Lack of care and attention led an experienced dentist to remove the wrong tooth from a teenage patient.
The Health and Disability Commissioner says it was basic dentistry, and the unnamed dentist got it wrong.
Anthony Hill said the 15-year-old was referred by an orthodontist last year to have three baby teeth removed.
The dentist removed two correctly but wrongly identified the third.
He extracted a permanent tooth instead, realising the error immediately by the length of the root.
The dentist re-inserted the tooth, but the teen had pain and needed a root-canal later.
The dentist apologised, and tried to minimise the damage.