PREOPERATIVE DISCUSSION AND DOCUMENTATION
Since dental damage is one of the most likely adverse outcomes during general anesthesia, it is recommended that the patient be made aware of this possibility during the preoperative evaluation, especially with an anticipated difficult intubation and/or a patient’s vulnerable preexisting dentition. Forewarning patients about this potential adverse incident preoperatively can substantially decrease the likelihood of facing an uninformed, unprepared, or angry patient postoperatively.
The preoperative presentation of a poor dentition should prompt the anesthesiologist to be descriptive in documenting this condition. “None loose” or “intact” are not always appropriately illustrative. Also, a notation referring to the patient’s periodontal status can be helpful. For example, “poor oral hygiene with generalized periodontal disease, multiple mobile teeth and partial edentulism in both arches” can succinctly summarize a patient’s dentition that is especially vulnerable to damage. In addition, the following entry made in a patient’s medical record preoperatively can save time disputing such a claim postoperatively: “the maxillary right central incisor (#8) has a fractured incisal edge which I have confirmed with the patient.” Any missing, damaged, or loose teeth should be confirmed with the patient and documented accordingly. Gatt et al.41 has proposed the introduction of a standardized uniform dental chart to accurately document the preoperative condition of a patient’s dentition. Detailed documentation of the patient’s preoperative dental condition also serves to minimize the potential for inflated dental treatment estimates following a perioperative dental incident.
RECOMMENDATIONS FOR PREVENTION OF PERIOPERATIVE DENTAL DAMAGE
Patients’ loose teeth present the anesthesiologist with the dilemma of having the teeth extracted preoperatively or proceeding with caution. In many instances, it is not practical to obtain a dental consultation and definitive treatment immediately before surgery. Securing a loose tooth is a cautious measure to prevent aspiration and aid in a tooth’s retrieval should it become dislodged. A 3–0 silk suture without the needle can be wrapped several times around the gingival margins of the mobile tooth and adjacent teeth for increased stability (Fig. 9). The suture can be secured with adhesive tape to the ipsilateral cheek and removed after the procedure upon recovery.
The presence of any abnormalities of the tongue, lip, or palate should also be noted. Being cognizant of lesions in any of these areas can reduce perioperative trauma of oral soft tissues. Although all intraoral swellings should be investigated and documented preoperatively, they are not all indicative of an infectious process. For example, a torus is a prominently benign bony growth that can develop in a patient’s palate or mandibular premolar region and would not require preoperative intervention.42 Particularly upon inspection of the patient’s maxillary anterior teeth, biting surfaces should be carefully scrutinized for any evidence of being worn, notched or chipped. Incomplete dental treatment, such as temporary crowns and implants, may become an issue perioperatively and the stability of any such provisional prostheses should be verified. Any removable prostheses (e.g., dentures, orthodontic appliances) or soft tissue piercings of the lip or tongue should be removed, labeled, and stored before the anesthetic induction to prevent any accidental loss or damage.
After induction of anesthesia when a patient’s mouth is being scissored open before laryngoscopy (“cross-finger” maneuver), excessive stresses may be placed upon the mandibular anterior or maxillary right posterior teeth. During this action, one should exercise caution and subject only posterior, not anterior teeth, to minimal vertical or oblique forces to decrease the likelihood of damage. This manipulation can also cause the mandible to “lock” in an open position. This disarticulation is caused by anatomical abnormities or extreme mouth opening forces, resulting in the condyle of the mandible to slide too far anteriorly along the articular eminence of the temporal bone. A simple maneuver can correct this situation. Directly facing the patient who remains under general anesthesia, thumbs can be placed bilaterally along the biting surface of the patient’s mandibular posterior teeth. The action of applying pressure inferiorly and then posteriorly (i.e., down and back) unhinges the condyle from its unnaturally anterior position, and returns the mandible to a more relaxed position (Fig. 10). In a one-sided dislocation, the mandible is deflected ipsilateral to the locked joint. To reduce the disarticulation of the condyle/disk, inferior pressure is applied to the mandible which is then moved gently in the contralateral direction.43
Since laryngoscopy is the most common procedure that may lead to dental damage, prevention of such an injury during this time warrants particular attention. Obviously, a technique involving gentle blade placement and motion, along with carefully applied forces, should be used. One maneuver that minimizes contact with teeth entails placing the right hand on the patient’s occiput and extending the neck, while the left little finger pushes down the chin, opening the mouth and creating access. Careless placement of the laryngoscope blade can cause laceration or abrasion of the lips, palate, and cheeks with possible ulceration and infection.40 Suctioning intraorally should be done with great care, preferably with the use of a 14F soft plastic catheter.
