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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 2  |  Page : 183-187

Accidental ingestion and successful retrieval of an endodontic file from the left hypochondriac region using endoscopy


Department of Conservative Dentistry and Endodontics, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India

Date of Web Publication9-Dec-2016

Correspondence Address:
Pravek Khetani
23/24, Khetani Bhawan Sindhi Colony, Shastri Nagar, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-7212.195430

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  Abstract 


Ingestion of the endodontic instrument during root canal treatment is an undesirable yet not uncommon mishap in the practice of endodontics. Such incidents are on a rise owing to the increase in number of endodontic cases being performed by the endodontists and the dental practitioners in the modern times. Serious complications may be encountered if such endodontic mishaps are not handled timely and efficiently. The present case report discusses the management of a typical case of ingestion of an endodontic file which was successfully retrieved by an endoscopy procedure.

Keywords: Endodontic file; endodontic mishaps; endoscopy; ingestion.


How to cite this article:
Khetani P, Sinha N, Dabas U, Dabas VK. Accidental ingestion and successful retrieval of an endodontic file from the left hypochondriac region using endoscopy. Endodontology 2016;28:183-7

How to cite this URL:
Khetani P, Sinha N, Dabas U, Dabas VK. Accidental ingestion and successful retrieval of an endodontic file from the left hypochondriac region using endoscopy. Endodontology [serial online] 2016 [cited 2019 May 25];28:183-7. Available from: http://www.endodontologyonweb.org/text.asp?2016/28/2/183/195430




  Introduction Top


Accidental swallowing of a dental prosthesis, dental instrument, or dental material during a dental procedure is often observed in the practice of dentistry. However, unexpected ingestion of an endodontic instrument during an endodontic procedure is the most undesirable happening in the practice of the endodontics. Although such mishaps are not observed on a regular basis, they do pose several clinical problems, undesirable consequences, and considerable distress on the part of the clinicians as well as patients. As a matter of fact, most of the times, ingestion of an endodontic instrument happens accidentally due to the factors including nonapplication of rubber dam, uncooperative patient, apprehensive nature of the patient, gagging reflex, viscous saliva, or restricted mouth opening. The dental literature is inundated with the instances of accidental ingestion of foreign bodies by patients during various dental procedures.[1],[2],[3] The ingested foreign body may include teeth, dental burs, restorations, inlay, dental instruments, rubber dam clamps, and gauze packs.[4],[5],[6],[7] Eighty-seven percent of the ingested foreign bodies entered the gastrointestinal tract while 13% entered the respiratory tract as reported by Grossman in 1971.[8] Approximately 90% of the foreign bodies entering the gastrointestinal tract pass spontaneously without being obstructed, about 10–20% cases require a nonsurgical intervention, and 1% or less require surgical removal.[9] Sharp objects are potentially dangerous and have a higher tendency of causing life-threatening complications such as choking, esophageal tissue perforation, intestinal puncture, or hemorrhage.[10] This paper discusses a case report of accidental ingestion of an endodontic file during an endodontic procedure and its successful retrieval within reasonable time period using endoscopy procedure.


  Case Report Top


A 53-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, Vyas Dental College and Hospital, Jodhpur, Rajasthan, with the chief complaint of pain and swelling in association with mandibular left second molar tooth for 2 weeks. On clinical examination, the mandibular left second molar exhibited a deep carious lesion and was tender to vertical percussion. Radiographic examination manifested pulpal involvement with the presence of periapical radiolucency. The tooth did not respond to either electric or cold pulp testing. The tooth was diagnosed with chronic periapical abscess and a conventional root canal treatment was planned.

The patient was explained the treatment procedure in detail before the commencement of the treatment. This was the patient's first dental visit, and he was little apprehensive about the entire procedure. Rubber dam was applied on the tooth to be treated; however, due to the severe gag reflex and coughing, it had to be removed. The patient requested to carry out the treatment without the rubber dam. Hence, access opening was made without rubber dam application. After the access opening, the orifices of the canals were located using DG 16 explorer and widened using gates glidden drills (Dentsply maillefer, USA). Working length was determined using an apex locator. Cleaning and shaping was carried out using Protaper rotary endodontic files (Dentsply Maillefer, USA) with copious irrigation with 3% sodium hypochlorite and hydrogen peroxide. Normal saline was used as the final irrigant. There was loss of working length in the distal canal during cleaning and shaping due to debris collection. Therefore, to regain the lost glide path, #15 K-file was inserted into the distal canal. During the manual filing procedure, the patient had a gagging reflex. As a result, the file slipped through the finger and the patient accidentally swallowed the file. Immediately, finger sweep method [11] was performed on the patient to retrieve the file. Thereafter, the patient's head was turned to the right side and sharp blows were delivered on his back.[12] However, both the procedures failed to retrieve the file and the patient complained of excessive gagging with the sensation of something sticking in his throat, suggesting of possible esophageal entrapment. The patient did not show any sign of respiratory distress indicating that probably the file had been ingested rather than aspirated.

