As a dental student,
you may have considered the possibility of a future patient’s accidental
ingestion of a dental instrument. One case of unintended ingestion involved a
female patient – let’s call her Mrs. Jones – who accidentally swallowed an
implant hex tool. The patient's care was further complicated by the fact that a
hospital emergency room failed to consult with her dentist before deciding to
undertake a complicated procedure.
Mrs. Jones presented to
a doctor – we’ll call him Dr. Smith – for treatment of peri-implantitis secondary
to four implants supporting a mandibular overdenture. She had been a patient of
this dental practice for over 20 years, although Dr. Smith had only recently
purchased this general dental practice and was meeting her for the first time.
Mrs. Jones had a history of dysphagia and had undergone swallowing therapy and
periodic esophageal dilation, but she did not tell Dr. Smith of this condition.
Upon examining Mrs.
Jones, Dr. Smith decided to remove the abutments in an effort to evaluate the
implants and treat the inflammation. As he had not placed the implants or
fabricated the appliance, this would enable him to evaluate the problem more
In the course of
removing one of the abutments, the wet instrument (approximately 4 cm in length)
slipped out of Dr. Smith's grasp, fell to the rear of the patient's mouth, and
disappeared down her throat. Immediately concerned that Mrs. Jones might have
aspirated the instrument, Dr. Smith sent her to a nearby hospital.
At the hospital,
radiographic exam revealed that the hex tool was located in Mrs. Jones'
stomach. A gastroenterology consultation was requested and, based on the
instrument's sharp-looking appearance, the consulting physician offered to
remove the device. The patient's informed consent did explain perforation of
the esophagus as a risk associated with the procedure. Subsequently, the
instrument was removed.
Because Mrs. Jones had
a narrow esophagus, the gastroenterologist was unable to use a sheath, which
might have been able to protect the walls of her esophagus. At the conclusion
of the procedure, the gastroenterologist noted that he may have lacerated the
esophagus. He immediately ordered a swallowing test that confirmed the
perforation, and a surgeon was consulted. Mrs. Jones was taken to the operating
room and the surgeon repaired the laceration. A few days later, Mrs. Jones was
discharged with instructions to follow a puréed diet.
During the next few
months, she underwent several additional medical procedures in an attempt to
help her with her swallowing and increase her ability to eat more substantive
foods. She seemed to be doing very well in her convalescence; however, her
condition suddenly worsened, requiring hospitalizations for a minor stroke,
atrial fibrillation, renal insufficiency, and a second stroke. Because of her
loss of some motor function, a gastrostomy tube was placed so she could be fed.
About two weeks
post-op, while having breakfast with her husband, Mrs. Jones complained that
she was still hungry even though she had been tube fed. He made her a scrambled
egg, fed it to her, and she appeared to aspirate it. She was rushed to the
hospital, but expired shortly after arrival. A lawsuit was commenced, naming
the dentist, the hospital, and the gastroenterologist as defendants. Given the
potential risk of a high-dollar verdict, the defendants elected to settle the
case out of court.
Though such cases are
frightening, they are also preventable. As a dentist, you will be able to use any
number of clinical mechanisms to prevent this type of injury. Some examples
- Tie a piece of dental floss, too long for the patient to swallow,
around or through the instrument before placing it in the mouth. This technique
is also helpful in endodontic procedures that must be performed without the
benefit of a rubber dam.
- Maintain the patient in as upright a position as the procedure
will allow, so that a dropped instrument will fall to the floor of the mouth
rather than to the back of the throat. This would also be the preferential position
for the placement of crowns on the posterior teeth, with special consideration
given to maxillary second and third molars.
- A throat pack of some sort can be employed. This alternative is
not as beneficial, because it could also lead to gagging, and the management of
the tongue might become an issue. It is, however, sometimes helpful in surgical
This case study poses
some interesting challenges, most of which could have been avoided if Dr. Smith
had used a clinical mechanism to prevent his patient from swallowing the dental