Exploring dentists’ experiences of endodontic file fracture during root canal treatment: a phenomenological study

Abstract

Objectives

File fracture represents a common and occasionally unavoidable occurrence during root canal procedures, carrying substantial negative implications for dental practitioners. This study explores dentists’ encounters with file fracture incidents during root canal treatment.

Methods

In this qualitative study using a phenomenological approach, 13 dentists were included through purposive sampling. The sampling continued until data saturation and semi-structured in-depth interviews were used to collect data. The 7-step Colaizzi approach was employed to analyze the collected data, and Lincoln and Guba’s criteria were used to ensure data credibility.

Results

The participant cohort comprised eight male and five female dentists, boasting an average of 10.15 ± 5.35 years of professional experience and an average age of 36.53 ± 6.35 years. Data segmentation revealed four themes alongside 18 sub-themes. These themes encompassed the fear of consequences, professional impasse, Integration decline, and the dilemma between moral and immoral decision-making.

Conclusion

The experiences of dentists during file fracture showed Fear of Consequences, Professional Impasse, Integration Decline, and the Dilemma between Moral and Immoral Decision-Making. File fracture episodes are distressing and taxing for dentists, harboring significant personal and professional repercussions. Such incidents precipitate emotional strain, compromise treatment efficacy, tarnish professional standing and identity, result in financial setbacks, and contribute to professional burnout. Consequently, policymakers must implement several measures, including strengthening legal and insurance protections, establishing secure reporting systems, developing a comprehensive, standardized, and practical document by the endodontic association, and mandating informed consent forms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06340-4.

Clinical Significance

The experience of file fracture during root canal treatment manifests in various ways for dentists, often resulting in adverse effects. It is crucial to implement practical strategies to prevent these adverse outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06340-4.

Introduction

Root and periapical diseases are among the most common pathologies encountered in dentistr [1]. These conditions typically arise from bacterial infiltration of the pulp via periodontal areas or dental caries, which leads to pulp necrosis, infection, and pain [2]. Root canal treatment is the primary solution for managing root and periapical diseases [3]. Its popularity has grown due to increased life expectancy, patients’ preference for retaining natural dentition, and greater awareness of the benefits of tooth preservation over extraction [4].

The main objective of root canal treatment is to restore periapical tissues by eliminating infectious or necrotic material from the root canal system while maintaining the tooth’s function in the oral cavity [5]. However, many dental professionals view root canal treatment as complex and stressful due to its biological intricacies, time demands, and significant costs [6].

Root canal treatment consists of three primary stages: access cavity creation, root canal preparation (involving mechanical and chemical debridement), and obturation. Each of these stages demands a high level of precision and skill [7]. The first step, access cavity preparation, is critical for locating the root canal orifices and allows for the subsequent cleaning and shaping of the canals. Files are used during this process to remove necrotic tissue, organic debris, and pulp remnants and to shape the canals in preparation for optimal root canal filling [8].

Despite technological advancements in endodontics, failure rates for root canal treatment remain substantial, with success rates reported between 76% and 86% [9–11]. Treatment failure can occur at any stage and may result from improper debridement, persistent bacterial contamination, inadequate root canal filling, coronal microleakage, complex canal anatomy, iatrogenic errors, or instrument-related problems, such as file fracture [10].

File fracture is the most common type of instrument failure during root canal treatment [12]. The incidence of file fractures has been reported to range from 0.5 to 5% [4, 13]. Due to their functional context, root canal files are prone to fracture within the canal [14]. File fractures are recurring, unwelcome complications that create significant challenges during treatment [15]. Common causes include improper use of instruments, material limitations, insufficient access, complex root canal anatomy, and potential structural defects in the instruments [16, 17]. Even with advancements in file design and material composition, file fracture remains a persistent problem in clinical practice [18].

File fracture physically obstructs proper canal shaping, impairs irrigation, and compromises filling, making it difficult to access the apical region. This increases the risk of treatment failure, infection, and inflammation and may trigger periapical tissue reactions [19]. File fracture can compromise treatment outcomes, particularly when a fragment has extruded from the apical portion of the root canal [20]. Dentists must then consider various management strategies for the fractured file, such as remove, bypassing the fragment, or leaving it in place, each with its success rates and associated risks [21]. Dealing with file fractures is a source of significant stress for dentists, often leading to feelings of fear, decreased self-confidence, and a sense of failure, which can negatively affect clinical practice and patient safety [22, 23].

