Medico-legal aspects of altered sensation following endodontic treatment: a retrospective case series

Injection of sodium hypochlorite into soft tissues of the oral cavity: A literature review with clinical preventive recommendations

Injection of sodium hypochlorite (NaOCl) solution instead of local anaesthetic (LA) solution is an iatrogenic error with serious consequences including medico-legal implications. Such cases have been reported despite recommended precautionary measures. The purpose of this article is to review the literature on such cases and present clinical preventive recommendations. Electronic search was conducted in PubMed/Medline, Google Scholar, Cochrane, Scopus, Lilacs, ScienceDirect, and Crossref databases for articles reporting accidental or mistaken or inadvertent injection of NaOCl instead of LA during dental or endodontic treatment. Articles reporting NaOCl accident due to extrusion or injection of NaOCl beyond root confines were excluded. A total of 11 articles were found and reviewed. Data pertaining to the patient, injected NaOCl, cause, clinical manifestations, management, hospitalization, healing and recovery, and long-term or residual effects were extracted, compiled, and analysed for interpretation and discussion. Injection of NaOCl instead of LA into the soft tissues leads to varying clinical manifestations with unpredictable extent, outcome, and recovery period. The onus lies with the clinician to prevent it. Therefore, a clinician must take all the precautionary measures and confirm the identity of LA and NaOCl solutions before delivering them. The presented clinical recommendations assist clinicians to prevent it, including its potential medico-legal consequences. However, in case of such an unfortunate event, it is crucial to immediately identify and quickly manage it to limit the tissue damage or complications.

Implications of root, pulp chamber, and canal anatomy on pulpotomy and revitalization procedures

OBJECTIVES

This review aims to discuss the implications of anatomy of the root, pulp chamber, and canals on pulpotomy and revitalization procedures (RPs) as treatment alternatives to root canal treatment procedures.

METHODS

This narrative review was undertaken to address two main questions - why remove vital pulp tissue in teeth with complex canal anatomy when it can be preserved? And why replace the necrotic pulp in teeth with mature roots with a synthetic material when we can revitalize? This review also aims to discuss anatomical challenges with pulpotomy and revitalization procedures.

RESULTS

Maintaining the vitality of the pulp via partial or full pulpotomy procedures avoids the multiple potential challenges faced by clinicians during root canal treatment. However, carrying out pulpotomy procedures requires a meticulous understanding of the pulp chamber anatomy, which varies from tooth to tooth. Literature shows an increased interest in the application of RPs in teeth with mature roots; however, to date, the relation between the complexity of the root canal system and outcomes of RPs in necrotic multi-rooted teeth with mature roots is unclear and requires further robust comparative research and long-term follow-up.

CONCLUSIONS

Whenever indicated, pulpotomy procedures are viable treatment options for vital teeth with mature roots; however, comparative, adequately powered studies with long-term follow-up are needed as a priority in this area. RPs show promising outcomes for necrotic teeth with mature roots that warrant more evidence in different tooth types with long-term follow-ups.  CLINICAL RELEVANCE: Clinicians should be aware of the pulp chamber anatomy, which is subject to morphological changes by age or as a defensive mechanism against microbial irritation, before practicing partial and full pulpotomy procedures. RP is a promising treatment option for teeth with immature roots, but more evidence is needed for its applications in teeth with mature roots. A universal consensus and considerably more robust evidence are needed for the standardization of RPs in teeth with mature roots.

Clinical and medico-legal considerations in endodontics

Endodontic treatment can be challenging for a number of reasons, including the microscopic nature of the clinical environment, reliance on tactile sensation and lack of direct visualization of the work being performed. Commonly, endodontic patients present with pain and distress, which can exacerbate an already difficult clinical situation. Complications may might arise prior to, or during treatment, despite practising with the utmost care and skill. Preventing and managing these complications can take considerable time and energy, and oftentimes assistance from or referral to more experienced colleagues is required. The aim of this review is to discuss medico-legal considerations in endodontics, with clinical correlations and a focus on the Australian legal landscape. [Correction added on 18 October 2023, after first online publication: The abstract was amended from a structured to an unstructured abstract.].

