Case studies and articles
Estimated read time: 5 mins
It may not have occurred to you that endodontic file fracture can precipitate both complaints and claims for compensation. The reason I say it may not have occurred to you is because it may not have happened, or it might have happened, and you were not aware it had.
According to the literature, the incidence of file fracture can be anywhere between 0.4% and 5%. There is also consistency in the literature about the most common causes of file fracture being operator inexperience and metal or instrument fatigue where instruments are re-cycled rather than discarded after single use.
While teeth can survive with a fractured instrument embedded in a root canal, the first and preferred option is usually to remove the broken instrument and complete the root canal conventionally. Not every clinician has the skills and resources to undertake an additional intervention. For the patient there can be prolonged discomfort, the inconvenience of this additional procedure and the associated costs where the patient agrees to pay themselves.
Non-negligent complications happen in all areas of healthcare. It’s a fact of life but the complication comes at a cost particularly where there is additional surgery, treatment, and extended stays in hospital. Where the complication is non negligent then the patient or their medical aid will need to pay for the additional costs of treating the complication. Often complication costs are factored into the overall cost of healthcare and while there may be funding available for the recovery of a broken endodontic instrument from the patient’s medical aid, it may not be sufficient to meet the costs of a time-consuming and tricky intervention.
Unfortunately, not every file fracture can be described as a non-negligent complication and it’s not a particularly easy conversation to have with a patient where you have to explain some piece of equipment broke in their tooth and you can’t get it out. Most lay people will associate breakage with carelessness rather than as a genuine accident. You don’t have to look very far on the internet to discover that the most common reasons for endodontic instrument failure are not “it’s one of those things”, but linked to operator competency and instrument fatigue, where the instruments are re-cycled beyond one interaction with the root canal and possibly re-cycled beyond one patient.
If we want our patients to treat us fairly and with respect we really need to provide them with sufficient information in the consent process so that news of a file fracture is not an unforeseen shock. Regardless of how it happens our patients still need to be informed in the consent discussion about the risk of instrument failure and what it will mean in terms of additional treatment and costs. The patient also needs to know the steps they can take to mitigate the risk.
Nearly all of the complaints and claims Dental Protection are asked to assist with involve patients who have not been made aware of the risk until it happens. Ethically that is unfair because they are deprived of the opportunity to mitigate that risk. The level of risk is mostly an aggregate of the complexity of the procedure, the technical competency of the dentist, and the condition of the files used by the clinician.
Defending the dentist is so much easier where the patient has been told that the risk of instrument failure is higher in a particular tooth because of its complex anatomy and where the outcome may be more predictable in the hands of a clinician who limits their practice to endodontics. The whole point of having expertise and specialist training is because some procedures are technically more difficult and in many cases the expert will produce better outcomes and that may be a way for the patient to mitigate their risk. Unless they know the facts, they can’t choose. Likewise with the equipment itself I think we would all want single use instruments where the literature suggests there are fewer breakages with instruments that are not exposed to fatigue. If it costs more then it costs more but the patient can only choose to spend more money if they know what the specific costs are and why. And finally, it helps to let them know that if an instrument breaks then there will be additional costs and another intervention to recover the instrument before completing the procedure. Where one or more of these steps are missing from the consent process then the patient could argue that the consent they gave was not properly informed and had they known then what they know now they would have asked to be seen by a clinician with sufficient expertise to lower the risk.
Discussing risks with a patient is not easy. We are probably not as good as we need to be because we worry about over-burdening our patients with negativity. I am convinced very few patients want to sue their dentist or even complain to the HPCSA. Those who do are generally the ones who weren’t able to mitigate a material risk in their treatment. The fact that they have complained is because the outcome is material to them and it’s a far easier conversation to get over the line if it happens before the file goes into the root canal system than after it has broken.