Replacement crown on tooth UR5
29. Dentist A restored Miss A’s tooth UR5 with a crown, which consists of a post and core. The dentist inserts a small metal rod (the post and core) into the root space, and then fits the overlying crown.
30. We have firstly considered if this was a reasonable treatment option for this tooth.
31. The X-ray shows most, if not all, of the tooth structure is below the gumline. Our adviser told us it is difficult to restore teeth where the treatment would go deep into the gum. The lack of tooth structure made the procedure less likely to be successful in the long term. But that does not mean it was wrong to attempt a restoration.
32. There is no specific standard to say if a crown should be attempted in these circumstances. As set out in paragraph 28 dentists must work within their knowledge, skills, professional competence, and abilities. We have seen no evidence to suggest dentist A did not do so when deciding to replace the crown. We have not found a failing in this.
33. Next, we considered if the work to replace the crown was done to recognised standards.
34. Miss A gave us photographs showing the crown and post after it had fallen out.
35. The BDJ article reviews what is a good post-crown. The article says 3 to 6mm of the treated root should be left undisturbed (by the post). This prevents bacteria re-entering the tooth.
36. We asked our adviser to look at the X-ray and they told us the dentist did leave that amount of root in place. They said this meant there was very little root/tooth structure remaining which meant any post length would have been short.
37. The BDJ article says a longer post is more retentive than a shorter post. It also says a longer post increases the chance of fracturing the root.
38. There is no specific standard setting out the length of post to use. It is clear from the BDJ article there are several factors to weigh up. We have no evidence to suggest dentist A did not act in line with GDC standards (set out at paragraph 28). We have not found a failing in how dentist A replaced the crown.
39. Unfortunately, because of the lack of tooth left, the crown did not last long, and the tooth ended up having to be removed. That does not mean the decision to do it, or the work done was not in line with the relevant standards. However, we appreciate this was upsetting for Miss A.
40. We do not uphold this part of the complaint.
Filling to tooth UL8
41. Miss A believes the dentist did not fill this tooth correctly and this meant the tooth was later extracted by the second practice.
42. The records show there was decay on tooth UL8 and dentist A removed this before filling the tooth.
43. After looking at the records, our adviser said the only option for this tooth was filling or extraction. It is a matter of clinical judgement which is more suitable. If there was visible decay in the tooth then attempting to remove it may have been reasonable, depending on the extent of the damage.
44. There are no X-rays from the Practice to show the extent of damage to the tooth at that time. The law says X-rays must not be done unless they have been justified as showing sufficient benefit.
45. We know that if a dentist can see decay or damage then treatment is often done without the need to X-ray. There are no specific standards around the process of filling a tooth. The records show the filling was carried out in line with the GDC Standard to provide good quality care.
46. The records from the second practice indicate the removal of tooth UL8 was not due to any issues with the previous filling. Dentist B at this practice removed the tooth due to gum disease.
47. Taking all that into account, we have not seen any evidence of failings in the treatment provided by dentist A when filling tooth UL8. We hope that provides some reassurance to Miss A.
48. We do not uphold this part of the complaint.
Fillings to front teeth, UR1 and UL1
49. The records show Miss A did not like the appearance of her upper front teeth due to her receding gumline. Dentist A warned Miss A she would eventually lose those teeth but as they were not causing pain, Miss A chose to have them filled.
50. Dentist A treated the teeth with composite fillings. The records from the Practice do not indicate how these fillings appeared when complete. However, the notes from the second practice, and the photograph supplied by Miss A, show that the two crescent-shaped fillings on the teeth were joined.
51. The GDC standards say dentists should provide good quality care based on current evidence and guidance.
52. Joined fillings create an environment where plaque is more likely to build up, and the different movements of the two teeth would lead to failure of the fillings. Joining the fillings is not in line with GDC standards of providing good quality care.
53. Dentist A has told us it is their usual practice to do separate fillings on separate teeth. However, we can see that did not happen in this case. It is our view that this falls so far below GDC Standards to provide good quality care that it is a failing.
Impact
54. We are grateful to Miss A for giving us clear details of her recollection of what happened.
55. Miss A told us these fillings caused pain and infection in her gum. She said due to this she could not speak properly and had to take days off work until the antibiotics prescribed by the second practice had worked.
56. Miss A says the fillings resulted in her needing hygienist appointments at a further cost. She says part of the porcelain fell out, but the rest could not be removed which meant her teeth could not be cleaned properly. She says this means she will incur additional hygienist costs.
57. We asked our dental adviser about the impact of having joined fillings. They said the joined filling would have prevented suitable interdental cleaning (cleaning between the teeth), which would have likely increased gum inflammation. This could be harmful to the health of Miss A’s gums, which was already poor.
