Collection Two 2025 | South Africa
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It may not have occurred to you that endodontic file fracture can precipitate both complaints and claims for compensation. The reason I say, it may not have occurred to you, is because it may not have happened (yet), or it might have happened, and you were not aware it had.
According to the literature, the incidence of file fracture can be anywhere between 0.4% and 5%. There is also consistency in the literature about the most common causes of file fracture being operator inexperience and metal or instrument fatigue where instruments are re-cycled rather than discarded after single use.
While teeth can survive with a fractured instrument embedded in a root canal, the first and preferred option is usually to remove the broken instrument and complete the root canal conventionally. Not every clinician has the skills and resources to undertake an additional intervention. For the patient there can be prolonged discomfort, the inconvenience of this additional procedure and the associated costs where the patient agrees to pay themselves.
Non-negligent complications happen in all areas of healthcare. It is an unpleasant fact, that often the complication comes at a cost, particularly where there are additional surgery, treatment, and extended stays in hospital.
In New Zealand, a fractured endodontic file, may be covered by ACC as a treatment injury claim if it were caused by a registered dentist, is not a normal side effect of treatment, and meets the eligibility criteria.
The dentist will need to lodge the claim with ACC and will need to complete the necessary forms. It is not uncommon for DPL to advise members on how to assist patients regarding treatment injury claims.
In short, the answer is money for remedial treatment and informed consent, tainted with the patient’s perception of what a ‘broken instrument left in a tooth’ implies.
While there may be ACC funding available for the recovery of a broken endodontic instrument, the maximum fee ACC will pay will not meet the usual fees charged by the dentist / endodontist to meet the costs of a time-consuming and tricky intervention. The gap can be significant.
It is not a particularly easy conversation to have with a patient where you have to explain a piece of equipment broke in their tooth and you cannot get it out. Most lay people will associate breakage with carelessness rather than as a genuine accident. You don’t have to look very far on the internet to discover that the most common reasons for endodontic instrument failure are not “it’s one of those things”, but linked to operator competency and instrument fatigue, where the instruments are re-cycled beyond one interaction with the root canal and possibly re-cycled beyond one patient.
Without doubt it is the conversation (upfront) during informed consent rather than the conversation after the file fracture, which will largely determine what the patient then does.
With poor information upfront, then the patient response often becomes:
Whilst it is not a mandatory requirement to have written signed informed consent for root canal procedures, given the relative occurrence of file fracture, it is definitely helpful, prior to treatment commencing, to have supplied written information regarding this (and other risks), of endodontic treatment. The NZDA Endodontic Treatment brochure (available NZDA website- ‘order merchandise’) is a useful resource in this regard. Have the discussion, provide the pamphlet, and note in the records that it was provided in addition to, and as part of, the informed consent.
To summarise – in this situation, if we want our patients to treat us fairly and with respect, they need to be informed, in the consent discussion, about the risk of instrument fracture and what, if fracture occurs, will mean in terms of additional treatment and possible costs.
It helps to let patients know, that if an instrument breaks, then there will be additional costs and another intervention to recover the instrument before completing the procedure.
Many of the complaints and claims Dental Protection are asked to assist with, involve patients who have not been made aware of the risk until it happens. Ethically that is unfair because such patients are deprived of the opportunity to mitigate that risk.
If we think at the level of individual patient needs, the level of risk of file fracture, is mostly an aggregate of the complexity of the procedure, the technical competency of the dentist, and the condition of the files used by the clinician.
Defending the dentist is so much easier where the patient has been told that the risk of instrument failure is higher in a particular tooth because of its complex anatomy and where the outcome may be more predictable in the hands of a clinician who limits their practice to endodontics. The whole point of having expertise and specialist training is because some procedures are technically more difficult and in many cases the expert will produce better outcomes and that may be a way for the patient to mitigate their risk. Unless patients know the facts, they cannot choose.
Likewise with the equipment itself, I think we would all want single use instruments where the literature suggests there are fewer breakages with instruments that are not exposed to fatigue. If it costs more, then it costs more but the patient can only choose to spend more money if they know what the specific costs are and why.
Where one or more of the above steps are missing from the consent process then the patient could argue that the consent they gave was not properly informed and had they known then, what they know now, they would have asked to be seen by a clinician with sufficient expertise, to lower the risk.
You have fractured the file, but do not inform the patient and do not record the file fracture and the subsequent discussion with the patient in the records. Realistically, when this situation lands at Dental Council (usually when the tooth flares up at a later date and, in pain needing urgent care, the patient sees another practitioner), any defence possible, is at best, weak and the situation for the practitioner, is significantly worse.
The likely perception will be, there is either:
Discussing risks with a patient is not easy. We are probably not as good as we need to be because prior to providing treatment, we worry about over-burdening our patients with negativity. Discussing a negative outcome (an untoward event) is even harder, but doing so is the only action that meets a practitioners ethical and mandated professional responsibilities.
The overwhelming conclusion is - it is a far easier conversation to get over the line if it happens before the file goes into the root canal system than after it has broken.
This interactive module on The Learning Hub highlights the common risks and pitfalls associated with endodontics and suggests ways of managing these areas of risk.
