POSTOPERATIVE FLARE-UP AND SWELLING

(management of abscess and cellulitis)

PREPARED BY:Dr ATIKA HASHMIHOUSE OFFICIER

OBJECTIVE:

• Introduction.• Causes.• Risk factors.• Symptoms.• Management.• Prevention.• Conclusion.• References.

FLARE-UP: It can defined as pain and/or swelling of the facial soft tissues and the oral mucosa in the area of endo-donticaly treated tooth that occur within the few hours (12-48 hours) or a few days following the root canal treatment.

Causes Of Endodontic Flare-up:

Microbial factorsMechanical factorsChemicalfactors

1.MICROBIAL CAUSES:

extrusion of debris

Incomplete

instrumentation

Secondary intra

radicular infection

2.MECHANICAL FACTORS:• Over instrumentation .• Extrusion of filling materials. • Incorrect working length .• Inadequate removal of pulpal tissue. 3.CHEMICAL FACTORS:• Apical extrusion of intra-canal medicaments.• Extrusion of irrigating solution .• Over extended Root fillings.

AgeTreatmen

t Procedur

es.

Gender

pulpal status

Tooth type

Pre-operative pain

Allergies.

“Predisposing factors”

“Predisposing factors”• Flare-up rarely occur in older patients due to

the narrowing of the diameter of the root canal and decreased blood flow in the alveolar bone resulting in weaker inflammatory response.

• Post-operative pain is more common among women than men .

• It is established that 47-60% of patients having asymptomatic necrotic pulp experience pain , defined from medium to acute during the first 24 hours after Tx.

• Bone destruction which is visible in dental radiograph is said to be a risk factor of flare-up .

• 80% of patients who feel tooth pain before the beginning of the treatment usually feel the pain after treatment .

• The flare-up rate is 4-9 times higher after one visit endodontic retreatment compared to retreatment by

two – visits.

• Incomplete debridement , over instrumentation

MAGEMENT OF FLARE-UP:1. Reassurance of patient.2. Complete debridement of canal system.3. Incision and drainage. -To evacuate of pus, microorganisms, and toxic products from the peri -radicular tissues.-It releases the peri radicular tissue pressure and provides significant pain relief.

4. Ca (OH)2 therapy.5. Intra-canal medicaments: Clinical studies have demonstrated that post-treatment pain is neither prevented nor relieved by medicaments such as formocresol , camphorated paramonochloro-phenol , eugenol , iodine , potassium iodide. The use of steroids, nonsteriodal anti-inflammatory drugs (NSAIDs), or a corticosteroid–antibiotic has been shown to reduce post-treatment pain.

6. Relief of occlusion.7. use of irrigating solution.8. Re-instrumentation.

PREVENTION:1. Selection of instrumentation techniques.2. Copious irrigation enhanced removal of

pulpal debris.3. Completion of procedures in a single visit. 4. Use of intra canal medicaments. 5. Not leaving teeth open for drainage.6. Maintaining the asepsis during procedure.

DENTAL ABSCESS:• A dental abscess is an loacalized infection of

the mouth, face, jaw, or throat that begins as a tooth infection.

• The original cause may be from a ;

• Deep cavity. • Periodontal (gum) disease.• A cracked tooth.• Trauma or sometimes even due to recent dental

procedures such as extractions and implants.

SIGN AND SYMPTOMS: Pain on chewing . Red, swollen gums . A bad, salty taste in the mouth. Swelling in the jaw or face. A red, swollen bump in mouth that have blood or pus oozing from it.

A tooth that is very tender or sore to touch.

Nausea ,Vomiting . Fever , Chills. Difficulty in swallowing , opening the

mouth, or breathing.

MANAGEMENT:1. Patient counseling and reassurance is done.2. Give antibiotics.3. Make a hole in the tooth to drain the pus and relieve the pain.4. Do a root canal to remove the infected pulp.

5. Remove the tooth. This may be needed if you don't want a root canal, or if you have one and it doesn't work.

To reduce pain and swelling:Put an ice pack wrapped in a towel against

the cheek.Pain killer , including acetaminophen or

ibuprofen . Do not smoke or use any kind of tobacco .

COMPLICATION OF ABSCESS: Osteomyelitis of the mandible. Maxillary sinusitis and orbital abscess. Ludwig’s angina. Cavernous sinus thrombosis . Persistent pyrexia of unknown origin. Septicaemia . Pulmonary abscess. Brain abscess. Mediastinal abscess and pneumonia

MANAGEMENT OF CELLULITIS:• Reassurance and counseling of patient.• Incision and drainage.• Acetaminophen, ibuprofen• Antibiotics.

CONCLUSION

Flare-ups are an undesirable occurrence in the course of endodontic treatment that causes distress to

both the patient and operator. Flare-up rate after endodontic treatment is 1.4-16% . Clinicians should employ appropriate measures in an

attempt to prevent the occurrence of flare-ups and should be able to treat the flare-up efficiently , when they do occur.

REFERENCES:1.Iqbal M, Kurtz E, KoH M, Incidence and factors related to flare-ups in a graduate endodontic programme InternationalEndodontic Journal, (42), 2009, 99-104.2.Morse DR, Koren LZ, Esposito JV, Goldberg JM, Belot RM, Sinai IH et al, Asymptomatic teeth with necrotic pulps and associated periapical radioluscencies: relationship of flare-ups to endodontic instrumentation, antibiotic usage and stress in threedifferent time periods, International journal of Psychosomatic research, (33), 1986, 5-87.3. Sathorn C, Parashos P, Messer H, The prevalence of post-operative pain and flare-up in single- and multiple- visit endodontictreatment : A systematic review, Internayional Endodontic Journal, (41), 2008, 91-99.4. Dean Baugh, James Wallace, The role of apical instrumentation in root canal treatment: A review of the literature, Journal ofEndodontology, 31(5), 2005, 333-340.5. J.F.Siqueira Jr, Aetiology of root canal treatment failure: why well-treated teeth can fail, International endodontic journal, (34),2001, 1-10.6. Lin LM, Pascon EA, Skribner J, Gaengler P, Langeland K. 1991, Clinical, radiographic and histopathological study of endodontictreatment failures, Oral surg oral medicine oral pathology oral radiology and endodontics, (71), 603-611.7. Siqueira JF Jr, Uzeda M, Fonseca MEL. 1996, Scanning electron microscopic evaluation of in vitro dentinal tubules penetration byselected anaerobic bacteria, Journal of Endodontology, (22), 308-10.8. Atlas RM, Principles of microbiology. 2nd edition, 1977, Dubuque, IA, USA, WCB Publishers.9. Fabricius L, Dahlen G, Ohman AE, Moller AJR, predominant indigenous oral bacteria isolated from infected root canals aftervaried times of closure, Scandinavian journal of dental research, (90), 1982, 134-144.10. J.F.Siqueira Jr, microbial causes of endodontic flare-ups, International endodontic journal, (36), 2003, 453-46311. Sundqvist G, Ecology of the root canal flora, Journal of endodontics,(18), 1982, 427-430.12. Siqueira JF Jr, Lima KC, Staphylococcus epidermidis and Staphylococcus xylosus in a secondary root canal inf