title: Patient fire during dental care: A case report and call for safety.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Bosack
authors.forename: Mark E
authors.initials: ME
authors.lastname: Bruley
authors.forename: Andrea M
authors.initials: AM
authors.lastname: VanCleave
authors.forename: Joel M
authors.initials: JM
authors.lastname: Weaver
mesh_terms: D000368:Aged; D002056:Burns / Q000209:etiology*; D003729:Dental Care / Q000009:adverse effects*; D005151:Facial Injuries / Q000209:etiology*; D005260:Female; D005390:Fires / Q000517:prevention & control; D006801:Humans; D009609:Nitrous Oxide; D010100:Oxygen; D061214:Patient Safety
chemical_list: D009609:Nitrous Oxide; D010100:Oxygen
keywords: Dental fire; burn; fire triangle; fuel; ignition source; nitrous oxide; oxidizer-enriched atmosphere; oxygen