Nuala Carney stresses the importance of detailed record-keeping as a protection against future claims and complaints.
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Dental Protection frequently helps members with complaints received from patients claiming that a root canal treatment (RCT) carried out several years earlier has now ‘failed’ and as a result the tooth needs to be extracted. Usually, the patient has transferred care to another dentist, and the ‘failure’ becomes apparent due to symptoms or a radiological finding.
While there is no doubt that failure to clean and obturate the root canal system may cause the tooth to be unrestorable, often the fault lies in the diagnosis by the second dentist who views the situation without the full historical information. Small details noted in the records at the time of treatment are often crucial in defending the members position and proving that there was no fault in the care provided.
Case study
A member contacted us after receiving a complaint from a patient he had treated more than five years previously. It concerned the root treatment he had carried out on LL6. The patient said that she had developed a swelling beside the tooth. The current treating practitioner took a radiograph and advised her that the root canal treatment was faulty, that there was infection around it, and that the tooth now needed to be extracted. Our member had now moved abroad and said he would be willing to cover the cost of the implant if it was shown that his treatment was at fault.
When the clinical records were obtained from the members previous practice, there was evidence of detailed record keeping at all stages of the root canal treatment. The treatment had been carried out over two visits and there were detailed notes of the preoperative consent and warnings given, the instrumentation used, and the materials and irrigants used. There were high quality working radiographs and evidence of obturation to the working length in three canals.
The patient was clearly advised on two occasions that she needed to have a crown placed on this tooth, particularly as the member identified that there were some occlusal and bruxism issues. He also noted that she was strongly advised to wear a hard night guard as there was evidence of occlusal wear on many of the teeth. She was specifically warned of the risk of root fracture. Both the member and the patient left the area to live elsewhere and the patient was not seen at that practice again.
We requested the current dental records from the patient and were provided with the radiograph of the tooth in its current state – which showed significant infection around the mesial root, but with a very nicely completed root canal treatment. The tooth had not been crowned. The infection included both the periapical area and extended up the mesial root, and looked as if the differential diagnosis was just as likely to be a fractured root as a problematic RCT. The patient was asked to confirm whether or not she had had a hard night guard made in the intervening period, and whether she was wearing one at night. The patient did not respond.
We concluded that the more likely cause of failure of the tooth was root fracture and suggested a second clinical opinion to review the diagnosis. We proposed a second expert opinion to the patient and offered to cover the costs of this. The endodontist confirmed that in fact the tooth had a vertical root fracture and also that the patient had admitted that she had not had a night guard made, as had been recommended. We were able to successfully defend the member’s position by explaining that the patient had been clearly warned of the high risk of a root fracture post endodontic treatment, that she had been made aware of the need for a crown and the cost of this, and also of the need for a night guard. The failure of the tooth was not due to the treatment carried out by our member but rather the failure of the patient to take the necessary steps to preserve the tooth. Therefor our member bore no responsibility for any further treatment costs required.
Our ability to defend this member’s position was based solely on the records and the level of detail contained regarding the crucial postoperative information and advice provided to the patient. Had this proof of warning not existed in the records, the patient would have been able to allege that she had received no warnings at all, and had she received them, she would have crowned the tooth and had a night guard made, which would have limited the risk of root fracture.
Unfortunately, when these types of complaints progress to a claim, we almost inevitably see histories of ‘prolonged periods of pain’ and ‘poor function’, sometimes even allegations of how traumatic the patient found the endodontic procedure that led to ongoing mental distress. These factors can significantly increase the value of the claim.
The point should also be made that dentists reviewing treatment carried out by a colleague should be careful of criticising previous treatment where they may not have all the relevant information. Negative comments can often stir up a completely unnecessary complaint, or worse, a claim, which may have very significant repercussions and impacts on the previous dentist.
The learning points from this case are:
- Evidence of preoperative warnings, and that they have been provided to the patient, is essential.
- The ‘particular patient’ warnings – if there are warnings that are relevant to this particular patient for this particular tooth, it is essential to capture that they have been given – even if extremely briefly. “Pat warned need for crown and night guard to prevent fracture warned re bruxism/ occlusal discrepancies” was sufficient in this case to defend our member’s position.
- Preoperative and postoperative radiographs indicate the need for treatment and the treatment as it was at the time it was provided.
- Be cautious in making judgements on work carried out in the past by other colleagues. It is often wise to seek further information and possibly seek another opinion before alleging that the treatment carried out was ‘substandard’ or ‘faulty’ in some way.
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Nuala Carney is a Dentolegal Consultant at Dental Protection.
Nuala believes in the value and importance of supporting dental professionals at every stage of their career and through the many challenges that can arise, both in and out of practice. She combines her dental, legal, and local knowledge as part of the Dental Protection team in Ireland
Nuala qualified from Trinity College Dublin in 1988 with honours, and completed the Specialist Fellowship Diploma of the Faculty of Dentistry (FFD RCSI) in 1994. She has experienced many different types of clinics, dental systems, challenges, and approaches to patient care.