Provision of root canal treatment

Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Complaint

The Commissioner received a complaint from a consumer about treatment she received from a dentist and an endodontist. The complaint is that:

• In mid-September 1996, the dentist, while performing a root canal filling on the consumer's right canine tooth, over drilled and caused a hole in the bone.
• A week later, the dentist inserted gutta percha, 1mm extra, beyond the apex of a root filled tooth.
• A week after the root canal treatment, the dentist hit the consumer's gum during a procedure to replace a temporary filling.
• The endodontist misinformed the consumer about the cause of the consumer's problem with her previous root canal filling.

Investigation

The Commissioner received the complaint on 15 January 1998 and an investigation was undertaken. Information was obtained from:

• The Consumer
• The Dentist
• The Endodontist
• The provider's employing authority

The Commissioner obtained independent advice from a dentist.

Details of Investigation

The Dentist

In early September 1996, the consumer consulted the dentist at her clinic. The consumer said an old filling on her right canine tooth had fallen out and the dentist replaced it.

During the investigation, the dentist said the consumer presented with pain and sensitivity from her right upper canine. Upon examination, the dentist found recurrent decay under an existing composite filling which she replaced with a deep composite filling with glass ionomer lining material. The dentist said she advised the consumer that the filling was very deep and could require further treatment such as root canal treatment.

Two weeks later the consumer consulted the dentist and complained the tooth was sensitive and throbbed. The dentist said that after they discussed options, a decision was made to perform root canal treatment on the tooth. The nerve was extirpated and dressed with ledermix, an anti inflammatory and antibiotic dressing, and then filled with a temporary filling. One week later, as the tooth was asymptomatic, the dentist performed the root canal treatment. The consumer said the dentist told her it was unnecessary to use a local anaesthetic during the root canal procedure as all the nerves had been removed previously. Shortly after the dentist started drilling, the consumer felt a very sharp pain and asked the dentist what the pain was caused by. The dentist replied that she had accidentally hit her gum. The dentist then injected the tooth with a local anaesthetic and finished the procedure.

The consumer said two weeks after the root canal filling as she was still in pain, she rang consulted the dentist who informed her this was normal and that such pain could persist for up to 3 months. There is no record of the consumer's phone call 2 weeks after the root canal treatment in the dentist's consultation notes. The consumer took Panadol for the pain which was at the corner side and base of her nose. The consumer said the pain was so intense at times that she had to be very careful and gentle when washing or wiping her face and she found this frustrating and stressful. The consumer said that sometime in December 1996 the pain had worsened and spread to the right base of the right nostril and so she contacted the dentist again. The consumer said the dentist told her it was normal to have pain for up to 6 months and prescribed some antibiotics in case the tooth was infected. Sometime in March 1997 the consumer rang the dentist again and explained that the pains had spread to the upper part of her nose. The dentist said to come in and see her. The consumer said the dentist took some x-rays and told the consumer she was going to seek a second opinion from her superior and would contact her. The dentist also prescribed some more antibiotics.

The dentist said the consumer next presented to her after the root canal treatment in late December 1996 with the tooth tender to bite and complaining of a "rheumatic" type pain. An x-ray was taken, which did not show any periapical radiolucencies and prescribed antibiotics and anti-inflammatory tablets and asked the consumer to contact her a week later. The dentist said the consumer did not call back.

There was conflicting evidence over the number and content of some of the consultations. The dentist's records noted visits on three days in September and one day in late December 1996 when the dentist recorded:

"1xPA- Root canal on 13 above. 3 months ago. Still TTP and overextended approximately 1mm. To ask specialist opinion. No charge. Pain is like Rheumatic pain. Prescribed 500mg Augmentin tablets. 1 week course."

The dentist's notes record the consumer collected her x-rays in mid-March 1997 and a prescription was sent. There is no mention of an x-ray or consultation being done on this day.

The dentist said she performed the root canal treatment using gutta percha and a permanent composite filling. An x-ray was taken which showed the root canal filling material extruding about 1mm beyond the apex. The dentist said this was not seen to be a problem as there was no abscess (infection) present and there was adequate seal at the apex and she advised the consumer of this. In her response to the Commissioner, the dentist informed that gutta percha is known to possess mild antibacterial effects and most root sealing cements used in conjunction with it may be mildly irritating. The dentist said:

"However apical tissue does heal in the presence of a mild degree of irritation, but it can cause a chronic inflammatory response in some cases as seems to be the case with [the consumer]. While I was less than happy to have an overfilled-1mm-root filling, I did not see it necessary to revisit the root treatment, but rather to observe. If the patient had returned to me and I had observed the problem I would have retreated at no cost. This is our policy."

The Endodontist

The consumer said she was advised by another dentist to see an endodontist or dental surgeon and in early April 1997, consulted the endodontist. The consumer said the endodontist informed her the dentist had accidentally enlarged a hole in the consumer's bone:

"He studied the x-rays and told me about the extra 1mm gutter pucker was too long and it hurt my nerves when it touched them. I asked him why [the dentist] inserted the extra 1 mm. He said that [the dentist] had to do that because she had accidentally enlarged a hole in my bone and she had to fill the hole. I asked him again would it be better to leave the hole unfilled so that the gutter pucker would not touch the nerves. He explained that the hole had to be filled otherwise infections would take place and it was for this reason that [the dentist] had to fill beyond the hole since she had enlarged it."

The consumer said the endodontist drew her some diagrams on a white board to show her what had happened to her tooth, the cause of the pain and the remedy. The consumer said the endodontist gave her the option of redoing the root canal or surgery. As the consumer's pain persisted she chose the surgical option and in mid-April 1997 the endodontist refilled the root canal and also the surgical correction of the root tip.

