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2. The advent of nickeltitanium files, rotary
instrumentation, “endosonics,”radiovisiography, the
endoscope, and the clinical microscope are but a
few innovations that have changed the way in which
endodontics is practiced.
This progress has increased both productivity and
quality of care.
Endodontic mishaps or procedural accidents are
those unfortunate occurrences that happen during
treatment, some owing to inattention to detail,
others totally unpredictable.
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3. Endodontic Mishaps
Access related
Treating the wrong tooth
Missed canals
Damage to existing restoration
Access cavity perforations
Crown fractures
Instrumentation related
Ledge formation
Cervical canal perforations
Midroot perforations
Apical perforations
Separated instruments and foreign objects
Canal www.indiandentalacademy.com
blockage
4. Obturation related
Over- or underextended root
canal fillings
Nerve paresthesia
Vertical root fractures
Miscellaneous
Post space perforation
Irrigant related
Tissue emphysema
Instrument aspiration and
ingestion
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5. How can mishaps be prevented?
It is true that experience can teach many
valuable lessons if one pays attention.
we learn from our own and others’ mistakes,
and that can be true of endodontic mishaps as
well.
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6. when a file separates in a canal, the floor
of the chamber is perforated while
searching for canal orifices,
or any of several other unfortunate
procedural accidents occur,
• Immediately inform the patient,
• Correct the mishap,and
• Re-evaluate the prognosis.
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7. ACCESS-RELATED MISHAPS
Treating the Wrong Tooth
•inattention
• misdiagnosis
Recognition that the wrong tooth has been treated
is
sometimes a result of re-evaluation of a patient
who
continues to have symptoms after treatment. Other
times, the error may be detected after the rubber
dam
has been removed.
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8. Correction includes appropriate treatment of both
teeth: the one incorrectly opened and the one
with the
original pulpal problem. It is not prudent to hide
such
an error from the patient. Mistakes happen in all
aspects of dental care. When a mistake does
happen,
the safest approach, even if embarrassing, is to
explain
to the patient what happened and how the
problem
may be corrected.
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9. Prevention.Mistakes in diagnosis can be
reduced by
• Attention to detail
• Arriving at a correct diagnosis
• obtain at least three good pieces of
evidence supporting the diagnosis.
1. For example, a radiograph showing a
tooth with an apical lesion may
suggest pulp necrosis.
2. a lack of response to electric pulp
testing.
3. A draining sinus tract leading to the
tooth apex should be proved
radiographically with a gutta-percha
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10. Once a correct diagnosis has been made, 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
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11. Missed Canals
Some root canals are not easily accessible or
readily
apparent from the chamber; additional canals
in the
mandibular molars are good examples of canals
mesial roots of maxillary molars and distal
often
roots of
left untreated.
Other canals are also missed because of a lack
of knowledge about root canal anatomy or failure
to adequately search for these additional canals.
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12. RADIOGRAPH OVER LOOKED CANAL
SECOND PATENT CANAL AFTER INSTUMENTATION
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13. Prevention. Locating all of the canals in a
multicanal
tooth is the best prevention of treatment failure.
•Adequate coronal access allows the opportunity to
find all canal orifices.
• Additionally, radiographs taken from mesial
and/or distal angles will help to determine if the
one canal that has been located is centered in
the root,recalling that an eccentrically located
canal is highly
suggestive of the presence of another canal.
• Knowledge of root canal morphology
and knowing which teeth have multiple canals
is a good foundation
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15. Recognition of a missed canal can occur during or
after treatment. During treatment, an instrument or
filling material may be noticed to be other than exactly
centered in the root, indicating that another canal is
present
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16. Endoscope and the surgical microscope may
be used to help detect extra canals.
The second mesiobuccal canal (arrow) is
readily www.indiandentalacademy.com
apparent under magnification.
17. Correction. Re-treatment is appropriate and
should be attempted before recommending surgical
correction .
Prognosis. A missed canal decreases the prognosis
and will most likely result in treatment failure. In
some
teeth with multicanal roots, two canals may have a
common apical exit. As long as the apical seal
adequately
seals both canals, it is possible that the bacterial
content in a missed canal may not affect the outcome
for some time.
