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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 12  |  Page : 1706-1714

The prevalence and causes of wrong tooth extraction


1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
2 Private Practice, Jeddah, Saudi Arabia
3 Oral Diagnostic Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission15-Apr-2019
Date of Acceptance20-Jul-2019
Date of Web Publication3-Dec-2019

Correspondence Address:
Dr. F M Jadu
Department of Oral Diagnostic, Faculty of Dentistry, King Abdulaziz University, P.O. Box 80200, Jeddah - 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_206_19

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   Abstract 


Background: Dental extraction is a common procedure that is subject to complications and errors including extraction of the wrong tooth. This study aimed to determine the prevalence and identify the causes of wrong tooth extractions and explore the attitude of dentists after extraction of a wrong tooth. Methods: A questionnaire was adapted to fit the needs of this project and was distributed among all the dentists in four teaching dental clinics. The questionnaire was available in both the English and Arabic languages. Results: Of the 486 questionnaires, 186 questionnaires were returned (response rate of 37%) and used for the analysis. The prevalence of wrong tooth extraction was 21.1%. The three most common reasons for extracting a wrong tooth were miscommunication (31.6%), inadequate referral (28.9%), and exhaustion of an overworked dentist (28.9%). Surprisingly, only 50% informed the patient and documented the incident in the patient's chart. Few dentists apologized to their patients or offered any kind of solution or compensation. Conclusion: Wrong tooth extraction is a prevalent yet preventable problem. Most of the common causes of this problem appear to be more system rather than individual related. There is a pressing need to implement the universal protocol for the prevention of wrong site, wrong procedure, and wrong person surgery.

Keywords: Medical errors, medical mistakes, surgical errors, tooth extraction, wrong-site surgery


How to cite this article:
Jan A M, Albenayan R, Alsharkawi D, Jadu F M. The prevalence and causes of wrong tooth extraction. Niger J Clin Pract 2019;22:1706-14

How to cite this URL:
Jan A M, Albenayan R, Alsharkawi D, Jadu F M. The prevalence and causes of wrong tooth extraction. Niger J Clin Pract [serial online] 2019 [cited 2019 Dec 12];22:1706-14. Available from: http://www.njcponline.com/text.asp?2019/22/12/1706/272201




   Introduction Top


Medical errors, unfortunately, take place in hospitals and in outpatient clinics. The Institute of Medicine (IOM) defines medical errors as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.”[1] The IOM emphasizes that this definition of medical errors is system related and not often the result of individual negligence or misconduct.

There are several forms of medical errors; the most common one is wrong-site surgery. Wrong-site surgery is defined as “surgery undertaken on the wrong person, the wrong organ or limb, the wrong side or the wrong vertebral level, and encompasses invasive procedures such as regional blocks, dermatological, obstetric, and dental procedures along with emergency surgical procedures not undertaken within the operating theatre.”[2] Risk factors for wrong-site surgery include incorrect patient positioning or preparation of operative site, providing incorrect information by the patient or the patients' family, incorrect or lack of patient consent, failure to use site markings, surgeon fatigue, multiple surgeons, multiple procedures on the same patient, unusual time pressures, emergency operations, unusual patient anatomy, and overall poor communication among and between the treating staff, the patients, and the patient families.[3]

Dental extraction is a very common dental procedure performed by general dentists and dental specialists, especially oral and maxillofacial surgeons (OMFS). Like other procedures, it is subject to complications and errors such as wrong tooth extraction. Wrong tooth extraction is defined as the extraction of a tooth other than the one intended.[4]

The prevalence of wrong tooth extraction is largely underestimated and very few publications exist in the literature due to the fear of admitting wrongdoing and the fear of consequences and repercussions of such admission. One study conducted in Nigeria estimated the prevalence of wrong tooth extraction was 13%.[5] Another study that took place in Israel found that most wrong tooth extractions were made by general dentists (71%).[6] The latter study also found that most cases of wrong tooth extraction involved extraction of the adjacent tooth (67%), while 15% were due to quadrant confusion, 13% were due to confusion between a primary and a permanent tooth, and 14% were due to incorrect marking of the tooth intended for extraction.

Wrong tooth extraction is a serious yet preventable complication with very little data available in the literature. Therefore, the aim of this study was to determine the prevalence of wrong tooth extractions among dentists in Saudi Arabia, identify the possible reasons for wrong tooth extractions, and explore the behavior of dentists after the extraction of a wrong tooth.


