MDDUS case study: root canal treatment
Mr X should have been advised immediately of complications during his treatment
[ WORDS: AUBREY CRAIG ]
Mr X attends his local dental practice for a routine dental examination. He advises the dentist that he has been working abroad for approximately three years and has not attended for any dental treatment during this time. Ms S, Mr X’s dentist, is advised that he has been experiencing some discomfort in the upper left quadrant of his mouth, for approximately three weeks. The discomfort is brought on with hot and cold liquids, as well as eating. The discomfort lasts for a few minutes but then goes away and Mr X has not found it necessary to take any analgesics for this discomfort. Ms S updates Mr X’s medical history and carries out a thorough extra-oral and intra-oral examination noting that, in relation to tooth UL5, there is a cavity present in this tooth. She advises Mr X that this tooth is the most likely cause of his symptoms. However, as he has not been for some considerable time, routine radiographs are taken of Mr X’s posterior teeth revealing two other cavities that will require restoration.
Mr X attends with Ms S for the required treatment. The cavity present in tooth UL5 is larger than originally expected, although there is no direct pulp involvement. Ms S advises Mr X that further treatment may be required to this tooth including either root canal treatment or extraction should symptoms recur. The other two teeth are restored routinely and Mr X receives a scale and polish in addition to the restorative treatment.
Unfortunately, Mr X returns to see Ms S some three weeks later advising her that, initially, there were no issues with the tooth, however, over the past couple of days discomfort has been increasing and he has had his sleep disturbed over the past couple of nights, necessitating him taking analgesics for this discomfort.
Ms S examines the tooth in question and notes that it is slightly tender to percussion, but there is no swelling or mobility associated with the tooth. Ms S advises Mr X that it is highly likely that the pulp within the tooth is dying off and, as warned, additional treatment is required. Mr X advises Ms S that he clearly recalls her advising him that additional treatment would be required and requests that the tooth is saved if at all possible. Ms S proceeds to take a periapical radiograph of the tooth and discusses her findings with Mr X. The radiograph shows that the tooth appears to have one root with early signs of infection present at the tip of the root and therefore Ms S advises Mr X that root canal treatment would be required to save the tooth. She also advises him that once the root is treated then the tooth should be crowned to protect it and prevent possible fracture and tooth loss.
Mr X is seen the next day by Ms S where, following administration of local anaesthetic and the application of dental dam, tooth UL5 is accessed. The remains of the pulp are removed, the canal irrigated, a working length determined by way of an apex locator and the tooth appropriately dressed.
Mr X returns to see Ms S the following week and reports no symptoms. At his request, local anaesthetic is administered and dental dam applied. Ms S proceeds to prepare the root canal using hand instruments. Following suitable preparation, further irrigation and drying of the canal, it is obturated with gutta-percha and an appropriate sealer. The tooth is restored and Mr X is advised that the tooth should be crowned but this should be delayed for approximately one month to ensure that the tooth remains symptom-free and healing begins. Ms S takes a post-root treatment radiograph and notes that the root treatment is approximately 7mm short of the radiographic apex. She does not advise Mr X of her findings but notes in the records that the root treatment is short and this is due to “instrument failure”.
Unfortunately, Mr X returns to the surgery some two days later as part of the dressing has come away. Mr X sees another dentist at the practice who reviews the post-root treatment radiograph taken by Ms S. This practitioner is somewhat alarmed in relation to the radiographic findings and discusses these with Mr X. Mr X states that he was not made aware of any issues with the root treatment and was planning to return to see Ms S some two weeks later for crown preparation. Mr X is advised that the tooth requires re-root treatment. Options are provided in relation to this being carried out at the practice, referral to the local dental hospital or referral to a specialist endodontic practitioner. Mr X requests that he is given some time to think about this and contacts the practice the next day requesting a specialist endodontic referral. This is duly actioned.
The practice then receives a letter of complaint from Mr X. This is provided to Ms S who seeks support from her indemnity provider. Ms S carefully reflects on the quality of care provided and, with the support of her indemnity provider, arranges that Mr X would be reimbursed any fees incurred by the specialist endodontist. Mr X is very pleased with this outcome and following successful completion of endodontic treatment returns to the practice to see Ms S for crowning of tooth UL5.
Analysis / Outcome
It is accepted that root canal treatment can be challenging. However, as part of the consenting process, it is important that pre-treatment radiograph is available allowing the practitioner and the patient to discuss any findings and, indeed, any difficulties that might be encountered including curved canals or sclerosed canals. However, it is important that:
- All practitioners comply with relevant regulations.
- The dental records of any patient should be accurate, complete and contemporaneous, reflecting discussions that have taken place between the practitioner and the patient.
- Patients should be advised immediately of any complications of treatment and that this is fully recorded in the dental records.
Aubrey Craig is head of dental division at MDDUS