Given the high prevalence of file fractures in clinical practice and their significant impact, combined with the limited number of qualitative studies on this issue, it is imperative to gain deeper insight into dentists’ experiences, concerns, emotions, and attitudes toward file fractures. A phenomenological research approach is particularly suited for exploring these experiences. Therefore, this study aims to investigate dentists’ experiences with file fracture incidents during root canal treatment.

Materials and methods

Study design

This descriptive phenomenological qualitative study is rooted in the philosophy of Edmund Husserl. Phenomenology is an approach to finding meaning and essence in individual experiences to facilitate understanding. It aims to explore rich and inherently complex phenomena in depth. In this approach, the researcher strives to achieve a deeper understanding of the phenomenon by setting aside preconceptions and prior experiences [24]. This study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [25].

Study setting and participant selection

This qualitative study was conducted in Kurdistan Province, located in western Iran. The region has a dental healthcare infrastructure comprising 430 general dentists and 36 specialists, among whom 5 are endodontists. Approximately 298 general dentists and all five endodontists in Kurdistan Province are estimated to perform root canal treatments. A purposive sampling strategy was employed to recruit participants with rich and in-depth experiences regarding the phenomenon [26] of file fracture during endodontic treatment. The target population for this research encompassed all dentists practicing in Kurdistan Province, Iran, who had direct, personal, and significant experience with file fracture during root canal therapy. The inclusion criteria for participation were: holding a Doctor of Medical Dentistry degree, or specialization in endodontics; having experienced at least one instance of file fracture during endodontic treatment; and demonstrating willingness to participate voluntarily in an in-depth interview, allocating sufficient time for this purpose. Furthermore, the ability to articulate the nuances of their experience with adequate depth and clarity was a crucial criterion in participant selection. To ensure the selection of information-rich participants representing a diverse spectrum of experiences, purposive sampling was guided by the principle of maximum variation, considering factors such as years in practice, age, gender, and the volume of root canal treatments performed. The interviewer, a faculty member with extensive familiarity with the dental community in Kurdistan Province, purposefully identified and approached individuals believed to possess insightful and varied perspectives on the phenomenon under investigation. This expert knowledge facilitated the efficient recruitment of dentists likely to provide valuable data relevant to the study’s objectives. All dentists who were purposefully selected and invited to participate agreed to be interviewed. This high level of engagement can be attributed to the following factors: the provision of flexible interview scheduling tailored to the participants’ preferences, the interviews being conducted by a trusted dental professional, the stringent assurance of complete confidentiality and privacy, the establishment of a safe and non-judgmental interview environment, and the participants’ intrinsic motivation to contribute meaning to their experiences of file fracture.

Data collection method

The study was conducted between February 2023 and May 2024. After receiving ethical approval, the researcher visited private dental offices and clinics across Kurdistan, Iran. Eligible dentists were informed about the study’s objectives, emphasizing voluntary participation. Data was collected through face-to-face, semi-structured, in-depth interviews conducted at a time and location chosen by the participants. The first author is a faculty member and a specialist in endodontics. He conducted all the interviews with the participants. It is important to note that while the interviewer is a specialist in endodontics and a faculty member, they did not hold a direct instructional role for any participating dentists at the time of the study. Interviews began with general questions such as: “What has been your experience with file fracture during endodontic treatment?“, “How do you perceive the experience of file fracture during treatment?“, and “What meaning does file fracture hold for you within the context of your practice?” To ensure conceptual clarity and depth of response, probing questions, including “Could you elaborate further?“, “Could you clarify your meaning?” and “How so?” were employed. Following the initial rounds of interviews and a preliminary analysis of the responses, the researcher began to discern recurring themes and patterns within the participants’ experiences. These emergent themes informed the development of more focused and targeted follow-up questions for subsequent interviews. For instance, if the emotion of fear was frequently articulated as a salient aspect of the experience, key probing questions were formulated to explore its nuances, such as “When you speak of fear, to what specific facets or dimensions of this emotion are you referring?“, “What factors or circumstances contribute to your experience of fear in these situations?” and “When you experience fear, what specific physical sensations do you notice in your body?” Throughout each interview, the researcher maintained attentiveness to novel insights and perspectives introduced by the participants. When a participant raised an aspect of the experience that had not been explored, the researcher employed spontaneous and probing questions to delve into that dimension. This inherent flexibility allowed for a deeper exploration of the participant’s lived experience and the identification of potentially new and significant viewpoints. Furthermore, the interview questions were continuously refined and revised in subsequent interviews to elicit more precise and richer responses, enhancing the depth and quality of the collected data. A sample of the interview guide is provided as supplementary material to illustrate the nature and scope of the questions used to guide participant interaction. During the data collection process, in addition to the verbal content of the interviews, non-verbal cues and emotional responses were meticulously recorded and documented. These supplementary data were utilized to corroborate and enrich the interpretation of the participants’ verbal accounts. The adequacy of the sample size in this qualitative study was evaluated based on the principle of data saturation [27]. Data saturation in qualitative research refers to the point at which further data collection does not yield any new essential information or provide a deeper understanding of the phenomenon under investigation. Achieving saturation indicates that the collected data sufficiently captures the research topic’s diversity, depth, and nuances, thereby contributing to the content validity of the findings [27, 28]. Data saturation was assessed through the ongoing examination of emerging themes and codes throughout the interview and analysis process. Saturation was considered to have occurred when no new relevant themes or codes were identified in two consecutive interviews. Nevertheless, three additional interviews were conducted to confirm data sufficiency. All interviews were recorded with permission, transcribed immediately afterward, and analyzed. No interview repetitions were necessary.

