Anaesthesia 2016 doi:10.1111/anae.

13560

Original Article
Risk factors for peri-anaesthetic dental injury
S. Y. Ham,1 J. Kim,2 Y. J. Oh,2 B. Lee,1 Y.-S. Shin3 and S. Na2

1 Consultant, Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
2 Consultant, Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei
University College of Medicine, Seoul, Korea
3 Consultant, Department of Anaesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University,
Seongnam, Korea

Summary
In this retrospective case–control study, we evaluated peri-operative dental injury risk factors following tracheal intu-
bation. Ninety-four of 290,415 patients experienced dental injury following tracheal intubation over a 10-y period. A
control group was matched for surgery type and intubating anaesthetist. The incidence of dental injury was 0.03%.
Univariate analysis revealed that previous and current difficult intubation, male gender, hepatitis, neurological dis-
ease, anticonvulsant use, pre-existing poor dentition and the use of airway devices (other than a laryngoscope) were
associated with dental injury. Multivariate analysis revealed that predictors of dental injury were: history of hepatitis,
odds ratio (95% CI) 10.1 (1.02–100.3); poor dentition, 8.8 (3.9–20.0); alternative airway device use, 3.1 (1.2–8.0); and
intubation difficulty, 3.7 (1.0–13.3). As well as confirming previously reported risk factors for dental injury during
tracheal intubation, this study also suggests hepatitis and the use of alternative airway devices as additional risk
factors.
.................................................................................................................................................................
Correspondence to: S. Na
Email: [email protected]
Accepted: 13 May 2016
Keywords: airway assessment: co-existing disease; difficult airway algorithm; hepatic dysfunction

Introduction between dental injury and patient comorbidities is

Traumatic dental injury is a well-known complication lacking. The objective of this study was to investigate
of tracheal intubation during general anaesthesia. risk factors for traumatic dental injury following tra-
Moreover, dental injury can lead to significant eco- cheal intubation, considering both direct factors and
nomic and legal consequences [1], so it is essential to associated patient conditions.
identify patient risk factors associated with dental
injury to use preventative measures. Methods
The incidence of dental injury following general This study was approved by our Institutional Review
anaesthesia has been variously reported as 0.02–0.07% Board. We retrospectively analysed all anaesthetic
[2–5]. Pre-existing poor dentition and difficult intuba- records from January 2006 to December 2015.
tion are well-known risk factors [4, 6], but previous Over the 10-y study period, general anaesthesia
studies on dental injury have focused on risks during with tracheal intubation was performed in 290,415
the procedure. Because of this, data on associations cases, and 94 patients with dental injury were

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Anaesthesia 2016 Ham et al. | Risk factors for peri-anaesthetic dental injury

