HEARING HEARD IN PUBLIC Registration No: 61037 ...

Sharma, S-B Professional Conduct Committee – Apr 2018 – Jan 2019 Page -1/109-

HEARING HEARD IN PUBLIC

SHARMA, Steven-Bal

Registration No: 61037 PROFESSIONAL CONDUCT COMMITTEE

APRIL 2018 - OCTOBER 2018 Outcome: Erased with immediate suspension

Findings of fact can be found from page 16, Determination from page 101

Steven-Bal SHARMA, a dentist, BDS Glasg 1986, was summoned to appear before the Professional Conduct Committee on 30 April 2018 for an inquiry into the following charge: Charge (as amended on 1, 3 and 9 May 2018) “That being registered under the Dentists Act 1984: Patient A 1) At all material times you were a United Kingdom registered Dental Practitioner in practise at

James Hull Dental Care, 12 Church Street, Epsom, Surrey, KT17 4PP (“the Practice”). 2) Between 15 October 2009 to 14 December 2011, Patient A (Schedule A1) attended a

number of appointments at the Practice in connection with her treatment for implants and restoration for which you had overall responsibility.

Treatment Planning & Informed Consent

3) You failed to provide Patient A with an adequate written treatment plan prior to implant surgery on 21 January 2010.

4) You failed to provide Patient A with an adequate updated written treatment plan which explained the risks of: a) The augmentation with Bio-oss and Bio-guide undertaken on 21 January 2010. b) The soft tissue graft of 17 March 2010.

5) Prior to placing implants, you failed to provide Patient A with all the relevant information to enable Patient A to give valid informed consent in that you failed to: a) Inform Patient A of the risks of placing implants and grafting with bio materials at the

same time. b) Advise Patient A about the specific risk of nerve damage relating to the implants at LL5

and LL6 which could lead to numbness or altered sensation of chin/lower lip which could be permanent.

c) Inform Patient A of options to minimise the risk of nerve damage. d) Inform Patient A of other treatment options.

1 Please note all Schedules are private documents that cannot be disclosed


6) You failed to provide Patient A with adequate information during the implant procedures, in that you: a) Failed to warn Patient A of the surgical risks of placing implants and simultaneous

grafting on 21 January 2010. b) Failed to discuss with Patient A the augmentation procedure of 21 January 2010. c) Failed to warn Patient A about the surgical risks of further implant placement at LL5

following removal of both implants on 17 March 2010. d) Failed to warn Patient A about the surgical risks of the augmentation procedure of 12

January 2011. e) Failed to warn Patient A about the risks of implant placement at LL7 on 28 September

2011. 7) As a result of the matters alleged in Head of Charge 6 you failed to provide the necessary

information in order to enable Patient A to give valid ongoing informed consent. Assessment and planning prior to implant procedure

8) Your pre-treatment investigations were inadequate in that you: a) You failed to check Patient A's medical history on 15 October 2009 or 21 January

2010. b) Failed to make study models. c) Failed to make a surgical guide. d) Failed to make adequate assessment of the occlusion. e) Failed to adequately evaluate the hard tissues. f) Failed to adequately and/or accurately assess site suitability of the implant sites

including: i) The available bone width of the proposed implant sites. ii) The bone height in relation to the inferior dental and mental nerves. iii) The proximity of the mental and inferior dental and mental nerves to the drilling

depths for the proposed implants. 9) Planned to place 11 mm and 13 mm implants at LL5 and LL6 when the bone height was

approximately 11 – 12.5 mm above the ID nerve. 10) Failed to report on the CT scan of 19 November 2009, including the quality of the scan and

noting of measurements. Implant procedure

11) Your treatment of Patient A on 21 January 2010 placed her at risk of harm in that: a) You placed 11mm and 13 mm long implants at LL5 and LL6 without an adequate

margin of safety to the proximity of the mental and inferior dental nerves to minimise the risk of reversible or irreversible nerve damage.


b) You placed implants at LL5 and LL6 without giving Patient A the option of using shorter implants or grafting the ridges first to increase width as compared to placing the implants and grafting simultaneously.

12) The treatment was ultimately unsuccessful in that:- a) The initial implants placed at LL5 and LL6 on 21.1.10 failed. b) Patient A reported a numb lip. c) LL5 was replaced. d) An implant was attempted at LL7 on 28 September 2011 but failed. e) The restored implant at LL5 remained but with extensive bone loss and a questionable

prognosis. f) The implant at LL5 has remained sensitive since the conclusion of the treatment.

13) You failed to take adequate peri-apical radiographs: a) at the time of implant insertion on:

i) 21 January 2010. ii) 17 March 2010 iii) 28 September 2011.

b) on or before taking impressions of LL5 and LL6 on 28 September 2011. Record Keeping

14) Your records for treatment for Patient A between 15 October 2009 to 14 December 2011 were inadequate in that you failed adequately to record: a) Medical and social history on 15 October 2009 and/or 21 January 2010 b) Extra-oral examination c) TMJ (Temporomandibular Jaw) Examination d) Basic Periodontal examination (BPE) e) Oral hygiene assessment f) Any assessment of the occlusion prior to placing implants g) The width of the proposed implant sites h) Justification for the CT scan of 19 November 2009 i) Surgical details of the implant surgery and augmentation carried out with Bio-oss and

Bio guide on 21 January 2010. j) Discussion with Patient A regarding the surgical risks of implant placement at LL5 and

6 on 21 January 2010 including potential nerve damage and the risk of failure of LL5 and LL6

k) Discussion with Patient A regarding the surgical risks of the augmentation procedure of 21 January 2010 and/or 12 January 2011 including the biomaterials used, risks, benefits of procedure or alternative solutions for solving the problem of the lack of bone at the intended implant sites


l) Dose and type of local anaesthetic used m) The clinical reasons why the soft tissue graft from the palate was undertaken on 17

March 2010. n) Discussion with the patient of risks, benefits, options or post-operative advice in

respect of further implant placement and the soft tissue graft of 17 March 2010 o) Details of the clinical procedure for the soft tissue graft of 17 March 2010 p) Information on the stability of the implants q) Warnings given to Patient A relating to risks of implant placement at LL7 on 28

September 2011 r) Details of appointments with Patient A on:

i) 12 November 2009 ii) 10 December 2009 iii) 10 February 2010 iv) 3 March 2010 v) 26 May 2010 vi) 2 June 2010 vii) 16 June 2010 viii) 6 October 2010 ix) 24 November 2010 x) 2 February 2011 xi) 29 June 2011 xii) 24 August 2011 xiii) 12 October 2011 xiv) 19 October 2011 xv) 26 October 2011 xvi) 23 November 2011

Handling of Patient A's complaint

15) From November 2012 after you were made aware of Patient A's complaint you failed to respond to Patient A's complaint in a timely manner.

Patient B 16) At all material times you were a United Kingdom registered Dental Practitioner in practise at

Leckhampton Dental Clinic, 31 Leckhampton Road, Leckhampton, Cheltenham, Gloucestershire, GL53 0BD.

17) Between 17 June 2008 and 17 December 2008, you provided treatment to Patient B. Assessment & Treatment Planning


18) You failed to undertake adequate assessments or treatment planning prior to placing implants at UL345 region and crowning of UL6 including: a) Extra-Oral Examination b) Soft tissue Examination c) Basic Periodontal examination (BPE) d) Assessment of the occlusion e) Study models f) A mock-up of the anticipated final tooth positions

19) You failed to adequately assess the sufficiency of bone prior to placing implants in that:- a) You did not report on the radiolucency of the OPT scan b) You did not take peri-apical radiographs after viewing the OPT scan c) You did not consider the need for a CT scan at UL45 after the OPT

20) You failed to produce a written treatment plan discussing risks, benefits or options, with particular reference to use of Zirconia one-piece implants and immediate loading

21) You failed to obtain valid informed consent from Patient B in respect of stage one treatment (implants).

Stage One - Placement of Implants

22) On 16 July 2008 you proceeded with one-piece implants knowing that the implants would be at an unfavourable angle which might result in further treatment which Patient B would not have desired.

23) On 16 July 2008 having placed the one-piece implants with the abutment emerging at an unfavourable angle you: a) Failed to inform Patient B of the unfavourable angle b) Failed to inform Patient B of the likelihood of bulky crowns on UL4 and UL5 as a result

of the unfavourable angle. c) Failed to inform Patient B of the likelihood for further restorative work arising from the

unfavourable angle(s) of the abutment(s). d) Failed to inform Patient B of alternative treatment options including removal of the one-

piece implants rather than allowing osseointegration, after which the implants could not be repositioned.

e) Allowed the implants to integrate. f) Only informed Patient B of the problem and the consequences when it was too late to

rectify, thereby necessitating further treatment of multiple veneers that you had recommended at the start, but which the patient had indicated that she did not want.

g) Following restoration of the implants, failed to inform the patient of the option to remove the implants to obtain a more favourable outcome.

24) As a result of your conduct at Head of Charge 22 and/or 23, you failed to obtain valid ongoing informed consent in respect of placing the one-piece implants.


25) Your conduct as alleged at Head of Charge 22 and/or 23 was: a) Misleading. b) Dishonest in that you placed single piece implant in the knowledge that it might create

restorative complications which you failed to inform the patient of at the time. Stage two - Veneers

26) You failed to carry out adequate assessments before placing veneers on 19 November 2008 in that:- a) WITHDRAWN. b) You failed to provide a revised treatment plan.

27) You placed a veneer on UR6 on 19 November 2008 : a) Knowing that a veneer was not suitable for that tooth. b) Having previously told Patient B that a veneer would not work on this tooth and that

she needed a crown. 28) You recorded in the notes that you had placed a crown on UR6 when in fact you had placed

a veneer. 29) You provided longer veneers than the adjacent teeth without informing Patient B of the risks

involved. 30) You failed to obtain valid informed consent from Patient B in respect of stage two treatment

(veneers). 31) The veneers repeatedly failed due to:

a) The fact that they were inappropriate for Patient B and/or b) They were poorly executed.

32) Your conduct as alleged at Head of Charge 27 and 28 was dishonest in that: a) you might obtain a financial advantage by subsequently needing to undertake further

restorative work and/or b) you were deflecting further enquiry by Patient B into the reasons why veneers had

been placed when the patient had been told they were not suitable. Record Keeping & Communication

33) Your records for treatment for Patient B contain insufficient detail in respect of:- a) Assessments b) Clinical examination c) Clinical procedures d) Post-operative advice e) Discussions about treatment options, risks and benefits f) The appointments of 26 August 2008, 23 September 2008, 15 October 2008, 21.

October 2008


34) The medical history recorded in the computer records is inaccurate according to the medical questionnaire completed by the Patient B.

35) Your records indicate that the patient was happy / satisfied with the treatment when in fact the patient had raised concerns with you which were not reflected in the notes.

36) Despite recording in the notes that there were no signs of bruxism on 17 June 2008, you told the patient that the reason her treatment failed was due to bruxism (which you said you had discussed with her during the treatment at the time) without reference to other possible reasons for failure of the treatment.

37) You conduct at paragraphs 35 and 36 was: a) Misleading b) Dishonest in that:

i) you were seeking to represent in the notes that the patient was content with the treatment when she was not.

ii) you provided the patient with an explanation for the failure of the treatment which was or may have been false and/or

iii) you failed to make reference to other possible reasons for the failure of the treatment to deflect enquiry from the nature and execution of the treatment you had carried out.

38) In breach of IRMER (2000) you failed to report on the: a) OPT dated 17 June 2008 b) Peri-apical radiograph of 16 July 2008 c) Peri-apical radiograph dated 25 March 2009 d) Undated left side bitewing radiograph

39) You did not treat Patient B with dignity and respect, including by: a) referring to Patient B as “senile”. b) standing very close to Patient B. c) raising your voice.

Patient C Between 2013 and 2014 at the Bupa Dental Centre Holborn, in your treatment of Patient C: Record Keeping

40) You failed to carry out and/or adequately record on 15 February 2013 or 22 March 2013, details of your implant assessment set out in Schedule A.

41) You failed to record on 22 March 2013, 5 July 2013 and 18 October 2013, details of the local anaesthetic set out in Schedule B.

42) WITHDRAWN: a) WITHDRAWN b) WITHDRAWN


c) WITHDRAWN d) WITHDRAWN

43) You failed to record on 5 July 2013, the justification for and type, dose and duration of the antibiotics given to the patient.

44) You failed to record details of the analgesic provided to the patient on 22 March 2013 and/or 5 July 2013.

45) You failed to record whether post-operative advice was given to the patient on 22 March 2013


46) You failed adequately to discuss and/or record that you had discussed the clinical evaluation and options for treatment and outcome in relation to: a) the extraction sinus lift and Bio-oss procedure on 22 March 2013. b) the implant placement and sinus tap with Bio-Oss on 5 July 2013.

47) You failed adequately to discuss and/or record that you had discussed the risks associated with the sinus tap procedure and Bio-oss carried out on 22 March 2013 and 5 July 2013 including: a) Sinus perforation b) Bone Graft Displacement c) Infection d) Use of sedation

Sedation

48) You carried out Intravenous Sedation without the presence of a trained nurse. Radiography 49) On 22 March 2013, you failed to carry out and/or record that you had carried out a periapical

radiograph: a) following the sinus tap and/or pre-operatively on 5th July 2013.

50) You failed to take post-operative periapical radiographs following the sinus tap on 5th July 2013.

51) You failed to record the evaluation of the OPG taken on 18 October 2013. Patient D 52) Between 2013 and 2014 at the Bupa Dental Centre Holborn, in your treatment of Patient D: Record Keeping

53) You failed adequately to carry out and/or record on 15 February 2013, details of your implant assessment set out in Schedule A.

54) You failed to record the clinical evaluation and diagnosis that lead to the prescription of antibiotics on 15 February 2013 and/or inappropriately prescribed antibiotics as a preventative measure.


55) You failed to adequately record the details of the implant procedure on 19 April 2013

including: a) WITHDRAWN b) WITHDRAWN c) Cover screws d) Healing Abutments e) Whether post-operative advice was given

56) You failed to adequately record on 19 April 2013, details of the local anaesthetic set out in Schedule B.

57) You failed to adequately record on 9 August 2013 details of the implant procedure including the size and height of abutments placed.

58) You failed to record details of your appointments with Patient D on: a) 30 August 2013 b) 6 September 2013 c) 13 September 2013

Treatment Planning and Informed Consent

59) You failed adequately to discuss and/or record that you had discussed the options for treatment and outcome in relation to the extraction of LR6 and placement of implants on 19 April 2013

Radiography

60) You failed to carry out and/or record that you had carried out a periapical radiographs: a) prior to the extraction of the LR6. b) pre-operatively to placing the implants at LR6 and LR7 on 19 April 2013. c) following the restoration of the implants between 9 August 2013 and 13 September

2013. Patient E Between 2012 and 2013 in your treatment of Patient E at the Bupa Dental Centre Holborn: Record Keeping 61) You failed adequately to carry out and/or record on 20 April 2012 and/or 11 May 2012,

details of your implant assessment set out in Schedule A. 62) You failed to record details of the local anaesthetic used during the implant procedure on 13

September 2013 set out in Schedule B. 63) You failed to record any details of your appointment with Patient E on 20 April 2012 and 15

November 2013. Treatment Planning & Informed Consent


64) You failed adequately to discuss and/or record that you had discussed the clinical evaluation and options for treatment and outcome in relation to the extraction of LR6 and the placement of an implant.

65) You failed adequately to discuss and/or record that you had discussed or provided the patient with written information outlining the risks associated with the extraction of LR6 and placement of implants including the risk of temporary or permanent Inferior Dental nerve damage.

Radiography

66) You failed to carry out and/or record that you had carried out periapical radiographs following the placement of the implant at LR6 on 13 September 2013.

Patient F 67) Between 2012 and 2013 in your treatment of Patient F at the Bupa Dental Centre Holborn: Record Keeping

a) You failed to carry out and/or adequately record details of your implant assessment on 7 December 2012 or 11 January 2013 set out in Schedule A.

b) You failed to liaise and/or record that you had liaised with Patient F’s GP to check the stability of Patient F’s diabetic condition.

c) You failed to record the type, dose, duration and expiry of the analgesic provided to the patient on 11 January 2013.

d) You failed to record the type, dose, duration and expiry of the antibiotics which were given to the patient on 11 January 2013.

e) You failed to record details of the local anaesthetic used on 11 January 2013 and 10 May 2013 set out in Schedule B.

68) WITHDRAWN: a) WITHDRAWN b) WITHDRAWN c) WITHDRAWN

69) You failed to adequately record details of the review of the implant procedure carried out on 24 July 2013 including materials and techniques used.

70) You failed to record details of appointments on 12 April 2013, 6 September 2013, 13 September 2013, 4 October 2013.


71) You failed to liaise and/or record that you had liaised with the periodontal specialist that had treated Patient F in order to confirm that the periodontal condition was stable.

72) You failed adequately to discuss and/or record that you had discussed with Patient F, the risks associated with implant treatment in the light of Patient F’s diabetic and periodontal condition.

Radiography

73) You failed to report upon the radiograph which had been taken on 6 December 2012.


74) You failed to carry out and/or record that you had carried out a periapical radiograph: a) Prior to the placement of the implant on 10 May 2013 b) Following the placement of the implant on 10 May 2013 and/or prior to restoration

Patient G Between 2011 and 2013 in your treatment of Patient G at the Bupa Dental Centre Holborn: Record Keeping

75) You failed to carry out and/or adequately record details of your implant assessment on 4 March 2011, 15 April 2011 or 15 July 2011 set out in Schedule A.

76) You failed to record the justification for the antibiotics which were prescribed on 16 November 2012 and 26 June 2013.

77) You failed to record the name, dose and period for which antibiotics and painkillers were prescribed on 16 November 2012 and 26 June 2013

78) You failed to record details of the local anaesthetic used as set out in Schedule B on: a) 15 April 2011 b) 15 July 2011 c) 16 November 2012 d) 26 June 2013

79) WITHDRAWN: a) WITHDRAWN b) WITHDRAWN c) WITHDRAWN d) WITHDRAWN e) WITHDRAWN

80) You failed to record details of appointments on: a) 18 January 2013 b) 2 August 2013 c) 13 September 2013 d) 4 October 2013 e) 22 November 2013 f) 6 December 2013.


81) You failed adequately to discuss and/or record that you discussed the clinical evaluation, and options and risks associated with treatment in relation to the LR78 on 15 April 2011 and 16 November 2012.


82) You failed adequately to discuss and/or record that you had discussed the risks associated with the placement of implants including the risk of temporary or permanent ID nerve damage.

83) You failed adequately to record which options you had discussed for treatment and outcome in relation to the mobility of the bridge on 30 September 2011.

84) WITHDRAWN. 85) You failed to discuss and/or record that you had discussed the risks, benefits and options

associated with the placement of implants on 26 June 2013. Radiography 86) You failed to carry out and/or record that you had carried out pre-operative radiographs prior

to the implant placement on 26 June 2013. Patient H Between 2011 and 2013 in your treatment of Patient H at the Bupa Dental Centre Holborn: Record Keeping

87) You failed to carry out and/or record details of your implant assessment on 12 April 2013 and/or 2 August 2013 set out in Schedule A.

88) You failed to record details of the local anaesthetic used during the implant procedure on 2 August 2013 and 12 April 2013 set out in Schedule B.

89) You failed to record the justification for the prescription of antibiotics prescribed on 2 August 2013 and 12 April 2013.

90) You failed to record the type, dose and period for which antibiotics and painkillers were prescribed for the patient on 12 April 2013.

91) You failed to record details of appointments on 22 March 2013, 28 June 2013 and 18 October 2013.

92) You failed to record the clinical reasons why an implant supported bonded crown was manufactured on 10th October 2013.

93) You failed to record the clinical details of the materials or techniques used to take an impression of the UR6 on 4 October 2013.


94) You failed to adequately discuss and/or record that you had discussed the risks and benefits in relation to the extraction and placement of the implant at UR6.

Radiography

95) You failed to carry out and/or record that you had carried out a periapical radiograph: a) following the extraction of the UR6 and prior to the placing of the implant at UR6 on 2

August 2013. b) following the placement of the implant on 2 August 2013.

Patient I Between 2013 and 2014 in your treatment of Patient I at the Bupa Dental Centre Holborn:


Record keeping

96) You failed adequately to carry out and/or record details of your implant assessment on 19 April 2013 set out in Schedule A.

97) You failed to adequately record surgical details of the extraction and implant placement on 19 April 2013 and 26th July 2013 in relation to the UL56 and LR56.

98) You failed to record details of appointments on 11 October 2013 and 18 October 2013. 99) You failed to adequately record details of when impressions were taken, or abutments and

crowns tried in for UL56 and LR56. Informed Consent and Treatment Planning 100) You failed adequately to discuss and/or record that you had discussed the options for

treatment and outcome in relation to the UL56 and LR56. 101) You failed adequately to discuss and/or record that you had discussed and/or provide the

patient with written information outlining the risks associated with the placement of implants including sinus perforation.

102) You failed to carry out any further investigation of the bone height or width prior to placement of implants at UL56.

103) You failed to provide an updated treatment plan to the patient outlining the risks associated with the use of shorter implants which obviated the need for sinus lifting.

Radiography

104) You failed to carry out and/or record that you had carried out a CT scan and/or periapical radiograph:

a) Pre-operatively to the placement of implants at UL56 and LR56 on 19 April 2013 and intra-operatively.

b) Following placement of implants at UL56 and LR56 on 19 April 2013 and 26 July 2013. c) On 30 August 2013 when the crowns on UL56 were noted to be loose.

Patient J In 2013 in your treatment of Patient J at the Bupa Dental Centre Holborn: Record Keeping

105) You failed to carry out and/or adequately record details of your implant assessment on 1 November 2013 set out in Schedule A.

106) You failed to record the clinical evaluation and diagnosis that lead to the prescription of antibiotics and/or inappropriately prescribed antibiotics as a preventative measure.

107) You failed to record the details of the local anaesthetic used on 1 November 2013 and 22 November 2013 set out in Schedule B.

Treatment planning & Informed Consent

108) You failed adequately to discuss and/or record that you had discussed the options for treatment and risks and benefits associated with the replacement of the UL1.


109) You failed adequately to discuss and/or record that you discussed the risks associated with placement of the implants on 22 November 2013 including the risk of bone loss.

Treatment

110) You failed to provide an adequate standard of treatment to Patient J in that you: a) placed the implant in the UL1 prematurely on 22 November 2013 when Patient J’s gums

and bone had not healed adequately; b) placed a healing abutment and fitted the denture on 22 November 2013 which had the

effect of inappropriately loading the implant from the time of placement thereby exposing the patient to increased risk of further bone loss or implant failure.

c) Failed to record details of a discussion with the patient regarding the implications of placing a healing abutment and implant rather than placing a cover screw.

Radiography

111) You failed to take a pre-operative periapical radiograph of the UL1 prior to placing the implant.

Patient K Between 2011 and 2013 in your treatment of Patient K at the Bupa Dental Centre: Record Keeping

112) You failed to carry out and/or record details of your implant assessment on 1 April 2011 or 2 August 2013 set out in Schedule A.

113) You failed to record details of the local anaesthetic used on 2 or 3 June 2011, 5 August 2011 and 9 September 2011 as set out in Schedule B

114) You failed to record whether a cover screw or healing abutment was connected to the implant at UL2 following the procedure on 2 or 3 June 2011.

115) You failed to record the type, dose and duration of antibiotics and painkillers prescribed on 2 August 2013.

116) You failed to record details of the material and techniques used to take impressions on 13 September 2013.

117) You failed to record details of your appointments with Patient K on 21 June 2013, 20 September 2013 and 4 October 2013.


118) You failed adequately to discuss and/or record that you had discussed the options, risks and benefits associated with the immediate placement of the implant on 2 or 3 June 2011.

Radiography 119) You failed to carry out and/or record that you had carried out a periapical radiograph:

a) On 2 or 3 June 2011 prior to the placement of an implant at UL2. b) On 9 September 2011 following the fit of the crowns c) Pre-operatively and post-operatively on 2 August 2013 when an implant was placed at

LR1


d) On 13 September 2013 when the lower implant was noted to have taken time to settle Patient L Between 2004 and 2005 in Tenby in your treatment of Patient L: Treatment

120) You failed to provide an adequate standard of treatment in respect of Patient L in that you: a) Placed a bridge at UL3-5 which was inappropriately designed in that it failed to protect

UL3 from caries. b) Failed to examine the Patient when she raised concerns that the restorations had the

appearance of amalgam fillings. Treatment Planning & Informed Consent

121) You failed to obtain informed consent in relation to Patient L’s proposed implant treatment in that: a) You failed to discuss the relevance of Patient L’s history of periodontal disease upon

the clinical outcome of the proposed implant treatment. b) You failed to discuss and/or provide Patient L with written information regarding the

risks associated with smoking upon the clinical outcome of the proposed implant treatment.

c) Prior to placing the implants, you failed: i) to discuss the clinical options for treatment, ii) to provide the patient with a written treatment plan which included information

regarding the risks and benefits associated with the implant treatment, d) You failed to inform the Patient that you had not placed Ankylos implants as you had

discussed with the Patient and had instead provided different brands. e) You failed to inform Patient L of the risks associated with the bridge design at UL3-5. f) You failed to inform Patient L of the reasons why you placed a bridge at UL3-5 rather

than utilizing the implant at UL4. g) You failed to inform the Patient that metal had been exposed following the adjustment

to the restorations. Aftercare 122) You failed to take periapical radiographs prior to and following restoration of the implants. 123) You failed to provide Patient L with adequate information regarding post-operative care

and/or the maintenance required for her implants following her treatment with you. 124) You failed to arrange any or any adequate follow up appointments for Patient L once the

implant treatment was completed. 125) You failed to inform and/or ensure that Patient L was informed that the Tenby practice

closed down. Record keeping

126) You failed to provide Patient L with access to her dental records


Advertising a specialism in implants 127) On or before 15 January 2014 your website stated:

a) That you are "the dentist's dentist". b) That you are "constantly sought after and referred to as has encyclopaedic knowledge of

dental implants". c) "Now dental implants are my specialism and I'm actually the dentist other dentists go to if

they need this type of work done!" d) That patients can be "assured of getting the very best advice and care". e) That you "adhere to the General Dental Council (GDC) Fitness to Practice policy".

128) By referring to dental implants being your specialism, you were implying specialist status in implants when: a) The use of the words 'specialism' or 'specialist' should be reserved for dentists who are

on a GDC specialist list. b) There is no GDC approved speciality of 'dental implantology'. c) You are not on any GDC Specialist List which might apply to implants such as

Restorative Dentistry or Prosthodontics and Periodontics. d) The GDC's Principles of Ethical Advertising states that "Registrants who are not on a

specialist list should not describe themselves as 'specialising in…' a particular form of treatment."

129) The statements from your website as set out at Head of Charge 128 were:- a) Misleading. b) Dishonest.

AND, by reason of the facts stated, your fitness to practise as a dentist is impaired by reason of your misconduct and / or deficient professional performance.” Mr Sharma was not present and was not represented. On 5 October 2018 the Chairman announced the findings of fact to the Counsel for the GDC: Hearing Chronology and Representation This Professional Conduct Committee hearing in respect of Mr Sharma was originally scheduled to last from 30 April until 18 May 2018. However, it was adjourned part-heard on 18 May 2018 as there was insufficient time to conclude the case within the allocated listing. When the hearing was adjourned on 18 May 2018, the Committee was part-way through its deliberations on the alleged facts. It resumed its deliberations from 3 September to 6 September and 2 October to 5 October 2018 and has now finalised its findings, which are set out in this Findings of Fact determination. As was the case in April/May 2018, Mr Sharma is neither present nor represented. Mr Tim Grey, Counsel, represents the General Dental Council (GDC).


