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Baskar PG Student Department Of Conservative Dentistry And Endodontics TNGDC DEFINITION : DEFINITION -moderate –to- severe postoperative pain or swelling that begin 12 to 48 hours after treatment and lasted at least 48 hours (pickenpaugh et al 2001) Severe pain and or swelling requiring an unscheduled visit(walton et al 1993) CRITERIA : CRITERIA Few hours to few days after endodontic procedure , patient has significant increase in pain or swelling or combination of two Pt initiates contact with the dentist Localized It may spread to facial spaces Active treatment is rendered INCIDENCE : INCIDENCE Very low, 1.5% to 5.5% Related - preoperative pathosis and signs and symptoms Lowest in vital pulp without periapical pathosis Highest in pulp necrosis -20% Risk factors : Risk factors Patient demographics frequently in females Pulpal /periapical diagnosis acute abscess , acute periapical periodontitis -- have more incidence presence of sinus tract decreases the incidence of flare up Presenting signs and symptoms Treatment procedures incomplete debridement over instrumentation extruded debris over fill and hyper occlusion ETIOLOGY : ETIOLOGY Immunologic response Infection Physical tissue damage Or combination of three CAUSES : CAUSES Microbial causes Non microbial causes Microbial causes : Microbial causes apical extrusion of debris incomplete instrumentation leading to changes in the endodontic micro-biota or in environmental conditions secondary intra radicular infection Apical extrusion of debris : Apical extrusion of debris Principal cause of postoperative pain-chemico mechanical preparation In Asymptomatic tooth –balance between the microbial aggression and the host defense in the periradicular tissues In chemico-mechanical preparation –if the microorganism are apically extruded , the host will face a situation-challenged larger irritants than before – transient disruption in the balance – host will mobilize an acute inflammation to re-establish the equilibrium. Slide 13: Iatrogenic over instrumentation –permits increased influx of exudates and blood into the root canal- -- enhances the nutrient supply to the remaining bacteria within the root canal can then proliferate and cause exacerbation of a chronic periradicular lesion. Exacerbation results - over-instrumentation –coupled with apical extrusion of infected debris Forcing micro- organism can generate periradicular inflammatory response –intensity depends on : Forcing micro- organism can generate periradicular inflammatory response –intensity depends on number(quantitative) virulence (qualitative ) Slide 15: All instrumentation techniques promote extrusion of debris –crown down technique are used –extrude less debris and should be elected for instrumentation Quantitative factor – under the control of the therapist Qualitative factor is more difficult to control Even a small amount of infected debris will exacerbate periradicular inflammation – such virulent clones are major reason of pre-operative symptomatic teeth are more predisposed to flare up Changes in endodontic micro-biota or in environmental conditions : Changes in endodontic micro-biota or in environmental conditions The patterns of micro-bial colonization within the root canal system revealed that microbial organization often resembled the morphological characteristics of a climax community, a self-replicating entity in which bacteria exist in harmony and equilibrium with their environment (Molven et ah. , Siqueira et ah. 2002b) Potent exogenous forces represented by chemo-mechanical preparation using antimicrobial irrigants and intra-canal medication are needed to eliminate such climax communities. Slide 17: The chemo-mechanical preparation should be completed in one appointment, and between visits, an intracanal medication should be left in the root canal. Incomplete chemo-mechanical preparation can disrupt the balance within the microbial community by eliminating some of the inhibitory species and leaving behind other previously inhibited species, which can then overgrow (Sundqvist ). If overgrown strains are virulent and/or reach sufficient numbers, damage to the periradicular tissues can be intensified, and this may result in lesion exacerbation Slide 18: Environmental changes -potential to induce virulent genes-likely more pronounced in incomplete root canal instrumentation. Environmental changes induce turn off virulence genes –remission of symptoms of previously symptomatic could ensue – result in success . Environmental changes turn on of virulence genes asymptomatic cases become symptomatic –persistent infection establish –cause of treatment failure Clinically impossible to predict the environmental changes –chemicomechanical should be completed in one session Secondary intra-radicular infection : Secondary intra-radicular infection Caused by – entry of bacteria between appointment s – both vital and non vital