|Year : 2014 | Volume
| Issue : 1 | Page : 58-62
To assess and create awareness among anesthetists regarding prevention and management of injuries to the teeth and their associated structures during general anesthesia
Amita M Tiku1, Rahul J Hegde1, Lipika A Swain2, Falguni R Shah3
1 Department of Pediatric dentistry Bharati Vidyapeeth University Dental College and Hospital, Navi Mumbai, Maharashtra, India
2 Department of Anesthesiology, TNMC and B Y L Nair Hospital, Mumbai, Maharashtra, India
3 Consultant Anesthesiologist, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
|Date of Web Publication||15-Feb-2014|
Amita M Tiku
22 Milan Apts, Pali Road, Bandra West, Mumbai - 400 050, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: The aim of this study was to assess the awareness among anesthetists regarding prevention and management of injuries to the teeth and their associated structures during anesthesia. Study design, Materials and Methods: Fifty anesthetists practicing in various hospitals in Mumbai participated in this study. A questionnaire was devised and distributed among them. The completion of the questionnaire by the respondents was taken as their consent to participate in the study. Statistical analysis: The data thus collected was analyzed using statistical package Medcalc (Version 22.214.171.124). Results: The results showed that the injury to the oro-dental tissues is a common finding during anesthesia. The maxillary incisors underwent injuries more commonly than the mandibular incisors. Padding of the teeth was the most common precaution taken to prevent injuries to the teeth which, however, is not adequate. The management for such injuries was inadequate and in many cases, the patients' referral to a dentist was not considered post-operatively. Conclusion: Pediatric dentists can play a major role in creating the awareness among the anesthesia providers regarding prevention of oro-dental injuries during anesthesia.
Keywords: Anesthesia, awareness, dental injuries, management, prevention
|How to cite this article:|
Tiku AM, Hegde RJ, Swain LA, Shah FR. To assess and create awareness among anesthetists regarding prevention and management of injuries to the teeth and their associated structures during general anesthesia. J Indian Soc Pedod Prev Dent 2014;32:58-62
|How to cite this URL:|
Tiku AM, Hegde RJ, Swain LA, Shah FR. To assess and create awareness among anesthetists regarding prevention and management of injuries to the teeth and their associated structures during general anesthesia. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Nov 15];32:58-62. Available from: http://www.jisppd.com/text.asp?2014/32/1/58/127059
| Introduction|| |
One of the causes of traumatic injuries to teeth is during general anesthesia. Injuries to teeth during anesthesia happen most frequently during laryngoscopy. Injuries to lips and other soft tissues are also common during these procedures. Many studies have been found in literature about injuries during anesthesia and precautions to be taken for prevention and management of such injuries ,,,, Injuries to the teeth have been associated commonly with general anesthesia and specially during endotracheal intubation.  Trauma to the teeth have been suggested to occur during laryngoscopy or from use of airways, mouth openers, props, or gags.  Dental injuries have been said to occur during 1% of general anesthesia.  Although the injuries are most commonly reported to be sustained during laryngoscopy, they require intervention in only 2% of cases.  The incidence of peri-operative dental damage as per some retrospective studies has been found to range from 0.02% to 0.07%.  However, one prospective study has reported a much higher frequency of dental trauma as much as 12.1% and overall incidence of oral injuries as 18%.  Although there has been a lot of progress in intubation techniques, damage to teeth has been reported as the commonest cause of complaint against anesthetists abroad.  Certain pre-conditions like dental caries, periodontal disease, restored teeth , presence of crowns, or fixed partial dentures increase the risk of the teeth to injuries. Some age groups also predispose teeth to such injuries.  It has been suggested that although pre-operative assessment of dentition may guide anesthetists about risk of dental injury; the majority of the incidents are not associated with predicted difficult intubation. 
