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The inadvertent ingestion or inhalation of foreign bodies is reported to result in approximately 4,000 deaths in the United States annually. The second most common cause of accidental aspiration relates to dental equipment and materials.1 With the advent of implant dentistry using small components and sharp instruments such as screwdrivers this problem is likely to increase.
The present authors have all provided expert opinions in legal cases pertaining to this mounting issue. Legal implications aside, dentists have an ethical responsibility to their patients to prevent harm and ensure appropriate postoperative care in such instances. To date there are few protocols that relate to management of accidental ingestion or aspiration in the dental office. The American Dental Association has no “white paper” or “best practice guidelines” pertaining to this issue. This article is aimed at presenting an in-depth management protocol on accidental ingestion or aspiration related to dentistry in general and, more specifically, to the issue of implant components and materials.
A Diversity of Protocols
As stated, the inadvertent ingestion or inhalation of implant-related components, such as screwdrivers, abutments, abutment screws, crowns, or other items, can lead to the presence of foreign bodies. Surprisingly, in a recent survey almost one-third of the participants claimed to have never dropped a driver or implant component,2 contrary to the authors’ personal clinical experiences. Additionally, the accuracy of self-reported responses cannot be verified, presenting a limitation of this study.
The present authors undertook a review of dental ingestion or inhalation management protocols, which encompassed an evaluation of 86 articles published in various journals over a span of 32 years. The analysis revealed a diversity of protocols, ranging from comprehensive to less-detailed approaches. It is noteworthy that currently there are no existing guidelines for handling implant drivers or restorative components. Hence, the purpose of this article is to present an updated and simplified algorithm that outlines the appropriate actions clinicians should take when faced with foreign body ingestion or inhalation events.
Common Risks and Concerns
Surgeons may have an advantage over restorative dentists when it comes to using drivers and implant components, primarily because patients are often under general anesthesia with a protective throat pack in place. Various guidelines have been published, suggesting different approaches to minimize the risk of foreign body ingestion or aspiration. These include keeping the patient in an upright position, utilizing floss ligation, employing 2” x 2” gauze, placing a rubber dam, or using isolation products that may or may not incorporate suction. For the mandibular arch, some clinicians like to have the patient maintain an upright position. However, when restoring implants in the maxillary arch, a supine position is common, which increases the risk of ingestion or aspiration.
The use of floss ligation for drivers presents challenges, as the floss can become entangled around the driver, hindering proper engagement with the torque wrench. Additionally, employing 2” x 2” gauze can be problematic for patients with a strong gag reflex, and improper technique with gauze may result in inadequate protection. Although rubber dam provides a safe and well-isolated field, restorative dentists utilize it only infrequently, mainly due to concerns of time and inefficiency. Even for root canal treatments, just 47% of clinicians “always use dental dams when performing root canals.”3 Isolation methods, with or without suction, may be more practical for many clinicians. Furthermore, the selection of gloves can impact tactile sensation and grip on drivers and components. Non-latex or ill-fitting gloves can lead to slippage and issues related to the dropping of objects.4
Many implant systems currently offer drivers and screw head designs that ensure a secure fit and minimize screw dislodgement during delivery. However, the introduction of angulated screwdrivers and corresponding screw head designs, such as hexalobular shapes, has reduced the frictional retention between these components. As these systems become more widely used, it is anticipated that clinicians dropping screws may become a more significant problem. Most iatrogenic complications in implant restorations involve ingestion rather than aspiration. Aspiration poses a severe medical emergency, as it compromises the airway and can lead to death. Dental instruments that are aspirated can cause obstruction, erosion, infection, pneumonia, fever, coughing, hemoptysis (coughing up blood), and atelectasis (partial or complete collapse of a lung or lobe). To retrieve these foreign bodies from the lungs, bronchoscopy is performed under conscious sedation.5 Generally, swallowed foreign bodies pass through the gastrointestinal system without symptoms and are expelled through stool within 2 to 4 weeks.6 However, the ingestion of screwdrivers or implant components is not without potential complications.7,8
Figure 1 illustrates a patient with an abutment driver lodged in the fundus. During an attempt to endoscopically remove the abutment driver, the esophagus was perforated, resulting in the need for open surgery to repair the perforation. The patient required several days in the intensive care unit and a prolonged hospital stay.
Limited Recommendations in the Literature
The existing dental literature provides limited recommendations on handling ingested or inhaled implant or restorative foreign bodies. Yadav et al presented a comprehensive algorithm for managing inadvertent aspiration or ingestion emergencies.9 However, this algorithm may lack the necessary simplicity required in emergency situations. In cases where the clinician does not possess advanced life support training, it could be argued that emergency medical services should be activated as soon as the patient is assessed as having “noticeable airway obstruction (symptomatic).” At this point, clinicians may provide additional first aid measures, such as placing the patient in a reverse Trendelenburg position and performing back blows or the Heimlich maneuver. However, caution is advised with back blows, as some recommendations suggest not administering them to an upright patient to avoid further movement of the foreign object down the respiratory tract. Furthermore, the American Red Cross and American Heart Association have differing recommendations.10,11
Abusamaan et al proposed a more simplified algorithm; however, it fails to assess the medical severity of the incident and neglects the need for emergency medical services or intervention by clinicians.12 El Wazani et al’s unlabeled flowchart also falls short by assuming that if the patient does not exhibit signs and symptoms of airway obstruction, he or she has not aspirated the object and it is unnecessary to seek evaluation and management at a local emergency department.13 It is important to note that even though 92.5% of foreign bodies are ingested rather than inhaled, inhalation should be assumed until it is ruled out through imaging due to the subtle sequelae that many patients may exhibit.14 Only 35.08% of aspiration patients show no symptoms, and just 59.64% develop a cough.15
Proposed Guidelines
The authors propose the following guidelines for managing ingested or inhaled foreign bodies (Figure 2). First, if an implant-related component is dropped, the clinician and staff should immediately attempt to locate the object. Step 1: If there is suspicion of ingestion or inhalation of a foreign body, the patient’s breathing must be assessed. Symptoms of complicated breathing, such as sudden coughing, choking, wheezing, stridor, shortness of breath, or persistent chest discomfort, indicate a possible aspiration event. Step 2: If any compromise to the patient’s ability to breathe is observed, emergency medical services (EMS) should be called immediately. EMS can always be canceled if deemed unnecessary, but wasting time with actions by the dentist or staff before summoning professional medical aid should be avoided.
