A dental practice in the Dacorum area

3. Mrs Y complains about the care and treatment provided by the Practice regarding a single tooth extraction (upper right lateral incisor), which took place on the 6 July 2018.

Mrs Y says the Practice:

· Failed to take the non-healing socket seriously

· Performed the extraction when it was unsafe to do so because her internal normalized ratio level (INR level) was too low (2.5)

· Failed to prescribe her with antibiotics before the extraction when she made her pre-existing medical conditions known (in particular Atrial Fibrillation), and the need for her to be prescribed antibiotics before the procedure

· Failed to provide her with antibiotics after the procedure

· Failed to drain the infection/pus that developed

· Failed to provide her with a follow up appointment whilst she waited to be seen by a specialist.

Impact:

4. Mrs Y says as a result of the above failings, she developed an infection which led to sepsis. She has also been diagnosed with Epilepsy, and her memory has been inhibited. Mrs Y had to learn to walk, write, and use her phone again. The medication she takes to control the seizures cause her to suffer side effects such as stomach pain, constipation and tearfulness.

5. Mrs Y has a history of mental health problems which have been worsened by the events following the tooth extraction. She has had to come to terms with being diagnosed with Epilepsy, learn to live with a life of seizures, and she continues to struggle with the appearance of her face following the infection. This often stops her from going out and causes her additional stress and embarrassment.

6. Mrs Y says her independence has been affected considerably. She cannot lock the bathroom door or be in the kitchen by herself when the cooker hobs are on in case she has a seizure. She cannot go out alone and whilst her husband cared for her before, she is now a lot more reliant on him, and other members of her family daily. Mrs Y says the events have not just affected her but have also affected her husband and son who have both had to witness her seriously ill and seizing.

Outcomes the complainant wants:

7. Mrs Y says that she would like the Practice to:

· Formerly apologise

· Acknowledge what they did was wrong, and acknowledge the immense and lengthened suffering this has caused her (including a life altering diagnoses of epilepsy, altered facial appearance and negative impact on her mental health)

· Financial remedy for what she and her family have had to go through.

8. Mrs Y has a medical history of Bicuspid Heart Valve disorder and Atrial fibrillation (AF). She had a stroke in 1990 and is diabetic. She has a history of bone loss, gum disease (with loss of attachment), chronic periodontitis, dentures, and previous tooth extractions.

9. On 19 June 2018, Mrs Y attended the Practice because she had been experiencing aching at UR1 (upper right 1) and UR2 (upper right 2) for approximately 2 weeks. She was diagnosed with severe generalised periodontitis (bone destruction), and perio related pain and mobility. The prognosis for her UR1, UR2, UL2 and LR3 (lower right 3) was poor, and recommendations were made for the teeth to be extracted.

10. Due to her medical history, Mrs Y advised the Practice her INR levels had to be checked prior to her undergoing the extraction. This check was carried out 5 July 2018 (the day before her planned extraction), and her INR levels were reported as being 2.5 at that time.

11. On 6 July 2018, Mrs Y had her upper UR1 and UR2 extracted.

12. She attended the Practice on 20 July 2018 to have the plugs and sutures removed and attended again on 27 July 2018 to have further extractions completed.

13. On the 10 August 2018, her records show she developed an infection. There was swelling and a small lump in the UR1-2 area. There was also some pus associated with the socket.

14. She had a further attendance on the 24 August 2018. The area was not healing, and a referral was made to Maxillofacial at Hospital A.

15. Mrs Y attended the Hospital on the 2 October 2018 where further arrangements were made for her to have a CT scan and deeper debridement procedures. A large round swelling was noted, with pus.

16. She had a CT scan on 15 October 2018 at Hospital B and in late October/early November, pus was still leaking from the socket. Mrs Y started to feel weak, confused and very unwell. Her mouth was sore, and an incisional biopsy was performed.

17. On 6 November 2018, Hospital A advised the lump was not malignant. Infection was still present, and the area inflamed. The consultant told Mrs Y the socket still hadn’t healed. It was decided a deeper debridement and biopsy was needed. Mrs Y received a phone call in November 2018 about her next appointment however, she told the clinic she could not make the appointment due to transport issues. The Clinic re-assured her it would call back soon with another appointment, but Mrs Y did not hear anything.

18. Mrs Y’s husband chased the clinic on several occasions and continued to be told “it will be very soon.”

19. Her health continued to deteriorate and on 6 December 2018, she went to see her GP feeling very ill, weak, confused, dizzy, was struggling to eat, and wanting to sleep all day. The GP diagnosed an infection and prescribed her antibiotics which offered some short-term relief.

20. By 9 December 2018 Mrs Y says she was bedbound and suffering with dizziness, fatigue, vomiting, confusion, and sore gums. She had a lack of appetite and was struggling to eat. She says bits of bone began to fall out of her mouth.

21. On 14 December 2018, Mrs Y had a seizure and was admitted to Hospital A. She was immediately treated for sepsis and was told by a consultant neurologist 19 December 2018, that the seizure was triggered by the damage the sepsis was causing. She was discharged with antibiotics.

