Dental abnormalities cause problems for both dentist and anaesthetist. The anaesthetic hazards associated with the 'passion gap' - a term used in the western Cape Province for removal of the top four incisor teeth, a practice widespread among members ot the Cape Coloured community - are discussed. Recommendations are made to assist the anaesthetist when dealing with such a patient

Allen, R. W. J.

Gasson, J.V.

Vivian, J.C.

English

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14. Letter from Dr A Morris to Dr P. Carstens, University of Toronto, 20January 1988.15. Thomson RB. Note on the venebral column of the Bushman race of SouthAfrica. Tram R Sac S Afr 1913; 3: 365-378.16. Shrubsall Fe. Notes on some Bushman crania and bones from the SouthAfrican Museum. Ann S Afr Museum 1907; 5: 227-270.17. Haughton SH, Thomson RB, Peringuey L. Preliminary note on the ancienthuman skull remains from the Transvaal. Tram R Sac S Afr 1917; 6: 1-14.18. Thomson RB. Complete unilateral interruption of the fissure of Rolando.J Anat PJrysio11911; 45: 433-437.19. Tricomi Allegra G. Sulla duplicita ed interruzione del sulcus rolandicus.Anat Anz 1907; 30: 481-496.SAMJ VOL 78 15 SEPT 1990 33520. Waterston D. Complete bilateral interruption of the fissure of Rolando. JAnat PJrysioll906-7; 41: 143-146.21. Bailey P, Von Bonin G. The Isocortex of Man. Chicago: University of IllinoisPress, 1951.22. Symingron J, Crymble PT. The central fissure of the cerebrum. J Anat1913; 47: 321-339.23. .peath of Dr R. B. Thomson. Farmers' Weekly 1937; 54: (Sept.) 1044.24. Tobias PV. Darwin, 'Descent' and disease. Tram R Soc S Afr 1972; 40:239-260. .25. Dart RA. Australopithecus africanus, the man-ape of South Africa. Nature1925; lI5: 195-199.Anaesthetic hazards of the 'passion gap'A case reportR. W. J. ALLEN, J. V. GASSON, J. C. VIVIANSummaryDental abnormalities cause problems for both dentist andanaesthetist. The anaesthetic hazards associated with the'passion gap' - a term used in the western Cape Provincefor removal of the top four incisor teeth, a practice widespreadamong members ot the Cape Coloured community - arediscussed. Recommendations are made to assist the anaes-thetist when dealing with such a patient.S AfrMed J 1990; 78: 335-336.When intubating a patient the anaesthetist must always becareful to avoid damaging the patient's teeth, especially in ourpresent litigation-conscious society. I The risk of injury to teethis greatly increased in the presence of dental disease or abnor-malities, crowns, bridges, or heavily restored teeth, in the veryyoung and in the elderly. By the same token such conditionscan make intubation difficult and persisting with instrumen-tation in difficult cases is more likely to lead to damage.2Furthermore, attention to the perfect preservation of teethshould not be such as to place the patient's life at risk.The 'passion gap' as seen in the Cape Coloured people, canbe the cause of unexpected difficulty at the time of intubation.Having graduated outside South Africa, the authors wereunfamiliar with this phenomenon on starting clinjcal anaestheticpractice in the Cape and so experienced some problems initially.A simple regimen has consequently been devised to help over-come the potential anaesthetic hazards of the 'passion gap'.Department of Anaesthetics, University of Cape Town andGroote Schuur Hospital, Cape TownR. W. J. ALLEN, M.B. B.CH. F.F.A R.c.s. (IREL.) (Present address:Royal Victoria Hospital, Belfast, N.!.)J. V. GASSON, M.B.CH.B..J. C. VIVIAN, M.B. RS., F.F.A.R.C.S., M.R.C.P.Accepted 4 Dec 1989.Case reportA 25-year-old Cape Coloured woman presented to the Mater-nity Unit, Groote Schuur Hospital, for elective caesareansection. The pre-operative assessment revealed nothing ofanaesthetic significance other than the presence of an 'innocent'frontal dental palate.Induction of anaesthesia (using the 'rapid sequence induc-tion' technique) proceeded normally until intubation wasattempted. This proved unexpectedly difficult. The laryngo-scope blade had slipped into the gap (Fig. 1) revealed onremoving the dental plate before entering theatre, thus pre-venting easy manipulation of the tongue and epiglottis. Theright lateral canine obscured visualisation of the larynx, hinder-ing easy introduction of the endotracheal tube into the mouth,and the inflatable cuff snagged constantly on this tooth andwas thus at risk of being punctured. A second tube with a longstylet in place was made ready and used to facilitate eventualsuccessful intubation. The rest of the operation proceededuneventfully and neither baby nor mother suffered ill-effects.The anaesthetist was alarmed