An article for physicians by physicians
Originally published May 2010
Any medical procedure where instruments are inserted into the mouth may result in dental injury, despite appropriate care. This article provides advice about obtaining and documenting consent for such procedures, and what to do should a patient allege wrongful damage to the teeth.
Despite the progress in the practice of medicine, dental injuries continue to trouble physicians and their patients. There have been significant advances in the practice of anesthesia, and many improvements in the equipment used for intubation, for example laryngeal masks, fibre optic scopes and other devices. At the same time, an increasing number of endoscopic and other procedures are now performed through the oral opening. Dental injury can arise from any of these, as the following cases illustrate. But there are steps you can take to reduce the risk to you and your patients.
Capped tooth displaced
A patient reported a capped upper middle incisor on the preoperative questionnaire. Following surgery under general anesthesia, the capped tooth was found to be displaced. A small claims court action was initiated, claiming the costs for dental repair. The anesthesiologist admitted that he had not discussed the risks of dental injury with the patient. A settlement was paid to the patient by the CMPA on behalf of the anesthesiologist.
A patient with poor dentition underwent general anesthesia for a basket extraction of stones in the ureter. In the recovery area, the patient spat his incisor out. He sued the anesthesiologist, claiming the loss of the tooth was due to negligence.
The anesthesiologist's documentation did not demonstrate an adequate discussion of the risks of dental injury, especially in light of the patient's known dental problems. A settlement was paid to the patient by the CMPA on behalf of the anesthesiologist.
Upper incisor chipped
An anesthesiologist assessed the airway of a patient before surgery. The patient was classified one on the Mallampati scale and was noted to have good dentition. The anesthesiologist explained the need for endotracheal intubation and the risk of dental damage.
The patient was induced and intubation attempted. Unexpected difficulty was experienced. After a second attempt at intubation, the surgeon stated he heard a cracking sound. The anesthesiologist examined the teeth and noted a chip of the left upper incisor. After the surgery, he appropriately disclosed this injury to the patient.
The patient commenced a small claims court action for damages. The judge ruled the anesthesiologist had informed the patient of the possibility of tooth damage, the patient had given informed consent and the anesthesiologist was not negligent.
Tooth, bridge missing
A gastroenterologist performed an endoscopic retrograde cholangiopancreatography. The patient was asked about dental work and possible problems, and a mouth guard was inserted to protect the teeth. The procedure report noted difficulty in sedating the patient. After the procedure, the patient was missing a tooth and alleged a bridge was also damaged. A peer medical expert reviewed the matter and supported the care given. The patient discontinued the action.
Risk management considerations
An analysis of CMPA cases reveals most medico-legal claims involving dental injury had pre-existing dental conditions including bridges, capped teeth, dentures, poor dentition or periodontal disease.
The review identifies the following risk management considerations:
- Have you done or reviewed the pre-anesthetic history and examination?
- Have you done an appropriate airway assessment and documented it?
- Is it likely to be a difficult intubation?
- Have you identified vulnerable teeth?
- Have you or another health care provider discussed the risk of dental injury with the patient?
- Have you or another health care provider documented the consent discussion?
If a dental injury occurs
If damage to teeth occurs, this needs to be disclosed to the patient. Items to be considered in the discussion could include the following: damage to teeth is considered an inherent risk of the procedure, any difficulty encountered during the procedure, as well as any precautions that were taken to avoid this complication.
If immediate dental treatment is required and is arranged by the treating physician, care should be taken to avoid allowing any inference the costs will be borne by the physician.
If a patient does allege her/his teeth were damaged during a procedure despite reasonable care by the physician, the physician should not offer or promise financial help but should contact the Association immediately for advice.
The bottom line
Dental damage is a risk of any procedure where instruments are inserted into the mouth. As the urgency of the situation permits, you can take several steps to reduce the risks to patients and yourself:
- examine the oral opening before airway management
- document any conditions that would increase the risk of dental injury
- discuss these conditions and risks with the patients
- document not only the findings and the procedure, but also the discussion with the patients