Prevention, management, and documentation of swallowed dental objects

BRIEF

REP ORTS

virus does not contain lip id and is rela­ tively stable at temperatures u p to 50 C .15 The thermal stability of the rhinovirus appears to be related to the presence of m agnesium chloride, a chemical required for the stability of the viral intercapsomeric b o n ds .15 The eventual loss of rhinovirus viability on the dental charts m ight be caused by the loss of the mag­ nesium chloride on drying of the viral in o c u lu m , thereby d e s ta b iliz in g the intercapsomeric bonds and denaturating the virus. The survival of Staph aureus and Strep pyogenes on dental charts was probably related to the effects of drying and to the nature of the diluent used. The results of the survival of Staph aureus and Strep pyogenes (Fig 3) showed that at 30 m in ­ utes after inoculation, both organisms in ­ creased in titer from the colony counts obtained at the time of inoculation. This result is most likely because the bacteria were in the growth phase as they were put into the RTF diluent, and subsequently had enough nutrients w ith in the cell to continue growth and replication for a short period. The drop in bacterial titer at 1 hour after inoculation to levels below that of the initial inoculum w ould in d i­ cate that the effects of drying and the lack of a nutrient source were taking effect. The survival of Strep pyogenes for up to 3 days compared w ith the greater than 5 days’ survival of Staph aureus was in d i­ cative of the fastidiousness and hardiness of each respective organism.

Summary This study indicated that when inocu­ lated onto dental charts, both viruses and bacteria were capable of survival allow ­ ing the potential for transmission of infec­ tion w ith in the dental office. The con­ scientious dental practitioner can take steps to reduce this possible mode of in ­ fection by removing contaminated surgi­ cal gloves or washing hands before han­ dling the chart. A n additional method of reducing this potential w o uld be to wipe the chart w ith an antiseptic solution. A l­ though this study has shown that there is a potential for the spread of infection w ith the organisms tested, the actual extent of dental chart contam ination and resultant illnesses contracted are the basis for further study. A d d itio n a l studies are needed to follow the pattern of chart dis­ tribution from person to person w ithin the dental office, determine the types and quantities of pathogens present in the m outh that w ould contaminate the charts, and sample the charts under actual c lin i­ cal conditions to determine the types and viability of the organisms present.

___________________________

Mr. Thomas was a graduate student, department of microbiology, and is now a first-year dental student; Dr. Sydiskis is associate professor, department of m i­ crobiology; Dr. DeVore is professor, department of oral surgery; and Dr. Krywolap is professor, depart­ ment of microbiology, University of Maryland Dental School, Baltimore, 21201. Address request for re­ prints to Dr. Sydiskis. 1. Codino, R.C., and Marshall, W.E. Control of in ­

fection in the dental operatory. Dent Surv 42-50, 1976. 2. Bureau of Economic Research and Statistics. Mortality of dentists, 1961-1966. JADA 76(4):831834, 1968. 3. Jackson, J.J., and Crawford, J.J. Principles of ster­ ilization and disinfection. In McGhee, J.R.; Michalek, S.M.; and Cassell, G.H., eds. Dental microbiology. Philadelphia, Harper and Row Publishers, Inc, 1982, p p 171-188. 4. Miller, R.L.; Burton, W.E.; and Spore, R.W. Aerosols produced by dental instrumentation. Proc First International Symp Aerobiol, 1963, pp 97-120. 5. Hausler, W.J., and Madden, R.M. Microbiologic comparison of dental handpieces: aerosol decay and dispersion. J Dent Res 45:52-58, 1966. 6. Brown, R.V. Bacterial aerosols generated by ultra high-speed cutting instruments. J Dent Child 32:112-117, 1965. 7. Larato, D.C., and others. Effect of a dental air turbine drill on the bacterial counts in air. J Prosthet Dent 16:758-765, 1966. 8. White, S.C., and Glaze, S. Interpatient micro­ biological cross-infection after dental radiographic examination. JADA 96(4):801-804, 1978. 9. Allen, A.L., and Organ, R.J. Occult blood ac­ cumulation under the fingernails: a mechanism for the spread of blood-borne infection. JADA 105(3): 455-459, 1982. 10. Pattison, C.P., and others. Epidemic hepatitis B in a clinical laboratory. JAMA 230:854-857, 1974. 11. Whitacre, R.J., and others. Dental asepsis. Seat­ tle, WA, Stoma Press, 1979, pp 13-26. 12. Tenovuo, J., and Anttonen, T. Application of a dehydrated test strip Hemastix, for the assessment of gingivitis. J Clin Periodontol 5:206-212, 1978. 13. Turner, R., and others. Shedding and survival of herpes simplex virus from “fever blisters.” Pediat­ rics 70:547-549, 1982. 14. Nerurkar, L.S., and others. Survival of herpes simplex virus in water specimens collected from hot tubs in spa facilities and on plastic surfaces. JAMA 250:3081-3083, 1983. 15. Dulbecco, R., and Ginsberg, H.S. Picornaviruses. In Davis, B.D., and others, eds. Microbiol­ ogy, ed 3. Hagerstown, MD, Harper and Row Pub­ lishers, Inc, 1980, pp 1086-1117.