   Materials and Methods Top


A questionnaire that was developed and validated by Adeyemo et al. to document the experience of wrong tooth extraction among Nigerian dentists was adapted to fit the needs of this project (the modified version is presented as Appendix A).[5] Then, in a cross-sectional study design and following ethical approval (REC 041-14), the modified questionnaire was distributed to the dentists and dental specialists who work in four different teaching dental clinics. A total of 486 questionnaires were distributed. The sample size was calculated to be 173 questionnaires for a nonrandom sample with a 95% confidence interval and a 5% margin of error and assuming a prevalence of approximately 13%. The questionnaire was available in both the English and Arabic languages and it included a cover page explaining the purpose of the research and emphasizing the confidentiality of all collected data.

The information collected in the questionnaire included demographic data related to the dentists such as gender, year of graduation, current rank, specialty, and years of experience. It also included questions specific to dental extraction procedures such as written referral requirements, tooth numbering system preferences, and radiograph requirements prior to extraction. Finally, the questionnaire included questions about the dentists' behavior and attitude after extraction of a wrong tooth. This last section included questions such as whether the incident was reported to the patient or guardian, whether the incident was documented in the patient's records, and whether any compensation was offered.

Statistical analysis for this study was done using the software SPSS version 22 (SPSS Inc, Chicago, IL, USA). Simple descriptive statistics were used to define the characteristics of the study variables through a form of counts and percentages for the categorical variables. To establish a relationship between categorical variables, this study used the Chi-Square test. Last, we hypothesize that there will be no difference among the dentist respondents with regards to rank, specialty, or years of experience in terms of experiencing a wrong tooth extraction. A P value < 0.05 was set for statistical significance.


   Results Top


One hundred and eighty questionnaires were returned at a response rate of 37%. Most respondents were females (65.5%) and most were general dentists with less than five years of clinical experience after graduation (66.7%). The demographic data for the respondents are shown in [Table 1].
Table 1: Demographic data of respondent dentists to a questionnaire examining the prevalence and causes of wrong tooth extraction in Jeddah, Saudi Arabia

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With regards to the extraction procedure specifically, most respondents reported always requiring a written referral letter (72%), confirming the tooth to be extracted with the patient or guardian (82.2%), confirming the tooth to be extracted with the dental assistant (76%), and requiring a labeled radiograph (73.9%). Only 56% of respondents always count the teeth before the extraction procedure. Most respondents also indicated that they prefer the FDI system for teeth numbering when communicating with the referrals (65.7%). These findings are demonstrated in [Table 2].
Table 2: Frequency of respondents by procedures followed prior to any dental extraction

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Only 38 of 180 respondents reported experiencing a wrong tooth extraction incident (21.1%), most of which were consultants (40.0%). As expected, OMFS were the group to most often experience a wrong tooth extraction (50.0%). Orthodontists and periodontists followed closely at 42.9% and 33.3%, respectively. These results are presented in [Table 3]. The reasons for the wrong tooth extraction are shown in [Figure 1], and the three most common causes were miscommunication (31.6%), inadequate referral (28.9%), and exhaustion of an overworked dentist (28.9%). The attitude of these respondents after the fact was somewhat surprising as only 52.6% documented the incident in the patient's file and only 50% informed the patient but even few offered any kind of apology, solution, or compensation. These results are demonstrated in [Figure 2].
Table 3: Stratification of respondents who have experienced a wrong tooth extraction according to rank, specialty, years of experience, and the tooth numbering system used

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{Figure 1}{Figure 2}

The overwhelming majority of respondents were not aware of the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery (70.6%). No statistically significant differences were noted among the different dental specialties in terms of experiencing a wrong tooth extraction procedure. However, consultants were more likely to experience such a complication and this finding was statistically significant at P = 0.034.


   Discussion Top


Wrong tooth extraction is a legal issue that is impossible to defend and at a prevalence of 21.1%, it constitutes a burden to the health system. The prevalence calculated in the current study is considered relatively high in comparison to other similar studies. A comparable study conducted among Nigerian dentists found the frequency of wrong tooth extraction was 13%.[5] This prevalence of wrong tooth extraction is also concerning because most respondents seem to have sound practices in place prior to a tooth extraction procedure, as most require a written referral and a labeled radiograph. Most respondents also claim to confirm the tooth to be extracted with the patient or guardian and with the dental assistant. So what are the causes for so many wrong tooth extractions?

