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An untrained dentist fitted braces on a 12-year-old girl, causing damage that required jaw surgery.
The dentist has been found in breach of the Code of Health and Disability Services Consumers' Rights after putting the braces on a girl in 2014. They were then removed and replaced with aligners, until the dentist said the treatment was complete in 2016.
Three years later, her mother took her to a specialist orthodontist as she was unhappy with her previous orthodontic treatment.
The orthodontist found the teen had severe root resorption to eight of her teeth and had two teeth that were severely compromised by short roots.
She recommended the teen have upper and lower braces and jaw advancement surgery.
However, her mother said the dentist had told her he was an orthodontist, or had led her to believe that.
She said she would not have taken her daughter to him for such a large amount of dental work had she known he was not an orthodontist.
She said the dentist should have identified her daughter's short roots and jaw problem in the X-rays he took in 2014.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the dentist breached the Code of Health and Disability Services Consumers' Rights for failing to refer the teen to a specialist at the outset, for undertaking treatment he was not trained, or sufficiently experienced, to provide, and for failing to keep full, accurate patient records that complied with the relevant professional and ethical standards.
"The absence of clear, well-documented clinical records hindered my investigation into the clinical aspects of this complaint," she said.
"In addition, more fulsome, detailed clinical records would have assisted the dental practitioners who subsequently provided treatment."
Caldwell also found that the dentist did not obtain adequate informed consent for the braces.
Not only was documentation of the informed consent process lacking, but the informed consent discussion took place on the day the braces were fitted, which did not allow adequate time for the teen and her mother to consider the treatment and its risks.
She recommended the dentist provide a written apology.