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. 20 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 . 21 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 23