Key points

  • Dental damage is the leading cause of complaint and medicolegal claims against anaesthetists.

  • Direct laryngoscopy is implicated in most cases of dental injury.

  • Severe periodontitis is an independent risk factor for cardiovascular disease.

  • A thorough preoperative dental assessment, explanation of risk, and clear documentation in the anaesthetic record is essential, particularly in individuals with risk factors for dental injury.

  • Departments should have an agreed management pathway for patients who have sustained dental injury as prompt treatment can improve tooth survival.

Anaesthetists routinely instrument patients' airways and may inadvertently cause dental injury. Detailed knowledge of dental anatomy and development, risk factors for dental injury and its management, however, is often lacking. Dental injury remains the most common area for complaint and litigation against anaesthetists. The cost and complexity of treatment and restorative dentistry has significantly increased in the last 5 yr. This article aims to review these topics to aid anaesthetists in making accurate preoperative dental assessments, provide appropriate consent, minimize the risk of perioperative dental injury, and manage it correctly, should it occur.

Development and anatomy of teeth

The role of teeth primarily concerns the processes of mastication and digestion but extends to provision of structural support to facial architecture, influencing facial aesthetics, and facilitation of speech.

Dental buds of primary (interchangeably called milk or deciduous) teeth develop from the 6th week in utero, forming in the opposing maxillary and mandibular bones. Adult teeth begin to develop behind their primary counterparts from 20 weeks in utero but do not undergo calcification until early infancy. ‘Primary eruption’ is the first appearance of teeth in infants, and occurs around the age of 6–12 months. This first dentition comprises 20 teeth (8 incisors, 4 canines, and 8 molars) (Fig. 1a).

Fig 1

(a) Paediatric and adult dentition. (b) Palmer notation for paediatric and adult dentition.

Fig 1

(a) Paediatric and adult dentition. (b) Palmer notation for paediatric and adult dentition.

Tooth development starts with formation of the crown. Completion of the root lags behind by many months or even years, rendering them prone to injury for some time. The maxillary incisors are the first to undergo full calcification by ∼18 months of age, while the last stage of molar root development is usually completed by 3 yr. Primary teeth begin to fall out (termed ‘exfoliation’) by the age of 6 to allow eruption of the permanent dentition. A period of mixed dentition follows and may last until the age of 12, when complete exfoliation of all primary teeth has usually occurred.

Development of permanent teeth variably lasts into late adolescence or early adulthood, with root formation usually completed in the early part of the third decade of life. Complete permanent dentition consists of 32 teeth, with each quadrant containing, in antero-posterior orientation, one central and one lateral incisor, one canine, two premolars, and the first, second, and third molars (Fig. 1a).

Structure of individual tooth

Each tooth is made up of a crown (the visible portion projecting into the mouth) and a root. The root is anchored into the jawbone by the periodontal apparatus (Fig. 2).

Fig 2

Tooth structure.

Fig 2

Tooth structure.

Teeth are subjected to immense loads generated by the muscles of mastication. The forces exerted on posterior teeth during normal chewing are ∼70–150 N, but may exceed 800 N1 during involuntary tooth grinding (bruxism). Their multi-layered structure and anchorage into the jawbones offers teeth some protection from these common stressors.

The crown

The crown is covered by enamel, a translucent, highly mineralized substance recognized as the hardest tissue in humans, albeit at the expense of brittleness. Produced by ameloblasts which lose function once a tooth is fully developed, damaged enamel cannot be regenerated.

The bulk of the tooth is formed by yellowish dentine—a bonelike, porous matrix of fluid-containing tubules. Its composition (60% mineral, 20% protein including type 1 collagen) provides flexibility and allows absorption of the forces encountered during mastication.

Dentine is produced throughout the tooth's lifespan by cells in the underlying pulp, which occupies the central part of the crown and root canals. Pulp also contains neurovascular tissue and performs nutritive, sensory, and restorative functions. The amount of pulp decreases with age and dental disease, resulting in diminished regenerative capacity.

The root and periodontium

Incisors are single-rooted, while premolars and molars have two to three roots. The root is covered by cementum, a collagen–proteoglycan substance structurally akin to bone. A key part of the periodontal apparatus, cementum forms crucial bonds between the root and alveolar bone while preventing the resorption of the root into bone.

