Should I use bleach in endo treatment?

For those of you who do endo quickly, i.e. 15 min to 45 min, I am curious to get your opinions. I saw Buchanan about a year ago and he said that NaOCl needs to be in the canals for a minimum of 35-45 min. to “chew-up” the tissue in lateral canals, or even in the main canal. When I do for example #9 and get my GT .10 to the terminus in two or three passes and I have been “in” the tooth for a total of 5 minutes, I’d sure like to fill it, but feel like it hasn’t been sterilized unless the NaOCl has been in there for 45 minutes. What do you think?
Garrisonmt, Official Townie

I don’t know, Matt. I do respect Buchanon, and David C.’s made that same point here. I suspect it has great merit, and that from an ideal-care standpoint, it may be the only way to absolutely positively remove as MUCH gunk as possible from a tooth’s root canal system. But I don’t do it either. I don’t even allow Clorox in a tooth. Until I see failures as a result of this, I cannot see doing it.
Marshall_white_dmd, Official Townie

If you believe that your instruments do the biomechanical cleansing, then use water or what ever. If you believe in multiple lateral canals, pulpal irregularities, then you will use NaOCl for 30-45 minutes once you establish apical patency in a small canal and 20-30 minutes in a large one, refreshing it every 5 minutes. The 15-minute, open file and fill; or the 15-minute, open file, soak for another 15-30 minutes, and then fill? It is not just Buchanan, it’s also Carr, Ruddle and many more who promote the active use of NaOCl after patency is established, then R-EDTA to remove any inorganic smear layer that may be plugging another portal of exit, then NaOCl for the final flush.
Davidc, Official Townie

In the last few weeks, since I applied David’s advice, I have found some UNBELIEVABLE accessory canals. For example: Would you believe that you can find accessory canals in coronal third (5mm below the bone level) on upper canine? Or maybe 90 degrees angled accessory canals 5mm below the furca on #19, plus aimed in mesial direction? How would someone negotiate these canals other than dissolve their content and fill it by vertical condensation? If it takes 20-45 minutes, so be it. The longest time I waited so far was 20 minutes, though. I am completely convinced that David’s approach is THE ONE. What he told us works so good that I feel he changed my philosophy about irrigation of canals.
Smile4u, Official Townie

Reimbursement for “Unexpected Results”

If you have an unfavorable outcome such as a failed root canal or crown etc., and you want to reimburse the fee to the patient, how do you cover yourself legally? What sort of letter should accompany the reimbursement to prevent any further legal action from the patient?
George, Official Townie

In my opinion, you don’t “cover” yourself legally by returning a fee. If you treated properly, you have no legal exposure to begin with, so the only reason for refund is to maintain goodwill and remove an irritant that may foster a patient’s seeking legal action. It doesn’t change whether there are legal grounds. Personally, I wouldn’t send any standard kind of letter. I would discuss it personally with patient, and if I returned a fee, they would already know the arrangement we had come to. Try this example…you’re mugged and robbed....the crook returns the money....are they no longer guilty of a crime?
David_f, Official Townie

I put a little release note on the back of a check. One patient I sent a release letter to and I told her no refund unless it’s returned signed and notarized. Funny thing, because that is one refund check I issued that has yet to be cashed. The patient started complaining from moment one in the office. I never should have touched the patient, but you know how it is. Bills to pay.
Mauty, Official Townie

Professional advice from dental attorney Jeff Tonner.

The first question is whether you should reimburse under these situations. I call them “unexpected results;” that is, where the DDS did nothing wrong, but the end result was not ideal. It is strictly a matter of philosophy. In Arizona, about 75% of dentists will refund, and 25% will not. There really is no right or wrong answer here.

As to a “letter” (writing), I have a form where the patient promises not to file a civil case, terminates the DDS/patient relationship (optional), and waives the right to file a dental board action. The last part may not be legal, but sometimes a good bluff is better than a good hand. I have never had a patient sign the release and then file a board complaint.

If the patient refuses to sign, I always tell the DDS to refund the money anyway. With a refund, the patient is less likely to start any legal proceedings, and the case becomes less attractive to the over-populated plaintiff’s bar.

Jeff Tonner is a dental defense attorney in Phoenix, Arizona. His practice encompasses the dental-legal arena defending dentists in malpractice or board action. Mr. Tonner can be reached by email at dentlaw@jefftonner.com or by phone at (602) 266-6060.