14. Before we decide if we should conduct a detailed investigation of 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 have not found any signs something went wrong.
15. We have carefully considered the concerns Mrs U brought to us in her complaint about the Practice. She told us the Practice’s dentist drilled her tooth more than necessary. She also told us they used their hands to place the filling, which was inappropriate.
16. Mrs U told us about the temporary filling falling out the next day. We were sorry to hear about the concerns Mrs U had about her care. We recognise why she became concerned when the filling fell out.
17. During a 111 triage, Mrs U reported pain from a broken/fractured filling and was referred for an ‘urgent care’ appointment at the Practice on 21 April 2022.
18. We spoke to our adviser about which national guidance relates to the care the Practice gave Mrs U. This helped us understand what should have happened. According to the NHS England Guideline, an urgent dental need includes ‘severe dental and facial pain: that is, pain that cannot be controlled by the patient following self-help advice including analgesia’.
19. The NHS England Guideline says it has drawn information from the SDCEP Guidance. In line with this guidance, an urgent dental need requires face-to-face professional care within 24 hours.
20. In terms of guidance for how the Practice should have carried out the treatment, the GDC Guideline applies. Section 7.1 of this guidance says dentists must provide good-quality care based on current evidence and authoritative guidance.
21. Initial management of a loose (dislodged) filling includes temporary restoration (filling). Our adviser told us a temporary filling would be an appropriate treatment option in this circumstance (based on the clinical examination/notes/X-ray provided).
22. Our adviser further explained, in the context of the service the Practice provided, good-quality care and treatment would include necessary use of an ultrasonic scaler or drill to prepare the filling site. It would also include the use of the most appropriate tool to apply the filling. Dentists have dental instruments designed for putting in fillings. Sometimes the best tool for the job can be a dentist’s finger.
23. We considered Mrs U’s complaint and relevant notes from the Practice and Practice B to show us what happened. The final response from the Practice and the notes show the dentist used an ultrasonic scaler to remove the dislodged filling. It does not state in dental records the dentist used a drill or hands. However, we understand it is not usual procedure to itemise all equipment used during treatment.
24. Our adviser told us it is unlikely the dentist used two hands to place the filling, but it is not uncommon for temporary/softer filling materials to be adapted (placed) using finger pressure.
25. It is unclear if part of Mrs U’s LR6 was drilled based on the X-rays as they are two-dimensional images and cannot give a full picture. Based on the notes, the dentist used a scaler, which does not cut into teeth and would have removed only what was already loose as it vibrates off dislodged parts.
26. It is not possible to comment on the structural integrity of the remaining tooth tissue of the LR6 based on the given evidence. We can assume (somewhat supported by the available clinical records and X-rays, and patient photographs) that there was unsupported buccal (cheek side of the tooth) tooth tissue remaining. This could have resulted in this part of the tooth fracturing following Mrs U’s meal the next day.
27. In considering Mrs U’s complaint, we have considered the dental records from her second emergency appointment on 22 April 2022 at Practice B. The dental notes state: ‘Diagnosis: LR6 – buccal enamel dentine fracture, caries?’ (an enamel dentine fracture is a fracture of the tooth enamel and the dentine, the tooth tissue under the enamel).
28. Dental caries (decay - a progressive disease in which the acid produced by plaque bacteria weakens and destroys the tooth enamel) will also compromise the health/structural integrity of a tooth.
29. These notes show the dentist at Practice B identified part of the tooth was broken in the first and second layers and queried whether or not it was due to decay. There could have been a number of reasons why the dentine fracture happened, which raises a question about the state of the tooth. The records from Practice B do not tell us if something went wrong with the care at the Practice.
30. The Practice’s clinical records from 21 April document the diagnosis of the LR6 dislodged filling and the removal of the dislodged filling and replacement with a temporary filling material, with postoperative instructions given, and this would be appropriate care at an urgent care appointment, in line with the relevant guidance.
31. The fact part of the tooth broke the next day does not necessarily mean there was a failing in the care the Practice provided. On balance, the evidence does not show the Practice drilled more than necessary. The evidence also does not show the Practice used inappropriate instruments to apply the filling, as the use of fingers would not be against the GDC Guideline. The evidence shows the Practice provided good-quality treatment of a temporary filling in line with the GDC Guideline.
32. We understand Mrs U’s concerns about the care and treatment she received from the Practice. After reviewing the information we received, we have not seen any signs something went wrong, so we will not investigate this matter further.