A dentist put a crown on the wrong tooth of a patient seeking treatment after a root canal. Photo / 123rf
A dentist put a crown on the wrong tooth of a patient seeking treatment after a root canal. Photo / 123rf
A woman who needed a dental crown following a root canal on one of her teeth was left in severe pain after a dentist mistakenly crowned the wrong tooth.
The tooth had been “perfectly healthy” before the botch-up but went on to also require a root canal, while the woman was left with the financial burden of having to pay for two crowns.
According to James' report, in September 2019 the woman, who is not named, underwent root canal treatment at her usual dental practice on a tooth identified in clinical records as tooth 15.
Her dentist advised her the tooth should be crowned in six months and she was given a quote for $1850 for her dentist to do the work.
However, the woman told the HDC that this was a lot of money for her and she later found another dental practice advertising crowns at a reduced price.
She made an appointment with a dentist at the practice, referred to in the report as Dr B, in 2020.
Deputy Health and Disability Commissioner Deborah James investigated the complaint. Photo / Supplied
The woman said she had an initial consultation and the crown was completed in two parts. An additional appointment occurred between treatments due to the woman experiencing severe pain, which Dr B put down to infection, and prescribed antibiotics.
The report stated that although the record of the appointments was handwritten and difficult to read, the number 16, referring to tooth 16, was recorded clearly at two of the appointments. There was no reference to tooth 15.
At the first appointment, the woman was “alarmed” when Dr B was unsure which tooth was to be crowned and asked her to indicate the tooth, which she pointed to.
She said she was reassured when he went to the computer as she thought he was checking her previous clinical records to clarify.
But following the appointment, she was in a great deal of pain and thought “this [was not] right”.
“She went back to see Dr B due to the pain, which she described as so severe that she was crying and finding it hard to cope several days after the procedure,” the report detailed.
“[The woman] stated that Dr B ‘was not fazed’ and said that the pain would settle. He prescribed antibiotics as he thought her pain was due to an infection.”
Two weeks later, she returned for the crown cap to be completed.
She told the HDC she was still in “terrible pain and yet [Dr B] proceeded to complete the crown treatment without hesitation, noting that it would fix the pain”.
In April 2021, the woman went to her usual dentist who had performed the earlier root canal treatment to tooth 15.
Dental records from this appointment confirm that a crown had been placed on tooth 16, not tooth 15.
The woman then filed a claim with ACC which covered the costs of a root canal on tooth 16.
Dr B, who is now retired, accepted he had made a mistake and said he was “truly sorry that this situation [had] arisen” and for the position the woman had been put in.
He expressed his willingness to apologise but said he had been unable to do so, as he had no contact with the woman.
Dr B told the HDC he would usually review clinical notes and radiographs before a crown procedure.
However, he does not recall the woman, or the treatment provided, in detail.
He gave the HDC a copy of the notes and advised there were no X-ray images, as “they appear to be lost”.
The woman said she had given Dr B a copy of her records from her usual dental practice before the procedure and does not recall him taking an X-ray.
She said in her complaint that the mistake had resulted in extra financial costs as tooth 15 still needed a crown and that the unnecessary treatment of tooth 16 severely compromised the integrity of the healthy tooth, which later needed a root canal.
In her report, James concluded the care Dr B provided the woman fell well below the standard expected of a competent dentist.
“Dr B did not obtain [her] history adequately or conduct an appropriate clinical examination, including taking or reviewing X-ray imaging. Consequently, he failed to identify the correct tooth to be crowned.
“Dr B also failed to maintain adequate records, and so did not comply with the professional standards set by the Dental Council of New Zealand.”
Accordingly, James found he had breached the Code of Health and Disability Services Consumers’ Rights.
James recommended Dr B provide a formal written apology to the woman for the deficiencies identified.
She also recommended that should he return to practice, the Dental Council consider whether a review of his competence is necessary.
The report stated that Dr B has not held a practising certificate with the council since 2021 and sold his practice when he retired.
Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff covering crime and justice, arts and entertainment, and Māori issues.
