Download In the United States, around 1500 people die yearly

A) Proposed Generic Heading:
Accidents & Emergencies : Review article & case reports.
B) Title:
FOREIGN BODY INGESTION AND ASPIRATION IN DENTISTRY: A REVIEW OF THE
LITERATURE AND REPORTS OF THREE CASES.
C)Authors:
*Ahed Al-Wahadni BDS, MDSc, PhD
Associate Professor, Dean, Faculty of Applied Medical Sciences.
Jordan University of Science & Technology
*Khaled Q Al Hamad BDS, MSc, MRD RCSEd.
Lecturer, Department of Restorative Dentistry, Faculty of Dentistry, Jordan University of Science &
Technology.
*Ahmad Al-Tarawneh DDS, M.Clin.Dent,
Specialist in Orthodontics (Queen Alia Hospital) Royal Medical Services.
*(Corresponding Author)
Khaled Q Al Hamad BDS, MSc, MRD RCSEd.
Irbid 211-10; P.O. Box 4047. JORDAN
Home phone/fax number: 00 962 2 7247224
Mobile:00962 796764691
E-mail address: [email protected]
1
FOREIGN BODY INGESTION AND ASPIRATION IN DENTISTRY: A REVIEW OF THE
LITERATURE AND REPORTS OF THREE CASES.
Abstract
This article reviewed several cases of foreign body ingestion or inhalation reported in the literature. Prevention,
complication, and management of this event were also discussed. Three case reports were presented. Two of the
cases were bridge ingestion and one was ingestion of an orthodontic band. The three cases were managed by
watchful waiting and the ingested foreign bodies came out in the stools with out complications.
Clinical Relevance:
The risk of ingestion or aspiration of foreign body during dental treatment is always present. This can lead to
drastic consequences or may pass uneventful. Understanding the possible complications of such events and the
strategies of prevention and management by the dental practitioners is mandatory.
Brief Objectives statement:
The objectives of this paper are to describe the strategies of prevention and management of ingestion and
inhalation cases and to discuss the possible complications of these events. Other objectives are to review the
cases reported in the literature and to report three ingestion cases.
2
Introduction
In the United States, around 1500 people die yearly of ingested foreign bodies in the upper gastrointestinal
tract.1 The most often ingested objects were coins, meat impaction, button batteries, and dental objects. Most of
these objects passed spontaneously, but about 10-20% needed to be removed endoscopically, and about 1%
required surgery. 2, 3, 4
The second most likely object to be ingested or inhaled was reported to be dental in origin5. Commonly ingested
or inhaled foreign bodies of dental origin involve: tooth picks; endodontic instruments such as files and
reamers; burs, impression and denture relining materials; dental appliances such as inlays, onlays, crowns,
posts, and cores, rubber dam clamps, fixed and removable prosthesis; orthodontic retainers, band and wires,
implant components and even parts of intra-oral tracing apparatus.6
Diagnosing ingested dental prosthesis can be difficult and delay in treatment may result in serious
complications. Some objects are made of materials that lack radiopacity, which makes it impossible to identify
their location; diagnostic bronchoscopy or computed tomography for localization is then needed. 7, 8,9
Certain patients are at higher risk of swallowing foreign bodies than others. The majority of incidents involving
the aspiration and or swallowing of foreign bodies occur before the age of fifteen.10 An accompanying medical,
mental or physical handicap in this age group may serve to increase the risk for theses incidents. Other high
risk groups include people with alcoholism, prisoners, psychotic individuals, the senile, mentally retarded
individuals, patients with dementia and Parkinson disease, patients who are nervous or restless, and patients
with an excessive gag reflex. Also, stroke patients should be considered at risk of ingesting foreign bodies
because dysphagia is a well recognized complication of stroke. 11, 12, 13, 14
Complete denture wearer were also reported to be at risk of foreign body ingestion in adults.15 This was ascribed
to the reduced tactile sensitivity of the palatal mucosa. In addition, patients with difficult access sites secondary
to anatomical restrictions, such as small oral cavity, and patients who are barrel chested and obese or pregnant
are at higher risk of ingesting or inhaling foreign bodies. Increased intra-abdominal pressure as in obesity or
