CC BY
27POST-OPERATIVE ENDODONTIC FLARE-UPS
Boitsaniuk S.,
PhD, Associate Professor Department of Dental Therapy
Patskan L.,
PhD, Associate Professor Department of Dental Therapy
Pohoretska Kh.,
PhD, Associate Professor Department of Dental Therapy
Levkiv M.
PhD, Associate Professor Department of Dental Therapy I. Horbachevsky Ternopil National Medical University,
Ternopil, Ukraine DOI: 10.5281/zenodo.7479737
ABSTRACT
Pain is a common feeling during an individual's life as an unpleasant sense. Endodontic pain may occur before, during, or after endodontic treatment. The causative factors of complications encompass mechanical, chemical and/or microbial injury to the pulp or periradicular tissues. Microorganisms are arguably the major causative agents of mish ups.
For effective endodontic pain management, the causative factors and treatment methods discussed below should be given due consideration to help the patient get rid of the unpleasant feeling of pain.
Keywords: endodontic treatment, flare-up, acute pain, exacerbation, postoperative pain, root canal infection.
INTRODUCTION
Pain and discomfort immediately after endodontic treatment are significant problems for dentists and patients, and their occurrence and management are of fundamental importance in endodontics [1, 2]. The occurrence of pain and/or swelling after an endodontic treatment is not uncommon in endodontic practice, and can be a frustrating event for dentists and a disappointing surprise for patients. Mish ups happen in any dental office that performs root canal therapy. There are difficulty for both the patient and dentists to handle them. On the patient side, they have to deal with the pain event. Of course, following the verbal communication, we must find pharmacological methods to help a patient deal with the pain and/or swelling [1, 2, 3].
The American Association of Endodontists (AAE) Glossary of Endodontic Terms defines a flare-up as "an
acute exacerbation of periradicular pathosis after initiation or continuation of root canal treatment." A flare-up is defined as the occurrence of severe pain and swelling following an endodontic treatment appointment, requiring an unscheduled visit and active treatment [4, 5].
Postoperative pain following endodontic treatment remains common, with a prevalence of 3 % to 58 % [6, 7]. This adverse event may be a result of various factors, including mechanical, chemical and bacterial irritation. As a result, patients should be warned to expect a slight amount of discomfort following endodontic therapy (Figure 1). Psychological factors have also been suggested as a possible cause of postoperative pain [8, 9].
Figure 1. Factors that influence the development of the post-endodontic flare-up.
Microbial causes
As we know root canal treatment means the cleaning of the canals in the tooth, the main intension of the treatment is to eliminate the disease causing microorganism in the tooth.
Our root canal contains many microorganisms presiding in it. These microorganisms will cause asymptomatic apical periodontitis in it. Along with the virulent factors they will enter the peri-radicular tissues. These microorganisms will proliferate in the apical area of the tooth and proliferate. The microbial density in the apex increases having majority of anaerobic microorganisms.
Development of pain precipitated by infectious agents can be dependent on several factors. These factors are as follows:
— Presence of pathogenic bacteria
— Presence of virulent clonal types
— Microbial synergism
— Number of microbial cells
— Host resistance [10, 11]
It has been suggested in some reports that the presence of certain bacterial species are associated more with particular peri-radicular diseases. In flare ups associated with symptomatic apical periodontitis cases, species of Porphyromonas endodontalis, Porphyromo-nas gingivalis, Prevotella and F. nucleatum bacteria were frequently isolated [6, 12].
Symptomatic periradicular lesions including teeth with abscess are associated more with Porphyromonas species [12, 13, 14]. Acute clinical symptoms are associated with Prevotella and Peptostreptococcus species. Pain on percussion is exhibited frequently due to Pep-tostreptococcus, Eubacterium, Porphyromonas endo-dontalis, P.gingivalis and Prevotella species presence [15]. All these reports is suggestive that Gram- negative anaerobic bacteria are closely associated with the occurrence of symptomatic endodontic infections including acute abscess [16, 17].
The mechanical factors
The second cause of post operative endodontics flare-up is the mechanical factors. The root canal treatment is a chemo-mechanical preparation which is the cause for successfull endodontics, during this procedure some amount of debris, necrotic tissues, microorganisms, irrigative solutions, from the root canal can be forced into the apical periodontal tissues which results in inflammation and post operative pain and disturbs the healing of periodontal tissues [18, 19].
Chemical factors
Substances used in endodontic treatment (such as: intracanal medicaments, irrigation solutions and sealer) might be toxic, causing irritation and flare up if they reached the periradicular tissues. The inflammatory response intensity is proportional to the amount of substances extruded [6, 18].
