Introduction
Medical malpractice is an act of a medical professional deviating from the set regulations
and standards that result in injury or damage to a patient. Another associated term
is “medical negligence,” that is, a careless action of a medical professional jeopardizing
the required standards of healthcare.[1] Dental malpractice is very similar to medical malpractice, where a dental professional
fails to follow the required standards of practicing dentistry, thereby harming the
patient.[2] Although the matter of medical practice errors among healthcare professionals is
well known and on the rise, the exact “numbers” have been always been difficult to
collect, making it almost impossible to have a well-defined image of the phenomenon.[2]
The better understanding of patient’s rights and organized protocols for compensating
any damages has involved more public attention. As a result, the number of reported
malpractice cases has increased remarkably in recent years among many parts of the
world.[3]
[4] Like any other healthcare professional, dentists are also exposed to risks of causing
damage to patients, leading to malpractice. In such kind of circumstances, if a dentist
risks the patients’ life, or tissues or incurs any other damages, the dentist may
have to face legal consequences.[5]
[6] There is no doubt that procedures performed by general dentists and endodontists
are highly technique sensitive, and require a high-level of training, knowledge, as
well as cognitive and psychomotor skills.[7] Among various disciplines of dentistry, endodontics-related cases witness the most
frequently filed malpractice claims.[8] For instance, endodontic malpractice claims have commonly been reported in 14% and
17% of Swedish[9] and USA[10] populations, respectively. In Italy, a recent study reported a reasonable number
of technical “errors” during endodontic procedures, including perforations (13%) and
broken instruments (6%).[11] In terms of reported malpractice claims, the majority of endodontic malpractice
claims have been filed by women corresponding to their higher frequency of attending
dental clinics compared with men.[12]
A remarkable proportion (> 33%) of filed claims were based on unconfirmed incidents,
hence reflecting the high-level of awareness and ease of patients with regard to making
such claims.[13] Therefore, to guarantee the endodontist’s own safety, record keeping and appropriate
documentation (such as informed consent and clinical data) of all cases of suspected
injuries is of vital value.[14] The failure to follow the standards and treatment protocols strictly may not only
compromise the quality of treatments and final outcome but also result in malpractice
claims.[15] On the other hand, commonly associated complications such as infection or persistent
pain in the absence of any obvious pathology are not considered as cases of malpractice.[16] With respect to malpractice versus procedural accident debate, medical malpractice
is defined as the negligence arising out of the doctor–patient relationship, whereas
negligence is the unreasonable act or omission by a provider that results in patient
harm.[17] Therefore, it is very obvious that due to the high-level of technique sensitivity,
endodontics is the most involved specialty (28%) in malpractice cases[18] compared with any other dental specialty, consequently requiring further attention.
The aim of this article is to highlight various aspects of malpractice in clinical
endodontics, and associated materials and challenges. In addition, commonly occurring
operating errors during endodontic treatment and possible consequences have been discussed.
Standard of Practice in Endodontics
In the context of endodontic malpractice, it is vital to understand the significance
and standards of endodontic practice. The standards of endodontic practice can be
defined as the appropriate degree of prospects for professional interventions expressed
by a professional or regulatory organization, which are based on evidence and designed
using the currently available scientific knowledge and expertise.[19] There is no concern or issue of doctor–patient choice if there is availability of
better technology that offers predominantly superior results. For example, the apical
surgery and retrograde root filling using ultrasonic tips and microscopy[20]
[21] surely improved the standards of endodontic procedures.
Similarly, biocompatible and bioactive biomaterials such as mineral trioxide aggregate
(MTA) and bioglass may perform better than amalgam for apical retrograde fillings.[22] Although the term “standards of care” is reasonably established in law, it is rarely
defined in medical terms. According to the tort law, it is defined as “the caution
and prudence that a reasonable person under a duty of care, in similar circumstances,
would exercise in providing care to a patient.”[23] There is a firm consensus among professional endodontists and legal personnel on
recognizing the level of endodontic care. It refers to any clinical procedure that
is carried out in the best interest of the patient and performed by a competent and
trained endodontist.
