Preventing iatrogenic events

It’s hard not to smile listening to “It’s A Beautiful Day” by U2.

It’s hard not to smile listening to “It’s A Beautiful Day” by U2. A beautiful day at the office can turn sour very quickly in the midst of an iatrogenic endodontic event. While, traditionally, iatrogenic events might be thought of as perforations, separated files, ledges, dentin mud blockages, etc, a broader view might include a dissatisfied patient, a procedure that took too long (either in the patient’s mind, the clinician’s mind, or both), or one that was performed with less than ideal anesthesia. What factors, then, can make the difference between the dental sunshine - the beautiful day we seek - and the less-than-ideal result? What can we as clinicians do to avoid these issues?

1) Lack of time, more than any other single factor, leads to untoward clinical results.Ideally, the clinician should build into the procedure a fee and efficiency of service that makes not only the procedure profitable but delivers the optimal service to the patient. Said differently, procedures accomplished where speed alone is used to generate profitability short changes the patient in that most often the only way to do things “faster” is not better nor are the biologic objectives of root canal treatment in such a setting often performed correctly (if at all), diminishing success and creating a loss of trust between the patient and clinician. For example, not irrigating effectively with enough irrigation can lead to debris left within the tooth and predispose to failure especially in the presence of coronal microleakage.

It is axiomatic that the tooth must be restored properly after endodontic treatment to provide coronal seal to protect the root canal. Even with the presence of bonded obturation materials such as Resilon and RealSeal (Pentron, Wallingford, Conn., and SybronEndo, Orange, Calif., respectively), it is essential to seal teeth in a timely fashion, ideally at the time of the procedure.

When we are time stressed, a mistake and lapse in judgment are often soon to follow. Resist the temptation, and give yourself the time needed to create excellence. As an aside, if you are not the best person to achieve an excellent result, consider referral to someone who can do so. This creates trust and provides the time needed to achieve the greatest level of excellence possible.

2) Lack of preoperative preparation (with regard to evaluating the patient, the tooth, and the procedure contemplated) and a lack of familiarity with the equipment and supplies to be used take the clinician further from the desired results.If, for example, the clinician is using the new Elements Obturation Unit and perhaps SystemB obturation technique simultaneously for the first time, what is the clinician’s level of familiarity with the given technique and equipment? While both the technique and the equipment are functional and easy to use, is the clinician first proficient with extracted teeth?

In additon it is essential to be familiar with the patient’s medical and dental history. Then, develop the appropriate treatment plan, contemplate how the proposed endodontics fits into the treatment plan and specifically how the given treatment will be carried out, and what iatrogenic risks factors are present. Ideally, the clinician should mentally rehearse the procedure first to take evasive action to avoid these potential iatrogenic issues.

3) Lack of anesthesia makes even the best technique irrelevant. Simply put, a patient who lacks adequate anesthesia is never comfortable and wants the procedure over, no matter how good the intentions of the doctor are. Achieving adequate anesthesia prior to beginning and testing anesthesia before starting are essential to creating comfort for the patient and clinician.

4) Lack of adequate postoperative treatment- planning can lead to disappointment. Has the patient agreed to place a crown or permanent restoration after endodontic treatment? Is the tooth restorable or can it be made restorable? An unsealed tooth after endodontics risks tooth loss due to microleakage and vertical fracture. Addressing the needed post-operative restorative treatment with the patient before the root canal will go far in building a platform for successful treatment.

Create the beautiful day that Bono and U2 describe for yourself in the office. Make the time to evaluate the patient, tooth, and procedure thoroughly before you begin. Have a plan for what comes after the procedure. It will pay handsome dividends.

Enjoy the sunshine!

Dr. Richard Mounce is in private endodontic practice in Portland, Ore. Dr. Mounce is the author of a comprehensive DVD on cleansing, shaping, and packing the root canal system for the general practitioner. The material is also available as audio CDs and as a Web cast pay-per-view. He lectures worldwide and is a widely published author. For more information, contact Dr. Mounce via email at Visit his Web site at

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