ENDODONTOLOGY MID TREATMENT FLAREUPS IN ENDODONTICS A DILEMMA

Author: Dr. Neeta Shetty .M.D.S. *

ABSTRACT
Endodontic emergencies constitute a major part of dental emergencies , which is an unscheduled visit by the patient to the dental clinic .Flareups during endodontic treatment is an undesirable occurrence for both patient and clinician .This paper reviews the predisposing factors responsible for flare-ups, their management and prevention of flare-ups. Key words-Emergency,Flareups, Pain, Swelling.

INTRODUCTION
Flareup is described as the occurrence of pain, swelling or the combination of these during the course of root canal therapy, which results in unscheduled visits by patients 1 .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.It is suggested that the incidence of interappointment emergency associated with endodontic therapy was 4.2% and unrelated to patients sex , age or the tooth location by Mor C et al 2 . Flareups may occur with the best of the therapy, but most flareups occur when improper treatment is rendered or when insufficient time is allowed for specific modalities in therapy according to Franklin S Weine .
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common following root canal therapy,it should be expected and anticipated by patients.However a flareup with severe pain and swelling is a rare occurrence ranging from 1.4% -16% 5.

CLINICAL CONDITIONS
Common clinical conditions associated with flareups are Apical peridontitis secondary to treatment A tooth which was symptomless before the initiation of endodontic treatment but becomes sensitive to percussion during the course of the treatment. Causes for this condition most frequently are over instrumentation or over medication or forcing debris into the periapical tissues. Incomplete removal of pulp tissues during the intial appointment- In some instances due to lack of time factor the endodontic therapy may consist of incomplete pulpectomy after a diagnosis of acute or chronic pulpitis.This situation generally occurs when the radicular pulp is already inflamed. Phoenix abscess-It is a condition that occurs in teeth with necrotic pulps and apical lesions that

Acute periapical inflammation is the

most common cause of mid treatment pain and swelling. Mid treatment emergencies are related to irritants left within root canal system, iatrogenic factors under the control of the operator and host factors 4 The occurrence of mild pain is relatively

* Reader, Department of Conservative Dentistry and Endodontics, Manipal College of Dental sciences, Mangalore.

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ENDODONTOLOGY
are asymptomatic . There is a exacerbation of a previously symptomless periradicular lesion.The reason for this phenomenon is thought to be due to the alteration of the internal environment of the root canal space during instrumentation which activates the bacterial flora . Recurrent periapical abscess - It is a condition where a tooth with an acute periapical abscess is relieved by emergency treatment after which the acute symptoms return. In some cases the abscess may recur more than once,due to micro organism of high virulence or poor host resistance. ETIOLOGY Dr Seltzer discussed a number of hypothesis thought to be related to the etiology of flareups 7. Alteration of the local adaption syndrome . Changes in periapical tissue pressure . Microbial factors. Effects of chemical mediators. Changes in cyclic nucleotides. Immunological phenomena. Various psychological factors. Alteration in local adaptation syndrome explained by Selye is one of the most accepted theory explaining flareups in symptomless tooth .He showed that there is a local tissue adaptation to applied irritants .Chronic inflammation persists if irritant is not removed .However when a new irritant is introduced to the inflamed tissue, a violent reaction may occur.When endodontic therapy is performed new irritants in the form of medicaments,irrigating solutions, chemically altered tissue proteins or debris may be introduced into the
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MID TREATMENT FLAREUPS IN ENDODONTICS A DILEMMA

periapical lesion leading to liquefaction necrosis indicative of alteration of local adaptation syndrome
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. During over instrumentation, due to lack of apical

stop and extrusion of a large amount of infected debris can result in severe periradicular injury, causing a flareup . Microbial factors play an important role in endodontic flareups.Apical extrusion of
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contaminated debris to the periapical tissues is one of the principle cause of post operative pain .Studies of microbial flora of the root canal shows the presence of a considerable variety of microorganisms. According to Sundquist most strains found in the root canals with necrotic pulp are obligately anaerobic microorganisms
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These

organisms can produce enzymes which are collagenolytic and fibrolytic.They also produce endotoxin which in turn activates Hageman factor, which leads to production of bradykinin a potent pain mediator.Chemical mediators which are activated during inflammation ,such as histamine ,serotonin ,prostaglandin, platelet activating factor, leukotrienes etc are all capable of producing pain 4

DIAGNOSIS AND MANAGEMENT

Establishing the cause the flareup is an important step towards management of mid treatment pain.It is necessary to forewarn the patient that he may experience slight pain after the appointment and advise an over-the-counter analgesic.When patient experience moderate to severe pain after the first appointment , the clinican must review the diagnosis to ensure the tooth under treatment has been identified correctly as the source of pain . If so the periapical and pulpal status have to be reviewed to determine whether the patient has a inflammatory condition or acute infection 1 .

