Dental guards: An alternative solution for loose tooth.

Sir,

Perioperative dental damage is the most common cause of medicolegal complaint related to anesthesia and it mostly (50-70%) occurs during tracheal intubation.[1] Presence of loose teeth increases the chance of dental trauma. Patient's anterior maxillary teeth may be sometimes wrongly used as a fulcrum for the laryngoscope blade by the anesthesiologist, making the left central incisors most venerable to dental trauma. A loose upper incisor is also at a higher risk of dislodgement. A dislodged tooth may be lost in the hypopharynx, esophagus, or may be aspirated into the lower airway. The risk of dislodgement increases in difficult airways.

A number of techniques have been described for prevention and management of dislodged tooth. For elective surgeries, preoperative extraction is one of the options. Tying the loose tooth with a silk through the interdental clefts has been described by Singhal et al.[2] and Lee et al.[3] Alternately, left molar approach have been successfully used by Gupta et al.[4] as a safe technique for intubation in patients with loose central incisors.

Dental protectors or guards [Figure 1] are mainly used by otolaryngologist for prevention of dental trauma during suspension laryngoscopy. We found that dental guard can be effectively used for preventing dislodgement of loose tooth. These guards cover the whole maxillary teeth and some portion of the gums. Hence, if dislodgement of any tooth occurs during intubation, it will remain inside the guard rather than falling into the hypopharynx or lower airway. The loose tooth can be retrieved from the guard after securing the airway. Dental guards are available in two sizes (Karl Storz endoskope); adult and young adult size for 8-12 years old. The adult size covers from incisors to premolars in all patients, leaving the molars uncovered in some patients, which are anyway less likely to be injured by laryngoscopy. We have successfully used this technique in many patients with loose tooth without any complication.

Figure 1

Dental guard

Dental protectors are also thought to decrease the incidence of dental trauma by decreasing the transmitted pressure of the laryngoscope. However, studies have shown no significant benefit with the use of mouth guards on prevention of dental injury.[56] One of the disadvantages of use of dental protector is that it decreases the interincisor space, due to its thickness, which may lead to difficulty in intubation. Aspiration of the appliance and prolongation of intubation time are other concerns.

We suggest the use of dental protectors as a safe, effective, and easy-to-use appliance for managing loose tooth during intubation. However, further studies may be conducted to establish its use over conventional techniques.