A three-year-old girl whose back teeth were crumbling and painful couldn't be treated immediately because her case didn't qualify as urgent.
She was one of thousands of children around the country waiting long periods for specialist care or operations because the public system was so overwhelmed.
Some parents were resorting to borrowing money so they could be treated privately.
Waikato woman Amanda Hines is one of them.
Her three-year-old, Addie, talked about her teeth all the time.
"She was crying in the middle of the night, we were bowling through the Pamol," Hines said.
"When she would eat something she would have pain just pulsating at the back of her mouth. She'd say 'Mummy, my teeth, my teeth'."
She was diagnosed with a condition where enamel doesn't form properly so, despite her good diet and regular brushing, her back teeth were crumbling away.
That was in August.
Hines said after trying for a long time to get through to the community dental clinic she got an appointment and a diagnosis.
Because Addie was so young, she needed to be treated under general anaesthetic.
The dental service initially told Hines Addie could not be referred for treatment to the DHB because of big backlogs and she would be assessed again in three months, she said.
Hines said she "made a lot of noise" and managed to get on the list but then, with no appointment forthcoming by November, she opted to have the work done privately.
Family members lent them money for the work, about $3000.
Addie was treated two weeks ago and was a different girl when she woke up the next day, Hines said.
"She just said 'Mummy, no sore teeth'."
The day after Addie's surgery, Hines said she was phoned by the DHB to say Addie had a date for her treatment.
That was frustrating but she was pleased a child whose family may not have been able to go privately would now have a place, she said.
In a statement, The Waikato DHB said the sequence of events for Addison's care did not match its records but it would not say more because it could not disclose patient information.
Children were not refused a place on the waitlist for oral health services, a spokesperson said.
But Dental Association president and the dentist who did Addie's work, Katie Ayers, said that was not always the case.
Oral health therapists around the country were under pressure to try to reduce the number of referrals onto the waiting list.
There was a sense if children could be monitored and given preventative or alternative treatment in the meantime that was preferable, she said.
Not all DHBs had the long waiting lists, but it was a problem in many in the upper North Island, she said
Parents who opted to go privately had often felt their child had waited too long or struggled with the uncertainty of having no surgery date and not knowing how long they would be in pain, she said.
The Waikato DHB said there were about 300 children on the waitlist for work under anaesthesia, with an average wait time of 100 days.
Some children were waiting longer than four months although the DHB did not specify how much longer.
It was increasing theatre time to bring down the waitlist and looking at different types of sedation that would allow them to treat children quicker, a spokesperson said
It would contact Amanda to talk about her concerns and to ensure Addie gets the right care in future, she said.