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Endodontic mishaps - Dr. Jagadeesh kodityala

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procedural errors in endodontics

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Endodontic mishaps - Dr. Jagadeesh kodityala

  1. 1. Endodontic Mishaps Dr. Jagadeesh. K P.G 3rd year
  2. 2. CONTENTS • INTRODUCTION • CLASSIFICATION OF ENDODONTIC MISHAPS • ACCESS RELATED MISHAPS. • INSTRUMENTATION RELATED MISHAPS. • OBTURATION RELATED MISHAPS. • MISCELLANEOUS ACCIDENTS. • DETECTION, CORRECTION AND PREVENTION. • CONCLUSION
  3. 3. Definition Endodontic mishaps or procedural accidents are those unfortunate occurrences that happen during treatment, some owing to inattention to detail, others totally unpredictable. - Torabinajed-1990
  4. 4. • Recognize • Correct • Re evaluate the prognosis
  5. 5. Recognition • First step in the management. • Clinical observation. • Radiographic observation. • Patients complaint
  6. 6. • Correction: Depending on type and extent of the procedural accident. • Re-evaluation: Effects of the entire treatment plan. Involve Dento-legal consequences.
  7. 7. • Incident and nature of mishap. • Procedures to correct it. • Alternative treatment options. • Prognosis of the affected tooth. Inform the patient
  8. 8. ENDODONTIC MISHAPS Access related Instrumentation Related Obturation related Miscellaneous 1. Treating wrong tooth 2. Missed canals 3. Damage to existing restoration 4. Access cavity perforations 5. Crown fractures 1. Ledge formation 2. Cervical canal perforations 3. Midroot perforations 4. Apical perforations 5. Separated instruments and foreign objects 6. Canal blockage 1. Over- or underextended root canal fillings 2. Nerve paresthesia 3. Vertical root fractures 1. Post space perforation 2. Irrigant related 3. Tissue emphysema 4. Instrument aspiration and ingestion
  9. 9. Access related accidents
  10. 10. Treating a wrong tooth REASONS : • Misdiagnosis • Isolating the wrong tooth RECOGNITION: • Realizing the mistake after rubber dam removal. • Persistence of symptoms.
  11. 11. PREVENTION: • Mistakes in diagnosis can be avoided by, obtaining at least three good pieces of evidence supporting the diagnosis for example, # Radiograph showing a tooth with an apical lesion. # Lack of response to electric pulp testing. # Draining sinus tract leading to the tooth apex proved radiographically with a GP point inserted in the tract.
  12. 12. CORRECTION: • Includes appropriate treatment of both teeth one incorrectly opened and the one with the original pulpal problem. • When a mistake does happen, the safest approach, is to explain to the patient what happened and how the problem can be corrected. • The embarrassing situation of opening the wrong tooth can be prevented by marking the tooth to be treated with a pen before isolating it with a rubber dam.
  13. 13. Missed canal ETIOLOGY: – Lack of thorough knowledge of root canal anatomy along with its variations. – Inadequate access cavity preparation. RECOGNITION : – During treatment, an instrument or filling material may be noticed to be other than exactly centered in the root, indicating the presence of another canal.
  14. 14. • Well angulated periapical film taken with cone directed straight on, mesioblique and distoblique reveals 3-D morphology of the tooth. • In addition to standard radiographs, digital radiography • Computerized digital radiography - hidden calcified, or untreated canals. • Magnifying loupes, Microscope
  15. 15. • Accurate access cavity preparation • Use of ultrasonics • Use of dye such as methylene blue • Use of sodium hypochlorite- “champagne bubble” test. Prevention • Good radiographs taken at different horizontal angulations. • Good illumination and magnification. • Adequate access cavity preparation. • Clinician should always look for additional canals in every tooth being treated.
