Who Sets the Standard of Care When It Comes to Clinical Endodontics?
Gregg A. Helvey, DDS, CDT; James A. Smith, Jr., DMD; Allen Ali Nasseh, DDS, MMSc
When addressing the issue of standard of care regarding endodontics-ie, at what point should a referral be made to a specialist for a root canal procedure?-the meaning of "standard of care" must first be identified. It is a legal term of art defined as, "that care which a reasonable and prudent practitioner would do under the same or similar circumstances."1 Furthermore, in some jurisdictions the standard of care is strictly local, whereas other jurisdictions may rely on a definition of the minimal level of care at a national level. Clinicians should investigate as to what the legal guidelines are in their locality.
That said, the discipline of endodontics is a recognized specialty by the American Dental Association (ADA). According to the American Association of Endodontists (AAE), general dentists are expected to meet minimum standards as stated in guidelines developed and published by the AAE as "standards of practice." These guidelines were developed to assist educational institutions and organized dentistry in developing minimum educational requirements and practice standards in endodontic treatment.2
For general dentists to practice at an acceptable level they must have knowledge of and experience in basic endodontics to perform nonsurgical root canal therapy on uncomplicated permanent teeth. Factors related to the clinician's level of understanding, competency, skill, and clinical experience should be considered when discussing adherence to the AAE standards. It is also important to understand that as new discoveries and technologies emerge, standards of practice change and the clinician is responsible for keeping up to date with the latest developments.
When should referral be made to a specialist? General dentists must analytically evaluate their own level of knowledge and experience and identify clinical situations in which they may not feel comfortable and recognize when the need for additional resources may be required. The AAE provides a Case Difficulty Assessment Form that general dentists can download from the organization's website under Case Assessment Tools.2 The form asks a series of questions about the case that aids in determining the level of difficulty, which is either minimal, moderate, or high, before treatment commences. Numerous factors that often may be overlooked can contribute to the difficulty in treating a case. The form provides a comprehensive evaluation that assists the clinician in recognizing all of the complexities that may affect the outcome.
To effectively discuss this subject, let's define "standard of care" along with several other related terms. The American Association of Endodontists' Fall 2014 Colleagues for Excellence publication, The Standard of Practice for Contemporary Endodontics,3 summarizes the following terms:
Standard of practice: This is defined as the acceptable level of performance or an expectation for professional intervention, formulated by professional organizations (like the AAE) based on current scientific knowledge and clinical expertise.
Standard of care: While there is no medical term for "standard of care," it is a phrase that is firmly established in tort law and is defined as, "the caution and prudence that a reasonable person under a duty of care, in similar circumstances, would exercise in providing care to a patient."
Best practice: This is defined as the recognized level of care provided by competent practitioners specifically trained in a particular area of specialization. The ADA recognizes endodontics as a dental specialty, and the American Board of Endodontics is the recognized certification board of this specialty. The AAE has developed and continues to develop and provide the dental profession and the public with information and education on endodontic best practices. "Best practice" is a dynamic model that progressively changes and improves as new technologies (eg, enhanced magnification via a dental operating microscope) are implemented. It is continually redefined by scientific discovery.
Based on this information one can see that the courts actually determine the "standard of care," and the profession establishes the standards for "best practice."
It is estimated that roughly 70% of endodontic procedures in the United States are performed by general dentists.4 Thus, a general dentist performing endodontic procedures should be cognizant of best practices as defined by the AAE and able to judge when the case difficulty is more than he or she can manage. Examples of increasing case difficulty include, but are not limited to: uncertain diagnosis of the origin of pain, tortuous canals, calcified canals, internal and external resorption, endodontic-periodontic lesions, extremely large periapical lesions, and roots that are in close proximity to the maxillary sinus, inferior alveolar nerve, or mental foramen. At the point that a general dentist begins to be uncertain or uncomfortable with a diagnosis or clinical treatment of an endodontic problem, then referral to an endodontist may be best for all concerned parties.
The term "standard of care" is legal jargon for the minimum standards required for any medical procedure to conform to the standard medical norms. This makes it a highly relevant term, as it defines the borderline between what is acceptable medical treatment and what is considered negligence and subject to potential malpractice litigation. This standard, however, is not the highest standard available for a given medical procedure but the minimum level of care required by law. While the goal of clinicians should be to practice above these standards, understanding the line of acceptable practice is paramount.
The standards of care are defined by a combination of a state's Practice Act and the common law. At any point, each state's published regulations and the collective sum of legal precedent help clarify these standards. The ADA states that the standard of care is set by the specialists. This is where the role of specialist experts and their function in defining these standards become important.
For better or worse, the standards of care are also local, as they are defined by a each state's Practice Act as well as the common law and standard practices by local specialists. Therefore, clinicians must be aware of the common practices by local specialists before concluding that their practice standard is adequate.
To make things more confounding, companies selling technology often advertise claims of "a new standard of care, or a higher standard of care," and may make other commercial exaggerations. Many modern tools, such as operating microscopes and CBCT technology, are indeed very helpful and represent an enhanced quality of care, but are currently not the standard of care. If they were, not using them would be considered negligence.
However, the use of such technologies in specific cases may be considered a standard. For example, the use of a rubber dam for isolation is universally established as a standard of care as determined by common law. If the clinician were to forego the application of rubber dam during nonsurgical root canal therapy and substitute it with non-equivalent equipment and the case failed due to contamination or the patient inhaled an object, the treatment would be considered below the standard of care and may be interpreted as negligence.
About the Authors
Gregg A. Helvey, DDS, CDT
Associate Professor, General Dentistry, Virginia Commonwealth University School of Dentistry, Richmond, Virginia; Master, Academy of General Dentistry; Private Practice, Middleburg, Virginia
James A. Smith, Jr., DMD
Adjunct Assistant Professor, Endodontic Department, University of Alabama at Birmingham School of Dentistry,
Birmingham, Alabama; Private Practice, Birmingham, Alabama
Allen Ali Nasseh, DDS, MMSc
Clinical Instructor, Department of Restorative Dentistry and Biomaterial Sciences, Harvard University School of Dental Medicine, Boston, Massachusetts; President, RealWorldEndo™, Wilmington, Delaware; Private Practice,
1. Selbst AG. Standard of care: so who decides? Oral Surg Oral Med Oral Path Oral Radiol Endod. 1997;83(6):637.
2. Treatment Standards. American Association of Endodontists website. https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/04/TreatmentStandards_Whitepaper.pdf. 2018. Accessed September 28, 2018.
3. The Standard of Practice for Contemporary Endodontics. Chicago, IL: American Association of Endodontists; Fall 2014. https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/07/col035fall2014standardofpracticeupdate.pdf. Accessed September 28, 2018.
4. Savani GM, Sabbah W, Sedgley CM, Whitten B. Current trends in endodontic treatment by general dental practitioners: report of a United States national survey. J Endod. 2014;40(5):618-624.