Dr Kiran Keshwara, Dentolegal Consultant at Dental Protection, views RCT complications through the prism of the law

As clinicians, we want to look after our patients and provide treatment to them in a caring manner with no intention or expectation that the treatment will fail or, worse still, result in a greater injury to the patient. However, as we all know, the nature of dentistry is such that sometimes things do go wrong and, in endodontics, this is made even harder by the fact that many times we are not able to determine all the relevant information, which may have resulted in us referring the patient for further treatment.

Complications or failure in treatment are not always a consequence of negligence; they can be simple adverse outcomes or “sometimes stuff just happens” moments. That does not take away the anguish felt by patient and practitioner alike, but it is an important fact to remember when considering treatment failures.

If something does go wrong with endodontic treatment, some patients will explore their options for compensation with a lawyer and, in this article, we will explore some of the aspects of treatment that a plaintiff lawyer will look at when considering whether a patient can bring a claim for compensation against you.

The first thing a lawyer will consider will be:

•  Assessment

Can you show that you have adequately and appropriately assessed the patient and their complaint?

•  History

Things to consider here include:

1) Medical – does the patient have a history that contraindicates certain treatments or certain medication?

2) Pain – the location and nature of the pain, how long the pain has been present, things that affect the quality of the pain such as temperature or eating hard foods

3) Dental – does the patient have a history of unexplained pain that has resulted in the patient having other teeth in the area extracted or endodontically treated?

•  Clinical – aspects such as:

1) Visual inspection – checking we can pinpoint the tooth the pain has originated from by thoroughly assessing the area of pain for cracks, caries, or previous large restorations.

2) Radiographic investigations – taking the necessary radiographs, such as intraoral radiographs or CBCTs, which help us determine which tooth is causing the pain and check the surrounding teeth as well.

Radiographs may also help indicate to us the number and length of canals as well as any potential difficulties we may encounter while accessing these canals – such as sclerosed canals, curved roots or unusual root canal morphology.

After the lawyer’s assessment of your patient comes a consideration of whether you used this assessment to come up with an appropriate (differential) diagnosis and treatment plan. For example, did you consider that the pain has originated from a crack in the tooth, or can the tooth even be restored? Has the tooth had a previous root canal treatment? Or, if the patient presents with a history of unexplained or unusual pain, is the pain in fact neuropathic in origin rather than odontogenic – and if that is the case, should the patient be referred for management of a neuropathic pain instead?

We need to be certain that we have identified the source of the pain, the correct tooth and the reason for the pain, and consider whether we can treat the tooth and if it can be restored, and we need to verify the steps we took in our clinical records. Consequently, a part of anyone’s treatment plan should always include the discussion of the options of no treatment or referral to an endodontist for an opinion and treatment.

If the assessment, diagnosis and treatment planning for a patient is appropriate and we can proceed with the treatment, we then need to consider whether a valid consent was in place.

Consent

Can you evidence through your records that the patient understood the nature and purpose of the treatment, and what alternatives were available to them, including the option of no treatment if appropriate? Did the patient understand the costs of their treatment, including potential flow on costs if specialist treatment is required? If you cannot evidence this, then you cannot evidence you had valid consent in place to proceed with treatment, and treatment without consent is viewed by the law as negligent.

A lawyer may then consider that there was something wrong with the actual treatment provided to the patient.

Questions about the clinical treatment provided can include:

•  Was a rubber dam used?

•  Were all the canals located and accessed?

•  Were working lengths appropriately checked and established?

•  Were the canals cleaned and irrigated with the appropriate syringe and irrigant?

•  Were the necessary radiographs exposed during and after treatment?

•  Was the obturation adequate to seal the canals to the correct working length? Avoid under- and over-filling canals.

•  Was an appropriate restoration placed on the tooth?

Of course, there are aspects of endodontic treatment that do sometimes occur such as perforations, missed canals or soft tissue hypochlorite injuries, and these can result in a variety of issues for the patient and clinician alike. When aware of these issues, it becomes vital that we explain the situation to the patient in a way that they can understand and then seek to refer the patient.

Luckily, many times, when we do come across a complication, we are able to refer patients to our endodontist colleagues who are usually able to assist in providing the necessary treatment to help save the patient’s tooth, and with sensible and honest communication with our patients we can usually avoid matters being taken further.

Learning points

Sometimes in the practice of dentistry things do not go to plan.

This is rarely due to an act of negligence.

Ensure that your records document everything thoroughly, including the conversation of consent with the patient.

Good communication both before and after any adverse event is key to a good outcome for all.