At the outset of the hearing on 30 April 2018, Mr Grey submitted that service of notification of hearing had been effected in accordance with the GDC (Fitness to Practise) Rules Order of Council 2006 (‘the Rules’). He then made an application under Rule 54 of the Rules, to proceed with the hearing notwithstanding Mr Sharma’s absence. The Committee had regard to Mr Grey’s submissions in respect of the application and the supporting documentation he provided. It accepted the advice of the Legal Adviser. Decision on service of the Notification of Hearing The Committee first considered whether notice of the hearing had been served on Mr Sharma in accordance with Rules 13 and 65. It received a bundle of documents containing a copy of the Notification of Hearing letter, dated 15 March 2018. Also contained within the bundle was a Royal Mail ‘Track and Trace’ receipt confirming that the letter was sent to Mr Sharma’s registered address by Special Delivery. The Committee took into account that there is no requirement within the Rules for the GDC to prove receipt of the letter. However, it noted from the ‘Track and Trace’ information that the letter was delivered and signed for at Mr Sharma’s registered address on 16 March 2018. A copy of the letter was also sent to him by email. The Committee was satisfied that the Notification of Hearing letter of 15 March 2018 contained proper notification of the hearing, including its start date, time and venue, as well as notification that the Committee could proceed with the hearing in Mr Sharma’s absence. On the basis of the information provided to it, the Committee was satisfied that notice of the hearing had been served on Mr Sharma in accordance with the Rules. Decision on whether to proceed with the hearing in the absence of Mr Sharma The Committee next considered whether to exercise its discretion under Rule 54 of the Rules to proceed with the hearing in the absence of Mr Sharma and/or any representative on his behalf. It approached the issue with the utmost care and caution, noting his right to attend and participate. The Committee had regard to the factors to be considered in reaching its decision as set out in the case of R v Jones [2003] 1 AC 1HL, and the public interest considerations referred to in Adeogba v GMC [2016] EWCA CIV 162 as well as the obligation on professionals to engage with their regulator. It took into account that fairness to Mr Sharma was of primary importance, but also remained mindful of the need to be fair to the GDC. The Committee also took into account the public interest in dealing with Mr Sharma’s case expeditiously. The Committee was mindful that factual allegations relate to issues going back to 2004. This case has a long history with the first referral made on 22 October 2014 and a further four separate referrals with the last being made on 24 February 2016. The information provided showed that there had been a number of attempts between 2015 and 2017 to list a PCC hearing in respect of Mr Sharma. Hearings dates were scheduled for July 2015, May 2016 and March 2017, none of which went ahead. The hearing scheduled for March 2017 was postponed at the request of Mr Sharma for personal reasons. The hearing was rescheduled to take place from 30 April to 18 May 2018, which is this current listing. It noted that Mr Sharma had engaged with the GDC from 2014 whilst his case was being investigated. However, his engagement decreased over a period of time. The Committee noted that Mr Sharma formerly had solicitors and counsel acting for him and that, in November 2017, the GDC and the defence solicitors discussed certain issues, including scheduling and the identity and meeting of the parties’ respective experts. However, by April 2018 it appeared that Mr Sharma no longer had lawyers acting for him. The Committee noted a


telephone call took place between the GDC’s solicitor at Blake Morgan LLP and Mr Sharma in person on 9 April 2018. The File note records that when Mr Sharma was asked if he would be admitting the allegations he replied, “absolutely no chance”. To the GDC’s solicitor’s question whether he would be attending the hearing he replied, “what do you think?” and when asked to clarify what he meant, he declined to do so. When asked whether the GDC witness evidence could be read he replied, “that doesn’t make any difference” but later said that he wanted the witnesses in attendance “as his barrister will want to cross examine them”. The GDC solicitor then asked Mr Sharma the identity of his barrister and was told it was “none of your business”. The Committee noted that the contents of this attendance note were reproduced in writing and sent to Mr Sharma by email on 10 April 2018. It further took account that the GDC sent an email to Mr Sharma dated 11 April 2018 in an attempt to arrange a teleconference “next week on a day and time suitable for you…to ensure that everything is on track for the hearing to commence”. Mr Sharma was again asked to confirm if he was going to be represented at the hearing and who they were. Mr Sharma did not respond to that email. The Committee noted that the last contact from Mr Sharma was an email dated 17 April 2018 in response to an email from the GDC on the same date when a file had been sent to him. He responded by asking for the file to be resent to him and said, “I am out of the country from Fri for two weeks”.

The Committee was satisfied from the information before it, that Mr Sharma had been aware of the current hearing dates since March 2017 and had formal notice of the hearing from at least 16 March 2018. It was satisfied that when Mr Sharma sent his email dated 17 April 2018, he knew that the hearing was listed to start on 30 April 2018. Considering all the information before it and Mr Sharma’s recent responses, it was satisfied that Mr Sharma had voluntarily decided not to attend the hearing and had chosen to go away when he knew the hearing was scheduled to commence. The Committee considered that Mr Sharma had had several opportunities to ask the GDC for an adjournment, but there was no indication that he made such a request. In the circumstances, the Committee concluded that it was unlikely that an adjournment of the hearing would secure Mr Sharma’s attendance on a future occasion. The Committee was satisfied that in effect that Mr Sharma had chosen to disengage with the process. The Committee was mindful that all professionals have an obligation to engage with their regulator, and that it would run entirely counter to the protection, promotion and maintenance of the health and safety of the public if a practitioner could effectively frustrate the regulatory process. Bearing in mind the age, number and complexity of the allegations and the public interest in the expeditious conduct of the GDC’s regulatory function, the Committee had no hesitation that it was fair and in the interests of justice for the hearing to proceed in the absence of Mr Sharma. Background and summary of the charge At all material times Mr Sharma was a registered General Dental Practitioner. The case against him is based on five separate referrals made to the GDC; the referrals relate to matters that took place from 2004 to 2013. Four of the referrals relate to the treatment Mr Sharma provided to 12 patients, Patients A to L, over the nine-year period at three separate dental practices. The allegations arising from these referrals include alleged failings in assessment, treatment planning and informed consent, radiography, sedation, the provision of treatment including the placing of implants and veneers, patient aftercare, record keeping and communication and the handling of a patient complaint. There are also allegations relating to Mr Sharma’s probity, associated with his treatment of one of the patients.


The remaining referral relates to Mr Sharma’s use of advertising for his practice, specifically his website. It is alleged that a number of statements that appeared on Mr Sharma’s website were misleading and dishonest. Decision on application made by the GDC to admit documents into evidence under Rule 57 Having determined to proceed with the hearing, the Committee considered whether to admit under R57 a 200-page bundle (“C4”) comprising Mr Sharma’s written responses to the GDC during the investigation stages of his case. This bundle of correspondence was collated by the GDC and contains individual written responses from Mr Sharma at various stages of the investigation. Mr Grey indicated that the GDC did not require this bundle for its case but submitted that the Committee might consider it fair to Mr Sharma to admit it. He told the Committee that Mr Simon Nery, the expert witness to be called by the GDC, had reviewed the bundle in question. Mr Grey submitted that it would be artificial for the Committee not to have all of the information upon which Mr Nery had based his opinions. In reaching its decision, the Committee took into account Mr Grey’s submissions and accepted the advice of the Legal Adviser. It noted that Mr Sharma’s written responses, as contained within the bundle, did not address directly the charges against him. It also took into account that, if the bundle were to be admitted into evidence, there would be no opportunity to challenge its contents, given the absence of Mr Sharma. Nevertheless, the Committee was mindful that the bundle contained the only responses available to it from Mr Sharma about the matters in this case. It also had regard to the fact that Mr Sharma’s responses had been considered by Mr Nery and had informed his expert opinion on some of the issues to be considered by the Committee. In all the circumstances and in the interest of balance and fairness to the absent Mr Sharma, the Committee determined to admit the bundle of Mr Sharma’s written responses into evidence. It would be a matter for the Committee as to the weight to be attached to this evidence when making its findings on the facts. In admitting the bundle, the Committee made clear that any evidence that related to remediation would not be considered as part of its decision-making at the fact-finding stage. It emphasised that such information would only become relevant at the next stage of the hearing should the case proceed that far. The Committee also noted that there was reference in Mr Sharma’s written responses to his fitness to practise history. This reference was supported by other information that was provided to the Committee in the primary hearing bundle, which Mr Grey conceded should not have been put before the Committee in relation to the fact-finding stage. In the light of this, the Committee directed itself, as judges of law, to ignore any information regarding Mr Sharma’s fitness to practise history when determining the facts. Decision on the application made by the GDC not to call the factual witnesses in this case The Committee went on to determine a further application made by Mr Grey to rely upon the written statements of its factual witnesses in this case, without calling them to prove those statements. In making the application, Mr Grey provided this Committee with the written skeleton argument provided by the GDC to a Preliminary Committee that sat in respect of Mr Sharma’s case in April 2018. That Committee determined that any direction regarding witnesses should be considered by this PCC at the substantive hearing. Therefore, Mr Grey asked this Committee to make directions, in the same or similar terms, as the directions sought by the GDC in April 2018. In summary, he


invited this Committee to direct that the GDC may dispense with the need to call witnesses of fact to give oral evidence and that their witness statements be taken as read. Mr Grey submitted that all the heads of charge in this case, save for those that relate to the issue of advertising, are reliant upon expert evidence, as opposed to factual evidence. Mr Grey accepted that, if his application was successful, there might be issues in relation to the weight that could be attached to the factual evidence as a result. The Committee noted Mr Grey’s submissions and accepted the advice of the Legal Adviser. The Committee concluded that it was fair, proportionate and in the interests of justice to accede to Mr Grey’s application. Accordingly, it directed that the GDC could dispense with calling the factual witnesses to give oral evidence at this hearing. Its reasons are as follows. There was no information before the Committee to suggest that any of the witnesses could not attend if required. The Committee noted that the witness statements were signed and contained declarations of truth. It did not consider that requiring them to attend, when the registrant was not here to cross-examine them and when the vast majority of the allegations depended upon the Committee’s view of the expert evidence, was necessary or proportionate. It did not consider that adopting this course, caused any prejudice to the absent Mr Sharma. The Committee had regard to the File note of 9 April 2018, detailing the telephone conversation that took place between Mr Sharma and the GDC’s solicitor. During that conversation Mr Sharma stated that he wanted all the GDC witnesses to attend the hearing. However, the Committee took into account that Mr Sharma had now chosen not to attend these proceedings. The Committee reminded itself that in acceding to the GDC’s application, the GDC’s witnesses would not give evidence on oath or be tested by questioning and it could take account of those factors in determining what weight to attach to their evidence. In making the direction allowing the GDC to dispense with the factual witnesses, the Committee reserved its right to require the GDC to call any of the witnesses, should it have questions of clarification for them. The Committee also made clear that, if Mr Grey changed his mind in respect of calling any of the witnesses, he would need to make a fresh application in that regard. Decision on the preliminary application made by the GDC to amend the charge under Rule 18 The Committee next acceded to an application, made by Mr Grey under Rule 18 of the Rules, to amend the charge and Schedules A and B to the charge. Mr Grey provided the Committee with a written list of the amendments proposed by the GDC, as well as a new version of Schedule B, which he intended as a replacement for the original Schedule B. Mr Grey’s submission was that all of the amendments proposed were corrections of typographical and administrative errors, save for the amendment to head of charge 113, where he asked that the date ‘3 June 2011’ be inserted. Mr Grey stated that it was not clear from the clinical records on which day the patient in question was seen by Mr Sharma, so the proposal was for the date reference in head of charge 113 to read: ‘2 or 3 June 2011’. In respect of Schedule A, Mr Grey requested minor amendments to Schedule A, which he said were required following the clarification of certain matters by Mr Nery and which reduced the scope of the allegations. In relation to the replacement of Schedule B, Mr Grey submitted that the original Schedule B did not reflect clearly the failings alleged. He explained that the new version of Schedule B made matters clearer by identifying each alleged failing with reference to individual appointments as opposed to reference to individual patients.


The Committee accepted the advice of the Legal Adviser. In granting the application, it had regard to the merits of the case and the fairness of the proceedings, and it was content that the proposed amendments could be made without causing injustice to Mr Sharma. The Committee was satisfied that the suggested amendments were to correct date inaccuracies and to clarify information that was already before it. It accepted that the amendments did not change the substance of the charge against Mr Sharma. The charge was amended accordingly. Decision on further application to amend the charge under Rule 18 During the course of the hearing, following the oral evidence of Mr Nery and Witness 2, Mr Grey made a further application to make additional amendments to the charge including a number of withdrawals. He applied in part to make these because of concessions from Mr Nery. Mr Grey submitted that none of them extended the scope of the charge against Mr Sharma, rather, they served to clarify a number of matters. Mr Grey provided the Committee with a written list of the further amendments proposed. After receiving advice from the Legal Adviser, the Committee accepted Mr Grey’s application. It was satisfied that the further amendments proposed, including a number of withdrawals, would not cause any injustice. Accordingly, the charge was further amended. Decision on further application to admit a document into evidence During the course of the hearing Mr Grey made an application to the Committee as judges of law to admit into evidence a Warning Letter dated 25 October 2007 from the GDC’s Investigating Committee to Mr Sharma. Mr Grey submitted that the topic and content of the letter rendered it admissible, in that it was relevant to the Committee’s consideration of the matters at head of charge 128, which concern Mr Sharma’s alleged advertising of his specialism in implants. Having considered Mr Grey’s submissions and having accepted advice from the Legal Adviser, the Committee determined not to admit the letter into evidence. The Committee considered that it was procedurally inappropriate to consider such a letter at the fact-finding stage. It acknowledged that, had Mr Sharma been present to answer questions on the contents of the letter, it may have reached a different conclusion. However, in the circumstances, with the Committee not knowing anything about the background to the warning and the limited information within the letter itself, the Committee decided that it would be unfair to admit it in the absence of the registrant. In reaching its decision, the Committee took into account the principle of fairness and the public interest. It decided that the potential prejudicial effect of admitting the letter was greater than its probative value. Accordingly, Mr Grey’s application was refused. The Committee’s assessments of the witnesses who gave oral evidence at the hearing The Committee received oral evidence from two witnesses, the expert Mr Nery and Witness 2, a Dental Services Manager at Bupa Dental Service Practice. (in relation to the later, the Committee determined during the hearing that it would be assisted by receiving oral evidence from Witness 2 and so directed his attendance). The Committee considered that Mr Nery was clear in giving his evidence and it found him to be knowledgeable on the clinical matters in this case. It also found that he was consistent and balanced in giving his opinions. The Committee was satisfied Mr Nery considered alternative arguments before reaching his conclusions. It also noted that on occasions, Mr Nery took time to seek clarification on certain matters and determined that he gave measured evidence and was


prepared to change his opinion. The Committee further took into account, that Mr Nery’s opinions were based on what the average general dental practitioner would do, as opposed to the ‘gold standard’. Overall, the Committee found Mr Nery to be a fair, reliable and well-informed witness, who recognised that all dentists could make mistakes. In relation to Witness 2, the Committee noted that he was an open and willing witness, who was able to provide sufficient explanations in response to the questions asked of him. Further, the Committee found that Witness 2 was clear in stating when he did not know the answer to a particular question. In the Committee’s view, Witness 2 was a credible witness and it concluded that it could place reliance on his evidence. Evidence The Committee received a substantial amount of documentary evidence which included Mr Sharma’s clinical records in respect of the 12 patients and, where relevant, the records of other treating practitioners. The Committee also had sight of some original radiographs and a CT scan in respect of Patient A and some original radiographs in respect of Patient B and photographs of Patient L. The Committee was also provided with witness statements from a number of witnesses, including Patients A, B, D, H and I. There was also a witness statement from Witness 2 who, in addition to his written evidence, attended the hearing at the request of the Committee to give oral evidence to the Committee. Witness 2 previously worked at the Bupa Dental Centre in Holborn as the Dental Service manager at the time Mr Sharma was employed there providing dental services. The Committee also received expert evidence from Mr Nery, called by the GDC. He produced three expert reports dated 14 May 2015, 16 November 2015 and 14 September 2016 and he also gave oral evidence. The Committee noted that some Heads of Charge alleged dishonesty, and that Mr Grey accepted Mr Sharma had no previous findings of dishonesty. Following advice from the Legal Adviser, the Committee put this into the balance in his favour. The Committee’s Findings of Fact The Committee considered all the evidence presented to it. It took account of the closing submissions made by Mr Grey on behalf of the GDC and it accepted the advice of the Legal Adviser. In accordance with that advice it considered each head of charge separately, bearing in mind that the burden of proof rests with the GDC and that the standard of proof is the civil standard, that is, whether the alleged facts are proved on the balance of probabilities. The Committee drew no adverse inferences from Mr Sharma’s absence. Taking all the above into account, the Committee’s findings in relation to each head of charge are as follows:

Patient A 1. At all material times you were a United Kingdom registered Dental Practitioner in

practise at James Hull Dental Care, 12 Church Street, Epsom, Surrey, KT17 4PP (“the Practice”).

Found proved. 2. Between 15 October 2009 to 14 December 2011, Patient A (Schedule A) attended

a number of appointments at the Practice in connection with her treatment for


implants and restoration for which you had overall responsibility.

Found proved. The Committee considered heads of charge 1 and 2 separately but found both heads proved on the same basis. It had regard to the clinical records for Patient A, which showed that Mr Sharma treated the patient at the Practice between 15 October 2009 and 23 November 2011. A subsequent treating dentist took over Patient A’s treatment from 14 December 2011.


3. (Previously read: You failed to provide Patient A with an adequate written treatment plan prior to implant surgery on 21 October 2010.)

Amended to read: You failed to provide Patient A with an adequate written treatment plan prior to implant surgery on 21 January 2010.

Found proved (as amended). The Committee accepted the evidence of Mr Nery, who stated in his report that a treatment plan should be tailored to each patient, including comments relevant to each individual case. In his oral evidence, Mr Nery explained that for a treatment plan for complex treatment such as implant surgery to be adequate, it should include the relevant risks, benefits and treatment options. The Committee had regard to the document entitled ‘treatment plan estimate’, dated 26 November 2009 contained in the clinical records for Patient A. It found no other document in the records that could be regarded as a written treatment plan. The Committee found that the treatment plan estimate outlined the proposals in relation to the patient’s pending implant surgery listing the costs. It also noted that there was a generic paragraph on the document which stated “We want you to understand the benefits of receiving treatment from your practitioner, any risks associated with that treatment and what other options may be available.” However, the Committee saw no detail in respect of the risks, benefits and treatment options specific to Patient A’s case. There was also no clear reference to the nature of the treatment ultimately proposed, for instance, details of the positions in which the implants were to be placed. In the Committee’s view, taking into account the evidence, all of this information should have been included. Instead, the Committee found that the document merely set out details of certain activities to be undertaken on particular dates and the estimated costs. In the circumstances, the Committee determined that the treatment plan estimate document was not an adequate written treatment plan. The Committee found that there was nothing to demonstrate that the treatment plan estimate was provided to Patient A. It noted that the copy of the document within the bundle was unsigned. However, the Committee decided that, even if the document was provided to the patient, it remained inadequate as a written treatment plan. The Committee next considered whether Mr Sharma had a duty to provide an adequate written treatment plan to Patient A. In doing so, it had regard to the GDC’s publications ‘Standards for Dental Professionals (May 2005)’ and


‘Principles of Patient Consent (May 2005)’, both of which were applicable at the material time. Having considered the relevant standards, the Committee was satisfied that Mr Sharma did have a duty to provide an adequate written treatment plan to the patient and in not doing so, he failed in that duty.

4. You failed to provide Patient A with an adequate updated written treatment plan which explained the risks of:

4.(a) (Previously read: The augmentation with Bio-oss and Bio-guide undertaken on 21 October 2010.)

Amended to read: The augmentation with Bio-oss and Bio-guide undertaken on 21 January 2010. Found proved (as amended) The Committee accepted Mr Nery’s evidence that, if bone augmentation with Bio-oss and Bio-guide had not been included as part of the patient’s original treatment plan, an updated written treatment plan including reference to the proposed bone augmentation should have been provided to Patient A. In his report, Mr Nery highlighted that Bio-oss and Bio-guide are both materials derived from animal bone and as such, patients should be told of the origin of these materials so that they can consent to their use. Mr Nery also explained to the Committee that there are specific risks associated with bone augmentation itself, including the risk of infection, pain, swelling and failure. He stated that these risks needed to be highlighted to the patient and also recorded for any written treatment plan to be deemed adequate. The Committee considered the original treatment plan for Patient A, namely the ‘treatment plan estimate’, of 26 November 2009. It noted that there was reference to “Bone Augmentation” on that plan, although the estimated cost for the augmentation appeared to have been crossed out on the document. The Committee further noted the generic paragraph referring to risks and benefits. However, it found no record of the risks specific to bone augmentation with Bio-oss and Bio-guide as explained by Mr Nery. The Committee also considered the subsequent treatment plan estimate for Patient A, dated 13 January 2010. This document also referred to bone augmentation, the associated cost of the treatment, as well as the generic reference to risks and benefits. However, as with the treatment plan estimate of 26 November 2009, the contents of this subsequent document did not give any indication of the particular risks associated with bone augmentation using Bio-oss and Bio-guide as explained by Mr Nery. Indeed, the Committee found that the changes between the first and second treatment plan estimates were unclear. The Committee concluded that, even if the treatment plan estimate of 13 January 2010 was provided to Patient A, it did not constitute an adequate updated written treatment plan. In deciding whether Mr Sharma had a duty to provide the patient with such a plan, the Committee accepted the evidence of Mr Nery that informed consent is an ongoing process and for consent to be valid patients should be properly informed of any changes to their treatment and any associated risks. The Committee also had regard to the GDC standards on informed consent which were applicable at


the time. It was satisfied that Mr Sharma did have a duty to provide an adequate updated written treatment plan to Patient A, as part of the ongoing consent process. By not doing so, he failed in that duty.

4.(b) The soft tissue graft of 17 March 2010.

Found proved. The clinical evidence indicated Mr Sharma’s proposal to carry out a soft tissue graft for Patient A at a previously failed implant site. It was Mr Nery’s evidence that the consent form, dated 17 March 2010, contained within the clinical records for Patient A did not satisfy the requirements of an adequate updated treatment plan in respect of the soft tissue graft. Mr Nery highlighted that the consent form did not provide an explanation of the purpose of the graft, nor did it provide an explanation of the risks of undertaking the graft. Mr Nery explained that such risks included potential infection at the graft and/or failed implant site, as well as failure of the graft itself. The Committee accepted the evidence of Mr Nery. In doing so, it had regard to the consent form of 17 March 2010, which it noted referred to the proposal for a soft tissue graft in Patient A’s case. However, in the absence of the relevant information referred to by Mr Nery, including the serious risk of the graft failing, the Committee determined that it did not constitute an adequate updated written treatment plan. The Committee found no other document in the clinical records that could be regarded as a written treatment plan for the soft tissue graft. The Committee determined that Mr Sharma failed in his duty to provide Patient A with such a plan for the same reasons given at 4a above.

5. Prior to placing implants, you failed to provide Patient A with all the relevant information to enable Patient A to give valid informed consent in that you failed to:

5.(a) Inform Patient A of the risks of placing implants and grafting with bio materials at the same time.

Found proved. 5.(b) Advise Patient A about the specific risk of nerve damage relating to the implants at

LL5 and LL6 which could lead to numbness or altered sensation of chin/lower lip which could be permanent.

Found proved. 5.(c) Inform Patient A of options to minimise the risk of nerve damage.

Found proved. 5.(d) Inform Patient A of other treatment options.

Found proved. The Committee considered heads of charge 5(a) to (d) separately, but reached the same finding in respect of each head of charge. The Committee accepted the evidence of Mr Nery that for a patient to be able to give valid informed consent, they would need to be made aware, amongst other things, of the risks and benefits of proposed treatment.


Mr Nery detailed the particular risks in relation to Patient A regarding the placing of implants and grafting with bio materials at the same time. He stated that it was not inappropriate for the procedures to be undertaken simultaneously, however, in doing so, there was an increased risk of an unreliable outcome and failure through leaving the implants fused to an inadequate depth of bone. Mr Nery stated that, if this happened, the patient would not receive the desired results and the implant site would be prone to infection. Mr Nery told the Committee that nerve damage was also a particular risk in Patient A’s case because the LL5 and LL6 are situated close to a nerve bundle known as the Inferior Dental Nerve (ID nerve). He stated that if the implants interfered with the ID nerve, this could lead to the patient suffering from altered sensation, or transient or permanent numbness. Mr Nery stated that Patient A should have been told of the risk to the ID nerve, as well as all the other risks associated with the proposed treatment. In the C4 bundle the Committee noted Mr Sharma maintained that he gave Patient A full explanations of treatment, the alternatives and the risks and benefits. The Committee considered the clinical notes for Patient A. It found nothing in the records to indicate that the patient was informed of the risks highlighted by Mr Nery. Nor did it find any reference to the patient having been informed of the options to minimise the risk of nerve damage or of other treatment options. The Committee also had regard to the relevant consent form of 28 September 2011. It saw on the form typed generic wording indicating that risks and benefits had been explained, however, it saw nothing that was specific to Patient A’s treatment. In the circumstances, given the serious nature of the risks identified by Mr Nery, the Committee considered the absence of any record of any explanation to the patient to be significant. The Committee noted from the witness statement of Patient A that she stated that Mr Sharma was always trying to do his best, but she does not specifically state that he explained to her the matters at 5(a) to (d). Taking all the evidence into account, the Committee was satisfied on the balance of probabilities that Mr Sharma did not inform the patient of the matters in question. It considered that had he done so, it would be more likely than not that those matters would have been recorded. The Committee was also satisfied that the matters listed at 5(a) to (d) related to information that would have enabled Patient A to give valid informed consent. It took into account the seriousness of the risks associated with Patient A’s treatment, as emphasised by Mr Nery. He was clear in his evidence, which the Committee accepted, that given the nature of the risks involved in the treatment, it was important that the patient was informed. The Committee also considered the relevant GDC publications ‘Standards for Dental Professionals (May 2005)’ and ‘Principles of Patient Consent (May 2005)’ and was satisfied that Mr Sharma had a duty to inform Patient A. Having found that he did not do so, the Committee determined that, prior to placing implants, Mr Sharma failed to provide Patient A with all the relevant information to enable her to give valid informed consent.

6. You failed to provide Patient A with adequate information during the implant


procedures, in that you:

6.(a) (Previously read: Failed to warn Patient A of the surgical risks of placing implants and simultaneous grafting on 21 October 2010.)

Amended to read: Failed to warn Patient A of the surgical risks of placing implants and simultaneous grafting on 21 January 2010.

Found not proved (as amended). It was the view of the Committee that the allegation in this head of charge is encompassed in head of charge 5(a) above, which it has found proved. The Committee considered that the GDC did not demonstrate any material difference between this head of charge and head of charge 5(a). It decided that this head of charge added nothing to the case and is duplicitous, irrespective of the fact that it refers to a different date. Accordingly, the Committee found this head of charge not proved.

6.(b) (Previously read: Failed to discuss with Patient A the augmentation procedure of 21 October 2010.)

Amended to read: Failed to discuss with Patient A the augmentation procedure of 21 January 2010.

Found not proved (as amended). The Committee noted that there was information recorded in the clinical records regarding the bone augmentation procedure. Further, on the consent form of 28 September 2011, there is mention of placing implants and bone augmentation. This evidence is supported by that of Patient A, who stated in her witness statement that she recalled having discussions with Mr Sharma about bone augmentation. The Committee considered it more likely than not therefore, that there was some discussion with Patient A regarding the augmentation procedure.

6.(c) Failed to warn Patient A about the surgical risks of further implant placement at LL5 following removal of both implants on 17 March 2010.

Found proved. 6.(d) Failed to warn Patient A about the surgical risks of the augmentation procedure of

12 January 2011.

Found proved. 6.(e) Failed to warn Patient A about the risks of implant placement at LL7 on 28

September 2011.

Found proved. The Committee considered heads of charge 6(c) to (e) separately, but reached the same finding in respect of each head of charge. The Committee noted that these three heads of charge refer to the surgical risks associated with Patient A’s treatment. These being the same risks outlined by Mr Nery, which have already been considered by the Committee. These included the risks of pain, swelling and failure in respect of the bone augmentation and the risk


of nerve damage when placing implants in the region of the ID nerve. The Committee took into account Mr Nery’s evidence that informed consent is an ongoing process and it was satisfied that Patient A should have been informed of the relevant risks on each of the occasions concerned. The Committee found nothing in the clinical notes for the patient to indicate that she was informed of any of the associated risks on any of the dates in question. It also considered the relevant consent forms of 17 March 2010, 12 January 2011 and 28 September 2011 and it saw no reference to the specific risks identified by Mr Nery. Furthermore, it took into account that there was no information in Patient A’s witness statement beyond some discussion of the augmentation procedure, to suggest that she had been made aware of all the associated risks. Taking all the evidence into account, the Committee was satisfied on the balance of probabilities that Mr Sharma did not make the patient aware of those risks set out at 6(c), (d) and (e). The Committee has already established that Mr Sharma had a duty under the relevant GDC standards and the principles of patient consent (May 2005) to inform Patient A of the risks as part of obtaining valid informed consent. The Committee decided that the evidence before it indicates that he failed in that duty to warn the patient of the matters at 6(c) to (e).

7. As a result of the matters alleged in Head of Charge 6 you failed to provide the necessary information in order to enable Patient A to give valid ongoing informed consent.

Found proved in relation to heads of charge 6(c) to (e) above. The Committee has already accepted the evidence of Mr Nery that informed consent is an ongoing process. It has also determined that Mr Sharma had a duty under the relevant GDC standards, as part of the consent process, to inform Patient A of all the necessary information relating to her treatment to enable her to give valid informed consent. This included information regarding the risks involved in the proposed treatment. Having found that Patient A was not warned by Mr Sharma of the surgical risks set out at 6(c) to (e) above, the Committee was satisfied that this head of charge is proved.

Assessment and planning prior to implant procedure

8. Your pre-treatment investigations were inadequate in that you:

8.(a) You failed to check Patient A's medical history on 15 October 2009 or 21 January 2010.

