We have started an investigation looking at the risks to identifying the correct tooth for extraction in dental practice.

The extraction of a tooth is an invasive procedure undertaken in a variety of settings. Despite national and local efforts to introduce safety standards for invasive procedures, errors continue to occur.

When a permanent (adult) tooth is extracted in error it is deemed a wrong site surgery. When considered along with other forms of invasive procedures, such as injections in the eye, wrong side chest drains and skin lesion removal, wrong tooth extraction was the most frequently reported type of wrong site surgery over the last five years.

Reference event

The investigation follows the case of a 7 year old. They were referred by a general dental practitioner to the local district care trust for fillings to their permanent molar teeth and the extraction of a decaying deciduous (milk) tooth.

Following an initial appointment at the health centre, a senior dentist made a treatment plan which included a referral for advice to an orthodontic specialist, fillings and tooth extractions. During the fifth and final appointment, the plan was to remove a single milk tooth that was showing signs of gross decay. During that procedure the neighbouring adult tooth was removed in error. The tooth was re-implanted after a short period outside the mouth and, at the time of the investigation, was healthy.

Having interviewed staff and observed tooth extraction taking place in both hospital operating theatres and dental surgeries, it was apparent that the process in both environments differed.

Investigation summary

This investigation will:

  • Understand how the application of safety standards for invasive procedures is influenced by clinical environment and if this might have a bearing on wrong tooth extraction.
  • Consider how safety procedures are applied to prevent wrong site surgery in other specialisms where invasive procedures are undertaken in non-operating theatre environments.
  • Understand to what extent safety barriers and controls, put in place to prevent the extraction of the wrong tooth, are effective at mitigating the risk of error.

Safety recommendations

As part of our final investigation report we may make safety recommendations to the appropriate national bodies in order to support the management of risks which arise as a result of the differing environments in which invasive surgery is conducted.

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