SciELO - Scientific Electronic Library Online

 
vol.38 número2Intoxicación por leche magnesia en una paciente pediátrica con constipación crónica: a propósito de un casoMedical expertise in social security decisions: an empirical analysis índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados

Revista

Articulo

Indicadores

Links relacionados

  • No hay articulos similaresSimilares en SciELO

Compartir


Medicina Legal de Costa Rica

versión On-line ISSN 2215-5287versión impresa ISSN 1409-0015

Med. leg. Costa Rica vol.38 no.2 Heredia jul./dic. 2021

 

Reporte de caso

Accidental ingestion of a three-way (air-water-spray) syringe tip during dental procedure recovered by gastroscopy: casereport

José Manuel Fernández Chaves1 

1 Specialist in Legal & Forensic Dentistry. Oral Surgery & Pathology. MSc. Health Services Administration. School of Dentistry, University of Costa Rica. Forensic Dentistry Unit, Department of Legal Medicine, Judicial Investigation Agency. Costa Rica. ORCID ID: https://orcid.org/0000-0001-6478-5407

Abstract

The ingestion or aspiration of dental material or instruments is one of the most feared complications in clinical dental practice, it can occur in both children and adults. The mouth is a moist, dark, small area; where the involuntary movements of the patient during the procedures and the small dimensions of the materials and instruments turn dental care into a challenge.

A swallowed or aspirated foreign body during dental treatment can result in serious complications and even death, these depend largely on the shape, size and anatomical pathway through which it passes.

This article describes an uncommon complication of which there is only one report in the literature worldwide, the ingestion of the tip of a triple syringe during a routine dental procedure that was recovered by esophagogastroduodenoscopy. It also highlights the importance of knowing the protocols for handling aspirated or swallowed foreign bodies where a fast and adequate approach during the first minutes can make the difference between life and death.

Keywords: Ingestion; accidental; aspiration; triple syringe; dental treatment; gastroscopy.

Introduction

In the literature there are many reports of ingestion or aspiration of foreign bodies during the performance of dental procedures, one of the first authors to describe them was Grossman in 1971 who defined that at that time 87% corresponded to swallowing and 13% to aspirations. (1) The frequency with which it can occur in daily clinical practice, according to the literature ranges from 0.0041 to 0.0044%. (2-4)

Objects such as endodontic files,(5-7) dental implants and/or components,(8) drillbits,(9) crowns,(10) orthodontic brackets and wires,(11)(12) parallelism pins,(13) fixed bridges,(12)(14) molar bands,(15) endodontic irrigation syringe tips,(16) dentalmirrors,(17) Erich arches,(18) are mentioned within the foreign bodies and there is a single case report of ingestion of a triple syringe tip.(19)

Ingested foreign bodies can be classified into: round, sharp or pointed objects, long, food bolus and others; according to the Clinical Guide of Endoscopy of the European Society of Gastrointestinal Endoscopy (ESGE) (20) (Table 1).

Table 1 Classification of ingested foreign bodies according to the ESGE. 

Type of object Examples
Round objects coin, button, toy, batteries or magnets
Sharp or pointed objects Fine objects: needle, toothpick, pins, bones, pieces of glass Irregular sharp objects: partial dental prosthesis, razor blade
Long objects Soft objects: laces, ropes Hard objects: toothbrush, cutlery, screwdrivers, pencils or pens
Alimentary bolus With or without bones
Other Illegal drug packages

The literature establishes that approximately 90% of objects can cross the gastrointestinal tract without producing major complications, 10% require recovery by endoscopy and less than 1% require surgical approach. (1)(4)(4)(20)

Some dental implements developed to isolate the field of work such as the rubber dam decrease the possibility of ingestion or aspiration of foreign bodies, however it is not always possible to perform this type of isolation. (21)

