A dentist over-excavated during a difficult RCT, causing a perforation

A man in his 30s visited his dentist complaining of severe toothache and sensitivity. After examining the patient, the dentist recommended root canal treatment at UL6. An appointment was booked and when the patient attended one month later he reported that the tooth was hypersensitive. The dentist dressed the tooth and a few weeks later carried out the root canal treatment using Protaper rotary files and an apex locator. He noted that there was a mesial hook on the mesio-buccal root, and advised the patient of the poor prognosis and referred him to a specialist.

The patient attended the specialist but did not return to see the dentist again. Some years later he brought a claim against the dentist, a DDU member. He alleged the dentist had failed to use reasonable skill and care in the technical execution of root canal treatment at UL6 In particular, he alleged that the dentist had:

failed to ensure that the rotary endodontic instruments and material were contained solely within the lumen of the root canal system
over-excavated the floor of the pulp chamber and created a perforation in the furcation area
failed to identify the shortcomings of the root canal treatment or to advise the patient of the perforation which was visible on the radiograph
failed to locate the mesio-buccal and disto-buccal canals and to clean, shape and obturate the canals to a satisfactory clinical standard.

The DDU appointed a dental expert who examined the records and a report from the dentist. The expert thought it likely that a perforation had been created during treatment. He added that once it became clear that the root canals were not easily detectable, the dentist should have been alert to the heightened risk of perforation. The expert further noted that the dentist should have been aware when the perforation had taken place and should not have instrumented the perforation to avoid making it larger than necessary.

The expert was further critical that our member used an apex locator during the root canal treatment. It was our expert's opinion, based on experience, that the device will not give an accurate reading and will give an obviously erroneous reading when there is some form of perforation present. Our member should have been aware, therefore, that he had created a perforation but there was no evidence to show this.

The expert also found that the perforation in the floor of the pulp chamber in the patient's UL6 was large and beyond repair. He further found that there was an area of radiolucency indicative of infection present in the furcation area between the roots. It was the expert's opinion that the area of radiolucency related directly to the presence of the perforation and that, if the root canal treatment had been completed satisfactorily, the area of radiolucency would not have been present. The expert opined that the prognosis for the UL6 was very poor as a consequence of the perforation and that extraction was indicated.

With our member's agreement, we settled the claim for £4,400 plus legal costs.

Richard Grimmett
Lead claims handler

Missed perforation

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