Preventing Wrong Tooth Dental Procedures

Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II

Wrong-site procedures are a common problem in dentistry. A 2016 study in The Journal of the American Dental Association reported that wrong-site, wrong-procedure, wrong-patient errors are the second most frequent dental adverse event.1 From a liability perspective, wrong-site procedures are a significant source of claims against dentists and oral surgeons. Between 2009 and 2018, The Doctors Company received 59 reports of extractions or other procedures on the wrong tooth or teeth. Thirty-nine percent of the reports came from general dentists, 54 percent came from oral maxillofacial surgery dentists, and the remaining 5 percent were from endodontists and periodontists. Thirty-six percent of the claims closed with an indemnity payment to the patient.

Wrong Tooth Case Study

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 an upper left molar. The general 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 patient pursued a claim against the oral surgeon.

There are several key contributing factors present in this case example, including communication between the provider and patient, communication between providers, and failure to follow recommended practices.

The general dentist provided a written referral, made a copy of the films, and gave both to the patient.  The general dentist did a good job of discussing her care and treatment plan with her and the patient complied with the referral. Unfortunately, she did not bring the referral form and x-rays with her, which is not uncommon. This is the first provider-patient communication misstep.

The second misstep occurred when the patient communicated the wrong tooth to the oral surgeon. This communication problem is more complex. The patient communicated incorrect information that the provider relied on, resulting in incorrect action. A solid informed consent discussion would have included the risk of extracting the wrong tooth and may have prompted reconsideration. Informed consent is also a good time to assess the patient’s expectations and discuss misunderstandings or anything unrealistic.

The root cause in this case is provider-to-provider communication. Patients commonly forget to bring referral materials to appointments, and this should be considered when making referrals. If the patient is being sent directly to another provider, it is probably appropriate to ask them to hand carry the referral materials. Otherwise, sending the information from provider to provider by mail, fax, secure email, a secure portal or some other secure electronic alternative is more likely to result in the referral provider receiving the necessary information. The oral surgeon clearly had concern that the patient was not indicating the correct tooth because the question was repeated. Following up on that intuition and asking someone to call the referring provider to confirm the tooth to be extracted could have prevented this claim.

Organizations such as the American Dental Association, The Joint Commission, and the Agency for Healthcare Research and Quality2 have recommended that dentists implement the universal protocol to reduce wrong-site procedures.2,3 The universal protocol is essentially a timeout taken immediately before a procedure is initiated or an incision is made to reduce the risk of wrong-patient, wrong-procedure, or wrong-side/wrong-site surgeries. Everyone who is participating directly in the procedure participates in the time out. The goal is to prevent error thereby reducing and improving patient safety. A time-out procedure is truly a patient-centered communication safety tool.

The universal protocol can easily be applied to dentistry as follows:

  1. Gather the dental team in the treatment room immediately before the invasive procedure.
  2. Have the referral documents or clearly marked dental diagram and x-rays, as applicable, available for the team to review.
  3. With the dentist leading, ask each team member including the patient or guardian, to verbally acknowledge:
    1. The patient is correct (confirm name and date of birth or other second identifier).
    2. The procedure is correct.
    3. The tooth or teeth are correct (check the referral documents).
    Note: If any of the above are not correct or missing, the procedure must be delayed until the problem is corrected.
  1. Document the timeout using a checklist or directly in the record. Include who participated, what was acknowledged, and any corrective actions taken.

A 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.


  1. Maramaldi P, Walji MF, White J, et al. How dental team members describe adverse events. J Am Dent Assoc. 2016;147(10):803–811. doi:10.1016/j.adaj.2016.04.015
  2. Smith RA. Mark my tooth. AHRQ PSNet WebM&M. July-August 2007. Accessed June 26, 2019.
  3. Joint Commission. Dental Service Standard Tips for Health Center Dental Services. Reminders Regarding Unique and Overlooked Risks for Dental Services in Health Centers: Universal Protocol. Revised June 2018. Joint Commission website. Accessed December 23, 2019

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 considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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