  16. 16. Munce discovery Burs Mueller bur LN bur
  17. 17. Dyes Methylene Blue dye, ophthalmic dyes such as fluorscein sodium and rose bengal
  18. 18. Explorer pressure White line test: In necrotic teeth, dentinal dust moves into orifices, fins and isthmus when performing Ultra sonic procedure without water. This dust can form white dot/ line that provides a visible road map.
  19. 19. Red Line test: • In vital teeth, blood emanates from orifices, fin and isthmus area and serves to map and visually aid in identifying anatomy below the pulpal floor Perio probing: • Circumferentially probing the sulcus around the tooth is an important strategy for locating canal. • Gives information as to emergence profile of clinical crown and orientational alignment of underlying root
  20. 20. Not all MB2 orifices lead to a true canal, a true MB2 orifice Was present in only 84% of molars in which a second orifice Was identified Magnification has been found to increase the detection rate of MB2 canals from 17.2% with the naked eye, to 62.5% with loupes and 71.1% using the surgical operating microscope
  21. 21. Mandibular premolar- 3 canals 1-1: 70% 1-2-2 : 24% 2-2 : 1.5% 1-2-1-1 : 4% 3-3 : 0.5%
  22. 22. Maxillary molar with 2 DB canals
  23. 23. Maxillary molar with 3 MB canals
  24. 24. Maxillary molar with 4 MB canals
  25. 25. Radix entomolaris
  26. 26. Fast break guideline A “fast break” is a term used to describe a situation where a root canal disappears on a radiograph as you move apically. This happens when the main canal splits into multiple smaller canals that are not discernible on a radiograph. CBCT axial views are indispensable determining the number and location of these canals
  27. 27. Damage to existing restoration • An existing porcelain crown presents the dentist with its own unique challenge. • PREVENTION: – Clamp adjacent tooth – Remove all temporary crowns. • To remove existing permanently cemented crown before treatment.
  28. 28. The Metalift Crown and Bridge Removal System removes inlays, three-quarter crowns, full crowns, and fixed bridges without destroying them, thus allowing them to be reused. CORRECTION: Minor porcelain chips can be repaired by bonding composite resin to the crown.
  29. 29. • Crown Dissembly Devices: a. Grasping instruments b. Percussive instruments c. Active instruments
  30. 30. Conservative Semi conservative Destructive 1. Richwill crown and bridge remover 2. Ultrasonics 3. Pneumatic (KaVo) CORONA flex 4. Sliding hammer 5. Crown tractors 6. Matrix bands. 1. Wamkey 2. Metalift crown and bridge removal system 3. Higa bridge remover 1. Tungsten carbide burs 2. Burs and Christenson crown remover
  31. 31. Ultrasonics: Indirectly helps in breaking cement seal A CT4 tip (Sybron endo) can be used to remove cement lute from around the margins of a poorly fitting crown The KaVo CORONAFLEX pneumatic crown and bridge remover:
  32. 32. The WamKeys
  33. 33. Access cavity perforations RECOGNITION: Access cavity perforation: • Above pdl attachment: Presence of leakage • Into the pdl space: Presence of bleeding CONFIRMATION: • Place a small file through the opening and take a radiograph.
  34. 34. Materials recommended for perforation repair: 1. Cavit, 2. Amalgam, 3. Calcium hydroxide paste, 4. Super EBA, 5.. Glass ionomer cement, 7. Tricalcium phosphate, 8. MTA 9. Biodentin
  35. 35. PROGNOSIS: • Sinai proposed that the prognosis depends on: – Location of perforation – Length of the time the perforation is open to contamination – The ability to seal the perforation – Accessibility to the main canal
  36. 36. • Thorough examination of diagnostic preoperative radiographs • Checking the long axis of the tooth and aligning the long axis of the access bur with the long axis of the tooth • The presence, location, and degree of calcification of the pulp chamber noted on the preoperative radiograph • A close attention to the principles of access cavity preparation: adequate size, and correct location, both permitting direct access to the root canals. Prevention
  37. 37. Crown fractures Recognition: • Usually by direct observation. • Infractions are often recognized first after removal of existing restoration in preparation of the access. Treatment: • If the fracture is more extensive, the tooth may not be restorable and needs to be extracted. • Crowns with infractions should be supported with circumferential bands
  38. 38. Prognosis: • Is likely to be less favorable than for an intact tooth, and the outcome is unpredictable. • Crown infractions may lead to vertical root fractures. Prevention: • is simple. i.e. reduce the occlusion • -Bands and temporary crowns are also valuable.
