Midtreatment flare up

2. ENDODONTIC EMERGENCIES
 Endodontic emergencies occurs with varying
frequencies of pain and swelling in patients before,
during and after root canal treatment.
 The pain in endodontic emergencies is related to two
factors .
 The most common causes are:
 - pulpal and periapical pathosis.
 - traumatic injury.

3. Diagnosis and management of
endodontic emergencies:
 the basic steps for successful management are:
Complete clinical
history examination
 Follow a systematic approach.
No treatment is indicated without clear diagnosis

5. Conditions requiring emergency
treatment:
 Acute reversible pulpits.
 Acute irreversible pulpits.
 Acute periapical abscess.
 Acute apical periodontitis.

7. Mid - treatment flare - up in
endodontic
 Flare up is described as the occurrence of pain,
swelling or the combination
of these during the course of
root canal therapy, which
result in unscheduled visits by
the patient.

8. Etiology: (multifactorial)
Usually due to irritants left within root canal
system.
 Iatrogenic factors.
 Host factors.
Vital pulp less likely to demonstrate symptoms.
Tooth with acute apical abscess + pain shows sever
emergency treatment in flare-ups.

9. Microbiology and immunology of
flare-ups
1) Alteration of local adaptation syndrome.
2) Changes in periapical tissue pressure.
3) Microbial factors.
4) Effect of chemical mediators.
5) Changes in cyclic nucleotides.
6) Immunological response.
7) Psychological factors.

10. 1-Alteration of local adaptation syndrome.
New irritant ch.inflammed tissue
Violent reaction may occur due to disturbance
in local tissue adaptation to the applied
irritants.

11. 2-Changes in periapical tissue pressure.
Teeth with increased periapical pressure
Excessive exudates pressure on nerve
ending pain
Teeth with less periapical pressure
Microorganisms + other irritants get aspirated
into periapical area pain

12. 3-Microbial factors.
Anaerobes in root canal produce enzymes,
endotoxins and other irritants
persistence of
periapical lesions

13. 4-Effect of chemical mediators.
• cell mediators
• Plasma mediators.
• Neotrophils products

14. 5-Changes in cyclic nucleotides.
 In flare up level of c GMP over
c AMP concentration.

15. Clinical conditions of flare-up:
1. Apical periodontitis secondary to
teatment:
 Tooth become sensitive to percussion.
 Throbbing or gnawing pain.
Causes:
 Over instrumentation.
 Over medication.
 Forcing debris into periapical tissue.

16.  Confirmatory test:
 Use paper point
 Mark W/L.
 Place the paper point in the canal.
Over-instrumentation the paper point
tip will disclosed a reddish or brownish
color

17. Clinical conditions of flare-up:
2. Incomplete removal of pulp tissue:
 Sensitivity to hot and cold or pain on
percussion is usually seen.
 Confirmatory test:
Sterile paper point short of W/L display
brownish discoloration.

18. Clinical conditions of flare-up:
3. Recrudescence of chronic apical periodontitis:
(phoenix abscess).
alteration of internal environment of root canal
space during instrumentation activates
bacterial flora.
Signs and symptoms:
- mobility, tenderness and swelling.

19. Clinical conditions of flare-up:
4. Recurrent periapical abscess:

20. Diagnosis and management:
Establishing the cause is an important step
towards the management.
Inter-appointment emergencies is divided into:
- Previously vital pulp with complete
debridement.
- Previously vital pulp with incomplete
debridement.
- Previously necrotic pulp without swelling.
- Previously necrotic pulp with swelling.

21.  Previously vital pulp with complete
debridement:
 Here chance of flare-up is less.
 Only patient reassurance and prescription of
mild to moderate analgesic.
 There is no need to re-opening the canal and
place corticosteroid.

22. Previously vital pulp with incomplete
debridement.
 Here pulp remnants considered to be a major
irritant, causing sever pain.
 W/L should be rechecked.
 Canal cleaned with copious irrigation of NaHCl
 Dry cotton pellet is placed + T.F
 Mild analgesic is prescribed.
 Relieve tooth from occlusion.

23.  Previously necrotic pulp without swelling.
 Establish accurate W/L.
 Complete instrumentation.
 Irrigation with copious amount of NaHCl.
 If there is drainage from the canal, after drying the canal
place Ca(OH)2 dressing and access is sealed.
 Analgesic and antibiotic.

24. 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.

25. General management of flare ups
1. Reassurance to the patient.
2. Complete debridment of root canal
system.
3. Establishment of drainage.
4. Relief of occlussion.
5. Ca(OH)2 therapy.
6. Intracanal medicament.
7. Medications.
8. Placebo.