A dental practice in the Telford and Wrekin area

6. Miss T complains about aspects of care and treatment she received from the Practice. She says it delayed putting in a referral for her to have her wisdom tooth extracted by approximately a year between September 2023 and August 2024.

7. She also says the Practice unnecessarily drilled into her teeth to fill surface holes during an appointment on 11 September 2024.

8. Miss T says she suffered in pain for longer because of the delay period. She says this resulted in her being unable to attend work because she could not speak or eat properly.

9. She says this also meant her teeth continued to be overcrowded. This caused further damage to one of her back molars and she has snapped and damaged retainers from grinding her teeth, which she says could have been avoided.

10. She says the unnecessary drilling of her teeth to fill surface holes has put her at risk of tooth loss, extra sensitivity, and future problems.

11. By bringing this complaint to us, Miss T would like the Practice to: • apologise for its failings and acknowledge the impact they had• make service changes to ensure no one else has the same experience• pay a financial remedy.

12. Miss T says the Practice should have made a referral in September 2023 for her wisdom tooth to be extracted.

13. The Practice made the referral on 1 August 2024.

14. Miss T had surface holes filled in six of her teeth during an appointment on 11 September 2024.

Referral

18. 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. Having done this, we have not found any indications that the Practice did anything wrong in its handling of Miss T’s wisdom tooth extraction referral.

19. Miss T says the Practice delayed putting in a referral for her to have her wisdom tooth extracted by approximately a year between September 2023 and August 2024.

20. NICE ‘Guidance on the extraction of wisdom teeth’ says a first episode of pericoronitis (inflammation of the gum tissue around wisdom teeth), unless particularly severe, should not be considered an indication for surgery. For adults, a dentist should consider extracting the tooth if there are repeated episodes of pericoronitis associated with the same tooth.

21. The records indicate Miss T did not have an appointment at the Practice in September 2023.

22. The records indicate the appointment where Miss T complained about her wisdom tooth was on 1 February 2024. The records suggest that Miss T was happy to leave and monitor her wisdom tooth but if the pain became too much she should return to the Practice to request a referral for extraction.

23. Our adviser says, in line with NICE guidance, a dentist should not refer a patient straight away for extraction of a wisdom tooth. This is because of the risk of nerve damage due to where it is located. It is appropriate to wait and to try manage the associated symptoms. Our adviser said it is also likely that the referral would have been rejected had it been made after the initial appointment on 1 February 2024, due to not meeting the criteria in the NICE guidance.

24. The records show Miss T’s next appointment was on 1 August 2024. Miss T requested that a referral be made for her wisdom tooth to be extracted as it had become more painful. The Practice made this referral on the same day.

25. Our adviser says Miss T attended the appointment on 1 August and complained of persistent or recurrent pain on the same tooth. Therefore, it was appropriate for the Practice to refer her for extraction at this stage.

26. We appreciate Miss T felt the lack of referral meant she suffered further damage to one of her back molars and that she had snapped and damaged retainers from grinding her teeth. We understand she felt this could have been avoided had her wisdom tooth been removed earlier. We hope it provides her with some reassurance to know that our adviser says these things would not have happened as a result of her wisdom tooth not being extracted.

27. Having considered all available evidence, we consider the Practice acted in line with NICE guidance by not referring Miss T for her wisdom tooth to be extracted when she complained about her symptoms during the first appointment on 1 February 2024.

28. We recognise Miss T suffered with pain and discomfort during this period and we also understand it affected her ability to work. That said, it was not until the next appointment on 1 August that Miss T further complained about her symptoms. Therefore, there was not an opportunity for the Practice to have done this earlier. We consider the Practice appropriately and promptly made the referral for wisdom tooth extraction following Miss T’s complaints on 1 August of persistent or recurrent pain in the same tooth.

29. For these reasons, we will not be taking any further action on this part of Miss T’s complaint.

Fillings

30. When we see indications that an organisation has got something wrong, we look at what outcome the complainant is seeking to see whether we can informally resolve their complaint. We can resolve a complaint without conducting a detailed investigation, if we can deliver the outcome we consider resolves the complaint at an earlier point in our complaint handling process.

31. Miss Shepherd says the Practice unnecessarily drilled into her teeth to fill surface holes during an appointment on 11 September 2024.

32. Our adviser explained that treatment for surface holes differs depending on whether the teeth have caries (decay) or not.

33. RCSE ‘Treatment of intrinsic discolouration in permanent anterior teeth’ guidance explains tooth discoloration can be a significant cosmetic, and in some instances, functional, problem. The treatment usually involves microabrasion (a mild rough paste), bleaching or whitening, or camouflage with a temporary filling.

34. The International Oral Health Journal’s expert consensus on ‘dental caries management’ says to manage patients with dental caries by using the ‘drill and fill’ model. This involves drilling out the decay in the tooth before filling it.

