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Electrosurgery Implant Risk Factors Xerostomia and Diet Fear Factor CHAPTER 29 Endodontic Records and Legal Responsibilities e169 of the general liability policy for an “accident” rather than leakage after compaction until a permanent restoration is as a malpractice incident compensable under the profes- cemented.305 Besides an adequate coronal sealing, an adequate sional liability policy. Call the patient periodically to check apical sealer should be well adhered to the canal walls. on healing, recovery, and any follow-up plastic or other The endodontic goal is to prevent bacterial contamination surgeries. of the periradicular tissue by predictably providing ade- quately cleaned, shaped, and filled root canal systems. Any Fear Factor residual bacteria should be entombed in the root canal filling. U.S. Centers for Disease Control and Prevention’s National A bacteria-tight apical seal should be designed to last long Center for Health Statistics report that cost is the overriding term with sealed portals to prevent reentry of microorgan- factor preventing adults from seeking dental care. Fear is the isms, which cause reentry recontamination and lead to end- second reason for delayed dental care. Medicaid recipients odontic failure.84,298 Younger patients are more susceptible to were at five times greater risk for worse dental health than bacterial penetration inside dentin tubules and thus recur- those with private coverage. Adults on Medicaid were twice as ring infections.177 likely to have not visited a dentist in more than 5 years.319 Dental fear may result in patients delaying or avoiding Electrosurgery dental care.199 Frequent cancellations and missed appoint- Electrosurgery can cause problems if mishandled. Damage to ments are characteristically associated with fearful dental the oral cavity caused by improper use of electrosurgical patients. Although it is ordinarily a defense of contributory devices consists primarily of gingival necrosis, osteonecrosis, negligence if patients do not follow a clinician’s treatment sloughing adjacent to the surgical field, and pulpal necrosis of recommendations, the patient’s advocate may contend that the affected teeth. defendant clinician negligently failed to diagnose a fearful All equipment should be properly maintained and certified patient. Fearful patients tend to avoid dental treatment because to meet the American National Standard (ADA specification they believe it may exacerbate a prior traumatic dental experi- no. 44 on electrical safety standards). Current equipment ence. Referral to clinicians who specialize in treating fearful should be checked to see that units meet these standards and patients should be considered to facilitate comprehensive that electrical cords and other components are in good repair. dental treatment and to avoid future emergency endodontic Electrical receptacles should meet the requirements of the care because of repeatedly canceled treatment visits. National Electrical Code for circuit grounding and ground fault Dental anxiety and finances are the two most important protection. During use, the dispersive electrode plate should barriers to patients obtaining regular dental care. Fearful dental be well away from metal parts of the dental chair and the patients avoid necessary treatment, delay recalls, and are reluc- patient’s clothing, because skin contact can cause burns. Use tant to undergo painful procedures. Therefore, it is essential of plastic mirrors, saliva ejectors, and evacuator tips is strongly that such patients be identified for proper management or recommended. referral for fear-reduction therapy. A patient who experiences intense anxiety in the dental chair, together with a history of Implant Risk Factors avoiding dental care, suggests a diagnosis of dental phobia. Patient risk factors such as grinding teeth or diabetes increase Fearful dental patients fear loss of control during clinical treat- the odds of implant failure.166 Higher implant failure rates ment and require reassurance and reaffirmation that they have occur with surgeons who have less than 5 years of implant the power to halt the procedure by raising a hand or using experience.166 another appropriate gesture. After trust is gained, additional procedures may be performed. Fluoride Varnish for Caries Prevention In addition to desensitizing techniques, the use of proven In 2006, the ADA Council on Scientific Affairs published topical-anesthesia delivery systems helps to ensure a relatively evidence-based research with fluoride recommendations for painless injection of local anesthetics. Topical-anesthetic caries prevention. The ADA recommends that fluoride varnish patches and oral-anesthetic rinses may prove a valuable aid for treatments for at-risk patients should be done between two to pain