Failed bonding
16. GDC standards state that dentists must obtain valid consent before starting treatment. The standards also state dentists should inform patients of the options for treatment, the risks and the potential benefits, the likely prognosis, the cost of the proposed treatment, their recommended option, and what might happen if the treatment is not carried out.
17. Mr K complains he was given a composite crown which fell out multiple times. He says the dentist admitted at a later appointment he had used the incorrect bond glue. Mr K also complains he was charged the highest rate for dental healthcare which failed and that he needs large scale private treatment to repair the damage.
18. The Practice said Mr K had been offered a composite crown as the tooth would not be able to withstand a conventional crown. It said he accepted this treatment option and was aware it might fail. The Practice noted he had returned in June, July and August to have the crown re-bonded when it became loose. It also said the risks of failure had been explained to Mr K and it could not refund his NHS Band 3 charge.
19. Adults registered with an NHS dentist in England must pay for their treatment, unless they have a valid exemption. There are three charge bands (valid from 1 April 2025 – 1 April 2026) which are categorised by the treatment type and cost:
• Band 1 – routine check-ups, preventative care, emergency treatment - £27.40 • Band 2 - fillings, extractions, gum disease management - £75.30 • Band 3 – crowns, dentures, bridges - £326.70.
20. Patients with treatments which cover more than one category will pay once for the highest treatment band irrespective of how many appointments they need for the course of the treatment.
21. In April 2022 Mr K received private treatment which involved composite bonding on four front teeth which included his upper left lateral incisor (UL2). Composite bonding is tooth-coloured resin material which is applied to the tooth surface and is suitable for minor repairs including chips and gaps. It also improves the cosmetic look of the tooth.
22. Mr K attended the Practice in early June 2025 after experiencing issues with his UL2. The dentist examined him and noted the UL2 was fractured and had suffered a severe loss of structure. The dentist advised Mr K his tooth was potentially unrestorable and that a composite crown was an option to try and save the tooth.
23. Composite crowns are made of a tooth-coloured plastic material which is bonded onto the surface covering the whole tooth to the gumline. They cost less than conventional crowns and can be moulded and shaded to match existing teeth and are less invasive to fit. Conventional crowns are made of stronger materials including porcelain which makes them more durable and costly. They also require more removal of the tooth structure to fit.
24. The records show the dentist discussed the low chance of the tooth being saved with Mr K and explained the NHS band 3 cost to him which he accepted. This was the correct cost in line with NHS charges explained earlier. Moulds to make the crown impressions were taken on the same day.
25. At the end of June 2025, the dentist attached the crown to Mr K’s UL2 with a resin cement with the records stating Mr K was happy with the appearance. The records also state the dentist informed him again that early failure of the crown was possible, and Mr K agreed to proceed despite the risks.
26. Mr K told us the crown detached within hours. He attended the Practice several days later and the dentist reattached the crown with Panavia which is a high strength dental bonding cement used for attaching crowns and veneers.
27. Mr K attended the Practice several weeks later in mid-July after the crown became detached a second time. The dentist re-cemented the crown with Panavia and added some additional resin filling material to the back of the tooth. The records show the dentist explained to Mr K if the crown failed again, they would need to explore other options.
28. In mid-August the dentist discussed the prognosis of Mr K’s UL2 after he attended to have the tooth recemented again. The dentist explained that due to the lack of ferrule (internal natural tooth structure), the crown could no longer be re-cemented.
29. The dentist advised Mr K the UL2 could be removed and replaced with an NHS denture, a private bridge, private implant or private denture, and explained the costs of each treatment option. The dentist also said the UL2 could be left as it was without being extracted as it was not showing any signs of infections or problems at that time.
30. Our adviser said it was reasonable for the dentist to try to save Mr K’s UL2 with a composite crown as they considered it unlikely a conventional crown would have been tolerated by the remaining tooth. Our adviser also said it was reasonable to use an adhesive resin cementation approach for the composite crown as this would avoid drilling any more of the tooth away.
