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Avoiding herodontics

12 June 2019
Ms B was suffering from pain that kept her awake at night. An examination by the dentist established tooth 27 was the cause of discomfort. The 27 had extensive dental decay and a missing buccal wall. Ms B had an otherwise intact arch and was keen to save the tooth – she did not want a dental extraction.

The dentist explained that endodontic treatment carried no guarantee of success,especially with the extent of damage to the enamel walls, and extraction was offered as the only realistic option.

Ms B was quite persistent in her demands for root treatment, along with a full coverage crown, and was unwilling to be referred to a specialist. The dentist felt pressurised by the patient and embarked upon the endodontic treatment against his better judgement.

Five visits later, only two of the canals had been located and the third may have been perforated as it bled on instrumentation.This was discussed with Ms B and the tooth was dressed.

Although the endodontic treatment was becoming more complicated, Ms B was still unwilling to consider an extraction and remained forceful in her request for the root treatment to be completed by the practitioner.

Further explanations were provided, but despite this Ms B remained convinced that a crown would solve the problem. She decided to visit a second dentist for the crown and was informed that the tooth had an incomplete root canal treatment.

The first dentist received a letter of complaint questioning why the endodontic treatment had not been completed in five visits and why had the patient been charged for this incomplete and unsuccessful treatment.

The dentist contacted Dental Protection for advice on how best to respond.

Whilst the clinical records were detailed, the practitioner was vulnerable in some areas regarding the clinical care provided: specifically in terms of the preoperative assessment, as the restorability status of the tooth at the outset was questionable. During the procedure the dentist could not place a rubber dam because of insufficient residual coronal tissue, which would lead to him being criticised if the matter went to the regulator, and a perforation occurred. With hindsight, the practitioner realised that the decision to carry out root canal therapy had been a poor one, and he should not have attempted the procedure in the first place; he should have been more forceful himself in referring the patient, as they were unwilling to listen to his advice.    

With Dental Protection’s advice and assistance the complaint was resolved by refunding Ms B for the initial endodontic treatment and also contributing towards the cost of the second dentist’s assessment.

Had Ms B made a complaint to the regulator, they would have taken a dim view of the poor preoperative assessment. Furthermore, in any matter such as this, there is always the possibility that the patient may make a a claim for clinical negligence, and the solicitors could potentially allege that Ms B had been subjected to an inappropriate procedure with associated pain and suffering. 

Learning points

• Be alert to patient-led dentistry and the demands of strong-willed patients. Unrealistic expectations should be identified and managed from the outset. The reasons why the treatment is inappropriate should be communicated effectively.
• Avoid being coaxed by persistent patients into carrying out treatments which have a slim to zero chance of success.
• Just because a patient consents to treatment, it doesn’t necessarily mean that the treatment is appropriate.
• In this particular case, the complaint was resolved by a detailed letter of explanation and a refund of fees.
• In trying to appease the patient, the dentist had spent over three hours attempting treatment that was essentially doomed to fail, and then had to spend even more time managing the resulting complaint.
• This case highlights the dangers of attempting heroic dentistry; dentists are unlikely to be thanked for lack of success.
• Consider referring patients who do not listen to or follow your advice.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
For more detailed advice on any issues, contact us

© 2019 The Medical Protection Society Limited

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