A dental practice in the Burnley area

7. Miss L complains about aspects of care she received from the Practice between June 2024 and January 2025. She states that:

• she did not require the onlay treatment to her UL6 tooth and this procedure was not explained to her • the dentist did not provide a quote for this procedure • the filling drilled during the procedure was larger than necessary • the onlay was not fitted appropriately.

8. Further, Miss L says in January 2025, she incorrectly received an NHS penalty charge notice because she had not provided evidence on her FP17DC form, to show she was exempt from paying for her dental treatment. Miss L was also told she owed the band three NHS dental charge of £319.19 which was the standard charge at the time of her treatment.

9. Miss L says she has had dental treatment that was not necessary, and she was not informed enough to make the decision to decline this. She says she had more appointments than necessary, and she had to come out of work to attend these. Miss L is anxious about the situation this has left her in with her dental care. She is upset she is owing money she did not expect to owe.

10. Miss L would like the cost of the treatment, £319.19, to be reimbursed by the Practice.

11. Miss L attended the Practice in June 2024 for a dental check-up. The dentist examined her and found her existing filling (a material used to fill a cavity or hole in a damaged tooth) had failed. They recommended fitting an onlay to her UL6 tooth. An onlay is a filling made outside of the mouth in a laboratory and then cemented on, to cover the biting surface of the tooth.

12. The Practice gave Miss L an FP17DC form to complete before starting her onlay treatment. This form is given to NHS patients to explain the costs of the proposed treatment. The form also includes a declaration section, which the patient must sign to confirm if they are liable for dental charges on the NHS.

13. Miss L returned to the Practice in July 2024 for preparation for the onlay treatment. She had the onlay fitted in October 2024.

14. Miss L attended the Practice again in November 2024 as the onlay had pulled out. The dentist prepared the tooth so the onlay could be replaced and fitted it again in December 2024. Miss L said the hole the onlay left in her tooth felt much larger than the original one. The dentist explained due to removing the old filling first, this was to be expected.

15. Miss L received an NHS penalty charge notice for non-payment of NHS dental treatment in January 2025, which she contested and had waived. Miss L was told she still owed the NHS band three treatment cost at the time, which was £319.19.

16. Miss L raised a complaint with the Practice in January 2025 and had a final response later in January 2025.

Requirement for onlay treatment to upper left 6 tooth

20. Miss L says she should not have undergone onlay treatment for her UL6 tooth. She feels it was ‘not required’ and was done ‘unnecessarily’. Further, she says the treatment was not clearly explained to her, so she could make an informed decision. This has caused Miss L to feel anxious.

21. We are sorry to hear Miss L has been left feeling like she underwent unneccesary dental care. We recognise this would cause her worry and frustration especially given the costs involved in her treatment. We have carefully looked at whether the Practice explained the risks and benefits of this procedure and if it was an appropriate course of treatment to fix her tooth.

22. GDC guidance sets out ‘nine principles’ which NHS dentists should follow when providing treatment to patients. Principle two explains dentists have a duty to ‘communicate effectively’ with patients. They should give ‘full clear and accurate information’ the patient can understand and a give a clear ‘explanation of treatment, possible outcomes and what to expect’.

23. Our clinical adviser reviewed Miss L’s records from June 2024. They explained the records are ‘very detailed’ in respect of the damage existing to UL6 and ‘the options available for restoring the tooth’.

24. We can see from these records the dentist has documented a detailed discussion with Miss L. It states they ‘discussed with the patient the tooth is broken’ and needed restoration. The dentist explained ‘there are several good options available’ for Miss L’s proposed treatment plan including ‘onlay, missing teeth and occlusion split (night guard)’. The dentist documented they then went on to explain the ‘risks and benefits’ of the different restorative options (including the onlay treatment). The dentist documented following this discussion that the patient ‘would like to progress with onlay’ as their treatment plan.

