Dental injuries in relation to general anaesthesia-A retrospective study

Clinical Issues - July 2024

Cleaning surgical instruments after use in a procedure involving chemotherapeutic medications Key words: deactivation, decontamination, cleaning, disinfection, chemotherapeutic medication. Paper count sheets sterilized inside instrument sets Key words: count sheets, instrument sets, printer ink, toner, toxicity. Off-label use of dental devices during direct laryngoscopy Key words: mouth guard, dental injury, direct laryngoscopy, anesthesia, intubation. Using intermittent pneumatic compression devices on patients in lithotomy position Key words: mechanical compression devices, compartment syndrome, lithotomy, venous thromboembolism, thromboprophylaxis.

Medico-legal liability of injuries arising from laryngoscopy

OBJECTIVE

Dental and mucosal injuries from laryngoscopy in the peri-operative period are common medico-legal complaints. This study investigated lawsuits arising from laryngoscopy.

METHODS

Westlaw, a legal database containing trial records from across the USA, was retrospectively reviewed. Plaintiff and/or defendant characteristics, claimed injuries, legal outcomes and awards were extracted.

RESULTS

Of all laryngoscopy-related dental or mucosal injuries brought before a state or federal court, none (0 per cent) resulted in a defence verdict against the provider or monetary gain for the patient. Rulings in the patient's favour were observed only when laryngoscopy was found to be the proximate cause of multiple compounding complications that culminated in severe medical outcomes such as exsanguination, septic shock or cardiopulmonary arrest.

CONCLUSION

Proper laryngoscopy technique and a robust informed-consent process that accurately sets patients' expectations reduces litigation risk. Future litigation pursuits should consider the low likelihood of malpractice allegation success at trial.

Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers

BACKGROUND

As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs.

METHODS

Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim.

RESULTS

Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002).

CONCLUSIONS

This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.

Teeth Damage during General Anesthesia

INTRODUCTION

Dental injuries during anesthesia, especially when advanced airway management is required, represent a legal problem. Factors such as poor dental condition and excessive pressure during intubation contribute to dental damage. The maxillary central incisors are commonly affected.

OBJECTIVE

The objective of this review is to know the incidence of dental injuries in adults undergoing anesthesia that requires airway management.

MATERIALS AND METHODS

The search was performed in MEDLINE (through Pubmed), ClinicalTrials.gov, Scopus, LILACS (through the Virtual Health Library Regional Portal), and SciELO for all available literature on the subject up to December 2022. Inclusion criteria involved articles that studied patients aged 18 years or older who underwent general anesthesia requiring airway management with tracheal intubation or insertion of a laryngeal mask airway.

RESULTS

Of all the articles, nine report dental injury associated with the type of airway management. Only one article does not have dental injury.

DISCUSSION

This study addresses dental injuries related to tracheal intubation during general anesthesia. Although techniques are used to prevent them, these injuries still occur. Laryngoscopy, especially with support on the upper central incisors, can cause damage to the teeth.

CONCLUSIONS

It is important that the anesthesiologist is aware of dental trauma and that orotracheal intubation or the placement of the laryngeal mask airway is performed systematically and rigorously, always considering the patient's dentition to choose the best approach in each specific situation.

Anti-Toothbreaker: A Novel Low-Budget Device Enabling Contactless Dental Protection and a Forbidden Technique during Direct Laryngoscopy for Endotracheal Intubation

BACKGROUND

Iatrogenic dental injury is the most common complication of conventional laryngoscopy during orotracheal intubation. The main cause is unintended pressure and leverage forces from the hard metal blade of the laryngoscope. The aim of this pilot study was to introduce and test a novel, reusable low-budget device not only providing contactless dental protection during direct laryngoscopy for endotracheal intubation, but also enabling, in contrast to established tooth protectors, active levering with conventional laryngoscopes for easier visualization of the glottis.

METHODS

A constructed prototype for intrahospital usage was evaluated by seven participants on a simulation manikin for airway management. Endotracheal intubation was performed with and without the device using a conventional Macintosh laryngoscope (blade size 4) and a 7.5 mm endotracheal tube (Teleflex Medical GmbH, Fellbach, Germany). Necessary time and success of first pass were determined. Degree of visualization of the glottis with and without the device was stated by the participants according to the Cormack and Lehane (CL) classification system and the Percentage of Glottic Opening (POGO) scoring system. In addition, subjective physical effort, feeling of safety regarding successful intubation, and risk for dental injury were queried on a numeric scale between 1 and 10.

RESULTS

All participants except one stated that the intubation procedure was easier with usage of the device than without it. On average, this was subjectively perceived as being approximately 42% (range, 15-65%) easier. In addition, time to first pass success, as well as degree of glottis visualization, subjective physical effort, and feeling of safety regarding risk for dental injury, were clearly better with usage of the device. Concerning feeling of safety regarding successful intubation, there was only a minor advantage. No difference in first pass success rate and number of total attempts could be observed.

CONCLUSION

The Anti-Toothbreaker is a novel, reusable low-budget device which might not only provide contactless dental protection during direct laryngoscopy for endotracheal intubation, but also enables, in contrast to established tooth protectors, active levering with conventional laryngoscopes for easier visualization of the glottis. Future human cadaveric studies are needed to investigate whether these advantages also prove themselves there.

Evaluation of dental status using a questionnaire before administration of general anesthesia for the prevention of dental injuries

Background

Dental evaluation and protection are important for preventing traumatic dental injuries when patients are under general anesthesia. The objective of the present study was to develop a questionnaire based on dentition-related risk factors that could serve as a valuable tool for dental evaluation and documentation.

Methods

We developed a questionnaire for dental evaluation before administration of general anesthesia, investigated the association between patient-and-dentist responses and mouthguard fabrication, and assessed response agreement between 100 patients.

