Care and treatment
22. When we investigate a complaint, we first look at whether there are signs the organisation did something wrong. We do this by comparing what should have happened with what did happen.
23. We have done this and have found there were missed opportunities by the dentist in identifying the nine cavities as early as August 2022.
24. Mr A explains that since being diagnosed with mouth cancer in 2012 he has always visited the dentist regularly and he understands the importance of his oral health.
25. He is concerned during his last appointment with the Practice on 13 November 2023, he was not informed of any cavities or treated for those.
26. Mr A has had to get treatment for the cavities by the private dentist in April 2024 as he has lost trust in the Practice, and they were not able to provide him with an NHS dentist.
27. Our adviser has thoroughly reviewed the medical records. Mr A attended the Practice on 11 August 2023 for an emergency appointment due to having sensitivity on the right and left hand side with the left being more painful. During this appointment, the notes say a periapical radiograph was taken, however this is incorrect. Our adviser confirm it is a Bitewing radiograph.
28. The Practice has said in its final response that Mr A should have been flagged as a high-risk patient suffering with decay due to his medical and dental history. If this has been done it could have led to a recommendation for shorter recall appointments of three months between examinations and the provision of additional preventative measures like fluoride varnish and mouthwash.
29. The Practice has not addressed the cavities that were present in the X-rays and has not recognised the impact of not treating these.
30. College of General Dentistry guidance, section 4.3.1 says as a medium risk patient (this patient) should have X-rays annually, a high-risk patient every six months and a low risk patient every two years.
31. Our adviser explains Mr A has been diagnosed as a medium/moderate caries risk patient so annual X-rays are recommended. His last bitewing radiographs were done in November 2022, therefore the August 2023 X-ray is in line with the guidance above.
32. Our adviser reviewed the X-ray from August 2023 and notes that decay was identified at the distal (back) of the LL7 and a filling was advised. The notes say Mr A was informed and said he will think about it.
33. Our adviser confirms the X-ray from August 2023 shows decay on UL4 distal, UL5 under the existing filling, UL7 mesial, LL4 DO, LL5 mesial and distal.
34. Our adviser explains the most recent X-rays show more than nine cavities, but this is just from a posterior view. In the treatment plan it also lists LR2, LR1, UR1, UL1, UL3, these cannot be seen in the radiographs as these are anterior teeth, therefore the adviser is unsure if these are to be restored due to decay or fractures.
35. Our adviser also said it is hard to fully diagnose from just this radiograph alone and examination of the patient is always important because you can also probe the teeth that look suspicious.
36. Our adviser also identified other areas that look suspicious but says other radiographs at a different angle such as a periapical may have been helpful.
37. Having reviewed the above our adviser explains Mr A should have been informed of the potential multiple decayed teeth and these should have been documented in the records and monitored going forward.
38. Our adviser explains decay rate massively varies in patients. Mr A suffers from a dry mouth, therefore decay will develop a lot faster than a normal patient due to the lack of saliva.
39. Mr A is a moderate risk to decay patient which means X-rays should have been taken every year. Also, Mr A has extensive decay risk due to previous round of radiotherapy.
40. Our adviser explains in practice the usual process is to tell a patient they have decay or require a filling. During this appointment the dentist will give the patient their options and provide details about the risk of not getting the cavity filled. The patient is entitled to decline a filling.
41. Similarly, if a patient says they will think about it, the dentist must document it and then revisit it when they see the patient next. Most patients do come back to have the filling done.
42. In the medical records the radiographic report from August 2023 mentions nothing about these potential other cavities. Mr A should also have been prescribed some Duraphat high fluoride toothpaste and mouthwash at this stage to help with his decay rate.
43. Our adviser also says as Mr A presented in his emergency appointment with sensitivity on both sides of his mouth and was noted as a medium caries risk patient, a right bitewing should have been taken but was not.
44. This is because it could have highlighted the cavities on the right hand side earlier.
45. GDC: Standards of the dental team (September 2013), Principle 6 - Work with colleagues in a way that is in patients’ best interests,
46. ‘Patients expect: - To be fully informed of the different roles of the dental professionals involved in their care - That members of the dental team will work effectively together.
• You must: 6.1 Work effectively with your colleagues and contribute to good teamwork.