Endodontic malpractice litigations in the United States from 2000 to 2021

Background/purpose

Little is known regarding the outcomes and distinguishing characteristics of lawsuits related to endodontic procedures. This study used a verdict-based data from United States of America to analyze the factors associated with endodontic malpractice lawsuits and mitigate the risk of litigation.

Materials and methods

The LexisNexis legal database was used to search for endodontic malpractice cases from January 1, 2000 to December 31, 2021 using the terms "medical malpractice" and (I) "endodontist" (II) "endodontics" (III) "root canal" (IV) "dental pulp." Each case was reviewed for reported medical characteristics and litigation outcomes.

Results

A total of 650 cases were initially identified, and 97 cases were included in the final analysis. Eighty-four (86.6%) of the 97 defendants were general practitioners; 42 cases favored the plaintiff, 53 (54.6%) favored the defendant, 1 was partial win/loss, and 1 was settled. The annual case mean was 4.41 ± 2.17 (Mean ± SD). The major allegations favored for the patients involving paresthesia, root perforation, rubber dam not use, wrong tooth therapy, and infections. Plaintiffs who claimed with post-procedural reasons had a significantly higher winning rate than non-post-procedural reasons (P < 0.05).

Conclusion

In the present study, 54.6% of endodontic litigation favored the dentists in the US. The authors recommend that general practitioners refer complicated cases to endodontists and treat carefully to avoid paresthesia, canal perforation and infections. Clinicians should always diagnose and treat correctly, shared decision making with the patient, use rubber dam routinely, and timely management to prevent malpractice claims.

Trifurcated Mental Foramina: A Cone-Beam Computed Tomography Incidental Finding During the Implant Treatment Planning

The mental foramen is a known skull anatomical structure located bilaterally on the mandible along the buccal cortical plate. It is located approximately between the roots of premolars in the anteroposterior dimension, and its supero-inferior level on the alveolar height varies in every individual. The position of the mental foramen is very crucial when surgical interventions are planned in the area. An accessory mental foramina can be very well detected in the three-dimensional (3D) imaging modality, especially in 3D volume rendering images. It can still be appreciated in two-dimensional (2D) imaging modalities such as a panoramic; however, at times it can be confused with periapical pathology, especially in cases where caries are present in the teeth. Three-dimensional imaging modality plays a critical role in identifying such anatomical variation, and hence, it is important to evaluate any surgical site in three dimensions prior to surgical intervention.

Factors influencing the occurrence and progress of sodium hypochlorite accident: A narrative and update review

Sodium hypochlorite (NaOCl) is one of the most commonly used irrigant because of its several advantages. However, it is highly cytotoxic and can lead to severe tissue damage. NaOCl accident occurs when it is extruded beyond root confines into periapical or periradicular tissues. It is an irrigant mishap which can be life threatening and/or cause residual or long term or permanent consequences with malpractice and medico-legal implications. There are many factors which can influence the occurrence and progress of NaOCl accident. These factors can be broadly categorized as patient (host)-, tooth-, operator-, and NaOCl-related factors. They can be further categorized as predisposing and extent factors. It is vital for a clinician to thoroughly understand and identify various influencing factors to prevent NaOCl accident with its associated consequences including any potential medico-legal issues. The purpose of this article is to provide a narrative review on various factors which predispose to the occurrence of NaOCl accident and influence its extent and/or outcome.

Inferior alveolar nerve injury following dental implant placement: A medicolegal analysis of French liability lawsuits

AIMS

This study thus aimed to review and analyze liability lawsuits resulting from implant surgery-related inferior alveolar nerve (IAN) injury over a twenty-year period in France.

