There are risks and risks.
I personally think it’s reasonable to be considering Ryan Gosling for the upcoming The Batman film and I would love to see Idris Elba in the mix for the role of James Bond. But would you consider Patricia Routledge as Batman, or Grayson Perry as James Bond? Almost certainly not, but routine treatments in dental practice are rapidly becoming the Hyacinth Bucket of the medical world - you wouldn’t volunteer to entertain her without there being immunity from the potential consequences.
A few days ago, I Tweeted this:
A handful of colleagues responded. Dentist @inurcitydentist lamented: “Every dentist is expected to do all treatments to a standard expected of specialists/consultants in each speciality.” Dr Adrian Walley responded: “The standard of what any reasonable dentist would do is no longer good enough. (Or) refer. All we’ll be doing soon is examinations.”
There seems to be a general sentiment among clinicians now, that if there’s any slight risk associated with proposed procedures, the safest course of action is to refer to a specialist.
Rapidly climbing up the “I Wouldn’t Touch That With A Bargepole” Hit Parade is of course, endodontics. From molar endo to premolars, many practitioners I know are shunning offering to treat these teeth, preferring to either recommend extraction (the most destructive, yet apparently acceptable alternative since extraction sites rarely go wrong years after removal), or referral to endodontic specialists.
And the change in attitudes all because of….anybody? That’s right - litigation and the threat of appearing in front of the GDC.
In the common law of torts , there is a doctrine named res ipsa loquitur, the translation of which is: “The thing speaks for itself.” The doctrine infers negligence from the very nature of an injury (or accident) in the absence of direct evidence on how any defendant behaved.
Basically, it doesn’t really matter what a dentist does. If a root-filling fails, it’s down to ‘inadequate’ treatment by the dentist – whether the points look long, short, or smack on. Unless it can be demonstrated that other factors intervened beyond your control or contributed to failure of endodontic treatments, you are, to use another legal term used in the law of tort – buggered.
Anecdotally, I’m hearing of more dentists being under assault from dental litigation with regard to failed endodontics and it is rapidly racing to snatch the top spot of ‘Things To Keep You Awake At Night” from ‘neglected’ perio.
A leading and respected academic was reported to have said a couple of years ago: “The GDC now thinks it is appropriate to judge GDPs against the gold standard of any treatment, rather than the formerly recognised standard of that which any reasonable practitioner would achieve.” And many clinicians now feel that this is a general and unstoppable trend. We are seeing it in practice.
This past fortnight, I read of a practitioner who had been at the business end of an investigation and one of the ‘wrongdoings’ unearthed was that the practitioner ‘failed to adequately protect an endodontically-treated tooth with a crown.’ I am assuming the tooth split, so the root in a way, spoke for itself.
But each case is unique. When is the best time to crown? Back in the eighties at my dental school, we were told to crown only after about six months of root-treatment and AFTER you could prove healing or complete resolution of symptoms. But what about if you had only a very thin shell of buccal and lingual wall remaining and it was imminently at risk of collapse and an intermediate restoration was not going to keep the tooth going? Do you crown? Well if you do and then the root-filling needs attacking again, you will be in the wrong, and if you don’t and the tooth is lost because of a catastrophic fracture that makes it unrestorable, you will also be in the wrong. The fact that it happened will make you guilty either way. Sad but true. This is the world we live in nowadays in the UK.
And the thing that is going to ‘get’ a good many practitioners is the Voldemort of general dental practice - “He Who Must Not Be Named” – rubber dam. Yes, it won’t matter one iota whether a patient got years of use out of your root-filling and it looked perfect on an x-ray, if it can be shown that you didn’t use a rubber dam, you are as guilty as Richard Nixon. You can claim there was no cover-up (literally since you didn’t use a dam) and still be guilty as sin. Not using hypochlorite as your disinfecting irrigant will potentially land you with no defence also. If you DO use chlorhexidine, you will probably have to trawl through the internet to find Spanish papers proving its efficacy to show to the fitness to practice committee. And they probably won’t take kindly to seeing a copy of them on your phone. I do remember a few practitioners I have worked with over the years using local anaesthetic as their ‘flushing agent’ of choice. They are doomed.
Although we are obsessed with our notes nowadays, there will be few practitioners who did root-treatments years ago that will have noted which irrigant was used and whether or not rubber-dam was utilised. Again, the fact that the root-filling failed will mean that there was an assumption that the procedure was carried out inadequately.
And the dental litigation ‘specialists’ know they are on to a winner with failed endodontics, particularly if the post-operative radiograph shows the slightest sign that the root-filling is deficient, no matter how much service is gave the patient. I’ve heard the argument that patients may been exposed to low grade bacterial infections for years because of inadequate obturation and it’s almost impossible to argue against, particularly since the systemic consequences of periodontal disease is the subject of much research at the moment. Hence the cost of settling cases are rising and the indemnity organisations are virtually throwing the towel in with barely a peep. “It happened. Let’s settle. We’ll just put his/her membership fees up.”
So what is the answer?
Aside from the cost implications of doing RCT in practice, do you shy away from doing, what was in the past a routine procedure, because of the fear of litigation? Or do you boldly go where no number 15 file has gone before and risk an attack from the Wimpole Street Klingons?
I have no answer and no right to offer an opinion, other than to say that towards the end of my active clinical days, I referred virtually everything endodontic. But there again, I was useless at RCT and had a morbid fear of rubber dam clamps.