Author: Dr. Ashok Kumar, Dr Syed Mukhtar-Un-Nisar Andrabi, Dr Sharique Alam.
Aligarh Muslim University, Aligarh, India.

ABSTRACT:

Aim: to report the conservative management of an accidentally ingested endodontic file which went into the gastrointestinal tract.

Summary: We report the conservative management of an accidentally ingested no.30k file by a 9year old patient during the endodontic treatment of tooth no. 36 in which rubber dam isolation was not used owing to the grossly decayed nature of the tooth. The ingested file passed out uneventfully within 30 hours after ingestion, while patient was kept under supervision throughout the period and periodic radiographs followed the progress of the instrument within the gastrointestinal tract.

Key learning points:

1. Ingestion of the endodontic instruments must be prevented by using rubber dam isolation for every case.
2. Whenever an instrument is ingested immediate endoscopic assessment and retrieval is indicated as long as the instrument is within the oesophagus.
3. Once the instrument crosses the pylorus a conservative approach is advocated with periodic radiographs and clinical assessment.
4. Surgery may be needed if the instrument gets lodged or if perforation develops.

INTRODUCTION:

Accidental ingestion of a foreign body can be commonly seen in children. In adults it can be seen in mentally impaired or patients with alcohol dependency or as intentional foreign body ingestion in prisoners or psychiatric patients (Pavlidis et al 2008). Dental and surgical procedures in the oral cavity can also sometimes lead to a foreign body ingestion or aspiration. Materials swallowed or aspirated during dental treatment can include teeth, restorations, restorative materials, endodontic instruments, implant parts, rubber dam clamps, gauze packs and impression materials. Intraoperative aspiration/ingestion of endodontic instrument can occur when rubber dam isolation is not done. Isolation by rubber dam not only maintains a sterile moisture free operating field but also prevents any accidental slippage of instruments into the oesophageal or tracheal tract. Rubber dam isolation is mandatory during every endodontic procedure (Cohen S, Schwartz SF 1987), however certain condition like nasal obstruction, grossly decayed teeth and presence of intraoral swelling may not be convenient for placement of rubber dam and the dentist may electively chose to work without its placement.

Most of the ingested foreign bodies pass through the gastrointestinal tract uneventfully, but chances of complications are more with long sharp objects. The risk of complications is increased with long sharp metal objects and animal bones, and may be higher in patients with adhesions due to prior abdominal surgery. Pre-existing intestinal disease such as Crohn’s disease or intestinal stenosis may predispose to complications (Venkataraghavan K et al 2010).This case report discusses the conservative management of an accidentally ingested no. 30Kfile by a paediatric patient during an endodontic treatment procedure in which rubber dam placement was not undertaken.

CASE REPORT:

A 9 year old girl reported to the Department of Conservative Dentistry and Endodontics, Dr Z.A Dental College, A.M.U, Aligarh, India, on 7th June 2010, with the chief complain of pain and swelling in lower left back region of the oral cavity since 2 days. On examination tooth no.36 was found grossly decayed and also there was an intraoral swelling involving the buccal vestibule. Endodontic treatment of the tooth was planned but the rubber dam was not placed due to the presence of intraoral swelling and the grossly decayed nature of tooth. During the cleaning and shaping process accidental slippage of 21mm no. 30k file occurred. The patient suddenly lurched forward and swallowed the file. Soon after the ingestion, patient complained of gagging and piercing sensation along the oropharynx. Immediate attempt to retrieve the file by patting the back of the patient in a head down position was made, but the attempt was unsuccessful. The patient was shifted to emergency surgical unit of the college hospital immediately. A specialist team of otorhinolarngologist were called, they suspected the instrument to be lodged in the upper pharynx and made attempts to visualise and retrieve the instrument, and however the instrument couldn’t be retrieved. PA- and lateral view x-rays of neck and chest was taken which revealed that the instrument was not lodged into the airways (fig.1). Abdominal x-ray revealed that the instrument was ingested and was present within the fundal part of the stomach (fig.2a-b). The patient was admitted in the hospital for monitoring by the gastroenterologist who suggested a wait and watch approach in the hope of its uneventful passage through the gastrointestinal tract before planning any endoscopic or surgical intervention. The parents were instructed to observe the stool of the patient to check for the passage of the endodontic instrument. The parents were also advised to give bulky diet to the patient