There are multiple variables that can increase the degree of difficulty of a procedure such as the age of the patient, the area to be treated, the type of procedure, the use of sedation, systemic conditions, etc. These variables together with the degree of experience have been described in this type of complication, however there is controversy in the studies because the information has been collected incompletely, this problem is presented in the same way in the dental records in Costa Rica both in physical and digital formats according to previous studies. (23)(24)

A review of 617 cases of aspiration and ingestion of foreign bodies, showed that in the different areas of dentistry the majority of ingestions correspond to Prosthodontics, secondly to Endodontics, in third place Restorative and in fourth place Oral Surgery, however the largest number of cases of aspiration reported corresponds to Implantology. (25)

Methodology

The case of a female evaluated in the Forensic Dentistry Unit of the Department of Legal Medicine is described together with a review of the literature. An extensive search was carried out in the following databases: PubMed, Scielo, ClinicalKey and Cochrane Library, using as filters "accidental", "ingestion","aspiration", "foreing bodies" and "dental ". Articles in English related to the ingestion or aspiration of foreign bodies during dental procedures were selected.

Case Presentation

A 16-year-old female presented herself to a consultation for a routine dental cleaning. During the procedure the operator used the spray to clean the oral cavity and the tip of the triple syringe came off and was swallowed by the user.

The patient did not show at that time any signs of respiratory distress, the procedure was being carried out in an hospital dentistry service so she was immediately transferred to radiology where a simple x-ray of the abdomen was performed, the foreing body was located in the gastrointestinal area. (Figure 1).

Later she was transferred to another hospital where she underwent an emergency esophagogastroduodenoscopy where the foreign body was recovered without the need for surgical procedures, no lesions were reported in the gastroesophageal mucosa (Figure 2).

Discussion

Among the multiple articles that report ingestion or aspiration of foreign bodies during dental treatment (1-23), there is only one report in addition to this article of a component of dental equipment as such, specifically a triple syringe tip(19).

Figure 1 Simple x-ray of the abdomen where the location of the foreign body at the gastrointestinal level is confirmed. 

Figure 2 Esophagogastroduodenoscopy, note the presence of the triple syringe tip at the duodenal level 

A triple syringe tip that is used for cleaning with water, spraying or air drying; it is just over eight centimeters in length (Figure 3), is made of stainless steel and has a pointed end that makes up the coupling (Figure 4) that is inserted into the handle of the syringe designed to be held under pressure by a retractable system that makes it easily removable to change it between the care of one patient and another (Figure 5).

Figure 3 Triple syringe tip 

Figure 4 Triple syringe tip coupling 

Figure 5 Retractable fastening system, arrows indicate where the ring should be pushed. 

Figure 6 Diagram of correct installation of a triple syringe tip (29

Figure 7 Water and air buttons 

Improper placement (Figure 6),wear and tear of the equipment, the use of an incompatible tip or the inadvertent manipulation of the retractable system can easily cause the device to disconnect during dental treatment, especially due to the pressure that is released by pressing the water and air buttons together to generate spray (Figure 7); however, it is difficult to establish which variables occur at the intraoperative level in a specific case.

The wide variety of instruments and materials required to perform dental procedures mean that although this complication is infrecuent, (2-4) all treatments require a high degree of attention to prevent these events from resulting in endoscopic (26) or surgical procedures such as laparotomies, lung resections and even death. (25)

On the otherhand, it is worth noting that although there are only two cases worldwide reported on the ingestion of a triple syringe tip, it is necessary to incorporate within the care protocols, the verification of the proper functioning and condition of the dental equipment, especially in components that are removable and can be detached during a treatment. (26)(28).

Recommendations

Among the recommended measures to follow in case of ingestions or aspirations during the dental consultation are:

  1. Have a previously established protocol that involves dental professionals, dental assistants and administrative staff that allows to react promptly and effectively.

  2. Verification of the condition of dental instruments and equipment as part of a periodic maintenance protocol that seeks the satisfaction of users. (29)

  3. It is specifically advisable to check the proper placement and functioning of the tip of the triple syringe outside the mouth of the patient before using air, water or spray.

