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Endodontic interappointment flare-Ups: A prospective study of incidence and related factors
0099-2399/92/1804-0172/$03.00/0 JOURNALOF ENDODONTICS Copyright © 1992 by The American Association of Endodontists
Printed in U.S.A.
VOL. 18, NO. 4, APRIL1992
CLINICAL ARTICLE Endodontic Interappointment Flare-Ups: A Prospective Study of Incidence and Related Factors Richard Walton, DMD, MS, and Ashraf Fouad, BDS, MS
Severe pain and/or swelling following a root canal treatment appointment are serious sequelae. Information varies or is incomplete as to the incidence of these conditions and related factors. In this study, data were collected at root canal treatment appointments on demographics, pulp/periapical diagnoses, presenting symptoms, treatment procedures, and number of appointments. Patients that then experienced a flare-up (a severe problem requiring an unscheduled visit and treatment) had the correlating factors examined. Statistical determinations were by chi-square analysis with significance at 0.05 or less. Nine hundred forty-six visits resulted in an incidence of 3.17% flare-ups. Flare-ups were positively correlated with more severe presenting symptoms, pulp necrosis with painful apical pathosis, and patients on analgesics. Fewer flare-ups occurred in undergraduate patients and following obturation procedures. There was no correlation between patient demographics or systemic conditions, number of appointments, treatment procedures, or taking antibiotics.
nation of both. The problem must be of sufficient severity that there is disruption of the patient's lifestyle such that the patient initiates contact with the dentist. Required then are both: (a) an unscheduled visit and (b) active treatment (incision for drainage, canal debridement, opening for drainage, etc.). Because of their nature, these interappointment endodontic flare-ups, when they occur, create difficulties for both patient and dentist. Although there are a few reports on the incidence, etiologies, and treatment of flare-ups, most related factors remain unspecified. INCIDENCE Studies report varying incidences of flare-ups. These variations are at least partially the result of examining different factors and conditions as related to flare-ups. For example, Morse et al. (2) reported an incidence of approximately 20% flare-ups (swelling was the only criteria) after treating asymptomatic teeth with pulp necrosis and chronic apical periodontitis. In contrast, Barnett and Tronstad (3) in a retrospective study determined an incidence of approximately 5.5% flareups (pain and/or swelling) in patients with a similar diagnosis (pulp necrosis with asymptomatic periapical lesion), but 1.4% in all patients regardless of diagnosis. Others (4-7) have reported varying percentages of incidence of flare-ups, again depending upon the factors considered. Problems with most of the above-mentioned studies are that many are retrospective, lack controls, have relatively small numbers of patients or have undefined variables.
A flare-up following a root canal treatment appointment is a significant problem. This is upsetting to both the patient and dentist and disruptive to a busy practice. The flare-up phenomenon is complex and, although not well understood, undoubtedly involves a number of aspects related to local tissue changes, microbial factors, immunological phenomena, and other entities (1).
FACTORS The aspects associated with flare-ups have also been examined. These generally are in the categories of patient-related factors, pulpal/periapical diagnosis, and treatment procedures. Although many specifics have been examined, those that seem to be most related to a significantly greater number of flare-ups are sex and age of patient (8), presence and size of a periapical lesion (3, 7, 8), a history of preoperative pain and/or swelling (8), reported allergies (8, 9), retreatment pro-
DEFINITION The interappointment flare-up is defined as follows: within a few hours to a few days after a root canal treatment procedure a patient has either pain or swelling or a combi-
172
Vol. 18, No. 4, April 1992
cedures (8), and overinstrumentation (10). This information is incomplete because most reports were retrospective studies or were incidental to other findings. A prospective study on a large group of patients is needed. This would provide adequate numbers and accurate data on the incidence and factors related to interappointment flareups. The purpose of this study was to conduct a prospective survey of endodontic patients. To be determined were the following: 1. The overall incidence of flare-ups as a percentage of all patient visits. 2. Correlation of the occurrence of flare-ups with (a) Patient demographics: age and sex. (b) Presenting patient factors: pulp and periapical diagnosis, presence of and level of pain, presence of and nature of swelling, whether on medications, and certain systemic conditions. (c) Treatment procedures: step performed in root canal treatment, number of appointments, and type of treatment (conventional or retreatment). (d) Operator groups: undergraduate, graduate, or faculty members. M A T E R I A L S AND M E T H O D S Data were gathered on 946 patient visits over a 4-month period. Included were all patients undergoing root canal treatment in the Endodontics Clinic by either undergraduate, graduate, or faculty. At each visit, information was obtained on each patient as to their demographics, presenting signs, symptoms and diagnosis; and treatment performed. A form in which the data were entered was generated for each appointment.
Treatment Procedures These were routine. The operator completed as much of the treatment as was feasible or indicated according to time, findings, diagnosis, complexity, and so forth. If additional appointments were necessary, the access was closed with a dry cotton pellet and a temporary filling. No medicaments (Ca[OH]2, steroids, etc.) were placed interappointment. The occlusion was not adjusted. At the conclusion of the appointment, the patient was given posttreatment instructions. These were essentially as follows: Expect the tooth to be sore for one or two days. This soreness should not be more than over-the-counter medication can take care of. If the tooth is more painful, particularly if it seems to be getting worse, call me. Also, if you notice swelling that is developing or increasing, call. If you have any other questions or problems, be sure and contact me.
