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Factors Associated With Endodontic Flare-Ups: A Systematic Review and Meta-Analysis.

Jun Ohshima1, Masayoshi Morita1, Yuzo Kawanishi1

  • 1Department of Restorative Dentistry and Endodontology, Graduate School of Dentistry, the University of Osaka, Suita, Osaka, Japan.

International Endodontic Journal
|April 24, 2026
PubMed
Summary

Endodontic flare-ups after root canal treatment are linked to specific patient and procedural factors. Preoperative pain, female sex, and treatment complexity increase risk, guiding better patient management.

Keywords:
endodonticspain managementpain measurementperiapical periodontitispostoperative complicationspostoperative paintreatment outcome

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Area of Science:

  • Endodontics
  • Dental Public Health

Background:

  • Endodontic flare-ups, severe pain/swelling post-root canal therapy, necessitate unscheduled interventions.
  • Identifying associated risk factors is crucial for managing patient outcomes in endodontic procedures.

Purpose of the Study:

  • To systematically review and perform a meta-analysis of clinical risk factors for endodontic flare-ups following root canal treatment.
  • Synthesize existing evidence to identify key predictors of postoperative endodontic complications.

Main Methods:

  • Comprehensive literature search across PubMed, Web of Science, and Scopus up to September 2025.
  • Inclusion of observational and interventional studies assessing risk factors for flare-ups.
  • Risk of bias and certainty of evidence assessed using ROBINS-I, Cochrane RoB 2, and GRADE approaches.

Main Results:

  • 15 studies with 24,320 cases analyzed; overall severe flare-up incidence was 2.83%.
  • Significant risk factors identified: female sex, mandibular location, non-vital pulp, preoperative spontaneous/percussion pain, periapical lesions, multiple-visit treatment, and re-treatment.
  • Preoperative spontaneous pain (RR=5.83) and percussion pain (RR=3.45) showed strongest associations.

Conclusions:

  • Clinical factors like preoperative pain significantly increase endodontic flare-up risk.
  • Findings aid clinicians in identifying high-risk cases and patient counseling, despite low overall evidence certainty.
  • Further prospective studies are recommended to solidify the evidence base for endodontic flare-up prediction.