Doug Kase
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 his
article has more to do with dealing with patient management and
standing up for what you are entitled to as opposed to the insightful
clinical techniques involved in the case. A few months back, I
had the opportunity to help out a referring colleague with an
endodontic complication on a tooth that he was working on. The
complication was one that I am sure has plagued every practicing DDS
who does root canal procedures. A # 8 or # 10 file was separated
in a curved and calcified mesiolingual canal in a mandibular first
molar. The patient was referred to our office to correct the
situation, and I was happy to help. The dentist had informed the
patient that the instrument had separated, so the patient was very
aware of the situation on presentation. When such a situation occurs,
as in this case, it is important to inform the patient of the
separation and of the risks and prognosis of the procedure and its
potential outcomes. These outcomes include instrument removal,
bypass, root perforations, or instrument retention—which could
eventually lead to apicoectomy or loss of the tooth. So even with
this knowledge, the patients still start off on the wrong foot because
they still feel that a mistake has been made and they have the
misconception they have “metal in their tooth” or, worse, “metal in
their jaw.” Thus for the specialist, it is of utmost importance
to protect the referring dentist by reassuring the patient.
Fortunately with the technology of ultrasonics and endodontic
microscopy, instrument removal has become an easier procedure.
Unfortunately, because some patients are angered by what has happened,
it is also important for the specialist to extinguish any smoldering
legal fires. Explaining to the patient that instrument separation
is a risk of endodontics is certainly helpful prior to the original
procedure. However, if that explanation is not included in the
original informed consent (written or oral) then explaining the risk by
educating the patient at the beginning of the rescue procedure will
certainly be a great help. A patient who is “in the know” will
ultimately become a happy patient. Thus the overall theme is
damage control.
Now down to the nitty gritty! Doing the right thing,
I informed the patient of the situation and got oral consent for the
procedure, which was immediately entered into the chart. Next was
the more painful part during which we discussed and agreed upon the
fee, which also was entered into the chart. It is very important
that the patient and doctor are on the same page under normal
circumstances for treatment plan and finances, let alone something that
ended in a bumpy manner for the general dentist and started off for the
endodontist in perhaps the same way. The case was a calcified
lower first molar # 30, so finding and negotiating the remaining canals
was a bit of a challenge (Figure 1). Using the microscope,
ultrasonics, and a couple of new explorers, I located the canals and
slowly negotiated them with .06 and .08 instruments under reciprocation
with plenty of RC-Prep and copious irrigation (Figure 2). Not to
blow our horns, but using reciprocation in a handpiece rather than hand
instrumentation alone will insure that you will not overstress the
metallurgical properties of the instrument and cause additional
instrument separation. The three remaining canals were fully
instrumented with SafeSiders®, and now it was time to tackle the
blocked canal. With a 21 mm .06 instrument, I was slowly and
carefully able to find a catch and start bypassing the separated
instrument. Checking with an apex locator, I found that I had
reached my measurement control. Using reciprocation, I
instrumented the canal. All the canals were obturated using the
EZ-Fill® technique. I chose to try a bypass rather than
opening the coronal aspect of the canal to remove with ultrasonics due
to the anatomically thin mesial root and depth of the instrument.
The final film shows no evidence of a retained instrument, although I
believe it was concealed by the filling material (Figure 3). The
patient was completely asymptomatic, and after three visits and
four-and-a-half hours of work, I was the hero, or so I thought.
It was time to settle up!
Without getting into extreme detail, the patient at that
point refused to assume any financial responsibility for the fee.
The patient’s position was that I would have to accept as full payment
what the general dentist would have to pay “for the damage he caused”
or what the insurance company would pay. Strongly reminding the
patient of the agreed upon fee and terms, the thought of “damage
control” came into mind. I reminded the patient that the general
dentist did everything correctly and also was not responsible legally
or financially. So, as a courtesy, I agreed to submit the bill to
the patient’s insurance provider with a co-payment amount to be paid by
the patient, and to bill for the balance, if any, after the insurance
payment was received. All said and done, the patient did not send a
co-payment, and a substantial balance remained due after I received the
insurance payment. The patient bitched, moaned, and
threatened. I stood my ground. The patient’s attorney and
insurance company called, and I stood my ground. The point being
that we all know this is a very litigious society in which we practice,
and it is important to keep in mind that when you are in the right do
not let the threat of legal action become a means of extortion.
We all work hard for what we deserve! (P.S. I eventually received
payment in full.)
September - October 2007
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FIGURE 1: The case was a calcified lower first molar # 30.
FIGURE 2: I located the canals and
slowly negotiated them with .06 and .08 instruments under reciprocation
with plenty of RC-Prep and copious irrigation.
FIGURE 3: Showing no evidence of a retained instrument, although I believe it was concealed by the filling material.
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