  39. 39. Instrumentation related mishaps
  40. 40. 1.LEDGE FORMATION: ‘’A ledge is an artificially created irregularity on the surface of the root canal wall that prevents the placement of instruments to the apex of an otherwise patent canal” It is a deviation from the original canal curvature without communication with the periodontal ligament, resulting in a procedural error termed ledge formation or ledging.
  41. 41. Etiology: (1) Not extending the access cavity sufficiently to allow adequate access to the apical part of the root canal (2) Complete loss of control of the instrument if the endodontic treatment is attempted via a proximal surface cavity or through a proximal restoration (3) Incorrect assessment of the root canal direction (4) Erroneous root canal length determination (5) Forcing and driving the instrument into the canal
  42. 42. (6) Using a noncurved stainless steel instrument that is too large for a curved canal (7) Failing to use the instruments in sequential order . (8) Rotating the file at the working length (that is, overuse of a reaming action) (9) Inadequate irrigation and/or lubrication during instrumentation (10) Over-relying on chelating agents
  43. 43. 11) Attempting to retrieve broken instruments (12) Removing root filling materials during endodontic retreatment (13) Attempting to prepare calcified root canals (14) Inadvertently packing debris in the apical portion of the canal during instrumentation (that is, creating an apical blockage) Jafarzadeh and Abbott, J Endod 2007
  44. 44. Recognition: • Root canal instrument can no longer be inserted into the canal to full working length. • loss of normal tactile sensation of the tip of the instrument binding in the lumen. • Radiographically, if the instrument point appears to be directed away from the lumen of the canal
  45. 45. Correction: • The use of a small file, No. 10 or 15, with a distinct curve at the tip can be used to explore the canal to the apex. • Tear-drop shaped silicone instrument stopper and watch- winding motion are valuable. • Use a lubricant, irrigate frequently to remove dentin chips, maintain a curve on the file tip, and, using short file strokes, press the instrument against the canal wall where the ledge is located.
  46. 46. • Accurate interpretation of diagnostic radiographs should be completed before the first instrument is placed in the canal. • Finally, precurving instruments and not “forcing” them is a sure preventive measure. • Using instruments with noncutting tips and nickel-titanium files • Patency of the canal should be maintained throughout the cleaning and shaping procedure. • Work sequentially increasing sizes of instruments without jumping to large numbers Prevention:
  47. 47. Zipping and Elbow formation • Zipping is the transportation of the apical portion of the canal. Etiology: commonly seen in curved canals • Failure to precurve the files • Forcing the instrument in curved canal • Use of large stiff instrument to bore out the canal Prevention: Precurve the initial small sized instruments Use incremental filing technique Use flexible files Never rotate the instruments in curved canal
  48. 48. • When a file is rotated in the curved canal at the apical area, a biomechanical defect results in the form of elbow. • In this case, the apical foramen will tend to become a tear drop shape or elliptical & be transported from the curve of the canal. • The wide apical portion of the elliptical portion is known as the zip while the narrow coronal portion is the elbow. • Elbow prevents optimal compaction in the apical portion and obturation ends at the elbow.
  49. 49. Zipping Elbow
  50. 50. Perforations • An artificial opening in a tooth or its root, created by boring, piercing , cutting or pathologic resorption, which results in a communication between the pulp space and the periodontal tissues. • Perforation is defined as the mechanical and or pathological communication between the root canal system and the external tooth surface. -AAE
  51. 51. Etiology: Caries - Resorptive defects - Mechanical or Iatrogenic events- like inserting larger size stainless steel straight file in a curved canal Root canal perforation: Cervical canal, Midroot, Apical perforations.