management of the fearful patient. four times annually, depending on risk classification. The use of psychological questionnaires, such as the Dental If fluoride trays are used, trays are effective only when used Anxiety Scale or the Modified Dental Anxiety Scale, may help for 4 minutes. One-minute foam or gel fluoride treatments are to identify such individuals.154 These simple questionnaires are ineffective. short, quick, and easy to complete, and users are provided with One of many benefits of fluoride varnish is very little sys- cutoff scores that help the clinician identify patients who have temic exposure, which does not require daily patient compli- psychological special needs. In this way, the clinician will be ance compared to fluoride trays. Fluoride varnish containing in a position to assist the dentally anxious or dentally phobic 5% sodium fluoride with 22,600 ppm fluoride ions help patient in accessing dental health care. occlude dentin tubules and aid remineralization. Leakage Xerostomia and Diet Long-term seal of the root canal system is determined apically A common side effect of cancer treatment is diminished saliva by the sealer and coronally by the final restoration.36,134,228,293 production, which increases the risk of dental demineraliza- Root canal–filled teeth should be permanently restored without tion, caries, and candidiasis. Milk may help because it moistur- undue delay to prevent leakage contamination of the previ- izes, lubricates, and buffers acids while contributing to enamel ously obturated canal system, because varying canal shapes remineralization. Demineralization aggravated by a chronic from round to oval prevent a 100% seal.84,85,202 Bonded seals lack of saliva may result in osteoradionecrosis. Therefore, dis- covering the canal surfaces should be used to control any eased teeth should be treated prior to cancer therapy. e170 PART III Expanded Clinical Topics DNA preserved in calcified bacteria on the teeth of ancient human skeletons has shed light on the health consequences of the evolving diet and behavior from the Stone Age to the present.3 Composition of oral bacteria changed markedly with the introduction of farming and again around 150 years ago. With the introduction of processed sugar and flour in the Industrial Revolution, the diversity in oral bacteria dramati- cally decreased, allowing domination by caries-causing strains. As a result, the modern mouth basically exists in a permanent disease state. Reasonable versus Unreasonable Errors in Judgment Although a clinician is legally responsible for unreasonable errors in judgment, mistakes occasionally happen despite adherence to the standards of reasonable care. A mistake does A not prove malpractice unless the mistake is caused by a mal- practice error or omission.141 For example, accessory or fourth canals on molar teeth are frequently difficult to locate and may tax the best clinicians. Failure to locate an accessory or fourth canal does not conclusively constitute an unreason- able error of judgment. Rather, this may represent a reason- able error of judgment in the performance of endodontics. Nevertheless, if the additional canal could have been diag- nosed radiographically with diagnostic quality radiographs at different angles, the existence of a fourth canal should have been considered. Instrument and seal the extra canal for suc- cessful obturation. Incorrect Tooth Treatment A reasonable, non-negligent mistake in judgment may occur because the clinician has difficulty localizing the source of endodontic pain. Vital pulps may on occasion be sacrificed in B an attempt to diagnose the pain source, but it is unreasonable and therefore inexcusable to treat the wrong tooth if it is inad- FIG. 29-29 A, Tooth #31 with three separated files, one in each canal. equately tested with pulp tests, misidentified on the referral K-files used for cleaning canals and also obturation (1996). B, No apparent slip, or if radiographs are mounted or read incorrectly. Also, radiographic changes in 1998. treating large numbers of teeth endodontically (e.g., an entire quadrant) when attempting to localize chronic pain suggests pain is probably not of pulpal origin, and other differential diagnoses should be ruled out including atypical facial pain, advising the patient of leakage potential may constitute fraudu- referred pain, or TMD pain. lent concealment (Figs. 29-29 and 29-30). Patients should be If the wrong tooth is treated because of an unreasonable informed of such mishaps for (1) referral consultation or treat- mistake in judgment, the clinician should be compassionate, ment; (2) advising the patient, who on his or her own may waive payment for all endodontic treatment, and offer to pay seek a second opinion; or (3) disclosure, so as to return if a the fee for
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