A dentist looks at X-rays of teeth.

Wrong site surgery – wrong tooth extraction

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

Our investigation looked at the risks to identifying the correct tooth for extraction in dental practice.

The extraction of a tooth is an invasive procedure undertaken in a variety of settings. Despite national and local efforts to introduce safety standards for invasive procedures, errors continue to occur.

When a permanent (adult) tooth is extracted in error it is deemed a wrong site surgery. When considered along with other forms of invasive procedures, such as injections in the eye, wrong side chest drains and skin lesion removal, wrong tooth extraction was the most frequently reported type of wrong site surgery over the last five years.

Reference event

The investigation followed the case of a 7-year-old. They were referred by a general dental practitioner to the local district care trust for fillings to their permanent molar teeth and the extraction of a decaying deciduous (milk) tooth.

Following an initial appointment at the health centre, a senior dentist made a treatment plan which included a referral for advice to an orthodontic specialist, fillings and tooth extractions. During the fifth and final appointment, the plan was to remove a single milk tooth that was showing signs of gross decay. During that procedure the neighbouring adult tooth was removed in error. The tooth was re-implanted after a short period outside the mouth and, at the time of the investigation, was healthy.

Having interviewed staff and observed tooth extraction taking place in both hospital operating theatres and dental surgeries, it was apparent that the process in both environments differed.

Investigation summary

This investigation:

  • Examined how the application of safety standards for invasive procedures is influenced by clinical environment and if this might have a bearing on wrong tooth extraction.
  • Considered how safety procedures are applied to prevent wrong site surgery in other specialisms where invasive procedures are undertaken in non-operating theatre environments.
  • Looked at to what extent safety barriers and controls, put in place to prevent the extraction of the wrong tooth, are effective at mitigating the risk of error.