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18. Damage to Existing Restoration
An existing porcelain crown presents the dentist
with
its own unique challenges. In preparing an
access cavity through a porcelain or porcelain-
bonded crown, the porcelain will sometimes chip,
even when the most careful approach using
water-cooled diamond stones is followed.
•Justman and Krell described a technique for
•removing provisionally cemented crowns that can
help prevent both crazing of the porcelain,
damage to
the margin, or aspiration of the crown by the
patient.
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19. Access Cavity Perforations
Undesirable communications between the
pulp space and the external tooth surface
may occur at any level: in the chamber or
along the length of the root canal. They
may occur during preparation of the access
cavity, root canal space, or post space.
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20. Recognition.
•If the access cavity perforation is above the
periodontal attachment, the first sign of the
presence of an accidental perforation will often be
the presence of leakage: either saliva into the
cavity or sodium hypochlorite out into the mouth, at
which time the patient will notice the unpleasant
taste.
•When the crown is perforated into the periodontal
ligament, bleeding into the access cavity is often
the
first indication of an accidental perforation.
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21. To confirm the suspicion of such an unwanted
opening, place a small file through the opening and
take a radiograph;
the film should clearly demonstrate that the file is
not
in a canal. In some instances, a perforation may
initially be thought to be a canal orifice; placing a file
into this opening will provide the necessary
information to identify this mishap
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22. Correction. Perforations of the coronal walls
above the alveolar crest can generally be repaired
intracoronally without need for surgical intervention
Supracrestal perforation repair. A, Note the
perforation (arrow) made in the mesial wall
during access preparation.
B, Repair was done with amalgam;
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23. Several materials have been recommended for
perforation repair:
1Cavit
2 amalgam,
3 calcium hydroxide
4 Super EBA,
5 glass ionomer cement,
6 gutta-percha,
7 tricalcium phosphate,
8 hemostatic agents such as Gelfoam.
9 calcium sulfate orhydroxyapatite
10 MTA.
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24. Prior to repair of a perforation,
•it is important to control bleeding, both to
evaluate the size and locations of the perforation
and to allow placement of the repair material.
• Calcium hydroxide placed in the area of
perforation
and left for at least a few days will leave the
area dry and allow inspection of perforation.
• Mineral trioxide aggregate, in contrast to all
other repair materials, may be placed in the
presence of blood since it requires moisture to
cure.www.indiandentalacademy.com
25. Prognosis for a perforated tooth must generally
be
downgraded. It is downgraded based on the
circumstances such as the perforation size and
the existing periodontal condition.
Furcation repair using mineral trioxide aggregate
(MTA). Eighteen months after
repair www.indiandentalacademy.com
26. Prevention. Thorough examination of diagnostic
preoperative radiographs is the paramount step
1 Checking the long axis of the tooth and aligning
the long axis of the access bur with the long axis of
the tooth can prevent unfortunate perforations of
a tipped tooth.
1. The presence, location, and degree of
calcification of the pulp chamber noted on the
preoperative radiograph are also important
information to use in planning the access
preparation.
3.Perforations can also often be associated with an
inadequate access preparation. Prevention of
procedural mishaps is best accomplished by
close attention to the principles of access cavity
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preparation
27. Crown Fractures
Crown fractures of teeth undergoing root canal
therapy are a complication that can be avoided
in many instances.
The tooth may have a preexistent infraction that
becomes a true fracture when the patient
chews on the tooth weakened additionally by
an access preparation.
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28. Recognition of such fractures is usually by direct
observation. It should be noted
Treatment. Crown fractures usually have to be
treated by extraction unless the fracture is of a
“chisel
type” in which only the cusp or part of the crown
is
involved; in such cases, the loose segment can
be
removed and treatment completed
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29. Prevention is simple:
•Reduce the occlusion before working length is
established. In addition to preventing this mishap,
•it also will aid in reducing discomfort following
endodontic therapy.
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31. INSTRUMENTATION-RELATED MISHAPS
Ledge Formation
•Ledges in canals can result from a failure to
make
access cavities that allow direct access to the
apical part
of the canals or from using straight or too-large
instruments in curved canals .
• The newer instruments with noncutting tips have
reduced this problem
•occasionally, even skilled and careful clinicians
develop canal ledges when treating teeth with
unsuspected aberrations in canal anatomy.