The periodontium is the unit supporting each tooth within its bony socket. In addition to cementum, this unit consists of periodontal ligaments (PDL), alveolar bone, and the gingiva.

PDL cells have fibroblast and osteoblast-like functions, forming the PDLs. These wrap around the dental root in a sling-like fashion, anchoring it into the bone while allowing small physiological movements to withstand the forces of mastication.

Alveolar bone is named after the bony sockets (alveoli) within it that accommodate individual teeth. It provides anchorage and, together with the gingival epithelial cuff, acts as a shock-absorber by dissipating forces away from teeth.

Dental disease

Dental disease is common, affecting 15–20% of middle-aged individuals and increasing significantly above the age of 65. Bacteria found in plaques that lie either above (dental caries) or below the dental margin (periodontitis) cause infection which weakens teeth and periodontium, ultimately leading to tooth loss. Interaction between host and microbial factors determines the severity of disease. Some common medical conditions predispose to dental disease and these should be considered in individuals who present with severe periodontitis (Table 1). Studies indicate that severe periodontitis predisposes to cardiovascular disease due to endothelial dysfunction and systemic inflammation caused by seeding of bacterial endotoxins during chewing.2

Table 1

Factors associated with periodontitis. The order of associated factors has been amended to present the most significant factors first, as suggested by the reviewers

Predisposing/risk factors 
 Smoking Single biggest modifiable risk factor; promotes cytokine proliferation and inflammation, connective tissue destruction 
 Poor oral hygiene Leads to a favourable environment for bacterial growth 
 Diet Sugary and acidic conditions promote bacterial growth 
 Substance misuse Alcohol, (Meth)amphetamines, and opiates may cause xerostomia; cocaine (mucosal application makes tissues susceptible); poor oral hygiene 
 Glycaemic control 
  Xerostomia (reduced salivary flow) Age-related
Sjogren's syndrome
Radiotherapy
Pharmacologically induced (see ‘Drugs’ and ‘Substance misuse’) 
  Drugs Dry mouth: antidepressants, antihypertensivesGingival hypertrophy (difficult to maintain oral hygiene): anticonvulsants, calcium channel blockers, cyclosporine 
  Genetic predisposition  
  Anxiety/stress  
Associated systemic disorders 
 Diabetes mellitus Multifactorial aetiology (microvascular disease, hyperglycaemia, immune dysfunction) 
 Autoimmune conditions Rheumatoid arthritis, Crohn's disease, Sjogren's syndrome 
 Immunocompromise HIV, hypogammaglobulinaemia, haematological malignancies, and their treatments 
 Down syndrome Likely multifactorial (reduced salivary flow, immune deficiency) 
 Connective tissue diseases Ehlers–Danlos syndrome, Marfans disease 
Predisposing/risk factors 
 Smoking Single biggest modifiable risk factor; promotes cytokine proliferation and inflammation, connective tissue destruction 
 Poor oral hygiene Leads to a favourable environment for bacterial growth 
 Diet Sugary and acidic conditions promote bacterial growth 
 Substance misuse Alcohol, (Meth)amphetamines, and opiates may cause xerostomia; cocaine (mucosal application makes tissues susceptible); poor oral hygiene 
 Glycaemic control 
  Xerostomia (reduced salivary flow) Age-related
Sjogren's syndrome
Radiotherapy
Pharmacologically induced (see ‘Drugs’ and ‘Substance misuse’) 
  Drugs Dry mouth: antidepressants, antihypertensivesGingival hypertrophy (difficult to maintain oral hygiene): anticonvulsants, calcium channel blockers, cyclosporine 
  Genetic predisposition  
  Anxiety/stress  
Associated systemic disorders 
 Diabetes mellitus Multifactorial aetiology (microvascular disease, hyperglycaemia, immune dysfunction) 
 Autoimmune conditions Rheumatoid arthritis, Crohn's disease, Sjogren's syndrome 
 Immunocompromise HIV, hypogammaglobulinaemia, haematological malignancies, and their treatments 
 Down syndrome Likely multifactorial (reduced salivary flow, immune deficiency) 
 Connective tissue diseases Ehlers–Danlos syndrome, Marfans disease 

