RD 4003 - Endodontology:

Informed consent for Root Canal

Treatment
Graham Quilligan
BDS, MFDS, MSc(Endo), PGCTLHE
 Endodontic
Litigation
• Many people still present for the first time to a
dentist with pain or toothache. This often means
that a large part of general practice is still dealing
with dental pain and commonly involves
commencing endodontic treatment where the tooth
concerned is restorable, strategic and the patient
is keen and motivated to retain it.

• For many years (decades), Endodontics has

consistently been the area of dental practice which
is subject to most claims. About 20% of all
claims which come through Dental
Protection relate to Endodontic procedures.
This is particularly pertinent for New Graduate
dentists, where the main areas of difficulty and
claims are related to the diagnosis of facial pain,
molar endodontics, and third molar removal.
 Endodontic
Litigation
How to avoid endodontic litigation:

• Carry out a thorough examination;

• Undertake all necessary special tests;

• Make a diagnosis and record it in notes;

• Discussion, discussion, discussion!!!!!!

 Endodontic
Litigation
What to Discuss:

• Choices for treatment/alternative options;

• Recommendations for treatment;

• Prognosis for treatments/approaches;

• Warnings - information about occurrence of

problems which may be encountered as a result
of treatment;
• Inherent risks of patients choice of treatment
modality!!
 Endodontic
Litigation
What to Record in Notes:

• Agreement to treat - consent;

• Local analgesic type and amount; warning re eating,
drinking, duration of effects;
• Rubber dam usage, any difficulties or extra details;
• Particular care for particular case eg rotated tooth;
• Canal lengths and reference points with
measurements, preparation sizes;
• Irrigation type, percentage and volume;
• Problems encountered along the way;
• Intra-canal dressing/obturation material/sealer;
• Coronal sealing materials and core material
• Final recommendations, post op expectations - e.g.
cusp coverage required
 Endodontic
Litigation
Some of the most common areas for
complaint and claims in endodontics are:

• 36% – Failed or inadequate RCT

• 28% – Fractured instruments
• 14% – Inhaled or ingested instruments
• 9% – Perforations
• 5% – Misdiagnosis
• 3% – Irrigant solutions
• 2% – Nerve damage
 The Endo
Chat
1.What is RCT/why do you need
RCT:
-Root canal treatment is undertaken to treat or prevent an infection occurring
inside the tooth;
-Treatment may be required after extensive decay in a tooth, a deep, fractured or
leaky filling or crown, repeated replacement of fillings, extensive gum disease and
its treatment, traumatic tooth injuries or a tooth that has developed a crack;
-Bacteria gain access to the nerve space in the middle of the tooth, the body
recognises this and causes an inflammatory reaction around the tip of the root.
This can be very painful.

**Occasionally, a healthy tooth may need root canal treatment to enable a crown to be retained
(referred to as ‘elective root canal treatment’)**
 The Endo
Chat
What is the success rate for root canal treatment

-Root canal treatment has a very high success rate, in the order of 85%;

-Interestingly, success rates are highest with specialists, next up are Dental
Students, then GDP’s!!!

-Success of the treatment may be influenced by the quality of the new

filling or crown. Root treated teeth generally need a cusp coverage
restoration to reduce the risk of fracture (Room analogy)

-If there is not enough tooth structure left following an assessment of the
amount of remaining tooth, extraction of the tooth may be necessary and
alternative treatments will be discussed (RESTORABILITY ASSESSMENT,
RESTORABILITY ASSESSMENT, RESTORABILITY
ASSESSMENT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)
 The Endo
Chat
What is the aim of root canal treatment:

- To create a funnel shape within the root canal(s) to allow the

disinfectant solution to kill as much of the bacteria as possible;

-We DO NOT kill all of the bacteria inside the tooth;

-We fill the root canal(s) with a rubber material to entomb the
surviving bacteria, creating an inhospitable environment;

-In most cases this is enough for our body to overcome the
inflammation/infection and heal the PAP;

-Unfortunatley, in some cases the bacteria are particularly virulent and

the pain/discomfort persists;

-These teeth may need root canal re-treatment, endodontic surgery or

extraction.
 The Endo
Chat What is involved in root canal treatment?
The treatment is carried out under local anaesthetic to ensure your comfort. Where a decision has been made
to proceed with root canal treatment, the procedure will involve:

1. Placement of ‘Rubber Dam’ (an isolation technique/rubber sheet) that enables the tooth to be

kept dry, protects your airway from small instruments being inhaled, prevents it from becoming

infected from your saliva and prevents disinfectant from being swallowed;

2. Entry to the centre of the tooth (root canals) by drilling through the tooth, filling or crown. If the

filling or crown is defective it may need to be removed and replaced with a temporary material;

3. Using specialised instruments to prepare the root canals for washing;

4. Taking multiple x-rays to check the length of the root canals and the quality of root filling;
 The Endo
Chat
5. Use of disinfectants to wash the root canals;

6. Placement of a root filling material to prevent the root canals from

becoming re-infected;

7. Occasionally root canal treatment takes multiple visits to get the

infection under control. If this is the case, the tooth is dressed with an

antibiotic paste and a temporary filling between appointments.

