How many of us feel calm and relaxed about our practices in the short and long term? Reasons differ but stressors include the possibility of recession, challenges finding staff, the rise and expansion of DSOs into the clinical marketplace, and changing patient behavior among many.
In the broad view of our profession, as individual clinicians, there is much we do not control. Conversely, there are many areas we do control, areas and actions which have a direct impact on our career satisfaction and enjoyment of practice, the primary of which is the quality of our patient care. Quality in this context is all inclusive, in that it encompasses everything that happens within the doors of our practices. Higher quality is the result of intentional planning, training, execution, and follow up. Conversely, a lack of quality can ultimately bottom out in malpractice claims and guilty verdicts stemming from a lack of the aforementioned planning, training, etc. This article was written to address several aspects of endodontic clinical preparation and general risk management that can improve patient service and ultimately raise the quality of patient care and satisfaction, ie, providing an endodontic diagnosis and being responsive and empathetic to patient communications, possible injuries, and complaints.
How a Case is Built
In recent years I have been retained extensively as an expert witness on both the plaintiff (patients) and defense side (doctor). Often, I am contacted by attorneys who first off want to know if they “have a case.” In other words, is the violation of the legal standard of care claim against the dentist credible given the patients report of events and the available records?
Most often, the records provided by general dentists to the plaintiffs’ attorneys are grossly incomplete (both in terms of what is provided and the actual notes) and handwritten (often illegible, and/or written by an assistant without a doctor’s countersignature). Radiographs tend to be out of date (untimely relative to the procedure), incomplete (no CBCT or PAs were taken where indicated), and not diagnostic (the films are elongated, foreshortened, don’t show the apex of the roots in endodontic cases, etc.) And, in endodontic cases there is almost universally a lack of a pulpal and periapical diagnosis prior to initiating treatment or making a treatment decision (ie, referral, lack of referral, delaying treatment, etc.).
Co-tango with the lack of diagnosis mentioned above, there is generally a complete omission of the history and appropriate testing. More specifically, the medical, dental, clinical history and examination are not recorded (if it happened at all). In short, a case has not been built to determine the current pulpal and periapical status and treatment is, for practical purposes, started without evidence. While writing an article about comprehensive endodontic diagnosis is beyond this articles scope, it is noteworthy that recording a chief complaint in the patient’s own words, and reviewing the medical, dental, and clinical history and recording the salient examination findings are essential notations in preparing an excellent clinical note. In addition, recording clinical (percussion, palpation, mobility, probing) and thermal /pulp testing (cold, hot, electric), periodontal, and radiographic findings are similarly essential. The above materials ultimately provide evidence and/or make the case for treatment, delaying treatment, or referral. Rarely, if ever, in my review of a large number of successful malpractice claims have the above steps been taken and recorded, quite the opposite.
It is noteworthy that poor recordkeeping is not, in and of itself, an act of malpractice. This stated, records are the defense, and the higher the quality of the records, the higher the quality of the defense. The converse is true. Interestingly, I have seen cases where the doctor realistically practiced above the standard of care, but the records were so poor the doctor had few ways to defend what was otherwise quite defensible.
Dealing With Patient Injuries
Out of the above lack of preparation for treatment, injuries can occur which subsequently lead to malpractice claims. A short list of endodontic claims includes broken files without informing the patient, lack of endodontic diagnosis, lack of informed consent and extraction of otherwise restorable teeth, injuries to the mandibular canal, injuries which occurred during treatment without rubber dam, etc. Ideally, if a proper examination and diagnosis is made, the clinician is honest with themselves with regard to their skills and resources (staffing, equipment, referral options, etc.), and the treatment is planned appropriately (taking these skills and resources into account), the vast majority of these injuries become foreseeable and preventable.
The foreseeable and preventable nature of these injuries is most evident in my view with regard to the recent phenomenon of injuries from extrusion of calcium hydroxide and endodontic sealer into the mandibular canal and associated structures. The extrusion of these materials can cause catastrophic permanent injury to the patient (disfigurement, permanent complete numbness along the nerve distribution, partial numbness, and dysesthesias, among other negative sequalae). Tragically, in many of the cases I have reviewed, the error of extrusion of these materials has been exacerbated by a delay in, or lack of, referral to competent microsurgeons and/or endodontists for evaluation and treatment. In essence, the clinician did not anticipate the initial risk of extrusion in treatment planning the case, did not obtain a CBCT where indicated, extruded a clinically significant amount of these materials into the mandibular canal and associated structures, and when the patient returned with the aforementioned sequalae, nothing was done to diagnose and treat the issue.
Compounding the aforementioned injuries, all too often, there is a distinct lack of communication, empathy and follow up which tips the balance toward a malpractice claim. Once injured, the patient is (correctly) insulted when the doctor will not see them, does not return their calls, does not refund money, and/or provides no care or options where indicated. The above lack of positive actions and empathy after injury are directly correlated in my experience with filing of malpractice claims. I’ve never met a plaintiff who liked the dentist they sued.
The Importance of Records
It’s easy to Monday morning quarterback and criticize from a distance, being a practicing endodontist, I understand the stresses, patient demands, clinical limitations, and difficulties of providing care to highly anxious and disagreeable patients. Clearly, the dental operatory can be a difficult space to work in. This said, the lack of excellent records mentioned above is also correlated with doctors working in a hurried environment where speed and turnover may be valued over service quality. In short, the doctor is in a hurry and stressed, and, in this environment does not operate optimally leading to a lack of examination, lack of diagnosis, lack of communication, lack of planning, lack of risk assessment, etc., with potentially catastrophic consequences.
The Importance of Excellent Training
As a case in point, in a recent deposition I reviewed the general dentist stated they did not know that extrusion into the mandibular canal was a risk of lower molar endodontics. Clearly it is, and, this lack of knowledge, combined with a lack of visualization, magnification and tactile control, and misuse of calcium hydroxide led to a permanent and debilitating injury. The claim amount, if successful, far exceeds the doctor’s insurance limits. As a result, the doctor may be paying for this injury out his/her pocket for the rest of their career.
The above phenomenon may be accentuated in a DSO setting, where doctors are often moving between offices, frequently working with different staff and different materials, and may be performing procedures infrequently, especially molar endodontics in anatomically sensitive areas. It underscores the importance of excellent training, skill assessment and appropriate referral where indicated.
Risk management, endodontic and otherwise, whether in a DSO, or private practice starts with having enough time to carefully evaluate the chief complaint and/or clinical situation, especially if the patient is symptomatic. Secondarily, accurate diagnosis has at its core a competent and thorough clinical and radiographic examination considering all the risk factors present (tooth location, calcification, perforation risk, separated file risk, patient anxiety, limitation of opening, among many others). Thirdly, after a diagnosis is made, the clinician must decide if they are the best person to manage the given patient and clinical challenge, and/or if referral is indicated and act accordingly, which includes providing detailed informed consent.
And finally, if an injury occurs, it is essential to acknowledge the injury immediately and take appropriate action with urgency and compassion. Altering records, hoping the problem goes away, becoming uncommunicative and/or refusing a refund is clearly unproductive and difficult to defend in court. As clinicians, we should not fear malpractice claims because we can certainly reduce our risk (almost to zero) with the steps outlined above, and, if an injury were to occur, taking responsibility and treating the patient as if they were family. I welcome your feedback.
ABOUT THE AUTHOR
Dr. Mounce graduated from Northwestern Dental School and received his endodontics certificate from Oregon Health Sciences University. He is a frequent expert witness and has lectured widely around the globe. He can be reached at richardmounce@mounceendo.org.
Disclosure: Dr. Mounce reports no disclosures.
