REVIEW OF LITERATURE The term flare up has become popular for describing post treatment symptoms (Coh en).

swelling and pain combined or swelling alone that necessitates unscheduled e mergency appointments (Morse) with in a few hours after a root canal treatment procedure a patient ha s either pain or swelling or a combination of both (Walton). Oliets criteria for case selection : Positive patient acceptance. Sufficient available time to complete the procedure properly. Absence of acute symptoms requiring drainage via the canal and or continuous flow of exudate or blood. Absence of anatomical obstacles (calcified canals, fine tortuous canals, bifu rcated or accessory canals). Procedural difficulties (ledge, blockage, perforations, inadequate fills). Indications for single visit endodontics Uncomplicated Vital teeth. Uncomplicated teeth with necrotic pulp and draining sinus tract. Patients who require heavy sedatives on every visit. Patients who require prophylatic antibiotics before every visit due to systemic problems. Agonizing pricks of local anesthesia could be avoided. Fractured anterior teeth where esthetics is a concern and a temporary post and crown are required. Contraindications Painful teeth with necrotic pulp and no sinus tract for drainage. Acute apical periodontitis and severe pain. External, internal or apical resorption. Furcation involvement. Uncontrolled bleeding canals. Immature apex. Advantages No of appointments are reduced time saving. Microbial contamination during inter- appointment period are eliminated. Loss or leakage from temporary inter - appointment seal are eliminated. Root canal space can be used Immediately for post & core. Familiarity with internal anatomy of canal facilitates a quality obturation. Disadvantages Clinician and patient fatigue. No opportunity to place and Intra canal medicament or disinfectant. Risk of leaving infected debris in the root canal.

The fear that patients will probably develop post-operative pain and that the ca nal has been irretrievably sealed has probably been the greatest deterrent to si ngle- visit therapy. Yet the literature shows no significant statistical differ ence in pain experienced by patients treated with single or multiple appointmen ts. Pekruhn R B (1981) A clinical investigation was conducted to compare the incidence and severity of postoperative pain in single-visit and multiple-visit conventional endodontic t herapy. Although the single-visit patients seemed to experience more discomfort than did the multiple-visit patients after the first postobturation day, the dif ferences were not statistically significant. When the total number of pain days was considered, there were no significant differences between the two groups. Th us, single-visit endodontic therapy appears at least equal in desirability to mu ltiple-visit therapy from the point of view of painfulness to the patient. (16) Roan J.B ,Dryden JA ,Grimes E.W (1983) In the following study a series of 359 endodontic cases were followed and evalua ted by the frequency of reported postoperative pain. A statistical analysis of t he data obtained attempted to identify a relationship between pain experienced a nd the anatomic location, the pulpal vitality as determined by hemorrhage, or th e number of treatment visits used in completing the case. Data obtained indicate d no relationship between pain experience and pulp vitality, no statistically si gnificant relationship to the anatomic location, and a significant relationship to the number of visits used. The data indicate a 2 to 1 higher frequency of pai n reported following treatment completed in multiple visits as compared to that reported for those completed in one visit.(21) Trope M (1991) The purpose of the study was to compare the flare-up rate for single-visit endod ontics among teeth without radiographic or clinical signs of apical periodontiti s, those with radiographic or clinical signs of apical periodontitis not previou sly root-treated, and those with apical periodontitis where retreatment was perf ormed. All teeth were instrumented to a predetermined minimum size with a 0.5 pe r cent solution of sodium hypochlorite being used as the irrigant. The root cana l was obturated without regard to the presence or absence of symptoms or diagnos is of the apical condition. The patients were given written post-operative instr uctions and a prescription for 600 mg ibuprofen to be taken if mild to moderate pain developed. If severe pain and/or swelling developed, the patient was instru cted to telephone immediately and was considered to have had a flare-up. Teeth w ithout signs of apical periodontitis did not have any flare-ups. One flare-up oc curred in 69 teeth with signs of apical periodontitis not previously root-treate d. The majority of the flare-ups (3 of 22 teeth) occurred in teeth with signs of apical periodontitis requiring retreatment. (22) Walton R et al (1992) In this study, data were collected at root canal treatment appointments on demog raphics, pulp/periapical diagnoses, presenting symptoms, treatment procedures, a nd number of appointments. Patients that then experienced a flare-up (a severe p roblem requiring an unscheduled visit and treatment) had the correlating factors examined. Statistical determinations were by chi-square analysis with significa nce 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 analgesic s. Fewer flare-ups occurred in undergraduate patients and following obturation p rocedures. There was no correlation between patient demographics or systemic con ditions, number of appointments, treatment procedures, or taking antibiotics.(23 ) Changgeng Yi Xue Za Zhi (1994) The purpose of this study was to investigate the clinical variables influencing endodontic flare-ups. Three hundred and thirteen teeth receiving endodontic trea tment at the Endodontic Department, Chang Gung Memorial Hospital were studied fr om December 1992 to February 1993. Among them, 21 teeth with significant pain an d 9 with apical swelling were noted after the first appointment of treatment. Th

