A dentist has been found to have breached the health code after performing a root canal on the wrong tooth.

A report released by Deputy Health and Disability Commissioner Kevin Allan today detailed how a dentist diagnosed a patient's tooth as needing a root canal - but then did the work on the wrong tooth.

The report stated how the patient presented at a dental service for inflamed gums, pus, and pain between her lower two front teeth.

The dentist diagnosed tooth 41 and gave the woman the options of root canal treatment or extraction. The woman decided to proceed with root canal treatment.

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In April last year, the patient went in for the treatment, but when performing the procedure, the dentist performed the root canal treatment on tooth 31 rather than tooth 41.

However, when reviewing the radiographs after the procedure, the dentist realised that he had performed the root canal treatment on the wrong tooth.

He immediately informed the woman of the error, apologised, and advised her that regrettably tooth 41 still required treatment based on the original diagnosis.

Subsequently, the patient was referred to a specialist endodontist and the root canal treatment on the correct tooth was completed.

A internal review was launched by one of the directors of the dental service, which concluded that this was "unacceptable, but could not have been mitigated by the practice and can be attributed solely to human error."

In the report, Deputy Commissioner Allan considered that by failing to isolate the correct tooth for the root canal treatment, the dentist did not provide services with reasonable care and skill.

However, he noted the dentist took appropriate action after the error was identified.

The report stated the dentist "sincerely regrets the stress and injury he caused".

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"He said that he is now acutely cognisant of the extent of injury and trauma that his errors as a healthcare professional can have, and that this will be a sombre reminder that he will take into the rest of his career.

"He said that he will do his utmost to ensure that he does not make the same error again."

Allan recommended the dentist provide a written letter of apology to the patient for his breach of the Code, and participate in relevant training.

A patient statement provided in the report said she "acknowledged that mistakes can happen, but felt that this should not have occurred".

"She appreciates that [the dentist] apologised, and hopes that he can learn from his mistakes," the report said.