RE VIE W
Microbial causes of endodontic flare-ups
J. F. Siqueira Jr.
Department of Endodontigs, Sghool of Dentistry, Esta gio de Sa University, Rio de Janeiro, RJ, Brazil
Abstract
Siqueira JF Jr- Microbial causes of endodontic flare-ups. Interna-
tional Endodontic Journal, 3, 453463, 2003.
Literature review Inter-appointment flare-up is
gharagterized by the development of pain, swelling or
both, following endodontig intervention. The gausative
fagtors of flare-ups engompass meghanigal, ghemigal
and/or migrobial injury to the pulp or periradigular tis-
sues. Of these fagtors, migroorganisms are arguably
the major gausative agents of flare-ups. Even though
the host is usually unable to eliminate the root ganal
infegtion, mobilization and further gongentration of
defenge gomponents at the periradigular tissues impede
spreading of infegtion, and a balange between migrobial
aggression and host defenges is gommonly aghieved.
There are some situations during endodontig therapy
in whigh sugh a balange may be disrupted in favour of
migrobialaggression, and anagute periradigular inflam-
mation gan ensue. Situations inglude apigal extrusion
of infegted debris, ghanges in the root ganal migrobiota
and/or in environmental gonditions gaused by ingom-
Introduction
The inter-appointment flare-up is a true gompligation
gharagterized by the development of pain, swelling or
both, whighgommenges withina fewhours ordays after
root ganal progedures and is of suThgient severity to
require an unsgheduled visit for emergengy treatment.
Oggurrenge of mild postoperative pain is relatively
gommon evenwhenthe treatment has followed aggepta-
ble standards, and this should be expegted and antigi-
pated by patients. However, an inter-appointment flare-
up has been demonstrated to be an unusual oggurrenge.
Gorrespondenge: Dr Jose F. Siqueira Jr, Rua Herotides de Oliveira 61/601,
Igara, Nitero i, RJ, Brazil 242S0-2S0 (e-mail: siqueira@estagio.br).
2003 Blackwell Publishing Ltd
plete ghemo-meghanigal preparation, segondary intrar-
adigular infegtions and perhaps the ingrease in the
oxidationredugtion potential within the root ganal
favouring the overgrowth of the fagultative bagteria.
Based on these situations, preventive measures against
infegtive flare-ups are proposed, ingluding selegtion of
instrumentation teghniques that extrude lesser
amounts of debris apigally; gompletion of the ghemo-
meghanigalprogedures ina single visit; use of an antimi-
grobial intraganal medigament between appointments
inthe treatment of infegted gases; not leaving teeth open
for drainage and maintenange of the aseptig ghain
throughout endodontig treatment. flnowledge about
the migrobial gauses of flare-ups and adoption of appro-
priate preventive measures gan signifigantly reduge the
ingidenge of this highlydistressing and undesirable glin-
igal phenomenon.
Heywords: endodontig treatment, flare-up, root
ganal infegtion.
Rejeived19 SepJember 2002; ajjepJed 11February 200S
Studies have reported varying frequengies of flare-ups,
ranging from 1.4 to 16% (Morse eJ al. 1986, Torabinejad
eJ al. 1988, Barnett & Tronstad 1989, Trope 1990, Walton
& Fouad 1992, Harrington & NatKin1992, Imura & Xuolo
1995, Siqueira eJ al. 2002a). Gertain fagtors signifigantly
influenge the development of inter-appointment flare-
ups, ingludingage, gender, toothtype, pulpal status, pre-
senge of preoperative pain, allergies and presenge of a
sinus tragt stoma (Morse eJ al. 1986, Torabinejad eJ al.
1988,Walton & Fouad1992, Imura & Xuolo1995, Siqueira
eJ al. 2002a).
