Untoward Outcomes and Solutions Flashcards by sophie rosen

Diseased Outcome:
■ Solution Options:
(4)

■ Extraction
■ Non-surgical Retreatment
■ Surgical Retreatment
■ Monitoring ?

How well did you know this?

Not at all

Perfectly

Monitoring DISEASE is a NON OPTION:
“Supervised Neglect”
(2)

Can be a basis for Legal Action
Patient may decline TX recommendations*

How well did you know this?

Not at all

Perfectly

Not all periapical lesions are active disease
(3)

-Is the lesion still healing, or growing larger?
-Symptomatic or asymptomatic?
-Is the lesion larger on CBCT than the PA shows?
When in doubt, refer!

How well did you know this?

Not at all

Perfectly

Patient may select EXT over any Recc.
(3)

Lost Faith or Fear of Additional Fees/Failures
Weary of Unresolved Issues / Definitive Solution
May be the High Prognosis Optio

How well did you know this?

Not at all

Perfectly

Extraction:
Always preferable to retain healthy natural tooth for life:
(4)

■ Most Efficient Chewing
■ Normal biting force and sensation
■ Natural appearance
■ Protects other teeth from excessive wear or strain

How well did you know this?

Not at all

Perfectly

Sometimes Extraction is the only solution - or

■ Patient may demand EXT following unsuccessful initial RCT
■ Educate* – Don’t argue

How well did you know this?

Not at all

Perfectly

Concentrate on Replacement
(3)

■ Implant
■ FPD
■ RPD

How well did you know this?

Not at all

Perfectly

No replacement has a— either!

100% success rate

How well did you know this?

Not at all

Perfectly

Non-surgical Retreatment
■ A RCT tooth may not heal as expected
for a number of reasons:
(3)

■ Complicated, undetected, or untreated canal
anatomy
■ Delay in placement of definitive coronal
restoration
■ Inadequate previous RCT or Leaking coronal
restoration

How well did you know this?

Not at all

Perfectly

New problems:
(3)

■ New decay
■ Loose, cracked, or broken restoration
■ Tooth or root fracture

How well did you know this?

Not at all

Perfectly

If you are going to be successful in
solving the problem, you first must
determine exactly the — of
the problem *

etiology

How well did you know this?

Not at all

Perfectly

AAE suggests that — should generally
be the first option considered

NSRT

How well did you know this?

Not at all

Perfectly

NSRT Prognosis is generally poorer than

1st RCT
■ Failure rate of endodontic re-treatment was 16.6%
- R. B. Pekruhn, “Incidence of RETX Failure” JOE, ‘Feb ’86 P70
■ Overall Success Rate for ReTX was 65% with An
Additional Category of Uncertain (18.3%)

■ 90+% v. 60-75 %-?: You call it
■ Endodontist’s experienced best GUESS

How well did you know this?

Not at all

Perfectly

REFER
MOST*

RETX

How well did you know this?

Not at all

Perfectly

—% retention after 5 years

89%

How well did you know this?

Not at all

Perfectly

Non-surgical Retreatment:
Technique
■ Problem must be identified:
(3)

■ Is it tooth or root FX? (? - hopeless)
■ Missed canal
■ Inadequate previous RCT
- Cleaning & Shaping
- Obturation

How well did you know this?

Not at all

Perfectly

— must be done to provide access to previous
obturation material

Deconstruction

How well did you know this?

