Heavy is the Head: Complaints about dental crowns – sharing insights and learning

This blog, Heavy is the Head: Complaints about Dental Crowns, is part of a series to support your learning and encourage good practice and continuous improvement to achieve positive patient outcomes.

Dental crowns (‘caps’) are custom-made restorations designed to fit over teeth, providing either partial or full coverage. Full coverage crowns encase the entire visible part of the tooth above the gum line, including the occlusal (chewing/biting) surfaces. 

Crowns are indicated where there is insufficient remaining tooth structure to predictably hold a direct restoration (filling), to improve a tooth’s fracture resistance e.g. after root canal treatment, to modify tooth form, or as part of fixed prosthodontics (bridge retainer or implant restoration).

The clinical workflow for crowns typically involves tooth preparation (the removal, or ‘shaving away’ of tooth structure), followed by impression-taking or digital scanning. A provisional (temporary) crown is usually placed before the try-in and definitive cementation of the final restoration. 

Data from the 2023 UK Adult Oral Health Survey reported 27% of 1,619 adults examined had at least one crowned tooth; mean of 0.8 crowns per individual.¹ Among those aged over 65 years, 58% had at least one crown, rising to an average of 2.3 crowns for individuals aged 75 years and above.

With an ageing Western population keeping their dentition into later life, and a UK adult population exceeding 55 million, the absolute number of crowned teeth is likely to be considerable.² However, as with all dental restorations, crowns are susceptible to failure. 

Although the provision of crowns may be declining, they remain a notable source of complaints and litigation. In 2025, dental crowns accounted for 12% of allegations in Fitness to Practise (FtP) cases relating to single patient complaints, ranking fifth overall. A similar pattern was seen with the 2024 Dental Complaints Service data.

In recent months, I have seen an increasing number of cases involving these treatments, particularly where multiple crowns are provided for a single patient. While crown provision is a routine part of dental practice, it is not without risk. As the saying goes, “heavy is the head that wears the crown”. In a clinical context, sometimes, it is not only the patient who bears this weight but the clinician too. In this blog, I will highlight some recurring themes with these concerns.

Case examples 

Concerns relating to crown treatments can be diverse. Below are illustrative examples. 

Example 1 

Patient A presented with a minor chip affecting their lower left second molar tooth (LL7), which had an existing medium-sized filling. Symptoms were a sensation of roughness and mild food trapping. 

Documentation of the baseline assessments was highly limited. Although a pre-treatment radiograph was taken, it only captured half of the LL7 tooth. Despite this, the dentist documented no concerns, and a full coverage, all ceramic tooth-coloured crown was recommended, and a written treatment plan was supplied, with a cost estimate of £1,300.

Patient A already had a crown at an upper molar tooth and, prior experience was assumed to be sufficient for consent.

Following tooth preparation, a provisional crown was put in place. This dislodged the same day. Patient A developed severe sensitivity and returned for emergency care. Temporary filling material was placed over the prepared tooth by the dentist. The patient later described this as "a horrible lump of chewing gum wedged between my teeth".

At the fitting appointment, the definitive crown was cemented into place. However, there was no documented assessment of their symptoms, or evaluation of the standard of the crown fit and the occlusion (bite). Two days later, Patient A contacted the practice, complaining about a high, “heavy”, and uncomfortable bite and severe throbbing pain from their LL7 area.

Having lost confidence, Patient A requested their records and sought a second opinion. A different dentist diagnosed a dental infection and recommended removal of the crown, followed by root canal treatment and crown replacement. The existing LL7 crown was recorded as being “ill-fitting”. 

Patient A raised concerns with the GDC, saying that the second dentist had questioned the clinical necessity of a full-coverage restoration and the extent of the tooth preparation undertaken. Reflecting on their experience, Patient A stated, “She shouldn’t have talked me into having such expensive treatment which I probably didn’t need…”.

Learning points with Patient A 

In this case, the GDC clinical adviser was critical of: 

Not obtaining informed consent or not making adequate records of any consent- related discussions.