Spread of periodontal infection

Spread of infection results from a breakdown in local and systemic defences. Spread can result in either localized complications, systemic seeding of the infection, or both. Supragingival plaques spread infection to dental pulp, resulting in pulpitis which can ultimately perforate alveolar bone and cause abscess formation. Infection in subgingival plaques leads to gingivitis, periodontal abscesses, and spreading infection to the orofascial planes of the head and neck. Anaesthetic considerations for patients with dental abscesses are covered elsewhere.3

Dental disease in children

Primary teeth are particularly vulnerable to injury as their enamel and dentine is thin. Equally, as root development lags behind, alveolar attachment is weaker. Due to the proximity of primary dental roots to the non-calcified permanent crowns, damage to primary teeth—either traumatic or carious—may directly affect the development of the underlying successor, potentially causing disturbance of growth or abnormal shape of the permanent tooth.

Restorative dentistry

The range of restorative and reconstructive treatments has vastly expanded over the last decade (Tables 2 and 3). Moreover, with increasingly sophisticated materials used, recognition of these vulnerable restorations and prostheses is becoming more difficult. The presence of restorative treatments should alert the anaesthetist not only to the potential for damage to the prosthesis, but also to the presence of underlying periodontal disease.

Table 2

Restorative and reconstructive dental treatments. Natural lifespan of most treatments ∼10–15 yr unless indicated specifically

Type of treatment Description and associated problems 
Direct restoration (cavity filled in situ 
 ‘Filling’ Usually made from amalgam, gold, or composites (‘white fillings’) 
Prone to expansion or shrinkage when setting, leading to tooth fracture or further decay 
Approximate lifespan 7–12 yr 
Indirect restorations (filling created ex situ 
 Inlays/onlays Gold or porcelain. Inlay is a filling made and set outside the mouth, then bonded and thus is less prone to expansion or shrinkage. Onlay refers to an inlay which covers a dental cusp 
 Crown Commonly referred to as a ‘cap’, this is an Onlay which completely covers the tooth surface. Usually required when significant damage to the tooth exists 
 Veneer A thin layer bonded to tooth surface to improve appearance of fractured or discoloured teeth. Made from porcelain or composite resin 
Prosthesis  
 Bridge Fixed partial denture, anchored to adjacent teeth 
 Denture Partial removable prosthesis—attached to adjacent teeth via clasps 
Complete prosthesis—may be associated with underlying mucosal irritation or gingivitis. Chronic irritation may cause hyperplasia and granuloma formation 
 Implant Titanium screw inserted into alveolar bone undergoes ossointegration, tightly bonding to bone. A prosthesis (single tooth, bridge or denture) is then added via an abutment 
Recession of gingiva can occur over time causing weakening of implant 
Approximate lifespan 10–20 yr 
Type of treatment Description and associated problems 
Direct restoration (cavity filled in situ 
 ‘Filling’ Usually made from amalgam, gold, or composites (‘white fillings’) 
Prone to expansion or shrinkage when setting, leading to tooth fracture or further decay 
Approximate lifespan 7–12 yr 
Indirect restorations (filling created ex situ 
 Inlays/onlays Gold or porcelain. Inlay is a filling made and set outside the mouth, then bonded and thus is less prone to expansion or shrinkage. Onlay refers to an inlay which covers a dental cusp 
 Crown Commonly referred to as a ‘cap’, this is an Onlay which completely covers the tooth surface. Usually required when significant damage to the tooth exists 
 Veneer A thin layer bonded to tooth surface to improve appearance of fractured or discoloured teeth. Made from porcelain or composite resin 
Prosthesis  
 Bridge Fixed partial denture, anchored to adjacent teeth 
 Denture Partial removable prosthesis—attached to adjacent teeth via clasps 
Complete prosthesis—may be associated with underlying mucosal irritation or gingivitis. Chronic irritation may cause hyperplasia and granuloma formation 
 Implant Titanium screw inserted into alveolar bone undergoes ossointegration, tightly bonding to bone. A prosthesis (single tooth, bridge or denture) is then added via an abutment 
Recession of gingiva can occur over time causing weakening of implant 
Approximate lifespan 10–20 yr 
Table 3

Materials used for dental restorations

Material Properties 
Gold–alloy Inert, durable substance; comparable hardness to enamel, therefore does not damage opposing teeth. Expensive and visually noticeable 
Amalgam Affordable, prone to expansion when sets, thus causing cracking or fracture of tooth 
Ceramic/porcelain Expensive; tooth coloured, thus frequently used in anterior restorations 
Older types brittle and prone to cracking 
New harder porcelain may cause excessive wear on opposing teeth 
Composite resin Affordable, tooth coloured, therefore aesthetically suitable for anterior dental restorations 
However, less durable than other materials and may shrink, crack or chip 
Glass ionomer cement (GIC) Tooth coloured but aesthetically inferior to porcelain or composite resin 
Brittle but less prone to shrinkage and cracking than composite resin 
Material Properties 
Gold–alloy Inert, durable substance; comparable hardness to enamel, therefore does not damage opposing teeth. Expensive and visually noticeable 
Amalgam Affordable, prone to expansion when sets, thus causing cracking or fracture of tooth 
Ceramic/porcelain Expensive; tooth coloured, thus frequently used in anterior restorations 
Older types brittle and prone to cracking 
New harder porcelain may cause excessive wear on opposing teeth 
Composite resin Affordable, tooth coloured, therefore aesthetically suitable for anterior dental restorations 
However, less durable than other materials and may shrink, crack or chip 
Glass ionomer cement (GIC) Tooth coloured but aesthetically inferior to porcelain or composite resin 
Brittle but less prone to shrinkage and cracking than composite resin 

Perioperative dental assessment

Examination

While it is usually impractical to carry out a full dental assessment routinely, in cases where there is significant concern about the state of dental health, evaluation, and documentation of the following may be valuable:

  • presence of periodontal disease as evidenced by an erythematous, retracted gumline; visible roots;

  • evidence of infective complications of periodontal disease, e.g. abscesses or sinuses;

  • presence of cracks, chips, and severe discolouration;

  • identification of loose teeth by gentle palpation with a gloved hand;

  • position of missing or loose teeth;

  • position and condition of dental restorations.

Notation

Several methods for the identification of individual teeth exist. The Palmer notation is most commonly used by dentists in the UK. Symbols (┌ ┐└ ┘) mark the relevant quadrant and teeth are numbered 1–8 starting in the midline, as viewed by the assessor. For primary dentition, the letters A–E replace the numbers (Fig. 1b).

The Palmer notation is further adapted in the ‘letters and numbers' system; each quadrant is assigned two letters (for instance, LL, left lower; RU, right upper) followed by a number 1–8.

Internationally, the World Health Organization's ISO system is often used. Each quadrant is designated a number 1–4, and each individual tooth a further number 1–8 as per the Palmer notation.

In the USA, the Universal Numbering System is primarily used. Adult teeth are labelled with a number 1–32 starting with the third right maxillary molar and moving in an anti-clockwise direction. For primary dentition, letters A–T are used.

Dental injuries under anaesthesia

Dental injuries under general anaesthesia (GA) are the most common cause of complaint and medicolegal claims against anaesthetists. While the true incidence is unknown, retrospective studies estimate an incidence between 0.02% and 0.1% of all GAs.4 Prospective studies report rates up to 25% in patients undergoing direct laryngoscopy when examined closely after operation.5 The Royal College of Anaesthetists' guidance on dental damage quotes a risk of 1:4500,6 in line with US figures from analysis of nearly 600 000 cases.3

Retrospective data suggest a five-fold risk of injury to teeth with pre-existing pathology, highest in patients between 50 and 70 yr as these are more likely to have teeth weakened by periodontal disease while remaining dentulous.7 Patients with dental restorations are 3.4 times more likely to sustain dental injury.8 Interestingly, studies demonstrated no increase in risk for emergency intubations and even from inexperienced laryngoscopists,9, 10 although the risk is 20-fold in individuals deemed difficult to intubate.8 Risk factors for dental injury are summarized in Table 4.

