Trends in endodontic claims in Italy

Bioceramic versus traditional biomaterials for endodontic sealers according to the ideal properties

Odontology, as a scientific discipline, continuously collaborates with biomaterials engineering to enhance treatment characteristics and patients' satisfaction. Endodontics, a specialized field of dentistry, focuses on the study, diagnosis, prevention, and treatment of dental disorders affecting the dental pulp, root, and surrounding tissues. A critical aspect of endodontic treatment involves the careful selection of an appropriate endodontic sealer for clinical use, as it significantly influences treatment outcomes. Traditional sealers, such as zinc oxide-eugenol, fatty acid, salicylate, epoxy resin, silicone, and methacrylate resin systems, have been extensively used for decades. However, advancements in endodontics have given rise to bioceramic-based sealers, offering improved properties and addressing new challenges in endodontic therapy. In this review, a classification of these materials and their ideal properties are presented to provide evidence-based guidance to clinicians. Physicochemical properties, including sealing ability, stability over time and space, as well as biological properties such as biocompatibility and antibacterial characteristics, along with cost-effectiveness, are essential factors influencing clinicians' decisions based on individual patient evaluations.

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.

Maxillary sinusitis caused by retained dental impression material: An unusual case report and literature review

Surgical procedures in posterior area of maxillary might cause an oroantral communication and iatrogenic sinusitis. An undetected oroantral communication can cause the penetration of foreign bodies, such as dental impression materials, in the maxillary sinus, thereby contributing to persistent sinusitis. Given the occurrence of a very rare clinical and medicolegal case of persistent and drug-resistant sinusitis due to radiologically undetected fragments of silicone paste for dental impression in the maxillary antrum, a literature review was pursued through sensitive keywords in relevant databases for health sciences. All retrieved articles were considered and data about the kind of impression materials thrusted into the maxillary sinus, the diagnostic issues, the reported range of symptoms, and the occurrence of medicolegal issues were analyzed. The diagnosis resulted to be quite challenging and belatedly especially in case of healed oroantral communication and when the material retained in the maxillary sinus has similar radiodensity compared to the surrounding normal or inflammatory tissues. The case was then discussed in comparison with the reviewed literature for both clinical and medicolegal issues. Hints were provided to professionals to face the challenging diagnosis in similar rare cases and to avoid the possible related litigation.

Court decisions in criminal proceedings for dental malpractice in Taiwan

BACKGROUND/PURPOSE

Malpractice claims place heavy economic and emotional burdens on both dentists and patients. Recently, medical malpractice lawsuits are decreasing in prevalence but increasing in severity. The percentage of dental malpractice payments is also growing among the health profession. The present study aimed to explore criminal convictions in dental malpractice litigation and to analyze the factors affecting the judgment in dental disputes in Taiwan.

METHODS

The keywords "dentist," "professional negligence," "medical malpractice," and "professional liability" were used to search Taiwan's Law and Regulations Retrieving System for criminal dental malpractice cases in all district courts from January 1, 2000 to June 30, 2021. The eligible judgments were summarized and analyzed.

RESULTS

Overall, 425 cases were identified, with 28 dental disputes included in the final analysis. The dentists lost in 10 cases (35.7%). The average claim time was 36.75 ± 16.34 months. Taipei and Taichung dealt with more lawsuit cases (n = 8). Local clinics were the most common institution of the defendants (75%) and had the highest number of convictions (n = 9). Implant dentistry was the most common specialty involved. Expert testimony of the Medical Review Committee (MRC) had a high K coefficient of agreement with court judgments regarding professional negligence (p < 0.001).

CONCLUSION

The overall criminal conviction rate was 35.7%. Implant therapy and local clinics had the highest rate of lawsuits and a considerably higher conviction rate. All guilty dentists were fined or given probation. The court judgments were highly consistent with the expert testimony of the MRC.

Patient Safety Incidents and Adverse Events in Ambulatory Dental Care: A Systematic Scoping Review

BACKGROUND

There have been efforts to understand the epidemiology of iatrogenic harm in hospitals and primary care and to improve the safety of care provision. There has in contrast been very limited progress in relation to the safety of ambulatory dental care.

OBJECTIVES

To provide a comprehensive overview of the range and frequencies of existing evidence on patient safety incidents and adverse events in ambulatory dentistry.

METHODS

We searched MEDLINE and EMBASE for articles reporting events that could have or did result in unnecessary harm in ambulatory dental care. We extracted and synthesized data on the types and frequencies of patient safety incidents and adverse events.

RESULTS

Forty articles were included. We found that the frequencies varied very widely between studies; this reflected differences in definitions, populations studied, and sampling strategies. The main 5 PSIs we identified were errors in diagnosis and examination, treatment planning, communication, procedural errors, and the accidental ingestion or inhalation of foreign objects. However, little attention was paid to wider organizational issues.

CONCLUSIONS

Patient safety research in dentistry is immature because current evidence cannot provide reliable estimates on the frequency of patient safety incidents in ambulatory dental care or the associated disease burden. Well-designed epidemiological investigations are needed that also investigate contributory factors.

