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Dental injury in the operating room What
anesthesiologists need to know ?
Wanwimol Anawatchapan DDS, Graduate Diploma (
Endodontology ) Department of dentistry ,
Songkhlanakarin hospital
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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
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Anesthetist Dentist
Understanding the problem , appropriate prophylac
tic for patients most at risk
Significant reduce incidence of damage during
intubation
Chadwick Lindsay, 1998
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Incidence , frequency and distribution of
dental injury
Tewari et al , 2007
Type of dental injury Survey frequency
Fracture 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
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Incidence , frequency and distribution of
dental injury
Maxillary left central incisor (no.9) may be the
greatest risk of dental injury because of
position of laryngoscope
Newland Ellis , 2007
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Factors predisposing to dental trauma
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Factors 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
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Factors predisposing to dental trauma
Pre-existing poor dentition dental prosthesis

• Caries, large restoration
• Periodontal disease
• Crown and Bridgework
• Implants
• Abnormally positioned teeth
• Mixed dentition
• Previous dental trauma
• Amelogenesis imperfecta
• Dentinogenesis imperfecta

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Caries, large restoration
Caries, large restoration cavities made tooth
weaken and fractured more likely
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Periodontal disease
Periodontal disease Bony support of tooth is
lost , teeth are dislodged more easily
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Crown and Bridgework
Crown and Bridge prone to damage during
anesthesia , Bridge is readily displaced or
detached by force.
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Implants
Implants should be quite strong but if damaged
are expensive to replace
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Previous dental trauma
Previous dental trauma old trauma may have a
devitalized and more brittle tooth
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Abnormally positioned teeth
Abnormally positioned teeth are more likely to
be loaded and loosened , fractured or avulsed
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Mixed dentition
Mixed dentition 5-12 years with primary and
permanent teeth
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Amelogenesis imperfecta
Amelogenesis Imperfecta enamel is poorly
formed and the teeth are very weak
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Dentinogenesis imperfecta
Dentinogenesis Imperfecta dentine is poorly
formed , softer than usual , roots are slender
and very prone to fracture






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Early Treatment
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Early Treatment
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
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Early Treatment
Immediate search for loose fragment X-rays of
the Neck and chest
If a portion of tooth is dislodge to minimize
risk of aspiration
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Early Treatment
Lost primary teeth No treatment is required
(can affect underlying permanent tooth germ) 
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Early Treatment
Fracture give rise to sensitivity ,
pain need to be restored
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Early Treatment
Loosened, Mobile or displaced Teeth May
need splinting
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Early Treatment
Dislodgement or Avulsion 1.Replantation
2.Denture 3.Implantation
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Avulsion
A First Aid for avulsed tooth
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 )
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Storage media
1. HBSS (Hanks Balanced Salt Solution)
best used, maintain vitality of
PDL cells for 24 hrs. 2. Milk
UHT room temp. for 6 months
maintain vitality of PDL cells for
3-6 hrs, bacteria free, pH and
osmolarity compatible with cells 3. Saline
isotonic and sterile 4. Saliva incompatible
osmolarity , pH and presence of
bacteria 5. Water hypotonic, rapid cell lysis
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HBSS, UHT milk, Saline
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Minimizing Dental Trauma and Claim
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Minimizing dental trauma
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
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Tooth protector ( mouth guard )
2-3 mm. thickness Protect against tooth fracture
and dislodgement Absorbing impact forces and
spreading loads across several teeth
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Tooth protector ( mouth guard )
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
recommendSuggest for high risk cases(implant ,
bridge)
Skeie Schwartz ,1999
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Minimized Dental Trauma
Preanesthetic evaluation mouth and teeth
(visual inspection and palpation) Past dental
treatment especially upper anterior teeth Record
finding in the patient s record chart (present
of crown/bridge, implant or loose tooth)
Newland Ellis, 2007
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Standardized uniform dental chart
Record on dental chart for documenting
state of dentition before anesthesia
Absence of the record of dental examination may
make a claim difficult to defend
Gatt et al, 2001
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Preoperative assessment
There is a difficult situation for intubation
Possibility of dental damage
Especially presenting tooth mobility bridges,
large restoration, malocclusion and implant
Patients must be informed about the possibility
of dental damage and sign consent
Johnson Lockie , 2005
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Case presentation
Case presentation
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Case presentation
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Case presentation
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Case presentation
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Case presentation
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Case presentation
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Case presentation
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Conclusion
Dental trauma associated with anesthesia can
t be avoided
Increase awareness of problemMore
standardized dental assessmentPatient education
and advise preoperativelyCan help to decrease
trauma and claim
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