Do I have grounds to make a claim against my dentist

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So I am an NHS patient at my local dentist since last summer. At the first consultation the dentist x-rayed my teeth and examined me and said all fine and back in 12 months.

in March this year I noticed an area of swelling behind my teeth on my palate as well as a small bony area at the front. I went to see my dentist straight away as I know they look for oral cancers.

She examined me again and another x ray and found no issues but sent a routine referral to my local max fax dept ‘to check im not missing anything’

fast forward to august- still no appt from max fax team but had my usual annual check up at the dentists again and I mentioned the lump which was still there. Different dentist this time basically shrugged and said ‘well the referrals been made and it might be an abscess’

a few weeks later I was really starting to get worried as our local max fax secretaries informed me that the appointment was likely to be early next year!

i called the dental receptionist and asked them to expedite the referral as I’m concerned this could be something significant. She spoke to the dentist and then called me back to say that the dentist won’t expedite the referral and if I’m concerned to cal my GP! I asked does she think it’s nothing to worry about then and she said that she could she couldn’t comment.

i actually work in a large London teaching hospital and because I was so concerned I approached the max fax team there directly so kindly saw me.

After more x-rays, a CT scan and a biopsy I essentially have a rare cystic mass which was bulging I to lay palate and eroding it away. The mass has also caused bone loss in my jaw and now involves 3 of my teeth which may need to be extracted.

i am devastated as these are healthy teeth and the lump has been there since March. I went back to my dental surgery this week as I need an urgent dental assessment before the surgery can take place and I saw the dentist I saw the second time.

she was extremely sheepish and seemed quite shaken and basically said I need to see a private Endodontics as beyond her capabilities. Tellingly they didn’t charge me for this consultation

I am now left with bone loss in my jaw and teeth which need extracting potentially because the dentist didn’t recognise this was a potentially serious issue back in March and didn’t refer me in urgently. I have been beating myself up that I didn’t push more at the time but as my DH pointed out- I went as soon as I found something and I trusted their judgement.

im now left with potentially costly surgery and a potentially disfiguring mass in my face and not sure how to proceed- any ideas?

Did the mass not show up on the original x-ray? Its a tricky one because they did check the area, x-ray it and then refer you straight away, even though it took ages from there on. So I’m not sure there is much legal ground here? The dentist hasn’t missed it, they have acknowledged it and referred to maxfax.

I would request a copy of your notes & X-rays if you haven’t already. That way you can see the dates of referral and if the x-ray looked clear or indicated the start of the mass.

I’m sorry you’re going through this OP but I don’t think you do have any claim against the dentist for this.

They did all the checks they could have done, they sent a referral as a “just incase”, because they had no reasons to be concerns but wanted to be sure, and as they had no concerns themselves they had no reason to expedite the referral.

No one can give you an answer for sure on here. There are so many factors at play and clinical negligence is a very tricky area. You need to see a specialist clinical negligence solicitor.

You will need specialist advice because it hinges on whether the mass should have been seen on the x-ray or not. I'm not sure the delays after you asked to be seen again are grounds for legal action. Talk to a solicitor.

Thanks everyone

At the time the dentist said all looked fine but the mass was already bulging into my palate in March so I find it hard to believe there wasn’t anything at all on the images.

i don’t get to see my images at this dental practice. I wonder as well if they should have referred me in for a 2ww referral as a mass with no obvious cause is perhaps even more likely to be something significant

I think once I’m finally getting treated and have got a bit of headspace I’ll speak to a solicitor and see what they think. I’m really not a litigious person, i work in the NHS myself. I just feel so let down and scared at the moment

This is awful. I think I would be asking the dentist for a copy of all the x-rays they took so that hopefully someone else can look them over and see if anything was showing on those initial x-rays or subsequent ones and whether it was missed.

I am sorry that you are going through this.

Why dont you get to see your xrays? They should have definitely shown you them and discussed what can/can’t be seen.