Patients with a Mallampati score of 3 and prominent “buck” teeth have been reported to experience blade-tooth contact in more than 90% of intubations,16 prompting the modification of the laryngoscope blade to avoid dental damage.44 Lee et al.16 reported that using a Macintosh blade with a low-height flange (i.e., Callander modification) reduced the frequency of direct contact between the blade and the maxillary teeth by more than 80%. In contrast, a similar modification of a Miller blade was found to decrease the blade’s effectiveness for laryngeal visualization.45 Angulated blades, such as the McCoy and the Belscope, have been reported to provide greater tooth-blade distances and better visibility than regular curved or straight blades.46,47
Several studies have examined the preventive use of devices that protect teeth during laryngoscopy.48 Various prefabricated or custom-made mouthguards (i.e., those used preventively in sports) do not guarantee an endotracheal intubation free of dental trauma.21 Burton and Baker8 found that the vast majority of anesthesiologists did not use a protective guard routinely, and 45% had never used one. The use of mouthguards has no significant effect on the incidence of dental injury.49 The main disadvantage of these tooth protectors is that their thickness decreases the amount of space within the oral cavity, leading to poor visibility and increased difficulty in guiding the endotracheal tube into the larynx. They also prolong the intubation time, increase the likelihood of oral trauma, and create additional hazards, including aspiration of the appliance. However, for bronchoscopists and endoscopists who tend to use a rigid scope for their procedures, mouthguards have been recommended.49
The oral airway has been found to be a major cause of injury to teeth50,51 and 20% of dental injuries were reportedly caused by Guedel oral airways.18 Oropharyngeal airways should be used with caution for patients with vulnerable anterior teeth and should not be used as a bite block.52,53 Nasopharyngeal airways are a better choice for those patients who are especially at risk for dental injury.30
In preparation for extubation, a soft roll of gauze can be placed on the biting surfaces of the patient’s mandibular premolar/molar region. It should be large enough to be easily retrieved. A bite block can also be made from a wooden tongue depressor, wrapped several times at one end with 1 in. or 2 in. cloth adhesive tape, and inserted with the bundle positioned between the mandibular and maxillary molars on either side of a LMA or opposite to a unilaterally positioned endotracheal tube. When a patient involuntarily bites during emergence from anesthesia, forces will be dissipated throughout stronger multirooted molars rather than weaker single-rooted incisors. Functioning as a fulcrum, this posteriorly positioned roll will also indirectly open the anterior of the mouth, preventing contact and damage to anterior teeth and/or any of their cosmetic restorations upon removal of the airway device. During emergence from anesthesia, the gauze roll will also prevent the patient from clenching down on an endotracheal tube or LMA, which could adversely affect oxygenation. Adequately controlling postoperative shivering will lessen excessive teeth clenching, grinding, or masseter muscle spasm.