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33. One of the anatomic complexities in root
canal
therapy is the curved root, which is generally
evident on radiographs. However, roots that
curve toward or away from the central x-ray
beam, that is, toward the buccal or lingual,
are much more difficult to discover.
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34. Recognition. Ledge formation should be suspected
when the root canal instrument can no longer be
inserted into the canal to full working length. There
may be a loss of normal tactile sensation of the tip
of
the instrument binding in the lumen. This feeling is
supplanted by that of the instrument point hitting
against a solid wall:.
•When ledge formation is suspected, a radiograph
of
the tooth with the instrument in place will provide
additional information.
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35. 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. The curved tip should be
pointed toward the wall opposite the ledge. This is a
situation in which the “tear-shaped” silicone instrument
stops are valuable. The “tear” is pointed in the same
direction as the curve of the instrument.
• “watch-winding” motion often helps advance the
instrument.
Whenever resistance is met, the file is slightly
retracted, rotated, and advanced again until it
bypasses the ledge.
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36. Prevention. The best solution for ledge formation
is prevention. . Awareness of canal morphology is
imperative throughout the instrumentation
procedure.
Finally, precurving instruments and not “forcing”
them is a sure preventive measure.
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38. Perforations
Accidental canal perforations may be
categorized by location.
Radicular perforations can be identified as
either cervical, midroot, or apical root
perforations.
Cervical perforation Midroot
www.indiandentalacademy.com Apical
39. Perforations in all of these locations may be
caused
by two errors of commission:
(1) creating a ledge in the canal wall during
initial instrumentation and perforating through
the side of the root at the point of canal
obstruction or root curvature and
(2) using too large or too long an instrument and
either perforating directly through the apical foramen
or “wearing” a hole in the lateral surface of the root
by overinstrumentation (canal “stripping”).
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40. Cervical Canal Perforations
The cervical portion of the canal is most often perforated
during the process of locating and widening the
canal orifice or inappropriate use of Gates-Glidden burs
Recognition often begins with the sudden appearance
of blood, which comes from the periodontal ligament
space
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41. Correction of the perforation may include both
internal and external repair.
•A small area of perforation may be sealed from
inside the tooth.
•If the perforation is large, it may be necessary
to seal first from the inside and then surgically
expose the external aspect of the tooth and
repair the damaged tooth structure;
VISIBLE FURCATION
PERFORATION GIC
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42. Midroot Perforations
Lateral perforations at midroot level tend to 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.(“stripping”)
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43. Recognition. “Stripping” is a lateral perforation
caused by over instrumentation through a thin wall in
the root (distal wall of the mesial roots in mandibular
first molars )
•stripping is easily detected by the sudden
appearance of hemorrhage in a previously
dry canal or by a sudden complaint by the
patient. A paper point placed in the canal can
confirm the presence and location of the
perforation..
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44. Correction; Access to midroot perforation is most often
difficult,
and repair is not predictable.Calcium hydroxide has been
used in the hope of stimulating a biologic barrier against
which to pack filling material.
Anticurvature filing,(Abou Rass)
the importance of maintaining
Bulk zone
mesial pressure on the enlarging
instruments to avoid the delicate
“danger zone” of the distal wall
where the root is so thin
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45. Apical Perforations
Perforations in the apical segment of the root
canal
may be the result of the file not negotiating a
curved canal or not establishing accurate working
length and
instrumenting beyond the apical confines.
Perforation of a curved root is the result of
“ledging,”“apical transportation,” or “apical
zipping.”
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46. “Transportation” as “removal of canal wall
structure on the outside curve in the apical half of
the canal due to the tendency of files to restore
themselves to their original linear shape during
canal preparation.”
“Apical zip” is also defined as “an elliptical shape
that may be formed in the apical foramen during
preparation of a curved canal when a file extends
through the apical foramen and subsequently
transports that outer wall.
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47. Recognition. An apical perforation should be
suspected
if the patient suddenly complains of pain during
treatment, if the canal becomes flooded with
hemorrhage, or if the tactile resistance of the
confines of the canal space is lost. If any of these
occur, it is important to confirm one’s suspicions
radiographically and attempt to correct them before
further damage is done.
