Management of Flare-ups at two Tertiary Dental Centres in Singapore

Objectives: To describe the profile of inter-appointment flare-ups, management techniques and reduction of symptoms. Methods: Ethics approval for this observational study was obtained. Patients presenting with an endodontic inter-appointment flare-up (pain and/or swelling resulting in an unscheduled visit), were recruited at 2 tertiary dental centres in Singapore with informed consent. Patients reported pain score based on a Visual Analogue Scale (VAS: 0 to 100) immediately before intervention, immediately after, 4 hours after, and after 1, 4 and 7 days. At flare-up appointment, data including demographics, endodontic diagnoses before the flare-up, clinical findings, and subsequent flare-up management techniques were collected. Results: Over 7 months, 36 patients (15 males, 21 females; median age 49.5 years [22-87]; 30 Chinese, 3 Malays, 3 Indians and others) were recruited. Prior to the flare-up, diagnoses included Pulp Necrosis (n=12), Symptomatic Irreversible Pulpitis (n=10), Previously Initiated Therapy (n=8), Previously Treated (n=5), Reversible Pulpitis (n=1) and Symptomatic Apical Periodontitis (n=19), Asymptomatic Apical Periodontitis (n=8), Normal Periapex (n=4), Acute Apical Abscess (n=3), Chronic Apical Abscess (n=2). Twenty patients received an incomplete debridement in a previous dental visit. At flare-up appointment, a combination of management techniques were employed, including canal redebridement (n=22), occlusal reduction (n=11), medication (n=9), incision and drainage (n=3), open drainage (n=1), and tooth extraction (n=3). Median pain score was 66 at time of flare-up (0-89), 20 immediately after management (0-100) and 2 after 7 days (0-59). There was a statistically significant reduction of pain scores after 1 day. Conclusion: In this on-going survey, pain following incomplete debridement of an infected tooth accounted for more than half the flare-ups. There was significant reduction of pain 1 day after flare-up management. Within the limitations of this study with small sample size, complete debridement of infected root canal systems could reduce the incidence of flare-ups.