pregnancy may cause dysphagy especially in a reclined position. Impaired central nervous system functions can
also increase the likelihood of foreign body ingestion. This can be influenced by medication with sedatives,
tranquilizers, opiates, or depressant.11
Objects ingested into the gastrointestinal tract usually pass through the esophagus into the stomach and out
through the gut without significant problems. Usually about 60% enter the stomach without lodging in the
esophagus and 80% to 90% are passed in 7-10 days.6 The foreign object can get stuck anywhere either in the
3
gastrointestinal (GI) tract or the pulmonary tract; possible sites in the GI tract are the pharynx, upper esophageal
sphincter, middle third of the esophagus, lower esophageal sphincter, pylorus, duodenum, distal ileum, ileocecal
valve, appendix, sigmoid colon, and anal canal. In the respiratory tract, the object could get stuck anywhere
ranging from the trachea to the smaller bronchi, usually it goes to the hilum of the right lung. 16
Swallowing or aspiration of a foreign body is a complication that may arise from any procedure in the oral
cavity. This article reviewed the ingestion and aspiration cases reported in the literature and also discussed the
prevention strategies, possible complications, and management of foreign body ingestion or inhalation. Three
case reports of ingesting were also presented.
Review of Ingestion and Aspiration Cases Reported in the Literature.
The literature that addresses the aspiration or ingestion of dental objects is replete with case reports and
descriptions of individual adverse events.
Tiwana et al., 17 conducted an institutional review on the incidence of foreign body inhalation or ingestion. They
found that aspiration or ingestion is an infrequent occurrence. There were only 36 reports of aspiration or
ingestion during the- 10 year study interval. They also reported that ingestion occurred more frequently than
inhalation. This was explained by the effect of coughing that occurs when there is a foreign object in the patient
airway, which makes it more difficult for aspiration to occur. The authors also reported that aspiration or
ingestion occurred most commonly in procedures involving fixed prosthodontic therapy-specifically those
involving cementation of permanent crowns-and adjunctive procedures such as placement of cast post and core,
onlay and implant-related procedures.
Nwaorgu et al., 18 did a retrospective review of impacted acrylic denture cases over a16-year period. They found
that 22 adults had impacted esophageal acrylic dentures. The common symptoms in all patients were difficulty
with swallowing, throat pain and discomfort, followed by tenderness in the neck. Dentures were extracted
through esophagoscopy (17 cases) and cervical esophagotomy (3 cases). Observed complications included
pulmonary edema in one case and esophageal perforation in five patients.
Taylor NG19 reported swallowing of partial denture following severe bout of coughing. The patient was
admitted to the hospital with a 10 day history of severe abdominal pain. A diagnosis of perforated viscus was
made. At laparotomy, a perforation of the sigmoid colon was identified and the affected segment resected. A
transverse colostomy was carried out. The pathologist found an acrylic partial denture lodges in the specimen.
The prosthesis had avoided detection on preoperative abdominal radiographs because of its radiolucent
property.
4
Cooke and Baxter20 reported three cases of accidental impaction of partial dentures in the upper gastrointestinal
tract. In the first case the patient swallowed her acrylic partial denture whilst taking analgesic to relieve her
headache. In the second case the patient swallowed his denture in a discotheque after having drunk few pints of
beer. In the last case the patient swallowed his denture whilst playing in the school. In the three cases reported,
the patient had their swallowed dentures removed from the upper esophagus under general anesthesia. The
authors recommended that the possibility of ingestion of acrylic dentures should be considered when designing
partial dentures. Dentures with inherent poor stability and retention should be avoided. Design problems were
also discussed by Dunn & Avery.21 The authors reported a case of unilateral partial denture ingestion. The
denture provided no cross-arch stabilization and this had increased the chance for denture swallowing.
