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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 412-417

Inadvertent pulmonary aspiration of endodontic hand instrument -procedural negligence and litigation: Case report

1 Department of Dentistry, BPS GMC for Women, Khanpur Kalan, Rohtak, Haryana, India
2 Department of Dentistry, GMC, Jalaun, Uttar Pardesh, India
3 Department of Oral and Maxillofacial Surgery, PGIDS, Rohtak, Haryana, India

Date of Submission20-Jun-2020
Date of Decision02-Jul-2020
Date of Acceptance19-Aug-2020
Date of Web Publication3-Sep-2021

Correspondence Address:
Dr. Monika Khangwal
BPS GMC for Women Khanpur Kalan, Sonipat, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_156_20

Rights and Permissions

Aspiration/ingestion in dentistry is rare but serious complication. Dentist should be tremendously conscientious during any intercession, especially in supine position and the management of small instrument. A 21-year-old male patient reported in apprehension with a complaint of aspiration/ingestion of endodontic hand file instrument while undergoing root canal treatment. A prompt Non-Contrast Computed Tomography of the thorax was done, which discovered an endodontic file in the right bronchus. The patient was well-versed about the existence of the instrument and was instantly admitted to the Pulmonary Medicine Department. High-risk consent was duly signed by the patient before treatment. Flexible fiberoptic Bronchoscopy was considered for retrieval of the instrument under local anesthesia. A successful bronchoscopy was performed, and the endodontic instrument was retrieved. The patient was kept under observation for any symptoms. Follow-up chest-X ray done immediately and after 6 months. Consequently, focused Ethical standard practice guidelines, including rubber dam isolation, should be followed in dentistry/endodontic procedure to lessen unreasonable, difficult perilous situations, and negligence litigations.

Keywords: Aspiration, bronchoscopy, foreign body, ingestion, root canal treatment

How to cite this article:
Khangwal M, Rahman H, Solanki R, Goyal R. Inadvertent pulmonary aspiration of endodontic hand instrument -procedural negligence and litigation: Case report. Saudi Endod J 2021;11:412-7

How to cite this URL:
Khangwal M, Rahman H, Solanki R, Goyal R. Inadvertent pulmonary aspiration of endodontic hand instrument -procedural negligence and litigation: Case report. Saudi Endod J [serial online] 2021 [cited 2021 Dec 1];11:412-7. Available from: https://www.saudiendodj.com/text.asp?2021/11/3/412/325390

  Introduction Top

Aspiration/ingestion of unfamiliar items has been widely reported and has a peculiar historical incidence. Failure to follow safety rules and carelessness always result in accidents. On historical note in 1692, a 4-year Prussian Prince had swallowed a shoe buckle. Now, this buckle is put on the show of in the Hohenzollern Museum (Austria).[1] In dentistry, ingestion/aspiration of the instrument is exceptional but can result in serious complications. Dental procedures account largely for foreign object aspiration in the respiratory system. Objects that are documented during procedural accidents are inlays/onlays, single-unit crowns during cementation, orthodontic brackets, rubber dam retainers, endodontic instruments, teeth, and cotton/gauge.[2],[3] Ingestion of different types of objects depending on size, shape, nature, and location decides the severity of the complication. The small blunt object is less likely to be hazardous as compared to large sharp instruments. Small objects if swallowed inadvertently can get stuck in the gastrointestinal (GI) and monotonously egested out through the GI tract, but sharp instruments such as endodontic files, burs, and post may cause perforation. In comparison to ingestion, aspiration is more serious and may leads to hospitalization. In accordance to Webb[4],[5] 92.5% of accidental swallowing enters into the GI tract and 7.5% in the pulmonary system. Grossman documented that 87% of endodontic files slip into the GI tract and 13% in the pulmonary system.[6] In a routine dental setting, menace of accidental aspiration may be augmented by various factors that result in the mutilation of the defensive airway mechanisms. In such incidence, operator should maintain the patient airway and instantaneously seek for medical care. As per litigation, these occurrences are counted as operator inattention. He/she should be sentient of the legal accountability and should take the suitable precautionary events to intercept any troublesome circumstance.[7] This current case presentation was to report and document pulmonary aspiration of an endodontic hand file during root canal procedure in an adult, its treatment/retrieval and its lawful facets. Furthermore, it focuses on Ethical standard practice guidelines including rubber dam isolation in dentistry/endodontic procedure to lessen unreasonable difficult perilous situations and negligence litigations.

  Case Report Top

A 21-year-old male patient reported to the department in fright and apprehension with a complaint of engulfment of the instrument while undergoing root canal treatment at some private dental clinic. He also presented with extreme pain in the right lower second molar (#47) region. He explained that while treatment instrument had slithered accidentally from dentist's finger into the posterior region, following which it had been aspirated due to excessive salivation and gag reflexes. The operator did not follow rubber dam isolation protocol as per the narration by the patient and also attempted to convince the patient that the instrument will be egested out with time. However, the patient was annoyed and in nervousness without wasting time stepped to the department. A complete history of the present illness was taken. After the accident, the patient had no complaint of cough, choking, breathlessness, or respiratory discomfort. The patient was relaxed by counseling so that he can cooperate for further proceedings. Even on complete intra-oral and throat examination by tongue depressor, no instrument could be discovered. Hence, patient was taken to the Department of radiodiagnosis to verify the position of the instrument. On examination of Non-Contrast Computed Tomography (NCCT) of the thorax and abdomen, a radiopaque object resembling endodontic file was observed in the right bronchus [Figure 1]a and [Figure 1]b. The patient was well-versed about the existence of the instrument and was instantly admitted to the Department of Pulmonary Medicine to challenge its removal as soon as possible. While chest auscultation patient presented with normal breathing sounds and respiratory rate. High-risk consent was duly signed by the patient. All the vital signs were within the normal range. Flexible fiberoptic bronchoscopy was considered for examination and retrieval of the instrument under local anesthesia. Complete procedure and its conclusions were explained to the patient. A successful bronchoscopy was performed under local anesthesia, and endodontic instrument hand file was retrieved [Figure 1]c and [Figure 1]d. Inclusive bronchus inspection was done to rule out any grievance or internal bleeding with flexible fiberoptic bronchoscopy [Figure 1]e. Later, routine root canal treatment of #47 was done under rubber dam. The patient was kept under observation for any symptoms. Follow-up chest-X-ray was done immediate and after 6 months [Figure 2].
Figure 1: (a) Non-Contrast Computed Tomography thorax (anterio-posterior view) showing endodontic instrument stuck at the opening of the upper lobe bronchus.(b) High magnification of the area demarcated by the square in a.(c) A bronchoscopy showing endodontic hand file instrument stuck at the opening of the upper lobe bronchus with sharp edge stuck in medial subcarinal mucosa as well as bronchial wall.(d) Retrieval of instrument with flexible fiberoptic bronchoscopy.(e) Post retrieval of endodontic instrument from bronchus with no injury or internal bleeding

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Figure 2: Six months of follow-up chest X-ray

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  Discussion Top

Incidence of procedural dental errors

Documentation of dental procedural accidents has been widely reported by much-appraised literature. In Japan, 3.6%–27.7% of all catastrophes of ingestion/inhalation occurred more in adults as compared to children, as recorded by Tamura et al.[8] Inadvertent engulfment cases in children below 3 years are more reported than aspiration. Tiwana et al.[9] reviewed that incidence of mishap during prosthodontic treatment is more than the orthodontic procedure. Susini et al.[10] accounted for the frequency of aspiration during endodontic practice was 0.001/100,000, and the occurrence of ingestion was 0.12/100,000, correspondingly. It is also revealed that 90% of ingested unfamiliar items pass through stools monotonously, and only 10% of cases entail endoscopic retrieval, and 1% will still necessitate operation.[4],[5] Bronchoscopy has been stated to be effectual in the recovery of aspirated things but has certain complications.[11] Meticulous documentation is essential to encourage dentists to be diligent and be sentient of the avoidance, handling, and treatment in such procedural accidents.

High-risk facets

The operator should be conscientious of certain patient-related risk factors which highly predispose them to such ominous condition like ingestion/inhalation. Young age (1–2 years), elderly, edentulous patients, sedated, intoxicated, alcoholic, mentally retarded, traumatized patients, compromised motor functions, psychosis, head-and-neck tumors and neurologic conditions such as stroke, dementia, cerebral palsy, Alzemier's or Parkinson's disease, amyotrophic lateral sclerosis are at high risk.[12],[13] These compromised patients have altered states of perception, weakened gag reflex, unsynchronized swallowing, or other abnormal defensive esophageal/airway mechanisms, increasing their susceptibly to accidental ingestion or inhalation.[7],[14],[15],[16],[17] Furthermore, overweight patient, pregnant, sliding hiatal hernia in their reclined position during dental procedures increases intra-abdominal pressure which influences the deglutition reflex.[18] Sedation hampers defensive ingestion and cough reflexes. Edentulous patients, denture wearers, and patients with poor dentitions have altered perceptible sensitivity of palate, resulting in delayed deglutition reflex.[19] During dental procedures, local anesthesia, supine or semi-recumbent position, unnecessary or unpredicted patient movement, insufficient illumination, greasy (saliva contact) small dental instrument, and inefficient supporters increase the menace of aspiration and ingestion.[20] It was reported that head position (tilted back), inefficient oropharyngeal barrier, and several posterior (molar) extractions also accounted considerably for accidental inhalation/ingestion.[21] Hence, patient's inclusive medical records/history and complete physical assessment should be executed during the preliminary appointment.

