endodontic Mishaps / /certified fixed orthodontic courses by Indian dental academy

ENDODONTIC MISHAPS

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com


INTRODUCTION:
Endodontic mishaps or procedural accidents are those that happen
during treatment,some owing to inattention to detail and others
totally unpredictable.

Mishaps will be discussed under following headings:
RECOGNITION
CORRECTION
HOW WILL THEY AFFECT THE PROGNOSIS?
PREVENTION


CLASSIFICATION:

ACCESS RELATED:

-TREATING THE WRONG TOOTH

-MISSED CANALS

-DAMAGE TO EXISTING RESTORATION

-ACCESS CAVITY PERFORATION

-CROWN FRACTURES.


INSTRUMENTATION RELATED:

-LEDGE FORMATION

-CERVICAL CANAL PERFORATIONS

-MIDROOT PERFORATIONS

-APICAL ROOT PERFORATIONS

-SEPARATED INSTRUMENTS&FOREIGN OBJECTS

-CANAL BLOCKAGE.


OBTURATION RELATED:

-OVER OR UNDER EXTENDED ROOT CANAL FILLINGS

-NERVE PARASTHESIA

-VERTICAL ROOT FRACTURES.


MISCELLANEOUS:

-POST SPACE PERFORATION

-IRRIGANT RELATED

-TISSUE EMPHYSEMA

-INSTRUMENT ASPIRATION AND INGESTION


TREATING THE WRONG TOOTH:

It falls within the category of inattention on the part of dentist

Misdiagnosis may happen and should not be automatically
considered under the category of endodontic mishap.

If the tooth 23 is fractured and 24 is isolated and opened then
it can be considered as endodontic mishap.


RECOGNITION:

-It is the result of re-evaluation of the patient who continues to have the
symptoms even after treatment.

CORRECTION:

-Appropriate treatment of both the teeth ,one inappropriately opened and
the one with original pulpal problem.
-Both the teeth should be filled properly.

PREVENTION:

-Mistakes in the diagnosis can be reduced by paying proper attention to
detail and obtaining as much information as possible before making
diagnosis. www.indiandentalacademy.com

-Before making a diagnosis good evidence supporting the diagnosis shoul
be present.
-For example:A radiograph of a tooth showing a peri-apical lesion may
suggest pulpal necrosis.

-To obtain a definitive diagnosis it is necessary to have additional
information such as:
 lack of response to electric pulp test
 a draining sinus leading to the tooth apex to be proved
by placing guttapercha point in the tract and taking
radiograph.


-Once the correct diagnosis is made embarassing situation of opening a
wrong tooth can be prevented by marking the tooth to be treated.


MISSED CANALS:
-Some root canals are not easily accessible or readily apparent from
chamber.
-Additional canals in mesial roots of maxillary molars and distal roots
of mandibular molars are common canals which are left untreated.

RECOGNITION:

-It can occur after treatment or during the treatment.

-During treatment an instrument or filling material may be noticed to be
other than or centered in root indicating presence of another canal.


MANDIBULAR ANTERIORS WITH 2 CANALS


-Advent of high resolution magnification has increased the ability
to locate the canals.

CORRECTION:

Retreatment is appropriate and should be attempted before
any surgical procedure.


PROGNOSIS:
A missed canal decreases the prognosis and most likely will
result in treatment failure.

PREVENTION:
-Locating all the canals in a multicanal tooth is the best way
to prevent the treatment failure.
-Adequate coronal access allows the oppurtunity to find
canal orifices.
-Additional radiographs taken from mesial or distal angles
will help to determine if the one canal located is centered
in root.


DAMAGE TO EXISTING RESTORATION:

-An existing porcelain crown presents with its unique challenges.

-In preparing an access cavity through a porcelain or porcelain bonded
crown the porcelain may sometimes chip off or fracture.

CORRECTION:
-Minor porcelain chip offs can be treated by bonding
composite resin to crown.

-However,longevity of such repairs is unpredictable.


PREVENTION:
-Removal of a provisionally cemented new crown prior to endodontic
therapy may pose problem.

-These crowns can be difficult to remove and often a margin will be
damaged.

-To prevent damage to an existing,permanently cemented crown is to
remove it before treatment.

-Preservation of integrity of restoration is sometimes possible by using
special devices such as Meatllift croen,Bridge removal system.
It allows for removal with little or no damage to crown.

