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endo > iatrogenic good times > Flashcards

iatrogenic good times Flashcards

1
Q

iatrogenic errors defined

A

Patient comes in with a correctable problem. We correctly DX the problem and institute TX to correct.
Even though attempting to help the patient, we MAY create a bigger problem which may NOT be correctable.
This is an iatrogenic error (our bad) and should be largely preventable with education, focus, care and experience.

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2
Q

best way to not have iatrogenic errors

A

prevention via intelligent case selection

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3
Q

If you can’t look at the case and be certain of an excellent result in your hands, you are honor bound to:

A

If you can’t look at the case and be
certain of an excellent result in your
hands, you are honor bound to refer the
case to the appropriate specialist*

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4
Q

what should be done before any tx with pt?

A

Always Start with proper Case Presentation*
* Presentation of possible TX options (risks v. benefits)
* Honest explanation of all possible misadventures before treatment is started (use non-technical terms)
* Patient must have all questions answered before TX
is accepted
* Patient must understand* and sign informed consent before TX begins.

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5
Q

when should mishaps be explained? why?

A

before they happen
Explaining away mishaps AFTER they occur destroys credibility and voids the consent and your permission to proceed. Creates distrust & additional LIABILITY.

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6
Q

murphys law and endo

A

“The BIGGEST problems ALWAYS occur when you have the LEAST time to deal with them”
If you don’t have time to fix it right in the 1st place,
how will you now do it better with even LESS time?

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7
Q

types of iatrogenic good times

A
  1. Wrong Tooth (commission)
  2. Missed Canal(s) (omission)
  3. Separated Instrument
  4. Ledging, Blockage & Transportation (Zipping) Apical perforation
  5. Blow Outs
  6. Short & Long Fills
  7. Perforations & Strip-perfs
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8
Q

entry into wrong tooth
* prelude to?
* Be certain you can prove and document your?
* mark tooth/dam?
* Reconfirm all?

A
  • often becomes a prelude to an expensive tour of our Court system.
  • Be certain you can prove and document your Diagnosis and Treatment Plan
  • Be sure you make a mark on the tooth you want to work on BEFORE you place the rubber dam*** Access w/o rubber dam when indicated – except for Board Exams.
  • Reconfirm all information one more time.It’s always your fault and there is NO EXCUSE*
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9
Q
  1. WRONG TOOTH: What do you do?
A
  • Procedure:
    – FIRST: LEAVE THE ROOM & COMPOSE YOURSELF
    – Plan on Free Work
    – Compensate the patient . . . Or his Attorney
  • Take Responsibility
  • Score Card:– You RCT the wrong tooth at N/C
    – You also RCT the RIGHT tooth at N/C for “Good Will”
    – You pay for the Crown on the wrong tooth
    – You may also pay for the crown on the RIGHT tooth
  • Pray you don’t screw up anything else
    doing all this free work.
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10
Q

missed canals

A

Missing a Canal will guarantee a FAILURE (sooner or later)
Fix it now or pay to have it fixed (+ new crowns)
refer cases when not positive of canal anatomy

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11
Q

missing entire roots

A

Look for this 4th root (4th canal - DL) : May be evident only as a “Bulls eye”Especially in Native Americans and
some Asian populations.
D-L Root exits coronal portion of tooth in a lingual direction and often curves abruptly back to the facial -
Difficult
maybe referral

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12
Q

file seperation approaches

A

4 approaches: When Prevention Fails!
1. remove the instrument (REFER)
2. bypass the instrument
3. apical surgery & retrofill
4. TE + alternate treatment option

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13
Q

File Separation
TX Decision & Prognosis depend upon:

A

-The location of the separated instrument (deep in canal or around curve very ???)
-If the canal has been or can be adequately cleaned & shaped, disinfected and filled.

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14
Q

important consideration with file seperation

A
  • How much of the tooth will be destroyed to attempt to remove the separated file
  • ***what is best for the patient & the tooth.
    This is serious, difficult and constitutes a
    REFERRAL situation in most cases.
    OFTEN- the more you do to fix the problem,
    the worse it gets! Stop,Think,Refer
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15
Q

Tell the Patient of the file seperation at the time, then Fill, then Wait and see if it will do OK without further intervention?

A

rarely does this make sense

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16
Q

blow out

A

OK – you messed up WL and created a “Blow out”. Now what?
* Assessment: You have NO “ACZ” (Cannot pack GP tightly against nothing)
* Tooth is now COMPROMISED

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17
Q

options for blowout remedy

A

You must re-establish a new APICAL STOP WITHIN the
root. (SSB)
a. Back off (shorten) WL & Enlarge IF possible* OR
b. Surgical Resection & Retroseal OR
c. Extract and Replace

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18
Q

Anemic and short Fills

A
  • Anemic & Short fills less of a problem:
    – Remove old GP or other filling material
    – Re-shape to correct length and shape IF POSSIBLE
    – Obturate correctly N/C B4 someone else sees it!
  • You are out only your time & ego here
19
Q

long fills

A
  1. Defective apical control zone
  2. Cannot predictably retrieve GP beyond apex (X-Ray)
    – No good NSRCT Option (Surgery is often necessary)
    – Good reason to do Check Film at MC Stage
20
Q

worst of all errors

A

Perforations are the MOTHER of all iatrogenic misadventures. The most damaging to prognosis and the most difficult to repair –

21
Q

best solution to avoid perf

A

prevention (case selection)

22
Q

most commn error in clinic

A

perf

23
Q

who often perforates

A

Careless or Distracted

24
Q

common perf scenarios (state of tooth)

A
  • Anything through a crown is dangerous (usually Grad. Endo).
  • Posts are very productive for perfs.
  • No crown on the tooth is not as easy as you might think.
25
Q

Commonly Seen
Perforations & Common Causes

A
  1. Failure to recognize the angulation of long axes of the root.
  2. Failure to accurately measure and stay short of the furcation.
  3. Failure to remove adequate extra-coronal restoration in order to clearly visualize pulpal landmarks.
  4. Spatial disorientation with inadequate access ***.
26
Q

sequence of dealing with perforations

A
  • Disclosure @ Consent?
  • Recognition
  • Confirmation
  • Notification of patient
  • Control hemorrhage
  • Assessment
  • Treatment & Follow-up
27
Q

cues of perforation
– Unexpected?
– No mark?
– drop-through?
– file angle?
– Pain?