  4. Staff update on the management of airway obstructions by foreign bodies and cardiopulmonary resuscitation.

  5. Prior coordination with nearby hospital centers that can provide prompt care in the event that an emergency transfer is required.

Informed consent

The mother of the patient signed the informed consent and requested this case be published to raise awareness among the personnel who provide dental services and prevent this type of situation from recurring.

Bibliography

1. Grossman LI. Prevention in endodontic practice. J Am Dent Assoc [Internet]. 1971;82(2):395-6. Available from: http://dx.doi.org/10.14219/jada.archive.1971.0052 [ Links ]

2. Kenichi Obinata, Takafumi Satoh AMT and MN. An investigation of accidental ingestion during dental procedures. J Oral Sci. 2011;53(4):495-500. [ Links ]

3. Hisanaga R, Takahashi T, Sato T, Yajima Y, Morinaga K, Ohata H, et al. Accidental Ingestion or Aspiration of Foreign Objects at Tokyo Dental College Chiba Hospital over Last 4 Years. Vol. 55, Bull Tokyo Dent Coll. 2014. [ Links ]

4. Hisanaga R, Hagita K, Nojima K, Katakura A, Morinaga K, Ichinohe T, et al. Survey of Accidental Ingestion and Aspiration at Tokyo Dental College Chiba Hospital. Bull Tokyo Dent Coll. 2010. [ Links ]

5. Taintor JF, Biesterfeld RC. A Swallowed Endodontic File: Case Report. J Endod. 1978;4(8):254-5. [ Links ]

6. Lambrianidis T, Beltes P. Accidental swallowing of endodontic instruments. Endod Dent Traumatol. 1996;12(6):301-4. [ Links ]

7. Thakral A, Sen S, Singh VP, Ramakrishna N, Mandlik VB. Aspiration of an endodontic file. Med J Armed Forces India. 2015 Dec 1;71:S509-11. [ Links ]

8. Jain A, Baliga SD, Jain A. Accidental Implant Screwdriver Ingestion: A Rare Complication during Implant Placement [Internet]. Vol. 11. 2014. Available from: www.jdt.tums.ac.ir [ Links ]

9. Kunaparaju K, Shetty K, Jathanna V, Nath K. Endoscopic retrieval of an accidentally ingested bur during a dental procedure: a case report. Available from: https://doi.org/10.1186/s13037-020-00273-3 [ Links ]

10. Mark NM, Lessing JN, Ak C ¸ Oruh Md B‚. Crowning achievement: a case of dental aspiration Case report. 2015 [cited 2021 May 31]; Available from: http://dx.doi.org/10.1016/j.radcr.2015.09.001 [ Links ]

11. Puryer J, Mcnamara C, Sandy J, Ireland T. An Ingested Orthodontic Wire Fragment: A Case Report. Available from: www.mdpi.com/journal/dentistry [ Links ]

12. Venkataraghavan K, Anantharaj A, Praveen P, Rani SP, Krishnan BM. Accidental ingestion of foreign object: Systematic review, recommendations and report of a case [Internet]. Vol. 23, Saudi Dental Journal. Elsevier; 2011 [cited 2021 May 31]. p. 177-81. Available from: /pmc/articles/PMC3723260/ [ Links ]

13. Ramaraj P, Ajeya Ranganathan H, Nithin V, Lakshmi G. Accidental intraoperative ingestion of a paralleling pin during implant placement. J Indian Soc Periodontol [Internet]. 2020 Jul 1 [cited 2021 May 31];24(4):383-6. Available from: /pmc/articles/PMC7418543/ [ Links ]

14. Mahmoud M, Imam S, Patel H, King M. Case Report Foreign Body Aspiration of a Dental Bridge in the Left Main Stem Bronchus. Case Rep Med. 2012;2012. [ Links ]

