When silence turns to pain: Decoding endodontic flare-ups

This is the authors' abstract. We don't add key points for this paper.

Endodontic flare-up remains one of the most clinically challenging and unpredictable complications of root canal therapy, turning a relatively routine procedure into an acute emergency with sudden onset of pain and/or swelling within hours to days of an appointment. Although it has been studied for decades, the multifactorial etiology with microbial, mechanical, chemical and immunological factors still challenge clinicians in terms of its predictable prevention and management. This review aims to collate current evidence on the definition, epidemiology, classification, etiopathogenesis and risk factors of endodontic flare-ups, with particular emphasis on the roles of microbial persistence (especially Enterococcus faecalis), host inflammatory mediators and iatrogenic factors such as apical extrusion of debris and irrigants. Evidence-based preventive and management strategies ranging from occlusal reduction, intracanal medicaments, pharmacological control of pain and inflammation to judicious use of antibiotics are discussed along with contemporary diagnostic aids such as cone beam computed tomography and emerging artificial intelligence assisted radiographic analysis. We propose a clinical decision-making algorithm to assist the practitioner from diagnosis to resolution. The overall incidence of severe flare-up is low (2-9% in contemporary series), but its unpredictable nature and impact on patient trust mean that there is a need for continued research into individualized risk stratification and minimally invasive prevention.