Reduce the Risk of Wrong-Tooth Dental Procedures

Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II, The Doctors Company

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 and maxillofacial surgeons. Between 2010 and 2019, The Doctors Company received 47 reports of extractions or other procedures on the wrong tooth or teeth.

In these cases, leading contributing factors included poor communication among providers and poor documentation. Provider communication factors involved failing to review the referral record, losing the referral form during a patient transition, and failing to communicate the patient’s condition. Documentation factors involved inadequate informed consent, failure to document clinical findings, and failure to document decision making. The findings were equally distributed between dentists and oral and maxillofacial surgeons.

Wrong-Tooth Case Study

The patient, a 25-year-old female, 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 consented to removal of wisdom teeth #1 and #16.

The patient was placed in a treatment room and prepped by the dental assistant. When the assistant summoned the surgeon, she told 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 and did not 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 necessitated that the patient had to undergo subsequent bone grafting and implant procedures to ensure occlusion. As a result, she suffered ongoing jaw pain and depression.

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

Case Discussion

The main contributing factors in this case were the surgeon’s two failures to confirm the procedure by: (1) relying on the guidance of the assistant without reviewing the referral form and the informed consent documents and (2) not verifying the procedure with the patient before administering sedation.

To reduce the risk of wrong-tooth procedures, the American Association of Oral and Maxillofacial Surgeons recommends the use of three simple processes, collectively known as the universal protocol: preprocedure verification, site marking, and performing a time out. In dentistry, marking the tooth is not practical and is replaced by confirming the correct tooth/teeth during the preprocedure process and the time out.2

Preprocedure Process

A day or two before the patient is scheduled, have support staff ensure that important documents, such as the informed consent, referral form with dental diagram, and dental films are available. Reconfirm the information the morning of the procedure. Proactive planning permits time to locate missing documents.

Time-Out Process

The time-out process is important for reducing 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 x-rays (as applicable), available for the team to review.
  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 not correct or documents are missing, the procedure must be delayed until the problem is corrected.

  1. Document the time out using a checklist or note it directly in the record. Include who participated, what was acknowledged, and any corrective actions taken.

Reduce the risks associated with 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.

Many states have established mandatory reporting systems for surgical errors—systems that would include reporting requirements for any wrong-tooth procedure. Dental professionals are required to know and follow their state’s adverse event reporting laws.

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


  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:1016/j.adaj.2016.04.015
  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.

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