Flare Up in Endodontics
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About This Presentation
Flare up is defined as pain or discomfort or swelling that requires an unscheduled patient visit
and active intervention by the dentist.
Slide Content
GOOD
MORNING
MORNING
Flare Up in
Endodontics
An example of chaos: A basic
overview and an evidence
based update
Endodontics
An example of chaos: A basic
overview and an evidence
based update
TABLE OF CONTENTS
Basic treatment
protocols
following the flare
up
MANAGEMENTETIOLOGYINTRODUCTIONPREVENTION
020301 04
Brief introduction
to the concept
Incidence,
Criteria, Risk
Factors and
Causes for Flare
Up
How to avoid the
mishap
Basic treatment
protocols
following the flare
up
MANAGEMENTETIOLOGYINTRODUCTIONPREVENTION
020301 04
Brief introduction
to the concept
Incidence,
Criteria, Risk
Factors and
Causes for Flare
Up
How to avoid the
mishap
INTRODUCTION
"Happiness is your dentist telling you it won't hurt and
then having him catch his hand in the drill."
~ Johnny Carson
An ongoing and frequently vexing problem in
endodontics is the development of pain and
swelling during or after endodontic therapy.
An inter-appointment flare-up is an unhappy
event.
After an appointment, the patient calls or returns to
the dentist‘s office in distress.
This is upsettingto both the patient and the
dentist and is disruptive to a busy practice.
"Happiness is your dentist telling you it won't hurt and
then having him catch his hand in the drill."
~ Johnny Carson
An ongoing and frequently vexing problem in
endodontics is the development of pain and
swelling during or after endodontic therapy.
An inter-appointment flare-up is an unhappy
event.
After an appointment, the patient calls or returns to
the dentist‘s office in distress.
This is upsettingto both the patient and the
dentist and is disruptive to a busy practice.
Endodontic Inter
appointment
emergency
Endodontic cellulitis
exacerbation
phenomenon
S
Y
N
O
N
Y
M
Inter-appointment flare up
Post-endodontic flare-up
appointment
emergency
Endodontic cellulitis
exacerbation
phenomenon
S
Y
N
O
N
Y
M
Inter-appointment flare up
Post-endodontic flare-up
DEFINITIONS
qFlareupisdefinedasanunscheduledemergencyappointmentnecessitatedbypain&swelling
combinedorbyeitheralone.
qFlareupisdefinedaspainordiscomfortorswellingthatrequiresanunscheduledpatientvisit
andactiveinterventionbythedentist.
qFlareupisanacuteexacerbationofanasymptomaticpulpaland/orperiradicularpathosisafter
theinitiationorcontinuationofrootcanaltreatment.
qFlare-up is moderate-to-severe postoperative pain or moderate to severe swelling that begins
12 to 48 hours after treatment and lasts at least 48 hours.
Pickenpaughet al. (2001)
AAE (1998)
Walton&Foad(1992)
Morse(1990)
qFlareupisdefinedasanunscheduledemergencyappointmentnecessitatedbypain&swelling
combinedorbyeitheralone.
qFlareupisdefinedaspainordiscomfortorswellingthatrequiresanunscheduledpatientvisit
andactiveinterventionbythedentist.
qFlareupisanacuteexacerbationofanasymptomaticpulpaland/orperiradicularpathosisafter
theinitiationorcontinuationofrootcanaltreatment.
qFlare-up is moderate-to-severe postoperative pain or moderate to severe swelling that begins
12 to 48 hours after treatment and lasts at least 48 hours.
Pickenpaughet al. (2001)
AAE (1998)
Walton&Foad(1992)
Morse(1990)
IntEndodJ 2003;36:453-63.
A flare-up can be defined as pain and/or swelling of
the facial soft tissues and the oral mucosa in the area
of the endodontically treated tooth that occur within
a few hours or a few days following the root canal
treatment, when clinical symptoms (tooth pain when
biting, chewing or by itself) are strongly expressed
and the patient visits a health care institution sooner
than scheduled.
A flare-up can be defined as pain and/or swelling of
the facial soft tissues and the oral mucosa in the area
of the endodontically treated tooth that occur within
a few hours or a few days following the root canal
treatment, when clinical symptoms (tooth pain when
biting, chewing or by itself) are strongly expressed
and the patient visits a health care institution sooner
than scheduled.
Inter-appointment Flare Up Criteria
üWithinafewhourstoafewdaysafteranendodonticprocedure,a
patienthassignificantincreaseinpainorswellingoracombinationofthe
two.
üTheproblemisofsuchseveritythatthepatientinitiatescontactwiththe
dentist.
üThedentistdeterminesthattheproblemisofsuchsignificancethatthe
patientmustcomeforanun-scheduledvisit.
üAtthevisit,activetreatmentisrendered.Thatmayincludeincisionfor
drainage,canaldebridement,openingthetooth,prescribingappropriate
medications,ordoingwhateverisnecessarytoresolvetheproblem.
üWithinafewhourstoafewdaysafteranendodonticprocedure,a
patienthassignificantincreaseinpainorswellingoracombinationofthe
two.
üTheproblemisofsuchseveritythatthepatientinitiatescontactwiththe
dentist.
üThedentistdeterminesthattheproblemisofsuchsignificancethatthe
patientmustcomeforanun-scheduledvisit.
üAtthevisit,activetreatmentisrendered.Thatmayincludeincisionfor
drainage,canaldebridement,openingthetooth,prescribingappropriate
medications,ordoingwhateverisnecessarytoresolvetheproblem.
MEASUREMENT
ØPainisasubjectiveperceptionthatisdifficulttoquantifylet
alonecomparebetweendifferentindividualsandassuchisa
problematicmarkerfordetectingflare-up.
ØInanefforttoquantifyandmeasurepain,thevisualanalogue
scale(VAS)hasbeenproposedbySeymouretal.
ØThisisamathematicalprogressionfrom0to100,0beingno
painand100beingthemostseverepainimaginable.
ØPainisasubjectiveperceptionthatisdifficulttoquantifylet
alonecomparebetweendifferentindividualsandassuchisa
problematicmarkerfordetectingflare-up.
ØInanefforttoquantifyandmeasurepain,thevisualanalogue
scale(VAS)hasbeenproposedbySeymouretal.
ØThisisamathematicalprogressionfrom0to100,0beingno
painand100beingthemostseverepainimaginable.
A flare-up is defined as an
increase of 20 or more points on
the VAS for a given tooth, within
the periods of 4 h and 24 h
after the initial treatment
appointment.
Ernest H. Ehrmann,HaroldH. Messer, Robert M. Clark,
AustEndodJ 2007; 33: 119–130
increase of 20 or more points on
the VAS for a given tooth, within
the periods of 4 h and 24 h
after the initial treatment
appointment.
Ernest H. Ehrmann,HaroldH. Messer, Robert M. Clark,
AustEndodJ 2007; 33: 119–130
‘Flare-up Index’ by RIMMER
qThisextendsfrom0to45andencompassesninevariables.These
includenotonlydifferentdegreesofpainbutalsoswellingandtrismus.
qThisindexhasnotfoundacceptanceasitisaltogethertoocomplicated.
qFlareupindexattemptstoshowtheeffectivenessofthetreatmentor
infectivenessofthetreatment.
qThisextendsfrom0to45andencompassesninevariables.These
includenotonlydifferentdegreesofpainbutalsoswellingandtrismus.
qThisindexhasnotfoundacceptanceasitisaltogethertoocomplicated.
qFlareupindexattemptstoshowtheeffectivenessofthetreatmentor
infectivenessofthetreatment.
QuestionnaireFor range
Existence of pain after the first visit0 -1
No of days with pain X pain degree / day0 -21
How many days were analgesic taken?0 -7
How many times emergency treatment was needed?0 -7
Does pain still exist in what degree?0 -3
Are Analgesic still being taken?0 -1
Did Swelling appear and what degree? 0 -3
Existence of limitation of mouth opening0 -1
Systemic involvement (temp, fatigue)0 -1
TOTAL 0-45
Existence of pain after the first visit0 -1
No of days with pain X pain degree / day0 -21
How many days were analgesic taken?0 -7
How many times emergency treatment was needed?0 -7
Does pain still exist in what degree?0 -3
Are Analgesic still being taken?0 -1
Did Swelling appear and what degree? 0 -3
Existence of limitation of mouth opening0 -1
Systemic involvement (temp, fatigue)0 -1
TOTAL 0-45
INCIDENCE
•Theoverallincidenceofflare-
upsislow.
•Rangesfrom1.5%to5.5%
•Increasesindirectrelationship
totheseverityofthepatient’s
pre-operativepathosis
andsigns/symptoms.
Pulp necrosis and
acute apical abscess.
Present with more
severe pain and
swelling
Vital pulp without
periapical pathosis.
Walton R, Fouad A. Endodontic interappointment flare-ups. a prospective
study of incidence and related factors. J Endod1992: 18: 172–177.
•Theoverallincidenceofflare-
upsislow.
•Rangesfrom1.5%to5.5%
•Increasesindirectrelationship
totheseverityofthepatient’s
pre-operativepathosis
andsigns/symptoms.
Pulp necrosis and
acute apical abscess.
Present with more
severe pain and
swelling
Vital pulp without
periapical pathosis.
Walton R, Fouad A. Endodontic interappointment flare-ups. a prospective
study of incidence and related factors. J Endod1992: 18: 172–177.
AuthorResult
Morse reported (1987) 2.2%
Walton reported (1992)3.17%
Mura reported (1995)1.58%
Kakahurareported ( 2001) 1.23%
Pickenpaugh(2001) 1.58%-9%
Morse reported (1987) 2.2%
Walton reported (1992)3.17%
Mura reported (1995)1.58%
Kakahurareported ( 2001) 1.23%
Pickenpaugh(2001) 1.58%-9%
Risk Factors For Developing A Flare-Up
1.Patient Related (Demographic)
2.Pulpal/Periapical Diagnosis
3.Presenting Signs And Symptoms
4.Treatment Procedures.
1.Patient Related (Demographic)
2.Pulpal/Periapical Diagnosis
3.Presenting Signs And Symptoms
4.Treatment Procedures.
WHY?
UGstudentpatientsexperienced
fewerflareupsthanfacultyor
PG.WHY?Discuss.
Walton R, Fouad A. Endodontic Interappointment flareups.aprospective study
of incidence and related factors. J Endod1992: 18: 172–177.
UGstudentpatientsexperienced
fewerflareupsthanfacultyor
PG.WHY?Discuss.
Walton R, Fouad A. Endodontic Interappointment flareups.aprospective study
of incidence and related factors. J Endod1992: 18: 172–177.
Risk Factors For Developing A Post
Endodontic Flare-up
Patient Factors
•Age/Gender
•Pulpal Necrosis
•Acute Apical Abscess
•Large Periapical Radiolucency
•Acute Apical Periodontitis
Endodontic Flare-up
Patient Factors
•Age/Gender
•Pulpal Necrosis
•Acute Apical Abscess
•Large Periapical Radiolucency
•Acute Apical Periodontitis
Age
Agedoesnotseemtobeasignificantfactor.
Severalinvestigationshavefailedtofindanyevidenceindicatingthatageisariskfactor
fordevelopmentofflare-ups.
ImuraN, ZuoloM. Factors associated with endodontic flare-ups: a prospective study. Int
EndodJ 1995: 28: 261–265.
Walton R, Fouad A. Endodontic Interappointment flareups.aprospective study of incidence
and related factors. J Endod1992: 18: 172–177.
Agedoesnotseemtobeasignificantfactor.
Severalinvestigationshavefailedtofindanyevidenceindicatingthatageisariskfactor
fordevelopmentofflare-ups.
ImuraN, ZuoloM. Factors associated with endodontic flare-ups: a prospective study. Int
EndodJ 1995: 28: 261–265.
Walton R, Fouad A. Endodontic Interappointment flareups.aprospective study of incidence
and related factors. J Endod1992: 18: 172–177.
Patients in the age group of 40-59 years had the most
flare ups and those under the age of 20 had the least.
TorabinejadM, Kettering J, McGraw J, Cummings R,DwyerT, Tobias T. Factors
associated with endodontic interappointment emergencies of teeth with necrotic
pulps.J Endod1988: 14: 261–266.
flare ups and those under the age of 20 had the least.
TorabinejadM, Kettering J, McGraw J, Cummings R,DwyerT, Tobias T. Factors
associated with endodontic interappointment emergencies of teeth with necrotic
pulps.J Endod1988: 14: 261–266.
Gender
Several studies found
higher numbers of
post-treatment pain
and flare-ups in
females.
Genet J, Hart A, WesselinkP, ThodenVan VelzenS. Preoperative and operative factors
associated with pain after the first endodontic visit. IntEndodJ 1987: 20: 53–64.
TorabinejadM, Kettering J, McGraw J, Cummings R,DwyerT, Tobias T. Factors associated
with endodontic interappointment emergencies of teeth with necrotic pulps.J Endod1988: 14:
261–266.
Several studies found
higher numbers of
post-treatment pain
and flare-ups in
females.
Genet J, Hart A, WesselinkP, ThodenVan VelzenS. Preoperative and operative factors
associated with pain after the first endodontic visit. IntEndodJ 1987: 20: 53–64.
TorabinejadM, Kettering J, McGraw J, Cummings R,DwyerT, Tobias T. Factors associated
with endodontic interappointment emergencies of teeth with necrotic pulps.J Endod1988: 14:
261–266.
