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49. Andreasen JO: Effect of extra-alveolar period and storage media

upon periodontal and pulpal healing after replantation of mature
permanent incisorsin monkeys, Int J Oral Surg 10:43, 1981.
50. Blomlof L et al: Storage of experimentally avulsed teeth in milk
prior to replantation,

J Dent

Res 62:912,

1983.

51. Krasner P, Person P: Preserving avulsed teeth for replantation,

JADA 123:80, 1992.
52. Trope M, Friedman S: Periodontal healing of replanted dog teeth
stored in Viaspan, milk and Hank's balanced salt solution, Endod
Dent Traumatol 8:183, 1992.
53. Andreasen JO: Relationship between cell damage in the periodontal ligament after replantation and subsequent development of
root resorption. A time-related study in monkeys, Acta Odontol
Scand 39:15, 1981.
54. Coccia CT: A clinical investigation of root resorption rates in reimplanted young permanent incisors: a five year study, J Endodon
6:413,1980.
55. Loe H, Warhaug J: Experimental replantation of teeth in dogs and
monkeys, Arch Oral Bioi 3:176, 1961.
56. Morris ML et al: Factors affecting healing after experimentally de./> layed tooth transplantation, J Endodon 7:80, 1981.
57. Trope M, Hupp JG, Mesaros SV: The role of the socket in the
periodontal healing of replanted dogs' teeth stored in ViaSpan for
extended periods, Endod Dent Traumatol13:171, 1997.
58. Andreasen JO: The effect of removal of the coagulum in the alveolus before replantation upon periodontal and pulpal healing of
mature permanent incisors in monkeys, Int J Oral Surg 9:458,
1980.
59. Andreasen JO: Effect of splinting upon periodontal healing after
replantation of permanent incisors in monkeys, Acta Odontol
Scand 33:313,1975.

60. Nasjleti CE et al: The effects of different splinting times on replantation of teeth in monkeys, Oral Surg Oral Med Oral Path
Oral Radiol Endod 53:557, 1982.
61. Berude JA et al: Resorption after physiologic and rigid splinting
of replanted permanent incisors in monkeys, J Endodon 14:592,
1988.
62. Antrim DD, Ostrowski JS: A functional splint for traumatized
teeth, J Endodon 8:328, 1982.
63. Oikarinen K: Comparison of the flexibility of various splinting
methods for tooth fixation, Int J Oral Maxillofac Surfs 17:125,
1988.
64. Barbakow FH, Austin JC, Cleaton-Jones PE: Experimental replantation of root-canal-filled and untreated teeth in the vervet
monkey, J Endodon 3:89, 1977.
65. Andreasen JO, Kristerson L: The effect of extra-alveolar root filling with calcium hydroxide on periodontal healing after replantation of permanent

incisors

in monkeys,

J Endodon

7:349, 1981.

66. Dumsha T, Hovland EJ: Evaluation of long-term calcium hydroxide treatment in avulsed teeth-an in vivo study, Int Endod J 28:7,
1995.
67. Trope M et al: Effect of different endodontic treatment protocols
on periodontal repair and root resorption of replanted dog teeth,

J E1'ldodon

18:492,

1992.

68. Trope M et al: Short vs. long-term calcium hydroxide treatment

of established inflammatory root resorption in replanted dog teeth,
Endod Dent TraumatoI1l:124, 1995.
69. Trope M: Clinical management of the avulsed tooth, Dent Clin
North Am 39:93, 1995.

LEGAL
ENDODONTIC

EAT.MENT
G. GAROCHALIAN

echnologic advances in dentistry have not only

improved the quality and prognosis of endodontic treatment, they have also provided an avenue,
albeit a sometimes uncontrolled one, for patient education. Patients can easily obtain information from commercial institutions and the Internet regarding their dental and legal rights. Because of this, claims involving
dental malpractice, including the practice of endodontics, are on the rise.
Risk management and prevention are crucial to limiting malpractice claims. The best defense in dental malpractice litigation is a thorough examination, an accurate diagnosis, a comprehensive treatment plan, patient
education and informed consent, and appropriate endodontic treatment. Moreover, complete dental treatment records, including a properly administered written
informed consent, document the quality of treatment
provided. The risk management to'ols of consistent patient education and accurate record keeping greatly reduce the legal exposure of dentists performing endodontic procedures.
Every state provides guidelines establishing the minimum requirements dentists must meet. Many states provide sample documents such as written informed consent
forms that have been approved for use in the state. Dentists have a responsibility to seek and obtain this information if it is available in the states where they provide
dental care.

