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Selected Investigations Completed April - September 1998 > Part II, Case no. E.1283/97-98

Part II - Full Texts of Selected Investigations

Case No. E.1283/97-98 - Failings in dental treatment

Matters considered: Inadequate diagnosis; treatment inappropriate and poorly explained

Complaint against: A general dental practitioner in the East Sussex, Brighton and Hove Health Authority area

Complaint as put by Mr M

1. The account of the complaint provided by Mr M was that he attended the dental practice in November 1996 and was treated by the general dental practitioner (the dentist). He had experienced symptoms on the lingual surface (back) of a lower front tooth which he thought might have been caused by some filling material there. The dentist proposed fitting a veneer (thin covering) to the tooth. Mr M understood that this would be fitted to the lingual surface of the tooth, and believed that that surface of the tooth was prepared. However, the veneer was fitted to the labial surface (front) of the tooth and he subsequently suffered painful symptoms. The following day the veneer was removed and filling material was applied to the lingual surface of the tooth. On 14 December 1996 Mr M complained to the dental practice, and the dentist replied on 16 January 1997. A conciliation meeting took place on 1 April 1997 but Mr M remained dissatisfied. He requested an independent review of his complaint, but that was refused. Mr M then wrote to the Ombudsman.

2. The matters investigated were that:

1. the cause of the problem with Mr M's tooth was not identified;
2. the treatment itself was inappropriate; and
3. the treatment was not adequately explained to him.

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Investigation

3. The statement of complaint for the investigation was issued on 16 January 1998. Two independent professional assessors (EPAs) were appointed to advise on the clinical issues in this case and their report is attached at Appendix A. The Ombudsman's investigator interviewed Mr M and, together with a professional assessor, interviewed the dentist and the principal at the practice where the dentist was working at the relevant time. The principal's actions are not the subject of the investigation. Relevant papers were examined, including Mr M's clinical records.

Guidance

4. In May 1993 the General Dental Council (the body which regulates the professional conduct and standards of dentists) published a booklet entitled 'Professional Conduct and Fitness to Practise'. It includes the following:

'consent: dentists must obtain valid consent prior to carrying out treatment. For consent to be valid the dentist must himself or herself have explained to the patient the treatment proposed, the risks involved in the treatment, and alternative treatments ...

'referral for further advice/treatment: when accepting a patient for treatment, a dentist assumes a duty of care which includes the obligation to refer the patient for further professional advice or treatment if it transpires that the task in hand is beyond the dentist's own skills ...

'standard of care: the public is entitled to expect that a dentist will provide a high standard of care and the Council is liable to take a serious view of any neglect of a dentist's professional responsibilities to his or her patients for their care and treatment ...'

Evidence of Mr M

5. Mr M said that his problems began in September 1996 after he attended a different dentist (the first dentist) for a check-up. He noticed that a small chip was missing from a lower front tooth. The first dentist filled it, but afterwards the back of the tooth was rough. Two days later he began to experience an unpleasant, chemical taste in his mouth, which he attributed to the filling material. He attended another dentist (the second dentist) who tried to remove the filling material, but his symptoms recurred. On 12 November he attended the dentist's surgery, complaining of the taste and of a burning sensation in his mouth and explaining that he thought it might be a reaction to the filling material. She removed about half the thickness of the tooth at the back. He was given an appointment for the following week. The dentist said she would talk then about restoring the tooth.

6. When he returned on 19 November he told the dentist that the taste had gone but that he was still experiencing a burning sensation, as if he had been eating chilli. There was no pain. The dentist wanted to refer him to a specialist, but he was in considerable distress and wanted the problem sorted out as soon as possible. The dentist then called the principal into the surgery and there was a discussion among all three about the best course of action. He could not remember the conversation exactly but recalled that the principal suggested a porcelain veneer for the back of the tooth. He accepted the proposal because it seemed a logical way to address the problem. He would not have agreed to a veneer on the front of the tooth, as this would not have been logical when the problem was on the back. The principal left, and the dentist began preparing the tooth. She took away about 2-3 mm from the tip of the tooth and scored the back of the tooth near the gum. The treatment was quite painful. She wanted to know the name of the first dentist, saying that she needed to discuss the problem with him. Mr M reluctantly gave her the information.