The patient was immediately informed about the accident and was advised to stay calm and cooperative. After few minutes, the patient became stable and was relieved of the discomfort which he initially had in his throat. Subsequently, the patient was taken to the Radiology Department of the General Hospital of Vyas Dental College to verify the presence and location of the file.

The general surgeon on duty was consulted, who advised an anteroposterior (AP) view chest X-ray. An AP view X-ray of the chest was taken, which appeared normal with no evidence or presence of K-file [Figure 1]. Hence, an abdominal radiograph was taken to verify the presence of the missing file. The abdominal radiograph confirmed the presence of a radio-opaque object around 21 mm in length, resembling K-file lying in a horizontal position in the left hypochondriac region of the abdomen [Figure 2]. Subsequently, a gastroenterologist from a nearby Government Hospital was consulted, who suggested two options pertaining to the management: Either to leave the K-File in the stomach and wait for it to be expelled in the stool or to attempt the retrieval of the file from the stomach using an endoscope. Accordingly, the patient was informed about both the options. The patient consulted his family members in this regard and opted for the endoscopy procedure.
Figure 1: Anteroposterior view chest X-ray showing no indication of the presence of file

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Figure 2: Anteroposterior abdomen X-ray showing the presence of file in the left hypochondriac region

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Due to sufficient time interval between patient's last meal and the proposed endoscopy procedure, the gastric emptying had already taken place which was a favorable factor to facilitate endoscopy procedure. The potential complications of the endoscopy were discussed with him, and informed consent was obtained from him. The patient was shifted to the operation theater for the endoscopy procedure [Figure 3]. An analogical K-file was provided to a gastroenterologist for the easy identification and analysis of the file to assist in the easy and safe retrieval process. A spring grasping forceps was used for the retrieval of the K-file [Figure 4]. The exaggerated gag reflex hampered the endoscopic procedure. There was a lot of mucous secretion throughout the procedure, compromising the visibility of the file in the stomach. Furthermore, the viscous mucous made the grasping of the file complicated which in turn delayed the retrieval process. Nevertheless, K-file was retrieved successfully [Figure 5] and [Figure 6]. The procedure was completed approximately in 80 min. The patient was a bit apprehensive at the beginning of the endoscopy nevertheless was cooperative throughout the procedure. The patient complained of mild discomfort after the procedure, so he was put on cold diet to soothe his throat. The patient was discharged after the postoperative instructions and was recalled after 2 days for the endodontic treatment. The patient was advised to take alprazolam 0.25 mg prior to the appointment to reduce his anxiety. On his follow-up visit, the patient was asymptomatic and the entire endodontic treatment was thereafter carried out under rubber dam isolation. The soft palate was also anesthetized with a topical local anesthetic spray (Nummit spray, ICPA Health Products Ltd., Mumbai) prior to the rubber dam application to reduce the gagging reflex.
Figure 3: Endoscopy being performed in the operation theater

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Figure 4: A spring grasping forceps was used to retrieve the K-file

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Figure 5: K-file handled and retrieved by the spring grasping forceps

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Figure 6: #15 K-file after retrieval

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  Discussion Top


Previous studies on ingestion and aspiration have reported a higher prevalence with children and elderly patients with impairment of sensory and motor nerve responses.[13] In case of elderly patients, foreign body might be easily ingested once it falls into the oropharynx due to diminished protective reflexes.[14] Hence, a comprehensive medical history should be taken as it may assist in diagnosing motor-neural disorders or psychological status of the patient which can prevent mishaps during treatment. The present reported case was also an elderly patient aged 53 years who accidently swallowed a K-file during root canal procedure.

Other factors that increase the chances of aspiration are the anatomical restrictions such as a small oral cavity, macroglossia, or tooth alignment. Lower molars have been reported with the highest prevalence among all teeth with ingestion, and it has been correlated to their close proximity to the pharyngeal cavity as seen in the present case.[13] Accidental ingestion has also been reported higher with dental practitioners with experience <5 years, though it can happen with the most experienced practitioners too.[13]

Ingestion of a foreign body is a potentially dangerous event, which might lead to severe complications such as esophageal tissue perforation, choking, intestinal ulceration, and hemorrhage.[15] It is very important to determine whether the foreign body has entered the digestive tract or the respiratory tract since it is the factor determining the line of treatment. Moreover, clinical signs and symptoms also play a vital role in deciding the treatment plan. There is a plethora of diagnostic aids which can help in the identifying the exact location and size of the foreign object such as abdominal and chest X-ray, endoscopy, and computed tomography (CT) scans. The choice of aid depends on the nature of the material ingested. The abdominal X-ray is indicated when there is a history of a swallowed or aspirated radio-opaque object and CT scans are preferred for radiolucent materials. Endoscopy is indicated in cases where the ingested object is sharp, elongated and has a high-risk of esophageal injury.[12]

The endodontic file has been previously reported to pass out through the gastrointestinal system in 90% of the cases, uneventfully within 7 days of the accident.[16],[17] Objects <2 mm in thickness and 6 inches in length can easily pass through the alimentary canal without causing obstruction.[8] With sharp object, the most common sites of perforation are the lower esophagus and terminal ileum.[8] In the present case also, we could have waited and followed the same approach; however, due to the associated risk involved in it, the patient preferred an endoscopic retrieval of the file which was retrieved easily by endoscopy without any complication.

