Ethics In Endodontics Notes

Ethics In Endodontics

Ethics is a moral concept that has been considered worthy of major contemplation since the beginning of human life on earth.

The word “ethics” is derived from the Greek word “ethos” meaning custom or character.

Nature Of Endodontics Ethics

1. It is related with the evaluation of human conduct and standard for judging whether actions performed are right or wrong
2. It is the philosophy of human conduct, away from stating and evaluating principles by which problems of behavior can be solved
3. It is an attempt to determine the goals of living.

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Root Canal Ethics

In present situation, patients are more keen to understand what the problem is and the possible treatment options to save the teeth. Before commencing a treatment, the dentist should take treatment records as well as informed consent of the patient which are the most important tools in the prevention of dental malpractice claims.

1. Treatment Records

Each dentist should have a standardized protocol for diagnosis and management of pulpal and periapical diseases. In addition to establishing a standardized protocol, the endodontist should record written documentation of the treatment provided. It includes the following procedure:

1. A detailed written medical history should be taken if medical consultation is required, and the consultant’s remarks should be recorded in the fie
2. The chief complaint of patient should be recorded in his or her own words and treatment should be planned accordingly
3. The dental history of the patient should also be recorded. If any treatment previously given affects the present outcome of the treatment, it should be explained to the patient and recorded in the performa
4. The extraoral and intraoral examinations should be conducted and recorded in the performa
5. An important part of performa, that is, the examination of affected tooth/teeth should be done thoroughly. Both subjective and objective tests related to diagnosis and treatment should be done and recorded in the performa. If required, a dental specialist can be referred.
6. Radiographs of good diagnostic quality should be taken and interpreted. The dentist should record the findings of radiographs in the performa
7. A detailed pulpal and periodontal examination should be done and recorded in the performa
8. Provisional diagnosis and proposed treatment plan should be presented to the patient. It should be recorded in the performa also
9. The medication, if prescribed, should also be recorded in the dental performa
10. The informed/written consent regarding the treatment outcomes should be recorded and included in the performa
11. The final prognosis/outcomes should be clearly mentioned
12. The dentist should always sign the performa.

2. Common Elements of Negligence and Malpractice

1. Failure to meet the standard of care
2. Failure to diagnose properly
3. Use of poor standard dental materials
4. Failure to refer
5. Use of infected/unsterilized instruments
6. Overinstrumentation and formation of abscess/sinus.

3. Common Malpractice Errors Against Endodontics

1. Failure to meet the standard of care
2. Instrument separation
3. Treating a wrong tooth
4. Performing procedure not up to mark
5. Failure to get informed consent
6. Paresthesia.

Informed Consent

As a general rule, the information presented to a patient must be presented in terminology that is easily understood by the patient. The dentist should tell the advantages, risks, and cost related to the patient’s problems.

Informed consent should also be duly signed by the patient and the date should also be recorded. Failure to provide adequate information to the patient is also a breach of code.

The written, informed consent should include the following:

1. The diagnosis for each affected tooth should be recorded
2. The treatment plan should be recorded in brief
3. The date on which consent was taken should be recorded in the consent form
4. The potential complication which may occur during or after the treatment should be written in the consent form
5. The success rate of treatment should also be mentioned in the consent form
6. Alternative treatment options, such as tooth extraction, or no treatment should be told to the patient and should also be mentioned in the consent form
7. The patient or his/her guardians should sign the consent form along with date.

No specific form should be used in every case. In endodontics, the incidence of complications is relatively low if done by a specialist. The endodontist should tell the patient about the following facts:

1. Despite best efforts by endodontists, few cases of root canal failure are reported
2. Sometimes overextensions occur in root canal therapy. If it is minor, then no treatment is required because these cases heal well and remain asymptomatic
3. Slight-to-moderate pain may occur after root canal therapy
4. A fie may break in the canal during root canal therapy, then, the patient should be informed about this occurrence
5. Perforation may also occur during root canal therapy. Tell the patient about the perforation and explain him/ her that it can be repaired with newer materials.

Dental Negligence

Dental negligence is defined as a violation of the standards of care. In a layman term, malpractice means negligence. Dental negligence occurs mainly due to two reasons—either a clinician does not possess a required qualification or despite of qualification, he or she acts carelessly.

1. Related to Local Anesthesia

There are certain problems that can occur while injecting local anesthesia in patients. Some cases that can lead to allegations of negligence are:

1. Syncope (fainting)
2. Fracture of the needle in situ
3. Hematoma
4. Trismus
5. Drug allergy
6. Injection of incorrect solution
7. Infection
8. Injection of expired solution.

2. Syncope (Fainting)

Although syncope usually occurs in the dental clinic, it can be reduced if proper counseling of the patient is done before initiating treatment.

The doctor should explain each and every step of the dental procedure to the patient. If at all it happens even after taking proper care, the clinician and his assistant should be ready to manage the situation effectively.

