A dental practice in the Wigan area

5. Miss B complains the Practice failed to include her UR second molar and UR wisdom tooth in her treatment plan between 2016 and 2021, when it fitted her with braces.

6. Miss B says she now requires braces to reposition her UR second molar to correct alignment issues and have her UR wisdom tooth removed. She says a dentist told her the only alternative is that she has her UR second molar removed due to risk of infection.

7. Miss B told us she worries this will cause her physical discomfort and daily routine disruptions. She says the further orthodontic work will cost her a minimum of £3,700 which she has not budgeted for, creating an unfair financial burden.

8. Miss B says she feels frustrated, exhausted and disregarded by the Practice’s lack of accountability.

9. By bringing this complaint to us, Miss B wants an acknowledgement of failings, service improvements and a financial remedy.

10. Miss B was an NHS orthodontic patient at the Practice from 2016 to 2021. During this time, the Practice fitted her with fixed appliances (braces), followed by retainers (removable braces), to correct her teeth alignment issues.

11. In September 2024, Miss B attended a routine dental check-up at another dental Practice. During this appointment, the dentist performed an X-ray image of her teeth. The X-ray showed her UR second molar had not erupted through her gum and her UR wisdom tooth was impacted (when a tooth is partially or fully blocked from erupting through the gum) against her UR second molar.

12. Miss B complained to the Practice in September 2024 about it not removing her UR wisdom tooth and bringing her UR second molar down, when it treated her between 2016 and 2021. The Practice responded to her complaint in October 2024.

Did not include her UR wisdom tooth and UR second molar in her treatment plan

16. Miss B complains the Practice failed to include her UR second molar and UR wisdom tooth in her treatment plan between 2016 and 2021, when it was providing orthodontic treatment to her.

17. Miss B told us she believes from what another dentist has told her, that her UR wisdom tooth has stopped her UR second molar erupting through her gum. She believes the Practice should have removed her UR wisdom tooth and pulled her UR second molar down.

18. Miss B told us because of this, she now needs further orthodontic treatment at a significant cost. She also says she feels frustrated, exhausted and disregarded by the Practice’s lack of accountability, which we are sorry to hear about.

19. In its complaint response, the Practice said it conducted a full examination, X-ray, and the orthodontist had a discussion with Miss B at the start of her treatment in November 2016. Following this, it said it provided Miss B orthodontic treatment on a non-extraction basis (without removing teeth), using fixed appliances followed by retainers.

20. The Practice said the X-ray from November 2016 shows both of Miss B’s second molars were in favourable positions for normal eruption. It acknowledged Miss B’s wisdom teeth were angled behind her second molars but explained it did not see any indication this would stop the eruption of her second molars.

21. The Practice said it did not consider removing Miss B’s UR wisdom tooth was clinically necessary. It said it expected Miss B’s UR second molar to erupt, although delayed, and saw no signs of future complications. The Practice said Miss B’s general dentist would have monitored her unerupted UR second molar.

22. We noted in the Practice’s electronic clinic records it refers to paper notes. We asked the Practice to provide us with these notes and Miss B’s treatment plan. The Practice told us it was unable to provide us with these documents, as they are not included in its archived records. It explained its treatment plan is documented in the electronic records.

23. We asked our adviser if the Practice should have included Miss B’s UR second molar and UR wisdom tooth in her treatment plan.

24. Our adviser explained because Miss B’s UR second molar had not erupted, the Practice should have discussed this with her at the start of her treatment and when it removed her fixed braces in April 2019.

25. Our adviser explained the Practice should have documented these discussions and considerations, along with any considerations of her UR wisdom tooth’s position in relation to her second molar in her treatment plan. This is in line with recognised good practice.

26. Our adviser noted no evidence in the clinical records that the Practice considered or discussed Miss B’s unerupted UR second molar or UR wisdom tooth. Our adviser could also see no evidence that the Practice considered or asked Miss B’s general dentist to monitor her unerupted UR second molar.

27. Our adviser explained second molars typically erupt by 12 years of age, although variation is common. Because of this and Miss B being 15 at the start of her treatment, our adviser explained it is reasonable the Practice may have wanted to allow more time for her UR second molar to erupt.

