The Importance Of Informed Consent In Endodontics

Introduction

Endodontics is one of the most demanding and technically challenging branches of dentistry requiring great deal of precision and rational decision making. The unpredictable nature of treatment outcomes predisposes a dental practitioner to litigation and malpractice lawsuits. Failure to communicate the potential outcomes, mid procedural complications and post- operative discomfort opens channels for dento-legal problems. Therefore, a thorough informed consent accompanied with immaculate record keeping are crucial components of best practices followed in endodontics. In addition to informed consent, treatment planning for root canal therapy requires an understanding of the potential complications and long term prognosis of the tooth.

Ethical perspective

Endodontic-related cases are the most commonly filed malpractice claims among the rest of the branches of dentistry accounting for 17% claims filed in the US population. It is not merely due to technique sensitivity of a procedure and skill set of the operator but “negligent non-disclosure” of information has been ascertained to be the most common reason for litigation (Selbst, 1990). In this case, a standard of care would be provided by the dentist however, crucial information pertaining to the procedure was withheld from the patient which manifested as a consequence of the procedure. Additionally, in the dental context, preparation of a tooth without a discrete consent or additional procedures completed without a patient’s prior knowledge constitute assault/ battery.

Components of informed consent pertaining to endodontics

Complex nature of the procedure along with unpredictability of response of tissues to an endodontic procedure lead to a comparatively higher chance of intra operative and postoperative complications. Therefore, careful case selection, accurate diagnosis and appropriate dissemination of pertinent information to the patient prior to the procedure reduces litigation (Webber. 2010). An option of referring a patient to an endodontist especially when a general dental practitioner does not have adequate training or equipment to deal with a complex case would be prudent and ensure provision of standard of care to the patient. A guide developed by AAE facilitate rational decision making and treatment planning based on the level difficulty associated with a specific case. Dental record keeping forms the mainstay of defending a legal battle in case a malpractice lawsuit is filed by a patient. Therefore, dental records should have a clear indication of the procedure that was performed, rationale behind undertaking the given procedure, complications encountered and their associated management. Consent specific to endodontic therapy should contain information such as the benefits, risks, alternatives including option of no treatment, associated costs, short and long term prognosis and an option of referral to an endodontist.

Treatment planning in endodontics

Accurate clinical diagnosis forms a small fraction of treatment planning for endodontic therapy. The most critical issue dictating the decision-making process is that if it is justified to perform root canal therapy on the tooth. Endodontic procedure should be instituted only if the clinical findings are consistent with patient’s chief concern and a comprehensive treatment plan is in place. Secondly, the tooth in question has been deemed restorable and has a good periodontal prognosis contributing to a good overall prognosis. Esteves, Correia & Araüjo suggest three main criteria to determine the restorability of the tooth- ferrule effect, relation of crown to root length and predictability of treatment outcome (2011). Lastly, performing a thorough difficulty analysis in order to determine if the case will be managed by a general practitioner or referred to an endodontist. An alternative to endodontic therapy and retention of a natural tooth is extraction and replacement with dental implants apart from removable and fixed partial dentures. Dental implants offer a versatile treatment option for teeth which may have a slightly complicated but endodontically good prognosis. Patients often perceive dental implants as being more superior treatment option as compared to root canal therapy particularly in case wherein a retreatment is a viable treatment option. Simple endodontic procedures can save a number of teeth that are otherwise referred for dental implants. With a paradigm shift towards dental implants and the skillset of implantologists, patients are often referred to oral surgeons for consultation while the endodontists are cut off from the entire process of treatment planning (Rosenberg, 2007). Root canal therapy if treatment planned and instituted properly retains natural dentition and eliminates patient discomfort offering them a cost-effective treatment option as compared to dental implants.

Conclusion

Similar to other branches of dentistry, endodontic therapy is associated with various risks and complications. Strict adherence to standards of care and well documented dialogue between the operating practitioner will aid in reducing malpractice claims. Prognosis of a tooth undergoing root canal therapy is determined by a multitude of factors which if not taken into consideration may result in poor clinical outcome and agony for the patient. Cases with inherent complexities wherein the risk of procedural complication are high, it is prudent to refer the case to an endodontist. All the possible alternatives, specific risks, benefits and costs need to be presented to the patient which will open channels of communication and facilitate rational decision making. With dental implants being another possible treatment option in complicated and retreatment cases, patients are more inclined towards choosing dental implants as the treatment option over endodontics. Therefore, endodontics need to be in loop during treatment planning in order to facilitate retention of teeth with good prognosis.

References

• Alrahabi, M., Zafar, M. S., & Adanir, N. (2019). Aspects of Clinical Malpractice in Endodontics. European journal of dentistry, 13(3), 450–458. doi:10.1055/s-0039-1700767
• American Association of Endodontists. Endodontic case difficulty assessment form. Chicago: AAE, 2005. Retrieved on December 29, 2019 from http://www.aae.org/rootcanalspecialists/dentalprofessionalsandstudents/casediffi
• Dawson, A.S. and Cardaci, S.C. (2006), Endodontics versus Implantology: To extirpate or integrate?. Australian Endodontic Journal, 32: 57-63. doi:10.1111/j.1747-4477.2006.00019.x
• Esteves, H., Correia, A., Araüjo, F. (2011). Classification of Extensively Damaged Teeth to Evaluate Prognosis. Journal of the Canadian Dental Association,77:b105. Retrieved on January 2, 2020 from https://jcda.ca/article/b105
• Givol, N., Rosen,E. , Taicher,S., Tsesis, I. (2010). Risk Management in Endodontics. Journal of Endodontics 36(6). 982-984. https://doi.org/10.1016/j.joen.2010.03.030
• Nichols P.V. (2013) Dento-legal Medicine. Legal and Forensic Medicine, 327-355. https://doi.org/10.1007/978-3-642-32338-6_94
• Rosenberg P. A. (2007). Treatment planning: a new paradigm. European journal of dentistry, 1(2), 65. Retrieved on December 29, 2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609953/
• Selbst, A.G, (1990). Understanding informed consent and its relationship to the adverse treatment events in conventional endodontic therapy. Journal of Endodontics, 16 (8), 387-390. https://doi.org/10.1016/S0099-2399(06)81911-4
• Webber, J. (2010). Risk Management in clinical practice. Part 4. Endodontics. British Dental Journal 209(161-170). Retrieved from on December 29, 2019 from https://www.nature.com/articles/sj.bdj.2010.721#Bib1