Data analysis

Data analysis was conducted concurrently with data collection, following the seven-step Colaizzi approach [29]. This method is suitable for uncovering meaning in phenomenological research.

• Step 1 involved repeated readings of the transcribed interviews to gain an overall understanding.

• Step 2 identified 465 key statements linked to conceptual meanings.

• Step 3 involved extracting meanings and concepts from the open codes. Initially, 367 codes were identified, but duplicates were eliminated, reducing the number to 272. By merging standard codes, 108 main codes were identified. researchers bracketed their assumptions reflexively.

• Step 4 clustered based on similarities, classifying the 108 main codes into 18 sub-themes and four main themes.

• Step 5 described and integrated the themes with the research content.

• Step 6 the results were combined to thoroughly describe the phenomenon under study by finding relationships between themes.

• In Step 7, the results were returned to participants for validation and verification. Data management was facilitated using MAXQDA software version 0.9.5.

Trustworthiness

To ensure the rigor and accuracy of the findings, Lincoln and Guba’s (1994) four criteria of credibility, transferability, dependability, and confirmability were applied [30].

• Credibility was enhanced through long-term engagement with the participants. To further strengthen the trustworthiness of the findings by minimizing potential researcher bias, the technique of bracketing was employed. This involved regular reflexive journaling, discussions with colleagues regarding potential preconceptions, and a conscious focus on understanding the participants’ perspectives during the interviews. Furthermore, to ensure the accuracy of the recorded data and provide participants with an opportunity to validate their accounts, member checking involving the provision of interview transcripts was conducted. Additionally, colleague feedback and member checking were employed to validate the codes and categories.

• Dependability was established by thoroughly describing each study stage, allowing readers to evaluate the methods in detail.

• To ensure the confirmability of the findings, the interview transcripts and the coding process, including the categorization of codes and interpretations, were rigorously reviewed by two experts in qualitative research to ascertain their accuracy and credibility. Elements emphasized by the experts were finalized. Regarding instances where the experts offered comments or suggestions for refinement, necessary modifications were implemented in the codes and their categorization following deliberation and consultation with these experts. This consultative approach, incorporating expert insights, significantly enhanced the coherence and trustworthiness of the research findings.

• Transferability was assessed by comparing the experiences of three non-participating dentists with the findings, ensuring that the results were consistent with their interpretations.

Ethical considerations

This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1402.664). Before the study commenced, its objectives were thoroughly explained to all participants, who provided written informed consent. Confidentiality was emphasized, with pseudonyms used to protect participant identities. Collected data were securely stored on an encrypted server. Participants were assured of their right to withdraw from the study at any stage without any repercussions.

Results

Thirteen dentists (5 females and 8 males) participated in the study, with a mean of 10.15 ± 5.35 years of professional experience and an average age of 36.53 ± 6.35 years. Most (n = 7) worked in private offices, and most (n = 11) held general dentistry degrees. (Table 1)

Table 1.

Demographic characteristics of the participants

participant	Age (year)	Gender	Education	Work location	Number of root canal treatments(Monthly)	Number of broken files (Monthly)	File reuse times	Type of file (Hand files or Rotary files)	Job experience(years)	Interview duration (min)
1	33	Male	General	private practice and clinic	42	2	3	both	6	86
2	52	Male	General	private practice	25	1	3	both	23	90
3	32	Female	General	clinic	35	3	8	both	5	60
4	36	Male	General	private practice	55	2	4	both	10	44
5	34	Male	General	private practice and clinic	70	5	6	both	7	45
6	40	Male	General	private practicer	80	3	4	both	14	42
7	43	Male	Endodontic Specialist	private practice	96	1	1	both	15	53
8	31	Female	General	private practice and clinic	30	3	8	both	7	73
9	30	Female	General	clinic	30	2	6	both	5	45
10	29	Female	General	clinic	40	3	5	both	4	55
11	41	Male	Endodontic Specialist	private practice	130	3	2	both	13	40
12	36	Female	General	private practice and clinic	50	3	5	both	11	52
13	38	Male	General	private practice	60	2	3	both	12	40
Mean ± SD	36.53 ± 6.35	-	-	-	57.15 ± 3.04	2.58 ± 1.08	4.38 ± 2.28		10.15 ± 5.35	50.00 ± 18.56

A total of 367 initial codes were identified, which were reduced to 108 after removing duplicates and merging standard codes. Based on the interview data, four main themes and 18 sub-themes emerged. The primary themes included Fear of Consequences, Professional Impasse, Integration Decline, and the Dilemma between Moral and Immoral Decision-Making (Table 2).

Table 2.

Extracted Sub-Themes and themes associated with dentists’ experiences of endodontic file fracture during root Canal treatment

Themes	Sub-Themes
Fear of consequences	Fear of Treatment Failure
	Fear of Legal Consequences
	Fear of Judgment
Professional impasse	Professional Burnout
	Costly Compensation
	Loss of Professional Self-esteem
	Damage to professional reputation and identity
	Initiation of a Series of Failures
	Uncertain Treatment
	Falsely accused
Integration decline	Emotional Distress
	Feeling Guilty
	Endodontic Nightmare
	Faulty Cycle
Dilemma between moral and immoral decision-making	moral Concealment
	Ethical Commitment
	Ethical Doubt
	Situation Management

Fear of consequences

Fear of treatment failure

Dentists frequently experience anxiety related to treatment failure after a file fracture, fearing that they may not be able to complete the root canal treatment successfully. They are concerned that patients will return with complications such as pain or reinfection, which may ultimately lead to tooth extraction.

“When I fracture a file, I still worry even if I bypass it. I’m afraid the patient will return with pain or an infected tooth. That’s why I never forget a patient whose file I fractured, and whenever I see that patient, I feel much stress.”

(Participant 10)

Fear of legal consequences

Dentists are often concerned about the possibility of legal action being taken by patients following a file fracture. This concern stems from the fear of lawsuits damaging their professional reputation.

“When this happens, I’m always worried that the patient will go to the Legal Medicine Organization and file a complaint against me. It would tarnish my reputation. I work in a clinic, and if they find out I’ve been sued, they’ll fire me. Reputation is significant for a doctor.”

(Participant 3)

The legal process is perceived as exhausting, time-consuming, and stressful, with dentists fearing court proceedings and the toll it takes on their time and professional image.

“My biggest fear is going to court. The court process is complicated and lengthy. On the other hand, they mistreat you in court. I’m willing to pay compensation, but the court is tough because it takes time, and you must take sick leave. They mistreat you there and question your professional performance. In the end, you have to pay compensation. Going to court is a losing situation.”

(Participant 4)

Fear of judgment

Dentists also fear being judged by their colleagues and patients following a file fracture. They worry that such incidents may undermine their professional reputation, credibility, and the trust of their patients.

“I’m worried that my patient will go to my colleague and tell them that I fractured a file in their tooth. If this happens, my reputation will be tarnished, and my shining professional career will be questioned.”

(Participant 11)

“I’m afraid my colleagues will find out that I fractured a file in a patient’s tooth and judge me for it. They might say I’m not good at root canal treatment. On the other hand, I’m worried the patient will go to another doctor and tell them that their tooth’s file fractured, and they’ll think I’m not a good doctor and sue me.”

(Participant 8)

Female dentists, in particular, expressed a heightened concern about judgment due to societal biases, fearing that they might lose the fragile trust of their patients.

“Many times, I hear from people that female dentists are not good at their work, so I try to do the best for my patients. When I break a file during root canal treatment, I worry much more than male dentists in my class because I am afraid I will lose people’s trust, which is very fragile.”

