19. When we look to determine if there was a failing in the care and treatment complained about, we first consider what should have happened in line with relevant policies, guidelines, standards and good clinical practice. We then use all available evidence to determine if what should have happened, did happen. If it did not, we then consider if what did happen fell so far short of what should have happened that it amounts to a failing.
20. If we identify there has been a failing in the care and treatment provided, we then consider the impact of this failing. If the failing has had a negative impact on the complainant, we consider what actions the organisation has already taken to put things right. If we consider it has not done enough to put things right, we may make recommendations for further action.
Treatment
21. Ms A complains she told her dentist at five routine examinations that she had sensitive and achy teeth, but they did not investigate the cause of her pain.
May to September 2019
22. The dental records say Ms A reported pain on 15 May 2019 in tooth LL6. The dentist did an X-ray which did not identify any visible damage to the tooth. The dentist recorded that they suspected a crack under the filling in the tooth. They set a treatment plan of antibiotics and for Ms A to return for removal of the filling and further investigations.
23. The dental records say the dentist carried out these investigations on 29 May 2019. When the dentist opened the tooth, they found a mesial crack (crack on the front edge of the tooth) and the pulp was necrotic (soft tissue at the centre of the tooth had died). The dentist recorded there was no crack on the chamber floor and they decided to try to restore the tooth with root canal treatment.
24. The NHS says root canal treatment is needed when dental X-rays show that the pulp has been damaged. Root canal treatment can save a tooth that might otherwise have to be removed completely. After the bacteria have been removed, the root canal is filled, and the tooth sealed with a filling or crown (tooth shaped cap).
25. The dental records say Ms A returned to Practice on 25 June 2019, complaining of pain and swelling near tooth LL6. The records say the dentist offered antibiotics, or to open and drain the tooth, and Ms A chose antibiotics. The dentist then took impressions for a crown to be made. The records say a crown was fitted on 11 July 2019. Ms A told us the Practice did not take an impression for a crown, and that she was left with a black filling.
26. Our adviser explained the Practice provided correct treatment in terms of investigation of Ms A’s pain and swelling, identifying a crack and necrotic tooth, and then root canal treatment and a crown for cuspal protection.
27. The dental records say Ms A returned to the Practice on 18 September 2019 with an abscess in tooth LL6. The dentist prescribed antibiotics and booked in re-root canal treatment, and routine examination, for 27 September 2019.
28. The dental records for the next appointment say ‘today’s X-ray shows widening of the periodontal ligament [soft tissue between the tooth and the bone] all around confirming splitting of the root. Discussed with patient and agreed XLA [extraction]’. The dentist then extracted tooth LL6.
29. Our adviser said the X-ray did show mesial lamina dura widening which indicated reinfection of the tooth, and unsuccessful root canal treatment. However, they said it was not apparent from the X-ray that the cause of re-infection was a fractured root. They explained the fractured roots are not very clear on the X-ray, and the tooth could have been failing due to re-infection rather than a fracture. Our adviser said extraction is one option for a failed root canal treatment but, as per the GDC guidance below, there should have been an offer to refer Ms A to a specialist endodontist for a re-root canal treatment and to confirm any fractures under a microscope.
30. GDC ‘Scope of Practice’ sets out the skills and abilities of each registrant group and describes additional skills they might develop after registration. The guidance says ‘you may expand your scope by developing additional skills, or you may deepen your knowledge of a particular area by choosing more specialised practice.’
31. The guidance also says ‘You should only carry out a task or type of treatment or make decisions about a patient’s care if you are sure that you have the necessary skills and are appropriately trained, competent and indemnified. If a task, type of treatment or decision is outside your scope of practice or you do not feel that you are trained and competent to do it, you must refer the patient to an appropriately trained colleague.’
32. The GDC says ‘Specialist endodontists provide care for patients who require complex endodontic treatment which include, but are not limited to, complicated root canal treatment including failed treatment, management of traumatised and immature teeth, and surgical procedures to the tooth root and surrounding tissues. Their services may be needed where patients require care outside the scope of general dental practitioners or when multidisciplinary collaboration is necessary.’
33. Failed root canal treatment is within the scope of practice of an endodontist rather than a general dental practitioner. The Practice should have considered a referral to a private endodontist, and provided this option to Ms A, before extraction of the tooth.
34. We found the Practice did not act in line with the relevant guidance on this point. It did not discuss with Ms A the option of a referral to private endodontist referral before the dentist extracted the tooth.
35. We go on to discuss the effect this had on Ms A later in this report.
January 2020
36. The dental records say Ms A attended a routine examination on 16 January 2020, where she complained that all her molars were tender. The dentist examined Ms A’s teeth and could not find anything abnormal, they recorded that they suspected severe bruxing (teeth grinding). The dentist provided an upper soft occlusal mouth guard.
37. The NHS says treatment for teeth grinding is not always needed, a dentist may recommend a mouth guard or mouth splint which are worn at night and protect teeth from damage.
38. Our adviser explained that given Ms A’s history of fractures, she needed occlusal protection. They said as the X-ray show no signs of tooth decay and all teeth were fine, a mouth guard was the correct treatment in line with the NHS guidance. We have found the Practice provided appropriate care and treatment at this time.
Antibiotics
39. Ms A complains the Practice prescribed antibiotics three times prior to the tooth extraction on 27 September 2019.
40. The dental records say the Practice prescribed antibiotics to Ms A on 15 May, 10 June and 18 September 2019.
41. NICE guidelines say ‘when prescribing antimicrobials, prescribers should follow local (where available) or national guidelines on prescribing the shortest effective course; the most appropriate dose and route of administration. When deciding whether or not to prescribe an antimicrobial, take into account the risk of antimicrobial resistance for individual patients and the population as a whole. When prescribing any antimicrobial, undertake a clinical assessment and document the clinical diagnosis (including symptoms) in the patient's record and clinical management plan.’