15. Mahto RK, Rana SS, Kharbanda OP. Accidental swallowing of a molar band. Turkish J Orthod. 2019;32(2):115-8. [ Links ]

16. Govila CP. Accidental swallowing of an endodontic instrument. A report of two cases. Oral Surgery, Oral Med Oral Pathol. 1979;48(3):269-71. [ Links ]

17. Shetty UA, Naik S, MD’Cruz A, Jayanth S, Maben S. Accidental ingestion of mouth mirror head- Unforeseen experience in dental practice. Int J Dent Res. 2018;3(1):3-5. [ Links ]

18. Mahashweta Nag, ajeev Pandey, Varun Arya RK. Case Report Accidental ingestion of segment of an Erich bar: An unusual case report. J Res Dent Sci. 2019;10(1):165-9. [ Links ]

19. 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 [Internet]. 2016;48:489-96. Available from: http://dx.doi.org/ [ Links ]

20. Susini G, Pommel L, Camps J. Accidental ingestion and aspiration of root canal instruments and other dental foreign bodies in a French population. Int Endod J. 2007;40(8):585-9. [ Links ]

21. Madarati A, Abid S, Tamimi F, Ezzi A, Sammani A, Abou Al Shaar MB, et al. Dental-dam for infection control and patient safety during clinical endodontic treatment: Preferences of dental patients. Int J Environ Res Public Health [Internet]. 2018 Sep 14 [cited 2021 May 31];15(9). Available from: /pmc/articles/PMC6165332/ [ Links ]

22. Libânio D, Garrido M, Jácome F, Dinis-Ribeiro M, Pedroto I, Marcos-Pinto R. Foreign body ingestion and food impaction in adults: better to scope than to wait. United Eur Gastroenterol J. 2018 Aug 1;6(7):974-80. [ Links ]

23. Hernández Carazo D, Solano Romero K, Torres Guevara E, Trejos Cisneros JJ, Fernández Chaves JM. Determinación de la simbología más utilizada en expedientes odontológicos en Costa Rica en el año 2019 con fines de identificación de seres humanos. Med leg Costa Rica. 2020;37(1):179-91. [ Links ]

24. Fernández Chaves JM. Utilidad de expedientes odontológicos disponibles en Costa Rica en el año 2018 para la identificación de víctimas de desastres según el protocolo de INTERPOL. Med Leg Costa Rica. 2019;36(1):32-42. [ Links ]

25. Hou R, Zhou H, Hu K, Ding Y, Yang X, Xu G, et al. Thorough documentation of the accidental aspiration and ingestion of foreign objects during dental procedure is necessary: review and analysis of 617 cases. 2016; [ Links ]

26. Tsitrou E, Germanidis G, Boutsiouki C, Koulaouzidou E, Koliniotou-Koumpia E. Accidental ingestion of an air-water syringe tip during routine dental treatment: a case report. J Oral Sci. 2014;56(3):235-8. [ Links ]

27. Silva RF. Retrieving dental instruments through endoscopy: A literature review. World J Stomatol. 2015;4(4):137. [ Links ]

28. Kalenderian E. Lessons learnt from Dental Patient Safety Case Reports. 2015; [ Links ]

29. Fernández Chaves JM. Evaluación de la satisfacción de los usuarios con la atención recibida en la Unidad de Odontología Forense del Departamento de Medicina Legal del Organismo de Investigación Judicial en el segundo semestre del 2018. Med leg Costa Rica. 2020;37(1):162-78. [ Links ]

30. Catalog AD. 2021 Authorized Dealer Catalog Q1 Edition - View current catalog online [Internet]. 2021. Available from: https://www.a-dec.com/resource-center [ Links ]

1Source: DeCS (Descriptors in Health Sciences)

Received: July 13, 2021; Accepted: August 16, 2021

Correspondence:Dr. José Manuel Fernández Chaves1 -- jfernandezch@poder-judicial.go.cr

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License