(Participant 9)

Professional impasse

Professional burnout

Participants expressed that fracturing a file places considerable physical and psychological stress on them. The effort required to bypass or remove the fractured file drains their energy and often leads to feelings of professional disillusionment, reduced efficiency, and job dissatisfaction.

“Fracturing a file exhausts a person physically and psychologically. You know, when a file fractures, I get to the point where I become disgusted with myself as a dentist and think, ‘I wish I had another job or that I wasn’t cut out for dentistry.‘".

(Participant 10)

Costly compensation

Fracturing the file can be very costly for dentists financially and spiritually because this error can cause loss of income, decrease of clients, payment of compensation, and negative publicity.

“It’s very costly for dentists to fracture a file because you have to spend a lot of time and energy on the patient, and with the same cost, I have to give them at least the time of two other patients. On the other hand, it interferes with the scheduling of my other patients, and sometimes I have to cancel the next patient.”

(Participant 6)

“Fracturing a file can sometimes be very costly financially. I once fractured a file that led to tooth extraction, and I had to do an implant for the patient at my own expense and also refer her to a specialist at my own cost.”

(Participant 2)

Loss of professional self-esteem

After a file fracture, dentists often experience a loss of self-confidence and professional self-esteem. This frequently results in them avoiding challenging root canal treatments, and they may refer more complex cases to endodontic specialists.

“It reduces my self-confidence in performing root canal treatment, and I feel like I don’t have the ability and skills for it. That’s why I avoid challenging root canal treatments for teeth 6 and 7 for a while, and if I see in an X-ray that the root anatomy is complex or the patient is elderly and their tooth is calcified, I don’t challenge myself and refer them to a specialist.”

(Participant 8)

Damage to professional reputation and identity

Participants shared that fracturing a file can tarnish their professional reputation and identity, jeopardizing the trust of their patients and colleagues. This can affect their standing within their clinic and among peers.

“Fracturing a file can significantly harm a dentist, serving as negative publicity for the dental profession and undermining its professional identity. In the early days of my career in a tiny town, I had a patient to whom I disclosed that I fractured the file in their tooth. However, I provided the treatment properly, and their tooth would have no problem. However, that patient ruined my reputation, so half the town recognized me as a dentist who places files in patients’ teeth.”

(Participant 13)

“Fracturing a file in the clinic has no positive aspect. Other dentists view you differently because they think your endodontic work is not good and are reluctant to refer endodontic cases to you. They often give you simple cases.”

(Participant 3)

Initiation of a series of failures

Participants noted that fracturing a file makes root canal treatment more complex and increases the likelihood of subsequent errors, such as tooth perforation. The stress and preoccupation caused by the initial error can lead to further mistakes.

" Fracturing a file initiates a series of failures, and these successive failures can occur in two directions. First, any action we take may lead to problems later. Second, the likelihood of subsequent errors increases because after fracturing the file, one’s nerves are shaken, concentration decreases, the mind is preoccupied, and plans are disrupted. I think fracturing a file might be like the proverb, “Good beginnings promise a good end.”

(Participant 1)

Uncertain treatment

Fracturing a file compromises the ideal conditions for root canal treatment, making the treatment outcomes uncertain. This uncertainty can weaken the tooth’s prognosis and reduce the treatment’s longevity, leaving dentists stressed about the final result.

“When a file fractures, it’s unclear what will happen. The tooth might survive without issues for years or develop an infection later. This uncertainty is stressful. No matter how well you work afterward, it’s still unclear how it will end, and you can’t offer the ideal treatment to the patient.”

(Participant 12)

Falsely accused

Fracturing a file is a multifactorial event, but dentists often feel unfairly blamed as the sole cause. This sense of unjust responsibility, mainly when using overworked instruments or operating under clinic-imposed limitations, adds to their frustration.

“Sometimes I don’t believe it’s my fault when a file breaks. I work in a clinic where I reuse a file more than eight times because they don’t give me a new one. That file becomes fatigued and breaks with the slightest pressure.”

(Participant 3)

Integration decline

Emotional distress

Many participants reported feeling intense emotions such as anger, stress, worry, and fatigue after a file fracture. They described the experience as highly unpleasant and stressful, leading to reduced concentration and heightened tension throughout the day.

“When the file fractures, for a few moments, I feel like time has stopped, and then a huge amount of stress overwhelms me. My heart starts pounding, my hands tremble, and I become nervous. I get so stressed that no one dares to talk to me. The days when I fracture a file, it’s a very stressful event for me that brings a lot of worry and anxiety. On those days, I feel bad all day, my nerves are shot, I have no patience, and I argue with everyone.”

