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Never events in dentistry

23 August 2021

The extraction of a wrong tooth has been classified as one of the Never Events in dentistry1. Other examples of Never Events include mismatched blood transfusions, foreign bodies and retained instruments, equipment (such as microvascular clamps) or swabs left in a patient post-surgery, wrong-site surgery or local anaesthetic administration, and scalding a patient2.

However, wrong site tooth extraction has been removed from England’s NHS list of Never Events2,3, with the change coming into effect on 1 April 2021. The implication of this development indicates that there are no longer any dentistry-specific adverse incidents classified as Never Events related to the extraction of the wrong tooth. Incidents of wrong site extraction are however still classified as Patient Safety Incidents and should continue to be appropriately reported and managed2.

Patients experience very few dental procedures as feared and as daunting as a tooth extraction. Consent to an extraction is grounded in a trust relationship with the healthcare provider to perform the procedure correctly and with the utmost of care. If the oral healthcare provider extracts the wrong tooth, or perhaps more teeth than just the problematic tooth, it can lead to betrayal of that trust.

The harm caused when extracting the wrong tooth has far reaching consequences. Apart from the initial pain and anguish caused during the procedure itself, a different frame of mind kicks in when discovering the adverse incident. The need for corrective procedures, the permanent loss of a potentially healthy tooth, and also the possibility of long-term damages and risks are real challenges to deal with and to overcome.

In circumstances like these, a simple refund, or an offer to have another extraction done for the correct tooth, will not necessarily resolve the issue. Many complications may result from the extraction of a wrong tooth. If the original tooth which required extraction is still present in the patient’s mouth, depending on the reason for extraction, the case will need to be re-evaluated. The procedure often will need to be repeated to complete what should have been accomplished in the first place. This may entail ‘doubling-up’ the pain, recovery times and all risks involved.

Long-term problems can also arise in some cases, including:

• Persistent pain and/or swelling

• Developing abscesses and infections

• Nerve damage and paralysis

• Prolonged discomfort when talking or eating

• Damage to sinuses (after the removal of an upper molar)

• Undesired spaces and/or orthodontic challenges

• Change in position and occlusion of remaining teeth. 

Wrong tooth extraction is a serious yet preventable complication that ultimately influences the function and support of other teeth and the dentition as a whole. This can cause teeth to gradually change position, possibly altering the alignment of teeth, the position of the bite, and even the shape of the patient’s face and appearance in some cases.

Many of these complications may result from unplanned extraction of a particular tooth. Anticipated problems and contingency plans for one tooth may be entirely different for another, and often treatment planning need to be reviewed and altered, such as during orthodontic treatment. By extracting teeth other than those which were intended, the oral healthcare provider may expose not only the patient but also themselves to greater and unforeseen risks.

Fear of admitting wrongdoing, the subsequent consequences of such admission may be reasons why only limited publications exist in the literature on wrong extractions. The prevalence of wrong tooth extraction is thus largely underestimated. It was indicated that most cases of wrong tooth extraction involved extraction of the adjacent tooth (67%), quadrant confusion (15%), confusion between primary and permanent teeth (13%), and 14% due to incorrect marking of the tooth intended for extraction. The Root-cause analysis indicate poor documentation, unclear diagnosis, suboptimal checks and/or cross checking of relevant clinical information, orthodontic extractions, extractions in the mixed dentition, and ambiguity regarding the notation of molar teeth, especially in heavily restored dentition with missing and migrating teeth, as just some of the common indicators of wrong tooth removal2.

Application of human factors to lower risk

The implications for litigation should not be underestimated. However, as with most medical errors, there are always a number of layers that lead up to an adverse incident, as popularised by Reason’s Swiss cheese model4. Building in some method of verification or checking prior to executing a procedure such as tooth extraction can prevent possible complications or adverse incidents and also improve patient and provider safety. 

While aviation and healthcare are diverse professions, there are many similarities between flying a commercial aircraft and healthcare surgery, particularly in relation to minimising risk and managing potentially fatal or catastrophic complications. Checklists are continuously used in aviation as reminders and to ensure that all the necessary checks have been completed. Financial and operational pressures on aviation techniques and the continued prevalence of fatal accidents eventually lead to the general acceptance that checklists were a safety net rather than a magnifying glass for incompetence and poor performance5. In healthcare, examples can be the active participant use and engagement with the WHO surgical safety checklist which are effectively implemented globally to make it safer to perform surgery6. In reference to a checklist in dentistry, the tooth can for instance be checked and confirmed with the dental assistant2. By lowering authority gradients, colleagues feel both empowered to speak up and valued as essential members of the team and can contribute to a reduction in errors.  Cancelling a tooth extraction if there is doubt or ambiguity will be much safer for the patient than proceeding since similarly, in commercial aviation, pilots will also not hesitate to cancel a flight if there are any concerns that could compromise passenger safety5.

Case study

Background and chronology of events: A patient of an orthodontist, aged 11 years, needed an extraction of a primary tooth/canine (63) and her mother called the orthodontist’s office to confirm that the correspondence was sent to the dentist office to confirm her appointment.

Because the orthodontist was not in office (on leave), the secretary was requested to mail the dentist stating the 63 needs to be extracted of the above-mentioned patient. 

It came to the orthodontist’s knowledge after 2pm that day, the secretary called the orthodontist with the news that she made the mistake of stating tooth 36 (permanent molar) instead of 63, and the dentist extracted the permanent molar (36).

The parents and patient were upset and devastated about the news. The orthodontist called the mother to explain that he has never been in such a situation before and need to enquire how to manage it. From an orthodontic perspective, the missing 36 can managed by moving her second molar (tooth 37) into that space, but will need to look at her X-rays. The orthodontist explained this to the mother during the telephone call. The orthodontist undertook to be in contact once enquired how to manage the situation further.

The orthodontist called the South African Dental Association’s legal advisor and they suggested a face-to-face meeting with the parents. The orthodontist wanted to express regret for the predicament caused and try to work out how the parents would want to proceed, having regard to the options of possible compensation for pain and suffering or for refunding of their medical expenses among others. 

Outcome of case

The orthodontist indicated that he would feel more comfortable with further advice from Dental Protection before going into the meeting with the parents. The meeting is still to be confirmed.

Learning points

Human factors to implement to reduce the risk of wrong tooth extraction:

• Lower team authority gradients – any member of the oral healthcare team can speak up if concerned irrespective of grade or position

• Improve situational awareness - ask the team to confirm the tooth (teeth) to be extracted

• Avoid miscommunication error: if there is potentially conflicting information – often in relation to molar teeth – seek advice from the prescribing practitioner or another colleague if possible

• Check and double-check radiographs, consent, and clinical examination findings

• If in doubt, do NOT proceed.

1Hasan, R., Never events in dentistry. BDJ Student, 2020. 27(2): p. 47-47.
2Brennan, P.A. and K. Shakib, Wrong-site tooth extraction removed from the list of NHS never events – implications for OMFS. British Journal of Oral and Maxillofacial Surgery, 2021.
3No dentistry-specific mishaps remain on Never Events list. British Dental Journal, 2021. 230(5): p. 276-276.
4Reason, J., Understanding adverse events: human factors. Quality in Health Care, 1995. 1995(4): p. 80-89.
5Davidson, M. and P.A. Brennan, Leading article: What has an Airbus A380 Captain got to do with OMFS? Lessons from aviation to improve patient safety. British Journal of Oral and Maxillofacial Surgery, 2019. 57(5): p. 407-411.
6World Health Organization, WHO Surgical Safety Checklist. 2009: