Patient fire during dental care: A case report and call for safety.

BACKGROUND AND OVERVIEW: Fire risk is present whenever there is a convergence of fuel, oxidizer, and an ignition source, which is called the fire triangle. A heightened awareness of fire risk is necessary whenever a fire triangle is present. The authors provide a sentinel event case report of fire in a dental office.

CASE DESCRIPTION: A 72-year-old woman received second-degree facial burns from a fire that ignited near the nasal hood supplying a nitrous oxide-oxygen mixture. The presumed ignition source was heat generated during the preparation of a titanium post with a high-speed, irrigated carbide bur. The patient was transferred to the local emergency department and subsequently discharged after possible pulmonary complications were ruled out. The patient was then transferred to a regional burn unit and was discharged home with second-degree burns.

CONCLUSIONS AND PRACTICAL IMPLICATIONS: When the source of a fuel cannot be removed from the immediate area, soaked with water, or covered with a water-soluble jelly, the dentist should stop the open flow of oxygen or nitrous oxide-oxygen mixtures to the patient for 1 minute before the use of a potential ignition source, and intraoral suction should be used to clear the ambient atmosphere of oxidizer-enriched exhaled gas.