31. Mr K told us on the first occasion the crown detached the dentist told him they had used the wrong glue when bonding the crown. Unfortunately, there are no records which confirm this conversation. We are not doubting Mr K’s account of what was said about the incorrect glue. The lack of documentary evidence means we cannot take a view on this.
32. The type of cement or adhesive used is not recorded in the records at the initial fitting of the composite crown. Our adviser said based on the steps used for cementation it is clear a resin cement was used which was entirely appropriate. In future appointments Panavia was stated as the cement used.
33. Our adviser said that repeated failure of the crown does not indicate Mr K’s treatment was below standard and there is nothing to suggest the dentist used the incorrect cement at any of his appointments.
34. We recognise Mr K has a broken front tooth which is obvious and prominent. We can see from his records the dentist warned him at the initial examination stage and the subsequent fitting stage the tooth had a guarded prognosis, and that early failure of the crown was possible.
35. Our adviser said the risks were adequately explained to Mr K. This is in line with GDC guidelines mentioned earlier which state the dentist should explain the risks and benefits of the proposed treatment, the likely prognosis and whether the treatment is guaranteed.
36. There is no indication of a failing here and we will take no further action.
Alternative options
37. CQC dental guidelines state patients should be given enough information and time to consider any proposed dental treatment including the risk and benefits of treatment, any alternatives and costs.
38. Mr K complains he was not given any additional options for treatment at his initial examination in June 2025 when he presented with his fractured UL2. He said he was offered an NHS bridge and plate at an appointment in November, but this was not offered in previous appointments.
39. The Practice said it informed Mr K in mid-July he would need to consider other treatment options due to failure of the composite crown. It also said in mid-August Mr K had been offered an extraction, NHS dentures, a private bridge, implant or denture, or no treatment and accept the gap.
40. The dentist decided to place the composite crown on Mr K’s UL2 at his examination in early June. There is nothing in the records to suggest the dentist offered alternative treatment options to Mr K before this.
41. Our adviser said considering the risk of failure of the UL2 composite crown Mr K should have received all treatment options at his initial examination before the dentist confirmed the proposed treatment plan.
42. Mr K’s crown failed a second time and was reattached at an appointment in mid-July. The records state the dentist said other options would need to be considered if the restoration failed again. There is nothing in the records to show the dentist explained what these options would be.
43. Mr K attended the Practice again in August to have his crown recemented. The dentist discussed with Mr K the prognosis of the UL2 and explained the crown could not be recemented or placed due to the lack of tooth structure.
44. The dentist also explained the various options available to Mr K. These included doing nothing and accepting the gap, removing the UL2 and replacing it with an NHS denture or having a bridge, implant or denture fitted privately. The dentist advised Mr K the UL2 did not need to be extracted as it was not showing signs of infection or problems.
45. Mr K said the Practice suggested he needed large scale private treatment to repair the damage. The records show when it became clear the UL2 could not be saved Mr K was offered alternative treatment options. Our adviser said the UL2 was already damaged and there is no evidence the dentist caused any additional damage to the tooth which needed repairing. The composite crown was a last attempt to save his tooth, and the dentist explained this to him.
46. Mr K should have been offered alternative options at his initial assessment in early June. He was given alternative treatment options in August after several failures of his crown. On balance we consider it likely Mr K would have opted for the composite crown even if he had been offered alternative treatments as this was the only option which might have saved his tooth.
47. Alternative options would have involved extracting the tooth and Mr K would have been left with a gap. His other option was to leave the tooth as it was. Mr K was unhappy with the appearance of the tooth which is why he first attended the Practice in June. From what he has told us about how the appearance affects him, we consider it unlikely he would have left it as it was.
48. As we have seen earlier, the risks and benefits were explained to Mr K. The Practice did not offer any alternative treatment options at his initial examination which it should have in line with CQC guidelines mentioned earlier.
49. There is an indication of a failing here as the dentist should have advised Mr K about alternative options for treatment at his initial examination. Mr K says that he has a visible broken tooth as a result of what happened.
50. We have decided not to investigate this complaint further as we do not consider this injustice is a result of any mistakes made by the dentist.