ENDODONTOLOGY
Pain associated with instrumentationIt can manifest as Acute periapical peridontitis or as Phoenix abscess. Acute periapical peridontitis occurs due to overinstrumentation ,extrusion of canal contents through the apex ,leaving the tooth in traumatic occlusion or placing too much of intracanal medicament
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MID TREATMENT FLAREUPS IN ENDODONTICS A DILEMMA

the working length, complete removal of the remaining vital pulp tissue and relieving the tooth from occlusion. Pain associated with pulpal necrosisStudies suggest that the incidence of flare-ups is higher with necrotic pulp tooth than in vital tooth.Tayfun Alacam et al in his study found that the incidence of flare-ups in tooth with necrotic pulp is 7.17%10 .The best method of managing the necrotic pulp is to establish accurate working length of tooth and complete instrumentation of root canal in the first appointment . Removal of debris from the canal should be the goal.When there is a flareup the tooth should be reopened , observe for the presence of pus .If there is pus in the canal without soft tissue swelling it indicates an acute abscess in early stages,in such cases pain is more severe .If only pain is present copious irrigation should be used and all debris are removed . An intracanal medicament is placed and resealed. If pain is present along with swelling then drainage should be established either through the apex of the tooth or the soft tissue .It as been advocated that antibiotics and analgesics such as NSAIDS be prescribed.The use of antibiotics alone without establishing drainage is not considered appropriate.The concept of leaving the canal open for drainage is controversial .Seltzer and Weine dont advocate it ,since exposure to oral flora serves no useful purpose and may actually cause subsequent flareups when additional treatment is undertaken
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. Absence of an apical stop and

presence of blood in the apical portion of the root canal usually indicates overinstrumentation 4. Treatment constitutes of reopening the tooth ,irrigation with a combination of irrigants such as sodium hypochlorite and chlorhexidine ,placement of a suitable intracanal medicament and relieving the tooth from occlusion. According to Seltzer, intracanal medication reduces the possibility of flareups due to the forcing of infected debris into the periapical tissues operative pain . Phoenix abscess is a difficult condition to deal with and it occurs subsequent to intial instrumentation of the canal with a pre existing chronic periapical lesion.The sign and symptoms mimic that of acute periapical abscess.Treatment consist of irrigation , debridement of the root canal and drainage either through the canal or trephination depending on the intensity of the pain .Antibiotics and analgesics can be prescribed. Pain subsequent to vital pulp extirpationMid treatment pain following complete removal of vital pulp is uncommon .When pain is intense it indicates incomplete removal of vital pulp tissue from the root canal and if the tooth becomes tender , the inflammation process has involved the periapical tissues .Treatment consist of reestablishing
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.Cohen advocated relieving

occlusion prior to root canal therapy to prevent post

PREVENTION OF FLAREUPS Flare ups causes a dilemma to the clinican when it is difficult for the patient to comprehend that they enter the office pain free, but experience a sustained increase or severe pain during or after

ENDODONTOLOGY
treatment.Certain precaution that are taken by a clinican can prevent flare-ups in most instances. Proper diagnosisIdentify the correct tooth causing pain. Ascertain whether tooth is vital or non vital. Identify if tooth is associated with periapical lesion. Determine correct working length.Radiographs. Apex locaters Complete extirpation of vital pulp. Irrigation Preferably with combination of irrigants such as sodium hypochlorite and chlorohexedine. Avoid filing too close to the radiographic apex. Preform apical trephination only if necessary. Reduce tooth from occlusion especially if apex is severely violated by
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MID TREATMENT FLAREUPS IN ENDODONTICS A DILEMMA

when the treatment rendered is of the highest standard.It is the duty of the clinican to explain it to the patient. Prompt and effective treatment of flareups is an essential part of the overall endodontic treatment . REFERENCES 1. 2. Gerald W Harrington,Eugene Watkin.Mid treatment Flareups.DCNA; 36:1992 409-423. Mor C, Rotstein I, Friedman S.Incidence of interappointment emergency associated with endodontic therapy.J Endod ;18:10,1992 509-511. Franklein S.Weine .Endodontic Therapy Fifth Edition,Mosby;203-237. Mahmoud Torabinejad , Richard E. Walton, Managing endodontic emergencies.JADA. 1999; 122:99 103. Jose F.Siqueira,Isabela N.Rocas,Amauri Favieri,Andreia G .Machado, Sergio M. Gahyva, Julio C.M.Oliveira. Incidence of post operative pain after intracanal procedures based on an antimicrobial strategy. J Endod.2002;28:457-460. P.Carrotte.Endodontic Part 3. Treatment of endodontic emergenies. BDJ .2004 ;197:299-305. Samuel Seltzer, Irving J. Naidorf . Flareups in endodontics.1 Etiological factors. J Endod .2004;30:476-481. Samuel Seltzer, Irving J. Naidorf . Flareups in endodontics. II. Therapeutic Measures. J Endod. 2004;30:482-488 Shephen Cohen.Pathways of the pulp. Mosby; 6th edition 1997:44-46.

overinstrumentation. Placement of intracanal medicaments. Prescription of mild analgesics and antibiotics whenever condition warrants it .

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CONCLUSION
The occurrence of mild pain and discomfort following endodontic treatment is common even

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10. Tayfun Alacam ,Ali Cemal Tinaz .Interappointent emergencies in teeth with necrotic pulps. J Endodon 2002;28:375-377.

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