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Swallowed and aspirated dental prostheses and instruments in clinical dental practice
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Swallowed and aspirated dental prostheses and instruments in clinical dental practice: A report of five cases and a proposed management algorithm Mazen Abusamaan, William V. Giannobile, Preeti Jhawar and Naresh T. Gunaratnam JADA 2014;145(5):459-463 10.14219/jada.2013.55 The following resources related to this article are available online at jada.ada.org (this information is current as of June 29, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/5/459
This article cites 26 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/5/459/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
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ORIGINAL CONTRIBUTIONS
Swallowed and aspirated dental prostheses and instruments in clinical dental practice A report of five cases and a proposed management algorithm Mazen Abusamaan, MD; William V. Giannobile, DDS, MS, DMSc; Preeti Jhawar, DO; Naresh T. Gunaratnam, MD
A
ccidental swallowing or aspiration of dental prostheses and instruments can occur during dental procedures or as a result of dislodgement of the prostheses. Complications arising from aspirated or ingested prostheses and instruments include bowel perforation, abscesses or fistula formation, obstruction, respiratory compromise and death. Most dentists recommend conservative treatment if the patient is asymptomatic; however, this approach may not be prudent in all cases. We present five cases of aspiration or ingestion of a dental prosthesis or an instrument. Although the literature contains general guidelines for managing aspirated or ingested foreign bodies, clear guidelines are lacking for dental instruments. In this report, we propose a management algorithm targeted toward dental practice.
case reports
Case 1. A 47-year-old woman swallowed a dental implant screwdriver during a dental procedure. The dentist had not used a floss tie on the end of the instrument. Her dentist reassured her that the instrument likely would pass in her stool and made no efforts to retrieve the instrument.
abstract Background. Accidental swallowing or aspiration of dental instruments and prostheses is a complication of dental procedures. Failure to manage these complications appropriately can lead to significant morbidity and possibly death. Case Descriptions. The authors present three cases of accidental swallowing of dental instruments during procedures and two cases of aspiration, one during a procedure and one long after the procedure. Although three of these five cases of foreign-body aspiration or ingestion were caught early and the patients were referred for endoscopic retrieval, two patients experienced prolonged symptoms that affected their quality of life before intervention occurred. Practical Implications. The authors reviewed the literature and propose an evidence-based algorithm for management of such complications. Adherence to the proposed algorithm may decrease morbidity and mortality and improve patient outcomes. Key Words. Accidental; ingestion; aspiration; endoscopy; algorithm; dental instrument; prosthesis. JADA 2014;145(5):459-463. doi:10.14219/jada.2013.55
Dr. Abusamaan is a resident, Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. Dr. Giannobile is the Najjar Endowed Professor of Dentistry and Biomedical Engineering, School of Dentistry and College of Engineering, and the chair, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor. Dr. Jhawar is a fellow in gastroenterology, Botsford Hospital, Farmington Hills, Mich. Dr. Gunaratnam is the director of research, Huron Gastroenterology, 5300 Elliott Dr., Ypsilanti, Mich. 48197, e-mail [email protected]. Address correspondence to Dr. Gunaratnam.
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ORIGINAL CONTRIBUTIONS
Figure 1. Abdominal radiograph reveals a dental implant screwdriver impacted in the right lower quadrant.
Figure 2. Dental implant screwdriver visualized and retrieved from the ileocecal valve during a colonoscopy.
impacted at the ileocecal valve and was removed during a colonoscopy (Figure 2). To date, the patient has remained symptom free two years after the procedure. Case 2. A 64-year-old man swallowed an endodontic file during root canal therapy. His dentist referred the patient to a hospital emergency department; an abdominal radiograph confirmed the presence of the file in his stomach. One of us (P.J.) performed an esophagogastroduodenoscopy (EGD) and removed the instrument without complications. Case 3. A 54-year-old man visited his primary care physician’s office because of a four-month history of coughing and wheezing. A chest radiograph revealed a focal consolidation in the right lung base. The physician prescribed antibiotics and a bronchodilator, with minimal improvement. He referred the patient to a pulmonologist one month later; on inquiry, the patient revealed that he had lost his crown four months before visiting his primary care physician. Chest computed tomography (CT) showed calcification at the bronchus intermedius. The pulmonologist retrieved the crown from the right middle bronchus via a bronchoscopy by means of a birdcage retractor. The patient did not experience any complications. Case 4. A dentist referred a 75-year-old patient to a pulmonologist after he aspirated a portion of a restorative crown during a dental procedure. The patient underwent evaluation in the emergency department, and a chest radiograph showed a foreign body in the right distal mainstem bronchus. The pulmonologist extracted the foreign body from the right distal lower lobe airway by means of bronchoscopy, without complications. Case 5. An 85-year-old man swallowed an endodontic file while undergoing endodontic treatment. The dentist referred the patient to a gastroenterologist after a flatplate radiograph obtained the next morning showed a foreign body in the region of the gastric antrum (Figure 3). An EGD revealed the file—which measured about 2.4 centimeters—in the stomach, and the gastroenterologist retrieved it without difficulty. Discussion
Figure 3. Abdominal radiograph demonstrating an endodontic file in the stomach.
Two months later, the patient developed pain in the right lower quadrant and was referred for further evaluation. An abdominal radiograph confirmed the presence of the instrument in the right lower quadrant (Figure 1). It was
The cases described above illustrate a variety of presentations of aspirated or ingested dental instruments or prostheses. Treatment in each case varied and ranged from emergent endoscopic interventions to conservative follow-up. All of the ingested or aspirated objects posed a high risk of causing serious complications. The case of the patient who ingested the dental implant screwdriver was not managed appropriately, and she was at a high risk of experiencing bowel perforation and sepsis and of dying. The literature contains more than 100 cases of ingested and aspirated foreign bodies. Eighty percent of these objects were swallowed, and the remaining 20 percent ABBREVIATION KEY. CT: Computed tomography. EGD: Esophagogastroduodenoscopy.
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ORIGINAL CONTRIBUTIONS
TABLE
Preventive approaches to reduce the risk of aspirating or swallowing dental instruments and materials. ASPIRATION OR SWALLOWING RISK
PREVENTIVE MEASURE
High- and Slow-Speed Dental Handpieces, Scalpel Blades, Larger Instruments
Develop systematic approach to confirm that connections are secure to avoid release of prophylaxis angles, blades or similar instruments
Dental Restorative Materials (Such as Amalgam, Crowns)
Use rubber dams when possible; in cases of bridgework, use throat packs, at a minimum, for all cementation and try-in procedures
Tooth Extraction
Use throat packs in all cases; position the patient to reduce the risk of aspirating extracted teeth or tooth roots
Endodontic Files and Related Instruments
Use rubber dams when at all possible; use throat packs when rubber dam placement is not feasible
Dental Implants
Use throat packs during implant installation and osteotomy creation; attach floss to screwdrivers for retrieval if dropped into the oral cavity
were aspirated.1,2 Most cases of foreign-body ingestion are reported in the pediatric population. In adults, those with psychiatric disorders, mental retardation and alcoholism, as well as those seeking secondary gain and those who have undergone recent dental procedures, are at an increased risk.3 Our review of case reports regarding an aspirated or ingested dental instrument indicates a steady increase in the use of endoscopy for successful retrieval. In addition, a literature review revealed several cases of aspirated or ingested foreign bodies: a patient who underwent an elective laparoscopic appendectomy for removal of a dental bur impacted in the appendix after unsuccessful endoscopic retrieval4; a patient who died of acute aortic bleeding due to esophageal penetration of the prosthesis into the aortic arch5; and a 23-year-old man with a lump in his throat who was treated for a thyroid condition for more than one year until a plain radiograph confirmed the impaction of a dental prosthesis.6 Aspiration. An aspirated foreign body is a medical emergency that requires immediate intervention. A dislodged dental prosthesis in the throat should be removed immediately by means of suction or a forceps. If that fails and the clinician has confirmed the foreign-body aspiration, he or she must consult immediately with a physician for urgent bronchoscopy. Retrieval can be achieved by means of a suctioning device attached to the bronchoscope or instruments used to grasp the object.7 Multidisciplinary approaches may be necessary, with the use of intubation and rigid bronchoscopy in more difficult cases (such as a foreign body in the distal airway) to avoid a thoracotomy.8,9 Perforation. Foreign bodies that are swallowed usually are discovered after a complication occurs.10 In a prospective study of 33 patients treated surgically for intestinal perforation secondary to foreign-body ingestion, the authors reported that the most frequent predisposing factors (73 percent) were dentures or an orthodontic appliance.11 Although perforation is the most feared complication of ingested foreign bodies, reported rates of perforation are less than 1 percent,12 and it tends to occur
more often with sharp objects. We define sharp objects as those having any edge or point that is able to pierce an organ. Once the foreign body passes the ligament of Treitz, the risk of complications increases. The risk of perforation can be as high as 35 percent if the sharp object reaches the ileocecal valve.13 Risk factors that increase the likelihood of perforation include impaction of the foreign body in areas of acute angulation or physiological narrowing in the gastrointestinal tract, such as the upper and lower esophageal sphincter, pylorus, duodenum, ileocecal valve, appendix, hepatic and splenic flexures of the colon, sigmoid colon and anus. Diseases and disorders such as esophageal dysmotility, esophageal webs or strictures, bowel adhesions, inflammatory bowel disease, tumors, diverticula, hernia and blind bowel loops also can increase the risk of serious complications.14 Other reported complications include ulcer, abscess, fistula formation and obstruction.10,15,16 Migration of the swallowed foreign body to the pleura, heart, kidney or liver also has been reported.17 Ingestion. Management of ingested dental objects depends on the nature of the object, the anatomical location of the object and the patient’s clinical condition. An impacted sharp esophageal object constitutes a medical emergency that requires referral for emergent endoscopic retrieval. Surgery, such as a cervical esophagectomy, may be required if endoscopic retrieval fails and the patient develops fever, abdominal pain, vomiting, hematemesis or melena, or if the object does not advance within three days.5,13,18,19 Endoscopy is preferred to surgery because it is less invasive, safer (complication rates of less than 1 percent) and less expensive, and it can be performed without hospitalization. Clinicians also should refer patients for urgent endoscopic retrieval in cases involving an impacted blunt esophageal object. Localization of an impacted foreign body by means of radiography is important before endoscopic extraction to enable the clinician to determine the type of endoscopic approach.20 Contrast radiography or CT may be required to localize radiolucent objects such as toothpicks and many dental prostheses such as those JADA 145(5) http://jada.ada.org May 2014 461
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ORIGINAL CONTRIBUTIONS
Lost dental instrument, prosthesis or dental material
Obtain chest radiograph, abdominal radiograph or both
Aspirated object Perform urgent bronchoscopy
Ingested object
Blunt object with regular edges and < 2.5-cm diameter and < 6-cm length
Sharp object or > 2.5-cm diameter or > 6-cm length
If object has not passed within seven days or patient becomes symptomatic, confirm with imaging and refer patient for endoscopic removal
Refer patient immediately for endoscopic removal—ideally within four hours—while object still is in the stomach
Figure 4. Proposed algorithm for managing aspirated or ingested dental instruments, prostheses or dental materials. cm: Centimeter.
made of acrylic and composite materials.21-24 Dentists should consider using radiopaque materials to improve localization.14 When a sharp object is identified in the stomach, an immediate EGD is recommended25—ideally within four hours. This allows the endoscopist to retrieve the object from the stomach, which is the easiest area from which to remove foreign bodies endoscopically. Once the foreign body passes the ligament of Treitz, retrieval can be difficult and the risk of complications increases. As illustrated in the first case presented earlier, failure to remove a dental implant screwdriver soon after ingestion can result in abdominal pain. This patient also was at high risk of experiencing bowel perforation because the sharp object was impacted in a thin portion of the bowel. Monitoring. Conservative monitoring is appropriate if the patient ingested a dental object that is not sharp or irregularly shaped, is less than 2.5 cm in diameter and is less than 6 cm in length.20,26 Confirmatory radiographic documentation of passage is mandatory when using a conservative approach. During the period of watchful waiting, the patient should eat a high-fiber diet, watch stool to confirm passage of the object and look for symp-
toms, such as fever, pain, black stool or bleeding, that can suggest ongoing complications.17 If passage of a blunt foreign object is not confirmed within seven days, or if the patient becomes symptomatic, the clinician should obtain an abdominal radiograph and refer the patient to a physician for endoscopic removal. Failure to address appropriately cases of swallowed or aspirated objects at high risk of causing complications also may pose a significant medical liability risk. Conclusions
To avoid complications during dental procedures, clinicians should take preventive measures such as using rubber dams and throat packs consistently (Table).27 They should refer all patients who have aspirated objects for emergent endoscopic retrieval. If a prosthesis or an instrument has been ingested, clinicians should consider early referral for endoscopic retrieval on the basis of the size and shape of the object. Conservative management of ingested objects can be considered if the object poses a low risk of causing complications. Follow-up is mandatory to confirm the passage of objects managed conservatively. In the event that preventive measures fail or were
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not practiced, following the proposed algorithm (Figure 4) may enhance patient safety in dental practices. n Disclosure. None of the authors reported any disclosures. 1. Koch H. Operative endoscopy. Gastrointest Endosc 1977;24(2):65-68. 2. Adewumi A, Kays DW. Stainless steel crown aspiration during sedation in pediatric dentistry. Pediatr Dent 2008;30(1):59-62. 3. Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc 1983;29(3):208-210. 4. Klingler PJ, Smith SL, Abendstein BJ, Brenner E, Hinder RA. Management of ingested foreign bodies within the appendix: a case report with review of the literature. Am J Gastroenterol 1997;92(12):2295-2298. 5. Taha AS, Nakshabendi I, Russell RI. Vocal cord paralysis and oesophago-broncho-aortic fistula complicating foreign body-induced oesophageal perforation. Postgrad Med J 1992;68(798):277-278. 6. Carson GB, Schneider LG. Lump in the throat. Oral Surg Oral Med Oral Pathol 1982;54(2):253. 7. Bunno M, Kawaguchi M, Yamahara K, Kanda C. Removal of a foreign body (artificial tooth) from the bronchial tree: a new method (published online ahead of print Oct. 1, 2008). Intern Med. doi:10.2169/ internalmedicine.47.1173. 8. Weber SM, Chesnutt MS, Barton R, Cohen JI. Extraction of dental crowns from the airway: a multidisciplinary approach. Laryngoscope 2005;115(4):687-689. 9. Pingarrón ML, Morán Soto MJ, Sánchez Burgos R, Burgueño García M. Bronchial impaction of an implant screwdriver after accidental aspiration: report of a case and revision of the literature. Oral Maxillofac Surg 2010;14(1):43-47. 10. Tsai CY, Hsu CC, Chuah SK, Chiu KW, Changchien CS. Endoscopic removal of a dental prosthesis in the hepatic flexure of the colon. Chang Gung Med J 2003;26(11):843-846. 11. Rodríguez-Hermosa JI, Codina-Cazador A, Sirvent JM, Martín A, Gironès J, Garsot E. Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies (published online ahead of print Nov. 12, 2007). Colorectal Dis. doi:10.1111/j.1463-1318.2007.01401.x. 12. Pavlidis TE, Marakis GN, Triantafyllou A, Psarras K, Kontoulis TM, Sakantamis AK. Management of ingested foreign bodies: how justifiable is a waiting policy? Surg Laparosc Endosc Percutan Tech 2008;18(3):286-287.