If the patient called with a problem which seemed severe, the treating student or faculty member instructed the patient to return to the clinic immediately. A decision was then made as to whether active treatment was necessary. Simply talking to the patient, or only prescribing or dispensing medication
Flare-Ups: Related Factors
173
did not constitute a flare-up. Treatment was then performed as deemed appropriate. A second flare-up following the initial flare-up was not considered or included in the survey. At the emergency visit, the patient's form, as generated during the first treatment visit, was recovered and identified as a flare-up.
Evaluation Analysis was in two aspects: (a) overall incidence of flareups as expressed by a percentage of all patients visits and (b) percentage of flare-ups that occurred as related to various factors such as patient demographics, diagnosis, and treatment procedures. These percentages were compared statistically to determine those factors which were significantly related to an increased or decreased incidence of flare-ups. The chi-square analysis was used to compare the variables (p ___0.05). RESULTS The overall incidence of flare-ups was relatively small (3.17%). When a flare-up did occur, it was primarily related to presenting factors, that is, patient signs/symptoms and diagnosis of the involved tooth and related tissues. Treatment procedures were generally unrelated to an increase or decrease in flare-ups. The one demographic factor that correlated with an increased number of flare-ups was a greater occurrence in females as compared with males. The detailed results are below.
Incidence of Flare-Ups Nine hundred forty-six patient visits, equally divided between male and female, resulted in a total of 30 flare-ups. This was an overall percentage of 3.17%.
Demographic Factors As to age of patients, there were no increases in flare-ups when analyzing groups by decades. No pattern of flare-ups was seen with a greater tendency in any age group (Table 1). Sex of patients (Table 2), that is male versus female, did show a difference of a two times greater prevalence of flareups in females (n = 20) over males (n = 10). However, this difference was not statistically significant (p = 0.067). TABLE 1. O c c u r r e n c e o f flare-ups according to age groups* Age (yr)
Total No. of patients
No. of FlareUps
<20 20-29 30-39 40-49 50-59 60-69 70-79 >80
51 211 227 144 89 131 62 10
0 9 9 1 5 3 1 0
Percentage 0 4.3 4.0 0.7 4.5 5.3 1.6 0
* There was no statisticallysignificantdifferenceamongthe groups (p _<0.05).
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Journal of Endodontics
TABLE 2. Flare-ups according to sex, with no statistically significant differences (p _< 0.05)
Sex
Total No. of Patients
No. of FlareUps
Percentage
Male Female
463 463
10 20
2.2 4.3
TABLE 3. Flare-ups in different arches and tooth groups*
Tooth Group Mandibular Anterior Premolar Molar Maxillary Anterior Premolar Molar
Total No. of Patients
No. of FlareUps
Percentage
52 85 278
1 6 10
1.9 7.0 3.6
102 120 276
2 3 8
2.0 2.5 2.9
19.2 20
10
* No differences were determined statistically (p _< 0.05).
Examining by tooth groups or between arches (maxillary versus mandibular) showed no significant difference (Table
PAIN
SWELLING
FIG 1. Patients presenting with pain and/or swelling experienced a significantly greater number of posttreatment flare-ups.
3). 8 -
Patient Presenting Factors Patient symptoms, that is pain and/or swelling at the initial appointment, were very important in being associated with a much higher incidence of interappointment flare-ups. As the severity of pain and/or swelling increased, there was a definite tendency for the patient to develop severe posttreatment problems (Fig. 1). The most important factor was severe preoperative pain which resulted in an incidence of flare-ups of over 19%. Next in incidence was the patient reporting with localized and/or diffuse swelling with an occurrence of 15 % having flare-ups. Pulp and periapical status was also significantly related (or unrelated) to flare-ups. Teeth with vital pulps resulted in relatively few flare-ups for an overall percentage of 1.3%. In contrast, pulp necrosis correlated to an incidence of 6.5%, a statistically significant increase as compared with vital pulps (Fig. 2). The periapical diagnosis of acute apical abscess was also significantly greater in flare-ups incidence as compared with less symptomatic or less severe apical pathoses (Fig. 3). Sinus tract presence never correlated with a flare-up.
6.5*
0
0
////
,
FIG 2. AS the severity of pulp pathosis increased, patients had significantly more flare-ups•
Treatment Factors Number of visits (single versus multiple visits) was not significant (Table 4). Medications, i.e. antibiotics and/or analgesics prescribed prior to the treatment either by the referring dentist or for unrelated medical reasons, did correlate with an increased number of interappointment flare-ups (Tables 5 and 6). The incidence of flare-ups was greater in patients taking either analgesics or antibiotics preoperatively; however, only the analgesics factor was significantly different.
