| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Clinical Section |
Wythenshawe Hospital, Manchester, UK
Birmingham Dental Hospital, Birmingham, UK
Wythenshawe Hospital, Manchester, UK
Address for correspondence: Mr J. J. Allwork, FTTA, Orthodontics, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK. Email: john.allwork{at}smuht.nwest.nhs.uk
Received 13 June 2006; accepted 26 February 2007
 |
Abstract |
|---|
 Top Abstract IntroductionCase reportDiscussionConclusionsReferences |
|---|
Key words: Ingested orthodontic components, surgical intervention, special needs orthodontics
|
Introduction |
|---|
|
TopAbstractIntroductionCase reportDiscussionConclusionsReferences |
|---|
|
Case report |
|---|
|
TopAbstractIntroductionCase reportDiscussionConclusionsReferences |
|---|
The first appliance objective was to expand the upper arch with a removable quadhelix. This decision was made on the basis of the patient’s cardiac history requiring antibiotic prophylaxis; the ease with which the quadhelix could be disengaged, activated and reinserted without causing a bacteraemia and perceived patient tolerance.
The quadhelix was fastened by elastomeric separating rings, which were refreshed with new ones when the appliance was progressively expanded. Having been worn uneventfully for five months the removable component of the appliance dislodged from the sleeves welded to the molar bands and was accidentally swallowed while the patient was eating yoghurt for breakfast at school.
The boy and his mother promptly attended the orthodontic department. He presented without any signs or symptoms of respiratory distress or gastrointestinal tract irritation. An erect anterior–posterior chest radiograph was taken to determine the location of the appliance. The radiograph (Figure 1
) confirmed that the quadhelix was situated in the region of the lower oesophagus.
|
) was a concern and it was predicted that a laparotomy might be necessary.
|
). The surgeon deemed that the risk of visceral perforation was high if the quadhelix were to be retrieved in a retrograde manner with grasping forceps. It was therefore mobilized and passed distally into the stomach. A mini-laparotomy was then performed. Access to the stomach was gained via a 5 cm epigastric midline incision and the foreign body was removed from the stomach via a small gastrotomy incision. The stomach was closed in two layers with 3/0 polydioxanone sutures (PDS). The mini-laparotomy wound was also closed with 3/0 PDS and the subcutaneous tissues with 3/0 Monocryl.
|
|
Discussion |
|---|
|
TopAbstractIntroductionCase reportDiscussionConclusionsReferences |
|---|
Fortunately, if a foreign body is lost at the back of the mouth, it is more likely to enter the gastrointestinal tract rather than the respiratory tract.2
Objects ingested that are small and blunt, such as orthodontic brackets, would be expected to pass through the gastrointestinal tract completely and uneventfully, usually over a 7–10 day period.3,4 The British Orthodontic Society advises that this is likely to occur for smooth and flexible objects that are less than 5 cm in length. In such circumstances, it is advisable to monitor natural evacuation of the foreign body by checking the patient’s faeces.5 Transit time is unpredictable and more than 50% of foreign bodies will pass in the stools unnoticed.6 The use of aperients to aid evacuation is debatable; it has been suggested that their action may increase the risk of visceral perforation and that a ‘wait and see’ policy is best adopted.7
Large or sharp objects, as seen in this case, can subsequently become impacted and require urgent removal. Foreign bodies most frequently lodge in the upper oesophagus and if they cause obstruction may result in aspiration.7 Symptoms of dysphagia, odynophagia, haematemesis or vomiting may indicate oesophageal obstruction or impaction. Sharp objects are more likely to result in perforation. If perforation occurs within the gastrointestinal tract it is most likely to take place in the oesophagus. Other sites of possible impaction and perforation include the pylorus, the duodenum, the duodenojejunal flexure and the ileocaecal region. This may also be seen at sites of previous intestinal surgery or stenosis or in areas of congenital anomalies such as Meckel’s diverticulum. Following perforation the presenting features will vary according to the site and may include mediastinitis or appendicitis.8,9 Symptoms may be remote from the time of ingestion. A recent case study by Mehran et al.10 reported that patients may not always demonstrate classical signs and symptoms of perforation. They highlight the need to consider gastrointestinal perforation secondary to ingestion of a foreign body as a differential diagnosis for the patient that presents with atypical abdominal pain.