As a pediatric dentist while working on children under anesthesia, we can prevent and manage such injuries successfully. However, as general anesthesia is given to children more commonly for many other medical reasons, a dentist may not be present during such procedures. It would be, therefore, appropriate to increase the awareness regarding the management of traumatic injuries to the teeth during anesthesia among the anesthetists. As we interact frequently with anesthetists, we can be of utmost importance to create awareness among the anesthetists to reduce the incidence of such complications. Studies have been carried out abroad addressing the prevalence and incidence of traumatic injuries to the teeth during anesthesia. ,,, However, to our knowledge, no study has been reported in India to assess the awareness of the anesthetists related to prevention and management of such injuries. Therefore, it was decided to conduct a survey among the anesthetists practicing in Mumbai to assess their awareness regarding dental injuries during anesthesia and to create awareness among them regarding the same.
| Materials and Methods|| |
The study was conducted among some anesthetists practicing in various hospitals in Mumbai. A questionnaire was devised and distributed among 100 anesthetists, with a request to reply the anonymously filled proforma within one week. The questionnaire was designed in such a way that the first four questions were to know their experiences related to traumatic injuries to teeth and their associated structures during anesthesia. Questions four to nine were devised to assess the practices they followed to manage such an injury. And the last question was devised to know if they would be interested to update their knowledge regarding the same. A reminder was sent to the non-respondents. The completion of the questionnaire by the respondents was taken as their consent to participate in the study. The data thus collected were coded and analyzed using statistical package Medcalc (Version 126.96.36.199).
| Results|| |
Only 50 respondents filled and returned their questionnaire within the stipulated time-frame giving a response of 50%.
All the anesthetists performed risk assessment prior to the induction of anesthesia [Table 1]. In their experience, the most common dental injuries was lip injury (58%) followed by tooth loosening (28%) and fracture of the teeth (14%) respectively [Table 2]. Ninety-six percent of the respondents felt that injury to the teeth and its associated structures was seen most commonly during laryngoscopy procedure, 2% felt that injury happens during the endotracheal tube biting, and only 2% felt that the airway removal was a common cause of dental injury [Table 3].
|Table 3: The most common causes of oro-dental injuries during anesthesia|
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Forty-four percent respondents answered that the teeth which were injured most commonly were the maxillary left incisors, maxillary right incisors (26%), mandibular right incisors (22%), and the mandibular left incisors (8%) respectively [Table 4].
For the mobile teeth, during pre-anesthetic evaluation, 76% advised their removal prior to the induction, Twenty-four percent did not advise any treatment preoperatively but warned the patients about the possible complications [Table 5]. For the prevention of injuries to the teeth, 84% used padding, 6% used mouth guards, 2% used others like mouth props, and 8% did not use any measures respectively [Table 6]. For subluxated tooth during anesthesia procedure, 70% did complete self-removal of the tooth, 14% left the subluxated tooth without doing anything, and 12% sought dentist's assistance [Table 7]. For an avulsed tooth, 82% handed over the teeth to the relatives, 8% asked for dental assistance, 6% disposed the teeth, and only 4% stored it in media respectively [Table 8]. With regards to the measures taken after the dental injury, 56% sought dental assistance, 38% gave no emergency care for the dental injury, and 6% rendered symptomatic treatment for only soft tissue injuries respectively [Table 9]. It was observed that 94% of the anesthetists thought that they required to upgrade their knowledge and awareness regarding the prevention and management of injuries to the teeth and associated dental structures during anesthesia [Table 10].
|Table 5: Percentage of anesthetists referring patients for pre-operative extraction of mobile teeth|
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|Table 7: Measures taken by anesthetists for managing subluxated teeth during anesthesia|
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|Table 9: Measures taken for managing any other dental injuries during anesthesia|
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|Table 10: Number of anesthetists who wanted to increase their awareness related to dental injuries during anesthesia|
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| Discussion|| |
Dental injuries are common findings during endotracheal intubation, laryngoscopy, use of oro-pharyngeal airways, during the induction and withdrawal of general anesthesia, and due to the incorrect use of mouth openers, props, and mouth gags as well.  Although the common injuries to the front teeth arise from the pressure upon them during laryngoscopy for endotracheal intubation, they are avoidable when appropriate care is taken. , Bucx reported that the force applied on the maxillary incisors during laryngoscopy in adult patients was 49 Newtons on an average (4.99661 kg force).  Biting down vigorously upon the endotracheal tube or laryngeal mask airway (LMA) shaft during emergence from anesthesia or forceful removal of an airway, shivering during the recovery phase which may cause spasm of the masseter muscle leading to an excessive clenching of the teeth have also been associated as causes for injuries.  Enamel hypoplasia and dilaceration of the primary incisors after laryngoscopy in neonates are certain other complications, which have been reported. , Tooth injuries are said to range from micro-fractures of the natural tooth substance, actual avulsion, pulp necrosis, damage to crowns, and bridges. ,, Careless placement of the laryngoscope blade can cause lacerations of the lips, palate, and cheeks, and this can be very uncomfortable for the patient postoperatively. It has been suggested that soft paraffin ointments be applied to any cuts to minimize post-operative discomfort. ,
In our study, it was observed that the respondents felt that the lip injury was the commonest (58 %), followed by tooth loosening (28%) and fracture of teeth (14%) respectively.