MATERIALS AND METHODS

A retrospective descriptive study was performed to analyze judicial decisions pertaining to IAN injury from a legal database between 2000 and 2020. Inclusion criteria comprised all closed malpractice cases that involved an oral and maxillofacial surgeon or a dentist who performed a mandibular implant surgery resulting in IAN injury. The following data were recorded: judicial decision reference (including jurisdiction and date of final court ruling), timing between the incident and final court ruling, number of involved practitioners, patient's age and gender, practitioner's age and gender, implant type, number of implants, location of iatrogenic implant(s), allegation of IAN injury, alleged cause of injury, justification(s) for conviction, compensation amount and legal costs.

RESULTS

Twelve judicial decisions from high civil courts relating to ten closed cases of liability lawsuits were included and analyzed. All of involved practitioners were dentists or oral surgeons, working in the private sector. Eventually, 85% of them were convicted. Mean indemnification was 17,340€ and highest indemnification was 42,828€ (inflation-adjusted in 2020 euros). Mean interval between the incident and final ruling was 87,1 ± 34,2 months.

CONCLUSIONS

Permanent nerve injury following dental implant placement can result in legal action. In the event of lawsuit, the risk of being convicted is high. Practitioners performing oral implantology procedures should practice effective risk management to avoid time-consuming unwanted litigations and administrative proceedings.

The double-edged sword of calcium hydroxide in endodontics: Precautions and preventive strategies for extrusion injuries into neurovascular anatomy

BACKGROUND

Nowhere in the consideration of dental care involving endodontics does a patient become more vulnerable to potentially life-changing injuries than during a root canal procedure on the mandibular dentition that may invade and injure the neurovascular anatomy.

CASE DESCRIPTION

The authors present a series of 5 cases wherein using calcium hydroxide as a disinfection strategy in endodontics caused serious neurologic injury to the treated patients. The mechanism in all cases was the inappropriate use of needle applications resulting in significant overfill into the inferior alveolar nerve space. Although calcium hydroxide has been recognized and used as a meaningful disinfectant in endodontic therapy for many years, the dangers and risks associated with a needle delivery technique are discussed and analyzed with recommendations based on current research to minimize risk.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

A literature search revealed that the 5 cases are not solitary cases; indeed, consequences of calcium hydroxide overfills have been described before. Therefore, a clinician initiating root canal therapy on a mandibular posterior tooth should always be mindful of the vital neurovascular anatomy, which commonly approximates the ends of these roots. Preoperative cone-beam computed tomographic imaging and the thoughtful delivery of medicaments in treatment can help the clinician manage close proximity to neural anatomy and avoid potential injuries.

A Review of Medicolegal Considerations of Endodontic Practice for General Dental Practitioners

Treating a live human being to their health has been considered as a noble profession since the ancient times. Doctors are duty bound by their professional ethics to provide the best treatment to their patients. Endodontics is the specialty branch of the dental science of saving natural teeth in the oral cavity. During endodontic procedures, a mishap can occur any time in a day-to-day practice and may be treated as negligence which in turn ends into some legal complications. To prevent and tackle such future medicolegal issues related to endodontic treatment, the knowledge of the legal aspect of such clinical situation is necessary.

Choice of Endodontic Fiber Posts and its Influence on Dental Malpractice: An in vitro Evaluation

AIMS AND OBJECTIVES

The fiber post type used in restoring endodontically treated teeth may affect the dental expert decision in the case of dental malpractice. The aim of this study was to evaluate the low-cost commercial fiber post in comparison with a higher cost or well-known documented fiber post system.

MATERIALS AND METHODS

A total of 20 premolars were selected for the study; following endodontic treatment, specimens were randomly divided into two groups of 10 specimens each according to the type of fiber post used: (1) Low-cost commercial fiber post (OYAPost, Taper Lucent, OYARICOM) and (2) higher cost well-known fiber post (Rely X Fiber post, 3M ESPE). Both fiber posts were cemented using self-adhesive cement (Rely X Unicem). Samples were subjected to push-out bond strength and to failure analysis. One-way analysis of variance was used (p < 0.005).

RESULTS

There was no significant difference between the bond strength of the two tested groups (p > 0.05), while statistically significant difference (p < 0.05) was noted between the different post space regions (cervical, middle, and apical).