MorCetalsuggestedthatthe
incidenceofinter-appointment
emergencyassociatedwith
endodontictherapywas4.2%
andunrelatedtopatients
sex,ageorthetooth
location.
MorC, RotsteinI, Friedman S.Incidenceof interappointment emergency
associated with endodontic therapy.JEndod;18:10,1992 509-511
incidenceofinter-appointment
emergencyassociatedwith
endodontictherapywas4.2%
andunrelatedtopatients
sex,ageorthetooth
location.
MorC, RotsteinI, Friedman S.Incidenceof interappointment emergency
associated with endodontic therapy.JEndod;18:10,1992 509-511
Systemic Conditions
This aspect has been largely
uninvestigated.
A study reported that allergies were
significantly related to flare-ups.
Although this could not be replicated in
another study BY WALTON.
TorabinejadM, Kettering J, McGraw J, Cummings R,DwyerT, Tobias T. Factors
associated with endodontic interappointment emergencies of teeth with necrotic
pulps.J Endod1988: 14: 261–266.
This aspect has been largely
uninvestigated.
A study reported that allergies were
significantly related to flare-ups.
Although this could not be replicated in
another study BY WALTON.
TorabinejadM, Kettering J, McGraw J, Cummings R,DwyerT, Tobias T. Factors
associated with endodontic interappointment emergencies of teeth with necrotic
pulps.J Endod1988: 14: 261–266.
Pulp and Periapical Status
Itisgenerallyacceptedthattheflare-uprateaftertheextirpation
ofavitalpulpiseithernon-existentorverylow,evenifthepulps
werepainfulbeforeinstrumentation.
Negmet al
Vital Pulp Few Flare-ups
Pulpal Necrosis Higher Incidence Of Flare-ups.
Itisgenerallyacceptedthattheflare-uprateaftertheextirpation
ofavitalpulpiseithernon-existentorverylow,evenifthepulps
werepainfulbeforeinstrumentation.
Negmet al
Vital Pulp Few Flare-ups
Pulpal Necrosis Higher Incidence Of Flare-ups.
RICHARD E. WALTON
Interappointment flare-ups:incidence, related factors,prevention, and management
ENDODONTIC TOPICS 2002.1601-1538
As the severity of pulp pathosisincreases, patients are more likely to
experience a flare-up.
Interappointment flare-ups:incidence, related factors,prevention, and management
ENDODONTIC TOPICS 2002.1601-1538
As the severity of pulp pathosisincreases, patients are more likely to
experience a flare-up.
RICHARD E. WALTON
Interappointment flare-ups:incidence, related factors,prevention, and
management
ENDODONTIC TOPICS 2002.1601-1538
Interappointment flare-ups:incidence, related factors,prevention, and
management
ENDODONTIC TOPICS 2002.1601-1538
Theperiapicaldiagnosisofacuteapical
abscessandacuteapicalperiodontitis,both
painfulentities,havebeenshowninmoststudies
toalsoresultinasignificantlyhigherflare-up
rate
Inaddition,theradiographicpresenceofa
periapicallesion,particularlylargerlesions,
alsoservesasariskfactorfordevelopmentof
flare-ups.
>16-22mm
abscessandacuteapicalperiodontitis,both
painfulentities,havebeenshowninmoststudies
toalsoresultinasignificantlyhigherflare-up
rate
Inaddition,theradiographicpresenceofa
periapicallesion,particularlylargerlesions,
alsoservesasariskfactorfordevelopmentof
flare-ups.
>16-22mm
Factors Related To A ReducedRisk For
Developing A Post-endodontic Flare-up
Patient factors Treatment factor
Vital PulpObturation
Sinus Tract
Developing A Post-endodontic Flare-up
Patient factors Treatment factor
Vital PulpObturation
Sinus Tract
SINUS TRACT
Interestingly, the presence of
a sinus tract virtually ensures
that a flare-up will not
occur.
The tract functions as a RELIEF VALVE ~
releasing pressure -reducing tissue levels of
inflammatory mediators -preventing the sudden
increase in pain.
Interestingly, the presence of
a sinus tract virtually ensures
that a flare-up will not
occur.
The tract functions as a RELIEF VALVE ~
releasing pressure -reducing tissue levels of
inflammatory mediators -preventing the sudden
increase in pain.
Treatment Plan
•Whetherthecaseinvolves
conventionalvs.re-treatment
•Ifthedentistchoosessingleor
multiplevisits
•Performspartialvs.complete
debridement
•Treatmentprocedure
•Whetherthecaseinvolves
conventionalvs.re-treatment
•Ifthedentistchoosessingleor
multiplevisits
•Performspartialvs.complete
debridement
•Treatmentprocedure
1.Rotarymotionseemstonegativelyimpactthepostoperativepainafterrootcanaltreatment.
2.Overall,rotarymotioncausesmorecasesofpostoperativepain,regardlessofpainintensity
andtime.
3.Reciprocatingmotionhasbeendemonstratedtobringaboutlesserbacterialextrusion
comparedtomultifilerotarysystemsandconsequently,thereisaminorfrequencyofpain.
4.Theassociationofdebrisextrusionandincreaseofbacterialcoloniesintheconventional
multi-filerotarysystemisgreaterwhencomparedtothereciprocatingsingle-file
instrumentation.
2.Overall,rotarymotioncausesmorecasesofpostoperativepain,regardlessofpainintensity
andtime.
3.Reciprocatingmotionhasbeendemonstratedtobringaboutlesserbacterialextrusion
comparedtomultifilerotarysystemsandconsequently,thereisaminorfrequencyofpain.
4.Theassociationofdebrisextrusionandincreaseofbacterialcoloniesintheconventional
multi-filerotarysystemisgreaterwhencomparedtothereciprocatingsingle-file
instrumentation.
The available evidence indicated that maintaining AP
(1)Did not increase postoperative pain in teeth with nonvital pulp
(2)Did not increase postoperative pain in teeth with vital pulp
(3)Did not cause (0%) flare-ups
(4)Maintaining AP did not increase analgesic use
(5)Did not increase postoperative pain when a single-visit or 2-visit root
canal treatment approach was used
JOE —Volume -, Number -, -2018
(1)Did not increase postoperative pain in teeth with nonvital pulp
(2)Did not increase postoperative pain in teeth with vital pulp
(3)Did not cause (0%) flare-ups
(4)Maintaining AP did not increase analgesic use
(5)Did not increase postoperative pain when a single-visit or 2-visit root
canal treatment approach was used
JOE —Volume -, Number -, -2018
Re-treatment
•Thereisnouniversalagreementastowhether
retreatmentresultsinahigherincidenceof
post-treatmentpainormoreflare-upsthan
conventionalrootcanaltreatment
•Most studies indicate that there is no
difference.
MorC, RotsteinJ Endod1992: 18: 509–511.
MattscheckD, Law A, Noblett W. Retreatment versus initial root canal
treatment: factors affecting post-treatmentpain. Oral SurgOral Med Oral Path
Oral RadiolEndod2001: 92: 321–324.
•Thereisnouniversalagreementastowhether
retreatmentresultsinahigherincidenceof
post-treatmentpainormoreflare-upsthan
conventionalrootcanaltreatment
•Most studies indicate that there is no
difference.
MorC, RotsteinJ Endod1992: 18: 509–511.
MattscheckD, Law A, Noblett W. Retreatment versus initial root canal
treatment: factors affecting post-treatmentpain. Oral SurgOral Med Oral Path
Oral RadiolEndod2001: 92: 321–324.
Studyfoundhigh
incidenceofflareup
inretreatmentcases
13.6%
Trope . IEJ 1991.
incidenceofflareup
inretreatmentcases
13.6%
Trope . IEJ 1991.
Number of Visits
Thereisnoconsistencyintheliterature;somestudiesshow
numbersofvisitstobeafactor.
Whereasothersshownodifference,whencombiningand
consideringalldiagnoses,signsandsymptoms.
ImuraN, ZuoloM. Factors associated with endodontic flare-ups: a prospective
study. IntEndodJ 1995: 28: 261–265.
Eleazer P, Eleazer K. Flare-up rate in pulpallynecrotic molars in one-visit versus
two-visit endodontic treatment. J Endod1998: 24: 614–616.
Thereisnoconsistencyintheliterature;somestudiesshow
numbersofvisitstobeafactor.
Whereasothersshownodifference,whencombiningand
consideringalldiagnoses,signsandsymptoms.
ImuraN, ZuoloM. Factors associated with endodontic flare-ups: a prospective
study. IntEndodJ 1995: 28: 261–265.
Eleazer P, Eleazer K. Flare-up rate in pulpallynecrotic molars in one-visit versus
two-visit endodontic treatment. J Endod1998: 24: 614–616.
Compellingevidence
indicatingasignificantly
differentprevalenceof
postoperativepain/flare-up
ofeithersingle-ormultiple-
visitrootcanaltreatmentis
lacking.
Sathorn C, ParashosP, Messer H. The prevalence of postoperative pain and
flare-up in single-and multiple-visit endodontic treatment: a systematic review.
International Endodontic Journal, 41, 91–99, 2008.
indicatingasignificantly
differentprevalenceof
postoperativepain/flare-up
ofeithersingle-ormultiple-
visitrootcanaltreatmentis
lacking.
Sathorn C, ParashosP, Messer H. The prevalence of postoperative pain and
flare-up in single-and multiple-visit endodontic treatment: a systematic review.
International Endodontic Journal, 41, 91–99, 2008.
Majorityofendodontistshavefoundthatsinglevisitendodontics
doesnotcausemoreflare-upsthanmulti-visittreatments.
Basedonclinicalandscientificprinciples,thepractitionermust
decideifrootcanaltreatmentistobecompletedinoneormore
appointmentsaccordingtoeachspecificcase.
doesnotcausemoreflare-upsthanmulti-visittreatments.
Basedonclinicalandscientificprinciples,thepractitionermust
decideifrootcanaltreatmentistobecompletedinoneormore
appointmentsaccordingtoeachspecificcase.
ØTeethwithoutapicalperiodontitisdidnotflare-up
andmaybetreatedinasinglevisit
ØTeethwithapicalperiodontitisbutnoprevious
roottreatmentcanbetreatedinasinglevisit,
withalowprobabilityofaflare-upoccurring
ØTeethwithapicalperiodontitiswhichneed
retreatment,theflare-upratewashighestand
single-visitroottreatmentwouldbeinadvisable
M. TROPE
andmaybetreatedinasinglevisit
ØTeethwithapicalperiodontitisbutnoprevious
roottreatmentcanbetreatedinasinglevisit,
withalowprobabilityofaflare-upoccurring
ØTeethwithapicalperiodontitiswhichneed
retreatment,theflare-upratewashighestand
single-visitroottreatmentwouldbeinadvisable
M. TROPE
Debridement
Incompletedebridementhasbeen
traditionallyassumedtobeacause
offlare-ups.
However,studieshaveshownthis
factortobeunrelatedtotherisk
ofdevelopingaflare-up
BalabanF, Skidmore A, Griffin J. Acute exacerbations followinginitialtreatment
of necrotic pulps. J Endod1984:10: 78–81.
Incompletedebridementhasbeen
traditionallyassumedtobeacause
offlare-ups.
However,studieshaveshownthis
factortobeunrelatedtotherisk
ofdevelopingaflare-up
BalabanF, Skidmore A, Griffin J. Acute exacerbations followinginitialtreatment
of necrotic pulps. J Endod1984:10: 78–81.
POLL TIME
1.How many of you feel that prophylactic antibiotics cause
reduction in the development of inter appointment flair up?
•Yes: OF Course. Prophylactic antibiotics should be given
routinely.
•Nope:It has no effect on the development of pain.
•I don’t know: You tell me, you’re taking this seminar.
1.How many of you feel that prophylactic antibiotics cause
reduction in the development of inter appointment flair up?
•Yes: OF Course. Prophylactic antibiotics should be given
routinely.
•Nope:It has no effect on the development of pain.
•I don’t know: You tell me, you’re taking this seminar.
Therapeutics
Studies showed prophylactic
antibiotics to be unrelated to
flare-ups .
Anotherstudyreportedthat
patientstakingantibiotics
weremorelikelytohavea
flare-upthanthosethatwere
not. PickenpaughL, Reader A, Beck M, Meyers W, Peterson L. Effect of prophylactic amoxicillin on
endodontic flare-up in asymptomatic, necrotic teeth. J Endod2001: 27: 53–56.
Walton R, ChiappenelliJ. Prophylactic penicillin; effect on post treatment symptoms following root
canal treatment of asymptomatic periapical pathosis. J Endod1993: 19: 466–470.
Studies showed prophylactic
antibiotics to be unrelated to
flare-ups .
Anotherstudyreportedthat
patientstakingantibiotics
weremorelikelytohavea
flare-upthanthosethatwere
not. PickenpaughL, Reader A, Beck M, Meyers W, Peterson L. Effect of prophylactic amoxicillin on
endodontic flare-up in asymptomatic, necrotic teeth. J Endod2001: 27: 53–56.
Walton R, ChiappenelliJ. Prophylactic penicillin; effect on post treatment symptoms following root
canal treatment of asymptomatic periapical pathosis. J Endod1993: 19: 466–470.
The outcome showed that prednisolone resulted in a statistically significant
reduction in post endodontic pain at 6, 12, and 24 hours.
30mg/30
mins before
the
procedure.
reduction in post endodontic pain at 6, 12, and 24 hours.
30mg/30
mins before
the
procedure.
Analgesics
1.Thereisgoodevidencethatpre-treatmentanalgesicsminimize
interandposttreatmentpain.
