FLARE UP

The American Of Endodontists defines

flare ups as an acute exacerbation
( increase in severity ) of a
periradicular pathosis after the
initiation or continuation of root canal
treatment.
CAUSES
The causes are often multi factorial;-
Urgent care for mid treatment emergencies
depends on :
- Contributing factors
- Treatment modalities
- Prevention
Inadequate debridement
Persistent pain / onset of acute pain – residual pulp tissues
Degeneration of the pulp tissue > Bacteria and their toxins remain
in the root canal > Release their toxins > These acts as continuous
irritant.
Overmedication –penetrates in the periapical tissues

Teeth with necrotic pulps( with or without periradicular lesions)

are more prone to develop flare ups than vital teeth.
Thorough debridement of root canal system should eliminate the
pain.
DEBRIS EXTRUSION ( Pulp tissue fragments, necrotic tissue,
micro organisms, dentin filings, and canal irrigants )
Extrusion > periapical inflammation > mid treatment or post
treatment pain.
Pulpless teeth are more problematic – Infected.
Problem related to instrumentation techniques.
Sonic instrumentation – least extrusion( forced out)
Conventional technique – most extrusion.
Crown down(in this technique gates glidden drills and larger files
are first used in coronal 2/3rd of the root canal and progressively
smaller files are used until the desired working length is achieved
and confirming apical patency – and Balanced force < Step back.
Apical dentinal plug prevents debris extrusion – prevents over
instrumentation. ( Long term prognosis is variable).
OVER INSTRUMENTATION
Gross over instrumentation – acute apical
periodontitis producing inflammatory pain.
Sometimes a profuse exudate also comes from
the canals.
Placing calcium hydroxide preparations against or
slightly through perforated foramen can control
problematic exudates.
OVER FILLING
Extrusion of Gutta Percha, Sealer or both cause pain (
esp. in pulp less teeth).
ZoE sealer – chronic inflammation.
Overfilling along with over instrumentation causes pain.
Gross over fillings – Nerve damage due to chemical
toxicity.
Paraformaldehyde – neurotoxic – irreversible nerve
damage.
Extreme conditions – surgical intervention.
ONE APPOINTMENT ENDODONTICS

2% - severe pain
Rest – little or no spontaneous pain.
No documented literature as to the incidence of
post operative pain when two techniques are
compared.
RETREATMENT

Higher incidence of flare ups.

Host response to extruded filling materials and
toxic solvents.
Periapical pathosis – Related to flare ups.
More due to iatrogenic mishaps.
PERIAPICAL LESION
Some researchers have found apical radiolucencies to
be correlated with the increased frequency of flare ups.
Pulps of infected cases have more bacterial strains and
are more infected.
Bacteria may cause an acute problem if inoculated
periapically.
HOST FACTORS
Intensity of pre operative pain and amount of patient
apprehension are related to the incidence of post
operative pain.
Patients with dental phobias – difficult to treat – low
psycho physiologic tolerance –
presedation ( oral or IV ).
Age, gender, presence of allergies, tooth position etc.
Pain will diminish to low levels within 72 hours. During this critical
period the clinician should know how to alleviate the patients pain
quickly and effectively and prevent its recurrence.
RELAXING THE PATIENT
Pain is directly related to anxiety.
Premedication.
Conscious IV sedation, GA, Oral sedation with
anxiolytics.
Triazolam 0.25mg pre op – safe and effective.Can
also be given sub lingually.
CLEANING AND SHAPING

Complete and effective cleaning and shaping in the

initial visit.
Crown down/ step down ;- in this technique gates
glidden drills and larger files are first used in coronal
2/3rd of the root canal and progressively smaller files
are used until the desired working length is achieved
and confirming apical patency –
Sp by this there is less likelihood of flare ups.
CALCIUM HYDROXIDE THERAPY – Counters the remaining bacteria
within throot canal system
Intracanal dressings are therapeutic in prevention of flare ups.
Reduces bacterial colonies and their bacterial by products.
Antimicrobial effects – at least 1 week.
-Removing smear layer helps in better diffusion in the dentinal
tubules (bacterial lipopolysaccharides which induce inflammatory
reactions diffuse in the dentin).
-Calcium hydroxide hydrolyses lipid moibility of bacterial
liposaccharides, rendering it incapable of producing biological
effects.
Obliterates Root canal space – minimizing ingress of tissue
exudate – source of nourishment of bacteria.