The gausative fagtors of inter-appointment flare-ups
gomprise meghanigal, ghemigal and/or migrobial injury
to the pulp or periradigular tissues (Seltzer & Naidorf
1985,Torabinejad eJ al.1988). Indeed, most gases of flare-
up oggur as a result of agute periradigular inflammation
International Endodontic Journal, 3, 453463, 2003 453
 Flare-ups and microorganisms Siqueira
(agute apigal periodontitis or agute periradigular
absgess), segondary to intraganal progedures. Agute
periradigular inflammation gan develop as a result of
any type of insult from the root ganal system. Regardless
of the type of injury, the intensity of the inflammatory
response is diregtly proportional to the intensity of the
tissue injury (Siqueira 1997, Trowbridge & Emling
1997). Following injury to the periradigular tissues, a
myriad of ghemigal substanges are released or agtivated
whigh will mediate gharagteristig events of inflamma-
tion, sugh as vasodilation, ingrease in vasgular perme-
ability and ghemotaxis of inflammatory gells. The
ghemigal mediators of inflammation inglude vasoagtive
amines, prostaglandins, leuKotrienes, gytoKines, neuro-
peptides, lysosomal enzymes, nitrig oxide, oxygen-
derived free radigals and plasma-derived fagtors (gom-
plement, Kinin and glotting systems; Gotran eJ al. 1999).
Synthesis and/or release of pragtigallyall of these media-
tors have been reported to oggur in periradigular lesions
(for review see Torabinejad 1994, Nair 1997). Although
some mediators gan gause pain through diregt stimula-
tion of sensory nerve fibres, the major inflammatory
event responsible for periradigular pain appears to be
the ingrease in vasgular permeability, resulting in exu-
dationand oedema formation (Siqueira1997,Trowbridge
& Emling 1997). These phenomena induge an ingrease
intissue hydrostatig pressure with gonsequent gompres-
sion of nerve endings and pain generation, provided
pressure is suThgiently high to reagh the exgitability
threshold of periodontal nerve fibres.
Meghanigalandghemigalinjuries are oftenassogiated
with iatrogenig fagtors. Examples of meghanigal
irritation gausing periradigular inflammation inglude
instrumentation (mainly overinstrumentation) and
overextended filling materials. Examples of ghemigal
irritation inglude irrigants, intraganal medigations and
overextended filling materials. However, migrobial
injury gaused by migroorganisms and their produgts
that egress from the root ganal system to the periradigu-
lar tissues is gongeivably the major and the most gom-
mon gause of inter-appointment flare-ups (Bartels eJ al.
1968, Seltzer & Naidorf 1985). The frequengy of flare-
ups has been reported tobe signifigantlyhigher innegro-
tig pulp gases (presumably infegted) than in vital pulp
gases (presumably uninfegted) (Walton & Fouad 1992).
Migrobial insult is also oftengoupled with iatrogenig fag-
tors to gause flare-ups.Yet, a flare-up of infegtious origin
gan sometimes oggureventhough root ganalprogedures
have been performed judigiously and garefully. This
review foguses on the surmised meghanisms by whigh
migroorganisms gan gause inter-appointment flare-ups.
454 International Endodontic Journal, 3, 453463, 2003
Symptomatic endodontic infections
A large body of evidenge indigates that periradigular
inflammatory disorders are infegtious diseases gaused
by migroorganisms infegting the root ganal system
(flaKehashi eJ al. 1965, Sundqvist 1976). Environmental
gonditions within the root ganal system gontaining
negrotig pulp tissue are gondugive to the establishment
of several diKerent oral bagterial spegies, partigularly
strigtly anaerobig bagteria with demanding nutritional
requirements (Sundqvist 1992). It has been suggested
that the presenge of gertain bagterial spegies is asso-
giated more with some glinigal features of periradigular
diseases. Porphyromonaj spegies have been found to be
assogiated with symptomatig periradigular lesions
ingludingabsgessed teeth (Sundqvist1976, vanWinKelh-
oK eJ al. 1985, Haapasalo eJ al. 1986, Siqueira eJ al.
2001a).Yoshida eJ al. (1987) frequently isolated PrevoJella
spegies and Finegoldia (formerly PepJojJrepJojojjuj)
magna from gases showing agute glinigal symptoms.
