A dental practice in the Wirral area

3. Mr E complains about the care and treatment provided by the Practice. He specifically complains it:

• placed a filling on his front right tooth without colour matching this to the rest of his tooth, and that this chipped soon after the appointment • refused to rectify the filling unless he paid privately • refused to rectify a failed root canal.

4. Mr E says having a different coloured and chipped filling is stressful and has impacted his confidence. He explains that because the Practice refused to rectify his filling and root canal, an NHS hospital (the hospital - not part of this complaint) is carrying out this treatment instead. He says this has resulted in unnecessary costs in travelling to the hospital.

5. Mr E would like an acknowledgement of the failings and apology for the impact caused. He wants a financial payment to cover the cost of parking at the hospital and toll charges.

6. What follows is our summary of events. We have not included all the details as those involved are already aware of this information. However, we have included this brief background to put this complaint in context.

7. In late July 2024, Mr E attended the Practice with a broken tooth – upper right central incisor (UR1). It arranged an appointment for Mr E to see a dentist six days later towards the end of July for treatment.

8. Mr E attended the Practice at the end of July for treatment.

9. Between September and November, Mr E spoke to the Practice about his filling not been coloured matched, was chipped and about repeat root canal treatment (re-RCT).

10. In early November, the Practice referred Mr E to the hospital for his filling (UR1) and re-RCT.

Filling

14. Mr E complains the Practice:

• placed a filling on his front right tooth without colour matching this to the rest of his tooth, and that this chipped soon after the appointment • refused to rectify the filling unless he paid privately.

15. The Practice directed us to its emails to Mr E, meeting notes and dental records for its response to Mr E’s complaints.

16. In early September 2024, a dentist records in the dental notes that Mr E asked it to replace the filling as he was unhappy with the colour and was also chipped. They told Mr E that cosmetic work is not covered by NHS, as treatment must be clinically necessary. They offered to smooth the tooth (UR1) as a temporary measure.

17. Mr E saw a dentist at the Practice in early October. They said the filling was sound except for a chip, and so whilst repairing the chip, they would try trimming the top layer of the new filling and place a lighter shade on (rather than removing the whole filling). They said this would be beyond the usual scope of NHS and would be done as a good will gesture.

18. In early November, a dentist said his UL1 (upper left) tooth needs RCT ideally before a new crown.

19. The Practice said it is recorded in the notes the dentist was happy to send an NHS referral or private referral (filling and RCT). It said Mr E asked how long an NHS referral would take. The dentist explained they could not give a timeframe, but it would not be quick. It explained it may not be accepted on the NHS referral system at the hospital.

20. We have addressed Mr E’s complaints separately below:

Colour match

21. CGD: Second Edition: Standards in dentistry: Section 2.8 - Direct restorations, are guidelines on placing fillings. This says that the dentist must select appropriate material and seek occlusal harmony (where teeth contact in a way that supports optimal jaw function). Our adviser said this was done in this case. In relation to shade selection there is no specific guidelines. This would be down to good dental practice and experience.

22. Our adviser explained that the NHS’s responsibility is to place fillings that are functional and ensure the patient is not in any pain. Although cosmetic work is not covered under the NHS, it is good dental practice to try and match the shade of the filling with the tooth as close as possible, with the resources available. The NHS often has fewer shades to choose from, unlike private dental care where the shades and colour tone are more varied to create more realistic tooth anatomy, by layering different colours of composite.

23. We recognise there will be variations in how different people see shade.

24. The NHS has a good selection of shades to choose from for composite. For example, a VITA shade guide can be used to assess the colour of the tooth first, and show the patient before restoring so they have been involved in the colour selection process.

25. Although we cannot say either way – from the records - whether the dentist placed the VITA guide up to Mr E’s UR1 tooth before selection was made, there are no guidelines to say this should be done first. Based on dental experience, our adviser explained the more experienced dentists will be able to select which composite shade just by looking at the relevant tooth.

26. The dental notes for the consultation at the end of July 2024 record the dentist, ‘showed pt [patient] fill [filling] prior to leaving surgery, pt happy with appearance’. There is no record of Mr E raising any issues about the shade of the filling at the time.

27. Our adviser said, the above evidence indicates the dentist attempted to match Mr E’s UR1 composite shade in line with good clinical practice and experience.

28. When Mr E was seen by a restorative consultant at the hospital, the clinical letter (January 2025) states ‘UR1 is significantly darker than the natural tooth structure’. As explained earlier, there are variations in how people see shade. Furthermore, our adviser explains the shade of the tooth could have changed from the date of the consultation in July 2024 to when Mr E was seen by the consultant, making the composite stand out more.

29. We recognise Mr E’s concerns on whether a dentist at the Practice placed a filling on his front right tooth without colour matching this to his tooth and the upset this caused. Informed by clinical advice and dental records, the Practice placed the filling, including an attempt to match the composite shade, in line with CGD guidance and good clinical practice and experience. There is no indication of a failing.

Damaged filling

30. The relevant guidelines are:

• A Guide to Good Occlusal Practice (BDJ Clinician’s Guides) • GDC: Standards for the dental team – Principle 2 – Communicate effectively with patient.

31. Our adviser said there is no evidence the new filling was chipped as a result of how the filling was placed in by the dentist, during the appointment at then end of July 2024. It chipped due to occlusal factors which change with time as teeth and the jaw change.

32. In occlusion dentistry, guidelines focus on achieving balanced and harmonious tooth contacts for optimal oral health and longevity of restorations, avoiding any interferences, which includes fillings that cause an obstruction.

