A dental practice in the West Northamptonshire area

5. Mrs U complains about aspects of the care and treatment she received from the Practice between 2006 and 2022.

6. Mrs U says the Practice made her aware of an impacted tooth (UR3) in 2006. An impacted tooth is a canine tooth which does not grow into its usual place. Instead, the tooth grows into the gum or the jawbone. In this case, this was caused by Mrs U having an ectopic canine tooth on the right side of her mouth (URC).

7. An ectopic tooth is one which is not growing in the right place in the mouth. Its actual position and direction of growth can impact on the surrounding teeth. For Mrs U, the URC was impacting on the growth of the upper right 3 tooth (UR3). The UR3 tooth is the first molar tooth. There are usually two teeth between the URC and the UR3 tooth.

8. Mrs U says the dentist did not make her aware of the risks of her impacted tooth and did not detect deterioration in her condition during the period 2006 to 2022.

9. Mrs U discovered significant issues with the impacted canine, including infection and root reabsorption, when she moved dental practice. Root reabsorption is when the body breaks down the root of the tooth. This can cause issues with the functionality of the tooth.

10. To fix these issues Mrs U had to have a root canal treatment and bone grafts on her jaw. Root canal treatment is the removal of infected tissue from a tooth. A bone graft is the transplant of bone material to help heal damaged bone or replace missing bone. Mrs U says her bone grafts had be done privately due to another condition which meant bone could not be taken from her hip.

11. Mrs U says she also needed to have several teeth removed in a very visible area of her mouth. She had temporary teeth fitted but this caused problems for her when eating. She has been fitted with temporary teeth. She says she cannot leave the house because she is self-conscious, and this has had a severe effect on her mental health.

12. Mrs U said she wants her private treatment costs covered. She says this cost in excess of £10,000.

13. Mrs U was registered with the Practice from 1999 until 2022.

14. In 2006 her dentist informed her she had an impacted UR3 tooth. This was discussed with Mrs U and no further action was taken to address it.

15. In 2022, Mrs U moved dental Practices. The new Practice took radiographs which showed the impacted canine. The dentist expressed concern at the angle of the tooth and referred Mrs U to Kettering General Hospital (the Hospital).

16. The Hospital undertook further investigations of the UR3. In September 2023, it informed Mrs U her impacted tooth had caused extensive root reabsorption of surrounding teeth and an infection. Mrs U says to repair the damage she had to have several teeth removed and a bone graft.

Failure to communicate risks and appropriately treat impacted tooth

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 seen any indications that something has gone wrong.

21. Mrs U says when her impacted UR3 tooth was identified in 2006, her dentist did not explain the risks and what could happen. She says that she was left with the tooth for a significant time, and it was causing damage to her other teeth. No further issues were identified, or treatment recommended.

22. Mrs U says she did not realise there was a problem with her teeth until 2022 when she changed dental practices. The new dental practice took X-rays and identified damage to surrounding teeth and an infection. The new dental practice made referrals for further treatment which has led to significant dental work and distress for Mrs U.

23. We asked our dental adviser what the relevant guidance is for the treatment and care of an impacted tooth in adults and what care should be provided in those cases. They explained that Mrs U’s dental care at the Practice extends back to 1999. They explained because of the long history of care, the standards which were in place between 1999 and 2012 are not known.

24. For care provided between 1999 and 2012, we are relying on our adviser’s professional experience and knowledge in line with our ‘Ombudsman’s Clinic Standard’. This sets out that we will seek to establish what good clinical practice is, including a range of sources and relevant information. In this case, the knowledge shared by our adviser about treatment of impacted teeth, is part of our evidence to establish what is and was at the time, good clinical care.

25. From 2013, the standards for care come from the GDC’s ‘Standards for the Dental Team.’ The relevant standards state dentists must ‘must provide patients with treatment that is in their best interests, providing appropriate oral health advice and following clinical guidelines relevant to their situation.’

26. It says ‘You [dentists] may need to balance their oral health needs with their desired outcomes. If their desired outcome is not achievable or is not in the best interests of their oral health, you [dentists] must explain the risks, benefits and likely outcomes to help them to make a decision.’

27. We asked our dental adviser what should have happened, when Mrs U’s impacted canine tooth was identified. They explained there are no specific protocols in place for adults with impacted teeth. Children who have impacted teeth or ectopic canine teeth need much more careful monitoring, but adults do not.

28. They said the recommended approach for an adult with an impacted tooth would be to monitor the tooth. During check ups the dentist should examine the surrounding teeth for pain, swelling or discomfort when biting. They should also check for any mobile teeth surrounding the impacted tooth.

29. If any of the above symptoms are present, then the dentist should take X-rays and make an urgent referral to the Oral and Maxillofacial Surgery department. X-rays should only be done if the patient presents with symptoms. A dentist cannot do X-rays routinely. This is to limit the patient’s exposure to radiation in line with the ALARA principle. The ALARA principle means to make exposure of patients to radiation as low as reasonably achievable.

