ENDODONTIC FLARE UPS

THIS PRESENTATION DEALS WITH ENDODONTIC FLARE UPS IN BRIEF

1. Inter-appointment FLARE UPS Dr. Rohit Bansal

2. CONTENT INTRODUCTION CLINICAL CONDITIONS ASSOCIATED WITH FLARE UP AETIOLOGICAL FACTOR RISK FACTORS PREVENTIVE MEASURES MANAGEMENT CONCLUSION

3. INTRODUCTION

4. The inter-appointment flare-up is a true complication characterized by pain or swelling or both which commences within a few hours or days after root canal procedures and is of sufficient severity to require an unscheduled visit for emergency treatment. Studies have reported varying frequency of flare-ups ranging from 1.4 to 16% (Morse et al, 1986; Torabinejad et al,1988; Barnett and Tornstad , 1989; Trope,1990; Walton and Fouad , 1992; Harrington and Natkin , 1992; Imura and Zuolo , 1995; Sequiera et al, 2002).

5. It is important to know that flare-ups can occur even in the best of treatments but they usually happens due to improper treatment or when insufficient time is allowed for specific modalities in therapy. Weine American Association of Endodontics (AAE) defines a Flare-ups as “ An acute exacerbation of periradicular pathosis after initiation or in continuation of root canal treatment. ”

6. CLINICAL CONDITION ASSOCIATED WITH FLARE-UPS

7. 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.

8. 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.

9. PHOENIX ABSCESS It is a condition that occurs in teeth with necrotic pulps and apical lesions that 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.

10. 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.

11. AETIOLOGICAL FACTORS

12. MICROBIAL FACTORS Microorganisms in the root canal system take part in the pathogenesis of asymptomatic apical periodontitis and together with virulent factors they are able to enter periradicular tissues. Various species microorganisms proliferate in the apical area of the root canal. Microbial density in 5 mm of the apical root area may reach up to 10 6 bacteria, with predominating anaerobic microorganisms. Because of its complicated anatomy (accessory canals, apical deltas) and high bacteria density, the apical root canal area is said to be “dangerous” for the pathogenic bacteria, the host and the dentist.

13. Local adaptation syndrome In a case of asymptomatic apical periodontitis there is a balance between infectious micro flora and defensive mechanisms of human immune system in the periodontal tissues. During the chemomechanical preparation of the root canal after extrusion of infected debris from apical foramen to periradicular tissues, the inflammation is increased due to imbalance between microorganisms and human immune system caused by irritants getting in the apical periodontal tissues: vessels dilate, their permeability increases and inflammation cell chemotaxis begins.

14. Its intensity depends on the virulence of microorganisms and their amount in the periodontal tissues. Specificity in anaerobic infections is low and numerous combinations of normally low virulent oral bacterial species have the capacity to induce an acute infection in the root canal and periapical tissues. The low virulence is compensated by the increase in numbers by the growth and multiplication and by the poly-microbial nature of the primary endodontic infection.

15. The concomitant outgrowth of bacteria through apical foramen into the periradicular tissues cannot be prevented since the bacteria are in an active growing phase, sometimes even stimulated by host factors such as blood components and serum. If the root canal is not adequately chemo-mechanically prepared and between visits is not filled in with intracanal medicaments, the synergistic interaction of microbes in the root canal changes therefore activating virulence genes of pathogenic strains and that causes increased inflammatory response.

16. If aseptic rules are not followed during the endodontic treatment, insufficient patient mouth hygiene, working without rubber dam system, uncleaned carious tissue or old non-hermetic filling and secondary infection in the root canal can be a cause of post-operation pain and flare-up. Between visits microorganisms can also enter the root canal through non-hermetic temporary filling or in case of it falling out. After endodontic treatment infection might enter through temporary coronal filling left for longer than two weeks or through non-hermetic and cracked permanent coronal restoration.

17. MECHANICAL FACTOR During asymptomatic apical periodontitis root canal system of the tooth is infected therefore microorganisms are able to reach the apical third of the root canal, apical foramen and apical deltas. Chemo-mechanical preparation is one of the factors causing success of endodontic treatment.

18. During it pieces of debris, necrotic pulp masses, irrigative solutions and microorganisms from root canal access apical periodontal tissues and causes inflammation and postoperative pain that disturbs healing of periradicular tissues Despite chosen technique, during mechanical formation of root canal some amount of infected debris are extruded into the periodontal tissues

19. Studies show that minimal amount of extrusion of debris through the apical foramen is reached using crown-down technique with engine-driven Ni-Ti systems. Comparable study performed by Reddy and Hicks shows that cleaning canals with hand endodontic instruments using step-back technique, average amount of extrusion of debris into the periradicular tissues is 2.58 mg, while using NiTi rotational mechanical instruments with crown-down technique it is less than 0.5 mg.

