At a seminar given by Endodontist Glenn Weston the above words were suggested as what we would like the patient to think when the event of file fracture occurs during endodontic treatment. Needless to say, these are words that are not commonly heard in a dental office when an endodontic file breaks inside a canal! Yet we are all too aware that the performance of such treatment is a delicate operation involving fine and often calcified anatomy using delicate and sometimes fragile instruments. File fracture is a common enough event but it can be said that the event is often not understood by the patient. Patients do not necessarily appreciate the surgery at the same level as the dentist. It can be said that they have a very different perspective!

Who is in control?

People feel safer when they perceive that they are in control. Lay people are often inherently talented at weighing benefits and risks. Most patients recognise that different treatment options represent a trade-off in terms of aesthetics, time, comfort and cost. If you try and convince a patient that he or she will not be affected personally by a known dental risk, you might tell him/her that the chances are “one in 200”. Patients would prefer to hear that there is zero risk of an adverse outcome, but as we all know that is not true. How do we impart this important information to patients, so that they can make an informed decision and consent to treatment? On one hand we would like them to accept our treatment recommendations and to put themselves unreservedly in our hands. After all, we have their best interests at heart. Of course such wishes belong in a more paternalistic era of treatment when patients asked fewer questions and (it has to be said) had fewer options for treatment! So what do we need to communicate to patients about the treatment choices we are discussing and recommending?

An article which reviewing negligence claims and complaints in Australia in regards to consent makes for interesting reading.

Communication pre-treatment: consent is a process, not a form

“Malpractice complaints and claims in regards to informed consent are not uncommon events. When they arise they are most likely to centre on mundane factual disagreement over who said what and when, not contests over what should have been disclosed. This underscores that for the informed consent process, like most other areas of clinical dental practice, regular and careful documentation of interactions with patients is a prudent risk-management strategy. Documentation of the details of consent discussions in the lead-up to clinical or surgical procedures is particularly important, as the vast majority of informed consent disputes involve complications following operations.

Courts do not accept that merely handing a consent form to a patient, however well designed and exhaustive the form may be, is a valid way of obtaining informed consent. Consequently, clinicians must decide which risks to discuss and emphasise. For busy dentists, this necessitates choices, because time is limited and effort devoted to consent discussions has an opportunity cost. Courts regard the possibility of an adverse outcome occurring as an important element in determining what qualifies as a “material risk” that must be disclosed, but it is only one of several elements. The severity of an outcome associated with a risk also matters. Rarity and severity are considerations which operate together. A small risk of a catastrophic outcome usually warrants emphasis, as does a high risk of a relatively minor adverse outcome; but not a low risk of a minor adverse outcome. A common example in the case of oral surgery to remove a lower molar would be the risk of possible jaw fracture, which would require specialist surgical treatment to immobilise the jaw and would involve the patient in significant levels of pain, swelling and incapacity to work as well as a period of hospitalisation and interference in their daily life. Such would be regarded as an example of a small risk with a catastrophic outcome.

It also has to be recognised that details of risk tend to matter more towards the elective end of the treatment spectrum than the urgent end, which goes some way to explaining the higher incidence of post treatment dissatisfaction associated with cosmetic dental procedures.”[1]

Communication post treatment: honesty is the best policy…

Good communication to ensure informed consent principles have been met prior to treatment is but one arm of communication. What about the situation which arises when a mistake has been made, or when there is a treatment event that exposes the dentist to a complaint?

In these situations of course, honesty is the best policy. If something untoward occurs during treatment, inform the patient and assure him or her that you will work with them to rectify the problem. An honest and apologetic approach, coupled with a genuine wish to assist the patient, can defuse any negative emotions that the patient may initially express and avoid a claim being pursued. If remedial treatment is required, discuss the options of carrying it out yourself if you are suitably competent to do so, or refer the patient elsewhere. Leave it to the patient to decide which path to choose. It is desirable and helpful that, wherever possible, cost not to be a consideration at this point. Offers of financial assistance, when appropriate, often help minimise any friction with the patient and bring about resolution of the matter.

Case: a perforation during root canal therapy

A patient presented for emergency treatment of pain on the lower right side of her mouth. The dentist commenced RCT on the deeply filled 46, during which he perforated the lateral wall of the mesial root. This was confirmed radiographically. It was explained to the patient that the perforation had occurred and had reduced the prognosis for long-term retention of the tooth. A specialist Endodontic consultation was recommended should the patient wish to continue with the treatment. The patient, fortunately, was not too concerned and was more interested in having the tooth extracted and a bridge placed. She declined specialist referral. After further discussion, the dentist suggested that she consider what had been discussed before making a final decision on the future of the tooth. The following day the patient experienced severe pain and attended another dentist at the practice who adjusted the temporary filling, provided a script for antibiotics and analgesics, and referred the patient to the Endodontist. One month later, the patient wrote to the practice principal accusing the assistant dentist of being “negligent” in his treatment of her. She stated that she had not been given any antibiotics or painkillers by him, the temporary filling had not been completed properly, and he should not have commenced RCT if he was not capable. She advised that she would now be continuing treatment with the Endodontist.

The original treating dentist sent a courteous letter of reply to the patient outlining how the perforation had come about and been addressed, and reminding her of their detailed discussion about the problems with, and treatment options available for, tooth 46 at a visit prior to the RCT appointment. As a result of those discussions, it had been agreed that although the tooth may have to be eventually extracted, they would attempt to salvage it with RCT. The patient had been informed that no guarantees could be given and that there was a failure rate of around 10-15%. The dentist ended by saying that he was nevertheless happy to offer the patient a full refund ($200) for the treatment he had provided to 46 because of the unfortunate outcome and his primary concern for the satisfaction and wellbeing of his patients.

Five months later the dentist had still heard nothing in reply and the patient had failed to take up the offer of refund. The RCT was completed by the Endodontist and the patient was apparently happy with the service that had been provided. A crown was planned to be placed in the near future by another dentist at the practice.

Comment

Unexpected complications of a procedure are more easily dealt with when the patient has been warned about them prior to the procedure being commenced.

Perforations are more common when treatment has been carried out in an emergency appointment when staff can be rushed and unprepared. When a perforation occurs, it can be tempting to hide it by not taking adequate radiographs which would assist in demonstrating the problem. However, by doing so, this may only delay its discovery (often by a future practitioner) when the inconvenient truth inevitably comes out. It was fortunate in this case that the perforation did not render the tooth unsalvageable. The outcome was assisted in part by both the dentist’s prompt admission of the problem and specialist attention at an early stage. It is important to follow up on patients who

have been referred to ensure that they follow through with care. A patient who was well-informed prior to treatment plus a well-worded letter of explanation and genuine expression of regret were important in preventing this matter from escalating.

As always, if you are unsure of what to say to the patient or are having difficulty in coming to a prompt resolution with him/her, contact your state Branch for advice.

Bibliography

[1] Bismark MM, Gogos AJ, Clark RB, Gruen RL, Gawande AA et al (2012 Legal Disputes over Duties to Disclose Treatment Risks to Patients: A Review of Negligence Claims and Complaints in Australia. PLoS Med 9(8): e1001283

By Dr Roger Dennett – ADA NSW
Peer Advisor – ADA NSW Branch