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7. He returned on 26 November for the veneer to be fitted. The dentist did a lot of painful work at the back of the tooth, but eventually said that she was satisfied that the veneer was fitted properly. She told him that the veneer might feel uncomfortable at first, being big and bulky, but that he would get used to it. As soon as he got out into the cold air he was in agony. Hot drinks also caused him pain. He looked in a mirror and was surprised to find that the veneer had been fitted to the front of the tooth, although he could not see anything on the back. The front and top of the tooth had been covered by the veneer and the back of the tooth had been smoothed. The enamel was very thin and there was one spot which looked dull and was painful to the touch. He rang the surgery immediately and was given an appointment for the next day. He noticed that the bottom of the veneer overlapped the gums, which bled when he brushed his teeth.

8. When he returned the next day the dentist's immediate reaction was to remove the veneer. She did not explain why the veneer had been fitted to the front rather than the back. The tooth was then shorter than his other teeth. He thought that some dentine had been uncovered and he was still in pain, but the dentist seemed unconcerned. He insisted that she put some covering over the painful area. This she did, leaving a bulbous lump of material on the back of the tooth. He was not unduly concerned about her using filler as that which she had already used to fix the veneer had not given him any symptoms, and he assumed that she had checked with the first dentist to make sure that she avoided the one which had caused problems. The pain was reduced, but a few days later his original symptoms returned. Mr M considered that the dentist must have used the same filler as the first dentist although she knew it had caused problems. He discovered later that she had not contacted the first dentist to find out what material he had used.

9. Mr M said that since being treated by the dentist he had consulted three other dentists and a number of specialists. A crown was fitted and subsequently removed. He had continued to suffer from unpleasant tastes in his mouth. He was still under the care of a specialist. After he complained the dentist offered to refund the fee he had paid for his treatment. He considered that unacceptable.

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Clinical records

10. An entry, dated 12 November 1996, on Mr M's dental record card states that on examination he was complaining of a chemical reaction to 'material—filler' used on a lower front tooth. An entry, dated 19 November, states:

'still burning sensation [lower front tooth], can't touch tooth with tongue + dry mouth, bad taste—sour ... Discussed situation with [the principal], both decided with the patient that [porcelain] veneer best option ... Patient [very] insistent that wants [treatment] done soon rather than wait for a referral ...'

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Evidence of the dentist

11. The dentist was invited to provide her written comments on the complaint when the investigation was proposed. She did not take up that invitation.

12. The dentist told the investigator that she qualified in July 1995 and then undertook a year's vocational training. She had been at the practice for about three months when she treated Mr M.

13. The dentist said that on 12 November Mr M described his symptoms as distress and discomfort associated with his lower right central incisor. He described a burning sensation on the end of his tongue and a bad taste coming from the lingual surface of his tooth, saying that he thought there might be a chemical reaction to the filling material which was on the tooth. On examination there was little to see. There was a slight chip in the tooth, and Mr M described some 'filler' having been chipped off by a previous dentist. She could see a small amount of filling material on the tooth which she assumed was a composite material. At that stage she could make no diagnosis. Given the small amount of damage to the tooth she did not consider that it was likely that there was damage to the pulpal tissue. She had taken an x-ray which showed no evidence of abnormality. It would also have been her practice to test the sensitivity of the tooth. As nothing about that is recorded in the notes she suggested when interviewed that the result must have been normal. The dentist had felt that she might not have been the right person to treat Mr M; she had offered to refer him to a specialist. He was insistent that something should be done at that visit because of his discomfort. He seemed reluctant to take her advice. She was still unable to form a diagnosis, and considered that her only conservative option was to remove the filling material and re-assess the position one week later. She therefore removed all visible traces of the composite material.