A similar case was reported by Brunello & Mandikos.22 A 67-year-old man swallowed a unilateral removable
partial denture which became lodged in the mid-esophagus. The denture was located by radiographic
examination of his chest and removed by a rigid esophagoscopy under general anesthesia.
Colaizzi et al., 23 reported the swallowing of a central bearing plate by an edentulous patient during the
construction of complete dentures. Through the use of lateral and posteroanteriro radiographs of the chest,
laryngoscope, and biopsy forceps, the object was removed from the hypo pharyngeal region of the pharynx.
Similar cases of swallowed partial dentures were also reported by Cottrell & Hanley24, and Rizzatti-Barbosa et
al.25
In the case reported by Nelson6, an onlay was ingested by the patient when he attempted to speak during the tryin visit. After four weeks of ingestion of the onlay, a colonoscopy was performed. The onlay was lodged below
a fold of the colon and was retrieved with a snare. There was no evidence of perforation or inflammation, and
the rest of the colon was normal. During the four weeks of observation, the patient was instructed to examine
her stool. A periodic follow-up radiographs were taken to monitor the progress of the onlay. Surprisingly, the
ingested onlay did not pass through the gut and drastic measures were required for removal.
Seals et al., 4 reported a case of pulmonary aspiration of a metal casting. The patient was in the supine position.
An explorer was used to examine the marginal fit, and the second premolar casting became dislodged and
disappeared into the posterior pharynx and could not be retrieved. The patient was evaluated by a pulmonologist
and underwent fiberoptic bronchoscopy within four hours of aspiration. The crown was clearly visualized,
occluding the medial-basal segment of the right lower lobe. After several unsuccessful attempts at retrieval with
a basket-type forceps, a four-pronged claw forceps was used to remove the object without further difficulty or
complications.
5
A swallowed crown case was reported by Ulosy & Toksavul.26 A 45-year-old male patient was seeking the
replacement of his missing teeth with a fixed partial denture (FPD). During the metal try-in of the 4-unite
posterior FPD the patient accidentally ingested the metal framework. Lateral chest and abdominal radiograms
revealed that the metal framework was located in the gastrointestinal system. The patient was advised to
examine his stool. Five days later, abdominal radiograph was repeated and showed that the metal framework
was no longer in the gastrointestinal system.
A similar case of swallowed crown was also reported by St John & Hutchins.27
Pulmonary aspiration of a two- unite bridge during a deep sleep was reported by Basoglu et al,. 28 the aspiration
in this case was not related to any dental procedures or systemic disease. A 37-year-old male patient had a
aspirated his bridge while sleeping and the bridge remained unidentified for one year despite the radiographic
controls. The patient was suffering from dyspnoea on exertion, sputum and cough. He was initially diagnosed
with Pneumonia and was treated with antibiotics. There was no improvement in the symptoms and was refereed
to another facility. Chest radiographs was taken and revealed a minimal consolidation in the lower right zone
and radio-opaque density in the right intermediate bronchus. On careful examination of the patient history, the
patient stated that year ago, he woke up without the 2-unite bridge in his month. His dentist ignored this and
constructed a new bridge for him. Rigid bronchoscopy failed to remove the bridge from the right intermediate
bronchus. A vertical bronchotomy was performed on the intermediate lobe bronchus and the aspirated bridge
was removed from the bronchial lumen.
Hazards of oral implant treatment include the inadvertent ingestion or inhalation of components or instruments
dropped accidentally into the oropharynx. Screw driver swallowing during the implant treatment was reported
by Worthington.12
Safety during Endodontic treatment is an important and integral procedure. Rubber dam isolation of the tooth
receiving Endodontic treatment represents the minimum safety standard of care.29 Whitten et al.,30 found in their
national survey that only 59% of the general dentists and 91% of the endodontists routinely use a rubber dame
during root canal treatment.
