PEAK. Accidental ingestion of a hypodermic needle during root canal treatment: a case report

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1 PEAK Accidental ingestion of a hypodermic needle during root canal treatment: a case report Vaibhav Jain, BDS Abhishek Dubey, BDS Jitendra Kumar, BDS Sonal Srivastava, BDS Manaswita Tripathy, BDS This PEAK article is a special membership service from RCDSO. The goal of PEAK (Practice Enhancement and Knowledge) is to provide Ontario dentists with key articles on a wide-range of clinical and non-clinical topics from dental literature around the world. PLEASE KEEP FOR FUTURE REFERENCE. Supplement to November/December 2015 issue of Dispatch magazine

2 Reprinted with permission from General Dentistry, September/October On the web at Academy of General Dentistry. All rights reserved. Foster Printing Service: , Accidental ingestion of a hypodermic needle during root canal treatment: a case report This atypical case report describes the accidental swallowing of a hypodermic needle by a patient during root canal treatment. The needle was safely removed by gastrointestinal endoscopy after 24 hours, but the incident emphasizes the need for rubber dam placement and proper vigilance during all endodontic and restorative procedures to prevent such events, which can be lifethreatening or fatal. This case report also guides clinicians in the steps that must be followed if such an accident occurs. Despite the best efforts of dentists as they perform procedures, certain materials may fall into the oropharynx of the patient, creating the risk of swallowing or aspiration. Today many dentists prefer sit-down dentistry, in which the patient is in a supine or semisupine position during treatment; this positioning has increased the possibility of such occurrences. 1 Any foreign body can be aspirated or ingested. Aspirated foreign bodies can cause serious complications, such as sudden choking and asphyxia, whereas ingested foreign bodies generally pass spontaneously through the gastrointestinal (GI) tract and do not result in any complications. However, very sharp or pointed objects may cause perforations along the gastrointestinal tract. According to Ozkan et al, foreign body ingestion has a complication rate of less than 1% but may lead to perforation associated with peritonitis. 2 These cases mostly require surgical intervention. Ingested foreign bodies also can migrate from the esophagus to the thorax and mediastinal space and may lead to life-threatening complications such as pneumothorax, mediastinitis, pericarditis, pulmonary complications, and vascular injuries

PRACTICE ENHANCEMENT AND KNOWLEDGE A B Fig. 1. A. Radiograph of the lateral cervical spine. B. Radiograph of the chest. This case report describes the ingestion of a hypodermic needle used Fig. 2.

Finally, it was decided to use flexible for irrigation of root canals and its digital lateral cervical radiograph and retrieval from the stomach using flexible an anteroposterior chest radiograph to

This flexible endoscope is This article also emphasizes the use of to the ear, nose, and throat department usually used for locating lesions, tumor proper preventive measures, such as of the college

3 PRACTICE ENHANCEMENT AND KNOWLEDGE A B Fig. 1. A. Radiograph of the lateral cervical spine. B. Radiograph of the chest. This case report describes the ingestion of a hypodermic needle used Fig. 2. Anteroposterior radiograph of the abdomen. immediate trauma caused by the needle. The patient was advised to obtain a explored to rule out any likelihood that the needle was hidden there. Finally, it was decided to use flexible for irrigation of root canals and its digital lateral cervical radiograph and retrieval from the stomach using flexible an anteroposterior chest radiograph to fiber-optic GI endoscopy to examine the fiber-optic GI endoscopy after 24 hours. locate the needle. He was then referred upper GI tract. This flexible endoscope is This article also emphasizes the use of to the ear, nose, and throat department usually used for locating lesions, tumor proper preventive measures, such as of the college for further intervention. masses, obstructions, or foreign bodies rubber dam placement, and provides The chest radiograph and lateral cervical in the upper GI tract. The patient was the protocol for treatment that should spine radiograph did not show any stable throughout the procedure and did be followed if an incident of foreign body evidence of the needle in the oropharynx, not develop any complications. The GI aspiration or swallowing occurs. larynx, esophagus, trachea, bronchi, or endoscopy showed no evidence of the lungs (Fig. 1). The absence of the needle needle in the oropharynx, supraglottic Case report in both radiographs suggested that the area, or esophagus (Fig. 3A). A small A 26-year-old man was referred to the needle had moved down the esophagus, ulceration, cm, was noted near Department of Oral and Maxillofacial so an anteroposterior abdominal the upper esophageal sphincter; this Surgery of KVG Dental College & radiograph was advised. However, even lesion might have been caused by the rigid Hospital, Sullia, India, with the complaint an abdominal radiograph failed to show esophagoscope used earlier (Fig. 3B). of accidental swallowing of the 23-gauge any evidence of the needle, which can be The endoscope was advanced hypodermic needle during a root canal explained by the superimposition of high- into the stomach, and the needle was treatment procedure. The patient density vertebrae (Fig. 2). discovered embedded in the thick wall of the stomach (Fig. 3C). The needle allegedly swallowed the needle, which Because the radiographs failed to had detached from the syringe during locate the position of the needle, direct was covered with food particles. It was irrigation of the root. The general exploration of the oropharynx and retrieved with the help of an endoscopy- condition of the patient was good; he esophagus with rigid esophagoscopy was assisted tissue punch, usually used for was conscious, cooperative, and alert. planned. The patient was administered obtaining a biopsy specimen. The needle He did not present any signs of choking general anesthesia for the procedure, was bent at about 80 degrees, which is or difficulty in breathing. No bleeding which was inconclusive the needle still usually done to facilitate irrigation of root was reported from the throat or in could not be located. The dead spaces canals (Fig. 3D). No bleeding from the the saliva, ruling out the possibility of such as the piriform fossae were also tissue-punched site was observed. 3

A B C D Fig. 3. Views during gastrointestinal endoscopy. A. Supraglottic area. B. Upper esophageal sphincter. C. Stomach lining with needle. D. Retrieved needle.

Document every step to avoid medicolegal complications The patient was comfortable and was discharged after being kept under observation for 24 hours.

is found, reassure patient and resume treatment This case report serves as a reminder to all dental staff and emphasizes the STOP TREATMENT IMMEDIATELY Start basic life support and summon emergency

surgically, and ensure patient is risk free Assess general condition of patient and check for signs of active bleeding If patient is asymptomatic Locate foreign body using cervical radiograph/chest

4 A B C D Fig. 3. Views during gastrointestinal endoscopy. A. Supraglottic area. B. Upper esophageal sphincter. C. Stomach lining with needle. D. Retrieved needle. CHART: Management protocol for a foreign body missing from the oral cavity. Document every step to avoid medicolegal complications The patient was comfortable and was discharged after being kept under observation for 24 hours. Discussion Any foreign body that goes missing from oral cavity Spit out by patient Aspirated by patient Ingested by patient Search for foreign body in nearby surroundings and cuspidor If foreign body is found, reassure patient and resume treatment This case report serves as a reminder to all dental staff and emphasizes the STOP TREATMENT IMMEDIATELY Start basic life support and summon emergency services Assess general condition of patient and ensure patent airway If patient is choking and exhibits signs of asphyxia If patient is asymptomatic Retrieve foreign body endoscopically or surgically, and ensure patient is risk free Assess general condition of patient and check for signs of active bleeding If patient is asymptomatic Locate foreign body using cervical radiograph/chest radiograph/ct/mri/endoscopy Discharged in stool of patient need to take proper precautions and pay close attention during any procedure. Momentary carelessness can result in serious complications for both the patient and dentist. Any foreign body that goes missing from the oral cavity can follow 1 of 3 paths: expulsion, aspiration, or ingestion. The Chart explains the protocol that must be followed if such an accident occurs. To avoid medicolegal complications, it is important to document every step taken to retrieve the foreign body in a systematic manner. According to the reported literature, the majority of foreign bodies pass harmlessly through the GI tract, and conservative management with watchful clinical and radiological observation is generally recommended; 10% to 20% of swallowed foreign bodies require nonoperative intervention such as endoscopy, and only about 1% require surgery. 2,7-9 According to the American Society for Gastrointestinal Endoscopy (ASGE), surgical intervention should be considered if an object has failed to progress along the tract after 3 days, and the patient should be advised to report vomiting, abdominal pain, elevated temperature, hematemesis, or melena immediately. 10 The ASGE also reported that emergency endoscopic intervention is required in cases of sharp foreign body ingestion, because the risk of complication is as great as 35% when a sharp object has been swallowed. 10 In the present case report, the needle had penetrated the patient s stomach lining. This situation could have led to local inflammation, pain, bleeding, scarring, and obstruction, or the needle could have eroded through the GI tract. 4

