A dental practice in the Derbyshire Dales area

Mr H complains that a dentist at the Practice did not make clear the risks and any limitations in the treatment proposed, did not complete his root canal treatment (RCT) on 12 December 2024 appropriately, and did not treat the issues he raised post-surgery from 19 December to 20 March 2025 appropriately.

He says a consequence of not being fully informed about the potential risks and not understanding the limitations of RCT carried out at this Practice was unnecessarily prolonged distress, swelling and pain, and delays in actions to alleviate post-surgery problems. He says the RCT led to an infection and caused him to experience prolonged distress, swelling and pain, requiring four months of painkillers and because the RCT was not done properly he had to seek private corrective treatment. He adds that the prolonged pain and swelling adversely affected his quality of life, ability to work and sleep.

Mr H is seeking an acknowledgement of the mistakes, an explanation of why it happened and what went wrong, service improvements to avoid repeats of similar mistakes by the dentist and a financial remedy.

On 25 November 2024 Mr H visited the Practice due to pain in his lower left first permanent molar (LL6) and an X-ray was taken. At this appointment the dentist discussed extraction of this tooth and RCT with Mr H. An RCT removes an infection from inside of the tooth. The tooth is then cleaned and filled to prevent it from getting infected again.

Mr H visited again on 12 December. At this appointment the dentist confirmed the options of extraction and RCT, again, then Mr H underwent an RCT of his LL6. The dentist treated three root canals and took X-rays. A root canal is a narrow tube inside the root of a tooth which contains the nerve and blood supply to the tooth. Most people’s lower molars have two to three canals, but people can have between one and four of them.

Mr H visited the Practice again on 19 December presenting with pain in his LL6 and was prescribed metronidazole (an antibiotic medicine used to treat infections). He says this temporarily helped with the pain and swelling. The dentist advised of his options, which were extraction or referral to a specialist for the RCT to be done again if things got worse.

Mr H continued to experience pain, swelling and discomfort and on 20 March he visited the Practice again because of this. The dentist prescribed antibiotics again and said she could extract the tooth or refer him to a private endodontist. An endodontist is a dental professional who specialises in diagnosing and treating issues relating to the dental pulp and surrounding tissues. Dental pulp is the soft, innermost tissue of a tooth.

Mr H then went to a private endodontist on 6 May. The endodontist said there was a missed entomolaris canal and redid the LL6 RCT. An entomolaris canal is an additional root uncommonly found in lower molars.

7. Before we decide if we should investigate a complaint in more detail, we look at a few different factors. We consider whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.

8. If what happened fell far short of what should have happened, we call this a failing. We also look at whether what happened had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.

We have done this and have not found any indications that something has gone wrong.

Communication

9. Mr H told us that he did not remember signing a consent form or treatment plan and the dentist did not make him aware of the limitations of NHS practice.

10. The Practice provided a copy of the treatment plan that Mr H had signed and said that the dentist had told him the common risks of RCT, including the possibility of failure and offered other options of extraction or referral to a specialist endodontist.

GDC Standards say that dentists must obtain valid consent and consider what a reasonable person would expect to know before deciding to proceed with treatment. They also say that records can be written in a concise way. This means that dentists do not have to discuss every possible risk associated with a proposed treatment. Our adviser indicated that this means dentists should discuss the most common or most relevant risks with the patient and that a timely, written treatment plan including key information should be provided for the patient to sign.

11. Records indicate that the dentist communicated the common risks of RCT and other treatment options to Mr H before they carried it out. This included the risk of failure, which is what unfortunately transpired. These were detailed on the treatment plan Mr H signed before the treatment.

The dentist did not outline as a potential risk the possibility of a missed canal. Our adviser informed us this is not a common risk although it can be mentioned. Based on this, we think that although the dentist could have told Mr H about the possibility of a missed canal, given its rarity, this was not a requirement. Clearly, in Mr H’s case, with hindsight, he feels that this information would have been useful – either at this point, or afterwards, which we address later - but there is no indication that such a risk was so relevant or important to Mr H that the dentist should have raised it in addition to the more general risk of failure. We consider that the dentist informed Mr H appropriately of the common risks in line with relevant guidelines prior to his RCT.

Mr H and the Practice disagree about whether he was informed of possible limitations in NHS treatment, compared with specialist. We do not have any evidence to support either position – nothing is documented in the records, but that in itself is not unusual. They do not have to be verbatim. Our adviser explained that in this case, an appropriate consent process would ordinarily include informing the patient of reasonable alternative options, including treatment by a practitioner with enhanced skills or a specialist, where this may influence prognosis or treatment experience.

They noted, however, that although specialists will possess greater knowledge and skills and often more advanced equipment, there is no guarantee that their treatment will be successful. We also do not know whether Mr H would have made a different choice had he been told he could pay to see a specialist; after all, it is only with hindsight that we know about the complication that caused the procedure to fail.

