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

Chadwick & Lindsay, 1998 Chadwick & Lindsay, 1998

Understanding the problem , appropriateUnderstanding the problem , appropriateprophylacticprophylactic

for patients most at riskfor patients most at risk

Significant reduce incidence of damageSignificant reduce incidence of damage during intubationduring intubation

Anesthetist + DentistAnesthetist + Dentist

Type of dental injurySurve

y freque

ncyFracture of crown and/or root 44.8 %

Luxation (loose, mobile) 20.8 %Avulsion (dislodgement) 20.8 %Other injury ; soft tissue laceration , prosthesis damage

13.6 %

Tewari et al , 2007

Newland & Ellis , 2007

Maxillary left central incisor (no.9)

may be the greatest risk of dental injury because of position

of laryngoscope

Factors predisposing to dental traumaFactors 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

Pre-existing poor dentition & dental prosthesisPre-existing poor dentition & dental prosthesis

Factors predisposing to dental traumaFactors predisposing to dental trauma

Caries, large restorationPeriodontal diseaseCrown and BridgeworkImplants Abnormally positioned teethMixed dentitionPrevious dental traumaAmelogenesis imperfectaDentinogenesis imperfecta

Caries, large restoration

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

Periodontal disease

Periodontal disease: Bony support of tooth is lost , teeth are dislodged more easily

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

Crown and Bridgework

Implants

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

Previous dental trauma

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

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

Abnormally positioned teeth

Mixed dentition

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

Amelogenesis imperfecta

Amelogenesis Imperfecta : enamel is poorly formedand the teeth are very weak

Dentinogenesis imperfecta

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

“ 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

Immediate search for

loose fragment

X-rays of theNeck and chest

If a portion of tooth is

dislodge

to minimize risk of

aspiration

Lost primary teeth

No treatment is required (can affect underlying

permanent tooth germ) 

Fracture

give rise to sensitivity , pain

need to be restored

Loosened,Mobile or displaced

Teeth

May needsplinting

Dislodgement or Avulsion

1.Replantation 2.Denture 3.Implantation

Is it permanent tooth?  

Yes No 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 )

A First Aid for avulsed tooth

1. HBSS 1. HBSS ((Hank’s Balanced Salt SolutionHank’s Balanced Salt Solution)) : best used, maintain vitality of: best used, maintain vitality of PDL cells for PDL cells for 24 hrs24 hrs..2. Milk :2. Milk : UHT; room temp. for 6 monthsUHT; room temp. for 6 months maintain vitality of PDL cells for maintain vitality of PDL cells for 3-6 hrs3-6 hrs, bacteria free, pH and , bacteria free, pH and osmolarity compatible with cellsosmolarity compatible with cells3. Saline : isotonic and sterile3. Saline : isotonic and sterile4. Saliva : incompatible osmolarity , pH and presence of bacteria5. Water : hypotonic, rapid cell lysis

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

2-3 mm. thickness2-3 mm. thickness

Protect against tooth fracture andProtect against tooth fracture and

dislodgementdislodgement

Absorbing impact forces and spreading Absorbing impact forces and spreading

loads across several teethloads across several teeth

Skeie & Schwartz ,1999Skeie & Schwartz ,1999

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 recommend

Suggest for high risk cases(implant , bridge)

Minimized Dental TraumaMinimized Dental Trauma

Preanesthetic evaluation : mouth and teeth (visual inspection and palpation)

Past dental treatment especially upper anterior teeth

Record finding Record finding in the patient ’s record in the patient ’s record chart (present of crownchart (present of crown//bridge, implant bridge, implant or loose tooth) or loose tooth)

Newland & Ellis, 2007

Standardized uniform Standardized uniform dental chartdental chart

Gatt et al, 2001

Record on dental chart for Record on dental chart for documenting state of dentition documenting state of dentition

before anesthesiabefore anesthesia

Absence of the record of Absence of the record of dental examination may make dental examination may make

a claim difficult to defenda claim difficult to defend

There is a difficult situation for intubation Possibility of dental damage

Patients must be informed about the possibility of dental damage

and sign consent

Especially presenting tooth mobility bridges, large restoration, malocclusion

and implant

Preoperative assessment

Johnson & Lockie , 2005

Dental trauma associated with anesthesia Dental trauma associated with anesthesia can’ t be avoidedcan’ t be avoided

Increase awareness of problemIncrease awareness of problemMore standardized dental assessmentMore standardized dental assessment

Patient education and advise Patient education and advise preoperativelypreoperatively

Can help to decreaseCan help to decrease trauma and claim trauma and claim