25. Taking all this into account, it appears the dentist acted in line with GDC guidance. Our adviser confirmed there was a high standard of record keeping, which captures a clear, detailed discussion with Miss L about her diagnosis and potential treatment options. We can see the dentist gave Miss L ‘full, clear and accurate’ information about the condition of her tooth and explained the risks and benefits of each treatment to outline what she ‘could expect’ and the ‘possible outcomes’. We have seen no indications to suggest the communication fell below the standard expected and would prevent Miss L from making an informed decision about her onlay treatment.

26. We next consider whether the onlay was an appropriate recommended treatment option to repair Miss L’s broken UL6 tooth.

27. The onlay guidelines explain onlays are better than ordinary filling materials when a tooth has been ‘damaged, a previous filling no longer serves its purpose or requires more protection than a normal filling can provide’.

28. In this instance, the X-ray and dental records from Miss L’s appointment in June 2024 indicate the previous filling at her UL6 tooth had failed. As the ordinary filling material had not worked, our adviser confirmed it was appropriate to recommend an onlay filling to repair the tooth. Our adviser explained this was ‘less destructive’ than other treatment options.

29. On this basis, it appears the Practice’s recommended onlay treatment was appropriate and in line with the onlay guidelines. Miss L’s previous filling had been ‘damaged’ and was ‘no longer serving its purpose’. This indicates her UL6 tooth needed ‘more protection’ than a normal filling, so it was appropriate for the dentist to recommend an onlay to repair it. We have seen no indications of failings for this part of the complaint.

Fitting the onlay to the UL6 tooth

30. Miss L complains when the dentist prepared her UL6 tooth for the onlay, they created a much larger hole compared to the original filling. Further, the dentist did not fit the onlay correctly, as it later fell out and she had to have another appointment to get it replaced. Finally, Miss L is unhappy about the number of appointments she needed to go to for the onlay to be fitted.

31. Principle seven of the GDC guidelines explains dentists have a duty to ‘provide good quality care based on current evidence and authoritative guidelines’. It says dentists should only carry out procedures when they are ‘confident’ and have the ‘appropriate knowledge and skills to perform the task safely’.

32. The onlay guidelines sets out the difference between a routine (inlay) filling and onlay fillings. It explains onlays are ‘often larger than inlays and are used to cover the biting surface of the tooth’. This is because an onlay is used ‘to restore the missing tooth structure to maintain function of the tooth’.

33. In line with the onlay guidelines, our adviser explained once Miss L’s old filling was removed, it is expected for the hole (which needs the onlay repair) to feel ‘significantly larger’ that the previous filling hole. This is because an onlay is used to cover the whole biting surface of the tooth, rather than a smaller inlay filling.

34. On this basis, we do not consider there are any indications of failings for this part of the complaint. We hope to reassure Miss L that the fact she could feel a larger hole in her tooth is normal practice and does not indicate the dentist caused further, unnecessary damage to the tooth.

35. The onlay guidelines explains ‘typically onlay restoration will take two appointments’. In the first appointment, the dentist needs to take a ‘mould’ of the tooth and fit a ‘temporary filling’ in the damaged tooth. In the second appointment, the dentist will then remove the temporary filling, fit the onlay and then check the ‘bite and fit’ before polishing it to make sure it is comfortable.

36. The records indicate Miss L’s dentist arranged an appointment in late July 2024 to prepare her UL6 tooth for the onlay treatment and they put in place a temporary filling. In October 2024, the dentist arranged a second appointment to remove her temporary filling, fit a permanent onlay and complete the course of treatment.

37. We can see Miss L had two appointments, as expected in the onlay guidelines. As such, we cannot say there are indications the Practice arranged an excessive number of appointments to complete her treatment.

38. Sadly, the records show that in November 2024, Miss L visited the Practice again as her onlay filling on her UL6 tooth had fallen out. The records show it had come away after eating something ‘hard and sticky’.

39. We are sorry to hear Miss L’s onlay fell out shortly after she had completed the course of treatment. Understandably, this would have been disappointing and upsetting for her. We recognise this also left her with ongoing concerns that her initial onlay was not fitted appropriately.

