Section 4: Damage to the teeth

Risks associated with your anaesthetic Section 4: Damage to teeth, lips and tongue

uring a general anaesthetic, it is possible for your teeth to be damaged. DThis happens in about 1 in 4,500 general anaesthetics. Serious damage to the tongue is rare. Minor damage to the lips or tongue is very common. This article tells you more about why damage can happen, what makes damage more likely, what you can do to help prevent it and what will happen if damage does occur.

Why does damage happen? Rarely, pressure from an airway device General anaesthesia is a state of controlled causes damage to nerves which control unconsciousness. When you are movement and sensation (feeling) in the anaesthetised, you become less able to tongue. This causes numbness and loss of breathe freely through your nose or mouth. normal movement of the tongue for a Your anaesthetist will choose a way of period of time. These changes are almost making sure that you can breathe properly. always temporary, with recovery taking a This is essential for your safety, and usually few weeks or months. requires an artificial airway or breathing tube to be placed in your mouth or throat. How does damage to teeth occur? The devices used are described in more The use of artificial airway devices to detail in Section 2 in this series. Insertion keep you breathing safely after you are of these devices can cause damage to the anaesthetised is not always teeth or soft tissues of the mouth or nose. straightforward. Anaesthetists are trained in the use of airway devices, but, even in What type of damage may occur? skilled hands, there may be some Lacerations (minor cuts) or bruising to the difficulty and a certain amount of force is lips and tongue are very common, used. This can sometimes lead to damage probably occurring in about 1 in 20 to teeth, lips or tongue. general anaesthetics. These injuries heal For major operations on the chest, very quickly and can be treated with abdomen, head, neck or spine, you will simple ointments such as Vaseline. need a tracheal tube to be placed through Teeth or dental work such as crowns, your mouth or nose into your trachea bridges or veneers may be broken, (windpipe). This is usually done after you chipped, loosened or completely removed are anaesthetised. The instruments used by accident. The most frequently damaged to place this tube may cause damage, teeth are the upper maxillary incisors (top especially if placement is difficult. Other front teeth).1,2 Damage to a tooth requiring types of tube may be used for other subsequent removal or repair occurs in operations and these carry less risk of about 1 in 4,500 general anaesthetics. damage to teeth.

1 Risks associated with your anaesthetic O Information for Patients: The Royal College of Anaesthetists Section 4: Damage to the teeth

The surgeon can also damage your teeth,  pregnant women requiring an lips or tongue during operations in the emergency general anaesthetic mouth or throat, including examinations  people who are very overweight. under anaesthetic of the throat, the lungs The following have a higher risk of or the oesophagus (gullet). damage to teeth.2,3 What about false teeth?  Anyone with one or more of the above You will usually be asked to remove false factors. teeth before a general anaesthetic. This is  Any person with teeth in poor because they may be dislodged or damaged condition (large amounts of decay or as your anaesthetist places the artificial failing dental work). Nearly two thirds airway device as described above. of injuries to teeth happen in people Occasionally your anaesthetist may ask with teeth in a poor condition. you to leave your false teeth in place. This  Anyone having an operation or is most likely to be if you have teeth of examination of the mouth, neck, jaw your own in amongst the false teeth and or oesophagus (gullet). your anaesthetist thinks that the false teeth  Anyone who needs to have a tracheal will help protect your own teeth. In this tube inserted after the operation has case there is a risk that the false teeth may started.2,3 This is sometimes necessary be damaged. if the existing airway becomes unsatisfactory during the operation, Who is at increased risk of damage and insertion of the endotracheal to teeth? (breathing) tube may be more difficult. Anyone undergoing a general anaesthetic What steps are taken to prevent is at some risk. Wherever possible, your damage to my teeth? anaesthetist will assess your airway before All anaesthetists are trained to be aware of the anaesthetic starts. He/she may: the potential for damage to teeth. He/she  look in your mouth will take care during the insertion of  ask you to move your neck airway devices and excessive force will be  ask you about your teeth and any avoided as much as possible. If you have caps, crowns or loose teeth that you any features that predict difficulty with may have. airway devices, your anaesthetist will He/she will then be able to tell you if you choose a suitable technique which will have any features that predict difficulty in allow safe insertion. This should be inserting tubes into the airway. However, discussed with you beforehand. difficulties can also arise unexpectedly. Teeth may be protected with mouth- Certain factors are associated with guards similar to those used in contact difficulty. These include: sports. A study of the use of mouth-  reduced mouth opening guards found no evidence to support their  reduced neck movement routine use. However, if you have a high  prominent upper teeth or small lower risk of damage to your teeth, your jaw anaesthetist or surgeon may choose to use  certain medical conditions such as a mouth-guard, as there is some evidence rheumatoid arthritis and ankylosing that this helps protect your teeth in these spondylitis circumstances.3

