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Dental loss related to an endotracheal tube.

The incidence of anaesthesia-related dental injuries has recently been cited at around 1:2000 (1) and reviews of claims to defence organisations in the United Kingdom and the United States of America confirm that dental trauma is the most commonly reported anaesthetic morbidity (2). We would like to report a dental complication due to endotracheal tube placement in the setting of panfacial trauma.

An 18-year-old patient presented with facial injuries following a motor vehicle accident. He was initially combative. Anaesthesia was induced in the emergency department and the trachea was intubated over a bougie with manual in-line immobilisation of the cervical spine. The maxillary incisor teeth were noted to be loose but correctly positioned, prior to and immediately after intubation. Radiological imaging, an hour later, demonstrated no brain injury, skull base fracture or cervical spine injury. The patient was extubated successfully the following day without neurological complication, but the CT reconstructions, reviewed the following day, displayed mandible fractures and the maxillary incisors protruding forwards around the endotracheal tube. The incisors were repositioned with temporary splinting applied by the maxillofacial team following the extubation. However, while the mandible was stabilised surgically a week later, the incisor malposition resulted in non-viability and their subsequent removal.

Rapid sequence induction with cervical spine protection is considered an acceptable method for securing the airway in emergency trauma patients (3). Once the airway has been secured, however, thought should be given to the reduction of other morbidities, including dental injuries. Following traumatic avulsion or malposition, there is a period of time during which a tooth can be successfully replaced in its socket. Viability of subluxed teeth is hugely variable and is dependent on the degree of subluxation, the time spent out of position and correct repositioning. In the case described, a combination of the orotracheal tube and hard collar had forced the upper incisors forward around the tube, contributing to dental loss.

[FIGURE 1 OMITTED]

While it is difficult to see how this situation could have been avoided, dental splinting immediately after intubation may have been beneficial. Success would be dependent on the patient refraining from biting down at any point prior to extubation. Further options include the early elective replacement of the tube with a nasotracheal tube provided a base of skull fracture, a contraindication to nasal intubation has been excluded, or the elective replacement of the tube with a submental tube. We acknowledge that airway protection should always be considered a priority over the dentition and tube changes should only be attempted if there is certainty that there will be no airway compromise.

R.LANGFORD

A. L. NASTRI

Melboume, Victoria

References

(1.) Newland MC, Ellis SJ, Peters KR, Simonson JA, Durham TM, Ullrich FA et al. Dental injury associated with anaesthesia: a report of 161,687 anaesthetics given over 14 years. J Clin Anesth 2007; 19:339-345.

(2.) Owen H, Waddell-Smith I. Dental trauma associated with 2. anaesthesia. Anaesth Intensive Care 2000; 28:133-145.

(3.) Dunham CM, Barraco RD, Clark DE, Daley BJ, Davis FE 3rd, 3. Gibbs MA et al. Guidelines for emergency tracheal intubation immediately after traumatic injury. J Trauma 2003; 55:162-179.
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Title Annotation:Correspondence
Author:Langford, R.; Nastri, A.L.
Publication:Anaesthesia and Intensive Care
Geographic Code:1USA
Date:Jan 1, 2009
Words:521
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