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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 3  |  Page : 165-169

Accidental ingestion of segment of an Erich bar: An unusual case report


Department of Oral and Maxillofacial Surgery, SGT University, Gurugram, Haryana, India

Date of Submission01-Aug-2019
Date of Acceptance30-Aug-2019
Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Rajeev Pandey
Department of Oral and Maxillofacial Surgery, SGT University, Gurugram, Haryana
India
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DOI: 10.4103/srmjrds.srmjrds_58_19

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  Abstract 

Accidental aspiration or ingestion during dental procedure is a rarely occurring phenomenon. It is considered as a potential health problem worldwide. Aspiration of dental instruments is rare but require immediate management because it can compromise airway. Ingestion although considered less dangerous, it can also lead to complex gastroenterological procedures due to intestinal perforation and obstruction. Here, we present an unusual case of ingestion of a segment of the Erich arch bar measuring about 4 cm during arch bar wiring in a trauma patient having mandibular fracture.

Keywords: Accidental, Erich arch bar, ingestion, mandibular trauma


How to cite this article:
Nag M, Pandey R, Arya V, Kashyap R. Accidental ingestion of segment of an Erich bar: An unusual case report. SRM J Res Dent Sci 2019;10:165-9

How to cite this URL:
Nag M, Pandey R, Arya V, Kashyap R. Accidental ingestion of segment of an Erich bar: An unusual case report. SRM J Res Dent Sci [serial online] 2019 [cited 2019 Nov 23];10:165-9. Available from: http://www.srmjrds.in/text.asp?2019/10/3/165/269220


  Introduction Top


Iatrogenic accidents are rare and unpredictable during the dental procedure. Aspiration or ingestion of dental instruments or armamentarium or materials forms a very dangerous situation, in which most cases require immediate attention and immediate management. It is more common in the following extreme age groups: very young or very old age groups, mentally retarded, persons with poor motor skills, alcoholics, anatomic variations such as cleft lip and palate patients, and high gag reflex patients.[1] Aspiration is rare but require immediate treatment to secure the airway and prevent chest infections. In most cases of ingestion, conservation treatment is recommended although few of them may require gastroenterologist intervention if size of the ingested material is large or it is sharp.[2] Common complication associated with ingested materials included intestinal perforation and obstruction.[2] The current case report highlights the ingestion of a segment of the Erich arch bar during dental procedure, which was measuring about 4 cm in length and 0.5 cm in width and stands as a rare case in the dental literature. The article also presents initial management strategies and various safety protocols for managing such events.


  Case Report Top


A 25-year-old male patient reported to the Emergency Department of SGT Hospital, Gurugram, Haryana, India, on May 27, 2019, with an alleged history of fall from a three-wheeler vehicle, while it had flipped on the road around 7 am in the morning. The patient reported to the department of oral and maxillofacial surgery 2 h later around 9 am. There was a history of oral bleed, but neither history of amnesia, loss of consciousness, ear or nasal bleed, nor vomiting. The patient was conscious, cooperative, and well oriented to time, place and complained of severe pain on the right side of his face. The Glasgow Coma Scale was 15/15. On local examination, two abrasions approximately measuring 2 cm × 2 cm × 0.1 cm each were present on the mastoid region and the angle region of the mandible on the left side. Diffuse swelling was present on the right side of his face and bilaterally over the preauricular region. Mouth opening was restricted, and step defect was observed in the 31, 32 regions along with segment mobility. Ellis Class II tooth fracture was present in relation to 11, 31, 32, 41, and 42. Noncontrast computed tomography of the face and head region was advised, and the final diagnosis of parasymphysis fracture of the left side of the mandible and ramus fracture of the right side of the mandible extending from the angle till the coronoid process [Figure 1] and [Figure 2]. Bridle wiring was done for the primary stability of the parasymphysis fracture on the left side. The patient was admitted in the ward, and antibiotics, analgesics, and intravenous fluids were started for the patient. The patient was planned for open reduction and internal fixation after arch bar wiring using the Erich arch bar.
Figure 1: Three-dimensional cone-beam computed tomography image showing parasymphysis fracture

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Figure 2: Three-dimensional cone-beam computed tomography image showing ramus fracture

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The arch bar wiring for maxillomandibular fixation was planned under local anesthesia. For maxilla, bilateral posterior superior alveolar nerve block, anterior superior alveolar nerve block, greater palatine nerve block, and incisive nerve block were given. For mandible, bilateral inferior alveolar nerve block, lingual nerve block, and long buccal nerve block were given.