Endodontic Errors Categorization
There exists a range of endodontic errors and endodontic malpractices committed by
dental professionals during everyday clinical procedures. The typical injuries in
endodontic malpractice are perforation and broken instrument.[11] Operator-related factors had no impact on endodontic malpractice claims.[24] According to the Danish Dental Complaint Boards (DCBs), practitioner’s malpractice
was considered if the patient was not informed about the potential consequences, persistent
periapical pathology, or defective root canal fillings in a simple canal anatomy.
However, severe bone and soft tissues injury while using paraformaldehyde-based solutions
have been categorized as cases of malpractice in all types of root canals.[16] In addition, the DCB defined other reasons for endodontic malpractice including
defective or poor quality of apical seal, short of length root fillings, and over
filled, over instrumented and unfilled root canals.[16]
For the ease of understanding, endodontic errors can be classified into preoperative,
intraoperative, or post-operative errors. The majority of procedural errors occur
during the intraoperative phase, including preparation of access cavity, missing canals,
fracture of instruments, ledge, irrigant extrusion through apical foramen, under filling,
and overfilling of the root canal obturation. According to Bjørndal and Reit,[16] the endodontic malpractice claims were subcategorized as follows:
-
Technical complications as a result of improper treatment; for example, instrument
fracture, perforation, and defective root fillings. A problem experienced by the patient
because of treatment procedure directly; for example, infection, postoperative pain
or tooth fracture case may be classified as “incorrect treatment.”
-
Persistent pain: the patient felt pain for an unacceptably longer period following
treatment.
-
Wrong treatment: the patient complained that the operator has treated either a wrong
tooth or treated a tooth due to an incorrect reason.
-
Prolonged treatment: prolonged management of patient, including extra appointments
and associated complications.
-
Lack of information: insufficient information was provided to the patient regarding
vital diagnostic or treatment procedures.
-
Others: such as claims that are not associated with endodontic procedures, including
an “unnecessary” endodontic procedure based on false diagnostic or a nonendodontic
problem.[16]
Alternatively, endodontic errors can be classified on the basis of operative stages
([Fig. 1]) such as preoperative (before starting the active treatment), intraoperative (during
endodontic procedures), and postoperative (after the completion of endodontic treatment)
errors.
Fig. 1 Classification of various endodontic errors based on the operative stage.
Preoperative Errors
Preoperative errors such as incorrect diagnosis usually leads to misinterpretation
or lack of information, either based on clinical or radiographic interpretation.[25] Failure to locate the cause of pain results in misdiagnosis and wrong tooth being
treated. To avoid such kind of mistakes in diagnosis, each and every suspected tooth
should be investigated and tested for pulp vitality and appropriate diagnosis.
Intraoperative Errors
Working without Rubber Dam
Rubber dam remains mandatory and highly recommended for contemporary nonsurgical endodontic
procedures.[26] The use of rubber dam during endodontic procedures ([Fig. 2]) confers at least three main advantages[27]:
Fig. 2 A typical clinical image of rubber dam isolation during endodontic treatment; the
tooth under treatment has been isolated from the oral cavity, hence preventing saliva
contamination and spread of infection, and accidental aspiration or ingestion of endodontic
instrument or any biomaterials.
-
Isolation and control of crossinfection,
-
Protection from accidentally dropping instruments into pharynx or esophagus
-
Improving treatment efficiency
Failure to use a rubber dam indicates that the clinician does not understand the microbial
nature of the disease process and the importance of applying the rubber dam. The rubber
dam provides protection to the patient[28] and creates an aseptic environment. It enhances the vision, retracts tissues, and
makes treatment more efficient. Soft tissues are protected from laceration by rotary
instruments, chemical agents, and medicaments. Irrigating solutions are confined to
the operating field. Most importantly, endodontic treatment under rubber dam is vital
for patients’ safety and protecting them from aspiration and swallowing of dental
materials and endodontic.[29] An additional advantage is that the dentist and auxiliary employees are also protected.[30] The risk from aerosols is minimized[31]
[32] and the dam provides a barrier against the patient’s saliva and oral bacteria.[33] Application of the rubber dam may also reduce the potential for transmission of
systemic diseases such as acquired immunodeficiency syndrome (AIDS), hepatitis, and
tuberculosis.[30]
[31]
The use of the rubber dam in the United States is considered the standard of care;
thus, expert testimony is not required in cases involving patients who swallowed or
aspirated instruments or materials due to lack of rubber dam isolation. The juries
are considered competent to determine negligence. Evidence exists that many general
dentists unnecessarily place themselves at risk for not using the rubber dam while
performing endodontic procedures.[34] The consequences may include failure to protect the patient from aspiration or swallowing
instruments, the spread of infection to dental staff from contaminated aerosols, and
the decreased success rate for treatment due to lack of asepsis.[34]
Root Canal and Pulp Chamber Perforations
Perforation is a type of communication of root canal to the external root surface
([Fig. 3A], [B]). The usual cause is iatrogenic due to improper use of endodontic instruments while
accessing the preparation of cavity and exploring the root canals.[35]
[36]
[37] Perforations complicate the root canal treatment further, for instance, searching
for calcified/curved canals may result in strip perforation.[38] Misplaced, endodontic, post for permanent restoration is another potential iatrogenic
cause of root perforation.[35] There are several noniatrogenic causes such as caries and root resorption.[36]
[39] Such kinds of serious implications are reported in 2 to 12% of root-treated teeth.[36]
[40] Upon establishment of an infected perforation, the affected tooth is likely to have
a poor prognosis and may be lost due to associated complications.
