Although more than 41,000 endodontic procedures are performed every day in the United States, treatment failures and adverse outcomes may occur. This article describes one scenario that led to a professional liability claim and malpractice allegations.  
 
Claim Case Study
Practitioner: General practitioner
Claimant: 50-year-old male, history of hypertension (controlled), poor oral hygiene and mild to moderate periodontal disease.
 
Risk management topics: patient/case assessment, informed consent, specialty referral
 
Facts:
The patient presented to the insured dentist for urgent care because of a “toothache” on the lower left side. The dentist performed a clinical examination and obtained a periapical radiograph of the area. The image revealed a periapical radiolucent lesion associated with tooth 19. The doctor recommended endodontic therapy rather than extraction. The tooth had an existing restoration with recurrent decay and sufficient tooth structure remained for a successful restoration. After obtaining the patient’s informed consent, the dentist initiated endodontic therapy.
 
The dentist noted that the distal canal of 19 appeared calcified approximately 3 mm from the root apex. Indeed, the canal was not negotiable past that point during treatment. As a result, the canal fill was short of apex. As part of the informed consent discussion, the dentist informed the patient that the tooth might require retreatment or surgery due to the calcified and non-negotiable canal. He also advised that, in some cases, extraction of the tooth may be necessary.
 
Although the doctor recommended a crown for tooth 19, and the office scheduled the patient for a comprehensive examination, no further treatment occurred. The office did not hear from the patient again until approximately 18 months later via a letter. The letter indicated that the patient developed an infection on the lower left portion of his mouth shortly after the root canal procedure, and he sought care with another dentist. The new dentist opined that the tooth would require endodontic retreatment, consistent with the insured dentist’s explanation. The patient then saw an endodontist, who reportedly stated that the condition of tooth 19 was serious. Ultimately, four separate visits with the endodontist were required to complete the retreatment.
 
The treating endodontist noted: “The root canal fill was short in the distal canal, leaving tissue and resulting in the formation of a lesion of endodontic origin requiring retreatment. The mesial roots were blocked several mm short of the apical terminus.” A radiograph taken prior to retreatment showed a short fill of the distal canal and a large surrounding radiolucency. The mesial canals fills were not alleged to have been inadequate. However, all three canals were retreated. When retreatment proved to be unsuccessful, the endodontist performed apical surgery a few months later. The patient indicated that the tooth stabilized, and a final restoration was in process.
 
Key Allegations:
Failure to perform root canal treatment to the standard of care, failure to refer to an endodontist.
 
Alleged Injury/Damages:
Continuing infection due to a failed endodontic therapy, requiring a complicated retreatment and surgery. The plaintiff/patient demanded $20,000 in damages, which included pain and suffering and all related treatment costs. 
 
Analysis:
The patient alleged that his problems with tooth 19 were caused by mistreatment during the original root canal procedure. Since the treatment of tooth 19 fell within the scope of services that a specialist would provide, the plaintiff in this case planned to retain an endodontist expert witness. He also obtained a report from the treating specialist. In most cases, a general practitioner who performs endodontic therapy will be held to the standard of care required of an endodontist. The plaintiff asserted that filling the distal canal substantially short of the root apex breached the standard of care.
 
The dentist contended, “The canal was not negotiable any further at the time of treatment.” Therefore, he was required to choose between making a referral to an endodontist and taking a chance that a short fill would be successful. The endodontist was able to treat the apical portion of the canal, proving it was negotiable and refuting the insured dentist’s justification for the incomplete fill. Had the endodontist also been unable to successfully instrument and fill the apical third of the canal, the claim would have been more defensible.
 
Outcome:
The claim settled for $7,500.
 
Risk Control Comments:
The dentist discussed the benefits and risks of endodontic therapy with the patient, including the possibility of retreatment and/or apicoectomy. The discussion also included extraction and no treatment as alternatives. The patient signed a consent form, which was included in the patient dental care information record.
 
Endodontic therapy is within a general dentist’s scope of practice. However, because this treatment is also within the scope of an endodontist, the alternative of specialty referral should be offered. During the informed consent process, this alternative was not discussed with the patient. Although the dentist performed endodontic therapy several times each month, he had very limited experience with calcified canals. The defense expert believed that referral was indicated due to this limited experience and the questionable prognosis for tooth 19.
 
Failure to consider referral compromised patient care and defense of the case. Notwithstanding the disclosure of risks, a signed informed consent form does little to protect a practitioner if the standard of care is not subsequently met. Although the dentist was hesitant to consider settlement negotiations initially, he understood that going to trial would involve significant time away from his practice and other patients and would cause stress for the dentist and his office personnel.
 
The defense team noted that the patient required root canal therapy, in part due to his infrequent dental visits and relatively poor oral hygiene. Patients are responsible for their own oral health. Whether the dentist treated or referred, the patient would have required extraction or endodontic treatment, and, perhaps, apicoectomy. The defense team effectively used these issues to their advantage and negotiated a settlement well below the plaintiff’s initial demand.
 
Dentists may wish to consult these resources on endodontic care from the American Association of Endodontists (AAE):

• Endodontics: Colleagues for Excellence (newsletter)
• AAE Treatment Planning and Case Assessment Tools
• AAE Guidelines and Position Statements, including the AAE Whitepaper, Treatment Standards
• Additional AAE clinical resources

 
Article by: Ronald Zentz, RPh, DDS, FAGD, CPHRM
CNA Dental Risk Control
 
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These are illustrations of actual claims that were managed by the CNA insurance companies.  However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA.   This material is for illustrative purposes and is not intended to constitute a contract.  No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
 
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