DOI: The Greek E-Journal of Perioperative Medicine 2018;17(b): 8-14

 Author: Dubey A. MDS

 Department of Pedodontics & Preventive dentistry, College of Dentistry, Jazan University, Jazan, Saudi Arabia.



Anesthesiologist always works around the oral and peri oral soft and hard tissue. Oral/nasal intubation might injure hard tissue or “knock out” the tooth. The present study was conducted among anesthetic specialist to assess the measures that they would take to manage an avulsed tooth that might occur during intubation & laryngoscopy. The present study involved 40 anesthetists working in private hospitals. They were asked to answer a questionnaire designed to evaluate the line of action that an anesthetist would follow in case of an iatrogenic tooth avulsion. Anesthesiologists were aware that trauma to oro-facial region might occur during intra oral manipulation. However few knew the correct protocol to be followed in handling the avulsed tooth. There is a need to make anesthetist aware that immediate reimplantation and stabilization of a permanent avulsed tooth should be done.



Trauma to the dentition can occur during endotracheal intubation using classic laryngoscopy. The overall incidence of dental injury is estimated to be between 0.06% and 12%1. Risk factor for dental injury during tracheal intubation is periodontal involvement of tooth and/or difficult laryngoscopy as in case of decreased mouth opening, macroglossia, retruded mandible, forwardly placed maxillary incisors, shortened thyromental distance and when extension of neck is limited2.

Different dental injuries reported during anesthetic procedure are subluxation, crown fracture, and tooth avulsion. Warner et al analyzed dental injuries in 598,904 consecutive cases and found that the upper incisors were the most commonly involved teeth3. Anaesthetists mostly use the maxillary incisors as a fulcrum and exert great forces on them which probably lead to their injury4. Blade-tooth contact is extremely frequent in patients with reduced mouth opening or with Mallampati higher than II. Oropharyngeal airways, such as Laryngeal masks, should also be used with caution in individuals with vulnerable anterior teeth or prostheses2,5.

In a study by Hoffman et al. 20.8% of all dental traumas was avulsion. This is such a relevant problem that the Medical Defence Union has already named it the most frequent cause of compensation during general anesthesia6.

The present study was carried out among anesthetists regarding their knowledge and attitude towards management of avulsed teeth.


The present study involved forty anesthetists working in private hospitals or nursing homes in Raipur, Bhilai, and Durg city of Chhattisgarh state in India. All the participants were anesthetic specialists.

A questionnaire was prepared which had nine questions about tooth avulsion (Table 1). For each question, multiple options to answer were provided. The questions were prepared to explore their knowledge and to know the line of action that an anesthetist would follow in case of an iatrogenic tooth avulsion. Written consent was taken from them for participation. The questionnaires were given to anesthetists and were asked to answer.


Majority of anesthetists (95%) felt that they have sufficient knowledge pertaining to management of avulsed tooth (Table 1). They had gained knowledge mostly through CDE programs, scientific articles on dental trauma emergency care and during tenure of medical course (Table 1). Most of the anesthetist knew the proper way of holding an avulsed tooth (70%) however many felt (40 %) that avulsed tooth should be reimplanted in recovery area. Moreover around 60% of anesthetists were not willing to reimplant as they felt it was not their specialty (45%). A large number of the anesthetists (70 %) answered that dentist should be called 6 hours post operatively.If we have a look at the percentage of anesthetists who marked the correct option (Table 2), most of the anesthetists knew that one should hold the avulsed tooth by its crown (70%). Around one third (30%) rightly marked that an avulsed tooth should be reimplanted immediately. Less than half (45%) of the anesthetists knew that avulsed primary tooth should not be reimplanted.

Table 1.Questionnaire along with response for assessment of awareness among anesthetists regarding emergency management of avulsed tooth.

Question Number Percentage
1. Do you have any knowledge pertaining to management of avulsed tooth?
Yes 38 95
No 02 05
2. If yes, what is your source of information?
CDE program 26 65
During tenure of medical course 04 10
Health talks on TV/Radio 02 05
Scientific articles on dental trauma emergency care 08 20
3. How to hold avulsed tooth?
Crown 28 70
Root 08 20
Anywhereontooth 02 05
Don’tknow 02 05
4. Whentoreimplanttooth?
Immediately 12 30
Duringanesthesia 08 20
Recoveryarea 16 40
Notimeconstraints 04 10
5. Are you willing to reimplant tooth?
Yes 16 40
No 24 60
6. Reasonforunwillingness?
Lackofadequateknowledge 12 30
Legal 08 20
Nothisspecialty 18 45
Others 02 05
7. Where to keep tooth before reimplantation?
Dried & wrapped up in gauze 16 40
Normalsaline 12 30
Child’ssaliva 02 05
Antisepticsolution 08 20
Hankssolution 02 05
8. When to reach dentist after avulsion?
Within 30 minutes 02 05
Within 01 hour 04 10
 6 hourspostoperatively 28 70
Afterdischargingthepatient 02 05
Don’tknow 04 10
9. Should we reimplant primary tooth?
Yes 18 45
NO 22 65


Table 2.Percentage of anesthetists who marked the correct option.

