Doug Kase
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 NCE AGAIN, my loyal readers, I will delve into the dark and unavoidable world of risk management and endodontics, and—more specifically—minimizing your exposure. Now, of course, you all certainly must realize that in this litigation-prone world in which we professionally live, an incident can happen in the blink of an eye that could culminate in some sort of a legal action. Whether the dentist is at fault or not at fault, or the incident is simply a case of a bad outcome from good and proper dentistry, s**t happens, and a patient doesn’t require much motivation to initiate a malpractice action, particularly in this economic environment.
As an endodontist who has had the experience of reviewing and defending my fellow dentists in quite a few cases, I have seen the most innocent and well-intentioned treatment blossom into an ugly, gut-wrenching and time-consuming event. Yes, I know, we all have malpractice insurance! However, having insurance still doesn’t mean that there may not be long-lasting effects, one of which is certain to be time out of the office, which in turn translates to lost income. So, with that having been said, how do we minimize our exposure?
The first thing to mention to reduce your exposure is to pick up a pen and document everything that is important and pertinent to your diagnosis and treatment, starting with a thorough medical history.
Documenting a chief complaint in the patient’s words would be a great start. Then move on to clinical tests and radiographic review to confirm your diagnosis. Write it all down, and make sure that it’s documented in some legible manner. One of the major problems that I have encountered when reviewing dental or medical records is that many are basically illegible by any definition of the word. Abbreviations are okay, but make sure that they are consistent and that all of them are readable! Lack of proper documentation means that a dispute ultimately ends up as the dentist’s word against the patient’s, and a fair amount of the time the patient wins, particularly if it ever gets to a jury of their peers.
Next comes informed consent. You should by some means, either written or oral, inform the patient of the diagnosis, treatment plan, alternatives, and general risks, and then place that into the written record. One of the common statements on a plaintiff’s bill of particulars is that informed consent for the particular procedure was never obtained and thus the treatment and risks were an unknown.
An open line of communication is very important. With regard to legal actions that were initiated due to a mishap from an endodontic procedure, the most common causes are ultimately from an uninformed patient. Whether it is the knowledge that a patient gains during the process of obtaining informed consent or an explanation of the possibility of an unintentional mishap during treatment, a patient “in the know” can ultimately be a happy and understanding patient.
So, endodontically, how else can we minimize our risk exposure? Separated instruments are certainly our nemesis. If you separate an instrument, make sure that your patient knows about it before you dismiss the patient or send the patient to a specialist to bypass the instrument or remove it. Separating an instrument is not an act of malpractice, but not informing the patient of the treatment alternatives and prognosis is. With this distinction in mind, I tend to utilize procedures that have a lower level of risk, but yield the same final results.
Separation is a common risk with rotary NiTi instruments, and the safety margin for their use is shrinking, as illustrated by the ever-changing parameters on how to use them and in what cases to use them. SafeSiders® instrumentation in a reciprocating handpiece will certainly achieve the same tapered results as rotary without exceeding the metallurgical properties of the instruments. Thus, the SafeSiders’ greatly decreased risk of instrument separation certainly limits your exposure to this problem while maintaining the standard of care that we have come to associate with our final obturation when performing modern-day endodontics, the result of having a well-tapered (.06 or .08) and well-obturated canal. (See Figures 1, 2, and 3.)
Thin and wispy fills that do not extend to the apex are another common issue, particularly if the ultimate outcome is loss of tooth and the complications that result. Such a case becomes difficult to defend, particularly when the plaintiff’s expert can compare the result to more textbook results. Of course, extenuating circumstances, such as calcifications, can greatly affect the final result, but when a patient has the case retreated and the result is dramatically different, defending the original work becomes dramatically harder.
Other endodontic issues center on the use of the rubber dam. All I can say is use the damn dam! If you have not used a rubber dam, you will have a very hard time defending yourself if a patient aspirates or swallows an instrument or irrigation solution. On rarer occasions, irrigation solution beyond the apex can also lead to issues. Please make very sure that the needle tip is loosely fitted in the canal and use light pressure only (2 drops per second).
As technology advances, the bar has been raised as well. The microscope and ultrasonics are becoming standard operating equipment, giving us access to MB2s, MMs, and other calcified canals. Thus, final results that don’t come close to the level to which that bar has been raised may be misconstrued by some as a deviation from the standard of care that we have become accustomed to, and may become involved in a liability action.
April - June 2009
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