Inadequate Documentation and Failed Root Canal Therapy Associated with a Case of Serious Infection and other Injuries
Dental Expressions® -- From the CNA Claim Files
Accurate and thorough records are one of the most powerful risk management tools, as the information captured can support that the professional services provided met or exceeded the standard of care. In addition, comprehensive, timely documentation reduces the opportunity for treatment errors and communication problems. One of the most significant challenges in defending professional liability claims occurs when diagnosis, treatment, referral, consultation and/or adverse events are not supported by appropriate documentation.
Claim Case Study
Practitioner: General dentist
Claimant: 48-year-old male with a history of type 1 diabetes (T1D) and hypertension.
Risk management topics: inadequate records and documentation, inadequate radiographs and diagnostic work-up; failure to seek dental endodontic consultation or refer for care; abandonment (inadequate emergency care)
Facts:
An established patient presented with pain from biting pressure related to a mandibular first molar. The insured dentist (dentist 1) obtained an intraoral periapical radiograph and recommended root canal therapy (RCT). Following the completion of the RCT, dentist 1 placed a composite restoration at a subsequent visit. Several months later, the patient sought care for two painful areas— one in the posterior maxilla and the other in the mandible, near the prior RCT. While dentist 1 was out of the office for several days, the patient sought care from another dentist (dentist 2).
Dentist 2 recommended that the root canal filling in the mandibular first molar be removed and that the tooth be re-treated. A radiograph showed a slightly underfilled distal canal with a small periapical radiolucency. The patient then returned to dentist 1. Since the patient’s discomfort had subsided, dentist 1 scheduled appointments to complete preventive and restorative care over several weeks, before addressing the RCT re-treatment.
Following completion of the re-treatment procedure with dentist 1, the patient had a reoccurrence of pain and presented to dentist 2, as dentist 1 was not available that day. Dentist 2 administered a local anesthetic for pain relief, removed occlusal contacts from the first molar tooth, prescribed an antibiotic and suggested referral to an endodontist, or extraction of the tooth.
A few days later, the patient sought care at a local hospital emergency department (ED). Examination revealed substantial swelling and fever due to an apparent infection in the vicinity of the re-treated first molar tooth. The swelling required a visit to the operating room for incision and drainage, as well as removal of the offending mandibular first molar. The diagnosis: lateral pharyngeal abscess with hematoma, extending into the floor of the mouth. Post-surgery, the patient continued to seek treatment for ongoing paresthesia, hyperalgesia, and other complaints.
Key allegations:
RCT treatment below the standard of care; inadequate records, including inadequate diagnostic work-up and radiographs; failure to obtain needed consultations or refer for care; and abandonment/inadequate emergency care.
Alleged injury/damages:
Infection, tooth loss/disfigurement, medical expenses, pain and suffering, mental anguish.
Analysis:
A review of the records and expert opinions for this claim highlight a number of risk management topics, including the following:
--Recordkeeping and documentation. When RCT or any other treatment is recommended, objective clinical findings, test results and diagnosis must support the treatment plan and be adequately documented. While a radiograph was taken to aid in the diagnosis in this case, the findings were not recorded. Moreover, as RCT may be complex, it should be performed only after obtaining and documenting the patient’s informed consent, including disclosure of the nature of treatment, treatment alternatives and foreseeable risks (such as tooth loss and infection), as well as the risks associated with no treatment. The patient record did not include a written/signed consent form or a supporting progress note.
--Specialist treatment/referral. While all dentists may perform root canal therapy, non-endodontists should offer referral to an endodontist as a viable treatment alternative to reduce the risk of a failure-to-refer allegation. Dentists must honestly assess their own skill and experience and discuss the alternatives with the patient. In this case, file sizes and file lengths were not documented, and no post-fill radiograph was produced or documented in the records. Later radiographs revealed radiolucent areas associated with other teeth with RCT performed by dentist 1. Root canal fillings were well short of the root apices. Although dentist 2 recommended that the patient consider re-treatment of the molar RCT by an endodontist, the patient returned to dentist 1, having been a long-time patient at the insured’s office. However, re-treatment was delayed for unknown reasons and other treatment needs were addressed instead. If a referral to a specialist was suggested or made prior to the initial RCT or re-treatment, it was not documented.
--Abandonment. Dentists should inform patients how to access care in the event of a dental emergency, whether it occurs during customary business hours or after hours. Treatment may be provided by the dentist or by colleagues with whom the dentist has made such arrangements. In this case, the dentist was not available to manage the patient’s pain and swelling immediately after the root canal re-treatment, and he failed to inform the patient of emergency care options. He subsequently failed to examine the patient, who later sought care at a local hospital. Failure to effectively manage the patient’s post-treatment emergency care needs left dentist 1 open to an allegation of abandonment.
Outcome:
The total incurred (indemnity payment plus legal fees and other claim expenses) was approximately $150,000.
If you become a defendant in a malpractice action, a comprehensive dental record is your primary mode of demonstrating the care provided. At a malpractice trial, the jury will be told, and the defendant dentist must acknowledge, that all pertinent patient information (personal and clinical) should be documented in the dental record. If the record is then found to be deficient, the dentist’s credibility as a witness is significantly impacted.
It is difficult for a plaintiff to challenge an accurate and unaltered dental record, written at the time of treatment. The practitioner who is aware of the importance of keeping detailed records and does so consistently enhances both patient safety and legal defensibility. On the other hand, poor records make it exceedingly difficult to effectively defend a dentist against a claim or lawsuit, although excellent care may have been provided.
Readers may be interested in the following resources related to antibiotic prescribing and RCT patient assessment/referral.
Article by: Ronald Zentz, RPh, DDS, FAGD, CPHRM
CNA Dental Risk Control
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