The Top Five Complaints Endodontics

Endodontics – what could go wrong?  

All dentists understand the technical ability required to successfully treat the endodontically-compromised tooth.  There are many procedural pitfalls in the discipline of endodontics.  This article will explore some of the common issues reported to ADA SA. As members of the Association, you have access to online lectures via the ADA digital media library and to journal articles via the ADA National Library. ADA SA will be running a series of face-to-face courses in Adelaide during 2024 to explore ways of avoiding and managing procedural mishaps – we hope to see you there!  

Common problems:  

File separation – the most-reported endodontic incident in SA is separation of instruments within the canal space.  Studies indicate that the prognosis of an RCT will not be adversely impacted due to a file separation event, as long as the case is managed by a specialist endodontist. In one study, Parashos and Messer¹ show that the best long-term prognosis for the tooth occurs when the instrument becomes lodged within a fully de-contaminated canal system. The position of the fractured instrument in the canal will determine how the endodontist is able to manage the problem. In another study, Al Fouzan² found that about one-third of fractured instruments are bypassed rather than removed (so, don’t tell your patient the specialist will remove the instrument! – this may not be necessary or even achievable). It is worthwhile noting that most specialist endodontists will not attempt to retrieve a file which has lodged beyond the curvature of the root.  

Sodium hypochlorite incident with/without perforation – Sodium hypochlorite incidents are the second most-reported endodontic complication by Adelaide GP dentists. Such incidents are often characterised by a sudden, sharp pain during irrigation followed by rapid swelling and edema of adjacent soft tissues and possible profuse bleeding from the root canal. Copious irrigation of the affected tissues with normal saline is required immediately. Antibiotics, analgesics, corticosteroids, and ice pack compression (first 24 hrs) followed by warm compresses (second 24 hrs) may be helpful in the immediate post-operative phase. Again, specialist management is required.³  Hypochlorite incidents often follow a perforation event.  Other factors that are associated with an increased risk of a sodium hypochlorite accident include: incorrect working length, widening of the apical foramen and binding of the irrigating needle.⁴  Measures to prevent sodium hypochlorite incidents include: use of side-exit Luer-Lock needles, ensuring the needle is a minimum of 2mm short of working length, avoiding binding of the needle or exerting excessive pressure during canal irrigation.  

Perforations -Perforations may occur during post preparation or as a complication of root canal therapy.  A recent study found that serious accidental perforations account for up to 29% of all iatrogenic errors during endodontic treatment.⁵  Several factors can influence the prognosis of a tooth that has sustained a perforation; the most important being size, location and timeliness of treatment.⁶  A perforation larger than 3mm will likely result in loss of the tooth. Root perforations in the cervical one-third of the root (with the potential for an oral communication pathway to develop) have the least favourable prognosis following repair and patients should be advised that, long-term, the tooth will likely be lost. Roots with a (repaired) perforation defect should never be restored with a post unless such a post is placed by a  specialist endodontist or prosthodontist. 

Other common issues reported during 2022/2023 year included failure to locate a canal (often MB2), ledging/blocking canals, failure to identify or manage a crack/fracture before or during treatment, failure to relieve pain and failure to identify the correct tooth for treatment.

Avoiding problems – assessment and treatment planning:  

An excellent overall guide has been prepared by Yeng et al.⁷ General hints and tips for GP dentists include:  

• Remember to warn patients BEFORE placing a large/deep restoration that RCT may be required.
• If replacing a crown on a tooth with an existing RCT, carefully reassess the integrity of the coronal seal, the root filling itself and the periapical status- if there is any doubt redo the RCT first even if the tooth is asymptomatic 
• All treatment options (including NO treatment and the option of having specialist treatment) should be discussed before commencing an RCT 
• X-Rays – good quality images (diagnostic quality) showing all root apices and surrounding tissues must be obtained before, during and after endodontic treatment 
• Remove all restorations at stage 1 to improve visualisation and access 
• Posterior teeth – always reduce cusps out of occlusion and either place a suitable temporary restoration with cusp coverage or an orthodontic band to support the tooth during endodontic treatment.
• Pre-measure instruments using the pre-op radiograph as a guide to prevent overpreparation or perforation
• check the bucco-lingual tooth orientation before opening into the pulp chamber. 
• RCT must always be performed with rubber dam isolation in place . In some cases this can be in the form of a rubber dam cuff which will allow visualisation of the orientation of the long axis of the tooth to assist in the access to the pulp chamber.
• Restoration of a root-filled tooth is part of an RCT – your pre-operative assessment should identify whether the tooth is able to be restored and the patient must be advised of the requirement for a well-placed definitive restoration (and the timing/cost for this). If you are treating a posterior tooth, a cusp-capping restoration such as a crown will be required. 

Managing procedural problems  

Whenever a procedural mishap occurs, good practice involves open communication - telling the patient what went wrong. Providing your patient with factual information about the complication and reassurance about how things can be managed will help the patient understand what lies ahead. This might include, for example, the extent to which additional fees or charges might apply. Your willingness to explain the situation and support the patient through the rectification journey may well prevent a regulatory or civil complaint being made against you. If you are unsure what to do, call your ADA Peer advisor for a free, confidential discussion. Remember, most procedural mishaps (which cannot be managed immediately and effectively by the treating practitioner) are notifiable events. You should report any such occurrences to you PII provider and seek assistance, support and advice. 

*Cited references are available upon request

**ADA SA acknowledges and thanks Professor Geoffrey Heithersay AO for his expertise and assistance in the preparation of this article.

Dr Jane Pinchback, Peer Advisor, ADA SA