30. We asked our dental adviser, whether the dentist in Mrs U’s case, undertook the correct action when the impacted tooth was identified. They explained Mrs U’s impacted tooth was identified in 1999. Records show an X Ray was done in 1999 and the impacted tooth was notable.

31. There are no notes reporting on the X Ray because this was not done in clinical Practice at the time. However, on the 27 July 1999 the URC tooth was treated by the dentist and a small filling was provided. The dentist would have known the tooth was impacted at this time.

32. The next notable point is in May 2005. An X Ray was taken and showed the impacted UR3 and a retained URC. Again, no notes were made about the X Ray for reasons explained above.

33. On 22 September 2006, the dentist discussed options with Mrs U about her URC tooth. The options offered were extraction and a referral maxillofacial department referral for the impacted UR3. The dentist said this would be followed by extraction of URC and creation of an upper partial denture on NHS.

34. Our dental adviser explained no treatment was done. This suggests the patient did not want to have further treatment. They said after this discussion the patient developed cavities in their upper front teeth which were restored a few times by the dentist.

35. Our dental adviser said the care provided in 2006 was appropriate. There is discussion evident, showing the dentist discussed potential issues with the tooth and what preventative action could be taken. However, note-taking at the time was not required to be as fulsome as we expect today so not every detail is recorded.

36. Based on their own clinical experience, our dental adviser’s view is that the risks of impacted teeth were explained, as treatment was offered to mitigate those risks. The treatment suggested was also appropriate. It seems Mrs U did not accept the treatment plan and it was reasonable for the dentist not to plan further treatment at that point. There was no indication that treatment was essential at this point, and would have been preventative if it had been done.

37. We also asked our adviser, if the dentist should have taken further action after 2006 leading up to the issues Mrs U experienced in 2022. They explained that for the dentist to do further investigation, they would need to have seen some of the symptoms outlined above.

38. In addition, when looking out for swelling, discomfort or pain, our adviser explained the dentist should look out for bone loss. If bone loss was evident, this could mean that the impacted tooth was causing issues in other areas of the mouth. This could include putting pressure on other teeth, causing root reabsorption, cysts around the tooth and disruption of the alignment of teeth causing gum problems.

39. Our adviser said the X-rays provided show no problems with bone loss. There are also no signs of root problems with the teeth surrounding the URC or the impacted tooth (the upper right 3). This is important as it shows the impacted UR3 tooth was not putting harmful pressure on other surrounding teeth. This reduced the need for surgical intervention and only required ongoing monitoring.

40. Our dental adviser explained if Mrs U began to experience problems with any of her teeth surrounding the URC or UR3, then more X-rays should have been done. However, further issues are not documented and therefore more investigation was not required.

Summary of our view

41. Our adviser has explained what has happened in Mrs U’s care and what actions should have been taken. We can see Mrs U was offered treatment options in 2006, likely due to the risks of her URC tooth being discussed with her. Our adviser has said this was appropriate.

42. For ongoing care of the of the URC and UR3, we can see Mrs U did not have any further signs that treatment was needed. She did not report swelling, pain or discomfort and X-rays did not show bone loss or root problems.

43. The GDC standard which is relevant from 2013 says the dentist should have provided treatment in line with their best interests, providing appropriate advice. We can see the dentist did not reconsider treatment options after 2013. We think this was appropriate because Mrs U did not report any symptoms which might warrant the need for more X-rays.

44. In addition, when X-rays were done for other purposes, this did not indicate any relevant problems with bone loss or tooth roots. For this reason, it would not have been appropriate for the dentist to have provided further treatment options or X-rays to investigate the tooth. It is our view that the dentist acted in line with professional standards and relevant guidelines.

45. We recognise that Mrs U has suffered terribly with the infection and removal of teeth following issues which were discovered in 2022. We also acknowledge Mrs U feels this could have been avoided had preventative action been taken by her previous dentist. However, as we have explained there was no indication that action needed to be taken by the dentist and therefore we do not see evidence of a potential failing in care.

46. We understand this may be a disappointing decision for Mrs U and apologise if that is the case. We understand Mrs U was having some restorative dental treatment and we hope that this has been successful and improved her quality life. We thank Mrs U for giving us the opportunity to assess her case and to ensure that correct practices were followed in her care.

1. We have carefully considered Mrs U’s complaint about the Practice. We were sorry to hear Mrs U has had such severe issues with her impacted tooth resulting in a serious infection, tooth removal and bone grafts.

2. We recognise this must have been upsetting for Mrs U and that this led her to developing social anxiety and being unable to go out in public. We hope Mrs U has since had further repairs and treatment and is having an improved outlook for her dental health.

3. We have carefully considered the complaint Mrs U brought to us. We have looked at the dental records and sought clinical advice. From this assessment we have not seen any indication that the dentist’s care between 2006 and 2022 was out of line with appropriate dental practice.

4. We recognise this might be an upsetting decision for Mrs U who has experienced a significant ordeal. However, we are unable to link this experience to the dentist’s care.