(Participant 8)

Feeling guilty

Participants often experience feelings of guilt and remorse after a file fracture, typically blaming themselves for the incident. They reflect on their actions, feeling responsible for not checking the file or rushing through the procedure.

“When the file fractures, I feel distraught with myself; I have a guilty conscience and blame myself for not checking the files, working too fast, not using manual files, or not paying enough attention. These thoughts haunt me constantly for a few days.”

(Participant 5)

3.3. Endodontic nightmare

For many dentists, file fracture is perceived as a catastrophic event, likened to a nightmare, making an already challenging root canal treatment even more complex and stressful.

“File fracture may be relatively common and sometimes unavoidable, but I think it’s a terrifying nightmare for every dentist performing endodontics. For me, fracturing a file is never normal; each time it happens, it’s like a disaster.”

(Participant 3)

“File fracture is my biggest fear and nightmare in root canal treatment, especially in teeth 6 and 7. The root canal treatment of these teeth is already challenging enough, and when a file fractures in the root canals, it makes the job ten times harder and more challenging.”

(Participant 10)

Faulty cycle

Dentists described a feeling of being trapped in a “faulty cycle” after a file fracture, where the unexpected failure creates confusion and demoralization. They feel as though they have lost control of the treatment process, which amplifies their sense of failure.

“Fracturing a file creates a feeling like falling into a dark well suddenly; everything becomes dark for a few moments, and you lose control over everything. You don’t know what to do, and you feel hopeless and demoralized, afraid you won’t be able to bypass that narrow and dark canal.”

(Participant 1)

“Fracturing a file during root canal treatment is like entering a faulty cycle; it makes you feel confused and demoralized because no matter how hard you try to perform excellent root canal treatment, there’s still a possibility you’ll make a mistake again.”

(Participant 6)

Dilemma between moral and immoral Decision-making

Moral concealment

The findings of this study indicate that a significant number of dentists, despite acknowledging the patient’s right to be informed, admitted to often concealing file fracture incidents from patients. The reasons cited for this behavior included the belief that disclosing such information could negatively impact the patient’s emotional state (increasing stress, fear, or discomfort). Consequently, a discreet management of the issue was reported as the preferred approach.

“I know it’s the patient’s right to know, but I don’t tell them because they don’t know what a file is or how it works. If you tell them, you worry them unnecessarily, make them subconsciously feel pain, and develop a fear of dentistry even more. To prevent these things, I don’t tell the patient anything.”

(Participant 5)

“When a file fractures, I try to fix it myself quickly in a way that the patient doesn’t understand, and I try to explain it to them in a way that makes it seem like a natural occurrence.”

(Participant 13)

Moral commitment

Conversely, some dentists feel a strong moral obligation to inform patients about the file fracture and make efforts to compensate for the error. This may include offering discounts, covering referral costs, or providing free services to minimize the patient’s damage.

“As a dentist, I feel responsible for this issue and try to compensate the patient in any way possible. For example, I don’t charge the patient for reopening the tooth; if I refer them to a specialist, I cover the specialist costs.”

(Participant 4)

“Although my endodontic treatment may not have been performed well, I try to compensate in the prosthetic phase and deliver a beautiful tooth to the patient, and in the end, I offer them a good discount.”

(Participant 2)

Moral dilemma

Dentists frequently face a moral dilemma regarding whether or not to disclose the file fracture to the patient. Various factors, including treatment prognosis, the stage at which the file fractured, and the patient’s personality, can influence their decision-making process.

“I always feel uncertain after file fracture. I don’t know whether to tell the patient. It’s confusing for me, as there are consequences either way when I tell them, and when I don’t, I feel guilty. That’s why I often try to hint at it indirectly.”

(Participant 9)

“I believe disclosing or not disclosing file fracture to the patient is a moral challenge. If I know that the treatment prognosis is good, I won’t tell them. However, if the prognosis is poor or if a referral is needed, and I’m sure how the patient is alert, I explain the situation to them.”

(Participant 12)

Situation management

Participants emphasized the importance of managing the situation appropriately after a file fracture. Maintaining composure, gaining the patient’s trust, and controlling the treatment process are crucial steps in minimizing the negative consequences of the incident.