-After root canal treatment the crown can be re-cemented.

ACCESS CAVITY PERFORATIONS:

-Undesirable communication between pulp space and the external tooth
surface may occur at any level in chamber or along the length of root
canal.

-They may occur during preparation of access cavity.

-In process of searching for canal orifices,perforations of crowns can
occur,either peripherally through sides or through floor of chamber
into
furcation.


RECOGNITION:

-If perforation is above the periodontal attachment the first sign of
presence of an accidental perforation will often be presence of leakage
either saliva into cavity or sodium hypochlorite into mouth.
-When the crown is perforated into periodontal ligament,bleeding into
access cavity is often the first indication.
-To confirm the suspicion of such an unwanted opening place a small
file through the opening and a radiograph is taken which will clearly
demonstrate that the file is in canal.


CORRECTION:
-Perforations of canal walls above the alveolar crest can generally be
repaired intracoronally without the need for surgical intervention.

-Perforations into the periodontal ligament or into the furcation should
be corrected as soon as possible to minimize injury to the tooth supportin
structures.

-It is also important that the material used to repair should provide a good
seal and does not cause further tissue damage.
Several materials used are as follows:
• AMALGAM
•CALCIUM HYDROXIDE PASTE
•GLASS IONOMER CEMENT
•GUTTA PERCHA

-Prior to repair of a perforation,it is important to control bleeding,both
to evaluate size &locations of perforations and to allow placement of
repair materials.

PREVENTION:

-Examination of pre-operative radiographs.

-Checking long axis of the tooth and aligning the long axis of the access
bur with long axis of tooth can prevent unfortunate perforations of a
tipped tooth.


CROWN FRACTURES:
RECOGNITION:
-By direct observation
-Infractions are often recognized first after removal of existing restoration
in preparation of access.

TREATMENT:
-Treated by extraction.

PROGNOSIS:
-Crown fractures may lead to the roots,leading to vertical root fractures.


-Often associated with excessive and inappropriate dentin removal
during cleaning and shaping phase.
-Excessive canal preparation to accommodate large pluggers,spreaders
can lead to weakening of tooth structure and fracture of root tip.
-”Canal stripping” is the term used when root perforations result from
excessive flaring during canal preparation.
-Such flaring can weaken the tooth.


LEDGE FORMATION:
RECOGNITION:

-Ledge formations should be suspected when root canal instruments
can no longer be inserted into the canal to full working length.

-There may be loss of normal tactile sensation of the tip of the
instrument binding to the lumen.

-When ledge formation is suspected, a radiograph of tooth with
instrument in place will provide additional information.

-If radiograph shows that instruments point appers to be directed
away from the lumen of canal,completion of canal preparation must

LEDGE FORMATION


CORRECTION:

-A small file is used no.10 or 15 with a distinct curve at the tip.

-Curved tip should be pointed wall opposite to the ledge.

-Tear-shaped silicone instrument stops should be used.

-Tear is pointed in the same direction as the curve of instrument.

-Watch-winding motion always helps advance the instrument.

-Where-ever resistance is met instrument is retracted,rotated and
advanced again until it bypasses the ledge.

Completion of www.indiandentalacademy.com
canal is best accomplished by:

1. USAGE OF LUBRICANT
2. IRRIGATE FREQUENTLY TO REMOVE DENTIN CHIPS
3. MAINTAIN A CURVE TIP ON THE FILE.
4. SHORT FILES ARE USED.
5. TIP OF THE FILE IS CHECKED FREQUENTLY TO BE CERTAIN
THAT THE CURVED IS MAINTIANED.
6. POSSIBILITY OF PERFORATION IS ENHANCED BY EDTA
HENCE IT IS NOT USED.


PREVENTION:
-Accurate interpretation of diagnostic radiographs should be
completed before the first instrument is placed in the canal.

-Awareness of canal morphology is imperative throughout
instrumentation.

-Failing to pre-curve instruments and forcing large files into
curved canals,are the most common causes of mishaps.


PERFORATIONS:
Accidental perforations may be categorized by
location:

RADICULAR PERFORATION

CERVICAL MIDROOT APICALROOT

Perforation may be caused by following errors:
perforating through the side of root at point of canal obstruction.
using too large or too long instrument and either perforating directly
through apical foramen or through the lateral surface of root.