Occurs following breach of the aseptic chain Sources Remnants of plaque Calculus or caries Leakage of rubber dam Contamination of endodontic instruments Temporary restoration Fracture of tooth structure Increase of the oxidation – reduction potential : Increase of the oxidation – reduction potential Alteration of the oxidation-reduction potential (Eh) -can beacause of exacerbation following the endodontic procedures (Matusow ). When the tooth is opened, oxygen penetrates into the root canal system, and the microbial growth pattern changes from anaerobic to aerobic. Energy yield of facultative anaerobes is more marked in the presence of oxygen than under anaerobic conditions, and a faster growth rate is expected. It is believed that if facultative anaerobes, such as streptococci, are present in the root canal infection and they resist intracanal procedures, they may overgrow as a result of the increase in the Eh potential and then deflagrate acute periradicular inflammation MICROBIAL CAUSES : MICROBIAL CAUSES Porphyromonas species –associated with periradicular lesions including abscessed teeth (hapasalo et al ) Percussion pain frequently displayed peptostreptococus species,Eubacterium, P.gingivalis and provtella Using molecular diagnosis method –Trepenema denticola –high prevalence values of symptomatic infections –acute apical periradicular abscess Slide 22: Gram negative anaerobic bacteria were closely associated with the etiology of symptomatic periradicular lesion including cases acute periradicular Non microbial causes : Non microbial causes Chemical and physical factors Intensity of pain depends upon –intensity of injury, intensity of tissue damage,and intensity of inflammatory response – all are interconnected Iatrogenic events-mechanical irritation and over instrumentation. Over extended filling materials mechanically compress the periradicular tissues and my induce pain Chemical irritation include apical extrusion of irrigants or intracanal medication. Diagnosis : Diagnosis premedical and dental history clinical examination areas of swelling , discoloration, ulcerations , exudation , defective and or lost restorations , cracked or fractured teeth and apparent changes in occlusal relationships . Slide 26: Clinical testing should include percussion, apical palpation, bite stick challenge, thermal stimulation and periodontal probing. Properly angulated radiographs This combined clinical and radiographic test may reveal that the symptoms are non odontogenic, are related to another tooth, or in fact, related to the recently treated tooth. Preventive measures to infectious flare-ups : Preventive measures to infectious flare-ups Guidelines to reduce incidence of flare up selection of instrumentation techniques that extrude less amounts of debris apically; completion of the chemo-mechanical procedures in a single visit; use of an antimicrobial intracanal medicament between appointments in the treatment of infected root canals; not leaving teeth open for drainage; Maintaining the aseptic chain during intracanal procedures. Selection of instrumentation techniques that extrude less amounts of debris apically : Selection of instrumentation techniques that extrude less amounts of debris apically Linear filing motion creates more debris than rotational action Crown-down technique –extrude lesser amount of debris Copious irrigation enhances removal of excised dentine, microbial cells and pulpal debris . Crown –down technique with copious irrigation is said to be ideal to prevent flare up Completion of the chemo-mechanical procedures in a single visit : Completion of the chemo-mechanical procedures in a single visit Ideally, chemo-mechanical procedures should be completed in a single appointment. Maximum removal of irritants from the root canal system may reduce the risks of inter-appointment discomfort caused by surviving microbial species that either overgrow as a result of elimination of inhibitory species or become more virulent as a result of changes in the environmental conditions. Use of an antimicrobial intracanal medicament between appointments in the treatment of infected cases : Use of an antimicrobial intracanal medicament between appointments in the treatment of infected cases Low incidence of Flare up – when calcium hydroxide /camphorated para-monochlorophenol/glycerin paste Intracanal medicaments –prevents recontamination of root canal Intracanal medicaments –is not effective flare up caused by extruded microorganism during the chemico-mechanical procedures Do not leave teeth open for drainage : Do not leave teeth open for drainage Alfred Walker argued against the practice of leaving teeth open for drainage: 'This method is as unscientific as it is antiquated (...). The practice of leaving the pulp canals of teeth open and unsealed for the purpose of drainage is contrary to the accepted surgical practice, is unnecessary and is, in consequence, a bad practice.' Slide 32: To leave