A minor chip at a moderately restored molar tooth does not, in itself, always justify a full-coverage restoration. Crown preparation is invasive and may involve the irreversible removal of up to 60-70% of coronal tooth structure by volume for tooth-coloured crowns.³

Furthermore, irreversible pulpal damage, estimated at 4-8% within 10 years of active treatment is also a recognised complication.⁴ 

The dental pulp includes the tooth’s neurovascular complex, and in Patient A’s case, pulpal complications subsequently occurred, requiring root canal treatment. Such risks are likely to be materially relevant. Pre-treatment photographs suggested that less invasive options such as composite repair or partial-coverage restorations (e.g. an onlay) may have been (more) appropriate.

Assuming that prior patient experience negates the need for a contemporaneous consent discussion is inconsistent with the Professional Standards. Patient A said they would not have gone ahead had they been properly informed. The clinical records contained no evidence of a meaningful consent discussion and the clinical adviser concluded that informed consent had not been obtained.

Inadequate assessment, evaluation and record-keeping 

This case highlights the importance of proper clinical and radiographic assessment prior to recommending a crown.

The adviser identified concerns about the standard of assessments undertaken or the lack of adequate documentation.

The radiograph obtained was of limited diagnostic value, not capturing the distal (rear) root at the LL7 tooth. Despite this, the patient was reassured that no anomalies were present. This undermines clinical decision-making and risks misleading the patient, who is entitled to accurate information.

Substandard crown treatment 

The clinical adviser queried the technical standard of care. The dislodgement of the provisional crown on the same day, followed by the use of an inadequate temporary filling material, contributed to Patient A’s discomfort and loss of confidence. 

While provisional restorations are inherently less durable and fixed using a weaker cementation material, early dislodgement can sometimes also reflect deficiencies in tooth preparation or provisional crown fabrication. A poorly fitting temporary crown may compromise patient comfort and leave the prepared tooth vulnerable to unwanted movement, thermal sensitivity, bacterial ingress, and mechanical irritation. In this case, the absence of an adequate provisional solution following initial failure further undermined trust, particularly in the context of the fees charged, which elevated expectations.  

Photographs of the crown, the underlying tooth preparation and radiographs provided by the second dentist suggested a poor standard of tooth preparation, with features consistent with over-preparation and possible iatrogenic damage.

The images also alluded to sub-optimal adaptation of the crown to the underlying tooth preparation, with evidence of a poor seal at the crown–tooth interface (margins).

Not adequately assessing or documenting occlusal verification

The second dentist also recorded the crown was “proud” of Patient A’s bite. Occlusal discrepancies (bite) are common sources of post-operative complaints with crowns.

In some cases, restorations may be intentionally placed high of the bite - ‘supra-occlusally’ - and allow for adaptation and accommodation. However, this approach requires careful case selection, clear clinical justification, and prior discussion with the patient. 

Concerns about acting in the patient’s best interests 

The clinical adviser also questioned whether the dentist had acted in their patient’s best interests, particularly given the limited loss of tooth tissue and the absence of significant symptoms at presentation. This raised doubt as to whether a full-coverage crown was clinically necessary. 

Example 2 

Patient B, a male in their early 30s, visited a dentist who referred to themselves on their website as, “specialising in crown treatments”, despite having experience limited to short continuing professional development (CPD) courses. The patient presented with six heavily filled upper front teeth, with a displeasing smile; the existing fillings were described as stained and poorly contoured. At the initial consultation, based on their own online searches, Patient B expressed a strong preference for full-coverage crown restorations.

Clinical photographs revealed un-aesthetic fillings, signs of inflamed gums, and poor oral hygiene. The records showed some radiographs had been taken; however, the intention was for Patient B to return for further assessment, including taking dental impressions, and a diagnostic wax-up to aid treatment planning and visualisation of the proposed outcome. However, these steps were not completed.

Patient B was keen to go ahead without delay. They returned the following week for the crown preparations to be undertaken. During this appointment, the dentist was reported to have struggled with the procedure. Patient B described notable gum bleeding and a feeling that the dentist became flustered and rushed. The impression-taking procedure was experienced as particularly traumatic.

At the fitting appointment two weeks later, Patient B identified several concerns with the definitive restorations. The crowns appeared mismatched in colour, were misaligned and excessively long, and when fitted they resulted in disruption to their occlusion, with their back teeth no longer meeting correctly. When these concerns were raised, the patient reported being told to, “allow time to adjust” and to avoid being “overly picky”. 

