Dental injuries resulting from tracheal intubation - a retrospective study

Protective potential of different mouthguard thicknesses against perianaesthetic dental trauma: a patient specific-finite element study

Perianaesthetic dental trauma is a common anaesthesia-related complication. Theprevious studies have shown a lack of knowledge regarding mouthguard usage and controversial results related to perianaesthetic dental trauma prevention. This study aimed to conduct a finite element analysis of the compressive and tensile stresses on the tooth-periodontal ligament-bone complex using custom-made mouthguards of different thicknesses and glass fibre splints to prevent perianaesthetic dental trauma. Custom-fitted ethylene-vinyl acetate mouthguards of two different thicknesses (2 and 3 mm) and glass fibre splint were modelled. A linear static finite element analysis was performed by applying a rigid Macintosh laryngoscope to the palatal surface of the maxillary central incisors at 150 N. The model without a mouthguard and glass fibre splint showed the highest stress values at the palatinal root surfaces during the impact. Increasing the mouthguard thickness significantly decreased the stress-strain values regardless of the presence of the glass fibre splint. Maximum stresses in the group using the 3 mm mouthguard were the lowest compared with the other groups.

Comparison of Macintosh Laryngoscope, King Vision®, VividTrac®, AirAngel Blade®, and a Custom-Made 3D-Printed Video Laryngoscope for Difficult and Normal Airways in Mannequins by Novices-A Non-Inferiority Trial

Background: Endotracheal intubation (ETI) is a cornerstone of airway management. The gold standard device for ETI is still the direct laryngoscope (DL). However, video laryngoscopes (VLs) are now also widely available and have several proven advantages. The VL technique has been included in the major airway management guidelines. During the COVID-19 pandemic, supply chain disruption has raised demand for 3D-printed medical equipment, including 3D-printed VLs. However, studies on performance are only sparsely available; thus, we aimed to compare 3D-printed VLs to the DL and other VLs made with conventional manufacturing technology. Methods: Forty-eight medical students were recruited to serve as novice users. Following brief, standardized training, students executed ETI with the DL, the King Vision® (KV), the VividTrac® (VT), the AirAngel Blade® (AAB), and a custom-made 3D-printed VL (3DVL) on the Laerdal® airway management trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma, and user satisfaction. Results: The KV and VT are proved to be superior (p < 0.05) to the DL in both scenarios. The 3DVL's performance was similar (p > 0.05) or significantly better than that of the DL and mainly non-inferior (p > 0.05) compared to the KV and VT in both scenarios. Regardless of the scenario, the AAB proved to be inferior (p < 0.05) even to the DL in the majority of the variables. The differences between the devices were more pronounced in the difficult airway scenario. The user satisfaction scores were in concordance with the aforementioned performance of the scopes. Conclusions: Based upon our results, we cannot recommend the AAB over the DL, KV, or VT. However, as the 3DVL showed, 3D printing indeed can provide useful or even superior VLs, but prior to clinical use, meticulous evaluation might be recommended.

Dental trauma in endoscopy: A systematic review and experience of a tertiary endoscopy centre

BACKGROUND

Dental injury is the leading cause of litigation in anaesthesia but an underrecognized preventable complication of endoscopy.

AIM

To determine frequency and effects of dental injury in endoscopy, we present findings from an audit of outpatient endoscopy procedures conducted at a tertiary university hospital and a systematic review of literature.

METHODS

Retrospective review of 11265 outpatient upper endoscopy procedures over the period of 1 June 2019 to 31 May 2021 identified dental related complications in 0.284% of procedures. Review of literature identified a similar rate of 0.33%.

RESULTS

Pre-existing dental pathology or the presence of prostheses makes damage more likely but sound teeth may be affected. Pre-endoscopic history and tooth examination are key for risk stratification and may be conducted succinctly with limited time outlay. Tooth retrieval should be prioritized in the event of dental injury to minimize aspiration and be followed by prompt dental consultation for specific management.

CONCLUSION

Dental complications occur in approximately 1 in 300 of upper endoscopy cases. These are easily preventable by pre-endoscopy screening. Protocols to mitigate dental injury are also suggested.

