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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 62-65

Management of a mid-treatment flare-up

Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Cinderella D'souza
MGM Dental College and Hospital, Junction of NH4 Sion Panvel Expy, Sector 18, Navi Mumbai - 410 209, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohr.ijohr_1_19

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The primary aim of endodontic treatment is biomechanical preparation of the root canal and to hermetically seal it with no discomfort to the patient, providing conditions for the periradicular tissues to heal. The occurrence of interappointment pain and swelling is not a rare event even when endodontic treatment has followed acceptable standards. A flare-up can be defined as pain and/or swelling of the facial soft tissues and the oral mucosa in the area of the endodontically treated tooth that occur within a few hours or a few days following the root canal treatment, when clinical symptoms are strongly expressed and the patient visits a health care institution sooner than scheduled. Flare-up can manifests as pain of varying intensity which occurs following an access opening without instrumentation. Although the reasons for such exacerbations are not always clear, there are a number of hypotheses for its occurance: alteration of the local adaptation syndrome, changes in periapical tissue pressure, microbial factors, effects of chemical mediators, changes in cyclic nucleotides, immunological phenomena and various psychological factors. This case report describes the management of Mid-treatment flare-up in the Permanent Maxillary anterior teeth.

Keywords: Apical extrusion, calcium hydroxide, root canal treatment

How to cite this article:
D'souza C, Shenoy VU, Sumanthini M V, More A. Management of a mid-treatment flare-up. Indian J Oral Health Res 2018;4:62-5

How to cite this URL:
D'souza C, Shenoy VU, Sumanthini M V, More A. Management of a mid-treatment flare-up. Indian J Oral Health Res [serial online] 2018 [cited 2019 Aug 24];4:62-5. Available from: http://www.ijohr.org/text.asp?2018/4/2/62/257145

  Introduction Top

A flare-up is defined as pain and/or swelling of the soft tissues in the area of the endodontically treated tooth that occur within a few hours/days following root canal treatment (RCT), and the patient visits an endodontist unscheduled.[1] The reasons for flare-up are not clear, yet a number of hypotheses exist:[2] alteration of the local adaptation syndrome, changes in periapical tissue pressure, microbial factors, effects of chemical mediators, changes in cyclic nucleotides, immunological phenomena, and various psychological factors. Mid-treatment flare-up rate varies from 1.4% to 16%[3],[4] up to 50%.[5],[6]

This case report describes the management of a mid-treatment flare-up with permanent maxillary anterior teeth.

  Case Report Top

A 24-year-old female patient reported to the department of conservative dentistry and endodontics, with a chief complaint of pus and blood discharge from gums in relation to the upper-right front teeth for 4 years, on applying finger pressure. She gave a history of trauma to the upper front teeth. There was a color change with the anterior teeth, nontender on percussion and palpation. Permanent maxillary left central incisor (21) was carious (mesiopalatally on the cervical margin) [Figure 1].
Figure 1: Photograph showing intraoral swelling in relation to 12 and anterior deep bite

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An intraoral swelling in the labial alveolar mucosa with the permanent maxillary right lateral incisor (12) measuring approximately 3 mm × 3 mm, soft in consistency, nonfluctuant, and nontender on palpation was observed [Figure 1]. Periodontal probing depths with permanent maxillary right and left central incisors (11, 21) and right lateral incisor (12) were within the normal limits and did not respond to thermal and electrical pulp tests.

Intraoral periapical radiograph [Figure 2] showed widening of the periodontal ligament (PDL) space with 11, 12 and 21 and a well-defined periapical radiolucency around 1, which extended on the mesial root surface of 12. 21 showed radiolucency on the mesial aspect of the cervical third of the crown involving enamel and dentin. Medical history was noncontributory.
Figure 2: (a) Working length radiographs of 11, 12 and (b) 21

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Pulp necrosis with asymptomatic apical periodontitis secondary to trauma with 11, 12, and 21 was diagnosed and nonsurgical RCT was planned.


The patient was explained about the procedure and informed consent was obtained. All procedures were carried out under rubber dam isolation (Hygienic Dental Dam, Coltene/Whaledent, Inc., Switzerland).

Caries was excavated with respect to 21 and temporized with zinc oxide eugenol (ZOE) cement (DPI, India).

Access cavity preparation was carried out with 11 and 21, and tentative working length (WL) was determined; RCs were irrigated with saline and were dried and a closed dressing was placed. The patient was recalled the next day for continuation of 12 treatment.

The patient reported the next day with a swelling on the right side of the face extending from the lower border of the mandible involving the lower eyelid and the ala of the nose, which was raised [Figure 3]a. Skin temperature over the swelling was warmer than her body temperature and nontender. Intraorally, the swelling extended from the distal aspect of 13 to the mesial aspect of 21 [Figure 3]b in the alveolar mucosa involving the attached gingiva. The mucosa over the swelling appeared pale, fluctuant, and nontender, with fluid discharge from a punctum. The patient was asymptomatic.
Figure 3: (a) Extraoral photograph showing swelling on the right side of the face extending to the lower eyelid, with the ala of the nose raised on the same side. (b) Intraoral photograph of patient showing swelling with respect to 11, 12

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A diagnosis of mid-treatment flare-up was arrived at.

