Raises awareness of the factors increasing the risk of wrong tooth extraction.
Provides a summary of processes that can be implemented to minimise risk of wrong tooth extraction.
Highlights the incidence of wrong tooth extraction.
Over recent years there has been an increased emphasis on improving patient safety in all branches of medicine, with reducing wrong tooth extraction being a priority in dentistry. The true incidence of wrong tooth extraction is unknown but it is considered an avoidable harm and is a significant source of dental litigation. Interventions to reduce wrong tooth extraction include educational programmes encompassing human factor training, patient assisted identification, the use of checklists, marking of surgical sites and implementation of patient safety guidelines. Identified risk factors which make wrong tooth extraction more likely include; suboptimal checks and/or cross checking of relevant clinical information, unclear diagnosis, unclear documentation, ambiguity regarding notation of molar teeth, orthodontic extractions, and extractions where there are multiple carious teeth and extractions in the mixed dentition. Accurate and timely reporting of wrong tooth extraction incidents followed by analysis and sharing of findings together with implementation of improved practice will help to minimise risks of wrong tooth extraction.
Subscribe to Journal
Get full journal access for 1 year
only $20.79 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Pemberton MN . Developing patient safety in dentistry. Br Dent J 2014; 217: 335–337.
Francis R . Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013.
Berwick D . A promise to learn – a commitment to act: improving the safety of patients in England. London: Department of Health, 2013.
NHS England. Patient Safety Domain Team, The Never Events list; 2013/14 update. London: NHS England, 2013.
NHS England. Patient Safety Domain, Revised Never Event Policy and Framework. London: NHS England, 2015.
Dental Defence Union. Rise in extraction error claims reports DDU. 2013. Available at https://www.theddu.com/press-centre/press-releases/rise-in-extraction-error-claims-reports-ddu (accessed May 2016).
McKernon S L, Taylor K H, Reid S, Balmer M C . Incorrect tooth extractionNever say never? Oral Surg 2016; 10: 30–35.
Pemberton M N, Ashley M P, Saksena A, Dickson S . Wrong tooth extraction: an examination of 'Never Event' data. Br J Oral Maxillofac Surg 2016; 55: 187–188.
Thusu S, Panesar S, Bedi R . Patient safety in dentistry – state of play as revealed by a national database of errors. Br Dent J 2012; 213: E3.
Mettes T, Bruers J, van der Sanden W, Wensing M . Patient safety in dental care: A challenging quality issue? An exploratory cohort study. Acta Odontol Scand, 2013; 71: 1588–1593.
Peleg O, Givot N, Halamish-Shani T, Taicher S . Wrong tooth extraction: Root cause analysis. Quintessence Int 2010; 41: 869–872.
Brunton P . Patient safety in dentistry – state of play as revealed by a national database of errors. Br Dent J 2012; 213: 127.
Seiden S, Barach P . Wrong Side/ Wrong Site, Wrong Procedure and Wrong Patient adverse events. Arch Surg 2006; 141: 931–939.
Bailey E . Contemporary views of dental practitioners' on patient safety. Br Dent J 2015; 219: 535–540.
Renton T, Sabbah W . Review of never and serious events related to dentistry 2005–2014. Br Dent J 2016; 221: 71–79.
Algie C M, Mahar R K, Wasiak J, Batty L, Gruen R L, Mahar P D . Interventions for reducing wrong-site surgery and invasive clinical procedures. Cochrane Database Syst Rev 2015; 12: CD009404.
Lee J, Curley A, Smith R . Prevention of Wrong-Site Tooth Extraction: Clinical Guidelines. J Oral Maxillofac Surg 2007; 65: 1793–1799.
Adeyemo W L, Oderinu O H, Olojede A C, Fashina A A, Ayodele A O . Experience of wrong-site tooth extraction among Nigerian dentists. Saudi Dent J 2011; 23: 153–156.