CONCLUSION

Based on the evidence from the study, it can be concluded that the type of fiber post should not affect the dental expert decision in the case of dental malpractice/lawsuit.

CLINICAL SIGNIFICANCE

All types of low-cost fiber posts may behave similarly to other higher cost or well-documented fiber posts.

Extrusion of Root Canal Sealer in Periapical Tissues - Report of Two Cases with Different Treatment Management and Literature Review

Background: Extrusion of root canal sealers may cause damage to the surrounding anatomic structures. Clinical symptoms like pain, swelling and paresthesia or anesthesia may be present. The purpose of this presentation is to describe two cases of root canal sealer penetration into periapical tissues. A different treatment management was followed in each case.

Case reports: A 55 year-old man underwent root canal retreatment of the right mandibular first molar tooth due to a periapical lesion. Postoperative periapical radiographs revealed the presence of root canal sealer (AH26) beyond the apex in the distal root in proximity to the mandibular canal. The patient reported pain for the next 7 days. Radiographic examination after 1 year showed complete healing of the periapical area and a small absorption of the root canal sealer. A 42 year-old woman was referred complained of swelling and pain in the area of the right maxillary first incisor. Radiographic examination showed extrusion of root canal sealer in the periapical area associated with a periapical lesion. Surgical intervention was decided upon, which included removal of the sealer, apicoectomy of the tooth and retrograde filling with MTA. After 1 year, complete healing of the area was observed.

Conclusion: In conclusion, cases of root canal sealer extrusion, surgical treatment should be decided on only in association with clinical symptoms or with radiographic evidence of increasing periapical lesion.

Single-visit endodontic treatment of mature teeth with chronic apical abscesses using mineral trioxide aggregate cement: a randomized clinical trial

BACKGROUND

Mature teeth with chronic apical abscesses characterized by intermittent discharge of pus through an associated sinus tract. This communication between oral mucosa and periapical inflammation is challenging for the sealing ability of root canal obturation material. Therefore, the study aim was to compare the outcomes of endodontic treatment using mineral trioxide aggregate (MTA) cement to the conventional gutta-percha cone and root canal sealer as an obturation material in mature teeth with chronic apical abscesses.

METHODS

Mature teeth with chronic apical abscesses referred to our clinic for root canal treatment between 2010 and 2012 were treated in a single visit and distributed among treatment (T) and control (C) groups using a predetermined randomization block (TCTC). After chemo-mechanical preparation, teeth in group T received MTA cement mixed in a 0.26 water to powder ratio, and teeth group C received gutta-percha and root canal sealer using the warm vertical technique. The treatment outcomes were defined as obturation length, periapical healing, resorption of extruded material, and survival rate at least 2.5 years after treatment. Three endodontists blinded to the type of obturation material documented treatment outcomes. Statistical analysis at P < 0.05 was conducted to measure difference between the groups.

RESULTS

Thirty-six teeth were treated between 2010 and 2012, and 32 teeth were evaluated in 2015. Complete periapical healing was observed in 87.5 % of MTA-treated teeth and 75.0 % of gutta-percha-treated teeth. Adequate obturation length was reported in 50.0 % of MTA-treated and 37.5 % of gutta-percha-treated teeth. Complete resorption of extruded material was evident in 83.3 % MTA-treated teeth and 100.0 % gutta-percha-treated teeth. The survival rate of MTA-treated teeth was 100 % at 3, and 5 years, while the survival rate of gutta-percha-treated teeth was 83.3 % at 3, and 5 years. There was no significant difference between the groups in term of periapical healing, survival rate, obturation length, or resorption of extruded material.

CONCLUSIONS

The outcomes of single-visit endodontic treatment of mature teeth with chronic apical abscesses using MTA cement were better, but not statistically significant, compared to conventional treatment.

TRIAL REGISTRATION

ISRCTN15285974 . Registered retrospectively 23 June 2015.

