SPSO Individual Decisions

C complained to us about the care and treatment that they and their two children had received from a dentist. They said that they were told by the dentist that they and the children did not have any cavities, but when they attended another dentist, they were told that they had cavities and needed fillings. One of the children also needed crowns and experienced an abscess. We took independent advice from a dentist. We found that the dentist complained about had failed to take bitewing X-rays (detect decay between teeth and changes in the thickness of bone caused by gum disease) for C and their children, which was unreasonable. There were also failings in relation to documentation. Whilst it was reasonable that one of the children was told that they had no cavities, we found that based on the evidence available, C and the other child had cavities that needed treatment when they attended the dentist. We also found that the abscess experienced by one of the children was not avoidable, however, the dentist did not follow the relevant guidance on treating the abscess and gave the child antibiotics with no justification for their prescription. There was also no evidence available to demonstrate that the dentist discussed and explained treatment plans to C on all occasions. Given these failings, we found that the dentist's practice fell below the expected standard and upheld complaints about the care and treatment provided to all three patients. C also complained to us about the way in which their complaint had been handled. We found that the dentist had not responded to C's concerns regarding their own care and treatment, or that of one of the children. Consequently, we found that the dentist had not handled C's complaint in line with the NHS Complaint Handing Procedure and we also upheld this complaint.

Ms C complained about the treatment she received from the dentist. Ms C was referred to the dentist as she required sedation during dental procedures. Ms C said she was told by the referring dentist that the tooth, which had a missing filling, was salvageable and could be crowned, however when the tooth was assessed, the dentist felt it was not salvageable. Ms C complained that the actions of the dentist led to an infection, cutting of the bone and was essentially unreasonable. We took independent advice from a dentist. We found that Ms C's treatment by the dentist was reasonable and found no failings in the treatment offered. When the planned treatment changed, Ms C was brought back from sedation so she would be in a position to consent to treatment. The treatment was carried out in a reasonable manner. Therefore, we did not uphold the complaint. Related reading View Decision Report 201805707 as a PDF (23.72 KB) Updated: May 22, 2019

Mrs C underwent dental work. After she submitted the invoice to her dental insurer, they refused to cover most of the costs as the work had been charged on a private treatment basis and the insurance policy only covered NHS costs. Mrs C complained that her dentist had never discussed this with her. She said that if she had known that the work was going to be charged at private costs she would not have agreed to it. Mrs C's dental records included entries documenting discussion about the work being charged on a private basis, and an entry stating that she was given a written estimate. A copy of the written estimate was provided to us, showing itemised NHS and private treatment costs. We concluded that the fact that the work would be charged on a private treatment basis had been discussed with Mrs C. As such, we did not uphold her complaint. Related reading View Decision Report 201700159 as a PDF (10.97 KB) Updated: March 13, 2018

Ms C complained about the care and treatment provided by her former dental practice in relation to the fitting of a bridge (a device to replace a missing tooth or teeth). Ms C complained that the bridge had not been fitted properly and was loose from the start; that it did not match the colour of her other teeth; that she was not told that an existing crown would have to be removed to accommodate the bridge; and that the whole process had not been adequately explained to her. Our investigation included taking independent advice from one of our dental advisers and a review of Ms C's dental records from her former and current dental practices. Our adviser was of the view that the care and treatment provided to Ms C was reasonable and appropriate. Ms C had attended the practice for a number of years and had difficulty with the teeth in question since 2004. The adviser was of the opinion that all treatment options had been discussed with Ms C and sufficient information had been provided to her to enable her to make fully informed decisions about her treatment. Related reading View Decision Report 201400163 as a PDF (11.11 KB) Updated: March 13, 2018

Mrs C complained about the treatment that her son (child A) received from his dentist. She complained that the dentist failed to identify that her son was missing two lower premolar teeth. Mrs C said that this caused her son stress, led to a delay in diagnosis and impacted on the cost and the potential success of his future dental treatment. Child A had attended for a routine examination. A bitewing x-ray (a type of dental x-ray) was taken which showed spacing between his lower premolar and the first molar, but the dentist did nothing about this. Mrs C only found this out when her child attended another dentist several months later. He was referred for orthodontic assessment and it was identified that both his lower second premolars were congenitally absent (not present since birth). We obtained independent advice from our dental adviser who explained that bitewing x-rays are normally taken to detect dental decay. Although this is the primary reason for using bitewing x-rays, they could be expected to show that the lower premolars were not developing. The adviser said that the dentist missed an opportunity for early diagnosis of the absence of the two lower second premolars and said that it would have been reasonable for the dentist to have investigated further at that time. The adviser also explained that there are guidelines on the use of x-rays in dental practice, which recommend that even in the event of a child being assessed as having a low risk of decay, bitewing x-rays should be taken at intervals of 12 to 18 months whilst they have baby or milk teeth. We found that the dentist did not follow these guidelines in child A's case, so we made a recommendation about this. Nevertheless, the adviser also said that an earlier referral to an orthodontist would not have achieved anything further, and that any delay in child A's treatment was marginal and would have made no difference to possible treatment. Given this, although on balance we upheld Mrs C's c