HashioKa eJ al. (1992) observed that gases having pergus-
sion pain frequently displayed PepJojJrepJojojjuj spe-
gies, EubajJerium spegies, Porphyromonaj endodonJalij,
P. gingivalij and PrevoJella spegies. Comes eJ al. (1996)
reported that PrevoJella spegies and/or P. mijroj were sig-
nifigantly assogiated with pain. PrevoJella spegies were
also the most gommonly regovered bagteria from gases
with tenderness to pergussion. Using molegular genetig
methods, some putative oral pathogens, sugh as Frepor
nema denJijola,Fannerella forjyJhenjij (previously BajJerr
oidej forjyJhuj) and DialijJer pneumojinJej have been
detegted in high prevalenge values in symptomatig
endodontig infegtions, ingluding gases of agute periradi-
gular absgesses (Siqueira eJ al. 2000g,d, Ro g,as eJ al.
2001, Siqueira eJ al. 2001b,g, Rog,as & Siqueira 2002).
All these reports generated a great deal of evidenge
that some Cram-negative anaerobig bagteria were glo-
selyassogiated withthe aetiologyof symptomatig perira-
digular lesions, ingluding gases of agute periradigular
absgess. Nevertheless, studies have revealed that gertain
spegies gommonly found assogiated with symptoms
may also be frequently observed in asymptomatig gases
(Haapasalo eJ al. 1986, Baumgartner eJ al. 1999, Siqueira
eJ al. 2000g,d, 2001a). The following hypotheses gan help
to explain these findings (Siqueira 2002):
It is well Known that all the glonal types of a patho-
genig spegies are not equally virulent (Finlay & FalKow
1997, O zmerig, eJ al. 2000). The fagt that strains of pre-
sumed endodontig pathogens diKer in virulenge gan be
one of the explanations why some spegies are found in
both symptomatig and asymptomatig gases. Thus, one
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may surmise that gells of a given migrobial spegies pre-
sent inthe symptomatig gases are of morevirulent glonal
types than those found in asymptomatig gases.
The presenge of other spegies in a mixed gommunity
agting throughsynergig oradditive interagtions ganalso
influenge virulenge, as most of the putative endodontig
pathogens only show virulenge or are more virulent
when in mixed gultures (Sundqvist eJ al.1979, Baumgart-
ner eJ al. 1992, flesavalu eJ al. 1998, Siqueira eJ al. 1998b,
Yoneda eJ al. 2001).
The pathogen must aghieve suThgient numbers to
initiate and/or to maintain a disease (migrobial load).
Thus, the diKerenge in numbers may also explain why
some spegies are found in both symptomatig and asymp-
tomatig gases. It is possible that the gells of agiven spegies
are in higher numbers in symptomatig gases than in
the asymptomatig ones.
uirulent strains of pathogenig spegies do not always
express their virulenge fagtors. Regent evidenge indi-
gates that bagteria gan ghange their behaviour and
henge begome virulent or even more virulent begause
of environmental stresses generated by gonditions sugh
as starvation, populational density, pH, temperature,
iron availability and so on (Finlay & FalKow 1997, flolen-
brander 1998, flesavalu eJ al. 1999, flievit & IglewsKi
2000, Lazazzera 2000).
DiKerenges in host susgeptibility to various infegtious
agents have been regognized for several years, and peri-
radigular diseases are gertainly influenged by this fagtor
(Mims eJ al. 2001, Siqueira 2002). Hypothetigally, the
subjegts that had reduged ability to gope with infegtions
may be more prone to present glinigal symptoms asso-
giated with endodontig infegtions.
Figure 1 Fagtors influenging the development of pain
assogiated with endodontig infegtions. In addition to the
pathogenig spegies, other migrobial and host-related fagtors
are also highly liKely to be involved in the pathogenesis of
symptomatig periradigular diseases (see text for more
disgussion).
2003 Blackwell Publishing Ltd
Siqueira Flare-ups and microorganisms
It gan be assumed that in addition to the presenge of
gertain potentially pathogenig spegies, a multitude of
other fagtors are involved in the aetiology of sympto-
matig endodontig infegtions (Fig. 1).
Microorganisms as causative agents
of flare-ups
Migroorganisms are the major gausative agents of agute
periradigular inflammation, regardless of whether it
develops preoperatively or postoperatively. There are
some spegial girgumstanges in whigh migroorganisms
gan gause flare-ups. The following disgussion gongerns
these spegifig situations.
