Gum disease treatment as a private patient
11. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
12. Mr J complains the Practice advised he had gum disease which required treatment as a private patient at his appointment in July 2024. In its response, the Practice said it examined Mr J’s teeth on 1 July and diagnosed him with gum disease (periodontitis). It said Mr J had localised extensive bone loss on his lower front teeth and took X-rays to confirm this diagnosis.
13. The Practice final response said clinical guidelines for the treatment of gum disease (periodontitis) recommend an individual oral hygiene plan and a deep clean, followed by a reassessment after three months. It said the dentist initially advised this treatment could be carried out under NHS arrangements but could also be carried out by the Practice hygienist. It says that because Mr J already had an appointment with the hygienist booked immediately after his dental appointment, it recommended he keep this appointment because the hygienist would be able to carry out the recommended gum disease treatment.
14. The Practice said it did this because waiting times for an NHS referral for periodontitis treatment can be very long and would have come under Band 2 of NHS dental treatment, at a cost of £46.90. It said the cost for Mr J to receive the treatment through the Practice hygienist, at the appointment which was already booked, was £49.
15. The appointment Mr J had booked with the hygienist was on a private basis, and he had seen the hygienist privately on five previous occasions. The Practice apologised to Mr J if it had not explained this clearly enough to him and offered to refund the excess £3.
16. We reviewed this issue through examining Mr J’s dental records and General Dental Council guidance.
17. General Dental Council (GDC) ‘Standards for the Dental Team’ guidance 1.1.1 says dentists ‘must discuss treatment options with patients and listen carefully to what they say’ and ‘give them the opportunity to have a discussion and to ask questions.’ Guidance 1.7.2 says dentists working in mixed NHS and private practices must make clear to patients which treatments can be provided under the NHS and which can only be provided on a private basis. Guidance 1.7.4 says patients must not be pressurised into having private treatment if it is available to them under the NHS and this option is preferred.
18. The records of Mr J’s July appointment show Mr J was diagnosed with periodontitis and the condition was explained to him. They show Mr J was advised the condition was for life and risk factors were explained. They say Mr J was given the option to see the hygienist for his treatment, rather than being referred for NHS treatment. The records say Mr J was told there was no obligation for him to see the hygienist. They say Mr J understood the treatment plan and was happy to proceed. We consider this is in line with relevant GDC guidance.
19. Mr J says he was not told that he could receive the periodontal treatment he required as an NHS patient. We have carefully considered Mr J’s evidence and what the Practice recorded at the time of the appointment.
20. When the evidence from one party conflicts with the evidence from the other party, we will weigh up the evidence from both parties to try to reach a view on what is more likely to have happened. In this case, given the Practice recorded that it told Mr J about his treatment options, and he agreed to the plan, we think it is more likely than not these options were discussed with him. We have also seen he attended the hygienist appointment as discussed at the dental appointment. This does not mean we have discounted Mr J’s recollection, which we have considered carefully. We have reached a view on what we believe the evidence tells us on balance.
21. Taking into account the evidence available, we have not seen evidence the Practice told Mr J he could only have privately funded treatment for periodontitis. Despite this, we can see the Practice apologised and offered to refund the difference in cost. Given the minimal impact of the potential miscommunication, we consider this apology sufficient and in line with NHS Complaint Standards which say organisations should provide fair and accountable responses. We will therefore not be considering this part of the complaint further.
Bleeding during dental examination
22. Mr J complains the Practice dentist deliberately poked his gum too hard during his dental examination in July 2024, which caused it to bleed.
23. In its final response, the Practice said that gum disease was diagnosed during the appointment in July.
24. We reviewed this issue through examining Mr J’s dental records and relevant guidance.
25. The examination of Mr J’s gums is documented in his dental records. The records show that inflammation of the gums was noted and moderate bleeding was recorded, with general bleeding scores of more than 20%. The bleeding score is a way dentists can assess oral hygiene in patients with periodontitis.
26. NHS patient information on gum disease says bleeding can be a symptom of gum disease. If gum disease was present, it would not be unusual for dental examination to result in bleeding. From the dental records, there is no evidence of excessive force being used during his assessment.
27. There are some occasions when we decide we should not investigate a complaint made to us. One of these occasions is when an investigation would not be practical, would not reach a satisfactory conclusion and there would be no value in providing that response through an investigation.
28. The records show there is no suggestion of excessive force being used during the examination of Mr J’s gums. We acknowledge Mr J’s experience and accept his interpretation of the examination was different. We do not think it is likely that we could reach a definitive conclusion on this point. Defining excessive force is subjective and it is impossible for us to reach a view on this from the written records. An investigation into this matter would not be practical and could not reach a satisfactory conclusion. We will therefore not be considering this part of the complaint further.
