Continual vigilance by the whole dental team, care in daily clinical routines and the avoidance of complacency, can prevent most accidental injuries.
When carrying out treatment in the area of the mouth and face - especially when working on supine patients -- there is an ever-present risk of collateral injury to the other oral and facial tissues that are not inherent complications of the procedures being undertaken. These accidental injuries most obviously involve dentists, but many of them can just as easily involve dental hygienists and therapists. Other members of the dental team can also play a direct role in both causing and preventing these injuries.
Not only is the oral environment a confined space, with restricted access, but the very nature of the dental tissues and the materials used to restore them requires powerful instrumentation that needs to operate in the immediate proximity of vulnerable soft tissues.
There is a possibility that members of the dental team might become so accustomed to the above facts in their working lives that daily routines could start to mask the reality and lead to complacency.
One of the reasons for complacency in relation to effective risk management is the relative infrequency of adverse incidents. It is important, therefore, to remind ourselves of how easily things can go wrong, of what can go wrong, and of what each member of the dental team can do to prevent accidental injuries.
For the purposes of this review, the types of injuries that can occur are categorised as follows:
- Burns
- Caustic/chemical burns
- Lacerations
- 'Crush' injuries
- Supine injuries
- Mechanical injuries
- Other injuries
Burns
Extreme caution needs to be taken whenever hot instruments or materials are being used in or near the mouth. The procedures most commonly linked with accidental burn injuries arise in endodontics, in association with the use of hot gutta-percha.
Faulty/defective dental handpieces, micro-motors, or ultrasonic scalers which overheat, are a common source of burns to the lip and cheek. Diathermy electrodes can similarly cause extensive burns to the lip, tongue and oral mucosa, as can cryosurgery units. Where these injuries cross the vermillion border of the lip, the resulting disfigurement can sometimes be considerable, and very distressing to the patient.
Caustic burns
A number of chemicals used in association with dental treatment are either highly acidic or highly alkaline; either can result in caustic burns to the face, eyes and oral tissues.
Some clinicians still use chromic acid and similar compounds to treat pericoronitis, phosphoric acid is present in some cement systems, and hypochlorite (bleach) solutions in a range of concentrations is used in endodontics. Hydrogen peroxide is also used in bleaching techniques, in various strengths.
Glutaraldehyde is still used in some practices as part of their infection control procedures, and can represent a particular hazard both for the staff members who are handling the solutions, and for patients. Patients have been known to suffer severe caustic burns in the past, when instruments have been immersed in glutaraldehyde in temporary storage, and used before rinsing off any residual disinfectant solution.
Acid etching gels and solutions are similarly in widespread use in most dental surgeries and because of this, familiarity can sometimes breed contempt All staff members (especially those who are new or employees in training, need to be aware of the very real risks presented by all of these materials.
Problems are sometimes encountered when using a 3-in-1 syringe to wash away these solutions, resulting in 'splatter' of potentially caustic materials. The patient's eyes - as well as those of the clinician and nurse - are particularly vulnerable here. This highlights the importance of using protective glasses/ goggles to prevent a range of ocular injuries.
Lacerations
Powerful instruments, rotating at high speeds, are inevitably a hazard when introduced into a confined area such as the mouth. The most common injuries are those to the lip, tongue, cheek and floor of the mouth during cavity or crown preparation.
Discs (both cutting and polishing) can cause devastating injuries to the patient's lip and tongue, and to the floor of the mouth. Wherever possible, a disc guard should be used.
Other laceration injuries can be caused to various intra-oral tissues (including the gingiva, cheek, palate and floor of the mouth) when sharp instruments slip during minor oral surgery or other procedures.
Scalers are a common cause of such injuries.
Most laceration injuries heal remarkably quickly and uneventfully, although some do need sutures to control bleeding and to ensure close tissue approximation in the first instance. The most important aspect of the management of these injuries is to acknowledge what has happened, and reassure the patient, giving them the option of proceeding with the treatment that day, or postponing further treatment until another day.
While there is a natural wish not to alarm the patient unnecessarily, taking too casual and dismissive an attitude can be misinterpreted by the patient as being uncaring or unsympathetic.
Patients are not always prepared to accept that these cuts and lacerations are simply an unavoidable accident, and - just one of those things'. It is essential to show concern and understanding - even if this sometimes seems disproportionate to what might appear to be a very minor injury. The patient will (at best) see the injury as an unfortunate and unwelcome inconvenience and (at worst) will view it as an avoidable act of incompetence.
This is not the time to get drawn into a 'chicken and egg' debate as to whether the injury was caused by a sudden movement on the part of the patient, or whether the injury itself caused the patient to move suddenly.
Ensure that dental instrumentation is kept well out of the way when patients are being seated in, or leaving, the dental chair. There have been instances where patients have received laceration injuries to their hands, arms or legs from burs or ultrasonic scaler tips, located within dental instrumentation units.
Crush injuries
These can arise in a number of ways, but they most commonly arise during minor oral surgery procedures, resulting from the accidental trapping of some lip or cheek tissue in extraction forceps, or inadvertently crushing the lower lip between an instrument and the lower incisor teeth.
