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   Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 24  |  Issue : 4  |  Page : 383-386  

Accidental intraoperative ingestion of a paralleling pin during implant placement


Department of Oral and Maxillofacial Surgery, KVG Dental College and Hospital, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India

Date of Submission06-Sep-2019
Date of Decision29-Dec-2019
Date of Acceptance20-Jan-2020
Date of Web Publication02-Jun-2020

Correspondence Address:
H K Ajeya Ranganathan
Department of Oral and Maxillofacial Surgery, KVG Dental College and Hospital, Sullia, Rajiv Gandhi University of Health Sciences, Bengaluru - 574 327, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_467_19

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   Abstract 


Foreign body ingestion although unusual may be possible during dental treatment when placing any implants, prosthetic crowns, restoration, endodontic treatment, or orthodontic treatment. When the ingestion occurs, it is always crucial to locate the foreign body within the patient's body by taking bi-planar radiographs. Any features of airway distress or obstruction should be ruled out and if it is located in the gastrointestinal (GI) tract, the nature and size of the material will decide the protocol of retrieval of the ingested object. However, there is always a risk of intestinal perforations or obstructions secondary to the ingestion. Here is a case report wherein there was an accidental ingestion of the paralleling pin during the first stage of the implant placement with indications of various GI investigations and recommendations to avoid instrument ingestion.

Keywords: Foreign body ingestion, gastrointestinal perforation, implant, paralleling pin


How to cite this article:
Ramaraj P N, Ajeya Ranganathan H K, Nithin V M, Lakshmi G V. Accidental intraoperative ingestion of a paralleling pin during implant placement. J Indian Soc Periodontol 2020;24:383-6

How to cite this URL:
Ramaraj P N, Ajeya Ranganathan H K, Nithin V M, Lakshmi G V. Accidental intraoperative ingestion of a paralleling pin during implant placement. J Indian Soc Periodontol [serial online] 2020 [cited 2020 Aug 4];24:383-6. Available from: http://www.jisponline.com/text.asp?2020/24/4/383/285703




   Introduction Top


Occasionally, the instruments slip off from operators' grip during a dental procedure which might enter the pharynx, resulting in respiratory distress or gastrointestinal (GI) disturbance. Most commonly ingested instruments include endodontic files/broaches, orthodontic brackets, and implant components.[1] Most of the radiopaque instruments are located radiographically, however, colonoscopic/bronchoscopic investigation and retrieval may be necessary if the material is radiolucent.[2],[3] The ingested instruments usually pass through uneventfully, but occasionally tend to get impacted at the ileo-cecal valve or recto-sigmoid junction, which might require an endoscopic or surgical intervention.[4],[5] We report a case of ingestion of a paralleling pin during bilateral implant placement with recommendation of few preventive techniques.


   Case Report Top


A male patient aged about 67 years with partially edentulous maxillary and mandibular arches presented to the department of oral and maxillofacial surgery for the implant-supported prosthesis. The patient was planned for implant-supported triple-unit bridge for the mandibular arch bilaterally from the first molar to the first premolar and interim denture for the maxilla due to excessive bone resorption in the maxillary arch.

Surgical phase of implant placement bilaterally was planned in a single visit. Insertion of two implants on the right side with alloplastic bone grafting was uneventful. While checking for the parallelism in the region of 34, the paralleling pin [Figure 1] accidentally slipped off the operator's hand and was ingested involuntarily by the patient. There were no signs of aspiration such as cough, chocking, or breathlessness. The patient was informed about the condition. The procedure was aborted, and efforts were made to locate the paralleling pin in the oral cavity. The patient was taken to the radiology department, and erect abdomen posteroanterior (PA) view was taken which revealed the pin in the esophago-gastric junction [Figure 2]. The patient was re-assured about the condition, and the procedure was resumed. The patient was put on high-fiber diet and laxatives, and X-ray was repeated after a week that revealed absence of the foreign body in the GI tract (GIT) suggestive of its safe exit [Figure 3]. The patient was followed up uneventfully for a week.
Figure 1: Prototype of the paralleling pin that was ingested

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Figure 2: X-ray PA Abdomen showing the ingested paralleling pin

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Figure 3: X-ray PA Abdomen with no paralleling pin after 1 week

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   Discussion Top


Whenever a foreign object enters into the system, the object will be constantly moving unless it has been impacted or locked into any particular structures such as valves and sphincters. However, the body as a reflex turns the blunt end of the instrument front so that the tissues encountered by the ingested instrument be guarded, and the potential damage to the lining of the tissue is still possible that would result in perforation of the structures.[1]

Accidental ingestion occurs mostly in children and elderly patients and those with mental disorders.[5] Patients with history of surgery for head and neck cancer, could experience paresthesia, rendering the patient imperceivable to the sensory stimulus resulting in the failure of reflexes such as coughing out or any other signs of respiratory distress.[6] In our case, the patient was bilaterally anesthetized, resulting in total anesthesia of tongue and floor of the mouth, which would probably have resulted in the failure perception of the foreign body in the mouth.