Extrusion in the periapical tissues may reduce inflammatory

reaction by reducing substance adherence capacity of
macrophages.

Its pH – Tissue dissolving and anti bacterial effects

Kills anaerobic bacteria and prevents flare ups.

Can dissolve necrotic tissue – aids in sodium hypochlorite tissue
dissolution.

Cannot killl enterococcus species – Biggest cause of failure.

OTHER INTRACANAL MEDICAMENTS
Used in multi visit treatment.
Prevents bacterial growth – minimize symptoms associated
with re infection.
Decision to use – Antibacterial efficacy, toxicity and
specificity of the drug.
Formocresol.
Clindamycin impregnated fibres
Calcium hydroxide and chlorhexidine gluconate etc.
OCCLUSAL REDUCTION
Teeth with periapical inflammation are very sensitive to Occlusal
forces.
Occlusal reduction or selective adjustment of cusps – palliative
measure.
Hyper occlusion due to temporary fillings should also be adjusted.
LEAVING TOOTH OPEN
Only when drainage does not stop within 20 min.( max – 24 hours).
INCISION AND DRAINAGE FOR SWELLING;-
Establish drainage and prescribe antibiotics.
Re instrument in incomplete or fresh cases to achieve
drainage
Surgical trephination( making hole ) in teeth with
apical blockage.
Attempting a periradicular surgery at the time of acute
infection in contraindicated.
PERIAPICAL SURGERY
Non surgical RCT is preferred in case of flare ups – non
invasive.
Non surgical treatment may be impractical due to –
restorative issues, failing treatment, gross over fills, or
necessary correction of procedural accidents.
Surgical trephination – palliative(soothing)treatment.
ANTIBIOTICS AND ANALGESICS
Antibiotic – control infection ( phenoxymethyl
penicillin is drug of choice, metronidazole can be
added to the regimen to enhance killing of aerobes.
If drainage can be achieved – no antibiotics
necessary.
NSAIDS – control of pain. If needed supplement
NSAIDS with opioids.
ANTIBIOTIC PROPHYLAXIS CONTREVERSIAL
Moderate to severe pain – erythromycin base medicine base is
effective in reducing the incidence of post operative pain.
Penicillin – Bactericidal action and efficacy. Given before
treatment it prevents infection from spreading.
Side effects – nausea, diarrhea, vomiting and may be
anaphylactic reaction.
NSAIDS – ORAL AND INJECTABLE
Effective both pre and post treatment.
Pain due to inflammatory and immunologic pathways so
NSAIDS are preferred to narcotics.
Diclofenac, Ketoprofen – intracanal medicament to control
pain.
Flubiprofen (NSAID) + Tramadol ( centrally acting analgesic) –
superior short term relief.
CORTICOSTEROIDS – ORAL AND INJECTABLE
( greatest response in first 24 hrs post operative)
Corticosteroids reduce inflammation and pain blocking the
inflammatory cascade.
Local infiltration of dexamethasone – histologic anti
inflammatory effects, reduces immunoreactivity of calcitonin
generated protein and substance P, reduces nerve sprouting
response to dentin cavity injuries.
Oral methylprednisolone + penicillin – effective in reducing
post op pain.
 ONE VISIT ENDODONTICS

Multi visits can be associated with bacterial contamination.

HYPOCHLORITE ACCIDENT
Accidental injection into the periapical tissues.
Defn – A hypochlorite accident to any event where sodium
hypochlorite is expressed beyond the apex of the tooth and
the patient immediately manifests some combination of
following symptoms-
1. Severe pain even in areas where previously anesthetized for
dental treatment.
2. Swelling.
3. Profuse bleeding, both interstitially and through the tooth.
MANAGEMENT
Recognize the problem – regional block with long
acting anesthetic – flushing of the canals with sterile
water – calm the patient – observation for 30 min –
if bleeding exudate seen encourage it – leave tooth
open foe 24 hrs – antibiotic coverage ( penicillin
500mg, 5 times a day – 7 days) – analgesics for pain
( acetaminophen – narcotic combination) –
prescribe corticosteroids – refer and reassure.