| Abstract|| |
Ingestion of instruments is a potential complication that can occur during dental procedures. We report a case of accidental ingestion of an endodontic barbed wire broach during root canal treatment and its subsequent retrieval by endoscopic methods. Although prevention is the best approach, proper management of such an event is also crucial. The objective of this report is to draw attention to the potentially serious complications that can occur if preventive techniques are not practised, and to discuss the accepted guidelines for management of such an event.
Keywords: Accidental ingestion, barbed wire broach, endoscopic retrieval, foreign body, gastrointestinal tract, rubber dam
|How to cite this article:|
Mohan R, Rao S, Benjamin M, Bhagavan RK. Accidental ingestion of a barbed wire broach and its endoscopic retrieval: Prevention better than cure. Indian J Dent Res 2011;22:839-42
Accidental ingestion of dental instruments is a potential complication that can occur during dental procedures. A case of accidental ingestion of a barbed wire broach during root canal treatment and its subsequent retrieval by endoscopy is being presented. Guidelines for prevention and also management of such an event are being discussed.
|How to cite this URL:|
Mohan R, Rao S, Benjamin M, Bhagavan RK. Accidental ingestion of a barbed wire broach and its endoscopic retrieval: Prevention better than cure. Indian J Dent Res [serial online] 2011 [cited 2014 Sep 3];22:839-42. Available from: http://www.ijdr.in/text.asp?2011/22/6/839/94681
| Case Report|| |
A 28-year-old male patient was undergoing root canal treatment for root canal infection of the right 2 nd lower molar, at a rural general dental clinic. During the procedure, while the endodontic broach was being placed into the root canal, the patient experienced a sudden gag reflex. This resulted in slipping of the broach, with subsequent swallowing. No rubber dam had been placed before commencing the procedure and the patient swallowed the broach. He was subsequently referred to our institute for further evaluation and management.
He presented to our hospital approximately 5 hours after the event. On presentation, the patient was comfortable, hemodynamically stable, and had no respiratory distress. Examination of the abdomen was unremarkable except for minimal tenderness in the epigastrium, with no clinical signs suggestive of bowel perforation or peritonitis. Plain X-rays of the neck and chest were normal. X-ray of the abdomen showed that the swallowed broach was located in the upper abdomen [Figure 1] and [Figure 2] with no associated features of perforation or peritonitis. Considering the time duration since the event and the position of the barbed wire broach on the X-ray, its location was inferred to be the proximal gastrointestinal tract (GIT), the most probable location being the stomach. As the patient was asymptomatic, we decided to manage him conservatively and await spontaneous evacuation of the swallowed object per rectally. He was advised soft diet and admitted for observation. His stools were checked after each act of defecation.
|Figure 1: X-ray of the abdomen showing the barbed wire broach (black arrow) in the upper abdomen|
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|Figure 2: Closer view of the X-ray abdomen showing the barbed wire broach (black arrow)|
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The patient was completely re-evaluated after 72 hours. There had been no passage of the barbed wire broach along with stools since admission. His general condition and abdomen examination findings remained the same as on initial presentation. A repeat X-ray abdomen showed the swallowed broach to be in the same position as in the initial X-ray with no evidence of distal transit. As this was suggestive of impaction within the GIT, we decided to perform an endoscopic evaluation (Upper GI Endoscopy) of the proximal GIT and attempt endoscopic retrieval of the foreign body.
At endoscopy, the barbed wire broach was noted to be in the distal stomach, impacted in the mucosa of the distal part of the lesser curvature. It had pierced the mucosal folds tangentially, and was embedded in the wall of the stomach, buried up to the handle. Using an endoscopic grasper, the handle of the broach was grasped, gently pulling it out of the gastric mucosal fold. The site of penetration of the mucosa was inspected for bleeding and perforation. The barbed wire broach was then retrieved along with the withdrawal of the endoscope, under full visualization throughout the retrieval process. Post endoscopic removal, erect X-rays of the chest and abdomen were again taken to rule out bowel perforation. After confirmation, the patient was started on liquids followed by normal diet. He was discharged 24 hours post procedure with advice to take 10 ml of antacid syrup preparation, three times daily, for a week.
| Discussion|| |
Ingestion of dental instruments is a potential complication that can occur during any dental procedure.  Standard practice guidelines recommend use of rubber dams during all intraoral dental procedures. Other recommended protective methods are gauze throat screens or floss ligatures.  Rubber dams prevent accidental ingestion or aspiration of instruments, irritation of the oral cavity by irrigants used during the procedure, and salivary contamination of the operative field during the procedure. Although clear recommendations regarding rubber dam usage exist, a review of literature revealed many reports of various types of instruments being accidentally ingested into the GIT. Orthodontic instruments, dental implants, crowns, endodontic instruments and files being accidently ingested have been reported, with the authors stressing on the importance of rubber dam usage during all intraoral procedures. ,, However, the literature review also revealed that practices of rubber dam usage vary widely among practitioners, across different parts of the world, and that failure to use a preventive rubber dam is a universal phenomenon. ,,
Failure to use rubber dams is usually due to various reasons. It may be due to non-availability of such products or due to economization.  It may also be due to reluctance by the dentist or the patient. The dentist may be not trained in its proper use, finding its placement cumbersome and time consuming. Surveys conducted among dentists have noted that rubber dam usage is more by those who attend education programs regularly and constantly update their knowledge. Sometimes, an occasional patient may find its placement uncomfortable and object to its use. ,
During a procedure, the patient can accidentally swallow or aspirate an instrument due to the numbing effect of local anesthetic agents. Local anesthetic agents can also cause abolition of the gag reflex. Handling of small instruments in a limited working area is sometimes difficult and requires special care as the patient is usually supine or semi-recumbent in position. In addition, contact with saliva makes the instruments slippery and difficult to handle, posing an increased risk of aspiration or ingestion.  Instruments of poor quality can break unexpectedly, and instruments with multiple components can get accidentally detached and can be ingested. ,
In the majority of patients, clinical signs and symptoms suggestive of ingestion are immediately evident. Ingestion is usually associated with dysphagia, retrosternal discomfort and pain, or abdominal pain.  Sometimes, a patient may swallow instruments unknowingly with no clinical signs suggestive of such an event. Simple measures such as counting of instruments at the end of the procedure can help to detect occurrence of such an event.
