Neglected orodental facts during general anesthesia and intensive care unit admission in pediatric population.

Perianesthetic dental trauma is not uncommon with an incidence as low as 0.02%-0.07% up to 12.1% of cases of the general anesthesia (GA) 1. Incidence of overall oral trauma is reported as high as 7% of individuals who underwent GA 2. Indeed, emergency endotracheal intubation and less experienced staff probably increase the chance of traumatizing hard and soft oral tissues 3. The majority of incidental dental traumas during GA occur in attempting intubation (75%), followed by extubation (16%) and in the recovery phase (9%) 4. Dental trauma includes milder forms such as enamel fracture or tooth subluxation to more severe forms of crown fractures and tooth avulsion. Anterior dislocation of mandible condyle leading to a locked position of temporomandibular joint, tongue injuries and a variety forms of pressure-induced lesions of the oral cavity soft tissues are also explained 1,5. During life, dentition includes three phases: deciduous (6 months 6 years), mixed (6 -12 years) and permanent dentition (beyond 12 years) 6. Upper incisors are reported to be more affected during intubation 4. These teeth are single-rooted with a low surface area when compared to multiple-rooted posterior teeth with a significant higher surface area around the roots within the alveolar bone. The higher traumatic injuries may be explained by unintentional forces directed to the tooth when an anesthesiologist uses this tooth as a fulcrum to guide the laryngoscope blade especially during the difficult and previously failed attempts 4. As the child finishes the deciduous dentition and enters the transitional phase of mixed dentition at around the age of 6-8 years, the underlying permanent incisor would exert its eruptive forces by loosening the corresponding deciduous 6. This may challenge both the child and intensivist by a high probability of deciduous dentition to be avulsed with subsequent chance of permanent teeth damage by excessive forces and wrong attempt to re-implant the avulsed tooth. Another special consideration for toddlers is the presence of “baby bottle syndrome” or early childhood caries (ECC) 1. This syndrome is derived from long exposure to the high sugar content liquids especially at night during the age of 18-48 months. Upper incisors and lower molars are affected most, yet lower incisors are spared due to the tongue’s protective function 1. These teeth with rampant and extensive caries are more susceptible to mechanical trauma and more likely to crack or avulse 1. Pediatric intensive care unit (PICU) admitted patients who are remarkably at risk for dental trauma when compared to adults for their immature root formation and possibility of physiologic subluxed teeth during their dentition phase 7. One should keep in mind having adequate knowledge about additive hazards when the physician attempts to intubate a pediatric patient with class II malocclusion (i.e., protrusion of maxilla) and excessive overjet 7 or abnormally large and over extruded front teeth, so called “Bugs Bunny teeth”. In addition to forceful intubation or extubation, vigorous suctioning of posterior teeth, pressure induced damage to the adjacent tissues by insertion of the laryngeal mask airway (LMA), masseteric spasm derived by hypothermic-induced shivering and biting forces against antagonist teeth or endotracheal tube (ETT) should all be taken into account. Hence, intubation, extubation and suctioning should be performed with a great care. If the child has a loose tooth and avulsion or aspiration is deemed, a careful suturing (3-0 silk suture) of the affected tooth to the adjacent sound tooth just around the crown of the teeth may prevent avulsion and aspiration 1. It is clear that attenuated mechanical elimination and poor oral hygiene in intensive care units increase the dental plaques. Dental plaque consists of more than 300 microorganism species which are embedded into an extracellular matrix 6,8.