14. On 19 November Mr M complained of the same symptoms. The dentist again suggested referral, but Mr M again refused. She therefore asked her principal for advice. The principal also considered that a referral would be the best course of action but, in the light of Mr M's refusal, suggested a porcelain veneer for the lingual surface of the tooth as an alternative. The dentist agreed to try it. She had explained to Mr M that the veneer would cover the chipped area of the tooth and the area which had been giving rise to symptoms with an inert substance. Mr M was content with the proposed treatment and so she proceeded. Little preparation of the tooth was necessary: she had smoothed the incisal edge, and removed about half a millimetre of enamel from around the back of the tooth at gum level. She could not remember whether there was any dentine exposed. Mr M had not complained of discomfort or pain during the preparation. The tooth did not require dressing.

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15. The dentist said that when Mr M returned on 26 November for the veneer to be fitted, she found that the technician had incorrectly made the veneer to cover the labial aspect and incisal edge, rather than the lingual surface and incisal edge (ie for the front of the tooth rather than the back). She explained to Mr M that the treatment was going to be different, and where the veneer would now be fitted. She could not remember whether she made any reference to a mistake having been made by the technician. She had considered the option of remaking the veneer. However, she did not think that she put that option to Mr M: he did not give her the chance. He had been desperate for treatment. She assumed that Mr M had understood, and he had appeared happy with what she was proposing. She then fitted the veneer. She did not do any further work on the tooth, and her only recollection of smoothing it was to remove excess material used to fix the veneer.

16. The dentist said that Mr M returned on 27 November complaining of pain with changes of temperature. Sometimes the mouth became sensitive when treatment had been carried out. The dentist said she then considered that the only two options were to leave things to settle for a few days or to remove the veneer. She suggested leaving it for a while, but Mr M was not prepared to do that. He was adamant that he wanted the veneer removed. She acceded to his request and removed the veneer. With hindsight she felt that she had lost the initiative, and that Mr M had taken over the treatment planning. She could see no clinical reason to use any filling material, but placed some composite on the lingual aspect of the tooth at Mr M's request. She had been aware she might have used the same material which had apparently precipitated his problems in the first place, but added that Mr M had left her with little choice.

17. The dentist said that with the benefit of hindsight, she should have insisted that Mr M was referred to a specialist, but that it was very difficult to send someone away without having helped them. He had been very insistent about wanting treatment immediately. She felt that she had allowed herself to be 'cornered' into doing something which she might not otherwise have done. She said that she had considered the possibility of an allergy to the filling material, but understood it to be a rare phenomenon. Checks for any allergy could have been done by a specialist, had Mr M agreed to a referral. She had originally seen no purpose in contacting the other dentists who had treated Mr M because at that stage she had not intended to use any similar materials.

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Evidence of the principal

18. The principal said that, when consulted by the dentist, she had suggested replacing the filling but Mr M was adamant that he did not want that. As there was already some tooth tissue lost, she considered that little more preparation would be needed to fit a veneer. The use of an inert material, such as porcelain, would overcome both the problems of taste and irritation by providing a smooth, inert, durable surface. She was aware that that was an unusual course of action but felt that it was an appropriate response to Mr M's problem. She and the dentist had considered referring Mr M to a specialist but he had insisted that he could not wait. The principal said that she had considered the implications of having to use a 'white material' to fix the veneer, given Mr M's complaints about 'white fillers'. She concluded that there was a significant difference between the small amount of material which would be exposed in the mouth when the veneer was fitted, and the large amount of material left on the surface of the tooth with an ordinary filling. She said that she had put the suggestion of a veneer to the dentist, who was able to make her own decisions. She considered the dentist to be a good dentist who tried to do her best for everyone. She described Mr M as rather demanding.