2.Pre-treatmentpainandanxietycontrolmayreduceincidenceof
flare-ups
1.Thereisgoodevidencethatpre-treatmentanalgesicsminimize
interandposttreatmentpain.
2.Pre-treatmentpainandanxietycontrolmayreduceincidenceof
flare-ups
CAUSATIVE FACTORS
Chemical
Microbial
Mechanical
Chemical
Microbial
Mechanical
Mechanical Injury
1.Inadequate Debridement
2.Over Instrumentation
3.Periapical Extrusion Of Debris
4.Incorrectly Measured Working
Length
1.Inadequate Debridement
2.Over Instrumentation
3.Periapical Extrusion Of Debris
4.Incorrectly Measured Working
Length
Irrigating Solutions
Intracanal Medicaments
Over Extended Root Fillings
Chemical Injury
Intracanal Medicaments
Over Extended Root Fillings
Chemical Injury
ETIOLOGY
1.Alteration Of The Local Adaptation Syndrome
2.Changes In Periapical Tissue Pressure
3.Microbial Factors
4.Effects Of Chemical Mediators
5.Changes In Cyclic Nucleotides
6.Immunological Phenomena
7.Various Psychological Factors
SELTZER .NAIDORF.FLARE UPS IN
ENDODONTICS:ETIOLOGIC FACTORS.JOE 2004
1.Alteration Of The Local Adaptation Syndrome
2.Changes In Periapical Tissue Pressure
3.Microbial Factors
4.Effects Of Chemical Mediators
5.Changes In Cyclic Nucleotides
6.Immunological Phenomena
7.Various Psychological Factors
SELTZER .NAIDORF.FLARE UPS IN
ENDODONTICS:ETIOLOGIC FACTORS.JOE 2004
1. Local Adaptation Syndrome
üSelye-thereisalocaltissueadaptationtoappliedirritants.
üOrdinarily,theC.Tbecomeinflamedwhentheyareexposedtoanirritant.
üChronicinflammationpersistsiftheirritantisnotremoved;thereislocal
adaptation.
üWhenanewirritantisintroducedtoinflamedtissue,aviolentreaction
mayoccur.
üSelye-thereisalocaltissueadaptationtoappliedirritants.
üOrdinarily,theC.Tbecomeinflamedwhentheyareexposedtoanirritant.
üChronicinflammationpersistsiftheirritantisnotremoved;thereislocal
adaptation.
üWhenanewirritantisintroducedtoinflamedtissue,aviolentreaction
mayoccur.
AIR INJECTED SCAIR POUCH FORMATION
The inflammatory lesion may be adapted to
the irritant, and chronic inflammation may exist without perceptible pain or swelling.
When endodontic therapy is performed, new
irritants in the form of medicaments,
irrigating solutions, or chemically altered
tissue proteins may be introduced into the
granulomatous lesion.
A violent reaction may follow, leading to
liquefaction necrosis, indicative of an alteration of the local adaptation syndrome.
the irritant, and chronic inflammation may exist without perceptible pain or swelling.
When endodontic therapy is performed, new
irritants in the form of medicaments,
irrigating solutions, or chemically altered
tissue proteins may be introduced into the
granulomatous lesion.
A violent reaction may follow, leading to
liquefaction necrosis, indicative of an alteration of the local adaptation syndrome.
2. Changes In Periapical Tissue Pressure
ØVariouspathologicalconditionsusually
produceawiderangeofpositivepressures.
ØTheexperimentsofMohometalhave
indicatedthatendodontictherapymayalso
causeachangeintheperiapicaltissue
pressure.
ØVariouspathologicalconditionsusually
produceawiderangeofpositivepressures.
ØTheexperimentsofMohometalhave
indicatedthatendodontictherapymayalso
causeachangeintheperiapicaltissue
pressure.
Bacterial, chemical and physical irritants likely act in combination to produce changes at the periapex
that result in inflammation and ultimately pain and/or swelling.
that result in inflammation and ultimately pain and/or swelling.
Periapical Pressure >Atmospheric Pressure
Excessive Exudate
Not Resorbed By The Lymphatics
Pain By Pressure On
Nerve Endings.
Excessive Exudate
Not Resorbed By The Lymphatics
Pain By Pressure On
Nerve Endings.
PERIAPICAL PRESSURE < ATMOSPHERIC PRESSURE
Microorganisms and altered tissue proteins
Aspirated into the periapical area in
accentuation of the
inflammatory
response
SEVERE PAIN
Microorganisms and altered tissue proteins
Aspirated into the periapical area in
accentuation of the
inflammatory
response
SEVERE PAIN
3. Microbial Factors
1.Presence of pathogenic
bacteria
2.Presence of virulent
clonal types
3.Microbial synergism or
additism
4.Number of microbial cells
5.Environmental causes
6.Host resistance
7.Herpes virus infection
Microbial injury caused by microorganisms and their products that egress from the root canal
system to the periradiculartissue is conceivably the major and most common cause of
interappointment flare ups.
Development of pain precipitated by infectious agents can be
dependent on several factors, most of which are likely to be
interconnected
1.Presence of pathogenic
bacteria
2.Presence of virulent
clonal types
3.Microbial synergism or
additism
4.Number of microbial cells
5.Environmental causes
6.Host resistance
7.Herpes virus infection
Microbial injury caused by microorganisms and their products that egress from the root canal
system to the periradiculartissue is conceivably the major and most common cause of
interappointment flare ups.
Development of pain precipitated by infectious agents can be
dependent on several factors, most of which are likely to be
interconnected
Presence Of Pathogenic Bacteria
qBacteriodes,FusobacteriaandPeptostreptococciarethe
mostfrequentanaerobicisolatesinflare–up.
qF.nucleatumisassociatedwiththedevelopmentofmost
severeformsofinterappointmentendodonticflareups
qB.melanogenicusactssynergisticallywithotherobligate
anaerobesandfacultativeanaerobes.
Bacteria Flare Up
qBacteriodes,FusobacteriaandPeptostreptococciarethe
mostfrequentanaerobicisolatesinflare–up.
qF.nucleatumisassociatedwiththedevelopmentofmost
severeformsofinterappointmentendodonticflareups
qB.melanogenicusactssynergisticallywithotherobligate
anaerobesandfacultativeanaerobes.
Bacteria Flare Up
F. nucleatumappears to be
associated with the
development of the most
severe forms of
interappointment
endodontic flare-ups.
associated with the
development of the most
severe forms of
interappointment
endodontic flare-ups.
Presence of Virulent Clonal Types
§Clonaltypesofagivenpathogenicbacterialspeciescansignificantly
divergeintheirvirulenceability.
§Adiseaseascribedtoagivenpathogenicspeciesisinfactcausedby
specificvirulentclonaltypesofthatspecies.
§Presenceofvirulentclonesofcandidateendodonticpathogensinthe
rootcanalmaybeapredisposingfactorforinterappointmentpain,
providedthatconditionsarecreatedforthemtoexertpathogenicity.
§Clonaltypesofagivenpathogenicbacterialspeciescansignificantly
divergeintheirvirulenceability.
§Adiseaseascribedtoagivenpathogenicspeciesisinfactcausedby
specificvirulentclonaltypesofthatspecies.
§Presenceofvirulentclonesofcandidateendodonticpathogensinthe
rootcanalmaybeapredisposingfactorforinterappointmentpain,
providedthatconditionsarecreatedforthemtoexertpathogenicity.
MicrobialSynergism
Mostofthepresumedendodonticpathogens
onlyshowvirulenceoraremorevirulentwhen
inassociationwithotherspecies.
Aerobes use O2and liberate CO2
Anaerobes use CO2and survive and exert
virulence
Prevent complete colonization by aerobes
Number Of Microbial Cells
Ifthehostisfacedwithahighernumber
ofmicrobialcellsthanitisusedto
dealingwith,acuteexacerbationofthe
peri-radicularlesioncanoccur.
Thiscanbeaccidentallyprecipitatedby
endodonticprocedures(notnecessarily
iatrogenicones).
Mostofthepresumedendodonticpathogens
onlyshowvirulenceoraremorevirulentwhen
inassociationwithotherspecies.
Aerobes use O2and liberate CO2
Anaerobes use CO2and survive and exert
virulence
Prevent complete colonization by aerobes
Number Of Microbial Cells
Ifthehostisfacedwithahighernumber
ofmicrobialcellsthanitisusedto
dealingwith,acuteexacerbationofthe
peri-radicularlesioncanoccur.
Thiscanbeaccidentallyprecipitatedby
endodonticprocedures(notnecessarily
iatrogenicones).
Environmental Causes
Agreatdealofevidenceindicatesthattheenvironmentexertsanimportantroleininducing
theturningonortheturningoffofmicrobialvirulencegenes.
Studieshavedemonstratedthatenvironmentalchangescaninfluencethebehaviourofsome
putativeoral(andendodontic)pathogens,includingP.gingivalis,F.nucleatum,P.intermedia,
andoraltreponemes.
Iftherootcanalenvironmentalconditionsareinsomewayalteredbyintracanalprocedures
andasaresultbecomeconducivetotheexpressionofvirulencegenes,microbialvirulence
canbeenhancedandinterappointmentpaincanensue.
Agreatdealofevidenceindicatesthattheenvironmentexertsanimportantroleininducing
theturningonortheturningoffofmicrobialvirulencegenes.
Studieshavedemonstratedthatenvironmentalchangescaninfluencethebehaviourofsome
putativeoral(andendodontic)pathogens,includingP.gingivalis,F.nucleatum,P.intermedia,
andoraltreponemes.
Iftherootcanalenvironmentalconditionsareinsomewayalteredbyintracanalprocedures
andasaresultbecomeconducivetotheexpressionofvirulencegenes,microbialvirulence
canbeenhancedandinterappointmentpaincanensue.
Host Resistance
Differentindividualspresentdifferent
patternsofresistancetoinfections,
andsuchdifferencescancertainly
becomeevidentduringindividual‘s
lifetime.
Individualswhohadreducedability
tocopewithinfectionsmaybe
morepronetodevelopclinical
symptomsafterendodontic
proceduresininfectedrootcanals.
Differentindividualspresentdifferent
patternsofresistancetoinfections,
andsuchdifferencescancertainly
becomeevidentduringindividual‘s
lifetime.
Individualswhohadreducedability
tocopewithinfectionsmaybe
morepronetodevelopclinical
symptomsafterendodontic
proceduresininfectedrootcanals.
Herpes Virus Infection
1.Herpesviruses~interferewiththehostimmuneresponse~
triggerovergrowthofpathogenicbacteriaand/ordiminishthe
hostresistancetoinfection.
2.Inducethereleaseofproinflammatorycytokinesbyhost
defensecells.
Arecentstudyobservedthatactiveinfectionsofperiradicular
lesionsbyhumanCMVand/orEBVweresignificantlyassociated
withsymptomatology.
Thus,thepossibilityexiststhatactiveherpesvirusinfectionsin
periradicularlesionsmayinitiateorcontributetoflare-ups.
1.Herpesviruses~interferewiththehostimmuneresponse~
triggerovergrowthofpathogenicbacteriaand/ordiminishthe
hostresistancetoinfection.
2.Inducethereleaseofproinflammatorycytokinesbyhost
defensecells.
Arecentstudyobservedthatactiveinfectionsofperiradicular
lesionsbyhumanCMVand/orEBVweresignificantlyassociated
withsymptomatology.
Thus,thepossibilityexiststhatactiveherpesvirusinfectionsin
periradicularlesionsmayinitiateorcontributetoflare-ups.
Circumstances In Which Micro-
organisms Can Cause Flare-ups
DuringBMP,ifthemicroorganismsareapically
extruded,thehostwillfaceasituationinwhichit
willbechallengedbyalargernumberofirritants
thanitwasbefore.
Consequently,therewillbeatransientdisruptionin
thebalancebetweenaggressionanddefenceinsuch
awaythatthehostwillmobilizeanacute
inflammationtore-establishtheequilibrium.
vApical Extrusion Of Infected Debris
organisms Can Cause Flare-ups
DuringBMP,ifthemicroorganismsareapically
extruded,thehostwillfaceasituationinwhichit
willbechallengedbyalargernumberofirritants
thanitwasbefore.
Consequently,therewillbeatransientdisruptionin
thebalancebetweenaggressionanddefenceinsuch
awaythatthehostwillmobilizeanacute
inflammationtore-establishtheequilibrium.
vApical Extrusion Of Infected Debris
vIatrogenic Over Instrumentation
üPromotestheenlargementoftheapicalforamen.
üPermitstheincreasedinfluxofexudatesandbloodintothe
rootcanal.
üEnhancesthenutrientsupplytotheremainingbacteriawithin
therootcanalthatcanthenproliferateandcause
exacerbationofachronicperiradicularlesion.
ChavezdePazVillanueva2002
üPromotestheenlargementoftheapicalforamen.
üPermitstheincreasedinfluxofexudatesandbloodintothe
rootcanal.
üEnhancesthenutrientsupplytotheremainingbacteriawithin
therootcanalthatcanthenproliferateandcause
exacerbationofachronicperiradicularlesion.
ChavezdePazVillanueva2002
Alsocancause
mechanicalinjuryto
theperiradicular
tissuewhichis
usuallycoupledwith
theapicalextrusion
ofsignificantdebris.
Forcing
microorganismsand
theirproductsinto
peri-radiculartissues
cangenerate
inflammatory
responsewhose
intensitywilldepend
onthenumberand
virulenceofmicro
organisms.
mechanicalinjuryto
theperiradicular
tissuewhichis
usuallycoupledwith
theapicalextrusion
ofsignificantdebris.