13. Eisen GM, Baron TH, Dominitz JA, et al; American Society for Gastrointestinal Endoscopy. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55(7):802-806. 14. Hacker JF 3rd, Cattau EL Jr. Management of gastrointestinal foreign bodies. Am Fam Physician 1986;34(2):101-108. 15. Rajesh PB, Goiti JJ. Late onset tracheo-oesophageal fistula following a swallowed dental plate. Eur J Cardiothorac Surg 1993;7(12):661-662. 16. Rashid F, Simpson J, Ananthakrishnan G, Tierney GM. Swallowed dental bridge causing ileal perforation: a case report. Cases J 2008;1(1):392. 17. Bloch DB. Venturesome toothpick: a continuing source of pyogenic hepatic abscess. JAMA 1984;252(6):797-798. 18. Imam SZ, Ikram M, Fatimi S, Iqbal M. Cervical esophagotomy for an impacted denture: a case report. Ear Nose Throat J 2009;88(3):833-834. 19. Moriwaki Y, Sugiyama M, Arata S, Toyoda H, Kosuge T, Suzuki N. Therapeutic strategy for removal of a large dental prosthesis with a sharp clasp, embedded in the esophagus. Endoscopy 2007;39(suppl 1):E303-E304. 20. Triadafilopoulos G. Ingested foreign bodies and food impactions in adults. www.uptodate.com/contents/ingested-foreign-bodies-and-foodimpactions-in-adults?source=search_result&search=esophagus+foreign+ bodies&selectedTitle=1 percent7E13. Accessed April 2, 2013. 21. Stiles BM, Wilson WH, Bridges MA, et al. Denture esophageal impaction refractory to endoscopic removal in a psychiatric patient. J Emerg Med 2000;18(3):323-326. 22. Absi EG, Buckley JG. The location and tracking of swallowed dental appliances: the role of radiology. Dentomaxillofac Radiol 1995;24(2): 139-142. 23. Rizzatti-Barbosa CM, Cunha FL, Bianchini WA, de AlbergariaBarbosa JR, Gomes BP. Accidental impaction of a unilateral removable partial denture: a clinical report. J Prosthet Dent 1999;82(3):270-271. 24. Hashmi S, Walter J, Smith W, Latis S. Swallowed partial dentures. J R Soc Med 2004;97(2):72-75. 25. Dhandapani RG, Kumar S, O’Donnell ME, McNaboe T, Cranley B, Blake G. Dental root canal treatment complicated by foreign body ingestion: a case report. Cases J 2009;2(1):117. 26. ASGE Standards of Practice Committee; Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastroint Endosc 2011;73(6):1085-1091. 27. Hill EE, Rubel B. A practical review of prevention and management of ingested/aspirated dental items. Gen Dent 2008;56(7):691-694.
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Swallowed and aspirated dental prostheses and instruments in clinical dental practice: A report of five cases and a proposed management algorithm Mazen Abusamaan, William V. Giannobile, Preeti Jhawar and Naresh T. Gunaratnam JADA 2014;145(5):459-463 10.14219/jada.2013.55 The following resources related to this article are available online at jada.ada.org (this information is current as of June 29, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/5/459
This article cites 26 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/5/459/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
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ORIGINAL CONTRIBUTIONS
Swallowed and aspirated dental prostheses and instruments in clinical dental practice A report of five cases and a proposed management algorithm Mazen Abusamaan, MD; William V. Giannobile, DDS, MS, DMSc; Preeti Jhawar, DO; Naresh T. Gunaratnam, MD
A
ccidental swallowing or aspiration of dental prostheses and instruments can occur during dental procedures or as a result of dislodgement of the prostheses. Complications arising from aspirated or ingested prostheses and instruments include bowel perforation, abscesses or fistula formation, obstruction, respiratory compromise and death. Most dentists recommend conservative treatment if the patient is asymptomatic; however, this approach may not be prudent in all cases. We present five cases of aspiration or ingestion of a dental prosthesis or an instrument. Although the literature contains general guidelines for managing aspirated or ingested foreign bodies, clear guidelines are lacking for dental instruments. In this report, we propose a management algorithm targeted toward dental practice.