Fig. 3 Periapical radiographs showing perforation of root canals communicating with the
internal root canals to the external root surface, hence leading to blood contamination
of the pulp space and potential infections; (A) bur perforation (arrow) of lateral wall of pulp chamber, leading to obturation materials
and misdirecting into the gingival tissues, and (B) apical perforation (arrow) due to mechanical over instrumentation leading to extrusion
of the obturation through the apical foramen.
A careful examination (clinical and radiographic) is very crucial to assess the morphology,
and dimensions of the pulp chamber and root canals. Indeed, a strong theoretical knowledge
about the internal anatomy and morphological features of the root canals is essential.[41]
[42]
[43] Additionally, it is important to assess the relative root inclination/curvature,
axis, possibility of pulp stones, and restoration types. Supplementary radiographs
to rule out above-mentioned conditions can be indicated if needed.[44]
Ledge Formation
Considering the complexity of root canal treatment, the most frequently reported complication
during endodontic instrumentation is the diversion of canals from its curvature ([Fig. 4A], [B]). This can be further complicated by lack of communication with the periodontal
ligament (PDL), leading to a practical error called ledge formation or ledging.[45] It results when instrumentation is performed at a shorter length than the required
working length, leading to canal blockade at the “short point,” hence ledge formation.[46]
Fig. 4 Inappropriate mechanical instrumentation during cleaning and shaping of root canals;
(A) schematic presentation of ledge formation typically using a large-sized or rigid
file in a curved root canal (B) a periapical radiograph showing incomplete cleaning and shaping of a root canal due
to ledge formation (arrow) or obstruction.
The ledge formation may exclude the possibility of attaining sufficient canal preparation
(an incomplete instrumentation) and disinfection of the root canals, leading to short
obturation. The lack of cleaning and shaping apical in the ledge results in residual
infection, leading to recurrent periapical pathology. Considering these facts, ledge
formation has been related to unfavorable endodontic treatment outcomes.[47]
[48] In addition to ledge formation, cleaning and shaping of curved root canals may result
in other errors such as apical transportation[49]
[50]
[51] and zipping.[52]
Hypochlorite Accidents
In 1920, Crane et al[53] described using sodium hypochlorite (NaOCl) for root canal debridement and disinfection.
