or witho,ut swelling.

Procedures

analgesics,'and psychologic preparation gf patients (particularly those with preoperative pain) will decrease interappointment symptoms in the mild to moderate levels.6a There are, however, no demonstrated treatment or therapeutic measures that will reduce the number of interappointment flare-ups. In other words, no particular relationship of flare-ups to actual treatment procedures
has been shown.l'7

Use of long-acting anesthetic solutions, complete cleaning and shaping of the root canal system (possibly),

Verbal lnstructions Most important is the preparation of patients for what to expect after the appointment. They should be told that discomfort ("soreness") is likely and that the discomfort should subside within a day or two. Increases in pain, noticeable swelling, or other adverse signs necessitate a call and sometimes a visit. This explanation reduces the number of calls from unnecessarily concerned

Previously Vitatl Pulps with Complete D6hridement If complete removal of the inflamed vital pulp tissr.res was accomplished at the ftrst visit, this situation is unllkely to be a true flare-Up, and patient reassumnce and the prescription of a mild to rnoderate anaiges,ic (see liigrrle 9-6) often will suffice. Generally, nothing is to be gair-red by opening these teeth; the pain will ustrally regress spontaneously, but it is impor.tant to check that the temporary restoration is not in trau,matic occlusion. Placing corticosteroids in the canal or giving an intraoral or intramuscular inlection of these medications after cleaning and shaping reduces inflammation and somewhat lowers the level of moderate pain.6s'tz Flare-ups, however, have not
been shown to be prevented by steroids, whether administered intracanal6z or systernically.

fatients.

Previously Vital Pulps with lncomplete Ddbridement It is likely that tissue temnaots have become inflamed
and are now a rRajor irritant. The working length should be rechecked, anrd the canal(s) should be careliiily cleaned

Therapeutic Prophylaxis A popular preventive approach has been the prescribing of antibiotics in an attempt to minimize postoperative symptoms. This approach has been demonstrated to be
not useful and needlessly exposes the patient to expensive, potentially dangerous drugs, as previously described.6s-67 In contrast, certain NSAIDs have been shown to reduce poste4dodontic treatment pain.al'42 For the patient at

with copious irrigation of sodium hypochlorite. A dry cotton pellet is then placed, followeel by a temporary
a mild to mcyderate analgesic is prescribed (see Figure 9-6). Occasionally, a previously vital pulp (with or without complete ddbridement) will develop into an acute apical abscess. This wikl occur some time after the appolntment and indicates tha,t pulpal remnants have become necrotic and are invaded by bacteria,

filling, and

risk for flare-up, 6OO to 800 mg of ibuprofen should be given while the patient is in the chair and thgn taken by