Persistent pain and neurosensory disturbance after dental implant surgery: pathophysiology, etiology, and diagnosis

Many studies have documented the successful outcomes of dental implants, but have also reported the association of sensory disturbances with the surgical implant procedure. Postsurgical pain is a normal response to tissue injury, and usually resolves after the tissue heals. However, some patients who receive dental implants experience persistent pain even after normal healing. This article describes the basic anatomy and pathophysiology associated with nerve injury. The incidence and diagnosis of these problems, in addition to factors that result in the development of chronic persistent neuropathic pain and sensory disturbances associated with surgical implant placement, are discussed.

Pregabalin in the treatment of inferior alveolar nerve paraesthesia following overfilling of endodontic sealer

A case of orofacial pain and inferior alveolar nerve (IAN) paraesthesia after extrusion of endodontic sealer within the mandibular canal treated with prednisone and pregabalin is described. A 36-year-old woman underwent root canal treatment of the mandibular second right premolar tooth. Post-operative panoramic radiograph revealed the presence of radiopaque canal sealer in the mandibular canal. Damage to IAN consecutive to extrusion of endodontic sealer was diagnosed. Non-surgical management was decided, including: 1 mg/kg/day prednisone 2 times/day, once-daily regimen, and 150 mg/day pregabalin, two doses per day, monitoring the progress with periodic follow-up visits. Six weeks after the incident the signs and symptoms were gone. The complete resolution of paraesthesia and the control of pain achieved suggest that a non-surgical approach, combining prednisone and the GABA analogue pregabalin, is a good option in the management of the IAN damage subsequent to endodontic sealer extrusion. Key words:Endodontics, inferior alveolar nerve, neuropathic pain, orofacial pain, paraesthesia, pregabalin.

Trends in endodontic claims in Italy

According to the scant data available in the literature, endodontic claims are common among dental professional liability cases and the second most common type of claim. This study aimed to describe the characteristics of endodontic claims in Italy and the most frequently disputed errors, and the discussion below includes consideration of ethical and medico-legal aspects thereof. We retrospectively analysed 120 technical reports written on cases of professional malpractice in endodontics in the last 5 years. The complainant patients were males in 22.5% of the cases, while females made up the remaining 77.5%. In the dentist sample, male operators were more often involved in litigation cases (80%) than female operators. The most frequently claimed technical errors were: lack of a complete filling of root canal/s (71.7%), the perforation of tooth structure (12.7%), extrusion of sealing materials beyond the apex of the tooth (9.6%) and the fracture of an endodontic instrument (5.9%). In 1.7% of cases it was found that the expert did not make any errors performing the endodontic therapy. In only very few cases (2.7%) no therapy was considered necessary, while the most common therapeutic solution involved in endodontic misconduct was tooth extraction (53.0%). In many cases the dentist preferred to extract the endodontically undertreated tooth and substitute it prosthetically rather than trying to re-treat it. The discrepancy between the total number of cases examined and those that eventually go to court leads us to believe that the majority of endodontic malpractice cases are resolved in out-of-court settlements.

Quality-Shaping Factors and Endodontic Treatment amongst General Dental Practitioners with a Focus on Denmark

There is a gap between the endodontic outcome that can be achieved and the outcome observed on the basis of worldwide general dental practitioner data. The quality of root canal treatment (RCT) is shaped by the dentist's knowledge, attitude, and skills, but it may also be influenced by the patient's demands and degree of satisfaction. The topic has only been sparsely investigated. Although dental health has increased over the years in Denmark, the number of performed root fillings has also increased, probably because the number of tooth extractions have declined and more molar teeth have been treated. Caries appears to be the main cause for performing RCT and a preventive approach by employing stepwise excavation may reduce RCT, but this strategy does not remove the gap. Factors influencing RCT quality could be the status on adoption of nickel-titanium rotary technology, more focus on infection control (rubber dam use, knowledge of factors important for prognosis), as dentists often think that they are good at doing RCT, but often perform inadequately, an alteration of clinician's awareness of their performance in the context of dental practices, seems warranted. Finally, the development of new preventive modalities for pulp and apical inflammation are crucial.