that an apparently innocuousdental abnormality could cause such difficulty and embar-rassment.DiscussionSome 86% of the 2800 000 members of the coloured com-munity live in the Cape Province, mainly in the urbanisedparts of the Cape Peninsula. They are the product of misce-genation between the original Hottentot tribes of the Cape,slaves imported by the Dutch East India Company from theEast, the early white settJers and, later, blacks. Within thispopulation there are two small distinctive communities: theGriquas and the Cape Malays.3,4Why does the 'passion gap' exist among the Cape Coloureds?The popular belief is that the teeth are removed for sexualreasons. Perhaps this is true in some cases, but the main reasonfor the gap is dental decay with the front teeth being particu-larly susceptible and extraction being the commonest form oftreatment (given the community's socio-economic background),336 SAMJ VOL 78 15 SEPT 1990Fig. 1. Cape Coloured woman displaying her 'passion gap'.although this is not always done professionally (Dr N.Myburgh, Faculty of Dentistry, University of the WesternCape - personal communication). In this community adequatedental services are not available, few fillings are provided,health educaton is poor and minimal appreciation of gooddental hygiene exists. 5 Cenainly there is a cultural aspect: thegap is a mark of beauty and a sign that adulthood has beenanained. Furthermore, the wearing of dentures or plates isoften viewed as a status symbol (Professor M. Whisson,Department of Anthropology, Rhodes University - personalcommunication).Tooth mutilation is observed in other African racialgroupings, being performed for numerous reasons: tribal identi-fication, tribal tradition, sake of appearance, religiouspractices.6,7The phenomenon is prevalent among obstetric patientsat Groote Schuur Hospital where over a 6-month period in1989 the average caesarean section rate was 125 per month.Over half of these section patients were coloured women andour own survey showed that almost 75% of them had a 'passiongap', with,most wearing dental plates (unpublished data). Thegap is also seen among coloured men, especially among thelower social strata and gang members, but the incidence isdifficult to determine. In this group homosexuality is offeredas an explanation, especially in the prison sening, but simpledental decay is the most likely reason. 5A few simple manouevres are suggested to help overcomethe anticipated intubation difficulties associated with the'passion gap'. In order to 'fill the gap', thereby preventing thelaryngoscope or tube slipping into it, the following bridgingtechniques can be used: (I) placing a wooden spatula across thegap resting on the remaining teeth on either side; (il) insertingan upside-down Guedel airway into the gap; or (iil) allowingthe dental plate/bridge to stay in place. The use of swabs tofill the gap is not recommended, since these do not provide asolid bridge.Modifying the intubation technique as follows can provehelpful: (I) introducing the tube laterally thereby both avoidingthe sharp canine teeth and the problem of the tube lodgingbetween the laryngoscope and the canine; (il) introducing thelaryngoscope laterally so avoiding the gap - but this maymake visualisation of the cord difficult; and (iil) using a long,preformed stylet and railroading the tube over it.As with any difficult intubation, awareness and anticipationof the problem and the planning of some precautionarymeasures can help avoid serious znishaps.REFERENCES1. Wright RE, Manfield FFV. Damage to teeth during the administration ofgene.-al anesthesia. Anesth Ana/g 1974; 53: 405-408.2. Harman M. Complications of tracheal intubation. In: Lano li', RoseD. M,eds. Difficulties in Tracheal Incubation. London: BailIiere Tindall, 1985:36-47. .3. Bureau for Information. South African Profile. Pretoria: PromediiPublications, 1986.4. Marais JS. The Cape Coloured People, 1652-1937. London: Longman Green,1939: 1-31.5. Louw NP, Moola MH. The dental needs and demands of the CapeColoured people in the Cape Peninsula. ] Dent Assoc S Afr 1979; 34:715-718.6. Van Rippen B. Practices and customs of the African natives involving dentalprocedures.] Allied Dent Soc 1918; 13: 1-22.7. Briedenham SJ, Van Reenen JF. Tooth extraction and tooth mutilatingpractices amongst the Herero-speaking peoples of South West Africa(Namibia).] Denr Assoc S Afr 1985; 40: 531-536.

Anaesthetic hazards of the 'passion gap' A case report

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Anaesthetic hazards of the 'passion gap' A case report

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