Procedure did make a difference as to the incidence of flare-ups. However, the incidence of flare-ups was inversely related to either obturation alone or when obturation was combined with cleaning and shaping in the same appointment. Therefore, overall, obturation correlated with significantly fewer posttreatment flare-ups (Fig. 4). Nature of treatment, i.e. conventional root canal treatment or retreatment of failures, showed no significant difference in flare-up incidence with either modality (Table 7).
Vol. 18, No. 4, April 1992
Flare-Ups: Related Factors
20
175
5.5
5.3
13.1
10
2
1"
SAP
NORMAL
CAP
AAP
AAA
/'///
0 "
F~G 3. Patients presenting with acute apical abscess (AAA) experienced significantly more flare-ups than less severe apical pathosis. Note that sinus tract (SAP) resulted in no flare-ups. CAP, chronic apical periodontitis; AAP, acute apical periodontitis.
TABLE 4. Number of treatment visits*
No. of Visits
Total No. of Patients
No. of FlareUps
Percentage
Multiple Single
739 196
24 5
3.3 2.6
* There was no difference in flare-up incidence between single and multiple visits (p _<
o.0s).
FIG 4. The only procedure related to significantly fewer flare-ups was obturation. Note that partial cleaning and shaping was no different statistically than complete cleaning and shaping.
TABLE 7. Conventional versus retreatment, with no difference in flare-up incidence (p _< 0.05)
TABLE 5. Flare-ups in patients being administered antibiotics* Antibiotic Status
Total No. of Patients
No. of FlareUps
Percentage
Yes No
95 845
6 24
6.3 2.8
Treatment
Total No. of Patients
No. of FlareLips
Percentage
Conventional Retreatment
795 145
25 5
3.1 3.5
zl¢:
* There was no statistically significant difference between groups (p -< 0.05).
TABLE 6. Flare-ups in patients taking analgesics* Analgesic Status
Total No. of Patients
No. of FlareUps
Percentage
Yes No
168 772
13 17
7.7 2.2
* There were significantly more flare-ups in the analgesics group (p <- 0,05).
Operator Comparing the incidence of flare-ups with patients of faculty, graduate students, and undergraduate students showed that the dental student patients had significantly fewer flareups as compared with the other two groups (Fig. 5).
o FACULTY
GRAD STUDENTS
UNDERGRADS
FIG 5. Undergraduate student patients experienced significantly fewer flare-ups than faculty or graduate students.
DISCUSSION We found it most interesting and important that the overall incidence of flare-ups in our patients was relatively low. Our
finding of approximately 3% is similar to those percentages reported by Barnett and Tronstad (3) and Trope (7). These studies are considerably lower than the finding of others which
176
Walton and Fouad
found an incidence ranging from 11 to 33% (1, 2, 4, 5, 9). The reasons for the differences cannot be readily explained but could relate to different patient populations, varying treatment modalities, and other methods of assessment. However, criteria for identifying the flare-up, at least as described by other authors (2, 5), were similar to ours in that they specified that the patient return for an unscheduled visit with significant signs and symptoms that required treatment. Based on our results from a prospective study, the average practitioner should have few flare-ups. In fact, patients of general dentists should experience fewer flare-ups than the endodontist who generally is managing a larger percentage of emergencies. Many of these emergencies involve acute apical abscess with pulp necrosis; we found these to be markedly greater in the incidence of flare-ups. Therefore, if a practitioner is not seeing large numbers of patients with presenting emergencies but is still experiencing a disproportionate number of flare-ups, he or she should reassess his or her treatment modalities. Some related factors differ between ours and other studies. We found sex, age, allergies, and retreatments to be statistically nonsignificant whereas others (8, 9) found these to be significant. Differences could relate to the design of the studies; ours was prospective, theirs was retrospective. Also, there could be regional differences in population groups. The overriding factor as to predicting a flare-up was the presenting condition (signs, symptoms, and diagnosis). Patients with particular findings will also have other considerations. For example, patients on emergency visits or with adverse symptoms are more likely to be taking analgesics and/ or antibiotics before the appointment. This is the likely reason why patients on these medications had a higher incidence of flare-ups. It is unlikely that the flare-up was caused by the therapeutic agent. On the other hand, it was interesting that flare-ups occurred in higher percentages in these patients; antibiotics did not seem to be preventive as has been reported by others (5, 11). Another significant difference between ours and others' studies is in the group of patients which presented with asymptomatic periapical lesions. Others (1, 2, 5, I 1) reported an 1 t to 25% incidence of flare-ups; we found 3.5% of these patients to have flare-ups. The difference could be that our criteria were more stringent, therefore, resulting in a lower percentage. However, stated criteria of others were similar to ours. In fact, in the Morse et at. (2) and Mata et al. (5) reports only patients reporting severe swelling, and not just pain alone, were classified as flare-ups. If we considered only those flare-up patients returning with swelling, our overall incidence would drop even further to 0.73%. Furthermore, we had no patients with a flare-up consisting of swelling alone (with minimal pain) if their preoperative diagnosis was chronic apical periodontitis (asymptomatic periapical lesion). The finding that the treatment procedures in our patients made no difference is comparable to other studies. One study (10) which did relate to treatment factors showed an increase of flare-ups with overinstrumentation (penetration beyond the apex). In contrast, Morse et al. (12) did not observe more problems when files were intentionally inserted into periapical lesions. We did not examine this specific factor; the attempt is always to try to contain instruments, irrigants, and obturating materials within the canal. Therefore, it cannot be stated with certainty that physical or chemical damage to periapical
