Available online at www.ijpcr.

com
International Journal of Pharmaceutical and Clinical Research 2015; 7(2): 148-150

ISSN- 0975 1556

Research Article

Flare Up in Endodontics: A Review

Tharangini Raveenthiraraja, Pradeep Solete
No 162, Poonamalee High Road, Chennai 77

Available Online: 26th February, 2015

ABSTRACT
An endodontic flare-up is a complication of endodontic treatment which is defined as an acute exacerbation of
aymptomatic pulpal or periapical pathoses after the initiation or continuation of root canal treatment. Flare-up is a true
complication where, within a few hours to a few days, after the endodontic procedure a patient has significant increase in
pain or swelling or a combination of the two, wherein the patient must come in for an unscheduled visit, for emergency
treatment. In this review article we underline the etiology, clinical conditions, causes, diagnosis, various treatment
modalities for relief of pain and swelling in such cases and prevention of flare-up.

Keywords: flare up, endodontics

INTRODUCTION was symptomless before the initiation of endodontic

Flare-up is described as the occurrence of pain, swelling treatment but becomes sensitive to percussion during the
or the combination of these during the course of root course of the treatment. Causes for this condition most
canal therapy, which results in unscheduled visits by frequently are over instrumentation or over medication or
patients1. Pain may occur soon after initiating endodontic forcing debris into the periapical tissues.
treatment for an asymptomatic tooth or shortly after the Incomplete removal of pulp tissues during the initial
initial emergency treatment or during the course of the appointment: In some instances due to lack of time factor
treatment. It is suggested that the incidence of the endodontic therapy may consist of incomplete
interappointment emergency associated with endodontic pulpectomy after a diagnosis of acute or chronic pulpitis.
therapy was 4.2%2. This situation generally occurs when the radicular pulp is
Flare-ups may occur with the best of the therapy, but already inflamed.
most flare-ups occur when improper treatment is rendered Phoenix abscess: It is a condition that occurs in teeth with
or when insufficient time is allowed for specific necrotic pulps and apical lesions that are asymptomatic .
modalities in therapy according to Franklin S Weine3. There is a exacerbation of a previously symptomless
Acute periapical inflammation is the most common cause periradicular lesion. The reason for this phenomenon is
of mid treatment pain and swelling. Mid treatment thought to be due to the alteration of the internal
emergencies are related to irritants left within root canal environment of the root canal space during
system, iatrogenic factors under the control of the instrumentation which activates the bacterial flora6 .
operator and host factors4. The occurrence of mild pain is Recurrent periapical abscess: It is a condition where a
relative. tooth with an acute periapical abscess is relieved by
emergency treatment after which the acute symptoms
ETIOLOGY return. In some cases the abscess may recur more than
Dr Seltzer discussed a number of hypothesis thought to once, due to microorganisms present.
be related to the etiology of flareups5. These would Causes Of Flare-Ups: If during endodontic treatment the
include: periradicular tissues are damaged during the
 Alteration of the local adaption. manipulations in the root canal, then an acute
 Changes in periapical tissue pressure . inflammatory response, called a flare-up, begins. Even
 Microbial factors. though the flare-up activates the defensive system of the
 Effects of chemical mediators. body which starts fighting the infection, the flare-up
 Changes in cyclic nucleotides. brings also about undesirable effects for the patient – pain
 Immunological phenomena. and swelling7.
Clinical symptoms: The next factor determining the post-
 Various psychological factors.
operative pain is clinical symptoms that were there before
the treatment such as tooth pain when biting, chewing or
CLINICAL CONDITIONS
by itself and sensitivity to percussion8. 80% of patients
Common clinical conditions associated with flareups are
who feel tooth pain before the beginning of the treatment
Apical peridontitis secondary to treatment: A tooth which
usually feel the pain and after9, 10, 11 pain enhances the