ree teeth with persistent pain and one with apical swelling were also found one week after completion of endodontic therapy. The results showed significant impr ovement of clinical symptoms and signs one week after completion of endodontic t reatment in comparison with pretreatment and after the first appointment (p < 0. 025). The factors such as presence of pretreatment complaints, periapical lesion s and vital pulp had significant effects on the incidence of endodontic flare-up s after the first appointment of treatment (P < 0.025). In contrast, patients s ex, the number of visits, and whether this was a retreatment case or not had no significant effect on the frequency of these endodontic flare-ups.(14) Imura N . , Zuolo ML (1995) In this prospective study the aim was to assess the incidence of flare-ups (a se vere problem requiring an unscheduled visit and treatment) among patients who re ceived endodontic treatment by the two authors in their respective practices dur ing a period of one year, and also to examine the correlation with pre-operative and operative variables. The results showed an incidence of 1.58% for flare-ups from 1012 endodontically treated teeth. Statistical analysis using the chi-squa re test (P<0.05) indicated that flare-ups were found to be positively correlated with multiple appointments, retreatment cases, periradicular pain prior to trea tment, presence of radiolucent lesions, and patients taking analgesic or anti-in flammatory drugs. In contrast, there was no correlation between flare-up, and ag e, sex, different arch/tooth groups and the status of the pulp.(5) Eleazer PD, Eleazer KR (1998) This retrospective study compared one-visit versus two-visit endodontic treatmen t. The same technique and materials were used before and after making the sole c hange to one-visit endodontic treatment in 1991. Treatment records of 402 consec utive patients with pulpally necrotic first and second molars were compared. In 201 patients, treatment was provided by debridement and instrumentation, followe d by obturation at a second visit; whereas the second group received single visi t therapy. Flare-ups were defined as either patient reports of pain not controll ed with over-the-counter medication or as increasing swelling. Sixteen flare-ups (8%) occurred in the two-visit group versus six flare-ups (3%) for the one-visi t group. This showed an advantage for one-visit treatment at a 95% confidence le vel. In a second comparison, one-visit patients who had previously received twovisit treatment for a different molar with necrotic pulp served as their own con trol. No significant differences were present in this subgroup of 17 patients. ( 20) Albashaireh ZS, Alnegrish AS (1998) This prospective study was conducted to determine whether there is any signific ant difference in the incidence of post-obturation pain after single- and multip le-visit root canal treatment (RCT). The frequency of post-obturation pain was r ecorded and evaluated over an observation period of 30 days in 291 of 300 consec utive patients receiving RCT. The patients were assigned randomly and consecutiv ely into either single- or multiple-visit groups. The canals of all teeth were p repared and filled by a single operator using the step-back and lateral condensa tion techniques. The data were analyzed statistically to determine the relations hip, if any, between the pain experienced and pulpal vitality, tooth type, pre-o perative pain, and the sex and age of the patient. RESULTS: Nine of the 300 pati ents were excluded from the analysis as they failed to attend for postoperative reviews. A significantly higher incidence (P < 0.01) of post-obturation pain was found in the multiple-visit group (38%) than in the single-visit group (27%) wi thin 24 hrs of obturation. The incidence of pain decreased thereafter, with all patients being symptoms free at the end of the observation period. No significan t correlation was found between post obturation pain and any other factor, with the exception that teeth which had non-vital pulp prior to treatment were associ ated with a significantly greater (P < 0.005) incidence of post-obutration pain. Pain was significantly higher in the multiple-visit RCT group and significantly associated with the treatment of the non-vital pulp.(4) DiRenzo et al (2002)