After getting the concept, several chemicals have been explored for root canal irrigation.[54]
[55]
[56]
[57]
[58] Several studies[59]
[60]
[61]
[62]
[63]
[64]
[65] have reported various harmful effects on soft oral tissues following inadvertent
contact with NaOCl or calcium hydroxide Ca(OH)2. To avoid any unwanted consequences, an extreme care is required while using intracanal
medicaments such as NaOCl and Ca(OH)2.[13]
Factors associated with incidence of NaOCl or Ca(OH)2 injuries included type of teeth; for example, molars are less likely to be affected
compared with premolars to sustain the NaOCl/Ca(OH)2-associated injuries. Similarly, the risk of NaOCl/Ca(OH)2 injuries is two-fold higher among patients treated in public sector clinics compared
with patients treated in the private sector. The verified NaOCl/Ca(OH)2 injuries revealed no usual association with the age of patient or practitioner.[13] Although NaOCl is a potent intracanal irrigant,[53] it has to be handled with appropriate safety measures. It is considered very safe
if used with all precautions, proper suction, and rubber dam application. However,
occasionally, complications may result from accidental spillage in the following manner:
-
Damage to clothing, eyes, skin, and oral mucosa[59]
-
Expression of NaOCl outside root canals and consequent (hypochlorite accident)[66]
-
Accidental misuse or extrusion to maxillary sinus.[67]
[68]
-
Wedging of a needle in the canal or into a perforation[69]
[70]
-
Robust expression of NaOCl, causing its penetration into periradicular tissues, which
may lead to inflammation, discomfort, serious injury to periapical tissues, and life-threatening
emergency.[67]
Loose insertion of needle, careful irrigation using a light pressure, and perforated
needle[67] prevents irrigating solution from being forced into alveolar bone. Sudden and sharp
pain during irrigation followed by a diffuse swelling suggests likely penetration
of solution into the periradicular tissues. The acute episode subsides spontaneously
with time. In teeth with open apices, the use of less concentrated irrigant, or saline,
prevents the possibility of irrigant accidents. Surgical drainage and antibiotics
are not indicated in the initial stage. Usual management is supportive; analgesics
(non-steroidal anti-inflammatory drugs) should be prescribed and patients reassured.
As the outcome is very unpredictable, evaluation must be performed frequently to follow-up
the progress of healing.
Separated Instruments
An unfortunate occurrence is the fracture of endodontic instruments (such as file,
reamer) inside the root canal ([Fig. 5A–C]) which may obstruct the access to the root apex, endodontic treatment, and prognosis.[71] The fracture of instrument incidences mainly depend on multiple factors such as
type of instrument (files, reamers), material (stainless steel [SS], nickel–titanium
[NiTi]), fatigue strength, and clinical handling. For instance, the fracture rates
of SS instruments have been reported significantly lower (0.25% and 6%), compared
with the fracture rate of NiTi instruments (1.3% and 10.0%),[72]
[73] corresponding to better elasticity and cyclic fatigue strength of SS alloy. The
fracture of endodontic instrument is almost impossible to avoid and may occur by an
experienced operator working with all precautionary measures, thereby frustrating
both practitioners and patients. Common reasons for instrument separation are torsional
or flexural fatigue and crystallographic defects.[74]
[75] These instruments do not show any sign of cyclic fatigue, discoloration, and cracks
of bends. To prevent such complications, endodontic instruments should be used with
care and must be discarded after using two to three times. In addition, proper training
of using endodontic instruments is vital in preventing these complications.[76]
[77]
[78]
Fig. 5 Periapical radiographs showing the endodontic instruments fractured during root canal
treatment: (A) a broken endodontic file (arrow) extruded through the apical foramen which may cause
irritation or foreign body reaction in the periapical area (B) a broken endodontic file (arrow) obstructing access to the apex and making cleaning
and shaping of apical part of root canal challenging (C) a endodontic file (arrow) in the apical third of the root canal, hence compromising
the further cleaning and shaping of apical seal of the affected root canal.
Aspiration or Ingestion
Aspiration or ingestion of endodontic instruments is a critical situation that can
be avoided using proper precautionary measures. The rubber dam is considered the standard
of care to avoid such complications and subsequent lawsuits.[14] Alternatively, using throat packs should be considered for patients who are not
able to tolerate rubber dams.[79] The main signs included disappearance of an instrument and coughing or gagging by
the patient. The situation must be further investigated immediately using radiographic
imaging. These patients must be referred immediately for medical services in relation
to definitive diagnosis and respective treatment. Failure to do so may result in serious
consequences and death.[79] It has been reported that 87% of lost instruments are swallowed and the remaining
13% are aspirated.[80] In case of all aspirated and majority of ingested instruments, hospitalization and
surgical intervention is usually required to remove the lost instruments.[81]
[82]
Postoperative Pain
Postoperative pain following endodontic treatment is a common symptom reported by
patients. According to a meta-analysis, postoperative pain has been estimated in 5.4%
patients,[83] while according to prospective observations, approximately10.0% patients reported
pain 6 months following treatment.[84] In terms of diagnosis, the associated pain can be broadly classified as either odontogenic
pain (such as fractured teeth, missed/untreated root canals, and residual infection)[85] or nonodontogenic pain (such as headache, and neurovascular and referred cardiogenic
pain).[86] Additional painful conditions of nonodontogenic origin include referred myofascial
and cervicogenic pain.[87] After a follow-up of six months or more, the majority of patients (56%) reported
nonodontogenic pain,[88] suggesting that the nonodontogenic etiologic factor must be considered during follow-up.
