Endodontic Post-Treatment Flare-Ups

Endodontic
Post-Treatment
Flare-Ups
The University of Iowa
College of Dentistry
Iowa City, Iowa
Richard E. Walton,
D.M.D. M.S.
Professor, Department of
Endodontics
PARIA CANYON /BUCKSKIN CANYON
Flare Up
n
Definition:
– Post-treatment event
– Severe pain and/or swelling
– Patient contacts dentist
– Active treatment necessary
Al-Negrish ARS et al.
Flare up rate related to root canal treatment of
asymptomatic pulpally necrotic central incisor teeth.
J Dent 34: 635, 2006
n
n
n
n
Compared one vs two visits
Pts recorded pain levels 2 and 7 days PO
Moderate & severe pain classified as “flare-up”
(incorrect use of the term)
Results:
~12% at 2 days, 4% at 7 days (Mod-Severe)
~4.5% severe pain at 2 days
“THE WAVE”
Is the Flare-Up
Immunologic?
n Infection?
n Tissue Damage?
n Combination?
n
Physical
Bacterial
Chemical
Infection
Tissue Damage
Immune Response
Inflammation
Chemical Mediators
Transudation/Exudation
Pain/Swelling
ZION
What Micro-organisms
Are Responsible?
n
n
n
n
n
n
Black-pigmented gram + bacilli?
Peptostreptococci?
Fusobacterium?
Viruses?
Others?
Combination?
Fusobacterium nucleatum in
Endodontic Flare-Ups
n
Sampling of canals in teeth with flare-ups
n
Good techniques of sampling, culturing and identification
n
All canals showed bacteria, mixed flora
n
More severe symptoms showed more F. nucleatum
n
Gram-negative anaerobic coccoid rods (Prevotella and
Porphyromonas) also common
Chavez de Paz 0000E 93:179, 2002
30
Number of Cases
25
20
15
15
11
9
0
10
5
10
10
6
5
2
7
3
3
0
Gram-negative anaerobic Gram-positive facultative Gram-positive facultative Fusobacterium nucleatum Gram-positive anaerobic Gram-positive anaerobic
coccoid rods (25 cases)
rods (17 cases)
cocci (16 cases)
(10 cases)
rods (8 cases)
cocci (5 cases)
Severe Pain Group (n=10)
Nonsevere Pain Group (n=18)
n
The Problems
– Multifactorial
– Localized
– Lack of controlled clinical studies
n The
Answers
BRYCE CANYON
Endodontic
Post-Treatment
Flare-Ups:
Incidence
Incidence of Flare-Ups
High (11% - 25%)
– Balaban et al. 1984
– Mata et al. 1985
– Morse et al. 1987
– Al-Negrish et al. 2006
Low (.4% - 6%)
n
n
n
n
n
n
n
n
n
Barnett & Tronstad, 1989
Trope, 1990
Walton & Fouad, 1992
Imura & Zuolo, 1995
Sim, 1997
Eleazer & Eleazer, 1998
Pickenpaugh et al., 2001
Glennon et al, 2004
Iqbal et al, 2009
International Journal of Psychosomatics Part One
Clinical Study
Infectious Flare-ups: Induction and Prevention
Asymptomatic Teeth with Necrotic Pulps and Associated
Periapical Radiolucencies:
Relationship of Flare-ups to Endodontic
Instrumentation, Antibiotic Usage and Stress in Three
Separate Practices at Three Different Time Periods
Part 1: 1963-1979
Morse D et al, 1986
Infectious flare-ups and serious sequelae
following endodontic treatment: A prospective
randomized trial on efficacy of antibiotic
prophylaxis in cases of asymptomatic pulpalperiapical lesions.
Morse D et al, 1987
Interappointment Flare-Ups:
Incidence and Related Factors
Richard E. Walton
Ashraf Fouad
JOE 18: 172, 1992
Data
n Total
# of Patient Visits
n Total # of Flare-ups
n Overall % of Flare-ups
946
30
3.2%
Endodontic
Post-Treatment
Flare-Ups:
Related Factors
Clinical Article
Factors Associated with
Endodontic Interappointment
Emergencies of Teeth with
Necrotic Pulps
Mahmoud Torabinejad, James D. Kettering, James C. McGraw,
Raleigh R. Cummings, Thomas G. Dwyer, and Timothy S. Tobias
J Endod 1988
Related Factors
Patient Presenting
n Age (Older vs. Younger)
Age
Age
<20
20-29
30-39
40-49
50-59
60-69
70-79
80-89
Flare-ups
0
9
9
1
5
3
1
0
Total Pts.