40. Our adviser explained onlays are cemented in place. It is a known risk the cement can be dislodged if a force is applied to them that is stronger than the cement, for example a sticky or firm food. Our adviser confirmed this does not indicate any problem with the original fitting of the onlay. Further, there is nothing in the records to suggest the dentist did not apply the original onlay fitting correctly.

41. On this basis, we consider the dentist acted in line with GDC guidelines. It appears they provided ‘good quality care’ and fitted the permeant onlay filling ‘safely’ and ‘confidently’ during the appointment in October. We have seen no indications of failings for this part of the complaint.

Costs of treatment

42. Miss L told us the Practice did not provide a quote for her onlay treatment or explain what costs would be involved. This caused her shock when she later received an NHS penalty notice and bill for band 3 dental treatment. Miss L says she was left feeling anxious about the financial pressure of paying the bill.

43. We appreciate it must have been worrying for Miss L to receive a bill unexpectedly, along with a penalty charge notice. We do not wish to underestimate how stressful it must have felt to have this additional financial pressure.

44. The NHS Business Services Authority (NHSBSA) guidelines explain NHS dentists must give ‘an FP17DC or an FP17DC(w)’ form for all patients who are going to start ‘Band 2 and Band 3 courses of treatment’. This form is given to the patient to sign. It outlines the treatment proposed, the NHS dental band of this treatment and the expected charges for this band of treatment.

45. The records indicate Practice staff correctly gave Miss L an FP17DC form to sign for her onlay treatment. Miss L signed the form to confirm she consented to treatment. Our adviser explained this evidence indicates the Practice met its duties to explain the treatment and costs involved in line with the above NHSBSA guidance.

46. Our adviser explained on the FP17DC form, there is a section where the patient must sign to declare their intention to pay the NHS charges or to claim exemption from them. This declaration is the responsibility of the patient. If exemption is incorrectly claimed the NHSBSA will ask the correct fee to be paid and can also charge a penalty.

47. Taking this evidence into account, we are satisfied Practice staff met their obligations under the NHSBSA guidelines. They correctly shared the FP17DC form with Miss L prior to her treatment. The form includes all the relevant information about the costs involved in her onlay treatment. We can see Miss L signed this form which indicates she consented to the onlay procedure.

48. We recognise it would have been upsetting for Miss L to later incur a penalty charge notice. The evidence we have seen indicates it is the patient’s responsibility to sign and declare their personal circumstances on the FP17DC form. This is to explain if they are exempt from paying for their treatment. We therefore cannot hold Practice staff accountable for the FP17DC form being completed incorrectly.

Conclusion

49. We thank Miss L for bringing her complaint to our attention. We hope our explanation brings some assurance of the need for the dental treatment she had, the clinical care provided by the Practice was in line with NHS dental standards and guidance, and the procedures followed around treatment explanations and billing were also in line with standards and guidance.

1. We have carefully considered Miss L’s complaint about the treatment she received for her upper left six (UL6) tooth from the Practice between June 2024 and January 2025.

2. We are sorry to hear Miss L feels her treatment options to repair this tooth were not clearly explained to her and the ‘onlay’ fitted on the tooth was not necessary. Sadly, the onlay later came out. This left Miss L with concerns it was not fitted properly, and she had to attend further appointments which caused her inconvenience and frustration. We are also sorry to hear she got a bill she did not expect for this treatment. We can see how this situation has left her feeling anxious and upset. We hope to reassure Miss L we have carefully listened to her concerns and thoroughly considered her complaint.

3. Having done so, it appears the Practice appropriately carried out the onlay procedure to her UL6 tooth. It appears this was necessary and proportionate to her clinical presentation, in line with standards and guidance.

4. We can assure Miss L the onlay filling appears to have been the correct size to repair her UL6 tooth and her onlay coming off after the fitting, does not indicate there was a problem with the initial fitting.

5. The evidence we have seen indicates Practice staff gave Miss L the correct FP17DC form to complete prior to her treatment in line with the relevant guidance. This explains the costs involved in her treatment. We consider it took appropriate steps to fully advise and inform her about the dental charges.

6. We explain our reasons in detail below.