2 Risks associated with your anaesthetic O Information for Patients: The Royal College of Anaesthetists Section 4: Damage to the teeth

Is there anything I can do to injury and pre-existing health of the tooth. prevent damage to my teeth? Damage to veneers, crowns or bridges If your teeth or gums are in poor may require repair. condition or any teeth are loose, it is If you are being treated in an NHS hospital important to visit your dentist before a with a dental department, the anaesthetist planned operation for a check-up and will make arrangements, if you wish, for dental assessment. Alert the anaesthetist you to be seen as soon as possible by a to any loose teeth or dental work before dental surgeon. If there is no hospital your operation. dentist, or if you prefer to do so, you can arrange to be treated by your own dental If you know there have been difficulties practitioner. with placing a tube in your airway or you have had damage to your teeth during a Treatment by an NHS hospital dentist is previous anaesthetic, it is important to tell usually free of charge to you. If you are treated by your own dentist, the hospital your anaesthetist. You should tell may or may not wish to assist with the cost someone involved in your care as early as of treatment. You will need to discuss this possible, as it may be necessary to find with the hospital and your anaesthetist. If previous anaesthetic records to find out the damage occurs while you are being exactly what happened. Your GP, your treated as a private patient in a private surgeon or your nurses (on the ward or in hospital, then you would have to make a the clinic) will be able to help you claim against the individual anaesthetist. organise this. If you were informed that there was a risk If your anaesthetist tells you that there were of damage to your teeth and the difficulties, it is very helpful if you know anaesthetist took a reasonable amount of what the difficulties were. If you are not care, then you may need to accept that sure, ask your anaesthetist to write them this was an unavoidable risk. down so that you can show the letter to anaesthetists in the future. How likely is damage to teeth, lips and tongue? What happens if my teeth are Minor injuries to the lips or tongue are damaged during an operation? very common and are usually unreported Your operation should proceed as which means accurate figures do not exist. planned. If a tooth has become A small study of 404 patients suggested completely dislodged it must be secured that minor injuries occur in about 1 in 20 or removed before you wake up. If there patients.4 is chipping or cracking of a tooth, the Damage to a tooth which requires anaesthetist will record the damage and subsequent repair or extraction happens in you will be informed when you have about 1 in 4,500 general anaesthetics. This recovered. figure comes from a large study of just Immediate treatment will involve pain under 600,000 patients.5 relief if required and an explanation of Nerve damage to the tongue due to pressure what has happened. The tooth may from airway devices is reported, but accurate require repair, re-implantation or figures do not exist. It is likely to be rare or extraction depending on the nature of the very rare.

3 Risks associated with your anaesthetic O Information for Patients: The Royal College of Anaesthetists Section 4: Damage to the teeth

Summary in people with teeth in previously poor Serious damage to the tongue is rare. condition. Mouth-guards can reduce but Minor injuries to the lips or tongue are not eliminate the chance of damage in very common. The overall risk for high-risk patients. serious damage to teeth is around 1 in A visit to the dentist before a routine operation 4,500 general anaesthetics. If you have an is advisable if your teeth are not in good increased risk for damage to teeth, this condition. If injury does occur, arrangements may be identified before the anaesthetic can made on your behalf (if you wish) for starts. The majority of damage happens treatment to be undertaken by the NHS.

Authors References Dr David Euan Mcintosh, BMedSci, MRCS 1 Chadwick RG, Lindsay SM. Dental injuries during Specialist Registrar in Anaesthetics general anaesthesia. Br Dental J Northern School of Anaesthesia 1996;180(7):255–258. 2 Owen H, Waddell-Smith I. Dental trauma Dr Stuart A Hargrave, FRCA associated with anaesthesia. Anaesthesia & Intensive Consultant Anaesthetist Care 2000;28(2):133–145. The Newcastle Upon Tyne Hospitals NHS Trust 3 Skeie A, Schwartz O. Traumatic injuries of the teeth Past President, Association of Dental Anaesthetists in connection with general anaesthesia and the effect of use of mouthguards. Endodontics & Dental Traumatology 1999;15(1):33–36. Editor 4 Fung BK, Chan MY. Incidence of oral tissue trauma Dr Tom Cripps, FRCA after the administration of general anaesthesia. Consultant Anaesthetist Acta Anaesthesiol Sin 2001;39(4):163–167. Melrose General Hospital 5 Warner ME et al. Perianesthetic dental injuries: President, Association of Dental Anaesthetists frequency, outcomes, and risk factors. Anesthesiology 1999;90(5):1302–1305.

The Royal College of Anaesthetists January 2006

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4 Risks associated with your anaesthetic O Information for Patients: The Royal College of Anaesthetists