The Dental Defence Union (DDU) has warned that removal of teeth in general dental practice is becoming an increasingly challenging area and has issued advice to dentists to help them avoid the pitfalls.

In the last six years, the DDU has opened an increasing number of complaints and claims files involving extractions.

In the first half of the period, the average number of files opened each year where a tooth extraction featured was 159, compared to 194 in the second half, an increase of 22%.

While not all the allegations against members were justified, it highlights tooth removal as a growing area of concern, with the most common problems including allegations of inadequate consent, removing the wrong tooth and post-operative pain.

In his article in the DDU Journal, Paul Robinson, an oral and maxillofacial surgeon and chairman of the DDU dental advisory committee, looks at the dento-legal issues surrounding removing teeth.

He comments: ‘The average extraction is taking place at an older age which makes it more likely that teeth will already be extensively restored and there may be more complicated medical histories.

At the same time, the average dental graduate has less experience as there are fewer easy teeth suitable for students to treat. These two broad areas of change, combined with patients' increasing interest in their teeth and the spectre of litigation, makes extractions an increasingly difficult area.'

Mr Robinson uses case histories to show how an apparently straightforward extraction can go wrong and outlines some steps which may have avoided the problem in each case. He advises: ‘Good communication is arguably of most importance so that the patient understands why you are advocating a particular form of treatment, and understands and accepts the risk of any potential complications. Remember: what you tell your patient pre-operatively is sound professional advice; what you tell them afterwards may be viewed as an excuse.'

Mr Robinson's advice for DDU members includes:
• Be prepared to refer patients to a specialist or for hospital management at an early stage if factors such as the surrounding bone levels, the patient's medical history, and your own experience and training mean that the case is outside your competence
• Extraction procedures should only be delegated to those whose level of skill and experience is appropriate
• A risk-benefit analysis, discussed with the patient, is a useful tool to assess the level of risk against the benefit of treatment and the level of symptoms. Other treatment options should also be considered, including the option of no treatment. This discussion should also be documented in the clinical records
• If you decide extraction is the best option, it's still important to discuss with the patient pre-operatively the risks such as nerve damage
• If anything goes wrong during the procedure, the patient should be informed and then appropriate management should be arranged as soon as possible, for example an urgent referral. An apology should also be offered if appropriate.