Despite the many advances in the practice of medicine, dental injuries continue to trouble patients and their physicians. Significant advances and improvements have been made in the equipment used for airway management, for example video laryngoscopy, specialized laryngeal masks, and fibre-optic scopes. At the same time, an increasing number of endoscopic and other procedures are now performed through the mouth. As the following cases illustrate, dental injury can arise from any of these procedures, and there are steps physicians can take to reduce the risk.
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 as a Mallampati I 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 with a GlideScope AVL, 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 initiated a small claims court action. 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 physician discussed with the patient the implications of the patient’s dental work. 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 medical-legal difficulties related to dental injury involved patients that had pre-existing dental conditions including bridges, capped teeth, dentures, poor dentition, or periodontal disease.
The review identifies the following considerations to manage risk:
- Have you done or reviewed the pre-anesthetic history and examination?
- Have you done an appropriate airway assessment and documented it?
- Do you believe it is likely to be a difficult intubation?
- Have you identified vulnerable teeth?
- Have you or another healthcare provider discussed the risk of dental injury with the patient?
- Have you or another healthcare provider documented the consent discussion?
If a dental injury occurs
If damage to teeth occurs as a consequence of a medical procedure, physicians need to disclose this to the patient. The discussion could include the following:
- damage to teeth is considered an inherent risk of the procedure
- any difficulty encountered during the procedure
- precautions that were taken to avoid this complication
A meeting with the patient in which the physician is not perceived to be dismissive or unsympathetic can go a long way toward resolving any concerns the patient may have about their dental injury. The CMPA’s handbook, Disclosing harm from healthcare delivery: Open and honest communication with patients, can assist physicians in preparing for these discussions.
If dental treatment is required to repair the injury, the physician should generally refrain from offering or committing to pay the costs of repair without first seeking advice from the CMPA. Among other things, it is possible that any voluntary payment made by the physician in relation to the patient’s dental treatment may have to be reported on hospital and medical regulatory authority (College) applications and renewals, even if no complaint or legal action has been initiated or threatened.
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 mouth before airway management.
- Discuss with your patient any conditions the patient may have that would increase the risk of dental injury, and document this discussion.
- Document the procedure and any findings in the medical record.