Forcing
microorganismsand
theirproductsinto
peri-radiculartissues
cangenerate
inflammatory
responsewhose
intensitywilldepend
onthenumberand
virulenceofmicro
organisms.
1.Allinstrumentationtechniqueshavebeen
showntopromoteapicalextrusionofdebris
2.Crowndowntechniquesusuallyextrudeless
debrisandshouldbeelectedfor
instrumentationofrootcanals.
DUMMER AND FAVIERI
Hence, Quantitative Factor is more
likely to be under the control of the therapist.
showntopromoteapicalextrusionofdebris
2.Crowndowntechniquesusuallyextrudeless
debrisandshouldbeelectedfor
instrumentationofrootcanals.
DUMMER AND FAVIERI
Hence, Quantitative Factor is more
likely to be under the control of the therapist.
Qualitative Factor is more difficult to control.
Virulent clonal types of pathogenic bacterial species
Propelled to the peri-radicular tissues
Even a small amount of infected debris
Potential to cause or exacerbate the peri-radicular inflammation
Virulent clonal types of pathogenic bacterial species
Propelled to the peri-radicular tissues
Even a small amount of infected debris
Potential to cause or exacerbate the peri-radicular inflammation
(SUNQUIST 1992).
Bacterial
organizations
within infected
root canals
associated with
periradicular
lesions.
Bacterial
organizations
within infected
root canals
associated with
periradicular
lesions.
Changes In The Endodontic Microbiata
Or In Environmental Conditions
1.Thechemo-mechanicalpreparationshouldbecompletedinoneappointment,and
betweenvisits,anICMshouldbeleftintherootcanal.
2.Incompletechemo-mechanicalpreparationcandisruptthebalancewithinthe
microbialcommunitybyeliminatingsomeoftheinhibitoryspeciesandleaving
behindotherpreviouslyinhibitedspecies,whichcanthenovergrow.
3.Ifovergrownstrainsarevirulentand/orreachsufficientnumbers,damagetothe
peri-radiculartissuescanbeintensified,andthismayresultinlesionexacerbation.
(SUNQUIST 1992).
Or In Environmental Conditions
1.Thechemo-mechanicalpreparationshouldbecompletedinoneappointment,and
betweenvisits,anICMshouldbeleftintherootcanal.
2.Incompletechemo-mechanicalpreparationcandisruptthebalancewithinthe
microbialcommunitybyeliminatingsomeoftheinhibitoryspeciesandleaving
behindotherpreviouslyinhibitedspecies,whichcanthenovergrow.
3.Ifovergrownstrainsarevirulentand/orreachsufficientnumbers,damagetothe
peri-radiculartissuescanbeintensified,andthismayresultinlesionexacerbation.
(SUNQUIST 1992).
Induce turn-offof virulence genes
Remission of the symptoms of
previously symptomatic cases could
ensue
Success of the endodontic
treatment even in situations where
microorganisms are not completely
eradicated from the root canal.
Induce turn-on virulence genes,
A previously asymptomatic case may become
symptomatic or
A persistent infection can establish itself in the root
canal system.
Persistent infections may be difficult to eradicate,
and they are main cause of treatment failure
Environmental Changes
Because it is clinically impossible to predict whether
environmental changes will lead to turn-on or turn-off
of virulence genes, BMP should be completed in one
session, whenever it is possible.
Remission of the symptoms of
previously symptomatic cases could
ensue
Success of the endodontic
treatment even in situations where
microorganisms are not completely
eradicated from the root canal.
Induce turn-on virulence genes,
A previously asymptomatic case may become
symptomatic or
A persistent infection can establish itself in the root
canal system.
Persistent infections may be difficult to eradicate,
and they are main cause of treatment failure
Environmental Changes
Because it is clinically impossible to predict whether
environmental changes will lead to turn-on or turn-off
of virulence genes, BMP should be completed in one
session, whenever it is possible.
Secondary Intra-radicular Infections
Introductionofnewmicroorganismsintotherootcanalsystem
duringtreatmentusuallyoccursfollowingabreachofasepticchain.
ØRemnants Of Dental Plaque
ØCalculus/Caries On The Tooth Crown
ØLeaking Rubber Dam
ØContaminated Endodontic Instruments
ØLeaking Temporary Restoration
Introductionofnewmicroorganismsintotherootcanalsystem
duringtreatmentusuallyoccursfollowingabreachofasepticchain.
ØRemnants Of Dental Plaque
ØCalculus/Caries On The Tooth Crown
ØLeaking Rubber Dam
ØContaminated Endodontic Instruments
ØLeaking Temporary Restoration
Microorganismscanenterinbetweenappointments,
after
1.Leakagethroughthetemporaryrestorative
material
2.Breakdownoffractureorlossofthetemporary
restoration
3.Fractureoftoothstructure
4.Recurrentdecayexposingtherootcanalfilling
material
5.Delayintheplacementofpermanentrestorations
after
1.Leakagethroughthetemporaryrestorative
material
2.Breakdownoffractureorlossofthetemporary
restoration
3.Fractureoftoothstructure
4.Recurrentdecayexposingtherootcanalfilling
material
5.Delayintheplacementofpermanentrestorations
BEST DOUBLE SEAL?
POLL TIME
1.What’s your opinion on an open dressing in endodontics?
•Closed Dressing is given. Period.
•Closed most of the time: Only in severe case, Open for a day or
two followed by closed dressing.
•Open dressing after an acute episode for drainage, then closed.
1.What’s your opinion on an open dressing in endodontics?
•Closed Dressing is given. Period.
•Closed most of the time: Only in severe case, Open for a day or
two followed by closed dressing.
•Open dressing after an acute episode for drainage, then closed.
https://www.researchgate.net/post/In_case_of_apical_swelling_with_pus_How_many_
days_should_we_keep_open_the_canal_to_discharge_the_pus
days_should_we_keep_open_the_canal_to_discharge_the_pus
Exposure of the root canal to salivary
products logarithmically
üIncreases bacterial growth
üIntroduces new microorganisms
üActivates the alternate complement
pathway
üMay enhance bradykinin production
products logarithmically
üIncreases bacterial growth
üIntroduces new microorganisms
üActivates the alternate complement
pathway
üMay enhance bradykinin production
EXCEPTIONHOWEVEREXISTS:Casesof
uncontrolledmassiveexudation:Weine-
“Ifthedrainagerefusestostoporifthereisnottimeor
spacetoallowfordrainage,thetoothmaybeleftopen
andthepatientdismissed.Thetoothmaybereclosed,
withoutfiling,whenallsymptomshavedisappeared,
usuallyin2-3days”
uncontrolledmassiveexudation:Weine-
“Ifthedrainagerefusestostoporifthereisnottimeor
spacetoallowfordrainage,thetoothmaybeleftopen
andthepatientdismissed.Thetoothmaybereclosed,
withoutfiling,whenallsymptomshavedisappeared,
usuallyin2-3days”
1936 Alfred Walker: “This method is an unscientificas
it is antiquated. The practice of leaving the pulp canals
of teeth open and unsealed for the purpose of drainage
is contrary to the accepted surgical practice, is
unnecessary and is a consequence of a bad practice”.
1975, 1982 Weineet al: “Establishment of drainage
followed by complete chemo-mechanical
preparation, placement of an antimicrobial
preparation, and coronal closure at the same
appointment result in reduced risk of persistent
symptomsas well as in fewer appointments to
complete the therapy when compared with teeth
left open for drainage”
2003 J. F. Siqueira: “If no pus drains through the
root canal even after apical trephination, it will not
do even if the tooth is left open for many days”
it is antiquated. The practice of leaving the pulp canals
of teeth open and unsealed for the purpose of drainage
is contrary to the accepted surgical practice, is
unnecessary and is a consequence of a bad practice”.
1975, 1982 Weineet al: “Establishment of drainage
followed by complete chemo-mechanical
preparation, placement of an antimicrobial
preparation, and coronal closure at the same
appointment result in reduced risk of persistent
symptomsas well as in fewer appointments to
complete the therapy when compared with teeth
left open for drainage”
2003 J. F. Siqueira: “If no pus drains through the
root canal even after apical trephination, it will not
do even if the tooth is left open for many days”
ØTheoreticallytheremaybemoreoxygeninatoothleftopenandtherefore
feweranaerobicbacteria,whichmaybeeasiertoeliminate,however,theremay
beintroductionofbacteriasuchasE.faecalis,whicharemoredifficultto
eliminate.
ØTherecommendationistoavoidpracticesthatintroducemicroorganismsinto
rootcanalsystems.Theavailableevidencedoesnotshowbenefitfromthepracticeof
opendrainage.
ØThecurrentqualityguidelinesfornon-surgicalendodonticsdonot
includeopendrainageasatreatmentmodalityandtheaimof
treatmentisstatedas‘eithertomaintainasepsisoftherootcanal
systemortodisinfectitadequately’.European Society of Endodontology. Quality guidelines for endodontic treatment:
consensus report of the European Society of Endodontology.
IntEndodJ 2006; 39: 921–930.
feweranaerobicbacteria,whichmaybeeasiertoeliminate,however,theremay
beintroductionofbacteriasuchasE.faecalis,whicharemoredifficultto
eliminate.
ØTherecommendationistoavoidpracticesthatintroducemicroorganismsinto
rootcanalsystems.Theavailableevidencedoesnotshowbenefitfromthepracticeof
opendrainage.
ØThecurrentqualityguidelinesfornon-surgicalendodonticsdonot
includeopendrainageasatreatmentmodalityandtheaimof
treatmentisstatedas‘eithertomaintainasepsisoftherootcanal
systemortodisinfectitadequately’.European Society of Endodontology. Quality guidelines for endodontic treatment:
consensus report of the European Society of Endodontology.
IntEndodJ 2006; 39: 921–930.
Increase of the oxidation-reduction
potential
•WhentoothisopenedO2penetratesintorootcanalsystemand
microbialgrowthpatternchangesfromanaerobicaerobic
conditions.
•Iffacultativeanaerobessuchasstreptococciarepresentinroot
canalinfectionandresistintracanalprocedures,theymay
overgrowasaresultofincreaseintheredoxpotentialandignite
acuteperi-radicularinfection.
MATUSOW
potential
•WhentoothisopenedO2penetratesintorootcanalsystemand
microbialgrowthpatternchangesfromanaerobicaerobic
conditions.
•Iffacultativeanaerobessuchasstreptococciarepresentinroot
canalinfectionandresistintracanalprocedures,theymay
overgrowasaresultofincreaseintheredoxpotentialandignite
acuteperi-radicularinfection.
MATUSOW
Entrance of oxygen into the root canal
during treatment may favour the
overgrowth of facultative bacteria that
resisted chemomechanicalprocedures.
This mechanism is only conjectural,
and there is no clear evidence
substantiating this theory.
during treatment may favour the
overgrowth of facultative bacteria that
resisted chemomechanicalprocedures.
This mechanism is only conjectural,
and there is no clear evidence
substantiating this theory.
4. EFFECTS OF CHEMICAL MEDIATORS
During the inflammatory response, chemicals can be derived from cells or plasma.
Cell Mediators
•Histamine
•Serotonin (5-hydroxytryptamine (5-HT)
•Prostaglandins (PGs)
•Platelet-activating factor (PAF)
•Leukotrienes (LT)
•Various lysosomal components
•And some lymphocyte products called lymphokines
During the inflammatory response, chemicals can be derived from cells or plasma.
Cell Mediators
•Histamine
•Serotonin (5-hydroxytryptamine (5-HT)
•Prostaglandins (PGs)
•Platelet-activating factor (PAF)
•Leukotrienes (LT)
•Various lysosomal components
•And some lymphocyte products called lymphokines
Plasma Mediators
vPlasmin
vFibrinopeptides And Fibrin Degradation
Products
vBradykinin
vPre-kallikrein Activator
vHageman Factor
Highly potent pain inducer
vPlasmin
vFibrinopeptides And Fibrin Degradation
Products
vBradykinin
vPre-kallikrein Activator
vHageman Factor
Highly potent pain inducer
Neutrophil Products
vHydrolyticenzymes
vLysozyme
vCollagenases
vCathepsins
vF3-glucuronidase
vPeroxidase
vAmylases
vLipases
vRibonucleases
vDeoxyribonucleases
vLacticdehydrogenases.
The release of those enzymes produces damage to nearby
cells and other tissue elements. Severe pain and swelling
may result.
vHydrolyticenzymes
vLysozyme
vCollagenases
vCathepsins
vF3-glucuronidase
vPeroxidase
vAmylases
vLipases
vRibonucleases
vDeoxyribonucleases
vLacticdehydrogenases.
The release of those enzymes produces damage to nearby
cells and other tissue elements. Severe pain and swelling
may result.
5. CHANGES IN CYCLIC NUCLEOTIDES
üAccordingtothehypothesisofBourneetal,thecharacterandintensityof
inflammatoryandimmuneresponsesisregulatedbycertainhormonesand
mediators.
üThisregulationismediatedbyageneralinhibitoryactionofcyclicAMPonthe
releaseofmediatorsfrommastcells.basophils,monocytes,andpolys.
üIncreasedintracellularlevelsofcyclicAMP,inducedbyPGsandhistamine,may
inhibitdegranulationofmastcellsandhelpinreducingpain.
üWhereasanincreaseincyclicGMPstimulatesmastcelldegranulationwhichresults
inincreaseinpain.
