Lecture 4: Iatrogenic Misadventures & their Sequelae Flashcards
What is an iatrogenic error?
when we make a mistake that causes a problem in the patient
Iatrogenic errors (our bad) should be largely ____ with education, focus, care and experience
preventable
______ always beats repair
prevention
Most important KEY to success and prevention of predictable errors/incidents:
Case selection
List the components of intelligent case selection: (7)
- 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 ____ of an _____ result in your hands, you are honor bound to refer the case to the appropriate specialist
certain; excellent
In order to prevent iatrogenic error, always start with proper:
case presentation
Prior case presentation includes presentation of treatment options including the:
risks vs. benefits
T/F: you should provide an honest explanation of ALL possible misadventures BEFORE treatment is started (and use non-technical terms)
True
When must a patient must have all question answered?
BEFORE treatment is accepted
Destroys our credibility and voids the consent and your permission to proceed; creates distrust & additional liability:
Explaining away mishaps AFTER they occur
Murphy’s lesser known laws as applied to endodontics explains:
“The BIGGEST problems ALWAYS occur when you have the..”
LEAST time to deal with them
Iatrogenic misadventures (Errors of both omission & commission) include: (7)
- wrong tooth (commission)
- missed canal(s) (omission)
- separated instrument
- ledging, blockage & transportation (zipping) apical perforation
- blow outs
- short & long fills
- perforations & strip-perfs
Often becomes a prelude to an expensive tour of our court system:
wrong tooth entry
In regards to wrong tooth entry, it is always:
your fault & there is no excuse
What is the “procedure” if you treat the wrong tooth?
- Leave the room & compose yourself
- Plan on free work
- Compensate the patient…or his attorney
What is the MOST important part when you’ve treated the wrong tooth?
TAKING RESPONSIBILITY & do the right thing
Describe the treatment plan + payments if you happen to treat the wrong tooth:
(score card)
- RCT the wrong tooth at no cost
- RCT the right tooth at no cost
- Pay for the crown on the wrong tooth
- you may also pay for the crown on the right tooth
Prevention is always better, cheaper, & faster than:
remediation
Missing a canal will guarantee:
failure
If you miss a canal you should:
fix it now or pay to have it fixed (+new crowns)
The “Bulls Eye” on a radiograph signifies:
4th root
The 4th root (bulls eye) is especially found in:
native america & some asian populations
The bulls eye is the ____ that exits coronal portion of tooth in a lingual direction and often curves abruptly back to the facial - difficult to treat
DL root
If you say you’ve never made this error, its likely you haven’t done much endo. The goal is to proceed with care to prevent this from occurring:
file separation
4 approaches when prevention of file separation fails:
- REMOVE the instrument & refer
- BYPASS the instrument
- APICAL SURGERY & RETROFILL
- TE + alternative treatment option
In regards to file separation, treatment decision & prognosis depend on:
- location of the separate instrument (deep in canal or around curve are very questionable)
- if the canal has been or can be adequately cleaned & shaped, disinfected & filled
- How much of the tooth will be destroyed to attempt to remove the separated file
- What is best for the patient and the tooth
A file separation is serious, difficult & constitutes a ______ situation in most cases
Referral
With file separation, often the more you do to fix the problem-
the worse it gets
T/F: Rarely does it make sense to tell the patient of the a separated file at the time of the problem. Fill then wait and see if it will do okay without further intervention
True
In what situations should you not tell the patient that a file has separated?
- if canal is clean
- if its not too long or short
- if you can follow the patient
T/F: Missing a canal will guarantee failure
True
In what situation is it easy to miss a whole root?
4th DL root (Bulls eye)
T/F: File separation is a serious and difficult problem but rarely constitutes referral situation in most cases
False- constitutes a referral situation in most cases
T/F: Rarely does it make sense to tell the patient of the file separation at the time
True
Plan A for a BLOW OUT:
Re-establish a new apical stop within the root
Anemic and short fills are _____ of a problem than an blow out
less
In regards to a long fill, there is no good:
nonsurgical RCT option
(because you cannot predictably retrieve GP beyond the apex)
What are the MOTHER of all iatrogenic misadventures?
(most damaging to prognosis and the most difficult to repair)
Perforations
What is the best solution for a perforation?
Prevention
What is the most common iatrogenic injury at UMKC undergrad clinic?
Perforation
Common causes of perforations include:
- 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
What is the sequence for dealing with perforation?
- disclosure & consent
- recognition
- confirmation
- notification of patient
- control hemorrhage
- assessment
- treatment & follow-up
What are some clues that help to recognize perforation?
- unexpected hemorrhage
- no mark at 7 mm on bur
- sudden (loose) drop-through
- unusual file angle
T/F: Pain is a reliable clue for perforation
false
With a perforation, to what ratio should you dilute your NaOCl?
10:1
With a perforation prognosis is always compromised but depends on:
- extent (smaller the better < 1mm)
- location (closer to attachment = worse)
- timing of repair (immediate = best chance)
Why do we prefer an IMMEDIATE repair with a perforation?
Infection & loss of bone occur very rapidly = loss of natural matrix = difficult of repair = decreased prognosis (direct salivary contact)
T/F: an undetected perforation can become a serious infection within days or even hours.
True- note the rapid spread of infection and greatly increased loss of bone structure within few weeks
If you perforation results in the need to refer your patient, what should you do in the mean time?
- disinfect area
- protect found canals with easily removable material
- create easily removable temp that seals over perforation
Type of perforation that is not as serious of a problem:
supragingival perforation
With a subgingival perforation the closer the perforation to the attachment the:
worse the prognosis
What type of perforation is possibly the worst iatrogenic injury?
Strip perforation
A _____ is caused when a large instrument is misdirected or used too aggressively
strip perforation
What is the most difficult perforation to repair?
Apical strip perforation
An apical perforation starts with a:
ledge
List some examples of incidents:
perforation, separated instrument & NaOCl accident
For all incidents an incident report is required and must be filled out within:
48 hours