TREATMENTRECORDS
Clearly, the most important tools in the prevention
and/or defense of a dental malpractice claim are the
patient/plaintiff treatment record and signed informed
consent. Each state has its own unique Dental Practice
Act that usually contains minimum requirements for in-

formation to be included in the patient record. Licensed

practitioners have the responsibility of knowing what
their individual state Dental Practice Acts dictate regarding treatment documentation. Nevertheless, some
basic recommendations should be considered in any
treatment record.
As a prelude to the aforementioned recommendations, each practitioner should establish a standardized
protocol regarding procedures required for the diagnosis
and treatment of pulpal and periapical pathosis. For example, after evaluating the patient's chief complaint, the
clinician must complete a thorough review of the patient's medical and dental history. Subjective information
should include the patient's description of symptoms associated with the chief complaint. The clinician can then
perform a series of objective tests as part of the clinical
examination. These include not only pulpal and periapical tests, but also a localized periodontal examination of
the area of the suspect tooth or teeth. In addition, appropriate diagnostic radiographs are made and interpreted. Finally, the clinician comprehensively evaluates
all the gathered information to establish a pulpal and
periapical diagnosis. At the conclusion of the diagnostic
process, all treatment options are explained and the patient is given an opportunity to ask questions. Depending
on the patient's desires, one of the suggested treatment
plans may be initiated.
In addition to establishing a standardized approach
to diagnosis and treatment, the practitioner should develop a systematic approach to written documentation
of the treatment provided:
1. A detailed written medical history identifying predisposing conditions that may affect prognosis or
patient management is essential. If medical consultation with an appropriate health care provider is
189

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2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Color Atlas of Endodontics

indicated, the results of that consultation should be

recorded.
The patient's chief complaint and dental history
should be reviewed and recorded in his or her own
words. Analysis and evaluation of previous treatment records and radiographs should be noted.
An extraoral examination should be conducted and
the results, including medical and dental referrals,
should be recorded.
An intraoral examination should be conducted and
the results, including medical and dental referrals,
should be recorded.
An examination of the affected tooth or teeth should
be completed. Both subjective and objective tests
should be completed and recorded. If necessary, a
timely referral to a dental specialist may be indicated
and recorded.
Current radiographs of diagnostic quality should be
made and interpreted. The radiographs provide information regarding the particular tooth or teeth
and allow the clinician to make and record observations regarding the periradicular structures. Again, a
timely referral to a dental specialist may be indicated
and recorded.
A periodontal examination should be conducted and
the results, including dental specialty recommendations and medical referrals, should be recorded.
Based on the systematic evaluation of the examination results, a pulpal and periapical diagnosis should
be ascertained and recorded.
A proposed treatment plan and options presented to
the patient should be recorded. This record should
include the prognosis for treatment.
Informed consent should be obtained and included
in the patient's treatment record. A written document is preferred to oral consent.
The treatment rendered, including any medications
prescribed, should be detailed in the patient treatment record.
A statement indicating that postoperative instructions and requirements for future visits were reviewed with the patient or legal guardian should be
included in the record.
The provider should always sign the record.

In addition to the importance of providing a complete and accurate account of treatment provided to patients, written dental records should be maintained with
the following recommendations in mind:
1. Clinicians should know their state mandates regarding record keeping and retention of dental records as
defined in each state's Dental Practice Act.
2. Entries may become public record. Therefore subjective commentary is inappropriate. Financial details
should not be listed with the chronologic record of

--

3.

4.
S.
6.
7.

8.

treatment. In addition, documentation of conversations with attorneys and insurance carriers has no
place in the treatment record.
Always keep the original record, radiographs, consultation reports, and any other documents related to
patient care.
All records should be typed or written in black or
blue ink.
All records must be legible.
Avoid using abbreviations or codes that are not generally accepted in the profession.
Never destroy a record, rewrite information, or use
correction fluid or paper. The mere appearance of
alteration of the record creates an aura of impropriety. If an entry must be corrected, put a single
line through the unwanted verbiage and continue
recording the findings. If information is inadvertently left out of the treatment record, make an additional entry entitled Addendum. The addendum
should be signed and reflect the date the data were
entered.
Ensure that patients sign and date informed consent
documents for every procedure.

In addition to the requirement of maintaining accurate treatment records, dentists have a legal obligation
to review the diagnosis and treatment options with their
patients and obtain informed consent to continue with
or refuse endodontic treatment.

INFORMEDCONSENT
The doctrine of informed consent is based on the legal
maxim that every human being of adult years and sound
mind has a right to determine what shall be done with
his or her own body. A provider who performs a procedure without the consent of the patient commits an assault and incurs liability. The informed consent document is an agreement by the patient, after full disclosure
of facts needed to make an informed and intelligent decision, to allow a specific treatment to be performed. The
courts have established that providers have a duty to disclose information that a reasonably prudent practitioner
would disclose to patients regarding any grave risks of
injury resulting from a proposed course of treatment.1
Moreover, the courts clearly state that health care
providers, as an "integral part" of their responsibilities
to their patients, have a duty of reasonable disclosure regarding available alternatives to proposed treatment options as well as the potential complications inherent in
each treatment option.2
With respect to informed consent regarding endodontic care provided to a patient, the American Association of Endodontists (AAE) is consistent with the
courts in its recommendations. As a general rule, the
AAE advises that the informed consent requirement is

"'"

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Chapter Twelve

Legal Considerations in Endodontic Treatment

fulfilled after the practitioner "has discussed with his or

her patient all relevant information so as to assist the patient in making an informed decision with respect to undergoing that proposed procedure."3
As a general rule the information presented to a patient must be presented in terminology that can be easily
understood. At the very least, the written informed consent should include the following3:
1. The date the informed consent document was
presented and signed by the patient or legal
guardian
2. The diagnosis for each tooth involved, including
both a pulpal and a periapical component
3. A description of the treatment recommended
4. A review of potential complications and postoperative risks associated with the proposed treatments
5. The prognosis regarding the success of each of
the treatment options
6. Alternative treatment options, including no
treatment or extraction
7. A review of potential complications associated
with proposed alternative treatment options
8. The prognosis regarding the success of alternative treatment options
9. A general acknowledgment that the patient or legal guardian was given an opportunity to ask
questions and that all questions were answered
to the patient's or legal guardian's satisfaction
10. Signature and date spaces for the patient or legal guardian to sign
No specific form can be used for every case. Furthermore, each practitioner should develop an informed consent form that is consistent with the requirements outlined in their individual state's Dental Practice Act. The
AAE has developed a sample written informed consent
that is to be used solely as an example; it is not to be
considered a standard or accepted example of a written
informed consent for every state (Figure 12-1). Moreover, the use of a written informed consent form in no
way substitutes for a personal review by the practitioner
of proposed treatment options or alternatives, including
their potential risks.

ABAN DONME NT
By initiating endodontic treatment, the dentist has accepted the legal responsibility to follow the case to completion or until the case can be referred to a specialist.
This responsibility includes not only completing endodontic therapy, but also being available for subsequent
inter-appointment and postoperative emergency care. If
the dentist fails to comply with his or her obligations to
complete treatment and provide adequate emergency
care, he or she is exposed to liability on the grounds of
abandonment. Therefore the treating dentist should al-