22. By 14 January 2019, her health began to deteriorate again. She was dizzy, confused, had no appetite and was struggling to keep food down. She had another seizure 30 January 2019 and was re-admitted to hospital. She was treated for sepsis, acute kidney injury (AKI) and discharged.

23. She deteriorated again in February 2019 and had another seizure. She attended Hospital C in London for an electroencephalogram (EEG). She was referred to a neurologist and a physiotherapist for home visits to help with her mobility as by this stage, she could barely walk.

24. On 28 February 2019, she attended the outpatient appointment with the neurologist in a wheelchair. It was confirmed she had developed epilepsy and would have to take lamotrigine to help prevent further seizures.

25. The biopsy was completed with the maxillofacial clinic at Hospital A in March 2019.

26. At her April 2019 follow up, she was told the socket still hadn’t healed and would require surgical intervention. This was to be carried out at Hospital D. She was told this procedure would involve trimming the gums back to encourage re-growth. Mrs Y attended Hospital D in July 2019 for the surgery but upon review, she was told she no longer required it because her gums were healing well. She was later discharged from the care of the Hospitals.

34. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not found any indications that something has gone wrong.

Unsafe to carry out extraction due to low INR

35. From the medical records, we can see Mrs Y’s INR level was 2.5 the day before the extraction. Mrs Y says she was advised by the nurse who took the INR it was too low for the extraction to take place.

36. The Scottish Dental Clinical Effectiveness Programme, Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs 2015 (the SDCEP), states where an INR level is below 4, ideally 24 hours before the procedure takes place, (but can be up to 72 hours before), it is safe to extract teeth.

37. Based on page 1 of the Clinical Guidelines from the SDCEP and the advice from our clinical advisor, it is our understanding it was safe and in line with the relevant standards for the Practice to perform the extraction on 6 July 2018. Mrs Y’s INR level was taken the day before the extraction, and the result was below 4. We believe there to be no indications of failings on the part of the Practice in performing the extraction.

Alleged failure to provide antibiotics prior to extraction

38. Mrs Y says due to her past medical history, she should have been prescribed antibiotics before the procedure and if the Practice did this, she would not have suffered the way she did, post procedure.

39. The faculty of General Practitioners (FGDP) have the following guidance: Antimicrobial Prescribing in Dentistry Good Practice Guidelines, third Edition, 2020 (FGDP 2020 guidelines). This updated the earlier guidance: Antimicrobial Prescribing for General Dental Practitioners Second Edition, 2012 (APGDP 2012 guidelines).

40. The APGDP 2012 guidelines were the guidelines in place at the relevant time, however they are not routinely available online. We went to great lengths to obtain a copy of the APGDP 2012 guidelines and managed to get a copy from the British Dental Associations (the BDA). These were sent in paper format and after comparing the APGDP 2012 guidelines against the FGDP 2020 guidelines, we could see there were no relevant changes that would impact the complaint. We have therefore referenced the relevant sections from both editions within this statement.

41. Part 11.1.1 of the 2012 guidelines state;

‘there is no evidence for the use of antimicrobials to prevent postoperative infection as a result of the surgical removal of impacted teeth or roots.... conversely evidence exists that prophylactic use of antimicrobials has no effect on post-operative pain, swelling, infection or wound healing.’ The use of antibiotics can cause adverse effects and result in increased resistance. Antibiotics should only be used where there is a clear clinical indication to do so. This is to reduce the risk of infections becoming resistant to antibiotics.

42. The FGDP 2020 guidelines at page 49 say - systemic antimicrobials are not recommended for the management of gingivitis (a form of periodontal disease). At page 90, it also says ‘antimicrobial prophylaxis is not recommended routinely for diabetic patients undergoing dental procedures.’

43. We have also considered the Scottish dental clinical effectiveness programme (SDCEP 2016) which can be used and applied in England. Section 4 of the SDCEP 2016 guidelines considers bacterial infections (pages 27-38).

44. On page 27, the last paragraph states; ‘antibiotics should not be used as prophylactic prescriptions to prevent infections after a routine dental procedure.’

45. It also goes on to state; ‘as a first step in the treatment of bacterial infections, use local measures,’ for example draining pus from a dental abscess by extraction of the tooth / root canals, and attempting to drain soft tissue pus by incision.

46. As with the 2012 and 2020 guidelines above, and the SDCEP 2016 guidelines say prolonged courses of antibiotic treatment can encourage the development of drug resistance and emphasises the prescribing of antibiotics must be kept to a minimum and used only when there is a clear need to do so.

47. When looking at the above guidance’s collectively, and the advice received from our clinical advisor, we can see the Practice acted in line with the relevant guidelines/standards in not prescribing Mrs Y with antibiotics before the extraction. Antibiotics are not generally prescribed to prevent postoperative infection following a tooth extraction as there is no evidence to support the effectiveness of doing so.

Alleged failure to prescribe antibiotics post extraction

48. Mrs Y says the Practice did not supply her with any antibiotics following the extraction despite there being an infection. We have reviewed Mrs Y’s clinical records and these show she was prescribed amoxicillin at her 10 August 2018 appointment when she attended the Practice. We discussed this with Mrs Y to get her version of events and she maintains the Practice did not prescribe antibiotics. If it did, Mrs Y says she would not have suffered the way she has, and the infection would not have been so serious that it led to further complications.

