Anaesthetic dental damage

Quick guide

• 16% of Avant anaesthetic claims relate to dental damage.
• Discuss and contemporaneously record risks of the procedure with the patient.
• Notify Avant if you are contacted by a patient or hospital regarding dental damage.

A common call received from anaesthetists by our medico-legal advisers is when a patient complains of dental damage – often the loss of or damage to a tooth – during surgery. A recent analysis of our anaesthetic claims data indicates claims or complaints relating to dental damage account for 16% of all anaesthetic issues.

Assessing the risk of dental damage

Anaesthetists owe a duty to their patients to take reasonable care to avoid foreseeable risks of harm. Dental damage is a recognised complication of surgery, particularly intubation. Other factors that may increase a patient’s risk of dental damage include:

• poor dental health including loose and diseased teeth and diseased gums
• pre-existing dental structures including crowns, fillings, bridges and implants
• comorbidities such as chronic conditions e.g. autoimmune disease, diabetes, leukaemia
• a history of smoking
• the presence of baby teeth
• the position of the patient during surgery
• the patient’s ability to open their jaw, which may result in difficulties with intubation.

Routine practice should include a pre-operative examination of the patient’s dentition, mouth opening ability and other standard airway assessments. Questioning the patient about significant events in their dental history such as caps, crowns or injury will assist with your risk assessment.

Warning of risks

Sometimes the risk of dental damage can't be avoided, especially during an urgent intubation. It is therefore essential to include discussion of these risks in your pre-operative consultation with all patients, including those not expected to receive a general anaesthetic.

Issues that should generally be discussed with all patients include:

• general risks of the anaesthetic procedures
• common side effects and complications
• significant adverse outcomes, even though they are rare
• risks that are material to the particular patient, including the possible or likely impact of any comorbidity or dental structures
• the proposed approach to the procedure and degree of uncertainty about the outcome
• complications that could result in costs that are not rebatable.

If the patient is assessed as being a high risk for dental damage, you should spend sufficient time discussing this with the patient to ensure all their questions are answered. It can be helpful to advise the patient what changes in technique you will adopt to minimise the risk of damage, for example, using video scopes, plastic rather than metal equipment, minimising manoeuvring of the neck or using a mouthguard. In addition to reassuring and informing the patient, this reinforces the consent discussion.

Providing pre-operative printed information to patients is a useful way of informing patients about the anaesthetic process, the general risks of the procedure and what information you will be seeking prior to surgery. However, anaesthetists should not rely on information sheets as a substitute for a discussion.

Documenting consent

A contemporaneous record of your consent discussion with the patient is essential. Any notes of the discussion about the risk of dental damage in the clinical records are likely to carry more weight than a reference in the surgeon’s consent form. For this reason, even if dental risks are covered by the general consent form (for example, an ENT procedure), we recommend you also make a similar note in the anaesthetic record as evidence you also discussed the risk of dental damage through routine anaesthetic care.

If the patient is at a high risk of dental damage, you should ensure the extent of the discussion is evident in your notes. However, even if the risk is low, it should still be documented that the issue was covered. A standard phrase such as “dentition examined, and risks discussed” is sufficient in low risk cases.

In all situations, documentation of the discussion – or the reasons the discussion was not held, such as the urgent nature of the care – is essential.

How to respond if dental damage occurs

While in most cases care will be taken to avoid any risk of dental damage, in some cases it is unforeseen or unavoidable.

Where dental damage is discovered intraoperatively, we recommend you:

• prioritise care of the airway, especially if blood loss is associated with the damage
• take immediate and appropriate care of the tooth (if it has been dislodged)
• if appropriate, consult a maxillofacial surgeon during surgery to attend to damaged or dislodged teeth
• advise the post anaesthetic care team so extra care can be taken in the recovery phase
• advise the patient about what has happened as soon as they are suitably awake
• refer the patient to their dentist if dental care cannot be provided in the hospital
• where relevant, give clinical information in writing to the patient to provide to the anaesthetist in any future procedures.

If a patient notifies you of damage postoperatively we recommend you:

• advise the patient, as appropriate, regarding care of the tooth and tell them to visit their dentist as soon as practical
• document in the patient's medical records and anaesthetic chart that dental damage has occurred and its extent
• Inform the hospital through the standard process for adverse event notification
• inform the surgeon as a professional courtesy along with any advice you have given the patient.

Saying sorry

When dental damage occurs, be prepared to instigate an open disclosure process when the patient recovers from the surgery.

Depending on the circumstances, this may occur in person or over the telephone. Provide the patient with details of the incident, respond to the patient’s questions and make yourself available if they have any further questions at a later date (e.g. give them your business card, business mobile number). In particular, you should apologise to the patient that this incident occurred, ensuring you use the phrase “I am sorry that this happened”. This is not the same as admitting liability.

What happens next?

If the patient was warned about the prospects of dental damage and this is recorded in consent forms, and you have not departed from acceptable professional standards during the surgery, our ability to defend you against any claim is significantly increased.

If you realise after the fact that you have not recorded a comprehensive outline of your pre-operative discussion with the patient, you can add an entry to the patient’s medical records providing further details. However, the entry must be dated and timed at the time you add it to the record, not backdated to the time the conversation occurred.

If you realise after the fact that you failed to mention the risk of dental damage to the patient, you should contact us immediately for advice. It is important not to falsify any documentation. There are many examples of medical practitioners who attempted to cover up a situation in this way, making the issue significantly more serious once discovered.

Restitution

If approached by a patient or a hospital in relation to dental damage, we do not recommend that you agree to pay out of your own pocket for any dental restoration work.

You may, however, consider waiving your gap fees or not pursuing unpaid fees as a gesture of goodwill and without any admission of liability, so that the patient can use these funds towards the cost of dental restorative work. Ultimately, this is a matter for you to determine.

Alternatively, ask the patient to put their request in writing accompanied by receipts or quotes, advising them you will consider their request and get back to them, and contact Avant to discuss.

Patients always have the right to make a claim or complaint irrespective of your best efforts with their care. If a patient sustains a dental injury, before responding to the patient or the hospital, contact our claims team at nca@avant.org.au or call 1800 128 268.

This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.