Risk Management in Endodontics

doi:10.1016/j.joen.2010.03.030

Journal of Endodontics

Volume 36, Issue 6, June 2010, Pages 982-984

https://doi.org/10.1016/j.joen.2010.03.030 Get rights and content

Abstract

Introduction

Endodontic claims are the most frequently filed malpractice claims in dentistry. The aim of this study was to categorize and review errors and complications related to endodontic procedures that resulted in legal actions against the treating practitioner.

Methods

All dental malpractice complaints reported to the Medical Consultants International Company (MCI) in Israel between the years 1992–2008 were retrospectively analyzed according to a structured form. All complaints were categorized as either financial risk bearing (eg, justified) or financial non-risk bearing (eg, nonjustified). The treatment errors that were found in the files were categorized according to phases of treatment: preoperative, intraoperative, and postoperative errors.

Results

A total of 720 complaints were analyzed including 520 complaints (72.2%) that were found to be justified and 200 complaints (27.8%) that were judged as not justified. Most of the treatment errors occurred during the intraoperative phase. In lower anterior teeth and in cases involving more than 1 tooth, significantly more errors were found during instrumentation and root canal filling (P < .05). There was a similar distribution of operator errors and of negative outcomes for teeth with elective endodontic treatment and teeth with endodontic treatment as a result of a pathologic process.

Conclusions

The technical skills of the dental practitioners performing root canal treatments require improvement. All possible risks and complications should be considered and explained to the patient before treatment.

Section snippets

Materials and Methods

Most of the dental practitioners in Israel (85%) are obligated to report any incidence or suspicion of legal action against them to the Medical Consultants International Company (MCI) as part of their professional liability insurance. All dental malpractice complaints that were reported to MCI between the years 1992–2008 (5217 total) were retrospectively analyzed.

Cases related to endodontic procedures included 720 patients, which were 13.8% of the total dental malpractice complaints. These 720

Results

A total of 720 complaints were analyzed, including 520 complaints (72.2%) that were found to be justified and 200 complaints (27.8%) that were judged as not justified.

The complaints included 221 (30.6%) male and 499 (69.4%) female patients. Mean age was 38.5 years (standard deviation, 13.9), ranging from 7–77 years. Average age for female and male patients was 39 ± 13.5 and 38.2 ± 14.1 years, respectively.

Data regarding the reason for RCT were available for 661 cases; 193 cases were elective

Discussion

The percentage of endodontic claims from total dental malpractice claims was 13.8%, second only to prosthodontics complaints. This percentage is similar to data in previous studies 2, 3.

Bjorndal and Reit (20) evaluated the reasons for and outcome of malpractice claims handled by the regional and national Danish Dental Complaint Boards. In their study no access to original material such as letters, office records, and radiographs was available. In the present study, dental history, the dentist's

Conclusions

1.
Technical skills of the dental practitioners performing RCT should be improved.
2.
Elective RCT bears the same risks as nonelective RCT. All possible risks and complications should be taken into consideration even before performing elective RCT, and the patient should be informed about alternative treatment options.
3.
Proper explanations before treatment (ie, proper informed consent) might save grief both to the patient and to the dentist.
4.
Proper documentation is of outmost significance.

References (25)

A.G. Selbst
Understanding informed consent and its relationship to the incidence of adverse treatment events in conventional endodontic therapy
J Endod
(1990)
C.P. Hapcook
Dental malpractice claims: percentages and procedures
J Am Dent Assoc
(2006)
M.K. Iqbal et al.
A review of factors influencing treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy
J Endod
(2008)
M. Torabinejad et al.
Endodontic or dental implant therapy: the factors affecting treatment planning
J Am Dent Assoc
(2006)
I. Tsesis et al.
Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique
J Endod
(2006)
S. Sharma et al.
Severe tissue necrosis following intra-arterial injection of endodontic calcium hydroxide: a case series
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2008)
D.J. Kleier et al.
The sodium hypochlorite accident: experience of diplomates of the American Board of Endodontics
J Endod
(2008)
M. Pelka et al.
Permanent mimic musculature and nerve damage caused by sodium hypochlorite: a case report
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2008)
A.H. Gluskin et al.
Thermal injury through intraradicular heat transfer using ultrasonic devices: precautions and practical preventive strategies
J Am Dent Assoc
(2005)
J. Escoda-Francoli et al.
Inferior alveolar nerve damage because of overextended endodontic material: a problem of sealer cement biocompatibility?
J Endod
(2007)

M.A. Pogrel

Damage to the inferior alveolar nerve as the result of root canal therapy

J Am Dent Assoc

(2007)

L.M. Lin et al.

Do procedural errors cause endodontic treatment failure?