The irrigative solutions used in the endodontic treatments and the intra canal medicaments, root canal filling substances are in different compositions and might be toxic. This cause chemical irritation and post operative pain and sensitivity too.
Studies shows that complications are commonly seen during obturation of root canal by resorcinol paste
which is a formaldehyde based material. The main drawback of formaldehyde is that it is cytotoxic, it causes necrosis to the living tissues and if they are extruded from the canal, they cause pain and swelling [11].
Treatment of flare-ups
The treatment of endodontic flare-ups includes local treatment, psychological management and usage of medicaments.
Local treatment
Re-instrumentation.
Definitive treatment may involve re-entering the symptomatic tooth. The access cavity should then be opened. Working lengths should be reconfirmed, patency to the apical foramen obtained and a thorough debridement with copious irrigation performed. Remaining tissue, microorganisms, and toxic products or their extrusion are arguably the major elements responsible for the post-treatment symptoms. Drainage will allow for the exudative components to be released from the periradicular tissues, thus reducing localized tissue pressure [10, 17, 19].
Cortical trephination.
Cortical trephination is defined as the surgical perforation of the alveolar bone in an attempt to release accumulated periradicular tissue exudates [6, 20]. Various studies have evaluated the effectiveness of cortical trephination to prevent and relieve posttreatment pain. Chestner et al. reported pain relief in patients with severe and persistent periradicular pain when cortical trephination was performed [6, 21 ].
Incision and drainage (I and D).
The rationale for an I and D procedure is to facilitate the evacuation of pus, microorganisms, and toxic by-products from the periradicular tissues. Moreover, it allows for the decompression of the associated increased periradicular tissue pressure and provides significant pain relief. If the abscess occurs after the obturation of the root canal system, incision of the fluctuant tissue is perhaps the only reasonable emergency treatment, provided if the root canal filling is adequate [22, 23].
General treatment
Pain Medications.
We typically use some combination of antibiotics and pain killers prescriptions.
Many studies show the pre-treatment administration of analgesics and anti-inflammatory drugs minimize the post-operative pain and reduce the incidence of flare-ups. A combination of the non-steroidal antiinflammatory agents (NSAID's) and an opiate are effective in reducing the incidence of flare-ups [24, 25].
Corticosteroids seem to be effective in reducing postoperative pain after endodontic treatment. Administration of Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or paracetamol can help to manage postoperative pain [26].
Non-narcotic analgesics, NSAIDs and acetaminophen have effectively been used to treat the endodontic pain in patients. The combination of a NSAID and ace-tominophen taken together show extra analgesia for treating dental pain. For pain that is not controlled by NSAIDs and acetominophen, narcotic analgesics are
required. These may be given in combination with NSAIDs for extra effects. [9, 27].
Antibiotics.
In a review on the use of systemic antibiotics for the control of post-treatment endodontic pain, Fouad concluded that their use is without justification. Current advances in our understanding of the biology of the infectious and inflammatory process, along with the known risks associated with antibiotics, such as the emergence of multi resistant bacterial strains, strongly indicate that the clinician should seriously re-evaluate their prescribing habits. Pretreatment systemic antibiotics should be prescribed only when clear indication of using antibiotics is present to treat any existing infection. Such a use of antibiotics is judicious and considered as therapeutic intervention [28].
Antibiotics administered after endodontic treatment (4-day regimen) reduce the flare-up incidence to about 2%, but hypersensitivity responses, sensitization, resistant microbes, and drug-taking compliance are potential problems [29, 30].
CONCLUSION
Endodontic flare-ups are an undesirable occurrence in the course of endodontic treatment that cause distress to the patient. Clinicians should employ appropriate measures directed at prevention of occurrence of flare-ups and should be able to treat these efficiently when they do occur.
The occurrence of mild pain and discomfort following endodontic treatment is common even when the treatment rendered is of the highest standard. It is the duty of the clinician to explain it to the patient.