After the placement of maxillary arch bar from 16 to 26, mandibular arch bar wiring was planned, and it was decided to place the split arch bar for the mandibular arch due to step deformity in 31 and 32 regions. First, the arch bar was placed over the greater segment from 46 to 31. While arch bar placement of the smaller segment from 32 to 36 was started a segment of arch bar consisting of six hooks was adapted, and a 26G wire was placed around 36 tooth for the arch bar. While the wire was being twisted, the patient suddenly started coughing, and the unstabilized arch bar segment slipped into the oropharynx while he came back to his semi-supine position. All attempt to locate the segment in the oral cavity failed, and it was assumed that the patient had either ingested or aspirated the wire segment. Clinically, aspiration was ruled out, as there was no coughing reflex and no breathing problem. All surgical procedures were stopped, and the patient was shifted to radiology for chest X-ray posteroanterior (PA) view to rule out aspiration and X-ray abdomen to confirm ingestion. Chest X-ray was clear [Figure 3], and the segment of the arch bar was detected in the X-ray abdomen [Figure 4]. The patient had no gastroenterological signs such as pain or any discomfort at that time. The patient was sent for urgent general surgery opinion and was advised conservation management and was started on soft high-fiber diet to aid in the passage of the arch bar through the intestinal tract.
Figure 3: Chest X-ray showing no foreign object

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Figure 4: Abdomen X-ray showing segment of arch bar in the abdomen

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Next day, the patient passed stools in the morning, and it was checked thoroughly, but arch bar segment was not retrieved. Twenty-four hours after the incident, suddenly the patient started complaining of sharp, shooting pain in the left lumbar region of the abdomen. Immediately, general surgery consultation was done. The general surgeon told that there was no evidence of any intestinal perforation or obstruction and injection diclofenac 75 mg intramuscularly was given to relief the patient of pain. Abdominal X-rays one at erect and one at supine positions were advised and obtained. Both the X-rays revealed the position of the arch bar in the jejunum of the small intestine on the left side [Figure 5] and [Figure 6]. During subsequent hours, the patient had shifting moderate pain in the lower back region, which was managed using painkillers and vitals were monitored. The patient was kept under strict observation of a general surgeon for immediate action if any emergency treatment required. Next day, 36 h after the incident, the patient passed stools, and on close inspection, the arch bar was egested uneventfully [Figure 7]. X-ray of the abdomen was repeated to confirm and to rule out any complication. The X-ray was clear [Figure 8].
Figure 5: Abdomen X-ray (supine) showing arch bar in the jejunum

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Figure 6: Abdomen X-ray (erect) showing segment of arch bar descended down

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Figure 7: Egested arch bar segment

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Figure 8: Abdomen X-ray (erect) showing no evidence of any foreign body (arch bar segment)

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After that, the patient had no complaints of abdominal tenderness or pain, vomiting, hematochezia, or melena. The patient was kept under the observation for the next 24 h to avoid any abdominal discomfort to the patient and the prevention of any unforeseen events. Next day, the patient underwent open reduction and internal fixation under general anesthesia for the management of mandibular fracture without any complication.