Two cases of swallowed endodontic instruments were reported by Lambrianidis & Beltes. 31 Another case of
accidental swallowing of dental clamp was reported by Majia et al. 32
New technology devices such as apex locator and rotary devices can pose a safety threat. Fishelberg29 reported
a case in which the apex locator was used during endodontic treatment with rubber dame isolation. The lip clip
disappeared during the treatment. The patient reported no discomfort and nothing were visualized on oral
6
examination so it was assumed that the patient did not swallow it. The x-ray revealed that the lip clip was in the
patient oral pharynx. The case was treated by an oral surgeon who removed the lip clip using a McGill forceps.
The case demonstrated that the use of the rubber dame is only one component of patient safety. It is necessary
to make sure that no component of any dental apparatus is near the oral cavity without complete
immobilization.
While Endodontic procedures can be performed with rubber dame, the orthodontist cannot use rubber dame for
his patient with arch wires and stainless steel attachments.
Orthodontic components are mostly small, and in combination with saliva, handling can be difficult. The patient
may also be prone if component become detached or fractured during service. As patients always carry the
appliance in mouth, the chances of accidental swallowing or aspiration of any part of the appliance is very high.
Milton et al.,7 reported three cases of foreign body ingestion involving patients undergoing orthodontic
treatment. In the first case, the band on the lower right first molar was lost. In the second case, portion of a
lower arch wire became detached during breakfast. In the third case, a stainless steel sectional wire was lost.
The cases were managed first by locating the ingested object using radiographs and then by watchful waiting.
All patients remained asymptomatic during the waiting period although none of the foreign objects were
retrieved. No active intervention was deemed necessary and the patients resumed their orthodontic treatment
uneventfully.
A case of accidental swallowing of a metal casting crown that occurred during orthodontic treatment was
reported by kharbanda et al.16 The crown was swallowed subsequent to separation, while placing the
orthodontic band. The crown route in the GI tract was monitored by radiographs and passed out uneventfully,
on the fifth day with excreta.
Quick & Harris33 reported a case of an orthodontic patient who accidentally ingested a section of orthodontic
wire and coil spring from a fixed expansion device placed in the maxillary dental arch.
Chlorohexidine gluconate (CHG) ingestion usually causes relatively mild symptoms. Hirata & Kurokawa 34
reported a case of accidental ingestion of 200ml of Maskin (5% CHG) by an 80-year old woman with dementia
in a nursing home. She was intubated for airway protection in the nearest hospital and referred to the critical
care unite because of hypotension and rapid deterioration of consciousness. Despite intensive treatment, the
patient died of acute respiratory distress syndrome (ARDS) 12 hours after ingestion. The serum concentration of
CHG was markedly high , although CHG reportedly has poor enteral absorption. The authors suspected that
7
CHG was absorbed through the pulmonary alveoli following aspiration, not from the gastrointestinal tract. The
authors concluded that CHG had the potential for fatal ARDS when aspiration occurred following ingestion.
Failure of solder joints and bur disintegration are not uncommon or unexpected, in light of rigorous asepsis
protocols. A case was presented by Hodges et al.,35 in which an eighteen –year-old female with mental
retardation swallowed a mirror head. The solder joint connecting the mirror portion fractured and dislodged the
mirror head into the oral cavity. No signs of respiratory distress were detected. A thorough examination of the
area around the patient and the patient's oral cavity proved unsuccessful. The patient was transferred to the
department of emergency medicine for examination. Chest and abdominal radiographs were obtained.
Interpretation of the radiographs determined that it had entered the gastrointestinal tract and was located in the
fundus of the stomach. The patient's caretakers were instructed to use a high fiber diet and to inspect the
patient's stools for one week. On the fourth day following the dental visit, the mirror head was expelled without
incident.
It can be concluded from the review of cases that ingestion cases were more common than inhalation cases.
Most of these cases required only monitoring without active intervention. Serious complications did not occur
commonly except in few cases. 6, 34 This review also showed that the patient are prone to ingestion or inhalation
cases not only during dental treatment, but also after treatment as the patients carry the appliances or prostheses
in their mouths.
