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Advice regarding cost is also required. A written estimate is mandatory for all NHS patients, regardless of whether the endodontics is to be carried out privately. Remember that NHS Terms of Service in Scotland do not permit the mixing of private and NHS treatment on a single tooth. An NHS patient considering private endodontics must be advised why this treatment is being offered outwith the NHS and provided with a cost estimate of any restoration.


Problems….. Endodontics is fraught with potential complications and some can be indicative of a lack of care and attention by the dentist. For example, inhalation of an instrument will almost inevitably be the result of a failure to use rubber dam and not using an irrigation syringe with luer-lock attachment and side vents may contribute to the forcing of sodium hypochlorite into apical tissues. Offering a defence in such situations can be very difficult. Other problems may be simply beyond your


control, such as instrument failure. However, if a complication is not recognised, or if its occurrence and possible remedies are withheld from the patient, then the practitioner will be left in a very weak position. Thankfully, many endo-related problems involve less calamitous outcomes, such as recurrent pain or sinus. Regardless of operator skill and experience,


not all root treatments will be successful and this need not be the result of poor technique. However, they ought to be a matter of regret and the ethical dentist will always endeavour to reassure the patient and remedy the situation, perhaps by offering repeat treatment or referral to a specialist. Unfortunately, there will still be circumstances in which complaints or even litigation may follow. Just how successfully such cases can be


defended depends on a number of factors. Pre-op assessment, treatment planning and reliable consent are important but the most common line of criticism with regards to failed endodontics is the quality of the final root filling. Problems can occur even with the most perfect canal obturation. In cases where the canal filling appears deficient, there may be a perfectly reasonable explanation for this which was accepted by the patient before treatment commenced. The sad truth is, however, that post-operative films showing obturation of a poor standard are often an accurate indicator of a lack of care in shaping and filling the canals. Excuses for poor work based upon


commercial and time constraints simply will not suffice. Painstaking canal preparation, assisted by appropriate radiographs to establish the working lengths (or, at the very least, use of an


PHOTO: CHRIS KNAPTON/SCIENCE PHOTO LIBRARY


apex locator) and followed by a film which records a good final obturation are essential. Clearly, adherence to this regimen will maximise the chance of a successful treatment and stress-free day and demonstrate an adequate standard of care should problems later arise.


One final medico-legal requirement underpinning all of the above is record keeping. No matter how comprehensive the consenting process or how carefully the working length was measured, without evidence of these processes in contemporaneous legible notes your defence in any subsequent complaint or a claim will be limited. It is critical that each stage of the treatment, from the initial history to post-operative instructions, is clearly recorded for future reference.


Conclusion Endodontic technique must be learned in the first instance from teaching staff and experienced colleagues and perfected by subsequent repetition, while always keeping up with new developments. Reference to the general guidelines discussed above should help avoid complaints and litigation. However, if problems do occur, please seek advice from MDDUS at an early stage.


Case study Patient A attends the practice of dentist B complaining of broken down lower right premolars. Consent is obtained for root canal treatment followed by crowns. However, after completion of endodontics, the patient decides, for commercial reasons, to source the crowns in Eastern Europe. Patient A is subsequently examined by an overseas dentist, who declines to provide crowns because the root fillings are well short of the radiographic apices and poorly condensed.


On returning to the UK, the patient writes to dentist B requesting compensation. Refund of all treatment fees is provided but further remuneration to cover travel expenses is considered inappropriate. Patient A accepts the proffered compensation but then writes to the GDC, whose subsequent investigation focuses not only on the deficient obturations but also on the absence of any record that final X-rays were taken and checked. No defence can be put forward to these allegations and dentist B receives a written warning from the GDC.


Doug Hamilton is a dental adviser at MDDUS


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