just made my first iatrogenic traumatic pulp exposure :( care to cheer me up?

Discussion in 'Dental' started by deeyala, Nov 24, 2005.

  1. deeyala

    deeyala Member
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    it just happened today,i feel awful.. she was a 60 yrs old patient with a class 2 cavity (lower 1st molar).. problem is, it's entirely my mistake because i failed to notice her teeth had a great amount of attrition on the occlusal surface and that dentin was literally showing on the 'supposedly cusp tips'. the occlusal table was FLAT and i was going to fill the cavity with amalgam and just went on cutting to the "standard depth"...... and BINGO.!.. pinpoint exposure :(
    and what is with the "standard depth".............!!???? and what about the patient who came for a simple procedure and is now going to have to make mutiplte visits for 'direct pulp capping' and most probably is going to wind up doing endo,,,
    it's my last year and only now did i start doing accidental exposures..
    i feel like a complete failure and i am nver going to be a good dentist:(
    thanks everyone for hearing me rant..
     
  2. ItsGavinC

    Dentist Moderator Emeritus 15+ Year Member

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    Don't stress it, it's going to happen.

    We don't use much amalgam in our clinic, but we still have quite a few pulp exposures simply due to chasing the caries. Direct pulp capping might be successful (there's an excellent thread in the recent issue of DentalTown magazine about this!), but our standard route is typically pulpotomy followed by RCT. Typically our patients might pay for the pulpotomy ($65), and then that fee goes towards the RCT. If we caused the exposure (ie, we weren't cleaning out decay), then all services to restore that tooth would be free.

    The article in DentalTown talks about tremendous success with a specific pulp cap method involving cleaning the tooth down with bleach, etc.

    But in any event, exposures happen. Granted you weren't chasing caries, but certainly this provides a good learning exercise and you'll always be aware of the where the pulp chambers are.
     
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  3. grmaster1

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    That's not the spirit to have--you're not not perfect!

    Just put some dycal, vitrebond, complete an IRM restoration, and refer to an endodontist--it happens to the best of us...

    Happy Turkey day!
     
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  4. JavadiCavity

    JavadiCavity DDS 2008
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    See it for what it is...an accident. Just make sure you learn from it.
     
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  5. aphistis

    Moderator Emeritus 10+ Year Member

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    You jump straight to full endo? My understanding is that a direct cap or Cvek is the best initial treatment, and RCT is only indicated if it fails.
     
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  6. simpledoc

    simpledoc Senior Member
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    dont worry! dental school is where you do mistakes and learn! you better finish up all the mistakes in school than in your private practice ;)
    anyways what surprises me is that with so much attrition of the teeth (and also considering the patient's age) am wondering why the pulp hadn't recessed? anyways, i have found that it is always better to inform the patient about the evil "pulp exposure syndrome" any time a bur is touched on a tooth (either for a crown prep or for a cavity prep)
    good luck and dont worry too much! ;)
     
  7. tx oms

    tx oms Welcome to Thunderdome
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    If you're going to use amalgam the prep has to be deep enough to resist the compressive forces. What is it suppose to be, about 1.5mm? I can't really remember. Anyway, I wouldn't feel too bad. Did the lady have occlusal decay or does your school force you to create an occlusal extension on every class II box?
     
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  8. toofache32

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    See if you can botch the endo....then you can get oral surgery credit as well. Milk that tooth for all it's worth baby!
     
  9. dentalman

    dentalman Senior Member
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    Pinpoint (Less than 1.5mm or something like that) exposures made iatrogenically (not a carious pulp exposure) may be just fine. Place some dycal, and wait and see. It is better to learn how to handle this in dental school, because no matter how good you are, it will happen again.
     
  10. deeyala

    deeyala Member
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    thanks everyone for saying it "does happen', you quite impeoved my mood :) but still it doesn't make me feel less guilty..
    my school doesn't require i do the pulp capping myself (i could refer it to another) but i feel i should. after all, it's my fault


    it had occlusal decay, too.. but ahem,err, quite superficial... the esposure was occlusal, AND i forgot to mention i made the exposure while removing a temporary filling...!!!!
    ie i have no excuse whatsoever :(

    i feel far too guilty to be able to handle another one

    it might have recessed, but on the X ray (post-exposure) the pulp dentin ratio was quite huge with very apparent pulp horns (i cut through the mesial one).. could such a case be unusual (and thus makes me feel a bit better about myself?)
     
  11. toofache32

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    Just don't extract the wrong tooth like I did in dental school. Ironically, I still went into oral surgery.
     
  12. deeyala

    deeyala Member
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    :D :D :D thanks, toofache32.. you made my day
     
  13. sjdent

    sjdent Senior Member
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    Oh well. We all screw up.....like me on my first build up Jr. year, when I ran the slow speed right into a 70 yr old lady's pulp. Niiice. Did I mention that a freshman was assisting me at the time, and I was trying to be all cocky and confident, explaining what I was doing? Hee hee. I marched the lady right over to endo 5 min. later. she didn't care......it's all about how you phrase it. A wise instructor told me what to say in situations when you even *slightly* think it *may* be a pulp exposure, carious or just removing say, an old amalgam.....make yourself the hero. Ex..."Mr. Jones, the decay is so deep on this tooth blah blah, that I'm going to TRY to stay away from the pulp, but sometimes we just can't avoid it if the decay goes there." I say it all the time, and patients totally understand.