20. While performing the chemomechanical preparation of root canal, it is essential to reach the end point of root canal which is the physiological apex of the root – the conjunction of cementum and dentine. The mechanical irritation of periradicular tissues is caused by over-instrumentation of the root canal and filling material extrusion through the apical foramen.

21. One of the iatrogenic factors causing the flare-up of the endodontic treatment is incorrectly measured working length of the root canal (WL). WL is a distance between the highest chosen point of the coronal part of the tooth and the conjunction of cementum and dentine called the physiological apex of the root which is the place where the chemomechanical preparation and filing of the root canal has to be finished.

22. Langeland estimated that the conjunction of cementum and dentine in the area of apex is localized in the distance of 0.5-3 mm from the visible anatomical apex of the root and moderately in the distance of 1-2 mm from the radiological apex of the root. The Brunton et al study results show that when the tip of endodontic instrument working part is withdrawn 1 mm from the radiological apex of the root, the physiological apex of the root is correctly localized only 16% of cases

23. If WL measured is too long, the apical constriction in the area of physiological apex of the root is destroyed, infected debris and filling material of the canal are extruded to the periodontal tissues, periodontal tissues is being mechanically stimulated and exudation and blood enters the canal, therefore microorganisms left in the root canal can multiply and proliferate in the beneficial conditions. If WL measured is too short, pulp remnants and bacteria are left in the apical third of the canal therefore success and prognosis of endodontic treatment is significantly decreased

24. Immature Teeth The apical constriction is not present when roots are not fully formed, also it might be resorbed due to inflammation of periradicular tissues or iatrogenically destroyed by incorrectly measured WL, recapitulation and drainage of apical abscess through the root canal.

25. Radiographic Method WL measuring by the dental radiograph depends to the condition of the root and periodontal tissues. According to Weine: -1 mm from the radiological apex of the root, if no alveolar bone and root resorption is detected; -1.5 mm from the radiological apex of the root, if alveolar bone resorption is detected; -2 mm if alveolar bone and root resorption is detected. Apex Locators

26. CHEMICAL FACTORS Irrigation solutions, intracanal medicaments, root fillings and substances, that are in their composition , used in endodontic treatment might be toxin therefore they cause chemical irritation and post-operation pain and sensitivity after entering the periradicular tissues. Pastes that are used with gutapercha for filling the root canal have different level of toxicity by the time they consolidate. The more filling from the root canal is extruded to periodontal tissues, the more intense inflammatory reaction is.

27. Some researches show that flare-ups are often after endodontic retreatment of teeth filled with resorcinol – formaldehyde resin. Pastes containing formaldehyde are cytotoxic, can cause necrosis after contacting live tissue and extruded into apical periodontal tissues initiate inflammation which causes pain and swelling. If formaldehyde is exuded as by-product during consolidation, periodontal tissues are damaged temporarily, though it is insoluble and might be only surgically eliminated.

28. RISK FACTORS

29. DEMOGRAPHIC FACTOR Studies on evaluating the probability and intensity of the pain occurring after treatment show that patient is not a significant factor in development of the fl are-up ElMubarak et al show opposing results, assessing that post-operative pain was more common among younger patients (18-33 years old). Flareup and post-operative sensitivity rarely occur in older patients due to the narrowing of the diameter of the root canal therefore less debris is extruded below the apex of the root and decreased blood flow in the alveolar bone resulting in weaker inflammatory response.

30. It is established that post-operative pain is more common among women than men comparing the sexual influence to the development of the fl are-up. Pain threshold and toleration depend on sexual hormones and their proportion during different stages of menstrual cycle.

31. GENERAL HEALTH STATUS Flare rate after endodontic treatment procedures is low in patients using systemic steroids as treatment for systemic diseases. Steroids suppress the acute inflammatory response during the chemomechanical preparation of the root canal when mechanical, chemical and/ or microbial factors irritate the apical periodontal tissue. Torabinejad et al points that patients tendency to allergies is associated with development of a flare-up after endodontical treatment, however Wolton and Fouad study disproves this hypothesis.

32. PULPAL AND PERIRADICULAR HEALTH Results of the studies defining the connection between the frequency of flare-up after endodontic treatment, pain intensity and condition of the pulp (viable or necrotic) are controversial. 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 endodontic treatment.

