In the first visit an X-ray was taken, with the dentist, whose name is suppressed, commenting that the patient's teeth were "very well cared for".
But the patient claims the doctor failed to raise the issue of early mineral loss - clearly visible on the X-ray.
There was no reference to mineral loss on the patient's clinical notes from the visit.
The patient continued to be seen for annual checkups for the next two years. During a 2013 visit, the dentist noticed a lesion on a tooth, but there was no evidence in clinical notes that this was discussed with the patient.
A year later the patient returned to the practice, with the dentist performing "restorative treatment" on the tooth.
By January 2015, a year since the restoration work, the patient contacted her dentist concerned about a dark spot on the tooth.
A week later restoration work was again undertaken on two teeth - one of which was the same tooth that was operated on 12 months prior.
The dentist stated in his clinical notes that he "did not trust" his original work.
The patient visited again in August 2015 and then June 2016. No issues were reported, and there were no records of advice provided to the patient in clinical notes.
The patient then moved overseas for three years, returning to the practice for a check-up in February 2019.
Two further lesions were identified, but the dentist advised the patient to return in six to nine months to reassess any remedial action.
During the same appointment the patient raised concerns about her painful wisdom teeth, but was told by the dentist they were fine.
The patient returned to the practice that same month for remedial work on a tooth, as well as another restoration on the same tooth that had now received remedial work three times.
But the patient grew worried about the advice she had received. Four months later, she visited another dentist while overseas.
The new dentist found multiple lesions across seven teeth - one described as being so large that the patient was warned she could lose the entire tooth.
The same wisdom teeth the patient complained of earlier were also discovered to have lesions. They were removed shortly afterward.
In June 2020, when the patient visited yet another dentist, they recommended remedial work undertaken on a tooth by her previous dentist be redone - the fourth time the treatment needed fixing.
All up, the patient says she attended upwards of 20 dentist appointments in the period since her final appointment with her original dentist in 2019.
In her investigation, the Deputy Commissioner found the issues with the most severely damaged tooth should have been picked up by the New Zealand dentist in 2019.
The dentist also failed to provide the patient adequate information about the issues affecting her wisdom teeth.
The failure on both counts constituted a breach of the Code of Health and Disability Services Consumers' Rights.
The dentist at the centre of the complaint is no longer practicing and has already issued a formal apology for the harm caused to the patient.
Caldwell ordered the dentist to reflect on the impact statement of the patient and ordered him to undergo a competence review if he is ever to resume practicing.
