Gary Glassman, DDS, FRCD(C), Chief Dental Officer, dentalcorp
Several years ago, I read an article published in a popular magazine by a patient who was denouncing the endodontist who had just treated them. After a quick computer search of my patients’ files, I was relieved when it was apparent that this was not my patient. However, I reread the article several times hoping to sympathize with their complaints and empathize with the endodontist in question.
The patient who had nonlocalized pain visited an endodontist's office on a Friday morning before a long weekend. There was no doubt they needed a root canal. It was not clear, however, which tooth needed the treatment.
The patient had two choices. Tolerate the pain until it is localized or treat the tooth that was the most probable cause. In pain and desperate to go a much-anticipated weekend camping trip and not having any other options of dental intervention, they chose to proceed with root canal treatment. A few days later, they returned to the endodontist because the pain persisted. The endodontist now advised that the tooth next to the one treated also needed root canal treatment.
This scenario is not unfamiliar to those of us who treat patients in pain. The reality is that in most cases, we make accurate diagnoses, we consult with our patients in an informative and caring manner, advising them of all their treatment options.
Recognizing the more common malpractice pitfalls and ensuring that you have taken due diligence to avoid them is a necessity when performing endodontic treatment (or any surgical technique for that matter).
In the case of an uncertain diagnosis, it is always better to err on the side of caution. Even if the patient is demanding something be done. Stand your ground and let them know that with time, a proper diagnosis can be made. You could also offer to be available in case of emergency or prescribe analgesics to try and help manage the pain. Most importantly, be firm in your convictions and let them know that the last thing you want to do is treat a tooth that may not be the source of the pain. Ask the patient to consider how they would feel if we ended up treating the wrong tooth? Or how they would feel if we removed the vital tissue from a healthy tooth?
Diagnosis is not always enough. Even if all tests are properly performed and the proper radiographs are taken, make sure you document your findings to avoid a malpractice action.
If you review the discipline or misconduct hearings section of your regulatory college’s publication, you will find that those who are sanctioned have not kept proper records. If your records are incomplete, imprecise, inaccurate, or deficient, it is quite possible that the regulator or judge’s impression will be that the treatment you provided was no more thorough than the records.
Let's now assume that the diagnosis was correct, the tooth was endodontically treated and the documentation was flawless. But the patient returns two years later with pain and a lesion of endodontic origin around the apices, blaming you and requesting a refund for what they perceive as an incompetent job.
After checking the root canal treatment, you notice no issue. All seventeen canals were well obturated to within an acceptable distance from the apices, the tooth was restored with a precision fit crown, and you have the x-rays or scans to prove it. Do you give the patient back the money spent and wish them well? Do you offer to send them to another endodontist and pay for further assessment and treatment? Do you accept no responsibility at all and dismiss the patient from your practice? This rhetoric may sound trite, but these scenarios have occurred with patients who have sought opinions from myself, as well as from my colleagues.
Prevention is always the best medicine. Before treatment is initiated, the patient should always be informed that dentistry is not an exact science and not all treatment is successful all the time. If a natural tooth can decay, crack, chip, or otherwise degrade, so too can a restored tooth, crown, or other appliance. We are human beings performing biological procedures on other human beings. Brynolf and others, many years ago found that true histological success in endodontically treated teeth showed periradicular healing only 7% of the time. Mind-boggling, isn't it? How you manage each patient's situation is unique, but it is important to be compassionate and understanding.
It is a standard of practice to use a dental dam when performing endodontic treatment. Yet, many practitioners still do not. Not only does a dental dam provide an isolated field for treatment, but more importantly, it prevents the aspiration or swallowing of those fine reamers and files. So, reduce the risk, practice safe endo, and always place a dental dam.
Unfortunately, procedural misadventures are possible. Perforations, missed canals, and separated instruments rank as the most common. Is it malpractice if a procedural accident occurs? It is not – but it is a departure from the standard of care if the patient is not informed of the complication and its potential consequences. There is no need to hide the fact. Files break, sometimes within the canal, and often with no adverse after-effect. But be sure to inform your patient.
Dentistry is stressful enough without having to deal with the extra stress of departing from what is considered standard of care and risking a malpractice action. Consider referring those complex cases or diagnostic perplexities to an endodontist, as they most likely have an experientially different grasp of the internal tooth anatomy and surgical techniques compared to your own. Referring to and/or consulting with a specialist on complex cases is the best possible risk management for the referring clinician. It also helps foster relationships with colleagues that will be there when you’re in need.
Originally published in Oral Health journal.
About the Author
Dr. Gary Glassman is dentalcorp’s Chief Dental Officer. He helps facilitate the company’s continued growth and champions programs to support the Practice network in the delivery of optimal patient care. He is a world-renowned Endodontist, global lecturer, and the author of numerous publications.