• 6.1.1 You should ensure that any team you are involved in works together to provide appropriate dental care for your patients.’
47. During 2023, Mr A was seen by two different dentists and neither of them pointed out the possible other cavities on the left bitewing radiograph taken on 11 August 2023.
48. Similarly, there is no evidence to suggest previous radiographs were reviewed.
49. Therefore, the decay that was picked up in August 2022 was missed by the next appointment in 2023. This is not in accordance with the guidance above.
50. Based on the above advice and guidance we have received, we found that the multiple cavities Mr A had should have been picked up as early as August 2023.
Front Teeth
51. We also found there is little evidence in the medical notes that show the front tooth filling that failed was rectified or repaired or was even considered during the examinations that took place.
49. Mr A is concerned that between September and December 2023 his front filling (UR1) had fallen out. He is adamant they were not fixed despite numerous attempts of making the dentist aware of this.
50. The Practice has not addressed this specifically in its final response.
52. 51. Our adviser has reviewed the medical records and notes the only mention of a front tooth being restored is the LL3 on 21 September 2023.
53. The filling LL7 was only done 7 September 2023, two weeks prior to it failing.
54. Following this, the records show the dentist filling it for the last time and trying an alternative material. LL3 and LL7 were prepared and restored.
55. Our adviser explains the medical notes for this section are poor and not clear. There is evidence of repeat failures of the LL3, but nothing in the notes that show repeated attempts were made to rectify it.
56. Based on the information above, we requested further medical records from the Practice, X-rays and information about front teeth fillings from November 2022.
57. Our adviser notes the only additional information those notes provide is a mention of a filling on the UR1. The Practice confirmed there are no additional notes relating to the front teeth.
58. On 23 August 2022, it says a filling was lost on UR1 and it was fixed during the same appointment. It was then lost three weeks later and fixed again on 26 October 2022.
59. The Practice has confirmed in an email dated 10 February 2025 that it does not have any records of X-rays for November 2022.
60. Based on this, the lack of medical records from 2022 indicates certain things were not done during Mr A’s appointments, such as X-rays. The notes we do have show in August 2022 UR1 was fixed twice, after that there is no mention of UR1.
61. Therefore, we can say with certainty there is no evidence that attempts were made to rectify the filling on the front teeth (UR1).
62. Therefore, we have found this is a failing.
63. We go on to consider the impact for failing to identify nine fillings and the failure to rectify the front tooth filling below.
Impact
63. We have found the Practice could have identified and treated the nine cavities as early as August 2022 as decay is visible on the X-ray from 2022.
64. Similarly, we have found there were multiple opportunities for the other dentist at the Practice to identify the decay when Mr A had an appointment with them in 2023.
65. We know from the medical records that when Mr A attended for his appointments in 2022 and 2023, previous X-rays were never reviewed or acted on. This means that if Mr A had never seen the private dentist who told him he needed nine fillings, he would have never known he needed treatment.
66. The Practice’s failure to identify and treat nine fillings and lack of robust assessment during these appointments had a direct and adverse impact on the care Mr A received. He was shocked and distressed to hear that he needed so much treatment and had the dentists who examined him reviewed the previous X-rays there would have been a strong likelihood that they would have diagnosed the multiple cavities and treated them accordingly.
67. In addition to the distress Mr A experienced in finding out about the cavities, he also faced financial pressures in having to pay for private treatment that is ongoing.
68. Because of the multiple instances the Practice failed to treat Mr A’s cavities, understandably he lost trust and faith in them. This meant he sought treatment from a private provider in an urgent attempt to start work on his teeth. This has impacted Mr A’s distress as he worries financially about how he will complete his treatment plan.
69. Mr A made numerous attempts to let the Practice know his front tooth (UR1) filling had failed. This included calling the Practice in October 2023 to ask for an appointment to fix the filling.
70. We found that despite Mr A’s attempts at alerting the Practice to fix his front tooth filling there is no evidence in the records to show that further investigations or treatment was carried out on UR1. Therefore, it is likely that no attempts were made to rectify UR1.
71. Considering the lack of treatment and diagnosis of multiple cavities and lack of evidence to show UR1 was rectified, we believe it was reasonable for Mr A to pursue private treatment.