Several years ago, I read an article in a popular magazine written by a patient who denounced the endodontist who had just treated them. I did a quick computer search of the patient’s file and was relieved to find that this was not my patient. However, I read the article several more times, hoping to understand their complaint and to sympathize with the endodontist.
A patient with nonlocalized pain visited the endodontist on the Friday morning before a long weekend. There was no doubt that they needed a root canal. However, it was unclear which tooth specifically needed treatment.
The patient was faced with two choices: either endure the pain until it was under control or treat the tooth most likely to be the culprit. Due to the unbearable pain, the urgency to attend a long-awaited weekend camping trip, and the lack of other dental intervention options, the patient ultimately elected to undergo a root canal. A few days later, due to continued pain, the patient returned to the endodontist. The endodontist recommended that a root canal be performed on the tooth next to the treated tooth.
This situation is not unfamiliar to those of us who treat patients with pain. The truth is, in most cases, we are able to make an accurate diagnosis and consult with patients in an informative, caring manner, advising them on all treatment options.
When performing root canal treatment (or any surgical procedure), it is imperative to be aware of the more common malpractice pitfalls and ensure due diligence has been exercised to avoid them.
If the diagnosis is unclear, it is always better to err on the side of caution. Even if the patient asks for certain actions to be taken, stand your ground and let them know that with time, a correct diagnosis can eventually be made. You can also offer to help in an emergency or prescribe some pain medication to try to relieve the pain.
Most importantly, stand 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 imagine how they would feel if we ended up treating the wrong tooth? Or how would they feel if we removed important tissue from a healthy tooth?
A diagnosis is not always enough. Even if all exams have been done correctly and the correct x-rays have been taken, be sure to document your findings to avoid malpractice.
If you look at the sections on disciplinary or misconduct hearings in the regulatory college publications, you will find that those disciplined did not keep proper records. If your records are incomplete, imprecise, inaccurate or defective, the regulator or judge will most likely consider that the action you have taken is no more comprehensive than the records.
Now suppose the diagnosis is correct, the tooth is treated with a root canal, and the records are correct. But two years later, the patient returns with excruciating pain and periapical lesions and accuses you of asking for a refund on the grounds that they believe you did not handle it properly.
After checking the root canal treatment, you find that there is no problem. All 17 root canals have been completely sealed, the distance to the apex is within acceptable limits, the tooth has been restored with a precision-fitting crown, and you have X-rays or scans to prove this. Do you refund the patient’s payment and wish them well?
Do you recommend that the patient be referred to another endodontist and pay for further evaluation and treatment? Do you simply remove the patient from your practice without accepting any responsibility? This statement may sound cliché, but these situations do happen to patients who seek advice from me and my colleagues.
Prevention is better than cure. Before starting treatment, patients should always be informed that dentistry is not an exact science and not all treatments will work all the time. If natural teeth can decay, crack, chip, or otherwise degrade, then so can restored teeth, crowns, or other devices.
We are human beings, performing biological surgery on other humans. Years ago, Brynolf et al. found that true histologic success rates were only 7% of periapical healing in endodontically treated teeth. Incredible, isn’t it? Dealing with each patient’s situation is different, but empathy and understanding are essential.
It is standard practice to use a dental dam when performing endodontic treatment. Yet, many practitioners still do not do it. Not only does the dam provide an isolated area for treatment, but more importantly, it prevents the tiny reamer and file from being aspirated or swallowed. So reduce the risk, perform endodontic treatment safely, and always place a dental dam.
Unfortunately, accidents happen during surgery. Perforations, missed canals, and instrument separation are the most common. If a surgical error occurs, is it medical malpractice? Of course not—but if the patient is not informed of the complication and its potential consequences, it is a violation of the standard of care. There is no need to hide this fact. Files sometimes break in the root canal, usually without causing adverse consequences. But be sure to tell the patient.
Dentistry is stressful enough without the risk of deviations from standard care and malpractice lawsuits. Consider referring these complex cases or diagnostic challenges to an endodontist, as they will likely have a different understanding of the internal anatomy of the tooth and surgical techniques than you do.
For the referring physician, referring complex cases or consulting a specialist is the best way to manage risk. It also helps to build relationships with colleagues who can help when you need them.
Related topics:
