Foreign body ingestion and aspiration

Vol. 88 No. 6 December 1999

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY MEDICAL MANAGEMENT UPDATE

Editor: James R. Hupp

Foreign body ingestion and aspiration N.U. Zitzmann, Dr med dent,a S. Elsasser, Dr med,b R. Fried, Dr med,c and C.P. Marinello, Dr med dent, MS,d Basel, Switzerland UNIVERSITY OF BASEL

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:657-60)

The ingestion or aspiration of instruments or materials used in treatment can occur in every field of the dental profession. Foreign bodies vary in size and shape and range from endodontic instruments, burs, posts, root copings, teeth, orthodontic brackets, and impression materials to temporaries, implant components, and restorations.1,2 Some objects are made of materials that lack radiopacity, which makes it impossible to identify their position; diagnostic bronchoscopy or computed tomography for localization is then required.3,4 In endodontics, it is possible to minimize the risk of inhalation or ingestion of root canal instruments by using a rubber dam on a routine basis. However, there are situations in which the use of a rubber dam may not be feasible. For implant treatment, the main precaution is to tether any screwdriver that has a small hole in its handle for this purpose; however, such tethering is not possible with other components.

PATIENT-RELATED FACTORS It has been reported that the patients who most often swallow foreign bodies form select groups; these groups include prisoners, psychotic individuals, people with alcoholism, the senile, mentally retarded individuals, patients who are nervous or restless, and patients with an excessive gag reflex (Table I).1,5 A relationship aAssistant Professor, Clinic of Fixed and Removable Prosthodontics and TMJ Disorders. bAssistant Professor, Department of Internal Medicine, Medical ICU. cAssistant Professor, Department of Internal Medicine, Division of Gastroenterology. dProfessor and Chairman, Clinic of Fixed and Removable Prosthodontics and TMJ Disorders. Received for publication Aug 5, 1999; accepted for publication Aug 6, 1999. Copyright © 1999 by Mosby, Inc. 1079-2104/99/$8.00 + 0 7/13/102157

Table I. Predisposing factors to be checked with medical questionnaire, patient’s medical history, and during examination Is on medication and/or has used a sedative Abuses alcohol and/or drugs Is serving a long-term prison sentence Is psychotic Is senile Is mentally retarded Has experienced a traumatic loss of consciousness (eg, during an accident13) Has a hiatal hernia and symptoms of reflux esophagitis Is pregnant and/or overweight, with increased intra-abdominal pressure Is barrel-chested or obese, with difficult access sites Is nervous and/or restless and may move unexpectedly Has hyperactive gag-reflexes Has limited mouth opening, a small oral cavity, or macroglossia Wears complete dentures

between foreign body ingestion and the wearing of complete dentures has been reported and ascribed to the reduced tactile sensitivity of the palatal mucosa.6 In addition, patients with difficult access sites secondary to anatomical restrictions (eg, small oral cavity, short palate, macroglossia, large neck) and patients who are barrel-chested and obese are at greater risk of ingesting or inhaling foreign bodies. The deglutition reflex can be affected in patients with hiatal hernia and symptoms of chronic peptic esophagitis. When there is increased intra-abdominal pressure, as in overweight patients and pregnant women, dysphagy may also be present, especially in a reclined position.1 Inhalation of foreign bodies tends to occur more often in patients with impaired central nervous system functions. This can be influenced by medication with sedatives, tranquilizers, opiates, or depressants. In the light 657

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Table II. Precautionary measures to prevent aspiration or ingestion of foreign bodies 1. Related to patient Identify high-risk patient Consider (1) treatment with patient under general anesthesia or (2) alternative treatment options Use gauze screen to protect oropharynx in sedated or conscious patient Treat patient with swallowing or coughing problem in upright position 2. Related to specific dental treatment 2.1. Endodontics and operative dentistry Use rubber dam for root canal treatment and post-cementation Check post-retention when impressions are made for indirect post and cores Remove amalgam fillings with rubber dam in place Use rubber dam for adhesive cementation of porcelain inlays 2.2. Fixed prosthodontics When porcelain-fused-to-metal restorations are removed with chisel, ceramic chips are immediately collected by dental assistant, keeping suction close to abutment Check fixation of restorations placed with nonpermanent cement Use custom impression tray to minimize amount of impression material required and leave palate open 2.3. Removable prosthodontics Check retention of removable appliances Take extra care during placement of small root copings Seal off oropharynx when relining posterior prostheses base with self-curing acrylic resin 2.4. Oral surgery and implantology Consider gauze partition during extractions (eg, multiple extractions of deciduous teeth with patient under nitrous oxide) Use dental floss to tether screwdriver Place gold screws in screw access holes of restoration and seal with gel for protection (extraorally)

of this, it is always important to carefully review the patient’s medical history during the initial appointment and perform a comprehensive physical examination.

PREVENTIVE PRECAUTIONS Preventive steps include using a rubber dam whenever possible, tethering any small instrument with a ligature, and placing a gauze screen across the oropharynx of the conscious or sedated patient (Table II). Patients in whom the coordination of the deglutition and cough reflexes are affected or the intraabdominal pressure is increased should be treated in a more upright position. The practitioner must ensure that temporary restorations are adequately fixed and that removable appliances are sufficiently retained. When screw-retained implant restorations are being placed, it is advisable to put the small gold screws into the screw access holes extraorally and seal them with vaseline or a gel; the restoration or the bar is then carefully placed and screwed onto the abutments. Because it is necessary to retighten the screws after a period of 10 to 14 days, the access openings are temporarily closed with white gutta-percha. CLINICAL MANAGEMENT OF FOREIGN BODY INGESTION OR ASPIRATION When a foreign body drops into the oropharynx, the patient should be positioned with his/her head reclined in reverse Trendelenburg position (in which the upper part of the body is raised 20 to 30 degrees) and asked to cough

(Fig 1). Symptoms such as choking, labored breathing and using the accessory musculature to aid respiration, asymmetric air movement on inspiration and expiration, inspiratory stridor, and croupy respiration on auscultation are indicators of laryngeal obstruction, and attempts must be made instantly to avoid respiratory arrest. If coughing fails to relieve the obstruction, the Heimlich maneuver should be performed.7 If this is not rapidly successful, the patient should be transferred immediately to the nearest emergency room. If the patient is asymptomatic, he or she should be reassured and informed calmly about the complication and the necessity of immediate medical examination. Frontal and lateral chest and abdominal roentgenograms should reveal whether the object has been swallowed or inhaled. Deciding whether removal of an ingested foreign body is necessary depends on the object’s type and location.8 Sharp, pointed, and elongated objects may fail to pass the fixed curves of the duodenum, and their ingestion may result in impaction or perforation. Early attempts should be made to remove them before the small intestine is reached. Elongated objects longer than 10 cm (6 cm in children) should also be removed. Blunt or rounded objects larger than approximately 2.5 cm in diameter will fail to pass the pylorus and will need to be removed by gastroscopy. If the foreign body has entered the gastrointestinal tract, attempts may be made to recover the object by esophagoscopy. Flexible endoscopy is the procedure of choice for extracting such objects.8 Once they have

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Fig 1. Appropriate behavior in cases in which foreign body aspiration or ingestion is suspected.

traversed the esophagus, most objects usually clear the rest of the gastrointestinal tract successfully, a process that takes several days to several weeks. Radiographic monitoring of the progress of such an object is advised. In the meantime, the patient will have to screen his or her stools and try to identify the foreign body. Use of a high-bulk diet may be helpful; however, there is no scientific evidence of the benefit of any special diet to

support such objects’ passage. Purgatives should be avoided because they increase the effect of the peristaltic contraction and thus make intestinal perforation more likely. If an object becomes impacted within the mucosal folds of the intestinal tract, rectoscopy, colonoscopy, or a surgical intervention may be necessary, depending on the object’s location. Areas of physiologic or pathologic narrowing, such as the pylorus,

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the ligament of Treitz, the ileocecal valve, the rectosigmoid junction, and the anus, are potential sites of impaction.6,8,9 Open abdominal surgery is also indicated if there is evidence of hemorrhage, intestinal obstruction, or perforation. In cases of perforation, a pneumoperitoneum can be seen on the roentgenogram; this indicates the location of the perforation.6,9 Accidental inhalation of dental appliances can be an even more serious event than ingestion and must always be treated as an emergency situation. Early complications of foreign body aspiration include acute dyspnea, asphyxia, cardiac arrest, and laryngeal edema. Thin, pointed instruments increase the risk of perforation and pneumothorax. Bronchoscopy is the treatment of choice for removal of the foreign body.10,11 If it is impossible to remove the foreign body by flexible bronchoscopy, rigid bronchoscopy is used as an appropriate alternative treatment option, but this requires the administration of general anesthesia. The advantages of rigid bronchoscopy include a larger working channel and better visualization of the central bronchial tree, but foreign bodies located more distally are out of reach. Whenever possible, the size and contour of the foreign body should be checked preoperatively with the pulmonologist so that the appropriate grasper tip can be selected. A small object may reach the subsegmental bronchus and require an extremely narrow bronchoscope (3.8 mm in diameter). If a radiographically visible object is lodged in the very small bronchi close to lung parenchyma, fluoroscopic guidance can be used for the removal with flexible bronchofiberscopy. It has been shown that in cases of foreign body aspiration, a delayed removal beyond 24 hours may be associated with increased morbidity and a longer hospital stay.1,12 Intense mucosal inflammation followed by mucosal edema around the foreign body then makes it difficult to manipulate the bronchoscope. Moreover, inflamed mucosa tends to bleed easily on instrumentation. Chronic retention of foreign bodies may cause even more technical difficulties during bronchoscopy because the formation of granulation tissue and inflammatory polyps around the foreign body may obstruct the bronchus.

importance. This applies to the identification of at-risk patients by means of comprehensive clinical examination and thorough patient history-taking. It also applies to the taking of preventive steps by all practitioners during treatment and to the management of patients in emergency situations. Sending a patient home in the belief that a foreign body that disappeared into the oropharynx has been swallowed and will pass through the gut is problematic. Should a foreign body be ingested, the patient must be examined clinically and radiographically, diagnosis must be performed immediately by a specialist, and the appropriate potentially life-saving treatment must be given.

CONCLUSION It must be emphasized that preventing complications of foreign body ingestion and aspiration is of great

REFERENCES 1. Prakash UBS, Cortese DA. Tracheobronchial foreign bodies. In: Prakash UBS. Bronchoscopy. 2nd ed. New York: Raven Press; 1994. p. 253-77. 2. Cameron SM, Whitlock WL, Tabor MS. Foreign body aspiration in dentistry: a review. J Am Dent Assoc 1996;127:1224-9. 3. Knowles JE. Inhalation of dental plates: a hazard of radiolucent materials. J Laryngol Otol 1991;105:681-2. 4. Ong TK, Lancer JM, Brook IM. Inhalation of a denture fragment complicating facial trauma. Br J Oral Maxillofac Surg 1988;26:511-3. 5. Worthington P. Ingested foreign body associated with oral implant treatment: report of a case. Int J Oral Maxillofac Implants 1996;11:679-81. 6. Maleki M, Evans WE. Foreign-body perforation of the intestinal tract. Arch Surg 1970;101:475-7. 7. Heimlich HJ. The Heimlich maneuver: prevention of death from choking on foreign bodies. J Occup Med 1977;19:208-10. 8. Brady PG. Management of esophageal and gastric foreign bodies. Gastrointest Endosc 1995;42:622-5. 9. Macmanus JE. Perforations of the intestine by ingested foreign bodies. Am J Surg 1941;53:393-402. 10. Lai YF, Wong SL, Chao TY, Lin AS. Bronchial foreign bodies in adults. J Formos Med Assoc 1996;95:213-7. 11. Donado Uña JR, de Miguel Poch E, Casado Lopez ME, Alfaro Albreu JJ. Tracheobronchial foreign body extraction with fiberoptic bronchoscopy in adults. Arch Bronconeumol 1998;34:76-81. 12. Bergermann M, Donald PJ, à Wengen DF. Screwdriver aspiration: a complication of dental implant placement. Int J Oral Maxillofac Surg 1992;21:339-41. 13. Kullbom TL, Adwers J. Unusal complication associated with severe maxillofacial trauma. Oral Surg Oral Med Oral Pathol 1974;37:355-8.

Reprint requests: Nicola U. Zitzmann, Dr med dent Department of Prosthodontics, Dental School Hebelstrasse 3 CH-4056 Basel Switzerland