PLP Endodontic Case Studies
Many PLP matters arise from failed endodontic treatment, a common cause of which is file separation. The following fact patterns highlight the features that distinguish defensible separated file cases from indefensible ones.
Mr. A presented to Dr. B, a general dentist, with severe pain in tooth 47. A radiograph revealed a periapical radiolucency and caries extending into the pulp of tooth 47. Dr. B’s records indicated that Mr. A was offered the option of endodontics followed by post/core and crown placement versus extraction and advised of the risk that root canal treatment could fail. Mr. A decided to proceed with the root canal.
Dr. B anaesthetized tooth 47 and initiated endodontic therapy, filing three canals.
Mr. A returned two and a half weeks later for continued treatment, during which a rotary file separated in the mesiobuccal canal. An attempt to retrieve the file was unsuccessful and Dr. B referred Mr. A to an endodontist. A radiograph taken by the specialist showed a separated file approximately 7mm in length in the apical third of one of the mesial canals. The endodontist recommended retreatment but the patient opted for extraction. Mr. A retained legal counsel, who wrote to Dr. B demanding compensation.
Ms. C was referred to Dr. D, a general dentist, for endodontic treatment after replacement of an amalgam by another dentist. Pre-treatment imaging showed a significant curvature of the mesiobuccal root.
During the procedure, a rotary file separated in one of the buccal canals. Dr. D continued treating the tooth and a second rotary file separated in another canal. Dr. D proceeded with obturation of the canals and placement of a permanent restoration. Upon completion, Dr. D advised Ms. C of the complication.
Ms. C came under the care of an endodontist who concluded that retreatment was not an option because of the location of the files and the tooth was eventually extracted. Ms. C retained a lawyer and commenced an action against Dr. D.
In Case #1, Dr. B did everything right:
- Mr. A’s chart confirmed the indications for treatment and that the patient was advised of his options.
- Dr. B appropriately referred Mr. A to an endodontist as soon as the complication occurred.
On the other hand, there were many concerns about Dr. D’s actions in Case #2:
- Dr. D should have considered referring Ms. C to an endodontist to perform the treatment because of the higher risk of file separation associated with significant root curvature.
- There was no evidence that Ms. C was advised of the increased risk of file separation because of her anatomy or that she was offered referral to a specialist.
- Dr. D should have stopped the procedure after the first file separated.
- Dr. D should not have completed obturation and permanent restoration of a tooth with two unsealed canals.
- Dr. D should not have waited until treatment was completed to tell the patient about the file separation.
Since file separation is not in and of itself indicative of negligence, PLP took a no liability position on behalf of Dr. B. The matter was not pursued by Mr. A and because no costs were incurred by PLP in defending Dr. B, no deductible was payable.
The action against Dr. D was considered indefensible and was settled with payment to Ms. C, triggering a deductible for Dr. D.
Dr. B’s case was defensible because of Dr. B’s good recordkeeping and because Dr. B did not make the situation worse by continuing treatment after separation of the file.
Assuming Dr. D had the skill to take on a case like Ms. C’s, Dr. D’s mistake was not in treating Ms. C or in breaking a file, but rather in not advising the patient of the option of having the procedure performed by a specialist and especially in persisting with the root canal after the incident occurred. Dr. D’s failure to recognize his limitations likely cost Ms. C her tooth and definitely cost PLP money.