A dental practice in the High Peak area

6. Mrs P complains about the care and treatment the Practice provided to her between 31 July 2023 and 9 October 2023.

7. Specifically, she says dentists:

• incorrectly diagnosed her with an infection in an upper front tooth (UR1), incorrectly gave her antibiotics for this and • did not provide her with timely appointments.

8. Mrs P says because of this she:

• was in pain for longer than necessary • had side effects from the unnecessary antibiotics • had increased anxiety, distress and worry due to the pain, distress and fear of losing her tooth • lost confidence in the Practice and • had to seek private treatment.

9. Mrs P would like the Practice to acknowledge failings, apologise, identify service improvements and reimburse the costs of her private dental care.

10. Mrs P was a patient with the Practice and the dentist who usually treated her was Dentist 1.

11. On 31 July 2023, Mrs P attended an appointment with another dentist (Dentist 2) at the Practice. Mrs P complained of pain and sensitivity in her upper right front tooth (UR1). Dentist 2 diagnosed a crack in UR1 and prescribed Mrs P with high fluoride toothpaste.

12. Mrs P had an appointment with Dentist 1 on 7 September 2023. She then had an appointment on 18 September when Dentist 1 told Mrs P she had an infection in UR1 would likely need root canal treatment (RCT). The Practice made an appointment for 26 October for the RCT.

13. Mrs P had an appointment with Dentist 2 on 21 September as her symptoms had not improved. The dentist prescribed amoxicillin antibiotics.

14. Whilst awaiting her appointment for RCT, Mrs P called the Practice to ask for an earlier appointment. The Practice provided an appointment for 28 September with Dentist 1, who prescribed metronidazole antibiotics.

15. Mrs P requested the RCT be brought forward and attended an appointment with Dentist 1 on 9 October. Following this appointment, Dentist 1 referred Mrs P to a specialist to complete the RCT on UR1.

16. Mrs P started treatment for RCT on her UR1 with a private dental practice on 13 October.

20. 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 anything went wrong in relation to the appointment on 21 September or the timing of appointments.

21. Due to the records available, we have been unable to reach a view on the other issues Mrs P has brough to us. We explain our reasons for this decision below.

Diagnosis and prescriptions

22. Mrs P says the dentists at the Practice incorrectly diagnosed her with an infection in UR1. She says a private dentist later confirmed she did not have an infection when she went to them for treatment. Mrs P says because of this misdiagnosis, the Practice dentists prescribed antibiotics for her on two occasions which she says were unnecessary. We are sorry to hear this caused Mrs P increased anxiety and side effects to the antibiotics.

23. Dentist 1 responded to Mrs P’s complaint on 5 January 2024. They said, on the 18 September 2023 there were signs of infection in Mrs P’s UR1 and she may need RCT or removal of her tooth. They said they removed the nerve of the tooth and placed a temporary filling.

24. They confirmed Mrs P’s appointment with Dentist 2 on 21 September but did not comment on the prescription of antibiotics (amoxicillin). They said, on 28 September Mrs P had an acute infection of UR1, was systemically unwell and they prescribed further antibiotics (metronidazole) as the most appropriate treatment. Systemically means affecting the whole body not just one area.

25. The stages leading up to an infection in the root canal are:

Reversible pulpitis SDCEP guidance says this is where the pulp of the tooth (the area which contains the nerve and blood vessels) is swollen and irritated. It says the symptoms are short-lived pain in response to hot and/or cold.

Irreversible pulpitis Our adviser explained this is where the irritation worsens, the patient gets swelling in the root which restricts blood supply and starts to kill off the tissue. SDCEP guidance says the symptoms are pain which may be difficult to localise to a single tooth, may last for several hours, may be dull and throbbing, may be worsened by heat, but applying cold may help. It says, ‘in some cases’ with irreversible pulpitis ‘achieving anaesthesia [numbing] is difficult’.

