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Dental injury in the operating room: What anesthesiologists need to know ?

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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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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%

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

Chadwick & Lindsay ,1998


Anesthetist + Dentist

Understanding the problem , appropriate


for patients most at risk

Significant reduce incidence of damage

during intubation

Chadwick & Lindsay, 1998


Incidence , frequency and distribution

of dental injury

Tewari et al , 2007


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


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


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


Crown and Bridgework

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


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


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


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


Early Treatment

Lost primary teeth

No treatment is required

(can affect underlying permanent tooth germ) 


Early Treatment


give rise to sensitivity , pain

need to be restored


Early Treatment


Mobile or displaced


May need



Early Treatment


or Avulsion






A First Aid for avulsed tooth

Is it permanent tooth?


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 )


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


Minimizing Dental

Trauma and Claim


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


Tooth protector ( mouth guard )

2-3 mm. thickness

Protect against tooth fracture and


Absorbing impact forces and spreading

loads across several teeth


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


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


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


Case presentation

Case presentation



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