Found proved in relation to 15 October 2009. Found not proved in relation to 21 January 2010. In reaching its decisions, the Committee took into account the evidence of Mr Nery that he would have expected Mr Sharma to have checked Patient A’s medical history at both of the appointments in question. Indeed, Mr Nery told the Committee that Mr Sharma had a duty to do so because of the risk of complications if the patient was on certain medications or had certain medical


conditions. The Committee also had regard to the relevant GDC Standards, which imposed on Mr Sharma a duty to make and keep accurate and complete patient records including a medical history. The Committee had regard to the clinical records for Patient A. It saw that Mr Sharma took a medical history for the patient on a number of occasions. In certain instances, this included the completion of Intra Venous Sedation Monitoring forms, which made reference to the patient’s medical history having been checked. The Committee noted, however, that in relation to 15 October 2009, there was an absence of any record indicating that Patient A’s medical history had been checked and there was no Intra Venous Sedation Monitoring form associated with this appointment. In fact, there were very limited records overall in relation to this date. Whilst the Committee noted from the clinical records that 15 October 2009 was just a consultation appointment with the patient, this was the appointment at which Mr Sharma had planned the patient’s treatment. Taking this into account along with the evidence of Mr Nery, the Committee concluded that Mr Sharma should have taken a medical history on 15 October 2009. In the absence of any written record that one was taken, the Committee determined on the balance of probabilities that Mr Sharma did not check the patient’s medical history. It was satisfied that he had a duty to do so. In respect of the appointment on 21 January 2010, the Committee noted the associated Intra Venous Sedation Monitoring form available in the clinical records. The form indicated that Patient A’s medical history was checked on this date. The Committee therefore concluded that despite there being no note in the clinical records it was more likely than not that Mr Sharma did check the patient’s medical history on that occasion.

8.(b) Failed to make study models.

Found proved. The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to make study models. Mr Nery told the Committee that study models were a necessary part of planning Patient A’s treatment. He said that study models would have been required to make a surgical stent or guide, which in turn, should have been used to ensure correct placement of the implants to guard against damaging the ID nerve. The Committee noted Mr Sharma’s written comments in C4, where he accepted that he did not make study models. He stated that, having assessed the ridge and occlusion chair-side, it was his clinical decision that nothing would be gained from making study models. Further, the Committee found nothing in the clinical records for the patient to indicate that study models were made by Mr Sharma. It was therefore satisfied that he failed in his duty to do so.

8.(c) Failed to make a surgical guide.

Found proved. The Committee has already found that Mr Sharma did not make study models. It has also accepted Mr Nery’s evidence that study models would have been


required to make a surgical guide. In the circumstances, the Committee concluded that Mr Sharma could not have made a surgical guide without having first made study models. It was satisfied that this was a failure on Mr Sharma’s part, in light of Mr Nery’s evidence about the importance of a surgical guide in ensuring safe placement of the implants.

8.(d) Failed to make adequate assessment of the occlusion.

Found proved. In the absence of any study models and consequently no surgical stent or guide to assist with the safe placement of the implants, the Committee was satisfied that Mr Sharma could not have adequately assessed the patient’s occlusion. It was further satisfied on the evidence already considered that Mr Sharma had a duty to make such an assessment.

8.(e) Failed to adequately evaluate the hard tissues.

Found not proved. The Committee considered that the alleged matter in this head of charge is encompassed in head of charge 8(f) below. It considered that this head of charge added nothing to what is detailed in 8(f). It also noted that Mr Nery did not specifically address this allegation at 8(e) in his evidence.

8.(f) Failed to adequately and/or accurately assess site suitability of the implant sites including:

8.(f)(i) The available bone width of the proposed implant sites.

Found proved. 8.(f)(ii) The bone height in relation to the inferior dental and mental nerves.

Found proved. 8.(f)(iii) The proximity of the mental and inferior dental and mental nerves to the drilling

depths for the proposed implants.

Found proved. The Committee considered heads of charge 8(f)(i) to (iii) separately, but reached the same finding in respect of each head of charge. Mr Sharma stated in his written comments in C4 that he assessed the implant sites “from direct view and palpation and calliper measurement…” However, the Committee accepted the expert opinion of Mr Nery that the use of callipers was not an acceptable method of assessment for site suitability. Mr Nery’s evidence was that good working measurements were “essential” to negate the risk of damage to the critical nerve structures present in the particular area of the patient’s mouth where implants were proposed. He stated that measurements should have been obtained from the CT scan taken of Patient A on 19 November 2009 after her implant consultation appointment with Mr Sharma. Mr Nery explained that it was evident that Mr Sharma had not adequately assessed the suitability of the implant sites as the implants he placed were too long. It was Mr Nery’s opinion that these implants would have been very close to


the ID nerve, leaving an inadequate margin of safety for preventing damage to the left ID and mental nerves. Mr Nery’s evidence was that it was advisable to keep a safe distance of 2mm from the ID nerve when placing implants. The Committee accepted the opinion and measurements taken by Mr Nery and was satisfied that the length of the implants chosen by Mr Sharma were unsuitable. Therefore, the Committee was satisfied that Mr Sharma did not carry out the assessments adequately or accurately as he either made an inaccurate measurement of the bone height or used the CT scan erroneously at 8(f)(i) to (iii) above. It was also satisfied on the evidence of Mr Nery that Mr Sharma had a duty to carry out these assessments adequately, considering the serious risk to the patient of nerve damage. Accordingly, the Committee found that there was a failure on Mr Sharma’s part.

9. Planned to place 11 mm and 13 mm implants at LL5 and LL6 when the bone height was approximately 11 – 12.5 mm above the ID nerve.

Found proved. The Committee had regard to the clinical records for Patient A. It also took into account the evidence of Mr Nery, who having also reviewed the records, reported that the length of the implants that Mr Sharma had planned to place at LL5 and LL6 were 11mm and 13mm respectively. Further, the Committee accepted Mr Nery’s assessment of the available bone height at the proposed implant sites, as set out in his report. Having taken into account the clinical information available, including the patient’s CT scan, Mr Nery stated that “The proposed site for LL5 had approx. 11-12.5mm bone height above the ID nerve…” and “The proposed site for LL6 had approx. 11-12.5mm bone height above the ID nerve…”. Thus, the implants Mr Sharma planned to use were too long for the available bone height. The Committee was therefore satisfied on the evidence that this head of charge is proved.

10. Failed to report on the CT scan of 19 November 2009, including the quality of the scan and noting of measurements.

Found proved. The Committee considered the clinical records for the patient and whilst it saw that there was a note indicating that Patient A would have to go for a CT scan, it found no evidence of a report on that scan of 19 November 2009. The Committee was satisfied on the evidence that, once the scan was taken, Mr Sharma had a duty to report on it, as this is a specific obligation under the IRMER 2000 regulations. In the absence of a report, it was satisfied that Mr Sharma failed in his duty.

Implant procedure

11. Your treatment of Patient A on 21 January 2010 placed her at risk of harm in that:

11.(a) You placed 11mm and 13 mm long implants at LL5 and LL6 without an adequate margin of safety to the proximity of the mental and inferior dental nerves to minimise the risk of reversible or irreversible nerve damage.


Found proved. The Committee was satisfied from the clinical records for Patient A and from the evidence of Mr Nery that Mr Sharma placed these implants as planned. Mr Nery set out in his report that Patient A had four implants placed on 21 January 2010 including two in the lower left jaw. He stated that “The purpose of the lower left implants was to allow replacement of the LL5 and LL6 with implants…”. He further noted that “The records show that J1052.3311, and J1052.3811 were placed at LL5 and LL6 respectively. These codes refer to 11mm x 3.3mm and 13mm x 3.8mm implants in the Camlog system.”

The Committee has already noted and accepted Mr Nery’s evidence regarding the available bone height above the ID nerve in relation to the implants, which was 11 – 12.5mm. It has also accepted Mr Nery’s evidence that it is advisable to keep a safe distance of 2mm from the ID nerve when placing implants. The Committee considered it clear from all of the measurements that the implants placed by Mr Sharma were approximately the same length of the available bone, meaning that there was no margin for error. The Committee was satisfied that this placed Patient A at risk of harm of damage to the critical nerve structures present in that area of her mouth.

11.(b) You placed implants at LL5 and LL6 without giving Patient A the option of using shorter implants or grafting the ridges first to increase width as compared to placing the implants and grafting simultaneously.

Found proved. The Committee had regard to the clinical records for Patient A and found no reference to a discussion or a plan about using shorter implants. There was also no information in the records regarding the possibility of grafting the ridges first to increase width, as opposed to placing the implants and grafting simultaneously. The Committee also considered the witness statement of Patient A and found no mention by her of any discussion with Mr Sharma about these matters. In the absence of any records or any indication from the patient that such matters were discussed, the Committee decided on the balance of probabilities that Mr Sharma did not give Patient A the options as described above. It was further satisfied that in not doing so, Mr Sharma placed the patient at risk of harm, as the evidence suggests that these options could have resulted in a better treatment outcome.

12. The treatment was ultimately unsuccessful in that:-

12.(a) The initial implants placed at LL5 and LL6 on 21.1.10 failed.

Found proved. The Committee had regard to the clinical records for Patient A where it is recorded that when the patient returned to see Mr Sharma in March 2010 both implants were mobile and were removed. Further, in her witness statement, Patient A stated that she had to have both implants re-done. The Committee was therefore satisfied as to the fact that the implants placed at LL5 and LL6 on 21 January 2010 had failed and the treatment was unsuccessful.


12.(b) Patient A reported a numb lip.

Found proved. The Committee had regard to the clinical records for Patient A where there is a handwritten note against the date 2 February 2010, referring to a telephone conversation with the patient in which she reported that her lip was numb. A reference to a numb lip also appears in the computerised clinical records for the patient in relation to an appointment on 17 February 2010. That record states “numbness around the chin and angle of lip”. Taking into account this evidence, the Committee was satisfied that this head of charge is proved.

12.(c) LL5 was replaced.

Found proved. The Committee had regard to the clinical records for Patient A, which indicate that the implant at LL5 was removed and replaced on the same day on 17 March 2010.

12.(d) An implant was attempted at LL7 on 28 September 2011 but failed.

Found proved. The Committee saw from the clinical records that the patient signed a consent form for surgery, dated 28 September 2011, for treatment including placement of an implant at LL7. It was then noted in the records in respect of a review appointment on 22 November 2011 that “implant LL7 failed – grade III mobility…”

On the basis of the records, the Committee was satisfied that this implant was attempted on 28 Sept 2011 but failed only two months later.

12.(e) The restored implant at LL5 remained but with extensive bone loss and a questionable prognosis.

Found proved. In finding this head of charge proved, the Committee accepted the evidence of Mr Nery that the relevant radiographs showed that the LL5 had a questionable prognosis because the bone loss in that area was so extensive.

12.(f) The implant at LL5 has remained sensitive since the conclusion of the treatment.

Found proved. The Committee accepted the evidence of Patient A, as contained in her witness statement, was balanced and measured and more likely than not to be accurate and credible. She stated that the implant in question “has never been fully comfortable. I remember telling Mr Sharma afterwards that it felt numb, and it has remained sensitive since.”

The Committee was satisfied on this evidence that Patient A’s LL5 remained sensitive from the conclusion of her treatment with Mr Sharma up until at least 11 February 2015, which appears to be the date of her witness statement.

13. You failed to take adequate peri-apical radiographs:

13. (a) at the time of implant insertion on:


13.(a)(i) 21 January 2010.

Found proved. 13.(a)(ii) 17 March 2010

Found proved. 13.(a)(iii) (Previously read: 28 September 2010)

Amended to read: 28 September 2011.

Found proved (as amended). The Committee considered heads of charge 13(a)(i), 13(a)(ii) and 13(a)(iii) separately but reached the same finding in respect of each head of charge. The Committee considered the clinical records and found no indication that peri-apical radiographs had been taken in respect of Patient A on the dates in question. It also took into account Mr Sharma’s written comments in C4 in relation to his treatment of Patient A. He stated that “when required I either utilised the library of existing radiographs or when indicated took new ones.” In deciding that Mr Sharma had a duty to take peri-apical radiographs, the Committee accepted the evidence of Mr Nery that the taking of peri-apical radiographs at the time of implant insertion on the said dates would have been necessary. He explained that such radiographs should have been used to check the depth of the implant sites to ensure that there had been no penetration of any important structures, such as the ID nerve and to enable the practitioner to assess the extent of bone loss.

13.(b) (Previously read: on or before taking impressions of LL5 and LL6 on 28 September 2010.)

Amended to read: on or before taking impressions of LL5 and LL6 on 28 September 2011.

Found proved (as amended). The Committee accepted the evidence of Mr Nery that the taking of periapical radiographs on or before taking impressions of LL5 and LL6 on 28 September 2011, would have enabled Mr Sharma to see whether the implants were properly placed. Mr Nery said that such information would have informed the next stage of appropriate treatment, which in Patient A’s case was the taking of impressions for the purpose of placing crowns. Mr Nery stated that Mr Sharma had a duty to ensure that he was fully informed regarding the position of the implants before undertaking the treatment. The Committee found no information in the clinical records to indicate that periapical radiographs had been taken before or at the time of taking the impressions and accordingly this head of charge was proved on that basis. In addition, although made in relation to a different investigation, the Committee also placed some weight on Mr Sharma’s reported comments recorded in a report of a meeting dated 6 December 2013, with Bupa’s Dental Clinical Director, in an interview with witness 3. When questioned in relation to concerns that he seemed to have been placing and restoring implants without preoperative radiographs, Mr


Sharma was recorded as stating that he did not consider them always necessary and disputed that they were mandatory. Taking all the evidence into account, the Committee was satisfied on the balance of probabilities that Mr Sharma failed to take adequate periapical radiographs.

Record Keeping

14. Your records for treatment for Patient A between 15 October 2009 to 14 December 2011 were inadequate in that you failed adequately to record:

14.(a) Medical and social history on 15 October 2009 and/or 21 January 2010

Found proved. 14.(b) Extra-oral examination

Found proved. 14.(c) TMJ (Temporomandibular Jaw) Examination

Found proved. 14.(d) Basic Periodontal examination (BPE)

Found proved. 14.(e) Oral hygiene assessment

Found proved. 14.(f) Any assessment of the occlusion prior to placing implants

Found proved. 14.(g) The width of the proposed implant sites

Found proved. 14.(h) Justification for the CT scan of 19 November 2009

Found proved. The Committee considered heads of charge 14(a)–(h) separately, but made the same finding in respect of each head of charge. The Committee considered Patient A’s notes. In relation to each of the matters listed at charge 14(a)-(h), it noted that there was nothing recorded in those notes. It accepted the expert opinion of Mr Nery that those matters should be recorded individually in the notes as each one of them should be considered when undertaking implant surgery-both at the planning stage and when commencing treatment. As all these procedures all should be carried out, the Committee was satisfied that there was an obligation to record them because adequate records are important for the safe delivery and continuity of care.

14.(i) Surgical details of the implant surgery and augmentation carried out with Bio-oss and Bio guide on 21 January 2010.

Found proved. In relation to this head of charge, the Committee considered the clinical records,


including the relevant consent form. It found that some information associated with the implant surgery and augmentation is recorded. It also saw that there were Bio-oss and Bio-guide branded stickers attached in the clinical notes. Notwithstanding this, it was the Committee’s view that the actual notes made by Mr Sharma simply amounted to a list of what he did in terms of the procedures undertaken. The Committee found nothing in the notes that the Committee regarded as adequate as “surgical details”. It accepted Mr Nery’s evidence and was satisfied that surgical details are required for patient safety and continuity of care and should have included, amongst other things, the flap design and whether local anaesthetic and sutures were used. In the absence of such information in the clinical records, the Committee was satisfied that this head of charge is proved.

14.(j) Discussion with Patient A regarding the surgical risks of implant placement at LL5 and 6 on 21 January 2010 including potential nerve damage and the risk of failure of LL5 and LL6

Found not proved. 14.(k) Discussion with Patient A regarding the surgical risks of the augmentation

procedure of 21 January 2010 and/or 12 January 2011 including the biomaterials used, risks, benefits of procedure or alternative solutions for solving the problem of the lack of bone at the intended implant sites

Found not proved. The Committee considered heads of charge 14(j) and (k) separately but made the same finding in respect of each head of charge. The Committee has already found at head of charge 5 that Mr Sharma failed to discuss with Patient A the associated surgical risks of her treatment, including the risk of nerve damage. It has also found at head of charge 6(d) that Mr Sharma failed to warn the patient about surgical risks on 12 January 2010. In light of its findings that the actions at heads of charge 5 and 6(d) were not undertaken, the Committee was satisfied that there was no obligation to record what was not done.

14.(l) Dose and type of local anaesthetic used

Found proved. The Committee saw on the consent form of 21 January 2010 that, whilst there was reference to local anaesthetic, there was no record of the type or dose of the local anaesthetic used. It accepted Mr Nery’s evidence and was satisfied that there was an obligation to record this.

14.(m) The clinical reasons why the soft tissue graft from the palate was undertaken on 17 March 2010.

Found proved. The Committee saw from the clinical records that, whilst the fact of a soft tissue graft was recorded, there are no clinical reasons for the graft recorded. It also noted that there is also no record of clinical reasons on the relevant consent form. It accepted Mr Nery’s evidence and was satisfied that there was an obligation to record this. Accordingly, it found this head of charge proved.


14.(n) Discussion with the patient of risks, benefits, options or post-operative advice in respect of further implant placement and the soft tissue graft of 17 March 2010

Found proved. In reaching its decision, the Committee took into account its findings at head of charge 6(c) that Mr Sharma had failed to warn the patient of the surgical risks in relation to a further implant at the LL5. It noted, however, that this head of charge goes beyond a record referring to just the risks of that treatment. This head of charge also relates to the soft tissue graft which was undertaken by Mr Sharma on 17 March 2010. The Committee found no record of the risks, benefits, options or post-operative advice in respect of the soft tissue grafts, which it considered on the expert’s evidence should have been recorded. Therefore, overall, the Committee found this head of charge proved.

14.(o) Details of the clinical procedure for the soft tissue graft of 17 March 2010

Found proved. The Committee had regard to the clinical records and noted that the only records in respect of the clinical procedure for the soft tissue graft were “raised mp flap at sites” and “closed wound site with vicryl sutures”. The Committee considered the clinical detail in the records to be inadequate. It did not regard it as a record capable of informing a subsequent treating dentist as to the clinical procedure. It therefore found this head of charge proved.

14.(p) Information on the stability of the implants

Found proved. In reaching its decision on this head of charge, the Committee had regard to the evidence of Mr Nery. He set out his opinion in his report that stability in this context relates to how sufficiently the implants are anchored to the bone. The Committee understood from the evidence of Mr Nery that any record as to stability would refer to the long-term prognosis of the implant, taking into account the sufficiency of the available bone. The Committee found no such record made by Mr Sharma and therefore decided that this head of charge is proved.

14.(q) Warnings given to Patient A relating to risks of implant placement at LL7 on 28 September 2011

Found not proved. In light of the Committee’s findings at head of charge 6(e) that Mr Sharma failed to warn Patient A about the risks of implant placement at LL7 on 28 September 2011, the Committee found this head of charge not proved. It concluded that Mr Sharma could not have recorded what he did not do.

14. (r) Details of appointments with Patient A on:

14.(r)(i) 12 November 2009

Found not proved.


14.(r)(ii) 10 December 2009

Found not proved. 14.(r)(iii) 10 February 2010

Found not proved. 14.(r)(iv) 3 March 2010

Found not proved. 14.(r)(v) 26 May 2010

Found not proved. 14.(r)(vi) 2 June 2010

Found not proved. 14.(r)(vii) 16 June 2010

Found not proved. 14.(r)(viii) 6 October 2010

Found not proved. 14.(r)(ix) 24 November 2010

Found not proved. 14.(r)(x) 2 February 2011

Found not proved. 14.(r)(xi) 29 June 2011

Found not proved. 14.(r)(xii) 24 August 2011

Found not proved. 14.(r)(xiii) 12 October 2011

Found not proved. 14.(r)(xiv) 19 October 2011

Found not proved. 14.(r)(xv) 26 October 2011

Found not proved. 14.(r)(xvi) 23 November 2011

Found not proved. The Committee considered heads of charge 14(r)(i) to (xvi) separately, but made the same finding in respect of each head of charge. The Committee had regard to the clinical records provided and noted that they include a list of appointments, which referred to all of the above dates which had


Mr Sharma’s name against them. However, the Committee could find no notes in the records associated with these appointments. There was no information presented to the Committee to demonstrate whether those appointments took place or whether they were simply diarised appointments that could have been cancelled by Patient A and/or Mr Sharma and/or the practice. The GDC did not produce any information to the Committee regarding the type of appointment system in use at the time. Given the lack of information before the Committee it was unable to infer that those appointments had taken place. Accordingly, the GDC has failed to prove on the balance of probabilities that the appointments took place and therefore the allegation is not proved as there is no obligation to record appointments if they did not take place. Accordingly, the Committee found heads of charge 14(r)(i) to (xvi) not proved.

Handling of Patient A's complaint

15. From November 2012 after you were made aware of Patient A's complaint you failed to respond to Patient A's complaint in a timely manner.

Found proved. The evidence showed that Patient A complained about her treatment with Mr Sharma in a letter sent to the practice in November 2012. The Committee had regard to the various emails sent in relation to the patient’s complaint. It noted that there was initial engagement by Mr Sharma with the practice regarding the complaint in emails dated 23 and 26 November 2012. However, there was nothing before the Committee to indicate that Mr Sharma actually engaged with Patient A regarding her complaint. The Committee noted from Mr Sharma’s written comments in C4 that he thought the practice was dealing with the matter. It was however, the evidence of Mr Nery, which the Committee accepted, that it was Mr Sharma’s responsibility, as the treating dentist, to respond to Patient A. The Committee also noted this was an obligation under GDC Standards. The Committee noted from Patient A’s witness statement that the matter was still ongoing as at April 2013, in that she indicated that she still had not had a response from him, even though he was made aware of her complaint in November 2012. The Committee accepted her account as credible. Taking all the evidence into account, the Committee was satisfied that Mr Sharma failed to respond to Patient A’s complaint in a timely manner.

Patient B 16. At all material times you were a United Kingdom registered Dental Practitioner in

practise at Leckhampton Dental Clinic, 31 Leckhampton Road, Leckhampton, Cheltenham, Gloucestershire, GL53 0BD.

Found proved. The Committee was satisfied from the clinical records for Patient B that at all material times Mr Sharma was practising as a dentist at the Leckhampton Dental Clinic.

17. Between 17 June 2008 and 17 December 2008, you provided treatment to Patient


B.

Found proved. The Committee noted the treatment history for Patient B, as contained in the clinical records. It was satisfied that between 17 June 2008 and 17 December 2008, Mr Sharma provided treatment to this patient.

Assessment & Treatment Planning

18. You failed to undertake adequate assessments or treatment planning prior to placing implants at UL345 region and crowning of UL6 including:

18.(a) Extra-Oral Examination

Found proved. 18.(b) Soft tissue Examination

Found proved. 18.(c) Basic Periodontal examination (BPE)

Found proved. The Committee considered heads of charge 18(a) to (c) separately, but made the same finding in respect of each head of charge. The Committee also took into account the evidence of Mr Nery, who said that he would have expected all of the assessments set out at 18(a) to (c) and (d) to (f) to have been recorded by Mr Sharma, if undertaken. Mr Nery stated that the purpose of the assessments was to establish whether the patient was suitable for implants. The Committee had regard to the clinical record for Patient B, where it is indicated that the patient was interested in Zirconia implants. The Committee took into account the notes relating to 17 June 2008, which was the patient’s first consultation with Mr Sharma in relation to implant treatment. Whilst it saw that there is a heading in these notes entitled “Implant Assessment”, it found that none of the information listed at 18(a) to (c) is included under this heading. The Committee noted in C4 that Mr Sharma made reference to soft tissue details having been recorded by him on a separate assessment sheet. However, there was no such document before the Committee and no reasonable explanation given for its absence. In this regard, the Committee reminded itself of the evidential burden on Mr Sharma to provide all the relevant records for this case. In the absence of anything in the clinical records for Patient B to indicate that Mr Sharma had undertaken the assessments referred to at heads of charge 18(a) to (c), the Committee concluded on the balance of probabilities that he did not undertake them. It regarded this as a failure on Mr Sharma’s part, in light of the evidence of Mr Nery that such assessments were required prior to commencing implant treatment.

18.(d) Assessment of the occlusion

Found proved. The Committee saw an indication within the clinical notes that Mr Sharma


undertook assessment of Patient B’s occlusion. For instance, there is a negative entry relating to the cross bite, which suggests that this was checked. However, the Committee considered that this record alone was not sufficient to demonstrate there had been an assessment of the patient’s occlusion that was adequate. It therefore found this head of charge proved on this basis. Accepting the evidence of Mr Nery, the Committee was satisfied that Mr Sharma failed in his duty in this regard.

18.(e) Study models

Found not proved. 18.(f) A mock-up of the anticipated final tooth positions

Found not proved. The Committee considered heads of charge 18(e) and (f) separately, but made the same finding in respect of each head of charge. The Committee noted that there is reference in the clinical records to a “Lab Making Mock Up” with an associated cost listed. In its view, this reference suggests that study models may have been made. The Committee also saw reference in the clinical records to the use of a stent, which it understood could only have been made if there were available study models. On balance, taking all the evidence into account, the Committee was not satisfied that the GDC proved that Mr Sharma failed to make study models and a lab made mock-up of the anticipated final tooth positions.

19. You failed to adequately assess the sufficiency of bone prior to placing implants in that:-

19.(a) You did not report on the radiolucency of the OPT scan

Found proved. The Committee noted from the evidence it received, that an OPT scan was taken on 17 June 2008 in respect of this patient. It was referred to the scan by Mr Nery who stated that there was an area of radiolucency on the scan, which could have indicated there was a problem with the sufficiency of bone. The Committee had regard to the clinical notes and saw nothing to indicate that Mr Sharma had reported on the OPT scan, which was an obligation under the IRMER 2000 regulations. The duty to do so was even more significant because of the radiolucency evident on the scan. Given this non-reporting the Committee concluded that it was more likely than not that Mr Sharma did not adequately assess the sufficiency of the bone. It accepted the evidence of Mr Nery that this was a failure on Mr Sharma’s part, as he should have carried out such an assessment prior to placing implants.

19.(b) You did not take peri-apical radiographs after viewing the OPT scan

Found proved. The Committee accepted the evidence of Mr Nery, who said that Mr Sharma


should have taken a periapical radiograph because of the presence of the radiolucency on the patient’s OPT scan. Mr Nery stated that a periapical radiograph would have enabled Mr Sharma to assess the sufficiency of the bone. The Committee did not receive a periapical radiograph and it found nothing in the clinical records to indicate that Mr Sharma took one after viewing the patient’s OPT scan. It accepted the evidence of Mr Nery and was satisfied that this was a failure on Mr Sharma’s part, as he should have taken a periapical radiograph prior to placing implants.

19.(c) You did not consider the need for a CT scan at UL45 after the OPT

Found proved. The Committee was satisfied on the evidence of Mr Nery that Mr Sharma should have considered the need for a CT scan after viewing the OPT, which would have enabled him to view the radiolucency in 3D format. Mr Nery stated that, if Mr Sharma did not take a periapical radiograph, he should have considered the need for a CT scan. The Committee found nothing in the clinical records to indicate that Mr Sharma gave this issue any consideration. It therefore decided that, it was more likely than not that he did not do so. The Committee accepted the evidence of Mr Nery and was satisfied that this was a failure on Mr Sharma’s part.

20. You failed to produce a written treatment plan discussing risks, benefits or options, with particular reference to use of Zirconia one-piece implants and immediate loading

Found proved. It was the evidence of Mr Nery that the use of Zirconia one-piece implants is unusual. He stated that this is because of the particular risk associated with one-piece implants, this being that the angle of the implants cannot be adjusted after placement, which means that there must be correct placement from the outset to enable immediate loading associated with one-piece implants. Mr Nery stated that in the circumstances of this heightened risk, there was a duty on Mr Sharma to produce a written treatment plan for Patient B which discussed the risks, benefits and options, with particular reference to the use of Zirconia one-piece implants and the associated immediate loading. The Committee considered Mr Sharma’s clinical records in respect of Patient B and found no written treatment plan setting out such information. It noted the relevant “treatment plan estimate”, but considered this merely listed the steps of the proposed treatment and the cost. There was no information relating to the risks, benefits or options, associated with Zirconia one-piece implants and immediate loading. The Committee was therefore satisfied that it was more likely than not that Mr Sharma did not produce such a written treatment plan for Patient B. By not doing so, he failed in his duty in this regard.

21. You failed to obtain valid informed consent from Patient B in respect of stage one treatment (implants).

Found proved.


