procedural accidents- whoops! did i do that? · cleaning and shaping. ledge formation root...
TRANSCRIPT
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Procedural Accidents-Whoops! Did I Do That?
Kweli K. Carson, DDS, MSDiplomate, American Board of Endodontics
Expert Witness, Maryland State Board of Dental Examiners
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Types of Procedural AccidentsCrown and root perforationsIatrogenic canal obstruction (due to dentin shavings or dental materials)Ledge formation Separated instrumentsSwallowed or aspirated instrumentsSodium hypochlorite incidentsUnderfilled or overfilled root canalsPost space perforationsVertically fractured rootsTreating the wrong tooth
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Preventing Procedural Accidents
Thorough clinical and radiographic examAccurate diagnosis and treatment planningUse the AAE Endodontic Case Difficulty Assessment Form and Guidelines to determine risk factorsRefer potentially difficult or challenging cases to an endodontist
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AAE Endodontic Case Difficulty Assessment Form and Guidelines
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Procedural Accidents Occur
During Access PreparationDuring Cleaning and ShapingDuring ObturationDuring Post Space Preparation and Post Insertion
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Procedural Accidents During Access Preparation
PerforationsCoronal - lateralCoronal - furcation
Iatrogenic canal obstructions
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Perforations
Iatrogenic perforation
Artificial opening in a tooth created by drilling, boring, piercing, or cutting through tooth structure (with burs, hand instruments)
Communication between pulp system and external tooth surface
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Perforation During Access Preparation
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Prevention During Access
Clinical examinationRotation, tipping of crownCast crown may not representoriginal tooth structure
Radiographic examination
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Prevention During Access
Orientation of burDepth of pulp chamber roofHeight of pulp chamberLocation of pulp horns
Level of chamber floorBe PatientENDO-Z bur (non-cutting tip)
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Recognition of Perforations During Access
Sudden appearance of persistent hemorrhage
Radiographic extrusion of a file into PDL or bone.
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Identification of PerforationsDuring Access
Dental operating microscope
Electronic apex locator
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Treatment of Perforations
Lateral perforations can be repaired with geristore, composite or a crown (microscope recommended).
Dr. Ronald Taylor
Al-Sabek, F. et alJOE 2005: Vol 31, Num. 3, pp 205-208
“In vitro interpretation indicates that Geristore is less cytotoxic to gingival fibroblasts [than Ketac-Fil or IRM]”
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Treatment of PerforationsFurcal perforations can be repaired with MTA or amalgam (microscope recommended) – a file or paper point should be placed in the canals to prevent blockage of canals with the repair materials.
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Perforation Material - MTA
Nakata, T. et al JOE 1998: Vol 23, Num. 4, pp 184-196
“MTA was significantly better than amalgam at preventing bacterial leakage in furcal perforation repairs.”
Mineral
Trioxide
Aggregate
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Factors Affecting Prognosis –Perforations
Relationship of perforation to the gingival sulcusTime lapse before perforation repairAdequacy of perforation repair Sterility of perforation repairMaterial used to seal perforation
Johnson W. et al JADA 1988: Vol 117, Num. 3, pp 473-476
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Iatrogenic Canal Obstructions
Restorative materials and dentin shavings can travel into canals during access
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Iatrogenic Canal Obstructions
PreventionAll necessary restorative materialshould be removed prior to exposingthe pulpPlace a small cotton pellet over thecanal orifices if access is enlarged Frequent and copious irrigationPlace files or paper points in canalsif using repair materials
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Procedural Accidents During Cleaning and Shaping
Ledge formationRoot perforations (apical, lateral, coronal)Separated instrumentsSwallowing or aspirating instrumentsExtrusion of irrigants into periapical tissues
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Ledge FormationCreated when the working length (WL) can no longer be negotiatedCauses – inadequate straight-line access, filing a curved canal short of WL, over-enlargement of a small curved canal, debris packed in apical canal area
NORMAL
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Ledge Formation
“Canal curvature was the most significant variable affecting the incidence of ledging”
Kapalas A. et al Endod Dent Traumatal 2000: Vol 16, Num. 5, pp 229-231
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Preventing Ledging During Cleaning & Shaping
Straight line accessUse small flexible files especially with curved canals (pre-curve if nec)Avoid forcing large files into curved canalsEstimated working length verified by apex locator or radiograph