Distressed by the outcome, Patient B requested treatment by another dentist at the practice. However, due to the perceived complexity of the case, alongside deficiencies in the clinical investigations and treatment planning, no colleague was willing to assume responsibility. 

Patient B was referred for specialist care and a refund was agreed. 

Learning points from Patient B 

The clinical adviser was critical of: 

Advertising and treatment beyond scope of practice 

The dentist described themselves as “specialising in crown treatments”, despite not being on the specialist register and their training being limited to short CPD courses. This raised concerns regarding potentially misleading advertising.

Undertaking treatment beyond one’s competence and training may place patients at risk and exposes the clinician to regulatory scrutiny. Placing crowns - especially multiple crowns - can result in complex and unwanted changes to the bite and aesthetics.

This case also highlights the importance of assessing whether patient expectations are realistic and achievable. Where they are not, clinicians have a duty to manage expectations appropriately or consider referral to a practitioner with the requisite experience.

Deficiencies in assessment, diagnosis and treatment planning 

Patient B presented with multiple poorly contoured restorations and clear gum inflammation. Given the complexity of the proposed treatment, a comprehensive assessment was needed, including detailed periodontal (gum) evaluation, as well as proper occlusal and aesthetic zone assessments to inform diagnosis and logical treatment planning.

Following stabilisation of oral health, further planning should have involved a structured diagnostic work-up. Although such steps were reportedly discussed, they were not undertaken. 

Concerns regarding consent 

There was no documented discussion of the material risks associated with crown treatment, nor of the potential impact on their periodontal health. In correspondence with the GDC, Patient B said: “My teeth have been unnecessarily ruined; butchered – I am not even 40 yet!”.

Treatment execution and standard of care 

Although Patient B was keen to proceed quickly, dental professionals must maintain professional boundaries and ensure that patient preferences do not compromise safe and effective care. Accelerated treatment without adequate assessment carries an increased risk of complications, disease progression, dissatisfaction, and long-term harm. Complex restorative cases require careful planning of both function and aesthetics, rather than expedited delivery.

The patient reported significant gum bleeding and a traumatic, rushed experience. These factors may reflect inadequate soft tissue management, not addressing periodontal health prior to treatment, limited experience with complex and multiple preparations, and/ or insufficient time allocated for a demanding procedure.

Concerns were also raised about the clinical outcome. Pre- and post-operative photographs provided by the patient supported these concerns.

Finally, other clinicians within the practice declined to assume responsibility for the case due to incomplete planning and concerns about its complexity. Poor planning not only weakens defensibility but also compromises safe handover and continuity of care. 

Conclusions 

Crown treatments are still a valuable aspect of restorative dentistry and can offer excellent long-term outcomes. However, these outcomes depend on adherence to fundamental principles.

“Heavy is the head that wears the crown”. In dentistry, this reflects the responsibility clinicians bear when prescribing more invasive and irreversible treatments. When these principles are not upheld, the consequences extend beyond clinical outcomes – to patient trust and professional accountability and sometimes culminate in regulatory scrutiny. 

The following sources of information may be helpful:  

• Standards for the dental team 

• GDC Scope of Practice Guidance 2025 

• Guidance on advertising

References: 

1. Adult oral health survey 2023
2. Indirect restorations: an update: Mackenzie L et al. Dental Update 2023; 50:5, 331-342.
3. Edelhoff D, Sorensen JA. Tooth structure removal associated with various preparation designs for anterior teeth. J Prosthet Dent. 2002 May;87(5):503-9.
4. Whitworth JM, Walls AW, Wassell RW. Crowns and extra-coronal restorations: endodontic considerations: the pulp, the root-treated tooth and the crown. Br Dent J. 2002 Mar 23;192(6):315-20, 323-7.  

This blog is part of a series by Shamir Mehta, please read his other blogs:  

Dental record keeping: what is professional, reasonable and in the interest of patients? 

Clear aligner treatment: What can we learn from complaints and concerns? 

How patient consent can help build trust and confidence

Drills, spills, and protocol: when dentistry doesn’t quite go to plan

‘Bonding boom’ - composite bonding insights for dental professionals

Fear of the GDC: A personal perspective on perception, reality and responsibility

A stitch in time saves nine: insights and reflections into complaint handling