  52. 52. Classification of root perforations, proposed by Fuss & Trope • Fresh perforation– treated immediately or shortly after occurrence under aseptic conditions, Good Prognosis. • Old perforation– previously not treated with likely bacterial infection, Questionable Prognosis.
  53. 53. • Small perforation (smaller than #20 endodontic instrument) – mechanical damage to tissue is minimal with easy sealing opportunity, Good Prognosis. • Large perforation– done during post preparation, with significant tissue damage and obvious difficulty in providing an adequate seal, salivary contamination, or coronal leakage along temporary restoration, Questionable Prognosis.
  54. 54. • Coronal perforation– coronal to the level of crestal bone and epithelial attachment with minimal damage to the supporting tissues and easy access, Good Prognosis. • Crestal perforation– at the level of the epithelial attachment into the crestal bone, Questionable Prognosis. • Apical perforation– apical to the crestal bone and the epithelial attachment, Good Prognosis. - Endodontic Topics 2006
  55. 55. Cervical canal perforations • Process of locating and widening the canal orifice or inappropriate use of Gates-Glidden burs. Recognition: • often begins with the sudden appearance of blood. • Rinsing and blot drying allows direct visualization • Magnification with either loupes, an endoscope, or a microscope is very useful • It may be necessary to place a small file and take a radiograph of the tooth • Electronic apex locators
  56. 56. Correction: :of the perforation may include both internal and external repair. Prevention: • may be achieved by reviewing each tooth’s morphology prior to entering its pulp space Prognosis: must be considered to be reduced in these types of perforations
  57. 57. Midroot perforations • Occur mostly in curved canals, either as a result of perforating when a ledge has formed during initial instrumentation or along the inside curvature of the root as the canal is straightened out. Recognition: • “Stripping” is a lateral perforation caused by over instrumentation through a thin wall in the root and is most likely to happen on the inside, or concave, wall of a curved canal, such as the distal wall of the mesial roots in mandibular first molars
  58. 58. • Stripping is easily detected by the sudden appearance of hemorrhage in a previously dry canal or by a sudden complaint by the patient. Correction: Access to midroot perforation is most often difficult, and repair is not predictable. • Repair of strip perforations has been attempted both nonsurgically and surgically. Prognosis: Both “stripping” perforation and direct lateral perforation of the root result in a reduction of the prognosis Loss of tooth structure and integrity of the root wall can lead to subsequent fractures or microleakage
  59. 59. Apical perforations • Result of the file not negotiating a curved canal or not establishing accurate working length and instrumenting beyond the apical confines. Recognition: • The patient suddenly complains of pain during treatment, • The canal becomes flooded with hemorrhage, • The tactile resistance of the confines of the canal space is lost
  60. 60. Correction: • Overinstrumentation Re-establish the tooth length short of the original length and then enlarge the canal, with larger instruments, to that length. • Create artificial apical barrier Prognosis: • With successful repair, apical perforations have less adverse effect on prognosis than more coronal perforations.
  61. 61. Separated instruments • Most commonly files and reamers are involved in these types of procedural mishaps. Common errors leading to this mishap are: - using a “stressed” instrument, - Inadequate lubrication - placing exaggerated bends on instruments, and - forcing a file down a canal before the canal has been opened sufficiently with the previous, smaller file
  62. 62. Sotokawa’s classification of instrument damage. Type I- Bent instrument. Type II- Stretching or straightening of twist contour. Type III- Peeling-off metal at blade edges. Type IV- Partial clockwise twist. Type V-Cracking along axis. Type VI- Full fracture.