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Root Perforations During C&S(apical, lateral, coronal)
APICAL LATERAL CORONAL
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Identification of Root Perforation
Observation of bleedingDirectIndirect (paper points)
RadiographsSmall file
Apex Locator
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Management of Root PerforationsTreatment plan depends on
AccessibilityVisibilityPerforation sizePeriodontal conditionsStrategic importance of toothPatient’s oral hygieneQuality of root canal treatmentExperience of the operator
Alhadainy, HAOral Surg Oral Med Oral Path 1194: Vol 78, Num. 3, pp 368-374
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Repair MaterialsMTA
Less leakage in lateral root perforations than amalgam or IRM
Lee, 1993
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Root Repair Materials
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Root Perforation (mesio-buccal) - Apicoectomy
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Root PerforationsIatrogenic perforation of a root surface during endodontic treatment or restorative procedures may:
Decrease prognosisCause secondary periodontal involvementCause the loss of the toothAlhadainy, HAOral Surg Oral Med Oral Path 1994: Vol 78, Num. 3, pp 368-374
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Separated InstrumentsPotential hazard that patients should be informed of prior to treatmentUsually occur in small, long, curved, calcified or irregular canals
“Factors attributed to breakage of rotary files include canal curvature and other anatomic challenges, practitioner experience, frequency of use, and speed of rotation”
Fishelburg G. et alCompend Contin Educ Dent 2004: Vol 25, Num 1, pp 17-24
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How to Minimize Separation
Straight line accessLight touch –gentle pressureNever force a file –take to resistanceConsistent RPM
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How to Minimize Separation
Use plenty of irrigation/lubricationEstablish finger rest –minimizes pulling into canalInstrument with rotaries to point of divergence or trouble spots
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How to Minimize Separation
File turning upon entryKnow exact WLClean and examine files frequently“When in doubt – throw it out”
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Treatment – Separated Instruments
Depends on locationUltrasonics to removeBypassLeave in place (guarded prognosis –possible apicoectomy in the future)
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If there is ONE thing you remember about endodontics from this lecture, remember this…
ALWAYS use a rubber dam!!
Swallowing or AspiratingInstruments
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Swallowing or AspiratingInstruments
“The use of rubber dam is an absolute essential during endodontic treatment”
Lambrianidis T. et alEndod Dent Traumatol 1996: Vol 12, Num 6, pp 301-304
“The placement of a rubber dam is considered the standard of care”
Fishelburg G. et alJOE 2003: Vol 29, Num 3, pp 683-684
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ALWAYS USE A RUBBER DAM!
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Extrusion of Irrigants into Periapical Tissues
Prevention – use side-slotted needle, keep needle moving, do not wedge needle into canalRecognition – prolonged severe pain followed by rapid diffuse swellingTreatment – reassurance, patient education, analgesics, multiple follow-up visits
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Procedural Accidents During Obturation
UnderfillingOverfillingVertical fracture (rare)
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UnderfillingCauses
Natural barrierLedge formationInsufficient flaringNo straight-line accessPoorly adapted master coneInadequate condensationpressure
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UnderfillingTreatment
Depends on several factorsRadiographic findingsPost presentCrown margins
Retreatment
Surgery (apicoectomy)
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OverfillingExtruded material can cause tissue damage and inflammationCaused by overinstrumentation through the apical foramenIf overfilling is suspected, do working radiograph prior to searing gutta percha (remove all gutta percha if necessary)Treatment – mainly surgery (apicoectomy)
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Vertical FractureCan be caused by condensation forces during obturation (rare)
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Procedural Accidents During Post Space Preparation
Misdirected post preparationPerforationPrevention
Examine radiograph carefullyUse heat to remove coronal gutta percha – to guide post drill
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Procedural Accidents During Post Insertion
Use of an excessively large post, leading to vertical root fracture
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Treating the Wrong Tooth
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Discussing Procedural Accidents With Patients
Be honest / Look them in the eyeReview your informed consent formInform them about the accidentTell them how prognosis is affectedDiscuss procedures necessary for correctionConsider referring the patientHelp them financially (depends on the issue)Call your malpractice carrier for advice
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Questions?
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Thank You!