*Author for Correspondence

 Raveenthiraraja et.al. / Flare up in Endodontics…

stress level in the body and effects immune function in a post operative pain23. Phoenix abscess is a difficult
negative way therefore increasing the probability of a condition to deal with and it occurs subsequent to initial
flare-up12. instrumentation of the canal with a pre existing chronic
Tooth which is being treated: Glennon et al study results periapical lesion. The sign and symptoms mimic that of
show that temporary pain is felt, 7 times more often when acute periapical abscess. Treatment consist of irrigation ,
the canals of the molar teeth are treated compared to other debridement of the root canal and drainage either through
teeth types. Higher frequency of pain in the lateral teeth the canal or trephination depending on the intensity of the
type is determined by the complicated complex anatomy pain .Antibiotics and analgesics can be prescribed. the
of the root canals and chemo mechanical preparation13, 14, working length, complete removal of the remaining vital
15
. pulp tissue and relieving the tooth from occlusion.
One and/or two visits during the treatment: Primary Pain associated with pulpal necrosis: Studies suggest that
endodontic treatment when the pulp is viable or the incidence of flare-ups is higher with necrotic pulp
endodontic retreatment when there are no visible clinical tooth than in vital tooth. Tayfun Alacam et al in his study
symptoms related to the changes in periradicular tissues, found that the incidence of flare-ups in tooth with
chemomechanical preparation and filling of the root canal necrotic pulp is 7.17%24.The best method of managing
is done by one visit. If the pulp is necrotic and there are the necrotic pulp is to establish accurate working length
radiological changes in periradicular tissues, endodontic of tooth and complete instrumentation of root canal in the
treatment is done by two visits: during the first visit the first appointment . Removal of debris from the canal
root canal is prepared chemomechanically, filled with should be the goal. When there is a flareup the tooth
intracanal medicaments for maximal root canal should be reopened , observe for the presence of pus .If
disinfection and the crown is hermetically sealed with there is pus in the canal without soft tissue swelling it
temporary filling, while during the second visit the filling indicates an acute abscess in early stages, in such cases
of the root canal is performed 16,17,18,19.Studies show that pain is more severe .If only pain is present copious
there is no direct link between manifestation of the post- irrigation should be used and all debris are removed . An
operative pain and amount of the visits during the intracanal medicament is placed and resealed. If pain is
endodontic treatment18,19. However some studies show present along with swelling then drainage should be
controversial results, i.e. that pain is more common after established either through the apex of the tooth or the soft
one visit endodontic treatment20, 21. Yold et al study tissue .It as been advocated that antibiotics and analgesics
summarizes that flare-up rate is 9 times higher after one such as NSAIDS be prescribed. The use of antibiotics
visit endodontic retreatment compared to retreatment by alone without establishing drainage is not considered
two – visits16. appropriate. The concept of leaving the canal open for
drainage is controversial.
DIAGNOSIS AND MANAGEMENT Prevention Of Flareups : Flare ups causes a dilemma to
Establishing the cause the flareup is an important step the clinican when it is difficult for the patient to
towards management of mid treatment pain. It is comprehend that they enter the office pain free, but
necessary to forewarn the patient that he may experience experience a sustained increase or severe pain during or
slight pain after the appointment and advise an over-the- after treatment. Certain precaution that are taken by a
counter analgesic. When patient experience moderate to clinican can prevent flare-ups in most instances.
severe pain after the first appointment , the clinican must Proper diagnosis: Identify the correct tooth causing pain.
review the diagnosis to ensure the tooth under treatment Ascertain whether tooth is vital or non vital. Identify if
has been identified correctly as the source of pain . If so tooth is associated with periapical lesion.
the periapical and pulpal status have to be reviewed to Determine correct working length: By using Radiographs
determine whether the patient has a inflammatory and Apex locaters. Complete extirpation of vital pulp.
condition or acute infection Irrigation -Preferably with combination of irrigants such
Pain associated with instrumentation: It can manifest as – as sodium hypochlorite and chlorohexedine. Avoid filing
Acute periapical peridontitis or as Phoenix abscess.Acute too close to the radiographic apex.Preform apical
periapical peridontitis occurs due to overinstrumentation; trephination only if necessary.Reduce tooth from
extrusion of canal contents through the apex ,leaving the occlusion especially if apex is severely violated by over
tooth in traumatic occlusion or placing too much of instrumentation. Placement of intracanal medicaments.
intracanal medicament . Absence of an apical stop and Prescription of mild analgesics and antibiotics whenever
presence of blood in the apical portion of the root canal condition warrants it.
usually indicates overinstrumentation 4.Treatment
constitutes of reopening the tooth, irrigation with a CONCLUSION
combination of irrigants such as sodium hypochlorite and The occurrence of mild pain and discomfort following
chlorhexidine ,placement of a suitable intracanal endodontic treatment is common even when the treatment
medicament and relieving the tooth from occlusion. rendered is of the highest standard. It is the duty of the
According to Seltzer, intracanal medication reduces the clinican to explain it to the patient. Prompt and effective
possibility of flareups due to the forcing of infected treatment of flareups is an essential part of the overall
debris into the periapical tissues22 .Cohen advocated endodontic treatment .
relieving occlusion prior to root canal therapy to prevent