28. Our adviser explained the 2016 X-ray image does not suggest Miss B’s UR wisdom tooth was stopping the eruption of her UR second molar. Therefore, our adviser explained it was reasonable for the Practice to have expected Miss B’s UR second molar would erupt, although delayed.

29. Our adviser explained there are no specific guidelines about the management of unerupted second molars. Any treatment considerations would be based on clinical judgement.

30. Our adviser told us sometimes teeth never erupt. Sometimes this does not cause a problem, but sometimes there can be problems relating to pain or infection. Our adviser explained it is not certain a problem will occur if not all the teeth erupt.

31. We asked our adviser if the Practice should have removed Miss B’s UR wisdom tooth.

32. The NICE guidance relating to the extraction of wisdom teeth advises against the preventative removal of teeth in the NHS, when there is no pain or infection.

33. Our adviser explained the X-ray from 2016 shows Miss B’s UR wisdom tooth is impacted (unable to erupt) due to its position against her unerupted UR second molar tooth. Although impacted, our adviser explained the appearance of Miss B’s UR wisdom tooth in this X-ray does not suggest it is preventing the eruption of her UR second molar, nor is there record she had pain or an infection.

34. Our adviser explained people can live with impacted wisdom teeth without any issues. There is no evidence in the records to suggest Miss B had pain or an infection during her treatment.

35. Our adviser noted the X-ray from another dental practice in 2024 does show Miss B’s UR wisdom tooth is now in a worse position than it was in 2016. Our adviser explained they cannot say this for certain this was, or is, contributing to the continued failed eruption of her UR second molar. Our adviser could also not say whether removing it will make her UR second molar to erupt.

36. Our adviser explained in terms of further treatment, Miss B could speak to her general dentist about removing her UR wisdom tooth, to see if her UR second molar then erupts. If she chooses to do this and her UR second molar still fails to erupt, then exposing the UR second molar surgically and applying further fixed braces could be considered.

37. Our adviser explained this treatment would be Miss B’s choice and is not clinically essential, as her both teeth could remain unerupted with no problems.

38. Our Principles of Good Administration state organisations must act in accordance with recognised quality standards, established good practice or both when delivering clinical care. Therefore, in this situation, we will use GDC standards and the professional judgement of our orthodontic adviser which is based on established good practice.

39. We are sorry to hear Ms B believes the Practice should have included her UR wisdom tooth and her unerupted UR second molar in her treatment plan.

40. GDC standards 4.1 state records should be contemporaneous, complete and accurate. While we recognise the Practice provided its considerations in its complaint response, there is no evidence showing its considerations or the discussions it had with Miss B about these teeth in its clinical records. Nor is there evidence it communicated its expectations regarding monitoring to her general dentist.

41. We recognise from what our adviser told us, the lack of documentation in the treatment plan about the Practice’s considerations and discussions does not follow good practice. Based on this and GDC standards, which says records should be ‘contemporaneous and complete’ we consider the Practice should have included any discussions or considerations about Miss B’s unerupted UR second molar and any considerations regarding the position of her UR wisdom tooth in her treatment plan.

42. However, there is no evidence to say that had the Practice included Miss B’s UR wisdom tooth and UR second molar in her treatment plan, it should have taken any specific action.

43. We understand from what Miss B has told us, she believes the Practice should have removed her UR wisdom tooth. We are sorry to hear Miss B believes this has stopped her UR second molar erupting.

44. The NICE guidance clearly advises against extraction for preventative reasons alone. We have not seen any evidence, nor has Miss B told us, she had symptoms of pain or infection at the time of her treatment.

45. We recognise from our adviser’s comments it would have been good practice for the Practice to document any considerations it gave to the position of Miss B’s UR wisdom tooth in her treatment plan. However, we consider the Practice acted in line with relevant NICE guidance and cannot say it did something wrong by not removing her UR wisdom tooth.

46. During our investigation, the Practice told us Miss B’s upper left second molar was initially part erupted and continued to erupt normally during her treatment. It said it considered her UR second molar also appeared to be erupting normally, although delayed, as its mesio-buccal cusps (the cheek side, outer points on a back tooth) are visible on her final dental moulds. Therefore, it considered her UR second molar would continue to erupt, although delayed, like her left side did.

47. We recognise the Practice has provided us with further information regarding its considerations. On balance we consider it is reasonable to say that had the Practice documented Miss B’s unerupted UR second molar in her treatment plan, it may still have reasonably decided to take no action.