Methods of Prevention
Prevention should begin with the taking of thorough medical and dental histories. Complex medical, mental, or
physical handicaps that include increased dental needs may predispose the patient to risk of aspiration or
ingestion incidents. In addition, factors related to patient care that invite consideration include sedation, general
anesthesia, local anesthetics, body and head positioning, loose teeth, four handed dentistry, removable
appliances/prosthesis, age, and instrument fatigue. 35
Local anesthesia, particularly mandibular block and palatal anesthesia, interferes with sensory and motor
control of the pharynx, tongue, and palate.36 This may increase the risk for ingestion or inhalation incidents.
Any patient who has a pharmacologically altered state of consciousness through the use of deep sedation or
general anesthesia must have a throat pack placed. 36 The loss of sensation from anesthesia and diminished
protective reflexes from sedation techniques may greatly compromise the patient's laryngeal reflex. 19 Before the
throat pack is removed, the oral cavity should be thoroughly examined, irrigated, and suctioned to remove any
loose debris. The oral cavity should again be examined and suctioned following removal of the throat pack. 35
8
The rubber dam is a common procedure for routine restorative and endodontic work. It is recommended as a
mean to provide a clean, dry operative field and to improve visibility and access.38 Protection of the patient
from high speed instrumentation is achieved as the rubber dame retracts the lips, cheeks, and gingival tissues. It
also prevents the movement of the tongue into the operative field. The rubber dam provides an effective barrier
against aspiration and swallowing of instruments or materials. Despite this, several survey studies reported the
limited use of rubber dam by the profession.39 Another survey showed that the use of the rubber dam varied
according to the age of the dentist and was found to be more popular among younger practitioners.40
Protection should be taken in the application of the dam it self. If a clamp does not fit the tooth properly or is
not seated completely, it can be dislodged during placement and be aspirated or swallowed. To prevent this, it
has been recommended that a piece of dental floss is tied through a hole or a round the bow of the clamp. 41, 42
However, the clamp can also break in the bow area during placement. A safer technique is to tie the floss
through both holes of the clamps in order to enable the recovery of either the broken or the dislodged clamp.38
Many dental techniques preclude the use of the rubber dam, particularly during routine oral surgery and
prosthodontic procedures. Frequently, sedation and bilateral anesthesia are used for various surgical procedures.
Hacker and Cattan 43 suggested that up to 80% of accidental impaction of dentures in adult probably result from
the loss of tactile sensitivity on the palatal surface. Contrary to this, Tiwana et al., 17 found in their institutional
review study that none of the patient who aspirated or ingested foreign bodies had received local anesthesia. An
alternative to the use of rubber dam is to place a gauze protective pack in the oral cavity distal to the area where
small items are being manipulated. Patients with an exaggerated gag reflex may not tolerate the gauze pack.
When neither a gauze pack nor a rubber dam can be used, positioning of the patient is an important
consideration. A more upright seating position with the patients head turned to the right or left may allow
dropped objects to fall to the floor of the mouth rather than directly into the oropharynx.
In the field of fixed prosthodontics, the rubber dam cannot be used while occlusion is being adjusted, and throat
packs are poorly tolerated by some patients, especially when the patient occludes the teeth. Several alternative
procedures were described in the literature. A cast pin or loop for floss ligature was suggested26, 44 but this
requires additional laboratory procedures for removal and polishing. Wilcos & Wilwerding 45 suggested the use
of an orthodontic elastic loop to prevent aspiration or ingestion of the FPD. Al rashed 46 described an alternative
technique for cast post and cores. The technique involves making a deliberate hole for floss ligature. The author
recommended filling the hole with composite restoration after cementation. Nakajima and Sato47 described a
cost effective technique for attaching the floss to the restoration. The floss is attached to the lingual surface of
9
the restoration with a small amount of gel-type instant glue. A small amount of auto polymerizing acrylic
monomer is applied with a cotton pellet to decrease the setting time of the glue. After cementation, the floss is
removed with a carver.