As stated above the dentist advised Mr H of potential risks prior to the RCT including potential failure of the RCT as per the consent form. After Mr H complained, the practice explained how it was not possible to identify the extra root (as outlined below) by referring to ‘limitations of NHS practice’, which includes standard X-ray machines. The signed treatment plan records that Mr H had the opportunity to ask questions and also that the dentist made no assurances concerning the results from the procedure. While we cannot know the verbal discussions that took place at the time, on balance, we consider this sufficient evidence the dentist made Mr H aware of the key information he needed before the RCT.

RCT

Mr H told us that the dentist did not complete the RCT properly, completed it too quickly and missed a root which caused an infection. He also said that the dentist did not use a waterproof dental dam. A dental dam or rubber dam is a thin square sheet used to isolate the operative site (in this case one tooth) from the rest of the mouth. It stops saliva and other fluids contaminating the treatment area.

The Practice said that the dentist who carried out the treatment was a registered general dentist and not a specialist. It said the dentist worked within the scope of their training, materials available and limitations of NHS practise. It said a fourth root is a rare anatomical variation that was very difficult to detect with standard technology available to general dentists. It explained the time required for treatment varies depending on the case.

It said that with any procedure, complications can arise and root canals can sometimes fail. It said when they are performed under limitations of NHS practice equipment and standard X-ray systems, more complex cases can be difficult to manage.

BES guidance indicates that the steps in a RCT are typically to administer an anaesthetic, fit a waterproof dental dam, open the tooth with a drill, clean inside the tooth with solution, shape the root to fill and fill the root. Our adviser told us that the dentist’s notes demonstrate a standard approach as expected for a RCT with most elements being described including the use of a rubber dam. They told us the X-ray images taken after the RCT indicate that appropriate treatment was carried out.

It transpired that Mr H had an anatomical variation called a ‘radix entomolaris’ which is rare and occurs in less than 5% of the population. It is known to be a challenging anatomical variation where there is an extra root canal. Our adviser told us it would not be expected that a fourth entomolaris canal would always be identified in general dental practice.

Our adviser reviewed the X-rays provided and told us that they cannot clearly see a root outline that would indicate an extra root, which would mean there was an additional canal to treat. Given the fourth canal was not identified, there is nothing to suggest the dentist completed the RCT inappropriately. They simply did not know the fourth canal was there and, based on the evidence available to them, could not reasonably have known.

We cannot comment on the exact duration of the RCT as there is no evidence in the records and this is not an expectation in endodontic record keeping. However, our adviser said that RCT can commonly take 30 to 60 minutes. So, even accepting Mr H’s complaint that it took 30 minutes, this is not in itself an indication that something went wrong.

As mentioned above, the dentist wrote in the notes that they used a rubber dam. Mr H told us that he believed one was not used. Our adviser could see not see any indications that this was the case. As we have no other evidence to suggest the dentist did not use a rubber dam, we conclude that on the balance of probabilities that a dental dam was used.

Post-surgery issues

Mr H told us that the dentist did not treat the issues he raised post-surgery appropriately because they did not tell him the pain and swelling could be caused by a missed root canal. He says he asked if all the canals had been treated and was assured that they had been. He said if he knew a canal might have been missed, then he may have gone to a private orthodontist earlier.

The Practice said it said it took steps in line with correct protocols followed by general dentists in situations when RCT has not been successful. It said that the dentist advised Mr H that symptoms can take time to settle following RCT and set out what happened at both follow-up appointments in December and March.

The GDC guidance says that dentists must work within their knowledge, skills, professional competence and abilities and refer patients to an appropriately trained colleague when needed.

Mr H went back on 19 December with symptoms of pain and swelling. The dentist prescribed antibiotics to treat any infection causing the symptoms and advised Mr H to return if it got worse for an extraction of the LL6 tooth or referral to a specialist.

We have already established that the dentist did not know – and could not reasonably have known – that there was a missed canal. So, it follows that we would not expect them to have raised this as a possibility at this stage. Importantly, whatever the cause of the failure, the options were likely the same for Mr H – referral to a specialist or extraction. And crucially, the dentist mentioned both of these things at this appointment.

Mr H returned on 20 March presenting with ongoing pain and swelling. The dentist prescribed antibiotics and offered to extract the tooth or refer to a private specialist. Mr H elected to seek further treatment independently. Any delay in arranging this referral appears to have been down to the timing of Mr H’s return to the Practice to confirm that his swelling and pain had not settled.

We have no doubt that Mr H suffered ongoing pain and discomfort after his treatment. It is, of course, incredibly unfortunate that it failed. That was one of the risks he consented to and is not necessarily an indication that the dentist got anything wrong. We hope this decision provides him with some reassurance about the treatment he received.

1. We have carefully considered Mr H’s complaint about the Practice and are sorry to hear of his difficult experience following his root canal surgery.

2. We have seen no indication that anything went wrong in Mr H’s treatment and care. We have, therefore, decided not to investigate in more detail or take any further action.

3. We acknowledge that, unfortunately, his treatment failed, and he was in pain for some time after it. That is not because the dentist got anything wrong – it is because of a rare complication that the dentist did not identify, and could not reasonably have identified.