The consumer lodged a claim for the dental treatment with ACC and this included a report from the endodontist. The consumer said that to her horror she discovered that in the endodontist's statement to ACC of mid-October 1997, he reported he did not find that the dentist's root canal filling caused a hole in the bone. The consumer said this denial made 'a lie' of the endodontist's professional advice to the consumer before the surgery he performed on her and she would not have allowed him to do the surgery if this was his advice.

In his letter to ACC, the endodontist states:

"With respect to [the consumer's] claim that the original root filling as placed by her dentist caused a hole in the bone that was drilled too big [resulting in complication in pain], I cannot see this to have any ground. Certainly root canal therapy was instituted and the fact of the matter was that the root canal therapy had to be followed up by endodontic surgery. There is a possibility that the original root canal therapy caused an over instrumentation of the root apex, such that debris may have been extruded through the apex into the surrounding bone to cause a chronic inflammatory response."

The endodontist said he did not misinform the consumer of the problem with her previous root canal therapy and that he treated the consumer, "to the highest degree of his technical ability with empathy and respect. I kept [her] informed of the treatment plan and informed her of the reason why her original root canal treatment failed."

The endodontist produced a report for ACC in relation to the consumer's previous root canal treatment. This included the technical nature of the problem and the cause of the pain which was not intentional but due to the anatomical nature of the root tip involved:

"I treated [the consumer] and I have notes to say that I explained to the patient clearly the nature of the problem and the appropriate treatment plan to follow but she was certain that her original dentist was at fault."

Advice to the Commissioner from a dentist

My advisor stated:

"[The consumer] refers several times to a 'hole in the bone'. I believe this is a misunderstanding on her part and what she in fact is referring to, is an enlargement of the apical foramen. The apical foramen is an opening at the tip of the root through which the nerve and blood supply enter and pass via the root canal to the pulp chamber in the crown of the tooth. When instrumenting the root canal to clean and reshape it prior to placing a root filling, it is possible to enlarge the foramen so that when the filling is placed it protrudes past the apex. The ideal finishing point for a root filling is at, or just short of the apex. Most, if not all, dentists will have an overextended root filling in their career. In my experience, an overextended root filling does not give rise to post operative symptoms. While it is possible that the overfill in this case contributed to the ongoing discomfort, I believe [the endodontist's] explanation for the cause of [the consumer's] problem is quite correct."

My advisor informs me that the likely cause for the consumer complaining that the dentist 'hit her gum' could be due to an instrument touching either some vital nerve tissue remaining in the apical part of the root canal or passing through to the periapical tissues. Both these situations occur in root canal treatment from time to time and would be accepted as being normal for such treatment.

My advisor comments that the consumer's complaint about the ongoing pain she suffered and the lack of further treatment on the dentist's part may have some substance. Unfortunately the written accounts of the patient and the dentist differ:

"[The consumer seems] confused about when the follow-up x-ray was taken - she says 6 months after treatment, while the dental records indicate 3 months later [in late December]. [The dentist] stated that she asked the patient to return one week after the x-ray was taken, but [the consumer] failed to do this," and further, "If [the dentist] requested [the consumer] to return 1 week after the x-ray […] and she failed to do so, [the consumer] can have no complaint with [the dentist]. I assume [the dentist] would have offered to retreat the tooth or refer [the consumer] to a specialist at that appointment.

On the other hand, [the consumer] states in her letter that she consulted [the dentist] with pain 3 months after the root filling and was told that it may be a further 3 months before the tooth settled down. If this is correct, it is my opinion that [the dentist] has failed to comply with accepted professional standards, as it is unreasonable to expect a patient to experience pain for 6 months following root canal treatment."

My advisor comments that the dentist exercised reasonable care and skill in treating the root canal. If the dentist requested the consumer to return 1 week after the x-ray in December 1997 and she failed to do so the dentist was not given the opportunity to follow up with appropriate treatment. However this evidence conflicts with that of the consumer who complains that she consulted the dentist with pain 3 months after the root filling and was told it would be another 3 months for it to settle down. I am advised it is unreasonable to expect a patient to experience pain for 6 months following a root canal treatment.

The Code of Health and Disability Services Consumers' Rights

 

 

Opinion: No Breach - Dentist

In my opinion the dentist did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.

Right 4(2)

The consumer was under the impression that the dentist drilled a hole in her bone. I am advised this is a misunderstanding on the consumer's part and that what occurred was the original root canal filling was over extended. An overextended root filling does not give rise to post operative symptoms such as the consumer experienced and although not ideal, is not uncommon and in accord with acceptable dental practice.

As far as the management of the consumer's pain is concerned the onus is on the dentist to show she managed the consumer's pain in a manner consistent with acceptable dental practise. The dentist's notes record she provided treatment in accord with acceptable dental practice. These notes are in conflict with the consumer's account of the dentist's management of her pain. The result is there is insufficient evidence to establish that the dentist did not manage the consumer's pain appropriately therefore in my opinion, the dentist has shown she took reasonable actions in the circumstances to manage the consumer's pain and as such did not breach the Code of Rights.

Opinion: No Breach - Endodonist

Right 4(2) and Right 6(1)

In my opinion, there is no evidence that the endodontist misinformed the consumer about the requirement for endodontic work before he performed it. There was no hole in the consumer's bone. The endodontist performed his work in a manner consistent with appropriate professional standards, and in my opinion did not breach the Code of Health and Disability Services Consumers' Rights.

For further information, contact: HDC Communications Section (09) 373 1060.