3. Fracture of the Needle in Situ

The incidence of fracture of the needle has been reduced in the modern era because of the wider availability of disposable needles and syringes. In the past, reuse of the needles and syringes was the main reason for this problem.

Several other conditions, such as hematoma, trismus, and, drug allergy, may also make the conditions worse for dentists in the dental clinic. So, good communication and rapport between the practitioner and the patient is the key factor in these circumstances to prevent the allegation of negligence.

The injection of an incorrect or expired solution causing harm is considered as an indefensible action. Such occurrences should be avoided in the dental office or extra care should be taken during the injection of local anesthetic.

4. Thermal or Chemical Burns (Iatrogenic Problems)

Both thermal and chemical burns are also a part of dental negligence.

1. 1. Thermal Burns
      Thermal burns can occur due to overheated instruments such as handpieces or when instruments are insufficiently cooled after sterilization. These can cause burns on the lips, oral mucosa, and cheeks. To prevent or minimize such occurrences
      • All rotary instruments such as air rotor/handpiece should be properly maintained and oiling should be done regularly
      • Burs used in these handpieces should be new and sharp
      • Excessive pressure should not be applied during cutting
      • Irrigation with normal saline should be done during surgical extractions.Any instrument which appears warm to the operator’s hands is likely to retain some heat which can cause problem when applied to oral structure immediately. It is usually found that claims based on these findings are difficult to defend. So, these circumstances should be avoided.
2. Chemical Burns
   Chemical burns are also common in the dentist’s clinic. These can be avoided by the following steps:
   • Provide proper training of dental assistants
   • Avoid use of strong chemicals in the oral cavity
   • Avoid overuse of chemicals
   • Avoid carrying the chemicals over the patient’s face
   • Accidental ingestion or inhalation.Sometimes incidents such as accidental ingestion or inhalation of certain objects may occur, for example,
   • A portion of tooth
   • Burs
   • Endodontic instruments such as fie or reamer
   • Crown/bridge.It is the dentist’s responsibility to make all provisions so that no instrument or object is ingested or inhaled. To prevent this, dentist should take the following precautions:
     • Use of rubber dam
       Use of floss to tie endodontic instruments and rubber dam clamps.
       If claims are made for this negligence, heavy compensation has to be paid because these cases are truly a case of negligence on the part of dentist.

4. Poor Quality of Radiographs

An improper radiographic film or poorly developed film can also lead to an allegation of negligence which is difficult to refute. So, treatment provided on the basis of poor-quality of radiographs should be repeated.

Since radiographs are only two-dimensional views of three-dimensional objects, in some cases it becomes necessary to take different radiographs in different angulations. Unable to take the radiographs is also liable to cause an allegation of negligence.

5. Failure to Provide Adequate Care

Failure to provide adequate care and treatment to a patient is also a part of dental negligence. Commonly seen cases of dental negligence performed by most of dentists in practice are

1. Failure to use rubber dam while performing endodontics
2. Failure to take good-quality radiographs
   Failure to periodically check the water unit connected to the dental unit
3. Failure to record and probe the periodontal pockets
4. Failure to follow barrier techniques such as the use of sterilized gloves, face masks, instruments, use of protective eye shields, and disposal of waste.

6. Negligence Related to Patient

The patient also has to follow some rules of behavior while undergoing treatment. In accepting treatment, the patient should

1. Cooperate during and after treatment
2. Follow home-care instructions given by the dentist
3. Immediately inform any change in health status
4. Pay his/her bills timely.Depending upon treatment, additional warranties may exist. If the patient does not follow any of these instructions or instructions given by the dentist, these should be recorded in the patient’s record.

Malpractice And The Standard Of Care

Good endodontic practice is defined as standard of reasonable care legally to be performed by a reasonably careful clinician.

A good clinician always maintains records. Records are considered as the single most evidence which a dentist can present in court.

The law recognized that there are differences in the abilities of doctors with same qualification as there are also differences in the abilities of people engaged in different activities.

To practice the profession, the clinician does not require extraordinary skills. In providing dental services to the community, the doctor is entitled to use his/her brain for judgment of cases and providing optimal care.

For preventing malpractice, certain guidelines should be followed: Do not provide treatment beyond your ability even if the patient insists

For patients requiring specialty care, refer them to a specialist In patients where certain diagnostic tests are required for his/her care, if he/she refuses for that, clinician should not undertake treatment otherwise the clinician will be at risk.

1. Standard of Care Set by Endodontists

Endodontists set a high standard of care as compared to general dentists. Endodontists should not forget their general dentist norms as these are required during care of endodontic treatment also. After a referral from the dentist, take new radiographs if required.

Endodontists should not provide rubber stamp treatment for what the clinician has asked. He/she should record complete medical and dental history before doing a thorough clinical examination.

The endodontist should examine specific tooth/teeth along with the general oral condition of the patient.

