The man's ulcer came after a dental roll was left in his mouth for twelve days. Photo / iStock

A dental roll caused a deep ulcer in an elderly man's mouth and earned a dentist a reprimand.

The patient, aged 87 at the time, had a filling placed in a lower left molar in August last year, according to a report published today by deputy Health and Disability Commissioner Rose Wall.

The procedure was challenging because of difficulty both in accessing the area and in moisture control, says Ms Wall, who names none of the parties. The dentist used around seven cotton rolls but did not keep a record of this.

The day after the procedure the man began to experience pain and had a swollen and sore tongue, which worsened in the following days. He couldn't sleep and eating and drinking were difficult.

"Mr A" saw a doctor, the dentist, a second doctor and finally a second dentist -- and he took antibiotics.

When the man visited the first dentist, Dr C, for investigation of the pain, he was unable to lift his tongue. The dentist took x-rays, suspected infection and prescribed antibiotics.

Twelve days after the filling was put in, the second dentist removed a dental cotton roll tucked underneath the man's left bottom molar beside his tongue.

"Mr A had a large, deep ulcer where the cotton roll had been sitting," Ms Wall says. "Having had the cotton roll removed, Mr A immediately felt better and, two days later, was feeling well."

Ms Wall says that in failing to account for the number of cotton rolls used, the dentist's care fell below the accepted standard.

"Dr C's management of Mr A's condition and concerns following treatment, including later failure to detect the retained cotton roll, was sub-optimal."

She ruled the dentist had failed to provide services with reasonable care and skill and so breached the code of patients' rights.

The dentist apologised to the man and Ms Wall asked the Dental Council to consider whether the dentist should undergo a competency review.