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Table of Contents   
REVIEW ARTICLE  
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 3-8
Prevalence of endodontic flare-up following intracanal medicament placement in permanent teeth undergoing endodontic treatment – A systematic review


Department of Conservative Dentistry and Endodontics, Government Dental College and Hospital, Nagpur, Maharashtra, India

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Date of Submission24-Jun-2021
Date of Decision02-Dec-2021
Date of Acceptance21-Dec-2021
Date of Web Publication02-May-2022
 

   Abstract 


Background: Endodontic flare-up can occur in teeth undergoing root canal treatment. Intracanal medicaments are most commonly used in between appointments to eliminate microbial flora in the canal. However, extrusion of medicaments in the periapical region can cause an inflammatory reaction leading to postoperative pain.
Aim: The aim of this study was to evaluate the prevalence of endodontic flare-up following intracanal medicament placement in permanent teeth undergoing endodontic treatment.
Study Design: A comprehensive search was done in MEDLINE through PubMed, Cochrane, EBSCOhost, and Google Scholar from July 31, 1999 to July 31, 2019 to identify randomized trials involving the use of intracanal medicaments in teeth undergoing root canal treatment.
Methods: The titles and abstracts of all retrieved articles were screened by two independent reviewers, and irrelevant studies were excluded. Full texts of the eligible studies were obtained and thoroughly assessed. Seventeen randomized control trials comprising 2665 subjects were included.
Statistical Analysis: Narrative synthesis was provided for the findings obtained from the studies, mainly focusing on the intervention details. Heterogeneity of the previously mentioned characteristics was assessed using the Chi-square test and I2 statistics.
Results: Placement of intracanal medicament was not associated with the occurrence of pain.
Conclusion: The present review suggests that intracanal medicament do not cause endodontic flare-up rather reduces inter-appointment pain during endodontic treatment.

Keywords: Endodontic treatment; flare-up; intracanal medicament

How to cite this article:
Wagh KS, Warhadpande MM, Dakshindas DM. Prevalence of endodontic flare-up following intracanal medicament placement in permanent teeth undergoing endodontic treatment – A systematic review. J Conserv Dent 2022;25:3-8

How to cite this URL:
Wagh KS, Warhadpande MM, Dakshindas DM. Prevalence of endodontic flare-up following intracanal medicament placement in permanent teeth undergoing endodontic treatment – A systematic review. J Conserv Dent [serial online] 2022 [cited 2022 Jul 5];25:3-8. Available from: https://www.jcd.org.in/text.asp?2022/25/1/3/344515



   Introduction Top


Pain is common during an individual's life as an unpleasant sense. Most of the time, endodontic treatment procedures are associated pain. Despite recent advances in pain management, pain has been reported with a prevalence of 2.53%–58%.[1]

Endodontic pain may occur before, during, or after endodontic treatment. A flare-up can be defined as pain or swelling of the facial soft tissues and the oral mucosa in the area of the endodontically treated tooth that occur within a few hours or a few days following endodontic treatment.[2] It requires an unscheduled visit and active treatment to relieve pain.[3]

The origin of the postendodontic flare-up can be mechanical, chemical, and microbial. Many patients complain of mild-to-moderate pain after endodontic treatment of teeth. Placement of intracanal medicament is often preferred when the tooth is treated in multiple visits.

Irrigation solutions, intracanal medicaments, and root fillings can cause chemical irritation and posttreatment pain. The more filling from the root canal is extruded to periodontal tissues, the more intense inflammatory reaction occurs. Resorcinol–formaldehyde resin-based intracanal medicaments are often associated with endodontic flare-up. These pastes are cytotoxic and cause necrosis after contacting live tissue or when extruded into apical periodontal area. This causes postoperative pain and swelling.[3]

The aim of this study is to gauge the prevalence of endodontic flare-ups following intracanal medicament placement in permanent teeth undergoing endodontic treatment.


   Methods Top


Protocol and registration

The present systematic review was registered at the National Institute for Health Research PROSPERO International Prospective Register of Systematic Reviews (registration number: CRD42019137524). This research protocol is designed according to the (Preferred Reporting Items for Systematic Review and Meta-Analyses [PRISMA]) guidelines 2009.

Eligibility criteria

The eligibility criteria for inclusion of the studies in regard to participants, intervention, comparator, and outcomes are as shown in [Table 1].
Table 1: Shows the eligibility criteria for inclusion of the studies in regard to participants, intervention, comparator, and outcomes

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Databases (MEDLINE through PubMed, Cochrane, EBSCOhost, and Google Scholar), relevant journals, books, bibliographies, reviews, and conference proceeding were searched from July 31, 1999 to July 31, 2019 using various combinations of following MeSH terms and keywords. Boolean operators odds ratio within the same category and between the disease and intervention category.

For disease category – nonsurgical root canal treatment, endodontic flare-up, postoperative pain, posttreatment endodontic pain, and inter-appointment pain

For intervention category – intracanal medicament, calcium hydroxide, intracanal dressing, triple antibiotic paste, and chlorhexidine digluconate

Study selection

The titles and abstracts of all retrieved articles were screened by two independent reviewers, and irrelevant studies were excluded. Full texts of the eligible studies were obtained and thoroughly assessed by the two reviewers for inclusion. Disagreements were resolved by the 3rd reviewer. Concerned study authors were communicated for the unreported data or additional details.

Data collection process

Data collection was performed using a customized data extraction form including contents such as title of the study, author's name, duration of study, year of publication, study setting, study design, study population, method of randomization, types of intervention, types of the comparator, characteristics of participants (age and gender), inclusion and exclusion criteria, indicators of acceptability of users, times of measurement, outcomes (primary and secondary), and concluding remarks.

Risk of bias in individual studies.

To evaluate the risk of bias in individual studies, Cochrane collaboration's risk of bias tool was used for randomized controlled trials.

Synthesis of results

The narrative synthesis was provided for the findings obtained from the studies, mainly focusing on the intervention details (postoperative pain, intracanal medicament, etc.), characteristics of participants (gender, age, and history of preoperative pain), and outcome assessment. Summaries of intervention effects for each study were provided by calculating risk ratio (for dichotomous outcomes) or standardized mean difference (for continuous outcomes). Heterogeneity of the previously mentioned characteristics was assessed using Chi-square test (significance: 0.1) and I2 statistics.

Literature search and study selection

[Figure 1] shows the study search process according to the PRISMA guidelines. The initial online search yielded a total of 726 studies. After the removal of duplicate studies, the remaining 89 studies were screened for title and abstract, and 41 studies were obtained. Out of 41 studies, 24 studies were found irrelevant (10 reviews and 14 irrelevant trials) and were excluded. Full-text articles of the remaining 17 studies were obtained and thoroughly assessed for eligibility criteria by two authors. These studies met the eligibility criteria and were included in the systematic review.
Figure 1: Flow chart of methodology according to (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines

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The general characteristics of the included studies are listed in [Table 2] for 17 randomized control trials.
Table 2: Details of population, study groups and outcome participants, intervention, comparator, and outcomes of included randomized controlled trials

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Randomized clinical trials included 2665 study participants. The age of participants ranged from 9 to 75 years with female dominance in most of the studies. Most of the studies used visual analog scale (VAS) for pain assessment. Assessment for incidence of postoperative pain was done at interval of 1-day, 1-week, 1-month, 3-month, and 6-month postobturation.

It was found that in most of the studies, calcium hydroxide was used as intracanal medicament. Placement of intracanal medicament was not associated with occurrence of pain rather it controlled the microbial growth and aid in reducing postoperative pain.

Quality of included studies

The results of the quality assessment were evaluated according to Cochrane Tool. Based on Cochran's quality assessment tool for randomized control trial, included studies showed good quality assessment [Figure 2]. Selection and attrition bias was found in most of the studies [Figure 3].
Figure 2: Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies

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Figure 3: Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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   Discussion Top


The incidence of postoperative pain is not a rare event even after following all standard protocols. Mild pain after chemo-mechanical preparation can develop in 10%–30% cases. Endodontic flare-up constitutes a true emergency and usually requires unscheduled visit for treatment. Postoperative pain is considered a poor indicator for long-term success of root canal treatment. Its incidence ranges from 1.5% to 5.5% and sometimes up to 50% in some studies.[11],[16] Various risk factors that significantly influence the inter-appointment flare-up can be related to patient or treatment procedure. After mechanical preparation of root canal, the intracanal medicaments restrict the proliferation of microbes. These medications have antibacterial, sedating, and anti-inflammatory properties. Intracanal medication rapidly reduces pulpal pain between the sessions of root canal treatment.[18] Various intracanal medications include calcium hydroxide, triple antibiotic paste, double antibiotic paste, Ledermix paste, 2% chlorhexidine gel, and corticosteroid-antibiotic compound. This review critically evaluated the available evidence on the prevalence of endodontic flare-ups following intracanal medicament placement in permanent teeth undergoing endodontic treatment or re-root canal treatment.

Previous studies used different scales and methods to assess pain after endodontic therapy. Among them, the VAS scale is considered to be a valid and reliable ratio scale for measurement of pain. Pain perception is highly subjective and variable experience modulated by various factors. Another methods used to record postoperative pain are Facial Grimace Scale. Ghoddusi et al. used a modified version of the 10° form of visual analog scale to measure the severity of pain 6 hourly for up to 72 h reported a 15% incidence of postoperative pain.[10]

Most studies have mentioned age of participants, whose age range is 18–75 years. Some studies by Abouelenien et al., Ehrmann et al., Ghoddusi et al. did not mention the age of participants in their study.[10],[11],[17] According to Ehrmann et al., patients with Ledermix intrcanal medicament experienced significantly less postoperative pain than with no intracanal medicament.[7] Mohmmadi et al. concluded that Ledermix is better intracanal dressing material compared to calcium hydroxide.[19] Yoldas et al. used calcium hydroxide mixed with 0.2% chlorhexidine as intracanal medicament in re-treatment cases. They observed higher incidence of postoperative pain in pretreatment symptomatic group.[9]

Sinhal et al. evaluated the incidence of inter-appointment flare-up in diabetic patients and found that both triple antibiotic paste and 2% chlorhexidine gel were effective in reducing inter-appointment flare-up and postoperative pain.[16] In this review, all included studies showed that postoperative pain is reduced following the use of intracanal medicaments.

Limitation of the present systematic review may be relative heterogeneity among studies with respect to patient age, gender, comparator groups, medicaments used, and outcome measurement.


   Conclusion Top


The results of the present systematic review suggest that minimal-to-moderate type of pain normally subsides with time. Intracanal medicament does not cause endodontic flare-up rather helps in reducing postoperative pain.

Financial support and sponsorship

Self-supported.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ghanbarzadegan A, Ajami M, Aminsobhani M. The effect of different combinations of calcium hydroxide as intra-canal medicament on endodontic pain: A randomized clinical trial study. Iran Endod J 2018;14:1-6.  Back to cited text no. 1
    
2.
Alamassi BY. Endodontic postoperative pain: Etiology and related factors – An update. Int J Dent Sci Res 2017;5:13-21.  Back to cited text no. 2
    
3.
Sipavičiūtė E, Manelienė R. Pain and flare-up after endodontic treatment procedures. Stomatologija 2014;16:25-30.  Back to cited text no. 3
    
4.
Fava LR. Acute apical periodontitis: Incidence of post-operative pain using two different root canal dressings. Int Endod J 1998;31:343-7.  Back to cited text no. 4
    
