Home > Publications > Selected Cases - Health >
Selected Investigations Completed April - September 1999 > Part II, Case no. E.544/98-99
Complaint against: Mr G Capon: a general dental practitioner in the Southampton and South West Hampshire Health Authority area
Complaint as put by Mrs A
1. The account of the complaint provided by Mrs A was that between 1991 and 1997 she was treated by her dentist, Mr Capon. On 10 September 1997 she told Mr Capon about problems she was suffering with her gums, teeth and dentures but was dissatisfied with his response. She felt that he was not interested in her problems. She then consulted a second dentist who told her that two of her teeth were suffering from decay and that her gums were inflamed and in poor condition.
2. The complaint investigated was that Mr Capon did not adequately assess and treat Mrs A's tooth decay and gum disease.
Investigation
3. The statement of complaint for the investigation was issued on 10 August 1998. Mr Capon's comments were obtained and relevant papers, including dental records and radiographs (X-rays) taken by Mr Capon and by Mrs A's second dentist, were examined. The Ombudsman's staff took evidence from Mrs A and Mr Capon. The Ombudsman appointed two independent professional assessors (general dental practitioners) to advise him on the clinical issues in this case: their report is included at paragraphs 11 to 24 of this report. I have taken into account the fact that the actions of general dental practitioners before April 1996 are outside the Ombudsman's jurisdiction: events before that date are referred to in this report to provide background information relevant to subsequent events.
Back to top
Legislation
4. Paragraph 20 of the National Health Service (General Dental Services) Regulations 1992, Schedule 1, Terms of Service for dentists includes:
'In providing general dental services, a dentist shall -
'.... provide .... care and treatment, to such extent, and at such intervals, as may be necessary to secure and maintain the oral health of the patient.'
Mrs A's evidence
5. Mrs A said that she attended Mr Capon's surgery regularly from 1991. Her mouth had been sore before she saw Mr Capon. Her gums occasionally bled and her teeth had been becoming looser. She believed that Mr Capon would provide preventive treatment to help her keep her teeth, rather than extract them. During the period she saw Mr Capon the condition of her gums worsened. By 1997 her gums still only bled occasionally, but they caused her more pain and difficulty in chewing. She had been unable to see Mr Capon for a period following her 3 July 1996 appointment because of medical problems which involved her being in hospital. However, she did not think that there had been any greater deterioration in the condition of her teeth and gums during that period than generally.
6. Mr Capon did cleaning work on her teeth himself, and told her things were fine. Her top teeth were loose. In 1997 Mr Capon did various work to her teeth. He did not tell her why he was doing the work or what might happen in the future. She explained, as she had before, about the problems with her teeth. When she told him about the pain he simply told her to rub her teeth with special toothpaste for sensitive teeth. When she complained of a bad taste in her mouth he told her to use mouthwash. At an appointment in September 1997, she told him that a bridge was loose and again about her gums. She did not feel that Mr Capon listened to what she said about that. Her next appointment with Mr Capon was for January 1998. However, instead she then consulted, privately, the second dentist (in October 1997). He said that her mouth was in a bad state.
Back to top
Mr Capon's evidence
7. Mr Capon said that Mrs A came to him saying that her previous dentist had said that at least six teeth would need to be removed but she wanted to keep them for as long as possible. He saw her approximately three-monthly until 1995. He provided regular treatment including thorough scaling (with an ultrasonic descaler) and polishing and oral hygiene instruction. He would always check tooth mobility, pocketing (space between the tooth and the gum) and bleeding. He told her she should clean her teeth thoroughly twice a day and use floss. He pointed out areas she was missing and demonstrated techniques. Because her prognosis was very poor he did not record in the clinical notes his monitoring of her condition. Her teeth and gums were so bad that it would have been repetitious to record their state at each visit. He did not expect that she would keep all her teeth but by 1996 her condition had stabilised. She was losing fewer teeth than before, an average of about one a year.
8. Mrs A's condition deteriorated again during the break in treatment between 1996 and 1997. The rate of degeneration could be swift when teeth were already in a poor state. Her medical treatment might also have affected matters. He told her about the state of her teeth and he planned, with her assistance, to continue to attempt to stabilise the situation as he had done before. At the appointment on 18 August 1997, he decided that Mrs A needed three fillings. (Note: the records show they were done that month.) He had not been aware that her bridge was loose; she had not told him that. He did, however, check bridges as part of his standard dental examination.
