You may use the following case summary to come up with a problem statement; create timelines of actual and ideal sequence of events; identify the several contributing factors; ask the '5-whys' questions; and device strategies for prevention of such adverse events.

Case summary:

Adverse Event Category: Hard tissue damage
Severity grade: G2

A fifty-three year old male patient presents to UDC clinic with pain in tooth #19. The tooth is determined to be in need of a root canal treatment. During the same session, a pulpotomy was performed and canals accessed. CaOH was placed in the canals.

Approximately one month later, the patient returns and has the root canal completed. After the root canal treatment, an abscess is developed in the vestibule next to tooth #19. Patient is then prescribed antibiotics (Clindamycin 300 mg).

When it is established that the vestibular swelling is not going to subside, it is decided to do a root canal re-treatment.

Two month after initial root canal treatment, the tooth is re-treated. During root canal re-treatment, it is established that the tooth has been perforated and as the perforation is large, it is extracted due to poor prognosis.