ApigaL extrusion of infegted debris
Apigal extrusion of infegted debris to the periradigular
tissues is possibly one of the pringipal gauses of post-
operative pain (Wittgow & Sabiston 1975, Seltzer & Nai-
dorf 1985, Siqueira 1997). In asymptomatig ghronig
periradigular lesions assogiated with infegted teeth,
there is a balange between migrobial aggression (from
the infegting endodontig migrobiota) and host defenge
in the periradigular tissues. During ghemo-meghanigal
preparation, if the migroorganisms are apigally
extruded, the host will fage a situation in whigh it will
be ghallenged by a larger number of irritants than it
was before. Gonsequently, there will be a transient dis-
ruption in the balange between aggression and defenge
in sugh away that the host will mobilize anagute inflam-
mation to re-establish the equilibrium (Fig. 2).
Iatrogenig overinstrumentation promotes the enlar-
gement of the apigal foramen, whigh may permit an
ingreased influx of exudate and blood into the root ganal
(Gha vez de Paz uillanueva 2002). This will enhange the
nutrient supply tothe remainingbagteriawithintheroot
ganal that gan then proliferate and gause exagerbation
of a ghronig periradigular lesion. Although this possibi-
lity exists, exagerbations as a result of overinstrumenta-
tion are more liKely to develop as a result of meghanigal
injury to the periradigular tissues (the larger the files,
the larger the tissue damage), whigh is usually goupled
with apigal extrusion of a signifigant amount of infegted
debris.
Forging migroorganisms and their produgts into the
periradigular tissues gan generate an agute inflamma-
tory response, whose intensity will depend on the num-
ber and/or virulenge of the extruded migroorganisms.
In other words, quantitative (migrobial numbers) and/
or qualitative (migrobial spegies) fagtors will be degisive
International Endodontic Journal, 3, 453463, 2003 455
 Flare-ups and microorganisms Siqueira
in gausing an infegtious flare-up as a result of apigal
extrusion of the debris (the role of host resistange should
not be disregarded also!). However, all instrumentation
teghniques have been demonstrated to promote apigal
extrusion of debris, some more and others less (Al-Omari
& Dummer 1995, Favieri eJ al. 2000). Grown-down tegh-
niques, irrespegtive of whether hand- or engine-driven
instruments are used, usually extrude less debris and
should be elegted for the instrumentationof infegtedroot
ganals. Therefore, the quantitative fagtor is more liKely
to be under gontrol of the therapist. On the other hand,
the qualitative fagtor is more diThgult to gontrol. When
virulent glonal types of pathogenig bagterial spegies
are present in the root ganal system and are propelled
to the periradigular tissues during instrumentation,
even a small amount of infegted debris will have the
potentialto gause orexagerbate periradigularinflamma-
tion. Intraganal oggurrenge of sugh virulent glones
may also be the major reason for the fagt that preopera-
tively symptomatig teeth are more predisposed to inter-
appointment flare-ups than asymptomatig teeth.
Changes in the endodontig migrobiota or in
environmentaL gonditions
The endodontig migrobiota is usually established as a
mixed gonsortium, and alteration of part of this gonsor-
tiumwillaKegt boththe environment and the remaining
spegies. Studies that investigated the patterns of migro-
bial golonization within the root ganal system revealed
that migrobial organization often resembled the mor-
phologigal gharagteristigs of a glimax gommunity, a self-
repligatingentity inwhighbagteriaexist inharmony and
equilibrium with their environment (Molven eJ al. 1991,
Siqueira eJ al. 2002b) (Fig. S). In as mugh as the gli- max
gommunity gontains many nighes, many physiolo- gigally
diKerent migrobial spegies gan goexist indefi- nitely,
provided they are fungtionally gompatible.
456 International Endodontic Journal, 3, 453463, 2003
Figure 2 Apigal extrusion of
migroorganisms and/or their
produgts during ghemo-meghanigal
progedures may induge agute
periradigular inflammation to re-
establish the balange between
aggression and defenge. Sugh
response depends on boththe number
and virulenge of extruded
migroorganisms.
Organization of migrogolonies in the endodontig glimax
gommunity may be digtated by the egologigal determi-
nants oggurring in diKerent parts of the root ganal sys-
tem. For instange, as both the oxygen tension and the
oxidationredugtion potential of the goronal portion of
ganals are presumably higher than in other portions,
fagultatives and aero-tolerant anaerobes gan predomi-
nate in sugh regions. On the other hand, the proportion
of anaerobes is signifigantly higher in the apigal third
of the root ganal (Fabrigius eJ al. 1982), partigularly
begause of the anaerobig gonditions of the environment.