The time of endoscopy is extremely important as too much delay may allow the file to cross the pyloric sphincter, into the duodenum after which retrieval may be impossible. Hence, if endoscopy is planned, it should be done preferably within 2 hrs but at the latest within 6 hrs after ingestion.[9]

As a rule of thumb, all the endodontic procedures should be carried out under rubber dam application to avoid any kind of mishaps such as swallowing of endodontic instruments, dental burs, and restorative and impression materials. The patient's head should be inclined to one side to avoid swallowing of any foreign body. Other preventive measures that can also be followed are gauge barriers, flossing of the hand files, checking of proper locking of instruments in headpieces, and using high evacuation suction. A limitation of the present case was that the file was not tied with a dental floss. As the rubber dam application was not possible, at least the file should have been tied with a dental floss which could have avoided this mishap.

Strategies to avoid aspiration or ingestion of foreign body are as follows.

  • Application of rubber dam
  • Consideration and education of apprehensive patient
  • Use a more upright position if possible
  • Use of a gauze throat pack
  • Use of high-velocity evacuation
  • Awareness and preparedness for the medical emergencies.



  Conclusion Top


Accidental ingestion of an endodontic instrument is the most unfortunate event during an endodontic procedure. Even though such mishaps may not be very commonly observed in a routine endodontic practice, they do pose several management problems, undesirable consequences, and considerable distress on the part of the clinicians as well as patients. Rubber dam application is mandatory in all the endodontic and restorative procedures to avoid any kind of mishap. During an endodontic procedure, both the dentist as well as the patient should be vigilant. Proper handling of dental instrument is of prime importance in cases involving the children, elderly patients, or apprehensive patients. All the needful precautions should be taken before and during the dental procedure as a small mistake may prove to be life-threatening for the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rizzatti-Barbosa CM, Cunha FL, Bianchini WA, de Albergaria-Barbosa JR, Gomes BP. Accidental impaction of a unilateral removable partial denture: A clinical report. J Prosthet Dent 1999;82:270-1.  Back to cited text no. 1
    
2.
Weiman MM, Weiman DS, Lingle DM, Brosnan KM, Santora TA. Removal of an aspirated gold crown utilizing the laparoscopic biopsy forceps: A case report. Quintessence Int 1995;26:211-3.  Back to cited text no. 2
    
3.
Cameron SM, Whitlock WL, Tabor MS. Foreign body aspiration in dentistry: A review. J Am Dent Assoc 1996;127:1224-9.  Back to cited text no. 3
    
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Holan G, Ram D. Aspiration of an avulsed primary incisor. A case report. Int J Paediatr Dent 2000;10:150-2.  Back to cited text no. 4
    
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Tiwana KK, Morton T, Tiwana PS. Aspiration and ingestion in dental practice: A 10-year institutional review. J Am Dent Assoc 2004;135:1287-91.  Back to cited text no. 5
    
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Hill EE, Rubel B. A practical review of prevention and management of ingested/aspirated dental items. Gen Dent 2008;56:691-4.  Back to cited text no. 6
    
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Leith R, Fleming P, Redahan S, Doherty P. Aspiration of an avulsed primary incisor: A case report. Dent Traumatol 2008;24:e24-6.  Back to cited text no. 7
    
8.
Grossman LI. Prevention in endodontic practice. J Am Dent Assoc 1971;82:395-6.  Back to cited text no. 8
    
9.
Birk M, Bauerfeind P, Deprez PH, Häfner M, Hartmann D, Hassan C, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016;48:489-96.  Back to cited text no. 9
    
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ElBadrawy HE. Aspiration of foreign bodies during dental procedures. J Can Dent Assoc 1985;51:145-7.  Back to cited text no. 10
    
11.
Bains R, Loomba K. Accidental swallowing of endodontic instrument: Could be a medical emergency. European J Gen Dent 2014;3: 202-4.  Back to cited text no. 11
    
12.
Parolia A, Kamath M, Kundubala M, Manuel TS, Mohan M. Management of foreign body aspiration or ingestion in dentistry. Kathmandu Univ Med J (KUMJ). 2009;7:165-71.  Back to cited text no. 12
    
13.
Obinata K, Satoh T, Towfik AM, Nakamura M. An investigation of accidental ingestion during dental procedures. J Oral Sci 2011;53:495-500.  Back to cited text no. 13
    
14.
Ulusoy M, Toksavul S. Preventing aspiration or ingestion of fixed restorations. J Prosthet Dent 2003;89:223-4.  Back to cited text no. 14
    
15.
Milton TM, Hearing SD, Ireland AJ. Ingested foreign bodies associated with orthodontic treatment: Report of three cases and review of ingestion/aspiration incident management. Br Dent J 2001;190:592-6.  Back to cited text no. 15
    
16.
Heimlich HJ. The Heimlich maneuver: Prevention of death from choking on foreign bodies. J Occup Med 1977;19:208-10.  Back to cited text no. 16
    
17.
Webb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988;94:204-16.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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