IJPCR, March 2015 - April 2015, Volume 7, Issue 2 Page 149

 Raveenthiraraja et.al. / Flare up in Endodontics…

REFERENCE 14. Naoum HJ, Chandler NP. Temporization for

1. Gerald W Harrington,Eugene Watkin.Mid endodontics. Int Endod J 2002; 35:964-78.
treatment Flareups.DCNA; 36:1992 409- 15. Ng YL, Glennon JP, Setchell DJ,
423. Gulabivala K. Prevalence of and factors
2. Mor C, Rotstein I, Friedman S.Incidence of affecting post - obturation pain in patients
interappointment emergency associated with undergoing root canal treatment. Int Endod
endodontic therapy.J Endod ;18:10,1992 J 2004;37:381-91.
509-511. 16. Sathorn C, Parashos P, Messer H. The
3. Franklein S.Weine .Endodontic Therapy prevalence of postoperative pain and fl are -
Fifth Edition,Mosby;203-237. up in a single- and multiple – visit
4. Mahmoud Torabinejad , Richard E. Walton, endodontic treatment: a systematic review.
Managing endodontic emergencies.JADA. Int Endod J 2008;41:91-9..
1999; 122:99 103. 17. Alonso-Ezpeleta LO, Gasco-Garcia C,
5. Samuel Seltzer, Irving J. Naidorf . Flareups CastellanosCosano L, Martín-González J,
in endodontics.1 Etiological factors. J López-Frías FJ, SeguraEgea JJ.
Endod .2004;30:476-481. Postoperative pain after one - visit root –
6. P.Carrotte.Endodontic Part 3. Treatment of canal treatment on teeth with vital pulps:
endodontic emergenies. BDJ .2004 comparison of three different obturation
;197:299-305 techniques. Med Oral Patol Oral Cir Bucal
7. Siqueira JF, Barnett F. Interappointment 2012;17:e721-7.
pain: mechanisms, diagnosis and treatment. 18. Undoye CI, Jafarzadeh H. Pain during root
Endod Topics 2004;7:93- 109. canal treatment: an investigation of patient
8. Walton RE. Interappointment fl are-ups: modifying factors. Contemp Dent Pract
incidence, related factors, prevention, and 2011;12:301-4.
management. Endod Topics 2002;3:67-76. 19. Figini L, Lodi G, Gorni F, Gagliani M.
9. Sathorn C, Parashos P, Messer H. The Single versus multiple visits for endodontic
prevalence of postoperative pain and fl are - treatment of permanent teeth: a Cochrane
up in a single- and multiple – visit systematic review. J Endod 2008;34:1041-7
endodontic treatment: a systematic review. 20. Ghoddusi J, Javidi M, Zarrabi MH, Bagheri
Int Endod J 2008;41:91-9. H. Flare – ups incidence and severity after
10. Marshall JG. Consideration of steroids for using calcium hydroxide as intracanal
endodontic pain. Endod Topics 2002;3:41- dressing N Y State Dent J. 2006;72:24-8.
51. 21. Seltzer S, Naidorf IJ. Flare - ups in
11. Glennon JP, Ng YL, Setchell DJ, endodontics: II. Therapeutic measures. J
Gulabivala K. Prevalence of and factors Endod 2004;30:482-8
affecting postoperation pain in patients 22. Gotler M, Bar-Gil B, Ashkenazi M.
undergoing two - visit root canal treatment. Postoperative pain after root canal
Int Endod J 2004;37:29-37. treatment: a prospective cohort study. Int J
12. Walton R, Fouad A. Endodontic Dent 2012;2012:310467
interappointment fl are - ups: a prospective 23. Shah SI, Qayyum Z, Shah SA, Khan S,
study of incidence and related factors. J Pasha F. Prophylactic use of antibiotics to
Endod 1992;18:172-7. prevent fl are - up in endodontic treatment.
13. Glennon JP, Ng YL, Setchell DJ, Pakist Oral Dental J 2011;31:427-31.
Gulabivala K. Prevalence of and factors 24. Pasqualini D, Mollo L, Scotti N, Cantatore
affecting postoperation pain in patients G, Castellucci A, Migliaretti G, et al.
undergoing two - visit root canal treatment. Postoperative pain after manual and
Int Endod J 2004;37:29-37. mechanical glide path: a randomized
clinical trial. J Endod 2012;38:32-6.

IJPCR, March 2015 - April 2015, Volume 7, Issue 2 Page 150