Impression procedures may put patients at risk of aspirating the impression material. In order to minimize this
risk, Cameron et al.,48 recommended that dentists should use the most viscous material available that will
achieve the desired level of accuracy for the particular procedure. They also recommended the use of a high
velocity evacuation, a custom tray, and the use of a more upright position.
The cases of foreign body ingestion that were reported in the literature demonstrated that patients are at risk of
swallowing removable prosthesis or orthodontic parts after the delivery of the treatment. The possibility of
ingestion of acrylic dentures should be considered when designing acrylic partial dentures in order to maximize
the retention and stability of these dentures. In the orthodontic clinic, all arch wires should be cinched down
distal to a bonded attachment, and secured before intra-oral cutting. The secure bonding of brackets to teeth
must be confirmed, and components such as expansion keys adapted appropriately, to allow attachment of
dental floss by the patient. With the use of the latter, parents should be made aware of the possibility of
swallowing or aspirating the key, and should be advised regarding the emergency management of the patient in
such an event.7
Orthodontic removable appliances have clasps with or without springs, which may get loose or break and may
be swallowed accidentally. All wire ends should be bent on the main wire to make them smooth and should be
properly gripped in acrylic base. Arch wires, brackets, band and ligature wires should be checked every visit
and should be changed if any reason is seen for their dislodgement. 16
The orthodontist should also be careful while placing separators for teeth restored with metal crowns. The brass
wire separators are more hazardous since the wire is passed into the gingival sulcus close to cast crown tooth
junction.16
Complications
Swallowing mishaps in dentistry could result in a cute medical and life threatening emergencies1. The ultimate
outcome depends upon the shape, size, and nature of the swallowed material. Fortunately, many objects which
are swallowed pass through the alimentary tract easily without complication. Eighty percent of the swallowed
foreign bodies are passed within a month, average time being one week and often patients are unaware.16
However, large foreign objects, particularly if they have sharp edges, carry the risk of serious complications,
such as perforation, hemorrhage, impaction, obstruction and even death. Blunt and small objects like inlays,
10
crowns and orthodontic brackets usually pass uneventfully but sharp objects like reamers, files, hypodermic
needles, clasps, orthodontic wires are dangerous as they can easily get stuck and may cause infection, pressure
necrosis and edema.30 This may lead to perforation, and /or fatal hemorrhage. The majority of swallowed
foreign bodies that cause obstruction lodge in the upper esophagus.49 This can lead to esophageal perforation
with secondary mediastinitis and esophagus obstruction with the risk of aspiration. Other gastrointestinal
complications include blockage, abscess, perforation, and peritonitis.
In a review of 2394 patients with esophagus foreign bodies, Nandi and Ong50 found that in 10 cases tooth picks
were impacted in the esophagus and dentures were impacted in 16 cases. They noted that once the object is
impacted in the esophagus it is unlikely to pass spontaneously. Edema may occur if removal of the object is
delayed, making later manipulation more difficult. They suggested that perforating the esophagus is more
dangerous than perforating any other part of the gastrointestinal tract, possible sequelae including mediastinitis,
hemorrhage and tracheo-esophageal fistulae.
The consequences of aspirating a foreign body or material can range from immediate obstruction of the airway
to long lasting complication. Early complications can include hypoventilation of the distal segment with
subsequent atelectasis and hypoxia. Later complications can include infection, such as lung abscess or
pneumonia, and atelectasis.
Tracheo—esophageal fistula caused by a foreign body is rare complication. Rajesh & Gioti 51 reported a case of
delayed onset tracheo-esophageal fistula due to a swallowed dental plate in a young patient.
When considering the potential complications of aspiration versus ingestion, the conclusion would be that
aspiration would have a higher morbidity rate than ingestion. However, the potential for morbidity in ingestion
cases is present in cases of impaction of dental prostheses (such as dentures caught in the cervical esophagus)
and the major surgery patients sometimes have to undergo to have the prosthesis removed.