33. Bone destruction which is visible in dental radiograph is said to be a risk factor of post-operative pain and flare-up. Chance of a flare is 9.64 times higher when the bone destruction is detected. The connection between size of the bone destruction area and post-operative pain was defined by Genet et al: bone destruction of 5 mm and more is said to increase the probability of pain occurring

34. CLINICAL SYMPTOMS The next factor determining the post-operative pain is clinical symptoms that were before the treatment such as tooth pain when biting, chewing or by itself and sensitivity to percussion. 80% of patients who feel tooth pain before the beginning of the treatment usually feel the pain and after it. Pain enhances the stress level in the body and effects immune function in a negative way therefore increasing the probability of a fl are-up.

35. TOOTH CONCERNED Glennon et al study results show that temporary pain is felt 1.7 times more often when the canals of the molar teeth are treated compared to other teeth types. Higher frequency of pain in the lateral teeth type is determined by the complicated complex anatomy of the root canals and chemomechanical preparation.

36. SINGLE VS MULTIPLE VISIT RCT Primary endodontic treatment when the pulp is viable or endodontic retreatment when there are no visible clinical symptoms related to the changes in periradicular tissues, chemomechanical preparation and filling of the root canal is done by one visit. If the pulp is necrotic and there are radiological changes in periradicular tissues, endodontic treatment is done by two visits: during the first visit the root canal is prepared chemomechanically , filled with intracanal medicaments for maximal root canal disinfection and the crown is hermetically sealed with temporary filling while during the second visit the filling of the root canal is performed. Studies show that there is no direct link between manifestation of the post-operative pain and amount of the visits during the endodontic treatment. However some studies show controversial results, i.e. that pain is more common after one visit endodontic treatment. Yold et al study summarizes that fl are-up rate is 4,9 times higher after one visit endodontic retreatment compared to retreatment by two – visits.

37. Studies show that there is no direct link between manifestation of the post-operative pain and amount of the visits during the endodontic treatment. However some studies show controversial results, i.e. that pain is more common after one visit endodontic treatment. Yold et al study summarizes that fl are-up rate is 4.9 times higher after one visit endodontic retreatment compared to retreatment by two – visits.

38. INTRA-CANAL MEDICAMENT Antimicrobial intracanal medicaments are essential when controlling the endodontic infection due to the insufficient amount of microorganisms that are eliminated during the chemomechanical preparation of the root canal. Harrison et al studies shows contrary that antimicrobial intracanal medicaments reduce postoperative pain caused by microorganisms that are left in the root canal and secondary infection.

39. PREVENTION OF FLARE UPS

40. 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 treatment. Certain precaution that are taken by a clinican can prevent flare-ups in most instances.

41. PRECAUTIONS Proper diagnosis- Identify 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 .

42. Avoid filing too close to the radiographic apex. Perform apical trephination only if necessary. Reduce tooth from occlusion especially if apex is severely violated by overinstrumentation . Placement of intracanal medicaments. Prescription of mild analgesics and antibiotics whenever condition warrants it .

43. MANAGEMENT

44. PRE-MEDICATION OF ROOT CANAL Medication of pulp chamber & root canal has been tried to reduce flare ups due to forcing of infected debris to periradicular area in Ist appointment before instrumentation. But Pearson et al (20) found out no significant difference in acute exacerbation episodes in premedicated root canals prior to instrumentation in comparison to completely instrumented canals without any premedication.

45. ESTABLISHING A DRAINAGE Inflammatory edema results due to chemical mediators whereas suppuration is caused by infections. Drainage relieves pain and swelling dramatically in suppuration cases, by removing intracanal dressing and keeping the access cavity open. Sometimes discharge does not drain, in those cases ,soft tissue incision in the most dependent part of swelling is advocated. After cessation of discharging exudate , the access cavity should be temporarily closed again, since it does not serve any purpose to leave root canal open to oral microbial flora.

46. RELIEF OF OCCLUSION Cohen suggested occlusal relief prior to endododontic therapy whereas Ingle, Weine and Grossman are of the opinion that occlusion should be relieved prior to root canal treatment in teeth which are painful to start with. Dorn et al advocated reduction of occlusion whenever the painful symptoms appear.

47. INTRACANAL MEDICAMENT Most of the intracanal medicaments like calcium hydroxide formocresol , eugenol , camphorated monochlorophenol and iodine potassium iodide have been studied. None appeared to be particularly effective, nor was there any significant relationship between inter-appointment pain and the type of therapy used.

