Iatrogenic Misadventures Flashcards
what is the most important key to success and prevention of predictable errors/incidents
case selection
______ always beats repair
prevention
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
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
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
what should you do to prevent operating on the wrong tooth
make a mark on the tooth before you place the rubber dam
what do you do if you operated on the wrong tooth
- leave the room and compose yourself
- plan on free work
- take responsibility
missing a canal will guaruntee:
a failure
what do you do if you see you had a missed canal
fix it now
what can the 4th root on mandibular molars look like on radiograph
bulls eye
what population are 4th roots common in
native american and asian
what are the 4 approaches to file separation
- remove the instrument - reefer
- bypass the instrument
- apical surgery and retrofill
- TE and alternate tx option
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
which transportation is the worst to repair
zipping
what causes a blow out
over instrumenting beyond apex
why are blow outs bad
you have no apical control zone- cannot pack GP tightly against nothing
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
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
what is the prognosis of long fills
- defective apical control zone
- cannot predictably retrieve GP beyond apex
- no good non surgical RCT option
what is the “mother” of all iatrogenic misadventures and the most damaging to prognose and difficult to repair
perforations
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
no
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