The use of ill-fitting/overextended impression trays (especially unmodified 'stock' trays), incorrectly placed mouth props, rubber dam clamps and matrix bands can all be responsible for 'crush' injuries, emphasising the need to be circumspect in ensuring the safety of all oral tissues, even when one's primary attention is being focused upon other tissues where treatment is being carried out.
A vigilant dental nurse who is aware of these risks can be particularly helpful in preventing injuries of this kind.
Supine injuries
In addition to the injuries described above, the supine position itself, in conjunction with the close support assistance of a dental nurse, does create the potential for instruments and dental materials being passed between nurse and clinician, to be dropped on to the face or eyes of the patient.
All such transfers of instruments or materials should take place in the 'safe zone' either behind the patient's head, or over the patient's chest.
The patient's eyes are particularly at risk when being treated in the supine position, and the surprising frequency of these injuries (and sometimes, the severity of the consequences) means that the need for suitable eye protection for patients cannot be over-stressed.
Mechanical injuries
Modern dental surgeries are full of pieces of equipment which often have a number of moving parts. They are frequently powered electronically, and operated remotely.
As a dental chair is moved from the upright to the supine position, or viceversa, there arises the possibility of trapping a patient's fingers, hands or legs between the moving parts, or between adjacent pieces of equipment. The same can arise with some designs of panoramic/OPT x-rays, where the patient is seated in a chair which moves relative to the equipment, or where the equipment moves relative to the chair in a fixed arc.
Several such injuries are reported every year.
Patients cannot be expected to be able to anticipate any or all of these hazards, so it becomes important that whoever is controlling the movement of the equipment checks that it is safe to proceed, giving any relevant advice to the patient in doing so. The equipment design should be such that any movement or electronic program can be immediately stopped and reversed, as soon as any risk of injuring a patient becomes apparent.
Particular care needs to be taken when treating young children, the elderly and the visually impaired.
Other injuries
The dental surgery environment contains a range of hazards which can lead to 'trip and slip' injuries; most of these can be avoided if proper attention is paid to surgery design, repairs and maintenance.
All dental equipment and instrumentation should be regularly checked, maintained and serviced in accordance with manufacturers' instructions. In one bizarre incident, a compressed air line split under pressure, resulting in a painful whiplash blow to the side of a patient's face.
A less obvious source of accidental injury is noise; several items of dental instrumentation emit high-decibel noise which can cause distress and physical damage to patients with some auditory conditions. Similarly, patients with hearing aids should be advised to remove or adjust them before any noisy dental instrumentation is used in close proximity to their ears. The use of well fitting headphones is an alternative means of protecting the patient against trauma from noise.
Complicating factors
The four most significant complicating factors in the injuries described above are:
(a) Visibility and access
(b) The presence of local anaesthesia
(c) The use of gloves
(d) Nervous patients
(a) Visibility and access
Many of these injuries are made more likely when the clinician, or assisting dental nurse (or both) has impaired access and reduced visibility. Good communication between the parties can allow procedures to be halted, and any necessary adjustments in position to be made, in order to maximise the protection of the patient.
The use of rubber dam can help to avoid many of the injuries described above, but there have been several occasions on which a hot instrument used in connection with endodontics carried out under rubber dam, has caused an unseen burn injury to the patient's tongue resting immediately under the surface of the rubber dam.
Ill-fitting rubber dam has also been known to allow the passage of materials and solutions through to the unprotected gingival tissues beneath, without the operator being aware of this fact.
(b) Local anaesthesia
When the patient's mouth has been numbed by the administration of local anaesthesia, they are oblivious to many of these injuries. This can exacerbate the problem because the dentist is not alerted to the damage that is being caused until it is too late.
(c) The use of gloves
Dental gloves worn by dentists, hygienists, therapists and dental nurses insulate them against any thermal injuries, rendering the operator unaware of the problem until the damage is done. Hot instruments recently removed from an autoclave, for example, must always be allowed to cool before use. Bulky solid metal instruments such as extraction forceps and elevators take longer to cool, as do all instruments when in sealed autoclave bags.
A gloved operator may be unaware that such instruments are still hot enough to cause a burn injury to the unprotected patient's tissues, for some time after their removal from the autoclave chamber.
(d) Nervous patients
Any procedures which carry the risk of accidental injuries should be undertaken in the anticipation and readiness that patients - particularly children and nervous patients - may move suddenly and without warning. Wherever possible, sufficient safeguards and protective devices should be in place to allow the procedure to be stopped without any injury to the patient.
Summary
The team approach to risk management enables the dental nurse to provide an extra dimension to risk awareness and risk control in the surgery environment, and can play an important part in eliminating injuries such as those described above.
As always, a sympathetic, caring and supportive response by the dentist and other members of staff goes a long way towards the speedy and amicable resolution of problems of this nature.
Showing concern, including perhaps a follow-up telephone call and review appointment, is central to the management of accidental injuries associated with dental care. Each and every step of the follow-up process and aftercare should be meticulously recorded in the patient's notes.