Learning Objectives
PLP cases arising from failed endodontic treatment often involve separated endodontic files. The following fact patterns highlight the features that distinguish defensible separated file cases from those that are indefensible.
Synopsis
Case #1
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 treatment.
Dr. B anaesthetized tooth 47 and initiated endodontic therapy, filing three canals.
Mr. A returned two and a half weeks later for continued treatment of tooth 16, 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.
Case #2
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 the curved buccal canal. Dr. D continued treating the tooth and a second rotary file separated in the other buccal 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.
Analysis
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 in the mesiobuccal canal.
- 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.
Outcome
Case #1: 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.
Case #2: The action against Dr. D was considered indefensible and was settled with payment to Ms. C, triggering a deductible for Dr. D.
Learning Outcomes
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 in persisting with the root canal treatment after the incident occurred. Dr. D’s failure to recognize his limitations likely caused the loss of Ms. C’s tooth. PLP incurred costs to settle the matter.