The Incidence and Nature of Claims against Dentists Related to Periodontal Treatment in Israel during the Years 2005-2019

BACKGROUND

In recent years, worldwide dental malpractice claims have dramatically increased. The purpose of the present study is to analyze periodontal therapy related claims in Israel that led to legal decisions.

METHODS

This retrospective cohort study includes malpractice claims against dental practitioners related to periodontology between 2005 and 2019. Only closed cases where a final decision was made were included. The chi-square test or Fisher exact test for categorical variables were performed and a p value of <0.05 was considered statistically significant.

RESULTS

During the study period there were 508 legal claims related to periodontal disease. Most plaintiffs were women (63.4%), and 71.3% of the patients were >35 years old. Most claims (82.8%) were settled out of court and ended in compromise. Claims concerning the treatment of periodontal disease by periodontists accounted only for 4.5% (23/508) of the cases while 95.5% (485/508) of the claims were for complications secondary to another treatment. Prosthodontic treatment was involved with the highest number 54.5%, followed by dental implants 17.7%, and endodontics 11.6%. The allegations were related to pain and distress (84.8%), aggravation of existent periodontal disease (83.3%), tooth loss (78.1%), and violation of autonomy (47%).

CONCLUSIONS

The main cause for lawsuits was related to aggravation of periodontal disease during prosthetic or implant therapy and related to suspected faulty or inexistent preoperative diagnosis and planning.

PRACTICAL IMPLICATIONS

Periodontal consultation before dental treatment may reduce malpractice risks, adverse events, and un-necessary changes of treatment plans.

Ethical Aspects concerning Instrument Separation and Perforations during Endodontic Treatment: A Cross-Sectional Study

Aim

During endodontic treatment, dentists may face various unwanted procedural accidents, at any stage of the treatment that might compromise endodontic treatment outcome and bring obstacles to dentists as well. This study aimed to address and analyze several ethical concerns relating to the behavioural conduct of dentists towards endodontic instrument separation as well as perforation of the crown and/or root during root canal treatment in Riyadh, Saudi Arabia.

Method

Hundred and eleven questionnaires were distributed among dentists working in Riyadh in university clinics and government and private sectors. Data were collected, reviewed, and statistically analyzed by Fisher's exact and chi-square tests at a 5% significance level, using SPSS software.

Results

54.5% of the respondents have encountered instrument separation. 53.2% stated that they would inform the patient about the instrument separation. 43.6% of the respondents had experienced perforation during root canal treatment, and 54.9% reported that they would inform the patient of the accident.

Conclusion

Within the limitation of this survey, we concluded that most of the dental professionals did not hesitate to adhere to the correct ethical conduct, and they would inform the patient if an incident occurred.

Accidental perforations during root canal treatment: an 8-year nationwide perspective on healthcare malpractice claims

OBJECTIVES

To assess occurrence and its variation over time of serious accidental perforations during endodontic treatment and the fate of perforated teeth by tooth type and characteristics of patients and dentists.

MATERIALS AND METHODS

Data, based on patient documents on healthcare malpractice claims, comprised all endodontic injuries (n = 970) verified by the Patient Insurance Centre in Finland in 2002-2006 and 2011-2013. Two specialists in endodontics scrutinized the documents. Accidental perforations were recorded by location (tooth type, chamber/canals) and dichotomized as avoidable (could have been avoided by following good clinical practice) or unavoidable (normal treatment-related risks). Fate of perforation cases was recorded as treatment discontinued, root canal(s) filled, or tooth extracted. Background information included patients' and dentists' sex and age and the service sector. Statistical evaluation used Chi-square tests.

RESULTS

Serious accidental perforations comprised 29% of all verified injuries. Most perforations were judged as avoidable: 93% in patients aged below 35 years, 87% when located in the pulp chamber or in molars (84%); 70% of all perforations and 75% of those in molars resulted in tooth extraction. The overall rate of serious accidental perforations was 17.6 cases per 100,000 endodontic patients per year.

CONCLUSIONS

The rate of serious accidental perforations increased over time. The majority was in molars and resulted in tooth extraction.

CLINICAL RELEVANCE

Accidental perforations comprise almost a third of serious injuries during root canal treatment. However, four of five perforations could be avoided by following good clinical practice. Therefore, training is needed before adopting new working equipment and methods.