Joumal of Endodontics
tissues in our patients would not result in a greater incidence of flare-ups, since we did not examine these factors. Most interesting was our finding that complete debridement of canals of necrotic pulps (and presumably with bacteria also) did not prevent, or even have an effect, on the incidence of flare-ups. In fact, the number of flare-ups in the partial versus the complete preparation groups was nearly equal, a finding that is supported by other studies (6, 8). Logically it would be desirable to remove intracanal irritants as a preventive measure; apparently this is not the case. Our low number of flare-ups following root canal treatment of teeth with vital pulps was consistent with the findings in other studies (3, 7). This is not surprising, since preexisting severe periapical pathosis would seem to "set the stage" for posttreatment problems. Similarly, our finding of no difference in flare-ups between single and multiple appointments is reinforced by data from other studies (6, 13). Apparently there is no basis to the common belief that extending treatment procedures over additional appointments will reduce periapical trauma and help prevent flare-ups. Most unexpected was the significantly lower incidence of flare-ups in dental student patients as compared with faculty and postgraduate students. There is no obvious explanation for this difference. We examined the nature of student patients with the assumption that the3, may have less emergencies, fewer patients with significant pulp/periapical pathosis, or other factors predisposing to flare-ups. This was not the case. One difference may be that faculty and postgraduate students see more advanced and difficult cases; however, this variable was not examined. Other possible reasons may be that (a) student patients are less likely to complain but will suffer through a posttreatment problem, or (b) that students take considerably longer at each appointment for cleaning, shaping, and obturation. This prolonged appointment could result in longer exposure of tissues to irrigants (sodium hypochlorite) and possibly more reduction in bacteria or other canal irritants. Again, these variables were not examined. Dr. Walton is professor and chairman, Department of Endodontics and Dr. Fouad is assistant professor, Department of Endodontics, University of Iowa Collegeof Dentistry, Iowa City, IA. Address requests for repdnts to Dr. Richard Walton, Department of Endodontics, University of Iowa College of Dentistry, Iowa City, IA 52242.
References 1. Seltzer S. Pain in endodontics. J Endodon 1986;12:505-8. 2. Morse DR, Koren LZ, Eposito JV, et al. Infections flare-ups: induction and prevention, lnt J Psychosom 1986;33(specialissue):5-63. 3. Barnett F, Tronstad L. The incidence of flare-ups following endodontic treatment. J Dent Res 1989;68(specialissue):1253. 4. Negro MM. Management of endndontic pain with nonsteroidal antiinflammatory agents: a double-blind, placebo-controlled study. Oral Surg 1989;67:88-95. 5. Mata E, Koren LZ, Morse DR, Sinai IH. Prophylactic use of penicillin V in teeth with necrotic pulps and asymptomatic periapical radiolucencies, Oral Surg 1985;60:201-7. 6. Balaban FS, Skidmore AE, Griffin JA. Acute exacerbations following initial treatment of necrotic pulp. J Endodon 1984;10:78-81. 7. Trope M. Relationship of intracanal medicaments to endodontic flareups. Endod Dent Traumato11990;6:226-9. 8. Torabinejad M, Kettering JD, McGraw JC, Cummings RR, Dwyer TG, Tobias "IT. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endodon 1988;14:261-6. 9. Goldman M, Rankin C, Mehlman R, Santa C. The immunologic implications and clinical management of the endodontic flare-up. Compend Contin Educ Dent 1987;10:126-30.
Voh 18, No. 4, April 1992 10. Georgopoulou M, Anastassiadis P, Sykaras S. Pain after chemomechanicat preparation, tnt Endod J 1986;19:309-14. 11. Morse D, Furst M, Belott R, Lefkowitz R, Spritzer I, Sideman B. Infectious flare-ups and serious sequelae following endodontic treatment: a prospective randomized trial efficacy of antibiotic prophylaxis in cases of asymptomatic pulpal-periapical lesions. Oral Surg 1987;64:96-109.
Flare-Ups: Related Factors
177
12. Morse D, Furst M, Belott R, Lefkowitz R, Spritzer I, Sideman B. A prospective randomized trial comparing periapical instrumentationto intracanaI instrumentation in cases of asymptomatic pulpal-periapical lesions. Oral Surg 1987;64:734-41. 13. Trope M. Flare-up rate of single-visit endodontics. Int J Ended 1991 ;24:24-7.
T h e W a y It W a s Often the old expression, "Even a blind pig finds an acorn once in a while," can be applied to pharmacotherapeutics. A good example is the early use of rust to treat anemia. This therapeutic regimen considerably predated our understanding of the relationship between iron and hemoglobin formation. Instead it was based upon the therapeutic doctrine of signatures, i.e., God inserted "clues" about the therapeutic powers of agents into the natural attributes of the substances. Thus, the red color of rust was supposed to bring back the "rosy" cheeks in a person made pale by anemia. This was great if the pig found rust, but how many others found cayenne peppers?
