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Dental injury in the operating room: What anesthesiologists need to know ?. Wanwimol Anawatchapan DDS, Graduate Diploma ( Endodontology ) Department of dentistry , Songkhlanakarin hospital. Incidence of perianesthetic dental injury ( PDI ) varies from 0.04% - 12.08%

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slide1

Dental injury in the operating room:

What anesthesiologists need to know ?

Wanwimol Anawatchapan DDS, Graduate Diploma ( Endodontology )

Department of dentistry , Songkhlanakarin hospital

slide2

Incidence of perianesthetic dental injury (PDI) varies from 0.04% - 12.08%

The most frequent anesthesia-related cause for claims, approximately one third of all claims

Chadwick & Lindsay ,1998

slide3

Anesthetist + Dentist

Understanding the problem , appropriate

prophylactic

for patients most at risk

Significant reduce incidence of damage

during intubation

Chadwick & Lindsay, 1998

slide4

Incidence , frequency and distribution

of dental injury

Tewari et al , 2007

slide5

Incidence , frequency and distribution

of dental injury

Maxillary left central incisor (no.9)

may be the greatest risk of dental injury because of position of laryngoscope

Newland & Ellis , 2007

slide6

Factors predisposing

to dental trauma

factors predisposing to dental trauma
Factors predisposing to dental trauma
  • Emergency
  • Difficult to intubation
    • Restricted mouth opening
    • Decreased mandibular mobility
    • Large tongue
    • Poor visualization of the hypopharynx
  • Pre-existing poor dentition and

dental prosthesis

Newland & Ellis, 2007

factors predisposing to dental trauma1
Factors predisposing to dental trauma

Pre-existing poor dentition & dental prosthesis

Caries, large restoration

Periodontal disease

Crown and Bridgework

Implants

Abnormally positioned teeth

Mixed dentition

Previous dental trauma

Amelogenesis imperfecta

Dentinogenesis imperfecta

caries large restoration
Caries, large restoration

Caries, large restoration: cavities made tooth weaken and fractured more likely

periodontal disease
Periodontal disease

Periodontal disease: Bony supportof tooth is lost , teeth are dislodged more easily

slide11

Crown and Bridgework

Crown and Bridge :prone to damage during anesthesia , Bridge is readily displaced or detached by force.

implants
Implants

Implants :should be quite strong but if damaged are expensive to replace

previous dental trauma
Previous dental trauma

Previous dental trauma:old trauma may have a devitalized and more brittle tooth

abnormally positioned teeth
Abnormally positioned teeth

Abnormally positioned teeth : are more likely to be loaded and loosened , fractured or avulsed

mixed dentition
Mixed dentition

Mixed dentition: 5-12 years with primary and permanent teeth

amelogenesis imperfecta
Amelogenesis imperfecta

Amelogenesis Imperfecta: enamel is poorly formed

and the teeth are very weak

dentinogenesis imperfecta
Dentinogenesis imperfecta

Dentinogenesis Imperfecta : dentine is poorly formed , softer than usual , roots are slender and very prone to fracture

slide19

Early Treatment

“ When injury occurred

dental consult may reduce damage”

Guideline for the management of

traumatic dental injuries

“ Fracture , Luxation , Avulsion of

permanent teeth ”

The International Association of Dental Traumatology : IADT, 2007

slide20

Early Treatment

Immediate search for loose fragment

X-rays of the

Neck and chest

If a portion of tooth is dislodge

to minimize risk of aspiration

slide21

Early Treatment

Lost primary teeth

No treatment is required

(can affect underlying permanent tooth germ) 

slide22

Early Treatment

Fracture

give rise to sensitivity , pain

need to be restored

slide23

Early Treatment

Loosened,

Mobile or displaced

Teeth

May need

splinting

slide24

Early Treatment

Dislodgement

or Avulsion

1.Replantation

2.Denture

3.Implantation

slide25

Avulsion

A First Aid for avulsed tooth

Is it permanent tooth?

YesNo

Pick up by the crown (Avoid touching the root) Not replant (risk of injure to

underlying permanent tooth germ)

Tooth can be reposition immediately?

Yes Consult dentist for reposition + splinting

No ( loose tooth could be airway risk)

Place the tooth in a suitable storage media consult dentist later

( HBSS , Milk or normal saline )

slide26

Storage media

1. HBSS (Hank’s Balanced Salt Solution)

: best used, maintain vitality of

PDL cells for 24 hrs.

2. Milk :UHT; room temp. for 6 months

maintain vitality of PDL cells for

3-6 hrs, bacteria free, pH and

osmolarity compatible with cells

3. Saline : isotonic and sterile

4. Saliva : incompatible osmolarity , pH

and presence of bacteria

5. Water : hypotonic, rapid cell lysis

slide28

Minimizing Dental

Trauma and Claim

slide29

Minimizing dental trauma

Devices :Absorb or distribute force on teeth

Adhesive plaster

apply to laryngoscope blade

Gauze roll and folled tape

Tooth protector (mouth guard)

Owen & Waddell-Smith , 2000

slide30

Tooth protector ( mouth guard )

2-3 mm. thickness

Protect against tooth fracture and

dislodgement

Absorbing impact forces and spreading

loads across several teeth

slide31

Tooth protector ( mouth guard )

10 years review of dental injury in hospital

use of mouth guard had no sig. effect on dental trauma associated anesthesia

Routine use of mouth guard is not recommendSuggest for high risk cases(implant , bridge)

Skeie & Schwartz ,1999

minimized dental trauma
Minimized Dental Trauma

Preanesthetic evaluation : mouth and teeth (visual inspection and palpation)

Past dental treatment especially upper anterior teeth

Record finding in the patient ’s record chart (present of crown/bridge, implant or loose tooth)

Newland & Ellis, 2007

slide33

Standardized uniform dental chart

Record on dental chart for documenting state of dentition before anesthesia

Absence of the record of dental examination may make a claim difficult to defend

Gatt et al, 2001

slide34

Preoperative assessment

There is a difficult situation for intubation Possibility of dental damage

Especially presenting tooth mobility bridges, large restoration, malocclusion and implant

Patients must be informed about the possibility of dental damage and sign consent

Johnson & Lockie , 2005

slide35

Case presentation

Case presentation

slide42

Conclusion

Dental trauma associated with anesthesia can’ t be avoided

Increase awareness of problemMore standardized dental assessmentPatient education and advise preoperativelyCan help to decrease trauma and claim

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