5.
Negm MM. Intracanal use of a corticosteroid-antibiotic compound for the management of posttreatment endodontic pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:435-9.  Back to cited text no. 5
    
6.
Siqueira JF Jr., Rôças IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, et al. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod 2002;28:457-60.  Back to cited text no. 6
    
7.
Ehrmann EH, Messer HH, Clark RM. Flare-ups in endodontics and their relationship to various medicaments. Aust Endod J 2007;33:119-30.  Back to cited text no. 7
    
8.
Walton RE, Holton IF Jr., Michelich R. Calcium hydroxide as an intracanal medication: effect on posttreatment pain. J Endod 2003;29:627-9.  Back to cited text no. 8
    
9.
Yoldas O, Topuz A, Isçi AS, Oztunc H. Postoperative pain after endodontic retreatment: Single- versus two-visit treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:483-7.  Back to cited text no. 9
    
10.
Ghoddusi J, Javidi M, Zarrabi MH, Bagheri H. Flare-ups incidence and severity after using calcium hydroxide as intracanal dressing. N Y State Dent J 2006;72:24-8.  Back to cited text no. 10
    
11.
Ehrmann EH, Messer HH, Adams GG. The relationship of intracanal medicaments to postoperative pain in endodontics. Int Endod J 2003;36:868-75.  Back to cited text no. 11
    
12.
Gama TG, de Oliveira JC, Abad EC, Rôças IN, Siqueira JF Jr. Postoperative pain following the use of two different intracanal medications. Clin Oral Investig 2008;12:325-30.  Back to cited text no. 12
    
13.
Dall AQ, Jouhar R, Khoso NA. Comparison of inter-appointment pain between ledermix and no intracanal medicament in acute apical periodontitis. J Liaquat Univ Med Health Sci 2011;10:106-11.  Back to cited text no. 13
    
14.
Singh RD, Khatter R, Bal RK, Bal CS. Intracanal medications versus placebo in reducing postoperative endodontic pain – A double-blind randomized clinical trial. Braz Dent J 2013;24:25-9.  Back to cited text no. 14
    
15.
Menakaya IN, Oderinu OH, Adegbulugbe IC, Shaba OP. Incidence of postoperative pain after use of calcium hydroxide mixed with normal saline or 0.2% chlorhexidine digluconate as intracanal medicament in the treatment of apical periodontitis. Saudi Dent J 2015;27:187-93.  Back to cited text no. 15
    
16.
Sinhal TM, Shah RR, Shah NC, Jais PS, Hadwani KD. Comparative evaluation of 2% chlorhexidine gel and triple antibiotic paste with calcium hydroxide paste on incidence of interappointment flare-up in diabetic patients: A randomized double-blinded clinical study. Endodontology 2017;29:136.  Back to cited text no. 16
  [Full text]  
17.
Samir Abouelenien S, Mohamed Ibrahim S, Gameel Shaker O, Mohamed Ahmed G. Evaluation of postoperative pain in infected root canals after using double antibiotic paste versus calcium hydroxide as intra-canal medication: A randomized controlled trial. F1000Res 2018;7:1768.  Back to cited text no. 17
    
18.
Alferra AS. Post-operative pain after using calcium hydroxide and ledermix intercanal medication with 5.25% sodium hypochlorite irrigation: A randomized controlled trial. Oral Health Case Rep 2018;4:01-14.  Back to cited text no. 18
    
19.
Ahmed MO. The Effect of Triple Antibiotic Paste as an Intracanal Medication with an Anti-Inflammatory Drug on Post-Operative Pain of Asymptomatic Uniradicular Necrotic Teeth. CU Theses; 2019.  Back to cited text no. 19
    

Top
Correspondence Address:
Dr. Kuntal Sureshrao Wagh
No. 117, Department of Conservative Dentistry and Endodontics, Government Dental College and Hospital, Nagpur - 440 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcd.jcd_332_21

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