A paper point inserted to the apex will confirm a
suspected apical perforation.
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48. Correction. Dealing with two foramina: one natural,
the other iatral. Obturation of both of these foramina
and of the main body of the canal requires the
vertical compacting techniques with heat-softened
gutta-percha. Often surgery is necessary.
APICAL
PERFORATION
A
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49. Separated Instruments and Foreign Objects
Many objects have been reported to break or
separate
and subsequently become lodged in root canals.
• Glass beads from sterilizers, burs, Gates-Glidden
drills, amalgam, lentulo paste fillers, files and
reamers, and tips of dental instruments have all
found their way into canals, complicating treatment.
•patient-placed foreign objects in addition to the
above, nails, pencil lead, toothpicks, tomato seeds,
hat pins, needles, pins, and other metal objects .
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50. REASONS FOR SEPARATION OF INSTRUMENTS IN CANAL
•Usually, the instrument is advanced into the
canal until it binds, and efforts to remove it then
lead to breakage,
•Other common errors leading to this mishap are
using a “stressed” instrument
• To negotiate curved canals, and forcing a file
down a canal before the canal has been opened
sufficiently with the previous, smaller file and
then using it in a reaming motion. The result is
fracturing of the instrument.
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52. 1. If the instrument fragment is totally within
the root canal system, one may attempt to
bypass it with a small file or reamer.
Bypassing is made easier with a lubricant
. The instrument segment thus becomes part of
the filling material. t
2.If the fragment cannot be bypassed, one can
prepare
and fill the canal to the level to which
instrumentation
can be accomplished.
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53. 3. If the fragment extends past the apex and efforts
to
remove it nonsurgically are unsuccessful, the
corrective
treatment will probably include apical surgery.
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54. Coranal flare c-
Broken instrument
rotary instrument
in mid root
I –engaged c-
-H-file&K-file
Anti clock wise After
twisting-I-lifted
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55. Steiglitz forceps Beaks of Steiglitz forceps
Rotary instruments such as Gates-Glidden
drills, if
stressed, will break close to the shank, leaving
a piece that can be grasped and easily
retrieved with The Stieglitz forceps
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56. Ultrasonic fine instruments have proven most
effective in loosening and “flushing out” broken
fragments
Ultrasonic unit Ultrasonic file holder c-15 file
Ultra www.indiandentalacademy.com from 15-35
sonic tips Ultrasonic files
57. Loupes with light attachment Microscope
microscopy and special fine
diamond tips a tunnel can be
created around the separated
instrument,which can then be
vibrated and dislodged
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58. MASSERANN KIT
1. It has end cutting trepan
burs&Extractor.
2. trepan burs provide
access for extractor
3. extractor into which
object to be retrieved is
locked.
4. sacrifice radicular
dentin.
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59. Cancellier kit
•When fractured file is loose but not free
Cancellier kit is used.
•Extractors are aset of hallow tubes
which fit into a handle-assembly
resembles a hallow plugger
•A drop of cyanoacrylate glue is placed
into hallow end of extractor adheres when
fitted over the file
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60. Cancellier tubes and cyanoacrylate
Ultradent tubes
Cancellier tube in position
Cancellier tube fitted topping out with artey forceps
over instrument
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62. Post removal kits Miniature post puller
Ruddle kit
Thomas kit
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63. Prevention of separation mishaps
•stressed” instrument is the one most likely to
separate
in a canal. the flutes, which may appear “unwound.”.
• Small instruments, such as Nos. 08, 10, 15, and 20,
should be examined carefully during use to check for
signs of stress. Instruments No. 08 and 10 should be
used only
once.
•Sequential instrumentation, using the “quarter-turn”
technique,
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64. OBTURATION-RELATED MISHAPS
Over- or Underextended Root Canal Fillings
Root canal filling material is sometimes
inadvertently extruded beyond the apical limit of
the root canal system,
ending up in the periradicular bone, sinus, or
mandibular canal or even protruding through the
cortical plate.
Gross overextensions can lead to symptoms
and treatment failure.
A frequent cause of this mishap is apical
perforation with loss of apical constriction
against which gutta-percha is compacted
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65. Underextension of root canal filling material may
be
caused by failure to fit the master gutta-percha
point
accurately. It can also result from a poorly
prepared
canal, particularly in the apical part of the canal.