John Smith
Printed in U.S.A.
VOL. 18, NO. 4, APRIL1992
CLINICAL ARTICLE Endodontic Interappointment Flare-Ups: A Prospective Study of Incidence and Related Factors Richard Walton, DMD, MS, and Ashraf Fouad, BDS, MS
Severe pain and/or swelling following a root canal treatment appointment are serious sequelae. Information varies or is incomplete as to the incidence of these conditions and related factors. In this study, data were collected at root canal treatment appointments on demographics, pulp/periapical diagnoses, presenting symptoms, treatment procedures, and number of appointments. Patients that then experienced a flare-up (a severe problem requiring an unscheduled visit and treatment) had the correlating factors examined. Statistical determinations were by chi-square analysis with significance at 0.05 or less. Nine hundred forty-six visits resulted in an incidence of 3.17% flare-ups. Flare-ups were positively correlated with more severe presenting symptoms, pulp necrosis with painful apical pathosis, and patients on analgesics. Fewer flare-ups occurred in undergraduate patients and following obturation procedures. There was no correlation between patient demographics or systemic conditions, number of appointments, treatment procedures, or taking antibiotics.
nation of both. The problem must be of sufficient severity that there is disruption of the patient's lifestyle such that the patient initiates contact with the dentist. Required then are both: (a) an unscheduled visit and (b) active treatment (incision for drainage, canal debridement, opening for drainage, etc.). Because of their nature, these interappointment endodontic flare-ups, when they occur, create difficulties for both patient and dentist. Although there are a few reports on the incidence, etiologies, and treatment of flare-ups, most related factors remain unspecified. INCIDENCE Studies report varying incidences of flare-ups. These variations are at least partially the result of examining different factors and conditions as related to flare-ups. For example, Morse et al. (2) reported an incidence of approximately 20% flare-ups (swelling was the only criteria) after treating asymptomatic teeth with pulp necrosis and chronic apical periodontitis. In contrast, Barnett and Tronstad (3) in a retrospective study determined an incidence of approximately 5.5% flareups (pain and/or swelling) in patients with a similar diagnosis (pulp necrosis with asymptomatic periapical lesion), but 1.4% in all patients regardless of diagnosis. Others (4-7) have reported varying percentages of incidence of flare-ups, again depending upon the factors considered. Problems with most of the above-mentioned studies are that many are retrospective, lack controls, have relatively small numbers of patients or have undefined variables.
A flare-up following a root canal treatment appointment is a significant problem. This is upsetting to both the patient and dentist and disruptive to a busy practice. The flare-up phenomenon is complex and, although not well understood, undoubtedly involves a number of aspects related to local tissue changes, microbial factors, immunological phenomena, and other entities (1).
FACTORS The aspects associated with flare-ups have also been examined. These generally are in the categories of patient-related factors, pulpal/periapical diagnosis, and treatment procedures. Although many specifics have been examined, those that seem to be most related to a significantly greater number of flare-ups are sex and age of patient (8), presence and size of a periapical lesion (3, 7, 8), a history of preoperative pain and/or swelling (8), reported allergies (8, 9), retreatment pro-
DEFINITION The interappointment flare-up is defined as follows: within a few hours to a few days after a root canal treatment procedure a patient has either pain or swelling or a combi-
172
Vol. 18, No. 4, April 1992
cedures (8), and overinstrumentation (10). This information is incomplete because most reports were retrospective studies or were incidental to other findings. A prospective study on a large group of patients is needed. This would provide adequate numbers and accurate data on the incidence and factors related to interappointment flareups. The purpose of this study was to conduct a prospective survey of endodontic patients. To be determined were the following: 1. The overall incidence of flare-ups as a percentage of all patient visits. 2. Correlation of the occurrence of flare-ups with (a) Patient demographics: age and sex. (b) Presenting patient factors: pulp and periapical diagnosis, presence of and level of pain, presence of and nature of swelling, whether on medications, and certain systemic conditions. (c) Treatment procedures: step performed in root canal treatment, number of appointments, and type of treatment (conventional or retreatment). (d) Operator groups: undergraduate, graduate, or faculty members. M A T E R I A L S AND M E T H O D S Data were gathered on 946 patient visits over a 4-month period. Included were all patients undergoing root canal treatment in the Endodontics Clinic by either undergraduate, graduate, or faculty. At each visit, information was obtained on each patient as to their demographics, presenting signs, symptoms and diagnosis; and treatment performed. A form in which the data were entered was generated for each appointment.
Treatment Procedures These were routine. The operator completed as much of the treatment as was feasible or indicated according to time, findings, diagnosis, complexity, and so forth. If additional appointments were necessary, the access was closed with a dry cotton pellet and a temporary filling. No medicaments (Ca[OH]2, steroids, etc.) were placed interappointment. The occlusion was not adjusted. At the conclusion of the appointment, the patient was given posttreatment instructions. These were essentially as follows: Expect the tooth to be sore for one or two days. This soreness should not be more than over-the-counter medication can take care of. If the tooth is more painful, particularly if it seems to be getting worse, call me. Also, if you notice swelling that is developing or increasing, call. If you have any other questions or problems, be sure and contact me.