191

ways have adequate ways for a patient to accesshim or

her in the event of an after-hours emergency.
This is not to say that the treating practitioner does
not have the power to sever the doctor/patient relationship unilaterally. A treating dentist may havevariousreasons for wanting to end his or her treatment obligations
with a particular patient. The dentist may arguethat the
patient failed to cooperate with recommended dentalcare,
failed to keep appointments, or failed to meet financial'
obligations. Regardless of the justification for treatment
cessation, a dentist who fails to follow the properprocedures may incur liability for abandonment litigation.
The best defense to an abandonment claimis preparation based on the concept of reasonable notice. Successful endodontic care is based on mutual trust between
the treating dentist and the patient. The treating dentist
should have a prepared procedural template to dismissa
patient unilaterally from the practice in situations in
which this trust has been compromised.
The clinician should take into account the following
considerations when developing a letter to provide reasonable notice of termination of endodontic care for a
particular patient. Termination should only be considered if no immediate threat to the patient's dentalor subsequent medical health is evident.
1. The letter should be firm, clearly stating the dentist's
plan to terminate the professional relationship.
2. The letter should detail the reasons for the proposed
severance. For example, if the patient has failed to
keep scheduled treatment appointments, the letter
should include the dates of the missed appointments.
3. The clinician should volunteer to provide copies of
the treatment record and the appropriate radiographs
to the new endodontic care provider.
4. The clinician should allow the patient a reasonable
time to locate a new practitioner. Reasonable time
may be influenced by different factors. For instance, a
reasonable time in a heavily populated metropolitan
area with an abundance of dental care practitioners
may be less than a reasonable time in a rural or secluded area with a limited number of dentists.
5. The clinician should volunteer to provide emergency
care limited to the treatment already provided while
the patient locates a new provider.
6. The letter should provide an opportunity for the patient to respond. The clinician should specifya telephone number and a contact person (either the providing dentist or an office employee).
7. The letter should be sent by certifiedmail with return
receipt requested.

SUMMARY
Clearly, the best defense against litigation associated
with endodontic treatment is adequate preparation.

...

j"
!

@.

In today's volatile professional liability environment, litigation

involving informed consent issues is more common than ever.
Corresponding
to the increase in litigation is a similar increase
in the rate of malpractice premiums.
While the endodontist may conform to applicable standards
of care in the performance of his or her procedur~s, that alone
will not prevent him or her from being subjected to a claim by
the patient for an untoward result. Failure to inform the patient
of the risk of an untoward result prior to the performance of
that procedure will just as likely result in a claim by the patient
for failing to obtain his or her consent.
As a general rule, informed consent is satisfied after the
endodontist has discussed with his or her patient all relevant
information so as to assist the patient in making an informed
decision with respect to undergoing that proposed procedure.

History
Informed consent originally developed from common law
principles of negligent non-disclosure. It has since evolved
from repeated interpretations
by the courts and state
legislatures into the patient's right to participate in the
decision-making process regarding the type of treatment he or
she is about to undergo. Because of the confusion created by
various interpretations
of the doctrine of informed consent by
the courts and state legislatures, it is difficult to formulate a
single, simple statement on the legal requirements of informed
consent.

Gene..al

guidelines

Despite these various interpretations

of informed consent, it is
generally accepted that to obtain the informed consent of the
patient, the endodontist needs to:
I. Disclose the following information in understandable
lay
language:
Diagnosis of the existing problem
Nature of the proposed treatment or procedure
Inherent risks associated with the proposed treatment
or procedure

.
.
.

.
.

procedure
Inherent risks associated

treatments or procedures
Prognosis of alternative treatments

Prognosis

. Feasible

alternatives

to the proposed

treatment

or

with the alternative

2. Provide a generalized opportunity

about any of the above.

or procedures

to question

the doctor

Diagnosis
It is required before treatment is rendered that there be a
diagnosis of the existing condition and that this diagnosis be
given in a manner that is readily understood by the patient.

No treatment
Keep in mind that choosing no treatment at all is always an
alternative to every treatment or procedure. However, the
likely results of no treatment must also be explained.

Lay language
It is important to nQte that the discussion regarding the
proposed procedure and alternatives and their prognoses must
be presented in language and terms understandable
by each
individual patient.

Doctor

must

discuss

The practitioner who is to perform the procedure must

personally present the details of the case, and the patient must
be able to question the provider regarding treatment or
alternatives. The office staff does not have the power to obtain
consent. A written consent form, while imperative
for
accurate record keeping, CANNOT be used as a substitute
for the doctor's discussion with each individual patient.
A thoughtful, well documented
dialogue between the doctor
and the patient can reduce misunderstandings
and incidence
of claims and suits alleging a lack of informed consent.