51
211
227
144
89
131
62
10
Not Significant p=0.35
%
0.0
4.3
4.0
0.7
4.5
5.3
1.6
1.0
Related Factors
Patient Presenting
• Age (Older vs. Younger)
n Sex (Male vs. Female)
Sex
n
n
473 Males with 10 flare-ups = 2.16%
473 Females with 20 flare-ups =
4.32%*
Significant p=0.01
Related Factors
Patient Presenting
• Age (Older vs. Younger)
• Sex (Male vs. Female)
n Emotional Status
Identification of a
Psychosocial Model as a
Predictor of Flare-Ups
A.S. Law
H.L. Logan
R.E. Walton
College of Dentistry, The University of Iowa
Several researchers have shown
that increased pre-operative levels
of stress can be associated with
increased levels of post-operative
discomfort and complications.
Purpose
Identify a combination of
psychosocial factors which would
predict whether a patient would
have a flare-up following a root
canal appointment.
Results
Predicted Group
Membership
Flare-Up No Flare-Up
Flare-Up
Number
of Cases
20
14 (70%)
6 (30%)
No Flare-Up
20
6 (30%)
14 (70%)
Percent of cases correctly classified = 70%
Using pre-operative pain, pre-operative distress,
expected pain and expected pain control
Related Factors
Patient Presenting
•
•
•
n
Age (Older vs. Younger)
Sex (Male vs. Female)
Emotional Status
Tooth (Mx vs. Md; Ant. vs. Post.)
Tooth Group
Md. Ant.
Md. Premolars
Md. Molars
Mx. Anteriors
Mx. Premolars
Mx. Molars
Flare-ups # Treated
1
52
6
85
10
278
2
3
8
Not Significant p=0.4
102
120
276
%
1.9
7.0
3.6
2.0
2.5
2.9
Related Factors
Patient Presenting
• Age (Older vs. Younger)
• Sex (Male vs. Female)
• Emotional Status
• Tooth (Mx vs. Md; Ant. vs. Post.)
n Presenting Pain
Preoperative Pain
°of Pain
No Pain
Mild Pain
Moderate
Severe
No. of Visits Flare-ups %
653
10
1.5
117
2
1.7
103
7
6.8*
52
10
19.23*
Significant p=0.0001
Related Factors
Patient Presenting
• Age (Older vs. Younger)
• Sex (Male vs. Female)
• Emotional Status
• Tooth (Mx vs. Md; Ant. vs. Post.
• Presenting Pain
n Presenting Swelling
Swelling
No. of Visits Flare-ups %
No Swelling
883
22
2.5
Localized &
or Diffuse
63
8
15.2*
Significant p=0.0001
Percentage of Flare-ups with
Preoperative Swelling or Pain
20
19.2
15.2
15
10
6.8
5
2.5
1.7
1.5
0
ne
o
N
Mil
d
Mo
ra t
e
d
Pain
e
re
e
v
Se
ne
o
N
sen
e
r
P
t
Swelling
Related Factors
Patient Presenting
• Age (Older vs. Younger)
• Sex (Male vs. Female)
• Emotional Status
• Tooth (Mx vs. Md; Ant. vs. Post.
• Presenting Pain
• Presenting Swelling
n Systemic Factors
– Medically Compromised
– Allergies
Allergies:
n
Hx. Of allergies = 244 / 926 = 26.4%
n
Flare-ups w/ Hx. of allergy = 10 / 244 = 4.1%
n
Flare-ups w/ no Hx. of allergy = 20 / 682= 2.9%
Not Significant p=0.377
Systemic Manifestations
n
Elevated temperature
n
Malaise?
n
Lymphadenopathy
Related Factors
Diagnosis
n Pulp
(Vital vs. Necrotic)
n Periapical (Lesion vs. No
Lesion)
n Sinus Tract
Related Factors
Diagnosis
n
Pulp (Vital vs. Necrotic)
Pulpal Dx.
No. of Visits Flare-ups %
Normal
37
0
0.0
Rev. Pulpitis
18
0
0.0
Irrev. Pulpitis
385
5
1.3
Necrotic
276
18
6.5*
N/A
210
6
2.9
Significant p=0.001
Percentage of Flare-Ups with
Different Pulpal Diagnoses
7
6.5
6
5
4
2.8
3
2
1
0
l
a
rm
o
N
1.3
0
0
is
is
t
t
i
i
lp
lp
u
u
P
v
vP
e
e
R
Irr
ic
t
o
cr
e
N
A
N/
Related Factors
Diagnosis
•
Pulp (Vital vs. Necrotic)
n Periapical
(Lesion vs. No Lesion)
Periradicular Diagnosis
No. of Visits Flare-ups %
Normal
442
4
0.9
AAP (Sympt)
122
6
4.9
CAP (Asympt)
228
8
3.5
AAA
84
11
13.1*
SAP (Chronic)
49
0
0.0
Significant p=0.0001
Percentage of Flare-Ups with
Different Periapical Diagnosis
14
13.1
12
10
8
6
4.8
3.4
4
2
0
0
SAP
0.9
Normal
CAP
AAP
AAA
Periapical Symptoms
No. of Visits Flare-ups %
SA Perio &
AA Abscess
216
18 8.7*
Asymptomatic
730
12
*Significant p=0.0001
1.7
PAIN
Related Factors
Diagnosis
•Pulp (Vital vs. Necrotic)
•Periapical
(Lesion vs. No
Lesion)
Sinus Tract
Related Factors
Treatment Plan
n Conventional
vs. Retreatment
n Single vs. Multiple Visit
n Partial vs. Complete Debridement
Related Factors
Treatment Plan
n Conventional
vs. Retreatment
Treatment
Treatment # of Visits
Flare-ups
%
Conventional
785
25
3.2
Retreatment
181
5
3.6
Not Significant p=0.81
RETREATMENT
n
As to P.O. pain, no difference between
initial vs retreament, overall
n
n
Mattscheck et al OOOOE 2001
Retreatment of ResorcinolFormaldehyde Resin may result in
greater flare-up incidence
n
Gound et al JOE 2003
Related Factors
Treatment Plan
Conventional vs. Retreatment
n Single vs. Multiple Visit
•
Single vs. Multiple Visits
No. of Visits Flare-ups
%
Multiple
Visits
773
24
3.1
Single Visit
193
5
2.6
Not Significant p=0.62
Sathorn, Parashos & Messer
Prevalence of PO pain and flare-up in
single vs multiple visit treatment: a review
Int Endod J 41:91, 2008
n
16 studies fit the inclusion criteria
n
Conclusion: “Compelling evidence
indicating a significant difference of
postoperative pain/flare-up of either
single- or multiple-visit RCT is lacking.”
Related Factors
Treatment Plan
Conventional vs. Retreatment
• Single vs. Multiple Visit
n Partial vs. Complete Debridement
•
Treatment Rendered
Tx.
No. of Visits Flare-ups
%
Pulpotomy
76
4
5.3
Partial C & S
205
9
4.4
Comp. C & S
144
8
5.6
Obturation
113
2
1.8*
C & S & Obturation 385
5
1.3*
*Significant p=0.037
Percentage of Flare-Ups with the
Type of Treatment Rendered
6
5.5
5.3
5
4.3
4
3
1.8
2
1.3
1
0
lp
Pu
my
o
t
o
Pa
&S
C
l
rtia
let
p
m
Co
&S
C
e
Ob
n
ti o
a
r
tu
S
C&
a ti
r
u
bt
O
d
an
on
Related Factors
Operational Procedures
n Overinstrumentation
n Extruded
Debris
n Extruded Irrigant
n Overfill
n Hyperocclusion
n Incomplete
Debridement
Operator
Status
No. of Visits Flare-ups
%
Faculty
191
8
4.2
Grad. Stud.
341
16
4.8
Undergrads
414
6
1.5*
*Significant p=0.027
Percentage of Flare-Ups with
Different Operators
5
4.6
4.2
4
3
2
1.5*
1
0
Faculty
Grad Students
Undergrads
On Analgesics
No. of Visits Flare-ups %
Analgesics
177
13 7.8*
No Analgesics
769
17
* Significant p=0.0002
2.2
On Antibiotics
No. of Visits Flare-ups %
With Ab.
104
6
6.4
With No Ab.
