Case Context

A 65-year-old patient’s front tooth was accidentally knocked out during intubation. The risk of dental injury was not discussed during the preoperative consent process. As the anesthesiologist, there is an ethical obligation to address the incident promptly and professionally.

Immediate Management

The dislodged tooth should be carefully retrieved and stored in normal saline or milk to preserve the periodontal ligament. Bleeding should be controlled with gauze pressure, and the dental or surgical team should be notified without delay. The incident must be documented in detail, including the time of injury, the intubation method used, the condition of the tooth, and whether the airway was difficult.

References

• Warner ME, Benenfeld SM, Warner MA, Schroeder DR, Maxson PM. Perianesthetic dental injuries: frequency, outcomes, and risk factors. Anesthesiology. 1999;90(5):1302–1305. doi:10.1097/00000542-199905000-00013
• Owen H, Waddell-Smith I. Dental trauma associated with anaesthesia. Anaesthesia and Intensive Care. 2000;28(2):133–145. doi:10.1177/0310057X0002800202
• American Dental Association. Management of avulsed permanent teeth. J Am Dent Assoc. 2013;144(6):670. doi:10.14219/jada.archive.2013.0175

Disclosure to the Patient and Family

Disclosure should be clear, empathetic, and transparent. Defensive language must be avoided. The explanation should cover the nature of the injury, how it occurred, and the steps being taken to address it.

References

• Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356(26):2713–2719. doi:10.1056/NEJMra070568
• Australian and New Zealand College of Anaesthetists. PS09: Guidelines on informing patients about potential dental injury during anaesthesia. 2021. Available from: https://www.anzca.edu.au/resources/professional-documents/standards-(1)/ps09-guidelines-on-informing-patients-about-pot.pdf

Preoperative Dental Assessments

Patients should be visually examined for loose, prosthetic, or prominent teeth, and questioned about prior dental work or recent dental problems. The risk of dental injury should be documented and discussed as part of the informed consent process.

References

• Yasny JS. Perioperative dental considerations for the anesthesiologist. Anesth Analg. 2009;108(5):1564–1573. doi:10.1213/ane.0b013e31819d1d14
• Fung D, Schwartz R. Airway management and dental trauma: a review. J Can Dent Assoc. 2007;73(6):527–530. Available from: https://www.cda-adc.ca/jcda/vol-73/issue-6/527.html

Integrating Dental Charts Preoperatively

Dental risk checklists should be incorporated into pre-anesthesia evaluation forms. Patients can be stratified into risk categories such as high risk for mobile or prosthetic teeth. Electronic medical records should include dental diagrams and alert systems for fragile teeth.

References

• Cheng S, Stevenson M, Yeoh C. Dental injury in anaesthesia: a 10-year review from a tertiary hospital. Anaesth Intensive Care. 2019;47(3):235–242. doi:10.1177/0310057X19844768
• Givol N, Gershtansky Y, Halamish-Shani T, Taicher S. Perianesthetic dental injuries: analysis of incident reports. J Clin Anesth. 2004;16(3):173–176. doi:10.1016/j.jclinane.2003.07.006

Key Risk Factors

Several factors increase the risk of dental trauma during anesthesia. Protruding incisors are prone to direct contact with the laryngoscope blade. Loose or diseased teeth can dislodge with minimal force. Prosthetic teeth are fragile and may fracture or detach. Difficult airways often require multiple or forceful attempts, further increasing risk. Patients with poor neck mobility face suboptimal blade positioning, and rigid laryngoscopes apply excessive pressure to the incisors.

References

• Newland MC, Ellis SJ, Peters KR, Simonson JA, Durham TM, Ullrich FA, Tinker JH. Dental injury associated with anesthesia: a report of 161,687 anesthetics. Anesthesiology. 2007;107(5):796–802. doi:10.1097/01.anes.0000287641.43251.22
• Rosenberg MB. Dental considerations in anesthetic practice. Anesth Prog. 1984;31(2):66–69. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2235515/

Protective Strategies

Preventive approaches include the use of custom dental guards or bite blocks, which protect the teeth from direct blade contact. Video laryngoscopes reduce the risk by minimizing pressure against the upper incisors. In high-risk cases, bougie-guided or awake fiberoptic intubation may be appropriate. During laryngoscopy, lifting should be gentle rather than levering against the teeth.

References

• Fukuda K, Kawamoto M, Kohase H, Umino M. Preventing dental injury during anesthesia: use of a mouthguard. Anesth Prog. 1998;45(1):20–22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148943/
• Bhargava AK, Karkhanis S, Vas L. Oral injuries during anaesthesia. Anaesth Intensive Care. 2001;29(2):127–129. doi:10.1177/0310057X0102900205

Airway and Dental Safety

Airway planning should incorporate dental risk. The ASA Difficult Airway Algorithm should guide management, with awake fiberoptic intubation considered in high-risk patients. Forceful techniques and rigid oral airways should be avoided where possible.

References

• Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the ASA Task Force. Anesthesiology. 2022;136(1):31–81. doi:10.1097/ALN.0000000000004002
• Warner MA. Prevention of dental injury during anesthesia. Anesthesiology. 1999;90(5):1301. doi:10.1097/00000542-199905000-00012

Disclosure Protocol (SPIKES Framework)

• Setting: Use a private, calm environment. Sit at eye level and ensure undivided attention.
• Perception: Assess patient understanding by asking what they recall prior to induction.
• Invitation: Request permission to explain the event, such as: “Is it okay if I tell you what happened during the procedure?”
• Knowledge: Deliver the facts clearly, for example: “During the intubation, one of your front teeth was unintentionally dislodged.”
• Empathy: Acknowledge emotions with phrases such as: “I understand this is upsetting, and I am truly sorry this happened.”
• Strategy and Summary: Explain steps taken and next actions, such as: “We retrieved the tooth and will arrange for an urgent dental consultation.”

References

• Baile WF, Buckman R, Lenzi R, et al. SPIKES—A six-step protocol for delivering bad news. Oncologist. 2000;5(4):302–311. doi:10.1634/theoncologist.5-4-302
• Canadian Anesthesiologists’ Society. Dental trauma and informed consent. Can J Anesth. 2018;65(5):511–514. doi:10.1007/s12630-018-1080-5

Training and System Improvements

Simulation-based training in dental injury management should be integrated into airway workshops. Operating rooms should be equipped with bite blocks, video laryngoscopes, and standardized dental charts. Training should also include empathetic disclosure and structured documentation. Hospitals should establish referral pathways for timely dental consultation following injury.

References

• Sessler CN. Preventing and managing dental injury in the operating room. Curr Opin Anaesthesiol. 2004;17(4):325–329. doi:10.1097/01.aco.0000137094.12837.7f
• Gupta S, Warner DO. Managing adverse events in anesthesia practice. Curr Opin Anaesthesiol. 2008;21(2):207–211. doi:10.1097/ACO.0b013e3282f4f036

Summary

Dental injury during anesthesia is preventable yet remains a frequent complication. Preoperative dental assessment, risk stratification, and protective strategies are essential. In the event of an injury, prompt retrieval and preservation of the tooth, bleeding control, and specialist referral are necessary. Disclosure should follow structured, empathetic communication frameworks. Finally, training, simulation, and standardized protocols help minimize risk and ensure professional, patient-centered management when injuries occur.