Dental Injury During Intubation

Dental injury during intubation is chipping, fracture, loosening, subluxation or avulsion of teeth, restoration damage, or tissue injury from laryngoscopy or airway device insertion. It is the commonest cause of anaesthetic claims.

Epidemiology. It affects about 1 in 150 to 1 in 1,000 general anaesthetics, with upper incisors involved in over 80% of cases. Risk increases fiftyfold or more with pre-existing dental disease and difficult airways.

Risk factors. Poor dentition (caries, periodontal disease, loose or crowned teeth, bridges), prominent incisors, limited mouth opening, difficult laryngoscopy, emergency intubation, inexperience, bite during emergence, and use of rigid devices.

Pathophysiology.

Levering the laryngoscope blade against upper incisors transmits force to the tooth. Mechanical compression, biting on the tube or airway, or blows during insertion cause fracture or luxation.

Missing or loose tooth, broken fragments, bleeding from the gingiva, pain, malocclusion and lip or gingival laceration. Avulsed teeth or fragments may be aspirated or swallowed.

Red flags.

• Missing tooth or fragment unaccounted for (aspiration).
• Cough, stridor or desaturation.
• Jaw fracture or malocclusion.

Inspect the mouth and count teeth and fragments. Chest radiograph (and abdominal radiograph) to locate a missing tooth, with bronchoscopy for airway fragments. Dental review with periapical radiograph and assessment of pulp, root and bone.

Differential diagnosis.

• Pre-existing damage.
• Temporomandibular joint injury.
• Mandibular fracture.
• Lip or gingival laceration alone.

Retrieve fragments and tooth. Control bleeding with pressure and suction.

• Permanent tooth avulsion: rinse the tooth gently (do not scrub the root), reimplant at once if possible, or store in milk, saline or the patient's saliva, and refer to dental care within 30 to 60 minutes. Splint for 2 weeks.
• Primary (milk) teeth: do not reimplant.
• Lax or subluxed tooth: splint by dental surgeon.
• Aspirated fragment: bronchoscopy; swallowed fragment: observe and repeat radiograph if not passed.
• Amoxicillin: 500 mg orally every 8 hours for 5 to 7 days after reimplantation or deep laceration; maximum 3 g daily; monitor rash; reduce in creatinine clearance under 30 mL/min.
• Tetanus immunisation if the wound is contaminated and cover is not current.
• Analgesia: paracetamol 1 g orally every 6 hours, maximum 4 g daily; reduce in hepatic impairment, malnutrition or under 50 kg.

Prevention. Examine teeth before surgery and record state, use mouth guards, avoid levering, use video laryngoscope in poor dentition, and warn patients of the risk.

Monitoring. Dental follow up at 1 week and 6 weeks (pulp vitality).

Referral and escalation. Dental or maxillofacial review the same day. Disclose, document and report the injury.