Doug Kase
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THE PAST YEAR, I have had the opportunity to participate in a few malpractice
cases. Wait . . . hold back the gasps! My participation took the form of
expert exam and testimony in the defense of my fellow dentists in regard
to any endodontic involvement that their case may have had. As such, my
assuming this role has given me the chance to observe some common problems
and themes of risk management that may infiltrate and perhaps interfere
with our ability to defend ourselves in the event of the dreaded malpractice
case.
To start—and this is usually where we should all
start with our patients—consider the issue of informed consent. The question
of written versus oral has always been an issue. Obviously, a signed consent
form would offer the best protection, but alternatively as long as you
inform the patient orally of the risks of endodontic treatment and note
in your chart that you have done so, you will have protected yourself as
well. Creating a standardized office “script” that you can read from would
be very helpful to maintain uniformity from patient to patient. It is important
to include, for example, the issue of calcified canals, which may result
in the dentist’s either not finding a canal or not negotiating the canal
to its full extent.
This leads us to the next recurring topic
in risk management and endodontics, which is a missed or inadequately filled
canal. If you cannot find a canal or you cannot negotiate it to the apex,
for heaven’s sake tell your patient and note it in your chart. It is not
malpractice to not find a canal, such as the MB2 canal in a maxillary first
molar, if you have made the effort to look for it and explained to the
patient the possible ramifications. Then, of course, enter it in your chart!
Next topic of course is your chart. There are certain
things that we all remember from grammar school, particularly our three
Rs. Forget for a minute about the reading and the ’rithmatic, and let’s
concentrate on the ’riting. For an expert trying to defend his brethren,
there is nothing more frustrating than trying to read a chart that is written
so illegibly that it might as well be in an intergalactic language. It
is one thing not to be able to understand the language, for that is subject
to interpretation; however, not to be able to make out any intelligible
markings really puts a damper on an effort to defend. What I am getting
at is to please write up your charts legibly and express yourself clearly.
A good defense is much more likely if everyone involved is able to read
a legible chart and understand the language.
Separated instruments are a real stomach turner! Any endodontists
who tell you that they have never broken an instrument must not have done
much endo in their lifetimes. Separated instruments are a usual risk of
endodontic treatment and should never be considered an act of negligence.
Just tell your patient that it happened and then enter it in your chart!
S**t happens! Thus far, I have not met any dentists so infallible that
they deserved to have Superman’s “S” tattooed on their chests. Don’t be
afraid to tell your patient the truth, for silence has a way of biting
you on the rear end. Breaking an instrument in a canal is not an intentional
act of malpractice, but only represents an effort to do a root canal on
a difficult tooth.
Remember that it all comes down to expectations.
Endodontics is 90 to 92 percent successful. Eight to ten percent of the
best cases fail for some unknown reason. Some we can fix, and others we
cannot. If your patient is informed and understands the risks involved
and we as dental professionals maintain open lines of communication to
our patients, this combination may help to minimize our exposure to any
malpractice issues in the future.
Kase’s Case
I GUESS you have all been waiting for the “Kase” of the month. When
I first saw the starting film for this lower second molar (Figure 1), I
took one look at those apices and said to myself, “Self, you are never
getting to the end of these canals!”
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FIGURE 1: The starting
film for a lower second molar.
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I quickly informed the patient of her bizarre anatomy
(her roots) and also informed her of the probability that I would not be
able to negotiate the apex due to the tortuous path my instruments would
have to follow. Additionally, due to the proximity of the apices to the
mandibular canal, there was a possibility of some paresthesia, more than
likely temporary, but possibly—though rarely—permanent. This of course
was entered into her chart very clearly along with her consent to proceed
after understanding all the alternatives.
Using an apex locater, I took measurement control,
and I achieved negotiation to the apex, starting with .06 (pink) instruments.
This was a situation where throwing out overly used instruments was certainly
warranted to avoid separation. Using a tremendous amount of RC Prep and
irrigation helped, but didn’t make matters easy. As I straightened out
the coronal aspect of the canal with Gates and Peeso reamers, I continued
to recheck my measurement control, for I knew that it would change as the
coronal canal curvature was straightened. I continued to instrument according
to the SafeSider/EZ-Fill technique and ultimately achieved a result that
I can reach around and pat my own back for. P.S., the patient is pretty
happy too. (See Figures 2 and 3.)
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FIGURES 2 and 3: The
ultimate result, after negotiating tortuous paths.
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November-December 2003
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