842
24
2.9
Not Significant p=0.069
Endodontic emergencies: a
retrospective study.
Sims. JOE 1997
n
n
n
3.2% incidence
Positively correlated with necrosis/AAA,
retreatments, first visit
No correlation with tooth group, sex, or in
younger and older patients
Factors Associated with Endodontic
Flare-Ups: A Prospective Study
Imura & Zuolo, 1995
n
n
n
1.58% incidence for flare-ups
Positively correlated with multiple
appointments, pretreatment pain,
apical pathosis
No correlation with age, sex different
arch/tooth groups and pulp status, or
analgesics and anti-inflammatories
ROOT-END SURGERY
Postoperative pain after root-end
resection and filling. Chong & Pitt Ford
OOOOE 100:762, 2005
--100 patients
--90% experienced some pain
--37% took no analgesics
--No flare-ups
Endodontic PostTreatment Flare-Ups
Prevention
Intracanal Medicaments
Commonly Used
Phenolics
Eugenol
CMCP
Cresol
Creosote
PCP
Aldehydes
Halides
Formocresol
I2Kl
Formaldehyde NaOCl
Others
Steroids
Ca(OH)2
Antibiotics
Proposed Action
to Prevent Flare-up
n Antimicrobial
n Pharmacologic
or chemical effect
on pulp and/or periapical tissues
Are These
Magic Bullets
???
Intracanal
Medicaments
Will They Prevent
a Flare-up?
Formocresol vs. Calcium hydroxide vs. Steroid/Antibiotic
Results: No difference
Trope M Endo Dent Trauma 1990
Prevention
Systemic Prophylaxis
n Antibiotics
n Analgesics
n Steroids
Post-Treatment
Endodontic Symptoms:
Effectiveness of
Prophylactic Penicillin
Chiappinelli & Walton
JOE, 1993
Background
n
Desirable to prevent or minimize pain and/or swelling
after a RCT procedure.
n
Many techniques and therapeutic measures have been
attempted to reduce severity and incidence.
n
Morse and co-authors have published numerous reports
presenting evidence supporting penicillin premedication.
n
Design of Morse et al. studies have several flaws,
including no controls and many confounding variables.
Purpose
In mild symptoms or asymptomatic cases with
necrosis/apical lesion: to compare effect of
Prophylactic Penicillin vs. Placebo vs. No
Medication as to post-treatment incidence of:
– Flare-ups (severe pain and/or
swelling)
– Mild-moderate discomfort
– Systemic side effects
Patients (80)
Group A (26)
(penicillin)
Group B (24)
(placebo)
Pre-treatment
evaluation form
A
penicillin
Group C (30)
(no med)
Pre-treatment
evaluation form
B
placebo
C
Root Canal Therapy
A
penicillin
B
placebo
C
Post-treatment Evaluation Card
Results
n
Incidence of flare-ups:
– One Flare-up (penicillin group)
– No difference in 3 groups
n
Incidence of mild-moderate pain:
– No difference in 3 groups (p=.28)
n
Incidence of side effects
– No difference
Incidence of Pain (%)
100
80
60
40
20
0
A-penicillin
B-Placebo
C-No Med
100
Percentage Reporting
90
80
A-penicillin
B-placebo
C-no meds
70
60
50
40
30
20
10
0
None
Mild
Moderate
Severity of Pain
Severe
Conclusions
n
Overall incidence of flare-ups (severe
symptoms) was very small.
n
Prophylactic Penicillin was unrelated to posttreatment pain at any level.
n
Both expected pain and presenting
symptoms correlated with post-treatment
symptoms.
Prophylactic Antibiotics
Unrelated to Post Treatment Pain or
Flare-ups
Walton & Chiappinelli JOE 1993
Eleazer & Eleazer JOE 1998
Pickenpaugh et al JOE 2001
Antibiotics are Ineffective
Because
n
The etiology is an antigen(s) (immunologic)
n
Bacteria involved are:
– Inaccessible
– Resistant (?)
n
The antibiotic does not reach the area
“The inciting allergen in an
endodontic flare-up is probably
NOT live bacteria; antibiotic
therapy will be ineffective”
Torabinejad, 1995
What About
Medico-Legal
Considerations?