üAccordingtothehypothesisofBourneetal,thecharacterandintensityof
inflammatoryandimmuneresponsesisregulatedbycertainhormonesand
mediators.
üThisregulationismediatedbyageneralinhibitoryactionofcyclicAMPonthe
releaseofmediatorsfrommastcells.basophils,monocytes,andpolys.
üIncreasedintracellularlevelsofcyclicAMP,inducedbyPGsandhistamine,may
inhibitdegranulationofmastcellsandhelpinreducingpain.
üWhereasanincreaseincyclicGMPstimulatesmastcelldegranulationwhichresults
inincreaseinpain.
cAMP
cGMP
cGMP
6. IMMUNOLOGICAL PHENOMENA
1.Inchronicpulpitisandapicalperiodontitis,thepresenceofmacrophages
andlymphocytesindicatesthatbothcell-mediatedandhumoralimmune
reactionsareinvolved.
2.Despitetheirprotectiveeffects,immunologicalmechanismsmay
contributetothedestructivephaseofinflammation.
3.Thetypeofclinicalresponsemaybedictatedbythetypeof
immunoglobulinelaborated.
1.Inchronicpulpitisandapicalperiodontitis,thepresenceofmacrophages
andlymphocytesindicatesthatbothcell-mediatedandhumoralimmune
reactionsareinvolved.
2.Despitetheirprotectiveeffects,immunologicalmechanismsmay
contributetothedestructivephaseofinflammation.
3.Thetypeofclinicalresponsemaybedictatedbythetypeof
immunoglobulinelaborated.
ØShouldthedominantimmunoglobulininthepulporperiapicallesionbelgG,
thereisapossibilityofanArthus-typereaction,aftercomplementactivation,
owingtothelocalformationofimmunecomplexes.
ØOntheotherhand,ifthedominantimmunoglobulinisIgA,complement-fixing
activityislow.
<
Pain and destruction
are the result of a shift
in the production of
lgGover IgA, causing
perpetuation and
aggravation of the
inflammatory process.
thereisapossibilityofanArthus-typereaction,aftercomplementactivation,
owingtothelocalformationofimmunecomplexes.
ØOntheotherhand,ifthedominantimmunoglobulinisIgA,complement-fixing
activityislow.
<
Pain and destruction
are the result of a shift
in the production of
lgGover IgA, causing
perpetuation and
aggravation of the
inflammatory process.
7. PSYCHOLOGICAL FACTORS
qFearofdentistsanddentalprocedures,
anxiety,apprehension,andmanyother
psychologicalfactorsinfluencethepatient‘s
painperceptionandreactionthresholds.
qPrevioustraumaticdentalexperiences
appeartobesignificantfactorsinthe
productionofanxietyandapprehensionin
dentalpatients.
qFearofdentistsanddentalprocedures,
anxiety,apprehension,andmanyother
psychologicalfactorsinfluencethepatient‘s
painperceptionandreactionthresholds.
qPrevioustraumaticdentalexperiences
appeartobesignificantfactorsinthe
productionofanxietyandapprehensionin
dentalpatients.
•Root canal therapy, especially, appears to be
painful to many patients either because of
antecedent experiences or from conversations
with others or from derogatory comments
made by communications media.
•The induced anxieties help to intensify and
perpetuate painful episodes.
“Nothing
personal, but I
HATE
dentists.”
“I can stand
PAIN
anywherebut
in the mouth.” “I‟drather
HAVE A
BABY than
be here.”
painful to many patients either because of
antecedent experiences or from conversations
with others or from derogatory comments
made by communications media.
•The induced anxieties help to intensify and
perpetuate painful episodes.
“Nothing
personal, but I
HATE
dentists.”
“I can stand
PAIN
anywherebut
in the mouth.” “I‟drather
HAVE A
BABY than
be here.”
CLINICAL
CONDITIONS
ASSOCIATED
WITH FLARE
UPS
CONDITIONS
ASSOCIATED
WITH FLARE
UPS
Apical Periodontitis Secondary To
Treatment
1.Atoothwhichwassymptomlessbefore
theinitiationofendodontictreatment
butbecomessensitivetopercussion
duringthecourseofthetreatment.
2.Causesforthisconditionmostfrequently
areoverinstrumentationorforcing
debrisintotheperiapicaltissues.
Treatment
1.Atoothwhichwassymptomlessbefore
theinitiationofendodontictreatment
butbecomessensitivetopercussion
duringthecourseofthetreatment.
2.Causesforthisconditionmostfrequently
areoverinstrumentationorforcing
debrisintotheperiapicaltissues.
Incomplete Removal Of Pulp
Tissues During The Initial
Appointment
1.Insomeinstancesduetolackoftimefactorthe
endodontictherapymayconsistofincomplete
pulpectomyafteradiagnosisofacuteor
chronicpulpitis.
2.Thissituationgenerallyoccurswhenthe
radicularpulpisalreadyinflamed.
Tissues During The Initial
Appointment
1.Insomeinstancesduetolackoftimefactorthe
endodontictherapymayconsistofincomplete
pulpectomyafteradiagnosisofacuteor
chronicpulpitis.
2.Thissituationgenerallyoccurswhenthe
radicularpulpisalreadyinflamed.
Phoenix Abscess
1.Itisaconditionthatoccursinteethwith
necroticpulpsandapicallesionsthatare
asymptomatic.
2.Thereisaexacerbationofapreviously
symptomlessperi-radicularlesion.
3.Thereasonforthisphenomenonisthoughtto
beduetothealterationoftheinternal
environmentoftherootcanalspaceduring
instrumentationwhichactivatesthebacterial
flora.
1.Itisaconditionthatoccursinteethwith
necroticpulpsandapicallesionsthatare
asymptomatic.
2.Thereisaexacerbationofapreviously
symptomlessperi-radicularlesion.
3.Thereasonforthisphenomenonisthoughtto
beduetothealterationoftheinternal
environmentoftherootcanalspaceduring
instrumentationwhichactivatesthebacterial
flora.
Recurrent Periapical Abscess
1.Itisaconditionwhereatoothwithan
acuteperiapicalabscessisrelievedby
emergencytreatmentafterwhichtheacute
symptomsreturn.
2.Insomecasestheabscessmayrecurmore
thanonce,duetomicroorganismofhigh
virulenceorpoorhostresistance.
1.Itisaconditionwhereatoothwithan
acuteperiapicalabscessisrelievedby
emergencytreatmentafterwhichtheacute
symptomsreturn.
2.Insomecasestheabscessmayrecurmore
thanonce,duetomicroorganismofhigh
virulenceorpoorhostresistance.
Microbial Mechanism Preventive Measures
1. Apical extrusion of infected debris
•Crown down instrumentation technique
•Rotary<Reciprocation instrumentation
•Coronal flare
•Copious and frequent irrigation
2. Changes in environmental conditions •Complete cleaning and shaping in one sitting
•ICM
3. Secondary intra radicular infection
•Strict aseptic measures
•Proper coronal seal
•Do not leave tooth open for drainage
4. Increase of oxidation reduction
potential
•Complete BMP in one sitting
•ICM
1. Apical extrusion of infected debris
•Crown down instrumentation technique
•Rotary<Reciprocation instrumentation
•Coronal flare
•Copious and frequent irrigation
2. Changes in environmental conditions •Complete cleaning and shaping in one sitting
•ICM
3. Secondary intra radicular infection
•Strict aseptic measures
•Proper coronal seal
•Do not leave tooth open for drainage
4. Increase of oxidation reduction
potential
•Complete BMP in one sitting
•ICM
PREVENTIVE
MEASURES
MEASURES
Relief of Occlusion
¢Occlusalreliefpriortoendodonticshas
beenadvocatedbyCohenforthe
preventionofendodonticpain.
¢Otherendodontists(OlgivleAL,
Ingle,NicholsE.)haverecommended
occlusalreliefonlyinthoseteethwith
pre-operativeacuteapicalsymptoms.
¢Occlusalreliefpriortoendodonticshas
beenadvocatedbyCohenforthe
preventionofendodonticpain.
¢Otherendodontists(OlgivleAL,
Ingle,NicholsE.)haverecommended
occlusalreliefonlyinthoseteethwith
pre-operativeacuteapicalsymptoms.
1.Sincemicroorganismsareresponsibleforexacerbating
inflammation,itwouldappearthattheintracanalplacementof
rootcanalantisepticsandgermicidesshouldatleastindirectly
reduceinterandposttreatmentpain.
2.AccordingtoSeltzer,intracanalmedicationreducesthe
possibilityofflareups.
Intracanal Antimicrobial Agents
inflammation,itwouldappearthattheintracanalplacementof
rootcanalantisepticsandgermicidesshouldatleastindirectly
reduceinterandposttreatmentpain.
2.AccordingtoSeltzer,intracanalmedicationreducesthe
possibilityofflareups.
Intracanal Antimicrobial Agents
1.Theuseofintracanalsteroids(NSAIDs)ora
corticosteroid–antibioticcompoundhasbeen
showntoreducepost-treatmentpain.
2.Rogersetal.demonstratedthatboth
dexamethasoneandketorolacwhenplacedinthe
rootcanalsofvitalteethafterpulpectomy
proceduresshowedstatisticallysignificantpain
reliefatthe12-htimeperiodascomparedtothe
placebogroup.Noadversereactionswerefound
followingtheirplacementwithintherootcanal
system.
J Endod1999;25:381–389.,Oral SurgOral Med Oral PatholOral Radiol
Endod2001;92:435–439.
corticosteroid–antibioticcompoundhasbeen
showntoreducepost-treatmentpain.
2.Rogersetal.demonstratedthatboth
dexamethasoneandketorolacwhenplacedinthe
rootcanalsofvitalteethafterpulpectomy
proceduresshowedstatisticallysignificantpain
reliefatthe12-htimeperiodascomparedtothe
placebogroup.Noadversereactionswerefound
followingtheirplacementwithintherootcanal
system.
J Endod1999;25:381–389.,Oral SurgOral Med Oral PatholOral Radiol
Endod2001;92:435–439.
1.Comparetheeffectofledermixpasteandcalciumhydroxideas
intracanalmedicamentonthemeanpostoperativepainafter
instrumentationoftherootcanals.
2.Calciumhydroxidewasfoundinferiortoledermixtreatmentin
controllingthepostoperativepainafterinstrumentationoftheroot
canals.
Pak Armed Forces Med J 2020; 70 (2): 368-72
intracanalmedicamentonthemeanpostoperativepainafter
instrumentationoftherootcanals.
2.Calciumhydroxidewasfoundinferiortoledermixtreatmentin
controllingthepostoperativepainafterinstrumentationoftheroot
canals.
Pak Armed Forces Med J 2020; 70 (2): 368-72
LEDERMIX PASTE
Medicinal active substance : 1g of paste contains:
Triamcinolone acetonide 10.0 mg
Demeclocycline calcium 30.21 mg
Rs. 9500
Medicinal inactive substance
Triethanolamine, Calcium chloride, Zinc Oxide, Macrogol 3000, Macrogol
400, Sodium Sulphite Anhydrous, Sodium Calcium Edetate, Colloidal Silicon
Dioxide
Purified water
At the first 24 hours, 30% of the
corticosteroid was released.
By the end of 14 weeks, the
remaining 70% has been released.
Mixing erythromycin with
Ca(OH)2improved the
effectiveness against E. faecalis as
compared to Ca(OH)2alone.
Medicinal active substance : 1g of paste contains:
Triamcinolone acetonide 10.0 mg
Demeclocycline calcium 30.21 mg
Rs. 9500
Medicinal inactive substance
Triethanolamine, Calcium chloride, Zinc Oxide, Macrogol 3000, Macrogol
400, Sodium Sulphite Anhydrous, Sodium Calcium Edetate, Colloidal Silicon
Dioxide
Purified water
At the first 24 hours, 30% of the
corticosteroid was released.
By the end of 14 weeks, the
remaining 70% has been released.
Mixing erythromycin with
Ca(OH)2improved the
effectiveness against E. faecalis as
compared to Ca(OH)2alone.
Irrigating Solutions
Harrisonetal.foundthattherewasa
higherincidenceanddegreeofpainin
patientswhosecanalswereeithernot
irrigatedorirrigatedwithsalinesolution,
comparedwiththoseirrigatedwith
5.25%sodiumhypochloriteand3%H2O2.
Harrisonetal.foundthattherewasa
higherincidenceanddegreeofpainin
patientswhosecanalswereeithernot
irrigatedorirrigatedwithsalinesolution,
comparedwiththoseirrigatedwith
5.25%sodiumhypochloriteand3%H2O2.
Corticosteriods
1.Theanti-inflammatoryactivityofcorticosteroidsisbasedpartly
ontheirabilitytoretardlysosomalreleasefromcellsby
inhibitingfusionoflysosomeswiththeirtargetmembranes.
2.Inaddition,corticosteroidsinhibittheliberationoffree
arachidonicacidfromthephospholipidsofthecellmembrane
byphospholipases.
1.Theanti-inflammatoryactivityofcorticosteroidsisbasedpartly
ontheirabilitytoretardlysosomalreleasefromcellsby
inhibitingfusionoflysosomeswiththeirtargetmembranes.
2.Inaddition,corticosteroidsinhibittheliberationoffree
arachidonicacidfromthephospholipidsofthecellmembrane
byphospholipases.
Anumberofinvestigatorshavereportedthatcorticosteroidsplacedinto
therootcanalcontrolpainsuccessfully.
LangelandK, LangelandLK, Anderson DM. Corticosteroids in dentistry.IntDent J 1977;27:217.
