Broken instruments and other common problems in endodontics should be dealt with in a caring, supportive and professional manner.
The most common dento-legal problem involving endodontic procedures is probably the broken instrument. ‘Fracture’ and ‘breakage’ are particularly emotive words and so phrases such as ‘separated instrument’ are preferable. While instrument separation is not itself automatically considered to be negligent practice, failure to recognise the complication and to advise the patient that it has occurred can seriously undermine any defence.
It is absolutely essential that clinicians understand and adopt correct procedures as far as their instrument use is concerned. It makes good sense to read and follow the manufacturer’s instructions with great care, and to inspect and discard instruments at the first sign of damage. This applies to all techniques, whether they involve rotary techniques or reciprocating-action handpieces.
Tell the patient
Dental Protection advises members to tell patients if something has gone wrong, for whatever reason, apologise if appropriate, and explain how it can be rectified. Where necessary, reassurance should be given to any patient who is concerned about an adverse treatment outcome.
When complications and errors arise, you should be prepared to give your patients objective factual information about what has happened, in a caring and supportive fashion. You are encouraged to explain any clinical issues in terms that the patient is likely to understand. In this way, a clinician can comply with The Dental Council Code of Practice relating to Professional Behaviour and Ethical Conduct, which states:
“You must tell your patient of the nature and possible consequences of an adverse event should one occur in the course of treatment.
You must respond openly, honestly and professionally to any questions from your patient or, where appropriate, a parent, guardian or carer, in language they can understand.”
Patients have a right to be informed of any matters that relate to treatment provided for them; you should try not to withhold objective factual information, or an expression of regret or sympathy where appropriate. Saying that you are sorry that an incident has occurred, or expressing your regret that a patient is upset or unhappy, is not necessarily an admission of guilt, fault or liability.
Managing the situation
When procedural error does occur there may be a need for referral to a specialist endodontist. Indeed, there are a number of other situations when a second opinion from a more experienced colleague might be offered to the patient – particularly if you feel that a situation is beyond your own skill set. Apart from the retrieval of a fractured instrument these might include:
- anaesthetic problems;
- trauma and its sequelae;
- removal of root fillings if proved difficult;
- canal location;
- post removal;
- perforation repair; and,
- surgical endodontics.
When referrals are received, it is helpful to have available any previously taken radiographs that are of diagnostic quality to aid diagnosis and avoid duplication. Digital radiographic images should be transferred in a standard format (e.g., jpeg) or printed with a quality printer on photographic paper. While some colleagues will also accept digital images via email, care should be taken to ensure that patient details remain secure and cannot be accessed by a third party.
There will inevitably be challenges encountered in endodontics, but the procedure continues to offer a predictable treatment strategy. As with any dental treatment, careful case selection, open patient communication, recognising your limitations and knowing when to refer will all help to improve the predictability of root canal treatment and patient satisfaction. An adverse incident does not necessarily mean that a patient will make a complaint or a claim. In fact, a clinician can use an adverse incident to good effect to demonstrate his or her professionalism. A clinician who understands the patient’s concerns and takes the time to reassure the patient and to resolve the clinical issue, can become more highly thought of in the eyes of the patient.
Dr Susan Willatt BDS MBA LLM
Susan is Head of Dental Services and Secretary to the Board of Dental Protection. She is part of the team that supports members in Ireland