Mrs Claire Morgan
Dental Council member and Deputy Chair Patient Safety Group, ºìÐÓÊÓƵ
Consultant in Restorative Dentistry and Patient Safety Specialist, Barts Health Trust Royal London Hospital
Keeping our Children Safe: minimising the risk of wrong tooth extraction in children
My dental blog for this year’s World Patient Safety Day focuses on wrong tooth extractions in children and how in healthcare we have sought to reduce this risk.
Never event
Prior to 2021 wrong tooth extraction (WTE) according to NHS England’s wrong site surgery data, was the highest recorded ‘Never Event’. Wrong tooth extraction was removed from the Never Event list in 2021 on the grounds that systemic barriers were not strong enough to prevent this patient safety event, a requirement to meet the definition of a Never Event. Unlike most single or paired anatomical organs, there are 32 permanent teeth with some looking very similar. Since April 2015, on average 38 wrong tooth extractions have been registered as a Never Event in England each year, it is generally accepted that this was/is an underestimation of the problem.
Wrong tooth extraction can equally occur in children, with the added complication that there are 20 teeth in the deciduous dentition. Interestingly deciduous wrong tooth extraction was only considered a Never Event if the extraction had been carried out under general anaesthesia, with the thought process that if general anaesthesia is involved this places children at increased risk. As with all patient safety events there is no single cause of WTE, therefore the problem must be viewed through a systems lens such as the systems engineering initiative for patient safety (SEIPS) considering: tasks, tools and technology, people, internal organisations, physical environments, and external influences.
Tooth extraction in children
Teeth in children are may be extracted for the following reasons:
- Caries which is unrestorable.
- Orthodontic needs which can be done to relieve crowding, often these will be permanent premolar teeth of which there are 2 in each mouth quadrant looking fairly similar. Another orthodontic reason might be impaction of maxillary canine teeth, which cannot be brought into the mouth and hinder tooth movement. Orthodontic reasons maybe a common cause of wrong tooth extraction as the teeth may not be diseased and less identifiable as needing extraction.
- Trauma of a deciduous tooth or unrestorable permanent tooth.
- Acquired or developmental anomalies often affecting enamel, which can deem a tooth unrestorable.
- Resorption of roots which might occur following tooth trauma or impaction
Acquired or developmental anomalies often affecting enamel, which can deem a tooth unrestorable. - Also on occasion a submerging deciduous molar tooth which becomes infra occluded where there is no permanent successor.
- Natal teeth which are rare but can be present from birth. These will generally be extracted as they can potentially hinder breast feeding but of more concern is the risk of aspiration as they often have underdeveloped roots and are mobile. 
Why children might be more at risk
It cannot be quantified if children are at greater risk than adults of wrong tooth extraction. But some factors that may contribute include:
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Developing, mixed dentitions and identification.
There will often be a delay in a dental extraction from prescription/referral, during which time teeth present may change due to natural exfoliation of deciduous teeth and eruption of permanent teeth. There is variation in the age of tooth exfoliation and eruption, though the deciduous dentition normally starts to appear at about 6 months with a fully established set of primary teeth present by 3 years of age. At the age of 6 years the permanent dentition erupts; the deciduous dentition is generally replaced by the age of 12 years with the last permanent molar erupting into the mouth at the age of 13 years. However wisdom teeth, if present and not impacted, generally erupt from the age of about 17 to 21 years of age. Therefore, there is a constant change in a child’s mouth as the dentition develops. The period when there can be both deciduous and permanent teeth in the mouth is termed the mixed dentition, which is from 6 to 12 years complicating tooth identification further.
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Prescription/referral of extraction and communication.
In children it will be more common for the prescriber of the extraction not to be the dentist who will carry out the extraction. The prescription/referral may be from primary care practitioner to secondary care setting or different specialty for example orthodontist to paediatric dentist, or oral surgeon. Risks to safety are greater during transitions of care and how the extraction prescription/referral is conveyed can impact; information provided for tooth extraction must be explicit and clearly communicated using tools such as the ‘situation, background, assessment, recommendation’ (SBAR) handover tooth. Differing tooth nomenclatures can also lead to miscommunication and therefore the Palmer notation is recommended where possible. In some electronic systems this is often not possible in which case the Alphanumeric system with Palmer numbering is nomenclature may be a safer nomenclature for communication.
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General anaesthesia.
The operating theatre is considered the most common setting for adverse surgical outcomes, which is where many dental extractions for children carried out in secondary care occur. There is no direct patient input at the point of extraction if carried out under general anaesthesia, which potentially increases risk of wrong tooth extraction. Although conceded consent will be taken from parents/carers prior to surgery, not the child unless Gillick competent; though if dentists can on occasion have difficulty in identifying all teeth how can parents?
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Microdontia and other developmental disorders.
Some permanent teeth do not develop to normal size or shape and can then appear similar to a deciduous tooth which adds to the complexity of tooth identification.
The surgical safety checklist
The surgical safety checklist launched by the World Health Organisation in 2008 has been shown to reduce surgical incidents leading to patient harm by as much as one-third.
The recognition of wrong tooth extraction as a real problem in dentistry promoted the use of the surgical safety checklist for dental extractions. This move has been supported nationally by the National Safety Standards for Invasive Procedures (NatSSIPs). Guidance was originally produced in 2015 and more recently updated as NatSSIPs 2, housed with the Centre for Perioperative Care (CPOC) with two sets of standards: organisational and sequential. The new guidance aims to improve safety, build on team-working and efficiency with the promotion of specialty specific proportionate to the risk of harm checks. In addition to WHO 5 sequential steps, 3 further have been introduced including consent and procedural verification; the patient is seen as a participant which in the case of a child will be the parent or carer. NatSSIPs is underpinned by systems, human factors and learning for improvement.
Checklists are routinely used in secondary care in surgical dentistry both when extractions are carried out under local and general anaesthesia. The use of extraction checklists are also promoted in primary care, and they have been shown to be the only evidence based effective safety intervention in dentistry. It is essential there is a second clinician to verify the stages involved, be it a dental nurse or dentist which leads to improved team working. ‘Standardisation, Harmonisation and Education’ of NatSSIPs 2 are seen as key to the checking process.
The future
With a more safety conscious environment, it is hoped that wrong site surgeries including dental extraction will reduce. With the shift from analogue to digital in healthcare and the move to electronic consent and checklists, great care must be taken to avoid an initial spike in wrong site surgery or indeed other safety events.
It is a well-established, that any new digital technology may have its own ‘teething’ problems and be an added distraction for any surgical team. With an emphasis on human factors i.e. how humans interact with their environments, team and simulation training is becoming main stay for all dental undergraduate and resident specialty curricula, and indeed development for all the dental team.
The Faculty of Dental Trainers at Royal College of Surgeons of Edinburgh has developed its own and unique human factors training known as Dental Non-Technical Skills(DeNTS) which is accessible to all registrants. They have also developed a tool for Dental Nurses to observe non-technical skills (DNOT) to support dentists during surgery to reduce the risk patient safety incidents, thus reducing hierarchies and encouraging team working.
References
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NHS England. SEIPS quick reference guide and work system explorer Version 1, August 2022. https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-SEIPS-quick-reference-and-work-system-explorer-v1-FINAL.pdfÌý
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Mistaken Identity. Surgeons News, ºìÐÓÊÓƵ June 2023Ìý
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Bailey E, Tickle M, Campbell S, et al. Systematic review of patient safety interventions in dentistry. BMC Oral Health. 2015;15:152Ìý