A woman who underwent a root canal treatment and was subsequently crowned on the wrong tooth has been left in severe pain and financially burdened by unnecessary dental work. The incident, which occurred in 2019, resulted in a dental crown being placed on a healthy tooth, which later required a root canal, and the woman was forced to pay for two crowns instead of one.
The case came to light after the woman lodged a complaint with the Dental Council of New Zealand, which was referred to the Office of the Health and Disability Commissioner (HDC) in 2022. An investigation by Deborah James, Deputy Health and Disability Commissioner, has now revealed a series of mistakes that fell well below the expected standard of care.
According to James’ report, the woman underwent root canal treatment at her regular dental practice on tooth 15 in September 2019. Her dentist advised that she would need a crown in six months and provided a quote of $1850 for the procedure. However, seeking a more affordable option, the woman consulted a new dentist, referred to as Dr. B, at another practice in 2020.
During her initial consultation with Dr. B, the woman reported that he was unsure which tooth needed crowning and asked her to point it out. She did so, believing Dr. B was checking her clinical records for confirmation. Despite this, she experienced significant pain after the treatment, which Dr. B attributed to infection and treated with antibiotics.
Further complications arose during subsequent appointments, where Dr. B continued with the crown procedure despite the woman’s persistent pain. Two weeks later, the woman returned to her regular dentist, only to discover that a crown had been placed on tooth 16—rather than the intended tooth 15. As a result, the woman filed a claim with ACC, which covered the cost of a root canal for tooth 16.
Dr. B, who has since retired, admitted his mistake and expressed regret over the situation. He stated that while he typically reviews clinical records and X-rays before performing a crown procedure, he had no recollection of the specific details of the woman’s case and claimed that the X-rays were lost. However, the woman noted that she had provided Dr. B with her dental records and did not recall him taking any X-rays during the procedure.
James concluded that Dr. B’s care fell below the expected standard, highlighting several key failings: inadequate patient history, lack of a thorough clinical examination, and the failure to take or review X-rays. She found that Dr. B had breached the Code of Health and Disability Services Consumers’ Rights, and recommended that he provide a formal written apology to the woman.
Although Dr. B has retired and no longer holds a practicing certificate, the report suggested that the Dental Council may need to review his competence should he decide to return to practice in the future. The woman, meanwhile, has been left to bear the financial and emotional consequences of a preventable error.
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