A recently filed lawsuit has gained a lot of attention in the media, as a pediatric dentist in Las Vegas allegedly caused an intraoral fire in a five-year-old female patient.
Reports say that the dentist at the Just For Kids dental practice used a diamond bur to smooth the girl’s teeth while she was under anesthetics. The procedure then caused a spark that ignited the throat pack in the girl’s mouth and produced a fire that lasted a second or two, according to the lawsuit filed by the girl’s attorneys.
The complaint says that the girl suffered burns to her epiglottis, throat, tongue, mouth, lips, and surrounding areas and that some of the injuries may be permanent and disabling.
“It is my opinion that Just For Kids breached the standard of care by failing to adequately protect the airway, committing a series of acts which set up a truly ‘incendiary’ situation,” the family’s expert witness, a local oral and maxillofacial surgeon, said in an affidavit.
Unfortunately, the vast majority of civil legal actions that involve alleged malpractice are settled prior to trial with nondisclosure agreements in place. The only dental professionals who learn about the facts of these cases usually are experts retained by the attorneys involved. The recorded reviews and opinions of these experts are considered attorney work product and are subject to nondisclosure agreements under most terms of settlement.
Ideally, the dental profession as a whole could learn valuable lessons from these malpractice cases, but too much of this material is hidden from examination. Even when cases are publicized, like this one, details are puzzling or sparse. For example, diamond burs rarely if ever emit sparks while they are being used on tooth structure. Also, what is meant by reports saying that the patient was under anesthetics?
Joel M. Weaver, DDS, PhD, has been a pioneer in dental anesthesiology and has even studied the risks of fire in the dental chair, providing direct answers without needless esoteric jargon or a condescending attitude.
Weaver also has always exemplified the epitome of a truly inspirational educator, encompassing his peer reviewed papers, speaking from the lectern, and his mentorship of junior colleagues. For instance, he has unabashedly discussed how he has used K-Y Jelly as a safe water-based clinical lubricant instead of petroleum jelly, which is highly flammable. Patient safety always took precedence over any false sense of propriety in his practice.
“A patient was undergoing maxillofacial surgery with general anesthesia maintained through a nose mask with a concentration of 25% oxygen, 75% nitrous oxide, and a small percentage of halogenated anesthetic. The patient had a moustache,” Weaver said, describing one case.
“As the surgeon was grinding a filling with a tungsten-carbide bur, an incandescent spark flew from the bur and arced out of the patient’s mouth, over his upper lip, and landed in his moustache,” he said.
“Because of the high concentration of oxygen, effectively 50% because of the nitrous oxide, the moustache immediately burst into flame and ignited the nasal mask. The fire then flashed back toward the anesthesia machine along the gas delivery hoses,” Weaver continued.
“As soon as the fire was noticed, the nasal mask was removed from the patient’s face, but not before significant burning of his nose and upper lip had occurred. Had a water-based lubricant been used to coat the moustache hair, the spark would not have caused the fire,” Weaver said.
The Fire Triangle
Dentists should understand the fire triangle, which represents the three elements that a fire needs to ignite: heat, fuel, and an oxidizing agent, usually oxygen. When these elements are present and combined in the right mixture, fire happens. Fire can be prevented or extinguished by removing any one of the elements in the triangle.
Though rare, fires occur in operating rooms at least 650 times a year, with at least two or three deaths. There may be as many as 500 more cases that are unreported or near misses. Surgical environments are home to all three elements of the fire triangle, with oxygen or nitrous oxide serving as oxidizers, lasers and other devices providing the ignition, and tissue and other materials serving as fuel.
When dentists are using diamond burs to create endodontic access, adjust occlusion, finish, or remove crowns, they should use copious amounts of water spray. Also, burs operating on tooth structure don’t get nearly as hot or provide sparks, unlike metal restorations or especially dental ceramics. This can be a critical understanding when adjusting newer pediatric zirconium pre-fabricated crowns, particularly on a patient with supplemental oxygen and/or nitrous oxide.
“Komet USA’s ZR Diamonds have a special coating, a densely packed diamond grain layer, and are made with a specific grit that allows them to be used for adjusting and removing zirconia crowns while also ensuring they do not heat up,” said Niall McCarthy, senior corporate trainer for Komet USA. “This assuming that everyone is using water spray.”
Oxygen is always present to some degree in clinical dentistry, as we are working with living human beings requiring an airway. Risks are elevated when necessary supplemental oxygen is delivered in sedation and general anesthesia cases.
Restorative dentists often elect to turn off the flow of oxygen and nitrous oxide to patients when providing final adjustments to ceramic crowns, which require diamond burs. Of course, this action must comport with the patient’s overall safety.
Sources of fuel may include patient bibs, patient hair, any petroleum lubrication products, oral gauze or cotton rolls, protective throat packs, sterile surgical drapes, nasal hoods and cannulas, plastic headrest covers, rubber dams, surgical head caps, alcohol-based products, volatized restorative bonding agents, endotracheal tubes, and other items. Obviously, there’s a great deal of potential fuel for an oral fire in dental treatment.
Lasers and electrosurgery tips should be shielded, and they never should be in immediate proximity to combustible fuels. K-Y Jelly or other water-based lubricants should replace petroleum-based products. Throat packs and throat screens should be well moistened with distilled water or sterile saline solution.
“Oral fires happen—fairly rare, but predictable. At University Las Vegas Nevada School of Dental Medicine, Oral Maxillofacial Surgery, we always used moist throat packs,” said Daniel L. Orr, DDS, MS, PhD, JD, MD, former director of oral maxillofacial surgery at the school. “Enamel doesn’t spark, but metal does.”
The full details specific to the Las Vegas lawsuit may never be publicly released, unless the litigants don’t settle and a civil trial ensues. But nearly all such alleged malpractice legal cases are dropped by plaintiffs, are dismissed by a judge, or reach settlement prior to trial. The dental profession and general public are therefore roadblocked from potentially very important learning.
Speculation about the causal matters of a legal case is generally foolish without access to and a clear understanding of all of the relevant facts. Trial by the news media is grossly limited and remiss. Unfortunately, that’s all most of us may ever see.
Oral fire prevention is a concern that won’t disappear. It’s of particular interest for practitioners involved with sedation and general anesthesia. Our expanding plethora of restorative options including dental ceramics and diamond burs is also a factor. Injudicious utilization of lasers and electrosurgery may present additional oral heat, and therefore combustion risks, as well.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at firstname.lastname@example.org or smilesofsantafe.com.