Further complications caused by ingested foreign bodies include intestinal obstruction, abscess formation, haemorrhage, fistula and mucosal ulceration.7 Prompt removal of foreign bodies impacted in the gastrointestinal tract will therefore decrease morbidity.
The majority of foreign bodies impacted in the upper part of the gastrointestinal tract can be removed endoscopically with a magnet probe or grasping forceps.6 Objects that are large or sharp may cause further tissue damage on withdrawal and will require careful surgical removal as in this case. Guidelines for the management of ingested foreign bodies by the American Society for Gastrointestinal Endoscopy, suggest that if a sharp-pointed object cannot be safely removed endoscopically then daily radiographs should be taken to monitor the progress of the object. They recommend that surgical intervention is required for objects that fail to progress for three consecutive days as demonstrated by serial radiographs.11
Inhalation of foreign bodies presents a more serious scenario. Aspiration of a foreign object with partial or complete airway obstruction can be fatal and immediate removal is critical.12 The patient in distress should be asked to cough. If this is ineffective then back blows should be administered or, in trained hands, abdominal thrusts (Heimlich manoeuvre). Should these measures fail to dislodge the object and respiratory failure ensues, positive airway pressure should be maintained by artificial respiration and assistance should be summoned without delay as it may be necessary to create a surgical airway.13,14 Patients that require abdominal thrusts should be referred to a medical practitioner to exclude internal injuries.15
The aspiration of small objects may go unnoticed initially, but may later develop serious consequences such as pneumonia or a pulmonary abscess.7,12 A history of choking, coughing and wheezing at the time of the event may raise suspicions of this possibility. Small foreign bodies preferentially pass through the right main bronchus since its angulation is more vertical and of greater diameter than that of the left. Once a foreign body is suspected to be lying within the respiratory tract, urgent referral to a respiratory specialist should be made. It may then be removed with the assistance of a flexible bronchoscope or failing that, a thoracotomy.
Accidental swallowing of foreign objects in dentistry frequently appears in the literature. Reports of large objects including dentures and even toothbrushes have been swallowed by patients with normal physical and mental abilities.3,16 In this case, the patient’s special needs may have contributed to the ingestion of the removable quadhelix.
|
Conclusions |
|---|
|
TopAbstractIntroductionCase reportDiscussionConclusionsReferences |
|---|
Orthodontic practitioners should be familiar with the early management of ingested foreign objects and competent at making an appropriate specialist referral if required. If there is doubt as to whether a foreign body has been inhaled or ingested then radiographic investigation is performed. A foreign body may not always be identified on the initial investigative radiograph and other views may be required. Some objects have been out of the field on chest and abdominal views but detected in the larynx on neck radiographs.17 Radiologists are fundamental in locating, monitoring the progress and guiding retrieval for swallowed foreign bodies. They should be given a similar object to the missing component so as to maximize benefit from any investigation.16 If a patient swallows a foreign object appropriate effective action is required with an expression of care and concern to prevent patient dissatisfaction and an act of negligence.
This case report highlights the need for orthodontists to consider all treatment options including limited objectives and tailoring them appropriately to patients with learning difficulties and specific physical impairments. They are a unique group and additional support from carers is mandatory in providing ethical orthodontic treatment.18 It is important to be sympathetic to yet realistic regarding parents’ expectations, who may want treatment to meet their aspirations rather than benefit their child. The risk-benefit equation should be weighed up and an acceptable compromise reached. In this case, one can speculate that the quadhelix component became free when the elastomeric rings either became unhooked from their fixtures or the rubber had perished and torn. It is important that the patient or carer regularly check that the rings are correctly sited and if in doubt contact the surgery for investigation and action.
