A dental practice in the Redbridge area

4. Miss B complains on 7 February 2024, the Practice performed the first stage of a root canal treatment on her lower left molar (LL6) without obtaining her informed consent. She also complains that the Practice failed to adequately manage her pain during the procedure.

5. As a result, Miss B said she experienced severe pain and emotional distress. She also explained she incurred £550 in private dental treatment costs to complete the root canal.

6. As outcomes to her complaint, Miss B would like £550, an apology, and service improvements.

7. In 2023, a dentist told Miss B that her lower left molar (LL6) might eventually require root canal treatment due to a deep cavity near the nerve. However, they agreed to leave the tooth untreated as it was not causing Miss B significant issues, aside from occasional minor sensitivity.

8. Root canal treatment involves a dentist drilling into the top of a tooth to remove infected or damaged soft tissue from its centre (the pulp). Once the pulp is removed, the space is cleaned, disinfected, and then filled and sealed with a filling or a crown.

9. Miss B’s NHS treatment plan in December 2023 included three fillings, one of which was for her LL6. A filling is when a dentist removes a smaller decayed part of a tooth and fills the hole with a mixture of metals to protect the tooth and prevent further damage. A filling is a less invasive procedure than a root canal.

10. During an appointment on 7 February 2024, a dentist at the Practice began filling Miss B’s teeth. Miss B recalls the dentist pointing out a small crack in the filling of her LL6, which she had not noticed. Miss B told us, at the time, she believed the dentist was simply filling her LL6. After the treatment, she realised that the dentist had started the first part of a root canal.

11. Miss B says the dental assistant was present throughout the entire appointment and held her hand. We contacted the Practice about this but unfortunately, the dental assistant has no recollection of the event.

12. On 12 February 2024, Miss B complained to the practice manager. She explained that during her appointment the dentist had told her she did not need a root canal and that she should return in three months for the treatment.

13. On 10 April 2024, Miss B met with the practice manager, who offered to arrange for another NHS dentist to complete the root canal treatment. Miss B was concerned that the available NHS dentists were less experienced. Given her concerns, she chose to pay for a private dentist, whom she believed to be more experienced, to complete the root canal treatment on her LL6.

Root canal consent 17. Miss B complains on 7 February 2024, the Practice performed the first stage of a root canal treatment on her lower left molar (LL6) without obtaining her informed consent.

18. When the dentist began treatment on the LL6, Miss B says she raised concerns, citing her previous dentist’s warning that the cavity was very deep, and the tooth might require a root canal in the future. She says the dentist dismissed her concerns, saying a root canal was unnecessary at that time. Miss B says the dentist did not tell her that they were about to begin the first stage of the root canal treatment.

19. The Practice has told us that the treatment provided was not the first stage of a root canal treatment but rather emergency removal of all the infected tooth pulp. The Practice says the dentist did not ask Miss B to sign a consent form for root canal treatment because the original treatment plan for the LL6 was for a filling. The Practice says the dentist explained the potential need for a root canal to Miss B before performing the filling. They say had Miss B returned for root canal treatment, they would have had her sign an updated consent form. However, as Miss B opted for private treatment, this did not happen.

20. While the Practice maintains that it informed Miss B about the potential need for more extensive treatment beyond a filling, Miss B’s account indicates that she was unclear about what treatment was being carried out at the time.

21. Informed consent, as outlined in principle three of the GDC standards, requires the dentist to ensure the patient fully understands the treatment being carried out.

22. Standard 3.1.4 specifically requires that dentists check and document that the patient has understood the information given. Standard 3.2 expands on this by stating that the dentist must ensure that the patient understands the decisions they are being asked to make. It is the dentist’s responsibility to ensure understanding, not the patient’s responsibility to say if they have misunderstood. There is no record in Miss B’s dental records that the dentist checked her understanding during the appointment.

23. Additionally, principle two emphasises the importance of effective communication with patients. Standard 2.3.4 advises that the dentist should confirm the patient’s understanding by asking questions and summarising key points of the discussion. Valid consent is not solely about obtaining a signed form, but about ensuring the patient is fully informed and their consent is based on that information.

24. Based on these principles, there are indications of failings in the Practice did not get fully informed consent from Miss B for her treatment on 7 February.

Pain

25. Miss B complains the Practice failed to adequately manage her pain during the treatment on 7 February. She says she was in excruciating pain, crying and shouting for the dentist to stop. She says instead of acknowledging her distress, the dentist insisted on continuing the treatment saying she could not stop because everything was already exposed.