The Committee has already found that Mr Sharma failed to provide Patient B with a written treatment plan in respect of her implant treatment. It took into account Mr Sharma’s comments as contained in C4. It noted that he made reference to a discussion with Patient B about her treatment. However, the Committee found that there was very limited detail before it of what was discussed with the patient. It had regard to the relevant consent form within the clinical notes, which was signed by the patient. The Committee noted that there was a generic standard paragraph on the form stating that “the operation, investigation or treatment” had been explained, including “its major and characteristic risk(s)”. However, the Committee saw nothing on the form that was tailored to the specific risks and benefits of Patient B’s treatment. It also found that there was nothing elsewhere in the clinical records to support such a discussion. Further, it took into account the witness statement of Patient B. She stated that Mr Sharma did not discuss any of the risks or benefits of the chosen treatment with her. Given the evidence regarding the complex nature of Patient B’s treatment, the Committee would have expected there to be some record of a discussion with the patient to indicate that she had been informed of all the relevant information. In the absence of any record and in light of Patient B’s evidence, the Committee concluded that it was more likely than not that Mr Sharma did not sufficiently discuss matters with the patient, including the risks and benefits of the proposed treatment. Taking into account Mr Nery’s evidence, Standards for Dental Professionals (May 2005)’ and ‘Principles of Patient Consent (May 2005)’, the Committee was satisfied that Mr Sharma had an obligation to do so. By not doing so, he failed in his duty to obtain valid informed consent from Patient B for the implant treatment.

Stage One - Placement of Implants

22. (Previously read: On 17 July 2008 you proceeded with one-piece implants knowing that the implants would be at an unfavourable angle which might result in further treatment which Patient B would not have desired.) Amended to read: On 16 July 2008 you proceeded with one-piece implants knowing that the implants would be at an unfavourable angle which might result in further treatment which Patient B would not have desired.

Found proved (as amended). In reaching its decision, the Committee accepted the evidence of Mr Nery that, given the radiolucency seen on the OPT scan of the patient, it was likely that there was a lack of bone in the area where Mr Sharma proposed to place the implants. Mr Nery explained that because of the lack of bone and the surgical guide which was pre-prepared and governs the angle of drilling, any implants placed would be at an unfavourable angle and Mr Sharma would have known this at the time. The Committee also noted the evidence of Witness B as contained in the patient’s witness statement. Witness B stated that at an appointment with Mr Sharma to review the implants on 26 August 2008 “I told him that I was horrendously concerned about the positioning of the implants…”. Witness B stated that only then did Mr Sharma say for the first time “This is the only positioning I could have done based on radiographs and how the lab calculated the drilling should be


done.” The Committee accepted Witness B’s account of what Mr Sharma told her on 26 August 2008. The Committee found that this supported the allegation that Mr Sharma knew from the outset of treatment that the implants would have to be placed at an unfavourable angle. The Committee also took into account Mr Sharma’s written observations in C4 regarding this matter, in which he describes using a stent to plan the positioning of the implants. In the circumstances, given Mr Sharma’s assertion that he looked at radiographs and used a stent, the Committee concluded that it was more likely than not that he knew the implants would be at unfavourable angles, yet he still went ahead with treatment. Accordingly, the Committee found this head of charge proved.

23. (Previously read: On 17 July 2008 having placed the one-piece implants with the abutment emerging at an unfavourable angle you:)

Amended to read: On 16 July 2008 having placed the one-piece implants with the abutment emerging at an unfavourable angle you:

23.(a) Failed to inform Patient B of the unfavourable angle

Found proved (as amended). The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to inform Patient B of the unfavourable angle. Mr Nery stated that it was Mr Sharma’s obligation as part of the ongoing consent process. The Committee also took into account the relevant GDC standards which, amongst other things, required Mr Sharma to communicate effectively with patients. The Committee found no evidence in the clinical notes to suggest that Mr Sharma did inform Patient B of the unfavourable angle. It also took into account the patient’s evidence as contained in her witness statement. The Committee accepted Patient B’s description of the impact on her when she saw the result of the treatment. She stated that Mr Sharma “had told me nothing about the positioning of the implants, which I assumed would be in line with my teeth. I was horrified to discover they were not”. Given the likely significance of such major dental work to Patient B the Committee found her account credible and accurate. Having had regard to Patient B’s evidence and the absence of any relevant record, the Committee was satisfied on the balance of probabilities that Mr Sharma had failed in his duty to inform Patient B of the unfavourable angle.

23.(b) Failed to inform Patient B of the likelihood of bulky crowns on UL4 and UL5 as a result of the unfavourable angle.

Found proved (as amended). The Committee took into account the evidence of Patient B, as contained within her witness statement. She stated that “When I returned home after the treatment I discovered that the implants were facing outwards at an angle out-of-line with the rest of my teeth and appeared like miniature tusks.” In respect of the subsequent crown treatment, Patient B stated “The crowns placed on the two implants are very bulbous and bulging in the middle in order to incorporate the position of the implants. They look like barrels and were not what I expected.”


The Committee considered that it was clear from Patient B’s evidence that she had been unprepared for what she saw in the mirror. It was satisfied on the balance of probabilities that Mr Sharma had failed in his duty to inform her of the likely final appearance caused by the bulky crowns.

23.(c) Failed to inform Patient B of the likelihood for further restorative work arising from the unfavourable angle(s) of the abutment(s).

Found proved (as amended). The Committee was satisfied from the evidence of Mr Nery that the only way to rectify the ill-placed implants following their integration was by way of further restorative work. It was the view of the Committee that Mr Sharma knew, or should have known, Patient B was a dentally aware and aesthetically motivated patient. It considered it was clear what the patient wanted from her treatment with the registrant. The Committee accepted Patient B’s account that Mr Sharma did not inform her of the likelihood of further restorative work, and concluded that Mr Sharma should have told Patient B about the failings in treatment and the likelihood of further restorative work. The Committee was satisfied on Mr Nery’s evidence that there was a duty to do this.

23.(d) Failed to inform Patient B of alternative treatment options including removal of the one-piece implants rather than allowing osseointegration, after which the implants could not be repositioned.

Found proved (as amended). The Committee accepted the opinion of Mr Nery that there was a duty on Mr Sharma as part of the treatment planning and ongoing consent process to inform Patient B of alternative treatment options as soon as it became known that the implants were at an unfavourable angle. The Committee found nothing in the clinical notes or in Patient B’s witness statement to suggest that alternative treatment options were discussed or that the implants were removed by Mr Sharma at any stage. Accordingly, it was satisfied that this head of charge is proved on the balance of probabilities.

23.(e) Allowed the implants to integrate.

Found proved (as amended). The evidence before the Committee was that Patient B went home with the implants with the next appointment not being until 26 August 2008 by which time the implants would have integrated.

23.(f) Only informed Patient B of the problem and the consequences when it was too late to rectify, thereby necessitating further treatment of multiple veneers that you had recommended at the start, but which the patient had indicated that she did not want.

Found proved (as amended). The Committee considered that this head of charge simply reiterates what is factually stated by Patient B in her witness statement.


Nevertheless, having considered and accepted Patient B’s evidence, the Committee’s factual finding is that the patient did not become aware of the problem and the consequences until an appointment on 23 September 2008. She stated that “At this point it was made clear to me that I would need to have considerable work done…” The Committee was satisfied on all the evidence that it was too late, as at 23 September 2008, to rectify the issues with the patient’s initial treatment and that the further treatment described was required.

23.(g) Following restoration of the implants, failed to inform the patient of the option to remove the implants to obtain a more favourable outcome.

Found not proved (as amended). The Committee considered this head of charge poorly drafted and unclear. It noted that the restoration of Patient B’s implants was not undertaken until 23 September 2008, by which point, on Mr Nery’s evidence, removal was not possible. The Committee therefore determined that it could not have been a failure on Mr Sharma’s part not to inform the patient of an option that was not possible.

24. As a result of your conduct at Head of Charge 22 and/or 23, you failed to obtain valid ongoing informed consent in respect of placing the one-piece implants.

Found proved. The Committee was satisfied that, after placing the implants at an unfavourable angle, Mr Sharma had a duty as part of the ongoing consent process, to inform Patient B of the relevant matters at head of charge 23 above. It took into account that one of the possible options in this patient’s case was the immediate removal of the one-piece implants. By not informing the patient of this option and other alternative treatment options, the Committee concluded that Mr Sharma removed any opportunity for her to make informed choices. It was therefore satisfied that he failed to obtain valid ongoing informed consent in respect of placing the one-piece implants.

25. Your conduct as alleged at Head of Charge 22 and/or 23 was:

25.(a) Misleading.

Found proved. Given its finding that Mr Sharma knowingly proceeded with what was inappropriate treatment which might have led to further cost to Patient B, the Committee was satisfied that Mr Sharma’s overall conduct at heads of charge 22 and 23 was misleading.

25.(b) Dishonest in that you placed single piece implant in the knowledge that it might create restorative complications which you failed to inform the patient of at the time.

Found proved. The Committee considered that head of charge 25 was poorly drafted in that the stem refers to the conduct at head of charge 22 and/or 23 and yet a further particularisation of dishonesty is given in limb (b) where the dishonesty is particularised as being “in that you placed single piece implant in the knowledge that it might create restorative complications which you failed to inform the patient


of at the time”.

Head of charge 22 referred to proceeding with the implants on the 16 July 2008 whereas head of charge 23 detailed communication failures after the implants had been placed. Given Mr Sharma’s absence and the serious nature of the allegation of dishonesty, the Committee considered that it was appropriate to construe the allegation narrowly namely to consider whether the GDC had proved that Mr Sharma was dishonest on the basis of what he genuinely believed at the time of placing the implants (head of charge 22) as opposed to his conduct after placing the implant (head of charge 23). The Committee had regard to how the GDC put its case on dishonesty, which was, in effect, that Mr Sharma embarked on this treatment in the knowledge “that Patient B would have to pay him more to rectify the problem”. The GDC’s case on dishonesty was therefore that Mr Sharma undertook work that he knew would require further restorative work for financial gain. The Committee applied the test of dishonesty as set out in Ivey v Genting Casinos (UK) limited [2017] 3WLR p1212. Accordingly, it first sought to ascertain, as far as it was able on the information before it Mr Sharma’s actual state of knowledge or belief as to the facts. The Committee found that as Mr Sharma had had a stent prepared for the placing of the implants and that he therefore must have known before the implants were positioned that they would be at an unfavourable angle. Nonetheless he proceeded with their insertion. The Committee was satisfied that he knew this would necessitate further treatment and further treatment that Patient B would not have desired. The Committee specifically considered alternative explanations including whether Mr Sharma was acting recklessly or negligently or with unconscious incompetence and rejected these alternatives as to his likely state of mind. The Committee noted his denial of dishonesty in C4, but on the information before it, it was satisfied that the GDC had established, on the balance of probabilities, that his most likely belief at the time as to the facts was an intention to proceed with inappropriate work leading to further costs and likely financial gain for himself. This was because he knew Patient B was concerned about costs but also about her appearance; he knew that the placing of the implants in this case would leave the implants at an unfavourable angle; he knew it would likely lead to further treatment to achieve a better aesthetic result and a likely financial gain for himself and at no stage did he did not reassess the situation or offer Patient B an alternative. The Committee had no hesitation that such a motivation and such conduct as it has found was dishonest by the objective standards of ordinary decent people.

Stage two - Veneers

26. You failed to carry out adequate assessments before placing veneers on 19 November 2008 in that:-

26.(a) WITHDRAWN. 26.(b) You failed to provide a revised treatment plan.

Found proved.


The Committee accepted the evidence of Mr Nery that Mr Sharma was obliged to provided Patient B with a revised treatment plan. Mr Nery stated that it was Mr Sharma’s duty as part of the ongoing consent process. Mr Nery explained that if a patient’s treatment changed an updated treatment plan including the changes and costs was required. The Committee had regard to the clinical records for the patient and saw nothing which it considered constituted a revised treatment plan. It also took into account the evidence of Patient B. She stated in her witness statement that she agreed to Mr Sharma providing further treatment and that a “further treatment plan” was provided to her. In considering the document to which Patient B referred the Committee noted that it was a ‘treatment plan estimate’ that simply listed an itemised bill of costs associated with the proposed further treatment. The Committee saw no information on that document relating to the planning of the further treatment, or any reference to the risks, benefits and treatment options specific to Patient B’s case. In the circumstances, the Committee determined that the treatment plan estimate document could not be regarded as a revised treatment plan. Given the lack of such treatment plan in the records the Committee considered it more likely than not that no revised treatment plan was provided to Patient B. Given Mr Nery’s evidence, the Committee was satisfied that Mr Sharma had a duty to provide one and therefore he failed to discharge that duty. It also noted that Mr Sharma in his C4 documents stated that his “treatment planning presentation was primitive”.

27. You placed a veneer on UR6 on 19 November 2008:

27.(a) Knowing that a veneer was not suitable for that tooth.

Found proved. In finding this head of charge proved, the Committee accepted the evidence of Mr Nery that it was very unusual for veneers to be placed on molar teeth, where they would be prone to failure. The Committee was satisfied that Mr Sharma knew this to be the case not least because according to Patient B’s evidence, which the Committee accepted, he told her that “a veneer on UR6 would not have been strong enough.”

27.(b) Having previously told Patient B that a veneer would not work on this tooth and that she needed a crown.

Found proved. The Committee had regard to the clinical notes for Patient B and noted that in relation to the appointment on 19 November 2008, Mr Sharma recorded “UR6, Tooth Crown Fit” and “bonded veneers with trans choice 16…”. Despite the lack of clarity on these notes as UR6 and 16 is the same tooth (implying that both the veneer and crown were placed on the same tooth on the same day), the Committee was satisfied that it was in fact a veneer that Mr Sharma placed on UR6 on 19 November 2008. This was because the Committee accepted that Patient B was dentally aware, having had veneers for at least 14 years, and accepted as accurate her account that she noticed Mr Sharma was going to place a veneer and not a crown as they had previously discussed on 23 September 2008. Further, the Committee accepted the note made by the


subsequent treating dentist at the Leckhampton Dental Practice on 31 March 2009 as accurate. That dentist recorded that a veneer had been placed on UR6. The Committee accepted Patient B’s evidence as accurate that Mr Sharma had told her on 23 September 2008 that she needed a crown on UR6 and that “a veneer on the UR6 would not have been strong enough.” The Committee was supported in its conclusion that it is more likely than not that Mr Sharma did tell Patient B that a veneer would not be strong enough by the expert evidence of Mr Nery. He opined that veneers on molars are very unusual due to the occlusal forces on these teeth. The Committee was therefore satisfied that Mr Sharma had placed a veneer instead of the treatment to which Patient B was expecting and its understood she paid for, namely a crown.

28. You recorded in the notes that you had placed a crown on UR6 when in fact you had placed a veneer.

Found proved. The Committee was satisfied from the evidence of Patient B and the notes made in the patient’s clinical records by the subsequent treating dentist on 31 March 2009 that Mr Sharma placed a veneer on the UR6. This is contrary to what Mr Sharma recorded in the patient’s notes, which was that a crown had been placed on the tooth. Accordingly, the Committee found this head of charge proved.

29. You provided longer veneers than the adjacent teeth without informing Patient B of the risks involved.

Found proved. The Committee was satisfied from the evidence of Mr Nery that Mr Sharma provided Patient B with veneers that were longer than the adjacent teeth. Mr Nery’s evidence was based on what had been written in the clinical records by the subsequent treating dentist and on a photograph, which the Committee also had sight of, that he saw of the patient’s mouth. Mr Nery’s conclusions are clearly set out in his report. He stated that where a veneer extends past the tooth, the patient would need to be informed of the risks associated with the longer veneer, such as the risk of breakage and the risk that the veneer could fall off. The Committee considered the clinical records made by Mr Sharma in respect of Patient B, which included a number of entries. However, it saw no mention of the risks highlighted by Mr Nery. The Committee further noted that Patient B stated in her witness statement that, when she saw Mr Sharma on 4 December 2008 to re-fit a veneer that had fallen off her UR1, the only explanation he gave her for the veneer coming loose was something to do with her bite. Patient B wrote in her witness statement “nothing more was said.” In all the circumstances, the Committee was satisfied that Mr Sharma did not inform the patient of the risks associated with longer veneers.

30. You failed to obtain valid informed consent from Patient B in respect of stage two treatment (veneers).

Found proved.


In view of its findings at heads of charge 27, 28 and 29, the Committee was satisfied that Mr Sharma failed in his duty to obtain valid informed consent from Patient B in respect of the veneers. The Committee’s findings demonstrate that the patient was not provided with all of the necessary information relating to this second stage of treatment and therefore could not have given her informed consent.

31. The veneers repeatedly failed due to:

31.(a) The fact that they were inappropriate for Patient B and/or

Found proved. The Committee noted from the clinical records and from the witness statement of Patient B that Mr Sharma had suggested that it was bruxism that had caused the repeated failure of the veneers. Whilst the Committee took into account that it is stated in the notes made by the subsequent treating dentist that Patient B reported biting hard on occasion, that dentist also highlighted that the patient had not had any problems with the veneers that she had fitted some 14 years previously. It is noted that those veneers were “the same length as the shortened teeth placed.” Further, it was the evidence of Mr Nery that it was unlikely that Patient B was a bruxist. He highlighted that there had been no evidence of bruxism over the previous 16 or so years. He stated that it was therefore unlikely that the patient had formed the habit over a short period of time during her treatment with Mr Sharma. The Committee concluded therefore that the veneers must have failed for reasons other than bruxism. Mr Nery indicated that veneers can suffer an innocent failure but, that innocent failure was less likely here because the veneers repeatedly failed. The Committee accepted his opinion. The only noticeable difference between these veneers and Patient B’s previous veneers was their length. Her new veneers were longer. Taking into account all the evidence, the Committee concluded that it was more likely than not that the repeated failure of the longer veneers fitted by Mr Sharma was due to the fact that they were inappropriate for the patient as they were too long.

31.(b) They were poorly executed.

Found not proved. In making its finding, the Committee interpreted poor execution to mean poor placement. The Committee noted the information within the clinical records that other dentists had tried, but failed to successfully re-cement veneers when they came off. In light of this, it decided that there was insufficient evidence to find that it was poor placement by Mr Sharma that was the cause of the repeated failings.

32. Your conduct as alleged at Head of Charge 27 and 28 was dishonest in that:

32.(a) you might obtain a financial advantage by subsequently needing to undertake further restorative work and/or

Found proved. The Committee sought to ascertain what was Mr Sharma’s knowledge and belief


as to the facts. The Committee found that Mr Sharma placed a veneer on UR6 knowing that it was not suitable for that molar tooth and having previously told Patient B that she needed a crown. The Committee was also satisfied that Mr Sharma must have known that the veneer was highly likely to fail and that this would necessitate further restorative work. The Committee specifically considered other possible bases for such conduct other than seeking to gain a financial advantage. Having carefully considered all of the evidence it was not persuaded that other causes such as negligence or incompetence lay behind his conduct. It noted that the UR6 was not prepared for a crown given the comments of the subsequent treating dentist, and that a veneer was pre-ordered from the laboratory. It considered, given that a veneer was totally unsuitable for a molar tooth, this indicated at least a degree of premeditation on his part. The Committee was satisfied that the most likely explanation for Mr Sharma’s conduct was the hope of financial gain from subsequent restorative work. The Committee was satisfied that such conduct with that motivation would be considered dishonest by the objective standards of ordinary decent people.

32.(b) You were deflecting further enquiry by Patient B into the reasons why veneers had been placed when the patient had been told they were not suitable.

Found proved. The Committee noted that Mr Sharma recorded in the clinical records for 19 November 2008, that a crown was fitted on UR6 when in fact he fitted a veneer on UR6 on that day. It also noted that the record entry he made on 21 October 2008 detailed that he prepared the UR6 for a crown with an associated financial charge. The entry on 21 October 2008 asserting that “Tooth Crown Prep” was undertaken was false. The notes from the subsequent dentist showed that a veneer was fitted not a crown and thus the “crown prep” could not have been done. Similarly, the entry found proved at charge 28 (that on 19 November 2008 Mr Sharma fitted a crown on UR6) is also false for the same reasons. The Committee was satisfied that Mr Sharma knew that Patient B was expecting to receive a crown. In her witness statement, Patient B stated that at the appointment on 19 November 2008, she had questioned Mr Sharma as to why he was placing a veneer, given that he had previously told her that a veneer would not be suitable for that particular tooth. In considering the issue of dishonesty as particularised at 32(b) the Committee considered that it was artificial to ignore its finding at 32(a) namely that Mr Sharma was seeking to obtain a financial advantage as part of the context of his conduct. While it noted that, apart from the false entry of “Tooth Crown Fit” on 19 November 2008, there was also an entry referring to a veneer at “16” (which is the same tooth as UR6), the Committee remained satisfied that innocent error was not the likely explanation for the false entry. There was an explicit entry that Mr Sharma had fitted a crown on UR6, the Committee did not think it plausible that this could have been a mistake in the circumstances. In the context, the Committee concluded that it was more likely than not that Mr Sharma deliberately made a false entry in the clinical records to try and deflect further enquiry from Patient B as to why he provided treatment different from what had been previously agreed. The Committee was satisfied that


such conduct would be regarded as dishonest by the standards of ordinary decent people.

Record Keeping & Communication

33. Your records for treatment for Patient B contain insufficient detail in respect of:-

33.(a) Assessments

Found proved. The Committee had regard to Mr Nery’s report in which he outlines what he would have expected to see in the patient’s clinical records in respect of assessments. He stated that, amongst other things, the records should have included information relating to a Basic Periodontal Examination (BPE), oral hygiene assessment and in relation to any radiographs taken, the recording of the justification, quality assessment and reporting. The Committee considered the clinical records for Patient B. It found that the information recorded by Mr Sharma did not include many of the factors outlined by Mr Nery in his report. This included the absence of any information relating to a BPE and oral hygiene assessment. There was also an absence of any report on the radiolucency shown on the OPT scan, which the Committee would have expected to form part of the patient’s assessment. The Committee was therefore satisfied that there was insufficient detail in Mr Sharma’s records in respect of assessment.

33.(b) Clinical examination

Found proved. The Committee considered that a number of the matters relevant to assessment, as referred to by Mr Nery in his report, were also relevant to clinical examination. Accepting Mr Nery’s evidence, the Committee found that there was insufficient detail in respect of clinical examination in Mr Sharma’s records in respect of clinical examination. For instance, it saw no reference in the records to a BPE having been undertaking or an oral hygiene assessment. In the circumstances, the Committee found this head of charge proved.

33.(c) Clinical procedures

Found proved. The Committee considered the clinical records and found that there were no details in respect of clinical procedures. It accepted the evidence of Mr Nery that one would expect to see recorded information on such procedures as flap design and the use of sutures. In the absence of any such information, the Committee was satisfied that this allegation is proved.

33.(d) Post-operative advice

Found proved. The Committee saw that there was some indication in the clinical records that Patient B was given some post-operative advice. It noted that she was provided with a telephone number to call post-operatively, if necessary. However, the


Committee found nothing written in the clinical records detailing what post-operative advice was given. It was therefore satisfied that the records contained insufficient information in this respect.

33.(e) Discussions about treatment options, risks and benefits

Found proved. The Committee has already found that there was nothing in the clinical records or on the consent form signed by the patient that was specifically tailored to her treatment. This included the absence of any information regarding what was discussed with patient B about treatment options, risks and benefits. This head of charge is therefore proved.

33.(f) The appointments of 26 August 2008, 23 September 2008, 15 October 2008, 21. October 2008

Found proved in respect of 26 August 2008, 23 September 2008 and 21 October 2008. Found not proved in respect of 15 October 2008. In relation to the dates 26 August 2008, 23 September 2008 and 21 October 2008, the Committee found that there were clear indications in the records of appointments with Patient B having taken place on these days. The Committee was satisfied, taking into account what Mr Sharma wrote in respect of these appointments, that the detail he recorded was insufficient. It found that his notes in relation to the appointments do not provide an adequate picture of what happened on those occasions. Therefore, the Committee found this head of charge proved in respect of these dates. With regard to 15 October 2008, the Committee noted that whilst this date was referenced in the clinical records, there is no other information. It therefore decided that there was insufficient evidence to prove that an appointment actually took place on this day. Accordingly, the Committee found this head of charge not proved in respect of this one date.

34. The medical history recorded in the computer records is inaccurate according to the medical questionnaire completed by the Patient B.

Found proved. The Committee noted that the medical questionnaire included in the records is undated. However, it considered it reasonable to infer that the questionnaire was completed by Patient B prior, or close to, her appointment on 17 June 2008, which is when she stated in her witness statement that she first attended the Leckhampton Dental Practice. In the circumstances, the Committee considered that the computerised records made by Mr Sharma on 17 June 2008 should have accurately reflected the information provided by the patient on the medical questionnaire. The Committee found, however, that there were significant differences between the computerised records and the medical questionnaire. For instance, it noted that Patient B indicated on the medical questionnaire that she was taking medication, whereas the computer records indicate that she was not taking any. The patient also declared on the medical questionnaire that she suffered from asthma, hay fever or eczema. There is no reference to her having


any of these conditions in the computerised records made by Mr Sharma. The Committee was therefore satisfied that the computer records are inaccurate.

35. Your records indicate that the patient was happy / satisfied with the treatment when in fact the patient had raised concerns with you which were not reflected in the notes.

Found not proved. The Committee noted that Mr Sharma did note on an occasion in the clinical records that the patient was happy. It was the view of the Committee that the patient may well have been happy at the time this note was recorded. However, the Committee also found in the clinical records reference to the fact that the patient had concerns and that these concerns had been dealt with. Whilst the Committee would have expected there to have been more detail in the records as to the specific concerns of the patient about her treatment, in its view, the lack of detail is not the central issue of this charge. The Committee considered that the mention that concerns existed means that Mr Sharma did not seek to represent that all was well with the treatment when it was not.

36. Despite recording in the notes that there were no signs of bruxism on 17 June 2008, you told the patient that the reason her treatment failed was due to bruxism (which you said you had discussed with her during the treatment at the time) without reference to other possible reasons for failure of the treatment.

Found proved. In her complaint to the GDC, Patient B referred to an email she received from Mr Sharma, dated 10 April 2014. This is an email of which the Committee has not had sight. However, Patient B quotes from the email, in which Mr Sharma said that she had a tendency to brux or grind her teeth and that [t] “this was explained at length to you when I treated you…”. The Committee accepted the recollection of Patient B as credible and reliable and her quoting from Mr Sharma’s email as accurate. Further, the clinical records of 17 June 2008 record no history of bruxism. There is no evidence of other possible reasons for failure being given by Mr Sharma. The Committee also noted Mr Nery’s observation, that Patient B had had veneers fitted some 14 years prior and had not reported experiencing problems associated with bruxism. In all the circumstances, the Committee was satisfied that the facts alleged in this head of charge are proved.

37. You conduct at paragraphs 35 and 36 was:

37.(a) Misleading

Found proved in relation to head of charge 36 only (as head of charge 35 not found proved) Having already found that the treatment Mr Sharma provided was inappropriate because of the length of the veneers, the Committee was satisfied that him telling Patient B that the failing of the veneers he placed were solely due to bruxism was misleading.


37.(b) Dishonest in that:

37.(b)(i) you were seeking to represent in the notes that the patient was content with the treatment when she was not.

As the Committee found head of charge 35 not proved, this associated head of charge falls away.

37.(b)(ii) you provided the patient with an explanation for the failure of the treatment which was or may have been false and/or

Found proved in relation to head of charge 36. The Committee was satisfied on the evidence of Mr Nery and from the clinical records that the repeated failings of the veneers, placed by Mr Sharma was not due to bruxism. It accepted Patient B’s statement that in the email dated 10 April 2014 Mr Sharma gave bruxism as the sole reason for failure. It saw from the notes made by the subsequent treating dentist that Patient B reported that she did, on occasion, bite hard. However, that dentist also commented on the length of the veneers that Mr Sharma had placed. Therefore, in the Committee’s view, the explanation of bruxism that Mr Sharma provided to the patient as the sole reason for failure was false. It was further satisfied it was not an innocent error or made negligently or incompetently. The Committee’s conclusion that it was more likely than not that his explanation of bruxism was an attempt to cover up the true cause of the repeated failure of the veneers. This was due to his selection of veneers that were too long. The Committee considered that his conduct in this regard would be considered dishonest by the standards of ordinary decent people.

37.(b)(iii) you failed to make reference to other possible reasons for the failure of the treatment to deflect enquiry from the nature and execution of the treatment you had carried out.

Found proved in relation to head of charge 36. The Committee found nothing in Mr Sharma’s clinical records for Patient B to indicate that she had bruxism. It was therefore of the view that Mr Sharma knew that his explanation in attributing bruxism to the patient was false, particularly given that she had had no problems with her previous veneers which she had had for at least 14 years. The Committee was satisfied from the evidence of Patient B that Mr Sharma provided no other explanations for the failure of the veneers he placed. It was further satisfied that, as a consequence of his giving just the one explanation, namely bruxism, when he had not highlighted the issue before, he was acting to deflect enquiry from the nature of the treatment he carried out. The Committee considered that Mr Sharma’s conduct in this regard would be considered dishonest by the standards of ordinary decent people.