Back to top
9. On seeing the radiographs taken by the second dentist (see paragraph 18) he agreed that they showed root decay in the UR3 (upper right canine tooth) - though they might also show a composite filling. He felt that the apparent cavity in UL2 (upper left second incisor) might in fact be a dressing. He felt that he would not have missed such a cavity when scaling and polishing Mrs A's teeth.
10. With hindsight, he considered that Mrs A's condition might have benefited more from the removal of teeth or from prolonged gum treatment. He now always noted relevant information about treatment in a patient's clinical records.
Independent Assessors' Report
Introduction
11. We were asked by the Ombudsman for an opinion on whether Mr Capon adequately assessed and treated Mrs A's tooth decay and gum disease.
Clinical records
12. Two sets of clinical records were available: those taken by Mr Capon between 1991 and 1997; and those taken by the second dentist who was consulted by Mrs A later in 1997. Radiographs were included with both sets of records.
Back to top
Mr Capon's records
13. Mr Capon's clinical records show that Mrs A was first seen on 6 November 1991 and attended the practice regularly and frequently until the end of 1994. She was seen twice in 1995 and twice in 1996. There was a gap in the appointments between July 1996 and July 1997.
14. The records are scant and refer only to items of treatment provided, arrangements for future appointments and charges made. Some treatments are not fully recorded. There is no reference to the pre-existing condition of the mouth except for incomplete charting of teeth present. Pre-existing fillings are not recorded. There is no note of the condition of the gums at any point in the records. Scaling and polishing of the teeth is recorded from 1992 until 1996 at approximately three-monthly intervals. There is no indication of improvement or deterioration in the gum condition. Among other recorded treatment, fillings were provided at UR3 buccal (the side of the tooth nearest the cheek or lip) and UL2 mesial (the side nearest the front of the mouth) in August 1997.
Back to top
The second dentist's records
15. The second dentist's records clearly indicate the advanced gum disease, with pocket depth chartings throughout the mouth. He also notes soft decay at UR3 and UL3. (Note: see paragraph 16, below.)
Comment on records
16. There is some confusion in the two sets of records about UL2 and UL3. Mr Capon, in a letter to Mrs A, remembers extracting UL2 and fitting a bridge. In his clinical notes, Mr Capon records that he carried out a filling on UL2 on 18 August 1997. The second dentist records this tooth as UL3. An examination of his radiographs suggests that either UL2 or UL3 is missing but that the space has closed, making it unclear whether the tooth described by Mr Capon and the second dentist is in fact UL2 or UL3. It does seem, however, that they describe the same tooth, which we will now refer to as UL2/UL3.
Back to top
Mr Capon's radiograph
17. The only radiograph taken by Mr Capon was a panoramic view dated 8 September 1993. Some teeth are almost invisible on this film. Although the film is poor, it is obvious that Mrs A's teeth and gums were in a parlous state as far back as 1993. Only 18 teeth were present at that time. The radiograph shows extensive bone loss, indicating longstanding gum disease, with furcation involvement certainly at LL7 and probably at LR7 and UR7 also. (This means that the loss of bone extended beyond the division of the roots of the teeth, making it exceedingly difficult to achieve the necessary standard of cleaning to prevent further deterioration.)
The second dentist's radiographs
18. These consist of a panoramic view, dated 28 October 1997, and several small films dated 12 November 1997 and 24 June and 8 July 1998. These confirm the poor gum condition. The panoramic view shows a large carious lesion (a large decay cavity) at UL2/UL3 distal (the side nearest the back of the mouth), with what seems to be a dressing (temporary filling material) present. There are also cavities at UR3 distal and UL4. Periapical radiolucencies (dark areas on the X-ray associated with the roots of teeth) are present at UR2 and UR3, and are often an indication of chronic infection at the apex of the root. The small films taken on 12 November 1997 confirm that the bridge at UL1 and UR2 was ill-fitting with gaps between the teeth and the bridge.