MoskowA, Morse DR, Krasner P, FurstML. Intracanal use of a corticosteroid solution as an endodontic anodyne. Oral Surg1984;58:600.
Thereisnodemonstratedbenefitinplacingmedicamentsoranyother
substanceincanalstohelppreventorresolveaflare-up.
Richard E. Walton, Endodontic Topics 2002
Steroids, administered in a single dose (e.g. 4–6mg of dexamethasone) may
also be of benefit to reduce pain.
LeisingerA, Marshall FJ, Marshall JG. Effect of variabledosesof dexamethasone on post treatment endodontic pain. J Endod1993: 19: 35–39.
therootcanalcontrolpainsuccessfully.
LangelandK, LangelandLK, Anderson DM. Corticosteroids in dentistry.IntDent J 1977;27:217.
MoskowA, Morse DR, Krasner P, FurstML. Intracanal use of a corticosteroid solution as an endodontic anodyne. Oral Surg1984;58:600.
Thereisnodemonstratedbenefitinplacingmedicamentsoranyother
substanceincanalstohelppreventorresolveaflare-up.
Richard E. Walton, Endodontic Topics 2002
Steroids, administered in a single dose (e.g. 4–6mg of dexamethasone) may
also be of benefit to reduce pain.
LeisingerA, Marshall FJ, Marshall JG. Effect of variabledosesof dexamethasone on post treatment endodontic pain. J Endod1993: 19: 35–39.
Antibiotics
1.Althoughantibioticsarewidelyusedintreatingalocalizedabscess,prospective
clinicaltrialsshowtheyareofnobenefitforreducingpostoperativepainorriskof
developingaflare-up.
2.Therearenosignificantstudieswhichshowthatanyspecificantibioticiscapableof
reducingoreliminatingpainfulexacerbationsduringendodontictherapy.
3.Inareviewontheuseofsystemicantibioticsforthecontrolofpost-treatment
endodonticpain,Fouadconcludedthattheiruseiswithoutjustification.
1.Althoughantibioticsarewidelyusedintreatingalocalizedabscess,prospective
clinicaltrialsshowtheyareofnobenefitforreducingpostoperativepainorriskof
developingaflare-up.
2.Therearenosignificantstudieswhichshowthatanyspecificantibioticiscapableof
reducingoreliminatingpainfulexacerbationsduringendodontictherapy.
3.Inareviewontheuseofsystemicantibioticsforthecontrolofpost-treatment
endodonticpain,Fouadconcludedthattheiruseiswithoutjustification.
1.However,itappearsthatantibioticsarefrequentlyprescribedto
theendodonticpainpatient.
2.Currentadvancesinourunderstandingofthebiologyofthe
infectiousandinflammatoryprocess,alongwiththeknownrisks
associatedwithantibiotics,suchastheemergenceofmulti-
resistantbacterialstrains,stronglyindicatethattheclinician
shouldseriouslyre-evaluatetheirprescribinghabits.
theendodonticpainpatient.
2.Currentadvancesinourunderstandingofthebiologyofthe
infectiousandinflammatoryprocess,alongwiththeknownrisks
associatedwithantibiotics,suchastheemergenceofmulti-
resistantbacterialstrains,stronglyindicatethattheclinician
shouldseriouslyre-evaluatetheirprescribinghabits.
Analgesics
Thereisgoodevidencethat
pretreatmentanalgesicsminimize
interandposttreatmentpain.
Dionne R. Preemptive vs. preventive analgesia: which approach
improves clinical outcomes? CompendContinEducDent 2000: 21:
51–456.
Gottschalk A, Smith DS. New concepts in acute pain
therapy:preemptiveanalgesia. Am Fam Physician 2001: 63:1979–
1984.
Pretreatmentpainandanxiety
control,includinganalgesics,
mayreduceincidenceofflare-
ups
TorabinejadM, CymermanJ, FranksonM, Lemon R,MaggioJ,
SchilderH. Effectiveness of various medications on postoperative
pain following complete instrumentation.J Endod1994: 20: 345–354.
Thereisgoodevidencethat
pretreatmentanalgesicsminimize
interandposttreatmentpain.
Dionne R. Preemptive vs. preventive analgesia: which approach
improves clinical outcomes? CompendContinEducDent 2000: 21:
51–456.
Gottschalk A, Smith DS. New concepts in acute pain
therapy:preemptiveanalgesia. Am Fam Physician 2001: 63:1979–
1984.
Pretreatmentpainandanxiety
control,includinganalgesics,
mayreduceincidenceofflare-
ups
TorabinejadM, CymermanJ, FranksonM, Lemon R,MaggioJ,
SchilderH. Effectiveness of various medications on postoperative
pain following complete instrumentation.J Endod1994: 20: 345–354.
Post Treatment Patient Care: Cohen*
Ibuprofen 200mg X 3
Acetaminophen 500mg X 2 5
Every 6 hours X 2 days
*No Allergies for an average 72kg man
Rx
Ibuprofen 200mg X 3
Acetaminophen 500mg X 2 5
Every 6 hours X 2 days
*No Allergies for an average 72kg man
Rx
MANAGEMENT
OF
FLARE UPS
OF
FLARE UPS
Althoughsomepatientsmay
experiencesomelevelofpainafter
RCT,veryfewexperiencethetrue
‘flare-up’,whichrequiresan
unscheduledofficevisitand/orthe
prescribingofanalgesics,systemic
steroidsandantibiotics.
Post-treatment Pain
experiencesomelevelofpainafter
RCT,veryfewexperiencethetrue
‘flare-up’,whichrequiresan
unscheduledofficevisitand/orthe
prescribingofanalgesics,systemic
steroidsandantibiotics.
Post-treatment Pain
Hargreaves and Seltzer: Pain Control
Diagnosis
Definitive Rx
Drugs
Psychological
Localized Treatment
Diagnosis
Definitive Rx
Drugs
Psychological
Localized Treatment
DIAGNOSIS
üPatientmedicalanddentalhistory
üClinicaltesting-percussion,apicalpalpation,bite-stickchallenge,thermalstimulationand
periodontalprobing.
üAreasofswelling,discoloration,ulcerations,exudation,defectiveand/orlostrestorations,
crackedorfracturedteethandapparentchangesinocclusalrelationships.
Unrelated
Sinus
Another
Tooth
TMJ Related
Condition
Post Injection
Sequalae
OdontogenicNon-Odontogenic
üPatientmedicalanddentalhistory
üClinicaltesting-percussion,apicalpalpation,bite-stickchallenge,thermalstimulationand
periodontalprobing.
üAreasofswelling,discoloration,ulcerations,exudation,defectiveand/orlostrestorations,
crackedorfracturedteethandapparentchangesinocclusalrelationships.
Unrelated
Sinus
Another
Tooth
TMJ Related
Condition
Post Injection
Sequalae
OdontogenicNon-Odontogenic
The big
REASSURANCE
is critical & perhaps the most
important aspect of treatment.
REASSURANCE
is critical & perhaps the most
important aspect of treatment.
MANAGEMENT STRATEGIES
1.Apical Trephination
2.Incision And Drainage
3.Cortical Trephination
a.-With Drain
b.-Without Drain
4.Antibiotic(?) Regimen With NSAIDs
5.Hot Saline Holds To Localize Diffuse Swelling
6.Culture And Sensitivity Testing
1.Apical Trephination
2.Incision And Drainage
3.Cortical Trephination
a.-With Drain
b.-Without Drain
4.Antibiotic(?) Regimen With NSAIDs
5.Hot Saline Holds To Localize Diffuse Swelling
6.Culture And Sensitivity Testing
Re-instrumentation
Adequate Anesthesia
Access Opening
Re-confirm WL
Patency To Apical Foramen
Thorough Debridement With Copious Irrigation
Adequate Anesthesia
Access Opening
Re-confirm WL
Patency To Apical Foramen
Thorough Debridement With Copious Irrigation
1.Weineadvocated‘violating’andenlargingtheapicalconstriction
toatleastasize#25endodonticfiletoallowfordrainage
throughthetooth.
2.Nonetheless,HarringtonandNatkinstatedthattrephination
throughtheapicalforamendoesnotensuredrainageofperi-
radicularexudation.
Apical Trephination
toatleastasize#25endodonticfiletoallowfordrainage
throughthetooth.
2.Nonetheless,HarringtonandNatkinstatedthattrephination
throughtheapicalforamendoesnotensuredrainageofperi-
radicularexudation.
Apical Trephination
Hot Saline Holds For Diffuse Swellings
-Localizedheat(hotsalinewater)tendstodrawpustothetissuesurface(localizesthe
swelling)sothatI&Dcanbeperformed
-1teaspoonfulofsaltinhotwater(ashotasistolerablebyintraoraltissues)inaglass~
300ml
-Holdthewaterincontactwithtissuestillitcools
-Usetheentireglassandrepeatevery4-8hours.
-Advicepatientagainstapplyingheattofacemaylocalizeswellingoverface&
subsequentscaring.
-Localizedheat(hotsalinewater)tendstodrawpustothetissuesurface(localizesthe
swelling)sothatI&Dcanbeperformed
-1teaspoonfulofsaltinhotwater(ashotasistolerablebyintraoraltissues)inaglass~
300ml
-Holdthewaterincontactwithtissuestillitcools
-Usetheentireglassandrepeatevery4-8hours.
-Advicepatientagainstapplyingheattofacemaylocalizeswellingoverface&
subsequentscaring.
Localized Treatment
ESTABLISHMENTOFDRAINAGE
1.Inthepresenceofsuppuration,drainageofexudateisthemosteffectivemethodfor
reducingpainandswelling.
2.Inmostinstances,theaccumulatedexudatewillsurgefromtherootcanal,affording
immediaterelief.
3.However,uponoccasion,noexudatewillemerge;itmaybeblockedbypacked
dentinalshavingsintheapicalthirdoftherootcanal.
ESTABLISHMENTOFDRAINAGE
1.Inthepresenceofsuppuration,drainageofexudateisthemosteffectivemethodfor
reducingpainandswelling.
2.Inmostinstances,theaccumulatedexudatewillsurgefromtherootcanal,affording
immediaterelief.
3.However,uponoccasion,noexudatewillemerge;itmaybeblockedbypacked
dentinalshavingsintheapicalthirdoftherootcanal.
1.Afteradequateanaesthsiapassinga
rootcanalinstrument,suchasafileor
reamer,throughthecakedmaterial
mayhelptoestablishtheflowof
exudate.
2.Duringdrainagecanalisleftopenfor
about15minsoruntilexudationhas
ceasedoraslightclearserumdrains.
3.Afteradequatedrainageandirrigation
therootcanalcanthenberesealed,
usuallywithoutfurtherdiscomfortto
thepatient.
rootcanalinstrument,suchasafileor
reamer,throughthecakedmaterial
mayhelptoestablishtheflowof
exudate.
2.Duringdrainagecanalisleftopenfor
about15minsoruntilexudationhas
ceasedoraslightclearserumdrains.
3.Afteradequatedrainageandirrigation
therootcanalcanthenberesealed,
usuallywithoutfurtherdiscomfortto
thepatient.
TheuseofdrainsfollowinganI&Dprocedureiscontroversial.
McDonaldandHovlandhavestatedthattheincisionalonewillusuallyprovidethe
neededdrainage.
Franketal.recommendedtheuseofarubberdraintomaintainthepatencyofthe
surgicalopening.
RubberDamDrain
PenroseDrain
CaillaryDrain-ribbed
McDonaldandHovlandhavestatedthattheincisionalonewillusuallyprovidethe
neededdrainage.
Franketal.recommendedtheuseofarubberdraintomaintainthepatencyofthe
surgicalopening.
RubberDamDrain
PenroseDrain
CaillaryDrain-ribbed
1.GutmannandHarrisonstatedthattheuseofdrainsfollowingI
&Dprocedureshasbeengreatlyabused.
2.Patientswithlocalizedordiffuseintraoralswellings,evenifmild
extraoralswellingispresent,donotusuallyrequiredrains
followingI&Dprocedures.
3.The drain may be made of either iodoform gauze or rubber dam
material cut in an “H” or “Christmas tree”shape
&Dprocedureshasbeengreatlyabused.
2.Patientswithlocalizedordiffuseintraoralswellings,evenifmild
extraoralswellingispresent,donotusuallyrequiredrains
followingI&Dprocedures.
3.The drain may be made of either iodoform gauze or rubber dam
material cut in an “H” or “Christmas tree”shape
A self-retentive
‘Christmas Tree’
drain made from
a sterilized rubber
dam 15 Blade
‘Christmas Tree’
drain made from
a sterilized rubber
dam 15 Blade
CORTICAL TREPHINATION
Inexceptionalcases,theexudateiseitherabsentorcannot
beevacuatedthroughtherootcanal.
Surgicalinterventionisthennecessary.
Theremovalofthealveolarboneovertheapexofthetooth
root(creationofanartificalsinustract),orasofttissue
incisionwhenswellinghasoccurredusuallyaffordsrelief.
Inexceptionalcases,theexudateiseitherabsentorcannot
beevacuatedthroughtherootcanal.
Surgicalinterventionisthennecessary.
Theremovalofthealveolarboneovertheapexofthetooth
root(creationofanartificalsinustract),orasofttissue
incisionwhenswellinghasoccurredusuallyaffordsrelief.
PROCEDURE
1.Followingtheadministrationoftheappropriateblockand/orinfiltrationanesthesia,the
surgicalareashouldbeisolatedwithsterile2×2gauzesponges.
2.Theincisionshouldbehorizontalandplacedatthedependentbaseofthefluctuantarea.
