Pulling teeth

[ethilo]

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I've had a few patients in residency with very loose teeth. Typically, it's either adult meth addicts or someone else with poor dentition that doesn't really care about their teeth, OR it's a child who is about to loose a primary tooth.

How do you approach teeth in your cases requiring intubation, LMA, or even just a MAC case if the tooth is REALLY loose?

So far, I've discussed with the patient (and/or their parents) the pros and cons of having that loose tooth remain in place and what I'm willing to do about it, then I leave it up to them to decide what we should do being made aware of risks like aspiration of the tooth / need for more procedures. I've pulled out 3 teeth this way after inducing -> sticking a piece of gauze in the back of their mouth (to prevent losing the tooth back there in an unprotected airway) -> pulling the tooth out with my fingers -> removing gauze -> proceeding with intubation / LMA.

I bring this up because one of my peds attendings said he used to offer to pull the tooth under general to prevent risk of inadvertent aspiration of tooth but decided he personally didn't feel like it was within his job description - should be done by a dentist. He now no longer does it and just avoids the tooth as much as possible.

 

[deleted126335]

child with deciduous tooth that is very loose: I tell the child and parents that "the tooth fairy may come today". Will occasionally pull with gloved hand...put in specimen cup with a dollar bill. Happens 2-3x year.

Adult with lousy teeth: Most are "brittle" as opposed to being loose. Those I don't touch and avoid as much as possible. Adult with very loose wiggly tooth I might take out if it can be removed with gloved hand only depending on how it looks. Happens about once every 5 years. Always let any adult with lousy teeth know that they might lose them intraop.

Document dental status and conversation in preop.

 

[Noyac]

I had a pt a few years back that had a very loose tooth. I told him it might come out today. He said, "if you can get it out, that would be great." I walked into our dental OR and asked the dentist exactly how I should pull it. Pull straight down with a twisting motion. Then he said you will probably save the guy about $150 by not having him go to dentist to pull it.

He was very grateful.

 

[sevoflurane]

I had a pt a few years back that had a very loose tooth. I told him it might come out today. He said, "if you can get it out, that would be great." I walked into our dental OR and asked the dentist exactly how I should pull it. Pull straight down with a twisting motion. Then he said you will probably save the guy about $150 by not having him go to dentist to pull it.

He was very grateful.

Nice. Had the exact same experience about 4 months ago. Very loose incisor that was getting a 37 Fr. DLT. Pulled it after induction and made a space for my DLT to sit nicely. Patient knew it was coming out soon anyways... so everyone won that day.

 

[sevoflurane]

I've pulled 4 or 5 teeth this way in my career. I've also had a couple just come out or fall apart due to extremely foul dentition while under GA.
You guys know the patient types. When this happens, I've always thought to myself that I should have just pulled it due to risk of aspiration- I think it's very reasonable to pull these when they are going to come out anyways.

 

[HalO'Thane]

I've had a few patients in residency with very loose teeth. Typically, it's either adult meth addicts or someone else with poor dentition that doesn't really care about their teeth, OR it's a child who is about to loose a primary tooth.

How do you approach teeth in your cases requiring intubation, LMA, or even just a MAC case if the tooth is REALLY loose?

So far, I've discussed with the patient (and/or their parents) the pros and cons of having that loose tooth remain in place and what I'm willing to do about it, then I leave it up to them to decide what we should do being made aware of risks like aspiration of the tooth / need for more procedures. I've pulled out 3 teeth this way after inducing -> sticking a piece of gauze in the back of their mouth (to prevent losing the tooth back there in an unprotected airway) -> pulling the tooth out with my fingers -> removing gauze -> proceeding with intubation / LMA.

I bring this up because one of my peds attendings said he used to offer to pull the tooth under general to prevent risk of inadvertent aspiration of tooth but decided he personally didn't feel like it was within his job description - should be done by a dentist. He now no longer does it and just avoids the tooth as much as possible.

I ask the parents of all of my pediatric patients whether their child has any loose teeth. If they are loose I then either have the patient wiggle the tooth or I check it myself. If it is extremely loose I usually offer to pull it (i.e. a visit from the Tooth Fairy) Usually not a problem if the tooth is extremely loose. Like you I do it after induction. There are a lot of trainees where I work, both on the anesthesia side and even the airway surgery side, so I follow Murphy's Law where if something can happen it will. So even loose teeth that I think may not be an issue with airway instrumentation I treat as a potential issue if it is in inexperienced hands.

 

[IlDestriero]

In my peds practice I ask and have the kids show me how loose they are. Then I tell them that "the tooth fairy may come while you're asleep in the OR." If they ask I let them know that a very loose tooth can be dangerous and sometimes has to be removed for safety. Then I check myself after they're asleep and make the decision if it stays or goes. I look again quickly at the end to make sure it's still there after extubation if I left it in. I place the bite block on the opposite side to try to decrease the likelihood that it gets traumatically removed.


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Il Destriero