The purpose of this prospective clinical study was to evaluate postoperative pai n after root canal therapy performed in 1 appointment versus 2 appointments. Sev enty-two patients requiring root canal therapy on permanent molars were included in this study. Patients were randomly assigned to either the 1-appointment or t he 2-appointment group. Both vital and non-vital teeth were included. The standa rdized protocol for all teeth involved local anesthesia, isolation and access, e ngine-driven rotary nickel-titanium canal instrumentation to a minimum size #5 ( .028 mm).04 taper Profile with step-back flaring, and irrigation with 2.5% NaOCl . Teeth in group 1 (n = 39) were obturated at the first appointment by using lat erally condensed gutta-percha and Roth 811 sealer. Teeth in group 2 (n = 33) wer e closed with a sterile dry cotton pellet and Cavit restoration and were obturat ed at a second appointment 7 to 14 days later. A modified Visual Analogue Scale was used to measure preoperative pain and pain at 6, 12, 24, and 48 hours after the first appointment. Statistical analysis was performed to compare groups at e ach interval by using an independent-samples t test with Bonferroni adjustment. There was no statistically significant difference between groups at preoperativ e intervals or at any of the 4 postoperative intervals (P <.01). There was no difference in postoperative pain between patients treated in 1 appo intment and patients treated in 2 appointments. The majority of patients in both groups reported no pain or only minimal pain within 24 to 48 hours of treatment . (18) Glennon JP , Nq . Yl , Setchell DJ , Gulabivala K (2004) This longitudinal, prospective study (i) investigated the prevalence of post pre paration pain during root canal treatment and (ii) evaluated the influence of fa ctors affecting the pain experience. Twenty practitioners, comprising general dental practitioners, MSc graduates an d endodontists, participated in this study. The patient sample (n=272) was deriv ed from consecutive patients attending the practitioners surgeries for a two-vi sit root canal treatment on a single tooth. Demographic, medical history, preope rative and intra-operative data as well as pain experience on days 1 and 2 after root canal preparation were recorded. Intensity of pain experienced was recorde d on a visual analogue scale (VAS) of 0-5. The data were analysed using logistic regression models. The prevalence of post preparation pain within 48 h after treatment was 64.7% ( n=176), but less than 10% of patients experienced severe pain (VAS 4 or 5) on ei ther day 1 or day 2. The presence of preoperative pain (OR=2.841, P<0.001), toot h type (OR=2.008, P=0.009), systemic steroid therapy for other medical reasons ( OR=0.181, P=0.023) and preoperative swelling (OR=2.433, P=0.040) were the only f actors to significantly influence post preparation pain experience. (17) Al Neqrish A.R , Habahbeh R(2006) The objective of this prospective study was to determine the flare up rate rel ated to root canal treatment of asymptomatic non vital maxillary central incisor teeth performed in one and two appointments and the relationship, if any betwee n pain and number of treatment visits. The frequency of post obturation pain and swelling was recorded and evaluated over an observation period of 1 week in a 1 20 consecutive patients undergoing root canal treatment. The patients were assig ned randomly into one of two groups of 60 patients each. The canals of all teeth were prepared and filled using the step-back preparation and lateral condensati on filling techniques. Eight of the 120 patients were excluded from the analysis as they failed to attend for postoperative reviews. Out of the 112 patients inv olved in the study 90 patients had no pain, 9 patients had slight pain, 8 patien ts had moderate pain, and 5 patients had severe pain after 2 days. After 7 days 104 patients had no pain, 4 patients had slight pain, 3 patients had moderate pa in and 1 patient had severe pain. No statistically significant difference in the incidence and degree of postoperative pain was found between one and two visit Endodontic procedures. The rate of post obturation flare up in asymptomatic Endo dontically treated non vital maxillary central incisors was 11.6 and 3.6% after 2 and 7 days, respectively.(13) Molander A et al (2007)

This investigation recorded the 2-year clinical and radiographic outcome of oneand two visit endodontic treatments and studied the significance of the bacteri ologic sampling results on the outcome. A randomization procedure allocated 53 t eeth to one-visit treatment and 48 teeth to two-visit treatment. At the end of t he study period, 32 teeth (65%) in the one-visit group and 30 teeth (75%) in the two-visit group were classified as healed. The statistical analysis of the heal ing results did not show any significant difference between the groups (p = 0.75 ). Forty-nine (80%) of the 61 teeth that were obturated after a negative microbi ologic sample were classified as healed. Teeth sealed after positive samples hea led in 44%. The present study gave evidence that similar healing results might b e obtained through one- and two-visit antimicrobial treatment.(24) Penesis V.A et al (2008) The primary objective of this randomized controlled clinical trial was to compar e radiographic evidence of periapical healing after root canal therapy completed in one visit or two visits with an interim calcium hydroxide /chlorhexidine pas te dressing. Ninety-seven patients met the inclusion criteria and consented to p articipate in this study. Patients were randomly assigned to either the one-visi t or two-visit group, and root canal therapy was performed with a standardized p rotocol. Patients in the two-visit group received an intra-canal dressing of cal cium hydroxide/chlorhexidine paste. Sixty-three patients, 33 in the one-visit gr oup and 30 in the two-visit group, were evaluated at 12 months. The primary outcome measure was change in apical bone density by using the peri apical index (PAI). Secondary outcome measures were proportion of teeth healed o r improved in each group. Both groups exhibited equally favorable periapical hea ling at 12 months, with no statistically significant differences between groups. (19) Sathorn C et al (2008) The aim of this systematic review was to assess the evidence regarding postopera tive pain and flare-up of single- or multiple-visit root canal treatment. CENTR AL, MEDLINE and EMBASE databases were searched. Reference lists from identified articles were scanned. A forward search was undertaken on the authors of the ide ntified articles. Papers that had cited these articles were also identified thro ugh Science Citation Index to identify potentially relevant subsequent primary r esearch. The included clinical studies compared the prevalence/severity of posto perative pain or flare-up in single- and multiple-visit root canal treatment. Da ta in those studies were extracted independently. Sixteen studies fitted the inc lusion criteria in the review, with sample size varying from 60 to 1012 cases. T he prevalence of postoperative pain ranged from 3% to 58%. The heterogeneity amo ngst included studies was far too great to conduct meta-analysis and yield meani ngful results. Compelling evidence indicating a significantly different prevalen ce of postoperative pain/flare-up of either single- or multiple-visit root canal treatment is lacking.(15)