(8) Wrong Tooth Extraction Prevalence

Abstract:

Objective:
Wrong tooth extraction (WTE) is a phenomenon that occurs frequently in dental practices worldwide. Despite numerous advances in the field of Oral surgery, this phenomenon tends to pose significant negative implications for providers nationwide along with negative consequences such as pain, bleeding, nerve injury and psychological issues for the patient to name a few. Current literature focuses on wrong-site surgery procedures as a whole and while including WTE in the analysis, does not separately quantify the prevalence and factors associated with this phenomenon in the United States. Our study aims to provide an analysis of the prevalence of WTE along with the major pitfalls leading to this phenomenon, in hopes of implementing a protocol for its prevention.

Methods:
In this study, we retrospectively collected data from 250 OMS National Insurance Company (OMSNIC) WTE insurance claims and extrapolated the prevalence of wrong-site tooth extraction between 1999 and 2017. Examined variables included specialty of the clinician performing the extraction, sex and age of patient, details of the event, stage the error occurred, how the error was managed, details of the outcome of the claim, and outcome for the patient. These factors along with stages during which the errors occurred were subjectively categorized and a root cause analysis was performed to determine the stages in which surgeons are most likely to make a mistake. The aforementioned factors were then used to propose a protocol for WTE prevention in various surgical settings.

Results:
The causes of WTE are multifactorial and include operator error, incorrect patient identification, unclear referral slips, perioperative confusion due to mixed dentition or impacted teeth, and communication failures. The results evidenced that maxillary molars were the most incorrectly extracted tooth being involved in 32.2% of claims. Peri-operative error accounted for 46.5% of claims, 48.1% of which were due to the surgeon making a blatant error during the procedure. In our study, Peri-operative error was defined as any error occurring during the process of the extraction and after a proper time-out should have been performed. 20.4% of claims involved miscommunication during the referral process including improper referral letters and in 66.2% of cases, a consent form was not signed for the tooth extracted. In cases were the surgeon was found to be at fault, the error was managed post-operatively through various means of replacing missing dentition.

Conclusions:
WTE is a preventable but frequent problem that can lead to severe consequences for the patient. Effective management of WTE is essential and includes immediate detection of the error, adequate communication with the patient and an action plan to remedy the situation. Based on our analysis, peri-operative errors including mistakes made by the surgery team after patient has been admitted and prepared for surgery were the most frequent cause of this phenomenon. As such, our protocol emphasizes the fact that proper prevention is key. Stringent protocols including the use of proper radiographs, verifying the tooth site with the surgical team should be implicated to minimize the risk of WTE. For the dental provider, the implementation of robust prevention strategies that encompass mindful techniques, education, communication, and collaboration among dental professionals could significantly reduce the incidence of WTE, enhance patient outcomes, and minimize the risk of legal litigation.

References:

1. Lee, Janice S., Arthur W. Curley, and Richard A. Smith. "Prevention of wrong-site tooth extraction: clinical guidelines." Journal of oral and maxillofacial surgery 65.9 (2007): 1793-1799.

2. Taicher, Shlomo. "Wrong tooth extraction: root cause analysis." Quintessence Int 41 (2010): 869-72.