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An Anesthesiologist’s Guide to Decreasing Dental Injury Claims

In November 2012, The Doctors Company conducted a study of 507 anesthesia claims that occurred between 2007 and 2012. Our analysis showed that tooth damage was the major injury in 23 percent of the claims.

Dental damage continues to be the most common cause of malpractice actions against anesthesiologists. Our Anesthesia Advisory Board outlined the following recommendations.

Preoperative Evaluation
All panel participants advocated that the anesthesiologist should conduct a thorough preoperative evaluation of a patient’s mouth. To help identify dentition that is particularly at risk, the evaluation should include:

  • A review of the patient’s dental history as well as an examination of his or her mouth
  • A specific discussion with the patient about any existing dentures, bridges, or caps
  • Particular scrutiny of the patient’s upper front incisors—the most likely teeth to be injured during the perioperative period—including an inspection of the teeth for preexisting damage and a preop note recording any existing chips or missing teeth

Some panelists recommended using preprinted dental diagrams to help eliminate frivolous claims. The diagrams are useful for anesthesiologists or patients to note specifically where abnormalities or preexisting injuries exist.

Informed Consent
Because dental damage commonly occurs, the informed consent should specifically mention this possibility. Give a brief description of how and why the intubation process may cause pressure on the teeth. By forewarning patients about the possibility of a problem, you decrease the likelihood of their being surprised or angry if damage occurs.

If any dental problems are identified preoperatively, the need to discuss the possibility of tooth damage becomes all the more critical. During preanesthesia evaluation, share information with the patient about any problems you identify. Be as precise as possible about the options for dealing with particularly vulnerable teeth.

One possibility is for surgery to take place as scheduled, with the patient agreeing in writing beforehand that his or her anesthesiologist cannot be held responsible for injuring teeth that are already damaged. Another option is to encourage the patient to cancel surgery until a professional dental examination and repair can be accomplished. In any case, uncomfortable as it may be, tell the patient in a straightforward way that no payment will be made for preexisting dental work damage or dental conditions.

Circumventing Anger
Most claims for dental damage occur because of problems with teeth that have not been identified preoperatively. For this reason, it is imperative to inform patients in advance that accidental dental injury is a risk of general anesthesia—both from intubation and postoperative biting on plastic oral airways.

Prior to discharge, make every effort to discuss any injury as soon as possible. Patients are more likely to become angry if they feel you are ignoring them or refusing to acknowledge responsibility for injured teeth or dental work.

Preventive Procedures
One panel participant discussed a system that virtually eliminated dental injury claims for a large practice group. The system includes the following steps:

  • Designate an anesthesiologist to contact any patient who complains of dental injuries. Having a mediator limits emotional interaction between the invovled patient and anesthesiologist.
  • Express empathy about the dental injury, but explain that damage can occur with the most expert practitioner.
  • Offer the injured patient a dental evaluation that is paid for by the anesthesia group.
  • Obtain a written estimate for necessary dental work, then negotiate an agreement to either reimburse the patient for the work required or issue a check to cover the expense of the work to be done at a later date.
  • Ask the patient to sign a liability release indicating that a check is accepted as payment in full for injuries.

You can also take the following steps:

  • Arrange in advance for a community dentist or oral surgeon to provide impartial consultations for a reasonable fee.
  • Avoid financial conflicts of interest by having the evaluating dentist or oral surgeon agree not to perform the dental repair.
  • Obtain a detailed, written report regarding the exact repair work necessary, and have the anesthesiologist or a designee phone other dentists to request verbal estimates. By obtaining an average range, you can make a reasonable offer to the patient for covering all or a portion of repair expenses.

Important NPDB Info
Medical professional liability insurers are required to report all claims settlements to the National Practitioner Data Bank (NPDB). Therefore, if an anesthesiologist insured by The Doctors Company asks us to pay a dental injury claim, the settlement will be reported to the NPDB. Settlements paid by an individual physician (not a corporation) do not require NPDB notification. Claims representatives from The Doctors Company can help guide you through the process and make sure your liability is minimized.

Conclusion
Although dental injuries can be decreased through the use of plastic dental guards, nasal airways, and early removal of oral airways, dental damage remains a fact of life for anesthesiologists. The techniques described in this article can minimize inconvenience and help alleviate legal actions that arise when dental damage occurs.

Claims representatives from The Doctors Company can assist you by acting as impartial negotiators with patients, helping to obtain dental repair estimates, and furnishing you with liability release forms.

 

By Ann S. Lofsky, MD (deceased), Anesthesia Consultant and Board Member Emeritus; updated by Pamela Willis, BSN, JD, Patient Safety Risk Management Account Executive.

 


 


Panel Members
Panel members who reviewed the cases are all board certified anesthesiologists: Lyndon Busch, MD, Texas; Mary Craddock, MD, Maryland; Michael Hiller, MD, Texas; Bruce Kingsley, MD, Arizona; Ann S. Lofsky, MD, California; Cherie Mohrfeld, MD, California; Howard Vincent, MD, California; Elliot Wohlner, MD, Colorado.


 

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J9121 3/13


FIRST IN PATIENT SAFETY   |    www.thedoctors.com/patientsafety

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