ENDODONTOLOGY MID TREATMENT FLAREUPS IN ENDODONTICS

ENDODONTOLOGY
MID TREATMENT FLAREUPS IN ENDODONTICS
–A DILEMMA
Author:
Dr. Neeta Shetty .M.D.S. *
ABSTRACT
Endodontic emergencies constitute a major part of dental emergencies , which is an unscheduled visit by the
patient to the dental clinic .Flareups during endodontic treatment is an undesirable occurrence for both
patient and clinician .This paper reviews the predisposing factors responsible for flare-ups, their management
and prevention of flare-ups.
Key words-Emergency,Flareups, Pain, Swelling.
INTRODUCTION
common following root canal therapy,it should be
Flareup is described as the occurrence of pain,
expected and anticipated by patients.However a
swelling or the combination of these during the
flareup with severe pain and swelling is a rare
course of root canal therapy, which results in
occurrence ranging from 1.4% -16% 5.
unscheduled visits by patients 1 .Pain may occur
CLINICAL CONDITIONS
soon after initiating endodontic treatment for an
Common clinical conditions associated with
asymptomatic tooth or shortly after the initial
flareups are -
emergency treatment or during the course of the
treatment.It is suggested that the incidence of
Apical peridontitis secondary to treatment
interappointment emergency associated with
A tooth which was symptomless before the initiation
endodontic therapy was 4.2% and unrelated to
of endodontic treatment but becomes sensitive to
patients sex , age or the tooth location by Mor C et
percussion during the course of the treatment.
al 2 .
Causes for this condition most frequently are over
instrumentation or over medication or forcing debris
Flareups may occur with the best of the therapy,
into the periapical tissues.
but most flareups occur when improper treatment
is rendered or when insufficient time is allowed for
Incomplete removal of pulp tissues during the
specific modalities in therapy according to Franklin
intial appointment- In some instances due to lack
3
S Weine .
Acute periapical inflammation is the
of time factor the endodontic therapy may consist
most common cause of mid treatment pain and
of incomplete pulpectomy after a diagnosis of acute
swelling. Mid treatment emergencies are related to
or chronic pulpitis.This situation generally occurs
irritants left within root canal system, iatrogenic
when the radicular pulp is already inflamed.
factors under the control of the operator and host
Phoenix abscess-It is a condition that occurs
factors 4 The occurrence of mild pain is relatively
in teeth with necrotic pulps and apical lesions that
* Reader, Department of Conservative Dentistry and Endodontics, Manipal College of Dental sciences, Mangalore.
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ENDODONTOLOGY
MID TREATMENT FLAREUPS IN ENDODONTICS – A DILEMMA
are asymptomatic . There is a exacerbation of a
periapical lesion leading to liquefaction necrosis
previously symptomless periradicular lesion.The
indicative of alteration of local adaptation syndrome
reason for this phenomenon is thought to be due to
7
the alteration of the internal environment of the root
stop and extrusion of a large amount of infected
canal space during instrumentation which activates
debris can result in severe periradicular injury,
6
the bacterial flora .
. During over instrumentation, due to lack of apical
causing a flareup .
Recurrent periapical abscess - It is a condition
Microbial factors play an important role in
where a tooth with an acute periapical abscess is
endodontic
relieved by emergency treatment after which the
contaminated debris to the periapical tissues is one
acute symptoms return. In some cases the abscess
of the principle cause of post operative pain
may recur more than once,due to micro organism
.Studies of microbial flora of the root canal shows
of high virulence or poor host resistance.
the presence of a considerable variety of
flareups.Apical
extrusion
of
5
microorganisms. According to Sundquist most
ETIOLOGY
strains found in the root canals with necrotic pulp
Dr Seltzer discussed a number of hypothesis
are obligately anaerobic microorganisms
thought to be related to the etiology of flareups 7.
7
These
organisms can produce enzymes which are
Alteration of the local adaption syndrome .
collagenolytic and fibrolytic.They also produce
Changes in periapical tissue pressure .
endotoxin which in turn activates Hageman factor,
which leads to production of bradykinin a potent
Microbial factors.
pain mediator.Chemical mediators which are
Effects of chemical mediators.
activated during inflammation ,such as histamine
Changes in cyclic nucleotides.
,serotonin ,prostaglandin, platelet activating factor,
leukotrienes etc are all capable of producing pain 4
Immunological phenomena.
DIAGNOSIS AND MANAGEMENT
Various psychological factors.
Establishing the cause the flareup is an
Alteration in local adaptation syndrome
important step towards management of mid
explained by Selye is one of the most accepted
treatment pain.It is necessary to forewarn the patient
theory explaining flareups in symptomless tooth
that he may experience slight pain after the
.He showed that there is a local tissue adaptation
appointment and advise an over-the-counter
to applied irritants .Chronic inflammation persists if
analgesic.When patient experience moderate to
irritant is not removed .However when a new irritant
severe pain after the first appointment , the clinican
is introduced to the inflamed tissue, a violent
must review the diagnosis to ensure the tooth under
reaction may occur.When endodontic therapy is
treatment has been identified correctly as the source
performed new irritants in the form of
of pain . If so the periapical and pulpal status have
medicaments,irrigating solutions, chemically altered
to be reviewed to determine whether the patient
tissue proteins or debris may be introduced into the
has a inflammatory condition or acute infection 1 .
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ENDODONTOLOGY
MID TREATMENT FLAREUPS IN ENDODONTICS – A DILEMMA
the working length, complete removal of the
Pain associated with instrumentationIt can manifest as – Acute periapical
remaining vital pulp tissue and relieving the tooth
peridontitis or as Phoenix abscess.
from occlusion.
Acute periapical peridontitis occurs due to
Pain associated with pulpal necrosis-
overinstrumentation ,extrusion of canal contents
Studies suggest that the incidence of flare-ups
through the apex ,leaving the tooth in traumatic
is higher with necrotic pulp tooth than in vital
occlusion or placing too much of intracanal
tooth.Tayfun Alacam et al in his study found that
6
. Absence of an apical stop and
the incidence of flare-ups in tooth with necrotic pulp
presence of blood in the apical portion of the root
is 7.17%10 .The best method of managing the
canal usually indicates overinstrumentation 4.
necrotic pulp is to establish accurate working length
Treatment constitutes of reopening the tooth
of tooth and complete instrumentation of root canal
,irrigation with a combination of irrigants such as
in the first appointment . Removal of debris from
sodium hypochlorite and chlorhexidine ,placement
the canal should be the goal.When there is a flareup
of a suitable intracanal medicament and relieving
the tooth should be reopened , observe for the
the tooth from occlusion. According to Seltzer,
presence of pus .If there is pus in the canal without
intracanal medication reduces the possibility of flare-
soft tissue swelling it indicates an acute abscess in
ups due to the forcing of infected debris into the
early stages,in such cases pain is more severe .If
medicament
8
.Cohen advocated relieving
only pain is present copious irrigation should be
occlusion prior to root canal therapy to prevent post
used and all debris are removed . An intracanal
periapical tissues
9
operative pain .
medicament is placed and resealed. If pain is
present along with swelling then drainage should
Phoenix abscess is a difficult condition to deal
be established either through the apex of the tooth
with and it occurs subsequent to intial
or the soft tissue .It as been advocated that antibiotics
instrumentation of the canal with a pre existing
and analgesics such as NSAIDS be prescribed.The
chronic periapical lesion.The sign and symptoms
use of antibiotics alone without establishing
mimic that of acute periapical abscess.Treatment
drainage is not considered appropriate.The concept
consist of irrigation , debridement of the root canal
of leaving the canal open for drainage is
and drainage either through the canal or
controversial .Seltzer and Weine don’t advocate it
trephination depending on the intensity of the pain
,since exposure to oral flora serves no useful purpose
.Antibiotics and analgesics can be prescribed.
and may actually cause subsequent flareups when
additional treatment is undertaken
Pain subsequent to vital pulp extirpationMid treatment pain following complete
3,8
.
PREVENTION OF FLAREUPS -
removal of vital pulp is uncommon .When pain is
Flare ups causes a dilemma to the clinican
intense it indicates incomplete removal of vital pulp
when it is difficult for the patient to comprehend
tissue from the root canal and if the tooth becomes
that they enter the office pain free, but experience
tender , the inflammation process has involved the
a sustained increase or severe pain during or after
periapical tissues .Treatment consist of reestablishing
22
ENDODONTOLOGY
MID TREATMENT FLAREUPS IN ENDODONTICS – A DILEMMA
treatment.Certain precaution that are taken by a
when the treatment rendered is of the highest
clinican can prevent flare-ups in most instances.
standard.It is the duty of the clinican to explain it to
the patient. Prompt and effective treatment of flare-
Proper diagnosis-
ups is an essential part of the overall endodontic
Identify the correct tooth causing pain.
treatment .
Ascertain whether tooth is vital or non vital.
Identify if tooth is associated with periapical
REFERENCES -
lesion.
Determine correct working length.-
1.
Gerald W Harrington,Eugene Watkin.Mid treatment
Flareups.DCNA; 36:1992 409-423.
2.
Mor C, Rotstein I, Friedman S.Incidence of
interappointment emergency associated with
endodontic therapy.J Endod ;18:10,1992 509-511.
3.
Franklein S.Weine .Endodontic Therapy Fifth
Edition,Mosby;203-237.
4.
Mahmoud Torabinejad , Richard E. Walton,
Managing endodontic emergencies.JADA. 1999;
122:99 103.
5.
Jose
F.Siqueira,Isabela
N.Rocas,Amauri
Favieri,Andreia G .Machado, Sergio M. Gahyva, Julio
C.M.Oliveira. Incidence of post operative pain after
intracanal procedures based on an antimicrobial
strategy. J Endod.2002;28:457-460.
6.
P.Carrotte.Endodontic Part 3. Treatment of
endodontic emergenies. BDJ .2004 ;197:299-305.
7.
Samuel Seltzer, Irving J. Naidorf . Flareups in
endodontics.1
Etiological
factors.
J Endod .2004;30:476-481.
8.
Samuel Seltzer, Irving J. Naidorf . Flareups in
endodontics.
II. Therapeutic Measures.
J Endod. 2004;30:482-488
9.
Shephen Cohen.Pathways of the pulp. Mosby;
6th edition 1997:44-46.
Radiographs.
Apex locaters
Complete extirpation of vital pulp.
Irrigation Preferably with combination of irrigants such
as sodium hypochlorite and chlorohexedine.
Avoid filing too close to the radiographic
apex.
Preform apical trephination only if necessary.
Reduce tooth from occlusion especially if
apex
is
severely
violated
by
overinstrumentation.
Placement of intracanal medicaments.
Prescription of mild analgesics and antibiotics
whenever condition warrants it .
CONCLUSION –
The occurrence of mild pain and discomfort
10. Tayfun Alacam ,Ali Cemal Tinaz .Interappointent
emergencies in teeth with necrotic pulps.
J Endodon 2002;28:375-377.
following endodontic treatment is common even
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