MANAGEMENT PLAN: WHEN DENTAL DAMAGE DOES OCCUR
When an incident of perioperative dental damage occurs, documentation of the injury is imperative. An evaluation of the damage by a dentist should be obtained as soon as possible to determine the extent of the injury and provide potential options for postoperative treatment. Confirming the location and ensuring the successful retrieval of any avulsed or broken teeth is also essential. If a tooth, crown, or other prosthesis is avulsed and its location is unknown, a chest radiograph should be obtained without delay to determine whether it has been aspirated or is on a passage to the stomach. Although most dental fragments will pass through the gastrointestinal tract without causing harm, large prostheses have the potential to obstruct and perforate.39 If the object has not been retrieved, intraoperative intervention may be necessary. The ingestion of a fixed partial denture followed by subsequent recovery with endoscopy during general anesthesia has been reported.54
If a permanent tooth is displaced from its socket, it should be stored in normal saline or cool fresh milk until it can be splinted or reimplanted.39 The success of reimplantation of an avulsed tooth after a traumatic intubation is primarily determined by the elapsed time since injury. If reimplanted within 30 min, the success rate has been reported to be as high as 90%.55
It should be noted that it is not always the anesthesiologist who is responsible for dental damage in the operating room. Surgeons, such as otolaryngologists, may inadvertently cause such an injury during rigid laryngoscopy. Also, endoscopists and bronchoscopists have caused trauma to a patient’s dentition. Determining which practitioner was directly involved with the dental trauma is suggested before a discussion with the patient.
Once the patient is sufficiently awake, a discussion of the perioperative dental incident should occur. Patients are more likely to become upset if they feel that this incident has been ignored or practitioners have refused to acknowledge any responsibility. Facilitating prompt attention to the dental damage before the patient’s discharge will ameliorate convenience and reduce expenses. At some health care facilities, dental clinics are on site that can provide an immediate assessment of the injury and suggest appropriate treatment. Due to the relatively small financial payout for repair, it is often not worth the time or expense to prolong a legal dispute over the incident.
If the injury has not been resolved before discharge, patients will typically seek dental treatment with their private dentist and submit a claim for reimbursement. In the case of patients who have not visited a dentist in several years, the treatment plan may also address some unrelated chronic intraoral conditions, culminating in a significantly increased cost estimate. Extractions, periodontal therapy, insertion and restoration of implants, crown and bridge fabrication, etc. may all be necessary measures for improving a patient’s overall dental condition. A reasonable reimbursement by the health care facility should only include the repair costs of the dental damage that was sustained perioperatively. A mediator, such as a hospital risk management member, can investigate patients’ claims of dental injuries; however, ideally the reimbursement process should include an independent dentist to evaluate the treatment plan and fees. Rather than relying upon the assessment of the injury by an administrator, review of the claim by a more appropriately educated individual can ensure an impartial judgment. It also diminishes the potential for the payer to be financially responsible for any extraneous treatment and inflated costs.
Perioperative dental damage is one of the most common anesthesia-related adverse events leading to claims. Understanding and recognizing the multiple risk factors associated with such injuries leads to prevention. During the preoperative evaluation, information about the patient’s intraoral soft and hard tissues should be obtained by the anesthesiologist. Adoption of a more extensive intraoral examination into one’s preoperative evaluation is not suggested for most patients, but in some instances a “hands-on” examination of the patient’s dental status is recommended to properly appreciate any vulnerable teeth or soft tissues. Patients exhibiting very poor oral hygiene and chronic oral neglect may be harboring an unknown odontogenic infection that can compromise surgical outcome, and those with known mobile teeth are at an increased risk for tooth avulsion and/ or aspiration. Decayed, restored, or periodontally involved teeth are more susceptible to becoming damaged perioperatively than a natural dentition. A preoperative discussion with the patient of the risk of dental injury and clear documentation can significantly reduce the magnitude of postoperative disputes and costs. If indicated, securing loose teeth can help reduce dental injury, as will other preventive measures, such as careful mouth opening, laryngosope placement, suctioning, and extubation maneuvers. Following an incident of perioperative dental damage, the goal is to obtain an immediate assessment and provide a fair reimbursement for treating the injury. Enhancing one’s awareness of the various perioperative dental considerations described in this article can minimize costs, while improving anesthetic outcome and patient satisfaction.
