JCD

10.5005/jp-journals-10031-1011
Interappointment Flare-up in Endodontics: A Case Report and an Overview
CASE REPORT

Interappointment Flare-up in Endodontics: A Case Report

and an Overview
Vanitha Shenoy, Rahul Kumar, MV Sumanthini

ABSTRACT acute apical abscess.2 Seltzer S and Naidorf5 explained

A problem that an endodontist can encounter during the course possible etiological factors for flare-ups and stated the
of root canal treatment is pain and swelling or both in the form reasons for such exacerbations as not always clear and
of flare-ups. The causes for this flare-up are numerous which explained some hypothesis which are interrelated. Different
include mechanical, chemical, microbial injury to the pulp or
periradicular tissues, whereby an acute periradicular
approaches and techniques have been mentioned for the
inflammation results. This situation can be prevented by management of flare-ups.6
selection of instrumentation technique, that extrude lesser
amount of debris apically, completion of biomechanical CASE REPORT
preparation in a single sitting, use of antimicrobial intracanal
medicament between appointment in the treatment of infected A 20-year-male patient presented to the Department of
cases with an appropriate coronal temporary restoration and
Conservative Dentistry and Endodontics, MGM Dental
maintaining asepsis throughout the root canal treatment. The
flare-up phenomena are complex and not well-understood which College and Hospital, Navi Mumbai, with severe pain and
involves a number of hypotheses for its etiology. A correct a large swelling on the right side of the face, extending
diagnosis and treatment aids in the resolution of the flare-up. from the lower border of the mandible involving the lower
This case report explains the management of an inter-
appointment flare-up, with an overview of flare-ups. eye lid (Figs 1A and B), since 3 days. The patient gave a
history of discontinued root canal treatment in relation to
Keywords: Root canal treatment, Pain, Swelling, Flare-up.
the maxillary right first molar (26). The intraoral
How to cite this article: Shenoy V, Kumar R, Sumanthini MV. examination revealed an access cavity that had been
Interappointment Flare-up in Endodontics: A Case Report and
an Overview. J Contemp Dent 2012;2(2):53-56.
prepared devoid of temporary restoration. The patient had
an intraoral periapical radiograph from his previous
Source of support: Nil
discontinued root canal treatment, which showed
Conflict of interest: None declared radiolucency in the crown and at the apex of the mesial
root (Fig. 1C). The concluding diagnosis for 26 was an acute
INTRODUCTION apical abscess (flare-up). The patients medical history was
The interappointment flare-up is a true complication where, noncontributory. The patient was explained of the problem
within a few hours to a few days, after an endodontic and reassured.
procedure a patient has significant increase in pain or For the flare-up emergency appointment, under rubber
swelling or a combination of the two, wherein the patient dam isolation (Hygienic Dental Dam, Coltene/Whaledent
must come in for an unscheduled visit, for emergency Inc), (Fig. 1D), the access cavity and the root canal was
treatment.1,2 The incidence of flare-ups is low and occurs irrigated with normal saline. The access cavity was
only in a small percentage. Morse et al reported an incidence modified, root canals located. Four root canals were
of approximately 20% flare-ups where swelling was the only located, mesio-buccal, distobuccal, palatal and
criteria, after treating asymptomatic teeth with pulp necrosis mesiobuccal 2 (MB 2) (Fig. 2A). Working length was
and chronic apical periodontitis.3 In contrast, Barnett and determined using an apex locator (Propex, Dentsply) and
Tronstad in a retrospective study determined an incidence confirmed with an intraoral periapical radiograph (see
of approximately 5.5% flare-ups, where pain and/or swelling Fig. 2A). Biomechanical preparation was completed
were the criteria, in patients with a similar diagnosis of pulp using ProTaper Ni-Ti rotary instrument (Dentsply,
necrosis with asymptomatic periapical lesion, but 1.4% in Maillefer) with a crown-down technique, under copious
all patients regardless of diagnosis.4 irrigation with normal saline, followed by 5% sodium
Thus, the incidence of flare-ups increases in direct hypochlorite solution (Dentpro, Chandigarh, India).
relationship to the severity of the patients preoperative Calcium hydroxide saline paste was placed in the root
pathosis and signs/symptoms. The lowest frequency of canal and a closed dressing of zinc oxide eugenol (DPI,
occurrence is generally with a vital pulp without periapical Mumbai, India) of a thin consistency was placed in the
pathosis, the highest frequency with patients who present access cavity. The patient was prescribed antibiotics and
with more severe pain and swelling, with pulp necrosis and analgesics for 5 days.
Journal of Contemporary Dentistry, May-August 2012;2(2):53-56 53
Vanitha Shenoy et al

