Protect Your Patient, Protect Yourself

Tod Tolan, MD, Oregon Anesthesiology Group, and Susan K. Palmer, MD, The Doctors Company Anesthesia Advisory Board Member.

Injuries to teeth, mouth, tongue, lips, and throat can occur during airway management without any negligence on the part of the anesthesia provider. Patients often present for surgery with teeth that are diseased1 or repaired, or they have bridges or dentures they refuse to remove, or severe gum disease that causes their remaining teeth to become loose or die postoperatively.

Dental injuries continue to be one of the most common claims against anesthesia providers. However, today’s choices for repair or replacement of lost crowns, chipped teeth, or cracked bridges may include expensive implantation of metallic jaw screws (dental implants) topped with perfect crowns. These expensive multi-stage procedures may be preferred by patients—especially if they expect that the anesthesia provider will bear the expense.

One way that anesthesia providers can decrease claims for expensive repairs to teeth is to perform and document presurgical dental exams. Following these suggestions may prevent a patient from bringing a claim against you:

  1. Inform the patient during your consent discussion that all teeth are at risk during general anesthesia and that diseased and repaired teeth are at greater risk for damage than normal healthy teeth.
  2. Perform and record a simple dental examination before and after anesthesia care. Revise your preanesthesia records to include a descriptive dental section that is easy to use.2
  3. Use oral protective devices to safeguard teeth, especially prominent front incisors, during and after general anesthesia. Teeth can be injured or lost during anesthesia and during emergence clenching.
  4. Plan intubation procedures carefully using intubation techniques that do not touch the front incisors (if possible).
  5. Be sure that postanesthesia care unit (PACU) nurses record all dental complaints or oral bleeding and that the nurses inform the anesthesia provider. Insist that an anesthesia team member examine the patient’s teeth and evaluate any complaint before the patient leaves the PACU area. Radiologic studies may be necessary if a patient reports that a tooth or fragment is missing, but it is not found.

Because even planned regional or local cases sometimes require airway manipulation, every patient should have a preanesthesia dental evaluation.

Claims for dental injury during anesthesia care are overwhelmingly about the front incisors (uppers and lowers), as illustrated below by the experience of claims in a large anesthesia private practice group.

Teeth Chart Diagram

Anesthesia providers can add a simplified diagram of the upper and lower incisors—similar to the one shown below—to quickly record the condition of a patient’s front teeth.

Incisors Diagram

Preventing Patient Injury
Protect maxillary and mandibular incisors during rigid laryngoscopy. Athletic mouth guards (if the patient already has a pre-molded guard) can protect upper incisors. Otherwise, commercial or homemade tooth guards can protect upper or lower incisors from the metal laryngoscope blade.

Prepare for emergence clenching. Patients can bite down on any type of midline airway. LMA, Guedel airway, or endotracheal tubes, when positioned in the midline, prevent the molars from occluding. This leaves the upper and lower incisors to bear the brunt of extraordinary clenching pressures, especially during emergence from general anesthesia.

Shift clenching pressures posteriorly and away from your patient’s incisors by inserting homemade or commercial bite blocks between the molars on at least one side of the mouth. Healthy premolars are designed to withstand the excess pressures of clenching (whereas incisors may loosen or break). Some commercially available devices include dental incisor pads and intermolar bite blocks.

Anesthesia providers should anticipate airway problems and modify difficult intubations in order to prevent oral injuries. Postoperative designation of a difficult airway will usually not excuse an anesthesia provider who is working in a nonemergent situation. By documenting the condition of a patient’s front incisors and using tooth guards or intermolar bite blocks, an anesthesia provider may prevent injury to any of the incisors and will be in a favorable defensive position if a dental claim is made.

The National Practitioner Data Bank requires physicians to report the incident if a patient makes a written demand for dental repair that is subsequently paid by the physician, the corporation, or the insurance provider.


  1. Warner ME, Benenfeld SM, Warner MA, Schroeder DR, Maxson PM. Perianesthetic dental injuries: frequency, outcomes, and risk factors. Anesthesiology. 1999;90(5):1302-05.
  2. Buffington CW, Vallejo MC. A simple preanesthesia dental examination. Anesthesiology. 2006 104(1);212-213.

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 healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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