case reports
Case 1. A 47-year-old woman swallowed a dental implant screwdriver during a dental procedure. The dentist had not used a floss tie on the end of the instrument. Her dentist reassured her that the instrument likely would pass in her stool and made no efforts to retrieve the instrument.
abstract Background. Accidental swallowing or aspiration of dental instruments and prostheses is a complication of dental procedures. Failure to manage these complications appropriately can lead to significant morbidity and possibly death. Case Descriptions. The authors present three cases of accidental swallowing of dental instruments during procedures and two cases of aspiration, one during a procedure and one long after the procedure. Although three of these five cases of foreign-body aspiration or ingestion were caught early and the patients were referred for endoscopic retrieval, two patients experienced prolonged symptoms that affected their quality of life before intervention occurred. Practical Implications. The authors reviewed the literature and propose an evidence-based algorithm for management of such complications. Adherence to the proposed algorithm may decrease morbidity and mortality and improve patient outcomes. Key Words. Accidental; ingestion; aspiration; endoscopy; algorithm; dental instrument; prosthesis. JADA 2014;145(5):459-463. doi:10.14219/jada.2013.55
Dr. Abusamaan is a resident, Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. Dr. Giannobile is the Najjar Endowed Professor of Dentistry and Biomedical Engineering, School of Dentistry and College of Engineering, and the chair, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor. Dr. Jhawar is a fellow in gastroenterology, Botsford Hospital, Farmington Hills, Mich. Dr. Gunaratnam is the director of research, Huron Gastroenterology, 5300 Elliott Dr., Ypsilanti, Mich. 48197, e-mail [email protected]. Address correspondence to Dr. Gunaratnam.
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Figure 1. Abdominal radiograph reveals a dental implant screwdriver impacted in the right lower quadrant.
Figure 2. Dental implant screwdriver visualized and retrieved from the ileocecal valve during a colonoscopy.
impacted at the ileocecal valve and was removed during a colonoscopy (Figure 2). To date, the patient has remained symptom free two years after the procedure. Case 2. A 64-year-old man swallowed an endodontic file during root canal therapy. His dentist referred the patient to a hospital emergency department; an abdominal radiograph confirmed the presence of the file in his stomach. One of us (P.J.) performed an esophagogastroduodenoscopy (EGD) and removed the instrument without complications. Case 3. A 54-year-old man visited his primary care physician’s office because of a four-month history of coughing and wheezing. A chest radiograph revealed a focal consolidation in the right lung base. The physician prescribed antibiotics and a bronchodilator, with minimal improvement. He referred the patient to a pulmonologist one month later; on inquiry, the patient revealed that he had lost his crown four months before visiting his primary care physician. Chest computed tomography (CT) showed calcification at the bronchus intermedius. The pulmonologist retrieved the crown from the right middle bronchus via a bronchoscopy by means of a birdcage retractor. The patient did not experience any complications. Case 4. A dentist referred a 75-year-old patient to a pulmonologist after he aspirated a portion of a restorative crown during a dental procedure. The patient underwent evaluation in the emergency department, and a chest radiograph showed a foreign body in the right distal mainstem bronchus. The pulmonologist extracted the foreign body from the right distal lower lobe airway by means of bronchoscopy, without complications. Case 5. An 85-year-old man swallowed an endodontic file while undergoing endodontic treatment. The dentist referred the patient to a gastroenterologist after a flatplate radiograph obtained the next morning showed a foreign body in the region of the gastric antrum (Figure 3). An EGD revealed the file—which measured about 2.4 centimeters—in the stomach, and the gastroenterologist retrieved it without difficulty. Discussion
Figure 3. Abdominal radiograph demonstrating an endodontic file in the stomach.
