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

1. Dental injury in the operating room: What anesthesiologists need to know ? Wanwimol Anawatchapan DDS, Graduate Diploma ( Endodontology ) Department of dentistry , Songkhlanakarin hospital

2. 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

3. Anesthetist + Dentist Understanding the problem , appropriate prophylactic for patients most at risk Significant reduce incidence of damage during intubation Chadwick & Lindsay, 1998

4. Incidence , frequency and distribution of dental injury Tewari et al , 2007

5. 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

6. Factors predisposing to dental trauma

7. 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

8. 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

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

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

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

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

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

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

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

16. Amelogenesis imperfecta Amelogenesis Imperfecta: enamel is poorly formed and the teeth are very weak

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

18. Early Treatment

19. 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

20. 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

21. Early Treatment Lost primary teeth No treatment is required (can affect underlying permanent tooth germ) 

22. Early Treatment Fracture give rise to sensitivity , pain need to be restored

23. Early Treatment Loosened, Mobile or displaced Teeth May need splinting

24. Early Treatment Dislodgement or Avulsion 1.Replantation 2.Denture 3.Implantation

25. 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 )

26. 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

27. HBSS, UHT milk, Saline

28. Minimizing Dental Trauma and Claim

29. 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

30. Tooth protector ( mouth guard ) 2-3 mm. thickness Protect against tooth fracture and dislodgement Absorbing impact forces and spreading loads across several teeth

31. 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

32. 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

33. 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

34. 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

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42. 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