According to the respondents of this study, the causes of wrong tooth extraction were either system related or individual related, but the two most common causes were system related, namely miscommunication and inadequate referral as demonstrated in [Figure 1]. The remaining causes of tooth extraction were all operator related and ranged from being overworked to lacking experience. Miscommunication seems to be a common finding among several studies,[4],[5],[7] whether it be an internal communication issue or an external communication issue with the referring doctor or dentist.[4],[7]

The surprising part of this study was the attitude of respondents to an incident of wrong tooth extraction because most shied away from documenting the incident and from claiming responsibility and offering any kind of solution or compensation. These results are slightly different from those of Adeyemo et al. where most of the respondents informed the patient (53.6%) and documented the event in the patient's records (68%). According to Lee et al., if the wrong tooth has been extracted, it is the legal obligation of the operator to inform the patient immediately when the error has been identified and then advise the patient for an appropriate line of action.[7] We realize, however, that the low response rate of 37% in this study may limit its generalizability and that nonresponders may have different attitudes. We are also hopeful that future studies, perhaps of a different study design, will venture to further explore this problem.

Another significant finding that was especially worrisome was that most respondents to the questionnaire of the current study were not aware of the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery (70.6% of 180). The universal protocol advocates three essential fail-safe steps that ensure the prevention of this error. These steps include a preoperative verification process, marking the operative site, and a time out immediately before starting the procedure. The protocol also strongly recommends the use of safe surgery checklists. These lists ensure effective communication and safe practices at three critical time points: before anesthesia administration, before the surgical procedure, and before the patient is dismissed. The lack of knowledge of the universal protocol may explain the relatively high frequency of wrong tooth extraction observed in this study and it definitely highlights the importance of making this knowledge available to all dentists and dental specialists.[4] The authors also strongly advocate the incorporation of this protocol in the teaching curricula and implementing it in all dental clinics, especially considering that wrong tooth extractions continue to be one of the major reasons for filing malpractice claims against OMFS.[7]

In the current study, the only statistically significant result was that consultants were more likely to experience a wrong tooth extraction, which is explainable by the mere fact of their lengthier careers. However, this finding was different from those of Adeyemo et al. where dentists were more likely to extract a wrong tooth in the 5 years of their practice. Not surprisingly, at least half of the OMFS who responded to our survey reported experiencing a wrong tooth extraction as did a significant number of orthodontists and periodontists who may not have performed the extraction themselves but were involved in the incident and perhaps the remedial action plan.


   Conclusion Top


Wrong tooth extraction is a common yet preventable problem among dentist and dental specialists. The most common causes are system related and can be easily prevented by the implementation of the universal protocol for the prevention of wrong site, wrong procedure, and wrong person surgery.

Acknowledgement

The authors would like to thank Mr. Kalvin Balucanag for his assistance with the statistical analysis.

Declaration of patient consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Appendix A Top






Dear participant,

You are invited to take part in a vital study about the extraction of wrong teeth. The study will be instrumental in enriching our understanding of why this mistake sometimes happens and will assist us in implementing and enforcing better prevention protocols. Your participation will be in the form of a questionnaire that you are kindly asked to complete. The questionnaire is only one page long and filling it out should take no more than 1 minute of your precious time. It is available in both the Arabic and English languages. All information provided will remain strictly confidential, and will be used solely for the purpose of the research project. If you have any questions, comments or concerns please feel free to contact the Principal Investigator:

Dr. Ahmad Jan DDS, MSc, MD-PhD, FRCDC, DipABOMS

Chairman, Oral and Maxillofacial Surgery Assistant professor and consultant, Oral and Maxillofacial Surgery Faculty of Dentistry, KAU Cell: 0542226691 Email address: amjan@kau.edu.sa

Thank you for your assistance and participation.







 
   References Top

1.
Kohn LT, Corrigan J, Donaldson MS. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (USA); 2000. p. 312.  Back to cited text no. 1
    
2.
Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL. Interventions for reducing wrong-site surgery and invasive procedures. Cochrane Database Syst Rev 2012;9:CD009404.  Back to cited text no. 2
    
3.
Devine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site surgery: A systematic review. Spine (Phila Pa 1976) 2010;35:S28-36.  Back to cited text no. 3
    
4.
Chang HH, Lee JJ, Cheng SJ, Yang PJ, Hahn LJ, Kuo YS, et al. Effectiveness of an educational program in reducing the incidence of wrong-site tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:288-94.  Back to cited text no. 4
    
5.
Adeyemo WL, Oderinu OH, Olojede AC, Fashina AA, Ayodele AO. Experience of wrong-site tooth extraction among Nigerian dentists. Saudi Dent J 2011;23:153-6.  Back to cited text no. 5
    
6.
Peleg O, Givot N, Halamish-Shani T, Taicher S. Wrong tooth extraction: Root cause analysis. Quintessence Int 2010;41:869-72.  Back to cited text no. 6
    
7.
Lee JS, Curley AW, Smith RA, Insitu te of Medicine. Prevention of wrong-site tooth extraction: Clinical guidelines. J Oral Maxillofac Surg 2007;65:1793-9.  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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    Abstract
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