Question Number Correct Percentage
1. How to hold avulsed tooth?  




2. When to reimplant tooth?  




3. When to reach dentist after avulsion?  




Within  30 minutes
4. Where to keep tooth before reimplantation?  



Normalsaline* 12
Child’ssaliva* 02
Hankssolution* 02
5. Should we reimplant primary tooth?  


  NO 18
*All the options mentioned are correct.



Injuries to the teeth have been associated commonly with general anesthesia especially during endotracheal intubation. Trauma to the teeth has been suggested to occur during laryngoscopy or from use of airways, mouth openers, props or gags.  Tooth injuries are said to range from micro-fractures of the natural tooth substance, Subluxation injury, and pulp necrosis to actual avulsion7.

The primary objective in management of avulsed tooth is to reimplant the tooth in its anatomical correct position with minimum possible delay thereby making an attempt to maintain the viability of periodontal cells and reestablish neuro-vascular supply to tooth6. Unfortunately only 30% of the anesthetist in the present study marked that the tooth should be implanted immediately. Moreover around 10 % felt that there are no time constraints linked to it. Nearly half (40%) were not willing to reimplant themselves as they felt it wasn’t their specialty or they did not have adequate knowledge.

One should always hold the tooth by its crown whenever we try to place the avulsed tooth back into the socket. Holding the tooth from its root end can damage the periodontal ligament fibres which aid in anchoring the tooth within the alveolar socket8.In the present study majority (70%) were aware of this fact however in another study by Mourao J et al, only 41.5 % of the anesthetists knew the correct way of holding the tooth.

Avulsed tooth should be placed in a storage medium if there is a delay in reimplantation to prevent drying of tooth. Drying leads to loss of normal physiologic metabolism of periodontal cells and make them non viable8.Nearly half (40 %) of the anesthetist in the present study felt that the tooth should be dried up and kept in gauze. The ideal medium for storing an avulsed tooth is Hank’s solution. In the present study, only 5 % marked that option for storing the avulsed tooth.

If a primary tooth is avulsed, one should not attempt to reimplant it as this may damage the permanent tooth or primary tooth might ankylose with the bone. Ankylosis of primary tooth will prevent its physiologic shedding and obstruct the way for eruption of permanent tooth9.In the present study around 45% of the anesthetists felt that even milk tooth should be reimplanted. Thus we find, though some anesthetists were aware of the protocol for management of avulsed tooth, still there is a lacunae in their awareness of the protocol for avulsed tooth management.

Proper preclinical assesment is the key to minimize dental injuries. The anesthesist should look for the risk factors that can lead to dental insult mainly the poor dental status and history of difficult intubation.[1]  Any patient who is awaiting an elective surgical procedure requiring a general anaesthetia should be advised to attend their dentist first. Preoperative dental treatment can address some dental risk factors. This might include the restoration of carious lesions, replacement of any lost or loose anterior restorations, splinting or extraction of any mobile teeth and the provision of a guard for use during surgery10.

Direct laryngoscopy using the paraglossal straight blade technique avoids dental damage in patients with mobile upper incisors and no right maxillary molars. It is a practical alternative method that differs from the traditional Macintosh laryngoscope in patients with a high risk of dental injury during the procedure3.

Different devices have been proposed to protect the teeth during direct laryngoscopy. Improved laryngoscope designs, e.g., the “Dental Protector Blade”, the “Improved Laryngoscope Blade”, or the “Callander Laryngoscope Blade” were proposed to reduce dental lesions. These laryngoscope designs have become widely accepted into clinical practice. Two types of dental shields have also been developed. One of these consists of individually adaptable shields using thermoplastic material, cellulose-acetate foil, or ethylene vinyl-acetate. The other group is preformed dental shields11.


Dental injuries are common during intubation worst being tooth avulsion. Knowledge of risk factors that put patient at risk to dental injury and proper pre- clinical assessment can reduce the incidence and severity of injury. Should tooth avulsion happen, locate the tooth intraorally, hold it by its crown, immediately try to reimplant the tooth in its anatomical location and call maxillo-facial surgeon to stabilize the tooth. Symposium and guest lectures by a dental specialist can help in educating/refreshing knowledge/creating awareness among the anesthetic specialists towards emergency management of avulsed tooth.


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  8. Andersson L, Andreasen JO, Day P et al. International Association of dental traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2012; 28(2):88-96.
  9. American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on management of acute dental trauma. Pediatr Dent. 2008-2009; 30(7 Suppl):175-83.
  10. Windsor J, Lockie J. Anaesthesia and dental trauma. Anaesthesia and Intensive Care Medicine. 2008; 9(8): 355-357.
  11. Monaca E, Fock N, Doehm, et al. The effectiveness of preformed tooth protectors during endotracheal intubation: an upper jaw model. AnesthAnalg. 2007; 105(5):1326-32.


Author Disclosures:

Author Dubey A. has no conflicts of interest or financial ties to disclose.


Corresponding author:

Dr. Alok Dubey,

Associate professor, Department of Pedodontics& Preventive dentistry,
College of Dentistry, Jazan University, Jazan, Saudi Arabia.
Τel: 00966505815277
E-mail :



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