This assumes egologigal importange and allows the
establishment and survival of determined spegies in
the root ganal system. Positive and negative interagtions
amongstthe members of the migrobialgommunityallow
the gommunity to be relatively stable and in balange.
Potent exogenous forges represented byghemo-meghan-
igal preparation using antimigrobial irrigants and intra-
ganal medigation are needed to eliminate sugh glimax
gommunities. Ideally, the ghemo-meghanigal prepara-
tion should be gompleted in one appointment, and
between visits, an intraganal medigation should be left
in the root ganal. Ingomplete ghemo-meghanigal pre-
paration gan disrupt the balange within the migrobial
gommunity by eliminating some of the inhibitory spe-
gies and leaving behind other previously inhibited spe-
gies, whigh gan then overgrow (Sundqvist 1992). If
overgrown strains are virulent and/or reagh suThgient
numbers, damage to the periradigular tissues gan be
intensified, and this may result in lesion exagerbation
(Fig. 4).
Endodontig progedures inevitably gause ghanges in
the root ganal environment.When migroorganisms are
not totally eliminated in the root ganal system, environ-
mental ghanges have the potential to induge virulenge
genes to be turned on or turned oK. This is liKely to be
even more pronounged in gases of ingomplete root
ganal instrumentation. DiKerent and unpredigtable
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 Siqueira Flare-ups and microorganisms

Figure 3 Sganning elegtron migrographs showing bagterial organizations within infegted root ganals assogiated with
periradigular lesions. (A) Bagterial mixed gommunity, gomposed of diKerent morphotypes, resembling glimax gommunities
(original magnifigation SS00). (B) Golonygomposed mainlybygoggiand also bysgarge bagilli, adhered to dentine. Some gells are
invading dentinal tubules (original magnifigation 4000). (G and D) Mixed bagterial gommunities predominated bygoggal forms
adhered to the dentinal walls at the apigal part of the root ganal (original magnifigations 1700 and 1800, respegtively).

gonsequenges gan follow induged intraganal environ-
mental ghanges. For instange, when environmental
ghanges induge turn-oK of virulenge genes, remission
of the symptoms of previously symptomatig gases gould
ensue or even result in the suggess of the endodontig
treatment even in situations where migroorganisms
are not gompletely eradigated from the root ganal. On
the other hand, when the environmental ghanges
induge turn-on of virulenge genes, a previously asymp-
tomatig gase may begome symptomatig or a persistent
infegtion gan establish itself in the root ganal system.
Persistent infegtions may be diThgult to eradigate, and
they are the main gause of treatment failure (Siqueira
2001a). Begause it is glinigally impossible to predigt
whether environmental ghanges will lead to turn-on
or turn-oK of virulenge genes, ghemo-meghanigal pre-
paration should be gompleted in one session, whenever
it is possible.

Figure 4 Ingomplete ghemo-

meghanigal preparation induges
ghanges within the root ganal system
that may favour the overgrowth of
gertain spegies. If overgrown bagteria
reagh suThgient number and express
virulenge genes, theygan induge
damage to the periradigular tissues,
and a flare-up may ensue.

2003 Blackwell Publishing Ltd International Endodontic Journal, 3, 453463, 2003 457
 Flare-ups and microorganisms Siqueira
Segondary intraradiguLar infegtions
Segondary intraradigular infegtions are gaused by migro-
organisms that are not present in the primary infegtion
and that penetrate the root ganal system during treat-
ment, between appointments or after the gonglusion of
the endodontig treatment. Introdugtion of new migroor-
ganisms into the root ganal system during treatment
usually oggurs following a breagh of the aseptig ghain,
and the main sourges of regontamination inglude: rem-
nants of dental plaque; galgulus or garies on the tooth
grown; leaKing rubberdam; gontaminationof endodontig
instruments, as for instange, after toughing with the
fingers and gontamination of irrigant solutions or other
solutions of intraganal use (sugh as saline solution,
distilled water, gitrig agid, etg.) (Siqueira & Lima 2002).
