A Quick Look Into a Probable Future

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I am truly hoping that by the time my loyal readers are eagerly perusing this edition of ENDOMAIL, we will all be thinking of how frigidly cold we were over the past few months as a severely unpleasant memory and looking forward to warmer and longer days - although, again truthfully, I think the snow won’t melt till June.

So to discuss the potential future of risk management and malpractice litigation as it applies to endodontics and in reality any other aspect of dentistry, we first must discuss the concept of standard of care. The dental standard of care is always in a state of flux, changing as techniques and procedures evolve. What was once the rule to be followed clinically can eventually be construed as deviation from the newly accepted standard of care if the proverbially legal stuff hits the fan. “Standard of care” is legally defined as the degree of care that a reasonable and prudent dentist would exercise under the same or similar circumstances. (Historically, the standard has been expressed in terms of a dentist “in the community with similar education and experience.”) Conduct failing to conform to the standard of care constitutes a breach of duty to the patient – an element of negligence. Remember, the general dentist is subject to the same standard of care that is determined by the particular specialty.

Now the reality is, with a long practice history behind us, we can count on one hand (hopefully) the amount of times that we have been threatened with a malpractice suit or have even progressed to actual litigation. As a defender of all dentists giving expert review regarding malpractice litigation associated with endodontic procedures, I have seen the “standard of care” change over time. For example, many moons ago prior to the incorporation of the microscope, looking for a calcified canal and deeming it non-negotiable was enough, as long as it was well documented. And a thin wispy .02 tapered canal and fill was certainly acceptable. And who ever thought of subjecting your patient to an incredibly expensive CT scan just to look for root anatomy or diagnose a case? Well along came Mr. or should I say Dr. Technology and the endodontic microscope came along, and rotary NiTi instrumentation came along, and suddenly .06 or .08 tapered obturation was adopted as the standard of care by the AAE for any endodontist doing root canal. 3D scanners are now affordable and becoming part of everyday endodontics for both diagnosis and treatment. What is more, scans are evolving to become the road map necessary to provide the patient and/or referrer with the correct information to do a proper RCT, so that performing a CBCT scan will also eventually be considered in the specialty standard of care.

*For example, This is a PA X-ray of tooth #9 (X-ray 1). A little suspicious. A CBCT scan (X-ray 2a & 2b) certainly shows us a better view of what’s really going on, diagnostically providing a road map to treatment with a bit of guarded prognosis.

For years in regards to instrumentation and obturation, .02 tapers using stainless steel reamers and/or files were the standard of care that was the acceptable “look” of proper endodontic treatment. Then along came nickel titanium and, according to the AAE, “*There is now a large body of conclusive research quantifying the use of rotary and hand nickel-titanium instruments. [Researchers] report that the use of this super-elastic metal alloy offers less straightening and better-centered preparations, compared to traditional stainless steel instruments, in preparing the wide range of anatomical variability seen in teeth.” Thus evolved the .06 to .08 greater tapered crown down prepared endodontic result. Looks great and has become the standard to judge what RCT is supposed to look like. The old .02 standard was now considered thin or wispy and under-condensed. Well the wheels keep turning and lo and behold there is a new wave of research that is indicating that this newer standard might actually be doing long- term damage to the root, especially to those roots that are deemed thinner and more curved. The greater tapers we have been creating can and do widen uniformly in 360 degrees, which can exceed the tolerance of the root in its thinnest diameter by widening the ovoid canal too far in the mesio-distal direction. Remember, canals that are ovoid (as most are) can be instrumented and widened safely in their wider dimension. If the instrumentation is indiscriminate and self-centering, then you are weakening the root and subjecting it to a greater chance of root fracture and possible strip perforations in curves and root invaginations. Also, beating another dead horse, rotary instrumentation is intimately associated with cyclic fatigue and subsequent instrument fracture, further perpetuating increased risk. Thus there is a better chance that creating a .04 taper using reciprocation rather than rotary is kinder to preservation of root structure and would reduce the risk of vertical fracture and strip perforations and preserve instrument integrity, thus reducing separation. How you achieve these improvements and what system you use is another long article, but suffice it to say it will only be a matter of time until standards once again change and some smart plaintiff’s attorney latches on to this fact in a loss-of-tooth (and related issues) malpractice law suit.

Here are some examples of .04 tapered endodontics achieved with reciprocal instrumentation and a combination of stainless and NiTi which clearly pass the muster in regards to what we expect from current technique: (X-ray 3,4,5)If push comes to shove in a malpractice case, a plaintiff’s attorney will use the lack of current available technology against the GP for not having, using or referring to a specialist who would obviously have access to any pertinent technology. Giving the patient the option of seeing a specialist to do the treatment, with decision not to utilize, is something that should be documented in your charts, because again, when it all comes out in the wash, a plaintiff’s attorney might use this against you.

The reality is, you should do what you can within your comfort zone and do it well (according to the standards established by the specialty) and refer what you can’t. Managing risk when doing any procedure comes down to common sense. Decisions should not be driven by the need to keep everything in house, but what’s best for the patient first, and what’s best for the DDS second. For years we have taught - and still teach - our valued referral family how to do the endodontics they feel they can do up to the endodontic standard of care and most of the time there is a happy ending. Malpractice suits are a reality, however, and even with an eventual positive outcome they are clearly a time/money vampire.

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