Iatrogenic Misadventures and their Sequelae

Question 1

What is the most Important KEY to success and prevention of predictable errors/incidents?

Answer 1

intelligent case selection

Question 2

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

Answer 2

refer the case to the appropriate specialist

Question 3

Patient must understand and sign _______________ before TX begins

Answer 3

informed consent

Question 4

What are the types of iatrogenic misadventures?

Answer 4

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

Question 5

Entry into the wrong tooth often becomes a prelude to…

Answer 5

an expensive tour of our Court system

Question 6

How do you avoid doing endo on the wrong tooth?

Answer 6

• Be certain you can prove and document you 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.

Question 7

What do you do if you do the wrong tooth?

Answer 7

• 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”

Question 8

Missing a Canal will guarantee a…

Answer 8

FAILURE

Question 9

Look for this ______ root : May be evident only as a “Bulls eye”

Answer 9

4th root (4th canal - DL)

Question 10

_____ Root exits coronal portion of tooth in a lingual direction and often curves abruptly back to the facial - Difficult

Answer 10

D-L

Question 11

What are the 4 approaches to file separation?

Answer 11

1. remove the instrument (REFER)
2. bypass the instrument
3. apical surgery & retrofill
4. TE + alternate treatment option

Question 12

When a file separates the TX Decision & Prognosis depend upon:

Answer 12

-The location of the separated instrument (deep in canal or around curve)
-If the canal has been or can be adequately cleaned & shaped, disinfected and filled.
- How much of the tooth will be destroyed to attempt to remove the separated file

Question 13

What are the issues associated with blockage, ledging, etc.

Answer 13

– Blockage
– Ledge
– Transportation of the canal/apex
– Zipping
– Apical Perforation

Question 14

What is a blow out?

Answer 14

You have NO “Apical Control Zone” (Cannot pack GP tightly against nothing)
* Tooth is now COMPROMISED

Question 15

What do you do if you mess up the WL and create a blow out?

Answer 15

You must re-establish a new APICAL STOP within the root.
a. Back off WL & Enlarge IF possible (step back)
b. Surgical Resection & Retroseal
c. Extract and Replace

Question 16

Anemic & Short fills _____ of a problem compared to blow out.

Answer 16

less

Question 17

What do you do with an anemic or short fill?

Answer 17

– 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!

Question 18

What do you do with a long fill?

Answer 18

1. Defective apical control zone
2. Cannot predictably retrieve GP beyond apex (X-Ray)
   – No good NSRCT Option

Question 19

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

Answer 19

Perforations

Question 20

__________ is the most common iatrogenic injury @ UMKC undergrad clinic

Answer 20

Perforation

Question 21

What is the common causes of perforation?

Answer 21

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

Question 22

How do you deal with a perforation (general steps/sequence)?

Answer 22

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

Question 23

What are the clues that you did a perforation?

Answer 23

– Unexpected hemorrhage
– No mark at 7 mm on the bur
– Sudden (loose) drop-through
– Unusual file angle
– Any confusing Situation (take a radiograph)
– Pain Not A Reliable Clue

Question 24

How do you control the hemorrhage after a perforation?

Answer 24

• Dry with paper points or cotton CAREFULLY
• Use hemostatic agents if necessary
• Direct non-invasive observation.
• Determine extent of Damage
• Use Saline
• Be careful – No Pressure!

Question 25

What is the prognosis of a perforation?

Answer 25

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

Question 26

Why do you need to immediately repair a perforation?

Answer 26

Infection and loss of bone occur very rapidly = loss of natural matrix = difficulty of repair = decreased prognosis (direct salivary contact)

Question 27

How does the endodontist repairs a perforation?

Answer 27

- “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

Question 28

What do you do for a supragingival perf?

Answer 28

Isolate, disinfect, place standard matrix, protect found canal(s) and restore with amalgam or composite

Question 29

What can you do for a perforation if you need to refer?

Answer 29

- 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

Question 30

The closer the perforation To the attachment, the _______ prognosis

Answer 30

worse

Question 31

What is the worst iatrogenic injury?

Answer 31

Apical Strip Perforation

Question 32

What causes a strip perforation?

Answer 32

large instrument is misdirected, or used aggressively

Question 33

How do you prevent an apical perforation?

Answer 33

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