1.CERVICAL CANAL PERFORATIONS:
Cervical portion of the canal is most often perforated during the process
of locating & widening canal orifice.


RECOGNITION:
-Begins with sudden appearance of blood which comes out from
periodontal ligament.

-Rinsing and blotting may allow direct visualization of perforation.

-If direct visualization is not possible then a small file is placed in that
area and radiograph is taken.


CORRECTION:

-A small area of perforation may be sealed from inside the tooth.

-If perforation is large it may be necessary to seal first from inside then
surgically expose the external aspect of tooth and repair the damaged
tooth structure.

-Most promising material for sealing perforations is MTA.

PROGNOSIS:
-Reduced
-Surgical correction may be necessary if a lesion or symptom
develops.


PREVENTION:

-Reviewing the morphology of the tooth.

2.MIDROOT PERFORATIONS:
-This is mostly in curved canals.

RECOGNITION:
-Stripping is the lateral perforation caused by overinstrumentation
through a thin wall in root and is most likely to happen on on inside
or concave wall of curved canal,such as the distal wall of mesial roots
in mandibular first molars .
-Stripping is easily detected by sudden appearance of heamorrhage in a
previously dry canal.

CORRECTION:
- Access to midroot perforation is most often difficult,
and repair is not predictable.
-Calcium hydroxide has beenused in the hope of stimulating a
biologic barrier against which to pack filling material.


PROGNOSIS:

-Reduced prognosis.

-Loss of tooth structure and integrity of root-wall can lead to subsequent
root fractures.

PREVENTION:

-Careful use of rotary instruments inside the canal and following
recommendations for canal preparation in curved root.


3.APICAL PERFORATIONS:

-Perforations in apical segment of root-canal may be the result of file not
negotiating a curved canal or not establishing accurate working length
and instrumentation beyond apical confines.

-Perforation of curved root is result of ledging.

Transportation –removal of canal wall structure on the outside curve
in apical half of canal due to tendency of files to restore themselves to
their original linear shape during canal preparation.

Apical Zip –an elliptical shape that may be formed in the apical foram
during preparation of a curved canal when a file extends through the
apical foramen.

RECOGNITION:

-If a patient complains of pain during treatment.

-If canal becomes flooded with hemorrhage.

-If tactile resistance of confines of canal space is lost.

-A paper point inserted to the apex will confirm a
suspected apical perforation.


CORRECTION:

-Obturation of both the foramina and of the main body canal requires
the vertical compacting techniques with heat softened gutta-percha.

-Apical perforation can also occur in a canal if instrument use exceeds
the correct working length.this destroys the resistance of root canal
preparation.


If perforation is by overinstrumentation corrective methods include:

-Re-establishing tooth length short of original length and then
enlarging the canal with larger instruments.
-Careful adaptation of primary filling point.
-Canal is cautiously filled to that length so that resistance form thus
created will prevent filling extrusion out of the apex.
-Creating an apical barrier is another technique.materials used are
dentinchips and calcium hydroxide powder.

PROGNOSIS:
-Less adverse effect on prognosis.


SEPARATED INSTRUMENTS
&
FOREIGN OBJECTS:
-Many objects have been reported to break or separate and become lodged
in root canals.

-Glass beads from sterilizers,amalgam,files and reamers.
-Instrument is advanced into the canal until it binds and efforts to remove
it then lead to its breakage.

-Other common errors are using a stressed instrument.

-Placing exaggerated bends on instruments to negotiate curved canals.

SEPARATION OF INSTRUMENT


CORRECTION:

-Remove the obstruction.

-Ultrasonic fine instrument have proven most effective in loosening
& flushing out broken fragments.

-

-Using microscopy and special fine diamond tips a tunnel can be created
around the separated instrument and then vibrated & dislodged.

-If the instrument fragment is totally within the root canal
system, one may attempt to bypass it with a small file or
reamer.
-Bypassing is made easier with a lubricant.

-The instrument segment thus becomes part of the filling
material.


-If the fragment extends past the apex and efforts to
remove it non-surgically are unsuccessful, the corrective
treatment will probably include apical surgery.


Prevention of separation mishaps
•stressed” instrument is the one most likely to separate
in a canal.
• Small instruments, such as Nos. 08, 10, 15, and 20, should
be examined carefully during use to check for signs of stress.


OVER-OR-UNDEREXTENDED
ROOT CANAL FILLINGS:

Although controversy may exist regarding termination of root canal
filling ,there is general consideration that ideal location is at or near the
dentino-cemental junction.