Prevention, management, and docum entation of swallowed dental objects Stuart L. Fischman,

DMD

foreign material entering the pharynx and swallowed by the patient either w ill enter the esophagus or be expelled through

coughing. The clinician should be aware of a protocol for the prevention and management of swallowed dental objects.

N.

o matter how careful the dental practitioner m ight be, there exists poten­ tial for objects to fall into the posterior portion of the pharynx during dental treatment .1'3 D uring the course of any clinical or hospital practice, a number of dental objects w ill be recovered from pa­ tients. Such objects include metallic cast­ ings (either crowns or inlays), rubber dam clamps, posts and cores, and prophylaxis Fig 1 ■ Swallowed crown located in lower right polishing cups (Fig 1, 2). In most cases, quadrant. 464 ■ JADA, Vol. I l l , September 1985

Swallowed post located in lower right quad-

B R IE F

Fig 3 ■ Prevention guidelines. ■ Use of rubber dam ■ Use of ligature ■ Help of dental assistant ■ Attention to chair position ■ Use of throat pack: intravenous sedation or general anesthesia Fig 4 ■ Suggested protocol for swallowed den­ tal objects. ■ Advise patient of incident ■ Arrange for radiograph: inform radiologist of nature of object and take abdominal film and chest film, if needed. ■ Review findings with radiologist. ■ Consult physician, if necessary. ■ Await patient attempt to recover object. ■ Repeat film in 1 week, if object not recovered. ■ Consult gastroenterologist, if object still pres­ ent.

Prevention As it is in all dentistry, prevention should be the initial concern (Fig 3). Proper use of a rubber dam, when possible, is the major preventive measure to take to avoid the swallowing of dental objects. A prop­ erly placed rubber dam is not only an asset to the dental procedure, but also is an effective method of preventing the as­ piration or swallowing of dental mate­ rials. When a rubber dam is placed, a liga­ ture should be used on the rubber dam clamp to prevent aspiration or swallow­ ing of the clamp or dam, or both, during placement. An alert dental assistant is also impor­ tant in preventing accidents of this type. The dental assistant frequently can re­ trieve material from the oropharynx by prompt use of the aspirator tip. The bene­ fit of four-handed dentistry cannot be overemphasized. For most dental procedures, the patient is placed in a supine or semisupine posi­ tion. The positions may actually facilitate the aspiration or swallowing of foreign objects, although making the primary dental procedure more satisfactory. Any time the patient’s reflexes are al­ tered, either by intravenous sedation or general anesthesia, the use of an oral or throat pack is essential. Proper use of the foregoing measures should prevent the swallowing of foreign objects, according to findings reported by Barkmeier and others.4

Suggested protocol If, in spite of using the best preventive measures, an object is swallowed during a dental procedure, the following protocol is suggested (Fig 4). First, it is essential to determine whether the patient’s airway is compromised. Airway obstruction is usually seen when the patient is gasping