3.Theincisionshouldbemadeusingascalpelbladethatispointed,suchasaNo.11orNo.
12,ratherthanaroundedNo.15blade.
4.GutmannandHarrisonrecommendusingeitheraNo.6orNo.8roundburinahigh-speed
handpiecetopenetratethecorticalplate.
5.AreamerorK-typefileisthenpassedthroughthecancellousboneintothevicinityofthe
periradiculartissues.
1.Followingtheadministrationoftheappropriateblockand/orinfiltrationanesthesia,the
surgicalareashouldbeisolatedwithsterile2×2gauzesponges.
2.Theincisionshouldbehorizontalandplacedatthedependentbaseofthefluctuantarea.
3.Theincisionshouldbemadeusingascalpelbladethatispointed,suchasaNo.11orNo.
12,ratherthanaroundedNo.15blade.
4.GutmannandHarrisonrecommendusingeitheraNo.6orNo.8roundburinahigh-speed
handpiecetopenetratethecorticalplate.
5.AreamerorK-typefileisthenpassedthroughthecancellousboneintothevicinityofthe
periradiculartissues.
Probing with a curette or hemostat into the
incisional wound to release exudate entrapped
in tissue compartments will facilitate a more
effective result
incisional wound to release exudate entrapped
in tissue compartments will facilitate a more
effective result
200$/Rs. 15,184
Endodontic
Spoon Excavator
Long
Shank
Endodontic
Spoon Excavator
Long
Shank
•Chestneretal.reportedpainreliefinpatientswithsevereandrecalcitrantperi-
radicularpainwhencorticaltrephinationwasperformed.Additionally,inthe
asymptomaticpatient,corticaltrephinationhasbeenshowntodecreaseby16–25%
post-operativepainincidencewhenperformedprophylactically.
•Moosetal.comparedthedifferenceinpost-operativepainreliefinpatientswithacute
peri-radicularpainofpulpaloriginwhentreatedbyeitherpulpectomyaloneor
pulpectomywithcorticaltrephination.Therewerenosignificantdifferencesbetween
thegroups.
radicularpainwhencorticaltrephinationwasperformed.Additionally,inthe
asymptomaticpatient,corticaltrephinationhasbeenshowntodecreaseby16–25%
post-operativepainincidencewhenperformedprophylactically.
•Moosetal.comparedthedifferenceinpost-operativepainreliefinpatientswithacute
peri-radicularpainofpulpaloriginwhentreatedbyeitherpulpectomyaloneor
pulpectomywithcorticaltrephination.Therewerenosignificantdifferencesbetween
thegroups.
Anapicaltrephinationproceduredidnotsignificantly(p>0.05)reducepain,percussionpain,
swelling,ornumberofibuprofentabletstakeninsymptomaticnecroticteethwithperiapical
radiolucencies.
Thetrephinationproceduredidsignificantly(p<0.05)reducetheuseofacetaminophenwith
codeineoverallforthe7days.
Inconclusion,becausetherewasnotasignificantreductioninpain,percussionpain,or
swellingwecannotrecommendtheroutineuseofanapicaltrephinationprocedure,asused
inthisstudy,insymptomaticnecroticteethwithradiolucencies.
swelling,ornumberofibuprofentabletstakeninsymptomaticnecroticteethwithperiapical
radiolucencies.
Thetrephinationproceduredidsignificantly(p<0.05)reducetheuseofacetaminophenwith
codeineoverallforthe7days.
Inconclusion,becausetherewasnotasignificantreductioninpain,percussionpain,or
swellingwecannotrecommendtheroutineuseofanapicaltrephinationprocedure,asused
inthisstudy,insymptomaticnecroticteethwithradiolucencies.
PHARMACO-THERAPEUTICS
1.Thereisnospecificanalgesicthatispreferentially
effectiveforthepaininducedduringrootcanal
therapy.
2.Avoidindiscriminateusageofopiod/steroidal
analgesics.
3.NSAIDsareshowntobeeffectiveinreducingpainin
mostofthesituations.Forseverepain,acombination
approach(steroidalandnonsteroidal)ismost
effective.
1.Thereisnospecificanalgesicthatispreferentially
effectiveforthepaininducedduringrootcanal
therapy.
2.Avoidindiscriminateusageofopiod/steroidal
analgesics.
3.NSAIDsareshowntobeeffectiveinreducingpainin
mostofthesituations.Forseverepain,acombination
approach(steroidalandnonsteroidal)ismost
effective.
WHO Analgesic Ladder
•Ifpainismoderatetosevere,opioidshouldbe
employedalongwiththenon-opioidanalgesics,
butatthisstageusealowpotencyopioid.
Forex:Codeine,oxycodone,hydrocodone
isusedfirst.
•Iftreatmentpainisinadequate(or)patients
presentswithseverepain,ahighpotency
opioid(morphine,hydro-morphine)
shouldbeselectedandprescribealongwith
thenon-opioidanalgesics.
•Ifpainismoderatetosevere,opioidshouldbe
employedalongwiththenon-opioidanalgesics,
butatthisstageusealowpotencyopioid.
Forex:Codeine,oxycodone,hydrocodone
isusedfirst.
•Iftreatmentpainisinadequate(or)patients
presentswithseverepain,ahighpotency
opioid(morphine,hydro-morphine)
shouldbeselectedandprescribealongwith
thenon-opioidanalgesics.
ANALGESIC TRADE NAME DOSE RANGE (MG) DOSAGE/DAY
(MG)
Acetaminophen Crocin, Dolo325-1000 4000
Aspirin Many 325-1000 4000
DiciofenacPotassium Cataflam 50-100 150-200
Etodolac Lodine 200-400 1200
Fenoprofen Nalfon 200 1200
Flurbiprofen Ansaid 50-100 200-300
Ibuprofen Brufen200-400 2400
Ketoprofen Orudis 25-75 300
KetorolacKetorolDT30-60 60
(MG)
Acetaminophen Crocin, Dolo325-1000 4000
Aspirin Many 325-1000 4000
DiciofenacPotassium Cataflam 50-100 150-200
Etodolac Lodine 200-400 1200
Fenoprofen Nalfon 200 1200
Flurbiprofen Ansaid 50-100 200-300
Ibuprofen Brufen200-400 2400
Ketoprofen Orudis 25-75 300
KetorolacKetorolDT30-60 60
Anxiety Reducing Drugs (Sedatives)
•Diazepam ~ 5 mg oral
•Lorazepam ~ 0.25 mg oral
•Triazolam ~ 5 mg oral
Rs. 30
Rs. 8
•Diazepam ~ 5 mg oral
•Lorazepam ~ 0.25 mg oral
•Triazolam ~ 5 mg oral
Rs. 30
Rs. 8
Acupuncture
1.Usedasanalternativetherapyforrelievingdental
pain,IntheGenevaWHO2003report,painin
dentistry,includingdentalpain,facial,and
postoperativepain,werelistedamongtheconditions
forwhichacupunctureappearstobeaneffective
treatment.
2.Canbeeffectiveinrelievingdentalpain,eitherduring
surgicalproceduresoraftersurgery.
3.Acupuncturewasreportedtobeeffective(atthe
90%+level)forthereliefof"tooth-relatedpain.
Wong LB. acupuncture in dentistry: its possible role and application. Proc
Sing Healthc. 2012;21:48e56.
Postoperative endodontic pain was
reduced to tolerable levels within 15 to
20 min. This relief lasted indefinitely in
almost 50% of the cases.
LI 4 or Large Intestine 4
SI 18 or Small Intestine 18
1.Usedasanalternativetherapyforrelievingdental
pain,IntheGenevaWHO2003report,painin
dentistry,includingdentalpain,facial,and
postoperativepain,werelistedamongtheconditions
forwhichacupunctureappearstobeaneffective
treatment.
2.Canbeeffectiveinrelievingdentalpain,eitherduring
surgicalproceduresoraftersurgery.
3.Acupuncturewasreportedtobeeffective(atthe
90%+level)forthereliefof"tooth-relatedpain.
Wong LB. acupuncture in dentistry: its possible role and application. Proc
Sing Healthc. 2012;21:48e56.
Postoperative endodontic pain was
reduced to tolerable levels within 15 to
20 min. This relief lasted indefinitely in
almost 50% of the cases.
LI 4 or Large Intestine 4
SI 18 or Small Intestine 18
Explanations and Instructions
ØDetailedexplanationsoftheprocedures,theexpectedbenefits,andthepossiblepain
responseshelptoallaythepatients'anxietyandapprehensionandreducetension.
ØPatientsweremorewillingtoendurepainifitwaspredicted.
ØSpecificinstructionssuchasapplicationofice,
exacttimingforingestionofanalgesics,and
possiblealterationsinthecharacterofpainalso
resultinanelevationofpainthreshold.
ØAninfrequentunexpectedanxietymaybe
inducedbypredictionsofpainandswellingthat
failtomaterialize,butsuchanxietiescanusually
beresolvedbyre-assurrances.
ØDetailedexplanationsoftheprocedures,theexpectedbenefits,andthepossiblepain
responseshelptoallaythepatients'anxietyandapprehensionandreducetension.
ØPatientsweremorewillingtoendurepainifitwaspredicted.
ØSpecificinstructionssuchasapplicationofice,
exacttimingforingestionofanalgesics,and
possiblealterationsinthecharacterofpainalso
resultinanelevationofpainthreshold.
ØAninfrequentunexpectedanxietymaybe
inducedbypredictionsofpainandswellingthat
failtomaterialize,butsuchanxietiescanusually
beresolvedbyre-assurrances.
CULTURE SENSITIVITY
1.Amongstthevariousmethodsofselfassessmentanddeterminingtheexactchoiceof
ICM(organismspecific)andselectionofappropriateantibiotics,culturingisthemost
reliableandtrusted.
2.However,routineuseofculturingcanbequitetediousandexpensiveandmaynot
serveitsexactpurpose.
3.Researchershaveshownthatroutineuseofculturinginnormaluncomplicatedcases,
hasnosignificantdifferencesinflareupratesadsuccessrates.
4.Casessuchasrecurrentabscesscasesandinpatientswhoareimmuno-compromized
warrantuseofculturingandsensitivitytesting.
1.Amongstthevariousmethodsofselfassessmentanddeterminingtheexactchoiceof
ICM(organismspecific)andselectionofappropriateantibiotics,culturingisthemost
reliableandtrusted.
2.However,routineuseofculturingcanbequitetediousandexpensiveandmaynot
serveitsexactpurpose.
3.Researchershaveshownthatroutineuseofculturinginnormaluncomplicatedcases,
hasnosignificantdifferencesinflareupratesadsuccessrates.
4.Casessuchasrecurrentabscesscasesandinpatientswhoareimmuno-compromized
warrantuseofculturingandsensitivitytesting.
TREATMENT
OF FLARE-
UPS IN
DIFFERENT
CLINICAL
SITUATIONS
OF FLARE-
UPS IN
DIFFERENT
CLINICAL
SITUATIONS
Vital Pulp
Flare-upsseldomoccurinthesesituations,butwhen
theydo,theproblemlikelyisrelatedtotissue
remnantsthathavebecomeinflamed.
Workinglengthsshouldbeverifiedandthecanals
carefullycleanedwithcopiousirrigation
Adrycottonpelletisthenplacedfollowedbya
temporaryrestoration.
Thepainwillusuallysubsideratherquicklyand
predictablyfollowingadministrationofanalgesics.
Flare-upsseldomoccurinthesesituations,butwhen
theydo,theproblemlikelyisrelatedtotissue
remnantsthathavebecomeinflamed.
Workinglengthsshouldbeverifiedandthecanals
carefullycleanedwithcopiousirrigation
Adrycottonpelletisthenplacedfollowedbya
temporaryrestoration.
Thepainwillusuallysubsideratherquicklyand
predictablyfollowingadministrationofanalgesics.
Previously Necrotic Pulp With No
Swelling
Theseteethmaydevelopaflare-upafterthe
appointment.
Theabscessisconfinedtoboneandisgenerally
verypainful.Management
Anaesthesia
Openingtooth
Drainage
Irrigation
Medicament
Resealing
Swelling
Theseteethmaydevelopaflare-upafterthe
appointment.
Theabscessisconfinedtoboneandisgenerally
verypainful.Management
Anaesthesia
Openingtooth
Drainage
Irrigation
Medicament
Resealing
Necrotic Pulps With Swelling
Localizedswelling.
The tooth should be opened and
the canals re-debrided and
closed.
Incision and drainage.
Localizedswelling.
The tooth should be opened and
the canals re-debrided and
closed.
Incision and drainage.
Non Localized Swelling
Non-localizedswellings,thatis,rapidly
spreadingintospaces,andthose
patientswithsystemicsignsofinfection,
requireantibiotics.
Ifthespreadofinfectionisalarming,
extraoraldrainagemaybeperformed
andthepatientmayevenbe
hospitalized.
Non-localizedswellings,thatis,rapidly
spreadingintospaces,andthose
patientswithsystemicsignsofinfection,
requireantibiotics.
Ifthespreadofinfectionisalarming,
extraoraldrainagemaybeperformed
andthepatientmayevenbe
hospitalized.
POST TREATMENT FLAREUPS
According to Seltzer nearly 1/3rd of
patients experience pain following
obturation
•Mild discomfort and tenderness
•Severe excruciating pain
•Pain with or without swelling
According to Seltzer nearly 1/3rd of
patients experience pain following
obturation
•Mild discomfort and tenderness
•Severe excruciating pain
•Pain with or without swelling
1.Forcesexertedduringspreaderpenetration
~1.4kgformore,pluggerinsertion.