identified. To collect as complete a dataset as possible, previous difficult intubation; anticonvulsants; pre-exist-
we identified patients by reviewing two sources of ing poor dentition; use of alternative airway device
patient data: consultations in the department of den- other than laryngoscope; difficult intubation. Statisti-
tistry for repair of dental injury resulting from general cally significant risk factors from univariate analysis
anaesthesia; and patient complaints of dental injury were entered into a subsequent multivariate regression
following general anaesthesia from the department of model. For the multivariate model, a stepwise selection
quality improvement. method was used to select variables that showed statis-
We used a retrospective, 1:2 matched case–control tical significance in the univariate analysis. Statistical
design. Considering the skill of the anaesthetist and significance was defined as p < 0.05.
the type of surgery, each case was matched to two
other cases that underwent general anaesthesia for the Results
same operation, by the same surgical department, on During the 10-y study period, 94 cases of traumatic
the same day or during the same week in the same dental injury following tracheal intubation under gen-
operating room with the same anaesthetist. If there eral anaesthesia were identified from patient records.
was no case that could be matched in the same operat- Patient characteristics are shown in Table 1. There was
ing room on that day, we picked patients from the no significant difference between the groups in age,
same week in the same operating room with the same height, weight, BMI, ASA, hypertension, or diabetes
anaesthetist. mellitus status. The dental injury group included a
Traumatic dental injury following general anaes- higher ratio of men compared with the control group.
thesia was defined as a change in dental status requir- Hepatitis (chronic hepatitis B or C) was more often
ing dental consultation, or a case in which the patient observed in the dental injury group. Among the five
complained about damage to teeth within one week patients with hepatitis in the dental injury group, four
after tracheal intubation. A history of difficult intuba- patients had hepatitis B and one patient had hepatitis
tion was defined as laryngeal view grade ≥ 3 in a pre- C. More patients had a history of neurologic disease
vious anaesthetic record, and difficult intubation was and more patients were taking anticonvulsants in the
also defined in the same way. The following data were dental injury group. There was also a statistically sig-
collected from electronic medical records: demographi- nificant difference between groups in the numbers of
cal data; medical histories; operative information; pre- patients with history of difficult intubation.
operative dental conditions; anaesthetic records; data There were statistically significant differences
related to the intubation procedure. between the two groups for pre-operative dental
All statistical analyses were performed using IBM pathology (Table 2). More patients in the dental injury
SPSS Statistics 20 (SPSS Inc., Chicago, IL, USA). Cate- group had bridges and loose teeth than in the control
gorical variables were compared between groups using group.
two-tailed Fisher’s exact tests and 2 9 2 tables, with During intubation, equipment other than a laryn-
likelihood ratio chi-squared tests for larger tables. Con- goscope (such as a light-wand or videolaryngoscope)
tinuous variables were inspected visually and tested for was used more frequently in the dental injury group.
normality of distribution using Kolmogorov–Smirnov The dental injury group had more patients with laryn-
tests. If the data were normally distributed, mean val- geal view grades ≥ 3 (Table 3).
ues were compared between groups using a two-sam- Multivariate logistic regression analysis revealed
ple test; otherwise, we used the Mann–Whitney U-test. that a history of hepatitis, pre-existing poor dentition,
We conducted logistic regression analysis to iden- use of an alternative airway device other than a laryn-
tify independent risk factors for dental injury following goscope, and intubation difficulty (laryngeal view ≥ 3)
tracheal intubation. To evaluate patient risk factors for were independent predictors of traumatic dental injury
dental injury, a univariate logistic regression analysis following tracheal intubation (Table 4).
was performed. Possible risk factors for the univariate Classifications and locations of traumatic dental
analysis were: sex; hepatitis; neurological disease; injury are listed in Table 5 and shown in Fig. 1. The

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Ham et al. | Risk factors for peri-anaesthetic dental injury Anaesthesia 2016

Table 1 Patient characteristics. Values are number (proportion) or mean (SD).

Control Dental injury

n = 188 n = 94 p value
Sex; men 87 (46.3%) 60 (63.8%) 0.005
Age; y 45.30 (21.73) 44.79 (20.29) 0.848
Height; cm 155.37 (21.00) 159.31 (20.15) 0.134
Weight; kg 56.30 (18.55) 60.00 (21.23) 0.134
BSA; m2 1.55 (0.37) 1.61 (0.38) 0.176
BMI; kg.m 2 22.64 (4.02) 22.70 (5.15) 0.922
Hypertension 41 (21.8%) 24 (25.5%) 0.484
Diabetes 16 (8.5%) 15 (16.1%) 0.055
Pulmonary tuberculosis 7 (3.7%) 2 (2.1%) 0.722
Hepatitis 1 (0.5%) 5 (5.3%) 0.017
Asthma 3 (1.6%) 1 (1.1%) 1.000
CVA 6 (3.2%) 1 (1.1%) 0.431
Heart disease 11 (5.9%) 8 (8.5%) 0.401
Neurologic disease 8 (4.3%) 11 (11.7%) 0.019
ASA class (1/2/3/4) 81/80/24/3 38/31/22/3 0.077
Difficult airway history 1 (0.5%) 6 (6.4%) 0.006
Anticonvulsants 4 (2.1%) 8 (8.5%) 0.023
Antihistamines 2 (1.1%) 3 (3.2%) 0.337
Antihypertensive 26 (13.8%) 20 (21.3%) 0.111
Anaesthesia time; min 165.8 (118.4) 182.1 (129.0) 0.291

BSA, body surface area; CVA, cerebrovascular accident.

Table 2 Pre-operative dental characteristics. Values Table 3 Intra-operative characteristics. Values are
are number (proportion). number (proportion).