8. Subsequent to the root filling the tooth will require a filling, a core or,

in many cases, a crown.

 Post-op
What you expect after treatment?

1) Postoperative discomfort or sensitivity lasting a few hours to several days, which may last
longer and radiate to other areas, with intensity from slight to extreme. Most commonly the
tooth is temporarily sensitive to biting following each appointment along with mild to
moderate localized discomfort in the area. Sometimes healing is delayed.

2) Postoperative swelling, infection in the vicinity of the treated tooth, facial swelling, and/or
discoloration of tissues which may persist for several days or longer. Occasionally a small
incision to drain the swelling is required.

3) Restrictive mouth opening (trismus), jaw muscle spasm, jaw muscle cramps,
temporomandibular joint difficulty, or change in bite, which occurs infrequently and usually
lasts for several days but may last longer.

4) Failure rate of 10-20% under optimal conditions. If failure occurs, additional treatment will
be required such as: retreatment, endodontic surgery or extraction of the affected tooth.
Retreatment (of previous unsuccessful endodontic therapy) failure rates are higher, but vary
due to suspected reason for failure.
 Post-op
What you can expect after treatment?

5) With some teeth, conventional endodontic (root canal) therapy alone may not be sufficient and additional
treatment may be
required. Examples are:
a) Significant overfills or underfills of the filling materials.
b) If the canal(s) are severely bent, calcified/blocked, split or other condition which prevents complete
treatment
c) If an endodontic instrument separates (breaks) in the tooth during treatment.
d) Periodontal (gum) disease or problem in which periodontal treatment may be needed.
e) Pre-existing fractures/cracks, Substantial infection in the bone, or Perforation of the root, tooth or sinus.
In some cases, follow-up visits may be recommended while in others an endodontic surgical procedure,
extraction, or other treatment may be required to resolve the problem. The doctor will explain the options
available.
6) Restoration Damage such as Porcelain Fracture while preparing an opening in the restoration or
removing restoration for access to the root canals. If damage occurs or another problem found such as a
cavity, many can be "patched" while others may require replacement of the restoration. Rarely, a restoration
may be loosened.
7) Premature tooth loss due to progressive periodontal (gum) disease and/or loosening of the tooth.
8) Complications resulting from use of instruments, materials, medications, anesthetics, and injections,
including altered sensation (tingling or numbness) of the tongue, lip, chin, cheek, gums, which is very rare
and usually temporary, but may be permanent.
 Likely Q’s from
Patients
Will I experience pain during treatment?
-Pain during treatment is a rare possibility. It may occur when the
nerve is inflamed. Under these circumstances, local anaesthesia is
not so effective. A number of strategies are open to the dentist
under these conditions. Some forbearance is required though to
achieve immediate progress in treatment.

-Mild discomfort after treatment may be caused by one or a

combination of several factors; local anaesthesia, rubber dam
placement or the treatment procedures, lasting between 24-72
hours after treatment. This is usually brought under control by the
use of painkillers and anti-inflammatories such as Paracetamol
and/or Ibuprofen.
 Likely Q’s from
Patients
How long does the treatment usually take?

-The process of finding, placing instruments into, preparing

and washing root canals is a highly skilful procedure and takes
time and patience during multiple and longer than normal
appointments.

- 2-3 hours per appointment

-5+ visits
 Likely Q’s from
Patients
What are the risks associated with root canal treatment?
The number of risks are minimised by a high standard of care.
However, sometimes unforeseen problems can occur and may
include the followings;
1. Pain during treatment;
2. Mild discomfort after treatment;
3. Leakage of antiseptic agents into the mouth;
4. Tooth fracture;
5. Failure of canal location and negotiation;
6. Blockage of root canals;
7. Fracture of files/instruments in the canal;
8. Root perforation;
9. Extrusion of antiseptic through the end of the root into the
surrounding soft tissue.
 Likely Q’s from
Patients
What happens after my root canal treatment?

-Following completion of the root canal treatment, the tooth will be filled with a
definitive filling material.

-You may then require a cast restoration such as a crown to protect the tooth from
fracturing.

-Failure to place a crown on the tooth after root canal treatment puts the tooth at
risk of fracture which may require the tooth to be extracted.

-The tooth is normally monitored periodically to make sure that the bone around
the root end is healing. This requires an X-ray usually 1 year following completion.

-The healing can take anything from one year to four years and sometimes longer.
 Likely Q’s from
Patients
What are the alternative treatment options?

1) No treatment at all. Your present oral condition will probably worsen

with
time, and the risks to your health may include, but are not limited to: pain,
swelling, infection, cyst formation, loss of supporting bone around your
teeth, and premature loss of tooth/teeth.
(Definitive diagnosis can be difficult and waiting until more
signs/symptoms develop may be recommended.)
2) Extraction with nothing to fill the space. This may result in:
shifting of teeth, change in bite, periodontal disease.
3) Extraction followed by a bridge, partial denture, or implant to
fill the space.
4) Retreatment -In the case of previous unsuccessful endodontic
therapy, endodontic surgery may also be an option.
Final Words
ASSESS

DIAGNOSE

DISCUSS

INFORMED CONSENT

DOCUMENT