38. In breach of IRMER (2000) you failed to report on the:

38.(a) OPT dated 17 June 2008

Found proved. The Committee found no report on this OPT in the clinical records of Mr Sharma. It was satisfied that he had a duty under IRMER (2000) to record such a report.


38.(b) Peri-apical radiograph of 16 July 2008

Found proved. The Committee was satisfied on the evidence and having had sight of the original radiograph that a peri-apical radiograph was taken on 16 July 2008 after the patient’s implants had been placed. It found no report on this peri-apical radiograph in the clinical records of Mr Sharma. It was satisfied that he had a duty under IRMER (2000) to record such a report.

38.(c) Peri-apical radiograph dated 25 March 2009

Found not proved. The Committee noted that the date of the peri-apical radiograph referred to in this head of charge falls outside the date range of Patient B’s treatment with Mr Sharma.

38.(d) Undated left side bitewing radiograph

Found not proved. The Committee found nothing on this radiograph or in the clinical notes to relate the radiograph to Mr Sharma. Nor was there any information to indicate that the bitewing radiograph fell within the date range of his treatment of Patient B.

39. You did not treat Patient B with dignity and respect, including by:

39.(a) referring to Patient B as “senile”.

Found proved. 39.(b) standing very close to Patient B.

Found proved. 39.(c) raising your voice.

Found proved. The Committee considered heads of charge 39(a) to (c) separately, but made the same finding in respect of each head of charge. The Committee took into account that it did not question Patient B or Mr Sharma on the context of the exchange that took place between them. However, it found that the patient’s evidence on the matters, as contained within her witness statement, was clear. It also noted from the clinical records that in a telephone call to the practice on 2 March 2009, Patient B had complained about Mr Sharma’s behaviour. In Mr Sharma’s written observations in C4 he said he had “no recollection of ever referring to this or any patient in this derogatory manner.” Having weighed the evidence, the Committee accepted the account of Patient B. In doing so, it had regard to the fact that her witness statement is supported by a statement of truth. The Committee considered it a significant event for Patient B, that it is likely to stand out in her mind and therefore it is an accurate reflection of events. Patient B says in her witness statement that she was referred to as senile, that Mr Sharma stood very close to her and that he raised his voice. It further


considered that her witness evidence is corroborated by the information in the clinical records which details a verbal complaint that she made to the practice closer to the time of the events. The Committee was satisfied on the balance of probabilities that Mr Sharma did behave as alleged and that in doing so, he did not treat Patient B with dignity and respect.

Patient C Between 2013 and 2014 at the Bupa Dental Centre Holborn, in your treatment of

Patient C:

Record Keeping

40. You failed adequately to carry out and/or record on 15 February 2013, details of your implant assessment set out in Schedule A.

Found proved on the basis that he did not adequately carry out an implant assessment set out in Schedule A on 15 February 2013 and 22 March 2013 The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to carry out an assessment prior to placing implants. He told the Committee that such an assessment should have included all of the relevant matters set out in Schedule A, which includes the taking of a medical history. In relation to the issue of an assessment, the Committee concluded that it was unfeasible that Mr Sharma would not have conducted some kind of implant assessment. It considered that he would have at least looked inside of the patient’s mouth. However, in determining the adequacy of the assessment he carried out, the Committee had regard to the clinical records for Patient C. It found none of the information that it would expect to see, as is outlined in Schedule A and based on the evidence of Mr Nery. The Committee considered that it was unlikely that a dentist would undertake an assessment without recording their findings. The Committee therefore decided on the balance of probabilities that Mr Sharma failed in his duty to carry out an adequate assessment. The Committee has interpreted this charge as requiring both the assessment and the recording to be in accordance with Schedule A. Given its finding that the assessment was not conducted in accordance with the requirements of Schedule A, the obligation to record does not arise.

41. You failed to record on 22 March 2013, 5 July 2013 and 18 October 2013, details of the local anaesthetic set out in Schedule B.

Found proved in respect of 5 July 2013 only. Found not proved in respect of 22 March 2013 and 18 October 2013. In reaching its findings, the Committee accepted the evidence of witness 2 that it was routine for the details of local anaesthetic to be stored centrally at this practice. This would have included details regarding the batch numbers and dates of expiry. The Committee also noted that witness 2 stated that the manufacturer, batch number and expiry date in relation to a local anaesthetic “may not be recorded in the patients notes but recorded elsewhere in the practice as part of a practice wide policy on the storage of medicines.”

Taking the evidence into account, the Committee found this head of charge not


proved in respect of 22 March 2013 and 18 October 2013. It noted that in relation to these two dates, Schedule B referred to the absence of a batch number and expiry date in the clinical records. The evidence of witness 2, accepted by the Committee, is that these details would have been held centrally and therefore there was no duty on Mr Sharma to record them. In respect of 5 July 2013, the Committee found this head of charge proved on the basis that Schedule B also referred to type, route and dose in relation to this particular date. The Committee had regard to the clinical records and found no record of the type, route and dose of the local anaesthetic administered to Patient C on this date. The Committee was satisfied, taking into account the evidence of Mr Nery and the requirement within the GDC Standards to make and keep accurate records, that Mr Sharma had a duty to record the type, route and dose, details which cannot be held centrally. By not doing so, he failed in his duty on 5 July 2013.

42. WITHDRAWN.

42.(a) WITHDRAWN. 42.(b) WITHDRAWN. 42.(c) WITHDRAWN. 42.(d) WITHDRAWN. 43. You failed to record on 5 July 2013, the justification for and type, dose and

duration of the antibiotics given to the patient.

Found proved. The Committee noted that the clinical records do not provide any of the information in relation to the justification, type, dose and duration of the antibiotics given to Patient C. It was satisfied from the evidence of Mr Nery that Mr Sharma had a duty to make a record of this information under the Facualty of General Dental Practice UK (FGDP) Guidelines on Antimicrobial Prescribing. The Committee also noted the section of Mr Nery’s report entitled ‘Antimicrobial prescribing records for General Dental Practitioners’, where it is stated “Whether writing a prescription or providing antimicrobials directly, a reasonable GDP would record the Justification for the prescription, and antimicrobial name, dose, frequency, duration and total quantity in the patient’s records.”

44. You failed to record details of the analgesic provided to the patient on 22 March 2013 and/or 5 July 2013.

Found proved. The Committee had regard to the clinical records and found no details recorded in relation to the analgesic provided to Patient C on these two dates. The records simply make reference to “pk’s” (painkillers). The Committee was satisfied from the evidence of Mr Nery that Mr Sharma had a duty to record details in respect of the painkillers given but he had failed to do so. He stated in his report that a reasonable GDP would record the “amount of painkillers prescribed”. Mr Nery explained to the Committee that it was important to record such information in case of any reaction by the patient. He also told the Committee of the requirement


to record details of the analgesic as contained in FGDP prescribing guidelines.

45. You failed to record whether post-operative advice was given to the patient on 22 March 2013

Found not proved. The Committee saw from Mr Sharma’s clinical records in relation to 22 March 2013 that he wrote “chairside ab’s and pk’s and poig”. POIG is commonly known to mean ‘post-operative instructions given’. The Committee was therefore satisfied that Mr Sharma had recorded that post-operative instructions were given to Patient C on this date.


46. You failed adequately to discuss and/or record that you had discussed the clinical evaluation and options for treatment and outcome in relation to:

46.(a) the extraction sinus lift and Bio-oss procedure on 22 March 2013.

Found proved on the basis that Mr Sharma failed to adequately discuss the evaluation and options for treatment and outcome in relation to the extraction of sinus lift and Bio-oss procedure on 22 March 2018. In reaching its decision, the Committee considered the clinical records 22 March 2013 including the relevant consent form. The Committee noted that there is reference to the procedure having been explained to the patient by way of a generic paragraph on the consent form which was signed by the patient, which referred to the operation, investigation or treatment having been explained to the patient including its major and characteristic risks. It saw nothing in the notes relating to the risk of failure or the specific risk relating to sinus lift and Bio-oss procedure. Given these significant risks, the Committee decided, on balance, that if Mr Sharma had adequately discussed the matter with Patient C, it would have been explicitly recorded. The Committee was satisfied from the evidence of Mr Nery, regarding the importance of highlighting the risks to the patient and that Mr Sharma had a duty to have an adequate discussion with Patient C. It also took into account his obligation under the relevant GDC Standards in relation to informed consent. By not having an adequate discussion with the patient, Mr Sharma failed in his duty to do so. Therefore, the obligation to record did not arise.

46.(b) the implant placement and sinus tap with Bio-Oss on 5 July 2013.

Found proved on the basis that there was a failure to adequately discuss the evaluation and options for treatment and outcome in relation to the implant placement and sinus tap with Bio-oss on 5 July 2013. The Committee found this head of charge proved on the same basis as 46(a) above.

47. You failed adequately to discuss and/or record that you had discussed the risks associated with the sinus tap procedure and Bio-Oss carried out on 22 March 2013 and 5 July 2013 including:

47.(a) Sinus perforation


Found not proved. 47.(b) Bone Graft Displacement

Found not proved. 47.(c) Infection

Found not proved. 47.(d) Use of sedation

Found not proved. The Committee considered heads of charge 47(a) to (d) separately, but made the same finding in respect of each head of charge. The Committee considered the stem at head of charge 47 along with the matters listed at the sub-heads (a) to (d) and concluded that they add nothing to head of charge 46, which the Committee has already found proved. It considered that heads of charge 47(a) to (d) were a further particularisation of the risks associated with the patient’s treatment, which the Committee decided had been discussed to an extent, but the discussion was not adequate.

Sedation

48. You carried out Intravenous Sedation without the presence of a trained nurse.

Found not proved. The Committee considered that this head of charge is not specific as to the nature of the training the nurse would have required. It does not say that the nurse should have held a specific certificate in sedation. Further, the Committee received no evidence that such a requirement was mandatory. The evidence of witness 2 was that Mr Sharma generally worked with the same nurse and that the nurse was a trained nurse. In the Committee’s view, the GDC has not proved that the nurse with whom Mr Sharma worked was not sufficiently experienced to work alongside him whilst he carried out Intravenous Sedation.

Radiography

49. On 22 March 2013, you failed to carry out and/or record that you had carried out a periapical radiograph:

49.(a) following the sinus tap and/or pre-operatively on 5th July 2013.

Found proved on the basis that Mr Sharma did not record carrying out a peri-apical radiograph. The wording in this charge lacked clarity. There was a sinus tap carried out on 22 March 2013 and a further sinus tap carried out on 5 July 2013. The Committee interpreted the allegation to mean that Mr Sharma did not take a peri-apical radiograph after the first sinus tap and/or pre-operatively before the second sinus tap. There were no peri-apical radiographs available to the Committee relating to these dates. The evidence of Mr Nery was that only one peri-apical radiograph would have been required in the circumstances; after the first sinus tap or pre-operatively


before the second sinus tap. In the Committee’s view, it was highly unlikely that Mr Sharma would have carried out the second procedure without taking a pre-operative peri-apical radiograph as according to Mr Nery this would have been the only means in detecting the failed implant. The Committee considered the time and expense that would have been involved in undertaking the second procedure and Mr Sharma would have had no reason to do it, if the first procedure had been successful. The Committee therefore decided that it was more likely than not that Mr Sharma did take at least one radiograph, which was all that was required, despite the absence of the radiograph before it. Accordingly, the failure to carry out the radiograph allegation was not proved. However, there is no note in the records of taking such a radiograph and therefore the failure to record is proved.

50. You failed to take post-operative periapical radiographs following the sinus tap on 5th July 2013.

Found proved. The Committee accepted the evidence of Mr Nery that it was necessary for Mr Sharma to have taken post-operative periapical radiographs following the second sinus tap on 5 July 2013. He stated that the radiographs would have been required to check the level of bone and to ensure that no particles had entered the sinus. The Committee found no indication in the clinical records that Mr Sharma had taken periapical radiographs. Further, it had regard to the witness statement of witness 3, the Dental Clinical Director for the practice. witness 3 provided information relating to a meeting with Mr Sharma on 6 December 2013, where concerns were raised about Mr Sharma’s radiographic practices. Mr Sharma is said to have informed witness 3 that he did not always take post-operative radiographs. Taking all the evidence into account, the Committee was satisfied on the balance of probabilities that Mr Sharma did not take post-operative periapical radiographs. By not doing so, Mr Sharma failed in his duty, as explained by Mr Nery.

51. You failed to record the evaluation of the OPG taken on 18 October 2013.

Found proved. The Committee was satisfied that Mr Sharma had a duty to record an evaluation of the OPG, as this is a requirement of IRMER (2000). It had regard to the clinical records for the patient for 18 October 2013. Whilst it noted that Mr Sharma recorded in the notes a justification for taking the OPG, it found nothing that constituted an evaluation. Accordingly, the Committee found that Mr Sharma failed to do so.

Patient D 52. Between 2013 and 2014 at the Bupa Dental Centre Holborn, in your treatment of

Patient D:

The Committee did not consider there was any decision to be made in respect of this head of charge. Although it considered it clear from the clinical records for Patient D that Mr Sharma treated the patient at this practice between 2013 and


2014.

Record Keeping

53. You failed adequately to carry out and/or record on 15 February 2013, details of your implant assessment set out in Schedule A.

Found proved on the basis that he did not adequately carry out an implant assessment set out in Schedule A. The Committee was satisfied that Mr Sharma failed adequately to carry out on 15 February 2013, details of his implant assessment set out in Schedule A. The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to carry out an assessment prior to placing implants. He told the Committee that such an assessment should have included all of the relevant matters set out in Schedule A, which includes the taking of a medical history. Mr Nery also stated that a CT scan may be required to assess the bone depth at the proposed implant site. In relation to the issue of an assessment, the Committee concluded that it was unfeasible that Mr Sharma would not have conducted some kind of implant assessment. It considered that he would have at least looked inside of the patient’s mouth. However, in determining the adequacy of the assessment he carried out, the Committee had regard to the clinical records for Patient D. It noted that there was information indicating that Mr Sharma took the patient’s medical history, as it is recorded that the patient is allergic to penicillin. However, it found none of the other information that it would expect to see, as is outlined in Schedule A and based on the evidence of Mr Nery. The Committee considered that it was unlikely that a dentist would undertake an assessment without recording their findings. The Committee therefore decided on the balance of probabilities that Mr Sharma failed in his duty to carry out an adequate assessment. The Committee has interpreted this charge as requiring both the assessment and the recording to be in accordance with Schedule A. Given its finding that the assessment was not conducted in accordance with the requirements of Schedule A, the obligation to record does not arise.

54. You failed to record the clinical evaluation and diagnosis that lead to the prescription of antibiotics on 15 February 2013 and/or inappropriately prescribed antibiotics as a preventative measure.

Found proved. The Committee found this head of charge proved on all bases. Having considered the relevant clinical records, the Committee accepted the evidence of Mr Nery that the prescription of antibiotics in question related to the extraction of Patient D’s LR6 on 15 February 2013. It was Mr Nery’s evidence that there was no justification for the prescription. He questioned why, if the tooth was the source of the infection, Mr Sharma would give antibiotics on the very same day as extracting the tooth. The Committee considered Mr Sharma’s clinical records for Patient D on 15 February 2013. Whilst it noted that he recorded a reason for extracting the LR6,


namely failed root canal treatment, the Committee found no recorded clinical evaluation and diagnosis in respect of the prescription of antibiotics. It was satisfied on the evidence that Mr Sharma had a duty to record such details and not doing so was a failure on his part. The Committee also noted that the tooth was extracted on this day. In the circumstances, the Committee accepted the opinion of Mr Nery that it was more likely than not that Mr Sharma prescribed the antibiotics as a preventative measure. The Committee accepted Mr Nery’s evidence that this was inappropriate and contrary to the prescribing guidelines as antibiotics would not be prescribed prophylactically.

55. You failed to adequately record the details of the implant procedure on 19 April 2013 including:

55.(a) WITHDRAWN.

55.(b) WITHDRAWN.

55.(c) Cover screws

Found proved. 55.(d) Healing Abutments

Found proved. 55.(e) Whether post-operative advice was given

Found proved. The Committee considered heads of charge 55(c) to (e) separately, but made the same finding in respect of each head of charge. The Committee was satisfied from the relevant GDC Standards that Mr Sharma had a duty to record these details of Patient D’s implant procedure on 19 April 2013. It also took into account the evidence of Mr Nery that such details are needed to show the history of the patient’s treatment, especially when foreign bodies are being introduced into a patient’s mouth and also in case of failure of the treatment. The Committee had regard to the clinical records and found no notes at all detailing the information set out at 55(c) to (e). The notes just recorded the fees. It also found no such details on the consent form for treatment. Accordingly, the Committee was satisfied that Mr Sharma failed in his duty to record them.

56. You failed to adequately record on 19 April 2013, details of the local anaesthetic set out in Schedule B.

Found proved. In reaching its decision on this head of charge, the Committee did not rely on Schedule B. The date featured in this allegation, namely 19 April 2013, was initially amended to 15 February 2013, following an application by GDC. However, it was re-amended back to 19 April 2013 on re-application by the GDC. Mr Grey confirmed in his submissions that 19 April 2013 was in fact the correct date. The Committee took into account however, that it has accepted the evidence of


Mr Nery regarding good practice when recording details of local anaesthetic. It has also satisfied itself that Mr Sharma had a duty to record such details as required by the relevant GDC Standards. Taking this into account, the Committee considered the clinical records made by Mr Sharma in respect of Patient D on 19 April 2013, including the relevant consent form. It noted from the consent form that local anaesthetic was used on this day. The Committee was satisfied that it was inconceivable that an implant procedure would be carried out. However, it found that the records in respect of its use were inadequate. The Committee found no notes in respect of the type or route of administration of the local anaesthetic. There was also no information in relation to the batch number and expiry date. Whilst the Committee took into account from witness 2’s evidence that the batch number and expiry date were stored centrally, it considered this irrelevant in the absence of any information about the type of local anaesthetic that was used. Accordingly, the Committee found that there was a failing on Mr Sharma’s part to record adequate details.

57. You failed to adequately record on 9 August 2013 details of the implant procedure including the size and height of abutments placed.

Found proved. The Committee accepted the evidence of Mr Nery that it was important for Mr Sharma to have recorded such information. Mr Nery stated that it was standard procedure to do so, as it served to provide useful information for any subsequent treating dentist or associated treatment the patient might undergo, such as the fitting of crowns. The Committee was therefore satisfied that Mr Sharma had a duty to record the information in question. The Committee considered the relevant clinical records but noted there was no relevant entry relating the size and height of the abutments placed. Accordingly, the Committee decided that the records were inadequate.

58. You failed to record details of your appointments with Patient D on:

58.(a) 30 August 2013

Found proved. 58.(b) 6 September 2013

Found proved. 58.(c) 13 September 2013

Found proved. The Committee considered heads of charge 58(a) to (c) separately, but made the same finding in respect of each head of charge. The Committee had regard to the patient’s appointment history as set out in the clinical records. There was nothing in the clinical notes of treatment undertaken on those dates. The available records show financial transactions for the relevant dates for procedures that would have required treatment by a dentist. The Committee noted that a scheduled attendance was listed and not cancelled and accepted w witness 2’s evidence that the appointments would have taken place on


those dates. Therefore, the Committee was satisfied that there were appointments on those dates and that under the relevant GDC’s standards, Mr Sharma was under a duty to record details of those appointments.


59. You failed adequately to discuss and/or record that you had discussed the options for treatment and outcome in relation to the extraction of LR6 and placement of implants on 19 April 2013 Found proved on the basis that Mr Sharma failed to adequately record the discussion. The Committee was satisfied from the witness statement of Patient D, which is supported by a declaration of truth, that the patient and Mr Sharma had a discussion relating to the treatment, including the risks and an explanation of the procedure. The Committee noted that Patient D did not assert that alternative treatment options featured as part of that discussion; the patient could not actually recall whether it did. Having had regard to Patient D’s account, the Committee concluded that the GDC has not proved that there was an inadequate discussion. However, the Committee noted from the clinical records that there is an absence of any record as to options for treatment and outcome. Whilst witness D’s statement suggests that there was a discussion, the Committee concluded that the records do not adequately reflect the content of the discussion between Mr Sharma and the patient. The Committee was satisfied from the relevant GDC Standards that Mr Sharma had a duty to record adequately the discussion and by not doing so, he failed in his obligation.

Radiography

60. You failed to carry out and/or record that you had carried out a periapical radiographs:

60.(a) prior to the extraction of the LR6.

Found proved on the basis that Mr Sharma failed to carry out periapical radiographs.

60.(b) pre-operatively to placing the implants at LR6 and LR7 on 19 April 2013.

Found proved on the basis that Mr Sharma failed to carry out periapical radiographs.

60.(c) following the restoration of the implants between 9 August 2013 and 13 September 2013.

Found proved on the basis that Mr Sharma failed to carry out periapical radiographs. The Committee considered head of charge 60(a) to (c) separately, but made the same finding in respect of each head of charge. The Committee was satisfied from the evidence of Mr Nery, which included reference to the relevant FGDP guidelines, as well as his opinion on the need for periapical radiographs in these three instances, that Mr Sharma had a duty to take


such radiographs. Mr Nery told the Committee that Mr Sharma had a duty, particularly in the complex case of Patient D, to take a periapical radiograph prior to the extraction of the LR6 for a safe and appropriate extraction. There was no record of such a radiograph in the period before 15 February 2013, save for a bitewing radiograph taken in September 2010, which the Committee was satisfied was not relevant to this extraction. Given the absence of a radiographic record, the Committee was satisfied that it was more likely than not that the radiograph was not taken. In relation to taking a periapical radiograph pre-operatively prior to placing the implants, Mr Nery stated that a periapical radiograph was the most appropriate method of assessing the position of the ID nerve. Therefore, taking a periapical radiograph prior to the implant treatment would have reduced the risk of harm to the patient. Given the absence of any periapical radiographs before the Committee or any record of any notes of it being taken, the Committee was satisfied that Mr Sharma did not take it when he had a duty to do so. With regard to the taking of a periapical radiograph following the restoration of the implants, the Committee noted that FGDP guidelines recommend that such radiographs are taken on the day of the treatment to confirm the position of the implants. Given the absence of any radiograph or any record of one being taken, the Committee found that Mr Sharma had failed in his duty to take a periapical radiograph. The Committee received no copies of any radiographs and it saw no mention in the notes of any of these radiographs having been taken by Mr Sharma or by any other practitioner. The Committee also took into account the statement of witness 3, who provided information relating to a meeting with Mr Sharma on 6 December 2013. Mr Sharma is said to have informed witness 3 that he did not always consider pre-operative radiographs necessary in implant treatment. Witness 3 stated that Mr Sharma “told me that he can tell when and where an implant can be used.” witness 3 also stated that Mr Sharma said that he did not always take post-operative radiographs “because this was the responsibility of the…as referring dentist to provide post-operative radiographs.” Given Witness 3’s evidence, which the Committee accepted, and the absence of any indication in the clinical records that periapical radiographs were taken, the Committee was satisfied on the balance of probabilities that the failure to take periapical radiographs as set out in heads of charge 60(a) to (c) are proved. The non-recording is not proved given the Committee’s findings that these were not taken.

Patient E Between 2012 and 2013 in your treatment of Patient E at the Bupa Dental Centre

Holborn:

Record Keeping

61. You failed adequately to carry out and/or record on 20 April 2012 and/or 11 May 2012, details of your implant assessment set out in Schedule A.

Found not proved.


The Committee carefully considered the chronology in relation to Patient E. It noted that no implant was undertaken until September 2013, some 18 months after the original date in this Head of Charge and when some sort of assessment was carried out. Having carefully considered the available records before it, the Committee was not persuaded that the GDC had established that there was an obligation to carry out and record an assessment by Mr Sharma at those dates.

62. You failed to record details of the local anaesthetic used during the implant procedure on 13 September 2013 set out in Schedule B.

Found not proved. The Committee noted that in relation to 13 September 2013, Schedule B refers to the absence of a batch number and expiry date in the clinical records. The evidence of witness 2 accepted by the Committee is that these details would have been held centrally and therefore there was no duty on Mr Sharma to record them.

63. You failed to record any details of your appointment with Patient E on 20 April 2012 and 15 November 2013.

Found not proved. The Committee considered separately the evidence it received in relation to the two dates set out in this head of charge. It appears that Patient E attended the Holborn Dental Centre on 20 April 2012 and saw another dentist who prepared a treatment plan detailing costs for possible implant treatment with Mr Sharma listed as the provider. While there is an appointment record with Mr Sharma listed as having an appointment with Patient E at the same time as the other dentist, this was not explained by any witness before the Committee and, in the circumstances, it could not be satisfied that the GDC had established any obligation upon him, as opposed to the other dentist, to record details of the appointment on this date. The Committee found this head of charge not proved in respect of 20 April 2012 for the same reasons as set out at head of charge 61 above. It found that there were no clinical records before it for Patient E starting prior to 11 May 2012. The Committee was satisfied from the patient’s appointment history that the patient attended for an appointment on 15 November 2013. It had regard to the clinical records and whilst it noted that there are no notes for 15 November 2013, it saw that against the date 27 November 2013, Mr Sharma recorded “notes from last visit”. Taking all the evidence into account, the Committee concluded that the “notes from last visit” to which Mr Sharma referred were for 15 November 2013. It was therefore satisfied that he did record the details of that appointment, albeit not contemporaneously, and therefore there was no failure on his part.


64. You failed adequately to discuss and/or record that you had discussed the clinical evaluation and options for treatment and outcome in relation to the extraction of LR6 and the placement of an implant.

Found proved on the basis that Mr Sharma failed to adequately to discuss the clinical evaluation and options for treatment and outcome in relation to


the placement of an implant. The LR6 extraction was in May 2012. The Committee regarded the extraction of Patient E’s LR6 as treatment separate to the implant surgery subsequently undertaken. The Committee noted that the implant treatment was not carried out until 13 September 2013. It therefore asked itself whether Mr Sharma discussed his clinical evaluation and options for treatment and outcome with the patient at this stage in the process. The Committee noted in the records “procedure explained and consent signed.” The Committee also noted the signed consent form of 13 September 2013, which provides some details of the procedure. The Committee noted that there was no statement from Patient E. It considered that the clinical notes did not detail the full scope of what would be regarded as an adequate discussion. The Committee found that the clinical records and the consent form do not detail the full scope of what would be regarded as an adequate discussion, that is, including a note of the risks and benefits of the treatment. In the circumstances, it found this head of charge proved given the inadequacy of the records. Accordingly, the obligation to record does not arise.

65. You failed adequately to discuss and/or record that you had discussed or provided the patient with written information outlining the risks associated with the extraction of LR6 and placement of implants including the risk of temporary or permanent Inferior Dental nerve damage.

Found proved on the basis that Mr Sharma failed to discuss that he had discussed or provided the patient with written information outlining the risks associated with the placement of implants including the risk of temporary or permanent Inferior Dental nerve damage. The Committee did not consider this head of charge in relation to the extraction of LR6. Accordingly, the section of the charge in relation to LR6 is not proved. In relation to the placement of the implants, the Committee had regard to the clinical records, including the relevant consent form and noted that there is mention of potential tenderness and swelling. However, the Committee found nothing in the notes in relation to the risk of damage to the ID nerve. There is no specific reference in the clinical records to the risk to the ID nerve. The Committee was satisfied given the lack of reference to in the clinical records, that this significant risk, was more likely than not, this was not discussed. Accordingly, this charge was found proved on that basis. The Committee was not satisfied that there was a duty to provide written information as to the risks in the head of charge.

Radiography

66. You failed to carry out and/or record that you had carried out periapical radiographs following the placement of the implant at LR6 on 13 September 2013.

Found proved. In respect of this patient, the Committee did not receive any copies of periapical radiographs. It considered the clinical records and found no indication that Mr


Sharma had carried out periapical radiographs following the placement of the implant at LR6 on 13 September 2013. The Committee took into account the witness statement of witness 3, in which it is stated that Mr Sharma did not always take post-operative radiographs, as he considered this to be the responsibility of the referring dentist. In all the circumstances, the Committee was satisfied on the balance of probabilities that Mr Sharma did not carry out periapical radiographs in this instance. It was satisfied that he had a duty to do so in accordance with FGDP guidelines, to confirm the final position of the implant. By not doing so, Mr Sharma failed in his duty.

Patient F 67. Between 2012 and 2013 in your treatment of Patient F at the Bupa Dental Centre

Holborn:

Record Keeping

67.(a) You failed to carry out and/or adequately record details of your implant assessment on 7 December 2012 or 11 January 2013 set out in Schedule A.