Step 3 (if necessary): The clinician should place a patient in respiratory distress in the reverse Trendelenburg position, with his or her feet facing downward and the head elevated 15 to 30 degrees. The patient should be encouraged to cough. If necessary, the clinician may attempt a modified version of the Heimlich maneuver while the patient is in the dental chair. However, the Heimlich maneuver should not be performed on patients who are able to speak, cough, or breathe. The dental team should be prepared to perform basic life support, including cardiopulmonary resuscitation. A team member should be instructed to gather the patient’s contact information and health history for EMS personnel.
Step 4: If the foreign body is located and retrieved with a return to normal respiration by the patient, the dental procedure may be completed. Step 5: However, if the foreign body cannot be located and retrieved, even upon the return of normal respiration, it is advisable to allow EMS to transport the patient to a hospital emergency room (ER). Even though patient respiration may appear to be normal, it is impossible for the clinician to know exactly where the foreign body is located, and this could lead to a medical emergency later. Additionally, if possible, it is crucial to provide the ER team with an object similar to the one that was inhaled or ingested, as this can aid in the detection of the foreign body through imaging. This simple step may prevent unnecessary medical retrieval procedures that can lead to severe harm to the patient as outlined in the case presentation in Figure 1.
If the initial assessment of breathing does not indicate a medical emergency, the clinician and supporting staff can attempt to locate and retrieve the foreign body. If successful, the clinician can continue implementing the previously mentioned precautions, including keeping the patient in an upright position, utilizing floss ligation, employing 2” x 2” gauze, placing a rubber dam, and/or using isolation products that may or may not incorporate suction. However, if the foreign body cannot be located and retrieved, it must be assumed that it has been aspirated until proven otherwise. In this case, proceed with Step 6: The patient should be escorted to the ER by the clinician or a staff member. The patient should not drive in case the aspirated object, which initially did not pose a problem, becomes a blockage leading to a crisis, such as loss of consciousness. The clinician should provide printed patient information and health history records to the ER staff. To reiterate, if possible, an object similar to the swallowed or ingested one should be given to aid in identifying the object through imaging.
Step 7: Imaging should be obtained and interpreted by qualified medical specialists. While the dentist may have knowledge of protocols for dealing with ingested objects of different sizes and degrees of sharpness, it is the responsibility of a trained medical specialist to provide care, recommendations, and management for cases of these types of inhaled or ingested objects.12
Step 8: After the ER visit, the clinician’s responsibilities include following up with both the medical specialist and the patient. It is important for the dental clinician to personally call the patient once he or she has been discharged from the ER. If the patient requires a hospital stay, it may be appropriate for the clinician to visit the patient or at least maintain contact with the patient’s family.
Finally, Step 9: The clinician should report the incident to his or her malpractice carrier. Depending on the jurisdiction where the clinician practices, there may be a professional legal obligation to report the incident to governing boards or bodies such as outlined in a state’s dental practice act.16 These legal obligations aside, it is imperative that clinicians recognize the ethical responsibility to minimize morbidity and mortality of those in their care. Whenever necessary, appropriate referral or escalation of medical response should occur without hesitation.
Conclusion
Inadvertent ingestion or aspiration of dental components, especially in implant dentistry, remains a critical yet under-addressed issue. With the lack of formal guidelines available, clinicians must adopt clear, ethical, and evidence-informed protocols to manage these emergencies. The proposed concise algorithm aims to provide easily memorable protocols for foreign body ingestion or inhalation management for dental clinicians and their teams. It offers a practical framework for immediate response and patient safety. Ultimately, preventing harm through preparation, quick decision-making, and appropriate medical referral reflects the profession’s highest ethical standards of care and responsibility.
ABOUT THE AUTHORS
Timothy A. Hess, DDS, MAGD, CDT
Affiliate Associate Professor, Restorative Dentistry, Affiliate Assistant Professor, Oral Medicine, University of Washington School of Dentistry, Seattle, Washington
Chandur P.K. Wadhwani, BDS, MSD
Associate Professor, Department of Periodontics, Oregon Health & Science University, Portland, Oregon; Private Practice limited to Prosthodontics, Bellevue, Washington
Thomas B. Dodson, DMD, MPH
Philip Worthington Professor and Chair, Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, Washington; Editor-in-Chief, Journal of Oral and Maxillofacial Surgery; Fellow, American College of Surgeons
Edmond L. Truelove, DDS, MSD
Professor Emeritus, Department of Oral Medicine, University of Washington School of Dentistry, Seattle, Washington
Queries to the author regarding this course may be submitted to authorqueries@conexiant.com.
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16. WAC 246-817-320. Report of patient injury or mortality. Washington Administrative Code (WAC). [Statutory Authority: RCW 18.32.035. WSR 95-21-041, § 246-817-320, filed 10/10/95, effective 11/10/95.]
