A Caucasian patient accidentally inhales an endodontic file during a dental procedure
Accidental inhalation of dental instruments is not a common occurrence during dental procedures. Although it is quite rare, accidental ingestion of dental instruments can have dramatic consequences. For example, obstruction, perforation and impaction of the digestive or respiratory tracts are common possibilities. Some dental instruments, such as endodontic files have sharp ends that can increase the likelihood of perforation. This article describes the case of a patient who accidentally swallowed an endodontic file during a root canal treatment. The passage of the file was followed using serial radiographs and it was eventually able to pass without the need for any further intervention.
In this case, a 62-year-old Caucasian male presented to the Emergency Department after he suspected the ingestion or aspiration of an endodontic hand file. He was receiving endodontic (root canal) treatment of a maxillary (upper) molar tooth at the dentist. According to the patient, he experienced two episodes of coughing and dyspnoea that lasted for several minutes each. Similarly, following this episode, the dentist noted that an endodontic file was missing. He was referred to the emergency department for investigating the potential ingestion of an endodontic file.
The patient’s past medical history was significant for ischemic heart disease which was managed with medications. Doctors performed a physical examination which showed normal bronchial and vesicular breath sounds with no signs of vomiting, abdominal pain, dysphagia, cough or respiratory distress. Examination of the oral cavity also did not show any significant findings, suggestive of the passage of the foreign body beyond the oropharynx.
Diagnosis and management
Radiographic imaging of the frontal chest and abdomen confirmed the presence of a 27-mm linear radiopaque foreign body. The foreign body was located in the right of the midline of the abdomen, at the level of the L2/3 disc, consistent with an endodontic file. Initially, the general surgeon advised inspecting and removing the endodontic file via gastroscopy. However, by the time the gastroscopy was scheduled, the abdominal radiograph showed that the endodontic file has migrated to the distal ileum/ ascending colon. Therefore, was beyond the scope of retrieval via an endoscopy. Doctors admitted the patient as an inpatient under the observation of the general surgery team.
Doctors further advised abdominal radiographs for monitoring the migration of the foreign body. A third radiograph that was taken on the 1st-day post-ingestion showed that the foreign body was in the transverse colon. However, the patient did not show any clinical signs of bowel perforation. Similarly, there was no radiographic evidence of pneumoperitoneum either. On the 2nd day, the endodontic file could not be visualized on radiographic imaging. This indicated that the endodontic file had been expelled. The patient showed no symptoms and was discharged.
Literature review: aspiration of foreign objects
Although ingestion and aspiration of foreign objects are more common in paediatric patients, it also occurs in adults. However, most adult cases are either accidental or occur in psychiatric patients. Ingestion or aspiration of foreign objects is quite rare during endodontic therapy. Studies have shown that the incidence ranges from 0.00012% to 0.004%. For this reason, literature on management is limited. Once an object passes the tongue, there is a limited chance that it will enter the digestive or respiratory tract.
The vast majority of objects in the gastrointestinal tract pass without intervention. However, in 10 to 20% of the cases, there is a need for nonsurgical management, whereas 1% require surgical management. Features that affect the management of ingested foreign objects include the location and type of object and the characteristics of the patient. It is generally seen that objects below 60mm in length and 25 mm in diameter, 90% of the time pass through the pylorus and ileocecal valve without any issues.
Sharper objects, for example, dental utensils and endodontic files, as with this case, are more likely to cause oesophagal perforation, intestinal puncture and haemorrhage. This is because these dental utensils are more likely to fail to pass the curves of the intestine. This may be life-threatening. In addition, a history of inflammatory bowel disease, diverticula, hernias, adhesions and tumours also increase the risk of impaction and perforation.
Patients with suspected inhalation and ingestion of a foreign body should be referred for immediate medical assistance
Signs of respiratory distress, GI obstruction and intestinal perforation including neck, throat/chest pain, choking, gagging, stridor or wheezing, abdominal pain and dysphagia should also be ruled out. In addition, the oral cavity and oropharynx should be thoroughly examined for misplaced objects. Once it has been ruled out that the object is no longer in the oropharynx, the radiographic examination should be the next step. The radiographic examination will determine whether the object has entered the respiratory or gastrointestinal tract. The study states, “posteroanterior and lateral chest radiographs, as well as an abdominal radiograph, are recommended”. Similarly, “this may aid in detection of complications such as free mediastinal/peritoneal air or subcutaneous emphysema”.
Similarly, while a majority of dental instruments are radiopaque, in some cases the objects are radiolucent. Based on the clinical picture, the patient should be referred for imaging with computed tomography, MRI or bronchoscopy, laparoscopy or endoscopy.
Source: Journal of Medical Case Reports