17. The GDC standards, principle 7, says dentists should provide good quality care based on established best practice. They should work within their own knowledge, skills, professional competence and abilities. This is the overarching standard. Our adviser has told us there are no specific standards for the clinical elements of the care Miss T has complained about. So they have given their advice based on what is established best practice.
The dentist did not properly examine and X-ray her wisdom tooth before trying to extract it
18. Our adviser says there is no specific guidance to say an X-ray must be done before extracting a tooth, it is recommended practice to do this as part of routine investigations and examination. This assists in making a decision about whether the tooth can be removed in practice, or whether referral should be made for dental surgery in hospital. They say the decision to remove a tooth in practice rather than in hospital is the dentist’s discretion, with the patient’s consent.
19. Our adviser gave us examples of reasons for not removing a tooth in the practice, in line with NHS England oral surgery referral guidance. These are if there is a curved root, the tooth was impacted under the gum which might require bone removal, there are root fragments that cannot be managed in the practice, a failed extraction, soft tissue injury and where it is therefore more likely to be a complicated removal.
20. Based on the notes we have seen, our adviser says the dentist carried out an appropriate examination and documented this including the reasons why extraction was suggested. This was because there was decay in tooth next to it, and to avoid further damage to that. Miss T agreed to the extraction.
21. However, both Miss T’s and the dentist’s account say the X-ray was taken after the dentist had made some attempts to remove the tooth. Miss T says it was only after the tooth was not coming out that the dentist decided to do an X-ray. This is not in line with standard recommended practice.
22. We asked our adviser what the X-ray showed, to understand whether an X-ray at the outset would have made a difference to the decision to extract the tooth in the Practice. Our adviser says the X-ray shows nothing that would have indicated it would be a complicated extraction or to suggest Miss T would have met the referral criteria before the attempted extraction.
23. So we identified a failing, but we cannot say this had the impact Miss T says. She believes she would have avoided the attempted and failed extraction in the Practice and been referred to a specialist straight away if the dentist had done the X-ray first. But the X-ray showed nothing that would have led them to a different course of action – they would still have tried to take the tooth out. This means we cannot say Miss T would have avoided her subsequent symptoms of ongoing pain and sensitivity after the attempted extraction.
24. Our adviser says a tooth breaking during extraction is a common and unavoidable complication as often the tooth may need to be split and removed in sections. They also say unfortunately complications during extraction procedures cannot be predicted, or avoided.
25. We understand this was a very distressing appointment for Miss T. When we weigh up the evidence, this shows us the dentist did examine her as they should, but they should have done an X-ray before trying to take the tooth out. It also shows us that if they had done the X-ray, it would not have changed their decision to go ahead with the extraction. So regrettably, the events and outcome would have been the same.
The dentist injected her anaesthetic in the wrong place and continued to do so despite the swelling
26. Our adviser says there is no guidance about the site of injection for local anaesthetic. It is a basic clinical skill, and the anaesthetic is injected next to the tooth being treated or extracted. Our adviser says the right thing to do, in line with established practice, is to ensure the patient is suitably numbed, and if not, more local anaesthetic injections should be given within dosage limits to ensure the area is numbed.
27. We cannot confirm the exact site of the local anaesthetic injection as there is no evidence of that. The records say Miss T had swelling in her cheek, which our adviser says indicates the solution passed more towards the cheek side than the gum. This is not strong evidence of a failing as it can sometimes happen, depending on the anatomy of the cheek muscles.
28. The records show the dentist massaged the area to see if the swelling went down, checked with Miss T if she had reacted before to local anaesthetic and with her consent continued by injecting more local anaesthetic to ensure the area was numb. Our adviser says the dentist did the right thing in this situation. The swelling reduced from massaging it. The dental and ED records do not indicate Miss T had any swelling in her airway, neck or tongue. Our adviser said this shows the swelling did not indicate an allergic reaction. There was also no indication Miss T had a reaction to local anaesthetic previously, she did not tell the dentist she had and there was no note of any previous reaction in her records when she had it previously for fillings.
29. Miss T confirmed to us she could feel pressure but she did not feel pain during the attempted extraction. It is common to feel pressure and if suitably numbed the patient should not feel pain. This indicates the dentist had appropriately numbed the area. We understand this was still an uncomfortable and distressing situation for Miss T. We cannot say this was as a result of anything that went wrong with the local anaesthetic.
30. We understand the swelling was very worrying for Miss T. Our adviser says swelling is common from extractions or attempted extractions particularly due to trauma to the area.
31. When we weigh up the evidence, we have not found any failings in how the dentist managed the anaesthetic injections. The evidence shows us they did this, and managed the complication of the swelling, in line with established good practice.
The Practice sent her home with no treatment, aftercare or advice
32. There is guidance on the NHS website on wisdom tooth removal about what advice will be given afterwards. This includes things such as taking paracetamol or ibuprofen, eating soft/liquid food and rinsing gently with warm salt water. It also gives details of symptoms which may require a further urgent appointment or help from NHS 111. This includes bleeding that does not stop, severe pain and swelling that is getting worse and painkillers are not helping, high temperature or feeling unwell.
33. Our adviser says this is generally the aftercare advice that should be given following extraction, including advice to attend the emergency department (ED) if required. Our adviser says it is not standard practice to prescribe antibiotics but sometimes dentists do so as a precaution to avoid any infection.
34. Miss T says the dentist did not explain any aftercare advice to her or provide any safety netting advice about attending the ED if her symptoms worsen. She says the dentist rushed her out as they were behind with other patients. Miss T says she was given a prescription but the dentist did not explain what this was or what it was for and she wanted to leave quickly. She says she therefore did not collect this. She also says she does not think the dentist told her they would make arrangements for her to come back to complete the extraction or refer her to hospital for removal.
35. Miss T’s records indicate the dentist did provide aftercare advice, safety netting advice about attending ED and a prescription for antibiotics. They also indicate the dentist told her to come back when she finished her medication so they could plan what to do with the tooth, either a further attempt at removal with more time or referral to hospital. The dentist confirmed this account during a telephone discussion with us, explaining they wrote the records after they had seen all their patients that day due to running behind schedule. They also provided further information about the prescription, which showed a prescription was issued but not properly logged at reception. This is likely because, as Miss T says, she left the Practice without collecting this.
36. Miss T strongly disputes what is in her records and the Practice’s account of what happened in relation to aftercare advice. We have had telephone discussions to get a detailed account from both Miss T and the dentist. These are very different accounts and do not correlate. We have considered whether there is any further impartial evidence to help us reach a conclusion but there is not. We cannot reach a balance of probabilities decision about what aftercare advice the dentist gave, if any. So there is not enough evidence for us to say the dentist got something wrong in their advice. This does not mean we have found the dentist definitely did everything right. But to say there was a failing, we would need strong evidence that this was the case, and we cannot see that here.
37. We hope Miss T does not feel our decision in any way diminishes the impact her experience has had on her. We appreciate how distressing this was for her and the difficulty she has had with her ongoing symptoms whilst she awaits removal of her tooth. We hope our decision gives her some reassurance that the dentist did not miss an opportunity to do things differently on the day that would have made her experience better.