What are the potential dental complications associated with intubation?

Dental Complications Associated with Intubation

Dental injury is classified as a moderate complication of intubation, occurring in approximately 1 in 4,500 patients requiring anesthesia services, with the upper incisors being most vulnerable to crown fractures, partial dislocations, and avulsions. 1, 2

Classification and Severity

Dental injury is formally categorized as a moderate complication in the standardized classification of intubation-related complications, distinct from severe complications like cardiac arrest, severe hypoxemia, or death. 1

Incidence and Epidemiology

• The overall incidence of dental injury requiring repair or extraction is 1:4,537 patients receiving anesthesia services. 2
• Dental injuries account for one-third of all confirmed or potential anesthetic claims in medicolegal contexts. 3
• The incidence increases substantially in ICU settings where intubation is often emergent and performed in critically ill patients with precarious cardiovascular and respiratory status. 1
• Patients 50 years of age and older are disproportionately affected. 4

Types of Dental Injuries

The spectrum of dental injuries includes:

• Crown fractures and root fractures of natural teeth (44.8% of cases). 5
• Partial luxation/subluxation (20.8% of cases). 5
• Complete avulsion (tooth dislodgement) (20.8-43% of cases). 6, 5
• Exfoliation (2% of cases). 6
• Soft tissue damage to gingiva and oral mucosa. 6
• Delayed complications appearing days to weeks after the procedure. 5

Anatomic Distribution

• Maxillary central incisors are the most commonly injured teeth, representing the majority of cases. 4, 2
• Upper incisors collectively account for over three-quarters of all dental injuries. 4
• In younger patients, dental hard tissue (crown fractures) predominates, while in older patients, periodontal structures (lateral dislocation) are more commonly affected. 4

Risk Factors

Patient-Related Factors:

• Pre-existing poor dentition (odds ratio = 50) is the strongest patient-related risk factor, including teeth with caries, marginal periodontitis, previous restorations, or periodontal disease. 2, 4
• In 67% of cases, damaged teeth were previously restored or weakened prior to injury. 5
• In 66% of litigation cases, greater risk was documented due to pre-existing dental pathology. 6

Procedure-Related Factors:

• General anesthesia with tracheal intubation (odds ratio = 89) versus other anesthetic techniques. 2
• Increased difficulty of laryngoscopy and intubation (odds ratio = 11), particularly when two or more attempts are required. 2, 1
• Emergency intubation in ICU settings where preparation time is limited. 1
• Cardiothoracic surgery patients demonstrate the highest risk among surgical populations. 4

Prevention Strategies

Pre-Procedure Assessment:

• All patients undergoing endotracheal intubation should have pre-operative dental assessment by the anesthetist to identify risk factors. 3
• Patients with higher-than-average risk should receive specialized examination by a dental surgeon when feasible. 3
• Document pre-existing dental conditions on the anesthetic chart to establish baseline status. 6

Protective Devices:

• Tooth protective guards should be considered for high-risk patients, though they are not universally recommended due to limited intraoral space. 6, 4
• Two types have been evaluated: standard mouthguards and silicone impression putty. 6
• Use of protective devices can down-modulate damage compensation in medicolegal contexts. 6
• The decision to use protective aids should be documented on the anesthetic chart. 6

Technical Considerations:

• Careful laryngoscopy technique minimizing force application to dentition. 2
• Anticipation of difficult intubation using validated scoring systems (MACOCHA score) to allow for better preparation. 1
• Standardized intubation protocols within each ICU to reduce idiosyncratic practices. 1

Clinical Pitfalls

• Delayed presentation: Some dental and gingival complications manifest days to weeks after intubation, requiring vigilance beyond the immediate post-procedure period. 5
• Incomplete documentation: Failure to document pre-existing dental pathology on the anesthetic chart complicates medicolegal evaluation and may result in unjustified claims. 6
• Underestimation of risk: The relatively high incidence (1:4,500) means dental injury is more common than many clinicians appreciate. 2
• Mouthguard limitations: While protective devices may reduce injury severity, they occupy valuable space in an already crowded airway and are not appropriate for all patients. 4

Medicolegal Considerations

• Accurate documentation on the anesthetic chart is essential to distinguish compensable from non-compensable injuries. 6
• Cases with proper documentation and protective device use may result in reduced compensation amounts. 6
• The costs of dental treatments following intubation injuries can be substantial, including advanced therapies such as butterfly bridges, titanium implants, and porcelain laminate veneers. 5
• Improved documentation and preventive measures can reduce litigation frequency, insurance premiums, and costs while improving physician-patient relationships. 6