the tooth open is the most direct way to permit the re-infection of the root canal system in addition to overcome any previous attempts to eradicate microorganisms within the root canal system. Establishment of drainage followed by complete chemo-mechanical preparation, placement of an antimicrobial intracanal medication, and coronal closure at the same appointment result in a reduced risk of persistent infection . Slide 33: After proper drainage and once the source of infection (intraradicular microorganisms) is effectively controlled, no more purulent exudate will form, and the abscess will consequently resolve. Even in the presence of diffuse swelling --without any purulent discharge, the tooth should not be left open to await drainage. If the tooth is left open, more microbial cells, species, products and substrate are allowed to gain access to the root canal and the periradicular tissues. Slide 34: Even in the few circumstances in which complete root canal preparation followed by intracanal medication and proper coronal seal are not effective in promoting resolution, the practice of leaving the tooth open is not justifiable. In these cases, the amount of purulent exudates that are close to the apical foramen is limited once the infection is spreading through the bone and the major amount of pus is on its way for sub-mucous or subcutaneous drainage. If no pus drains through the root canal even after a slight widening of the apical foramen using small sterile files, To expend all efforts in maintaining the aseptic chain during intracanal procedures : To expend all efforts in maintaining the aseptic chain during intracanal procedures clinicians should be aware of the need to perform endodontic treatment under strictly septic conditions as some cases of secondary infections may even be more difficult to treat than primary infections and may cause flare-ups, persistent symptomatology and/or failure of the root canal treatment (Siqueira 2002) Definitive treatment : Definitive treatment Re-instrumentation anesthetized To look for additional anatomy –and missed canals Enhanced magnification and illumination Working length reconfirmed patency obtianed Suppurative exudate may establish-drainage release localized pressure Cortical trephination : Cortical trephination Surgical perforation of the alveolar bone to release periradicular tissue exudate. Decrease in 16-25% postopertative pain incidence when performed prophylactically (chestner et al ) Incision and drainage : Incision and drainage Establishing drainage through the oral mucosa provides effective emergency management . It facilitates evacuation of pus, microorganism and toxic products from the peri-radicular tissues In RCT has not completed re-entering the root canal to eliminate etiologic factors via debridement ,irrigation and the placement of antimicrobial dressing Abscess after RCT incision of the fluctuant tissue ,provided root canal filling is adequate Poorly filled canals filling material removed to allow additional pus discharge through the root canal space Slide 39: Antibiotics are not indicated in cases of localized abscess, but they can be used to supplement clinical procedures in cases where there is poor drainage and if the patient has concomitant trismus, cellulitis, fever or lymphadenopathy Intracanal medications : Intracanal medications clinical studies have demonstrated that post treatment pain is neither prevented nor relieved by medications such as formocresol, camphorated paramonochlorophenol, eugenol, iodine potassium iodide, ledermix or calcium hydroxide. Irrigating solutions : Irrigating solutions the type of irrigating solution used makes little difference in the incidence of post-operative discomfort, providing that the irrigating solution is not forced beyond the foramen of the tooth. Harrison et al. Found that there was a higher incidence and degree of pain in patients whose canals were either not irrigated or irrigated with saline solution, compared with those irrigated with 5.25% sodium hypochlorite and 3% H202. Slide 42: Puttier and Crawford found that, in vivo, small amounts of endotoxin were detoxified by 2.6% solutions of NaOCl. On the other hand, formo-cresol, 5.25% NaOCl, and 3% H202 have not been found to increase the incidence of interappointment pain since the induction of pain in endodontic therapy is multifactorial, it is difficult to attribute a lower pain incidence specifically to the use of any particular irrigant. Occlusal reduction : Occlusal reduction Minimal agreement in literture to benefit reducing the occlusion to prevent post endodotnic pain . Creech et al . Routine occlusal reduction for the prevention of post –operative pain was in effective . Sensitive to biting and chewing is perhaps due to increased levels of inflammatory mediators that stimulate periradicular nociceptors . Corticosteriods : Corticosteriods anti inflammatory -ability to retard lysosomal release from cells by inhibiting