    I agree....you're going to do it again! We all have those moments. What have I done? Hmm...in 2 yrs, I've given a patient a hematoma, perfed a mand molar endo, and gave my patient temporary trismus. Sigh.

    Does that make you feel better?! :laugh: :laugh: :laugh:
     
  14. toofache32

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    I was being dead serious, by the way!
     
  15. iwillkamvariyou

    iwillkamvariyou Junior Member

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    Hey dude man, don't worry about it.

    I pulped out while prepping a tooth that had a cast post core in it...

    However, if you pulp out again - I WILL COME TO YOUR HOUSE AND KAMVARI YOU.
     
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  16. Yah-E

    Yah-E Toof Sniper
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    I extracted a wrong tooth and I had a iatrogenic pulper, I must be the winner of them all! My pulpal exposure case, she was only 21, I was prepping for a OL recurrent caries under a large existing deep amalgam on #31. Removed the existing amalgam without event, it was chasing the caries that I pulped it. The pt was already warned about the possibility of pulpal involvement so I was covered. Well, after exposure, the faculty suggested we pulp cap it with Fuji glass ionomer to see if the tooth responds and heals. A week post, the pt was in extreme pain and came back in the clinic with palpable submandibular swelling. We took a posterior PA radiograph, sure enough, the pulp capped tooth had a periapical radiolucency.

    Since it was a 2nd molar, I had to refer the pt to PG Endo because Predoc can only do 1st molar endos. Pt had the endo done and sent home with analgesics and antibiotics. Post-op follow up calls showed pt healing well, resolving swelling, and without pain.

    My wrong tooth extraction case:

    Happened in my 3rd year, 2nd semester on OMFS rotation. Pt is a mid 40s AA woman who had treatment planned for both upper and lower RPD. At that appointment, the pt was scheduled for extraction of #17 and #16 (3rd molars). I did the consent forms and the paper work all while I was looking at the Panorex. The pan showed #18 and #17 only teeth left in the LL quadrant. Both #17 & #18 had furca involvement, but #17 more than #18. In my head, I knew I was going to extract two teeth at that appointment and then I concentrated on the pan for #17 & #18 so much that I end up extracting both of those teeth.

    #18 was treatment planned as an abutment for the lower RPD.

    Extractions were without complications and I was closing practicing suturing. A faculty member came in as I was suturing:

    Faculty: Hey Andy, what's up?
    Me: Things are going great, I'm just closing.
    Faculty looked at my work for a second and then exited the operatory
    Faculty entered the operatory a minute later
    Faculty: Andy, why don't you close up and clean up the patient and come see me.
    Me: sure!
    I finished suturing and stepped out to see that faculty
    Faculty: Tell me where is #16 and #17?
    Me: (confused as to what he's refering to) What do you mean?
    Faculty: (again said) Tell me where is #16 & #17?
    Me: #16 is the maxillary.....

    As soon as I said the word "maxillary" from what I was going to say "maxillary 3rd molar", my world and time had stopped and it was right there and then I realized that I didn't extract any maxillary tooth at all and I extracted a wrong tooth on this patient! I remembered that hall way got longer and the ceiling got taller, everything was quiet and I started to sweat! The faculty and a resident asked to see the panorex and informed me to informed the patient of my mistake.

    To make matter worse, I had to go back in and anesthetize the patient again in upper left quadrant to extract #16 that the patient had came in for that appointment. I explained to the pt what had happened and how sorry I was, luckily for me, this particular patient was extremely warm and empathetic. I was very lucky. We offered the patient a free implant and crown, but the pt wanted RPDs and didn't want to wait for osseointegration time of 8 weeks.

    So there's my wrong tooth extraction story. Since then, I've extracted hundreds of teeth and never again extracting the wrong tooth. I carelessly knew that I had two teeth the extract and looked at the pan and stared at #17 & #18 because they were the only teeth left in that quadrant with poor periodontium, I extracted a wrong tooth.

    The wrong tooth incident and my recent pulpal exposure due to caries are the only "bad" events happened to me in dental school. (knocking on wood)

    Any one else brave enough to share their blemishs?
     
  17. deeyala

    deeyala Member
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    ok, i fractured the palatal root of an upper ist molar and couldn't get it out because i couldn't see it.. had to inform the patient of it and warn him of the possibility of infection..

    and i dismissed a patient whose mobile tooth i just extracted.. the socket smelled AWFUL, yet i didn't know it was a sign of infection so i dismissed him without antibiotics prescription..

    then comes the iatrogenic exposure..

    and they ALL happened this year in a ONE month interval....!
    now you can all see why i started having doubts about ever becoming a good dentist..
     
  18. 12YearOldKid

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    we all screw up in dental school. The fact that you worry and beat yourself up about mistakes means that you care enough to become a good dentist. The people who are NOT going to be good dentists are the ones who think they never make mistakes. If something turns out less than ideal for these people it's always a professor's fault, or the patient's, or the assistant's --- anything other than admitting "I screwed up." Those people never really get any better because in their minds they've already achieved perfection.

    Know anybody like that at your school? Those people scare the crap out of me.
     
  19. toofache32

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    That's it! I know that EXACT feeling!

    And the worst part of my day was definately going back in and getting out the correct tooth.
     

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