Signatures
Your consent form must be signed and dated by the patient
Oegal guardian if under 18 years of age) and should be signed
and dated by the practitioner as testimony to the fact that the
endodontist did discuss the elements of the consent form. The
signature of a witness is also recommended.

Consent

is limited

to. procedures

discussed

It is important to note that consent is limited to the

procedures discussed and is not open ended. Therefore,
informed consent should be thought of as an ongoing process
that may have to be modified if procedures change (i.e.,
nonsurgical to surgical, unexpected
results, or procedural
mishaps).

Designing

a form

The form should:

Document the date and time of the consent process
Include a statement that the patient was given the
opportunity to question the provider regarding treatment
or alternatives
Provide space for signatures by the patient, parent or
guardian, the provider, and a witness.
It should be clearly understood that no particular form could
possibly be suggested for use on a uniform basis. The form
provided is a sample and should not be considered a standard
form.
Consult
with
statutes

an attorney and check your state

These guidelines are not to be considered legal advice.

Members should consider their own particular needs and on
the basis of those needs, draft forms and procedures for use in
their own offices.
Recognizing that state statutes regarding informed consent
vary, it is recommended
that members consult their state
statutes when developing their own informed consent forms. A
copy of your state statute can be obtained from your attorney
or by writing to the local county bar association where you
practice or reside.

FIGURE12-1 AAEsampleinformedconsentform. (Courtesyof the AmericanAssociationof Endodontists,Chicago,IL)

Sample

Statement of Consent for Endodontic Treatment

and any other

1. I hereby authorize Dr.

and such

agents or employees of
assistants as may be selected by any of them to treat the condition(s)

2. The procedure(s) necessary to treat the condition(s)

described below:

have been explained to me, and I understand the

nature of the procedure(s) to be:

3. The prognosis for this(these) procedure(s) was described as:

4. I have been informed of possible alternative methods of treatment

including no treatment

at all.

5. The doctor has explained to me that there are certain inherent and potential risks in any treatment plan or
procedure. I understand that the following may be inherent or potential risks for the treatment I will
receive:
swelling; sensitivity; bleeding; pain; infection; numbness and/or tingling sensation in the lip, tongue,
chin, gums, cheeks, and teeth, which is transient but on infrequent occasions may be permanent;
reactions to injections; changes in occlusion (biting); jaw muscle cramps and spasm;
temporomandibular
joint difficulty; loosening of teeth, crowns,or bridges; referred pain to ear, neck, and
head; delayed healing; sinus perforations; treatment failure; complications resulting from the use of
dental instruments (broken instruments-perforation
of tooth, root, sinus), medications, anesthetics,
and injections; discoloration of the face; reactions to medications causing drowsiness and lack of
coordination; and antibiotics may inhibit the effectiveness of birth control pills.
6. It has been explained to me and I understand that a perfect result is not guaranteed or warranted and
cannot be guaranteed or warranted.
7. I have been given the opportunity to question the doctor concerning the nature of treatment, the inherent
risks of the treatment, and the alternatives to this treatment.

8. This consent form does not encompass the entire discussion I had with the doctor regarding the
proposed treatment.

Patient's signature

Date/time

Doctor's signature

Date/time

Witness's signature

Date/time
FIGURE 12-1, cont'd

For legend, see opposite page.

.
194

Color Atlas of Endodontics

Practitioners have an obligation to practice within the

guidelines established by the Dental Practice Acts of their
particular states. Copies of particular Dental Practice
Acts can be obtained from the individual State Board of
Dental Examiners or the local dental society. The information provided in this chapter is not intended to provide legal advice or substitute for legal counsel. In fact,
every practitioner who develops written and procedural
record templates is strongly encouraged to seek legal
counsel regarding record-keeping policies, preparation

of informed consent forms, and abandonment issues.

The dental record is the eyewitness in any litigation proceedings a dentist may face.

References
1. Ze Barth v Swedish Hospital Medical Center, 81 Wash 2d 12,499
P.2d 1, 8.
2. Cobbs v Grant, 8 Cal 3d 229,502 P.2d 1, 104 Cal.Rptr. 505.
3. American Association of Endodontists: Informed consent guidelines, Chicago, American Association of Endodontists.