Incidents and accidents during endodontic treatments
Introduction : Endodontics in daily practice is a discipline subject to many “pitfalls”.
The endodontic act is never simple, the straight canal is rare and even if … the difficulty can exist! From diagnosis to obturation, error is possible.
This is why we will consider all the accidents that may occur during the operation, analyze them in order to avoid them and, above all, manage them if the practitioner is confronted with such complications.
Terminology
Accident: A fortuitous and unfortunate event. A mishap, an unforeseen event which temporarily disrupts the normal course of an action or operation,
Sudden event that can cause more or less serious damage
Incidents: An event of a secondary nature, generally unfortunate but not excessively important, which occurs during an action and can disrupt its normal course.
The operating times of a root canal treatment: The endodontic procedure is now considered a surgical procedure in its own right. The notion of a surgical procedure justifies an indisputable operative rigor, both from a technical and biological point of view.
From diagnosis to obturation, there is a succession of closely linked stages and an operating error at any stage of the treatment compromises, sometimes irreversibly, the therapeutic result.
Incidents and accidents during endodontic treatments
In order to successfully carry out root canal treatment, it is necessary to “validate” each stage of the operation
Preoperative X-ray
Anesthesia
The operating field
Dentin curettage
Endodontic access cavity
Canal catheterization
Extirpation of the pulp parenchyma
Drying and hemostasis
Intraoperative radiography
Root canal shaping under abundant irrigation
Root canal filling
Postoperative X-ray
Incident occurring while taking an X-ray
The gag reflex
The manifestation of nausea in odontostomatology constitutes a problem frequently encountered by the practitioner.
Practical attitude towards a gag reflex
A number of techniques to reduce the gag reflex will be described.
Namely; distraction of the patient’s attention; we will continue with relaxation techniques including hypnosis and sophrology, then pharmacological relaxation treatments.
Accidents occurring at the time of tooth numbness
Dentistry makes extensive use of local or locoregional anesthesia. Although accidents are rare, their often sudden onset can sometimes be life-threatening.
Needle fracture This is a rare complication that occurs when the patient makes a sudden movement or due to a technical error.
What to do
In the case of a retro-tuberous injection: if the needle is visible or easily accessible after X-ray control, it must be removed using dissecting forceps, avoiding inopportune palpation. If an incision is made, it will not be continued.
If the scalpel does not encounter a needle immediately, significant debridement may cause backflow, causing needle migration.
Incidents and accidents during endodontic treatments
If the needle is inserted deep into soft tissue. It is necessary to:
Prevent the patient
Monitor immediate developments
Have a precise X-ray localization performed
Send it to a specialized service and the surgeon will be given the material used, as well as a needle identical to the one that was fractured, to allow him to make a macroscopic estimate of the object to be found.
Rupture of the anesthetic cartridge
A fairly rare incident occurring unexpectedly, where we can essentially mention a technical error and more exceptionally a material defect.
The explosion of the cartridge accompanied by the projection of fragments into the oral cavity, poses an immediate risk of injury by cutting, as well as a danger of swallowing or inhalation, these complications are very frequent in agitated and uncooperative subjects.
What to do
Once the surprise effect has passed and the patient has been reassured, and he will have been asked to keep his mouth open, the pieces will be collected directly with forceps. The practitioner will check by reconstituting the cartridge whether all the pieces of glass are present, which will have the effect of reassuring the patient and allowing the procedure to continue.
Painful injection
The injection is painful when the liquid is cold or when it is done quickly.
There is also a particular pain and resistance to anesthesia when the tissues are inflamed, or when they encounter nerve endings at specific points.
It is a shooting pain accompanied by a start from the patient.
How to prevent it. Never inject a cold anesthetic solution, preferably use a system for warming the anesthetic cartridges.
As soon as the penetration of the mucosa is made, a few drops of anesthetic are injected slowly, in a few seconds, the insertion of the needle can be continued painlessly until contact with the periosteum
Hemorrhagic accidents
Two scenarios may arise: in a subject with a normal hemostasis assessment, if a hematoma appears at the injection site, its resorption is rapid.
On the other hand, when the hematological assessment is disturbed, regional or local anesthesia in loose tissues (floor of the mouth) should be avoided. Significant hematomas may occur, causing compression (particularly of the respiratory tract) or infection.
Stress-related accidents.
