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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 48-52

Successful retrieval of an accidentally ingested endodontic file from the body of stomach using endoscopy: A case report


1 Department of Conservative Dentistry and Endodontics, Vokkaligara Sangha Dental College and Hospital, Bengaluru, Karnataka, India
2 Department of Surgical Gastroenterology, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
3 Private Practitioner, Conservative Dentistry and Endodontics, Bengaluru, Karnataka, India
4 Department of Oral Medicine and Radiology, Vokkaligara Sangha Dental College and Hospital, Bengaluru, Karnataka, India

Date of Submission18-May-2022
Date of Acceptance31-May-2022
Date of Web Publication29-Jun-2022

Correspondence Address:
Dr. M S Adarsha
Department of Conservative Dentistry and Endodontics, Vokkaligara Sangha Dental College and Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_12_22

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  Abstract 

Iatrogenic mishaps are often encountered in dental office but ingestion of sharp objects such as endodontic file is the most undesirable accident, which can result in fatal complications. Moreover, these accidents are considered as a negligence of dentist from a legal point of view. A 45-year-old patient complained pain in the right lower back tooth since 1 week. The tooth was diagnosed with chronic irreversible pulpitis and a conventional root canal treatment was planned. Patient accidentally swallowed the file during the extirpation of the pulp from distal canal of molar with a 20 K endodontic file. No sign of respiratory distress was reported. Immediately anterior–posterior X-ray of chest and abdomen was taken. The file was located in the body of stomach and was successfully retrieved by endoscopy. This case report signifies that the dentist must follow the standard operating procedure (SOP), for example, use of rubber dam and hand files secured with dental floss to prevent catastrophic mishaps. Endoscopic management is the early, safe, and effective emergency procedure to retrieve a foreign body, especially sharp objects in the gastrointestinal tract to prevent further complications.

Keywords: Endodontic file, endoscopy, iatrogenic mishaps, ingestion, prevention


How to cite this article:
Adarsha M S, Sahadev R, Preethan K N, Meena N, Jain L, Upasana L. Successful retrieval of an accidentally ingested endodontic file from the body of stomach using endoscopy: A case report. Int J Oral Care Res 2022;10:48-52

How to cite this URL:
Adarsha M S, Sahadev R, Preethan K N, Meena N, Jain L, Upasana L. Successful retrieval of an accidentally ingested endodontic file from the body of stomach using endoscopy: A case report. Int J Oral Care Res [serial online] 2022 [cited 2022 Aug 16];10:48-52. Available from: https://www.ijocr.org/text.asp?2022/10/2/48/348771




  Introduction Top


The most undesirable event in the field of endodontics is the iatrogenic ingestion of an endodontic instrument during root canal treatment. Although such iatrogenic errors are rare, they can cause several clinical problems, unfavorable consequences and anxiety among the clinicians as well as to the patients.[1]

Sharp objects such as endodontic files may be dangerous when ingested accidentally and can cause fatal complications such as choking, esophageal tissue perforation, intestinal puncture, septicemia, or hemorrhage.[1],[2],[3] The most common causes of these mishaps are non-application of a rubber dam, uncooperative patient, anxious nature of the patient, gagging reaction, viscous saliva, and restricted mouth opening.[1]

Ingestion cases are more common and less critical than aspiration.[1] Grossman[4] stated that 87% of the ingested foreign bodies entered the gastrointestinal tract, and 13% entered the respiratory tract. The majority of foreign bodies that enter the gastrointestinal tract pass spontaneously. Nonsurgical intervention is required in only 10%–20% of cases, while surgical removal is required in only 1% of cases.[5] This paper discusses a case report of accidental ingestion of an endodontic K file size 20 and its management.