Two months later, the patient developed pain in the right lower quadrant and was referred for further evaluation. An abdominal radiograph confirmed the presence of the instrument in the right lower quadrant (Figure 1). It was
The cases described above illustrate a variety of presentations of aspirated or ingested dental instruments or prostheses. Treatment in each case varied and ranged from emergent endoscopic interventions to conservative follow-up. All of the ingested or aspirated objects posed a high risk of causing serious complications. The case of the patient who ingested the dental implant screwdriver was not managed appropriately, and she was at a high risk of experiencing bowel perforation and sepsis and of dying. The literature contains more than 100 cases of ingested and aspirated foreign bodies. Eighty percent of these objects were swallowed, and the remaining 20 percent ABBREVIATION KEY. CT: Computed tomography. EGD: Esophagogastroduodenoscopy.
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TABLE
Preventive approaches to reduce the risk of aspirating or swallowing dental instruments and materials. ASPIRATION OR SWALLOWING RISK
PREVENTIVE MEASURE
High- and Slow-Speed Dental Handpieces, Scalpel Blades, Larger Instruments
Develop systematic approach to confirm that connections are secure to avoid release of prophylaxis angles, blades or similar instruments
Dental Restorative Materials (Such as Amalgam, Crowns)
Use rubber dams when possible; in cases of bridgework, use throat packs, at a minimum, for all cementation and try-in procedures
Tooth Extraction
Use throat packs in all cases; position the patient to reduce the risk of aspirating extracted teeth or tooth roots
Endodontic Files and Related Instruments
Use rubber dams when at all possible; use throat packs when rubber dam placement is not feasible
Dental Implants
Use throat packs during implant installation and osteotomy creation; attach floss to screwdrivers for retrieval if dropped into the oral cavity
were aspirated.1,2 Most cases of foreign-body ingestion are reported in the pediatric population. In adults, those with psychiatric disorders, mental retardation and alcoholism, as well as those seeking secondary gain and those who have undergone recent dental procedures, are at an increased risk.3 Our review of case reports regarding an aspirated or ingested dental instrument indicates a steady increase in the use of endoscopy for successful retrieval. In addition, a literature review revealed several cases of aspirated or ingested foreign bodies: a patient who underwent an elective laparoscopic appendectomy for removal of a dental bur impacted in the appendix after unsuccessful endoscopic retrieval4; a patient who died of acute aortic bleeding due to esophageal penetration of the prosthesis into the aortic arch5; and a 23-year-old man with a lump in his throat who was treated for a thyroid condition for more than one year until a plain radiograph confirmed the impaction of a dental prosthesis.6 Aspiration. An aspirated foreign body is a medical emergency that requires immediate intervention. A dislodged dental prosthesis in the throat should be removed immediately by means of suction or a forceps. If that fails and the clinician has confirmed the foreign-body aspiration, he or she must consult immediately with a physician for urgent bronchoscopy. Retrieval can be achieved by means of a suctioning device attached to the bronchoscope or instruments used to grasp the object.7 Multidisciplinary approaches may be necessary, with the use of intubation and rigid bronchoscopy in more difficult cases (such as a foreign body in the distal airway) to avoid a thoracotomy.8,9 Perforation. Foreign bodies that are swallowed usually are discovered after a complication occurs.10 In a prospective study of 33 patients treated surgically for intestinal perforation secondary to foreign-body ingestion, the authors reported that the most frequent predisposing factors (73 percent) were dentures or an orthodontic appliance.11 Although perforation is the most feared complication of ingested foreign bodies, reported rates of perforation are less than 1 percent,12 and it tends to occur