Incidents and accidents during endodontic treatments
Vagal malaise. This is the most frequently induced pathological manifestation during local anesthesia. Benign in nature, vagal malaise is most often due to the aggression represented by pain on injection and the “fear of the needle”. Linked to a failure of neurovegetative reactions, it is often encountered in vagotonic subjects who are predisposed to it.
It is characterized by bradycardia associated with low blood pressure and a weakening of consciousness due to reduced perfusion of the brain, deprived of its fundamental energy substrates. The subject is pale, has profuse sweating and sometimes complains of nausea and tinnitus. Beyond this degree of discomfort, there is vagal syncope which is a brief loss of consciousness, spontaneously reversible, which lasts from a few seconds to a few minutes.
Symptomatic treatment consists of placing the patient in the supine position with the legs raised.
If the discomfort persists (slow pulse and low blood pressure), an IV injection of 1 mg of atropine should be given in adults. If it worsens, an emergency medical team should be called, and any respiratory and cardiocirculatory failure should be treated before their arrival.
Hypoglycemic discomfort
Any aggression can disrupt the balance of blood sugar, and that induced by local anesthesia can promote the occurrence of a hypoglycemic accident, especially in a diabetic (feeling of discomfort, convulsive-type neurological disorders, loss of consciousness, etc.)
Allergic accidents
a. Minor accidents
They are represented by a feeling of malaise with hot flashes, a localized skin rash on the neck, face, upper chest, and tachycardia associated with slight hypotension. At this stage, any respiratory discomfort (dry or asthmatic cough) should alert the practitioner. The patient is then placed in the supine position and clinical monitoring should be established.
b. Major accidents
Giant urticaria, Quincke’s edema, increasing respiratory discomfort (laryngeal dyspnea), and a fortiori signs of respiratory obstruction (cyanosis, bronchospasm) require immediate medical assistance.
Accidents occurring during the creation of the endodontic access cavity
The access cavity is a critical step in successfully completing root canal treatment. Access must be thoughtful and dynamic; root canal negotiation is only possible if there is minimal or no coronal interference during canal instrumentation.
The 4-wall access cavity rule is still relevant because it makes the intervention easier.
Perforations;
Whether vestibular, lingual, mesial or distal, this accident is caused by poor preparation of the access cavity due to an error in judging the axis of the tooth, originating from a lack of knowledge of the morphology of the teeth or their inclinations.
The lateral perforation should be surgically exposed and sealed as a class V cavity, they are usually well repaired and have little influence on the diagnosis as long as hygiene can be maintained at the cervical level
Internal perforations of the pulp floor
Symptomatology
At the time the perforation is performed, the patient perceives
ligament sensitivity that is not so intense
and which looks like a puncture made on the gum with the tip
of a needle.
This perforation is followed by profuse bleeding.
This sign alone is often enough to make the diagnosis,
We will nevertheless confirm this by performing an X-ray.
with a file in place
It is recommended to prepare and obturate the canals before obturating the perforation, which helps to disinfect the perforation by the hypochlorite that floods the access cavity during canal shaping.
The canals are shaped under abundant irrigation
sodium hypochlorite, then sealed with gutta percha,
taking care to avoid the sealing cement rocket
in the perforation.
Incidents and accidents during endodontic treatments
Accidents occurring during catheterization
Cervical stop
The stop in the cervical region of the canal occurs as a result of interference of the instrument with the parietal surface located either at the level of the endodontic access cavity or at the canal entrance.
The etiological factors are insufficient access and direct visibility at the entrance and at the cervical third of the canal.
Cervical blockade can give rise to:
loss of working length,
difficulty in renegotiating the canal route.
It is possible to find the canal path,
beyond the stop, if the coronal segment is
properly straightened and, therefore, if any effect
sheath is completely removed.
False channel
A false canal is an artificial route from the pulp chamber or canal to the periodontal ligament.
Etiologies
– Presence of an obstacle to overcome.
Improper use of instruments.
The patient feels a ligamentous sensitivity, which is not so intense and feels like a needle prick. This perforation is followed by profuse bleeding, confirmed by taking an X-ray with an instrument in place.
The creation of a false canal brings the obligation to treat and seal it but the result remains random. In principle, the methods are the same as for the treatment of canals.
Accidents occurring during canal preparation
Dentin plugs
This is an incident that can become serious if it causes the definitive loss of the canal. The settlement of organic products, occurring during treatment, is due to inexperience, excessive precipitation, or by passing an instrument that is too large after a fine instrument.