The patient was contacted daily until the signs and DISCUSSION
symptoms subsided (Fig. 2B). After 7 days, the swelling Pain and swelling are the most common sign and symptom
had subsided and the patient was asymptomatic. Obturation that can occur during flare-up. The causes for this could be
of the root canal was completed using cold lateral an alteration of the local adaptation syndrome where Selye
compaction of gutta-percha (Dentsply, Maillefer) using AH demonstrated this factor by injecting air subcutaneously into
Plus sealer (Dentsply, Maillefer; Figs 2C and D). The access the backs of rats, causing the air-filled tissues to balloon
cavity was subsequently restored with silver amalgam out. He then injected various chemicals into this air-filled
(Dispersalloy, Dentsply, Maillefer). The patient was advised pouch, creating an acute inflammatory response, in the form
to have a full coverage crown with 26. of a granuloma pouch, wherein the pouch was lined with
granulation tissue. Subsequently the pouch was injected with
the same chemical irritants which had produced the original
inflammation and it was observed that there was no reaction
and the tissues had adapted to the irritant. Evacuation of
the content of the pouch resulted in healing but when a new
and different irritant was injected into the pouch, a violent
reaction leading to tissue necrosis occurred. In a clinical
situation, inflammation of periapical lesion may be adapted
to the irritant and chronic inflammation may exist without
perceptible pain or swelling. However, when endodontic
therapy is performed, a new irritant in the form of
A B medicaments, irrigating solutions or tissue proteins, altered
by chemicals may be introduced into the granulomatous
lesion and then a violent reaction may follow, leading to
liquefaction necrosis, indicating of an alteration, thus
showing that there is a local tissue adaptation to applied
irritants.7
A change in periapical tissue pressure is another cause
wherein measurements of periapical tissue pressure during
C D endodontic therapy in dogs teeth, revealed that both the
Figs 1A to D: Extraoral swelling, (A) frontal view, (B) lateral view, negative and positive pressures occur. 8 The pressure
(C) intraoral preoperative radiograph, (D) clinical photograph of fluctuated over an 8 hours period. In teeth with increased
access opening
periapical pressure excessive exudates, not removed by the
lymphatics, would tend to create pain by pressure on nerve
endings. When the root canals of such teeth were opened
the fluid would tend to be forced out. In contrast should the
periapical pressure be less than atmospheric pressure, micro-
organisms and altered tissue proteins could be aspirated into
the periapical area resulting in accentuation of the
inflammatory response and severe pain.5
Microbes are one of the important causes of flare-ups.
A B Prior to 1970s voluminous studies of the flora of infected
root canals showed the presence of a considerable variety
of microorganisms. Based on recent studies anaerobic
culturing techniques produce a far greater spectrum of
microbial isolates than purely aerobic techniques. 9
Anaerobes in mixed root canal infections may be responsible
for the production of enzymes and endotoxins, the inhibition
C D
of chemotaxis and phagocytosis, and endotoxins, and
Figs 2A to D: (A) Working length radiograph, (B) 7th day post-
operative photograph shows extraoral swelling has subsided,
interference with antibiotic activity resulting in the
(C) master cone radiograph, (D) postoperative radiograph persistence of painful periapical lesions.10 Bacteriodes
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Interappointment Flare-up in Endodontics: A Case Report and an Overview

