Practice removed a tooth without consent
11. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation 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 that something went wrong.
12. Miss A says when she attended the Practice with pain in her lower left seventh tooth (LL7), it removed her lower left sixth tooth (LL6). She says the LL6 was in perfect condition and she did not consent to its removal.
13. The Practice dental records show the dentist discussed the risks and alternative options for managing the condition with Miss A. In its complaint handling, the dentist said Miss A reported that her LL6 tooth was giving her pain and pointed to that tooth when asked.
14. The records also report that Ms A was ‘very sure’ the pain was coming from LL6. The records show Ms A indicated LL6 was ‘ttp +ve’ (meaning tender to touch) and that LL7 was ‘mildly ttp’ (tender). The records also indicate the dentist tested the sensitivity of both LL6 and LL7 and the lasting pain was found to be from LL6, which is the tooth the dentist extracted.
15. The records also say Ms A was sure in her request that this tooth be removed and that, during the procedure, she did not indicate by gesture, signs or verbally that she was not happy to continue.
16. Principle 3.1 of the GDC standards says valid consent must be gained before starting treatment and all relevant options and costs should be explained as part of this process. It further says dentists must make sure patients understand their decisions and that consent stays valid throughout the procedure.
17. We took clinical advice to help us decide whether the dentist got the needed consent first. Ms A’s records show the dentist discussed risks and alternative options and that Ms A agreed to have the tooth extracted.
18. Our clinical adviser says there is no specific procedure in place for patients to indicate they wish to stop if they are unable to speak, but the dentist was professional, giving Ms A the option of raising her hand if she felt the need to stop or speak. This is in line with principle one of the GDC standards, which says a patient should be listened to and have their preferences and concerns considered.
19. After considering the evidence we have not seen anything to suggest the wrong tooth was removed, and the evidence shows the dentist checked with Ms A which tooth was causing the pain.
Cleaning and protection process was not done correctly after the tooth removal
20. Ms A says that after the tooth was removed, the cleaning and protection process was not done properly and because of this she had pain and pus from the treated area.
21. The dental records show this process was done correctly and the Practice’s complaint says there was no need for stitches because most extractions heal by the gum tissue joining together naturally.
22. We asked our clinical adviser if it is normal practice to leave the gums to heal naturally. Our adviser told us the FGDP standards refer to different methods to make sure the wound stops bleeding. Standard practice is to let a blood clot form on its own, which is then gradually replaced by new bone and gums, as happened in Ms A’s case.
23. The FGDP standards say blood clotting agents should not be used at infection sites. As the suspicion was that Ms A’s tooth was infected, the dentist made the correct decision not to use these. The records do not say exactly how the dentist cleaned the area after extraction. We have not seen anything wrong in the dentist leaving the area to heal. The Practice followed standard practice in leaving the area to clot not using stitches or any other process.
24. The NHS England guide to having teeth removed refers to the fact that pain and abscess are known risks of extraction. While we understand and empathise with Ms A’s experience, pain is expected and does not mean anything went wrong.
Dentist punctured root of tooth
25. Ms A says during a visit to the day after the tooth removal, a dentist drilled the same area causing a puncture. She says she experienced more pain and had to visit a private dentist to have the area stitched and antibiotics prescribed.
26. The Practice records from 2 December 2021 show the dentist did a visual check of the extraction site and applied a dressing to LL7 to reduce pain and keep the area bacteria free, as the tooth looked tender. The records do not suggest any damage or suspected damage.
27. Our adviser told us it is not unexpected for nearby teeth to be tender after an extraction, especially as Ms A reported pain in this area before. The NHS England leaflet also says sometimes having a tooth removed can affect nearby teeth.
28. The records show a Gates Glidden dental drill was used and, like most instruments, there is a risk of perforation. If used carefully and correctly, the drill is considered safe for the patient and they are widely used in dentistry. The records show no bleeding happened after the procedure. The complaint response says stitches were needed as no flap was raised and no bone was removed.
29. The Practice response also says on examination a single canal with a diseased nerve was located. This was removed, a filling was added, and a painkiller and antibiotic was placed inside the tooth. It also says there was no sign of bleeding or pus, or any concealed canals (a common issue that can cause persistent pain). It also says that no record of damage or suspected damage was recorded in the notes made on the date of the examination.
30. Our adviser reviewed the images taken by the private clinic Ms A went to between 11 December 2021 and 29 January 2022. These show a clear shadow that could indicate a perforation. They advised the images are not of a good enough quality to see the nerves clearly but the nerve of the LL7 tooth may have been close to the roots of the extracted tooth, LL6.
31. As this image was taken after the private dentist’s examination and cleaning procedure, it is possible the perforation may have been caused then. The private clinic records from 26 January 2022 show this was thought to be the case. The notes say a CT scan from 11 December 2021 shows an instrument went through the canal and could have caused the perforation. It seems the private dentist discussed this with Ms A by telephone on 26 January 2022.
32. Continuing pain and difficulty eating are known side effects of dental extractions. In most cases it is expected that these settle after five to ten days on average, with nerve pain being the exception as that may last longer. We also note that Ms A’s GP was also considering atypical facial pain, which is a non-dental related cause of pain around the face.
33. Taking the available evidence into consideration, we have seen no sign of failings in the Practice’s care and treatment and we will not investigate this part of the complaint further.
Refusal to refer
34. Ms A says she requested a referral to a dental surgeon twice but the Practice ignored or denied her request. She also says the dentists she saw the next day told her not to return to the Practice.
35. The Practice records and its complaint responses do not show Ms A asked for a referral or that there was any discussion about this. The dentist who saw Ms A on the second appointment does not refer to any comments about advising her not to return.
36. When there are different accounts of what happened, we see if there is any other evidence to look at that might help us come to a decision.
37. As there is no other evidence available, we have been unable to reach a decision on this part of the complaint.
38. We fully appreciate the distress this situation caused Ms A and understand she is still experiencing pain and difficulties.