Bailey E, Tickle M, Campbell S . Patient safety in primary care dentistry: where are we now? Br Dent J 2014; 217: 339–344.
Renton T, Master S . The complexity of patient safety reporting systems in UK dentistry. Br Dent J 2016; 221: 517–524.
Pemberton MN . Surgical safety checklists and understanding of Never Events, in UK and Irish dental hospitals, Br Dent J 2016; 220: 585–589.
Kalenderian E, Walji M F, Tavares A, Ramoni R . An adverse event trigger tool in dentistry: A new methodology for measuring harm in the dental office. J Am Dent Assoc 2013; 144: 808–814.
Chang H H, Lee J J, Cheng S J et al. Effectiveness of an educational programme in reducing the incidence of wrong-site tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98: 288–294.
Hiivala N, Mussalo-Rauhamaa H, Murtomaa H . Patient safety incident prevention and management among Finnish dentists. Acta Odont Scand 2013; 71: 1663–1670.
Raja S, Rajagopalan C F, Patel J, Van Kanegan K . Teaching Dental Students About Patient Communication Following an Adverse Event: A Pilot Educational Module. J Dent Educ 2014; 78: 757–762.
Bergal L, Schwarzkopf R, Walsh M, Tejwani N . Patient participation in Surgical Site Marking: Can this be an additional tool to help avoid wrong-site surgery? J Patient Saf 2006; 6: 221–225.
World Health Organisation. WHO Surgical Checklist 2009, Safer Surgery Saves Lives. Switzerland: WHO Press, 2009.
Haynes AB, Weiser TG, Berry W R et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med 2009; 360: 491–499.
National Patient Safety Agency. Patient Safety Alert Update: WHO Surgical Safety Checklist. London: National Patient Safety Agency, 2009.
Saksena A, Pemberton M N, Shaw A, Dickson S, Ashley M P . Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist. Br Dent J 2014; 217: 357–362.
Perea-Pérez B, Santiago-Sáez A, García-Marín F, Labajo González E . Proposal for a 'surgical checklist' for ambulatory oral surgery. Int J Oral Max Surgery 2011; 40: 949–954.
Bailey E, Tickle M, Campbell S, O'Malley L . Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015; 15: 152.
Knepil G J, Harvey C T, Beech A N . Marking the skin for oral surgical procedures: improving the WHO checklist. Br J Oral Maxillofac Surg 2013; 51: 413–415.
OR Manager. JCAHO's answers on marking the site. 2003. Available at http://www.ormanager.com/wp-content/uploads/2007/05/ORM603SurgSitearticle.pdf (accessed January 2017).
Mao X, Jia P, Zhang L, Zhao P, Chen Y, Zhang M . An Evaluation of the Effects of Human Factors and Ergonomics on Health Care and Patient Safety Practices: A Systematic Review. PLoS One 2015; : e0129948.
Smith RA . Mark my tooth. US Department of Health and Human Services, Patient Safety Network. 2007. Available at https://psnet.ahrq.gov/webmm/case/156/mark-my-tooth (accessed January 2017).
Clinical Governance Directorate of the British Orthodontic Society. Orthodontic Extractions – Risk Management Guidelines. British Orthodontic Society Advice Sheets, 2014.
About this article
Cite this article
Cullingham, P., Saksena, A. & Pemberton, M. Patient safety: reducing the risk of wrong tooth extraction. Br Dent J 222, 759–763 (2017). https://doi.org/10.1038/sj.bdj.2017.448
British Journal of Oral and Maxillofacial Surgery (2021)
Implementation of “local safety standards for invasive procedures (LocSSIPs)” policy: not merely a tick-box exercise in patient safety
British Journal of Oral and Maxillofacial Surgery (2020)
European Journal of Dental Education (2020)
British Journal of Oral and Maxillofacial Surgery (2019)
Reducing Dental Plaque Scores in Long-term Care Facilities Using a Checklist and Random Inspections: A Pilot Study
The Bulletin of Tokyo Dental College (2019)