Mrs C complained about the treatment she received from her dentist when she attended with a broken tooth. She complained that the dentist removed a remaining part of her tooth without her consent, that he used a local anaesthetic, which she had asked not be used, and that he performed root canal treatment and inserted a crown poorly. She also complained that her complaint about this was inadequately handled. After taking independent advice from our dental adviser we found that the remaining part of Mrs C's tooth could not be saved and it was reasonable for the dentist to remove it. No formal written consent was required for this, but we noted that the dentist did not seek verbal consent, which would have been good practice. We were satisfied with the choice of local anaesthetics he used and found that an alternative was used because Mrs C said she had had an adverse reaction to the standard anaesthetic. However, we were critical that the dentist did not properly document his use of this, and of the work he carried out to prepare Mrs C's tooth for a crown. The root canal filling did not fill the entire root, leaving space for infection. Furthermore, the dentist perforated the filling material with the post that was inserted to hold the new crown. We upheld Mrs C's complaints about these aspects. We also found that Mrs C's complaint was not handled in line with the complaints procedure in place in the dentist's practice at the time. However, that procedure was not fit for purpose and Mrs C's complaint was actually handled in line with the level of service that we would expect patients to receive. As such, we found the complaints handling to be reasonable.

Mr C complained that his front tooth had been extracted unnecessarily and that his dentist had refused to provide him with the type of bridge work to replace it that he wanted. This was on the grounds that Mr C's oral hygiene was too poor to allow it to be carried out successfully, which Mr C disputed. We took independent advice from a dental adviser. He advised that the x-ray of Mr C's tooth did not show a clinical need for removal. He said that the x-ray did not differ substantially from an x-ray taken a year earlier, and this showed there had been little change in the prognosis for the tooth. The adviser said the tooth should have been allowed to remain in place and then monitored for any further deterioration. The adviser also noted that Mr C had, following a change of dental practice, been provided with the bridgework treatment he wanted. The adviser said that the clinical notes did not support the refusal to provide the type of bridgework Mr C requested, as the gum disease he had would have benefited from this type of treatment. He also said that the new dentist's decision to provide this treatment suggested that Mr C's gum disease should not have prevented the treatment being carried out. We accepted this advice and found that Mr C had had his tooth extracted unnecessarily and should not have been refused the type of bridgework he requested to replace it.

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about care and treatment provided by a dentist. Mrs A said that when she visited the dentist, he x-rayed her jaw and told her there was a gap in it, but it was nothing to worry about. However, Mrs A later found out she had a cancerous tumour which caused a break in her jaw bone, for which she needed treatment. We looked at Mrs A's clinical records, and took independent advice from our dental adviser. We found that, based on the records, the dentist had provided adequate care and treatment in the circumstances. The dentist had told Mrs A that she had some bone loss in her jaw, and about the possible causes of mouth ulcers. He advised Mrs A to return after two weeks to check if her symptoms had improved. He had said that if the symptoms had not improved at the review appointment in two weeks' time, he would refer her to hospital for further investigations, which could include investigation for an oral tumour. However, even though the dental practice contacted Mrs A to arrange a review appointment, she did not return. Related reading View Decision Report 201304079 as a PDF (11.14 KB) Updated: March 13, 2018

Mrs C complained that a dentist did not give her enough information about the treatment options available, and the costs, which she said resulted in her being treated as a private patient rather than by the NHS. After taking independent advice from our dental adviser, our investigation found that the medical records showed that Mrs C was informed of the options and received a written estimate for the cost of her treatment. Our adviser said that she had received the appropriate treatment and that from his examination of the records, he believed she had consented to the treatment being provided privately. The dentist had clearly and correctly explained the treatment options, and that the treatment she wanted could not be provided on the NHS without a six month delay. The adviser also said there was no guarantee that the dentist could have provided it in that way, as he would first have had to obtain NHS permission to do so. Related reading View Decision Report 201104023 as a PDF (11.06 KB) Updated: March 13, 2018