Infection Our adviser explained infection occurs when the root including the nerve kills itself because of a lack of blood supply. SDCEP guidance says key signs and symptoms of infection are localised pain which becomes more sensitive to chewing and touch and swelling of the gum, face or neck as the tooth is pushed against surrounding teeth. It says the patient may also have fever and tiredness.

26. SDCEP guidance says dentists should not “prescribe antibiotics unless there are signs of … systemic infection”.

27. FGDP guidance says penicillin antibiotics, which include amoxicillin, should be prescribed as a first-choice antibiotic for dental infections. The guidance goes on to say metronidazole can be used to treat infections in patients who have had a recent course of penicillin.

28. GDC standards says dentist must ‘make and keep complete and accurate records…each time that your treat a patient’. The standards also say dentists must ‘ensure that all documentation that records [their] work, including patient records, is clear, legible, accurate and can be readily understood by others.’

29. The clinical notes for Mrs P’s appointment on 7 September 2023 with Dentist 1 say she attended for a filling on a lower tooth (LR7). The notes show Mrs P said she had had pain in a front tooth. The dentist wrote ‘we may be able to fill crack with some bond and comp.’ The dentist did not record whether they did this, and if so, what materials they used, whether they gave Mrs P an injection or not, or if they drilled away any decay from the tooth. We do not consider the notes from this appointment meet GDC standards. We go on to address this further in our report.

30. The notes for the appointment on 18 September show the notes indicate the dentist may have filled a tooth on the previous appointment as they say ‘fill came off the day after’ but its placement was not recorded on 7 September.

31. Dentist 1 took an X-ray of the front of Mrs P’s mouth. The notes say ‘UR1 Pa radiolucency’. This means darkening around the root of the tooth and our adviser said this diagnosis would indicate a dead and chronically infected tooth. The notes show the dentists discussed removing the root of the tooth with Mrs P. The dentist did not prescribe antibiotics at this appointment.

32. Our adviser reviewed the X-ray and said, in their opinion, there is no indication of darkening around the root of UR1 and therefore no indication of an infection. They said infection can be present even if an X-ray does not show it, as X-rays show changes in bone and this can take time to show after an infection.

33. The notes describe Mrs P had a ‘dull throbbing pain’ which ‘radiates’ and the complaint response says she ‘experienced significant pain’ despite having had local anaesthetic. Our adviser said this is consistent with the description of irreversible pulpitis, and not with an infection as outlined in the SDCEP guidance.

34. Our adviser said it is difficult to know exactly what happened at this appointment as the notes are very limited and do not provide full details. The notes do not confirm the dentist removed the root although there are indications they planned to do so. We do not consider the notes from this appointment meet GDC standards.

35. In relation to the appointment on 21 September, our adviser said some of Mrs P’s symptoms suggested irreversible pulpitis, and some suggested an infection. Dentist 2 diagnosed an acute abscess (when an infection causes a pocket of pus) or irreversible pulpitis which our adviser said is reasonable because Mrs P’s presentation was unclear.

36. The notes indicate Mrs P felt unwell, had pain when Dentist 2 pressed over the bone around the tooth, had pain on ‘biting/touching tooth’ and there was swelling around the tooth next to it. Considering SDCEP guidance in paragraph 26, these are indications of a possible infection.

37. Our adviser said Dentist 2 was correct to prescribe Mrs P with amoxicillin because of this and we consider this was in line with FGDP guidance. For these reasons, we think there is no indication the Practice did anything wrong at this appointment. We will therefore not consider this part of the complaint further.

38. The notes for Mrs P’s appointment on 28 September with Dentist 1 say she had pain in the tooth, was still sore in the gum area and had a constant dull ache. The notes also say Mrs P had done a COVID-19 test as she was feeling unwell. There are no details of any examination or anything to indicate the dentist examined Mrs P. There are no details of a diagnosis.

39. The complaint response says Mrs P had an acute infection in the tooth when she attended this appointment. Our adviser said the notes do not support this other than Mrs P was generally unwell.