35. The records for 11 September 2024 indicate that on examination Miss T had two teeth, the upper right 2 (UR2) and upper left 2 (UL2) that were ‘stained – not caries’.

36. The records indicate UR3, UL3, UL6, and lower left 4 (LL4) had caries.

37. The records under the treatment section state that UR3, UR2, UL2, UL3, UL6, and LL4 caries had been removed.

38. Our adviser says, before putting in a composite filling (white filling), it is important to drill out any decay in the teeth. Once a dentist has drilled out the decay, it is ready to be filled. This is because it makes sure the filling adheres properly to the healthy tooth and prevents further decay. Therefore, it would be appropriate and in line with ‘dental caries management’ for the dentist to ‘drill and fill’ the carious teeth.

39. For this reason, we consider it was appropriate, and in line with the above guidance, for the Practice to drill into the teeth with caries (UR3, UL3, UL6, and LL4) to appropriately fill them.

40. However, the UR2 and UL2 teeth were reported on examination as being stained and did not have caries. Treatment outlined in RCSE guidance would have been required rather than drilling and filling these teeth.

41. Given the records state that caries had also been removed from UR2 and UL2, it appears the Practice inappropriately drilled into teeth that did not require it. This is not in line with the RCSE guidance and is an indication of a failing.

42. Our ‘NHS Complaints Standards’ explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’

43. The Practice did not respond to Miss T’s complaint regarding her teeth being drilled into. Therefore, we consider it has not appropriately apologised for its error or acknowledged the impact this had on her. Additionally, it has not had the opportunity to reflect on its service and how it could be improved going forward.

44. Our ‘Guide to Financial Remedy’ sets out our ‘severity of injustice scale’ (our scale). This is a guide which helps us decide an appropriate amount of financial remedy, depending on the injustice the person has suffered.

45. Our adviser told us that it is impossible to say whether this will have a future impact on Miss T. However, Miss T was considered a ‘high risk’ patient as she is a smoker and due to her overall oral health. This means there was always a potential for her to develop caries in the stained teeth, which would then require the ‘drill and fill’ treatment.

46. Nevertheless, we do not wish to underestimate the worry and distress it has caused Miss T not knowing whether this would cause her future problems.

47. Our scale explains in cases where a person has experienced a level of worry and distress that does not affect their day-to-day functioning or their ability to live a normal life, we would recommend payments between £120-£550. We recognise the worry and distress it has caused Miss T to think she may have future problems with the affected teeth. We consider Miss T’s complaint falls in this level.

48. We contacted the Practice. We explained about the worry and distress that has been caused. The Practice has confirmed it will write a letter of apology and acknowledge the impact this has had on Miss T. It will also outline the service improvements it will make to ensure the poor service is not repeated. The Practice says it will make a one-off payment of £150 to Miss T in recognition of the distress and upset the unnecessary drilling caused her.

49. We recognise Miss T says she could have problems with the affected teeth going forward. Sadly, we cannot consider a ‘potential future impact’ and we have not seen any evidence to show that her teeth have been further impacted as a result of the unnecessary drilling. Therefore, we can only consider the worry and distress it has caused Miss T as an impact.

50. Taking everything into account, we are satisfied the Practice’s proposed actions achieves all the outcomes Miss T wanted by bringing her complaint to us. We also consider these proposed actions are in line with our NHS complaint standards and are enough to put things right. Therefore, we consider it resolves the complaint.

51. We would like to thank Miss T for taking the time to bring her complaint to us. We would also like to thank the Practice for its cooperation and understanding during our consideration of this complaint.

1. We are very sorry to hear that Miss T felt the Practice delayed putting in a referral for her wisdom tooth to be extracted. We recognise Miss T suffered in pain and damaged another tooth and retainer that she feels could have potentially been avoided. We also understand the distress it caused when she was unable to attend work due to the pain and discomfort she was experiencing.

2. We are also sorry to hear that Miss T experienced unnecessary drilling of her teeth during an appointment on 11 September 2024. We appreciate the distress it has caused not knowing whether this would cause her future problems with the teeth affected.

3. We have carefully considered Miss T’s complaint about a Dental Practice in the Shropshire area (the Practice). Having considered all available evidence, we have seen no indications of failing in the Practice’s handling of the wisdom tooth extraction referral. Therefore, we will not be taking any further action on this part of Miss T’s complaint.

4. We have seen indications of a failing in the Practice’s care and treatment of Miss T during the appointment on 11 September 2024.

5. As a result of our involvement, the Practice has confirmed it will write a letter of apology to Miss T acknowledging the impact the poor service had on her. It will also outline the service improvements the Practice will make to ensure the poor service is not repeated. Additionally, the Practice has offered to make a one-off payment of £150 to Miss T in recognition of the distress and upset the unnecessary drilling caused her. We are satisfied these proposed actions are appropriate to resolve this complaint. We explain this in more detail below.