It may not have occurred to you that endodontic file fracture can precipitate both complaints and claims for compensation. The reason I say, it may not have occurred to you, is because it may not have happened (yet), or it might have happened, and you were not aware it had.
According to the literature, the incidence of file fracture can be anywhere between 0.4% and 5%. There is also consistency in the literature about the most common causes of file fracture being operator inexperience and metal or instrument fatigue where instruments are re-cycled rather than discarded after single use.
While teeth can survive with a fractured instrument embedded in a root canal, the first and preferred option is usually to remove the broken instrument and complete the root canal conventionally. Not every clinician has the skills and resources to undertake an additional intervention. For the patient there can be prolonged discomfort, the inconvenience of this additional procedure and the associated costs where the patient agrees to pay themselves.
Non-negligent complications happen in all areas of healthcare. It is an unpleasant fact, that often the complication comes at a cost, particularly where there are additional surgery, treatment, and extended stays in hospital.
In New Zealand, a fractured endodontic file, may be covered by ACC as a treatment injury claim if it were caused by a registered dentist, is not a normal side effect of treatment, and meets the eligibility criteria.
The dentist will need to lodge the claim with ACC and will need to complete the necessary forms. It is not uncommon for DPL to advise members on how to assist patients regarding treatment injury claims.
In short, the answer is money for remedial treatment and informed consent, tainted with the patient’s perception of what a ‘broken instrument left in a tooth’ implies.
While there may be ACC funding available for the recovery of a broken endodontic instrument, the maximum fee ACC will pay will not meet the usual fees charged by the dentist / endodontist to meet the costs of a time-consuming and tricky intervention. The gap can be significant.
It is not a particularly easy conversation to have with a patient where you have to explain a piece of equipment broke in their tooth and you cannot get it out. Most lay people will associate breakage with carelessness rather than as a genuine accident. You don’t have to look very far on the internet to discover that the most common reasons for endodontic instrument failure are not “it’s one of those things”, but linked to operator competency and instrument fatigue, where the instruments are re-cycled beyond one interaction with the root canal and possibly re-cycled beyond one patient.
Without doubt it is the conversation (upfront) during informed consent rather than the conversation after the file fracture, which will largely determine what the patient then does.
With poor information upfront, then the patient response often becomes:
Whilst it is not a mandatory requirement to have written signed informed consent for root canal procedures, given the relative occurrence of file fracture, it is definitely helpful, prior to treatment commencing, to have supplied written information regarding this (and other risks), of endodontic treatment. The NZDA Endodontic Treatment brochure (available NZDA website- ‘order merchandise’) is a useful resource in this regard. Have the discussion, provide the pamphlet, and note in the records that it was provided in addition to, and as part of, the informed consent.
To summarise – in this situation, if we want our patients to treat us fairly and with respect, they need to be informed, in the consent discussion, about the risk of instrument fracture and what, if fracture occurs, will mean in terms of additional treatment and possible costs.
It helps to let patients know, that if an instrument breaks, then there will be additional costs and another intervention to recover the instrument before completing the procedure.
Many of the complaints and claims Dental Protection are asked to assist with, involve patients who have not been made aware of the risk until it happens. Ethically that is unfair because such patients are deprived of the opportunity to mitigate that risk.
If we think at the level of individual patient needs, the level of risk of file fracture, is mostly an aggregate of the complexity of the procedure, the technical competency of the dentist, and the condition of the files used by the clinician.
Defending the dentist is so much easier where the patient has been told that the risk of instrument failure is higher in a particular tooth because of its complex anatomy and where the outcome may be more predictable in the hands of a clinician who limits their practice to endodontics. The whole point of having expertise and specialist training is because some procedures are technically more difficult and in many cases the expert will produce better outcomes and that may be a way for the patient to mitigate their risk. Unless patients know the facts, they cannot choose.
Likewise with the equipment itself, I think we would all want single use instruments where the literature suggests there are fewer breakages with instruments that are not exposed to fatigue. If it costs more, then it costs more but the patient can only choose to spend more money if they know what the specific costs are and why.
Where one or more of the above steps are missing from the consent process then the patient could argue that the consent they gave was not properly informed and had they known then, what they know now, they would have asked to be seen by a clinician with sufficient expertise, to lower the risk.
You have fractured the file, but do not inform the patient and do not record the file fracture and the subsequent discussion with the patient in the records. Realistically, when this situation lands at Dental Council (usually when the tooth flares up at a later date and, in pain needing urgent care, the patient sees another practitioner), any defence possible, is at best, weak and the situation for the practitioner, is significantly worse.
The likely perception will be, there is either:
Discussing risks with a patient is not easy. We are probably not as good as we need to be because prior to providing treatment, we worry about over-burdening our patients with negativity. Discussing a negative outcome (an untoward event) is even harder, but doing so is the only action that meets a practitioners ethical and mandated professional responsibilities.
The overwhelming conclusion is - it is a far easier conversation to get over the line if it happens before the file goes into the root canal system than after it has broken.
This interactive module on The Learning Hub highlights the common risks and pitfalls associated with endodontics and suggests ways of managing these areas of risk.
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