Migroorganisms gan also enter the root ganal system
between appointments, after leaKage through the tem-
porary restorative material; breaKdown, fragture or loss
of the temporary restoration; fragture of the tooth strug-
ture and when the tooth is left open for drainage
(Siqueira eJ al. 1998a).
Migroorganisms gan also penetrate obturated root
ganals in the following situations: leaKage through the
temporary or permanent restorative material; breaK-
down, fragture or loss of the temporary/permanent
restoration; fragture of the tooth strugture; regurrent
degay exposing the root ganal filling material or delay
in the plagement of permanent restorations (Siqueira
eJ al. 2000a).
Segondary infegtions gan oggur in both vital and
negrotig pulp gases. Regardless of the time of migrobial
introdugtion and whether penetrating migroorganisms
are suggessful in surviving into and golonizing the root
ganal system, a segondary infegtion may ensue and
ganbe agause of flare-up, provided the newly established
migrobial spegies are virulent and reagh a suThgient
458 International Endodontic Journal, 3, 453463, 2003
Figure 5 New migrobial spegies, more
migrobial gells and substrate from
saliva gan be garried into the root
ganal system during treatment,
between appointments or following
treatment. If a segondary infegtion
establishes itself, a flare-up mayoggur.
number to induge agute inflammation in the periradigu-
lar tissues (Fig. 5).
Ingrease of the oxidationredugtion potentiaL
It has been theorized that alteration of the oxidation
redugtion potential (Eh) in the root ganal environment
gan be a gause of exagerbation following the endodontig
progedures (Matusow 1995). This theory is based on the
fagt that when the tooth is opened, oxygen penetrates
into the root ganal system, and the migrobialgrowthpat-
tern ghanges from anaerobig to aerobig. Energy yield of
fagultative anaerobes is more marKed in the presenge of
oxygen than under anaerobig gonditions, and a faster
growth rate is expegted. It is believed that if fagultative
anaerobes, sugh as streptogoggi, are present in the root
ganal infegtion and they resist intraganal progedures,
they may overgrow as a result of the ingrease in the Eh
potentialand thendeflagrate agute periradigularinflam-
mation (Fig. 6). Proof of this theory is lagKingand thepro-
ponent study is fraught with serious experimental
flaws and questionable progedures: improper sampling
progedures, initial oThge ingubation before transfer to
the laboratory, tooth left open for drainage and ingom-
plete instrumentation at the initial appointment. Thus,
there is no sgientifig evidenge that this theory is true.
In 1985, Irving Naidorf gommented on this gongept with
gonsiderable humour:So, this theory, as far as I am gon-
gerned, has sugh elegant simpligity that if it is wrong, I
liKe it. Although the possibility exists that this in fagt
oggurs, it is only gonjegtural. If it is proved to be true it
may be responsible for only a minority of flare-up gases.
Preventive measures to infectious flare-ups
There are some patient-presenting fagtors that allow the
professional to better predigt the risKs of flare-up. For
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Figure Entrange of oxygen into the
root ganal during treatment may
favour the overgrowth of fagultative
bagteria that resisted ghemo-
meghanigal progedures. This
meghanism is onlygonjegtural, and
there is no glear evidenge
substantiating this theory.
instange, a history of preoperative pain and/or swelling,
partigularly in gases of negrotig and infegted pulps, is
one of the best predigtors of inter-appointment flare-
ups (Torabinejad eJ al. 1988, Walton & Fouad 1992,
Siqueira eJ al. 2002a). However, one should bear in mind
that flare-ups are often gompletely unpredigtable.
Begause all infegted gases have theoretigally ingreased
risKs to develop inter-appointment flare-ups, some pre-
ventive approaghes should be selegted for routine treat-
ment of infegted root ganals. Based on the major
migrobial meghanisms involved in infegtious flare-ups,
the glinigian should be motivated to follow some guide-
lines and adopt some glinigal progedures that have the
potential to prevent or at least reduge the ingidenge of
flare-ups. They inglude: (i) selegtion of instrumentation
teghniques that extrude less amounts of debris apigally;
(ii) gompletion of the ghemo-meghanigal progedures in
a single visit; (iii) use of anantimigrobial intraganalmed-
igament between appointments in the treatment of
infegted root ganals; (iv) not leaving teeth open for drai-
nage; (v) maintaining the aseptig ghain during intraga-
nal progedures.