According to Laurichesse, the prevention of the formation of dentin plugs follows five rules:
a/ Abundant and renewed irrigation
b/ Use of instruments in ascending order without ever skipping a number
c/ Summary by the last instrument freely reaching the apical limit after using each file number
d/ Absence of rotational movements of the instruments in the canal, the action of which is limited to one eighth of a turn
e/ Flexible use of instruments, without ever forcing.
The removal of a dentin plug is carried out as follows:
Straight channels
Rinse the canal thoroughly with hypochlorite, wait 2 to 3 minutes.
Insert a very thin (08), but rigid (MMC) and pre-bent instrument, until contact and make it act as in the case of difficult canals: contact, 1/8 turn while pushing, withdrawal in 1/8 turn reverse and return to contact. The bent end of the instrument will be presented in different directions until a sensation of “engagement” of the tip is obtained.
Curved and bent channels
The files must have a curvature or bend absolutely identical to that of the canal.
These files must be presented in the canal with their bend imperatively in the same plane as the plane of the canal bend.
When the onset of progression is felt, an X-ray should be taken immediately and further control images should follow as progression continues.
Shoulders or projections
Shoulders of the apical third
Their origin may be similar to that of the middle third, and in this case the solutions will be identical. However, most often these shoulders are created by the use in rotation of files of too large caliber not pre-bent in curved channels. Prevention is ensured by respecting the basic principles, namely:
Use of instruments in ascending order, without ever skipping numbers
Abundant irrigation between each instrumental passage
Careful recap
Pre-sewing of all instruments
Limiting rotational movements to 1/8 of a turn
limitation to number 25 of apical preparation instruments in case of severe bend
accentuation of the engagement grooves to eliminate all occlusal interferences.
Shoulder attenuation is achieved by using MME from 0.8 to 15/100, operated in back-and-forth movements, under abundant irrigation.
Root perforations
The means of prevention and recovery of the canal are always identical, except that it is exceptional to find a canal after a perforation.
Healing of a periodontal injury caused by perforation is possible if the following four criteria are met:
Recent and accidental appearance of the perforation
Absence of communication of the perforation with the oral environment, that is to say, total absence of septic inoculation of the desmodont
Smallness of the perforation which makes it present analogies with the accessory canals
The location of the lesions is important; for Seltzer, a perforation located “in the middle” or at the level of the coronal third of the root presents a “good” prognosis.
Incidents and accidents during endodontic treatments
Instrumental overruns
The causes of instrumental overshoot (prick by an instrument) can be multiple:
– Error or incorrect determination of the working length.
– Forced instrumental introduction.
– Unnoticed displacement of the stops.
– Presence of anatomical conditions favoring overshoot.
Management
– Stop the bleeding with a hemostatic solution.
– Administer an analgesic.
– Reestablish the LT.
– Prescribe anti-inflammatories and analgesics.
On preparation
It results in the weakening or tearing (stripping) of a wall, of the root.
It is the result of improper use of Gates drills and poor prior appreciation of root anatomy.
Gates drills should only be used to improve the axis of insertion of instruments.
Instrumental fractures
Fatigue from repeated sterilization cycle.
Exerting excessive force on the instrument .
Inadequate access cavity.
Poor technique of the practitioner.
Preparation without irrigation.
Patient fatigue and uncooperation.
Complicated canal morphology
Instrumental fractures
Pins and files:
* Preventive treatment: These are the finest instruments that are likely to fracture. This problem can be avoided by gently penetrating the canals under abundant irrigation, never forcing an instrument if it encounters an obstacle, never turning an instrument in the canal more than one-eighth of a turn.
* Curative treatment: The fracture is generally that of the tip, ultrasound will overcome this problem
Lentulo Pasta Jam: The Lentulo fracture mainly originates from technical errors that are easy to avoid:
– Lentulo not previously tested
– Never use a rotating lentulo
– Never force it beyond a bend.
Curative treatment usually consists of inserting another thinner lentulo along the fractured dough wad, the coils of one winding around the coils of the other, and proceeding to remove the whole thing carefully. If the instrument is stuck beyond a bend, try to disengage it with ultrasound .
Hemorrhages
The causes of intraoperative hemorrhage can be limited to 3:
Tear-off of pulp tissue
Repeated crossing of apical limits by instruments
Perforations and false routes
Preventing these accidents is simple, for Laurichesse 4 criteria must be respected:
Early establishment of precise apical limits thanks to electronic measurements confirmed by radiography
Respect for the working length determined by all instruments
Irrigation with sodium hypochlorite.
