Sir, the recent article by Cullingham et al.1 is another reminder to dentists about what should be a 'never' event in the surgical context.

Having worked in both practice and hospitals for over 40 years I can confirm that there is a potential problem that the wrong tooth may be extracted, and I feel that this potential is on the increase.

There is an increase in the number of cases being referred (from a 'treatment decision maker' to an operator), there are several differing tooth notation schemes, and often a wish by the referrer to explain their decision and in which they mention other teeth, all of which factors can cause miscommunication and confusion particularly in orthodontic cases and where gross pathology is not obviously visible.

I have become convinced that any communication must be simple and obvious ideally: please extract eg, Upper Right 5 and c; Upper Left 3 and 6 etc. The ADI two figure system has more potential to cause confusion and error and in my opinion should be banned. Also the word 'uncover' should be used rather than 'expose' as the latter has been confused with 'extract'. Where there are only two molar teeth present the anterior one should always be 6, and the distal one 8, hence reducing the risk of wrong extraction error.