References
1. El Mubarak AH, Abu-bakr NH, Ibrahim YE. Postoperative pain in multiple-visit and single-visit root canal treatment. J Endod. 2010;36(1):36-39. doi:10.1016/j.joen.2009.09.003
2. Glennon JP, Ng YL, Setchell DJ, Gulabivala K. Prevalence of and factors affecting postpreparation pain in patients undergoing two-visit root canal treatment. Int Endod J. 2004;37(1):29-37. doi:10.1111/j.1365-2591.2004.00748.x
3. Zuckerman O, Metzger Z, Sela G, Lin S. Refuat Hapeh Vehashinayim (1993). 2007;24(2):19-69.
4. Jayakodi H, Kailasam S, Kumaravadivel K, Thangavelu B, Mathew S. Clinical and pharmacological management of endodontic flare-up. J Pharm Bio-allied Sci. 2012;4(Suppl 2):S294-S298. doi:10.4103/0975-7406.100277
5. Onay, E.O., Ungor, M. & Yazici, A.C. The evaluation of endodontic flare-ups and their relationship to various risk factors. BMC Oral Health 15, 142 (2015). https://doi.org/10.1186/s12903-015-0135-2
6. Bassam S, El-Ahmar R, Salloum S, Ayoub S. Endodontic postoperative flare-up: An update. Saudi Dent J. 2021;33(7):386-394. doi:10.1016/j.sdentj.2021.05.005
7. Sathorn C, Parashos P, Messer H. The prevalence of postoperative pain and flare-up in single- and
multiple-visit endodontic treatment: a systematic review. Int Endod J. 2008;41(2):91-99. doi:10.1111/j.1365-2591.2007.01316.x
8. Seltzer S, Naidorf IJ. Flare-ups in endodontics: I. Etiological factors. J Endod. 1985;11(11):472-478. doi:10.1016/S0099-2399(85)80220-X
9. Seltzer S, Naidorf IJ. Flare-ups in endodon-tics: II. Therapeutic measures. 1985. J Endod. 2004;30(7):482-475. doi:10.1097/00004770-200407000-00006
10. Jayakodi H, Kailasam S, Kumaravadivel K, Thangavelu B, Mathew S. Clinical and pharmacological management of endodontic flare-up. J Pharm Bio-allied Sci. 2012;4(Suppl 2):S294-S298. doi:10.4103/0975-7406.100277
11. Tomer K, Saini N, Jain, S, Sabharwal G, Guin A. Endodontic postoperative flare up: A review. International Journal of Applied Dental Sciences 2022; 8(1): 285-292. doi:10.22271/oral.2022.v8.i1e.1439
12. Siqueira JF Jr, Rogas IN, Souto R, Uzeda M, Colombo AP. Microbiological evaluation of acute periradicular abscesses by DNA-DNA hybridization. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92(4):451-457. doi:10.1067/moe.2001. 118620
13. Van Winkelhoff AJ, Carlee AW Graaff Bac-teroides endodontalis and other blackpigmented Bac-teroides species in odontogenic abscesses. Infection and Immunity 1985: 49,494-8.
14. Haapasalo M, Ranta H, Shah H Black pigmented Bacteroides spp. in human apical periodontitis. Infection and Immunity 1986: 53,149-53.
15. Yoshida M, Fukshima H, Yamamoto K, Og-awa K, Toda T, Sasawa H Correlation between clinical symptoms and microorganisms isolated from root canals of teeth with periapical pathosis. Journal of Endodontics 1987: 13, 24-8.
16. Hashioka K, Yamasaki M, Nakane A, Horiba N, Nakamura H (1992). The relationship between clinical symptoms and anaerobic bacteria from infected root canals. Jour Endodontics 18,558- 61.
17. Lakshmi KA, Rao GU, Jayaraman M, Ramdhas A, Endodontic flare-ups: A review RGUHS Journal of Medical Sciences, January 2020: 10(1), 9-7.
18. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Ho-boken). 2011;63 Suppl 11:S240-S252. doi:10.1002/acr.20543
19. Sipaviciute E, Maneliene R. Pain and flare-up after endodontic treatment procedures. Stomatologija. 2014;16(1):25-30.
20. Di Spirito F, Scelza G, Fornara R, Giordano F, Rosa D, Amato A. Post-Operative Endodontic Pain Management: An Overview of Systematic Reviews on Post-Operatively Administered Oral Medications and Integrated Evidence-Based Clinical Recommendations. Healthcare (Basel). 2022;10(5):760. Published 2022 Apr 19. doi:10.3390/healthcare10050760
21. Rosenberg PA. Clinical strategies for managing endodontic pain. Endod Top 2002;3:78-92.
22. Siqueira JF Jr, Rôças IN. Bacterial pathogene-sis and mediators in apical periodontitis. Braz Dent J. 2007;18(4):267-280. doi:10.1590/s0103 -64402007000400001.
23. Peters DD. Evaluation of prophylactic alveolar trephination to avoid pain. J Endod. 1980;6(4):518-526. doi:10.1016/s0099-2399(80)80198-1
24. Shamszadeh S, Shirvani A, Eghbal MJ, As-gary S. Efficacy of Corticosteroids on Postoperative Endodontic Pain: A Systematic Review and Meta-anal-ysis. J Endod. 2018;44(7):1057-1065. doi:10.1016/j.joen.2018.03.010.
