Avoiding herodontics

Ms B was suffering from pain that kept her awake at night. An examination by the dentist established tooth 27 was the cause of discomfort. The 27 had extensive dental decay and a missing buccal wall. Ms B had an otherwise intact arch and was keen to save the tooth – she did not want a dental extraction.

The dentist explained that endodontic treatment carried no guarantee of success,especially with the extent of damage to the enamel walls, and extraction was offered as the only realistic alternative.

Ms B was quite persistent in her demands for root treatment, along with a full coverage crown, and was unwilling to be referred to a specialist. The dentist felt pressurised by the patient and embarked upon the endodontic treatment against her better judgement.

Five visits later, only two of the canals had been located and the third may have been perforated as it bled on instrumentation.This was discussed with Ms B and the tooth was dressed.

Whilst the endodontic treatment was becoming more complicated, Ms B was still unwilling to consider an extraction and was forceful in her request for the root treatment to be completed by the practitioner.

Further explanations were provided, but despite this Ms B remained convinced that a crown would solve the problem. She decided to visit a second dentist and was informed that the tooth had an incomplete root canal treatment.

The first dentist received a letter of complaint questioning why the endodontic treatment had not been completed in five visits and why she had been charged for this incomplete and unsuccessful treatment.

The dentist contacted Dental Protection for advice on how best to respond.

Whilst the clinical records were detailed,the practitioner was vulnerable in some areas regarding the clinical care provided. In terms of the pre-operative assessment, the restorability status of the tooth at the outset was questionable. During the procedure the dentist could not place a rubber dam because of insufficient residual coronal tissue and owing to a lack of anatomical landmarks, a perforation occurred. With hindsight, the practitioner realised that the decision to carry out root canal therapy intervention had been a poor one, and she should not have attempted the procedure in the first place.

With Dental Protection’s advice and assistance the complaint was resolved by refunding Ms B for the initial endodontic treatment and also contributing towards the cost of the second dentist’s assessment.

Had Ms B pursued the matter with a claim for clinical negligence, the solicitors could potentially allege that Ms B had been subjected to an inappropriate procedure with associated pain and suffering.

Learning points

• Be alert to patient-led dentistry and the demands of strong-willed patients. Unrealistic expectations should be identified and managed from the outset. The reasons why the treatment is inappropriate should be communicated effectively.
• Avoid being coaxed by persistent patients into carrying out treatments which have a slim to zero chance of success.
• Just because a patient consents to treatment, it doesn’t necessarily mean that the treatment is appropriate.
• In this particular case, the complaint was resolved by a detailed letter of explanation and a refund of fees.
• In trying to appease the patient, the dentist had spent over three hours attempting treatment that was essentially doomed to fail, and then had to spend even more time managing the resulting complaint.
• This case highlights the dangers of attempting heroic dentistry; dentists are unlikely to be thanked for lack of success.
• Unrealistic expectations should be managed carefully from the outset.