If the patient called with a problem which seemed severe, the treating student or faculty member instructed the patient to return to the clinic immediately. A decision was then made as to whether active treatment was necessary. Simply talking to the patient, or only prescribing or dispensing medication
Flare-Ups: Related Factors
173
did not constitute a flare-up. Treatment was then performed as deemed appropriate. A second flare-up following the initial flare-up was not considered or included in the survey. At the emergency visit, the patient's form, as generated during the first treatment visit, was recovered and identified as a flare-up.
Evaluation Analysis was in two aspects: (a) overall incidence of flareups as expressed by a percentage of all patients visits and (b) percentage of flare-ups that occurred as related to various factors such as patient demographics, diagnosis, and treatment procedures. These percentages were compared statistically to determine those factors which were significantly related to an increased or decreased incidence of flare-ups. The chi-square analysis was used to compare the variables (p ___0.05). RESULTS The overall incidence of flare-ups was relatively small (3.17%). When a flare-up did occur, it was primarily related to presenting factors, that is, patient signs/symptoms and diagnosis of the involved tooth and related tissues. Treatment procedures were generally unrelated to an increase or decrease in flare-ups. The one demographic factor that correlated with an increased number of flare-ups was a greater occurrence in females as compared with males. The detailed results are below.
Incidence of Flare-Ups Nine hundred forty-six patient visits, equally divided between male and female, resulted in a total of 30 flare-ups. This was an overall percentage of 3.17%.
Demographic Factors As to age of patients, there were no increases in flare-ups when analyzing groups by decades. No pattern of flare-ups was seen with a greater tendency in any age group (Table 1). Sex of patients (Table 2), that is male versus female, did show a difference of a two times greater prevalence of flareups in females (n = 20) over males (n = 10). However, this difference was not statistically significant (p = 0.067). TABLE 1. O c c u r r e n c e o f flare-ups according to age groups* Age (yr)
Total No. of patients
No. of FlareUps
<20 20-29 30-39 40-49 50-59 60-69 70-79 >80
51 211 227 144 89 131 62 10
0 9 9 1 5 3 1 0
Percentage 0 4.3 4.0 0.7 4.5 5.3 1.6 0
* There was no statisticallysignificantdifferenceamongthe groups (p _<0.05).
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Walton and Fouad
Journal of Endodontics
TABLE 2. Flare-ups according to sex, with no statistically significant differences (p _< 0.05)
Sex
Total No. of Patients
No. of FlareUps
Percentage
Male Female
463 463
10 20
2.2 4.3
TABLE 3. Flare-ups in different arches and tooth groups*
Tooth Group Mandibular Anterior Premolar Molar Maxillary Anterior Premolar Molar
Total No. of Patients
No. of FlareUps
Percentage
52 85 278
1 6 10
1.9 7.0 3.6
102 120 276
2 3 8
2.0 2.5 2.9
19.2 20
10
* No differences were determined statistically (p _< 0.05).
Examining by tooth groups or between arches (maxillary versus mandibular) showed no significant difference (Table
PAIN
SWELLING
FIG 1. Patients presenting with pain and/or swelling experienced a significantly greater number of posttreatment flare-ups.
3). 8 -
Patient Presenting Factors Patient symptoms, that is pain and/or swelling at the initial appointment, were very important in being associated with a much higher incidence of interappointment flare-ups. As the severity of pain and/or swelling increased, there was a definite tendency for the patient to develop severe posttreatment problems (Fig. 1). The most important factor was severe preoperative pain which resulted in an incidence of flare-ups of over 19%. Next in incidence was the patient reporting with localized and/or diffuse swelling with an occurrence of 15 % having flare-ups. Pulp and periapical status was also significantly related (or unrelated) to flare-ups. Teeth with vital pulps resulted in relatively few flare-ups for an overall percentage of 1.3%. In contrast, pulp necrosis correlated to an incidence of 6.5%, a statistically significant increase as compared with vital pulps (Fig. 2). The periapical diagnosis of acute apical abscess was also significantly greater in flare-ups incidence as compared with less symptomatic or less severe apical pathoses (Fig. 3). Sinus tract presence never correlated with a flare-up.
6.5*
0
0
////
,
FIG 2. AS the severity of pulp pathosis increased, patients had significantly more flare-ups•
Treatment Factors Number of visits (single versus multiple visits) was not significant (Table 4). Medications, i.e. antibiotics and/or analgesics prescribed prior to the treatment either by the referring dentist or for unrelated medical reasons, did correlate with an increased number of interappointment flare-ups (Tables 5 and 6). The incidence of flare-ups was greater in patients taking either analgesics or antibiotics preoperatively; however, only the analgesics factor was significantly different.
Procedure did make a difference as to the incidence of flare-ups. However, the incidence of flare-ups was inversely related to either obturation alone or when obturation was combined with cleaning and shaping in the same appointment. Therefore, overall, obturation correlated with significantly fewer posttreatment flare-ups (Fig. 4). Nature of treatment, i.e. conventional root canal treatment or retreatment of failures, showed no significant difference in flare-up incidence with either modality (Table 7).