  63. 63. Correction: Four approaches: 1. Attempt to remove the instrument fragments . 2. Attempt to bypass it with a small file or reamer. 3. if instrument does not extend beyond the apex, prepare and obturate till the segment (true blockage) 4. If the fragment extends past the apex, the corrective treatment will probably include apical surgery.
  64. 64. • Essential prerequisites for instrument separation management include – Dental operating microscope – Illumination – Ultrasonics Instrument Fractured Coronally: • Can be bypassed, a small file is 1st introduced alongside it. • Use of Stieglitz plier or small haemostat (mosquito forceps) if the tip grasp can be obtained. • Endosonics is used to loosen the instrument within the root canal then fine ultrasonic tips such as CPR 4& CPR 5 are placed on the lateral surface of fractured instrument.
  65. 65. Instrument Fractured Below Orifice Level: Access is modified using a non end cutting tungsten carbide bur such as Endo Z or LA access bur. Ruddle’s method of instrument removal:
  66. 66. • 25 guage dental injection needle is taken • 0.14mm steel ligature wire • Needle is cut at the bevel end and opposite end of wire is passed Tube & Headstroem file method (spinal tap needle): • By Suter • Space is created around the object. • A tube is then located over it & two are locked together by gently screwing a H-file down the center of the tube. Modified needle technique (lasso & anchor)
  67. 67. Extractor system: Roydent • System consists of only bur and 3 extraction devices. • Bur is very conservative and removes minimal amount of dentin. • The extractor surrounds the obstruction with small prongs that can be tightened onto the object enabling removal.
  68. 68. Brasseler Endo extractor kit: • Includes 4 sizes of trephine burs and extractors • Cyanoacrylate adhesive is used to bond hollow tube to the exposed end of the file. • Snugness between the tube and obstruction plays a key role; minimal 2mm overlap is required. • Time required for adhesive to set 5min snug fit & 10min for loose fit – Trephine burs are larger – Burs cut very aggressively when new and dull out rapidly.
  69. 69. Cancellier Kit: Consists of a series of graded hollow tubes that are held in a long handle. • Cyanoacrylate cement (Superglue) is used to bond the point & tube together before removal. • Adhesive requires a setting time of 5min for maximum bonding.
  70. 70. Endo Eze System: A cheaper alternative to the Cancellier kit is Endo-Eze tips. These come in different gauges and can be used in a similar manner. The tip of the needle is very malleable and can easily be bent so that the magnified view into the root canal is not obscured.
  71. 71. Mounce extractor: • Hand held instruments which can be used with dental operating microscope. • Similar to ball burnisher where slots are cut into the ball end. • Cyanoacrylate is used to bond the extractor & file for its removal. • Can mostly be used in coronal aspect of the canal.
  72. 72. The Meitrac System: Consists of Trephines, Extractors designed to remove intraradicular obstructions of different diameters. Meitrac I – remove instruments with diameter 0.15 -0.5mm Meitrac II – retrieval of silver points of diameter 0.5-0.9mm
  73. 73. Instrument Retrieval System ( IRS) 2 different sizes of hollow microtubes with 45˚bevel and a lateral/sidecut out window at the tip and screw wedges.
  74. 74. Masserann Kit • The kit consists of a series of trephining drills and 2 sizes of tubular extractors (1.2 & 1.5mm) • Create a space in the root canal around the coronal 2mm of the metallic object • Extractor tube passes over it. • Extractor plunger is screwed down locking the object against a knurled ring in the tube wall.
  75. 75. Braiding
  76. 76. Studies by Yoshitsugu on separated file removal concluded • Separated files > 4.5 mm in any canals, or those in curved canals > 60°, were extremely difficult to retrieve with ultrasonics alone; it took longer than 9 minutes to remove them, • Separated files shorter than 4.5 mm long were easy to retrieve with ultrasonics alone and the removal time was within the range of 5 minutes. • If ultrasonic removal time exceeds 5 minutes, different technique should be used to retreive it such as loop device.
