Anesthesia Care: Strategies for Preventing Dental Injuries

Brent Lee, MD, MPH, FASA, Director, Clinical Excellence and Performance Improvement, North American Partners in Anesthesia, and Karen Fielder, RN, JD, Vice President, Chief Risk Officer, North American Partners in Anesthesia

Tooth damage, the most common injury related to surgical intubation, accounts for nearly 22 percent of anesthesiology claims, according to The Doctors Company Anesthesiology Closed Claims Study. This percentage, which has essentially stayed the same over the past 14 years, is particularly troubling—especially considering the efforts over the past 10 years to make intubation safer, improve intubation and airway devices, and refine anesthesia protocols.

The average dollar amount paid for dental injuries is still lower than for other types of anesthesia-related claims. From 2013 to 2018, data from The Doctors Company study showed that the mean indemnity for paid tooth damage claims was $2,600. Despite the relatively low amount for each claim, all claims contribute to the overall rising costs of medical malpractice insurance. It is, therefore, in everyone’s best interest—most importantly the patient’s—to keep the number of such incidents as low as possible.

Causes and Risks of Tooth Damage

A review of tooth damage claims closed by The Doctors Company from 2013 to 2018 indicates that most injuries are to the upper incisors and occur during endotracheal intubation. Damage can also occur when too much force is used during extubation. Risk factors that contribute to injuries include patient anatomy related to the mouth and jaw (e.g., a short neck, overbite, or airway challenges) and oral and dental health (e.g., severe gum recession, poor teeth condition, overbite, loose teeth, and periodontal disease). Patients with preexisting dental disease are much more likely to experience dental injury. Age is also a risk factor; patients 50 to 80 years old have the most injuries. Devices—especially rigid equipment used incorrectly such as laryngoscopes, oropharyngeal airways, bite blocks, suction devices, and dental props and mouth gags—can also cause tooth damage.¹

How to Reduce Dental Injuries and Related Claims

The following strategies can help anesthesia clinicians minimize tooth damage and consequently reduce filed dental claims:

Preanesthesia

• Review the patient’s medical records. Identify any history of previous experiences with anesthesia, specifically looking for any physical conditions that could have an impact on dental issues.
• Complete a thorough patient examination and dental assessment. Before anesthesia is administered, complete a preoperative examination to assess the patient’s dental health, evaluate vulnerable (loose or damaged) and missing teeth and soft tissue, and determine anesthesia risk factors that may increase the likelihood of dental injury.
• Discuss 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 preanesthesia exam (e.g., poor dentition, gum recession, or anatomical challenges). Convey the possibility of dental injury and trauma, especially if the patient is deemed high risk.
• Document findings and the patient conversation. On the preoperative assessment note, use a diagram to assist in recording the preoperative condition of the patient’s dentition and a description of the airway. (Dental diagrams may already be included in the EHR.) Fully document the shared decision-making conversation with the patient, including an explanation of the risks, benefits, and alternatives of the anesthetic plan. Have the patient sign an anesthesia consent form. Documenting in detail all physical findings, including a review of risks and a summary of the patient discussion, will help improve care during the procedure. It will also be useful in the future if the anesthesia clinician must defend the quality and level of care provided to the patient.
• Develop a tailored anesthesia plan. Create a plan that addresses findings and comorbidities discovered during the patient interview, physical exam, and review of the patient’s medical history. The plan should include preventive actions (e.g., inserting guards, bite blocks, or gauze) that will be taken to minimize dental injuries. It should also include mitigation strategies for patients who may be difficult to intubate, as they are more likely to have dental injury. Equipment must be available for emergency situations including airway obstruction causing difficulty intubating or ventilating the patient. Obstructive sleep apnea, neck swelling, hematomas, and laryngospasms are some possible causes of airway obstruction. Discuss the airway management plan with the surgical team to ensure that everyone is prepared if a difficulty is encountered.

During the Procedure
If the risk of dental injury is significantly high, place a tooth protector around or on the teeth prior to instrumentation of the airway. If using a video laryngoscope for intubation, carefully insert the laryngoscope and maintain awareness for any unintended dental pressure using a mouth/screen/mouth/screen viewing technique. After any intubation or manipulation of the airway, complete an inspection of the mouth, teeth, and lips, noting any damage. Document any observed injuries or absence thereof (atraumatic intubation) in the intraoperative record.

Post-anesthesia
After the procedure is complete, carefully inspect the teeth again following extubation and document any findings. This can be done in the operating room or recovery area. Prior to discharge and when the patient is fully awake, discuss any incidents, injuries, or interventions performed during surgery. If the patient is still sedated or groggy, share the full details—including what caused the problem—with a family member. Create a follow-up plan for the patient (including a dental consultation, if needed), and document any recommendations in the patient’s medical record.

Stay Aware

Anesthesia clinicians are well trained in using airway devices and incorporating proper safety measures in their anesthetic practices. They are committed to delivering safe, high-quality care and making the patient comfortable. Despite these best efforts, however, dental trauma can occur, leading to insurance claims and even litigation. Awareness of the risks and challenges that cause dental injury can help anesthesia clinicians avoid these problems in the future.

If you have any questions, contact The Doctors Company Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

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