“Remember, God protects fools and drunks, and once I’ve been informed, I am no longer a fool.” - Bruce Voss, MD
Recently, I found the above quote in a technical scuba diving manual. In its wisdom, I am reminded of how endodontic iatrogenic events can be avoided.
Creating successful results has two components: accentuating winning strategies and avoiding those that are not only unproductive but also destructive (i.e., the creation of iatrogenic events).
It is easy to list a set of principles that, if employed correctly, can help one avoid iatrogenic events. But these can be successful only if one will heed the strategies in actual practice.
In many ways, preventing iatrogenic mistakes is a function of being informed and taking evasive action to prevent problems before they occur. Such preparation includes:
- Preoperatively visualizing potential iatrogenic events before they occur through a careful preoperative evaluation of the tooth
- Having correct visualization of the tooth during treatment (ideally a surgical operating microscope)
- Training with the given technique and clinical materials to be used
In my opinion, most paramount of these strategies is the first one - the ability to determine when and where iatrogenic events will happen before they occur. Much like a hitter in baseball should try to see the ball in order to make contact, such “seeing” involves a vision that is part instinct, part experience, and part intuition. Generally, these elements are blended together so one can see the issue before it occurs.
Hurried results are most likely unfavorable. While efficiencies can be created in endodontic treatment by proper placement of instruments and good coordination between the clinician and the assistant, a mentally focused clinician who has anticipated potential problems (i.e., “seen the ball and anticipates its flight”) can avoid the vast majority of iatrogenic problems by hitting the ball.
Mental anticipation of potential problems is a function of reviewing the tooth in a methodical manner that “covers all the bases.” The evaluation of the tooth preoperatively is comprehensive and ideally done the same way every time.
Evaluation of the tooth would include, among other things, evaluating the various risk factors for iatrogenic problems. This would include but would not be limited to: significant three-dimensional curvature, calcified canals, access and visualization difficulties, whether these challenges are from a patient with a limited opening, or access that must be made through a crown and in which the pulp chamber is obscured by the metal of the crown.
Knowledge of the materials and supplies being used can make a significant difference in prevention of iatrogenic events. For example, if it is the first time that a rotary nickel system is being used, it would be of obvious benefit to practice extensively in extracted teeth. This would allow one to learn what is required to fracture a file, or what rotational speed is most comfortable in the clinician’s hands. The worst possible scenario would be a clinician who utilizes materials and methods that have not been well-rehearsed and tested on the desktop before they are used in vivo.
One challenge in providing results is that the actual requirements often change as the case emerges. Anticipated risk factors may not materialize while others might. Mentally, a clinician must remain flexible and alert that the original plan might not be the best one executed. For example, if a clinician is using .06 tapered K3 RNT instruments (SybronEndo, Orange, Calif.), and they are not advancing in the manner desired, it is valuable to shift to a .04-tapered file as needed. Specifically, if a clinician is using a .06 25 K3, and it will not advance passively beyond a midroot curvature, it is valuable to use a .04 No. 15, 20, 25, 30 and 35 K3, then attempt to reuse the .06 25 K3. It is likely that, after gaining a minimal enlargement with the .04 files, the .06 K3 will fit into place nicely and without undue pressure.
Significant focus, evaluation of the tooth preoperatively, and flexibility in treatment methods and techniques can pay significant dividends in creating excellent results without risking iatrogenic events. Once informed, “I am no longer a fool.”
Dr. Richard Mounce lectures globally and is widely published. He is in private practice in endodontics in Portland, Ore. Among other appointments, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau, Korror, Palau (Micronesia). He can be reached at Lineker@aol.com.