The proposed guidelines for the prevention of endocarditis in dentistry19 are included in the scope by NICE to resolve conflicts in existing protocols regarding prophylaxis of people undergoing interventional procedures. These are expected to be issued in March 2008.20 If approved, antibiotic prophylaxis for dental treatment may be restricted to patients who have had a previous endocarditis, or cardiac valve replacement surgery or those with surgically constructed systemic or pulmonary shunts or conduit.19 The patient described here did not fall into one of these categories and under this guidance would no longer require the administration of antibiotics for procedures causing muco-gingival manipulation. This would affect the decision to use a removable quadhelix. A fixed option would be preferable, affording more security against the risk of dislodgement. For similar situations where individuals still require antimicrobial chemotherapy the dilemma on the most suitable appliance to achieve treatment objectives remains.
|
References |
|---|
|
TopAbstractIntroductionCase reportDiscussionConclusionsReferences |
|---|
2 Sfondrini MF, Cacciafesta V, Lena A. Accidental ingestion of a rapid palatal expander. J Clin Orthod 2003; 37: 201–2.[Medline]
3 Kharbanda OP, Varshney P, Dutta U. Accidental swallowing of a gold cast crown during orthodontic tooth separation. J Clin Pediatr Dent 1995; 19: 289–92.[Medline]
4 Webb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988; 94: 204–16.[Medline]
5 British Orthodontic Society. Advice Sheet 9. Guidelines for the management of inhaled or ingested foreign bodies. London: BOS, 2003.
6 Arana A, Hauser B, Hachhimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr 2001; 160: 468–72.[CrossRef][Medline]
7 Milton TM, Hearing SD, Ireland AJ. Ingested foreign bodies associated with orthodontic treatment: report of three cases and review of ingestion/aspiration incident management. Br Dent J 2001; 190: 592–96.[CrossRef][Medline]
8 Antao B, Foxall G, Guzik I, Vaughan R, Roberts JP. Foreign body ingestion causing gastric and diaphragmatic perforation in a child. Pediatr Surg Int 2005; 21: 326–28.[CrossRef][Medline]
9 Lam PY, Marks MK, Fink AM, Oliver MR, Woodward A. Delayed presentation of an ingested foreign body causing gastric perforation. J Paediatr Child Health 2001; 37: 303–4.[CrossRef][Medline]
10 Mehran A, Podkameni D, Rosenthal R, Szomstein S. Gastric perforation secondary to ingestion of a sharp foreign body. JSLS 2005; 9: 91–93.[Medline]
11 Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002; 55: 802–6.[Medline]
12 Quick AN, Harris AM. Accidental ingestion of a component of a fixed orthodontic appliance—a case report. SADJ 2002; 57: 101–4.[Medline]
13 Hinkle FG. Ingested retainer: a case report. Am J Orthod Dentofacial Orthop 1987; 92: 46–49.[CrossRef][Medline]
14 Dibiase AT, Samuels RH, Ozdiler E, Akcam MO, Turkkahraman H. Hazards of orthodontics appliances and the oropharynx. J Orthod 2000; 24: 295–302.
15 Resuscitation Council (UK). Paediatric Basic Life Support in Resuscitation Guidelines 2005. London: Resuscitation Council (UK), 2005; 69–83. Available at: http://www.resus.org.uk/pages/pbls.pdf
16 Absi EG, Buckley JG. The Location and tracking of swallowed dental appliances: the role of radiology. Dentomaxillofac Radiol 1995; 24: 139–42.[Abstract]
17 Abdel-Kader HM. Broken orthodontic trans-palatal arch-wire stuck to the throat of orthodontic patient: is it strange? J Orthod 2003; 30: 11.
18 Becker A, Shapira J, Chaushu S. Orthodontic treatment for disabled children—A survey of patient and appliance management. J Orthod 2001; 28: 139–44.
19 Gould FK, Elliott TSJ, Foweraker J, et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006; 57: 1035–42.
20 National Institute for Health and Clinical Excellence. Prophylaxis for infective endocarditis, 2007. Available at: http://www.nice.org.uk/page.aspx?o=408798 (accessed 22th February 2007).
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