Management
The immediate priority when a foreign body drops into the oropharynx is to ensure a clear airway. If the latter is
compromised, this will give rise to symptoms of laryngeal obstruction such as choking, labored breathing and
the use of accessory musculature to aid respiration, inspiratory stridor, asymmetric air movement on inspiration
and expiration, croupy respiration on auscultation. The patient should be placed in a reclined position and
encouraged to cough. If coughing fails to relieve the object, the Heimlich maneuver should be performed.52 This
procedure needs to be rapidly successful; otherwise the patient should be transferred immediately to the nearest
11
emergency room. Mean while, the practitioner and his/her team must instigate emergency life support measures
including airway provision via a cricothyroidomy, if appropriate.
If the patient is asymptomatic and the airway is not compromised, he or she should be reassured and informed
calmly about the complications. The situation should be maintained and monitored as the search of the oral
cavity and the local areas is carried out. If the object is not retrieved, the patient should be transferred to
hospital, so that appropriate radiographic and clinical examination can be carried out. Frontal and lateral chest
and abdominal roentgenograms should enable the physician to determine whether the object has been
swallowed or inhaled.
The decision on the necessity of removal of foreign object depends on the object's type and location. As has
been mentioned earlier, sharp or elongated objects may fail to pass the fixture curves of the duodenum. As a
general rule, objects longer than 5cm are unlikely to pass the duodenum.7 Early attempts should be made to
remove them before 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.11
The management of patients who have swallowed foreign bodies relies on regular assessment and serial
radiography. Radiographs allow the clinician to confirm the presence of a foreign body, and to assess its size,
shape and position and to allow for indications of intestinal perforation, such as pneumoperitoneum. In addition,
radiographs can be used to monitor for onward progress, and confirm passage of the foreign body. 53 In the
meantime, the patient will have to screen his or her stools and try to identify the foreign body. 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 peristaltic contraction and thus make intestinal perforation more
likely. The patient should be evaluated for symptoms of intestinal perforation or obstruction, such as pain or
vomiting, and examined for signs such as tenderness or guarding. If the foreign body has entered the
gastrointestinal tract, attempts should be made to recover the object by esophagoscopy.11 The procedure of
choice for extracting such objects is flexible endoscopy.54 Depending on the object's location; Rectoscopy,
colonoscopy, or surgical intervention may be necessary in the incidence of impaction of the foreign body within
mucosal folds of the intestinal tract. Open abdominal surgery is also indicated if there is evidence of
hemorrhage, intestinal perforation, or obstruction.
In contrast to swallowed foreign body, accidental inhalation of foreign object can constitute a true medical
emergency. Early complications include acute dyspnea, asphyxia, cardiac arrest, and the laryngeal edema. 11
12
Thin pointed objects increased the risk of perforation and pneumothorax. The management of inhaled objects
was described by several authors.7, 11, 38 Once a foreign body has been localized to the respiratory tract using
appropriate radiography, retrieval should be carried out as soon as possible. Bronchoscopy is the treatment of
choice for the removal of the foreign body objects. If it is impossible to remove the foreign body using flexible
bronchoscopy, rigid bronchoscopy is used as an alternative treatment. Rigid bronchoscopy provides larger
working channels and better visualization of the central bronchial tree, but foreign bodies located more distally
are out of reach. If the object is lodged in very small bronchi close to the lung parenchyma, fluoroscopic
guidance can be used for the removal with flexible bronchfiberscopy.
Chronic retention of foreign bodies may cause even more technical difficulties during bronchoscopy because
the formation of granulation tissues and inflammatory polyps around the foreign object may obstruct the
bronchus.