1. Lockhart PB, Feldbau EV, Gabel RA, Connolly SF, Silversin JB. Dental complications during and after tracheal intubation. J Am Dent Assoc 1986;112:480–83
2. Warner M, Benenfeld S, Warner M, Schroeder D, Maxson P. Perianesthetic dental injuries: frequency, outcomes, and risk factors. Anesthesiology 1999;90:1302–5
3. Newland MC, Ellis SJ, Peters KR, Simonson JA, Durham TM, Ullrich FA, Tinker JH. Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years. J Clin Anesth 2007;19:339–45
4. Chen JJ, Susetio L, Chao CC. Oral complications associated with endotracheal general anesthesia. Anaesth Sinica 1990;28:163–69
5. Gaiser RR, Castro AD. The level of anesthesia resident training does not affect the risk of dental injury. Anesth Analg 1998;87:255–57
6. Givol N, Gershtansky Y, Halamish-Shani T, Taicher S, Perel A, Segal E. Perianesthetic dental injuries: analysis of incidence reports. J Clin Anesth 2004;16:173–76
7. Owen H, Waddell-Smith I. Dental trauma associated with anesthesia. Anaesth Intensive Care 2000;28:133–45
8. Burton J, Baker A. Dental damage during anaesthesia and surgery. Anaesth Intensive Care 1987;15:262–68
9. Brosnan C, Radford P. The effect of a toothguard on the difficulty of intubation. Anaesthesia 1997;52:1011–14
10. Cass NM. Medicolegal claims against anaesthetists: a 20 year study. Anaesth Intensive Care 2004;32:47–58
11. Chopra V, Bovill JG, Spierdijk J. Accidents, near accidents and complications during anaesthesia. Anaesthesia 1990;45:3–6
12. Holzer JF. Current concepts in risk management. Anesthesiol Clin North Am 1984;22:91–102
13. Kain Z. The National Practitioner Data Bank and malpractice payment. Anesth Analg 2006;103:646–49
14. Chadwick RG, Lindsay S. Dental injuries during general anaesthesia. Br Dent J 1996;180:255–58
15. Chidyllo SA, Zukaitis JA. Dental examinations prior to elective surgery under anesthesia. NY State Dent J 1990;56:69–70
16. Lee J, Choi J, Lee Y, Lee Y, Kim E, Kwon O, Hastings R. The Callander laryngoscope blade modification is associated with a decreased risk of dental contact. Can J Anaesth 2004;51:181–84
17. Chadwick RG, Lindsay SM. Dental injuries during general anaesthesia: can the dentist help the anaesthetist? Dent Update 1998;25:76–8
18. Vogel C. Dental injuries during general anaesthesia and their forensic consequences. Anesthetist 1979;28:347–49
19. Bucx M, Snijders C, van Geel R, Robers C, van de Giessen H, Erdmann W. Forces acting on the maxillary incisor teeth during laryngoscopy using the Macintosh laryngoscope. Anaesthesia 1994;49:1064–70
20. Rosenberg MB. Anesthesia-induced dental injury. Int Anesthesiol Clin 1989;27:120–25
21. Aromaa U, Pesonen P, Linko K, Tammisto T. Difficulties with tooth protectors in endotracheal intubation. Acta Anaesthesiol Scand 1988;32:304–7
22. Wheeler RC. Dental anatomy, physiology and occlusion. Toronto: JB Lippincott, 1974;3–24
23. Shafer WG, Hine MK, Levy BM. Oral pathology. Toronto: WB Saunders, 1983:406–78
24. Baum L, Lund MR, Philips RW. Textbook of operative dentistry. Toronto: WB Saunders, 1981:12–27
25. Boehm TK, Scannapieco FA. The epidemiology, consequences and management of periodontal disease in older adults. J Am Dent Assoc 2007;138suppl:26S–33S
26. Carranza FA. Glickman’s clinical periodontology. Toronto: WB Saunders, 1984:1–62
27. Carranza FA. Glickman’s clinical periodontology. Toronto: WB Saunders, 1984:192–299
28. White A, Kander P. Anatomical factors in difficult direct laryngoscopy. Br J Anaesth 1975;47:468–74
29. Yasny JS, Silvay G. The value of optimizing dentition before cardiac surgery. J Cardiothorac Vasc Anesth 2007;21:587–91
