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An incorrect extraction

08 January 2019

A patient attended a new practitioner for the first time and a routine examination was completed. The patient reported previous problems from both lower wisdom teeth which had caused discomfort, swelling and infection, for which antibiotics had previously been prescribed. However, the patient was not reporting any specific problems at that time.

As part of the examination, the dentist took the view that an assessment of the wisdom teeth would be advisable, and the patient agreed to two periapical radiographs. The x-rays were processed and, as was usual practice, the dental nurse placed the films into a plastic film packet. Tooth 38 was identified to be carious, but was incorrectly recorded as tooth 48.

Tooth 48 displayed an area of radiolucency around the crown of the tooth which suggested to the dentist that there had been repeat episodes of infection, and that potentially this tooth would need to be removed should there be a recurrence of symptoms. The patient was informed that tooth 38 was un-restorable and needed to be removed.

The patient was aware of the reason for removal of the tooth and booked an appointment to return the following week to have the tooth removed.

One week later the patient returned and the dentist checked the records and x-rays, informed the patient what was involved in the procedure in so far as numbing the tooth and removing it, and of his impression that it would be a straightforward removal.

The dentist checked the records, which corresponded with the x-ray, and proceeded to numb tooth 48 and the tooth was removed without complication. Postoperative advice was given and the member checked the area for haemostasis. During a review of the socket and mouth, the dentist identified that the carious tooth was still present.

The dentist checked the records and radiographs, as well as the tooth that had just been removed, and identified the mistake. The patient was informed immediately of the error and an entry of the same was documented in the records. The dentist apologised profusely and the patient understood and accepted the situation.

The dentist later called Dental Protection to seek advice on whether anything further needed to be done and how to follow up on the error made. As there was no complaint letter, the advice was that the patient should be contacted again to ensure that they were healing well and invited to attend a review appointment.

The member was advised to discuss the issue at the next practice meeting and to carry out a risk assessment and analysis to determine how a repeat situation could be avoided in the future. The patient did not make any formal complaint and there was no further outcome.


This case highlights:

  • The importance of double-checking radiographs with an intra-oral examination and with the clinical records to ensure that there are no discrepancies.
  • The importance of having failsafe processes for orientation and labelling of radiographs, being mindful that human errors do occur.
  • Prior to an irreversible intervention, clinicians should ensure that they are content with the rationale for the specific tooth removal and this is backed up with a clinical diagnosis, which is well documented in the clinical records.
  • All records should be completed contemporaneously to reduce the risk of incorrect recording.
  • It is vital to be honest and open with patients when treatment does not go as planned.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits Dental Protection members enjoy as part of their subscription. 
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