Flare ups described as occurrence of pain, swelling or combination of both during the course of root canal therapy which result in unscheduled visit by the patient

1. Mid treatment
Flare ups in endodontic
Done by:-
Dr. Sarah Abd Al-Salam
Supervise by:-
Dr. Sawsen Al-Rubaie

2. Contents
 Flare ups definition
 Predisposing factors
 The etiology
 Clinical condition of the flare ups
 The hypothesis or microbiology of flare ups
 Diagnosis and management
 Precaution to prevent flare ups

3. Flare ups in endodontics
Flare ups is described as the occurrence of severe pain
,swelling or the combination of these during the course of root
canal therapy which result in unscheduled visit by patient

4. Pain may occur soon after intiating endodontic treatment for
an asymptomatic tooth or shortly after the initial emergency
treatment or during the course of treatment

5. Flare ups may even occur with the best of therapy but these
flare up usually due to improper treatment or when
insufficient time is allowed for specific modalities in therapy

6. Predisposing factors
 Age
 Gender
Tooth type
Pulpal status
 Preoperative pain
 Allergies
 Sinus tract

7. Causes of flareup
Mechanical Chemical Microbial

8. Mechanical causes
 Over instrumentation of root canal

9.  Incorrectly measured working length
 Inadequate removal of pulp tissue

10. Chemical causes
 Irrigation solutions
 Intracanal medicaments
 Over extended root filling

11. Microbial causes
Microorganisms are the major causative agents of acute periradicular
inflammation regardless of whether it develop preoperatively or
postoperatively
There are some special circumstance in which microorganisms can
cause flare ups
 Apical extrusion of infected debries
 Change in endodontic microbial
 Secondary intraradicular infection
 Increase of the oxidation reduction potential

12. Apical extrusion of debries

13. Change in endodontic microbia

14. Secondary intraradicular infection

16. Increase of the oxidation reduction potential

17. Clinical condition of flare up
 Apical periodontitis secondary to treatment
Causes for this condition are:-
 Over instrumentation or over medication or forcing
debries into periapical tissue

18.  Balance between the microbial aggression and host
defence of the periradicular tissue is disrupted
 Host will mobilize an acute inflammation to re establish
the equilibrium
 Apical foramen enlargement increase influx of exudate and
blood in the root canal

19. Confirmatory test

20.  Incomplete removal of pulp tissue during the initial
appointment
In some instances due to the lack of time factor the endodontic therapy
may consist of incomplete inflamed pulp tissue after a diagnosis of
acute or chronic pulpities

21.  Recrudescence of chronic apical periodontitis
(Phoenix Abscess)
 Is the condition that occur in the teeth with necrotic pulp
and apical lesions that are symptomless

22.  The reason for this phenomena is thought to be due to the alteration
of the internal environment of root canal space during instrumentation
which activate the bacterial flora
 Mobility, tenderness and swelling are usually the sign and symptoms
found in phoenix abscess

23.  Recurrent periapical abscess :- It is the condition where a
tooth with an acute periapical abscess is relieved by emergency
treatment after which the acute symptoms return
In some cases , the abscess may recurrent more than once due to
microorganism of high virulence or poor host resistence

24. The hypothesis
There are a numbers of hypothesis thought to be related to the etiology
of flareups
 Alteration of local adaptation syndrome
 Change in the periapical tissue pressure
 Microbial factors
 Effects of chemical mediators
 Changes in cyclic nucleotides
Immunological phenomena
 Various psychological factors

25. Alteration of local adaptation syndrome
New irritant Inflamed tissue
Violent reaction may occur due to disturbance in local tissue
adaptation to the applied irritants

26. Change in periapical tissue pressure
Teeth with increased periapical pressure
Excessive exudate Pressure on nerve ending
Pain
Teeth with less periapical periapical pressure
Microorganism and other irritant get aspirated into periapical
tissue pain

27. Microbial factors
Anaerobic in root canal produce enzymes, endotoxin and other
irritant
Persistence of periapical lesions

28. Effect of chemical mediators
 Cell mediators ( Histamine, Serotonin, Prostaglandins,
Platelat activating factors and lysosome)
 Plasma mediators ( Hageman factor
Bradykinin and activating clotting cascade )
 Neotrophils products ( Collagenase, peroxidase, amylase,
lipase and other lytic enzymes cause sever pain)
New irritant

29. Change in cyclic nucleotide
In flare up Increase in the level of GMP over AMP
concentration
Pain

30. Immunological response

31. Psychological factor
Anxiety , apprehension , fear and previous history of dental
experience appear to play an important role in mid treatment flare ups

32. Diagnosis and management
 Establishing the cause of flare up is an important step towards
management of mid treatment pain
 It is necessary to warn the patient that he or she may experience
slight pain after the appointment

33. Previously vital pulp with complete
debridement
 In these conditions, chances of flare ups
are less
 Only patient reassurance and the
prescription of mild to moderate analgesics
 There is no need of reopening and placing
and placing corticosteroid

34. Previously vital pulp with incomplete
debridement
 Here pulp remnants considered to be a major
irritant, causing pain
 WL should be rechecked
 Canal cleaned with copious irrigation of NaHcl
 Dry cotton pellet is placed + TF
 Mild analgesic is prescribed
 Relieve tooth from occlusion

35. Previously necrotic pulp without swelling
The best method of managing the necrotic pulp:-
 Establish the accurate WL
 Complete instrumentation of root canal
 Irrigation with copious amount of NaHcl
 If there is drainage from the canal , after drying
the canal CaOH dressing is placed and the access
is sealed
 Prescribe analgesics and antibiotics

36. Previously necrotic pulp with swelling
 These cases are best managed by incision and drainage
 Canal should be opened , debrided and gently irrigated with NaHcl
 Ca(OH)2 should be placed and closed

37. General Management
 Reassurance to the patient

38.  Complete debridement of root canal system

39.  Establishing of drainage

40.  Relief of occlusion

41.  Calcium hydroxide therapy

42.  Medication:- commonly used systemic drugs are :-
 Analgesic
 Antibiotic

43. Analgesics
 NSAID

44. Antibiotic

45. Precautions to be taken to prevent
flare ups
Proper diagnosis of the
case
Determination of correct
WL
Complete extirpation
of the vital pulp

46. Complete chemo
mechanical
procedures in one visit Selection of
instrumentation
technique that extrude
less amount of debries
Placement of intracanal
medicaments between
appointment in the
treatment of infected
case

47. Do not leave teeth open for drainage

48. Prescription of analgesics and antibiotics whenever
condition warrants it

49. Conclusion
The occurrence of mild pain and discomfort is common even if the
treatment rendered is of highest standard . But still psychological
preparation , complete cleaning and shaping of root canal system , use
of long acting anesthetic and analgesics decrease the incidence of inter
appointment flare ups in mild to moderate levels

50. Thank you