Found proved on the basis that he failed to carry out the implant assessment on 7 December 2012 or 11 January 2013 at set out in Schedule A. The Committee was satisfied that Mr Sharma failed to carry out an implant assessment on 7 December 2012 and 11 January 2013 set out in Schedule A. The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to carry out an assessment prior to placing implants. He told the Committee that such an assessment should have included all of the relevant matters set out in Schedule A. In relation to the issue of an assessment, the Committee concluded that it was unfeasible that Mr Sharma would not have conducted some kind of implant assessment. It considered that he would have at least looked inside of the patient’s mouth. The Committee had regard to the clinical records for Patient F. It found none of the information that it would expect to see, as is outlined in Schedule A and based on the evidence of Mr Nery. The Committee considered that it was unlikely that a dentist would undertake an assessment without recording their findings. The Committee therefore decided on the balance of probabilities that Mr Sharma failed in his duty to carry out an adequate assessment. The Committee has interpreted this charge as requiring both the assessment and the recording to be in accordance with Schedule A. Given its finding that the assessment was not conducted in accordance with the requirements of Schedule A, the obligation to record does not arise.

67.(b) You failed to liaise and/or record that you had liaised with Patient F’s GP to check the stability of Patient F’s diabetic condition.

Found proved on the basis that Mr Sharma failed to liaise with Patient F’s GP. The Committee accepted the evidence of Mr Nery that he would have expected Mr


Sharma to liaise with the patient’s GP regarding the patient’s diabetic condition. Mr Nery explained that this would have been necessary because of the high risk of treatment failure associated with diabetic patients. He explained that poorly controlled diabetes could result in poor dental treatment outcomes. The Committee was satisfied from Mr Nery’s evidence that Mr Sharma had a duty to liaise with the patient’s GP, as it would have been important for Mr Sharma to know whether the patient’s diabetes could have had an impact on the success of the implants. Mr Sharma needed to know whether the patient’s health condition was controlled. The Committee found nothing in the clinical records to indicate that Mr Sharma had been in contact with Patient F’s GP. In the absence of a record, the Committee concluded on the balance of probabilities that Mr Sharma failed to liaise with the GP. In relation to the record keeping aspect of this head of charge, the Committee decided that Mr Sharma could not record what he did not do.

67.(c) You failed to record the type, dose, duration and expiry of the analgesic provided to the patient on 11 January 2013.

Found proved. The Committee had regard to the clinical records for 11 January 2013 where it saw that Mr Sharma simply noted “pk’s” (painkillers). It was satisfied from the evidence of Mr Nery that Mr Sharma had a duty to record details in respect of the painkillers given. He stated in his report that a reasonable GDP would record the “amount of painkillers prescribed”. Mr Nery explained to the Committee that it was important to record such information in case of any reaction by the patient. He also told the Committee of the requirement to record details of the analgesic as contained in FGDP prescribing guidelines.

67.(d) You failed to record the type, dose, duration and expiry of the antibiotics which were given to the patient on 11 January 2013.

Found proved. The Committee noted that the clinical records, whilst recording that antibiotics were given, do not provide any of the information in relation to the type, dose, duration and expiry of the antibiotics given to Patient F on 11 January 2013. It was satisfied from the evidence of Mr Nery that Mr Sharma had a duty to make a record of this information under the FGDP Guidelines on Antimicrobial Prescribing. The Committee also noted the section of Mr Nery’s report entitled ‘Antimicrobial prescribing records for General Dental Practitioners’, where it is stated “Whether writing a prescription or providing antimicrobials directly, a reasonable GDP would record the Justification for the prescription, and antimicrobial name, dose, frequency, duration and total quantity in the patient’s records.”

67.(e) You failed to record details of the local anaesthetic used on 11 January 2013 and 10 May 2013 set out in Schedule B.

Found proved. The Committee considered what had been recorded in the clinical records in respect of these individual dates.


It found this head of charge proved in respect of 11 January 2013, as it saw that Mr Sharma did not record in the notes what type of local anaesthetic he used. Schedule B refers to there being no record of the type, dose, manufacturer, batch number and expiry date. Whilst the Committee accepted the evidence of witness 2 that the batch number and expiry date would have been held centrally at the practice, it considered that this was irrelevant if the type of anaesthetic used was unknown, as the batch number and expiry date would be untraceable in the circumstances. The Committee also found this head of charge proved in respect of 10 May 2013. Schedule B refers to there being no record of the dose, batch number and expiry date. The Committee saw from the clinical records that Mr Sharma recorded the type of anaesthetic he used, but no dose. Whilst it accepted that in this instance, the batch number and expiry date could be determined from the centrally held records, as the type of local anaesthetic is known, there is a requirement to record the dose given, which Mr Sharma did not do.

68. WITHDRAWN. 68.(a) WITHDRAWN. 68.(b) WITHDRAWN. 68.(c) WITHDRAWN. 69. You failed to adequately record details of the review of the implant procedure

carried out on 24 July 2013 including materials and techniques used.

Found not proved. The Committee considered that Mr Nery did not detail what a record of a review of the implant procedure should entail. Given the lack of evidence on this issue, the Committee was not satisfied that the GDC proved the allegation to the requisite standard.

70. You failed to record details of appointments on 12 April 2013, 6 September 2013, 13 September 2013, 4 October 2013.

Found proved. The Committee was satisfied from looking at the patient’s appointment history contained within the clinical records that it was more likely than not that all of these appointments took place. It found no written details in respect of any of the appointments and accordingly decided that this head of charge is proved.


71. You failed to liaise and/or record that you had liaised with the periodontal specialist that had treated Patient F in order to confirm that the periodontal condition was stable.

Found proved on the basis that Mr Sharma failed to liaise with a periodontal specialist. The Committee accepted the evidence of Mr Nery that a reasonable GDP would have liaised with a periodontal specialist to ensure that Patient F’s periodontal condition was stable. Mr Nery explained that an unstable periodontal condition


could impact on the success of the implant. Mr Nery also considered that it was incumbent on Mr Sharma to liaise with a specialist, given that the patient was an insulin dependent diabetic. Taking into account Mr Nery’s evidence, the Committee was satisfied that Mr Sharma had a duty to liaise with a periodontal specialist because of the heightened risk of failure in this patient’s case. The patient had a medical condition which, the Committee was informed, made the patient more susceptible to periodontal problems. The Committee also noted the requirement within the relevant GDC Standards that Mr Sharma worked with other dental colleagues. The Committee had regard to Mr Sharma’s clinical records for Patient F and whilst it saw that there was a note that the patient should be referred to a periodontal specialist, it found nothing to indicate that Mr Sharma had liaised with the specialist. It therefore decided on the balance of probabilities that Mr Sharma had failed in his duty to do so. The obligation to record does not therefore arise.

72. You failed adequately to discuss and/or record that you had discussed with Patient F, the risks associated with implant treatment in the light of Patient F’s diabetic and periodontal condition.

Found proved on the basis that Mr Sharma failed adequately to discuss the associated risks with Patient F. The Committee saw that the clinical records address the risks of tenderness and swelling. However, it noted from the evidence of Mr Nery, which it accepted, that the patient needed to know that there were additional risks in light of the patient’s diabetic condition. The Committee found nothing in the clinical records to indicate that Mr Sharma informed the patient of the additional risks, including problems associated with an adverse periodontal condition and the risk of failure of the implants. The Committee noted that Mr Sharma did record on the patient’s consent form of 10 May 2013 the pros and cons of the treatment, but these specific risks are not included. The Committee would have expected these additional risks to have been written down. Given the importance of discussing such matters with the patient, the Committee decided, on balance, in the absence of any detail in the records, Mr Sharma did not discuss the issues with Patient F. It considered that this was a failure on his part, as he had an obligation to do so under the Standards relating to informed consent, as explained by Mr Nery. The obligation to record did not therefore arise.

Radiography

73. You failed to report upon the radiograph which had been taken on 6 December 2012.

Found not proved. The Committee noted that the radiograph of 6 December 2012 was a radiograph that had been requested by another practitioner, but used by Mr Sharma. It was not persuaded that Mr Nery had provided a sufficient explanation as to why there was a duty on Mr Sharma to report on the radiograph in the circumstances.


Accordingly, it found this head of charge not proved.

74. You failed to carry out and/or record that you had carried out a periapical radiograph:

74.(a) Prior to the placement of the implant on 10 May 2013

Found proved on the basis that Mr Sharma failed to carry out a periapical radiograph. It was the evidence of Mr Nery, which the Committee accepted, that Mr Sharma would have needed to take another periapical radiograph prior to placing the implant in order to check the bone level. Mr Nery explained that this was necessary as after the extraction of a tooth there can be bone loss. He stated that before placing the implant Mr Sharma needed to know whether there was abundant bone above the ID canal. The Committee was satisfied from Mr Nery’s evidence that Mr Sharma had a duty to take a periapical radiograph for the reasons given. It did not receive a copy of any such radiograph and it found no indication in the clinical records that one had been taken by Mr Sharma. It therefore decided on the balance of probabilities that Mr Sharma failed in his duty to carry out a periapical radiograph as required. The obligation to record did not therefore arise.

74.(b) Following the placement of the implant on 10 May 2013 and/or prior to restoration

Found proved on the basis that Mr Sharma failed to record that he had carried out a periapical radiograph. The expert evidence was that a periapical radiograph should have been taken by Mr Sharma either immediately after placing the implant or prior to restoration, but not on both occasions. The Committee found nothing in the clinical records to indicate that Mr Sharma took a periapical radiograph immediately following the implant placement on 10 May 2013. It noted that there was no duty on him to take a radiograph at that point; as he could have taken one prior to restoration. However, there is nothing in the records to indicate that a periapical radiograph was taken on either occasion at placement of the implant or commencement of the restoration, and no copies of any radiographs were provided for the Committee. The clinical notes for 12 July 2013 detail that impressions were taken for a crown which is the commencement of the restoration process. The Committee is satisfied that there is no entry to show a periapical radiograph was taken on that day. The Committee is satisfied on the expert evidence that if a periapical radiograph had not been taken immediately after placing the implant, it ought to have been taken prior to the restoration. Accordingly, the Committee was satisfied that Mr Sharma had failed to take periapical radiograph and Head of Charge 74(b) is proved. The obligation to record does not therefore arise.

Patient G Between 2011 and 2013 in your treatment of Patient G at the Bupa Dental Centre

Holborn:

Record Keeping


75. You failed to carry out and/or adequately record details of your implant assessment on 4 March 2011, 15 April 2011 or 15 July 2011 set out in Schedule A.

Found proved on the basis that Mr Sharma failed to adequately carry out the implant assessment on the dates in question as set out in Schedule A. The Committee was satisfied from the clinical records that all these appointments took place. It also considered that it was more likely than not that Mr Sharma undertook some form of implant assessment on at least one of these dates, due to the inherent complexity of Patient G’s treatment. The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to carry out an assessment prior to placing implants. He told the Committee that such an assessment should have included all of the relevant matters set out in Schedule A. In relation to the issue of an assessment, the Committee concluded that it was unfeasible that Mr Sharma would not have conducted some kind of implant assessment. It considered that he would have at least looked inside of the patient’s mouth. The Committee had regard to the clinical records for Patient G. It found none of the information that it would expect to see, as is outlined in Schedule A and based on the evidence of Mr Nery. The Committee considered that it was unlikely that a dentist would undertake an assessment without recording their findings. The Committee therefore decided on the balance of probabilities that Mr Sharma failed in his duty to carry out an adequate assessment. The Committee has interpreted this charge as requiring both the assessment and the recording to be in accordance with Schedule A. Given its finding that the assessment was not conducted in accordance with the requirements of Schedule A, the obligation to record does not arise.

76. You failed to record the justification for the antibiotics which were prescribed on 16 November 2012 and 26 June 2013.

Found proved. The Committee noted from the clinical records that on both dates Mr Sharma gave antibiotics chairside. However, it found nothing in the records for either date that constituted a justification for prescribing antibiotics. The Committee was satisfied from the evidence of Mr Nery, which included reference to the FGDP prescribing guidelines, that Mr Sharma should have recorded the justification for prescribing antibiotics on both occasions. By not doing so, Mr Sharma failed in this duty.

77. You failed to record the name, dose and period for which antibiotics and painkillers were prescribed on 16 November 2012 and 26 June 2013

Found proved. The Committee noted from the clinical records that Mr Sharma prescribed antibiotics and painkillers to the patient on these dates. It found nothing in the records referring to the name, dose or period for which the medications were given. The Committee was satisfied from the evidence of Mr Nery, which included reference to the FGDP prescribing guidelines, that Mr Sharma should have


recorded this information. By not doing so, Mr Sharma failed in his duty.

78. You failed to record details of the local anaesthetic used as set out in Schedule B on:

78.(a) 15 April 2011

Found not proved. 78.(b) 15 July 2011

Found not proved. 78.(c) 16 November 2012

Found not proved. The Committee considered heads of charge 78 (a) to (c) separately, but made the same finding in respect of each head of charge. The Committee noted from the clinical records for the dates 15 April 2011, 15 July 2011 and 16 November 2012, that Mr Sharma did record the type, dose and route of the local anaesthetic used. As the Committee has accepted that the batch numbers and expiry dates were stored centrally, then the details recorded by Mr Sharma on these three dates are adequate and appropriate.

78.(d) 26 June 2013

Found proved. In respect of 26 June 2013, the Committee noted from the clinical records that Mr Sharma only recorded the route of the local anaesthetic, that is, that it was infiltrated around the patient’s upper arch. The Committee found no details of the type or dose of the local anaesthetic given. Whilst it accepted that the batch numbers and expiry dates were held centrally at the practice, it considered that this is irrelevant if the type of anaesthetic used was unknown. The batch number and expiry date would be untraceable in the circumstances.

79. WITHDRAWN. 79.(a) WITHDRAWN. 79.(b) WITHDRAWN. 79.(c) WITHDRAWN. 79.(d) WITHDRAWN. 79.(e) WITHDRAWN. 80. You failed to record details of appointments on:

80.(a) 18 January 2013

Found proved. 80.(b) 2 August 2013

Found proved. 80.(c) 13 September 2013


Found proved. 80.(d) 4 October 2013

Found proved. 80.(e) 22 November 2013

Found proved. 80.(f) 6 December 2013.

Found proved. The Committee considered heads of charge 80 (a) to (f) separately, but made the same finding in respect of each head of charge. The Committee was satisfied from the appointment history that all of these appointments took place. It noted that many of the appointments had financial transactions associated with them. It also accepted witness 2’s evidence that these appointments would have occurred. The Committee found no details of clinical entries recorded for these appointments. It was therefore satisfied that Mr Sharma failed in his duty to make and keep accurate records for this patient.


81. You failed adequately to discuss and/or record that you discussed the clinical evaluation, and options and risks associated with treatment in relation to the LR78 on 15 April 2011 and 16 November 2012.

Found proved in respect of 15 April 2011 on the basis that Mr Sharma failed to adequately discuss the clinical evaluation, and options and risks associated with treatment in relation to the LR78 on 15 April 2011 and 16 November 2012. Found not proved in respect of 16 November 2012. In relation to 15 April 2011, the Committee had regard to the clinical records, including the relevant consent form which was signed by the patient. It noted that there is reference in the notes to the procedure having been explained to the patient. As a consequence the Committee considered that this indicated that there had been some discussion between Mr Sharma and Patient G. Nevertheless, the Committee was satisfied that the clinical records together with the signed consent form did not detail the full scope of an adequate discussion. There is no record in relation to the clinical evaluation, options and the risks associated with the patient’s treatment, in particular as to the serious risk of damage to the ID nerve. The Committee was satisfied that had it been discussed, it would have been recorded. therefore, the Committee was satisfied on the balance of probabilities that Mr Sharma did not adequately discuss those matters. Therefore, the obligation to record does not arise. The Committee found this head of charge not proved in relation to 16 November 2012, as it noted from the clinical records that the LR78, the teeth particularised in this allegation, had already been extracted by this date. The records in respect of 16 November 2012 refer to an upper left tooth and not lower right teeth.


82. You failed adequately to discuss and/or record that you had discussed the risks associated with the placement of implants including the risk of temporary or permanent ID nerve damage.

Found proved on the basis that Mr Sharma failed to adequately discuss with the patient the risks associated with the placement of implants including the risk of temporary or permanent ID nerve damage. The Committee considered this Head of Charge to be a particularisation of the general failure listed at Head of Charge 81. In reaching its decision, the Committee considered the clinical records including the relevant consent form. Whilst the Committee noted that there is reference to the procedure having been explained to the patient by way of a generic paragraph on the consent form which was signed by the patient, it saw nothing in the notes or on the form relating to the risk to the ID nerve. Given that this is such a significant risk of the treatment, the Committee decided, on balance, that if Mr Sharma had adequately discussed the matter with Patient G, it would have been explicitly recorded. The Committee was satisfied from the evidence of Mr Nery, regarding the importance of highlighting to the patient the risk of ID nerve damage, that Mr Sharma had a duty to have an adequate discussion with Patient G. It also took into account his obligation under the relevant GDC Standards in relation to informed consent. By not having an adequate discussion with the patient, Mr Sharma failed in his duty to do so. Therefore, the obligation to record did not arise.

83. You failed adequately to record which options you had discussed for treatment and outcome in relation to the mobility of the bridge on 30 September 2011.

Found proved. The Committee had regard to the clinical records. Whilst it saw that it is noted that treatment options were discussed with the patient, there is no list of which options were discussed or any reference to outcome. The Committee was satisfied that Mr Sharma had a duty to record these matters in detail as part of his obligation to keep complete and accurate records. It was of the view that the limited record made by Mr Sharma was not adequate.

84. WITHDRAWN.

85. You failed to discuss and/or record that you had discussed the risks, benefits and options associated with the placement of implants on 26 June 2013.

Found proved on the basis that Mr Sharma failed to record that he had discussed with the patient the options. In reaching its decision, the Committee noted that this patient had had similar treatment since 2008. It therefore considered that it could be reasonably inferred that there had been an ongoing discussion with the patient about the risks and benefits of the implant treatment, as outlined by Mr Nery in his evidence. Taking into account the particular circumstances of this patient’s case, the Committee was not persuaded that there was a failure on Mr Sharma’s part to have a discussion.


However, the Committee was of the view that one would expect to see in the clinical records, notes specifically tailored to the patient’s treatment, including the relevant risks, benefits and options. Whilst the Committee found that some risks and benefits were recorded by Mr Sharma, there is no reference to options. Accordingly, the Committee found this head of charge proved in relation to Mr Sharma’s failure to record having discussed options with Patient G.

Radiography

86. (Previously read: You failed to carry out and/or record that you had carried out pre-operative radiographs prior to the implant placement on 26 June 2013 and prior to restoration.) Amended to read: You failed to carry out and/or record that you had carried out pre-operative radiographs prior to the implant placement on 26 June 2013.

Found proved (as amended) on the basis that Mr Sharma failed to carry out pre-operative radiographs. The Committee did not receive any copies of any such radiographs in respect of Patient G. It considered the clinical records and found no indication that Mr Sharma had carried out pre-operative radiographs prior to the implant placement on 26 June 2013. The Committee took into account the statement of witness 3, in which he stated that Mr Sharma said he did not take pre-operative radiographs, as he knew where to place implants. In all the circumstances, the Committee was satisfied on the balance of probabilities that Mr Sharma did not carry out pre-operative radiographs in this instance. It accepted the evidence of Mr Nery that Mr Sharma had a duty to do so in accordance with FGDP guidelines. By not doing so, Mr Sharma failed in his duty.

Patient H Between 2011 and 2013 in your treatment of Patient H at the Bupa Dental Centre

Holborn:

Record Keeping

87. (Previously read: You failed to carry out and/or record details of your implant assessment on 15 April 2011 set out in Schedule A.)

Amended to read: You failed to carry out and/or record details of your implant assessment on 12 April 2013 and/or 2 August 2013 set out in Schedule A.

Found proved (as amended) on the basis that Mr Sharma failed to carry out any implant assessment on both dates as set out in Schedule A. The Committee was satisfied from the clinical records that Mr Sharma saw Patient H on both of these dates. It was also satisfied from the evidence of Mr Nery that Mr Sharma had a duty to carry out an implant assessment, as set out in Schedule A. It was its view that Mr Sharma must have carried out some form of assessment on these dates. It decided that it was inconceivable that he would not have looked inside the patient’s mouth prior to commencing implant treatment. The Committee found nothing in the clinical records as to an assessment for either


date. The records are silent on the matters set out in Schedule A. The Committee has already found previously that Mr Sharma was under a duty to record his implant assessment. By not doing so, he failed in his duty. The Committee has interpreted this charge as requiring both the assessment and the recording to be in accordance with Schedule A. Given its finding that the assessment was not conducted in accordance with the requirements of Schedule A, the obligation to record does not arise.

88. You failed to record details of the local anaesthetic used during the implant procedure on 2 August 2013 and 12 April 2013 set out in Schedule B.

Found proved in respect of 12 April 2013. Found not proved in respect of 2 August 2013. In relation to 12 April 2013, the Committee noted from the clinical records that Mr Sharma did not record the type of anaesthetic that he used. Whilst the Committee took into account that the batch number and expiry date would have been held centrally at the practice, it considered that this was irrelevant if the type of anaesthetic used was unknown, as the batch number and expiry date would be untraceable in the circumstances. In relation to 2 August 2013, the Committee noted from the clinical records that Mr Sharma recorded the type and route of the local anaesthetic that he used. As the Committee has accepted that the batch number and expiry date of the local anaesthetic would have been stored centrally, then the details recorded by Mr Sharma on this date are adequate and appropriate.

89. (Previously read: You failed to record the justification for the prescription of antibiotics prescribed on 2 August 2013 and 12 April 2014. Amended to read: You failed to record the justification for the prescription of antibiotics prescribed on 2 August 2013 and 12 April 2013.

Found proved (as amended). The Committee noted from the clinical records that on both dates Mr Sharma prescribed antibiotics to the patient. However, it found nothing in the records for either date that constituted a justification for the prescribing of the antibiotics. The Committee accepted the evidence of Mr Nery, which included reference to the FGDP prescribing guidelines, that Mr Sharma should have recorded justification for prescribing on both occasions. By not doing so, Mr Sharma failed in this duty.

90. (Previously read: You failed to record the type, dose and period for which antibiotics and painkillers were prescribed for the patient on 12 April 2014.)

Amended to read: failed to record the type, dose and period for which antibiotics and painkillers were prescribed for the patient on 12 April 2013.

Found proved (as amended). The Committee noted from the clinical records that Mr Sharma prescribed antibiotics and painkillers to the patient on this date. It found nothing in the records referring to the type, dose or period for which the medication was given. The Committee accepted the evidence of Mr Nery, which included reference to the


FGDP prescribing guidelines, that Mr Sharma should have recorded this information. By not doing so, Mr Sharma failed in this duty.

91. You failed to record details of appointments on 22 March 2013, 28 June 2013 and 18 October 2013.

Found proved. The Committee was satisfied from the appointment history that all of these appointments took place. It noted that one of the appointments had financial transactions associated with it. It also accepted Witness 2’s evidence that these appointments would have occurred. The Committee found no details of clinical entries recorded for these appointments. It was therefore satisfied that Mr Sharma failed in his duty to make and keep accurate records for this patient.

92. You failed to record the clinical reasons why an implant supported bonded crown was manufactured on 10th October 2013.

Found not proved. Mr Nery gave evidence as to the potential inappropriateness of early placement of the crown and the need for the treating practitioner to give reasons for its early placement. The Committee noted, however, that this head of charge refers to the manufacture of the crown, as opposed to its placement. In the circumstances, the Committee found this allegation not proved.

93. You failed to record the clinical details of the materials or techniques used to take an impression of the UR6 on 4 October 2013.

Found not proved. Mr Nery stated that there was no duty to record details of the materials or techniques used to take an impression, and that he considered doing this to be more of a “gold standard”. Therefore, the Committee was not persuaded that Mr Sharma had a duty to record such details.


94. You failed to adequately discuss and/or record that you had discussed the risks and benefits in relation to the extraction and placement of the implant at UR6.

Found not proved in relation to the extraction. Found proved on the basis that Mr Sharma failed to adequately discuss the risks and benefits in relation to the placement of the implant. In relation to the issue of the extraction, the Committee saw from the clinical records that Mr Sharma had explained that the tooth was removed because it was failing and that there was swelling and tenderness. In the circumstances, the Committee considered that Mr Sharma had done all that was required prior to extracting the tooth and it therefore found this part of the allegation not proved. However, the Committee did find on the balance of probabilities that Mr Sharma had failed to adequately discuss with the patient the risks and benefits of the implant treatment. Mr Nery told the Committee in evidence of the heightened risk of failure associated with the early loading of an implant, as well as there being risks of swelling and infection. Given the importance of mentioning these issues to


the patient as part of the process of informed consent, the Committee was satisfied that Mr Sharma had a duty to discuss them with the patient. The Committee found no notes in the records to indicate that any of these matters were discussed with the patient. The Committee took into account the seriousness of the risks in particular the high risk of failure and decided that, if Mr Sharma had discussed them with the patient, they would have been recorded. It therefore determined that it was more likely than not that they had not been discussed. Accordingly, Mr Sharma failed in his duty to do so. Given its finding, the obligation to record does not arise.

Radiography


95.(a) following the extraction of the UR6 and prior to the placing of the implant at UR6 on 2 August 2013.

Found proved on the basis that Mr Sharma failed to carry out a periapical radiograph. The evidence of Mr Nery was that a periapical radiograph should have been taken by Mr Sharma following the extraction of UR6 or prior to placing the implant at UR6. Mr Nery explained that a periapical radiograph was necessary, as after the extraction of a tooth there can be bone loss. The Committee accepted Mr Nery’s evidence, in which he referred to the relevant FGDP guidelines. It was satisfied that Mr Sharma had a duty to take at least one periapical radiograph in respect of the treatment of the UR6. The Committee found nothing in the clinical records to indicate that Mr Sharma took a periapical radiograph following the extraction of the tooth or prior to placing the implant, and it did not receive a copy of a radiograph. The Committee further took into account the evidence of Witness 3 regarding Mr Sharma’s radiographic practice. It was satisfied on the balance of probabilities that Mr Sharma did not take a periapical radiograph and that this was a failure on his part.

95.(b) following the placement of the implant on 2 August 2013.

Found proved on the basis that Mr Sharma failed to carry out a periapical radiograph. The Committee was satisfied from the evidence of Mr Nery that Mr Sharma had a duty to take a periapical radiograph following the placement of this implant, as such a radiograph would have been required to check the position of the implant. The Committee found nothing in the clinical records to indicate that Mr Sharma took a periapical radiograph following the placement of the implant on 2 August 2013 and it did not receive a copy of a radiograph. The Committee further took into account the evidence of Witness 3 regarding Mr Sharma’s radiographic practice. It was satisfied on the balance of probabilities that Mr Sharma did not take a periapical radiograph and that this was a failure on his part.

Patient I


Between 2013 and 2014 in your treatment of Patient I at the Bupa Dental Centre Holborn:

Record keeping

96. You failed adequately to carry out and/or record details of your implant assessment on 19 April 2013 set out in Schedule A.

Found proved on the basis that Mr Sharma failed adequately to carry out an implant assessment on 19 April 2013 as set out in Schedule A. The Committee was satisfied from the clinical records that an appointment with Patient I took place on this date. In reaching its decision, it had regard to the witness statement of the patient, which is supported by a declaration of truth. The Committee noted that the Patient I’s witness statement indicated that the referring dentist had undertaken some elements of an implant assessment. The Committee was satisfied from the evidence of Mr Nery that Mr Sharma, as the treating dentist, still had a duty to carry out an implant assessment of his own. It was the view of the Committee that Mr Sharma must have carried out some form of assessment. It decided that it was inconceivable that Mr Sharma would not have looked inside the patient’s mouth prior to commencing implant treatment. However, in light of the evidence of Patient I and the limited information in the clinical records, the Committee concluded on the balance of probabilities that, whilst Mr Sharma may have undertaken some assessment of his own, it was not in accordance with what Mr Nery would have expected as set out in Schedule A. Accordingly, it determined that there was a failure on Mr Sharma’s part to carry out an adequate assessment.

97. You failed to adequately record surgical details of the extraction and implant placement on 19 April 2013 and 26th July 2013 in relation to the UL56 and LR56.

Found proved. The Committee accepted the evidence of Mr Nery that there was a requirement for Mr Sharma to record these details in accordance with the relevant GDC Standards. The Committee considered the clinical records for both dates and found none of the information Mr Nery said that he would expect to see, such as how the gum was lifted, the bone removed, the roots divided or detail of the implant placement and sites. Accordingly, the Committee found that Mr Sharma failed to record the necessary surgical details.

98. You failed to record details of appointments on 11 October 2013 and 18 October 2013.

Found proved. The Committee was satisfied from the appointment history that all of these appointments took place. It noted that both of these appointments had financial transactions associated with it. It also accepted witness 2’s evidence that these appointments would have occurred. The Committee found no details of clinical entries recorded for these appointments. It was therefore satisfied that Mr Sharma


failed in his duty to make and keep accurate records for this patient.