Not at all

Perfectly

GP must be softened to facilitate removal of obturation material
■ GP – soften with (2)
■ (3)
■ (3) difficult or impossible to remove
■ All Problems discovered/confirmed
■ All Deficiencies must be corrected & Success documented by recall

Study These Flashcards

solvents . . . or heat
Chloroform, Eucalyptol, Rectified spirits of Turpentine
Thermafil, insoluble pastes & Silver Points

Some NSRT cases may be done by skilled &
trained generalist

Study These Flashcards

■ Obvious, correctable problem
■ Within your competence level
■ Most should be referred

Surgical Retreatment
■ Indications:

Study These Flashcards

■ NSRT is completed & problem not resolved
■ Problem not accessible to NSRCT
■ Root Perforations or Resorptive Defects
■ DX Experimental Flap Procedure for VRF identification
■ Marked overextension of obturating material interfering with
healing.
■ Biopsy of suspect lesion
■ Separated Instrument not treatable by NSRT
■ Other blockages untreatable by NSRCT e.g. Ledges,
Transportations and Zips
■ Non-negotiable canals may be retrofilled (MTA)

Extraradicular
Biofilm
(2)

Study These Flashcards

■ Sometimes biofilm has
matured so much that it
grows beyond the apex
or lateral canals and
onto the root surface
■ Disinfecting the canal
will not reach these
bacteria and disease
can persist

Endodontic Micro-surgery:

Study These Flashcards

A clinical procedure intended to remove the root
tips, place a biocompatible material, and remove
the associated diseased soft tissue

A clinical procedure intended to remove the root
tips, place a biocompatible material, and remove
the associated diseased soft tissue
This procedure is referred to as

Study These Flashcards

“Apical Curettage”
(Not often done by itself – followed by RETROFILL)

Most Endodontists today would think it prudent to follow-up
apical curettage @ time of surgery by removing and beveling
root tip and insuring an obturation seal by placing a “retrofill” to
seal the canal. — appears to be the current material of choice
for the retrofill

Study These Flashcards

MTA

This procedure is termed “Apical Resection and Retrofill”

Most Endodontists today would think it prudent to follow-up apical curettage @ time of surgery by removing and beveling root tip and insuring an obturation seal by placing a “retrofill” to seal the canal. MTA appears to be the current material of choice for the retrofill

“Apical Resection and Retrofill” Desired result is a

regeneration of normal tissues and architecture in the area of surgical intervention AAE Illustration AAE Illustration

Stated another way: Endodontic Micro- Surgery (Periapical Surgery) is generally: A procedure most commonly done to remove ... --- obturation appears to be adequate but no healing following reasonable time is an indication for --- obturation If the tooth is asymptomatic and the peri-radicular defect is not persistent (i.e. healing proceeding within reasonable parameters), surgery is not indicated unless ...

persistent peri-radicular disease following apparently adequate endodontic treatment. Orthograde, Retrograde reasonable follow-up is exceeded (>24 months)

Further: OR: a procedure that is done when

conventional endodontics cannot reasonably be performed or conventional endodontics has failed and conventional RETX would be prohibitively difficult

OR: a procedure that is done when conventional endodontics cannot reasonably be performed or conventional endodontics has failed and conventional RETX would be prohibitively difficult. AAE states that Non-Surgical Retreatment (NSRT) is the preferred first course of action for a non-healing RCT if feasible. BUT

RETX cases with easiest access to apex via surgery may be chosen as most reasonable course of action

Surgical Retreatment CONTRAINDICATIONS

■ Dangerous Proximity to anatomical entities (ie) neurovascular bundles, IA canal ■ Extreme thickness of cortical plate ■ Periodontally involved teeth (2 disciplines involved: ? Prognosis of outcome) ■ Lack of Training, Skills, Equipment, Materials or Time ■ Inability to manage possible complications ■ Patient health considerations (ie) active leukemia, neutropenia, uncontrolled diabetes, bleeding considerations, on meds such as anticoagulants, recent MI ■ Pregnant and in first trimester ■ Better prognosis from alternate TX option (Implant?)