48. This is because, we understand from our advice there are no specific guidelines about the management of unerupted second molars, and any treatment considerations would be based on clinical judgement. We also understand there can be a variation in eruption times and people can live with unerupted teeth with no problems. Therefore, our advice suggests the Practice’s clinical judgement was reasonable.

49. We recognise from what Miss B has told us she is also worried about potential future problems relating to her unerupted UR second molar. We are sorry to hear this causes Miss B to worry.

50. From our advice, we understand people can live with unerupted second molars and impacted wisdom teeth without any issues. Alternatively, sometimes there can be issues such as pain or infection. Miss B has not told us she has had any of these symptoms and we cannot say for certain that she will have problems in the future. Our adviser explained because of this, any treatment now would be Miss B’s preference and not considered clinically necessary.

51. Given all of this, on balance we do not consider we can link the main impact Miss B is claiming, which is her need for further orthodontic work, to the Practice not including her UR second molar in her treatment plan.

52. We recognise Miss B also told us she feels frustrated, exhausted and disregarded by the Practice’s lack of accountability of any failings, which we are sorry to hear.

53. We cannot see the Practice has taken accountability in its complaint response for not including its considerations about Miss B’s UR second molar and UR wisdom tooth in her treatment plan. Therefore, we consider it needs to do more to put right Miss B’s impact of frustration, exhaustion and disregard.

54. Our severity of injustice scale helps us determine whether a financial remedy is appropriate in cases. Level one explains that for low impact injustices such as annoyance, frustration, worry or inconvenience arising from a one-off incident with no lasting effects we generally consider an apology to be sufficient. In these cases, we would not usually consider a financial remedy to be appropriate.

55. We consider Miss B’s impact of frustration, exhaustion and disregard stems from a one-off incident when the Practice responded to her complaint. This aligns with those described in level one in our severity of injustice scale. In these circumstances, our severity of injustice scale says an apology is enough to put right impacts like this.

56. We contacted the Practice to explain our initial considerations of this case, specifically about its poor documentation around its considerations. We also shared the impact Miss B told us about and the outcomes she wanted by bring her complaint to us. We explained we would not usually consider a financial remedy to be appropriate in these cases.

57. The Practice responded to us and acknowledged it should have included its considerations and discussed the non-eruption of Miss B’s UR molar with her, throughout her treatment. The Practice told us it has taken learning from Miss B’s complaint. Moving forwards, the orthodontist will ensure they include any discussions and considerations about unerupted molars, and they will improve their communication with general dentists, when referring patients back to them for monitoring.

58. Our principles of good administration say organisations should be open and accountable when it gets things wrong. Our principles also say organisations should take learning from complaints to contribute to service improvement.

59. We are satisfied the Practice has now taken full accountability for not documenting its considerations in Miss B’s treatment plan. It has acknowledged this mistake and taken learning from Miss B’s complaint to help improve its services. This is in line with the other outcomes Miss B wanted by bringing her complaint to us and our principles of good administration.

60. As such, we do not consider this complaint requires further investigation and will not be taking any further action.

61. We would like to thank Miss B for taking the time to bring her complaint to us.

1. We have carefully considered Miss B’s complaint about the Practice. We are sorry to hear Miss B feels the Practice should have included her unerupted upper right (UR) wisdom tooth and UR second molar in her treatment plan, when it fitted her with braces in 2016. We understand from what she has told us she worries about needing further braces, which we are sorry to hear.

2. We want to reassure Miss B we have not seen anything went wrong when the Practice decided not to remove her UR wisdom tooth. We recognise the Practice should have discussed Miss B’s unerupted UR second molar with her and documented any considerations about this and any it gave to the position of her UR wisdom tooth in her treatment plan.

3. We have decided we cannot link the Practice not including Miss B’s UR second molar and UR wisdom tooth in her treatment plan, to her need for further orthodontic work. We have explained our reasons for this in more detail in this statement.

4. However, we recognise Miss B is frustrated by the Practice’s lack of accountability of any failings. We are satisfied the Practice has now offered to put right this impact by acknowledging it should have included its considerations in her treatment plan and take learning from Miss B’s complaint, to improve its services in the future. As such, we will not be considering this further, and we explain our reasons for our decision in more detail below.