Iatrogenic Misadventures Flashcards
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 — error (our bad) and should be largely
preventable with (4)
iatrogenic
education, focus, care and experience.
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Intelligent Case Selection***
(Most Important KEY to success and
prevention of predictable errors/incidents)
- Honest appraisal of current skills/experience levels
- Thorough knowledge of morphology
- Realistic appraisal of shaping objectives
- Proper straight-line access; Good Technique
- Magnification/lighting/specialized equipment and supplies
- Time available to do a decent job
- Patient able to cooperate*
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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Always Start with proper
Case Presentation*
((4)
- 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.
Explaining away mishaps AFTER they
occur destroys
credibility and voids the
consent and your permission to
proceed.
Creates distrust & additional
LIABILITY.
Another of Murphy’s Lesser Known
Laws as applied to Endodontics:
“The BIGGEST
problems ALWAYS
occur when you have the
LEAST time to deal with
them” RRR
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?
Iatrogenic Misadventures:
(7)
- Wrong Tooth (commission)
- Missed Canal(s) (omission)
- Separated Instrument
- Ledging, Blockage & Transportation
(Zipping) Apical perforation - Blow Outs
- Short & Long Fills
- Perforations & Strip-perfs
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1. WRONG TOOTH
(4)
- Entry into the wrong tooth 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*
- WRONG TOOTH: What do you do?
* Procedure:
– FIRST: LEAVE THE ROOM & COMPOSE
YOURSELF
– Plan on Free Work
– Compensate the patient . . . Or his Attorney
- Take Responsibility(Most Important)
– What would YOU expect as the patient?
– DO “the RIGHT THING”
- WRONG TOOTH: What do you do?
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.
— is
always better,
cheaper &
faster than
remediation
Prevention
- MISSED CANAL
Missing a Canal will guarantee a
FAILURE (sooner or later)
Fix it now or pay to have it fixed (+ new crowns)
Look closely and expect the unexpected
- Missed the Whole Root
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
- File Separation
If you tell me you have never separated a
file . . . You simply haven’t done much
endo. Proceed with CARE***Prevent
4 approaches: When Prevention Fails!
- remove the instrument (REFER)
- bypass the instrument
- apical surgery & retrofill
- TE + alternate treatment option
Try to get all your file separation done in LAB before you get to
Clinic or real life. Much LESS EXPENSIVE*
- File Separation
TX Decision & Prognosis depend upon:
(2)
-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.
- File Separation
- How much of the tooth will be —
to attempt to remove the separated file
- ***what is best for the patient & the tooth.
This is serious, difficult and constitutes a
— situation in most cases.
OFTEN-
destroyed
REFERRAL
the more you do to fix the problem,
the worse it gets! Stop,Think,Refer
- File Separation
Rarely does it makes sense to Tell the Patient of the
problem at the time, then Fill, then Wait and see if it
will do OK without further intervention.
(3)
-if CLEAN
-if not LONG or SHORT
- if you can FOLLOW the patient – for sure
You can still apply 1 of the 4 approaches if it
becomes troublesome
Why did I say: “Tell the patient” ?
- Blockage, Ledging & Transportation
of the apex (Zipping)
* We examined the creation &
prevention of these problems
(5)
– Blockage
– Ledge
– Transportation of the canal/apex
– Zipping
– Apical Perforation
- “BLOW-OUTS”
- 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
- “BLOW-OUTS”
* Plan A:
You must re-establish a new
APICAL STOP WITHIN the
root.
a. Back off (shorten) WL &
Enlarge IF possible* OR
b. Surgical Resection &
Retroseal OR
c. Extract and Replace
- Anemic, Short & Long Fills
* 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
- Anemic, Short & Long Fills
* Long fills another story:
- Defective apical control zone
- Cannot predictably retrieve GP
beyond apex (X-Ray)
– No good NSRCT Option
(Surgery is often necessary)
– Good reason to do Check
Film at “Tree” Stage (Lecture
4)
- Perforations
- Perforations are the MOTHER of all iatrogenic misadventures. The most damaging to prognosis and the most difficult to repair –
- As always . . . PREVENTIONis by far the best solution. . .
- Perforations are a serious challenge to successful completion of the RCT and retention of the tooth.
- Perforation is the most common iatrogenic injury @ UMKC undergrad. Clinic
- PERFORATIONS: Occur with
Regularity
for the Careless or Distracted
- PERFORATIONS: Still More Fun
- Anything through a — is dangerous (usually Grad. Endo).
- — are very productive for perfs.
- No crown on the tooth is not as easy as you might think.
crown
Posts
- Commonly Seen
Perforations & Common Causes
(4)
- Failure to recognize the angulation of
long axes of the root. - Failure to accurately measure and stay
short of the furcation. - Failure to remove adequate extra-
coronal restoration in order to clearly
visualize pulpal landmarks. - Spatial disorientation with inadequate
access ***.
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7. Dealing with Perforation: Sequence
- Disclosure @ Consent?
- Recognition
- Confirmation
- Notification of patient
- Control hemorrhage
- Assessment
- Treatment & Follow-up
- Perforation: Recognition
* Your Clues:
– 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 — you recognize a problem, the
better the chance of successful resolution.
sooner
7.Perforation: Confirmation
- 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.
- Perforation: Control of Hemorrhage
* Dry with — – CAREFULLY*
* Use — agents if necessary
* Direct — observation.
* Determine extent of —
* Dilute your NaOCl now —
* Be careful – No —!
paper points or cotton
hemostatic
non-invasive
Damage
10:1
Pressure
- Perforation: Prognosis always compromised
* Depends:
(3)
– Extent: (smaller the better < 1mm.)
– Location: (closer to attachment = worse)
* Supra-gingival
* Subgingival
* Apical
* Strip
– Timing of Repair: (Immediate = Best
Chance*)
- Why Immediate Repair?
- 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***
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7. 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.
– Serious Prayer ?
. So – What CAN you DO?
- 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
Still Better: Prevent the Problem using CASE SELECTION
How does the endodontist repairs it?
- “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
- OR: It may not be THAT bad . . .
* Supragingival Perf.
(Isolate, disinfect, place standard
matrix, protect found canal(s) and
restore with amalgam or
composite)
Find unfound canal(s) and complete
RCT.
- Subgingival Perforation
* 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.
7.Strip Perforation (possibly the
WORST iatrogenic injury)
- A Strip Perforation is caused when a
large instrument is misdirected, or used
aggressively - This is the most difficult perf. to repair
favorably - Matrix is not practical.
- Maybe apical surgery: resection and
MTA retrofill – maybe Extraction ***
- Apical Perforation
- Problem starts with a ledge
- Added pressure leads to a root
perf. well below attachment. - Try to bypass ledge re-enter canal
& obturate canal - Fill perf. with GP or MTA
Orthograde (or Surgical ?)
Then SEAL canal permanently
Vitrebond, etc.
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7. So – What’s the Message here?
- CASE SELECTION***: If you see something like this - give a thought to REFERRAL BEFORE you shoot yourself in the foot.
- Do you think you can retain the pt. you perforated?
- How can the endodontist make you look GOOD?
- The endodontist may have problems too but at least you now have someone to BLAME
Here @ UMKC
* 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 ***