Quantifying Intubation Forces on Incisors and Tongue Base Across Exposure Difficulty and Experience in a Simulator

OBJECTIVE

Laryngoscopy simulators quantifying forces on critical structures in progressively challenging airways and operator expertise are lacking. We aimed to quantify laryngoscopy forces across expertise and exposure difficulty.

STUDY DESIGN

Prospective observational study Setting: Tertiary care medical center Methods: Force gauges were affixed to a difficult airway mannequin to quantify teeth and tongue forces across increasingly challenging airway exposure. Medical students (n=10), residents (n=11), and otolaryngology staff (n=10) performed direct laryngoscopy using a Miller size 3 laryngoscope with 1) normal neck/jaw mobility, 2) restricted neck extension, 3) restricted jaw opening, and 4) restricted neck/jaw mobility. Incisor and tongue pounds of force (lbf) were continuously measured.

RESULTS

As the difficulty setting increased, forces exerted by the students, residents, and staff on the incisors and tongue base increased (p=0.01). Between normal and maximally restricted settings, force delivered to the incisors increased by 6.95 lbf (standard error (SE) 1.29), 5.93 lbf (SE 0.98), and 5.94 lbf (SE 0.70) for the students, residents, and staff, respectively. At the tongue base, force increased by 0.37 lbf (SE 0.18), 0.46 lbf (SE 0.14), and 0.73 lbf (SE 0.15) for the students, residents, and staff, respectively. Esophageal intubations occurred in 50% of the students, 23% of the residents, and 45% of the otolaryngology staff at maximal difficulty, with none at the easiest setting (p=0.33). Compared to the residents, the staff applied significantly increased pressure on the tongue base during laryngoscopy (p=0.02).

CONCLUSION

Forces exerted on the incisors and tongue base varied across exposure difficulty and expertise levels, suggesting that they may be useful markers for training and competence assessment.

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.

Lost Dental Bridges During ICU Stay

Oral care is easily neglected in patients in an intensive care unit (ICU) because they are often intubated or have altered mental status. Although care workers pay careful attention to the mouth, tooth loss often occurs in the ICU. Here we report 3 cases of dental bridge loss undetected by the ICU staff. One patient was under mechanical ventilation via an endotracheal tube after emergency intubation, whilst 2 patients were drowsy but not intubated. Consecutive chest X-rays revealed dental bridge loss in all 3 cases, but this was not identified immediately. Along with other critical management approaches, these cases demonstrate how an initial evaluation of the oral cavity, with special attention to the number of teeth, and the existence of dental prosthetics is essential to preventing potential deleterious complications. The number of teeth and the existence of dental prosthetics must be documented in ICU patients.

Comparison of Dental Injury Rates in Perioperative Intubation and Suspension Laryngoscopy for Otolaryngology Procedures

Objective

Direct laryngoscopy is an essential skill during perioperative intubation and otolaryngology procedures. Dental injury is a common complication of direct laryngoscopy. However, the technique and tools used by anesthesiologists, nurse anesthetists, and others during perioperative intubation and by ear, nose, and throat surgeons for their procedures are different. The purpose of this review is to explore the literature for all studies detailing rates of dental injury in each of these settings and to compare them to see if the approaches have a significant difference in rate of dental injury.

Data Sources

PubMed.

Review Methods

A comprehensive search of PubMed was performed through February 2021 with search terms “dental” and “intubation” or “laryngoscopy.” PRISMA guidelines were followed. Studies documenting rates of dental injuries during intubation or during laryngologic procedures were included, and the 2 groups were compared.

Results

Twenty-three studies met inclusion criteria: 17 in the perioperative intubation group and 6 in the suspension laryngoscopy group. There was an increased incidence of dental injury in the perioperative intubation group (4.86%) as compared with the suspension laryngoscopy group (1.70%).

Conclusions

The difference in dental injury rate between the groups could be due to the differences in direct laryngoscopy technique or tools used, the presence vs absence of a dental guard, or a combination of these factors. More studies need to be performed to develop definitive and specific conclusions to recommend changes that prevent dental injury.

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.

Postintubation Dysphagia During COVID-19 Outbreak-Contemporary Review

The COVID-19 is a global pandemic. Its rapid dissemination and serious course require a novel approach to healthcare practices. Severe disease progression is often associated with the development of the Acute Respiratory Distress Syndrome and may require some form of respiratory support, including endotracheal intubation, mechanical ventilation, and enteral nutrition through a nasogastric tube. These conditions increase the risk of dysphagia, aspiration, and aspiration pneumonia. The data on the incidence and risks of dysphagia associated with COVID-19 are not yet available. However, it is assumed that these patients are at high risk, because of respiratory symptoms and reduced lung function. These findings may exacerbate swallowing deficits. The aim of this review is to summarize available information on possible mechanisms of postintubation dysphagia in COVID-19 patients. Recommendations regarding the diagnosis and management of postintubation dysphagia in COVID-19 patients are described in this contemporary review.

A Missing Tooth Found in the Nasal Cavity After an Attempt at Insertion of a Nasogastric Tube: A Case Report

Dental injury is one of the most common complications of tracheal intubation. Although teeth dislodged during tracheal intubation are usually found in the oral cavity, we encountered a case of a missing tooth found in the nasal cavity in an intubated patient. A 62-year-old man with 4 loose teeth in the upper jaw was scheduled for laparoscopic hernia repair. After our second attempt at insertion of a nasogastric tube via the left naris, we discovered that a tooth had been dislodged. A lateral-view radiograph revealed the dislodged tooth in the nasal cavity. The ectopic tooth was removed by an otorhinolaryngologist.

Comparison of the Contact Force Exerted on Teeth by Conventional Macintosh Laryngoscope Versus Video Laryngoscopes

During laryngoscopy, the laryngoscope blade sometimes comes in contact with the teeth, fracturing or dislocating them. However, no studies have compared the effects of newly marketed video laryngoscopes and the Macintosh laryngoscope (Mac) on teeth. In this study, we measured and compared the force exerted on the teeth of an intubating manikin by the Mac, the Airway Scope (Pentax), and the McGrath MAC (Covidien). The mean force exerted was 141.1 ± 15.7 kg by the Mac, 39.2 ± 10.3 kg by the Airway Scope, and 48.7 ± 6.7 kg by the McGrath MAC. No significant difference was observed between the Airway Scope and the McGrath MAC. When the Mac is inserted, the glottis has to be visually located from outside the oral cavity. However, a significant force is not necessary when inserting video laryngoscopes because a camera is mounted on the blade tip. In this laboratory model, the lower force exerted by the video laryngoscopes should contribute to a reduction in their impact on fracture or dislocation of teeth.

Impact of Quantitative Feedback via High-Fidelity Airway Management Training on Success Rate in Endotracheal Intubation in Undergraduate Medical Students-A Prospective Single-Center Study

Endotracheal intubation is still the gold standard in airway management. For medical students and young professionals, it is often difficult to train personal skills. We tested a high-fidelity simulator with an additional quantitative feedback integration to elucidate if competence acquisition for airway management is increased by using this feedback method. In the prospective trial, all participants (n = 299; 4th-year medical students) were randomized into two groups—One had been trained on the simulator with additional quantitative feedback (n = 149) and one without (n = 150). Three simulator measurements were considered as quality criteria—The pressure on the upper front row of teeth, the correct pressure point of the laryngoscope spatula and the correct depth for the fixation of the tube. There were a total of three measurement time points—One after initial training (with additional capture of cognitive load), one during the exam, and a final during the follow-up, approximately 20 weeks after the initial training. Regarding the three quality criteria, there was only one significant difference, with an advantage for the control group with respect to the correct pressure point of the laryngoscope spatula at the time of the follow-up (p = 0.011). After the training session, the cognitive load was significantly higher in the intervention group (p = 0.008) and increased in both groups over time. The additional quantitative feedback of the airway management trainer brings no measurable advantage in training for endotracheal intubation. Due to the increased cognitive load during the training, simple airway management task training may be more efficient for the primary acquisition of essential procedural steps.

Dental injuries in relation to general anaesthesia-A retrospective study

BACKGROUND

Dental injuries may occur during general anaesthesia, especially during airway management. The aim of this study was to describe cases of dental injury related to general anaesthesia, focusing on the type and extent of the injuries as well as the timing of recognition.

METHOD

We reviewed the nationwide electronic database available at the Danish Patient Compensation Association and scrutinized all claims classified as possible dental injuries in relation to general anaesthesia between 2007 and 2017.

RESULTS

During the 10-year study period, there were 2523 claims for compensation related to anaesthesia. Of these, 552 (21.9%) were cases of possible dental injuries following general anaesthesia. The most commonly injured teeth were the central maxillary incisors with 174 (25.3%) cases related to the left and 118 (17.2%) cases related to the right incisor. The most common injuries were fractures (41.2%) and subluxations (25.9%). Airway management included the use of Macintosh laryngoscope in 296 (64.4%) cases and a supraglottic airway device in 69 (15%) cases. Claims were more frequently approved if more than two intubation attempts were used (100% vs 82.8%, RR = 0.83, 95% CI [0.78-0.88], P = 0.0037). Injuries recognized in-hospital were more frequently approved than injuries recognized after discharge (91.6% vs 70.7%, RR = 0.83, 95% CI [0.70-0.86], P < 0.0001).

CONCLUSION

The most commonly reported dental injury related to general anaesthesia in the Danish Patient Compensation Association database was a fracture. Claims were more frequently approved if more than two intubation attempts were used and if the injury was recognized in-hospital.

Tumour or Tooth? A Case of Missed Tooth Aspiration

Aspiration of teeth is a rare, potentially fatal complication of tracheal intubation. Early diagnosis and treatment are key to preventing further complications. Interpretation of the physical examination and radiographic evidence together with a high degree of suspicion are necessary to achieve early diagnosis of foreign body aspiration. We examine one such case of a misdiagnosed tooth in lung event.

Dental injury associated with anaesthesia: An 8-year database analysis of 592 claims from a major French insurance company

INTRODUCTION

Dental injury is the most common incident associated with anaesthesia. Regarding recent recommendations on informed consent and changes in airway management practices, a large series of claims related to dental injury has not been recently described. The aim of this study was to analyse a recent database in order to describe the characteristics of dental injury in France.

METHODS

A database that prospectively collected claims reported to Le Sou Médical-MACSF between January 2003 and December 2010, was analysed. Five hundred and ninety-two cases were reported. The following characteristics were analysed: number and type of teeth injured, mechanism of injury, anaesthetic procedure, risk factors and dental outcome after injury.

RESULTS

Amongst the 1514 claims related to anaesthesia, 592 (39.2%) were classified as dental damage. Preoperative informed consent concerning possible perioperative dental injury was documented in only 34.8% of patients. Only one tooth was affected in 65.2% of patients, dental bridge injury in 12.8% of cases and damage to two or more teeth in 14% of patients. Incisors were involved in 50% of cases. Fracture was the most common type of injury (64.2%). Poor dentition was the most common risk factor (23.1%) followed by difficult intubation (15.4%). Both risks were combined in only 7.6% of cases. Tracheal intubation was the highest risk procedure (41.6%).

CONCLUSION

Dental injury remains the most common anaesthesia-related claim. Dental examination and documentation in patient medical files requires improvement and better informed consent on dental injury risk needs to be provided to patients.

Claims for compensation after injuries related to airway management: a nationwide study covering 15 years

BACKGROUND

Securing the airway is one of the most important responsibilities in anaesthesia. Injuries related to airway management can occur. Analysis from closed claims can help to identify patterns of injury, risk factors and areas for improvement.

METHODS

All claims to The Norwegian System of Compensation to Patients from 1 January 2001 to 31 December 2015 within the medical specialty of anaesthesiology were studied. Data were extracted from this database for patients and coded by airway management procedures.

RESULTS

Of 400 claims for injuries related to airway management, 359 were classified as 'non-severe' and 41 as 'severe'. Of the severe cases, 37% of injuries occurred during emergency procedures. Eighty-one claims resulted in compensation, and 319 were rejected. A total of €1,505,344 was paid to the claimants during the period. Claims of dental damage contributed to a numerically important, but financially modest, proportion of claims. More than half of the severe cases were caused by failed intubation or a misplaced endotracheal tube.

CONCLUSION

Anaesthesia procedures are not without risk, and injuries can occur when securing the airway. The most common injury was dental trauma. Clear patterns of airway management that resulted in injuries are not apparent from our data, but 37% of severe cases were related to emergency procedures which suggest the need for additional vigilance. Guidelines for difficult intubation situations are well established, but adherence to such guidelines varies. Good planning of every general anaesthesia should involve consideration of possible airway problems and assessment of pre-existing poor dentition.

Inherent variability in airway characteristics of simulation manikins: is it time we standardised assessments of crisis management skills?

Introduction

Learning of simulation-based crisis management skills involves technologically advanced manikins and use of automated scenarios. Progressions in preprogrammed scenarios require finite task completion such as successful airway intubations for achieving optimal learning outcomes aligned to curricular goals. The study was set to explore the existing variability among various simulation manikins in use at our institute for undergraduate medical education.

Methods

56 final-year undergraduate students, who had received prior training in airway management skills, performed intubations on each of the 5 different manikins (56×5=280 intubations). The manikins used were the Human Patient Simulator (HPS), iStan & Emergency Care Simulator (ECS) from CAE Healthcare and Mega Code Kelly (MCK) and Airway Trainer (AWTR) from Laerdal. The students’ performances were compared for success rates, ease of intubation, grade of laryngeal visualisation and presence of tooth injury on the manikins, Data from the intubations were cross-tabulated and evaluated by general estimating equation analysis using the Poisson model.

Results

iStan had the higher rates of failure to intubate (64.3%). iStan (62.5%) and HPS (57.1%) had statistically significant teeth injury (p<0.0001) compared to other manikins. HPS and AWTR had the least difficult grades of laryngeal visualisation (Cormack Lehane grades 1 and 2), while the most difficult grade of visualisation (Cormack Lehane grades 3 and 4) was reported in ECS (44.6%).

Conclusions

Each of the high-technology manikins used in automated scenarios for crisis management teaching and learning has heterogeneity in airway features. Since frequent airway management is a critical component of simulation scenarios, this can affect student performance when these manikins are used for formative and summative high-stakes assessments.

[Design and validation of an oral health questionnaire for preoperative anaesthetic evaluation]

BACKGROUND AND OBJECTIVES

Dental injuries incurred during endotracheal intubation are more frequent in patients with previous oral pathology. The study objectives were to develop an oral health questionnaire for preanaesthesia evaluation, easy to apply for personnel without special dental training; and establish a cut-off value for detecting persons with poor oral health.

METHODS

Validation study of a self-administered questionnaire, designed according to a literature review and an expert group's recommendations. The questionnaire was applied to a sample of patients evaluated in a preanaesthesia consultation. Rasch analysis of the questionnaire psychometric properties included viability, acceptability, content validity and reliability of the scale.

RESULTS

The sample included 115 individuals, 50.4% of men, with a median age of 58 years (range: 38-71). The final analysis of 11 items presented a Person Separation Index of 0.861 and good adjustment of data to the Rasch model. The scale was unidimensional and its items were not biased by sex, age or nationality. The oral health linear measure presented good construct validity. The cut-off value was set at 52 points.

CONCLUSIONS

The questionnaire showed sufficient psychometric properties to be considered a reliable tool, valid for measuring the state of oral health in preoperative anaesthetic evaluations.

Design and validation of an oral health questionnaire for preoperative anaesthetic evaluation

BACKGROUND AND OBJECTIVES

Dental injuries incurred during endotracheal intubation are more frequent in patients with previous oral pathology. The study objectives were to develop an oral health questionnaire for preanaesthesia evaluation, easy to apply for personnel without special dental training; and establish a cut-off value for detecting persons with poor oral health.

METHODS

Validation study of a self-administered questionnaire, designed according to a literature review and an expert group's recommendations. The questionnaire was applied to a sample of patients evaluated in a preanaesthesia consultation. Rasch analysis of the questionnaire psychometric properties included viability, acceptability, content validity and reliability of the scale.

RESULTS

The sample included 115 individuals, 50.4% of men, with a median age of 58 years (range: 38-71). The final analysis of 11 items presented a Person Separation Index of 0.861 and good adjustment of data to the Rasch model. The scale was unidimensional and its items were not biased by sex, age or nationality. The oral health linear measure presented good construct validity. The cut-off value was set at 52 points.

CONCLUSIONS

The questionnaire showed sufficient psychometric properties to be considered a reliable tool, valid for measuring the state of oral health in preoperative anaesthetic evaluations.

Hiding in Plain Sight: Clinically Unrecognized Fatal Tooth Asphyxia Revealed by the Forensic Autopsy

Fatal asphyxia by choking whether by food or foreign material remains an uncommon occurrence affecting mainly those at the extremes of age and with variable and sometimes misleading clinical presentations. Prompt clinical recognition of impending airway obstruction afforded by complete physical examination and assessment is paramount for prevention of morbidity and mortality in these cases. In the elderly, a death initially presenting with sudden cardiorespiratory collapse may be erroneously certified as due to natural disease without performance of an autopsy. Fortunately, deaths subsequent to cardiorespiratory collapse, where results of the clinical work-up fail to identify an etiology and medical history is insufficient, are reportable, falling under the jurisdiction of the medical examiner/coroner. The performance of an autopsy in the evaluation of a sudden death arising after hospitalization in which the etiology remains unclear can provide valuable information to our clinical colleagues that they can apply to more timely diagnosis and treatment. Furthermore, the forensic autopsy offers clarification and answers to questions of medicolegal importance. This is particularly true for choking deaths. Presented is a choking death after tooth aspiration whereby the forensic autopsy provided specific anatomic correlation to the clinical clues not recognized before death and provided the true cause of death.

A comparison of the Miller laryngoscope versus the prototype neonatal offset-blade laryngoscope in a manikin

Laryngoscope blades used to intubate newborn babies are relatively bulky and frequently exert high pressure on the upper jaw. We tested a prototype neonatal offset-blade laryngoscope (NOBL) developed to overcome these limitations. Our aims were to compare the pressure on the upper jaw exerted by a size 0 Miller laryngoscope and the NOBL on a neonatal manikin, as well as the time taken to intubate the trachea and the area of view of the larynx. Twenty healthcare professionals with more than five years of experience in neonatal intensive care took part; the findings were assessed using pressure-sensitive film and photographs. High-pressure indentation occurred in 17 (85%) attempts using the Miller versus 1 (5%) using the NOBL (p = 0.0001). The median (IQR [range]) pressure exerted with the Miller laryngoscope was 455 (350-526 [75-650]) kPa vs 80 (0-133 [0-195]) kPa with the NOBL (p < 0.0001). The area of pressure exerted with the Miller laryngoscope was 68 (32-82 [0-110]) mm(2) vs 8 (0-23 [0-40]) mm(2) with the NOBL (p < 0.0001). The time to intubate was 8.3 (7.3-10.1[4-19]) s for the Miller and 8.0 (5.6-9.6 [4-13.5]) s for the NOBL (p < 0.0001). The area of view blocked by the Miller laryngoscope was 38% of the oral orifice versus 12% with the NOBL. We conclude that the NOBL significantly reduced undesired pressure on the upper jaw during tracheal intubation and improved the view of the larynx compared with a conventional laryngoscope.

Compression force on the upper jaw during neonatal intubation: mannequin study

AIM

Neonatal intubation is a technically challenging procedure, and pressure-related injuries to surrounding structures have been reported. The primary objective of this study was to determine the pressure exerted on the upper jaw during tracheal intubation using a neonatal mannequin.

METHOD

Multidisciplinary care providers working at a neonatal intensive care unit were requested to intubate a neonatal mannequin using the standard laryngoscope and 3.0-mm (internal diameter) endotracheal tube. Compression force exerted was measured by using pressure-sensitive film taped on the upper jaw before every intubation attempt. Pressure, area under pressure and time taken to intubate were compared between the different types of health-care professionals.

RESULTS

Thirty care providers intubated the mannequin three times each. Pressure impressions were observed on the developer film after every intubation attempt (n = 90). The mean pressure exerted during intubation across all health-care providers was 568 kPa (SD 78). The mean area placed under pressure was 142 mm(2) (SD 45), and the mean time taken for intubation was 14.7 s (SD 4.3). There was no difference in pressure exerted on the upper jaw between frequent and less frequent intubators. It was found that pressure greater than 400 kPa was inadvertently applied on the upper jaw during neonatal intubation, far exceeding the 250 kPa shown to cause tissue injury in animal models.

CONCLUSION

The upper jaw is exposed to a significant compression force during intubation. Although such exposure is brief, it has the potential to cause tissue injury. Contact of the laryngoscope blade with the upper jaw occurred in all intubation attempts with the currently used design of laryngoscope.

Easy-to-implement oral cavity modification to expand simulation-based training in airway management

INTRODUCTION

Injuries to the oral cavity and teeth can occur during routine intubation and general anesthesia but often occur in emergency situations when the priority of securing the airway supersedes preanesthetic evaluation. This study demonstrates the feasibility of modifying the oral cavity to increase the dental fidelity during emergency airway management.

METHODS

A Laerdal Manikin was used to manipulate the preexisting Polyester (hard) and the Vinyl (flexible) dentition sets that are interchangeable among the Laerdal family of manikins. Items easily available in a dental laboratory such as dental acrylic and dental impression material were used to create modifications.

RESULTS

Laerdal dentition sets were altered to simulate common dental (tooth-related) trauma encountered during intubation such as a fracture, luxation, or avulsion injuries. Anatomic variations such as carious (decayed) teeth, loose teeth, and class II malocclusion (overbite) were also fabricated. Tooth luxation was engineered to occur with pressure by a laryngoscope, and bleeding teeth were also created to demonstrate excessive pressure applied during direct laryngoscopy. It is feasible to improve the realism of the Laerdal family of manikins with simple modifications.

CONCLUSIONS

This project proves the concept of feasibly fabricating anatomic variations to increase the fidelity of existing simulation manikins. Other anatomic variations present challenges to airway management, and future research will aim at creating additional modifications. In addition, future research will seek to quantify the improvement in airway management skills by anesthesia and emergency medicine providers by training on manikins with variable oral cavity anatomy.

ERCP: the unresolved question of endotracheal intubation

The anesthesia community is still divided as to the appropriate airway management in patients undergoing endoscopic retrograde cholangiopancreatography. Increasingly, gastroenterologists are comfortable with deep sedation (normally propofol) without endotracheal intubation. There are no comprehensive reviews addressing the various pros and cons of an un-intubated airway management. It is hoped that the present review will benefit both anesthesia providers and gastroenterologists. The reasons to avoid routine endotracheal intubation and the approaches for an un-intubated anesthetic management are discussed. The special situations where endotracheal intubation is the preferred approach are mentioned. Many special techniques to manage airway are illustrated.

Birth order--a risk factor for dental trauma?

BACKGROUND

Many character traits are influenced by birth order with greatest differences between first and lastborns.

AIM

To investigate the influence of birth order on the risk of dental trauma.

METHODS

Five hundred mothers in Switzerland were interviewed personally regarding dental trauma in their children. Inclusion criteria were a family size of at least two children. Data of 1282 children were collected.

RESULTS

Thirty-two percent of the children had sustained one or more dental trauma before the age of 16 (57% male, 43% female). In children who had sustained dental trauma twice, the gender ratio moved to 68% male and 32% female (P = 0.003). Regarding birth order, lastborns sustained more second dental traumas. Relative risk of second dental trauma was 2.1 times higher in lastborns than in firstborns (P = 0.02). Moreover, certain character traits in children are influenced by birth order. According to their mothers, lastborns were more curious, less calm and less deliberate than firstborns (P < 0.001). Second born without younger siblings were more athletic/active than firstborns (P = 0.011). Athletic/active children as well as not calm/deliberate children sustained second dental trauma more often than not athletic/active (P = 0.038) and calm/deliberate children (P < 0.001).

CONCLUSION

Birth order is a risk factor for sustaining dental trauma twice. Character traits of lastborns (curious, not calm/deliberate and aggressive) could be reasons for higher risk of dental trauma.

[French clinical guidelines for prevention of perianaesthetic dental injuries: long text]

INTRODUCTION

Dental injuries represent the most common claims against the anaesthesiologists. Dental lesions are frequent complications of orotracheal intubation and major causal factors are, firstly, preexisting poor dentition, and, secondly, difficult laryngoscopy and tracheal intubation. The aim of this work was to prioritize propositions for prevention in perianaesthetic dental injury and for care in case of dental trauma.