42. The NICE guidelines also say ‘if immediate antimicrobial prescribing is not the most appropriate option, discuss with the patient and/or their family members or carers (as appropriate) other options such as self-care with over the counter preparations, back up (delayed) prescribing or other non-pharmacological interventions, for example, draining the site of infection.’
43. The FGDP UK antimicrobial guidelines provide guidance on the use of antimicrobials in the management of oral and dental infections: when (and when not) to prescribe, what to prescribe (where indicated), for how long and at what dosage. The guidelines say antibiotics should be prescribed for a dental abscess (build-up of puss in the teeth caused by an infection), periodontal abscess (gum), necrotising periodontal disease (gum disease with tissue loss) and pericoronitis (inflammation of the gum tissue around wisdom teeth).
44. The dental records say that on 15 May 2019, the Practice prescribed metronidazole to Ms A. The dentist recorded they did not find any visible damage to the tooth, the X-ray had no findings and the recorded diagnosis was suspected crack under a filling.
45. There is no evidence in the records of an infection at this time. The Practice told us the dentist prescribed a course of antibiotics as they expected an infection to develop.
46. The FGDP UK antimicrobial guidelines do not recommend prescribing of antibiotics for a suspected crack, or the prophylactic prescribing (prescribing to prevent an infection) of antibiotics. The guidelines say ‘irresponsible or inappropriate use of antimicrobials include prescribing in the absence of an infection or where local measures will suffice, prescribing prophylactically and patient should be treated as soon as possible to avoid repeat prescribing of antimicrobials.’
47. Our adviser explained that in these circumstances the dentist should have advised Ms A to return if an infection developed, and prescribed antibiotics at that stage. We consider this would have been in line with the NICE guidelines.
48. We have found the Practice did not comply with NICE and FGDP UK antimicrobial guidelines when it prescribed antibiotics to Ms A on 15 May 2019.
49. The dental records say the Practice prescribed a further course of metronidazole on 10 June 2019 as Ms A had pain and a swollen cheek near LL6, which indicated an infection. The records say the dentist gave Ms A the option of antibiotics, or opening and draining the tooth, and she chose the antibiotics.
50. The dental records say the Practice prescribed erythromycin on 18 September 2019 as Ms A had developed an abscess in LL6, and it was recorded that she reported typical dental abscess pain.
51. Having considered all the evidence, we have found that the prescribing of antibiotics on 10 June 2019 and 18 September 2019 was clinically indicated as there were clear signs of an infection. Antibiotics were required to treat the dental infection. The Practice complied with NICE and FGDP UK guidance when it prescribed antibiotics to Ms A on these occasions.
The impact on Ms A
52. We have considered whether there has been any impact on Ms A as a result of the treatment she received for tooth LL6 and the antibiotics prescribed on 15 May 2019.
53. Our adviser told us that as LL6 sits in a socket on its own, treatment of that tooth would not have caused the sensitivity and pain Ms A has in her other teeth. They explained these problems are more likely to have been caused by bruxism and clenching teeth, not the treatment the Practice provided. A consultant in restorative dentistry and Ms A’s current dentist have also diagnosed bruxism. Ms A’s current dentist has recommended a soft nightguard for protection.
54. For those reasons, we are unable to link the later removal of tooth LR6 in September 2020, and the ongoing pain in Ms A’s upper teeth, to the care and treatment the Practice provided.
55. Whilst the Practice should have discussed the option of a referral to a private endodontist for further investigations before extracting tooth LL6, we are unable to say the tooth was unnecessarily extracted. This is because removal of the tooth is one treatment option where there is pulp necrosis. Removal of that tooth may have happened in any event if an endodontist was unable to save it.
56. We have not seen any evidence which suggests the Practice caused the deterioration of tooth LL6, or any other teeth.
57. We are therefore unable to link the injustice Ms A has told us about to the care she received from the Practice. We recognise Ms A has ongoing difficulties as a result of her dental health, and we are sorry if our decision causes any further upset.
58. Ms A is not happy that the Practice prescribed antibiotics three times leading up to the extraction of tooth LL6.
59. Whilst there is one occasion where the Practice should not have prescribed antibiotics to Ms A, as the infection had not developed at that time, we cannot see that the extra course of antibiotics caused an adverse impact on Ms A’s health. The dental records show she had a root canal filling two weeks after the antibiotics were prescribed and there was no sign of an infection, or poor health, at that time.
Conclusion
60. From the evidence we have seen, we have identified two failings. The Practice extracting tooth LL6 before offering Ms A a referral to a private endodontist, and the prescribing of antibiotics on 15 May 2019.
61. We have not been able to link these failings to the claimed impact of continued pain and distress, tooth loss and damage.
62. Ms A told us the only outcome she is looking for is financial remedy. Our Principles of Remedy explain that organisations should compensate the affected person appropriately if they are not able to return them to the position they would have been in if the poor service had not occurred. As we have been unable to link the injustice Ms A has told us about, to the failings we have identified, a financial remedy is not appropriate in these circumstances.
63. While we have not been able to say the failings identified have led to the impact Ms A has told us she experienced, we have partly upheld the complaint because of the failings identified.
64. We appreciate Ms A has been through a very difficult time and has ongoing dental pain. We are very sorry for the discomfort Ms A experiences. We hope she is able to obtain the treatment she needs to restore her dental health.