--- is prohibitively thickened in some cases, making access, visibility and hemostasis for retrofilling difficult if not impossible 22

Buccal shelf

skipped Pre surgical case assessment

■ Is there a better option for this patient? ■ Why propose Endodontic Micro Surgery? ■ What’s the Prognosis? ■ If RETX, what is the etiology of failure? ■ Has tooth been restored properly? ■ If not, Can it be? If not, why try to save it? ■ Is tooth periodontally sound? ■ Is tooth surgically accessible? ■ Is the tooth strategic and functional? ■ Will patient’s health allow surgery ■ Is patient on board with TX selection/limitations? ■ Are you competent & prepared ■ Would REFERRAL serve the patient’s BEST INTERESTS***

Surgical Technique

■ Anesthesia ■ Elevation of Flap ■ Location of apical lesion ■ Osteotomy & Curettage ■ Root bevel & hemostasis ■ Retrofill preparation and filling ■ Suturing and PO instructions

Anesthesia & Hemostasis ■ (4) ■ (anesthetic) IF not CI’d, infiltrated into papilla + regional block. (J Bahcall, DT Aug ’04 p72>) ■ --- also enhances profoundness of LA “DM/MCP”, Little, 4th ed, p 172 (we produce .007-.014mg epi/min in unstressed state-@what is in 1carp of LA,w 1/100K.) If one is stressed, epi can go to @---mg/min!!! ■ Epi for --- is a MUST! If epi is contra- indicated by patient’s MD, do not do surgery

Articaine vs Lido vs Carbo vs Marcaine PLUS Lido 2% w epi 1:50 Epi .3 Hemostasis

Apical Root Resection How much to resect- This area contains greatest # of (3) - S Kim “Principles of Endo Surgery” DCNA ’97;41:481-497 Create a -- bevel so the canal can be visualized & accessed. -- speed (1000-1500 rpm)– NOT ---. Use sterile saline drip to ..

3mm. deltas, isthmuses and iatrogenic blockages 45º Low air turbine cool during osteotomy & resection

Hemostasis and Identification ■ Control of --- is paramount! You must see what you are doing. ■ (5) for bleeders. ■ Crypt management

bleeding CaSulfate,, Hemodent, Astringodent, *Racemic Epinephrine, maybe Electrosurg Unit Telfa sponges w Hemodent

Root End preparation: How deep to retro fill? ■ Mattison, et al concluded that a minimum of --- *of amalgam significantly reduced apical leakage

3mm

For that matter, any retro filling material should be AT LEAST ---. into the canal space. This instrument design allows us to create --- of space to retain the material and provide an adequate seal. ■ Amalgam, SEBA, Geristore have been used for retrofill. --- is now the material of choice*

3mm 3-5 mm MTA

Apical Retroprep Removal of Gutta Percha with --- Establishment of parallel walled root end preparation at least --- mm deep.

Ultrasonic 3

These are apical micro-carriers (similar to an amalgam carrier) Used to

pick up and deliver the mixed MTA to the apical retroprep.

The MTA has been delivered to the apical retroprep and now, an instrument is used to ---- the MTA in the prep.

compact

Finishing up ■ Surgical area is Cleaned and Inspected and then --- ■ Patient should be --- evening of surgery to see “how well they are doing” ■ Post-op patient & suture removal prn (-- days)

Sutured called 5

POST-OP Instructions: ■ Use ■ If XS bleeding occurs, ■ Pain is usually 3/10. 3 ■ Soft diet for -- days ■ Do not smoke for -- days>surgery ■ Suture removal prn & POT check in -- days!

ice pack 20” on, 5”off for 1st day to reduce P&S, warm saline rinses qid 2nd day place a wet tea bag over incision 15” to stop bleeding IBU Q4H + narcotic RX if necessary. If XS pain occurs, call office 3-4 3 5

At UMKC-SOD

■ Opportunities poor for Endodontic Surgery in Undergraduate ■ Grad. Endo. does all EMS at UMKC ■ This presentation is designed to acquaint you with the surgical opportunities available as well as little about the technique. ■ Try to assist/observe in Grad. Endo. during Surgery ■ With additional training, general dentists may choose to do less complicated apical surgery in their practice.

Untoward Outcomes and Solutions Flashcards

(44 cards)