“Experience has shown me that it’s essential to maintain my composure and control myself after the file fractures so that the patient doesn’t feel my stress and fear at that moment. I try to ensure that my patient doesn’t get anxious and attempt to establish maximum cooperation and trust to manage this stressful and challenging event successfully.”

(Participant 7)

Discussion

This qualitative study aimed to explore dentists’ experiences with file fracture during root canal treatment. One of the initial experiences described by the participants was the fear of consequences, which included concerns about treatment failure, legal repercussions, and judgment. Dentists expressed significant anxiety regarding their ability to successfully remove or bypass the fractured file, fearing that failure could lead to tooth infections and recurring pain for the patient. Previous studies have also highlighted this predominant anxiety among dentists, particularly regarding unsuccessful treatment outcomes and patient complaints of pain and infection following root canal procedures [31, 32].

Another critical concern was the potential legal consequences of file fractures, including litigation, compensation claims, and reputational damage. Dentists in this study, consistent with findings from Alrahabi et al. (2019), often feared the legal ramifications and the possibility of being sued [33]. They were also apprehensive about being judged incompetent by their colleagues or patients, which could erode trust and damage their professional standing [33–35]. This fear is exacerbated by inadequate legal support and insurance coverage, leaving dentists vulnerable to reputational harm within their communities. Female dentists, in particular, reported heightened fear due to societal stereotypes that view dentistry as a male-dominated profession [35]. Although previous research shows no significant correlation between gender and file breakage rate [16, 18], the burden of professional errors such as file fracture appears to reinforce gender stereotypes, causing female dentists to experience more significant psychological stress and guilt. Another possible explanation for the heightened fear experienced by female dentists may be their inherent sense of responsibility. To address these challenges, dental associations should develop a comprehensive support system that includes legal, insurance, psychological, and educational resources. Additionally, endodontic associations should establish practical standards that could carry legal weight, offering protection for both dentists and patients. Such measures would reduce anxiety, improve confidence, and ultimately enhance the quality of dental care.

Another important finding of this study was the professional impasse dentists face after a file fracture. This theme included Sub-Themes such as professional burnout, costly compensation, loss of professional self-esteem, damage to professional reputation and identity, initiation of a series of failures, uncertain treatment outcomes, and Falsely accused. Dentists reported feeling a loss of self-confidence and self-esteem following a file fracture, which led to demotivation and burnout. This is consistent with previous studies that found dentists often feel inadequate and dissatisfied after experiencing a file fracture [35, 36]. Dentists also perceived file fracture as a precursor to further errors, which aligns with findings from Qutieshat et al. (2023), who noted that errors during root canal treatment often lead to subsequent procedural mishaps [36]. File fractures not only complicate root canal treatment but also diminish the predictability of treatment outcomes and reduce the longevity of the tooth [16, 17]. The emotional toll of file fractures, compounded by the lack of support systems, leaves many dentists struggling with job anxiety, decreased confidence, and professional burnout.

The study also revealed the theme of integration decline, manifesting through Sub-Themes such as emotional distress, Feeling Guilty, endodontic nightmares, and Faulty Cycle. Dentists reported that file fractures induced significant emotional distress, often leaving them feeling overwhelmed and anxious. This finding aligns with Lee et al. (2022), who emphasized that root canal treatment is inherently stressful, and errors such as file fractures exacerbate emotional distress and feelings of despair [23]. Dentists described file fracture as an unexpected and distressing event often likened to a nightmare that complicates an already complex procedure. Research by Amza et al. (2020) supports this perception, noting that file fractures are random and unsettling for dental practitioner [37]. Participants frequently feel trapped in a cycle of inadequacy, confusion, and helplessness following a file fracture incident. Concurrent with the findings of this study, previous research suggests that dentists often grapple with feelings of inadequacy, confusion, and diminished confidence in the aftermath of errors [38, 39]. Dentists frequently experience feelings of guilt and remorse post-file fracture, internalizing blame for professional errors during root canal treatment. Prior evidence suggests dentists harbor guilt over procedural errors during root canal treatment [40, 41]. This study revealed that dentists sometimes attribute file fractures to external factors such as manufacturing defects and excessive clinical use. Consistent with our findings, a 2020 study indicated that multiple factors, including the number of sterilization cycles, the frequency of file use, manufacturing defects, the metallurgical properties of different file types, canal complexity, and other variables influence file fracture [37]. Therefore, a standardized and mandatory protocol is imperative to establish guidelines regarding the permissible number of reuses for dental files in clinics and dental offices. Although dentists are aware that file fractures can occur due to factors beyond their control, such incidents are consistently associated with negative emotions, stress, and psychological distress. These feelings often arise from a strong sense of professional commitment and fear of potential consequences, posing, in general, breaking the file as a threat to the mental integrity of dentists.

