14. Before we decide if we should conduct a detailed investigation, we look at whether there are signs the organisation has got something wrong. We do this by comparing what happened with what should have happened. We have done this, and we have not found any indications that anything went wrong with the procedure carried out on Mrs M.
15. Records of the procedure clearly document Mrs M’s wish for extraction of all her lower teeth and to have a lower acrylic denture. Records note the dentist advised Mrs M to reconsider, as this procedure was not advised nor recommended by him. The dentist noted his recommendation, to maintain the remaining teeth and to wear a lower partial denture and offered two alternative options: to leave and do nothing or consider fixed options such as implants or a bridge.
16. Records note Mrs M was aware of all options available to her, after discussion of the advantages and disadvantages, the risks, benefit and suitability of each, and she continued to want to proceed with full extraction. The dentist noted: ‘All risks and side effects explained: Pain, bleeding, bruising and swelling – Post Operative Pain, Infection, Paraesthesia [pins and needles] or fracture. Patient understands risks and consents to Tx [treatment]’.
17. The dentist documented the actions taken to complete the procedure, including the anaesthetic and equipment used, the checks undertaken and that there were no complications. Our adviser confirms this is all in line with the appropriate approach to an extraction procedure.
18. The dentist documented the work he completed to ensure the denture’s fit, noting this was well-fitting and Mrs M was happy with the aesthetics (looks) and fit. The dentist advised Mrs M she may experience a difference in speech and eating, that it may feel strange and tricky to tolerate and may be slightly loose or tight. He informed her about after care, to wear the denture as much as possible, to take it out at night and place in cold water, to clean with a soft toothbrush and warm soapy water and advised that any symptoms should resolve in a few weeks.
19. Our adviser says the recorded evidence shows the dentist acted in line with GDC Standards Principle 1, ‘Put patients’ interests first’, specifically: ‘1.1.1You must discuss treatment options with patients and listen carefully to what they say. Give them the opportunity to have a discussion and to ask questions.
1.2.2You should take patients’ preferences into account and be sensitive to their individual needs and values.
1.4.2You must provide patients with treatment that is in their best interests, providing appropriate oral health advice and following clinical guidelines relevant to their situation. You may need to balance their oral health needs with their desired outcomes. If their desired outcome is not achievable or is not in the best interests of their oral health, you must explain the risks, benefits and likely outcomes to help them to make a decision.’
20. Our adviser says the recorded evidence shows the dentist acted in line with GDC Standards Principle 2, ‘Communicate effectively with patients’, specifically:
‘2.2.1You must listen to patients and communicate effectively with them at a level they can understand. Before treatment starts you must: • explain the options (including those of delaying treatment or doing nothing) with the risks and benefits of each; and • give full information on the treatment you propose and the possible costs
2.3.5You should make sure that patients have enough information and enough time to ask questions and make a decision’
21. Our adviser says the recorded evidence shows the dentist acted in line with GDC Standards Principle 3, ‘Obtain valid consent’, specifically:
‘3.1.1You must make sure you have valid consent before starting any treatment or investigation.
3.1.3You should find out what your patients want to know as well as what you think they need to know. Things that patients might want to know include: • options for treatment, the risks and the potential benefits; • why you think a particular treatment is necessary and appropriate for them; • the consequences, risks and benefits of the treatment you propose; • the likely prognosis; • your recommended option’
22. In addition, records show the dentist acted in line with NHS England’s oral surgery guidance, specifically:
•‘Clinicians providing oral surgery care should be competent to manage complications that may arise.
•The clinician should ensure that the cooperation, motivation, aspirations, and general health of the patient are consistent with the provision of oral surgery.
•Prior to the provision of oral surgery, a comprehensive oral health assessment should be undertaken; the information collected and the risks identified should be reviewed before oral surgery procedures are undertaken.
•Patient has received sufficient information about procedure to enable them to provide informed consent.
•Patient has information with respect to appropriate selfcare after oral surgery procedure has been completed.’
23. Considering all the above, we do not see any indication of failings in relation to the procedure carried out. Whilst this is Mrs M’s primary complaint, we know she is also concerned about the dentist’s actions when she called twice afterwards. We hope the following information can further assure her, as we again see no indication of failings.
24. Records note Mrs M called to report pain since the extraction, and our adviser confirms the symptoms documented, that she described, are consistent with dry socket. Our adviser explains Mrs M’s risk of having dry socket was increased, as explained on the NHS website, considering her age (over 25 years old), smoking status (an active smoker) and the extraction being difficult or complicated (having nine extractions at once would apply here). This was a reasonable conclusion for the dentist to have made, and reasonable this was done by phone.
25. Our adviser confirms telephone consultation on this matter was appropriate. Telephone triage is common in medical and dental practice, more so after COVID-19. This is considered established good practice and in line NHS England urgent dental care guidance, specifically:
‘The care patients receive should be timely, safe and effective while being tailored to meet the needs of the individual. Care decisions should be reached via a process of shared decision making. Care needs will range from remote triage and advice, to delivery of face-to-face care…
The triage service should be able to: • Consider remote prescribing’
26. The first time Mrs M called, the dentist documented giving advice for continued home after care, hot salt mouth washes, to take pain relief as required and he prescribed a course of antibiotic treatment. Our adviser confirms this is appropriate treatment and prophylaxis (to prevent) for infection.
27. When Mrs M called two days later, it is recorded she explained having sickness and diarrhoea after taking the previous antibiotics. The dentist prescribed an alternative drug, which our adviser again confirms was appropriate to the circumstances and in line with the above extract from NHS England urgent dental care guidance.
28. We are sorry to have learned Mrs M later became unwell and needed a short admission in hospital. We acknowledge that she feels something must have gone wrong during the extraction procedure to have led to that need. We hope we can assure her we do not find any indication of service failure in the extraction procedure or in the actions of the dentist thereafter.