Case Reports
Case 1
A 34- year old female was referred to the department of restorative dentistry for restoration of her missing lower
first premolar and first molar with a 4-unite FPD. The treatment was carried out by a final year undergraduate
student. In the cementation visit and during the occlusal adjustment of the FPD, the patient accidentally
swallowed the FPD. The patient was referred to the x-ray medical department at the basement floor in the same
building. Abdominal radiographs were immediately obtained and revealed that the bridge was located in the
large bowel ( Figure 1). The patient was experiencing no discomfort or change in general stability. The general
surgeon was consulted and he suggested waiting for few days. The patient was advised to examine here stool.
Three days later, the patient reported that the FPD passed in the stool uneventfully. Abdominal radiography was
repeated and showed that the FPD was no longer in the large bowel.
Case 2
16 years old female patient was referred to the Orthodontic Department at Royal Medical Services/Jordanian
Armed Forces for treatment of class I incisor relationship with moderate crowding and buccally impacted
UR3(13). The treatment plan was extraction of all first premolars and then upper and lower fixed appliance
therapy. Separators were placed in the first visit; one week later bands were selected and cemented on all 1st
permanent molars. Patient was referred for extraction of teeth. The patient returned for an emergency
appointment one month later. She reported that the band on the upper left permanent first molar was lost or
swallowed. The patient was referred to the radiology department and abdominal plain film was taken. The
13
radiograph revealed the lost band to be located within the small bowel, mainly in the duodenum (figure 2). The
patient and parents were made aware of the situation and the patient was advised to examine here stool. Two
days later the patient phoned and informed that the band came out in the stool. New appointment was given to
the patient for band replacement and the treatment plan was carried out uneventfully.
Case 3
Thirty-eight years old female patient was referred to the Restorative Department at Royal Medical
Services/Jordanian Armed Forces complaining of severe pain from her upper right first permanent molar. On
examination the tooth was an abutment for a three-unite bridge replacing missing upper right second premolar.
The clinical examination showed recurrent caries beneath the retainer on the upper right first molar which was
diagnosed to have irreversible pulpitis. The treatment plan was to remove the bridge; treat the carious lesion on
the upper right first molar; perform root canal treatment on the same tooth; and then fabricate a new bridge. A
putty index was taken of the bridge to aid the fabrication of the temporary bridge. The bridge was removed
intact and the carious lesion was treated. Pulp extrirpation was carried out on the upper right first molar. The
canals were dressed temporarily with non-setting calcium hydroxide. It was decided to use the same bridge as a
temporary prosthesis. The bridge was temporarily cemented with TempBond ® and the patient was given an
appointment after one week to finish the root canal treatment. In the appointment day the patient reported that
she ingested the bridge two days before the appointment. The patient was referred to the radiology department.
Anterior-posterior abdominal film was taken and revealed that the bridge was located in the descending colon
(figure 3). The patient was re-assured and advised to examine her stools. In the next day the patient stated that
the bridge came out in the stool. The Root canal treatment and the fabrication of the new bridge were completed
uneventfully.
Conclusions
During dental treatment, there is always a risk of swallowing foreign dental objects. While these events occur
infrequently, the potential morbidity associated with a single incident is too large to ignore. These incidences
require a lot of medical care and may result in a high financial cost to the dentist and potential malpractice
litigation.
Practitioners must be a ware of the preventive measures and the correct management of such cases. This applies
to the identification of at-risk patients through comprehensive clinical examination and thorough history.
14
Figure 1. Abdominal Radiograph showing the bridge in the large bowel.
15
Figure 2. Abdominal plain film showing the lost band within the small bowel.
16
Figure 3. Anterior-posterior abdominal film showing the bridge located in the descending colon.
17
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List of Figures
Figure
Captions
1
Abdominal Radiograph showing the bridge in the large bowel.
2
Abdominal plain film showing the lost band within the small bowel.
3
Anterior-posterior abdominal film showing the bridge located in the descending
colon.
21
Acknowledgment:
The authors would like to thank Mr. Saleh Saleh & Mr. Mohammad Obeidat for their
valuable help in this paper.
22