5 Spitz and Gracia et al reported that the duodenum is the most common site of perforation secondary to foreign body ingestion, whereas MacManus identified the ileocecal region as the most common site As in the present case, plain radiography sometimes is not effective in localizing radiopaque objects. Computed tomography or magnetic resonance imaging is indicated in such cases to enhance the detection of foreign bodies or complications (eg, perforations or migrations). 14 The incident described in the present case report suggests that rubber dam should be used in all endodontic and restorative procedures to provide a sterile operating field and to avoid the risk of inhalation or ingestion. Barkmeier et al emphasized the importance of using rubber dam and oral packing to minimize the occurrence of swallowed foreign objects. 15 Sit-down dentistry, in which the patient lies in a supine or semisupine position, considerably increases the risk that instruments, files, restorations, and other foreign objects will directly enter the oropharynx. Therefore, the clinician should observe greater caution when treating a patient lying in a supine or semisupine position. Foreign body aspiration can be fatal, so every dentist should be aware of basic life support steps, and all dental offices should develop and practice emergency response protocols. Jevon and Haas have provided sound guidelines for managing medical emergencies in the dental office and the professional responsibilities of dental practitioners. 16,17 Ingested foreign bodies mostly do not cause any complication and are discharged safely through the patient s stools, but the possibility of complications such as abscess, fistula, peritonitis, and septicemia should never be ignored. 18 Conclusion The majority of ingested foreign bodies pass spontaneously and do not cause any severe complications. However, careful clinical and radiographic monitoring of the patient is advised until the foreign body is eliminated from the body. Possible complications such as perforation, migration, and vascular injuries should always be kept in mind. 6 The clinician should ensure that the foreign object has left the body and the patient is completely healthy before discharge. All efforts should be made to prevent such accidents, and rubber dam or at least oral packing with gauze should be applied before any procedure such as endodontic treatment. It is also advisable to use locking syringes to prevent detachment of the needle from the syringe during injection. Most important, dentists should be vigilant at all times during procedures. Author information Drs. Jain, Kumar, Srivastava, and Tripathy are postgraduate students, KVG Dental College & Hospital, Sullia, India. Dr. Dubey is a postgraduate student, Dayananda Sagar College of Dental Science, Bangalore, India. 5

6 References 1. Malamed SF. Medical Emergencies in the Dental Office. 7th ed. St. Louis: Elsevier Mosby; 2014: Ozkan Z, Kement M, Kargi AB, et al. An interesting journey of an ingested needle: a case report and review of the literature on extra-abdominal migration of ingested foreign bodies. J Cardiothorac Surg. 2011; 6: Ghimire A, Bhattarai M, Kumar M, Wakode PT. Descending necrotizing mediastinitis: a fatal complication of neglected esophageal foreign body. Kathmandu Univ Med J (KUMJ). 2007;5(1): Kunishige H, Myojin K, Ishibashi Y, Ishii K, Kawasaki M, Oka J. Perforation of the esophagus by a fish bone leading to an infected pseudoaneurysm of the thoracic aorta. Gen Thorac Cardiovasc Surg. 2008;56(8): Cekirdekci A, Ayan E, Ilkay E, Yildirim H. Cardiac tamponade caused by an ingested sewing needle. A case report. J Cardiovasc Surg (Torino). 2003;44(6): Vesna D, Tatjana A, Slobodan S, Slobodan N. Cardiac tamponade caused by migration of a swallowed sewing needle. Forensic Sci Int. 2004;139(2-3): Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995;41(1): Nandi P, Ong GB. Foreign body in the esophagus: review of 2394 cases. Br J Surg. 1978;65(1): Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc. 1983;29(3): ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6): Spitz L. Management of ingested foreign bodies in childhood. Br Med J. 1971;4(5785): Gracia C, Frey CF, Bodai BI. Diagnosis and management of ingested foreign bodies: a ten-year experience. Ann Emerg Med. 1984;13(1): MacManus JE. Perforations of the intestine by ingested foreign bodies. Am J Surg. 1941;53(3): Suita S, Ohgami H, Nagasaki A, Yakabe S. Management of pediatric patients who have swallowed foreign objects. Am J Surg. 1989;55(9): Barkmeier WW, Cooley RL, Abrams H. Prevention of swallowing or aspiration of foreign objects. J Am Dent Assoc. 1978;97(3): Jevon P. Updated guidance on medical emergencies and resuscitation in the dental practice. Br Dent J. 2012;212(1): Haas DA. Management of medical emergencies in the dental office: conditions in each country, the extent of treatment by the dentist. Anesth Prog. 2006;53(1): Govila CP. Accidental swallowing of an endodontic instrument. A report of two cases. Oral Surg Oral Med Oral Pathol. 1979;48(3):

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Suspected Foreign Body Ingestion

Teresa Liang Suspected Foreign Body Ingestion 1. General Presentation Background: Of more than 100,000 cases of foreign body ingestion reported each year in the United States, 80% occur in children, with