99. You failed to adequately record details of when impressions were taken, or abutments and crowns tried in for UL56 and LR56.

Found proved. The Committee accepted the evidence of Mr Nery that it was important for Mr Sharma to record these details and that it was a requirement of the relevant GDC Standards. The Committee considered the clinical records. It found Mr Sharma’s notes in relation to the taking of the impressions and the tri-in of the abutments and crowns for UL56 and LR56, to be difficult to interpret due to a lack of detail. In the circumstances the Committee was of the view that they did not constitute adequate records. Therefore, Mr Sharma failed in his duty in this regard.

Informed Consent and Treatment Planning

100. You failed adequately to discuss and/or record that you had discussed the options for treatment and outcome in relation to the UL56 and LR56.

Found proved on the basis that Mr Sharma failed to adequately discuss with the patient the options for treatment and outcome. The Committee was satisfied that Mr Sharma had a duty under the relevant GDC Standards to discuss treatment options and outcome with Patient I as part of the informed consent process. In reaching its decision, it had regard to the evidence of Patient I, as set out in her witness statement. The patient stated that she did not think that she had discussed alternative treatments with Mr Sharma at any time. The Committee also took into account the clinical records and found nothing noted to indicate that there had been such a discussion between Mr Sharma and Patient I. It accepted Mr Nery’s evidence that, in the circumstances of this patient’s case, he would have expected to see details in the records about bridgework and dentures. Taking all the evidence into account, the Committee decided on the balance of probabilities that Mr Sharma failed in his duty to adequately discuss treatment options and outcomes with the patient. Therefore, the obligation to record does not arise.

101. You failed adequately to discuss and/or record that you had discussed and/or provide the patient with written information outlining the risks associated with the placement of implants including sinus perforation.

Found proved on the basis that Mr Sharma failed to adequately discuss the risks associated with the placement of implants including sinus perforation. The Committee carefully considered the clinical records made by Mr Sharma, which it saw included a record indicating that there was no sinus involvement. The Committee accepted the evidence of Mr Nery that this record implied that sinus involvement was an issue Mr Sharma considered. Whilst the Committee accepted that there may have been a discussion between Mr Sharma and Patient I about this particular risk, it found nothing in the clinical records to indicate that Mr Sharma had discussed with the patient the risks associated with the placement of


shorter implants given the apparent lack of bone depth noted in the records made by the previous treating dentist, such as the increased risk of failure. Taking into account the heightened risks emphasised by Mr Nery of what he considered to be an unconventional approach to treatment, the Committee concluded that, given the absence of any record of such a discussion, Mr Sharma failed in his duty to do so. In light of the Committee’s conclusion, the alternative record keeping allegation in this head of charge falls away. Further, the Committee was not persuaded on the evidence, that there was any duty on Mr Sharma to provide written information to the patient or, in any event, that this part of the allegation added anything to the charge, given Mr Sharma’s substantive failure to discuss specific risks of the patient’s treatment. Given its findings, the obligation does not arise.

102. You failed to carry out any further investigation of the bone height or width prior to placement of implants at UL56.

Found proved. Given the indication of the bone depth from the OPT radiograph seen by the Committee, it accepted the evidence of Mr Nery that further investigation of the issue was required. In this regard, Mr Nery stated that a periapical radiograph should have been taken by Mr Sharma to assess the height of the bone and that he should have possibly taken a CT scan to assess bone width. The Committee found nothing in the clinical records to indicate that Mr Sharma took any further steps. Accordingly, it found this head of charge proved.

103. You failed to provide an updated treatment plan to the patient outlining the risks associated with the use of shorter implants which obviated the need for sinus lifting.

Found proved. The original treatment plan was dated 25 February 2013. The Committee noted from the clinical records that an updated treatment plan was provided to Patient I, dated 19 April 2013. The updated treatment plan no longer required a sinus lift and as a result, as Mr Nery indicated, would necessitate the placement of shorter implants. There was however, no explanation why these changes were made. Taking into account the evidence of Mr Nery, the Committee was satisfied that the risk of using shorter implants and the associated risk should have been included in the updated treatment plan. In the absence of any such information in the plan, the Committee found this head of charge proved.

Radiography

104. You failed to carry out and/or record that you had carried out a CT scan and/or periapical radiograph:

104.(a) Pre-operatively to the placement of implants at UL56 and LR56 on 19 April 2013 and intra-operatively.

Found proved on the basis that Mr Sharma failed to carry out a CT scan


and/or periapical radiograph. 104.(b) Following placement of implants at UL56 and LR56 on 19 April 2013 and 26 July

2013.

Found proved on the basis that Mr Sharma failed to carry out a CT scan and/or periapical radiograph.

104.(c) On 30 August 2013 when the crowns on UL56 were noted to be loose.

Found proved on the basis that Mr Sharma failed to carry out a CT scan and/or periapical radiograph. The Committee considered heads of charge 104(a) to (c) separately, but made the same findings in respect of each head of charge. In reaching its decision, the Committee had regard to Mr Sharma’s clinical notes for Patient I and found no indication that a CT scan or a periapical radiograph was taken on any of the occasions set out at (a) to (c). The Committee also took into account the evidence of Patient I, as set out in her witness statement, which is supported by a declaration of truth. The patient does not refer to any radiographs taken by Mr Sharma, but instead stated that Mr Sharma was familiar with her notes, including that she had had x-rays taken before the commencement of her treatment with him. However, the Committee noted the evidence of Mr Nery that the presence of previous radiographs did not obviate the duty on Mr Sharma to take further investigative radiographs before and after placement of the implants, and when the patient’s crowns were noted to be loose in August 2013. The Committee accepted the opinion of Mr Nery as to the reasons why such further radiographs were necessary. Accordingly, it found all three allegations proved.

Patient J In 2013 in your treatment of Patient J at the Bupa Dental Centre Holborn:

Record Keeping

105. You failed to carry out and/or adequately record details of your implant assessment on 1 November 2013 set out in Schedule A.

Found proved on the basis that Mr Sharma failed to carry out details of his implant assessment as set out in Schedule A. The Committee was satisfied that Mr Sharma failed to carry out an implant assessment on I November 2013 set out in Schedule A. The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to carry out an assessment prior to placing implants. He told the Committee that such an assessment should have included all of the relevant matters set out in Schedule A. In relation to the issue of an assessment, the Committee concluded that it was unfeasible that Mr Sharma would not have conducted some kind of implant assessment. It considered that he would have at least looked inside of the patient’s mouth. The Committee had regard to the clinical records for Patient J. It found none of the information that it would expect to see, as is outlined in


Schedule A and based on the evidence of Mr Nery. The Committee considered that it was unlikely that a dentist would undertake an assessment without recording their findings. The Committee therefore decided on the balance of probabilities that Mr Sharma failed in his duty to carry out an adequate assessment. The Committee has interpreted this charge as requiring both the assessment and the recording to be in accordance with Schedule A. Given its finding that the assessment was not conducted in accordance with the requirements of Schedule A, the obligation to record does not arise.

106. You failed to record the clinical evaluation and diagnosis that lead to the prescription of antibiotics and/or inappropriately prescribed antibiotics as a preventative measure.

Found proved. The Committee found this head of charge proved on all bases. Having considered the relevant clinical records, the Committee accepted the evidence of Mr Nery that the prescription of antibiotics in question related to the extraction of Patient J’s UL1 on 1 November 2013. It was Mr Nery’s evidence that there was no justification for the prescription. He questioned why, if the tooth was the source of the infection, Mr Sharma would give antibiotics on the very same day as extracting the tooth. The Committee considered Mr Sharma’s clinical records for Patient J on 1 November 2013. Whilst it noted that he recorded a reason for extracting the UL1, the Committee found no recorded clinical evaluation and diagnosis in respect of the prescription of antibiotics. It was satisfied on the evidence that Mr Sharma had a duty to record such details and not doing so was a failure on his part. The Committee also noted that the tooth was extracted on this day. In the circumstances, the Committee accepted the opinion of Mr Nery that it was more likely than not that Mr Sharma prescribed the antibiotics as a preventative measure. The Committee accepted Mr Nery’s evidence that this was inappropriate and contrary to the prescribing guidelines as antibiotics should not have been prescribed prophylactically.

107. You failed to record the details of the local anaesthetic used on 1 November 2013 and 22 November 2013 set out in Schedule B.

Found not proved. The Committee noted from the clinical records for the dates 1 November 2013 and 22 November 2013 that Mr Sharma did record the type, dose and route of the local anaesthetic used. As the Committee has accepted that the batch numbers and expiry dates were stored centrally, then the details recorded by Mr Sharma on these two dates are adequate and appropriate.

Treatment planning & Informed Consent

108. You failed adequately to discuss and/or record that you had discussed the options for treatment and risks and benefits associated with the replacement of the UL1.

Found proved on the basis that Mr Sharma failed adequately to discuss the


options for treatment and risks and benefits associated with the replacement of the UL1. The Committee considered that, given the dental problems of this patient, as detailed in the clinical notes for 27 August 2013, which were made by another dentist, the patient needed to be warned by Mr Sharma that the UL1 would look longer than the UR1 following its restoration. The Committee noted the evidence that there was increased bone loss at the UL1 due to a previous infection and also the extraction of that tooth. Therefore, upon restoration a poorer aesthetic outcome was to be expected. The Committee was also satisfied on the evidence of Mr Nery that, given the presentation of this patient, Mr Sharma had a duty to discuss all options for treatment, including leaving a gap, having a denture, having a bridge or an implant. The Committee had regard to the clinical records made by Mr Sharma for Patient J, including the relevant consent form. It saw that the consent form referred generically to the risks of treatment, as well as a manuscript list of ‘pros and cons’ made by the registrant. However, there was nothing in that list or in the clinical records themselves about options for treatment or the particular risks in respect of the UL1. In view of the significant nature of the risks, the Committee decided that if Mr Sharma had discussed the specific risks and treatment options with the patient, he would have included it in his manuscript of ‘pros and cons’. On balance, in light of the lack of written detail, the Committee concluded that Mr Sharma failed in his duty to discuss these matters with the patient. Accordingly, the obligation to record does not arise.

109. You failed adequately to discuss and/or record that you discussed the risks associated with placement of the implants on 22 November 2013 including the risk of bone loss.

Found proved on the basis that Mr Sharma failed adequately to discuss the risks associated with placement of implants on 22 November 2013 including the risk of bone loss. The Committee considered that there is considerable overlap between this head of charge and head of charge 108 above. Nevertheless, it was satisfied that there was no indication in the clinical records that the specific risk of bone loss, given this patient’s presentation, was discussed with the patient. The Committee therefore determined, on balance, that this meant that there had been an inadequate discussion. In reaching its decision, the Committee took into account the letter dated 24 September 2013 from a specialist in Endodontics regarding Patient J. The letter indicates that the specialist had some discussion with the patient about the risks associated with the placement of implants, as well as the patient’s treatment options. However, the Committee was satisfied that Mr Sharma, as the treating dentist, had a duty to discuss the risks and benefits with Patient J and that the letter did not discharge his responsibility as the treating dentist. Given the Committee’s finding, the obligation therefore to record the discussion of risks does not arise.


Treatment

110. You failed to provide an adequate standard of treatment to Patient J in that you:

110.(a) (Previously read: placed the implant in the UL1 prematurely on 22 November 2013 when Patient J’s gums and bone had not healed adequately following prior root canal treatment;)

Amended to read: placed the implant in the UL1 prematurely on 22 November 2013 when Patient J’s gums and bone had not healed adequately;

Found proved (as amended). It was the evidence of Mr Nery that it was too soon after the extraction of the patient’s UL1, where there had been an infection and bone loss, to place an implant. The Committee accepted his opinion and was satisfied Mr Sharma failed to provide Patient J with an adequate standard of care in this regard.

110.(b) placed a healing abutment and fitted the denture on 22 November 2013 which had the effect of inappropriately loading the implant from the time of placement thereby exposing the patient to increased risk of further bone loss or implant failure.

Found proved. The Committee accepted the evidence of Mr Nery that the placing of the healing cap and the fitting of the denture on the same day as the implant was placed amounted to inappropriate loading. Mr Nery explained that such loading would increase micro-movement before osteointegration of the implant had occurred. He stated that this in turn would increase the chance of further bone loss and failure of the treatment. In the circumstances, the Committee was satisfied Mr Sharma failed to provide Patient J with an adequate standard of care in this regard.

110.(c) Failed to record details of a discussion with the patient regarding the implications of placing a healing abutment and implant rather than placing a cover screw.

Found not proved. The Committee decided that it had not received sufficient evidence from the GDC to satisfy it that such a discussion actually took place between Mr Sharma and Patient J. In the absence of such evidence, the Committee concluded that the GDC had not proved that a discussion occurred that required recording.

Radiography

111. You failed to take a pre-operative periapical radiograph of the UL1 prior to placing the implant.

Found proved. The Committee did not have sight of a periapical radiograph and it found no indication in the clinical records that such a radiograph had been taken in respect of Patient J’s UL1 prior to placing the implant. The Committee accepted Mr Nery’s opinion that an x-ray was needed in order to check the extent of the bone loss. The Committee therefore determined on the balance of probabilities that by not taking a periapical radiograph, Mr Sharma failed in his duty.

Patient K


Between 2011 and 2013 in your treatment of Patient K at the Bupa Dental Centre:

112. You failed to carry out and/or record details of your implant assessment on 1 April 2011 or 2 August 2013 set out in Schedule A.

Found proved on the basis that Mr Sharma failed to carry out the implant assessment on those dates. The Committee was satisfied that Mr Sharma failed to carry out an implant assessment on 1 April 2011 and 2 August 2013 set out in Schedule A. The Committee accepted the evidence of Mr Nery that Mr Sharma had a duty to carry out an assessment prior to placing implants. He told the Committee that such an assessment should have included all of the relevant matters set out in Schedule A. In relation to the issue of an assessment, the Committee concluded that it was unfeasible that Mr Sharma would not have conducted some kind of implant assessment. It considered that he would have at least looked inside of the patient’s mouth. The Committee had regard to the clinical records for Patient K. It found none of the information that it would expect to see, as is outlined in Schedule A and based on the evidence of Mr Nery. The Committee considered that it was unlikely that a dentist would undertake an assessment without recording their findings. The Committee therefore decided on the balance of probabilities that Mr Sharma failed in his duty to carry out an adequate assessment. The Committee has interpreted this charge as requiring both the assessment and the recording to be in accordance with Schedule A. Given its finding that the assessment was not conducted in accordance with the requirements of Schedule A, the obligation to record does not arise.

113. (Previously read: You failed to record details of the local anaesthetic used on 2 June 2011, 5 August 2011 and 9 September 2011 as set out in Schedule B) Amended to read: You failed to record details of the local anaesthetic used on 2 or 3 June 2011, 5 August 2011 and 9 September 2011 as set out in Schedule B

Found proved (as amended) in respect of 2 or 3 June 2011. Found not proved (as amended) in respect of 5 August 2011 and 9 September 2011. The Committee noted from the clinical records that the patient was administered a local anaesthetic on 2 or 3 June 2011. There is a note stating, “LA as per drug sheet”. However, the Committee saw nothing in the documentation provided to it, including the relevant Intravenous Sedation Form, indicating the type, route, dose, manufacturer, batch number and expiry date in relation to the local anaesthetic given, as set out in Schedule B. Accordingly, the Committee found this head of charge proved in respect of this date range. However, in relation to the dates 5 August 2011 and 9 September 2011, the Committee noted from the clinical records that Mr Sharma did record the type, route and amount of local anaesthetic. As the Committee has accepted that the batch numbers and expiry dates were stored centrally, then the details recorded


by Mr Sharma on these three dates are adequate and appropriate.

114. (Previously read: You failed to record whether a cover screw or healing abutment was connected to the implant at UL2 following the procedure on 2 June 2011.)

(Amended to read: You failed to record whether a cover screw or healing abutment was connected to the implant at UL2 following the procedure on 2 or 3 June 2011.)

Found proved (amended). Mr Nery stated that it is important to record these details, as they relate to the loading of the implant. The Committee was satisfied from Mr Nery’s evidence and the relevant GDC Standards that Mr Sharma had a duty to record them. It had regard to the clinical records for Patient K and found no notes relating to these matters. It was therefore satisfied that Mr Sharma failed in his duty.

115. You failed to record the type, dose and duration of antibiotics and painkillers prescribed on 2 August 2013.

Found proved. The Committee noted from the clinical records that Mr Sharma prescribed antibiotics and painkillers to the patient on this date. It found nothing in the records referring to the type, dose or duration for which the medications were given. The Committee was satisfied from the evidence of Mr Nery, which included reference to the FGDP prescribing guidelines, that Mr Sharma should have recorded this information. By not doing so, Mr Sharma failed in this duty.

116. You failed to record details of the material and techniques used to take impressions on 13 September 2013.

Found not proved. Mr Nery stated that there was no duty to record details of the materials or techniques used to take an impression, and that he considered doing this to be more of a “gold standard”. Therefore, the Committee was not persuaded that Mr Sharma had a duty to record such details.

117. You failed to record details of your appointments with Patient K on 21 June 2013, 20 September 2013 and 4 October 2013.

Found proved. The Committee was satisfied from the appointment history that all of these appointments took place. It noted that one of the appointments had financial transactions associated with it. It also accepted Witness 2’s evidence that these appointments would have occurred. The Committee found no details of clinical entries recorded for these appointments. It was therefore satisfied that Mr Sharma failed in his duty to make and keep accurate records for this patient.


118. (Previously read: You failed adequately to discuss and/or record that you had discussed the options, risks and benefits associated with the immediate placement of the implant on 2 June 2011.)


Amended to read: You failed adequately to discuss and/or record that you had discussed the options, risks and benefits associated with the immediate placement of the implant on 2 or 3 June 2011.

Found proved (as amended) on the basis that Mr Sharma failed to discuss the options, risks and benefits associated with the immediate placement of the implant on 2 or 3 June 2011. The Committee noted from the clinical records that it was Mr Sharma’s plan to immediately place the implant. It was the evidence of Mr Nery that when there is an immediate placement, there is a specific risk to the patient of gum and bone recession. Taking into account Mr Nery’s evidence, which the Committee accepted, it would have expected to see recorded details of a discussion with the patient about the options, risks and benefits associated with the plan. The Committee was satisfied that Mr Sharma had a duty to discuss these matters with Patient K because of the heightened risk associated with the proposed treatment. The Committee found nothing in the clinical records to indicate that a discussion took place. It also considered the relevant consent form, which it noted had a generic paragraph about the risks of treatment, but nothing relating to the risks associated with immediate implant placement or alternative options. In the absence of such a record, the Committee decided, on balance, that Mr Sharma did not discuss the matters with the patient. Given the Committee’s finding, the obligation therefore to record the discussion does not arise.

Radiography


119.(a) (Previously read: On 3 June 2011 prior to the placement of an implant at UL2.)

Amended to read: On 2 or 3 June 2011 prior to the placement of an implant at UL2.

Found proved (as amended) on the basis that Mr Sharma failed to carry out a periapical radiograph.

119.(b) On 9 September 2011 following the fit of the crowns Found proved on the basis that Mr Sharma failed to carry out a periapical radiograph.

119.(c) Pre-operatively and post-operatively on 2 August 2013 when an implant was placed at LR1 Found proved on the basis that Mr Sharma failed to carry out a periapical radiograph.

119.(d) On 13 September 2013 when the lower implant was noted to have taken time to settle Found proved on the basis that Mr Sharma failed to carry out a periapical radiograph.


The Committee considered heads of charge 119(a) to (d) separately, but made the same finding in respect of each head of charge. The Committee has already accepted the evidence of Mr Nery, in which he referred to FGDP guidelines regarding the necessity for pre- and post-operative periapical radiographs in relation to implant treatment. In particular it also noted his evidence in respect of head of charge 119(d) that it was not usual for an implant to take so long to settle, as it did in Patient K’s case, and therefore a periapical radiograph was also required on 13 September 2013. The Committee did not have sight of periapical radiographs and it found no indication in the clinical records that such radiographs had been taken in respect of Patient K on any of the dates in question. It therefore determined on the balance of probabilities that Mr Sharma failed to take any. Accordingly, the obligation to record does not arise.

Patient L Between 2004 and 2005 in Tenby in your treatment of Patient L:

Treatment

120. You failed to provide an adequate standard of treatment in respect of Patient L in that you:

120.(a) Placed a bridge at UL3-5 which was inappropriately designed in that it failed to protect UL3 from caries.

Found proved. The Committee took into account the evidence of Mr Nery regarding the inappropriateness of fitting a bridge secured to a natural tooth at one end and an implant at the other end. He stated that, in the circumstances, there was a significant risk of the bridge coming loose. Mr Nery stated that this inappropriately designed bridge in Patient L’s case caused the crown on the natural tooth, her UL3, to loosen allowing bacteria to get underneath it, which subsequently resulted in decay. The Committee had sight of a radiograph showing extensive decay under the crown of the UL3. The Committee accepted the evidence of Mr Nery that the decay of the natural tooth could have been avoided by opting for alternative methods, including by using a coping or by not using the UL3 as part of the bridge at all. Mr Nery highlighted “that this sleeper” implant at UL4 could have been used instead, and went on to describe Patient L’s treatment as “ appalling”. The Committee considered that Mr Sharma had a duty not to put Patient L at risk of harm from decay. By using an inappropriately designed bridge, he failed to protect Patient L from caries which she went on to develop in her UL3. Therefore, the Committee was satisfied that he failed to provide an adequate standard of treatment.

120.(b) Failed to examine the Patient when she raised concerns that the restorations had the appearance of amalgam fillings.

Found proved.


The Committee was satisfied from the evidence of Mr Nery that Mr Sharma had a duty to examine the patient and provide options to resolve the concerns she raised. It received photographic evidence of Patient L’s teeth taken by a subsequent treating dentist showing the restorations. Mr Nery pointed out the areas where the metal on the crowns was showing through the porceline. In her witness statement, Patient L stated that when she raised her concerns about the appearance of the restorations, Mr Sharma did not examine her. She stated that he “shrugged his shoulders” and offered no treatment to resolve the issues. The Committee noted that Mr Sharma left Tenby shortly afterwards. In assessing the reliability and accuracy of Patient L’s witness statement, the Committee took into account that it is supported by a declaration of truth. It also took into account that she stated that she “vividly” remembered Mr Sharma’s reaction, as she had not expected that kind of behaviour from him. The Committee was satisfied that Patient L’s evidence was credible and reliable and it also took into account that there is photographic evidence to support her account of the appearance of her teeth which showed extensive areas of exposed metal. The Committee thought it more likely than not that a patient paying such high sums of money would question such a poor aesthetic result. The Committee was satisfied this head of charge is proved on the balance of probabilities.


121. You failed to obtain informed consent in relation to Patient L’s proposed implant treatment in that:

121.(a) You failed to discuss the relevance of Patient L’s history of periodontal disease upon the clinical outcome of the proposed implant treatment.

Found proved. In reaching its decision on this head of charge and the other allegations in respect of Patient L’s treatment, the Committee had regard to the fact that there are no clinical records from Mr Sharma in respect of this patient, as he has asserted in his written observations in C4, that they were destroyed in a fire. The Committee put little weight on this un-corroborated assertion. The Committee also bore in mind that Patient L’s evidence was not tested. However, it took into account that her witness statement is supported by a declaration of truth. Further, given the expense of the treatment she embarked upon with Mr Sharma and the importance of that treatment to her, which the Committee considered apparent from her evidence, it concluded that it was more likely than not that she was an accurate historian and a credible and reliable witness. In relation to this head of charge, the evidence before the Committee was that this patient had a history of periodontal disease. It noted the letter dated 15 January 2003 from Person 6 referring Patient L to witness 5. The Committee considered from this letter that the patient’s periodontal disease was not a mild case that could easily be resolved. The extent of the patient’s periodontal problems was such that Person 6 suggested a full course of hygiene therapy under local anaesthetic before implants could be considered; implant treatment was by no


means guaranteed. Mr Sharma stated in his written observations in C4 that he had considered Patient L’s periodontal condition to be stable and that he would not have carried out implant treatment if he had noted periodontal disease. However, the Committee noted that by her own admission in her witness statement, Patient L stated that she did not go to see a hygienist. It therefore concluded that at the time she saw Mr Sharma, her periodontal condition was the same or possibly worse than when she saw Person 6. In the circumstances, the Committee considered that it was more likely than not that Patient L’s periodontal condition would have been apparent to Mr Sharma through examination, and, in any event, her history of periodontal disease should have been ascertained through questioning. Patient L stated in her witness statement that Mr Sharma did not discuss her oral health with her or the issue of periodontal disease. The Committee considered that, given the history of her treatment, Patient L would have been aware if periodontal matters had been raised by Mr Sharma. The Committee was therefore satisfied on the balance of probabilities that such matters were not discussed with the patient. It decided that even if Mr Sharma did observe that Patient L’s periodontal condition was stable, he still had a duty to discuss the relevance of her history of periodontal disease upon the clinical outcome of the proposed implant treatment. The Committee found that he failed in that duty.

121.(b) You failed to discuss and/or provide Patient L with written information regarding the risks associated with smoking upon the clinical outcome of the proposed implant treatment.

HOC 121(b) Found proved on the basis that Mr Sharma failed to discuss with Patient L the risks associated with smoking upon the clinical outcome of the proposed implant treatment. In reaching its decision on this head of charge, the Committee had regard to the fact that there are no clinical records from Mr Sharma in respect of this patient, as he has asserted in his written observations in C4 that they were destroyed in a fire. The evidence before the Committee was that Patient L was a smoker. The Committee was satisfied that Mr Sharma had a duty to discuss the issue of smoking with the patient, given the potential impact of smoking on implant treatment. The patient stated in her witness statement that Mr Sharma never discussed with her the associated risks of smoking. She stated that “If I had been told by Dr Sharma that treatment would not be as effective if I continued to smoke I would have stopped smoking or indeed not gone through with the treatment.” The Committee noted from his observations in C4 that Mr Sharma indicated that he would have discussed smoking issues with Patient L. However, it preferred the evidence of the patient on this matter who detailed her recollection in a statement which contained a declaration of truth prepared for this hearing, and who the Committee accepted had good reasons to remember events given her experience. Therefore, the Committee was satisfied on the balance of probabilities that Mr Sharma failed in his duty to have such a discussion with Patient L.


The Committee was not satisfied, however, that Mr Sharma had a duty to provide the patient with written information regarding the risks associated with smoking. It considered that the GDC did not provide sufficient evidence in this regard. Accordingly, it did not find this head of charge proved on that basis.

121.(c) Prior to placing the implants, you failed:

121.(c)(i) to discuss the clinical options for treatment,

Found proved. The Committee noted from the witness statement of Patient L that she had informed Mr Sharma that, “I had a bridge which clipped in and out of my mouth, but I wanted something more permanent” and, that she did not like the appearance of amalgam fillings. Having had regard to the relevant GDC Standards in relation to informed consent, the Committee was satisfied that Mr Sharma was under a duty to discuss with Patient L alternative treatments to implants, even if implant treatment was her preferred option. Patient L stated in her witness statement that there was no discussion between her and Mr Sharma about other treatment options and the Committee received no records to indicate that any such discussion took place. It found Patient L’s recollection credible and more likely than not to be accurate. It therefore found this head of charge proved on the balance of probabilities.

121.(c)(ii) to provide the patient with a written treatment plan which included information regarding the risks and benefits associated with the implant treatment,

Found proved. Patient L stated in her witness statement, which the Committee found to be credible and reliable, that “I do not remember being given a treatment plan by Dr Sharma, nor signing anything before starting on treatment, or at any point during the treatment.” In the absence of any other information to indicate that Mr Sharma provided a written treatment plan to the patient, which included information regarding the risks and benefits associated with the implant treatment, the Committee found this head of charge proved. It considered that if Patient L had been provided with such a document, she would have remembered receiving it.

121.(d) You failed to inform the Patient that you had not placed Ankylos implants as you had discussed with the Patient and had instead provided different brands.

Found proved. In her witness statement, Patient L stated that Mr Sharma told her that he was going to use 12 Ankylos implants, “which were apparently high quality implants. This tallied with my desire to have long lasting treatment”. She further stated that, following her treatment, Mr Sharma gave her empty Ankylos implant packets, which led her to believe that only Ankylos implants had been used. She exhibited the empty Ankylos packets in her statement. The Committee accepted Mr Nery’s expert opinion, which was based on the OPT taken by a subsequent treating dentist. Mr Nery told the Committee that there were eight implants in the patient’s upper arch that were Ankylos implants, but four implants in the patient’s lower arch that were not Ankylos implants. Mr Nery’s evidence, which the Committee accepted, was that Mr Sharma had a duty to


inform Patient L of this change from the original treatment plan. The Committee took into account that Mr Sharma knew that the patient was seeking a long-term solution by opting for the implant treatment. It was satisfied that by not informing Patient L that all of her implants were not Ankylos, he failed in his duty to keep her fully informed.