  Discussion Top


About more than 90% of foreign-body ingested comes out of the body uneventfully.[3] Basically, it depends on the size and shape of the objects. Small, round, and heavy objects will descend down the gastrointestinal tract (GIT) easily, whereas large, sharp, and complex-shaped objects will obstruct the GIT tract and may cause perforations. It has seen that 10% of ingested objects may require endoscopic intervention, and 1% may even require surgical intervention.[4] This case report is unusual as even after a thorough review of the literature not a single case has been reported accidental ingestion of the Erich arch bar measuring about 4 cm. The probable cause of this event may be because of the following:

  1. Bilateral upper and lower jaw local anesthesia leading to the loss of intraoral sensation by the patient leading to decrease gag reflex
  2. Supine position of the patient and sudden movements because of coughing reflex along with the loss of intraoral sensations due to local anesthesia.


This accidental case shows that aspiration or ingestion can happen with anyone at any time; hence, utmost precautions should be taken during any dental procedure inside the mouth. All items should be counted before the procedure and accounted for after the procedure. Any case of aspiration or ingestion require immediate medical intervention as in few cases it is life-threatening. The initial step is to recognize the situation followed by conforming it either as aspiration or ingestion situation. If clinical signs of aspiration, i.e., severe coughing reflex, choking, and cyanosis are present immediately, the Heimlich maneuver should be attempted. If the object is not dislodged, emergency expert medical intervention is indicated. Few cases may require even tracheostomy if total airway obstruction occurs. If no signs or symptoms occur, then the patient should be shifted to radiographical investigations in form of plain radiographs, including chest X-ray PA view and abdominal X-ray erect and supine.[5],[6] If dental object is aspirated, immediate endoscopic removal is recommended as rarely the aspirated object may spontaneously come out of the airway.

If the object ingested is sharp, complex-shaped or more 6.5 cm, and in the esophagus region, urgent endoscopic retrieval is indicated. Whereas, conservation management is recommended for all objects if the object has passed through the pylorus. In our case, also within minutes of the ingestion, X-ray of the abdomen showed that the arch bar segment had crossed the pylorus; therefore, conservation approach was followed after specialist opinion. It has seen that most objects take 2–4 days and some may even take 2 weeks to come out of the GIT tract. This can be followed if the patient remains asymptomatic, and routine plain X-rays are recommended to ensure there is no perforation or obstruction along with patient is passing proper gas and stools and no stomach ache or pain in the lower abdominal region or back region. Furthermore, stool should be checked each time for foreign body and occult blood. In our case, the patient had moderate pain from the 2nd day onward toward the lower back region, which was radiating down as the object was descending down due to this an emergency X-ray was done when pain started, and the patient was closely followed. Operation theater was prepared for any emergency procedure with a general surgeon in case any emergency arrives. It is said rightly that prevention is better than cure; therefore, all intraoral dental procedures should be done with utmost care during all steps or barriers should be done like gauze throat screen and use of rubber dam, use of floss ties (ligatures) to prevent this accidental situation.[7],[8] We recommend the use of floss tied arch bar for arch bar wiring patients to prevent similar accidents in the future [Figure 9].
Figure 9: Arch bar segment secured with dental floss to prevent accidental aspiration/ingestion

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  Conclusion Top


The clinical implication of this case report includes the prompt diagnosis leading to proper treatment and use of floss ligatures for all intraoral dental procedures where it is possible, especially for small and thin objects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bhatnagar S, Das UM, Chandan GD, Prashanth ST, Gowda L, Shiggaon N. Foreign body ingestion in dental practice. J Indian Soc Pedod Prev Dent 2011;29:336-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Fields RT Jr., Schow SR. Aspiration and ingestion of foreign bodies in oral and maxillofacial surgery: A review of the literature and report of five cases. J Oral Maxillofac Surg 1998;56:1091-8.  Back to cited text no. 2
    
3.
Prasad V. Accidental ingestion of foreign body in dental practice and its management. Int J Pedod Rehabil 2018;3:5-7.  Back to cited text no. 3
  [Full text]  
4.
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. 4
    
5.
Ismael G, Alameida LD, Lacerda TS. Prevention from swallowing or aspiration in dentistry for elderly patients. MOJ Gerontol Ger 2018;3:124-6.  Back to cited text no. 5
    
6.
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. Head Face Med 2016;12:23.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
  [Full text]  
8.
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. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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