  77. 77. Prognosis: • May not change very much if the instrument can be bypassed. • If surgical correction is needed, the prognosis may be reduced. Prevention: • Careful handling of instruments. • Discard stressed instruments • Instruments No. 08 and 10 should be used only once. • Sequential instrumentation, using the “quarter-turn” technique • Increasing file size only after the current working file fits loosely into the canal without binding
  78. 78. Canal Blockage • Blockage occurs when files compact apical debris into a hardened mass during enlargement. • Fibrous blockage occurs when vital pulp tissue is compacted and solidified against the apical constriction. Recognition: • when the confirmed working length is no longer attained. Correction: Recapitulation • Starting with the smallest file in the quarter-turn technique using a chelating agent. • If block out occurs at the curve, Precurve the instrument and redirect it.
  79. 79. Prognosis: • Depends on the stage of instrumentation completed when the block out occurs. • Teeth with vital pulps better prognosis than those with necrotic pulps. Prevention: frequent irrigation during canal preparation and use of lubricant
  80. 80. Loss of Working Length • It is actually secondary to the other procedural errors like ledges, canal transportation and fractured instruments. • In most instances, loss of working length can be attributed to rapid increase in the file size, overreliance on chelating agent & the accumulation of dentinal debris in the apical third of the canal. • Usually seen in curved canals due to straightening out of canal during cleaning and shaping procedure.
  81. 81. Obturation Related Mishaps
  82. 82. 1. OVER- OR -UNDEREXTENDED ROOT CANAL FILLINGS: Cause: Apical perforation with loss of apical constriction against which gutta-percha is compacted. • Failure to fit the master gutta-percha point accurately due to poorly prepared canal in the apical third. Recognition: By a post-treatment radiograph
  83. 83. Correction : • Of underextended filling is accomplished by re-treatment. • Of an overextended filling , if attempted to remove, the point will break off leaving a fragment loose in the periradicular tissue. • It may cause foreign body gaint cell reaction which may support formation of biofilms.
  84. 84. • if asymptomatic and not associated with lesions- do not require surgical removal • If symptomatic- surgical removal of the excess material Prognosis: depends on presence or absence of periradicular lesion and the content of the root canal segment that remains unfilled (necrotic and infected)
  85. 85. Prevention: • Accurate working lengths and care to maintain them will help prevent overextensions. • Confirmation and adherence to canal working length throughout the instrumentation procedure • Radiograph during the initial phases of the obturation to allow for corrective action
  86. 86. Nerve paresthesia • Overextensions and/or overinstrumentations are the causative factors most often found in paresthesia secondary to orthograde endodontic therapy. • The nerve damage may be transient or permanent. Correction: • Through nonintervention and observation • The most important process the dentist can practice is prevention.
  87. 87. Vertical root fractures • Instrumentation, obturation and post placement. • In both lateral and vertical condensation techniques, the risk of fracture is high if too much force is exerted during compaction. Recognition: • The sudden crunching sound, is a clear indicator that the root has fractured. • “Teardrop” radiolucency • A deep periodontal pocket of recent origin in a tooth with a long-present root canal filling
  88. 88. Confirmation: • Periodontal probing, • Transillumination test, • Dyes, • Bite test • Exploratory surgery is a good way to visualize the fracture Correction: Extraction Prevention: involves avoidance of overpreparing canals and the use of a passive, less forceful obturation technique and seating of post.
  89. 89. Miscellaneous 1.POST SPACE PERFORATION: Recognition: similar to instrumentation related lateral root perforations; sudden presence of blood in the canal or radiographic evidence. Prognosis is least affected if the perforation is totally within bone. • If it is closer to the gingival sulcus, the risk of periodontal pocket formation is high. Prevention is associated with a good knowledge of root canal anatomy and planning the post space preparation based on radiographic information regarding the location & direction of root.