49. Based on guidance from both the FGDP 2020 and the SDCEP 2016, antibiotics are not routinely prescribed following an extraction. Mrs Y’s medical records note she was suffering with a post-operative infection on 10 August 2018, and the presence of a small lump with pus on palpation. We recognise Mrs Y says she was not given any antibiotics following the extraction but the clinical records do. As there is a different version of events here, we have had to look at the evidence we have and on the balance of probabilities, there seems to be enough evidence to show Mrs Y was prescribed antibiotics by the Practice on 10 August 2018. The Practice then saw her again on 24 August 2018. At the 24 August 2018 attendance, there was less swelling and slight pus on palpation.

50. Without the presence of swelling, our clinical advisor says the Practice would not be expected to prescribe antibiotics. The swelling had reduced, and Mrs Y did not present with symptoms necessitating antibiotics. The Practice acted in line with the relevant standards/guidelines in not prescribing antibiotics on 24 August 2020.

51. Below is the link for the 2020 FGDP guidelines and having checked a hard copy of the 2012 guidelines we can see the same information is given in both and the Practice acted correctly.

https://www.rcseng.ac.uk/-/media/files/rcs/fds/publications/fds-amp-2020.pdf

52. Because the pus was draining through the socket and the socket was not healing as it should, the Practice made the decision to refer Mrs Y to Maxillofacial for further review and intervention on 24 August 2018.

53. Section 6.3 of The General Dental Council Guidance (GDC guidance’s) state you must delegate and refer appropriately and effectively. The Practice did this.

54. 6.3.3 states:

“You should refer patients on if the treatment required is outside your scope of practice or competence.” The Practice noted the socket was not healing as it should, and pus was still draining through it at the 24 August 2018 attendance. Mrs Y was referred to Maxillofacial for further review and intervention, and the Practice acted in line with the guidelines in making the referral following the 24 August 2018 attendance.

55. The SDCEP 2016 guidelines are also applicable here and consolidate the findings above that antibiotic shouldn’t be given after a routine dental extraction. The Practice followed the relevant guidelines/standards in not prescribing further antibiotics following the procedure.

Alleged Failure to drain pus from the socket

56. Mrs Y says the Practice did not drain the pus from the socket causing the infection to drain through the socket and into her body.

57. Point 1.4 of the General Dental Council Guidelines (the GDC guidelines) says a holistic and preventative approach towards patient care must be taken and must be appropriate to the individual patient.

58. 1.4.1 states “a holistic approach means you must take account of patients’ overall health, their psychological and social needs, their long term oral health needs and their desired outcomes.”

59. 1.4.2 says “you must provide patients with treatment that is in their best interests, providing appropriate oral health advice and following clinical guidelines relevant to their situation.”

60. Our clinical advisor says pus can only be removed and drained when there is a sizeable mass. If there is no collection of pus, then there is nothing to drain. Mrs Y’s medical records 10 August 2018 note a ‘small lump on gingivae’ which relieved ‘pus on palpation.’ This indicates the infection was already draining and the Practice managed to remove some pus by pressing on the small lump. Although infection was present, there was no sizeable mass of pus to be drained, no ball or collection of pus and no large swelling which could be cut and then drained.

61. It is our understanding therefore if an infection is present but draining from the tooth, this is an acceptable form of infection drainage, and the Practice followed the guidance in providing treatment which met Mrs Y’s needs.

No follow up appointment scheduled and failure to take non-healing socket seriously

62. Mrs Y complains she was not given a follow up appointment at the Practice whilst she waited to be seen at Maxillofacial following the referral being made. Mrs Y’s clinical records show a review / follow up appointment was arranged for the 25 September 2019 which Mrs Y cancelled at short notice. This was discussed with Mrs Y as part of our assessment and she does not recall cancelling any appointments with the Practice as to her knowledge, no appointment was ever made.

63. We therefore looked into whether Mrs Y was monitored correctly following the extraction. Our clinical advisor says the correct monitoring was in fact when the Practice realised the socket was not healing well after prescribing antibiotics on 10 August 2018 and made the referral. The Practice acknowledged the problem was outside their area of expertise and acted in line with 6.3 of the GDC guidelines in delegating and referring Mrs Y appropriately and effectively. This was the correct line of management for Mrs Y.

64. When considering the guidelines above and the clinical advice obtained from our advisor, it is our understanding the Practice acted in line with the relevant standards. There appears to be no indications of failings, and we are unable to take the complaint any further.

1. We have carefully considered Mrs Y’s complaint about a dental practice (the Practice) in the Dacorum area. We recognise Mrs Y has been going through a difficult time over the past three years and appreciate the impact this has had on her. We are very sorry to hear about her experience.

2. After much consideration, and obtaining clinical advice from an independent dental expert, we have seen no indication that anything went seriously wrong with the care and treatment provided to Mrs Y in relation to her tooth extraction on 6 July 2018.