12 • Clinical risk


GETTING TO THE


MDDUS dental adviser Doug Hamilton discusses some common clinical pitfalls in endodontics from a dento-legal perspective


P


rovision of endodontics is commonly required in order to secure dental health and relieve discomfort. Carried out efficiently and painlessly, it can provide the foundation for a functional dentition, build a


relationship of trust between dentist and patient and contribute to the establishment of a successful practice. However, it is also technically difficult and failure can result in the onset of unpleasant symptoms, followed by loss of teeth and expensive restorations. In an age of growing patient expectation, poor endodontics can also lead to litigation and regulatory scrutiny. Detailed guidance regarding endodontic


techniques is beyond the scope of this article but I can offer some general advice which, if heeded, will help to minimise problems in this complex area.


Diagnosis Dental practice can be busy and stressful – and if a patient with pain is ‘squeezed in’ there may be a temptation to provide relief by ‘getting the pulp out’ as quickly as possible. However, long before a size 10 reamer is picked up, key points must be addressed. For example, is the discomfort definitely of dental origin? If so, could this be relieved without root canal therapy? Answering these fundamental questions requires a careful history and examination. Symptoms such as marked localised


tenderness to pressure or pain which persists after thermal stimuli and/or disturbs sleep might well indicate a moribund pulp, in which case endodontics may be a reasonable treatment option. However, this diagnosis must be confirmed by thorough examination.


ROOT OF THE PRO Locating the symptomatic tooth can be


quite simple in some cases, for example in a complicated crown fracture or a lone-standing carious tooth. But acute pulpitis is notorious for presenting diffusely and when you are presented with heavily filled but otherwise unremarkable quadrants, locating the inflamed pulp can be time-consuming and difficult. Diagnostic aids such as ethyl chloride and percussion can be of great assistance in this process but cannot always be completely relied upon, particularly when treating the more anxious patient who may report pain in every tooth tested. Radiographs can be helpful, particularly if the pulp has become moribund due to secondary caries or a particularly deep restoration but there will still be occasions where a definitive diagnosis simply cannot be reached. In these cases, treatment should be delayed until symptoms localise or a second opinion can be obtained.


Assessment In most instances it will be possible to confirm the source of the patient’s problem. However, even if it seems likely that endodontics will be curative, that size 10 file must still remain untouched until other aspects of the case are considered. For example, is the tooth in question restorable? There is very little point in completing the most beautiful canal filling only for the final restoration to fail catastrophically at an early stage. Did the radiographs reveal potential


complicating factors, such as bifid roots or calcifications? The presence of anatomical anomalies such as these might contra-indicate root canal therapy or require the assistance of a specialist. Factors such as the prospects of a successful endodontic completion and a stable coronal restoration must be properly assessed before recommendations can be made to the patient.


Consent Informed consent must also be secured and in endodontics should include advice regarding alternatives such as extraction, as well as a description of the proposed procedure together with possible risks such as post- operative discomfort and infection recurrence.


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