Mrs C had been a patient of a dentist at the practice for 20 years. She visited him complaining of toothache and a history of loosening teeth, and he referred her for a specialist assessment, mainly to discuss an implant and bridge. The specialist she attended told Mrs C that she had chronic adult periodontal disease (a condition involving infections of the gums and bone that surround and support the teeth). This had resulted in significant bone loss, and she also had a chronic infection. The specialist suggested a number of options for dealing with the problem but warned that the damage done would be difficult to address. Mrs C complained that her dentist did not identify or treat her for periodontal disease and that, as a consequence, her teeth and gums had deteriorated to the extent that it would be difficult to maintain her remaining teeth or deal with the problem with which she had been left. As part of our investigation, we obtained independent advice from one of our dental advisers. Our adviser confirmed that the dental records made by Mrs C's dentist were minimal and that there was no explicit diagnosis or treatment plan. There was no evidence that he had told her that she had serious periodontal disease or that she had been given any preventative advice. Given Mrs C's symptoms, we found that the dentist should have at least carried out a basic periodontal examination and taken x-rays, but he did not do so.

Mr C complained that he was unreasonably charged for a temporary lower denture that he was unable to wear because it did not fit. He was unhappy about the appearance of his new upper denture and that his dentist refused to make a new denture without charge. Mr C said that he had told his dentist that he liked the appearance of his old denture, and wanted his new upper denture to look the same. The dental clinic told us that Mr C needed to have five teeth extracted, and they had advised him that his best clinical option was to have new temporary dentures made. Mr C instead opted to have his existing dentures adapted. We found that, as the dentist had warned that this could result in the denture being a poor fit, Mr C had not been charged unreasonably. In relation to the appearance of Mr C's new denture we found that dentures are provided by the NHS on the basis of clinical rather than cosmetic need. Mr C told us that he had not taken his glasses to these appointments and had simply assumed that the denture would be similar in appearance to his old one. There was no evidence that Mr C had told his dentist clearly at the relevant appointments that he was totally dissatisfied with the appearance or shape of the upper denture. As there was also no evidence that he had clearly told his dentist that he wanted his new denture to look the same as the old one, we did not uphold this complaint. Nor did we find it unreasonable that Mr C's dentist refused to make a new upper denture without charge. We noted that Mr C has the option of seeing a new dentist for a second opinion. Related reading View Decision Report 201202069 as a PDF (11.35 KB) Updated: March 13, 2018

Mr A's dentist gave him a filling in autumn 2011. This was a very large restoration and Mr A was treated for minor pain over the next few weeks. In early 2012 he returned to the practice with further pain associated with the tooth. The practice told him that the dentist who treated him had left, and had in fact practiced there under his own NHS contract. They offered treatment but told Mr A that they would charge for this. Mr A recalled that his previous dentist had told him that any follow-up treatment required on the tooth would be free of charge, and declined the offer of paid treatment. He returned to the practice the next month and again said that he would only consent to treatment if it was provided free of charge. He refused to sign forms consenting to paid treatment or a medical history form. Mr A complained about this to the practice, who explained their position and advised that they had taken steps to remove him from their treatment list on the basis that Mr A had lost confidence in them. Ms C, who is an advice worker, wrote to the local health board on Mr A's behalf and this was passed to the practice for a response. The practice repeated the information they had given Mr A about his treatment and his removal from their practice list. They also offered him the cost of the treatment he had experienced problems with, but noted this was not the full amount he had paid at that time, as that had included treatment for another matter. Mr A remained dissatisfied and Ms C complained to us on his behalf. We did not, however, uphold the complaint as we decided that there was no evidence of service failure. This was because the practice were correct in saying that the responsibility for treatment lay with the dentist who provided it and not themselves, now that he had left the practice. Related reading View Decision Report 201202705 as a PDF (11.54 KB) Updated: March 13, 2018

Mrs C complained that her dentist had not ensured the fit of a crown before cementing it in place, and that he would not refund her the full cost of fitting the crown to allow her to receive further treatment at a different dental practice. We found that the dentist had taken all reasonable steps to ensure the fit of the crown was suitable prior to the cementing, including having the crown remade at an earlier appointment, giving Mrs C the opportunity to check the appearance and position of the crown with a mirror and obtaining her consent before undertaking the cementing. We noted that Mrs C had already received a refund of the cost of the crown from the dentist as a goodwill gesture, and that other fees she had paid had been for different treatment. We found that if Mrs C was to seek further treatment elsewhere, she would be required to pay the cost of the crown again. As this cost had already been refunded, we did not find that Mrs C was entitled to any further refund. Related reading View Decision Report 201103654 as a PDF (16.73 KB) Updated: March 13, 2018