- Patients with recent restorations (e.g., amalgam and resin restorations, crowns) or trauma
- Medically-compromised patients
- Large/deep restorations and crowns (broken, leaking, open margins)
- Continuous bleeding after several attempts to dry, close or fill the root canal spaces
Pain severity: the patient may experience some pain
- Thoroughly assess the patient’s medical history: inquire about diabetes mellitus, bleeding disorders, history of radiation therapy, etc.
- Perform an intraoral examination:
- Conduct a visual examination, looking for any remaining pulp tissue in the canal spaces or trapped under pulp horns.
- Determine the source of bleeding in canals by placing paper points and locating the blood on the points.
- Verify if there is bleeding from the gingival tissues in poorly isolated teeth.
- Perform a radiographic examination:
- Include both periapical and bitewing radiographs.
- Radiographs can be taken to confirm length (along with apex locator) and determine perforations, strip perforations or possible mixed canals.
- An apex locator can be used to check if perforation or zipping of the apex is suspected.
Based on the clinical and radiographic examinations and the patient’s medical history, a diagnosis of irreversible pulpitis with bleeding from the root canal system is determined.
Refer to an endodontist if uncomfortable dealing with this situation.
- Ensure that over-instrumentation did not occur.
- Place an orthodontic or copper band, or build up the tooth prior to treatment, if adjacent gingival tissues are bleeding in poorly isolated teeth.
- Perform a complete and thorough cleaning and shaping, and irrigate to remove all pulpal material.
- Slot or tear-drop-shaped canals often have several foramina.
- Large isthmus areas between canals can have an apical delta configuration.
- C-shaped canals often have several portals of exit in the middle and apical thirds.
- Perform a radiographic evaluation to determine length (you can also use an apex locator), possible perforation, strip perforation or missed canals. If a perforation is noted, repair immediately with mineral trioxide aggregate (MTA) or equivalent material. If unable to perform this procedure, refer the patient to an endodontist.
- If bleeding stops: Irrigate with NaOCl and leave in the canals and pulp chamber for 10–15 minutes. Dry and place Ca(OH)2 in the canals and close.
If bleeding does not stop: Place sterile water in the canals for 10–15 minutes, to stop the breakdown of pulpal tissues.
- If all else fails, leave the tooth open for a maximum of 24 hours, reappoint for the next day, lightly instrument, irrigate, dry and close.
- Imura N, Zuolo ML. Factors associated with endodontic flare-ups: a prospective study. Int Endod J. 1995;28(5):261-5.
- Morse DR, Koren LZ, Esposito JV, Goldberg JM, Belott RM, Sinai IH, et al. Asymptomatic teeth with necrotic pulps and associated periapical radiolucencies: relationship of flare-ups to endodontic instrumentation, antibiotic usage and stress in three separate practices at three different time periods. Int J Psychosom. 1986;33(1):5-87.
- Walton R, Fouad A. Endodontic interappointment flare-ups: a prospective study of incidence and related factors. J Endod. 1992;18(4):172-7.
- Harrington GW, Natkin E. Midtreatment flare-ups. Dent Clin North Am. 1992;36(2):409-23.
- Harrison JW, Gaumgartner JC, Svec TA. Incidence of pain associated with clinical factors during and after root canal therapy. Part 1. Interappointment pain. J Endod 1983;9(9):384-7.
- Fabricius L, Dahlén G, Sundqvist G, Happonen RP, Möller AJ. Influence of residual bacteria on periapical tissue healing after chemomechanical treatment and root filling of experimentally infected monkey teeth. Eur J Oral Sci 2006;114(4):278-85.
- Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:846-71.
- Tsesis I, Faivishevsky V, Fuss Z, Zukerman O. Flare-ups after endodontic treatment: a meta-analysis of literature. J Endod 2008;34(10):1177-81.
- Torabinejad M, Kettering JD, McGraw JC, Cummings RR, Dwyer TG, Tobias TS. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endod 1988;14(5):261-6.