40. They said if there had been a clinical indication of an infection, prescribing metronidazole would have been in line with FGDP guidance. However, there is not enough information to say if Mrs P had an infection at that time. For these reasons, we are unable to make a decision on this part of her complaint.

41. We are sorry we have not been able to make decisions on parts of Mrs P’s complaint because of the Practice’s poor record keeping. We consider this, in itself is an impact on her.

42. As in the GDC standards in paragraph 28, clinical notes are made so there is an accurate record of the treatment a dentist provides. For the reasons outlined above, there is an indication the Practice did not meet these standards when recording the treatment it provided to Mrs P on 7, 18 and 28 September. We do not consider the records are ‘complete and accurate’ and we do not think they can be ‘readily understood by others’.

43. Before we decide if we should investigate a complaint, we should consider attempting a resolution where it appears that, with minimal intervention, we could achieve a satisfactory outcome for the complainant.

44. Our Principles say we expect organisations to acknowledge mistakes and apologise for the impact these mistakes had. They also say organisations should seek continuous improvement by ‘using the lessons learned from complaints to ensure that…poor service is not repeated.’

45. Mrs P would like the Practice to acknowledge failings, apologise, identify service improvements, and reimburse her costs of private dental care.

46. We contacted the Practice and explained what we have seen so far. The Practice acknowledged its record keeping lacked detail and apologised for the inconvenience and distress the matter caused Mrs P. The Practice confirmed it considers the treatment it provided to Mrs P to be clinically correct. The Practice provided us with details of an action plan it had set to address its poor record keeping. The Practice told us that Dentist 1 has now completed this action plan. The Practice has also agreed to write to Mrs P to apologise for its record keeping and the impact this has had on her.

47. Mrs P says she sought urgent private treatment because the dentists diagnosed an infection in UR1 and she feared losing her tooth. She says she did not have an infection and as such the costs of the private treatment were unnecessary.

48. We are unable to say if Dentist 1’s diagnoses on 18 and 28 September were correct, and consequently are unable to consider any remedy relating to these appointments. For the reasons outlined in paragraph 37, we think it is understandable Dentist 2 diagnosed a possible infection on 21 September. For this reason, we cannot consider Mrs P’s request for reimbursement of private dental costs.

49. Based on our communication with the Practice, we are satisfied it has agreed actions to put things right and resolve the record keeping issues in line with our Principles. For these reasons we have decided not to take any further action with this part of her complaint.

Timeliness of appointments

50. Mrs P says the Practice did not provide treatment for the problems she was having with UR1 in a reasonable timeframe or with the urgency it should have done.

51. We are sorry to hear Mrs P was in pain over the period complained about, we appreciate this was a difficult time for her.

52. Dentist 1’s response to Mrs P’s complaint gave the appointment dates from the Practice records. They said following the attempts at RCT on 9 October, they felt it appropriate to refer Mrs P for specialist care, which they did the following day.

53. SDCEP guidance says the timescales for access to emergency dental care are:

• Emergency – such as swelling threatening the airway. Patients should be contacted within 60 minutes • Urgent – such as pain which is not controllable with painkillers. These patients should be seen within 24 hours.

• Non-Urgent problems – such as pain which is manageable with painkillers. These should be seen within seven days.

• RCT - Our adviser said there is no guidance or targets for how long it is appropriate to wait for routine root canal treatment. They said the reality of NHS practice is there can often be long waits for this.

54. Mrs P said she started experiencing pain sometime in June 2023 and made an appointment for 14 July. She had to cancel this on the day, as she had a sore throat and the Practice advised her they could not see her because of her illness. The Practice made a further appointment for 7 September as Dentist 1 was on annual leave for all of August and this was their next available appointment.

55. Mrs P says her UR1 was still sensitive to hot and cold and when touching it. She called the Practice on 24 July to ask for an earlier appointment as she was due to go on holiday and did not want to go away in pain.