Aspects of Clinical Malpractice in Endodontics

The clinical dentistry and endodontic procedures involve very technique-sensitive procedures, therefore exposing the operator to risks of causes not only damage to patients but also leads to malpractice. Among various disciplines of dentistry, endodontics-related cases witness the most frequently filed malpractice claims. This is due to the fact that the endodontic treatment procedures involve operative and surgical procedures, using a variety of medicaments and techniques. The endodontic procedural errors can be preoperative errors (such as incorrect diagnosis and misinterpretation), intraoperative errors including root canal and pulp chamber perforations, ledge formation leading to apical transportation or zipping, hypochlorite accidents, and fracture of instruments. More critically, failure to use rubber dam may result in inhalation or ingestion of endodontic instruments. Under such circumstances, the endodontist may have to face legal consequences. Due to the increased healthcare load and patients’ awareness, it is important to know the legal ramifications of adverse effects, failed restorations, or other complications, to avoid any legal ramifications of endodontic procedures and associated techniques. Therefore, precautions must be taken to prevent any postsurgical complications, patient complaints, and/or failures. For this purpose, the operator must consider ethical principles and adhere strictly to the standards of healthcare while performing the diagnosis and treatment. A referral toward a specialist or consultant endodontist is always an appreciable option and should be considered in the best interest of the patient. The aim of the article is to highlight various aspects of malpractice in clinical endodontics, and associated materials and challenges. In addition, commonly occurring operating errors during endodontic treatment, possible consequences, precautions, and management have been discussed.

Complaints about dental practitioners: an analysis of 6 years of complaints about dentists, dental prosthetists, oral health therapists, dental therapists and dental hygienists in Australia

BACKGROUND

Previous research has found dental practitioners at elevated risk of complaint compared with other health professions. This study aimed to describe the frequency, nature and risk factors for complaints involving dental practitioners.

METHODS

We assembled a national dataset of complaints about registered health practitioners in Australia between January 2011 and December 2016. We classified complaints into 23 issues across three domains: health, performance and conduct. We compared rates of complaints about dental practitioners and other health practitioners. We used negative binomial regression analysis to identify factors associated with complaints.

RESULTS

Dental practitioners made up 3.5% of health practitioners, yet accounted for approximately 10% of complaints. Dental practitioners had the highest rate of complaints among fourteen health professions (42.7 per 1000 practitioners per year) with higher rates among dentists and dental prosthetists than allied dental practitioners. Male practitioners were at a higher risk of complaints. Most complaints about dentists related to treatments and procedures (59%). Around 4% of dentists received more than one complaint, accounting for 49% of complaints about dentists. In 60% of closed cases no regulatory action was required. Around 13% of complaints resulted in restrictive actions, such as conditions on practice.

CONCLUSION

Improved understanding of patterns may assist regulatory boards and professional associations to ensure competent practice and protect patient safety.

Operator-related aspects in endodontic malpractice claims in Finland

OBJECTIVE

We analyzed operator-related differences in endodontic malpractice claims in Finland.

MATERIALS AND METHODS

Data comprised the endodontic malpractice claims handled at the Patient Insurance Centre (PIC) in 2002-2006 and 2011-2013. Two dental advisors at the PIC scrutinized the original documents of the cases (n = 1271). The case-related information included patient's age and gender, type of tooth, presence of radiographs, and methods of instrumentation and apex location. As injuries, we recorded broken instrument, perforation, injuries due to root canal irrigants/medicaments, and miscellaneous injuries. We categorized the injuries according to the PIC decisions as avoidable, unavoidable, or no injury. Operator-related information included dentist's age, gender, specialization, and service sector. We assessed level of patient documentation as adequate, moderate, or poor. Chi-squared tests, t-tests, and logistic regression modelling served in statistical analyses.

RESULTS

Patients' mean age was 44.7 (range 8-85) years, and 71% were women. The private sector constituted 54% of claim cases. Younger patients, female dentists, and general practitioners predominated in the public sector. We found no sector differences in patients' gender, dentists' age, or type of injured tooth. PIC advisors confirmed no injury in 24% of claim cases; the advisors considered 65% of injury cases (n = 970) as avoidable and 35% as unavoidable. We found no operator-related differences in these figures. Working methods differed by operator's age and gender. Adequate patient documentation predominated in the public sector and among female, younger, or specialized dentists.

CONCLUSIONS

Operator-related factors had no impact on endodontic malpractice claims.

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.

Dental treatment injuries in the Finnish Patient Insurance Centre in 2000-2011

Objective The Patient Insurance Centre in Finland reimburses patients who sustained injuries associated with medical and dental care without having to demonstrate malpractice. The aim was to analyse all dental injuries claimed through the Patient Insurance Centre over a 12-year period in order to identify factors affecting reimbursement of claims. Methods This study investigated all dental patient insurance claims in Finland during 2000-2011. The injury cases were grouped as (K00-K08) according to the International Classification of Diseases (ICD-10). Calendar year, claimant's age and gender, dental disease group and health service sector were the explanatory factors and the outcome was the decision of a claim. Multiple logistic regression modelling was used in the statistical analyses. Results The total number of decisions related to dental claims at the PIC in 2000-2011 was 7662, of which women claimed a clear majority (72%). Diseases of the pulp and periapical tissues (K04) and dental caries (K02) were the major disease groups (both 29%). Of the claims 40% were eligible for reimbursement, 27% were classified as insignificant or unavoidable injuries and 32% were rejected for other reasons. The proportion of reimbursed claims declined during the period. Patients from the private sector were more likely to be eligible for compensation than were those from the public sector (OR = 1.89, 95% CI = 1.71-2.10). Conclusions The number of dental patient insurance claims in Finland clearly rose, while the proportion of reimbursed claims declined. More claims received compensation in the private sector than in the public sector.