Findings

19. In reaching my findings I have taken into account the report prepared by the Ombudsman's assessors on the clinical issues involved in this complaint (Appendix A), in addition to the oral and written evidence obtained during the investigation.

Complaint (a)
Cause of the problem not identified

20. When Mr M first consulted the dentist he had two problems: a lower tooth was chipped and there was an unpleasant taste and burning sensation in his mouth, which he thought was an allergic reaction to filling material on the chipped tooth. The external professional assessors tell me that these are not common symptoms. They also advise that, within the confines of a general dental practice, the dentist correctly tried to identify the problems and correctly concluded that a specialist opinion was needed. Mr M rejected that repeated recommendation. A third problem developed after the veneer had been fitted to the tooth, when Mr M began to experience pain with temperature changes. The assessors have indicated that it was reasonable of the dentist to suggest those symptoms might be due to residual sensitivity following preparation of the tooth for the fitting of the veneer. Mr M was not prepared to wait. I cannot see that difficulty in identifying the cause of the problems was due to any failing on the dentist's part. I do not uphold the complaint.

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Complaint (b)
Treatment was inappropriate

21. The dentist first tried to remove residual filling material and then, after taking advice from the principal, decided to fit a veneer to the back of the tooth. The assessors conclude that while that use of a veneer was unusual, it was an appropriate treatment. However, by mistake, a veneer was made for the front of the tooth. Instead of explaining that fully to Mr M and obtaining and fitting the veneer as originally planned, the dentist changed the plan and fitted the one made. That should not have been done. I acknowledge that the dentist, although fully qualified, was relatively inexperienced and found it difficult to resist Mr M's insistent demands for treatment. Although I do not underestimate the difficulties she faced in dealing with Mr M, I cannot condone her decision to fit the wrong veneer.

22. The dentist again let herself be persuaded by Mr M to act against her better judgment, when she later applied more filling to the back of his tooth although she did not think that clinically necessary. I am advised that white filling materials were the only ones which could have been retained without further preparation of the tooth. For that reason, if any material was to be applied to the back of the tooth, there was little choice but to use a white material. I note that the dentist felt under pressure from Mr M to put something on the back of his tooth, but the Ombudsman's professional assessors say that doing so was of 'doubtful clinical necessity' and given the possibility that the white material might be linked with the earlier symptoms, I consider that the dentist would have been better advised to follow her own judgment and not to apply the material to the back of the tooth. To the extent described in this and the previous paragraph, I uphold the complaint.

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Complaint (c)
Treatment not adequately explained

23. The plan to fit a veneer to the back of the tooth clearly was understood and accepted by Mr M. However there is a conflict of evidence as to whether the change of plan—to fit the veneer to the front rather than the back—was explained. Mr M is adamant that had he known that was intended he would not have agreed, because there was no logical reason for such treatment. He says he only realised exactly what had been done on 26 November when he got home and looked in the mirror. The dentist said that she had explained to him that the treatment would be different from that originally planned and noted on the clinical record that he was happy. It is impossible to determine exactly what the dentist said about the change of plan, as the conversation happened in the privacy of the dental surgery. However, Mr M has demonstrated a detailed and accurate recall of many of the events associated with his treatment and the dentist accepts that she did not discuss the option (which in my view was the natural and obvious one) of remaking the veneer. Her description of relations with Mr M suggest that she had felt somewhat intimidated by him, which might have made her reluctant to explain fully the problem with the veneer. I therefore conclude, on balance, that any attempt she made to explain the changed plan was inadequate. To that extent I uphold the complaint.