fusion of lysosomes with their target membranes. In addition, corticosteroids inhibit the liberation of free arachidonic acid from the phospholipids of the cell membrane by phospholipases. Slide 45: Steroids not only prevent the formation of PG's and thromboxanes but also LT's and other oxygenated derivatives. It would thus appear that the therapeutic effects of steroids, which are not shared by aspirin-like drugs, are due not only to the inhibition of PG formation but also the inhibition of LT formation. Slide 46: Cortisone also appears to have the ability to obtund pain, -effect on stabilizing membranes. The hormone may cause hyper-polarization of the nerves in the inflamed area or it may enhance the production of cyclic AMP, which in turn, activates a protein kinase. Kinase - phosphorylation of a protein constituent of the nerve cell membrane, leading to a change in membrane permeability. Increase of cyclic AMP causes a hyper-polarization that reduces transmission of nerve impulses Although the density of the inflammatory infiltrate in the periodontal ligament may be reduced by corticosteroids , they interfere with phagocytosis and protein synthesis. Antibiotics : Antibiotics Group A streptococci (Streptococcus pyogenes),- have a number of characteristics that exhibit antigenic variation of virulence. These include the hyaluronic capsule, the streptococcal chemotactic factor, and the M proteins. M proteins are responsible for the ability of these streptococci to resist phagocytosis . Strains of new M proteins have arisen in populations experiencing frequent infections Slide 48: The use of the most popular antibiotic, penicillin, is based on the predominance of penicillin-sensitive microorganisms reportedly found in infected root canals. Although most strains of bacteria found in endodontic infections are susceptible to penicillin, some, such as the anaerobic peptostreptococci, Bacteroides fragilis, are resistant. Slide 49: Despite many new antibiotics, bacteria have responded by the rapid evolution of genetic variants which are resistant to all antibiotics. It seems that, in time, totally resistant bacteria emerge and, in many cases, predominate. Increasing numbers of strains of pathogens, such as Streptococcus viridans and Staphylococcus aureus, originally susceptible to penicillin, are becoming resistant. Slide 50: Resistance is transferred from organism to organism by packages of genes, called plasmids. Such transference may occur both within and across species lines by conjugation. . Many of the genes specifying antibiotic resistance are found on movable elements of DNA called transposons. Penicillin-sensitive organisms, such as Bacteroides melaninogenicus, may produce lactamase (a penicillinase) which renders them penicillin-resistant. Such resistant strains may then protect other pathogens that would normally be susceptible to penicillin Slide 51: There appears to be a trend toward an increase in the number of anaerobic dental infections. In such cases, some antibiotics, such as clindamycin or tinidazole, may be effective, but the organisms may be resistant to erythromycin, demeclocycline, or doxycycline. In a few cases of cellulitis induced by mixed anaerobic and facultative streptococcal root canal infections, Matusow and Goodall obtained good resolution by root canal treatment and by using erythromycin. Slide 52: The rational selection of an appropriate antibiotic to control root canal infections should depend on culturing and sensitivity testing. However, there are no significant studies which show that any specific antibiotic is capable of reducing or eliminating painful exacerbations during endodontic therapy. Corticosteroids : Corticosteroids Systemic corticosteroids have been successfully used to reduce pain and swelling mainly in oral surgical procedures. In a controlled study, Marshall and Walton found that intramuscular injection of 4 mg of dexamethasone significantly reduced both the incidence and severity of pain 4 h after single-appointment endodontic the -spy. Alter 24 h, pain incidence was still less than in the controls that the results were not statistically significant Non-steriodal anti-inflammatory agents : Non-steriodal anti-inflammatory agents drug of choice for mild to moderate pain –aspirin- efficient non-narcotic analgesic. Aspirin has also been shown to cause hyper-polarization of the neural membrane due to an increase in permeability of the potassium and a decrease in that of the chloride ion. In patients with known sensitivity to NASIDS and who have gastrointestinal ulceration or hypertension due to renal effects of NASIDS, acetaminophen should be considered for post treatment pain. Slide 55: Ibuprofen is generally considered the prototype of NSAIDs -- documented efficacy and safety profile . Although there are few endodontic studies that compared one NSAID with another, 400 mg ibuprofen was shown to be similar to 50mg of ketoprofen. Pretreatment