According to Lockhart and colleagues, the teeth at risk were in the following order: Maxillary central incisors left (51%), right (16%), maxillary lateral incisors left (19%), right (8%), maxillary canines left (0%), right (5%) respectively.
Jaw-Jen Chen et al. reported that risk was as maxillary central incisor left (46.7%), right (13.3%); mandibular central incisor, right (2.2%); maxillary lateral incisor, left (20%), right (4.4%); mandibular lateral incisor, right (4.4%); maxillary canine, left (5.6%), right (1.1%); mandibular canine, right (2.2%) in that frequency.
In our study, the participants thought that the maxillary left incisor was the tooth most frequently injured followed by maxillary right incisors, lower right incisors, and lower left incisors respectively, which was also observed by Lockhart and his colleagues.
Before staring anesthesia, it is has been advised to make an evaluation of the dental state, any degree of difficulty to be expected in intubating the patient.  Use of fiberscope for endotracheal intubation has been recommended to reduce the incidence of damage of teeth during difficult intubation.  Others have suggested use of video laryngoscopy.  However, they may not be practically available in every set up. Some authors have advocated the attachment of a strip of poly foam to its flange to cushion the teeth and oral soft tissues. Gauze rolls and folded tape may reduce the chance of chipping teeth.  It has been suggested that adhesive plaster be applied to the laryngoscope blade.  Mouth guards have been tried by certain authors; however, its use remains controversial. It has been observed that their use had no significant effect on dental trauma associated with anesthesia. 
Certain recommendations to prevent injuries to the oro-dental tissues during anesthesia have been given.  Deciduous teeth about to exfoliate should be removed to prevent accidental dislodgement or otherwise their presence should be recorded. Utmost care needs to be taken to avoid displacement of the newly erupted permanent incisors of children. Teeth with multi-surface restorations are also at a risk and may fracture easily under force applied by a prop or mouth gag. Presence and position of crowns and bridges should be recorded. Proclined teeth are also susceptible to a levering effect when oro-pharyngeal airways are in place so care must be taken. 
It has been advised that in case of any dental injury, it is advisable to seek dental advice and document the findings. If the teeth are completely displaced from their sockets, they must be retained and kept in normal saline as possibility exists that they can be replaced if treatment is provided within hours.  Burton proposes that if the tooth is loosened, they should be returned back to their position by digital pressure and bone on either side be compressed and patient referred for dental opinion immediately and also avulsed tooth should be replanted immediately.  It has been said that a some proportion of dental injuries occur at the time of extubation in patients who have occluded their tracheal tube through biting, and this situation can be avoided by inserting a bite block.  Before planning for extubation, a soft roll of gauze can be placed on the biting surface of the patients mandibular molar and premolar region and should be large enough to be retrieved.  Mouth props and retractors should be placed carefully to prevent impinging on the tongue or other soft tissues. Suctions should be used carefully.  A complete dental check up to rule out dental injury should be carried out after extubation and recovery.
It has been highly recommended that the risk of damage to teeth should always be explained to the patients. 
As pediatric dentist works frequently on the children under general anesthesia, we can play a major role to reduce the incidence of such injuries in children by creating awareness among anesthesiologists.
In our study, the filling of the questionnaire itself was a factor for all the participants to realize that they need to update themselves regarding the precautions that can be taken to reduce incidence of such injuries. The senior-most anesthetists were informed about the guidelines, which are available and requested to convey to the staff working with them as it was difficult to gather all the anesthetists at the same time.  They were also told to inform patients to seek dental assistance for injuries, which can have impact if left untreated. However, creating awareness regarding such injuries on a large scale is warranted.
| Conclusions|| |
Injuries to teeth and associated structures can be minimized to a great extent if we understand risk factors and take appropriate measures. Also, informing the parent about the risk of dental injury and adequate documentation may reduce chances of litigation. Creating awareness among anesthetist will help them reduce such injuries while working for children in other surgical fields, thereby decreasing the morbidity rate.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]