Access opening was done with 12, and RC was negotiated. Temporary restoration with 11, 21 was removed. There was no drainage from either of the canals. WL was determined using an electronic apex-locator (Propex, Dentsply, India) and was confirmed radiographically [Figure 2]a, [Figure 2]b. Cleaning shaping, irrigation with 2 ml of 5% sodium hypochlorite (NaOCl) (Prime Dental Products Pvt. Ltd., India) followed by final irrigation using 10 ml normal saline was performed and RCs were dried using absorbent-points (MetaBiomed, Korea). Thin sterile calcium hydroxide [Ca(OH)2] (KitDent Supply, Thane, India) mixed with saline was placed as an intracanal medicament and the teeth were temporized with thin dressing of ZOE. The patient was prescribed antibiotics, recalled after 3 days.

After 3 days, the signs and symptoms presented by the patient earlier subsided completely [Figure 4].
Figure 4: Resolution of the intraoral swelling after 3 days

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Intracanal medicament was removed from 12, 11, and 21 canals irrigated with 5% NaOCl and was dried with absorbent points; a thick intracanal medicament was placed and recalled after 1 week.

In the next appointment, Ca (OH)2 was removed, the canals were irrigated with 5% NaOCl followed by saline. 1 ml of 17% EDTA (Prime Dental Products Pvt. Ltd., India) was left in the canals for 1 min and agitated manually using a master apical file to remove the smear layer, followed by copious saline irrigation. Master cone selection was done [Figure 5]a and [Figure 5]b sterilized by immersing in 5% NaOCl solution for 1 min and rinsed in distilled water. RCs were dried and obturated using gutta-percha (Diadent, Kumgang dental Industrial Co. Ltd, Korea) using cold lateral compaction with AH Plus sealer (Dentsply Pvt. Ltd, India) [Figure 5]c, [Figure 5]d. The orifices of 11, 12, and 21 were sealed with type II Glass Ionomer (GC FujiCEM 2, America), and the access cavities were restored with resin composite (3M ESPE Filtek Z350 XT).
Figure 5: (a) Mastercone radiographs of 11, 12 and (b) 21; (c) obturation radiographs of 11, 12 and (d) 21

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The patient was recalled after 24 h and after 1, 3, 6, 9, and 12 months for follow-up.

  Discussion Top

A flare-up of an infectious origin can occur, due to mechanical, chemical, and microbial injuries to the pulp or periradicular tissues, which are induced or exacerbated during RCT.[7]

Microorganisms cause an imbalance in host–bacteria relationship induced by intracanal procedures:[7]

  • Apical extrusion of debris
  • Incomplete instrumentation
  • Secondary intraradicular infections.[8]

During chemomechanical preparation, if microorganisms are extruded into the periradicular tissues, the host will be challenged by a larger number of irritants than before. Consequently, there would be a transient disruption in the balance between aggression and defense in such a way that an acute inflammatory response is mounted to reestablish equilibrium. The intensity of the response depends on the quantitative (number) and qualitative (virulence) nature of the extruded microorganisms.[7] This could have been the reason for the flare-up in the present case.

In the present case, definitive treatment was given by reassuring the patient, reentering the symptomatic tooth, reconfirming WL, patency to the apical foramen and a thorough debridement with copious saline irrigation carried out. Ca(OH)2 with an aqueous vehicle could reduce the bacterial load in the dentinal tubules.[9] Ca (OH)2 mixed with saline was given as an intracanal medicament for a week after which the canals were obturated. The antimicrobial activity of Ca (OH)2 is related to the release of hydroxyl ions in an aqueous environment.[10] The lethal effects of hydroxyl ions on bacterial cells are probably due:[11]

  • Damage to the bacterial cytoplasmic membrane
  • Protein denaturation
  • Damage to the DNA.

  Conclusion Top

This case report has presented the successful management of a flare-up. Systematic approach leads to successful management of flare-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Iqbal M, Kurtz E, Kohli M. Incidence and factors related to flare - ups in a graduate endodontic programme. Int Endod J 2009;42:99-104.  Back to cited text no. 1
Seltzer S, Naidorf IJ. Flare-ups in Endodontics: I. Etiological Factors. J Endod 1985;11:472-78.  Back to cited text no. 2
Siqueira JF, Barnett F. Interappointment pain: Mechanisms, diagnosis and treatment. Endod Topic 2004;7:93-109.   Back to cited text no. 3
Alves VO. Endodontic flare - ups: A prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:68-2.  Back to cited text no. 4
Udoye C, Aguwa E. Flare - up incidence and related factors in adults. J Dent Oral Hyg 2010;2:19-2.  Back to cited text no. 5
Ehrmann EH, Messer HH, Adams GG. The relationship of intracanal medicaments to postoperative pain in endodontics. Int Endod J 2003;36:868-75.  Back to cited text no. 6
Sharma S. Interappointment pain and flare up during endodontic treatment procedures: An update. Int J Appl Dent Sci 2017;3:348-51.  Back to cited text no. 7
Harrison JW, Baumgartner JC, Svec T. Incidence of pain associated with clinical factors during and after root canal therapy. Part 1. Inter-appointment pain. J Endod 1983;9:384-8.  Back to cited text no. 8
Han GY, Park SH, Yoon TC. Antimicrobial activity of Ca(OH)2 containing pastes with Enterococcus faecalis in vitro. J Endod 2001;27:328-32.  Back to cited text no. 9
Siqueira JF. Strategies to treat infected root canals. J Calif Dent Assoc 2001;29:825-37.  Back to cited text no. 10
Siqueira JF, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int Endod J 1999; 32:361-9.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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