with NSAID ketorolac trimethamine, when injected intra-orally or intramuscularly, produced significant analgesia in patients with sever odontogenic pain prior to treatment. Ibuprofen 600mg taken 6h is optimal for managing pulpal pain and periradicular pain of inflammatory origin. The combination of NASAID and acetaminophen taken together show additive analgesia for treating dental pain Pain after completion of endodontic therapy : Pain after completion of endodontic therapy - complains of pain- biting and chewing. -the number of treatment visits apparently makes little difference . The reported incidence of postoperative pain following single-or multiple-visit endodontic treatments varies considerably in some studies, single-visit procedures produced less pain. Endodontic treatment of posterior teeth also seems to produce more postoperative discomfort, especially after single-visit procedures Slide 57: Fox et al. -90% of the teeth treated endodontically in one visit were free of spontaneous pain after 24 h, whereas 82% had little or no pain on pressure. Pressure pain usually lasts longer than spontaneous pain. These painful episodes are usually caused by the pressures inherent in the insertion of the root canal filling materials or by the chemical irritation from the ingredients of the root canal cements or pastes. Overextending the root canal filling material beyond the foramen increases the incidence of subsequent pain. Slide 58: Periapical inflammation - in the firing of proprioceptive nerve fibers in the periodontal ligament. These effects are short-lived and abate within a 24- to 48-h period. No treatment is usually necessary. The persistence of pain on biting, especially when accompanied by swelling, is an indication that a severe, acute inflammation has developed. Slide 59: Such cases usually require surgical intervention, such as periapical curettage. Persistent sensitivity or pain for longer periods may indicate failure of resolution of the inflammation in the periradicular tissues. In rare cases, inflamed but viable pulp tissue may be left in the root canal and may receive nutrition from accessory canals in the area. Retreatment of the root canal is then indicated. Slide 60: Persistent sensitivity or pain for longer periods may indicate failure of resolution of the inflammation in the periradicular tissues. In rare cases, inflamed but viable pulp tissue may be left in the root canal and may receive nutrition from accessory canals in the area. Retreatment of the root canal is then indicated. Slide 61: Another possible cause for persistent pain after root canal therapy is a fracture of the crown or root. Cracks in the dentin may result from excessive pressure during the insertion of the root canal filling material or from masticatory pressures. These teeth eventually require extraction. In rare cases, paresthesia and pain of the lower jaw has been induced by over-instrumentation or overextension of root canal filling material, especially with par formaldehyde preparations. Although the paresthesias are usually temporary, a few have been reported to persist for longer than 1 yr especially after periapical surgery. Studies : Studies Teeth with vital pulps reported the lowest frequency of post-obturation pain (48.8%), while those with nonvital pulps were found to have the highest frequency of post-obturation pain (50.3%), Single visit endodontic therapy --be a safe and effective alternative to multiple visit treatment, especially in communities where patients default after the first appointment at which pain is relieved.(Adeleke O Oginni*-2008) Slide 63: Effect of Prophylactic Amoxicillin on Endodontic Flare-Up in Asymptomatic, Necrotic TeethJournal of Endodontics, a prophylactic dose of amoxicillin before endodontic treatment of asymptomatic, necrotic teeth had no effect on the endodontic flare-up. Endodontic cellulitis 'flare-up'. Case report(IEJ-2009) : Endodontic cellulitis 'flare-up'. Case report(IEJ-2009) The alteration of the oxidation/reduction potential (Eh), as a major factor for endodontic cellulitis flare-ups; to confirm the pathogenic potential of oral facultative streptococci; and that asymptomatic endodontic lesions tend to exist with mixed aerobic/anaerobic microbial flora. Flare-ups in endodontics and their relationship to various medicaments. Aust Endod J 2007, : Flare-ups in endodontics and their relationship to various medicaments. Aust Endod J 2007, The incidence of flare-ups after using three modalities (Ledermix, calcium hydroxide and no medication) to manage patients presenting for relief of pain of endodontic origin. A statistical analysis showed that there were no significant differences in flare-up rates at both the 4-h and 24-h periods between the three modalities. Slide 66: If we can really understand the problem, the answer will come out of it, because the answer is not separate from the problem. 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