Results

Protective mouthguards were fabricated for 27 patients who were identified as having a high risk of dental injury. There was a strong association between dentists' responses and mouthguard fabrication, depending on the general oral health status, use of ceramic prosthesis, presence of masticatory pain related to periodontal diseases, gingival edema, and implants (P < 0.05). Response agreement between patients and dentists for items related to dental pain, loss of dental pulp vitality, root canal therapy, dental trauma, aesthetic prosthesis, tooth mobility, and implant prosthesis was high (Cohen's kappa coefficient κ ≥ 0.6).

Conclusions

A high agreement was observed between patient-dentist responses and a strong association with mouthguard fabrication for items pertaining to ceramic prosthesis, masticatory pain, and dental implants. Patients with a "yes" response to these items are recommended to undergo a dental evaluation and use a dental protective device while under general anesthesia.

Medicolegal issues of peri-anaesthetic dental injuries: A 21-years review of liability lawsuits in France

Background/Aim

Peri‐anaesthetic dental injuries (PDI) represent a major source of potential malpractice claims against anesthesiologists. Studies about the medico‐legal aspects of PDI have mainly focused on liability insurance cases thus not encompassing those cases brought to court. The aim of this study was to assess the medico‐legal issues of PDI‐related liability lawsuits in France.

Material and Methods

A review of judicial decisions pertaining to PDI was conducted on a French legal database, spanning the period between January 2000 and October 2021. Characteristics of decisions, patients and anesthesiologists, peri‐operative care, dental injuries, and convictions were collected when available for analysis.

Results

Twenty‐four judicial decisions fulfilled the inclusion criteria and were analyzed. All cases of dental injuries took place during elective surgery, 16 in the private sector and 8 in the public sector. Most injuries concerned two or more teeth and the most predominant dental injuries were luxation or avulsion (70.8% of cases). Eight cases resulted in a final verdict in favor of the plaintiff, four in the private sector (conviction rate: 25%), and four in the public sector (conviction rate: 50%). The causes of conviction were either a lack of information (5/8), a breach in the standard of care or technical negligence (3/8). The average amount of indemnification for the plaintiff was 3614 Euros (3753 Euros in 2022 inflation‐adjusted Euros) excluding legal fees.

Conclusions

The analysis of PDI‐related liability lawsuits shows that medico‐legal issues differ from those of PDI‐related insurance claims. Avulsion and luxation of multiple anterior teeth during elective surgery appear to be a risk factor for liability lawsuits. In addition, inadequacy of patient information about PDI‐risk seems to be a risk factor for conviction. Lastly, dental injuries are less at risk of civil conviction than other anesthesia‐related damages.

Perioperative Dental Injury Associated With Intubated General Anesthesia

OBJECTIVE

Factors related to perioperative dental injury have likely changed as a variety of airway devices and preventive measures have been introduced. This retrospective chart review used data from an institutional registry to evaluate the incidence, timing, and contributing factors of patient self-reported dental injury and to assess the impact of dental injury on patient satisfaction.

METHODS

Multivariate logistic analysis was performed on the records of 14,820 patients using the incidence of dental injury as the dependent variable and covariates in the anesthesia registry and a postoperative questionnaire as independent variables to investigate factors significantly associated perioperative dental injury. In addition, satisfaction with the anesthesia service was compared between patients with and without injury using a matched-pair population.

RESULTS

A total of 101 dental injuries were identified. Of those, 25% were associated with intubation and extubation in the operating room, while most other injuries occurred postoperatively. Duration of anesthesia (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03) and emergency surgery (OR, 1.92; 95% CI, 1.11-3.30) were independently associated with perioperative dental injury. Dental injury did not significantly decrease a patient's satisfaction with the anesthesia service (P = .441).

CONCLUSION

Most perioperative dental injuries are unrelated to anesthesia procedures. However, the duration of anesthesia and emergency surgery were significantly associated with perioperative dental injury, while decreased patient satisfaction was not.

An analysis of anesthetists' awareness, knowledge, and attitudes toward peri-anesthetic dental trauma

BACKGROUND/AIM

Peri-anesthetic dental trauma is a common anesthesia-related complication. It is the reason for a significant number of malpractice lawsuits against anesthetists through insurance companies. The frequency, outcomes, and risk factors related to peri-anesthetic dental trauma have been well documented. The aim of this study was to evaluate anesthetists' awareness, knowledge, and attitudes toward peri-anesthetic dental trauma.

MATERIAL AND METHODS

This nationwide, cross-sectional, descriptive study comprising 220 anesthetists was conducted in Turkey between June 2019 and May 2020. A specific questionnaire was created using Google Forms and delivered to 591 participants via WhatsApp. Pearson's Chi-squared test and the Fisher-Freeman-Halton tests were used to analyze the results.

RESULTS

The overall response rate was 37.2% (220 out of 591 participants). Of the 80.5% of the participants who encountered peri-anesthetic dental trauma during their practice, 32.8% had encountered avulsion and 32.8% reported that they had caused soft tissue injuries. More than one-third of the participants (38.9%) stated that the patient group that was the most at-risk for peri-anesthetic dental trauma was older people with missing teeth. Half of the participants (50.9%) stated that avulsed teeth could be replanted; among them, 21.8% and 11.8% specified that the ideal replantation time was <30 min and that the ideal storage medium for the avulsed tooth was fresh milk, respectively. Furthermore, 88.1% of the participants noted that peri-anesthetic dental trauma occurred more frequently during emergency intubations and only 20.9% were aware of custom-made mouthguards.

CONCLUSIONS

Anesthetists lack knowledge around peri-anesthetic dental trauma and its interventions.