more often with sharp objects. We define sharp objects as those having any edge or point that is able to pierce an organ. Once the foreign body passes the ligament of Treitz, the risk of complications increases. The risk of perforation can be as high as 35 percent if the sharp object reaches the ileocecal valve.13 Risk factors that increase the likelihood of perforation include impaction of the foreign body in areas of acute angulation or physiological narrowing in the gastrointestinal tract, such as the upper and lower esophageal sphincter, pylorus, duodenum, ileocecal valve, appendix, hepatic and splenic flexures of the colon, sigmoid colon and anus. Diseases and disorders such as esophageal dysmotility, esophageal webs or strictures, bowel adhesions, inflammatory bowel disease, tumors, diverticula, hernia and blind bowel loops also can increase the risk of serious complications.14 Other reported complications include ulcer, abscess, fistula formation and obstruction.10,15,16 Migration of the swallowed foreign body to the pleura, heart, kidney or liver also has been reported.17 Ingestion. Management of ingested dental objects depends on the nature of the object, the anatomical location of the object and the patient’s clinical condition. An impacted sharp esophageal object constitutes a medical emergency that requires referral for emergent endoscopic retrieval. Surgery, such as a cervical esophagectomy, may be required if endoscopic retrieval fails and the patient develops fever, abdominal pain, vomiting, hematemesis or melena, or if the object does not advance within three days.5,13,18,19 Endoscopy is preferred to surgery because it is less invasive, safer (complication rates of less than 1 percent) and less expensive, and it can be performed without hospitalization. Clinicians also should refer patients for urgent endoscopic retrieval in cases involving an impacted blunt esophageal object. Localization of an impacted foreign body by means of radiography is important before endoscopic extraction to enable the clinician to determine the type of endoscopic approach.20 Contrast radiography or CT may be required to localize radiolucent objects such as toothpicks and many dental prostheses such as those JADA 145(5) http://jada.ada.org May 2014 461
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ORIGINAL CONTRIBUTIONS
Lost dental instrument, prosthesis or dental material
Obtain chest radiograph, abdominal radiograph or both
Aspirated object Perform urgent bronchoscopy
Ingested object
Blunt object with regular edges and < 2.5-cm diameter and < 6-cm length
Sharp object or > 2.5-cm diameter or > 6-cm length
If object has not passed within seven days or patient becomes symptomatic, confirm with imaging and refer patient for endoscopic removal
Refer patient immediately for endoscopic removal—ideally within four hours—while object still is in the stomach
Figure 4. Proposed algorithm for managing aspirated or ingested dental instruments, prostheses or dental materials. cm: Centimeter.
made of acrylic and composite materials.21-24 Dentists should consider using radiopaque materials to improve localization.14 When a sharp object is identified in the stomach, an immediate EGD is recommended25—ideally within four hours. This allows the endoscopist to retrieve the object from the stomach, which is the easiest area from which to remove foreign bodies endoscopically. Once the foreign body passes the ligament of Treitz, retrieval can be difficult and the risk of complications increases. As illustrated in the first case presented earlier, failure to remove a dental implant screwdriver soon after ingestion can result in abdominal pain. This patient also was at high risk of experiencing bowel perforation because the sharp object was impacted in a thin portion of the bowel. Monitoring. Conservative monitoring is appropriate if the patient ingested a dental object that is not sharp or irregularly shaped, is less than 2.5 cm in diameter and is less than 6 cm in length.20,26 Confirmatory radiographic documentation of passage is mandatory when using a conservative approach. During the period of watchful waiting, the patient should eat a high-fiber diet, watch stool to confirm passage of the object and look for symp-
toms, such as fever, pain, black stool or bleeding, that can suggest ongoing complications.17 If passage of a blunt foreign object is not confirmed within seven days, or if the patient becomes symptomatic, the clinician should obtain an abdominal radiograph and refer the patient to a physician for endoscopic removal. Failure to address appropriately cases of swallowed or aspirated objects at high risk of causing complications also may pose a significant medical liability risk. Conclusions
To avoid complications during dental procedures, clinicians should take preventive measures such as using rubber dams and throat packs consistently (Table).27 They should refer all patients who have aspirated objects for emergent endoscopic retrieval. If a prosthesis or an instrument has been ingested, clinicians should consider early referral for endoscopic retrieval on the basis of the size and shape of the object. Conservative management of ingested objects can be considered if the object poses a low risk of causing complications. Follow-up is mandatory to confirm the passage of objects managed conservatively. In the event that preventive measures fail or were
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ORIGINAL CONTRIBUTIONS
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