Check if your household insurance will cover you for such a claim, if it does it is definitely worth pursuing, based on your account. Even if you get nowhere the whole business will hopefully alert the dentist to be more careful in future.
In my long experience of NHS dentists the ones that actually do a proper mouth etc examination are few and far between - and they need to be held to account.

So sorry to read what you have been through. I'm not sure if this will help but it's a link to the GDC website and contains advice about the complaints process.

www.gdc-uk.org/raising-concerns/how-to-get-a-refund-or-make-a-complaint

Surely the surgery will be free and not 'costly'

So sorry this has happened to you

When a referral is made it is mandatory to include recent X-rays with the referral. The maxfac consultants in our area triage all referrals and will pick up anything suspicious and transfer to urgent or 2 week pathway.
If the lesion was cyst like in appearance it is not necessarily urgent. They develop over a very long period of time and a few months may have had no affect on the prognosis.
The first person to query it with is the consultant. Ask if they triage referrals. If they missed the obvious then it wasn’t obvious, and may only have been detectable with more advanced radiographs not available at your dentist.
You have 3 yrs from your diagnosis to take legal action. Maybe sort out the problem before becoming tied up with legal action.
If you have no joy with your consultant go to PALS first

Sorry you're going through this OP

I'd want the x-rays asap before they mysteriously disappeared in some flood or fire or some other trumped up excuse.

As those can potentially prove or disprove negligence they are very very important.

I'd probably want legal advice on how best to get them. But if not I'd prob ask for them to be emailed or copied and provided to me there and then.

They will know themselves how significant they are. If they've messed up I think they will likely have been disposed of already in some 'unfortunate accident'...

Not sure how best to get them without alerting them that you're taking legal advice though.

Dsar will give you access to xrays and notes. Often our xrays are reviewed in more detail after the appointment. However in your case the referral was made but unfortunately not seen as urgent. Have you now had an appointment from that referral? Presumably surgery will be on nhs?

A copy of the x rays will have been sent with the referral , it is what the consultant would have used to triage the referral . Most referrals are solely done on a digital system so there is not a hard copy that could be lost .

Any patient can ask for a copy of their x rays at any time, all you have to do is put a request in writing to the practice.

The vast majority of X-rays are digital and held on the practice computer. Any attempt to delete or change them or indeed delete or change notes is logged in a way the dentist cannot see and the original x Ray and notes are still held but where they cannot be accessed except if there is an official investigation and access is via the softwear company.

All practices have to have back up records, most often via the cloud or father and grandfather hardwear stored off site . So even if there were a fire or flood patients records are still safe.

@Mermaidflamingo my NHS dentist never shows me the pictures. Just takes them and tells me what she thinks. I’ve never thought about it before but the private dentists I’ve seen are much better at taking the time to do this

@Angrymum22 i haven’t actually been seen at all by the max fax team I was referred to as despite the referral being made in March I still don’t have the first appointment. My husband called their secretary and was told it’s likely around 40 weeks before id be seen so I have no idea if they triage these referrals. I’ve been seen by the team in the hospital I work in who have done all the work up and diagnostics.

@LaurieFairyCake the surgery I’m referring to is the potential root canal treatment, not the surgery I need to try a and remove the cyst. It’s really confusing but the max fax team have asked me to sort the dental side and the private dentist I saw today was a bit dismayed that I’m being expected to sort this myself and pay, as he said today this could be thousands.

I’m still reeling a bit from all of this but will try and get the treatment underway and then think about contacting a solicitor for advice before I take things further. The practice does have a complaints policy but the first step of that is to talk to the practice manager. I’m a bit worried if they get an inkling that I may be taking this further, that notes might get amended etc although I may be being a bit paranoid now

They cannot amend notes on dental software without an audit trail being left behind which would be discovered if complaint went to court or GDC and software company are the only people who will have access to that audit trail. In other words notes cannot be amended without it being found out.

You need to make your complaint via the practice , in writing , as a first step .

All max fac referrals are triaged using the x rays and any photos , as well as the information on the referral.