  Case Report Top


A 45-year-old female patient reported to the Department of Conservative Dentistry and Endodontics, V S Dental College and Hospital, Bangalore, Karnataka, complaining of pain in the right lower back tooth since one week. Intra oral examination revealed deep dental caries in relation to right mandibular second molar. Radiographic examination revealed pulpal involvement with the widening of periodontal ligament space. The tooth was diagnosed with chronic irreversible pulpitis and a conventional root canal treatment was planned.

The patient was explained the treatment procedure in detail by a endodontic certificate course student before the commencement of the treatment. She was little apprehensive about the entire procedure. Rubber dam application was not possible because of limited mouth opening and severe gag reflex, hence access opening was made without rubber dam and during the extirpation of the pulp from distal canal of molar with an 20 K endodontic file the patient felt pain and abruptly moved with jerky movements, causing the file to slide from the operator’s fingertips and was swallowed by the patient. The patient complained of severe gagging and a feeling that something was stuck in her throat. Immediately patient was placed in reverse Trendelenburg position (the upper part of the body is raised 20°–30°) and told her to cough.[6] Finger sweep method[7] was performed on the patient to retrieve the file. The patient’s head was then rotated to the right side and sharp blows were delivered on her back.[8] However, all the emergency protocol methods failed to retrieve the file. Thorough examination was carried out. There was no sign of respiratory distress, indicating that the file was most likely ingested rather than aspirated. The patient was briefed about the accident and given assurance.

Subsequently, the patient was taken to the Radiology Department of the KIMS Hospital, where the anterior–posterior X-ray of chest and abdomen [Figure 1] was taken to verify the presence and location of the file. The file was located in the body of stomach [Figure 2] and [Figure 3] and was decided to retrieve the file by endoscopy to prevent further complications, considering that the endodontic file is a sharp instrument. The potential complications of the endoscopy were explained to the patient, and informed consent was obtained from her. The endoscope located the file in the body of stomach and successfully retrieved the file using rat toothed forceps. The patient was discharged after the postoperative instructions and was recalled after 3 days for the endodontic treatment.
Figure 1: Posteroanterior chest and abdominal radiographs: radiopacity suggestive of a dental instrument

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Figure 2: Normal gastroesophageal junction

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Figure 3: Endoscopic images: foreign body seen in the body of the stomach and held with rat toothed forceps

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  Discussion Top


Many cases of iatrogenic ingestion or aspiration of dental instruments such as dental burs,[9] posts,[10] implant screws,[11] orthodontic brackets,[12] clamps and endodontic files[10] have been reported in the literature. These mishaps particularly ingestion/ aspiration of sharp objects are of great concern since they might result in life-threatening complications and are legally considered as an act of negligence.

Many studies have reported that children have a higher risk of accidental swallowing than adults.[13] Other risk factors associated with these catastrophic mishaps are the patients who are elder, have apprehensive nature, psychiatric problems, mentally and physically disabled, obesity and pregnant patients, severe gag reflex, limited mouth opening, difficult to access areas, short palate, and macroglossia.[14],[15]

In this case report, the patient was apprehensive, had limited mouth opening, and had a severe gag reflex. Hence, a thorough medical history should be taken, as it may aid in assessing the patient’s psychological state or any neurological disorders, lowering the risk of mishaps.[1] The dentist should pay close attention to the patient and inquire about their anxieties. Throughout the treatment, keep asking if the patients are in any pain; provide moral support, and reassurance.[16] The mandibular second molar was another contributing factor that increased the risk of swallowing in this case. Lower molars have been shown to have the highest occurrence of all teeth with ingestion, which has been connected to their proximity to the pharyngeal cavity, as observed in this case.[1] Therefore, operator must be attentive and careful when treating lower second molars. The fact that the file was not tied with dental floss, which could have prevented the accident, was a limitation in this case. In endodontics, the use of a rubber dam can dramatically reduce the likelihood of root canal instruments being aspirated or swallowed. Patients who are prone to such mishaps should be positioned in an upright position to avoid swallowing foreign objects, and any object that is prone to swallowing such as endodontic hand files should be tethered with a ligature (dental floss) if possible.[6]