METHOD

A GRADE consensus procedure consisting of three rounds was conducted. A purposively selected heterogeneous panel (n=15) of experts, comprising 10 practitioners in anesthesiology, one practitioner who is jurist and anaesthesiologist, two practitioners in maxillofacial surgery, and two practitioners in dentist surgery. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the board members. The guidelines represent the best current evidence based on literature search and professional opinion.

RESULTS

The entire panel completed all three rounds and 31 plus six propositions were written for adult and paediatric clinical practice in anaesthesiology, respectively. The experts highlight the interest of preoperative visit for minimizing dental injuries: the practitioner must identify risk factors for difficult intubation and ventilation, describe precisely patient's preoperative dental condition, including upper incisor most commonly involved teeth in dental trauma. Patients have to be informed by practitioner for risk dental injury and anaesthesiology staff must choose his anesthesia protocol before the induction of intubation narcosis, avoiding insufficient anaesthesia and lack of experience by the anaesthesiologist. The choice of accurate proceeding during laryngoscopy, tracheal intubation and extubation for example, can aid in the prevention of dental injury, reduce the number of claims and the cost of litigation process.

DISCUSSION

These guidelines delineate an approach for the prevention of perianaesthetic dental trauma and for the immediate or urgent care in case of perianaesthetic dental injury.

Perioperative dental injury at a tertiary care health system: An eight-year audit of 816,690 anesthetics

Among all complications of airway management, dental injury is the most common cause of patient complaints with medicolegal consequences. Over an 8-year period, data on dental injury were collected within a large university hospital system that included community, tertiary, and quaternary care centers. Patient characteristics were compared among all patients receiving anesthesia care using billing data collected from the same period. Of the 816,690 patients who received anesthesia care, there were 360 dental injuries, giving an overall incidence of 1:2,269 (0.044%). Patients receiving general anesthesia were at an increased risk for dental injuries, with an incidence of 1:1,754 (0.057%) compared with patients receiving monitored anesthesia care in whom the incidence was 1:12,500 (0.008%). Patients in the age group 18 to 65 years had a higher incidence of dental injuries of 1:1,818 (0.055%) compared with pediatric patients, who had an incidence of 1:7,692 (0.013%). Emergency procedures were not associated with an increased risk of dental injury in the 816,690 cases. However, of the 360 patients who sustained a dental injury, emergency procedures were associated with a higher incidence of injuring multiple teeth.

Unusual Displacement of a Mobilised Dental Bridge during Orotracheal Intubation

Dental trauma during tracheal intubation mostly happens in case of poor dentition, restricted mouth opening, and/or difficult laryngoscopy. 57-year-old man undergoing laparoscopic radiofrequency ablation of unresectable hepatocellular carcinoma had his dental work detached at induction of anesthesia. Oropharyngeal direct view, manual inspection, fibreoptic nosendoscopy, tracheobronchoscopy, and fiberoptic inspection of the esophagus and stomach were unsuccessful in locating the dislodged bridge. While other possible exams were considered, such as lateral and AP x-ray of head and neck, further meticulous manual "sweepings" of the mouth were performed, and by moving the first and second fingers below the soft palate deep towards the posterolateral wall of the pharynx, feeling consistent with a dental prosthesis was detected in the right pharyngeal recess. Only after pulling the palatopharyngeal arch upward was it possible to grasp it and extract it out with the aid of a Magill Catheter Forceps. Even though the preexisting root and bridge deficits were well reported by the consultant dentist, the patient was fully reimbursed. The lack of appropriate documentation of the advanced periodontal disease in the anesthesia records, no mention of potential risks on anesthesia consent, and insufficient protective measures during airway instrumentation reinforced the reimbursement claim.

Tooth aspiration: its relevance in medicolegal autopsies

Tooth aspiration in adulthood is an uncommon autopsy finding. The paper presents two cases in which maxillary incisors had been avulsed and inhaled during hospital treatment and in the course of maxillofacial trauma, respectively. In the first case, repeated attempts to remove the aspirated tooth by means of flexible bronchoscopy led to perforation of the bronchial wall with consecutive bleeding into the deep airways and fatal asphyxia. In the second case, the fact of tooth aspiration remained undetected throughout the 3-day survival time until death from craniocerebral trauma. The paper points out the forensic aspects of tooth aspiration against the background of the relevant clinical literature.