Table 4

Risk factors for dental injury

Anaesthetic factors Dental factors 
Difficult airway predictors
  •  Prominent incisors (‘Buck teeth’)

  •  Mallampati 3/4

  •  Inter-incisor gap <5 cm

  •  Limited head and neck movement

  •  Limited mandibular subluxation

  •  Receding mandible

  •  Obesity BMI >35 kg m−2

 
Restorative dental work any crowns, veneers, prostheses are at risk; in particular:
  • Anterior restorations

  • Brittle restorative materials, e.g. some ceramics or composite resin

  • Recent restorative/orthodontic treatment

 
Direct laryngoscopy; tracheal intubation Pre-existing dental pathology, previous root canal treatment 
Placement of double-lumen tubes Periodontitis 
Biting during emergence Caries 
Forceful removal of tracheal tubes/supraglottic airways Isolated teeth 
Vigorous oropharyngeal suctioning Mixed dentition (children aged 5–12) 
Anaesthetic factors Dental factors 
Difficult airway predictors
  •  Prominent incisors (‘Buck teeth’)

  •  Mallampati 3/4

  •  Inter-incisor gap <5 cm

  •  Limited head and neck movement

  •  Limited mandibular subluxation

  •  Receding mandible

  •  Obesity BMI >35 kg m−2

 
Restorative dental work any crowns, veneers, prostheses are at risk; in particular:
  • Anterior restorations

  • Brittle restorative materials, e.g. some ceramics or composite resin

  • Recent restorative/orthodontic treatment

 
Direct laryngoscopy; tracheal intubation Pre-existing dental pathology, previous root canal treatment 
Placement of double-lumen tubes Periodontitis 
Biting during emergence Caries 
Forceful removal of tracheal tubes/supraglottic airways Isolated teeth 
Vigorous oropharyngeal suctioning Mixed dentition (children aged 5–12) 

Direct laryngoscopy is implicated in 50–75% of all cases of dental injury. Maxillary incisors are the most commonly injured under GA. Representing 50% of cases, they are particularly prone to fracture, being small-rooted, of narrow cross-sectional area with a slight anterior axis.11 The left central maxillary incisor is most vulnerable to damage from the flange of the laryngoscope blade if used as a fulcrum, usually when attempting to improve the view during a difficult intubation. It is important, therefore, to avoid blade-to-tooth contact or transmission of any oblique or vertical forces through the incisors and canines. The posterior teeth are injured less frequently, being wider, multiple-rooted, and generally remote from laryngoscope positioning. Contact with the right third molar during laryngoscope insertion is the most common mechanism for posterior dental injury.

Aside from laryngoscopy, dental injury can also result from mouth-opening manoeuvres (‘scissors manoeuvre’), forcible removal of tracheal tubes, vigorous oropharyngeal suctioning, and insertion or removal of oropharyngeal and supraglottic airway devices (SAD). Up to 20% of injuries occur during emergence from anaesthesia. Involuntary biting during emergence is hazardous, particularly on the hard stem of some SADs. Approximately 85% of dental injuries are recognized at the time of injury by the anaesthetist;8 up to 15% are identified after operation by either the patient or recovery staff.

Nature of dental injuries

The nature of the injury sustained can be diagnosed using the trauma pathfinder (Fig. 3).

Fig 3

Trauma pathfinder for identifying the nature of dental injuries. Supplied and reproduced with kind permission from J.O. Andreasen and E. Fernandez-Rugerio.

Fig 3

Trauma pathfinder for identifying the nature of dental injuries. Supplied and reproduced with kind permission from J.O. Andreasen and E. Fernandez-Rugerio.

Over 50% of dental injuries under GA are crown fractures or subluxations.8 Tooth avulsion (completely out of socket) occurs in ∼10% of cases. Crown fractures are more common in younger patients, while avulsion and subluxation injuries are more common with advancing age as the anchoring periodontium weakens with age and periodontal disease.

Strategies to minimize the risk of dental injury

If severe dental pathology is identified before operation, patients should be advised to consult their dentist for restorative treatment or dental extraction before surgery. When preoperative treatment is not feasible and airway instrumentation unavoidable, the following strategies may be used to mitigate the risk of dental injury.

A loose tooth recognized before operation may be stabilized by knotting a suture or tie around its base and, where possible, to a fixed neighbouring tooth with the suture ends brought out and secured to the cheek using adhesive tape.12 This technique has the advantage of not only supporting the loose tooth by splinting it to an adjacent one, but also minimizes risk of aspiration and aids retrieval in the event of avulsion.

Blind intubation, using nasal tracheal tubes or intubating SADs, eliminate the need for instrumenting the airway with a laryngoscope; however, the success of these techniques depends on operator skill and anatomical factors. Furthermore, the risk of dental injury from SADs remains significant either from direct injury or from involuntary biting. Nasal fibreoptic intubation may be a more reliable technique as it bypasses the oral cavity completely and allows intubation under direct vision.