A

– Unexpected hemorrhage
– No mark at 7 mm on the bur
– Sudden (loose) drop-through
– Unusual file angle
– Any ? Situation (ck. A/L & XR)
– Pain Not A Reliable Clue
The sooner you recognize a problem, the better the chance of successful resolution.

28
Q

Perforation: Confirmation

A
  • STOP: Do NOT enlarge (the smaller the defect, the better the prognosis)
  • Use Apex Locator with small file (if it immediately pegs, it’s a perf. - not a canal) It is indicating the resistance of a PDL = outside the tooth.
29
Q

controlling perf hemorrhage
* Dry?
* Use hemostatic agents?
* observe?
* Determine extent of?
* NaOCl?
* pressure?

A
  • Dry with paper points or cotton –CAREFULLY*
  • Use hemostatic agents if necessary
  • Direct non-invasive observation.
  • Determine extent of Damage
  • Dilute your NaOCl now 10:1
  • Be careful – No Pressure!
30
Q

perf prognosis

A

Prognosis always compromised
* Depends:
– Extent: (smaller the better < 1mm.)
– Location: (closer to attachment = worse)
* Supra-gingival (best)
* Subgingival
* Apical
* Strip (worst)
– Timing of Repair: (Immediate = Best Chance*)

31
Q

why immeadiate repair of perf

A
  • Infection and loss of bone occur very rapidly = loss of natural matrix = difficulty of repair = decreased prognosis (direct salivary contact)
    An undetected or untreated perforation can become a serious infection within days or even hours. Note the rapid spread of infection and greatly increased
    loss of bone structure within few weeks***
32
Q

what should come to mind with perf?

A

Referral should Come to Mind:
* At this point it becomes obvious that we need one or more likely all of the following:
– Greater skills
– DOM
– Accessory lighting
– Specialized materials and equipment
– Experience in this serious challenge to retention of the tooth.

33
Q

what can I do with a perf before sending off to endo

A
  • Carefully disinfect the area (0.8% NaOCl)
  • Protect found canals with easily removable material (cotton, paper point, GP, file, etc)
  • Create an easily removable temp. seal over the perf. using “Cavit” at the very least or IRM.
  • Seal the tooth with a secure temp. filling over cotton
  • Refer to endodontist at once p.r.n.
  • Better yet be prepared with skills and supplies to repair your problem right now ***
    MTA
34
Q

how does endo repair a perf

A
  1. “Collacote” (Sulzer Dental) is useful as a matrix for repair MTA is placed over the perforation and allowed to set w/ H20
    Do NOT occlude any of the canals***
    Unfound Canal is identified with DOM and negotiated to completion
35
Q

supragingival perf repair

A

Supragingival Perf. (Isolate, disinfect, place standard
matrix, protect found canal(s) and restore with amalgam or composite)
Find unfound canal(s) and completeRCT.

36
Q

subg perf

A
  • The closer the perf. To the attachment, the worse the prognosis.
  • Matrix, isolate. Protect found canals + Pack with MTA (if below alveolar crest) or Geristore (above alveolar crest)
  • Periodontal defect may persist and require perio TX.
37
Q

Strip Perforation

A

possibly the WORST iatrogenic injury
* A Strip Perforation is caused when a large instrument is misdirected, or used aggressively

38
Q

strip perforation repair

A
  • This is the most difficult perf. to repair favorably
  • Matrix is not practical.
  • Maybe apical surgery: resection and MTA retrofill – maybe Extraction ***
39
Q

Apical Perforation
* Problem starts with?
* leads to?

A
  • Problem starts with a ledge
  • Added pressure leads to a root perf. well below attachment.
40
Q

apical perf tx

A
  • Try to bypass ledge re-enter canal & obturate canal
  • Fill perf. with GP or MTA, Orthograde (or Surgical ?)
    Then SEAL canal permanently Vitrebond, etc.
41
Q

How can the endodontist make you look GOOD?

A
  • The endodontist may have problems too but at least you now have someone to BLAME
42
Q

expanding education

A
  • Continue your Professional Education
    – We can only give you the absolute basics here
    – There is much more to learn
  • You can master the Technical in 10-15yrs.
  • The Business will take you the rest of your life.
  • Expand - Learn new things (not from salesmen)
  • THEN Add new services to your practice as you become qualified.
43
Q

if offering advanced services

A
  • If you offer advanced services . . .
  • Be certain you can deliver them to the Standard of Care . . .
  • Standard of Care . . . is the same for a generalist as for a specialist in the eyes of the Law.
44
Q

incidents at UMKC

A
  • Of the misadventures described:
  • Perforation, Separated Instrument &NaOCLAccident, etc. called “INCIDENTS” (remediation opportunities)
  • An INCIDENT REPORT is required (Must be on filled out within 48 hrs.)
  • Failure to generate the Incident Report in a timely manner is a serious problem
  • Any attempt to hide an INCIDENT may result in automatic loss of Clinical Privileges

endo (22 decks)

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