When an iatrogenic error occurs, prompt diagnosis and management as depicted in the flow chart[17] [Figure 4] are critical to avoid life-threatening complications. The initial step after losing an instrument in the oropharynx is to ascertain if the instrument has entered the digestive or respiratory tract.[18] If the patient shows no signs of respiratory distress and is asymptomatic, it is likely that a foreign object has entered the gastrointestinal tract, as seen in the present case report. The next step is to seek medical attention immediately and determine the size and anatomic location of the swallowed objects.[7] The diagnostic aids used are Chest and abdominal X-rays for radiopaque objects and computed tomography and diagnostic bronchoscopy for radiolucent objects.[1] In the present case report, an anterior–posterior X-ray of chest and abdomen revealed that the K file is in the body of stomach. The decision on retrieval of an ingested foreign body depends on the patient’s age, size, shape, composition, anatomic location of the object, and time since the ingestion the objects[15]
Figure 4: Carounanidy Usha, Sathyanarayanan Ramarao, Mithunjit., Sudhagar M. Accidental ingestion of irrigation needle during endodontic procedure: use of digital fluoroscopy in management. Journal of Scientific Dentistry 2015;5 (1): 46–51

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Ingested foreign objects usually pass through the gastrointestinal tract without causing any complications and are expelled in stool in 7 to 12 days,[19] for which the initial protocol is conservative management of serial radiographs and a fiber-rich diet.[20] Endoscopy is treatment of choice when an ingested object is sharp, elongated, or poses a high risk of esophageal injury.[19] In 90% of cases, endodontic files have been observed to transit through the gastrointestinal system without complication within 3–7 days[1],[21] following the accident. Endoscopic removal is required in approximately 10% of instances, while surgical intervention is required in only 1% [Table 1].[22]
Table 1: Recommended management protocol for ingested foreign bodies

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We preferred immediate endoscopic retrieval of file from the body of stomach, as studies have reported that passing a sharp foreign body into the stomach or duodenum might cause perforation when it reaches the ileocaecal valve (approximately 35%).[22],[23] In these conditions, endoscopic retrieval has an 86% success rate, with problems occurring in less than 2% of cases.[22],[23] Endoscopy should be scheduled as early as possible after iatrogenic ingestion, preferably within 2 hours, but no later than 6 hours because if it is delayed too long, the file may pass through the pyloric sphincter and into the duodenum, making retrieval impossible.[1] The prevention of such life threatening accidents is of great importance. Following are the strategies to avoid aspiration or ingestion of foreign body:[1],[22]

  1. Rubber dam Isolation.


  2. If patients have rubber dam allergy, rotary files should be used instead of hand files for root canal therapy.


  3. Floss should be tied to the hand files with the length of 18 inches or more


  4. Use a more upright position if possible


  5. Use of a gauze throat pack


  6. Use of high-velocity evacuation


  7. Work in a dry environment rather than a wet one to reduce the risks of the instrument slippage.


  8. Awareness and knowledge to handle the medical emergencies


  9. Educate and reassure the apprehensive patient


  10. Patients should also be instructed by their dentists to try to control swallowing reflux by turning their heads to the side if an object slips on their tongue.



  Conclusion Top


Ingestion of an endodontic file by accident is a potentially fatal complication. We dentists can prevent these iatrogenic mishaps by adhering to strict protocol such as rubber dam isolation. When such mishap occurs, endodontists must have knowledge and skills to efficiently manage such emergencies in their dental office.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khetani P, Sinha N, Dabas U, Dabas VK Accidental ingestion and successful retrieval of an endodontic file from the left hypochondriac region using endoscopy. Endodontology 2016;28:183-7.  Back to cited text no. 1
    
2.
ElBadrawy HE Aspiration of foreign bodies during dental procedures. J Can Dent Assoc 1985;51:145-7.  Back to cited text no. 2
    
