The root of the problem – practising outside your scope of practice
Paul Lambden tells a story of a dentist who treated a patient outside of his scope of practice.
Dr H is a popular and competent dentist who has worked in a suburban practice for nearly 10 years and knows his regular patients well.
So well, in fact, that he allowed his professional relationship to be compromised, resulting in a decision that came back to haunt him.
Root canal issue
Miss M attended last year with toothache affecting a lower right first molar. After a full examination Dr H found a periapical area on the distal root of the first molar.
Following a course of antibiotics, the tooth was better but still tender. Dr H looked at the root configuration and anatomy and found that the mesial root was very curved and one of the distal canals appeared sclerosed.
He explained the options for the tooth – extraction or root treatment.
If she chose root treatment he could make a referral to an NHS dental hospital, which was a long way away. Waiting times might be long and the hospital might reject the referral.
The alternative was a private referral, which would be local and more convenient. But expensive, costing between £500 and £800.
Miss M became distressed. She could not bear the pain, did not want to lose the tooth but could not afford several hundred pounds for the root treatment.
Dr H explained that the root treatment was beyond his scope of practice. He had neither the skill nor the equipment needed.
Miss M pleaded with him to do the root treatment. He said that he could not, but she persisted and told him that if he attempted it and was not successful, she would lose the tooth, which would occur anyway because she could not afford the alternatives. She said that she would appreciate it if he would just have a try.
He agreed and did his best. But his worst predictions were realised.
He could not get a reamer down the mesial root because of the curvature, nor down the disto-buccal canal, which was sclerosed.
He filled the remaining canals as best he could and told Miss M of his difficulties. She thanked him for his efforts. He never saw her again.
Receiving a claim
Nine months later, he received a solicitor’s letter, lodging a claim for a large sum of money.
The claim included pain, suffering, inconvenience, travel and distress, with the need for extraction of the molar, implant and crownwork. Together with the costs of implant replacement on a 15-20-year basis throughout the patient’s estimated life. The total claim was nearly £20,000.
Densura took on the case. Unfortunately, it was not possible to defend the actions because the treatment was outside the dentist’s scope of practice. The dentist did not record the agreement reached with the patient about making an attempt specifically at her request.
He also did not record the results of the treatment, the reasons that he was unsuccessful and the necessary steps to try to save the tooth.
The case was therefore indefensible and settlement was the only option.
The agreed final settlement, together with the claimant solicitor costs and the defence costs, was nearly £38,000.
Root treatment pointers
Remember that, if you do a root treatment:
- Always use a rubber dam
- Never take on a case beyond your scope of practice
- Always provide warnings and document the conversations you have
- Explain that the tooth is in very poor condition and root canal treatment (RCT) is a last resort
- Detail potential complications of RCTs
- Explain that RCTs may fail despite comprehensive treatment, resulting in tooth loss
- Inform that the tooth will be brittle and may fracture
- Warn of potential instrument fracture in the canal
- Say that sometimes an instrument perforates the root
- Advise that rarely the HCO3 used to sterilise the canal may leak from the tooth.
If you elect to proceed but find it too difficult, stop, notify the patient, explain the options and make the necessary arrangements. Don’t raise the patient’s expectations too high: many root treatments eventually fail.
With good records, appropriate consent and clear explanations, you can avoid the distress and such huge claim pay-outs.
This article is supported by an educational grant from Densura, a bespoke indemnity scheme originally designed for dentists working in corporates but now available to all dentists in practice in the UK.
For more information visit densura.com.