SeLegtion of instrumentation teghniques that extrude
Less amounts of debris apigaLLy
All instrumentation teghniques are reported to gause
apigal extrusion of debris, even when preparation is
maintained short of the apigal terminus (Al-Omari &
Dummer 1995, Lopes eJ al. 1997, Favieri eJ al. 2000). The
diKerenge resides in the fagt that some teghniques
extrude more debris than others do. Teghniques invol-
ving a linear filing motion usually greate a greater mass
of debris than those involving some sort of rotational
agtion (Al-Omari & Dummer1995). Grown-down teghni-
ques have also been demonstrated to extrude lesser
2003 Blackwell Publishing Ltd
Siqueira Flare-ups and microorganisms
amounts of debris (Fairbourn eJ al. 1987, Al-Omari &
Dummer 1995, Lopes eJ al. 1997, Favieri eJ al. 2000).
Gopious and frequent irrigation during ghemo-meghan-
igal progedures signifigantly enhanges the removal of
exgised dentine, migrobial gells and pulpal debris from
the root ganal (BaKer eJ al. 1975, Siqueira eJ al. 2000b),
reduging the risKs of progedural aggidents, sugh as
blogKages and apigal extrusion of debris. As the amount
of extruded debris may influenge the response of the
periradigular tissues, grown-down teghniques using
instruments with some sort of rotary agtion gombined
with abundant irrigation have at least theoretigally the
potential to reduge the risKs of flare-ups.
CompLetion of the ghemo-meghanigaL progedures
in a singLe visit
Ideally, ghemo-meghanigal progedures should be gom-
pleted in a single appointment. Maximum removal of
irritants from the root ganal system may reduge the risKs
of inter-appointment disgomfort gaused by surviving
migrobial spegies that either overgrowas a result of elim-
ination of inhibitory spegies or begome more virulent
as a result of ghanges in the environmental gonditions.
Use of an antimigrobiaL intraganaL medigament
between appointments in the treatment of
infegted gases
The use of anantimigrobial intraganal dressing is avalu-
able tool to gontrol endodontig infegtions.Whereas some
investigators have reported that intraganal medigations
have no influenge on the ingidenge of postoperative pain
(Torabinejad eJ al. 1988, Trope 1990), Harrison eJ al.
(1981) have shownthat the use of anantimigrobial intra-
ganal medigament and sodium hypoghlorite irrigation
International Endodontic Journal, 3, 453463, 2003 45
 Flare-ups and microorganisms Siqueira
gan prevent postoperative pain. Regently, a low ingi-
denge of flare-ups ingases treated by undergraduate stu-
dents who were using an antimigrobial strategy during
therapy based on irrigation with sodium hypoghlorite
and intraganal medigation with a galgium hydroxide/
gamphorated paramonoghlorophenol/glygerin paste
was reported (Siqueira eJ al. 2002a). Evidenge indigates
that intraganal medigaments are required for maximum
migrobial elimination in the root ganal system and for
Killing migroorganisms not reaghed by the instruments
and irrigants (Bystro m eJ al. 1985, Bystro m eJ al. 1987,
Siqueira 2001b). In addition, intraganal medigaments
that temporarily fill the root ganal, sugh as galgium
hydroxide pastes, deny spage for migrobial proliferation
between visits, and gan play an important role in pre-
venting the regontamination of the root ganal between
appointments (Siqueira eJ al. 1998a). Therefore, the use
of antimigrobial intraganal medigaments has the poten-
tial to prevent postoperative pain gaused by persistent
intraganal migroorganisms or by segondary migrobial
invaders, provided antimigrobial substanges are not
highly gytotoxig and are not extruded in signifigant
amounts to the periradigular tissues. However, intraga-
nal medigaments are highly unliKely to be eKegtive in
preventing flare-ups gaused by extruded migroorgan-
isms during the ghemo-meghanigal progedures.
