Getting to the root of the problem

PROVISION of endodontics is commonly required in order to secure dental health and relieve discomfort. Carried out efficiently and painlessly, it can provide the foundation for a functional dentition, build a relationship of trust between dentist and patient and contribute to the establishment of a successful practice. However, it is also technically difficult and failure can result in the onset of unpleasant symptoms, followed by loss of teeth and expensive restorations. In an age of growing patient expectation, poor endodontics can also lead to litigation and regulatory scrutiny.

Detailed guidance regarding endodontic techniques is beyond the scope of this article but I can offer some general advice which, if heeded, will help to minimise problems in this complex area.

Diagnosis

Dental practice can be busy and stressful – and if a patient with pain is ‘squeezed in’ there may be a temptation to provide relief by ‘getting the pulp out’ as quickly as possible. However, long before a size 10 reamer is picked up, key points must be addressed. For example, is the discomfort definitely of dental origin? If so, could this be relieved without root canal therapy? Answering these fundamental questions requires a careful history and examination.

Symptoms such as marked localised tenderness to pressure or pain which persists after thermal stimuli and/or disturbs sleep might well indicate a moribund pulp, in which case endodontics may be a reasonable treatment option. However, this diagnosis must be confirmed by thorough examination.

Locating the symptomatic tooth can be quite simple in some cases, for example in a complicated crown fracture or a lone-standing carious tooth. But acute pulpitis is notorious for presenting diffusely and when you are presented with heavily filled but otherwise unremarkable quadrants, locating the inflamed pulp can be time-consuming and difficult. Diagnostic aids such as ethyl chloride and percussion can be of great assistance in this process but cannot always be completely relied upon, particularly when treating the more anxious patient who may report pain in every tooth tested.

Radiographs can be helpful, particularly if the pulp has become moribund due to secondary caries or a particularly deep restoration but there will still be occasions where a definitive diagnosis simply cannot be reached. In these cases, treatment should be delayed until symptoms localise or a second opinion can be obtained.

Assessment

In most instances it will be possible to confirm the source of the patient’s problem. However, even if it seems likely that endodontics will be curative, that size 10 file must still remain untouched until other aspects of the case are considered. For example, is the tooth in question restorable? There is very little point in completing the most beautiful canal filling only for the final restoration to fail catastrophically at an early stage.

Did the radiographs reveal potential complicating factors, such as bifid roots or calcifications? The presence of anatomical anomalies such as these might contra-indicate root canal therapy or require the assistance of a specialist. Factors such as the prospects of a successful endodontic completion and a stable coronal restoration must be properly assessed before recommendations can be made to the patient.

Consent

Informed consent must also be secured and in endodontics should include advice regarding alternatives such as extraction, as well as a description of the proposed procedure together with possible risks such as postoperative discomfort and infection recurrence. Advice regarding cost is also required. A written estimate is mandatory for all NHS patients, regardless of whether the endodontics is to be carried out privately. Remember that NHS Terms of Service in Scotland do not permit the mixing of private and NHS treatment on a single tooth. An NHS patient considering private endodontics must be advised why this treatment is being offered outwith the NHS and provided with a cost estimate of any restoration.

Problems…

Endodontics is fraught with potential complications and some can be indicative of a lack of care and attention by the dentist. For example, inhalation of an instrument will almost inevitably be the result of a failure to use rubber dam and not using an irrigation syringe with luer-lock attachment and side vents may contribute to the forcing of sodium hypochlorite into apical tissues. Offering a defence in such situations can be very difficult.

Other problems may be simply beyond your control, such as instrument failure. However, if a complication is not recognised, or if its occurrence and possible remedies are withheld from the patient, then the practitioner will be left in a very weak position. Thankfully, many endo-related problems involve less calamitous outcomes, such as recurrent pain or sinus.

Regardless of operator skill and experience, not all root treatments will be successful and this need not be the result of poor technique. However, they ought to be a matter of regret and the ethical dentist will always endeavour to reassure the patient and remedy the situation, perhaps by offering repeat treatment or referral to a specialist. Unfortunately, there will still be circumstances in which complaints or even litigation may follow.

Just how successfully such cases can be defended depends on a number of factors. Pre-op assessment, treatment planning and reliable consent are important but the most common line of criticism with regards to failed endodontics is the quality of the final root filling. Problems can occur even with the most perfect canal obturation. In cases where the canal filling appears deficient, there may be a perfectly reasonable explanation for this which was accepted by the patient before treatment commenced. The sad truth is, however, that post-operative films showing obturation of a poor standard are often an accurate indicator of a lack of care in shaping and filling the canals.

Excuses for poor work based upon commercial and time constraints simply will not suffice. Painstaking canal preparation, assisted by appropriate radiographs to establish the working lengths (or, at the very least, use of an apex locator) and followed by a film which records a good final obturation are essential. Clearly, adherence to this regimen will maximise the chance of a successful treatment and stress-free day and demonstrate an adequate standard of care should problems later arise.

One final medico-legal requirement underpinning all of the above is record keeping. No matter how comprehensive the consenting process or how carefully the working length was measured, without evidence of these processes in contemporaneous legible notes your defence in any subsequent complaint or a claim will be limited. It is critical that each stage of the treatment, from the initial history to post-operative instructions, is clearly recorded for future reference.

Conclusion

Endodontic technique must be learned in the first instance from teaching staff and experienced colleagues and perfected by subsequent repetition, while always keeping up with new developments. Reference to the general guidelines discussed above should help avoid complaints and litigation. However, if problems do occur, please seek advice from MDDUS at an early stage.

Case study

Patient A attends the practice of dentist B complaining of broken down lower right premolars. Consent is obtained for root canal treatment followed by crowns. However, after completion of endodontics, the patient decides, for commercial reasons, to source the crowns in Eastern Europe. Patient A is subsequently examined by an overseas dentist, who declines to provide crowns because the root fillings are well short of the radiographic apices and poorly condensed.

On returning to the UK, the patient writes to dentist B requesting compensation. Refund of all treatment fees is provided but further remuneration to cover travel expenses is considered inappropriate. Patient A accepts the proffered compensation but then writes to the GDC, whose subsequent investigation focuses not only on the deficient obturations but also on the absence of any record that final X-rays were taken and checked. No defence can be put forward to these allegations and dentist B receives a written warning from the GDC. Doug Hamilton is a dental adviser at MDDUS