An endodontist should expose a new radiograph to know the status of the tooth/teeth before starting a treatment.

Endodontic  Abandonment

By initiating endodontic treatment, the dentist has taken the legal responsibility to complete the case or the case can further be referred to a specialist. He should also be responsible for postoperative emergency care.

If the dentist fails to comply with his or her obligation to complete the treatment, he/ she can be exposed to liability on the basis of abandonment.

A dentist/endodontist, if wants to end his or her treatment obligation, may have several reasons like a patient:

1. Failed to keep appointments
2. Failed to cooperate
3. Failed to follow home-care instructions
4. Failed to give payment at time.

To avoid abandonment claim, several precautionary measures need to be taken. These is:

1. No law can force the dentist to treat all patients despite severe pain, infection, or any other emergency condition. A dentist can do the emergency treatment, if patient and dentist both are interested but dentist should write clearly in the patient’s record that he has given emergency treatment only
2. Reasonable notice should be given to patient, if patient is willing to seek endodontic treatment from somewhere else. The dentist should provide copies of treatment record and radiographs.

Regardless of the justification given for treatment cessation, a dentist/endodontist who fails to follow the proper procedures may incur liability on the ground of abandonment. For prevention of abandonment claim, reasonable notice should be given to the patient.

The following points should be taken care of while preparing a notice:

1. Notify the patient if the dentist plans to terminate the treatment
2. Appropriate valid reasons for not continuing the treatment should be given in detail, for example, if patient is not following instruction properly, the notice should include instructions in writing
3. Provide all details about the treatment, that is, treatment records and diagnostic radiographs
4. Dentist should provide emergency care during the intermediate time
5. A patient can contact any time regarding previous treatment given by dentist. The card should be signed properly mentioning the contact number also.

Malpractice Cases

1. Injury from Slips of the Drill

A slip of the drill is usually the result of operator’s error. It can cause injury to tongue, oral mucosa, and lips. To avoid malpractice claim, the dentist should follow these steps:

1. Inform the patient about the incident and explain its remedy
2. Refer the patient to a specialist like an oral and maxillofacial surgeon or plastic surgeon
3. Dentist should bear the expenditure
4. Call the patient for a periodic checkup.

2. Inhalation or Ingestion of Endodontic Instruments

Rubber dams should be used in every conditions and its use is mandatory for endodontic work. It not only reduces the chances of aspirating or swallowing endodontic instruments but also reduces microbial contamination. If patient swallows or aspirates dental instrument, it is the operator’s fault.

He should follow the following steps:

1. Inform the patient about the incident and should regret what has happened
2. Refer the patient immediately for medical care
3. Pay all the bills of patient.

3. Broken File

These incidents usually occur in routine endodontic practice. But to avoid malpractice claims, you have to follow some guidelines. Before going into a discussion about these guidelines, consider some facts about broken or separated instruments:

1. Multiple use can result in fatigue of the instruments which further lead to failure of these instruments
2. Failure to follow the manufacturer’s instructions regarding use of the instruments can lead to failure
3. A manufacturing defect may also lead to failure
4. Teeth with separated files may remain asymptomatic and functional for years.

When an instrument gets separated in a tooth, the dentist should follow some guidelines which are as follows:

1. Explain the patient about the incident
2. Show the remaining part of endodontic instruments to the patient and assure that tooth will remain asymptomatic
3. Dental assistant should place the part of endodontic instrument and radiographs in the treatment record for future reference
4. Dentist should reassure the patient that he/she would follow this case closely.

4. Perforations

Any dentist who is performing endodontic treatment can cause perforation. It usually occurs in or around furcal flor. Despite getting panic at the time of the incident, the dentist should follow some basic steps:

1. Explain the patient about the incident that despite of best efforts, perforation has occurred
2. Record the findings in the treatment records of the patient
3. Assure that it can be quickly repaired with newer materials
4. Follow up the case regularly.

5. Overextensions

Overextensions usually happen to every dentist. The irony about overextensions is that no one agrees on exactly where overextensions begin. Does it begin at the apex? 1 mm beyond the apex or 2 mm? Rather than going into a controversial discussion, we should follow some basic steps which are as follows:

1. Explain the incident to the patient and mention patient that some of the biocompatible material has gone beyond the end of the root
2. There can be little more numbness for few days
3. Mostly these cases heal asymptomatically
4. Follow up the case closely.

Ethics In Endodontics Conclusion

• The dentist as a health professional holds a special position of trust within society. Therefore, society affords the profession certain privileges that are not available to members of the public at large.
• In return, the profession makes a commitment to society that its members will stick to high ethical standards of conduct. Having sociability, availability, and ability helps make you a better practitioner.
• Practicing within the standard of care and communicating appropriately will help you avoid litigation. One must maintain character with integrity at all times along with adhering to ethical guidelines and have moral behavior.