121.(e) You failed to inform Patient L of the risks associated with the bridge design at UL3-5.

Found proved. There are no records to indicate that Patient L was warned about the risks associated with the bridge design. The Committee took into account her evidence as contained in her witness statement. She indicated that she had not been made aware of any aspect of her treatment relating to the bridge design. The Committee accepted the patient’s account in this regard and was therefore satisfied that she could not have been informed of any of the risks. Accordingly, this head of charge is proved.

121.(f) You failed to inform Patient L of the reasons why you placed a bridge at UL3-5 rather than utilizing the implant at UL4.

Found proved. The Committee was satisfied that this head of charge is proved on the basis of Patient L’s evidence. She stated in her witness statement that she only became aware of the sleeper implant when Person 7, a subsequent treating dentist, highlighted the matter to her.

121.(g) You failed to inform the Patient that metal had been exposed following the adjustment to the restorations.

Found proved. The Committee accepted the account of Patient L as contained in her witness statement. It considered it clear from her evidence that she did not know that metal was exposed following the adjustment of her restorations. Further, the Committee was provided with photographs of the patient’s mouth showing the exposed metal. It was the evidence of Mr Nery that if metal had been exposed, Mr Sharma had a duty to inform the patient. The Committee accepted Mr Nery’s opinion and therefore determined that Mr Sharma had failed in his duty.

Aftercare

122. (Previously read: You failed to take periapical radiographs following prior to and following restoration of the implants.) Amended to read: You failed to take periapical radiographs prior to and following restoration of the implants.

Found not proved (as amended). The Committee had regard to the witness statement of Patient L. It noted that in her account, she only referred to “x-rays” having been taken pre-treatment. She is silent as to whether any more radiographs were ever taken. The Committee received no copies of any periapical radiographs, as there are no clinical records.


In all the circumstances, the Committee was not satisfied that the GDC has discharged the burden of proof to enable the Committee to find this head of charge proved on the balance of probabilities.

123. You failed to provide Patient L with adequate information regarding post-operative care and/or the maintenance required for her implants following her treatment with you.

Found proved. Patient L stated in her witness statement that after completion of the treatment “I had no further appointments with Dr Sharma and he had not arranged any follow-up care for me. No post-care instructions had been given…”. The Committee accepted her account. It also accepted the opinion of Mr Nery, as set out in his report that “Mr Sharma would be expected to ensure [Patient L] understood how to look after her restorations and dentition, and to have a review at 6 months. This is a vital part of care as implants reconstructions are susceptible to very similar periodontal complications as teeth…”. Taking into account the expert’s opinion, the Committee was satisfied that it was Mr Sharma’s duty to provide Patient L with adequate information regarding post-operative care and/or the maintenance required for her implants. It was satisfied that he did not do so and therefore failed in his duty.

124. You failed to arrange any or any adequate follow up appointments for Patient L once the implant treatment was completed.

Found proved on the basis that Mr Sharma failed to provide any adequate follow up appointments for Patient L. The Committee noted from the patient’s evidence that shortly after the completion of her implant treatment, the Tenby practice was closed down and no aftercare arrangements were put in place for her. The Committee also took into account Mr Sharma’s comments in his written observations in C4 which indicated that he had decided that he was not going to provide any future aftercare to the patient. Mr Sharma stated that he had referred the patient back to her original dentist. The Committee rejected this provided any basis for Mr Sharma not to arrange adequate follow-up appointments. This was because he had undertaken the implant treatment, and the Committee accepted Mr Nery’s opinion that in these circumstances it was his “absolute” duty. The Committee concluded that this meant providing the follow-up himself or arranging it with another suitable practitioner. There is no evidence that this duty was fulfilled by referring the patient back to her original dentist. In all the circumstances, the Committee was satisfied that Mr Sharma had failed in his duty to arrange adequate follow-up appointments for Patient L, particularly bearing in mind the complexity and extent of the treatment he had provided to her.

125. You failed to inform and/or ensure that Patient L was informed that the Tenby practice closed down.

Found proved on the basis that Mr Sharma failed to inform and ensure that Patient L was informed that the Tenby practice closed down.


It was the evidence of Mr Nery that as the Tenby practice was owned by Mr S, it was his duty to inform Patient L of its closure, particularly given that he had carried out so much dental work for her. The Committee accepted the evidence of Mr Nery regarding this duty. It considered it inappropriate that Mr Sharma could walk away from his patient. It was satisfied on the evidence of the patient that he failed in his duty to inform her that the practice had closed down.

Record keeping

126. You failed to provide Patient L with access to her dental records

The Committee was satisfied from Mr Nery’s evidence that Mr Sharma had a duty to provide Patient L with access to her record in line with the relevant GDC Standards and the Data Protection Act 1988. The Committee’s understanding, taking into account the evidence of Patient L, was that following the closure of the Tenby practice she did not know how to access her clinical records or even how to apply. The Committee considered that Mr Sharma should have let Patient L know that the practice had closed down and how she could access her records in the circumstances. By not doing so, he failed in his duty to provide her with access.

Advertising a specialism in implants 127. On or before 15 January 2014 your website stated:

127.(a) That you are "the dentist's dentist".

Found proved. 127.(b) That you are "constantly sought after and referred to as has encyclopaedic

knowledge of dental implants".

Found proved. 127.(c) "Now dental implants are my specialism and I'm actually the dentist other dentists

go to if they need this type of work done!"

Found proved. 127.(d) That patients can be "assured of getting the very best advice and care".

Found proved. 127.(e) That you "adhere to the General Dental Council (GDC) Fitness to Practice policy".

Found proved. The Committee considered heads of charge 127(a) to (e) separately, but made the same finding in respect of each head of charge. The Committee had sight of a statement from Mr Carson, a GDC employee, which refers to Mr Sharma’s advertising on his website in 2011 and 2013. The Committee also had sight of screenshots from Mr Sharma’s website which were exhibited by Mr Carson. It was clear from the website that the wording detailed in the allegations above referred to Mr Sharma. The Committee noted that the wording in allegation 127 (e) on the website screenshot says “adheres” and the


allegation says “adhere”, however it did not consider this to be a material difference. In his written comments in C4 Mr Sharma stated that ‘I employed a specialist web designer and host for my website around the start of January 2010, and wrongly assumed that they were familiar with the guidance and standards required of a registered dentist…The site has run for a number of years….’ Accordingly, head of charge 127 is found proved in its entirety.

128. By referring to dental implants being your specialism, you were implying specialist status in implants when:

128.(a) The use of the words 'specialism' or 'specialist' should be reserved for dentists who are on a GDC specialist list.

Found proved. 128.(b) There is no GDC approved speciality of 'dental implantology'.

Found proved. 128.(c) You are not on any GDC Specialist List which might apply to implants such as

Restorative Dentistry or Prosthodontics and Periodontics.

Found proved. 128.(d) The GDC's Principles of Ethical Advertising states that "Registrants who are not

on a specialist list should not describe themselves as 'specialising in…' a particular form of treatment."

Found proved. The Committee considered heads of charge 128(a) to (d) separately, but made the same finding in respect of each head of charge. Having determined that Mr Sharma used the words “dental implants are my specialism”, the Committee then considered whether the GDC has proved that he was implying specialist status in implants. The Committee considered the GDC Principles of Ethical Advertising. The Committee considered that the words specialism and specialist were ordinary English words for it to interpret as a matter of common sense. It was satisfied that a person who asserts that a subject is his specialism means he is a specialist in that subject. Accordingly, the Committee was satisfied that when Mr Sharma referred to dental implants as his specialism he was implying specialist status in implants. Further, from the principles referred to above the Committee was satisfied that the word “specialism” is reserved for dentists on a GDC specialist list; that there is no GDC approved speciality of dental implantology and that registrants not on a specialist list should not describe themselves as specialising in a particular form of treatment. It was satisfied that Mr Sharma was not on any specialist list. The Committee concluded, based on all the evidence before it, that by referring to dental implants being his specialism, Mr Sharma was implying specialist status in implants. Accordingly, head of charge 128 is found proved in its entirety.


129 The statements from your website as set out at Head of Charge 128 were:-

129.(a) Misleading.

Found proved The Committee considered the statements made by Mr Sharma on his website contravene the GDC Principles of Ethical Advertising. By stating implants were his specialism and that using terms such as ‘the dentist’s dentist’ and having an ‘encyclopaedic knowledge of dental implants’ and the other statements described, the Committee was satisfied that the public would be misled into believing that Mr Sharma had a specialist status in implant work, a status that does not exist. Having considered all the evidence, the Committee concluded that the statements from Mr Sharma’s website were misleading. Accordingly, this charge is found proved.

129.(b) Dishonest.

Found proved

The Committee was referred to the case of Ivey v Genting Casinos (UK) Ltd TA Crockfords [2017] UKSC 67. It first considered the actual state of Mr Sharma’s knowledge or belief of the facts. Having established that it then went onto determine whether his conduct was dishonest by the standards of ordinary, decent people. In the documents set out in C4 Mr Sharma indicated that he had engaged a specialist web designer and host for his website from the start of 2010 and that he had “wrongly assumed that they were familiar with the guidance and standards required of a registered dentist.” He asserted that the “word specialism was a regrettable mistake and should have read special interest” and that he had no intention to mislead or to be dishonest. He added that on receipt of the GDC’s letter he consulted the relevant standards of practice and immediately removed the site in its entirety. The Committee considered the totality of the statements on his website as set out in head of charge 127. The Committee rejected any assertion that the statements made on the website were as a result of a mistake or for example, were negligently or recklessly made. Any dental professional who engages a website designer retains the responsibility for the content of what the website says about him or her. The principles referred to previously are clear that “The onus is on [the dental professional] to be honest in your presentation of your skills and qualifications”. In any event, the Committee rejects Mr Sharma’s assertion that he genuinely assumed that the website designer was familiar with the guidance and standards required of a registered dentist, as implausible, particularly given the absence of any other evidence for example, from the designer himself. The Committee concluded that it was reasonable to infer that Mr Sharma, who in 2014 stated that he had been “involved with placing and restoring dental implants for almost 30 years” and that he had “a vast knowledge of the subject”, must have known that there was no specialism in implants, yet his website clearly implied that he was a specialist. Considering the content of the website cumulatively, the Committee was satisfied that Mr Sharma intended to deliberately mislead the


public into believing he was something that he was not. Having made this finding of fact the Committee was satisfied that his conduct was dishonest by the objective standards of ordinary decent people.

We move to Stage Two.” On 5 October 2018 the hearing adjourned part-heard. The hearing re-opened on 9 January 2019. On 10 January 2019 the Chair announced the determination as follows: “This is the resumed hearing of Mr Sharma’s case which was adjourned on 05 October 2018. Mr Sharma was not present or legally represented at the hearing and the Committee decided to proceed in his absence for the reasons set out in its determination dated 05 October 2018. Mr Grey appeared on behalf of the General Dental Council (GDC) at the hearing. Mr Grey submitted that the facts found proved amount to misconduct and that the misconduct was so serious as to amount to impairment of fitness to practise. He identified the standards, which in his submission, have been breached. Furthermore, Mr Grey submitted that the facts found proved also amount to Deficient Professional Performance (DPP). Mr Grey then addressed the Committee on the factors that it must consider in respect of current impairment, including Mr Sharma’s level of insight and any remediation. He also addressed the Committee on the need to have regard to the protection of the public and the wider public interest. This included the need to declare and maintain proper standards and maintain public confidence in the profession and in the GDC as a regulatory body. Mr Grey submitted that at the time Mr Sharma was clearly impaired and nothing has changed since and submitted that Mr Sharma’s fitness to practise is currently impaired by reason of misconduct and/or DPP. Mr Grey then addressed the Committee in regard to sanction and invited the Committee to consider whether this is a case where nothing short of erasure would be appropriate given the seriousness and the extent of the failings. He referred the Committee to the specific matters for consideration as set out in the ‘Guidance for the Practice Committees’ as published by the GDC in October 2016. The Committee considered all the information before it including the contents of C4, together with the submissions made by Mr Grey. It accepted the advice of the Legal Adviser. Decision on whether the facts found proved amount to misconduct: When determining whether the facts found proved amount to misconduct the Committee had regard to the terms of the relevant professional standards in force at the time of the incidents. The Committee, in reaching its decision, had regard to the public interest and reminded itself that misconduct was a matter for its judgment. The Committee has concluded that Mr Sharma’s conduct was in breach of the following Standards for Dental Professionals (2005) and the Standards for the Dental Team (2013). It was satisfied that Mr Sharma’s failings included a breach of the following standards: Standards for Dental Professionals (2005) Standard 1.1 Put patients’ interests before your own or those of any colleague, organisation or business.


Standard 1.3 Work within your knowledge, professional competence and physical abilities. Refer patients for a second opinion and for further advice when it is necessary, or if the patient asks. Refer patients for further treatment when it is necessary to do so.

Standard 1.4 Make and keep accurate and complete patient records, including a medical history, at the time you treat them. Make sure that patients have easy access to their records.

Standard 1.5 Give patients who make a complaint about the care or treatment they have received a helpful response at the appropriate time. Respect the patient’s right to complain. Make sure that there is an effective complaints procedure where you work and follow it at all times. Co-operate with

any formal inquiry into the treatment of a patient.

Standard 1.10 Do not make any claims which could mislead patients.

Standard 2.1 Treat patients politely and with respect, in recognition of their dignity and rights as individuals.

Standard 2.2 Recognise and promote patients’ responsibility for making decisions about their bodies, their priorities and their care, making sure you do not take any steps without patients’ consent (permission). Follow our guidance ‘Principles of patient consent’.

Standard 2.4 Listen to patients and give them the information they need, in a way they can use, so that they can make decisions.

This will include:

• communicating effectively with patients;

• explaining options (including risks and benefits); and

• giving full information on proposed treatment and possible costs.

Standard 5.2 Continuously review your knowledge, skills and professional performance. Reflect on them, and identify and understand your limits as well as your strengths.

Standard 5.3 Find out about current best practice in the fields in which you work. Provide a good standard of care based on available up-to-date evidence and reliable guidance.

Standard 6.1 Justify the trust that your patients, the public and your colleagues have in you by always acting honestly and fairly.


Standard 6.2 Apply these principles to clinical and professional relationships, and any business or educational activities you are involved in.

Standards for the Dental Team (2013) Standard 1.1 You must listen to your patients

Standard 1.1.1 You must discuss treatment options with patients and listen carefully to what they say. Give them the opportunity to have a discussion and to ask questions.

Standard 1.3.3 You must make sure that any advertising, promotional material or other information that you produce is accurate and not misleading, and complies with the GDC’s guidance on ethical advertising.

Standard 1.4 You must take a holistic and preventative approach to patient care which is appropriate to the individual patient

Standard 2.1 You must communicate effectively with patients – listen to them, give them time to consider information and take their individual views and communication needs into account

Standard 2.2 You must recognise and promote patients’ rights to and responsibilities for making decisions about their health priorities and care

Standard 2.3 You must give patients the information they need, in a way they can understand, so that they can make informed decisions

Standard 2.3.6 You must give patients a written treatment plan, or plans, before their treatment starts and you should retain a copy in their notes. You should also ask patients to sign the treatment plan.

Standard 3.1 Obtain valid consent before starting treatment, explaining all the relevant options and the possible costs. Standard 3.3 Make sure that the patient’s consent remains valid at each stage of investigation or treatment.

Standard 4.1 Make and keep contemporaneous, complete and accurate patient records.

Standard 7.1


Provide good quality care based on current evidence and authoritative guidance.

The Committee also had regard to the relevant guidance with regard to grading and recording dental x-rays: The Ionising Radiation (Medical Exposure) Regulations 2000 and determined that Mr Sharma’s conduct breached these regulations. He also breached the FGDP guidelines as they relate to prescribing. The Committee appreciated that the above breaches do not automatically result in a finding of misconduct. However, it was of the view that the breaches in this case are serious and fundamental and the Committee concluded that Mr Sharma’s conduct was a significant departure from the standards expected of a registered dental professional. In considering the gravity of Mr Sharma’s departures from the GDC’s Standards, the Committee took into account the opinion of the expert witness in this case, Mr Nery for the GDC. The Committee noted that the factual findings in this case included numerous clinical failings by Mr Sharma of which over 200 were found to be proved, in relation to twelve patients over a prolonged period of time, namely 2004 to 2015. It considered that these failings concern fundamental aspects of dentistry and directly impacted upon the overarching issue of patient safety. Given the significant number of charges, the number of patients and the wide-ranging nature of the matters where facts have been found proved, the Committee has identified the following themes (listed below) covering poor clinical and administrative practice and poor interaction with patients into which Mr Sharma’s failings fall:

• Record keeping

• Obtaining informed consent

• Effective pre-treatment assessment which includes using effective diagnostic tools

• Taking and recording of radiographs and in compliance with IRMER 2000

• Execution of restorative work including placing of implants & veneers and the prescribing of antibiotics

• Advertising

• Communication which includes complaints and treating patients with dignity

• Dishonesty in respect of advertising and misleading patients The Committee was satisfied that the clinical failings in these themes were wide-spread, prolonged, repeated and extremely serious. They went to the very heart of a dentist’s duty to ensure patient safety and to put patients’ interests first. The failures concern basic and fundamental obligations of an ordinary competent dentist and were what Mr Sharma manifestly failed to do. For example:

• The Committee found that Mr Sharma’s record keeping was incomplete, inadequate and lacked the basic and standard information required by any competent dental practitioner. The Committee noted that throughout Mr Nery’s evidence he highlighted the importance of record keeping for safe delivery and continuity of care and agreed with Mr Nery that Mr Sharma’s record keeping was overall far below the standards expected of a registered dental professional.


• A further example concerns the vital issue of consent. It was clear to the Committee that Mr Sharma’s repeated failures to obtain informed consent were tantamount to removing patients’ right to make their own informed decisions about their dental care. The Committee found there were numerous examples within the records to demonstrate that informed consent had not been obtained and this strikes at the core of patient care. The Committee concluded that this would be considered as unacceptable conduct by fellow professionals and it fell far below the standards expected.

• The Committee’s finding that Mr Sharma dishonestly tried to cover up the true cause of the failure of Patient B’s veneers and his dishonest intention to proceed with inappropriate work leading to further costs to the patient and likely financial gain for himself to be appalling conduct.

• With regard to advertising and the content of his website the Committee found that Mr Sharma acted in a manner that was misleading and dishonest and amounted to a wilful disregard for the expectations of his regulator. It noted that in 2007 Mr Sharma had received a warning letter from the GDC reminding him that particular care should be taken over reference to dental specialists and specialism. The previous warning aggravated this failure.

The public are entitled to expect their dentist to be honest. The Committee concluded that Mr Sharma’s dishonest and misleading conduct was a serious departure from the standards expected of a registered dental professional and would be considered deplorable by fellow professionals and members of the public. The Committee therefore concluded that Mr Sharma’s conduct, individually and cumulatively, fell seriously below the standards expected of a registered dental professional and amounted to misconduct. Deficient Professional Performance The Committee next considered DPP and noted that it had samples of treatment provided to twelve patients which it accepted was a fair sample of Mr Sharma’s work over a prolonged period of time. It was satisfied that this connoted a standard of professional performance which was unacceptably low. His failure to undertake treatment planning through, for example, lack of radiographs and use of all the surgical guides led to poor treatment outcomes, including poor aesthetics and failed implants. These failures led to additional cost to patients to rectify the poor standard of work, as well as risks to patient safety, for example, when placing implants inappropriately close to crucial nerve structures. Overall the Committee was satisfied that these repeated, wide-spread failings of basic competencies constituted DPP. Impairment The Committee then went on to consider whether Mr Sharma’s fitness to practise is currently impaired by reason of his misconduct and/or DPP. In doing so, the Committee has again exercised its independent judgement. Throughout its deliberations, it has borne in mind that its overarching objective is to protect the public, which includes the protection of patients and the wider public, the maintenance of public confidence in the profession and in the regulatory process, and the declaring and upholding of proper standards of conduct and behaviour. The Committee adopted the approach formulated by Dame Janet Smith in her Fifth Report from the Shipman case; that is, the PCC should ask itself:


‘Do our findings of fact in respect of the [dentist’s] misconduct, deficient professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he:

a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or

b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or

c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or

d. has in the past acted dishonestly and/or is liable to act dishonestly in the future.

The Committee considered the facts here engaged each of the above points. The Committee was of the view that Mr Sharma’s clinical failures are capable of being remedied but is mindful of the numerous attitudinal failings found proved that are harder to remedy. Mr Sharma chose not to engage with these proceedings. This Committee has received no submissions or evidence from Mr Sharma, even though he was offered the opportunity to do so on several occasions, most recently following the adjournment in October 2018, other than that submitted in C4. As a consequence, there was no current evidence before the Committee that he has taken any action to remedy his misconduct. Further, although there is some acknowledgement by Mr Sharma within documents in C4 that there may have been some limitations in respect of the content of treatment plans, a failure to report on radiographs and …‘room for improvement in respect of the record keeping’… there was no opportunity for the Committee to explore these views. In any event the Committee had nothing before it to demonstrate that Mr Sharma had any recognition or real insight regarding the seriousness of the conduct that gave rise to these proceedings. The Committee also had regard to CPD certificates that he submitted to the Investigating Committee (IC) in 2014 in C4. However, there was no recent evidence before it to demonstrate that this was embedded in his practice. The Committee found that the misconduct proved not only had the potential to place patients at unwarranted risk of harm, but, for example, in the case of Patient L actually did so. Moreover, Mr Sharma’s conduct brought the profession into disrepute. The Committee further found that Mr Sharma’s dishonest and misleading behaviour breached fundamental tenets of the profession. The Committee concluded that in the absence of any positive evidence of insight and remediation Mr Sharma presents an ongoing risk to patients. Furthermore, members of the public would be concerned by his acts and omissions and would expect his regulatory body to declare and uphold the standards expected of all registered practitioners. The Committee concluded that a finding of no impairment would undermine public trust and confidence in the profession and in the regulatory process. Furthermore, the Committee was aware that previous similar findings had been made against him and that some of the matters before this Committee occurred whilst he was subject to a conditions of practice order. The Committee considered that this demonstrated a worrying lack of insight into the seriousness of his misconduct. Taking these matters as a whole the Committee concluded that the risk of repetition was high. Dental professionals occupy a position of privilege and trust in society and must make sure that their conduct at all times justifies both their patients’ and the public’s trust in the profession. In this


regard the Committee considered the decision of Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). The Committee has borne in mind that its primary function is not only to protect patients but also to take account of the wider public interest, which includes maintaining confidence in the dental profession and the GDC as a regulator, and upholding proper standards and behaviour. The Committee was of the view that the misconduct identified is sufficiently serious to warrant a finding of impairment. Further, public confidence in the profession would be significantly undermined were the Committee not to make a finding of current impairment. Having regard to all of this the Committee has concluded that Mr Sharma’s fitness to practise is currently impaired by reason of misconduct and DPP. Sanction The Committee next considered what action, if any, to take in relation to Mr Sharma’s registration. The Committee reminded itself that the purpose of a sanction is not to be punitive although it may have that effect. The Committee took into account the GDC’s “Guidance for the Practice Committees, including Indicative Sanctions Guidance” (October 2016). The Committee bore in mind the principle of proportionality. The Committee considered the submissions made by Mr Grey under Rule 20 (1)(a) of the General Dental Council (GDC) (Fitness to Practise) Rules 2006 (the Rules). The Committee was provided with a bundle relating to the previous warning letters and adverse findings against Mr Sharma in relation to clinical failings similar to those found proved in this hearing. The Committee noted that on 25 October 2007 the IC issued Mr Sharma with a warning letter regarding inappropriate advertising practice in entries made on his website. In March 2010 a PCC found failings by Mr Sharma in relation to his clinical practice. Mr Sharma attended that hearing, was legally represented and that Committee found misconduct and impairment and imposed conditions on his registration. On 10 May 2011 a warning letter was issued by the IC about Mr Sharma providing a poor standard of care to a single patient only months after the order of conditions on his practice had been completed. On 10 October 2011 a further warning letter was issued by the IC about Mr Sharma failing to comply with a court order requiring him to provide disclosure of a patient’s dental records. Lastly, the Committee had regard to an advice letter dated 18 May 2012 to Mr Sharma in relation to the standard of care provided to a patient, failing to obtain appropriate consent and failing to communicate effectively. The Committee had regard to the previous warning letters and PCC findings against Mr Sharma. It took the view that Mr Sharma’s non-engagement, his previous fitness to practise history, together with its findings of fact strongly indicate that he has professional attitudinal problems that have not been remedied. For example, the Committee considered it extremely concerning that Mr Sharma indicated to Witness 3 that he could tell where to place implants without the use of radiographs. This indicated in the Committee’s judgement, unprofessional arrogance. The Committee identified no mitigating circumstances save for the submission of Mr Sharma’s CPD material in 2014 and his minimal recognition of the failures in his practice as found in C4. The aggravating factors included: the risk of harm, and the actual harm, to patients; Mr Sharma’s misleading and dishonest conduct; there was a wilful disregard for the GDC process, standards and guidance; Mr Sharma’s lack of insight; previous findings made against him of a similar nature; his misconduct was repeated and sustained over a period of time; breach of trust with patients; and there was financially motivated misconduct.


In light of the findings against Mr Sharma, the Committee has determined that it would be wholly inappropriate and irresponsible to conclude this case without taking any action or with a reprimand, as neither would restrict Mr Sharma’s registration, address the lack of insight and ongoing risk of harm to patients and the wider public. The Committee next considered whether a period of conditional registration would be appropriate in this case. The Committee was mindful that any conditions imposed must be proportionate, measurable and workable. The Committee considered that, in order for conditions to be workable, there would need to be insight, a measure of positive engagement and co-operation from Mr Sharma, all of which are absent. In any event, the Committee determined that it would not be possible to formulate appropriate and practical conditions which would address the dishonesty found proved. Further, Mr Sharma demonstrated a failure to address his clinical performance only months after completion of a conditions of practice order as indicated by subsequent warning letters. The Committee concluded that conditions would not be appropriate, workable, proportionate or sufficient in this case. The Committee then considered whether a suspension order would be proportionate and appropriate. It took the view that a period of suspension would not be sufficient in this case to adequately protect the public and the reputation of the profession. There is a real risk of repetition and a consequent risk of significant harm to patients. Mr Sharma lacks insight and his misconduct, including his dishonesty in this case, is part of his persistent failure to adhere to the standards of the profession. Mr Sharma has had, over a period of years, ample opportunity to reflect and to demonstrate an improvement in his attitude towards professional standards. The Committee considered that patients would still be at risk of harm from him once a period of suspension ended. The Committee then considered whether the issues identified are fundamentally incompatible with Mr Sharma remaining on the Register. It had regard to paragraph 7.34 of the ISG which states: Erasure will be appropriate when the behaviour is fundamentally incompatible with being a dental professional: any of the following factors, or a combination of them, may point to such a conclusion:

• serious departure(s) from the relevant professional standards;

• where serious harm to patients or other persons has occurred, either deliberately or through incompetence;

• where a continuing risk of serious harm to patients or other persons is identified;

• the abuse of a position of trust or violation of the rights of patients…;

• serious dishonesty, particularly where persistent or covered up;

• a persistent lack of insight into the seriousness of actions or their consequences.

The Committee considered each of those factors are present in this case and has decided that erasure from the register is the only appropriate and proportionate sanction to impose in the particularly serious circumstances of this case. The misconduct and DPP that the Committee has identified arises out of serious and sustained departures from Mr Sharma’s professional obligations. The Committee has considered the effect that erasure from the register is likely to have on Mr Sharma, but it finds that any lesser sanction than erasure would be wholly insufficient to protect the public, declare and uphold proper professional standards and maintain public trust and confidence in the profession and in the regulatory process.


The Committee has determined, and hereby directs, that Mr Sharma’s name be erased from the register.” _________________________________________________________________________ Decision on immediate order “The Committee has reached serious findings against Mr Sharma and is satisfied, for the reasons set out in its substantive determination, that he poses a risk to patients and that there is a high risk of repetition of the misconduct found. In these circumstances, the Committee has concluded that it would be inconsistent to allow him the opportunity to continue to practise during the intervening appeal period. Further, the Committee is satisfied that immediate action is necessary to protect the public and uphold public confidence in the profession. In accordance with the Dentists Act 1984 (as amended) the Committee has determined that it is necessary for the protection of the public and is otherwise in the public interest that Mr Sharma’s registration be suspended forthwith. The Committee therefore directs that Mr Sharma’s registration be suspended forthwith. Unless Mr Sharma exercises his right of appeal, Mr Sharma’s name will be erased from the Register 28 days from the date on which notice of this decision is deemed to have been served on him. Should Mr Sharma exercise his right of appeal, this immediate order for suspension will remain in place until the resolution of any appeal. That concludes this case.

HEARING HEARD IN PUBLIC Registration No: 61037 ...

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