When laryngoscopy is the technique of choice, tooth-to-blade contact may be reduced with the use of alternative blades such as the McCoy, a modified Macintosh with a short flange, plastic blades, or a retromolar approach with a straight blade.13

Similarly, studies in simulated difficult airway scenarios on manikins suggest that videolaryngoscopes may be associated with a significantly lower risk of tooth-to-blade contact and thus dental injury.14

The use of dental guards, as used to protect maxillary teeth during rigid bronchoscopy or in contact sports, has not been proven to avoid dental injury.11 Moreover, damage can result from the guard itself and may render laryngoscopy more difficult by narrowing the inter-incisor gap.

During emergence, shivering or pain may promote involuntary biting and must be avoided. The use of Guedel oropharyngeal airways as bite guards is not advocated, as the anterior teeth are subjected to significant forces during involuntary biting, risking fracture. A softer bite block of rolled gauze swabs placed between the molar teeth performs the same function while carrying a lower risk of dental injury.

Management of dental injury

General

Appropriate management after dental injury depends on the type of injury and whether it involves primary or permanent teeth. In all cases, the nature of the injury and the circumstances in which it occurred must be clearly documented in the patient record. A full explanation should be provided to the patient when fully awake and a plan for further management and follow-up with a dentist initiated.

When dental injury is recognized during anaesthesia, it is essential to localize avulsed, broken teeth, or prostheses. Laryngoscopy and retrieval of missing teeth, prostheses, or fragments using Magill's forceps should be attempted. If these cannot be found or retrieved, imaging in the form of a chest radiograph should be performed to determine if they have been aspirated into the lungs or oesophagus. It must be remembered, however, that not all dental prostheses are radiopaque and primary teeth are difficult to visualize on a chest radiograph. If there is doubt, a discussion with a radiologist as to the appropriate imaging should occur. If aspiration into the tracheobronchial tree is suspected, advice from a senior ENT or thoracic surgeon should be sought urgently.

Specific dental management

Avulsion of a permanent tooth is one of the most serious dental injuries and timely management determines tooth survival. In most situations, replantation, by pushing the tooth into its socket for several minutes, is the immediate treatment of choice. This may, however, not be appropriate in immunocompromised patients or those with severe periodontal disease due to the risk of bacterial seeding.

The viability of the avulsed tooth depends on the condition of the PDL cells, found on the root of the tooth which must not be handled. These, in turn, are dependent on the storage medium in which the avulsed tooth is placed and also the ‘dry time’ (the time the tooth spends either outside the mouth or a storage medium). After 60 min dry time, no PDL cells survive. It is therefore essential the tooth is either replanted or placed in a storage medium immediately. Tissue or cell culture transport media are optimal but may not be immediately available in theatre; alternatively, an osmolality balanced medium such as cold saline or milk may be used.

While immediate replantation may save the tooth, it may still be lost or extracted at a later stage. Replantation while the patient is still anaesthetized also poses the risk of redisplacement and aspiration into the lungs or oesophagus. Replantation of primary avulsed teeth in children must not be attempted due to risk of damage to the underlying permanent successor. In other types of injury such as crown fractures or broken prostheses, the fragments should be placed into a storage medium and given to the patient until urgent dental review can take place. A local protocol for the ongoing management of damage should be available in anaesthetic departments.

Medicolegal aspects of dental injury

Eleven per cent of anaesthesia-related claims made to the NHS litigation authority (NHSLA) from 1995 to 2007 were for dental damage. The cost of claims ranged from £0 to £20 800, with a total cost to NHSLA of £177 000.15 While this data set has limitations, there is a general trend towards increased cost of claims in the last 5 yr as dental treatments become more sophisticated. The total costs to NHSLA from 2009 to 2014 increased to £443 753 (personal communications). Analysis of claims made to the Medical Defence Union estimated that 63% of private claims made against anaesthetists were for dental injury.

Negligence claims require the claimant to prove, in a three-part test, that a duty of care existed and was breached, and that this directly led to the harm experienced. Lack of a clear record of the preoperative condition of a patients' dentition can make rebuttal of a subsequent claim difficult even if this is brought for a dental injury that is not typically associated with laryngoscopy or SAD insertion. Presently, the majority of dental claims are settled informally as the cost of defending cases in court is usually vastly disproportionate to the cost of dental repairs.

