A dentist who gave a woman a root canal on the wrong tooth breached the health code, the Health and Disability Commissioner has found.
In April 2018, a 48-year-old woman showed up for an appointment at an unnamed dental clinic after complaining of gum inflammation, pus and pain between her two lower front teeth.
The dentist who saw her diagnosed her with inflammation at the tip of the root of tooth 41 (the lefthand lower front tooth) and acute infection. The affected tooth was deemed "non-vital" or "dead" as there was no longer any blood flow to it.
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He told the woman she could either have the tooth extracted or undergo a root canal treatment, a common procedure that removes dead tissue and protects the tooth from future infection. The woman opted for the root canal, which was performed at a separate appointment two days later.
However, the dentist made a crucial mistake - he operated on the wrong tooth. In error, he applied a dental dam to tooth 31 (the righthand lower front tooth) and carried out the treatment on it, rather than its infected neighbour.
It was only once the root canal was complete and the woman had left the room that the dentist, reviewing his X-rays, realised he'd got the wrong tooth. After finding the woman still at reception, he took her to a surgery room, broke the news and apologised.
The unfortunate patient had to have a second root canal days later. This one was carried out by a different dentist who operated on the correct tooth.
In a report released on Monday, Deputy Health and Disability Commissioner Kevin Allan found the dentist in breach of the Code of Health and Disability Services Consumers' Rights.
"By failing to isolate the correct tooth for the root canal treatment, the dentist did not provide services with reasonable care and skill," he wrote.
Allan noted that the dentist did take appropriate action after identifying the error by immediately notifying the woman and apologising. He recommended the dentist apologise for his breach of the code and undertake relevant training to make sure it never happens again.
The dentist said he sincerely regrets causing his patient unnecessary stress and injury, and that the mistake will be a "sombre reminder" for the rest of his career.
The woman said she had trusted the dentist to carry out the procedure with competence and feels the double root canal shouldn't have happened. However, she acknowledged that mistakes can happen and appreciates that the dentist apologised to her.
A root canal involves a dentist drilling into the "pulp" of a tooth to draw out infection and refilling the cavity with a protective substance, and is generally regarded as one of the most painful medical procedures someone can undergo.