-Root canal filling material is sometimes inadvertently extruded
beyond the apical limit of the root canal system,ending up in the
peri-radicular bone, sinus, or mandibular canal or even
protruding through the cortical plate.
-Gross overextensions can lead to symptoms and treatment
failure.
-A frequent cause of this mishap is apical perforation with loss of
apical constriction against which gutta-percha is compacted.
-Underextension of root canal filling material may be caused by
failure to fit the master gutta-percha point accurately.
It can also result from a poorly prepared canal, particularly in the
apical part of the canal.


Rowe stated that, in teeth with apices approximating the inferior
alveolar canal, “the most frequent cause of damage is excess
filling material which has passed through the apices and either
caused pressure on the neurovascular bundle in the
inferiordental canal or produced a neurotoxic effect on
thenervetrunk”.

Use of paste-type filling material
.


RECOGNITION:
Recognition of an inaccurately placed root-canal filling usually takes place
when a post-treatment radiograph is taken.
CORRECTION:
Correction of an under-extended filling is accomplished by re-treatmen
-Removal of the old filling followed by proper preparation and obturation
of the canal.

Correction of an over-extended filling is more difficult.
-An attempt to remove the overextension is successful if the entire point
can be removed with one tug.
-If the overextended filling cannot be removed through the canal it
will be necessary
to remove the excess surgically if symptoms or radicular lesions develop
or increase in size.

-Root canal filling material such as gutta-percha and many
sealers are generally well tolerated by the surrounding
tissues, and overextended fillings do not automatically
require surgical removal if asymptomatic and not associated
with lesions.

PREVENTION:
-Attention to detail is the best form of prevention.Accurate
working lengths and care to maintain them will help prevent
overextensions.
-Incorporation of two simple steps into one`s RCT technique
can significantly decrease the chance of aberrant fillings:
 Confirmation and adherence to working length.
 Taking radiograph during initial phases of obturation.

NERVE PARESTHESIA:
-Both local factors and systemic diseases have been reported as causative
agents for paresthesia.

-Patients presenting with this symptom should routinely be screened
for an adjacent tooth necrotic pulp.

-Over-extensions and/or over-instrumentation are the causative factors
most often found in paresthesia secondary to orthograde endodontic
therapy.

-The nerve damage may be transient or permanent and may be instituted
by over-instrumentation,over-extension,or injury to the inferior alveolar
nerve.
-

CORRECTION:

-Correction of these iatral neuropathies is often through non-intervention
and observation.

-Use of systemic prednisolone to shorten the course of the condition,
prevent secondary fibrosis,and lessen the severity of sequelae.

PREVENTION:

-One should be judicious in selection of cases.


VERTICAL ROOT FRACTURES:
-Vertical root fractures can occur during different phases of
treatment: instrumentation, obturation, and post placement.


-In both lateral and vertical condensation techniques,the risk of
fractures high if too much force is exerted during compaction.

-During post placement,if the post is forced apically during seating or
cementation,the risk of fracture is high,particularly if the post is
tapered.


RECOGNITION:

-The sudden crunching sound,similar to that referred to the crepitus in
the diseased temporomandibular joint,accompanied with pain
reaction on the part of the patient,is a clear indicator that root is
fractured.
-A suggestive “teardrop” radiolucency may appear in the radiograph
of along-standing vertical root fracture.
-Finding a deep periodontal pocket of recent origin in a tooth with a
long-present root canal filling is most suggestive of a vertical
fracture.


Tear-drop
radiolucency

CORRECTION:
-In most of cases extraction is the only treatment available at this time.
-GIC repairs have been reported for furcal perforation.

PREVENTION:
-Avoidance of over-preparing canals and the use of a passive,less
forceful obturation technique and seating of posts.


POST SPACE PERFORATION:

A well done root canal procedure can be destroyed by a misdirected
post space perforation.

RECOGNITION:

-Sudden presence of blood in canal.

-Radiographic evidence.


CORRECTION:

-Sealing the perforation.

-Use of resin composite bonded to adjacent root dentin with a dentin
bonding agent .

PROGNOSIS:

-It is least affected when if perforation is within the bone.

-If it is closer to gingival sulcus then rate of pocket formation is
high.

-The tooth must be considered weakened.