@LIZS i haven’t seen the consultant team I was originally referred to as I still haven’t been offered an appointment despite being referred in March. I asked the max fax team in the hospital I work in to see me and they kindly squeezed me into their clinic despite not getting the referral

the surgery to treat the cyst will be on the NHS but it looks like any dental treatment associated with this will have to be paid by me. I’m going to try and push to be seen at a dental hospital for this but I don’t want the any further delays. I feel completely stuck between a rock and a hard place with this bit

The “whole business” could well finish her career. Dentists are leaving in droves, it’s such a stressful job.

OP I am so sorry you are going through this, it sounds awful. You must be so worried.
I do think what you have sounds very rare, which is probably why it was missed. I’m not sure what you want to achieve from litigation?

Do you want the dentist to learn from this? I guarantee she already has.
Do you want remedial treatment? The NHS is much better than private for cancers and you’ll get whatever dentistry is needed too. As a cancer patient ask for a referral to the Consultant in Restorative Dentistry who is on the multidisciplinary team for your Maxfac unit. They can do any endodontics, implants or prosthetics necessary.
Do you want money? You might get that.

I'd get a copy of the xrays, your notes and a copy of the referral letter. All these will tell you if the dentist has done enough to cover themselves or not.

I think you need to have a chat with a senior member of the maxfac team. I ended up being sued by a patient because an over enthusiastic junior member of the team made an assumption. As a result the patient ended up paying £000’s chasing compensation for a spontaneous event in their mouth. It was due to an extraction that had been carried out 50 yrs earlier. What complicated the whole episode was that the patient refused to have any form of X-ray.

Cysts form over a much longer period of time than abscesses. It is not always possible to see them on X-ray and in the position you describe they can be difficult to pick out on an intraoral X-ray. If the maxfac have carried out 3D imaging they will have been able to pick up a rare type of cyst far easier. Very few general dental surgeries ( and particularly NHS).
Cysts are very common. Unless they become infected they are symptomless apart from swelling in some cases. They are rarely classified as urgent, since in the vast majority of cases they have probably been present for 2-3 yrs.

You have been referred back to a GDP for root treatment because maxfac don’t do endodontic procedures. Unfortunately a lot of NHS dentists will not carry out root treatment in molars because it is a more specialist area and to guarantee keeping your tooth a specialist is necessary.

Not every tooth that dies causes an abscess, your tooth is dead but has produced a low grade inflammatory lesion that has produce a cyst rather than an abscess. You need the tooth root filled before the cyst is removed otherwise it will recur. Unfortunately there is a high risk of recurrence despite the treatment being carried out.

All this should have been discussed and the options for treatment given.

1. do nothing - with an explanation of what will happen if you do nothing
2. extract the tooth and remove the cyst

Longterm

1. leave the gap, there is no rule that you have to replace it
2. denture to fill the gap
3. bridge if clinically possible
4. implant if clinically possible

In order to pursue a claim your legal team would have to prove that the outcome would be different if your dentist had been able to see the cyst earlier and if treating the tooth earlier would have eliminated the cyst.
From experience, root treating a tooth with a cyst rarely solves the problem. It generally continues to grow and cause further bone loss.
So even if your dentist had seen the cyst the outcome would be the same. The referral situation is a red herring because even if they had used the 2 wk referral your case may have been downgraded based on the referral. In the same way that they can be upgraded during triage.

If you do take legal advice, all the information can be retrieved by you solicitor and handed to an expert witness who will determine if there is a case to answer. But be aware that the indemnity companies we use are less likely to pay out to make it go away. This was common practice because it was cheaper to pay out a few hundred pounds than spend upwards of 50k in order to win in court. But litigation specialists abused this system via no win no fee insurance so the indemnity companies are redressing the balance.

My case was dropped by the patient when her solicitor finally convinced her that it was not winnable. But not before the fees for both sides were over £100k. Bearing in mind that the claim was for less than £500 ( it ruined her holiday) and because it was no win no fee, her solicitor still got paid even though she didn’t it was a complete waste of time.

Speak to a solicitor but be aware that it will take 4-5 yrs for any result.

