Emily Howden offers an overview of key factors for GDPs to consider in relation to root canal treatment.
Root canal treatment is undoubtedly one of the more complicated skills in the armoury of a general dental practitioner (GDP). This, in combination with rising patient expectations, may account for some of the reasons that endodontics is one of the main causes for patients to make a claim in negligence against their dentist.
Patients are now more inclined to do their own research into dental treatment and can obtain information and statistics from a wide range of sources. For example, the NHS Choices website states that, 'Root canal treatment is usually successful. In about 9 out of 10 cases a tooth can survive for up to 10 years after root canal treatment.' Statistics like these can then become expectations for patients regardless of their individual situation.
Although dentists will be the ones providing endodontic treatment, all dental health professionals are likely to have experience of patients who have undergone it and should therefore have an understanding of issues that may occur during or after treatment. They should also be aware of the potential signs and symptoms that patients may present with when a tooth requires endodontic treatment.
Aside from the technical skill needed to provide it, there are additional skills that a GDP may find useful for a successful root canal treatment.
During pre-treatment assessment, case selection is vitally important. There is no guarantee that endodontic treatment will be successful, but a claim will be harder to defend if the dentist's records don't show that a thorough pre-treatment assessment was undertaken. This would usually include a relevant history, radiographs with the findings recorded, as well as vitality tests.
A tooth requiring endodontic treatment is already likely to be compromised. Assessing if it will be restorable after treatment, as well as the morphology of its canals and roots, can help to demonstrate its suitability for endodontic treatment. It may also be worthwhile to consider and record the patient's likely tolerance for this complex treatment.
Discussion with the patient
In line with GDC Standard 2.3.5, 'You should make sure that patients have enough information and enough time to ask questions and make a decision'. It would be appropriate to have a full and frank discussion with the patient, being honest and open about the risks and benefits of endodontic treatment while considering the other treatment options available.
Discuss the possible complications with the patient in full, along with their potential for healing and the likely outcome of the treatment. The costs should also form part of this discussion, along with a written treatment plan. All of this information will help the patient to understand the suggested procedure and to make an informed decision about their treatment.
A written consent form can be useful but does not replace the need for a detailed conversation with the patient.
Knowing when to refer
The GDC's Standard 6.3.3 says, 'You should refer patients on if the treatment required is outside your scope of practice or competence. You should be clear about the procedure for doing this'.
You should not provide treatment if it is beyond your expertise and if a referral would be in the patient's best interests. However, this can sometimes place GDPs in a difficult situation, especially if the patient does not fit the NHS referral criteria and can't afford this treatment privately with an endodontist, but is also reluctant to have the tooth extracted.
In these circumstances, the patient might apply pressure on the GDP to perform the treatment. This can result in unsuccessful treatment or the patient becoming dissatisfied that there is limited provision for specialist endodontic treatment on the NHS; either may result in a complaint being made.
To help avoid a complaint like this, get to know the local NHS referral pathways and criteria for acceptance of endodontic treatment. Explain to the patient empathetically and in full the treatment options available, together with the NHS referral criteria for endodontic treatment so that patients can understand the options available to them.
Emily graduated from Newcastle in 1999 and went on to work in both the NHS and private sectors in a wide number of different settings and practices. As well as her general dental practice work she has also worked as dental foundation trainer, helping to foster the next generation of dental professionals.
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