The Practice removed Miss U’s braces in July 2018 before the orthodontic treatment was completed
15. 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 seen any signs something has gone wrong.
16. Mrs U said Miss U’s dental treatment was not completed when her braces were removed. Mrs U said the evidence for this was Miss U still had a scissor bite (UR7), her teeth were not aligned, and her bite was wrong when the braces were removed.
17. Mrs U said the orthodontist did not explain there was an issue with UR7 before the removal of the braces. She said she would not have agreed to the removal of the braces if she had made been aware of the continuing problems. Mrs U said the orthodontist admitted he had not ‘done the best job’.
18. The orthodontist said it was his clinical opinion little further progress would be made, as Miss U had already received 25 months of orthodontic treatment. The orthodontist said he pointed out the poor alignment of UR7, but considered the alignment of the remaining teeth to be satisfactory before removing the braces. He said he did this with both Mrs U and Miss U’s consent.
19. The orthodontist said he advised Miss U of the importance of wearing retainers, and stressed if she did not wear them the alignment of her teeth would relapse and get worse.
20. We should explain here that we will not criticise a clinician’s clinical judgement unless we think something has gone wrong in the decision-making process, for example, if we think information has been overlooked when reaching a decision.
21. Our adviser confirmed there is no definitive guidance or standards for when braces should be removed. The BOS advice sheet ‘Consent in Orthodontics’ says if the aim of treatment is a compromise rather than an ideal outcome, the clinician should make this clear to the patient. The reasons why the clinician feels they are unable to achieve an ideal outcome should also be discussed with the patient and documented in the notes.
22. We can see it is documented in the dental records the orthodontist discussed the alignment of UR7 with Miss U, but she wanted to have the braces removed. We understand Mrs U does not agree with this version of events, and has said the orthodontist did not inform her of any problems before the braces were removed. She says she would not have allowed them to be removed if she had known about the problems.
23. On 16 July 2018, the Practice documented a scissor bite was present on UR7, and the orthodontist spoke with Miss U about correcting this. The Practice documented Miss U wanted the braces off, and staff gave her a mirror to check she was happy with the results before the removal of the braces.
24. Our adviser says when Miss U’s braces were removed, the alignment of her teeth was reasonably good apart from UR7.
25. We understand Mrs U and the Practice have different views of what happened, and so we have conflicting evidence. We appreciate Mrs U has said the orthodontist did not tell her about the scissor bite on UR7.
26. The dental records are an orthodontist’s account of what happened, and of the discussion at the appointment. The orthodontist wrote the dental records at the time of the appointment, and they contain enough detail. It appears from the records Mrs U and Miss U had an opportunity to check Miss U’s teeth and confirm they wanted to proceed with the brace removal.
27. Based on this and the above account of the consultation leading up to the removal of the braces, overall, we think it is likely the orthodontist did discuss Miss U’s teeth and the alignment.
28. Mrs U raised her complaint to the Practice approximately 14 months after Miss U’s braces were removed. The orthodontist said he reviewed Miss U four months after her braces were removed and there were no issues with the alignment of her teeth (apart from UR7) at this time.
29. We have seen no sign the Practice should not have removed Miss U’s braces at the time it did. We think the Practice acted within the guidelines by advising Miss U and Mrs U of the alignment of Miss U’s teeth, and UR7, prior to their removal. It appears more than likely all parties reached an agreement to remove the braces.
30. We appreciate a second dental practice had informed Miss U she would need further orthodontic treatment. This led her to believe the treatment the Practice provided was not completed as it should have been. Our adviser confirmed Miss U’s treatment had been successful, and the alignment of her teeth was reasonable.
31. Based on this, we have seen no signs the Practice got anything wrong when it removed Miss U’s braces.
The Practice did not correct Miss U’s scissor bite or align her teeth
32. Mrs U said Miss U’s upper right second molar was left twisted and not corrected before the braces were removed. Mrs U said the orthodontist did not explain Miss U had a scissor bite (UR7) before removing her braces. Mrs U said Miss U’s teeth were not aligned, which meant her bite was wrong and this has impacted her ability to chew.
33. The orthodontist said he had discussed the poor alignment of UR7 with Mrs U before removing Miss U’s braces. He said he only removed the braces once he was confident both Mrs U and Miss U agreed to conclude the course of treatment.
34. Upon receiving Mrs U’s complaint, the orthodontist said he would provide further treatment free of charge. He said he would be willing to provide a new course of upper and lower fixed orthodontic treatment, or specific treatment to correct only UR7 if Miss U preferred.
35. The BOS ‘Index of Orthodontic Treatment Need’ (IOTN) says a patient must be grade 4 and above to qualify for NHS treatment. Grade 4 says for a scissor bite to need treatment, it must be a group of teeth with scissor bites, and the teeth must be unable to meet, rather than a problem with one single tooth.
36. The OUP’s ‘A Dictionary of Dentistry’ entry, ‘Andrews’ six keys to occlusion’, documents the best alignment of teeth. The six keys to normal occlusion determine where the upper first molar should meet the lower second molar, the angle of the tip of the tooth, the alignment of bite, the rotation of the teeth, the space between the teeth and the occlusal plane (an imaginary line following the natural curve from the front to the back teeth) that make up a natural, healthy smile (smile aesthetics).
37. The orthodontist said at the time the braces were removed the alignment of Miss U’s upper and lower teeth, excluding UR7, was satisfactory and there was no issue with Miss U’s bite. The orthodontist stated he reviewed Miss U again four months after the braces were removed and did not see any problems with the alignment of Miss U’s teeth.
38. Our adviser said, after looking at the cast models dated July 2018, when Miss U’s braces were removed, Miss U’s bite and alignment were well finished, apart from UR7. This was in line with Andrews’ six keys to normal occlusion.
39. Our adviser says Miss U did have a scissor bite present on UR7 at the end of treatment in July 2018. Our adviser notes the eruption of UR7 took place while Miss U was receiving her orthodontic course of treatment. Our adviser confirms UR7 was a single scissor bite and does not qualify as needing treatment on the IOTN scale, as described above.
40. We can see the orthodontist offered to treat Miss U free of charge and to correct the scissor bite, once he became aware of Mrs U’s complaint. We understand both Miss U and Mrs U had lost confidence in the Practice and did not want to receive any further treatment from the Practice. We accept the orthodontist did offer to rectify the issues Mrs U complained about.
41. The GDC’s ‘Standards for the Dental Team’, section 3.1.5, says patients can withdraw their consent at any time, refuse treatment or ask for it to be stopped after it has started. Dentists must acknowledge their right to do this and follow their wishes.
42. As discussed in previous sections, overall, we think it is likely the orthodontist discussed the alignment of UR7 before removing Miss U’s braces. The Practice informed Mrs U and Miss U of the scissor bite present on UR7, and gave Miss U an opportunity to check her teeth with a mirror. Following this discussion it is documented Miss U wanted the orthodontist to remove the braces. In line with the GDC guidance, the orthodontist removed the braces.
43. While Miss U did have a scissor bite present at the end of treatment which was not corrected, as set out above, a single scissor bite does not qualify for NHS orthodontic treatment. The orthodontist said there was little further progress to be made, in his clinical opinion, and the decision was made to remove Miss U’s braces. Our adviser confirmed Miss U’s teeth were aligned when her braces were removed, apart from UR7.
44. Based on this, we have seen no sign the Practice has not acted in line with the guidance set out above. We have seen no signs the Practice did anything wrong in the treatment it provided in relation to Miss U’s scissor bite and the alignment of her teeth. We understand this will be disappointing for Miss U and Mrs U, and it is not our intention to cause any further distress.