Managing Endodontic Complications: The Pathophysiology and Treatment of Flare-ups

At its core, endodontics is a specialty centered on saving patients' teeth. Nonsurgical root canal therapy and nonsurgical retreatment, arguably the "bread and butter" of endodontics, not only facilitate the preservation of the natural dentition, but in many cases, alleviate pain. Most patients arrive for endodontic treatment expecting symptom relief. A small percentage of these patients, however, experience just the opposite. Within 48 to 72 hours, these select patients experience worsening symptoms, including swelling and pain, and may wonder what mishaps may have occurred during their treatment. These symptom exacerbations are referred to as endodontic flare-ups and are well-documented in the literature. In most cases their occurrence does not reflect a lack of practitioner judgment or skill, but rather a biologic event resulting from a shift in the delicate balance of the bacterial communities and inflammatory events at the periapex. This article reviews the pathophysiology and treatment of endodontic flare-ups, thereby informing patient communication strategies surrounding these events, to preserve both the teeth in question as well as patient relationships.