Communication around gum disease
29. Mr J complains the Practice did not tell him he had gum disease (periodontitis) before his appointment in July 2024. He says he was told about this condition for the first time during this appointment.
30. In its final response, the Practice said it had explained the risks and progression of periodontitis to Mr J in September 2021. It said Mr J was told he had periodontitis in May 2022 at a dentist appointment, and in August 2022 at a hygienist appointment.
31. We reviewed this issue through examining Mr J’s dental records and relevant guidance.
32. GDC ‘Standards for the Dental Team’ guidance 1.1.1 says dentists ‘must discuss treatment options with patients and listen carefully to what they say’ and ‘give them the opportunity to have a discussion and to ask questions.’
33. GDC ‘Standards for the Dental Team’ guidance 2.2.1 says dentists must ‘listen to patients and communicate effectively’ with them, explaining options with risks and benefits and giving full information on proposed treatment.
34. GDC ‘Standards for the Dental Team’ guidance 4.1.1 says dentists must keep ‘complete and accurate patient records’ including a medical history, each time they treat patients.
35. Mr J’s dental notes show he had an appointment with a dentist in September 2021. The notes show the dentist explained to him that he had periodontal disease. The dentist explained the causes, consequences and treatment. The records also show the dentist explained the link between periodontal disease and bones loss and that Mr J would require regular treatment.
36. Mr J’s next appointment with a dentist was in May 2022. The notes show the dentist informed Mr J he had periodontitis and advised treatment was required, alongside an improvement in oral health and cleaning, to prevent it getting worse. Treatment was arranged through the hygienist.
37. Mr J saw a hygienist in August 2022. The notes say the hygienist spoke to Mr J about his periodontitis in ‘great detail’ and explained the risks associated with the condition. The notes record that Mr J understood this explanation.
38. The records show Mr J was told he had periodontitis several times in 2021 and 2022. The records show that the risks of the condition were explained to Mr J and treatment was arranged. Mr J is noted as understanding these explanations and thorough records were kept. This is in line with GDC guidance.
39. We acknowledge Mr J does not feel that he received an adequate explanation of his gum disease. Having reviewed the available evidence, there is evidence the Practice communicated with Mr J prior to 2024 regarding his periodontitis. We will therefore not be considering this part of the complaint further.
Provision of referral details
40. Mr J complains the Practice did not advise whether he had been referred to a dental hospital for further treatment for several weeks after his appointment in July 2024, despite his efforts to chase this information. He said he had no records of the Practice attempting to contact him.
41. The Practice says it attempted to contact Mr J by phone for three weeks but were unable to get through. It has not been able to provide evidence of when these calls were made.
42. We reviewed this issue through examining Mr J’s dental records and relevant guidance.
43. GDC ‘Standards for the Dental Team’ guidance 2.3.11 says dentists should provide patients with clear information about any referral arrangements related to their treatment. In addition, guidance 4.1.6 says accurate records of referrals should be made in the patient’s notes. Guidance 6.3.5 says patients should have the referral process explained to them if a referral is necessary.
44. The records show the Practice referred Mr J to Restorative Dentistry services at a local NHS Trust four days after his appointment. The referral letter advised Mr J had been diagnosed with stage four, grade C periodontitis and required specialist management given his history of past trauma to his teeth. Mr J was not copied into this letter. The records show the referral was rejected in mid July 2024, on the grounds that the referral had not provided adequate details of whether a course of primary periodontal treatment had already been carried out. It said if evidence of treatment was provided, the referral could be considered. Mr J was not informed the Trust had declined his referral.
45. The records do not show that Mr J was kept informed about his referral. We consider on this occasion, the Practice did not act in line with the GDC standards. We appreciate this would have been frustrating for Mr J. Mr J has told us of the worry this caused him about his ongoing dental care. We can see that the records show that the referral was made in a timely manner and so we are satisfied his care pathway was not impacted by this lack of communication. However, we felt the Practice needed to do more to put this right.
46. The NHS Complaint Standards say organisations should provide meaningful apologies and transparent explanations when shortcomings are identified. We contacted the Practice and asked it to make a further apology. The Practice has now apologised for not keeping Mr J informed about the progress of referral and acknowledges this should have happened. It also apologised for the errors in communication, the distress it caused Mr J and outlined the internal learnings it has implemented to prevent a recurrence. We consider this response to be in line with our Complaint Standards. We will therefore not be considering this part of the complaint further.
47. We thank Mr J for taking the time and effort to bring his complaint to our attention. We accept how important Mr J’s complaint is to him and are very sorry about the stress this has caused him. We hope our explanation provides some reassurance about the care and treatment he received, although we appreciate our decision may be difficult to accept given his interpretation of some of the events complained about.
48. We would like to thank both parties for their cooperation and understanding throughout this process. We wish Mr J the best for the future.