PREVENTION:

-Planning the post space preparation based on the radiographic
knowledge,regarding location of root and its direction in alveolus.

-Gates-glidden and peeso drills are not likely to be at risk in causing
perforations but they can lead to excessive removal of tooth
structure.


IRRIGANT RELATED MISHAPS:

-Saline,hydrogen peroxide,alcohol,and sodium hypochlorite are the most
commonly used irrigants.

-Any irrigant regardless of toxicity cause problems if extruded into
peri-radicular tissues.

-Injection of hydrogen peroxide causes tissue emphysema.


RECOGNITION:

-An irrigant related mishap is readily evident.

-Patient complains of severe pain,and swelling can be violent and
alarming

-Initial response may be characterised by swelling,pain,interstitial
hemorrhage and ecchymosis.


TREATMENT:

-Because of potential spread of infection prescription of antibiotics
and analgesics for pain.

-Antihistamines can also be helpful.

-Ice packs applied initially to the area, followed by warm saline
soaks ,use of intramuscular steroids, and, in more severe cases
hospitalization and surgical intervention with wound debridement,
may be necessary.

-Monitoring the patient’s response is essential until the initial phase
of the reaction subsides.


PROGNOSIS:
-It is favourable,but immediate treatment,proper management and
close observation are important.
-The long-term effects of irrigant injection have included paresthesia
,scarring,and muscle weakness.

PREVENTION:
-Passive placement of the a modified needle.
-No attempt should be made to force the needle apically.
-Solution should be delivered slowly without pressure.
-In event that sodiumhypochlorite is injected into sinus, immediate
lavage of the sinus should be done through the same rootcanal
pathway of atleast 30ml of sterile water or saline should prevent
damage to sinus lining.


TISSUE EMPHYSEMA:
-Subcutaneous or peri-radicular air emphysema is,
fortunately,relatively uncommon.
- Tissue space emphysema has been defined as the
passage and collection of gas in tissue spaces or fascial
planes.
-It has been reported as an untoward event subsequent to
various dental procedures, such as an amalgam
restoration,periodontal treatment, endodontic treatment, and
exodontia.
- The common etiologic factor is compressed air being
forced into the tissue spaces.


RECOGNITION:
Usual sequence of events is rapid swelling, erythema,and crepitus
-Crepitus is the pathognomic feature of emphysema therefore
easily distinguished from angioedema.
-Dysphagia,and dyspnea have been reported as the major compaint
-Tissue emphysema remains in subcutaneous connective tissue
and usually does not spread to the deep anatomic spaces.


 Several diagnostic signs of mediastinal emphysema :

1.Sudden swelling of neck.
2.Patient may have difficulty in breathing.
3.Characteristic crackling can be induced when swollen regions are
palpated.
4.Mediastinal crunching noise is heard on auscultation.


ORRECTION:
reatment recommendations vary from palliative care and observation
immediate medical attention if the airway or mediastinum is
mpromised.
road-spectrum antibiotic coverage is indicated
all cases to prevent the risk of secondary infection.
ajority of reported cases have followed a
nign course followed by total recovery.


INSTRUMENT ASPIRATION AND INGESTION:

-Aspiration or ingestion of a foreign object is a complication that can
occur during any procedure.

-Endodontic instruments,used in absence of a rubber dam,can easily be
aspirated or swallowed if inadvertently dropped in the mouth.

-Standard care for endodontic therapy requires the use of a rubber dam.


RECOGNITION:

-In these cases it is better termed as “suspicion.”

-The patient must be taken to medical emergency facility for examination.

-The examination should include radiographs of the chest and abdomen.

-It is also helpful to bring a sample file along so that the physician,who
may be searching for an instrument in the alveolar tree,has a better idea
of size and shape of instrument.


CORRECTION:

-Correction in the dental operatory is limited to removal of objects that
are readily accessible in throat.

-High-volume suction,particularly if fitted with a pharyngeal tip,can be
useful in retreiving lost items.

-Hemostats and cotton pliers can also be used.

-Once the aspiration has taken place timely transport to medical
emergency facility is essential.

-The dentist should accompany the patient there.

PREVENTION:
-Usage of rubber-dam in all phases of endodontic
therapy.

Routine placement of floss around the rubber dam retainer will
allow retrieval in the event that the patient aspirates it.


endodontic Mishaps / /certified fixed orthodontic courses by Indian dental academy

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