Missing but important! Dislodgment of a loose tooth and its recovery during difficult intubation.

Sir,

Latrogenic dislodgement of a loose tooth during difficult intubation is a possible complication. Inability to retrieve the dislodged tooth can lead not only to cosmetic handicap but also medical and medicolegal consequences. We describe the successful retrieval of a missing tooth during anaesthesia and review the literature on similar complications.

A 54-year-old, 78 kg male presented with low backache of one-year duration. Magnetic Resonance Imaging revealed lumbar canal stenosis with L3-4 and L4-5 disc herniation. Past history included uneventful surgery for left frontal meningioma four years back and diabetes mellitus. There was no documentation of any difficult intubation at that time. He was scheduled for decompressive laminectomy under general anaesthesia. Pre-anaesthetic examination revealed short neck, restricted neck movement, Mallampati class II airway, loose lateral maxillary incisor and missing central incisor tooth. He was explained the possibility of dislodgement of loose tooth during intubation. The intubation was anticipated to be difficult but possible. Monitoring during the procedure included electrocardiogram, non-invasive blood pressure, pulse-oximetry, end-tidal carbon-dioxide (EtcO2) and anesthetic concentration. Following preoxygenation, Fentanyl 100μg and Propofol 150mg was administered to anaesthetize the patient. After ensuring adequate mask ventilation, Vecuronium 10mg was administered to facilitate tracheal intubation. On laryngoscopy, only epiglottis was visible and two attempts to intubate failed. Trachea was successfully intubated in the third attempt using McCoy laryngoscope. However, it was noticed that the loose maxillary incisor was missing and laryngoscopy done to visualize the missing tooth failed to locate it. Immediately trendelenberg position was obtained to prevent its distal migration. Fiberoptic nasal and oral visualization failed to locate the tooth and therefore fluoroscopy was performed, which revealed the presence of tooth in the nasopharynx. (Figure 1) Attempts at passing the nasogastric tube to push the tooth into the oropharynx failed and hence, nasal speculum and Magill's forceps were used to facilitate its downward movement. Repeat fluoroscopy revealed the presence of tooth behind the tracheal tube in the oropharynx that was successfully extracted. Rest of the anesthetic course was uneventful.

Figure 1

Dental injuries are common during intubation and are one of the commonest causes for medical litigations. This occurs more during difficult intubation as the anaesthesiologist uses the maxillary incisors as a fulcrum to obtain better view of the glottis.

Newland et al have reviewed 161687 anaesthetics over 14 years and observed 78 patients with dental injury.1 Similar findings were recorded by Warner et al in their review of six lakh patients, where they reported 1 in 4537 incidence of dental trauma.2 They noted that the maxillary incisors were more commonly involved and that this occurred more in patients with difficult airway and poor dentition. Both the risk factors were present in our patient, which increased the likelihood of dental trauma.

We attempted identification of the missing tooth initially with laryngoscope and then with fiberoptic scope. When both these failed, our timely decision to use fluoroscopy successfully located and facilitated the recovery of impacted tooth from the nasopharynx. The dislodged tooth might have migrated into the nasopharynx when trendelenberg position was obtained. It is important to identify and retrieve the missing tooth before the surgery to avoid both medical and legal consequences. If it goes unnoticed, sharp tooth can lead to potentially dangerous pulmonary and gastro-intestinal complications and also make its recovery at a later time, difficult.3–4

In conclusion, we report the successful retrieval of a dislodged tooth during anaesthesia and highlight the utility of fluoroscopy in locating the missing tooth when conventional methods fail. Further, our report reaffirms the need for exercising sufficient care in difficult intubation scenario, to avoid dental injury.