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66. N2 SARGENTI CONTROVERSY
Rowe stated that, in teeth with apices approximating the
inferior alveolar canal, “the most frequent cause of damage
is excess filling material which has passed through the
apices and either caused pressure on the neurovascular
bundle in the inferior
dental canal or produced a neurotoxic effect on the
nerve trunk”
USE OF PASTE TYPE OF FILLING
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67. Correction of an underextended filling is
accomplished
by re-treatment: removal of the old filling followed by proper
preparation and obturation of the canal.
Correction of an overextended filling is more
difficult. sometimes successful if the entire point
can be
removed with one tug. Many times, however, the
point will break off, leaving a fragment loose in the
periradicular tissue.
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68. If the overextended filling cannot be removed
through the canal, it will be necessary to
•remove the excess surgically if symptoms or
radicular lesions develop or increase in size.
•Root canal filling material such as gutta-percha
and many sealers are generally well tolerated by
the surrounding tissues, and overextended
fillings do not automatically require surgical
removal if asymptomatic and not associated with
lesions. Prevention. attention to detail is the best
form of prevention. Accurate working lengths and
care to maintain them will help prevent
overextensions
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69. Vertical Root Fractures
Vertical root fractures can occur during different
phases of treatment: instrumentation,
obturation, and post placement.
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70. Recognition is often unmistakable. The sudden
crunching sound, similar to that referred to as
crepitus
in the diseased temporomandibular joint,
accompanied
with pain reaction on the part of the patient, is a
clear indicator that the root has fractured.
•A suggestive “teardrop” radiolucency may appear in
the radiograph of a long-standing vertical root
fracture.
•.
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71. •.exploratory surgery is a good way to visualize
the fracture, but finding a deep periodontal
pocket
of recent origin in a tooth with a long-present
root
canal filling is most suggestive of a vertical
fracture
Correction. Unfortunately in most cases of
vertical
fracture, extraction is the only treatment
available at
this time.
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72. Irrigant-Related Mishaps
An unfortunate sequence of events is triggered after
the solution is injected into the root canal system
and forced into the periradicular tissues. With
alcohol or sodium hypochlorite, an immediate
inflammatory response followed by tissue
destruction ensues
Hypochloride accident
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73. Recognition
The initial response stage may be characterized
by swelling, pain, interstitial hemorrhage, and
ecchymosis.
Treatment– prescribe antibiotics in addition to
analgesics for pain.
Antihistamines can also be helpful. Ice packs
applied initially to the area, followed by warm
saline soaks ,use of intramuscular steroids,
and, in
more severe cases, hospitalization and
surgical intervention with wound débridement,
may be necessary.
Monitoring the patient’s response is essential
until the initial phase of the reaction subsides
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74. Tissue Emphysema
Subcutaneous or periradicular air emphysema
is, fortunately,relatively uncommon.
Tissue space emphysema has been defined
as the passage and collection of gas in tissue
spaces or fascial planes.
It has been reported as an untoward event
subsequent to various dental procedures, such
as an amalgam restoration,periodontal
treatment, endodontic treatment, and
exodontia.
The common etiologic factor is compressed
air being forced into the tissue spaces
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75. Correction. Treatment recommendations vary
from palliative care and observation to immediate
medical attention if the airway or mediastinum is
compromised.
•Broad-spectrum antibiotic coverage is indicated
in all cases to prevent the risk of secondary infection.
•majority of reported cases have followed a
benign course followed by total recovery.
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76. Instrument Aspiration and Ingestion
•Aspiration or ingestion of a foreign object
is a complication that can occur during any
dental procedure.
•Endodontic instruments, used in the absence
of a rubber dam, can easily be aspirated or
swallowed if inadvertently dropped in the
mouth.
The common denominator in
all is failure to use a rubber dam.
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77. Recognition . If an instrument aspiration or ingestion
is apparent, the patient must be taken immediately
to a
medical emergency facility for examination, which
should include radiographs of the chest and
abdomen.
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78. Routine placement of floss around the
rubber dam retainer will allow retrieval in the
event that the patient aspirates it.
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79. Thank you for watching
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