Control Dental injury Dental

n = 188 n = 94 p value Control injury
n = 188 n = 94 p value
Ceramic tooth 2 (1.1%) 3 (3.2%) 0.336
Mobile tooth 4 (2.1%) 23 (24.5%) < 0.001 Airway devices 11 (5.9%) 20 (21.3%) < 0.001
Implant 1 (0.5%) 3 (3.2%) 0.107 other than
Denture 3 (1.6%) 3 (3.2%) 0.401 laryngoscope
Bridge 0 6 (6.5%) 0.001 Light-wand 4 (2.1%) 12 (12.8%) < 0.001
Pre-op warning 1 (0.5%) 9 (9.6%) < 0.001 Videolaryngoscope 4 (2.1%) 5 (5.3%) 0.166
of dental injury Bronchoscope 1 (0.5%) 3 (3.2%) 0.110
Mouth guard 0 0 Other 2 (1.1%) 0 0.554
Double-lumen tube 4 (2.1%) 1 (1.1%) 0.668
Nasal intubation 7 (3.8%) 5 (5.4%) 0.542
Laryngoscopy grade < 0.001
1 156 (83.0%) 54 (57.4%) < 0.001
maxillary incisors, including teeth 21 and 11 (as num- 2 18 (9.6%) 18 (19.1%) 0.014
bered by the two-digit World Dental Federation nota- 3 4 (2.1%) 10 (11.0%) 0.002
4 1 (0.5%) 3 (3.2%) 0.100
tion system) were most commonly injured. The most Laryngoscopy 5 (2.7%) 13 (13.8%) < 0.001
commonly reported injuries were loosening/subluxa- grade ≥ 3
tion and crown fracture.
The most common surgical departments that trea-
ted patients in the dental injury group were general
surgery and ear, nose and throat surgery. Considering Among the 94 patients with dental injuries, the
the incidence of dental injury per surgical department, total hospital economic burden of restoring the dental
this was highest (0.06%) in the ear, nose and throat injury was estimated to be around £250 (€321/$358)
surgery department, which was approximately double per patient in Korea. Among the 94 patients, 68
the overall incidence (Table 6). patients received compensation from the hospital for

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Anaesthesia 2016 Ham et al. | Risk factors for peri-anaesthetic dental injury

Table 4 Logistic regression analysis for predictors of traumatic dental injury following general anaesthesia with tra-
cheal intubation. Values are presented as odds ratio (95% CI). Pre-existing dental pathology includes mobile teeth
and patients who underwent pre-operative dental treatment such as placement of a ceramic tooth, implant, denture
or bridge.

Univariate p value Multivariate p value

Sex 0.49 (0.29–0.81) 0.006* 0.86 (0.47–1.59) 0.633
Hepatitis 10.51 (1.21–91.26) 0.033* 10.13 (1.02–100.31) 0.048*
Neurologic disease 2.98 (1.16–7.69) 0.024* 2.27 (0.67–7.71) 0.190
Previous difficult intubation 12.75 (1.51–107.52) 0.019* 2.15 (0.21–22.00) 0.517
Anticonvulsants 4.28 (1.25–14.60) 0.020* 2.30 (0.48–11.00) 0.295
Pre-existing dental pathology 8.76 (4.06–18.89) < 0.001* 8.84 (3.90–20.03) < 0.001*
Use of alternative airway device other than laryngoscope 4.35 (1.99–9.53) < 0.001* 3.11 (1.21–8.02) 0.019*
Difficult intubation 5.87 (2.03–17.02) 0.001* 3.70 (1.03–13.27) 0.045*

*p < 0.05.

damaged teeth. The amount of compensation ranged Table 5 Classifications and locations of dental injury.
from £0.78 (€1/$1.12) to £2680 (€3440/$3833). Values are number (proportion).