30. Johnson A, Lockie J. Anaesthesia and dental trauma. Anaesth Intensive Care 2005;6:271–2
31. Bartlett DW, Smith BG. Etiology and management of tooth wear: the association of drugs and medicaments. Drugs Today 1998;34:231–9
32. Bartlett DW. The role of erosion in tooth wear: aetiology, prevention and management. Int Dent J 2005;55(suppl 1):277–84
33. Scully C. Drug effects on salivary glands: dry mouth. Oral Dis 9:165–76
34. Ship JA, Hu K. Radiotherapy-induced salivary dysfunction. Semin Oncol 2004;31(suppl 18):29–6
35. Shiboski CH, Hodgson TA, Ship JA, Schiodt M. Management of salivary hypofunction during and after radiotherapy. Oral Surg Oral Med Oral Path Oral Radiol Endod 2007;103(suppl 66):e1–e19
36. Clockie C, Metcalf I, Holland A. Dental trauma in anaesthesia. Can J Anaesth 1989;36:675–80
37. Misra S, Tahmassebi JF, Brosnan M. Early childhood caries—a review. Dent Update 2007;34:556–58
38. Tooth eruption: the primary teeth. J Am Dent Assoc 2005; 136:1619
39. Windsor J, Lockie J. Anaesthesia and dental trauma. Anaesth Intensive Care 2008;9:355–7
40. Herlich A, Garber JG, Orkin FK. Complications in anesthesiology. 2nd edition. (Dental and salivary gland complications). Philadelphia: Lippincott-Raven Publishers, 1996:163–74
41. Gatt SP, Aurisch J, Wong K. A standardized, uniform and universal dental chart for documenting state of dentition before anaesthesia. Anaesth Intensive Care 2001;29:48–50
42. Al-Quran FA, Al-Dwalri ZN. Torus palatines and torus mandibularis in edentulous patient. J Comtemp Dent Pract 2006;7:112–9
43. Small RH, Ganzberg SI, Schuster AW. Unsuspected temporomandibular joint pathology leading to a difficult endotracheal intubation. Anesth Analg 2004;99:383–5
44. Bizzarri D, Giuffrida J. Improved laryngoscope blade designed for ease of manipulation and reduction of trauma. Anesth Analg 1958;37:231–2
45. Kimberger O, Fischer L, Plank C, Mayer N. Lower flange modification improves performance of the Macintosh, but not the Miller laryngoscope blade. Can J Anaesth 2006; 53:595–601
46. Watanabe S, Suga A, Asakura N, Takeshima K, Kimura T, Taguchi N. Determination of the distance between the laryngoscope blade and the upper incisors during direct laryngoscopy: comparisons of a curved, an angulated straight, and two straight blades. Anesth Analg 1994;79:638–41
47. Bito H, Nishiyama T, Higarhizawa T, Sakai T, Konishi A. Determination of the distance between the upper incisors and the laryngoscope blade during laryngoscopy: comparisons of the McCoy, the Macintosh, the Miller, and the Belscope blades. Masui 1998;47:1257–61
48. Salisbury P 3rd, Curtis J Jr, Kohut R. Appliance to protect maxillary teeth and palate during endoscopy. Arch Otolaryngol 1984;110:106–7
49. Skeie A, Schwartz O. Traumatic injuries of the teeth in connection with general anaesthesia and the effect of use of mouthguards. Endod Dent Traumatol 1999;15:33–6
50. Solazzi RW, Ward RJ. The spectrum of medical liability cases. Int Anesthesiol Clin 1984;22:43–59
51. Pollard BJ, O’Leary J. Guedel airway and tooth damage. Anesth Intensive Care 1981;9:395
52. Dornette WH, Hughes BH. Care of the teeth during anesthesia. Anesth Analg 1959;38:206–15
53. Dornette WH. Care of the teeth during endoscopy and anesthesia. Clin Anesth 1972;8:213–17
54. Neustein S, Beicke M. Ingestion of a fixed partial denture during general anesthesia. Anesth Prog 2007;54:50–1
© 2009 International Anesthesia Research Society
55. Kainuma M, Yamada M, Miyake T. Early application of the cross-suture splint to teeth avulsed at tracheal intubation [Letter]. Anesthesiology 1996;84:1516