Remedy

24. I turn now to the question of an appropriate remedy for the failings identified above. In doing so I have taken into account the advice of the external professional assessors and information from the Ombudsman's own internal dental adviser. Had the dentist acted correctly, Mr M would have been left with a veneer on the back of his tooth. Instead, after the veneer had been removed from the front, he was left with a tooth prepared for a veneer at the back (and with some white filling material applied), but no veneer. I note (paragraph 9) that the dentist has already offered to refund to Mr M the full cost of the treatment she gave him, including that of an initial private appointment: that would be sufficient to cover the cost of removing the white filling material and applying a veneer to the back of the tooth. That would put him back in the position he would have been in had the dentist's treatment proceeded correctly. It therefore seems to me to be an adequate remedy for the failings I have identified. I recommend that the dentist refunds to Mr M the fees which he paid to her, as she has already offered.

25. I am aware that Mr M did not consider that offer adequate and that he did not in fact have another veneer made for the back of his tooth. He has since had significant other treatment on the tooth, from more than one other dentist and (paragraph 9) has been under the care of a specialist. However, despite their efforts, he continued to have problems with an unpleasant taste in his mouth. It is impossible to be certain what would have happened if the dentist had properly fitted a veneer to the back of Mr M's tooth. But, in the light of the professional advice that I have been given, I consider that it is most probable that his continued problems and need for further treatment would still have occurred. It therefore does not seem to me reasonable that the dentist should be held responsible for the cost of subsequent treatment, since the need for it did not arise from failings in her treatment but from the original problem with which Mr M first approached her (and for which she recommended specialist advice), and I do not consider that there are adequate grounds to suppose that she significantly aggravated that problem. I have also considered whether further recompense, above what the dentist has offered, would be appropriate. However, I cannot see that Mr M was subjected to such an unreasonable level of discomfort and inconvenience because of the dentist's failings as to justify such a payment.

Conclusion

26. I have set out my findings in paragraphs 19-25. The dentist has asked me to convey—as I do through my report—her apologies to Mr M for the shortcomings I have identified and has agreed to my recommendation in paragraph 24.

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Appendix A to E.1283/97-98

Report by external professional assessors.

Introduction

1. We were asked to advise on each aspect of Mr M's complaint:

1. the cause of the problem with Mr M's tooth was not identified;
2. the treatment itself was inappropriate; and
3. the treatment was not adequately explained to him.

Basis of our report

2. We received and reviewed relevant documents including:

1. Mr M's letter of complaint to the dentist dated 14 December 1996;
2. the dentist's reply dated 16 January 1997 and a copy of her letter to the Dental Defence Union dated 2 January 1997;
3. notes of interview with Mr M by the Ombudsman's investigator on 23 April 1998;
4. notes of interview with the principal by the Ombudsman's investigator and one of the EPAs on 25 May 1998;
5. notes of interview with the dentist by the Ombudsman's investigator and one of the EPAs on 26 May 1998; and
6. copies of dental records from the dentist and from a previous dentist. Relevant radiographs provided by the dentist.

Complaint (a)
Cause of problem with Mr M's tooth not identified

3. Initially there appear to have been two problems followed later by a third:

1. a lower incisor tooth had a fractured corner which required restoration and had been restored with a white filling material by a previous dentist;
2. there was an unpleasant taste in the mouth and a burning sensation as if chillies had been eaten. Mr M associated these symptoms with the placement of the filling material; and
3. after the veneer was fitted to the tooth there was discomfort (agony) to temperature changes.

4. The symptoms of the chemical taste and the burning sensation in the mouth are unusual. It could possibly have been associated with an allergic reaction to the filling material, but there are other causes. The appropriate course of action would have been to refer to a specialist hospital consultant who would have arranged for any necessary tests. The dentist had recommended referral, as indeed had the previous dentist. Mr M refused the referral and had pressed for treatment, as he was clearly distressed by his problems. The 'offending' filling material was removed with relief of only some of the symptoms. The tooth had been tested for vitality and a necessary radiograph had been taken to check for any pathology or abnormality in the area. The dentist was a relatively inexperienced general practitioner as she had only finished her vocational training year some three months earlier so she sought another opinion from the senior partner in the practice. Again referral was recommended but a course of treatment was outlined to restore the tooth.

