Endodontic blunders you want to avoid…Featured Products Promotional Features
Posted by: The Probe 9th July 2019
Most of you will have seen the statistics on endodontic success rates – 90% according to the British Endodontic Society, if carried out to a good standard.[i]This is an impressive feat when you consider the complexity of the treatment. Still, one can’t help but focus on that remaining 10%, especially given that the number of complaints made against dentists has risen considerably in recent years,[ii]and endodontic claims are notoriously hard to defend.[iii]
There are a number of reasons why treatment might be unsuccessful, ranging from the development of dental decay post-treatment, to failed restorations, in-surgery complications and poor healing. In some instances, it is the unfortunate truth that human error or poor practice is the cause of treatment failure and as such, practitioners can never be too careful with root canal therapy. This applies to all stages of the treatment pathway, including diagnostics.
Indeed, one of the worst things a practitioner can do is take on a case that is either too complex or beyond their capabilities due to an error in judgement. Even if there’s a chance that it might be possible, it is always best not to risk it. Otherwise, the safety of the patient could be compromised – not to mention that it could do more harm than good in terms of long-term endodontic outcomes. If in doubt, remember that any instance where the canal is not visible or starts mid-way down the root is regarded as a complex case. Likewise, teeth that have long roots, severe curvature, are difficult to access, or have been endodontically treated previously, are best left alone and should be referred to a specialist endodontist immediately. It’s not just complex cases where mistakes can occur, though – they can happen across the board.
Research suggests that one of the most common mistakes dentists make during endodontic therapy is failing to locate or identify all of the affected canals (one study found that 42% of 1100 endodontically failing teeth were as a result of missed canals). This can lead to continued inflammation and/or infection, resulting in retreatment and a significant decrease in the long-term prognosis of the affected tooth.[iv]Interestingly, molar teeth are thought to be especially at risk of this faux pas, with one study showing that – of the total missed canals identified – 11% involved a maxillary second molar and 44% a maxillary first molar.[v]It is for this reason that practitioners are always advised to take radiographs from a variety of angles, and why – when a canal anatomy is not clearly visible – it is advisable to utilise CBCT technology (with the patient’s consent, of course). It is thought that using the ‘same-lingual-opposite-buccal’ technique can also help to locate any extra canals, which is important to remember as it may come in use.[vi]
Another common error that can occur during root canal therapy is instrument breakage in the root canal or beyond the apex. This can be a result of factors such as unusual canal anatomy, severe curvature or calcifications, but if the working length is inaccurately calculated, or there’s forceful or overzealous instrumentation, then breakage can also take place. It is important to note, however, that while far from ideal (patients tend not to react too positively to being told they’ve got a fractured instrument in their mouth), evidence suggests that the instrument itself has little to do with endodontic failure. Rather, the prognosis is compromised when a concomitant infection is present.[vii]This usually occurs if disinfection and obturation of the part of the canal distal to the fractured instrument becomes difficult, which can lead to continuing infection.[viii]
Aside from that, there’s always the possibility that the crown or root may perforate if there’s improper access cavity preparation, post space preparation or canal instrumentation,vi or that the root canal may be either under or over filled.ivDentists should also be aware that if the coronal area is not adequately and completely sealed during the restorative phase, there is a higher risk of reinfection and coronal leakage.iv
With all this in mind, there’s a lot to be said for taking a cautious approach when it comes to root canal treatment, whether that’s embarking on further education to gain additional skills or choosing to refer to an experienced specialist endodontist. Ten Dental Facial offers a dedicated endodontic referral service across several of its practices so that dentists with less experience and confidence are able to ensure that treatment is carried out to the highest possible standard.
It goes without saying that endodontic treatments will never have a 100% success rate. However, with the right steps and by recognising that there are instances where it’s best to refer, the chances of an optimal outcome can be maximised.
For more information visit www.tendental.comor call on 020 33932623
[i]British Endodontic Society: Further Information. Accessed online 1 November 2018 at https://www.britishendodonticsociety.org.uk/patients/further-information.html
[ii]General Dental Council. Shifting the balance: a better, fairer system of dental regulation. Accessed online 1 November 2018 at file:///Users/officeone/Downloads/Shifting%20the%20Balance%20Pub.pdf
[iii]Dental Defence Union. (2015) Pulp fact – looking inside endodontic claims. Accessed online 1 November 2018 at https://ddujournal.theddu.com/issue-archive/issue-3/pulp-fact—looking-inside-endodontic-claims
[iv]Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent. 2016 Jan-Mar; 10(1):144-147. Accessed online 1 November 2018 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784145/
[v]Witherspoon DE, Small JC, Regan JD. Missed canal systems are the most likely basis for endodontic retreatment of molars. Tex Dent J. 2013 Feb; 130 (2): 127-39. Accessed online 1 November 2018 at https://www.ncbi.nlm.nih.gov/pubmed/23930451
[vi]Ramugade MM, Sagale AA. A Review of Medicolegal Considerations of Endodontic Practice for General Dental Practitioners. J Int Soc Prev Community Dent. 2018 Jul-Aug; 8(4): 283-288. Accessed online 1 November 2018 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6071360/
[vii]Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001;34 (1): 1 -10. Accessed online 1 November 2018 at https://www.ncbi.nlm.nih.gov/pubmed/11307374
[viii]Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized technique. J Endod. 1979;5:83–90. Accessed online 1 November 2018 at https://www.sciencedirect.com/science/article/pii/S0099239979801545