Avoiding Malpractice Injuries during Endodontic Therapy
The most important consideration involves adhering to the standard guideline and protocol
while conducting the endodontic treatment. The strict adherence to the treatment protocols
is associated with compromising the quality of treatment outcome which may lead to
a malpractice claims.[15] The vast majority of injuries resulting from malpractice of endodontic treatment
were deemed avoidable. The up-to-date knowledge of the subject and skills competency
are also one of the most crucial factors in preventing endodontic malpractice by enabling
the practitioners to diagnose, plan treatment, and perform endodontic procedure with
the desired prognoses. Therefore, the technical skills of the endodontists and dental
practitioners performing endodontics must be improved[15] with supervised working experience, workshops, and continuing professional development
activities. To reduce the likelihood of legal complaints, the endodontic treatment
plan, prognosis, and all possible complications should be discussed with the patient
followed by signing a written informed consent.[15] Additionally, the American Association of Endodontists has provided an assessment
form to evaluate the case difficulty which is a valuable tool for predicting the potential
complications and mishaps.[89] It is highly recommended to use rubber dam isolation to minimize the risk of crossinfection
and prevent accidental inhalation or ingestion of endodontic instruments of dental
materials.[90] Anatomical variation in the roots and root canal morphology are common. Therefore,
preoperative radiographs are essential and assist operators in correctly diagnosing
the extent of access cavity and negotiation of the root canals. In addition, radiographs
aid in reducing the chances of procedural errors such as perforation, stripping, or
ledge formation. If available, the operator must consider using advanced equipment
(such as well-controlled rotary systems and cone beam computed tomography), as using
such advanced technologies has been reported to reduce the risk of procedural errors
and malpractice incidences.[91]
Medicolegal Aspects
In a fault-based liability regime, such as in the United States (in which medical
malpractice cases are under the authority of each state and not the federal law),[1]
[92] United Kingdom[1]
[93] Canada, and Germany (in some of the cases),[94] the plaintiff will have to prove liability and damages, specifically duty, breach,
causation, and damages.[1]
[92] In different countries, there may be different variations of these components but,
in essence, most of them will require proof of negligence, damage, and causal connection
between the act of negligence and the damage caused.[95] There are some countries, such as Sweden and New Zealand, in which there is a no-fault-based
liability regime, and some other countries, such as France and Germany, in which in
some circumstances of medical malpractice, the regime follows no-fault-based liability.
In a no-fault-based liability regime, to compensate the injured individual, the question
of whether the healthcare provider was negligent or not is almost irrelevant. The
focus usually will be on the causation and damages factors–the proof that the claimed
injury was caused by the specific claimed medical treatment, and not from other reasons,
and the proof of damages.[95]
Conclusions and Recommendations
In the recent years, a sharp rise in the endodontic malpractice cases has been observed
worldwide. The current article reported various aspects of endodontic malpractice
and associated factors. To avoid the incidences of endodontic malpractice and minimize
the risks of procedural errors, the operator must consider ethical principles of clinical
practice and adhere strictly to the standards of healthcare while performing the diagnosis
and treatment. Sound theoretical knowledge about variations in the tooth internal
anatomy and associated factors leading to malpractice are valuable. Therefore, operators
must consider continuing professional development, including hands-on workshops, seminars,
refreshers courses, and training for using various endodontic devices. In the 21st
century, while the technology is changing rapidly, there is an increasing need to
keep the professional up to date with regard to recent developments and provide training
using the available equipment. In case of challenging situations, where the risks
of procedural errors are high, a referral toward a specialist or consultant endodontist
is always an appreciable option and should be considered in the best interests of
the patient. In addition, the cases of failure and malpractice incidents must be registered
in the local or institutional register, and should be used for discussion, feedback,
and further training. Such measures can be helpful for not only keeping a record of
endodontic malpractice cases but also helping in sharply reducing the number of such
incidences.
