lecture 7: iatrogenic misadventure and their sequelae Flashcards
the best prevention in endo is
intelligent case selection is key to success and prevention of predictable errors/incidents
case presentation includes what
- presentation of possible tx options like risk and benefits
- honest explanation of all possible things that could happen before you start the tx
- pt must have all questions answered before tx is accepted
- pt must understand and sign informed consent before tx begins and before anesthesia on pt
the 7 iatrogenic misadventures
- wrong tooth (commission)
- missed canals (omission)
- separated instruments
- ledging, blockage, and transportation apical perforation
- blow outs
- short and long fills
- perforations and strip perfs
what to do if you did the wrong tooth
- leave the room and compose yourself
- compensate pt
- take responsibility
bulls eye indicates
a 4th root and 4th canal DL. (difficult)
especially in NA and some asian pops
4 approaches for when your file separates
- remove the instrument (refer)
- bypass the instrument
- apical surgery and retrofill
- TE and alternate tx options
choose the one that is best for the pt and the tooth.
file separation tx decision and prognosis depends on what
- the location
- if the canal has been cleaned, shaped, disinfected and filled.
if you start seeing that you have blockage what should you do?
- stop, irrigate, recapitulate with a #10 file and try to take a file again
how do blow outs occur
you messed up WL
no you have no ACZ (apical constriction zone)
tooth is now compromised
what to do if you have a blow out
- re-establish a new apical stop within the root
a. back off the WL and shorten it and enlarge if possible
b. surgical resection and retroseal
c. extract and replace
if you have a long fill what should you do
- defective apical control zone
- cannot predictably retrieve GP beyond apex
no good NSRCT option bc surgery will be necessary
good reason to do tree stage XR
if you have an anemic or short fill what should you do
- remove old GP and filling material
- re-shape to correct length and shape if possible
- obturate correctly before someone else sees it
the mother of all iatrogenic misadventures
perforations
the hardest to repair and the most damaging
commonly seen reasons for perforations
- failure due to angulation of long axis of the root
- failure to measure and stay short of furcation
- failure to remove adequate extra-coronal restoration to clearly visualize pulpal landmarks
- spatial disorientation with inadequate access
clues to recognition you have perforated
- unexpected hemmorrhage
- no mark on the 7mm on the bur
- loose and sudden drop-through
- unusual file angle
- pain is NOT a reliable clue
once you have recognized you perforated what should you do
- stop and do not enlarge
- use apex locator
how to control hemorrhage of a perforation
- with paper points or cotton carefully
- hemostatic agents
- non-invasive observation
- determine extent of damage
- dilute with a different [ ] of NaOCl now 10:1
- NO PRESSURE
perforation prognosis depends on what 3 things
extent
location (close to attachment = worse)
timing of repair
why should you do an immediate repair with perforation
because infection and loss of bone occur very rapidly
what should you do to RCT you started as you refer it to an endo
- disinfect with 0.8%. NaOCl
- protect the found canals with removable material
- create an easily removable temp using CAVIT
- seal the tooth with a secure temp filling over cotton
- refer at once PRN
removable material to use
cotton
paper points
Gp
file
how will an endo repair the perforation
collacote -> matrix for repair
MTA is placed over the perforation and set with water.
once its closed, finish off the RCT
subgingival perforation vs supragingival perforations
subgingival is worse bc of bacteria
if you perforated below the alveolar crest what should you pack with
MTA
if you perforated above alveolar crest pack with
geristore
what is the most difficult perforation to repair
strip perforation bc large instrument is misdirected or was aggressively used
apical perforation
starts with a ledge
added pressure leads to a root perforation well below attachment
try to bypass ledge re-enter canal and obturate canal
fill perf with GP or MTA then SEAL canal permanently