Back to top
Discussion
19. Mrs A's periodontal (gum) problems clearly go back many years. Mr Capon accepts that Mrs A had a serious gum condition and he felt that he could help her in her desire to keep her teeth as long as possible. Given the poor state of Mrs A's gums, and her wish to retain her teeth, we would have expected Mr Capon to undertake intensive gum treatment. This would have involved time spent in educating Mrs A about the causes of gum disease and preventive home care techniques; and monitoring to record the progress of her condition and of the effects of treatment. It might also have included root planing under local anaesthetic and possibly even surgery. All of this should have been documented in the clinical record.
20. In interview, Mr Capon stated that the 'scale and polish' entries in the record cover some of the above items. But education and motivation of patients relies on the maintenance of continuous records, which can be used to identify progress and areas which need particular attention. In the absence of such records we do not believe that Mr Capon could have been providing the ongoing care which Mrs A needed.
21. Successful treatment of advanced gum disease depends heavily on home care. Some patients find intensive oral hygiene techniques too demanding and for this reason treatment can fail in spite of strenuous efforts by dentist or hygienist. It is, therefore, impossible to say that Mrs A's condition would have improved if she had been treated differently. However, for the reasons outlined above, we do not believe that Mrs A was given the help and advice necessary to her condition, and so did not have the opportunity to undertake home care to the best of her ability.
Back to top
22. We note Mr Capon's belief that Mrs A's condition deteriorated during the gap in treatment in 1996/97. It is true that gum disease can be worsened by a lapse in the standard of both home and professional care, and that illness can also lead to deterioration. There is, however, no record of any such deterioration or of any change in treatment regime in 1997 to take account of it.
23. The radiographs taken by the second dentist, and his clinical records, confirm that there was untreated decay in several of Mrs A's teeth at that time. There is no record in the notes of this decay at the last examination by Mr Capon in July 1997. We feel that the decay identified by the second dentist would undoubtedly have been present then. We note that in August Mr Capon filled the mesial and buccal surfaces of teeth UL2/UL3 and UR3 respectively. It also seems that UL2/UL3 mesial was replaced on 4 September. However, the second dentist's radiographs show both these teeth as having decay in the distal surface. There is no treatment plan in Mr Capon's records which relates to that decay.
Conclusion
24. Throughout our review of this case, we have been concerned about the general lack of thoroughness and accuracy in the record keeping and we have to conclude that both periodontal care and restorative treatment were probably not delivered appropriately. It is therefore our view that Mr Capon did not adequately assess and treat Mrs A's tooth decay and gum disease. Furthermore, we wonder whether Mr Capon may feel it helpful to improve his understanding of current practice in the treatment of periodontal disease by attending relevant postgraduate courses and by reviewing the appropriate literature.
Back to top
Findings
25. In reaching the following findings, I have taken into account the report of the assessors appointed to advise the Ombudman's staff on the clinical issues involved in this case, as well as the oral and written evidence obtained during the investigation.
26. Mrs A's teeth were in a poor condition before she began treatment with Mr Capon. His treatment of her before April 1996 is outside the Ombudsman's jurisdiction. My interest focuses on his treatment from that date. Mr Capon last saw and treated Mrs A on 10 September 1997 and that episode of treatment appears to have been completed: her next appointment was to have been in January 1998. Instead she went to another dentist on 28 October 1997. His records (and radiographs) show that her gums remained in a poor condition and that there was untreated decay in some of her teeth. The Ombudsman's advisers say that that would undoubtedly have been present when she was last examined by Mr Capon in July 1997, and was in some of the same teeth which he treated subsequently, but in different areas from those treated.
27. Mr Capon says that he monitored Mrs A's gum condition and regularly gave her teeth a thorough scale and polish. He says he did not enter details of the monitoring in the notes as the gum condition was so bad that entries would have been repetitious. The assessors express concern about the lack of thoroughness of his record keeping. Mr Capon says he has already improved that. The assessors conclude, on balance, that he did not adequately assess and treat Mrs A's tooth decay and gum disease. I agree with their view. I recommend that Mr Capon considers ways to improve his understanding of current practice in the treatment of periodontal disease. I uphold the complaint.
Back to top
Conclusion
28. I have set out my findings in paragraphs 25 to 27. Mr Capon has not accepted my invitation to apologise through this report to Mrs A or to agree to act on my recommendation in paragraph 27.
Previous < Contents > Next
Short text of this investigation
Back to top
|