Vol. 18, No. 4, April 1992
Flare-Ups: Related Factors
20
175
5.5
5.3
13.1
10
2
1"
SAP
NORMAL
CAP
AAP
AAA
/'///
0 "
F~G 3. Patients presenting with acute apical abscess (AAA) experienced significantly more flare-ups than less severe apical pathosis. Note that sinus tract (SAP) resulted in no flare-ups. CAP, chronic apical periodontitis; AAP, acute apical periodontitis.
TABLE 4. Number of treatment visits*
No. of Visits
Total No. of Patients
No. of FlareUps
Percentage
Multiple Single
739 196
24 5
3.3 2.6
* There was no difference in flare-up incidence between single and multiple visits (p _<
o.0s).
FIG 4. The only procedure related to significantly fewer flare-ups was obturation. Note that partial cleaning and shaping was no different statistically than complete cleaning and shaping.
TABLE 7. Conventional versus retreatment, with no difference in flare-up incidence (p _< 0.05)
TABLE 5. Flare-ups in patients being administered antibiotics* Antibiotic Status
Total No. of Patients
No. of FlareUps
Percentage
Yes No
95 845
6 24
6.3 2.8
Treatment
Total No. of Patients
No. of FlareLips
Percentage
Conventional Retreatment
795 145
25 5
3.1 3.5
zl¢:
* There was no statistically significant difference between groups (p -< 0.05).
TABLE 6. Flare-ups in patients taking analgesics* Analgesic Status
Total No. of Patients
No. of FlareUps
Percentage
Yes No
168 772
13 17
7.7 2.2
* There were significantly more flare-ups in the analgesics group (p <- 0,05).
Operator Comparing the incidence of flare-ups with patients of faculty, graduate students, and undergraduate students showed that the dental student patients had significantly fewer flareups as compared with the other two groups (Fig. 5).
o FACULTY
GRAD STUDENTS
UNDERGRADS
FIG 5. Undergraduate student patients experienced significantly fewer flare-ups than faculty or graduate students.
DISCUSSION We found it most interesting and important that the overall incidence of flare-ups in our patients was relatively low. Our
finding of approximately 3% is similar to those percentages reported by Barnett and Tronstad (3) and Trope (7). These studies are considerably lower than the finding of others which
176
Walton and Fouad
found an incidence ranging from 11 to 33% (1, 2, 4, 5, 9). The reasons for the differences cannot be readily explained but could relate to different patient populations, varying treatment modalities, and other methods of assessment. However, criteria for identifying the flare-up, at least as described by other authors (2, 5), were similar to ours in that they specified that the patient return for an unscheduled visit with significant signs and symptoms that required treatment. Based on our results from a prospective study, the average practitioner should have few flare-ups. In fact, patients of general dentists should experience fewer flare-ups than the endodontist who generally is managing a larger percentage of emergencies. Many of these emergencies involve acute apical abscess with pulp necrosis; we found these to be markedly greater in the incidence of flare-ups. Therefore, if a practitioner is not seeing large numbers of patients with presenting emergencies but is still experiencing a disproportionate number of flare-ups, he or she should reassess his or her treatment modalities. Some related factors differ between ours and other studies. We found sex, age, allergies, and retreatments to be statistically nonsignificant whereas others (8, 9) found these to be significant. Differences could relate to the design of the studies; ours was prospective, theirs was retrospective. Also, there could be regional differences in population groups. The overriding factor as to predicting a flare-up was the presenting condition (signs, symptoms, and diagnosis). Patients with particular findings will also have other considerations. For example, patients on emergency visits or with adverse symptoms are more likely to be taking analgesics and/ or antibiotics before the appointment. This is the likely reason why patients on these medications had a higher incidence of flare-ups. It is unlikely that the flare-up was caused by the therapeutic agent. On the other hand, it was interesting that flare-ups occurred in higher percentages in these patients; antibiotics did not seem to be preventive as has been reported by others (5, 11). Another significant difference between ours and others' studies is in the group of patients which presented with asymptomatic periapical lesions. Others (1, 2, 5, I 1) reported an 1 t to 25% incidence of flare-ups; we found 3.5% of these patients to have flare-ups. The difference could be that our criteria were more stringent, therefore, resulting in a lower percentage. However, stated criteria of others were similar to ours. In fact, in the Morse et at. (2) and Mata et al. (5) reports only patients reporting severe swelling, and not just pain alone, were classified as flare-ups. If we considered only those flare-up patients returning with swelling, our overall incidence would drop even further to 0.73%. Furthermore, we had no patients with a flare-up consisting of swelling alone (with minimal pain) if their preoperative diagnosis was chronic apical periodontitis (asymptomatic periapical lesion). The finding that the treatment procedures in our patients made no difference is comparable to other studies. One study (10) which did relate to treatment factors showed an increase of flare-ups with overinstrumentation (penetration beyond the apex). In contrast, Morse et al. (12) did not observe more problems when files were intentionally inserted into periapical lesions. We did not examine this specific factor; the attempt is always to try to contain instruments, irrigants, and obturating materials within the canal. Therefore, it cannot be stated with certainty that physical or chemical damage to periapical
