Case Study: Wrong Tooth Extraction

Avoiding wrong tooth extraction can be prevented with the use of proper protocols, including confirmed communication with referring dentists and documentation of verbal discussions with patients.

The patient, a 45-year-old female, presented to her dentist with an extensive history of tooth decay and multiple tooth extractions. Her primary complaint was pain in the upper left molar. The dentist examined and x-rayed the tooth and determined it was untreatable. He provided the patient with a written referral to an oral surgeon for extraction of tooth #12. The patient was also given a copy of the x-ray to take to the oral surgeon.

The patient presented to the oral surgeon for extraction of the tooth, but she did not provide the dentist’s written referral or x-ray. She stated to the oral surgeon that “the last tooth on the upper left side needed to be pulled.” The oral surgeon repeatedly asked the patient to confirm that the tooth to be extracted was the same tooth recommended by the dentist. The oral surgeon did not call the patient’s dentist to confirm the tooth to be extracted, and he proceeded to pull the last tooth on the upper left side as the patient had indicated. As a result, tooth #14 was incorrectly extracted. The patient realized after the procedure that the oral surgeon had extracted the wrong tooth and demanded that he pull tooth #12 at no cost to her. The oral surgeon refused. The patient alleged she suffered needless pain due to the extraction of a relatively healthy tooth. The patient pursued a claim against the oral surgeon.

Risk Management Discussion

An allegation of wrong tooth extraction is a common issue in dental claims. In this case, the oral surgeon did not require the patient to provide the written referral and x-ray from the referring dentist. Contacting the referring dentist prior to the procedure would have confirmed the recommended treatment for the correct tooth. The oral surgeon relied on the patient’s representation of the tooth, resulting in extraction of the wrong tooth.

The American Dental Association (ADA) has supported efforts to decrease the risk of wrong site surgeries to eliminate wrong site surgery, including wrong tooth extractions. However, the ADA acknowledges that there does not appear to be a reliable method to actually mark the teeth intended for extraction.

The following strategies can help dentists avoid wrong tooth extraction:

  • Obtain informed consent from the patient. Provide a description of the proposed treatment in terms that are easily understood by the patient.
  • Discuss any misunderstandings and unrealistic expectations with the patient.
  • Confirm patient understanding by asking the patient to verbally summarize the details of your discussion, and include verbal discussions in the dental record.
  • Review the dental record, including the medical history, appropriate charts, and dental radiographs. Indicate the tooth number(s) or mark the tooth site or surgical site on the diagram or radiograph, which should be included in the dental record.
  • Ensure that radiographs are properly oriented and visually confirm that the correct teeth or tissues have been charted.
  • Conduct a “time out” to verify the patient, tooth, and procedure with the dental assistant present at the time of the extraction (the two person rule).
  • Confirm your state’s time-out procedure requirements.

Contact the Department of Patient Safety and Risk Management for guidance and assistance in addressing any patient safety or risk management concerns.

By Kathleen Moon, ARNP, CPHRM, Patient Safety Risk Manager, Department of Patient Safety and Risk Management


The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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