58. We can see that when Miss A attended the second practice on 5 July, she had gum inflammation and bleeding (although the records do not say in which area). On 23 July the gums around teeth UR1 and UL1 were very inflamed.
59. Although there was inflammation, our adviser said there was no evidence of deterioration in the health of the gums around these teeth when Miss A attended the second practice.
60. We have considered if the inflammation resulted in Miss A needing additional hygienist treatment.
61. Later in July, Miss A required a scale and polish of her teeth. This was of the whole mouth, not just around UR1 and UL1. The hygienist told Miss A to return in three months for review. She did not return. We have seen no evidence to indicate Miss A has needed additional hygienist treatment because of the failure to correctly fill teeth UR1 and UL1.
62. Miss A told us that the joined fillings led to an infection which needed treating with antibiotics, caused her pain, and resulted in her taking time off work. The records do not say Miss A specifically complained of pain in the gums around these teeth. They do show her gums were very inflamed. At least some of that inflammation is likely to have been due to the difficulties in cleaning caused by the joined fillings.
63. We acknowledge this is likely to have caused Miss A some pain. We have thought carefully about whether we have sufficient evidence to link this to Miss A’s need for antibiotics and time off work but there are so many contributing factors, we cannot do this.
64. In summary, it is our view that not filling the teeth correctly led to the failure of those fillings. We have found this caused Miss A pain.
65. The Practice has not acknowledged any failings in the dental treatment it provided to Miss A, or their impact. We have made a recommendation later in the report for the Practice to acknowledge its failings and to apologise.
66. It is our view that an apology is a sufficient remedy for the pain Miss A experienced.
67. We have partly upheld this part of the complaint.
Injections
68. Miss A required anaesthetic injections to numb the area around tooth UL6 before it was filled.
69. Miss A said some of the anaesthetic liquid ran down her throat which was unpleasant. She says this meant dentist A did not do the treatment correctly.
70. We asked our adviser about this. They said occasionally dentists unintentionally squeeze some of the solution into the mouth when giving injections, and the solution has a bitter metallic taste. We acknowledge Miss A found it unpleasant when some of it went down her throat. We are satisfied this would have had no other impact on Miss A.
71. Although this was an unpleasant experience for Miss A, taking into account what our adviser told us, in our view this was not contrary to GDC standards that dentists should provide good quality care. We hope that provides some reassurance to Miss A.
72. We do not uphold this part of the complaint.
Cancelled appointments
73. Miss A says she went to the Practice for an appointment in March and the Practice cancelled this at the last second. She says she made an appointment for May and the Practice cancelled this on the day. She says on the same day she made an appointment for later in May and only an hour later she received a message cancelling this appointment.
74. Our Principles say organisations should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot. They should behave helpfully, dealing with people promptly.
75. The records show Miss A had an appointment scheduled for 8.30am in March. That same day, a relative of dentist A informed the practice manager by text message that dentist A would not be attending work as they had been ill overnight.
76. This was a last-minute unavoidable absence due to ill health. The records show the Practice cancelled the appointment at 8.18am. Unfortunately, it appears Miss A had already attended the Practice by that time.
77. The Practice did not open until 8am so this was the very earliest it could have informed Miss A of the cancellation. Due to Miss A having a scheduled appointment which was only 30 minutes after the Practice opened, we do not consider it unreasonable that the Practice did not notify her of the cancellation prior to her attendance.
78. The Practice rebooked the appointment for April, and it went ahead on that date as planned. Miss A also had further appointments which went ahead on the 10, 15, and 17 April.
79. Miss A then had an appointment booked for on 13 May. In the morning, dentist A contacted the Practice Manager to say they were unwell so would not be in work that day. The Practice told us it appeared from the text message that it would be a short illness.
80. In the morning of that day, the Practice cancelled Miss A’s appointment on its system. This was more than three hours before her scheduled appointment. Miss A says she received a phone call from the Practice telling her of the cancellation. We do not have any evidence to show what time the Practice called Miss A. During that call, the Practice rearranged the appointment for 23 May.
81. Later that day, the Practice Manager received a further text message with a sick note which showed dentist A’s absence would not be short. The Practice sent Miss A a text message that same day, cancelling the appointment later in May.
82. Unfortunately, absence due to ill health is unavoidable and this means occasionally appointments need to be cancelled. We have seen nothing to show the Practice did not act promptly to inform Miss A of those cancellations when it became aware they could not go ahead.
83. It is our view the Practice acted in line with our principles and as such, we do not uphold this part of her complaint.
84. Although we have not found a failing, we acknowledge it was frustrating for Miss A when her appointments were cancelled the same day, particularly as she had taken time off work for these. We are pleased that in its complaint response the Practice apologised for the cancellations.