Stop, and write it down

Dr L

Many practitioners take more than enough time to talk through the risks and warnings with patients and really engage in this process. However, as Dental Protection say time and time again, “If you did not write it down, it did not happen”.

I like endo, and if I had the choice between doing endodontic treatments or extractions I would always choose to do an endo. The other people I work with have realised this, and will often send me difficult endos because they know I enjoy them, and because I can generally get down difficult canals.

Mrs S was one such patient. She was referred to me with irreversible pulpitis of her 16 and the PA I was sent made it clear that her MB root was really curved.

When Mrs S came in she was in quite a bit of pain. I offered to numb her up as she said she couldn’t concentrate on what I was saying with the distraction of the pain. Mrs S gladly accepted the anaesthetic, and once I had her comfortable I sat and talked through what a root canal treatment was and what it would involve. I told her that her MB root was very curved and showed her the x-ray, explaining that as a result I may not be able to clean all the way down it, that I might zip or ledge her root, perforate, or that the root filling might fail. I then explained to Mrs S that the root filling kit we use comprises of lots of skinny pieces of metal, and that sometimes these metal files can snap off and get left behind in the tooth. I used pictures when I explained this to the patient, and went through a checklist to make sure I discussed all the potential risks with her.

At the end of my explanation I asked Mrs S if she understood, and if she wanted me to proceed. She said she did. I also asked her if she would rather see an endodontist specialist, but she said no because it was too expensive.

I extirpated the tooth, dressed it and sent Mrs S away. She came back about two weeks later for her first stage of RCT, and was feeling a lot better because she was pain free. I numbed her up, put rubber dam on, opened the tooth up and started to clean the canals. As expected, I found 4 canals and had no problems at all prepping the palatal or distal canals. Then disaster struck me mesially!

I was using a rotary endo and when I pulled the file out, it was definitely shorter than it had been when I put it in. I was stunned because I was being so gentle and I knew I had a good glide path. I took an x-ray and sure enough, there was a fractured file.

I attempted to remove the piece of file, but was concerned that I was just making things worse. I explained to Mrs S what had happened, and while it was difficult for her to talk because she had a rubber dam on, she indicated to me that she was happy for me to dress the tooth and for her to see the specialist to have the fractured piece of file removed.

I apologised to Mrs S, and she said it was ok. I referred her to the endodontist and then wrote my notes up.

To be honest, I was pretty upset with what had happened because I knew that breaking the file was a risk, but I didn’t really think it was going to happen. At that stage I was just relieved that Mrs S had been so nice about it. Unfortunately that sense of relief didn’t last long.

Within a week Mrs S had complained to both the practice and the local health complaints authority about my treatment. She said that I had never referred her to see an endodontist and that I hadn’t told her that I could break a file. She claimed that she had been made to pay twice and that I had overcharged her, and that I was doing treatments I shouldn’t have been doing because I was too young and inexperienced. I was devastated.

I rang Dental Protection to ask them what I should do, and they were really great and helped me work through everything. What they couldn’t do however was get around the fact that I had not written in my notes the conversations I had had with Mrs S on our first appointment.

I was so frustrated because I knew I had told her all of the risks, not only because I go through my checklist with every patient, but because my dental nurse and I both remembered doing so. Unfortunately, because I didn’t write it down I couldn’t prove that I had had those conversations, and as a result the Dental Board - who finally assessed the matter after much passing between the different authorities (which was really stressful) – instructed me to do some courses on record keeping and endo.

On reflection I’m glad I did the courses because they were interesting and I think I really have gained a great deal from them as a practitioner, but I still kick myself that I didn’t write down the conversations I had with Mrs S, because had I done so I would have been able to defend myself better against her complaint.