Anesthesiologists must consider a variety of factors when administering anesthesia to ensure the highest level of patient safety. One often overlooked area is the prevention of dental injuries during procedures. Although relatively rare, dental injuries can have serious clinical consequences, such as pain and infection, and significant financial and legal implications. Adopting preventive measures is paramount to mitigate the risk of such occurrences and to uphold the highest standards of care.¹
Nearly a third of the CAP claims filed against our anesthesiologists during a 10-year period from January 1, 2006, through December 31, 2017, involved tooth trauma. Although many of the cases concerned patients with pre-existing dental conditions, the physician documentation failed to include this information, and omitted any discussions regarding the risks of dental injury. While these types of claims typically result in lower dollar amounts paid as compared to other anesthesia-related claims, ultimately all claims impact the increased costs of medical malpractice.²
Understanding the Risk Factors
Dental injuries can occur during various medical procedures, including endotracheal intubation, insertion of laryngeal mask airways, and facial surgeries. Several factors contribute to the risk of dental trauma, including:3,4
- Anatomical Variations: Individual differences in dental structure and jaw alignment can increase vulnerability to injury.
- Procedure Complexity: The complexity and duration of the procedure influence the likelihood of inadvertent trauma.
- Patient Characteristics: Factors such as age, dental health, and presence of comorbidities can affect the susceptibility to injury.
Proactive Measures for Prevention
Preoperative Assessment:
Thorough preoperative assessment plays a pivotal role in identifying patients at higher risk of dental injuries. This assessment should include a comprehensive dental history, examination of the oral cavity, and consideration of radiographic imaging when necessary. Make sure to document any missing or loose teeth, dental work, condition of the gums, tongue, and the upper palate.2,3
Informed Consent:
During your informed consent discussion, be sure to cover dental health, anatomy, and risks with the patient. Ask the patient about known dental problems and dental history. Inform the patient of any relevant issues found during the preoperative exam (e.g., poor dentition, gum recession, or anatomical challenges). Advise on the risk of dental injury and trauma, especially if the patient is deemed high risk. Document the discussion with the patient and include your explanation of the risks, benefits, and alternatives of the anesthetic plan. Accurate and thorough documentation of the patient discussion and the preoperative assessment not only helps improve care during the procedure, but can also be useful should the provider need to defend the care provided to the patient.
Communication With Dental Professionals:
Collaboration with dental professionals can provide valuable insights into the patient's oral health status and aid in developing tailored strategies for injury prevention. Consulting with a dentist or oral surgeon may be particularly beneficial for patients with pre-existing dental conditions or those undergoing extensive facial procedures.
Utilization of Protective Devices:
The use of protective devices such as mouth guards or dental stents during intubation and other airway management procedures can effectively shield the teeth and reduce the risk of trauma. These devices should be carefully selected and appropriately sized to ensure optimal protection without compromising airway management.
Optimal Technique and Equipment:
Adherence to established guidelines for airway management techniques and utilization of appropriate equipment are essential for minimizing the risk of dental injuries. Techniques that minimize excessive force and movements, and use of specialized instruments designed to reduce trauma should be prioritized.³
Continuous Monitoring and Vigilance:
Continuous monitoring of the patient's airway and vigilant observation for signs of dental trauma throughout the procedure are critical preventive measures. Prompt recognition of any potential injury allows for timely intervention and mitigates further complications.4
Conclusion
Preventing dental injuries in anesthesiology requires a proactive and sometimes multidisciplinary approach that encompasses preoperative assessment, collaboration with dental professionals, utilization of protective devices, adherence to optimal techniques, and vigilant monitoring. By incorporating these preventive measures into clinical practice, anesthesiologists can significantly reduce the incidence of dental trauma and related claims, and uphold the highest standards of patient safety.
Monica Ludwick, Pharm.D., is a Risk Management and Patient Safety Specialist. Questions or comments related to this article should be directed to MLudwick@CAPphysicians.com.
¹Apfelbaum, J. L., Hagberg, C. A., Caplan, R. A., Blitt, C. D., Connis, R. T., Nickinovich, D. G., Hagberg, C. A., Caplan, R. A., Benumof, J. L., Berry, F. A., Blitt, C. D., Bode, R. H., Cheney, F. W., Connis, R. T., Guidry, O. F., Nickinovich, D. G., Ovassapian, A., & American Society of Anesthesiologists Task Force on Management of the Difficult Airway (2013). Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology, 118(2), 251–270. https://doi.org/10.1097/ALN.0b013e31827773b2. Accessed 3/8/24
²Kichler, D. Focused review: A look into Anesthesia. Risk Management and Patient Safety News, p.1. May 2020. Focused Review: A Look into Anesthesia | The Cooperative of American Physicians (capphysicians.com). Accessed 3/8/24.
³Yasny, Jeffrey S. DDS. Perioperative Dental Considerations for the Anesthesiologist. Anesthesia & Analgesia 108(5):p 1564-1573, May 2009. | DOI: 10.1213/ane.0b013e31819d1db5. Accessed 3/8/24
4Kotani T, Inoue S, Kawaguchi M. Perioperative Dental Injury Associated With Intubated General Anesthesia. Anesth Prog. 2022;69(1):3-9. doi:10.2344/anpr-68-03-02. Accessed 3/8/24