Reduce the Risk of Wrong-Site and Wrong-Tooth Dental Procedures

Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company, Part of TDC Group

In a review of dental malpractice claims closed by The Doctors Company between 2012 and the third quarter of 2023, our analysts found 44 reports of extraction or procedures on the wrong tooth or teeth. Implementing the simple and effective strategies in this article can help dental professionals reduce the risk of wrong-site or wrong-tooth procedures.

The two main contributing factors to wrong-site and wrong-tooth procedures are poor practitioner communication and documentation. Practitioner communication factors included failing to review the dental or referral record before the procedure, discrepancies between the referral record and the accompanying diagnostic images or the patient’s recollection, and miscommunications regarding the patient’s condition. Documentation factors involved inadequate or missing informed consent, failure to document clinical findings, and failure to document the decision-making process. All findings were equally distributed between dentists and oral and maxillofacial surgeons.

Recent advances in dental care, such as bone grafting and dental implants, have increased the complexity and cost of addressing wrong-site and wrong-tooth procedures and the associated indemnity payments when a claim is litigated. Consider the following case scenario.

Wrong-Tooth Case Study

A young adult presented to the oral and maxillofacial surgeon for extraction of two wisdom teeth following orthodontic care. The surgeon discussed the procedure with the patient, and the patient was scheduled for removal of wisdom teeth #1 and #16.

On the day of surgery, the patient was placed in a treatment room and prepped by the dental assistant. The assistant indicated to the surgeon that the patient was prepared for extraction of all four wisdom teeth (#1, #16, #17, and #32). The surgeon did not confirm the intended procedure with the patient or review the referral form or the informed consent documents. The patient was given moderate sedation, and all four teeth were extracted.

Teeth #17 and #32 had been moved forward during orthodontia for occlusion purposes. Removing them resulted in the need for bone grafting and implant procedures to achieve proper occlusion. As a result, the patient suffered ongoing jaw pain and depression.

Experts were not supportive of the care provided, and the case was settled.

Case Discussion

In this case, the main contributing factors were the surgeon’s failures to confirm the procedure by: (1) relying only on the assistant’s identification of the involved teeth, (2) not verifying the procedure with the patient before administering sedation, and (3) not checking the referral documents, consent, and radiological images.

To reduce the risk of wrong-tooth procedures, the American Association of Oral and Maxillofacial Surgeons recommends using three simple processes, collectively known as the universal protocol: preprocedure verification, site marking, and performing a time out. In dentistry, marking the tooth is impractical and is replaced by confirming the correct tooth/teeth during the pre-procedure process and the time out.1 Performing multiple checks during the preprocedure process increases the likelihood that problems will be identified early enough to be addressed properly.

Preprocedure Process

Proactive planning permits time to locate missing documents. A day or two before the planned procedure, have support staff ensure that essential documents, such as the informed consent, referral form with dental diagram, and dental radiography, are available and complete. Ensure the consent document specifies the tooth or teeth for removal by number. Confirm that the information on the referral form is consistent with the consent form. Review the dental images to ensure they are current, consistent with the referral form and consent, and represent the correct patient. Reconfirm that the procedural documents are available for the correct patient on the morning of the procedure, and validate the procedure, site, and consent with the patient upon arrival.

Time-Out Process

The time-out process is critical for reducing wrong-site and wrong-tooth procedures:

  1. Gather the dental team in the treatment room immediately before the procedure.
  1. Have the dental record and referral documents, including clearly marked dental diagrams and radiographs (as applicable), available for the team to review. To facilitate patient participation, delay administration of sedatives or anesthesia until after site and procedure confirmation.
  1. With the dentist or surgeon leading, ask each team member, including the patient or guardian, to verbally acknowledge:
  1. The patient is correct (confirm the patient’s name and date of birth or other second identifier).
  2. The procedure is correct.
  3. The tooth or teeth are correct (check the dental record, informed consent form, and referral documents).

Note: If any of the above points are incorrect or documents are missing, delay the procedure until the problem is corrected.

  1. Document the time out using a checklist or note it directly in the record by free texting or adding a surgical safety checklist template. Include who participated, what was acknowledged, and any corrective actions taken.

Artificial Intelligence

Chairside clinical decision support tools are becoming more widely available. While there are different types of products, the general purpose of the tool is to integrate artificial intelligence and machine learning (AI/ML) with dental radiography to improve detection and management of dental issues. Most systems in use at the end of 2023 evaluate the extent and severity of dental caries below the gum line. Systems are, however, available that can evaluate current dentition and create dental charts. These systems have shown promise in correctly identifying/numbering teeth, even in situations involving significant dental work.

Implementing an AI/ML solution is a significant financial and business commitment. Multiple factors related to cost, return on investment, patient safety, and provider and staff capability must be considered. For more information on AI/ML safety in healthcare, please visit TDC Group’s Artificial Intelligence in Healthcare resource page.

Adverse Event Reporting

Many states have established mandatory reporting requirements for adverse dental events—which may include reporting wrong-site and wrong-tooth procedures. Dental professionals must know and follow their state’s adverse event reporting laws.

Strategies and Assistance

As outlined in this article, you can reduce the risks associated with wrong-site and wrong-tooth dental procedures by using proper protocols, confirming communication with referring dental professionals, and including comprehensive informed consent, universal protocols, and good documentation in your practice.

For additional strategies and assistance, please contact The Doctors Company Department of Patient Safety and Risk Management at (800) 421-2368 or by email.


  1. Lee JS, Curley AW, Smith RA. Prevention of wrong-site tooth extraction: clinical guidelines. J Oral Maxillofac Surg. 2007;65(9):1793-1799. doi:1016/j.joms.2007.04.012

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.

J00804 01/24