The dilemma between moral and immoral decision-making was another central theme, comprising subcategories including moral concealment, ethical commitment, ethical doubt, and situation management. Dentists in this study often grappled with doubts and ambiguities, weighing factors such as patient awareness, treatment prognosis, and the need for referral when making their decision. Ba-Hattab et al. (2020) noted that dentists frequently face a moral dilemma when determining whether to inform patients about file fractures [42]. Many dentists resorted to concealment as a coping strategy, choosing not to disclose the fracture to avoid stressing the patient. Despite acknowledging the importance of transparency, evidence suggests that approximately half of dentists opt to conceal file fractures, driven by fears of legal repercussions, judgment, and loss of patient trust [13, 42]. Also, a study in 2022 showed that dentists often hide the error from the patient and colleagues [43]. They do not disclose the error to the patient due to the fear of legal problems, judgment, acceptance of the error, and losing trust [44]. While concealment may initially appear to be a strategy to avoid responsibility, it can exacerbate patient harm and increase the likelihood of legal action if the patient becomes aware of the adverse event. Therefore, it is imperative to obtain a detailed and explicit consent form that fully informs the patient of all potential risks, including instrument fracture during root canal treatment. This ensures that the patient understands the potential complications and can serve as legal documentation for adverse outcomes. The reluctance of general dentists to refer patients to endodontists was also highlighted in this study. Consistent with findings from a recent study in Iran (2024), general dentists often hesitate to refer patients due to fears of losing patients, legal concerns, and financial repercussion [45]. To address this, an intelligent online referral system could help streamline patient referrals and reduce the reluctance of dentists to involve specialists in complex cases. Dentists’ moral and professional obligations compel them to take responsibility for their errors, whether through compensation, discounts, or apologies. Dentists must manage these situations effectively, maintain their composure, and reassure patients, as highlighted by Mathew et al. (2015), who emphasized the importance of patient reassurance during stressful incidents such as file fractures [46]. To support dentists in handling these challenging situations, establishing a national reporting platform for dental errors and near-misses would be beneficial. A secure, confidential system for reporting errors would allow for data collection and analysis, helping to identify risk factors and develop preventive strategies to enhance dental practitioners’ knowledge and skills. This initiative could foster a culture of safety and accountability within the dental profession, ultimately improving patient outcomes and reducing the incidence of errors like file fractures.

Study limitations

This study was conducted with a qualitative approach and therefore faces limitations in generalizing the findings.

Conclusion

The experiences of dentist during file fracture showed Fear of Consequences, Professional Impasse, Integration Decline, and the Dilemma between Moral and Immoral Decision-Making.Dentists often experience profound fear, job burnout, loss of self-confidence, and guilt in response to file fracture during root canal treatment. File fractures negatively affect the quality and predictability of root canal treatments, and causes moral dilemmas regarding whether to disclose the file fracture to the patient or conceal it. Successfully navigating file fracture incidents is essential for maintaining trust between the dentist and the patient, ensuring treatment continuity, and minimizing litigation risk. Hence, health policymakers and professional organizations must implement supportive measures. These include strengthening legal and insurance protections for dentists, establishing secure and confidential reporting systems, developing comprehensive and standardized guidelines through the endodontic association, and mandating informed consent forms to better inform patients of potential risks.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

ZB, RJ, and MK collaborated in designing the study. ZB and RE conducted the data collection, while, RJ, and MK carried out the data analysis. The initial draft of the manuscript was prepared by ZB, RJ, and MK. All authors critically reviewed and approved the final version of the manuscript for submission.

Funding

By Kermanshah University of Medical Sciences (Grant number 50004008).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical approval for the study was obtained from the Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1402.664). Participants were fully briefed on the study’s objectives, with assurances of confidentiality and the right to withdraw from the study at any stage. Informed written consent was obtained from all participants prior to their involvement.

Consent to publication

Not applicable.

Generative AI and AI-assisted technologies in the writing process

While preparing this work, the authors used Gemini (Google AI) and Chat GPT to improve language and readability. After using this tool/service, the authors reviewed and edited the content as needed and took full responsibility for the publication’s content.

Competing interests

The authors declare no competing interests.