Iatrogenic Misadventures Flashcards by Olivia Bellantoni

what is the most important key to success and prevention of predictable errors/incidents

case selection

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______ always beats repair

prevention

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what are the other way to prevent errors

honest apprasisal of skills and experience levels
thorough knowledge of morphology
realistic apprasisal 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

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what should you start with with patients

-proper case presentation
- present tx options - risks and benefits
- honest explanation of all possible misadventures before tx is started
- pt must have all questions answered before tx is accepted
- pt must understand and sign informed consent before tx begins

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what are the possible iatrogenic misadventures and are they errors or omission or commision

wrong tooth: commission
missed canals: omission
separated instrument
ledging, blockage, and transportation, apical perforation
blow outs
short and long fills
perforation and strip perfs

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what should you do to prevent operating on the wrong tooth

make a mark on the tooth before you place the rubber dam

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what do you do if you operated on the wrong tooth

leave the room and compose yourself
plan on free work
take responsibility

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missing a canal will guaruntee:

a failure

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what do you do if you see you had a missed canal

fix it now

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what can the 4th root on mandibular molars look like on radiograph

bulls eye

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what population are 4th roots common in

native american and asian

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what are the 4 approaches to file separation

remove the instrument - reefer
bypass the instrument
apical surgery and retrofill
TE and alternate tx option

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in file separation tx decision and prognosis depend on:

the location of the separated instrument
if the canal has been or can be adequately cleaned and shaped, disinfected and filled

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which transportation is the worst to repair

zipping

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what causes a blow out

over instrumenting beyond apex

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why are blow outs bad

you have no apical control zone- cannot pack GP tightly against nothing

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what do you do if you have a blow out

make a new apical stop within the root
back off shorten Wl and enlarge OR
surgical resection and retroseal OR
extract and replace

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what do you do if you have an anemic and short fill

remove old GP or other filling material
re-shape to correct length and shape if possible
obturate correctly before someone else sees it

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what is the prognosis of long fills

defective apical control zone
cannot predictably retrieve GP beyond apex
no good non surgical RCT option

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what is the “mother” of all iatrogenic misadventures and the most damaging to prognose and difficult to repair

perforations

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what is the most common iatrogenic injury at UMKC

perforation

what are very productive for perfs

posts

what are the common causes of perfs

failure to recognize the angulation of the 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

what is the sequence in dealing with perforations

disclosure at consent
recognition
confirmation
notification of the pt
control hemorrhage
assessment
treatment and follow up

how do you recognize a perforation

- unexpected hemorrhage - no mark at 7mm on the bur - suddetn loose drop through - unusual file angle

what is not a reliable clue in perf recongition

pain

what do you do to confirm the perf

- stop and do not enlarge- the smaller the defect the better prognosis - use apex locator with small file- if it immediately pegs its a perf not a canal

what does the apex locator measure in a perforation

the resistance of a PDL

how do you control the hemorrhage in a perf

- dry with paper points or cotton - use hemostatic agent if necessary - direct non-invasive observation - determine extent of damage - dilute your NaOCl now 10:1 - be careful - no pressure

what does the prognosis of a perf depend on

- extent - location - timing of repair

how does extent effect prognosis in a perf

smaller the better. less than 1 mm

how does location affect the perf prognosis

- closer to attachment = worse - supra gingiva: good prognosis - subgingival: bad prognosis - apical or strip: okay prognosis

how does timing effect the prognosis of perf

immediate = best chance

why does immediate repair of a perf increase the prognosis

infection and loss of bone occur very rapidly = loss of natural matrix = difficulty of repair = decreased prognosis - direct salivary contact

what can happen with an undetected or untreated perf

it can become a serious infection within days or hours

what is the outcome of a perforation within a few weeks

rapid spread of infection and greatly increased loss of bone structure

if you perf and youre going to refer to an endodontist how do you close the tooth

- carefully disinfect with 0.8% NaOCl - protect found canals with easily removable material (cotton, paper point, GP, file) - create an easily removable temporary seal over the perf using Cavit at the very least or IRM - seal the tooth with a secure temporary filling over cotton - refer

what material can be used to fix a perf

MTA

how does the endodontist repair the perf

- collacote (sulzer dental) is useful as a matrix for repair - MTA is placed over the perforation and allowed to set with water - do not occlude any of the canals - unfound canal is identified with DOM and negotiated to completion

what do you do with a supragingival perf

- isolate, disinfect place standard matrix, protect found canal and restore with amalgam or composite - find unfound canal and complete RCT

the closer the perf to the attachment the _____ the prognosis

worse

what do you do with a subgingival perf

- matrix, isolate. protect found canals and pack with MTA if below alveolar crest or Geristore if above alveolar crest - periodontal defect may persist and require perio TX

when is a strip perforation caused

when a large instrument is misdirected or used aggresively

what is the most difficult perf to repair favorable

apical strip perforation

do you use a matrix in apical strip perf

what is the tx for apical strip perf

maybe apical surgery: resection and MTA retrofill - maybe extraction

how does an apical perforation happen

- problem starts with a ledge - added pressure leads to a root perforation well below attachment

what do you do with an apical perforation

fill perf with GP or MTA orthograde or surgical - then seal canal permanently with vitrebond

what do you do at UMKC if you have a misadventure

- an incident report is required within 48 hours - 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 privledges

true or false: the standard of care is the same for a generalist as for a specialist

true