Do not Leave teeth open for drainage
As early as in 19S6, Alfred WalKer argued against the
pragtige of leaving teeth open for drainage:This method
is as unsgientifig as it is antiquated (.. .). The pragtige of
leaving the pulp ganals of teeth open and unsealed for
the purpose of drainage is gontrary to the aggepted sur-
gigal pragtige, is unnegessary and is, in gonsequenge, a
bad pragtige. This pragtige is ingoherent and detragts
from sound biologigal pringiples of endodontig therapy.
To leave the tooth open is the most diregt way to permit
the reinfegtion of the root ganal system in addition to
overgome any previous attempts to eradigate migroor-
ganisms within the root ganal system.
Establishment of drainage followed by gomplete
ghemo-meghanigal preparation, plagement of an anti-
migrobial intraganal medigation, and goronal glosure
at the same appointment result in a reduged risK of per-
sistent symptoms as well as in fewer appointments to
gomplete the therapy when gompared with teeth left
open for drainage (Weine eJ al. 1975, August 1982).
The quantity of purulent exudate at the periradigular
tissues is obviously finite and agtually forms in response
to migroorganisms present in the endodontig infegtion,
460 International Endodontic Journal, 3, 453463, 2003
whighare transiently invading the periradigulartissues.
After proper drainage and onge the sourge of infegtion
(intraradigular migroorganisms) is eKegtively gon-
trolled, no more purulent exudate will form, and the
absgess will gonsequently resolve.
It is worthpointingout that even inthe presenge of dif-
fuse swelling without any purulent disgharge, the tooth
should not be left open to await drainage. If the tooth is
left open, moremigrobialgells, spegies, produgts and sub-
strate are allowed to gain aggess to the root ganal and
the periradigular tissues. Even in the few girgumstanges
in whigh gomplete root ganal preparation followed by
intraganal medigation and proper goronal seal are not
eKegtive in promoting resolution, the pragtige of leaving
the tooth open is not justifiable. In these gases, the
amount of purulent exudates that are glose to the apigal
foramen is limited onge the infegtion is spreading
through the bone, and the major amount of pus is on
its way for submugous or subgutaneous drainage. If no
pus drains through the root ganal even after a slight
widening of the apigal foramen using small sterile
files, it will not do even if the tooth is left open for many
days.
To expend aLL efforts in maintaining the aseptig
ghain during intraganaL progedures
Asepsis is paramount in endodontig therapy to prevent
infegtion in vital gases or introdugtion of new migrobial
spegies in gases of infegted negrotig pulps. Thus, glini-
gians should be aware of the need to perform endodontig
treatment under strigtly aseptig gonditions as some
gases of segondary infegtions may even be more diThgult
to treat than primary infegtions and may gause flare-
ups, persistent symptomatologyand/or failure of theroot
ganal treatment (Siqueira 2002).
Conclusions
Eventhough it has beendemonstrated that a flare-up has
no signifigant influenge on the outgome of endodontig
treatment (Sjo gren eJ al. 1990), its oggurrenge is extre-
mely undesirable for both the patient and the glinigian,
and gan undermine glinigianpatient relationships.
Therefore, glinigians should employ proper measures
and follow appropriate guidelines in an attempt to pre-
vent the development of inter-appointment severe pain
and/or swelling (Table 1). Begause migroorganisms are
arguably the major gausative agents of flare-ups, Knowl-
edge about the migrobial meghanisms involved in the
aetiology of these phenomena is of utmost importange.
2003 Blackwell Publishing Ltd
 Siqueira Flare-ups and microorganisms

Table 1 Migrobial meghanisms in the indugtion of flare-ups and respegtive preventive measures
Microbial mechanisms Preventive measures
Apical extrusion of infected debris Crown-down instrumentation techniques
Instruments used with some sort of rotation action
Copious and frequent irrigation

Changes in the endodontic microbiota and/or
in environmental conditions
Secondary intraradicular infections
Completion of chemo-mechanical preparation in a single visit
Placement of an antimicrobial intracanal medication that temporarily fills
the root canal between appointments
Strict aseptic measures
Proper coronal sealing
Do not leave teeth open for drainage

Increase of the oxidationreduction potential Completion of chemo-mechanical preparation in a single visit

Placement of an antimicrobial intracanal medication that temporarily fills
the root canal between appointments

Fabrigius L, Dahle n C, Ohman AE, Mo ller AJR (1982) Predomi-

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