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5. After the veneer had been fitted the patient returned the following day complaining that the tooth was sensitive to temperature changes (which can indeed be very painful for short periods of time), and that the veneer was fitted to the wrong surface. It is not uncommon that teeth can be sensitive after restorative treatment, particularly when they have been etched with an acid, which is essential when attaching a veneer. They may take a few days to a week to settle down and it is normal to reassure the patient to this effect, but to ask them to return if the situation persisted or became worse. The dentist suggested that the tooth was left for a short time to see if it would settle, but acceded to the request to remove the veneer, as Mr M was convinced that it was causing his problems because it had been fitted on the wrong side of the tooth. Again some filling material was placed on the tooth at his request, although there was doubtful clinical necessity. The white materials are the only ones that can be retained on the tooth in this situation and, therefore, there would have been little choice other than to have used one which, possibly, could have caused symptoms with the tongue and mouth originally. Mr M did not return to the practitioner with any further or persistent symptoms and, therefore, could not have been reassessed.

6. We would conclude that the dentist had correctly tried to identify the unusual problems within the confines of a general practice and had repeatedly expressed the need for a specialist opinion. She had allowed herself to be pressed into trying to help the patient by his insistence for treatment. The events that have followed with treatment by another dentist, treatment by a specialist at the local hospital and eventually with treatment at a dental teaching hospital have all failed to resolve the problem, which is obviously of a very complex nature.

Complaint (b)
Treatment inappropriate

7. Mr M was convinced that the filling material was the cause of his problems, and indeed some of the symptoms had improved after it was removed. In discussion with the senior dentist at the practice it was decided to provide a porcelain veneer to restore the chipped tooth as this was an inert material. It was to be placed on the lingual (back) surface of the tooth to cover the fractured area as the enamel chip had extended down this surface. This is an unusual position for a veneer: they are usually made for aesthetic reasons and placed on the labial (front) surface of the tooth to improve the appearance. This surface was minimally prepared to accept the veneer. It would appear that the laboratory made the veneer for the front of the tooth and it was fitted to this surface.

8. We would conclude that the prescription of the veneer for the lingual surface of the tooth was appropriate. However the wrong veneer was made and should not have been fitted. The mistake should have been admitted and a new, correct veneer constructed and fitted.

Complaint (c)
Treatment not adequately explained

9. Throughout these considerations Mr M has been very clear about what was happening to his tooth and has provided what appear to be very accurate diagrams. The discussion about the veneer by the dentist and her colleague involved Mr M and we believe he was in agreement with the reasonable treatment plan since he allowed the preparation to proceed.

10. We are unclear about what happened and what discussion took place when the veneer was fitted. The dentist said that she explained the veneer was to be fitted to a different position on the tooth, that Mr M was happy (a note to that effect was made on the record card), that he paid his account and left the practice. Mr M maintains that it was only when he got home he realised that it had been fitted, incorrectly, to the front of the tooth. He suffered subsequently increased temperature sensitivity to the tooth, returned the following day to have the veneer removed, and did not return to the dentist for further treatment.

11. On balance we believe Mr M to be a good witness to his treatment and we are doubtful whether, in layman's terms, he received an adequate explanation as to why the veneer was to be fitted to a different surface of the tooth. We also believe he was not told that the veneer had been constructed incorrectly to the prescription.

Conclusion

12. We are aware that the dentist, a relatively inexperienced general practitioner, was confronted by an articulate and strong minded patient with unusual and distressing symptoms, who had already seen two colleagues recently in the area. Whilst the treatment prescription was reasonable in the circumstances, the incorrect veneer should not have been fitted and the explanation about the incorrectly constructed veneer should have been given to Mr M.

13. We understand the dentist was considered a good dentist by her principal, and that she tried to help patients. Wisdom that comes with time is most useful to confirm the need to refer patients when the clinical situation is beyond a practitioner's experience.

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Explanation of terms

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Last updated: 12 January 2006