melaninogenicus, an anaerobic, Gram-negative rod, is binding of IgG or IgM to cell surface antigens, and by the
present in combination with other microorganism, which subsequent involvement of the complement system.5,13
produce endotoxin, which activates the Hageman factor, Finally, the various psychological factors, such as fear of
which leads to the production of bradykinin, a potent pain dentists and dental procedures, anxiety, apprehension, and
mediator. The endotoxins are capable of resisting ingestion many other psychological factors influence the patients pain
by polymorphonuclear leukocytes, even after ingestion, perception and reaction thresholds16,17 to the initiation of
intracellular killing is impaired11 and in the presence of flare-ups.
complement, endotoxin also enhances inflammation through As the etiological factors often cannot be precisely
the release of vasoactive chemicals. 12 Gram-positive determined, many treatment options have been suggested.6
bacteria are also involved in root canal flare-ups. Whether Cohen advocated occlusal relief prior to endodontics18 for
the flora of an infected root canal can change when the prevention of postoperative pain but other endodontists
endodontic treatment is performed or whether a change in recommended occlusal relief prior to endodontic therapy
the proportional of aerobes to anaerobes can cause clinical only in teeth with painful periapical symptoms19 whereas
exacerbations are still conjectural.2,5,13 some reduce the occlusion of teeth undergoing endodontic
The effect of chemical mediators during inflammatory therapy when painful symptoms develop.20
response can be derived from cells or plasma, which includes Establishment of drainage is the most effective method
histamine, serotonin, prostaglandins, platelet-activating for reducing pain and swelling. This can be accomplished
factor, leukotrienes, various lysosomal components and by removing the temporary dressing from the access cavity.
some lymphocyte products called lymphokines, all of which In most cases the accumulated exudates will drain down
are capable of causing pain. The plasma mediators are the root canal affording immediate relief. If no exudate
present in the circulation, the Hagmens factor (factor XII), emerges, the root canal may be blocked by packed dentinal
which when activated, are the cause for pain. Neutrophil shavings in the apical third of the root canal. Passing a sterile
products when the root canal is instrumented, an acute root canal file or reamer through this material helps establish
inflammatory response is initiated in the periapical tissues. the flow of exudates. In some the exudates may be absent
Various chemical mediators are released endogenously or or cannot be evacuated through the root canal, surgical
by inflammatory cells in acute periodontitis, which cause intervention is then the choice of treatment. It is advised to
pain.5,13 A change in cyclic nucleotide that is the cyclic temporarily close the access cavity18,21 rather than leave it
adenosine mono phosphate (AMP) is the second messenger open for drainage, as the salivary products increase bacterial
for many hormones, transmitting information to the interior growth, introduces new microorganisms that activates the
of the cell. Transmitters, such as histamine or epinephrine alternate complement pathway and may enhance bradykinin,
and serotonin, elaborated during the inflammatory response, leading to production of pain.
are capable of elevating cyclic AMP levels in the periapical Intracanal medicaments are used to afford relief from
tissues. The cyclic guanosine monophosphate (GMP) is also painful exacerbations during root canal therapy. Among
a second cyclic nucleotide, which is present in all living them are antimicrobial agents, such as formocresol, cresatin,
systems. Cellular regulations, including pain transmission, eugenol, camphorated monochlorphenol and iodine-
may be influenced by the interaction of cyclic AMP and potassium iodide have been studied and there has been no
cyclic GMP.5,13 significant relationship between flare-up and type of therapy
Immunological factors also play a role in chronic pulpitis used. Irrigating solution choice makes little difference in
and periapical periodontitis, the presence of macrophages the incidence of postoperative discomfort, as long as the
and lymphocytes indicates that both cell-mediated and irrigating solution does not get forced beyond the foramen
humoral immune reactions are involved. Despite their of the tooth. It is also difficult to attribute lower pain
protective effects immunological mechanisms may incidence specifically to the use of any particular irrigant.
contribute to the destructive phase of inflammation. Sulfa compounds and corticosteroids also have been used
Antigens from medicament-altered tissue, antigen-antibody in the management flare-ups but the results were not
complexes, and root canal filling materials have been promising.6 Systemic drugs in the form of antibiotics have
reported to be capable of invoking immunological been locally and systemically used for the relief of pain
reactions.14 Pulp and periapical destruction may then be the against various strains of organisms during endodontic
result of a shift in the production of IgG over IgA, causing therapy. There is no specific antibiotic that is capable of
perpetuation and aggravation of the inflammatory process.15 reducing or eliminating painful exacerbations during
Other possibilities for flare-ups may be based on activation endodontic therapy.6 Nonnarcotic analgesics relieve pain
of the kallikrein-kinin and coagulation systems, by the without altering consciousness, which are effective against
Journal of Contemporary Dentistry, May-August 2012;2(2):53-56 55
Vanitha Shenoy et al

most pain of dental origin. Nonsteriodal anti-inflammatory 10. Dahlen G, Bergenholtz G. Endotoxic activity in teeth with
necrotic pulps. J Dent Res 1980;59:1033.
agents are drug of choice for mild to moderate pain. Narcotic
11. Sundqvust GK, Eickerborn MI, Larsson AP, Sjogren UT.
analgesics are commonly prescribed for relief of severe pain. Capacity of anaerobic bacteria from necrotic dental pulps to
However, the prescription of the analgesic has to be in induce purulent infections. Infect Immune 1979;25:685.
accordance with the signs and symptoms.6 12. Mergenhagen SE. Complement as a mediator of the
The follow-up care of a patient with a flare-up should inflammatory response: Interaction of complement with
mammalian and bacterial enzymes. J Dent Res 1972;51:251.
be by contacting the patient daily until the symptoms 13. Seltzer S. Pain in endodontics. J Endod 2004;30:501-03.
subside. Communication may be made by telephone or by 14. Block RM, Lewis RD, Sheats JB, Burke Sh, Fawley J. Antibody
the patient reporting to the clinic. For those patients with formation and cell-mediated immunity to dog pulp tissue altered
severe or persistent problems which do not resolve, then by eight endodontic sealers via the root canal. Int Endod J 1982;
15:105.
additional treatment procedures are required.1
15. Brandtzaeg P. Immunology of inflammatory periodontal lesions.
Int Dent J 1973;22:438.
CONCLUSION 16. Scott DS, Hirschman R. Psychological aspects of dental anxiety
in adults. J Am Dent Assoc 1982;104:27.
Signs and symptoms of flare-ups may be severe in
17. Berggren U, Meynert G. Dental fear and avoidance: Causes,
magnitude, they are rarely serious, i.e. not life-threatening. symptoms and consequences. J Am Dent Assoc 1984;109:247.
They are localized and do not involve structures other than 18. Cohen S. Endodontic emergiencies. In: Cohen S, Burns RC,
those oral or local perioral. The condition and the cause (Eds). Pathways of the pulp (2nd ed). St Louis: CV Mosby Co,
1980;31.
have to be diagnosed, followed by a proper treatment plan,
19. Grossman Ll. Endodontic practice (10th ed). Philadelphia Lea
to treat the flare-up successfully. and Febiger, 1981;85:93.
20. Creech JL, Walton RE, Kaltenbach R. Effect of occlusal relief
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