Summary
C complained about the dental care and treatment that they received. C underwent root canal treatment (RCT) on their lower right tooth. C said that this was not performed appropriately and that they should have been referred earlier to an endodontist (a dentist with special training to treat problems affecting the inside of the tooth). C was also concerned that the dentist had caused injury to the inferior alveolar nerve (a nerve that runs through the lower jaw, providing sensation to the lower teeth, gum, lip and chin), left a gap in their tooth and caused a dent to another tooth.
We took independent advice from a dentist. We did not find conclusive evidence that the dentist caused injury to the inferior alveolar nerve or a dent to C's tooth. We noted that the dentist did refer C to the endodontist but we did not find conclusive evidence that this should have happened sooner. However, we concluded that the dentist did not follow current guidance on endodontic practice. There was no evidence of the use of special tests or periapical radiographs (an x-ray that shows the entire tooth, from the crown to the root tip and surrounding bone) taken before the RCT was performed. As such, it was not possible to determine the case complexity. The dentist also used incorrect solution to irrigate the tooth canal and used an old method for assessing the quality of the radiograph imaging taken. Therefore, we upheld C's complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: The dentist should take the following actions. Read through the Professional duty of candour from the General Dental Council and make reflective notes. Read through A Guide to Good Endodontic Practice and make some reflective notes. Read through Section 5.4.1 of Guidance Notes for Dental Practitioners on the Safe Use of X-ray equipment (Second Edition, 2020) and make some reflective notes. Read the following article (https://www.dentalprotection.org/uk/articles/tempted-to-change-the-records) from Dental Protection and make some reflective notes. Undertake a CPD course on Endodontics (e.g. Turas online courses from British Endodontic Society) https://learn.nes.nhs.scot/59573 In relation to complaints handling, we recommended: The dental practice’s complaints procedure should be revised to ensure it aligns with SPSO’s Model Complaints Handling Procedure: www.spso.org.uk/the-model-complaints-handling-procedures. If further assistance is required with this, the dentist / practice can contact the SPSO’s Improvement, Standards and Engagement Team: https://www.spso.org.uk/training or NHS Lothian.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202411526 as a PDF (28.59 KB) Updated: November 17, 2025