Classification n
Discussion Enamel fracture 5 (5.3%)
The main goal of this study was to determine and Loosening/subluxation 33 (35.1%)
investigate risk factors for traumatic dental injury fol- Avulsion 7 (7.4%)
Crown fracture 18 (19.1%)
lowing tracheal intubation. With a total of 94 cases of Crown and root fracture 5 (5.3%)
traumatic dental injury out of 290,415 cases of general Missing teeth 11 (11.7%)
Others 15 (16.0%)
anaesthesia with tracheal intubation during the 10-y
study period, the incidence of dental injury was 0.03%.
Previous publications report a range of 0.02–0.07% [2– awaiting liver transplantation were also demonstrated
5], so the overall incidence of dental injury in this to have poor oral health status and odontogenic infec-
study is similar to previous studies. tions [12]. Moreover, another study suggested that
We demonstrated that hepatitis and the use of there was a tendency towards worse dental health with
alternative airway devices were associated with risk of a higher Model for End-Stage Liver Disease (MELD)
dental injury following tracheal intubation under gen- score [13]. Nagao et al. [14] reported that periodontitis
eral anaesthesia. Other published studies investigating may be associated with the progression of viral liver
dental injury following tracheal intubation under gen- disease, and another study suggested a possible link
eral anaesthesia [4, 7, 8] identified number of intuba- between dental infection such as periodontitis and the
tion attempts [8], poor dentition [9] and intubation accelerated progression of liver disease [15]. However,
difficulty [4] as risk factors. the context or correlation between periodontitis and
Our study revealed that more patients in the den- viral liver disease is unclear. This research suggests a
tal injury group had a history of hepatitis. Moreover, a potential link between these two factors. The incidence
history of hepatitis showed statistical significance in of hepatitis in South Korea has been decreasing for
the multivariate logistic regression analysis performed several decades. It was reported as about 3% in 2012
to find predictors of dental injury. To the authors’ [16], and 7% in 2000 [17]. The incidence of dental
knowledge, hepatitis has not been reported previously injury following tracheal intubation was low in our
as a risk factor for dental injury. Publications that study, and because of this, other medical factors asso-
address the relationship between dental injury and ciated with hepatitis were difficult to evaluate. We can-
hepatitis are scarce, but it has been reported that hep- not demonstrate a causal relationship between dental
atitis C-infected patients have significant oral health injury and hepatitis; this would require a prospective
needs [10, 11], and patients with chronic liver disease study.

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Ham et al. | Risk factors for peri-anaesthetic dental injury Anaesthesia 2016

Figure 1 Locations of teeth commonly injured during tracheal intubation. Teeth are labelled with the two-digit
World Dental Federation notation system.

In previous publications, difficult intubation, pre- Table 6 Dental injury according to the operating
existing poor dentition and male sex were reported as department.
risk factors for dental injury [3, 18]. These were also
identified as risk factors in our study. Patients Patients with
with dental dental injury
Givol et al. [18] reported that intubation difficulty Department injuries by specialty
was a risk factor for dental injury, and another study Cardiothoracic surgery 4 (4.3%) 4/20704 (0.02%)
suggested it could be a predictive marker [3]. In accor- Neurosurgery 18 (19.1%) 18/35214 (0.05%)
General surgery 23 (24.5%) 23/90651 (0.03%)
dance with previous findings, there were more patients Ear, nose and throat 23 (24.5%) 23/36100 (0.06%)
with difficult intubations defined as a laryngeal view diseases
grade ≥ 3 in the dental injury group. In addition, diffi- Urology 5 (5.3%) 5/22798 (0.02%)
Orthopaedic surgery 7 (7.4%) 7/22102 (0.03%)
cult intubation was identified as a statistically signifi- Oral and maxillofacial 2 (2.1%) 2/6625 (0.03%)
cant predictor of dental injury in the multivariate surgery
Gynaecology 3 (3.2%) 3/23056 (0.01%)
logistic regression analysis, as were the use of alterna- Plastic surgery 3 (3.2%) 3/11007 (0.03%)
tive airway devices such as a light-wand or videolaryn- Ophthalmology 6 (6.4%) 6/17361 (0.03%)
goscope. Considering the fact that alternative airway Total 94 (100.0%)

devices are typically used to manage difficult intuba-

tion, our results support the view that difficult intuba-
tion is a predictive factor for dental injury. awareness of a history of difficult intubation made
A history of difficult intubation was also associated anaesthetists take extra care during the intubation pro-
with dental injury in our study. Univariate logistic cedure, thus reducing the incidence of dental injury.
regression suggested statistical significance, but multi- More patients had bridges and mobile teeth in the
variate logistic regression did not (Table 4), so that dental injury group than in the control group. This
history of difficult intubation was not a significant finding is in accordance with previous studies, which
independent predictor for dental injury. Previous stud- have suggested that dental caries, advanced marginal
ies have suggested that difficult intubation is a risk fac- periodontitis and existing restorations are all risk fac-
tor [4, 7], but few reports have focused on history of tors for dental injury [3, 7, 18]. Our study also sug-
difficult intubation [3]. It is possible that in our study, gests that pre-existing poor dentition is a risk factor,

