Iatrogenic Misadventures and their Sequelae Flashcards
What is the most Important KEY to success and prevention of predictable errors/incidents?
intelligent case selection
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
Patient must understand and sign _______________ before TX begins
informed consent
What are the types of iatrogenic misadventures?
- Wrong Tooth (commission)
- Missed Canal(s) (omission)
- Separated Instrument
- Ledging, Blockage & Transportation (Zipping) Apical perforation
- Blow Outs
- Short & Long Fills
- Perforations & Strip-perfs
Entry into the wrong tooth often becomes a prelude to…
an expensive tour of our Court system
How do you avoid doing endo on the wrong tooth?
- 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.
What do you do if you do the wrong tooth?
- 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”
Missing a Canal will guarantee a…
FAILURE
Look for this ______ root : May be evident only as a “Bulls eye”
4th root (4th canal - DL)
_____ Root exits coronal portion of tooth in a lingual direction and often curves abruptly back to the facial - Difficult
D-L
What are the 4 approaches to file separation?
- remove the instrument (REFER)
- bypass the instrument
- apical surgery & retrofill
- TE + alternate treatment option
When a file separates the TX Decision & Prognosis depend upon:
-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
What are the issues associated with blockage, ledging, etc.
– Blockage
– Ledge
– Transportation of the canal/apex
– Zipping
– Apical Perforation
What is a blow out?
You have NO “Apical Control Zone” (Cannot pack GP tightly against nothing)
* Tooth is now COMPROMISED
What do you do if you mess up the WL and create a blow out?
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
Anemic & Short fills _____ of a problem compared to blow out.
less
What do you do with an anemic or short fill?
– 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!
What do you do with a long fill?
- Defective apical control zone
- Cannot predictably retrieve GP beyond apex (X-Ray)
– No good NSRCT Option
________ are the MOTHER of all iatrogenic misadventures. The most damaging to prognosis and the most difficult to repair.
Perforations
__________ is the most common iatrogenic injury @ UMKC undergrad clinic
Perforation
What is the common causes of perforation?
- 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
How do you deal with a perforation (general steps/sequence)?
- Disclosure @ Consent?
- Recognition
- Confirmation
- Notification of patient
- Control hemorrhage
- Assessment
- Treatment & Follow-up
What are the clues that you did a perforation?
– 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
How do you control the hemorrhage after a perforation?
- 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!
What is the prognosis of a perforation?
- Depends:
– Extent: (smaller the better < 1mm.)
– Location: (closer to attachment = worse) - Supra-gingival
- Subgingival
- Apical
- Strip
– Timing of Repair: (Immediate = Best Chance*)
Why do you need to immediately repair a perforation?
Infection and loss of bone occur very rapidly = loss of natural matrix = difficulty of repair = decreased prognosis (direct salivary contact)
How does the endodontist repairs a perforation?
- “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
What do you do for a supragingival perf?
Isolate, disinfect, place standard matrix, protect found canal(s) and restore with amalgam or composite
What can you do for a perforation if you need to refer?
- 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
The closer the perforation To the attachment, the _______ prognosis
worse
What is the worst iatrogenic injury?
Apical Strip Perforation
What causes a strip perforation?
large instrument is misdirected, or used aggressively
How do you prevent an apical perforation?
- Try to bypass ledge re-enter canal
& obturate canal - Fill perf. with GP or MTA Orthograde (or Surgical ?) Then SEAL canal permanently
Vitrebond, etc.