Management of the accidental ingestion of the instrument into the gastrointestinal tract or airway

When there is any accidental ingestion occurred during any dental procedure, the treatment should be stopped and the patient should be informed about the condition, and the general condition of the patient should be assessed. Airway of the patient should be assessed immediately and if any airway distress is noted, immediate measures should be taken to secure airways such as clearing any obstructions in the oral cavity, laryngeal mask airway, and endotracheal intubation.[7] Prompt attempt should be made to locate the ingested foreign body by taking radiographs such as chest X-rays PA and lateral and erect abdomen PA and lateral with computed tomography scan, if required. A contrast examination generally should not be performed because of aspiration risk, and contrast coating of the foreign body and esophageal mucosa can compromise subsequent endoscopy and if the material is radiolucent, bronchoscopy is required if the foreign body enters respiratory tract. Colonoscopy is warranted if the foreign body are ingested into the gastrointestinal tract to locate it in the patient's body. With suspected foreign body ingestion, persistent esophageal symptoms should be evaluated by endoscopy, even in the setting of a negative radiographic evaluation.[8]

The timing for the intervention for an ingested foreign body in the host depends on the age of the patient, nature of material ingested, the physical configuration of the ingested object and location of the object in the host body, and the duration of time elapsed since ingestion of the object. Most patients who are clinically stable without symptoms of high-grade GI obstruction do not require urgent endoscopy because the object will commonly pass spontaneously [Table 1]. There are many protocols in the management of the ingested foreign bodies during any dental procedures or accidents [Table 2][9] and safety recommendation to avoid such accidents [Table 3].
Table 1: Timing of endoscopy for ingested foreign bodies

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Table 2: Algorithm in decision-making for the management of foreign body ingestion[9]

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Table 3: Recommendations for a safe dental procedure

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Many nonendoscopic techniques may be used to retrieve the foreign body from the esophagus with the use of Foley's catheter balloon and nasogastric tube with outfitted magnet, however, there are chances of mucosal injury during retrieval. Whenever an ingested object is >2.5 cm in diameter, its passage through the pylorus is unlikely and has to be removed by colonoscopy. Any foreign body in the stomach for >3 weeks should be removed endoscopically. Surgical intervention may be indicated if the patient develops symptoms of peritonitis and if the object is inaccessible to the endoscope.

Finally, if an accidental event occurs, the operator should not panic and must remain calm and composed. Reassuring and comforting the patient is the most important and if any distress symptoms occur, prompt addressing of the symptoms should be initiated and the location of the foreign body should be identified immediately.

Proper documentation of the event, size, shape, type of the ingested foreign body/instrument, and written informed consent of the patient for further intervention toward the retrieval of ingested bodies is an absolute must-in-view of the medico-legal implications.


   Conclusion Top


During any dental procedure, instruments that are potentially ingested should always be used with precautions such as tethering them with the length of dental floss or suture materials and always place a gauze screen in the oropharynx region to shield the instruments from getting ingested. It is always better to anticipate the possibility of instrument ingestion and preventing it to happen. If such accident does occur, apt management protocol should be initiated and safety of the patient should be taken care of.

Ignoring the safety precautions and ending up in such mishaps could cause a serious medico-legal consequence and jeopardize the practice of the dentist.

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.
de Souza JG, Schuldt Filho G, Pereira Neto AR, Lyra HF Jr., Bianchini MA, Cardoso AC. Accident in implant dentistry: Involuntary screwdriver ingestion during surgical procedure. A clinical report. J Prosthodont 2012;21:191-3.  Back to cited text no. 1
    
2.
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. 2
    
3.
Ong TK, Lancer JM, Brook IM. Inhalation of a denture fragment complicating facial trauma. Br J Oral Maxillofac Surg 1988;26:511-3.  Back to cited text no. 3
    
4.
Pavlidis TE, Marakis GN, Triantafyllou A, Psarras K, Kontoulis TM, Sakantamis AK. Management of ingested foreign bodies. How justifiable is a waiting policy? Surg Laparosc Endosc Percutan Tech 2008;18:286-7.  Back to cited text no. 4
    
5.
Jain A, Baliga SD. Accidental implant screwdriver ingestion: A rare complication during implant placement. J Dent (Tehran) 2014;11:711-4.  Back to cited text no. 5
    
6.
El Wazani B, Nixon P, Butterworth CJ. Accidental ingestion of an implant screwdriver: A Case report and literature review. Eur J Prosthodont Restor Dent 2018;26:184-9.  Back to cited text no. 6
    
7.
ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011;73:1085-91.  Back to cited text no. 7
    
8.
Ginsberg GG. Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995;41:33-8.  Back to cited text no. 8
    
9.
Yadav RK, Yadav HK, Chandra A, Yadav S, Verma P, Shakya VK. Accidental aspiration/ingestion of foreign bodies in dentistry: A clinical and legal perspective. Natl J Maxillofac Surg 2015;6:144-51.  Back to cited text no. 9
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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