J Am Dent Assoc

(2005)

Cited by (49)

Endodontic malpractice litigations in the United States from 2000 to 2021
2023, Journal of Dental Sciences
Citation Excerpt :
This result is approximate to that reported by Bjørndal et al.,12 wherein in 179 of the 482 (37.1%) endodontic claims, the dentist was liable, as determined by the Danish Dental Complaints Board. Furthermore, women file more lawsuits than men (60.8% vs. 37.1%), probably because women undergo more dental therapy than men.11,21 This finding is almost consistent with the report by Rosen et al. (women, 59.7%).14
Little is known regarding the outcomes and distinguishing characteristics of lawsuits related to endodontic procedures. This study used a verdict-based data from United States of America to analyze the factors associated with endodontic malpractice lawsuits and mitigate the risk of litigation.
The LexisNexis legal database was used to search for endodontic malpractice cases from January 1, 2000 to December 31, 2021 using the terms “medical malpractice” and (I) “endodontist” (II) “endodontics” (III) “root canal” (IV) “dental pulp.” Each case was reviewed for reported medical characteristics and litigation outcomes.
A total of 650 cases were initially identified, and 97 cases were included in the final analysis. Eighty-four (86.6%) of the 97 defendants were general practitioners; 42 cases favored the plaintiff, 53 (54.6%) favored the defendant, 1 was partial win/loss, and 1 was settled. The annual case mean was 4.41 ± 2.17 (Mean ± SD). The major allegations favored for the patients involving paresthesia, root perforation, rubber dam not use, wrong tooth therapy, and infections. Plaintiffs who claimed with post-procedural reasons had a significantly higher winning rate than non-post-procedural reasons (P < 0.05).
In the present study, 54.6% of endodontic litigation favored the dentists in the US. The authors recommend that general practitioners refer complicated cases to endodontists and treat carefully to avoid paresthesia, canal perforation and infections. Clinicians should always diagnose and treat correctly, shared decision making with the patient, use rubber dam routinely, and timely management to prevent malpractice claims.
Chamberless Endodontic Access for Treatment of Calcified Anterior Central Incisors
2021, Journal of Endodontics
Citation Excerpt :
This clinical case also demonstrates the application of retro u-file canal instrumentation in teeth without conventional previous endodontic access. Furthermore, the use of the CEA overcomes many of the challenges associated with traditional endodontic access in calcified anterior teeth, such as the medicolegal concern of endodontic operative technical errors during access cavity preparation, including removing cervical dentin in a wrong direction when working from the occlusal27. CEA could be criticized for reduced microbiologic debridement of the coronal aspect of the root canal system.
Modern techniques for treating maxillary anterior central incisors with calcified canals emphasize maintaining coronal dentin with small crown access. Alternatively, traditional retrograde surgical procedures are focused on creating an apical seal predominately limited to the remaining resected apical one third of the root canal space. A treatment option for calcified anterior teeth, with avoidance of traditional orthograde access, is presented. Chamberless endodontic access (CEA) to the canal is chosen in this case, leveraging a previous surgical treatment and osseous defect to create straight line canal access.
A tooth presenting with a chronic apical abscess and an apparent previous apical surgery was instrumented and obturated using a CEA avoiding the traditional orthograde approach to the root canal system. Straight line approach was achieved retrograde and canal instrumentation was performed using ultrasonic activated U-files. Canal obturation was accomplished with warm vertical condensation technique followed by placement of an apical retroseal.
A successful 52-month outcome demonstrated the viability of CEA facilitating retrograde instrumentation and obturation.
Use of CEA simultaneously protected the clinical crown and provided a successful clinical outcome. A viable option for treatment of an anterior calcified canal and abscess due to dental trauma, CEA mitigates many of the risks associated with the treatment of calcified root anatomy.
Impact of Case Difficulty on Endodontic Mishaps in an Undergraduate Student Clinic
2018, Journal of Endodontics
The aim of this study was to identify the effect of case difficulty on the number of endodontic mishaps and the number of treatment visits using 2 different instrumentation methods, hand files, and reciprocating engine-driven WaveOne files (Dentsply Maillefer, Ballaigues, Switzerland) in an undergraduate student clinic.
Endodontic treatment performed by fourth-year dental students using 2 different instrumentation methods was evaluated: hand files and reciprocating engine-driven WaveOne files. All cases were categorized according to the American Association of Endodontists case difficulty assessment form. Endodontic mishaps related to instrumentation and treatment visits needed to complete the treatment were recorded.
Of the 257 teeth included in the study, 141 were instrumented with hand files and 116 with WaveOne files. Eighty-two teeth (31.9%) were registered with at least 1 endodontic mishap. The most frequent endodontic mishap was overinstrumentation (17.5%). This was followed by loss of working length (8.56%), obturation more than 2 mm from the radiographic apex (8.56%), overfill with gutta-percha (6.61%), canal transportation (4.28%), instrument separation (2.33%), and lateral or strip perforation (1.56%). Several endodontic mishaps were significantly correlated. Cases in the high difficulty category had significantly more endodontic mishaps (P < .001) and required more treatment visits (P < .01). There were no significant differences in endodontic mishaps or the number of treatment visits between the hand and engine-driven groups. Several endodontic mishaps were associated with significantly more treatment visits (P < .05).