Documentation of a thorough preoperative dental assessment and any explanation of risk provided to the patient is essential. Individuals with risk factors for dental injury should be warned of a higher likelihood of damage. A simple diagrammatic representation using the Palmer notation is effective in indicating the locations and condition of dental prostheses and restorations, broken, vulnerable, or missing teeth. An overall impression of the state of the dentition and presence of periodontal disease should be recorded in addition.

Conclusion

Dental injury under anaesthesia is a common area for complaint against anaesthetists. A thorough preoperative dental assessment with explanation of risk is essential, particularly in individuals in whom severe periodontal disease is identified. These individuals may also be at increased risk of cardiovascular disease. Prompt recognition and treatment in the event of dental injury can improve tooth survival.

Declaration of interest

None declared.

MCQs

The associated MCQs (to support CME/CPD activity) can be accessed at https://access.oxfordjournals.org by subscribers to BJA Education.

References

1
Van Eijden
TM
.
Three dimensional analysis of human bite force magnitude and moment
.
Arch Oral Biol
 
1991
;
36
:
535
9
2
Dietrich
T
,
Jimenez
M
,
Krall Kaye
EA
,
Vokonas
PS
,
Garcia
RI
.
Age-dependent associations between chronic periodontitis/edentulism and risk of coronary heart disease
.
Circulation
 
2008
;
117
:
1668
3
Morosan
M
,
Parbhoo
A
,
Curry
N
.
Anaesthesia and common oral and maxilla-facial emergencies
.
Contin Educ Anaesth Crit Care Pain
 
2012
;
12
:
257
62
4
Warner
ME
,
Benenfeld
SM
,
Warner
MA
,
Schroeder
DR
,
Maxson
PM
.
Perianesthetic dental injuries: frequency, outcomes, and risk factors
.
Anesthesiology
 
1999
;
90
:
1302
5
5
Murao
J
,
Neto
J
,
Luis
C
et al
.
Dental injury after conventional direct laryngoscopy: a prospective observational study
.
Anaesthesia
 
2013
;
68
:
1059
65
6
Royal College of Anaesthetists
.
Dental trauma during anaesthesia
.
Available from http://www.rcoa.ac.uk/system/files/CSQ-DentalTrauma.pdf (accessed 3 July 2015)
7
Givol
N
,
Gershtansky
Y
,
Halamish-Shani
T
,
Taicher
S
,
Perel
A
,
Segal
E
.
Perianesthetic dental injuries: analysis of incident reports
.
J Clin Anesth
 
2004
;
16
:
173
6
8
Newland
MC
,
Ellis
SJ
,
Peters
KR
et al
.
Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years
.
J Clin Anesth
 
2007
;
19
:
339
45
9
Vallejo
MC
,
Best
MW
,
Phelps
AL
et al
.
Perioperative dental injury at a tertiary care health system: an eight-year audit of 816,690 anesthetics
.
J Healthc Risk Manag
 
2012
;
31
:
25
32
10
Brandão Ribeiro de Sousa
JM
,
de Barros Mourão
JI
.
Tooth injury in anaesthesiology
.
Rev Bras Anestesiol
 
2014
.
11
Yasny
J
.
Perioperative dental considerations for the anaesthesiologist
.
Anesth Analg
 
2009
;
108
:
1564
73
12
Singhal
SK
,
Chhabra
B
.
Loose tooth: a problem
.
Anesth Analg
 
1996
;
83
:
1352
13
Malik
MA
,
Hassett
P
,
Carney
J
,
Higgins
BD
,
Harte
BH
,
Laffey
JG
.
A comparison of the Glidescope®, Pentax AWS®, and Macintosh laryngoscopes when used by novice personnel: a manikin study
.
Can J Anaesth
 
2009
;
56
:
802
11
14
Huang
YF
,
Ting
CK
,
Chang
WK
,
Chan
KH
,
Chen
PT
.
Prevention of dental damage and improvement of difficult intubation using a paraglossal technique with a straight Miller blade
.
J Chin Med Assoc
 
2010
;
73
:
553
6
15
Cook
T
,
Scott
S
,
Mihai
R
.
Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995–2007
.
Anaesthesia
 
2010
;
65
:
556
63