33. The records show Mr E attended an initial appointment at the Practice in July, with a lost filling. Or adviser said, in most cases this will be down to occlusal changes with teeth. Teeth, with age want to move towards the midline, that means the position of the tooth in the arch in relation to other teeth around it changes. When a filling is done this affects the bite on any tooth opposing it.

34. The Practice booked a further appointment to put in a filling at the end of July.

35. At the filling appointment, our adviser said the dentist correctly made the filling shorter than Mr E originally liked. In line with the above guidelines, the dentist reasonably explained that due to occlusion (his bite) it was out of line, and building it up would result in another fracture.

36. The records show Mr E was fully informed of this, but he still wanted it made longer. Our adviser said this meant there was a higher chance of it being knocked off with his lower opposing tooth, when he bites.

37. The dentist also discussed that if there are repeat fractures, Mr E may want to consider or explore other options. Although not specifically recorded in the notes, the dentist was referring to crowns.

38. In line with the above guidance our adviser said the dentist responded correctly when Mr E informed them his filling had chipped. They correctly gave him the option of smoothing (trimming) the filling as a temporary measure in September, but he declined.

39. Mr E was then seen in early October. The notes say Mr E told the dentist he did not like the shade of the filling and wanted the whole filling removing. The dentist examined the tooth and recorded the UR1 filling was ‘sound except for small MI chip’ (mesio-incisal chip- the surface of the tooth the chip is related to), ‘shade reasonable’. The dentist offered to repair the chip and trim the top layer of the filling and replace with a lighter shade to address Mr E’s cosmetic concerns and fix the chip.

40. Our adviser said clinically the dentist was doing the correct thing. This is because removing an intact composite will cause more damage to the tooth underneath it. So, rather than taking off a whole filling that did not need to be removed, it was correct to trim back some of the material and add to it.

41. Informed by clinical advice, the is no evidence the new filling was chipped as a result of how it was placed by the dentist during the appointment at the end of July. In line with A Guide to Good Occlusal Practice and GDC standards, the dentist responded correctly when Mr E informed them his filling had chipped.

Rectify filling

42. Our adviser said there is no evidence the Practice refused to rectify the filling (regarding colour match), unless Mr E paid privately. As explained earlier, in early October, the dental notes record that as a good will gesture the Practice offered to trim back and address the colour match, in an attempt to address Mr E’s cosmetic concerns. There is no indication of a failing.

Root canal

43. Mr E complains the Practice refused to rectify a failed root canal. He believes it should have been carried out on the NHS, free of charge as the RCT was carried out within 18 months.

44. Within the Practice’s email to Mr E, dated 17 October 2024, it said a re-RCT is not available through the NHS.

45. Following this email the dentist recorded a telephone call with Mr E about the re-RCT. Mr E asked why a re-RCT was not able to be done on NHS. The dentist said a re-RCT is not available on NHS and carries a higher risk of perforation and complexity that is best undertaken by a specialist, which it said it had already booked. However, Mr E had cancelled the appointment.

46. During a meeting between the Practice and Mr E in late October, it told him a re-RCT is not a routine treatment, and clinicians will not undertake treatment that is beyond their competency. It said this is why it booked an appointment with an endodontist, who does root fillings.

47. In early November, the Practice referred Mr E to the hospital for a second opinion. This was because the Practice said it was difficult for it to manage Mr E’s expectations under NHS regulation. This related to the colour match of Mr E’s UR1 filling and re-RCT.

48. Mr E confirmed during our introductory call on 23 April 2025 the Practice had referred him to the hospital. The hospital had agreed to put in new fillings and redo his RCT. We understand this work is being carried out under the NHS.

49. Our adviser said there is no evidence the Practice refused to rectify a failed root canal.

50. The dental records show that in early October 2024, the dentist informed Mr E, after a radiograph was taken, that the root canal on his upper left central incisor (UL1) had failed. It informed him on re-RCT and the success rate. Mr E agreed to go private, and the Practice made a referral for private endodontics. Mr E later cancelled that appointment.

51. The Practice then referred him to the hospital. Our adviser said this meant his re-RCT UL1 and direct composites on UR1 and UL1 would all be done free under the NHS in a hospital setting.

52. The relevant guidelines are the BES: a guide to Good Endodontic Practice, and NHS England: The Levels of Complexity (LEC) tool. These guidelines help GDPS (general dental practitioners) assess the complexity of root canals and help determine if this is within their scope of practice or if they should refer out to a specialist.

53. Our adviser said, in Mr E’s case, the first root canal had failed as the root filling is short. From the medical records it is hard to see if there was any canal patency (whether the root canal is negotiable) beyond the length of the gutta percha (used as permanent filling in root canals) filling. Therefore, in line with the LEC tool the re-RCT was no longer in the remit of a general dentist and should be referred to a specialist, whether that is a private one or one based in an NHS hospital, as happened in Mr E’s case.

54. We acknowledge Mr E’s concerns on whether the Practice refused to rectify a failed root canal. We have carefully considered his complaint and all the relevant evidence. In line with BES and NHS England guidance, because of the complexities of the treatment, it was appropriate for the Practice to refer him to a specialist. We therefore cannot be critical of the Practice.

55. We are sorry to learn of Mr E’s complaint about the Practice and the impact this has had on him. Our primary investigation decision is not made without recognition of the impact this has had. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. We are sorry to learn of Mr E’s experiences with the Practice. We acknowledge the difficult circumstances around this complaint, and the impact this has had on him.

2. We have carefully considered his complaint about the Practice and we cannot see any indications of a failing. We have explained the reasons for our decision below.