Peri-operative dental damage

Publication: 21/07/2016  
Next review: 06/07/2025  
Clinical Guideline
CURRENT 
ID: 4695 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Peri-operative dental damage

Summary of Guideline

This guideline describes the management of dental damage occurring during general anaesthesia. It is aimed at all anaesthetists.

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Background

Dental damage is one of the most common complications of general anaesthesia, occurring in approximately 1 in 4500 cases.(1) Minor cuts or bruising to the lips and tongue are very common, occurring in approximately 1 in 20 general anaesthetics.(2) These injuries heal very quickly and can be treated with simple ointments.

The Medical Protection Society report around one third of all anaesthetic claims relate to dental damage occurring during general anaesthesia. More often than not, complaints were not due to clinical negligence, but where communication errors meant that patients were not aware of the risks of dental damage during anaesthesia.(3)

A thorough pre-operative assessment with clear documentation is imperative. Identifying patients at an increased risk of dental damage is key. Risk factors include; poor dental health, limited mouth opening, crowns, fillings and bridges, baby teeth and patients with protruding upper teeth or an isolated tooth.(4)

If dental damage does occur, an urgent dental assessment will be required and an open and honest conversation with the patient is paramount.

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Pre-assessment

All patients should be asked about the condition of their teeth at the pre-assessment clinic. Where poor dentition is identified, the patient should be advised to seek a dental assessment from their own dentist and undergo remedial treatment prior to their surgery. This advice should be clearly documented within the pre-assessment proforma.

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Pre-operative visit

The risk of damage to teeth under general anaesthetic is approximately 1 in 4500.(1) Most occur at intubation in patients over 50 years old with limited mouth opening.

  • All patients should be warned of the risk of dental damage as part of their pre-anaesthetic discussion. This should be clearly documented on the anaesthetic chart.
  • With the patient’s consent, you should examine any teeth that may be loose or vulnerable. Your findings should be clearly documented on the anaesthetic chart.
  • Where you believe the risk of dental damage is higher because of factors such as poor dentition or poor mouth opening, the patient should be warned that they are at increased risk of dental damage. This should be clearly documented.

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Conduct of anaesthesia

  • Where you have identified an increased risk of perioperative dental damage, you may wish to consider the use of adjuncts such as a dental guard or bite block. If a guard is used, this should be documented.
  • You should consider offering alternative techniques such as regional anaesthesia if this is appropriate. All discussions and decisions should be fully documented.
  • Many cases of dental damage occur either at extubation, or more commonly when a supraglottic airway is removed. It is therefore extremely important that you communicate any concerns about the patient’s teeth to the recovery nurse in PACU.

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In the event of dental damage

Dental damage may become apparent at the time of injury, identified by the patient whilst still in hospital, or identified by the patient following discharge from hospital.

  1. Tooth fragments should be retained if possible. They should be handed to the patient in a labelled pot. If any teeth or fragments are missing, chest and abdominal x-rays should be considered.
  2. Completely avulsed teeth should be placed immediately in sterile 0.9% sodium chloride as it may be possible to replace them whilst the patient is still in theatre. Water should NOT be used.
  3. Any dental damage should be discussed with the on-call maxillofacial team (contact through switchboard).
  4. Anaesthetic trainees should inform the on-call anaesthetic consultant for general acutes.
  5. The maxillofacial team may be able to attend theatre to review the patient themselves or will offer advice as to how to proceed.
  6. You may be advised to replant the tooth yourself. Only do this in a patient who is not immunocompromised and has an otherwise healthy mouth. Ensuring you DO NOT touch root surfaces, push the tooth into socket and hold for several minutes.
  7. Re-implanting baby teeth is not usually recommended. If you are unsure whether it is a baby or adult tooth that has been avulsed, await review from the maxillofacial team.
  8. When the patient has completely recovered from anaesthesia, you will need to explain to them what has happened. An apology should be given but no offer of payment or compensation should be made. An apology is not an admission of fault.
  9. Although there is currently limited capacity for such patients to be treated at the Leeds Dental Institute (LDI), all patients who have suffered dental damage during general anaesthesia should have an initial assessment there. The contact number to arrange a referral is 0113 343 6212 from 9.00am - 5.00 pm. A referral form can be found in Appendix 1 (see below).
  10. Patients should be advised that dental treatment may be required at their own dentist, depending upon the complexity of the work and the availability of appointments at the LDI.
  11. Document in the notes what the damage is, what warnings the patient was given, and what advice has been given to the patient after the damage. Please ensure that the patient’s contact details are clearly recorded within the notes.
  12. Complete a Datix form.
  13. All cases should be reported to Dr Ben Rippin by email (b.rippin@nhs.net)
  14. In all cases, consider whether Duty of Candour applies. A link to the trust Duty of Candour guidelines is below:
    http://lthweb.leedsth.nhs.uk/sites/risk-management/incident-reporting/being-open/duty-of-candour-flowchart/view
    A draft duty of candour form specific to dental damage can be found in Appendix 2 (see below).
  15. Ensure that the patient has a copy of the advice leaflet in Appendix 1 (see below).
  16. N.B. Compensation or reimbursement for any dental work will be considered on an individual case basis by the Trust Legal Team. All claims should be directed to the Trust Risk Management department.

For dental damage that becomes apparent after discharge

Please contact Clinical Governance lead Dr Ben Rippin (b.rippin@nhs.net) and copy in Head of Nursing Joan Ingram (joan.ingram@nhs.net) who will contact the patient directly to discuss the matter. They will then offer the patient an appointment to see an anaesthetic consultant at the pre-assessment clinic for the damage to be assessed.
Dr Ben Rippin, Consultant in Anaesthesia, Clinical Governance Lead
Dr John Adams, Medical Director (Governance & Risk)

July 2022

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Appendix 1 - Patient referral form

Printable version

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Appendix 2 - Example 'Duty of Candour' letter

Printable version

Provenance

Record: 4695
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base

Evidence Base:

  1. Warner ME et al. Perianesthetic dental injuries: frequency, outcomes, and risk factors. Anesthesiology 1999;90(5):1302–1305
  2. Fung BK, Chan MY. Incidence of oral tissue trauma after the administration of general anaesthesia. Acta Anaesthesiol Sin 2001;39(4):163–167
  3. http://www.medicalprotection.org/docs/default-source/pdfs/factsheet-pdfs/south-africa-factsheet-pdfs/dental-damage-anaesthesia.pdf?sfvrsn=8
  4. Owen H, Waddell-Smith I. Dental trauma associated with anaesthesia. Anaesthesia and Intensive Care 2000;28(2):133–145.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Not supplied

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