26. Miss B says the dentist repeatedly told her she should not be in pain, which made her feel as though the dentist did not believe her.

27. The Practice says the dentist empathises that Miss B was in a lot of pain and her aim was to get her out of pain while preserving her tooth.

28. For this treatment the records show the dentist used local anaesthetic (0.7 x 2.2ml articaine 4% with adrenaline) to numb the area before beginning the treatment. Manufacturer guidelines outline the maximum amount of anaesthetic a person should receive but do not specify a minimum dose. These guidelines recommend using the lowest dose of articaine that is effective for anaesthesia.

29. Because pain is experienced differently by each patient, effective pain management relies on communication between the patient and dentist. There is no mention in Miss B’s dental records of her expressing pain during the treatment. However, our adviser told us the amount of anaesthetic the dentist administered may not have been sufficient for the extensive dental treatment carried out.

30. Given the information available, we currently have no reason to doubt Miss B’s claim that she was in pain during the treatment. Without additional notes in the records, it is unclear whether the dentist communicated with Miss B about her pain level.

31. Our adviser told us if effective anaesthesia was not achieved, the dentist could have used an antibiotic or steroid paste with a tooth dressing to reduce inflammation, allowing the pulp to be removed under anaesthetic in a follow-up appointment. The Practice has told us that it did use a steroid paste to provide Miss B with pain relief and that the dentist gave additional anaesthetic when the treatment was still painful.

32. While we have taken this into account, if the Practice did not adequately address Miss B’s pain, it could be implied that Miss B’s consent was effectively withdrawn, and the Practice should have paused her treatment.

33. According to principle one of the GDC standards, the patient’s well-being and comfort must always a dentist’s the top priority. Standard 1.2.4 of the GDC standards says dentists ‘must manage a patient’s dental pain and anxiety appropriately’.

34. The NHS website also explains that patients should not experience severe pain when local anaesthetic is properly used. There are indications that the Practice failed to properly manage Miss B’s pain, which is not in line with the GDC’s principles.

Impact

35. Miss B described crying out loudly in pain during the procedure and said it was the worst pain she had ever experienced. Miss B told us a month after the appointment she was still grappling with the emotional impact of the experience.

36. Since the treatment, Miss B says she has developed a severe fear of attending the dentist, which has significantly affected her confidence and ability to seek necessary dental care.

37. She explained that she now struggles to attend even routine dental appointments. For example, she has had to cancel appointments with her current dentist due to fear and anxiety. She also told us that following the appointment she required sedation for a wisdom tooth removal due to her heightened anxiety and this was a procedure she previously would have managed without sedation. Miss B further described experiencing nightmares.

38. The Practice offered Miss B the option of continuing her dental treatment with alternative NHS dentists. She declined this offer and chose to seek private care instead. As NHS treatment was available to her, we do not consider it appropriate to reimburse the cost of her private root canal treatment.

39. That said, we fully acknowledge how distressing this experience was for Miss B, and we believe a financial remedy is appropriate to recognise the impact it had on her.

40. Following our investigation into Miss B’s complaint, the dentist has written to Miss B to apologise and offer £1,200. This payment reflects the emotional impact of her experience and corresponds with level three on our severity of injustice scale, which applies to single, traumatic, or highly distressing events without significant long-term consequences.

41. The Practice has also outlined several actions it is taking to improve patient care and prevent similar issues in the future. These include:

• strengthening the informed consent process through additional staff training • providing further clinical training on the management of emergency patients • improving patient communication practices • reinforcing standards for record-keeping and documenting consent • making treatment information available on the Practice website so patients can review their options before giving consent • exploring ways to better identify and understand patient anxiety or apprehension prior to appointments, to enable more effective support.

42. We consider this to be a fair response that recognises the distress Miss B experienced and supports the Practice in reflecting on and improving its approach to patient care.

43. We would like to thank Miss B for raising her concerns, as it is not always easy to do so. Her actions have helped prompt changes that may benefit other patients in the future.

1. We have carefully considered Miss B’s complaint about the Practice. There are indications that the Practice did not adequately manage Miss B’s pain or gain fully informed consent, which understandably contributed to her distress.

2. Following our investigation, the dentist involved in her care has written to Miss B to apologise for her experience. In recognition of the distress caused, the Practice has offered her a payment of £1,200 and is taking action to improve the quality of care for future patients.

3. We have concluded that the Practice has now taken appropriate steps to address the impact of these events on Miss B.