25. Suneelkumar C, Subha A, Gogala D. Effect of Preoperative Corticosteroids in Patients with Symptomatic Pulpitis on Postoperative Pain after Single-visit Root Canal Treatment: A Systematic Review and Meta-analysis. J Endod. 2018;44(9):1347-1354. doi:10.1016/j.joen.2018.05.015
26. Stamos A, Drum M, Reader A, Nusstein J, Fowler S, Beck M. An Evaluation of Ibuprofen Versus Ibuprofen/Acetaminophen for Postoperative Endodon-
tic Pain in Patients With Symptomatic Irreversible Pul-pitis and Symptomatic Apical Periodontitis. Anesth Prog. 2019;66(4):192-201. doi:10.2344/anpr-66-03-06
27. Keiser K, Hargreaves, K.M. Building effective strategies for the management of endodontic pain. Endodontic Topics, 2002;3: 93-105.
28. Bansal R, Jain A, Goyal M, Singh T, Sood H, Malviya HS. Antibiotic abuse during endodontic treatment: A contributing factor to antibiotic resistance. J Family Med Prim Care. 2019 Nov 15;8(11):3518-3524. doi: 10.4103/jfmpc.jfmpc_768_19.
29. Akbar I. Efficacy of Prophylactic use of Antibiotics to Avoid Flare up During Root Canal Treatment of Nonvital Teeth: A Randomized Clinical Trial. J Clin Diagn Res. 2015;9(3):ZC08-ZC11. doi:10.7860/JCDR/2015/12046.5620
30. Morse DR, Furst ML, Belott RM, Lefkowitz RD, Spritzer IB, Sideman BH. Infectious flare-ups and serious sequelae following endodontic treatment: a prospective randomized trial on efficacy of antibiotic prophylaxis in cases of asymptomatic pulpal-periapical lesions. Oral Surg Oral Med Oral Pathol. 1987;64(1):96-109. doi:10.1016/0030-4220(87)90123-x
THE BULGARIAN EXPERIENCE IN TREATING HEMANGIOMA WITH PROPRANOLOL IN
CHILDREN
Maslarska R.
MD, Pediatrician, Neonatologist, Head of Department of Neonatology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria DOI: 10.5281/zenodo.7479741
ABSTRACT
Hemangioma in children is a frequently encountered benign tumor originating from the endothelial cells. The Bulgarian experience in treating hemangioma with propranolol (Hemangiol) in children is presented in this research. 276 children with hemangioma in different locations were included in the survey, and they were analyzed based on the following criteria: sex, delivery mechanism, age at the beginning of propranolol treatment, localization and type of the hemangioma; method, duration and result of the Hemangiol treatment. The results show recovery in 83.7% of the cases.
Keywords: Hemangioma, Hemangiol treatment, children.
Introduction:
Hemangioma in children is a frequently encountered benign tumor originating from the endothelial cells [1]. The process of fully healing the lesion may take years. Hemangioma can be encountered relatively frequently - in 8-12% of all newborns and in 22% of preterm children, whereby they are more frequent in girls (women:men = 3:1) [1,2]. These skin cutaneous changes are one of the most frequent reasons for a consultation by dermatologists, pediatricians, or neonatal specialists in the first moths after the delivery.
Most hemangiomas in newborns are of little clinical importance, and are simply and aesthetic issue. In a significant percentage of children, however, hemangio-mas are associated with complications in the period after the birth and in early childhood and cause significant morbidity [1]. This necessitates that both pediatricians and neonatologists, as well as consulting dermatologists have in-depth knowledge of the issue. Timely diagnostics, full laboratory tests and imaging and adequate treatment are of particular importance in preventing complications from the condition. With the
introduction of oral propranolol many of the conventional treatment options have gone out of use.
Methodology: The goal of this research is to present the Bulgarian experience in treating hemangioma with propranolol (Hemangiol) in children.
The following tasks were specified in order to realise this goal:
1. A clinical characteristic of the patients treated with Hemangiol.
2. Tracking those patients.
3. Analysis and assessment of the Hemangiol treatment's success rate.
4. Formulating recommendations and procedure for patients requiring Hemangiol treatment.
The following statistics methods were used.
Descriptive statistics:
Quantitative variables were presented by summarizing statistics characteristics - mean, median, standard deviation (SD), minimal and maximal value.
Categorical variable are presented as absolute (N) and relative (%) frequencies.