  90. 90. Irrigant-related mishaps • An unfortunate sequence of events is triggered after the irrigating solutions are injected forcibly into the periradicular tissues. • Becker et al. described the damaging effects of an accidental injection of sodium hypochlorite beyond the apex. • Bhat reported the same effects with hydrogen peroxide. Injection of hydrogen peroxide causes tissue emphysema.
  91. 91. Recognition: • Patient may immediately complain of severe pain, and swelling can be violent and alarming. • Depends on type of solution used, the concentration, and amount of exposure. • The initial response stage may be characterized by swelling, pain, interstitial hemorrhage, and ecchymosis.
  92. 92. Correction: • It is advisable to prescribe antibiotics in addition to analgesics for pain. • Ice packs applied initially to the area, followed by warm saline soaks. • The use of intramuscular steroids, and, in more severe cases, hospitalization and surgical intervention with wound debridement, may be necessary.
  93. 93. J Clin Exp Dent. 2012;4(3):e194-8
  94. 94. Prevention of inadvertent extrusion of irrigants past the apex can be attained by using passive placement of a modified needle. The needle must not be wedged into the canal, and the solution should be delivered slowly and without pressure. Prognosis: • Favorable, but immediate treatment, proper management, and close observation are important. • Long term effetcs: paresthesia, scarring, and muscle weakness.
  95. 95. Tissue emphysema • Tissue space emphysema has been defined as the passage and collection of gas in tissue spaces or fascial planes. • Common etiologic factor is compressed air being forced into the tissue spaces. Two procedures in endodontics: • During canal preparation, a blast of air to dry the canal, and • During apical surgery, air from a high-speed drill can lead to air emphysema.
  96. 96. Recognition: Rapid swelling, erythema, and crepitus. • Tissue space emphysema remains in the subcutaneous connective tissue and usually does not spread to the deep anatomic spaces. • Migration of air into the neck region could cause respiratory difficulty, and progression into the mediastinum could cause death.
  97. 97. Diagnostic signs of mediastinal emphysema: -Sudden swelling of the neck. -Difficulty breathing and voice will sound brassy. -Characteristic crackling can be induced when the swollen regions are palpated. Correction: • From palliative care and observation to immediate medical attention if the airway or mediastinum is compromised
  98. 98. Preventive: measures: -using paper points to dry root canals. -If the air syringe is to be used, Jerome suggested horizontal positioning over the access opening, using the “Venturi effect” to aid in drying the canal. - In surgical procedures, apical access can be made with the slow- speed or high-speed handpieces that do not direct jets of air into surgery sites.
  99. 99. Instrument aspiration and ingestion • Endodontic instruments used in the absence of a rubber dam, can easily be aspirated or swallowed if inadvertently dropped in the mouth. Recognition: suspician • The patient must be taken immediately to a medical emergency facility for examination. (Radiographs of the chest and abdomen). Prevention: can best be accomplished by strict adherence to the use of a rubber dam during all phases of endodontic therapy. • Aspiration of a loosened clamp can be avoided by attaching floss to the clamp before placement
  100. 100. A successful operator learns from the past experiences and applies them to future challenges ultimately the beneficiary will be the patient, who will receive the best care Conclusion
  101. 101. References • Ingle’s Endodontics - 5th edition • Advanced Endodontics –John S Rhodes • Advanced Endodontics- Nageswar Rao • Endodontics – Problems Solving In Clinical Practice – Pitt Ford, Js Rhodes • Textbook of Endodontics- Nisha garg • Diagnosis and treatment of accidental root perforations, Endodontic Topics 2006 • Ledge Formation: Review of a Great Challenge in Endodontics. J Endod 2007 • Identifying root canals, Endodontic Strategies by Clifford ruddle
  102. 102. • Complications following an accidental sodium hypochlorite extrusion: A report of two cases. J Clin Exp Dent. 2012;4(3):e194-8. • Separated file removal: Yoshitsugu 2012 Dentistry today.

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