A complaint to the GDC will involve both your dentist and the maxfac dept you are being referred to so could end up in a very protracted case. And may result in them all having to attend hearings meaning that they will have to cancel clinics and postpone surgery. Although I suspect your case would not reach disciplinary stage.

Start with a complaint to the practice. If it was me and I had nothing to hide I would invite you in to review your X-rays first. Our referral system automatically sends the patient a copy of the actual referral but you could ask to see this. If they have nothing to hide they should show you all the paperwork.

I will add that I am totally transparent and if I make a mistake have immediately informed the patient. Maybe it’s the reason I’ve only ever been sued once. My boss ( I now work for someone after selling my practice to them) moans that I spend too much time talking to my patients. I think that communication is the most important part of treatment. Spending an extra five minutes can make a lot of difference to outcomes across all areas of medicine and dentistry. In the past it was perfectly normal to be kept waiting, sometimes for hours. I’m talking 30-40 yrs ago. But you knew that when your turn came it wouldn’t be rushed. So many things are missed because the service is penalised for not keeping on time.

@Angrymum22 Thanks so much for taking the time to write such a comprehensive reply. I think I’m just reeling from the news that I have this and fearful because it’s been such a long time until I started any investigations.

I think when this is over I will at least speak to the practice manager as although these are rare it needs to be something that the team are educated about.

I actually have an Ondodontic Keratocyst so it’s developmental and not related to infection in my tooth. I saw a specialist Endodontist yesterday at the request of my max fax team who assessed the teeth affected by the cyst and confirmed that all my teeth are vital and not infected. I need further explanation from my max fax team as so why I need to either extract or root canal healthy teeth as even the Endodontist didn’t understand why and is writing to the consultant.

also as the Endodontist was private, as my usual NHS dentist didn’t feel able to carry out the assessments. Therefore if I require root canals (and it could be up to 3) it could cost thousands.

I desperately want the cyst treated as it’s causing pain and swelling now

It will depend on the size of the cyst and how close to the roots of the teeth it is . The teeth may very well still be vital (alive) but max fac may be planning to remove bone very close to the end of the teeth which will, effectively, kill them off . The endodontist and surgical team need to liaise to work out exactly what is best to do and at what stage .
Odontogenic keratocysts are , indeed, rare I’ve never seen one in decades of practice and I’ve seen a lot of oral pathology. Good luck with treatment , it is frustrating when it involves several different clinicians and co ordinating everything can be a nightmare particularly if you need several molar teeth root treating which , in itself , is a relatively lengthy process .

Oh that’s interesting. Sorry I’m a geek.
keratocysts are unusual and yes have nothing to do with infection.

As for missing a keratosis in the upper jaw, it’s very easy due to all the anatomical structures. They are also rare.
I have only ever spotted one on radiograph and referred. The junior maxfac, who saw the patient, dismissed my concerns but his boss phoned me to apologise after the biopsy results came back. He said he’d slapped his junior round the head and told him not to make the assumption that us lowly GDPs know nothing.
It is much easier to diagnose with CT but they are often missed on radiographs because they are mistaken for maxillary sinuses.
In addition if you saw a 3D model of the palate you would understand why it’s difficult to spot. In the lower jaw it is much easier to see a cyst or space occupying lesion.
They can develop into something nasty but removal is best treatment.
I have another patient who despite being referred delayed treatment so his recovery has been prolonged. His lesion was in the same area as yours and despite the late treatment he is fine. It had perforated his palate but he had delayed treatment by several years not months.

Just to add the majority of cysts are usually diagnosed accidentally when radiographs are taken for other reasons. The last keratosis we saw in practice was symptomless and several of us had taken routine X-rays but it was in a position that was just off the film area. A bit like taking a photo of a landscape but missing the river just to the right of the scene.
It was as only when the cyst was causing pressure on the nerve and there was pain that it was investigated.
We don’t take radiographs unless clinically necessary. It’s all about risk v benefit. You could X-ray 1000 patients and see nothing unusual. Every one of those patients would have received an unnecessary dose of radiation which could potentially cause a mutation.