Case difficulty rather than the instrumentation method was the main determinant of endodontic mishaps in the undergraduate clinic. The American Association of Endodontists case difficulty assessment form is an important and valuable tool in undergraduate dental education to predict potential endodontic mishaps and the number of treatment visits.
Relationship between Root Apices and the Mandibular Canal: A Cone-beam Computed Tomographic Comparison of 3 Populations
2018, Journal of Endodontics
This study aimed to investigate the difference in the location of the inferior alveolar nerve (IAN) in relation to the apices of mandibular molars in 3 different populations using cone-beam computed tomographic (CBCT) imaging and to assess the proportion of teeth in close proximity (a distance of 1 mm or less) to the IAN.
Random CBCT images (N = 1224, Israel = 408, South Korea = 416, and India = 400) were examined. The shortest distance to the mandibular canal was measured by imaging software.
The mean distance was 4.81 ± 2.15 mm. The mean distances for Israel, South Korea, and India were 4.60 ± 2.37 mm, 5.45 ± 2.13 mm, and 4.35 ± 1.76 mm, respectively. The distance in samples obtained from South Korea was significantly larger than the distance in samples obtained from Israel and India (P < .05). Samples from Israel exhibited close proximity in 6.6% of samples versus 3% in samples from India and 0.7% of samples from South Korea, a statistically significant difference (P < .05).
Although variation in tooth morphology in different populations was widely researched, the variation in the location of the IAN in relation to tooth apices of different populations was not addressed in the literature. Our study reveals that a difference in the distance of the apices to the IAN exists between populations as well as a difference in the proportion of teeth in close proximity to the IAN.
Uncertain Decision-Making in Primary Root Canal Treatment
2017, Journal of Evidence-Based Dental Practice
A systematic review of literature was conducted to compare the success and survivability of primary root canal interventions.
The Preferred Reporting Items for Systematic Reviews and Meta Analyses protocol was adopted in this study to systematically assess and report systematic reviews related to success or survival or failure rates of primary root canal interventions. MEDLINE and Cochrane Oral Health Library were both searched by using specific search terms to identify relevant literature, until June 2016. The search was augmented by handsearching. Then, the quality of the included systematic reviews was assessed by using the Revised Assessment of Multiple Systematic Reviews (RAMSTAR) protocol.
Only 9 systematic reviews were identified. The RAMSTAR scores of the included reviews ranged from 43/44 to 29/44. Nevertheless, the later reviews did not provide sufficient evidence or statistically significant evidence to support any of the interventions used during primary root canal treatment. In addition, a number of key steps during primary root canal treatment, such as types of dental files, root canal instrumentation techniques, orthograde obturation materials, and techniques, were not assessed by systematic reviews.
The current status of evidence related to the success and survivability of primary root canal interventions is lacking. This puts dentists under marked degrees of uncertainty. Consequently, patients are potentially exposed to health care risks. It is then essential to develop tailored methods and tools for decision-making under uncertainty to aid both dentists and patients engaged in primary root canal treatment.
The Prognosis of Altered Sensation after Extrusion of Root Canal Filling Materials: A Systematic Review of the Literature
2016, Journal of Endodontics
Citation Excerpt :
A female predominance was described in several nerve injury studies, such as nerve injury related to local anesthesia injection, third molar surgery, and nerve injury caused by traumatic injuries (8, 30, 69, 70, 71). The reason for this sex discrepancy may be explained by the fact that relatively more female patients are seeking dental treatment (8, 71, 72). Sex anatomic variation is another possible explanation.
The aim of this study was to systematically review and evaluate the literature regarding the prognosis of altered sensation after extrusion of root canal filling materials and the possible factors influencing it.
A systematic search of the literature was performed to identify studies that reported on altered sensation after extrusion of root canal filling materials during endodontic treatments. The articles were evaluated for their relevance based on strict inclusion criteria, and the identified suitable articles were subject to data extraction and analysis.
Initially, 109 possibly relevant articles were identified. After screening and full-text evaluations, 28 articles that met the inclusion criteria were analyzed, reporting on a total of 84 patients with altered sensation after extrusion of root canal filling materials. All the included studies, except 1 case series, were case reports. Under the limited available data, the extracted data showed that 91% of the patients had fully or partially recovered over time. Most of the cases in the lower molars as well as most of the cases in which the obturation was performed using paraformaldehyde-containing sealer or cases in which an immediate treatment was not performed did not fully recover.
The current scientific knowledge regarding the prognosis of nerve injuries caused by overextruded endodontic materials relies primarily on case reports. Within the limitations of the published data, it seems that the tooth locations, types of extruded materials and the obturation technique, and treatment after the injury may affect the nerve injury prognosis.

View all citing articles on Scopus

View full text

Clinical ResearchRisk Management in Endodontics

Abstract

Introduction

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Conclusions

J Endod

J Am Dent Assoc

J Endod

J Am Dent Assoc

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Am Dent Assoc

J Endod

J Am Dent Assoc

J Am Dent Assoc

Clinical Research
Risk Management in Endodontics