2.Overheatingandmorethanlongertimeof
contactofheatedinstrumenttipwithrootcanal
walls~>10°Criseintemp.
3.Overfillingandoverextension
4.Overinstrumentation
5.Missedcanals
6.Sealerextrusion
7.Underobturationandinstrumentation
8.Occlusalpre-maturities
9.Poorcoronalseal
10.Othermishaps
>1.4kgf
~1.4kgformore,pluggerinsertion.
2.Overheatingandmorethanlongertimeof
contactofheatedinstrumenttipwithrootcanal
walls~>10°Criseintemp.
3.Overfillingandoverextension
4.Overinstrumentation
5.Missedcanals
6.Sealerextrusion
7.Underobturationandinstrumentation
8.Occlusalpre-maturities
9.Poorcoronalseal
10.Othermishaps
>1.4kgf
Management
1.Usually pain is mild and transient and managed with mild analgesics
2.Check occlusion
3.Take angled IOPAs
4.Reassure patients and recall patient in 1-2 days
5.Persistent pain and swelling
6.Removefillings
7.I & D if swelling is fluctuant and has perforate through the cortex
8.Cortical trephination
9.Systemic medication
10.Periapical Surgery
1.Usually pain is mild and transient and managed with mild analgesics
2.Check occlusion
3.Take angled IOPAs
4.Reassure patients and recall patient in 1-2 days
5.Persistent pain and swelling
6.Removefillings
7.I & D if swelling is fluctuant and has perforate through the cortex
8.Cortical trephination
9.Systemic medication
10.Periapical Surgery
Clinical
condition
Micro-
organismsIntracanalmedicament of choiceDuration
TripleAntibiotic
pasteRegeneration
•Immature teeth with open apex
•Wide apical foramen
•Over instrumentation
•Inter appointment flare up in
diabetics
•Weeping canals
1 –2 weeks
change the
dressing till the
lesion subsides
Ledermixpaste
Micro organisms
of pulp &
periodontal
infection
•Over instrumentation
•Flare ups
•Replantation
•Traumatized tooth
•External inflammatory root
resorption
•Inflammatory periapical root
resorption
•Severe pain and tenderness on
percussion
For a week but
not more than 2
weeks
condition
Micro-
organismsIntracanalmedicament of choiceDuration
TripleAntibiotic
pasteRegeneration
•Immature teeth with open apex
•Wide apical foramen
•Over instrumentation
•Inter appointment flare up in
diabetics
•Weeping canals
1 –2 weeks
change the
dressing till the
lesion subsides
Ledermixpaste
Micro organisms
of pulp &
periodontal
infection
•Over instrumentation
•Flare ups
•Replantation
•Traumatized tooth
•External inflammatory root
resorption
•Inflammatory periapical root
resorption
•Severe pain and tenderness on
percussion
For a week but
not more than 2
weeks
Intra canal
medicamentMicro-organismsClinical conditionDuration
Calcium
Hydroxide
Black-pigmented
bacteria,P.intermedia,
P.nigrescens,P. endodontalis,
P.gingivalis, F.nucleatum,
Veillonella, parvula,
Eubacterium&other species
•Primary infectionA week
Calcium
Hydroxide with
chloxhexidine
Enterococci& streptococci
followed by lactobacilli,
Actinomycesspecies,
peptostreptococci, Candida,
Eubacteriumalactolyticus,
Propionibacterium
propionicum
•Secondaryor persistent
infection
•Sinus tract closure
For 7 days, till the
lesion heals
medicamentMicro-organismsClinical conditionDuration
Calcium
Hydroxide
Black-pigmented
bacteria,P.intermedia,
P.nigrescens,P. endodontalis,
P.gingivalis, F.nucleatum,
Veillonella, parvula,
Eubacterium&other species
•Primary infectionA week
Calcium
Hydroxide with
chloxhexidine
Enterococci& streptococci
followed by lactobacilli,
Actinomycesspecies,
peptostreptococci, Candida,
Eubacteriumalactolyticus,
Propionibacterium
propionicum
•Secondaryor persistent
infection
•Sinus tract closure
For 7 days, till the
lesion heals
TAKE HOME MESSAGE
üProper diagnosis
üIdentify the correct tooth causing pain
üAscertain whether tooth is vital or non vital
üIdentify if tooth is associated with periapical lesion
üDetermine correct working length
üRadiographs
üApex locators
üComplete extirpation of vital pulp
üIrrigation: NaOCland CHX
üAvoid filing too close to the radiographic apex
üPreform apical trephination only if necessary
üReduce tooth from occlusion especially if apex is
severely violated by over instrumentation
üPlacement of ICM
üPrescription of mild analgesics and antibiotics whenever
condition warrants it
üProper diagnosis
üIdentify the correct tooth causing pain
üAscertain whether tooth is vital or non vital
üIdentify if tooth is associated with periapical lesion
üDetermine correct working length
üRadiographs
üApex locators
üComplete extirpation of vital pulp
üIrrigation: NaOCland CHX
üAvoid filing too close to the radiographic apex
üPreform apical trephination only if necessary
üReduce tooth from occlusion especially if apex is
severely violated by over instrumentation
üPlacement of ICM
üPrescription of mild analgesics and antibiotics whenever
condition warrants it
SUMMARY
•Various Definitions
•Flare Up Criteria
•Measurement: VAS Scale/Rimmer’s
Index
•Incidence
•Risk Factors
•Etiology
•Theories of Flare Up
•Preventive Measures
•Definitive Management
•Clinical Situations in Flare Up
•Various Definitions
•Flare Up Criteria
•Measurement: VAS Scale/Rimmer’s
Index
•Incidence
•Risk Factors
•Etiology
•Theories of Flare Up
•Preventive Measures
•Definitive Management
•Clinical Situations in Flare Up
CONCLUSION
vEventhoughithasbeendemonstratedthataflare-uphasnosignificant
influenceontheoutcomeofendodontictreatment,itsoccurrenceis
extremelyundesirableforbothpatientandtheclinicianandcan
underminetheclinician-patientrelationships.
vTherefore,clinicanshouldemploypropermeasureandfollow
appropriateguidelinesinanattempttopreventthedevelopmentof
inter-appointmentseverpainandorswelling.
vEventhoughithasbeendemonstratedthataflare-uphasnosignificant
influenceontheoutcomeofendodontictreatment,itsoccurrenceis
extremelyundesirableforbothpatientandtheclinicianandcan
underminetheclinician-patientrelationships.
vTherefore,clinicanshouldemploypropermeasureandfollow
appropriateguidelinesinanattempttopreventthedevelopmentof
inter-appointmentseverpainandorswelling.
REFERENCES
1.Walton R, Fouad A. Endodontic interappointment flareups. a prospective study of incidence and related factors. J Endod1992: 18: 172–177.
2.Morse D. Infection-related mental and inferior alveolar nerve paresthesia: literature review and presentation of two cases. J Endod1997: 23: 457–460
3.MorC, RotsteinI, Friedman S. Incidence of interappointment emergency associated with endodontic therapy. J Endod1992: 18: 509–511.
4.Trope M. Relationship of intracanal medicaments to endodontic flare-ups. EndodDent Traumatol1990: 6: 226–229.
5.Trope M. Flare-up of single-visit endodontics. IntEndodJ 1991: 24: 24–27.
6.Sim CK. Endodontic interappointment emergencies in a Singapore private practice setting. a retrospective study of incidence and cause-related factors.
Singapore Dent J 1997: 22: 22–27.
7.ImuraN, ZuoloM. Factors associated with endodontic flare-ups: a prospective study. IntEndodJ 1995: 28: 261–265.
8.Eleazer P, Eleazer K. Flare-up rate in pulpallynecrotic molars in one-visit versus two-visit endodontic treatment. J Endod1998: 24: 614–616.
9.TorabinejadM, Kettering /, McGraw I, et at Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps.JEndod
1988:[4:261-6.
10.SelzherS, NaidorfI. Flare-ups in endodontics I. Etiologyfactors. J Endod1985;11:472-278.
11.BystromA, SunquistG. Bacteriological evaluation of the effect of 0.5% sodium hypochlorite in endodontic therapy.OralSurgOral Med Oral PatholOral
RadiolEndod1983:55:307-12.
12.Siqueira J. Aetiology of the endodontic failure: why well treated teeth can fail. IntEndodJ 2001;34: 1-10.
13.SiquciraI. Reaction of periradiculartissues to root canal treatrnent: Benefits and drawbacks.. Endodontic Topics 2005;10:123-47.
14.Sundqvist G, FigdorO. Life as an endodontic pathogen. Ecological differences between the untreated and root-filled canals. EndodTopics 2003;6:3-28.
15.Mid treatment flareups in endodontics –a dilemma dr. Neeta Shetty, Endodontology
16.Selye H. The part of inflammation in the local adaptation syndrome. In: Jasmin G,
17.Robert A, eds. The mechanism of inflammation. Acta Montreal 1953;53–74.
18.MohornHW, Dowson J, Blankenship JR. Odonticperiapical pressure following vital pulp extirpation. Oral Surg1971;31:536.
19.Siqueira JF Jr. Endodontic infections: concepts, paradigms and perspectives. Oral
20.SurgOral Med Oral PatholOral RadiolEndod2002: 94: 281–293.
21.Sundqvist G. Bacteriological studies of necrotic dental pulps. Dissertation, University of Umea, Umea, Sweden, 1976.
22.Van WinkelhoffAJ, Carlee AW, de Graaff J. Bacteroides endodontalisand others black-pigmented Bacteroides species in odontogenic abscesses. Infect
Immun1985: 49: 494–498.
23.HaapasaloM, RantaH, RantaK, Shah H. BlackpigmentedBacteroides spp. in human apical periodontitis. Infect Immun1986: 53: 149–153.
24.Siqueira JF Jr, Roˆc ̧as IN, SoutoR, UzedaM, Colombo AP. Checkerboard DNA–
25.DNA hybridization analysis of endodontic infections. Oral SurgOral Med Oral PatholOral RadiolEndod2000: 89: 744–748.
1.Walton R, Fouad A. Endodontic interappointment flareups. a prospective study of incidence and related factors. J Endod1992: 18: 172–177.
2.Morse D. Infection-related mental and inferior alveolar nerve paresthesia: literature review and presentation of two cases. J Endod1997: 23: 457–460
3.MorC, RotsteinI, Friedman S. Incidence of interappointment emergency associated with endodontic therapy. J Endod1992: 18: 509–511.
4.Trope M. Relationship of intracanal medicaments to endodontic flare-ups. EndodDent Traumatol1990: 6: 226–229.
5.Trope M. Flare-up of single-visit endodontics. IntEndodJ 1991: 24: 24–27.
6.Sim CK. Endodontic interappointment emergencies in a Singapore private practice setting. a retrospective study of incidence and cause-related factors.
Singapore Dent J 1997: 22: 22–27.
7.ImuraN, ZuoloM. Factors associated with endodontic flare-ups: a prospective study. IntEndodJ 1995: 28: 261–265.
8.Eleazer P, Eleazer K. Flare-up rate in pulpallynecrotic molars in one-visit versus two-visit endodontic treatment. J Endod1998: 24: 614–616.
9.TorabinejadM, Kettering /, McGraw I, et at Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps.JEndod
1988:[4:261-6.
10.SelzherS, NaidorfI. Flare-ups in endodontics I. Etiologyfactors. J Endod1985;11:472-278.
11.BystromA, SunquistG. Bacteriological evaluation of the effect of 0.5% sodium hypochlorite in endodontic therapy.OralSurgOral Med Oral PatholOral
RadiolEndod1983:55:307-12.
12.Siqueira J. Aetiology of the endodontic failure: why well treated teeth can fail. IntEndodJ 2001;34: 1-10.
13.SiquciraI. Reaction of periradiculartissues to root canal treatrnent: Benefits and drawbacks.. Endodontic Topics 2005;10:123-47.
14.Sundqvist G, FigdorO. Life as an endodontic pathogen. Ecological differences between the untreated and root-filled canals. EndodTopics 2003;6:3-28.
15.Mid treatment flareups in endodontics –a dilemma dr. Neeta Shetty, Endodontology
16.Selye H. The part of inflammation in the local adaptation syndrome. In: Jasmin G,
17.Robert A, eds. The mechanism of inflammation. Acta Montreal 1953;53–74.
18.MohornHW, Dowson J, Blankenship JR. Odonticperiapical pressure following vital pulp extirpation. Oral Surg1971;31:536.
19.Siqueira JF Jr. Endodontic infections: concepts, paradigms and perspectives. Oral
20.SurgOral Med Oral PatholOral RadiolEndod2002: 94: 281–293.
21.Sundqvist G. Bacteriological studies of necrotic dental pulps. Dissertation, University of Umea, Umea, Sweden, 1976.
22.Van WinkelhoffAJ, Carlee AW, de Graaff J. Bacteroides endodontalisand others black-pigmented Bacteroides species in odontogenic abscesses. Infect
Immun1985: 49: 494–498.
23.HaapasaloM, RantaH, RantaK, Shah H. BlackpigmentedBacteroides spp. in human apical periodontitis. Infect Immun1986: 53: 149–153.
24.Siqueira JF Jr, Roˆc ̧as IN, SoutoR, UzedaM, Colombo AP. Checkerboard DNA–
25.DNA hybridization analysis of endodontic infections. Oral SurgOral Med Oral PatholOral RadiolEndod2000: 89: 744–748.
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