48. IRRIGATION SOLUTION Harrison et al found out that patients whose canals were not irrigated or irrigated with normal saline experienced more pain in comparison to those patients whose canals were irrigated with 5% sodium hypochlorite and 3% hydrogen peroxide or even 0.5% sodium hypochlorite alone, provided irrigating solution was not pushed to periapical region. However pain of endodontic origin is multifactorial and cannot be attributed to irrigant alone.

49. CORTICOSTEROIDS Moskow et al. have reported that corticosteroids placed in root canal control pain successfully. The anti-inflammatory activity of corticosteroids is based partly due to reduction of lysosomal release and partly due to inhibition of free arachidonic acid release from the phospholipids of cell membrane. The main disadvantage of using corticosteroids in endodontic therapy is their interference with phagocytosis and protein synthesis leading to rampant infection & repair impairment.

50. Systemic corticosteroids reduce pain & swelling in cases of single sitting flare ups. It was demonstrated by Marshall and Walton in their study by administering 4mg dexamethasone intramuscularly which significantly reduced pain & swelling within 4 hrs after single sitting endodontic therapy.

51. NSAIDS Non-narcotic analgesics like aspirin is good for mild to moderate pain whereas narcotic analgesics like pentazocine , codeine, morphine are potent to control severe pain. Non -steroidal anti-inflammatory drugs (NSAID) like ibuprofen, fenoprofen , naproxen etc are potent antiinflammatory agents and are helpful in reduction of swelling & pain.

52. SYSTEMIC ANTIBIOTICS Antibiotics are widely used locally and systemically in endodontic cases, but their role in pain reduction is limited. However systemic antibiotics have a definite role in situations where patient exhibits cellulitis , malaise, fever and toxemia. An appropriate antibiotic to control root canal infections should depend upon culture sensitivity testing. There are no specific studies regarding antibiotics role in reducing or eliminating pain in acute exacerbations during endodontic therapy.

53. PATIENT COUNSELLING Detailing the complete procedure, expected benefits and possible pain responses of root canal treatment to the patient, will help to reduce the patient’s anxiety, apprehension & tension because one prefers to know what will happen if he or she undergoes particular procedure. Postoperative instructions like proper scheduling of medicines , application of ice, following the appropriate regimen of taking medicines etc will elevate the patient’s pain threshold.

54. CONCLUSION

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

56. CLASSIFICATION OF ENDODONTIC EMERGENCY Pre Treatment Endodontic Emergencies: 1. Dentin Hypersensitivity 2. Pain of Pulpal Origin: Reversible Pulpitis Irreversible Pulpitis 3. Acute Apical Periodontitis 4. Acute Periapical Abscess 5. Traumatic Injury: Ellis Fractures 6. Cracked Tooth Syndrome

57. Intra Appointment or Under Treatment: 1. Mid treatment Flare ups 2. Exposure of pulp 3. Fracture of Tooth 4. Recently placed restoration – Trauma form Occlusion due to high points 5. Periodontal treatment

58. Post Endodontic Treatment: 1. Over Instrumentation while doing BMP 2. Overextended filling during Obturation 3. Under filling during obturation 4. Root Fracture 5. High points during Restoration

59. DENTINAL HYPERSENSITIVITY The presence of short and sharp pain occurring in presence of external stimulus thermal, chemical or tactile. This can be caused due to exposure of the dentinal tubules during endodontic procedure on the adjacent tooth It should be treated by identifying the location and by using Desensitizer over the tooth surface affected.

60. Cracked Tooth Syndrome The presence of fracture lines not deep but which involve the enamel and dentin causing pain in the pulp and periodontal involvement. This can be caused by biting on any hard substance or in presence of any para functional habits in case of Trauma. The patient is asked to bite on any substance and if patient complains of Pain during release of pressure it is a classic sign of cracked tooth syndrome. Immediate relief will be by de occluding the tooth and permanent solution can be by Endodontic treatment or Extraction based on the involvement of Fracture line.

61. ACUTE PERIAPICAL ABSCESS The presence of an abscess in the apical portion of the tooth caused due to the inflammation of the periodontal ligament resulting from pulpal infection or Trauma to the affected tooth. The treatment plan should be incision and drainage of the abscess to give immediate relief and Endodontic treatment.

62. Tissue or Air Emphysema It is the collection of Gas in the Tissue Spaces or the facial planes which is seen during Periapical surgery or Endodontic therapy where Air is forced towards the tissue either with an Air-rotor or the Air pump.

63. Hyper Occlusion or High Point Presence of excess restoration in between appointments can also lead to severe pain in less than 2 hours of the restoration which should be trimmed and high points removed to relieve the patient.

64. THANK YOU