A follow up lower abdominal radiograph was taken in the morning of the following day (8th June 2010) which revealed that the instrument had passed into the sigmoid colon (fig.3a-b). The patient had remained asymptomatic and had slept uneventfully during this period. During the evening evaluation of the patient the same day (8th June) the parents of the patient reported the passage of the instrument in the stool of the patient. This they reported to have occurred at about 30 hrs after the ingestion of the endodontic file. A follow up lower abdominal radiograph was taken to confirm the finding which did not reveal the presence of the instrument.

Fig.1a-b. PA-& lateral view of the neck showing no presence of the instrument within the airways or upper gastrointestinal tract.

Fig.2a-b. Abdominal x-ray showing the presence of the endodontic file in the fundal part of the stomach.

Fig.3a-b. Lower abdominal x-ray showing the instrument has passed to the sigmoid colon

DISCUSSION:

Aspiration and ingestion of dental instruments have been underreported due to the reticence of the dentist in reporting such cases. Susini and camps (2007) has reported the occurrence of ingestion of endodontic instrument as 0.08 cases per 100,000 root canals and that of aspiration of endodontic instrument as 0.0009 cases per 100,000 root canal therapies.

Endodontic instruments being long and sharp are liable to lodge within the alimentary tract and cause complications (dhanpandani et al 2009).

Lodgement of the instrument within the duodenum or colon may lead to peritonitis (Goulschim JP & Heling B. 1971) or acute appendicitis if it is lodged in the caecum (Barkeimer WW & Cooley RL 1978). The risk of perforation is more in patients with previous gastro-intestinal tract surgery or congenital gut malformations. The most common sites of perforation are the lower oesophagus and terminal ileum. Perforation is caused by direct penetration or pressure necrosis due to prolonged lodgement (Weiland et al 2002). Perforation of the gastrointestinal tract may not present with any abdominal symptoms so evaluation of the patient along with the assessment of the passage of the instrument through the gastrointestinal tract must be done and surgical intervention if required must be planned accordingly. Endoscopy or surgical intervention must be undertaken if patient develops significant symptoms or if the instrument lodges in the gastrointestinal tract and doesnot progress over time (Uyemura 2006). It has been reported that in a vast majority of cases instrument will pass out uneventfully through the stool (Tuiki et al 1981). An endodontic file can pass through the gastrointestinal tract asymptomatically and apparently atraumatically within 3 days (Kuo and Chen, 2008). However whenever a sharp object has passed into the stomach or duodenum, immediately its endoscopic removal must be tried and if the endoscopic attempts of retrieval fail and/or the instrument progresses beyond the duodenum then the patient must be kept under strict supervision and daily radiographs must be taken. If the symptomatology of the patient worsens or a systemic sepsis develops a laparoscopic or an open surgical intervention may be required (Rodriguez et al 2008).

Aspiration or swallowing of the instruments during endodontic treatment can be prevented by using the rubber dam isolation during every endodontic treatment procedure. Rubber dam isolation has now become an essential prerequisite for every endodontic procedure. It isolates the root canal system from oral fluids and as well as prevents such unfortunate accidents as described in this case report.

CONCLUSION:

Aspiration or ingestion of the endodontic instruments must be prevented by following the recommended protocol of the treatment. The rubber dam isolation must be used in every procedure to be done. Incase such an untoward incident occurs a correct protocol to manage those patients must be followed and immediate medical help must be sought. Conservative management can be advocated if the instrument appears to progress in the gastrointestinal tract and periodic radiographic monitoring of the position of the instrument within the gastrointestinal tract must be done. Surgical intervention can be needed in case the instrument is lodged or there is perforation or development of peritonitis.

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