Anti-inflammatory Agents
n Steroids
n Non-steroidals
n Antihistamines
Corticosteroids
MAY be Effective Therapy IF:
n They
can reach the area
n The etiology is
immunologic/inflammatory
n The etiology (or co-etiology)
is NOT infection
CAN FLARE-UPS BE AVOIDED
OR THE INCIDENCE MINIMIZED?
How to Avoid Flare-Ups
Don’t Treat:
n Patients
in Pain
n Patients with Swelling
n Pulp Necrosis
Reducing Incidence of Flare-Ups
Don’t:
n Treat
Females
n Prepare
Canals
Reducing Incidence of Flare-Ups
DO:
n
n
n
n
Treat Cases with Sinus Tracts
Obturation Only
Treat Vital Pulps Only
Hire Dental Students
If a Flare-Up Occurs
n Psychological
Management
– Reassurance (the Big “R”)
– Explanation
n Local
Anesthesia
Treatment Measures (Empirical)
n
Vital Pulp
-- Complete the Debridement
n
Necrotic Pulp without Swelling
– Debridement
– Drainage from the Tooth
– Trephination?
n
Necrotic Pulp with Swelling
– Debridement
– Incision for Drainage
Therapeutics
n
Likely of No Benefit are:
– Intracanal Medicaments
– Antihistamines
n
Systemic Medications
– Analgesics
n Opioid/NSAID
(Severe)
n NSAIDs (Moderate)
Antibiotics
n Localized
Abscess
– Antibiotics Not of Benefit
Fouad, Rivera, Walton OOO 81:590, 1996
Henry & Reader JOE 27:117, 2001
Matthews et al J Evid Based Dent 5:7, 2004
n
Cellulitis
– Antibiotics May be of Benefit
– Penicillin V / Metronidazole indicated
– Amoxicillin / Clavulanate for severe and
compromised patients
Baumgartner & Xia JOE 29:44, 2003
CONCLUSIONS
n
If the patient experiences a flare-up
– Is the dentist to blame?
– Is the patient responsible?
– Is it unpredictable (luck of the draw?)
THANK YOU
IN REVIEW
REGARDING THE FLARE-UP
n
What is the nature? Immunologic? Infection?
n
What is the microbiology? Are the microbes
causative or related?
n
What is the incidence? Why is there a large
difference in some studies?
What about patient factors?
n
Age?
n
Gender?
n
Emotional status?
n
Tooth type?
What about presenting:
n
Signs?
n
Symptoms?
n
Systemic factors; any disease or
condition related to flare-ups?
What about diagnosis?
n
Pulpal
n
Periapical
What about treatment factors?
n
Retreatment?
n
Single vs multiple visit?
n
Partial vs complete debridement?
n
C&S vs obturation?
What about:
n
Overinstrumentation?
n
Extruded debris?
n
Extruded irrigant?
n
Overfill?
n
Hyperocclusion?
n
Incomplete debridement?
What is the incidence of
flare-up with periapical SX?
Can flare-ups be prevented:
n
Analgesics?
n
Antibiotics (oral or parenteral)?
n
Steroids?
n
Anti-inflammatories?
n
Intracanal medications?
If a flare-up occurs
n
Who is at fault?
n
How is it treated?
– Vital pulp
– Necrotic pulp
n With
swelling
n Without swelling
Conclusions
As to Incidence:
– Studies showing high incidences
are questionable
– Occurrence is low
Conclusions
As to Related Factors:
– Demographics
n Age: No
n Sex: Female possibly
– Emotional Status: Yes
– Tooth Groups: No (?)
Conclusions
Other
Other Related
Related Factors:
Factors:
–– Patient
Patient Presenting:
Presenting:
n
nPain:
Pain: Yes
Yes
n
nSwelling:
Swelling: Yes
Yes
n
nPulp
Pulp Necrosis:
Necrosis: Yes
Yes
n
nApical
Apical Pathosis
Pathosis
–– Asymptomatic:
Asymptomatic: No
No
–– Symptomatic:
Symptomatic: Yes
Yes
Conclusions
Treatment Factors:
– Number of Visits: No (?)
– Canal Debridement: No
– Extrusion of Debris: Not likely
– Obturation: Yes (?)
– Retreatment: Maybe with
certain situations
Conclusions
n Medication
Preventing Flare-ups:
– Antibiotics: No
– Analgesics: Not Likely
– Anti-inflammatories: Not Likely