56. On 25 July, Mrs P accepted an appointment with Dentist 2 for 31 July. The booking notes show Dentist 2 had made an appointment available for Mrs P on 26 July but do not indicate why this appointment was not taken. There is also no indication in Mrs P’s complaint to the Practice or to us which provides any further information about this.

57. After considering the information available in relation to this appointment, we are not able to make a decision to say if the Practice did anything wrong.

58. When considering Mrs P’s complaint about appointments as a whole, the evidence does not indicate there was a significant impact from this. The Practice saw Mrs P before she went on holiday and this was before the Practice diagnosed an infection or prescribed antibiotics.

59. Mrs P attended the appointment on 31 July and she told us she was on holiday from 4 August until 18 August. She then attended the prearranged appointment on 7 September. Mrs P says she does not recall if she contacted the Practice for an appointment between 18 August and 7 September. We have not seen evidence to suggest she did.

60. Mrs P called the Practice on 14 September, when she said she was in pain and asked for an urgent appointment. The Practice offered an appointment the next day, 15 September. Mrs P could not attend that appointment, which was a Friday, so the Practice gave her an appointment for Monday 18 September, which she attended. At this appointment, Dentist 1 booked Mrs P an appointment for 26 October root canal treatment on UR1.

61. Mrs P called the Practice on 21 September complaining of pain in her tooth and the Practice gave her an appointment on the same day.

62. Mrs P called the Practice on 26 September as she was concerned she had to wait until 26 October for her next appointment. She says she asked to go on a cancellation list. The Practice provided an appointment for Mrs P on 28 September which she attended.

63. Mrs P spoke to the practice manager and asked for her RCT to be brought forward. The Practice provided an appointment for 9 October.

64. With the exception of the appointment on 31 July (paragraphs 54 to 56, on which we are unable to make a decision), we consider the Practice offered and provided appointments to Mrs P in line with SDCEP guidance. We have seen no indication of a failing here, so we will not consider this part of the complaint further.

65. GDC standards say dentists ‘should refer patients on if the treatment required is outside [the dentist’s] scope of practice or competence.’

66. BES guidance categorises patients needing root treatment by complexity. It says ‘local analgesia difficulties that cannot be resolved by routine measures’ fall into Level 2 and should be seen by someone with additional expertise.

67. On 9 October, Mrs P attended the appointment with Dentist 1, who began the RCT but stopped because Mrs P was in pain. The dentist informed Mrs P they would need to refer her to a specialist and did so the following day. Mrs P chose to have the RCT at a private dentist. We consider the dentist acted in line with GDC and BES guidance when they stopped treatment and referred Mrs P to a specialist.

68. It appears the dentist has acted in line with the GDC and BES guidance here. Because we have seen no indication something has gone wrong, we have decided not to investigate this further.

69. We are sorry the issues Mrs P brought to us caused her to lose faith in the care the Practice could provide. We are grateful for her telling us about her experience which we appreciate was a difficult time for her. We hope she is reassured by what we have seen and the measures the Practice has put in place to ensure its record keeping is improved.

1. We have carefully considered Mrs P’s complaint about the Practice.

2. We are sorry to hear Mrs P was distressed over the period complained about, and that she had side effects from the antibiotics the dentists prescribed.

3. In relation to Mrs P’s complaint about the dentist’s diagnosis and prescription of antibiotics on 21 September, we have not seen any indication the Practice did anything wrong. We also think the Practice provided Mrs P with timely appointments in line with guidance.

4. We are not able to make a decision in relation to the dentist’s diagnosis on 18 September and 28 September, or their prescription of antibiotics. This is because the Practice’s record keeping does not meet relevant standards. We appreciate this will cause Mrs P further concern and we are sorry we are unable to fully consider these issues. We have addressed this with the Practice and we are satisfied it has done enough to put this right.

5. For these reasons, we have decided not to consider Mrs P’s complaint further. We fully explain our decision in this statement.