Incidents and accidents during endodontic treatments
Accidents occurring during canal irrigation
Continuous and controlled irrigation throughout the canal shaping is essential for the disinfection of the endocanal system, but also for the prevention of accidents along the way.
Failure to comply with the rules for using irrigants can lead to complications, particularly the painful injection of sodium hypochlorite into the periapical tissues; this results in:
Sudden, severe pain with a burning sensation
Gradual swelling and severe edema
Heavy bleeding from the canal
Immediate formation of a hematoma and bruising on the skin
What to do in the event of accidental injection
Relieve pain immediately by administering a local anesthetic to the affected area.
Reassure the patient and inform him of the cause and the seriousness of the complications
Reduce edema by applying cold compresses at 15-minute intervals for the first 24 hours followed by application of hot compresses.
Prescribe analgesics to relieve pain, prophylactic antibiotics for superinfection and anti-inflammatory drugs to control the inflammatory reaction.
Schedule follow-up appointments at regular intervals to monitor the patient’s recovery and complete endodontic treatment once acute symptoms have resolved.
Swallowing and inhaling an instrument
Any practitioner may be confronted with this type of accident despite the precautions taken during their intervention. A sudden movement, an unexpected reaction from the patient, a moment of fatigue or a decrease in attention following a series of difficult interventions, may be the cause of this type of accident. The patient’s lying position, the humidity of saliva and the use of high-speed turbines also increase the risks.
a. If swallowed
The practitioner must first ensure that the patient is ventilated, then check the patient’s oral cavity, calmly explain the situation and inform him of the possible risks and symptoms.
The patient should then be referred to a specialist who will perform an X-ray to locate the foreign body. Monitoring of stools is recommended with an immediate diet rich in fiber (asparagus, leeks, possibly cotton wool, etc.).
b. In case of inhalation
It all depends on the clinical situation: the practitioner may be confronted with 3 situations
In the absence of breathing difficulties: The patient will be taken to a specialized facility to locate the foreign body and allow its extraction. The practitioner must ensure that the situation does not worsen and act quickly. He must also inform his patient of the symptoms and reassure him.
In the event of incomplete respiratory obstruction: The practitioner will ensure rapid transfer of the patient to a specialized setting (hospital or clinic) to perform an endoscopy.
In the event of complete respiratory obstruction: The practitioner is faced with a critical situation whose vital prognosis requires emergency measures until the SAMU arrives.
Accidents occurring during root canal filling
Accidents during obturation are often due to insufficient mastery of the technique , provided, of course, that the shaping is satisfactory; it is then appropriate for the practitioner to question himself. Technique cannot come to the aid of know-how. Apical surgery or endodontic surgery is sometimes the only recourse to the accident, its mastery is also a necessity
Overflow of the obturator material beyond the apical foramen
The excess of the ZOE paste and gutta cone constitutes a foreign body and a permanent irritating thorn for the apical connective tissue. An apical granuloma sets in with its inflammatory procession. If the excess paste is not eliminated by fistula, endodontic surgery will be performed which will establish an apical curettage with or without apicectomy.
Incidents and accidents during endodontic treatments
Accidents during endodontic treatment in children
1. Special feature of the temporary tooth
Even though their lifespan is limited, they are essential to the child’s development; both to help with the establishment of permanent teeth and for the acquisition of oral functions, namely chewing, speaking and swallowing.
The temporary tooth has a life span determined in time, its evolution is subject to the phenomena of resorption and its purpose is to be replaced by a permanent tooth.
2. Accidents during endodontic treatment
All accidents encountered during the endodontic treatment of the permanent tooth, can be encountered during the endodontic treatment of the temporary tooth which are always due to non-compliance with the technical rules.
An important point concerns anxiety or even phobia of the dentist which can increase the child’s non- cooperation and therefore increase incidents and accidents.
It should be noted, however, that any overflow of the root canal filling material will have harmful consequences on the germ of the permanent tooth which sits below. For this reason, the apical limit must be set at 2 mm from the level of resorption and resorbable materials such as calcium hydroxide or MTA must be favored.
Conclusion : Endodontic treatment is never easy. It requires the practitioner to be “on point”, the patient to be confident and the technique to be reliable in order to ensure the body has the best chance of achieving healing.
Endodontic practice is a mix of successes and failures. To be rewarding, it must involve an analysis of the factors that led to the outcome.
The constant improvement of our technology based on fundamental biological principles, should make it possible to limit failures and complications and to push back the limits of endodontics. In the event of complications, the practitioner must be able to manage and repair these situations as best as possible.