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Hodges ED, Durham TM, Stanley RT Management of aspiration and swallowing incidents: A review of the literature and report of case. ASDC J Dent Child 1992;59:413-9.  Back to cited text no. 3
    
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Grossman LI Prevention in endodontic practice. J Am Dent Assoc 1971;82:395-6.  Back to cited text no. 4
    
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Webb WA Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988;94:204-16.  Back to cited text no. 5
    
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Dionysopoulos D Accidental ingestion and aspiration of foreign objects during dental practice. Stomatological Dis Sci 2017;1: 87-9.  Back to cited text no. 6
    
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Bains R, Loomba K Accidental swallowing of endodontic instrument: Could be a medical emergency. European J Gen Dent 2014;3:202-4.  Back to cited text no. 7
    
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Parolia A, Kamath M, Kundubala M, Manuel TS, Mohan M Management of foreign body aspiration or ingestion in dentistry. Kathmandu Univ Med J (KUMJ) 2009;7:165-71.  Back to cited text no. 8
    
9.
Amarlal D, Jeevarathan J, Muthu MS, Venkatachalapathy A, Rathna Prabhu V Iatrogenic accidental ingestion of a dental bur. Indian J Pediatr 2009;76:333-4.  Back to cited text no. 9
    
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Susini G, Pommel L, Camps J Accidental ingestion and aspiration of root canal instruments and other dental foreign bodies in a French population. Int Endod J 2007;40:585-9.  Back to cited text no. 10
    
11.
Lana R, Mendoza JL, Lérida AI Accidental ingestion of unusual metallic foreign body. Rev Esp Enferm Dig 2004;96:874-5.  Back to cited text no. 11
    
12.
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;190:592-6.  Back to cited text no. 12
    
13.
Bains R, Loomba K, Sinha S, Bains VK Accidental swallowing of endodontic instrument: Could be a medical emergency. Eur J Gen Dent 2014;3:202-4.  Back to cited text no. 13
    
14.
Martín LP, Morán Soto MJ, Burgos RS, García MB Bronchial impaction of an implant screwdriver after accidental aspiration: Report of a case and revision of the literature. Oral Maxillofac Surg 2010;14:43-7.  Back to cited text no. 14
    
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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. 15
    
16.
Appukuttan DP Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clin Cosmet Investig Dent 2016;8:35-50.  Back to cited text no. 16
    
17.
Usha C, Ramarao S, Sudhagar MM, Accidental ingestion of irrigation needle during endodontic procedure—use of digital fluoroscopy in management. J Sci Dent 2015;5:46-51.  Back to cited text no. 17
    
18.
Saraf HP, Nikhade PP, Chandak MG Accidental ingestion of endodontic file: A case report. Case Rep Dent 2012;2012:278134 .  Back to cited text no. 18
    
19.
Tavargeri AK, Anegundi RT, Patil SB, Trasad V, Battepatti P Retrieval of swallowed endodontic file with gastro-scope. Saudi Endod J 2013;3:31-3.  Back to cited text no. 19
    
20.
Sankari V, Soundararaj A, Mathew CA, Kumar S A case of accidental ingestion and medical retrieval of dental implant hex driver. J Interdiscip Dent 2020;10:84-6.  Back to cited text no. 20
    
21.
Kuo SC, Chen YL Accidental swallowing of an endodontic file. Int Endod J 2008;41:617-22.  Back to cited text no. 21
    
22.
Rajesh Ebenezar AV, Vinita Mary A, Anil Kumar R, Srinivasan MR, Indira R, Ramachandran S Accidental swallowing and uneventful expulsion of a hand ProTaper endodontic file: A case report. ENDO (Lond Engl) 2010;4:315-8.  Back to cited text no. 22
    
23.
Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al; American Society for Gastrointestinal Endoscopy. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55:802-6.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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