By Jeremy Wale, JD

Nearly every hospital in the United States provides anesthesia services to patients. Most offer surgical services with general anesthesia, providing for safe operative care of patients. Such services bring risk exposures, many of which you can proactively mitigate.

General anesthesia demands a patient’s airway be protected, and may require a patient to be intubated. As such, related risks include, but are not limited to, dental and airway injuries and respiratory issues. Other potential risks associated with anesthesia delivery include incomplete informed consent discussions, inadequate patient monitoring, and delivery of inadequate or inappropriate medications.

Preventing Dental Injury During Anesthesia

One of the most common general anesthesia injuries is dental injury.¹ Examples include broken or chipped teeth, broken bridges, or dislodged implants. Oftentimes the anesthesiologist may not realize dental damage has occurred. It is not uncommon for cracked teeth or chipped veneers to go unnoticed until the patient detects and communicates the issue.

The patient’s dentition, emergencies, poor intubation or extubation technique, or tools used by the anesthesiologist can factor in dental injuries. Injuries most often occur “during intubation with a laryngoscope in patients where there is limited visibility to the hypopharynx.”² In fact, “50-75% of dental injuries occur during tracheal intubation.”³

Two types of patients are highest risk for dental injury: difficult patients to intubate and those with poor dentition. Difficult patients to intubate have a 20 times greater risk of dental injury.⁴ Patients with poor pre-existing dental status present a five-times greater risk of dental trauma than patients with good pre-existing dental status.

How can anesthesiologists help mitigate dental injury risk? Ensure familiarity with the patient’s general dental condition, which can help identify potential issues before they occur. This also may help in the event of an emergency.

Ensure the patient removes all removable appliances from his or her mouth prior to any procedure. This helps prevent damage to the patient’s appliance(s) or teeth.

A well-documented pre-anesthesia assessment of each patient’s dental condition provides an optimal start. This gives the anesthesiologist an opportunity to identify potential problems before he or she begins administering anesthesia—and to discuss those and formulate a plan to mitigate dental injury risk. Additionally, a thorough, documented informed consent discussion identifying potential issues with the patient’s dentition can be invaluable if dental injury occurs.

Likewise, a detailed pre-anesthesia assessment to evaluate the patient for difficulty of intubation will assist the anesthesiologist in avoiding dental injuries.⁵ Knowing areas of concern ahead of time aids preparedness to overcome challenges without damaging a patient’s dentition. Such an assessment is part of a comprehensive informed-consent patient discussion.

Some anesthesiologists add a dental exam to the pre-anesthesia form. That form may include a diagram of the teeth with space for anesthesiologist notations regarding potential areas for concern. This not only serves as strong documentation, but provides a good reminder to complete dental exams for each patient.

Several devices are available to minimize dental injury risk during general anesthesia.⁶ These devices typically are placed on or around the teeth to protect against damage. One institution, the University of Iowa Department of Otolaryngology, “has incorporated dental guards into a protocol for reducing dental injury during laryngoscopy.”⁷

Overseeing Anesthesia for Multiple Patients

In hospitals and surgery centers, it is not uncommon to have one anesthesiologist responsible for multiple patients simultaneously—supervising or consulting for multiple procedures at the same time. This typically occurs when there is a Certified Registered Nurse Anesthetist (CRNA) with each patient, and the physician anesthesiologist is responsible for supervising CRNA care.

Issues can potentially arise when the patient and/or family members are not informed of this team approach. While CRNAs generally are well qualified with specialty training and certification to administer anesthesia, patient knowledge is key. Most patients expect the anesthesiologist will be in the room for the entire procedure unless told otherwise.

If your facility uses the team-care anesthesiology approach, a thorough informed consent discussion explaining the care plan and anesthesiologist availability is advised. This discussion informs the patient and/or family members of the care to be provided and allows questions and concerns to be addressed.

Key Considerations for Your Hospital’s Anesthesia Services

The following summaries can help you and your facility’s leadership review policies and procedures to mitigate risks involved with anesthesia services. 

1. Evaluate and determine whether your anesthesiologists have sufficient knowledge of their patient’s dental health prior to providing anesthesia;
2. Evaluate and determine whether your anesthesiologists are adequately trained to identify potential risks to the dentition of anesthesia patients;
3. Review your facility’s pre-anesthesia form to ensure a dental exam is indicated for each patient undergoing general anesthesia;
4. Review your facility’s pre-anesthesia consent form and discussion to confirm a detailed discussion of possible dental injuries is covered and documented with each patient;
5. Ensure your pre-anesthesia consent discussion includes informing the patient whether an anesthesiologist or CRNA will be in the room monitoring the patient; and
6. Familiarize your anesthesia team with emergency protocols routinely.

It is important for patient care and hospital liability that you take steps to proactively manage the risk around your facility’s provision of anesthesia. Establishing sufficient protocol and frequently checking in with staff to ensure their understanding are essential steps in effective anesthesia management.

Sources3

1 Darawade D, Dubey A, Gondhalekar R, Dahapute S, et al. Assessment of the risk factors for oro-dental injuries to occur during general anesthesia and measures taken by anesthesiologist to prevent them. J Int Oral Health. 2015;7(7):77-79.

2 Darawade D, Dubey A, Gondhalekar R, Dahapute S, et al. Assessment of the risk factors for oro-dental injuries to occur during general anesthesia and measures taken by anesthesiologist to prevent them. J Int Oral Health. 2015;7(7):77-79.

3 Yasny J. Perioperative dental considerations for the Anesthesiologist. Anesth Analg. 2009;108(5):1564-1573.

4 Ribero de Sousa J, Barros Mourao J. Tooth injury in anesthesiology. Rev Bras Anestesiol. 2015;65(6):511-518.

5 Ribero de Sousa J, Barros Mourao J. Tooth injury in anesthesiology. Rev Bras Anestesiol. 2015;65(6):511-518.

6 Board Certified Otolaryngologist. American Medical Forensic Specialists Web site. http://www.amfs.com/news/articlesfrom-our-experts/dental-injuries-during-surgery/. Accessed June 3, 2016.

7 Board Certified Otolaryngologist. American Medical Forensic Specialists Web site. http://www.amfs.com/news/articlesfrom-our-experts/dental-injuries-during-surgery/. Accessed June 3, 2016.

– Jeremy Wale, JD is a ProAssurance Risk Resource Advisor.