Joumal of Endodontics
tissues in our patients would not result in a greater incidence of flare-ups, since we did not examine these factors. Most interesting was our finding that complete debridement of canals of necrotic pulps (and presumably with bacteria also) did not prevent, or even have an effect, on the incidence of flare-ups. In fact, the number of flare-ups in the partial versus the complete preparation groups was nearly equal, a finding that is supported by other studies (6, 8). Logically it would be desirable to remove intracanal irritants as a preventive measure; apparently this is not the case. Our low number of flare-ups following root canal treatment of teeth with vital pulps was consistent with the findings in other studies (3, 7). This is not surprising, since preexisting severe periapical pathosis would seem to "set the stage" for posttreatment problems. Similarly, our finding of no difference in flare-ups between single and multiple appointments is reinforced by data from other studies (6, 13). Apparently there is no basis to the common belief that extending treatment procedures over additional appointments will reduce periapical trauma and help prevent flare-ups. Most unexpected was the significantly lower incidence of flare-ups in dental student patients as compared with faculty and postgraduate students. There is no obvious explanation for this difference. We examined the nature of student patients with the assumption that the3, may have less emergencies, fewer patients with significant pulp/periapical pathosis, or other factors predisposing to flare-ups. This was not the case. One difference may be that faculty and postgraduate students see more advanced and difficult cases; however, this variable was not examined. Other possible reasons may be that (a) student patients are less likely to complain but will suffer through a posttreatment problem, or (b) that students take considerably longer at each appointment for cleaning, shaping, and obturation. This prolonged appointment could result in longer exposure of tissues to irrigants (sodium hypochlorite) and possibly more reduction in bacteria or other canal irritants. Again, these variables were not examined. Dr. Walton is professor and chairman, Department of Endodontics and Dr. Fouad is assistant professor, Department of Endodontics, University of Iowa Collegeof Dentistry, Iowa City, IA. Address requests for repdnts to Dr. Richard Walton, Department of Endodontics, University of Iowa College of Dentistry, Iowa City, IA 52242.
References 1. Seltzer S. Pain in endodontics. J Endodon 1986;12:505-8. 2. Morse DR, Koren LZ, Eposito JV, et al. Infections flare-ups: induction and prevention, lnt J Psychosom 1986;33(specialissue):5-63. 3. Barnett F, Tronstad L. The incidence of flare-ups following endodontic treatment. J Dent Res 1989;68(specialissue):1253. 4. Negro MM. Management of endndontic pain with nonsteroidal antiinflammatory agents: a double-blind, placebo-controlled study. Oral Surg 1989;67:88-95. 5. Mata E, Koren LZ, Morse DR, Sinai IH. Prophylactic use of penicillin V in teeth with necrotic pulps and asymptomatic periapical radiolucencies, Oral Surg 1985;60:201-7. 6. Balaban FS, Skidmore AE, Griffin JA. Acute exacerbations following initial treatment of necrotic pulp. J Endodon 1984;10:78-81. 7. Trope M. Relationship of intracanal medicaments to endodontic flareups. Endod Dent Traumato11990;6:226-9. 8. Torabinejad M, Kettering JD, McGraw JC, Cummings RR, Dwyer TG, Tobias "IT. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endodon 1988;14:261-6. 9. Goldman M, Rankin C, Mehlman R, Santa C. The immunologic implications and clinical management of the endodontic flare-up. Compend Contin Educ Dent 1987;10:126-30.
Voh 18, No. 4, April 1992 10. Georgopoulou M, Anastassiadis P, Sykaras S. Pain after chemomechanicat preparation, tnt Endod J 1986;19:309-14. 11. Morse D, Furst M, Belott R, Lefkowitz R, Spritzer I, Sideman B. Infectious flare-ups and serious sequelae following endodontic treatment: a prospective randomized trial efficacy of antibiotic prophylaxis in cases of asymptomatic pulpal-periapical lesions. Oral Surg 1987;64:96-109.
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12. Morse D, Furst M, Belott R, Lefkowitz R, Spritzer I, Sideman B. A prospective randomized trial comparing periapical instrumentationto intracanaI instrumentation in cases of asymptomatic pulpal-periapical lesions. Oral Surg 1987;64:734-41. 13. Trope M. Flare-up rate of single-visit endodontics. Int J Ended 1991 ;24:24-7.
T h e W a y It W a s Often the old expression, "Even a blind pig finds an acorn once in a while," can be applied to pharmacotherapeutics. A good example is the early use of rust to treat anemia. This therapeutic regimen considerably predated our understanding of the relationship between iron and hemoglobin formation. Instead it was based upon the therapeutic doctrine of signatures, i.e., God inserted "clues" about the therapeutic powers of agents into the natural attributes of the substances. Thus, the red color of rust was supposed to bring back the "rosy" cheeks in a person made pale by anemia. This was great if the pig found rust, but how many others found cayenne peppers?
John Smith