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Anaesthesia 2016 Ham et al. | Risk factors for peri-anaesthetic dental injury

and more patients in the dental injury group received study, the authors found that the most commonly
pre-operative warnings of possible anaesthesia-related reported injuries were enamel fracture and loosening
dental injury than the control group. or subluxation [4]. Although there are some minor dif-
The dental injury group had more men than ferences between reported types of injury in each
women, so that male sex may also be regarded as a study, they were generally similar.
risk factor for dental injury. Previous research on gen- In accordance with a previous report [7], the gen-
der differences in peri-odontal disease has reported eral surgery department managed the most dental inju-
higher frequencies of peri-odontal disease in males ries, but the ear, nose and throat surgery department
than females [19, 20]. A possible explanation for this showed the greatest frequency of dental injuries, per-
difference could be poorer oral hygiene practices in haps because of the use of surgical procedures requir-
men [21]. ing airway instrumentation. In another study [13], the
Xerostomia has been reported to cause rampant most commonly affected department was cardiotho-
decay and loss of teeth, and many drug classes such as racic surgery. The comparatively lower incidence of
anticholinergics, antidepressants, antihypertensives and dental injury in our cardiothoracic surgery department
anticonvulsants have been associated with xerostomia may reflect a recent trend to use of smaller and more
[22]. In our study, patients in the dental injury group flexible double-lumen tubes than were previously used.
were reported to take anticonvulsants more frequently The economic consequences of dental injury fol-
than patients in the control group, but there were no lowing tracheal intubation are significant [1], and if
significant differences between the groups for intake of risk factors for dental injury are identified during pre-
other classes of drugs that are known to cause xerosto- operative patient evaluation, it would make sense to
mia. We were therefore unable to demonstrate a sig- consider possible methods of avoiding dental injury.
nificant association between xerostomia and dental Some authors have advocated the use of mouth guards
injury, possibly because of the relatively small numbers [24], but Skeie et al. could only demonstrate a non-sig-
of patients with dental injury in our study. More nificant reduction in dental injury with mouth guards
patients in the dental injury group had a history of and suggested that they should not be used routinely
neurological disease, but it was not clear if anticonvul- [25]. Simply taking extra care in patients with known
sant intake or neurological disease are independent risk factors may be an effective strategy.
predictors of dental injury because of the wide variety One strength of this study is that, unlike other
of pathologies and medications in this patient group. studies, it included other possible risk factors such as
Upper incisors were the most commonly injured previous medical and intubation history and patient
teeth, as reported in previous studies [7, 8]. Also in comorbidities. To the authors’ knowledge, most previ-
accordance with previous results, tooth 21 and the left ous studies investigating risk factors for dental injury
side of the maxilla were more often affected than tooth following tracheal intubation focused on factors related
11 and the right side (Fig. 1) [7]. Bucx et al. [23] pre- to the intubation procedure itself rather than patient
viously demonstrated that great forces are exerted on comorbidities. Another strength of our study is that
the maxillary incisor teeth during laryngoscopy, with we matched potential confounding factors that could
or without a levering technique. A levering technique affect dental injury between groups. Intubation proce-
seems more likely to be used in cases of difficult intu- dure, surgical factors and the skill of the anaesthetist
bation, so it may be one of the possible mechanisms of were corrected for by matching the cases to two other
dental injury. cases that underwent general anaesthesia on the same
The most common form of dental injury in our day or during the same week in the same operating
study was loosening or subluxation, and the second room with the same anaesthetist.
most common was crown fracture, which was similar Our study also has some limitations. Because of
to previous studies [9]. Vogel et al. [7] reported that the retrospective design, we only included patients for
the most common types of dental injury were crown whom we could obtain sufficient information from
fractures and dislocations. In another retrospective electronic medical records, and it is possible that some

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Ham et al. | Risk factors for peri-anaesthetic dental injury Anaesthesia 2016

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