for breath with suprasternal retraction. Airway obstruction is a clinical emer­ gency requiring immediate attention. The subject of airway obstruction has been thoroughly reviewed in recent textbooks.5,6 If the airway is not compromised, the dentist should determine whether the ob­ ject was swallowed. An object may be “lost” in the mouth, and the patient may believe that it was swallowed. A careful search should be made of the patient’s clothing, the dental napkin, the cuspidor or aspirator containers, and the im­ mediate vicinity of the dental chair to de­ termine whether the object is outside of the patient’s mouth. Once it has been de­ termined that no acute airway obstruction exists, the search can be done in a careful and systematic way. If the object is not recovered in the search, it should be assumed that the pa­ tient has swallowed the object. The pa­ tient should, of course, be told. Informing the patient of this complication of dental treatment is not, and should not be inter­ preted as, an admission of liability or neg­ ligence. Failure to tell the patient may, however, be so interpreted. After advising the patient, arrange­ ments should be made for a medical ra­ diograph to be performed. This is most conveniently done at the radiologist’s of­ fice or at a hospital emergency room/ radiology facility. The dentist should speak with the attending radiologist to inform him or her of the time and nature of the suspected swallowing, as well as what material—metallic casting, rubber dam clamp, or fragment(s) of other material—should be sought in the ra­ diograph. The radiologist should be re­ quested to take an abdominal film to try to locate the material in the gastrointestinal tract. By the time the patient reaches the medical emergency room, the object is generally visible in the stomach or intes­ tine. If the object is not seen in the abdom­ inal film, a chest film should be taken to make certain that the material has not en­ tered the airway. In some cases, addi­ tional views may be requested by the ra­ diologist and, rarely, the object is not lo­ cated. If the object is not found, it must be assumed that it was never swallowed. The dentist should review the ra­ diographic findings with the radiologist, making appropriate notations on the pa­ tient’s dental record. A written report from the radiologist should be requested and added to the patient’s record. Consul­ tation with a physician, either the pa­ tient’s family physician or a gastro­ enterologist, may be sought. If the patient has a history of diverticulitis, ulcerative colitis, or other gastrointestinal abnor­ malities, consultation is in order. If the object is located in the gastro­ intestinal tract, the patient should be ad­

REP ORTS

vised to attempt recovery of the object. Normally, the material can be expected to pass in the stool within three days. If the patient is able to recover the object, it should be given to the dentist as “evi­ dence.” Should the object not be recovered within a week, a repeat abdominal film is recommended to determine whether the material passed unobserved in the pa­ tient’s stool. If the object is not seen in the gastrointestinal tract on the second film, the comment from the radiologist again should be recorded on the patient’s dental chart. If the object is still present on the film, consultation with a gastro­ enterologist is strongly recommended. Further management should be under medical supervision. This protocol has been presented to the dental students, residents, and faculty as­ sociated with the School of Dentistry of the State University of New York at Buf­ falo. The protocol has been satisfactorily followed for several years. When an ob­ ject is swallowed in the clinics at the school of dentistry, a member of the den­ tal staff at one of the teaching hospitals is informed and a dental resident meets the patient at the emergency room. The den­ tal resident expedites the patient’s treat­ ment in the emergency room and ra­ diology clinic. The verbal and written re­ ports of the radiologist are added to the patient’s emergency room record and the formal report is sent to both the dental school and dental service of the hospital. Repeat visits and procedures are similarly documented. It is hoped that the protocol suggested here will help dentists manage the com­ plication of clinical practice that occurs when a dental object is swallowed. The key concerns for the dental practitioner to remember are: prevention, management, and documentation. __________ !______________________ J K O A Dr. Fischman is director of dentistry, Erie County Medical Center, and professor of oral medicine, forensic dentistry unit, department of oral medicine, School of Dentistry, State University of New York, Buffalo, NY 14214. Address requests for reprints to the author. 1. Chipps, J. The dentist’s role in the management of foreign bodies. Dent Clin North A m 1:391-404, 1957. 2. Goultschin, J., and Heling, B. Accidental swal­ lowing of an endodontic instrument. Oral Surg 32:621-622, 1971. 3. Scott, A., and Dooley, B. Displaced post and core in epyglottic vallecula. J Gen Dent 26{l):26-27,1978. 4. Barkmeier, W.; Cooley, R.; and Abrams, H. Pre­ vention of swallowing or aspiration of foreign objects. JADA 97(3):473-476, 1978. 5. Korchin, L. Establishing an emergency airway. In McCarthy, F.M.,ed. Emergencies in dental prac­ tice. Philadelphia, W. B. Saunders & Co, 1979, pp 481-490. 6. Malamed, S. Handbook of medical emergencies in the dental office, ed 2, C. V. Mosby Co, St. Louis, 1982, pp 125-147.

Fischman : SWALLOWED DENTAL OBJECTS ■ 465