Most (80-90%) swallowed objects usually pass through the GIT and are expelled out per rectally without any need for intervention. However, intervention may be required if the foreign body perforates or gets impacted within the GIT. ,, The risk of perforation or of impaction depends on the (a) anatomical location, (b) size and (c) shape of the swallowed object.
The recommended guidelines for the management of swallowed object are also based on its (a) location, (b) size and (c) shape. A swallowed object impacted within the esophagus requires prompt removal because the esophagus lies in close proximity with the thoracic great vessels, the pericardium, the pleura and the tracheo-bronchial passages. ,, However, if the object has passed beyond the esophagus into the stomach, it has a 90% chance of successful distal progression and passage, usually over a 7-10 day period. , A perforation caused by direct penetration of the bowel by a sharp foreign body presents with immediate clinical features of mediastinitis or peritonitis depending on the level of perforation. Perforation of the esophagus causes mediastinitis with the patient presenting with retro-sternal pain and dyspnea. Perforation distal to the esophago-gastric junction causes peritonitis, with the patient presenting with abdominal pain, guarding, rigidity and distension.
Impaction of a swallowed object usually occurs at normal sites of narrowing along the GIT such as at the cricopharyngeal sphincter, constrictions in the esophagus, the gastro-esophageal junction, the pylorus, ligament of Trietz, ileo-cecal junction and the recto-sigmoid junction. , Some patients may have abnormal anatomy due to previous surgery or stricturing due to pre-existing illness, and this should also be kept in mind as chances of impaction are more in such patients.  If an impacted foreign body is left alone, over time, it can cause perforation, fistulation or intestinal obstruction. ,, Mucosal edema occurs at the site of impaction, with ischemic pressure necrosis of the bowel wall, subsequently leading to perforation of the bowel or fistulation into an adjacent structure. Fistulation can occur into adjacent bowel loops resulting in entero-enteric fistula, into vascular structures causing entero-vascular fistula, or to respiratory passages causing tracheoesophageal fistula.  Impaction within the lumen of the appendix can cause appendicitis. 
The risk of perforation and impaction is related to the size and shape of the swallowed object. Chances of perforation are more with sharp and pointed objects as these have unpredictable patterns of progression and migration. ,, The reported rates of sharp objects causing perforation is about 1%, with the stomach and duodenum being the commonest sites. Objects of length greater can 5 cm can get impacted in the 2 nd or 3 rd part of the duodenum, , as they will not be able to traverse the duodenal curve. Rounded foreign bodies of diameter greater than 2.5 cm cannot pass through the pylorus of the stomach easily and hence can get impacted there. , Removal of a sharp foreign body should be planned if there is no distal progression beyond 3 days. A blunt foreign body needs to be removed if it gets impacted and stays in the same place for greater than 7 days. ,,
The ideal method to locate a swallowed object is by serial X-ray evaluation. An X-ray helps to localize the site, show evidence of obstruction, show onward progression and also confirm passage of the swallowed object. , However, it should always be borne in mind that X-ray evaluation is of no utility if the foreign body is radiolucent. In such instances, computed tomography (CT) scan is the ideal modality of evaluation.
Endoscopic removal of foreign bodies is a safe and effective mode of management of swallowed objects. ,, Ideally, a trial run or a simulation should be attempted on a similar shaped object prior to the actual attempt on the patient. Hence, while referring a patient for further management, it is advisable to send a sample of the swallowed object along with the patient so that the treating doctor will have an idea of the size, shape and contour of the swallowed object. This would also help to decide on the instrumentation required for the retrieval. Removal should always be under direct endoscopic vision, grasping the head of the swallowed object. ,, Failure at endoscopic retrieval is an indication for proceeding to surgical removal, either by open or laparoscopic technique. ,, The use of laxatives is of no proven use and may actually increase the chances of perforation. 
When an accidental event occurs, it is very important to remain calm and composed. The patient must be reassured and carefully evaluated. Pain, nausea and vomiting should alert the clinician to the possibility of impaction or perforation. Tenderness with guarding over the abdomen and clinical signs of bowel obstruction are suggestive of impaction. Presence of these clinical symptoms and signs are indicators for the need for immediate evaluation and intervention. If the patient is asymptomatic and comfortable, an expectant line of management may be safe, and time may be taken planning further course of action. One must always remember that clinical signs and symptoms may occur late and all cases of accidental ingestion require thorough clinical and radiological evaluation.
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Department of Surgery, K. S. Hegde Medical Academy, Deralakatte, Mangalore, Karnataka
[Figure 1], [Figure 2]