Physiologic contemplations

Deglutition is a complex physiologic function comprising phases: the preparatory phase, the voluntary stage, the pharyngeal stage, and the esophageal stage. Disturbance in these phases, poor muscular harmonization, anatomic deformities, epiglottic abnormalities, neurologic ailment, and inadequate vocal cords closure may predispose to inadvertent aspiration due to weakened function of the medulla or pons.[22]

Sign and symptoms

The incidence of signs and symptoms depends on the size, shape, sharpness, moving, or fixed or perforating ingested objected. In general, it is egested out, but in case of any obstruction, the most commonly observed symptoms are coughing, gagging, cramps, nausea, vomiting, dysphagia, peritonitis, and odynophagia. Endodontic reamers, files, toothpicks may cause perforations in curved duodenum, which can be fatal due to liver abscess and sepsis.[15] In the case of aspiration, there might be coughing, diminished oxygen dispersion, choking, gagging, inconsistent breathing, inspiratory stridor, huskiness, cyanosis, tracheal shift, and flatness to auscultation.[23] Atelectasis, vocal cord paralysis, infection, pneumonia, and complete airway obstruction arise on long-term retention of unknown items.[24]

Emergencies clinical management and treatment/retrieval

Aspiration is a severe terrible condition than ingestion, and one must be alert to deal with these emergencies. Such mishap can be surmounted with relaxed, clam attitude and proper knowledge of professionals to manage and protect them. The practitioner must be able to distinguish the signs and symptoms of the airway and gastric obstruction. The patient should keep coughing, but if he is unable to do so, according to Red Cross, commendations five-and-five” technique should be followed, i.e., again and again, the application of 5 puffs on back and 5 abdominal forces.[24],[25],[26] According to the Australian Resuscitation Council, chest push forces are suggested as an alternative to abdominal thrusts.[27] In Heimlich maneuver, patient leans forward enclose arms around the waist to apply upward thrust at the base of the diaphragm so as to put forth pressure on lungs and expectantly driving out stuck items from the airway. In pregnant or obese patients only chest thrusts are recommended.[28] If the patient is stable, quick consideration of the lost or missing instrument and its constituent in the oral cavity and surrounding should be done. In this current situation, Heimlich maneuver or forceful coughing failed to recover, so the patient was conciliated and updated about the impediments and quickly admitted to the pulmonary medicine department to substantiate the location and retrieval of the object. NCCT provides enhanced 3D visualization of the small dental instrument in contrast to 2-D conventional radiograph.[29],[30] Hence, in the present case, NCCT of thorax/abdomen and Flexible fiberoptic bronchoscopy was considered for the precise position of inhaled/ingested object.[8],[9] Bronchoscopy is preferred for retrieval of aspirated items. There are two types of bronchoscopy-flexible or rigid. Rigid bronchoscope promise controlled visualization and effortless retrieval of instruments in immense bleeding but under general anesthesia.[31],[32] Flexible fiberoptic bronchoscopy is a comparatively safe, simple, cost-effective, higher success rate and can be executed under local anesthesia.[11] Since in current report patient approached without any respiratory obstructive symptoms or any internal bleeding rationally flexible fiberoptic bronchoscopy was selected for the treatment. It renders promising results in distally stuck objects, involuntarily ventilated patients or in fracture (spine, jaw, skull) cases.[33] The ingested foreign body might stuck in the angulated and narrow areas such as the pharynx, upper and lower esophageal sphincter, pylorus, duodenojejunal junction, ileocecal junction, appendix, rectosigmoid junction, anus, or congenital gut deformities.[15],[34],[35] Its removal depends on size, shape, composition, anatomic position, and time since engulfment.[34],[35] Flexible endoscopy can be used to retrieve such objects.[33] Obstruction with complication, i.e., perforation commonly seen in the upper esophagus and so object should swiftly be removed by esophagoscopy within 24 h.[36],[37] 80%–90% of foreign bodies, together with the sharp items (endodontic instruments) are egested out monotonously through stool in numerous days to weeks.[5],[34],[38] Consumption of high-fiber diet may be supportive for easy egestion. Conversely, the menace of perforation is more with Sharp, piercing, and lengthened objects (>6 cm in length), and hence, urgent endoscopy should be planned to stop its access into the small intestine. Gastroscopy is planned if the object is > 2.5 cm, as its course through pylorus is complicated.[39],[40] Surgical intervention may be essential if the object is stuck within mucosal folds of ileocecal strictures leading to profuse bleeding or obstruction.

Preventing stratagems

Various stratagems are deployed to avert inadvertent aspiration and ingestion, but the key to handle such mishaps is prevention. In routine dental practice, rubber dam is effectual and most common precautionary defensive and isolation method.[41] Segregation of the functioning area during dental intercessions is crucial or even mandatory in certain cases such as endodontic treatment. Complete isolation of the field can be achieved only using the rubber dam.[42] It enhances the effectiveness of treatment by providing improved access to the functioning area, offers a dry field for enhanced visualization, lessen haziness of mirror due to mist, augments visual distinction, guard patients during procedures, reduces patient conversations, and support them to stay in mouth open position during treatment.[43],[44] Segregation with rubber dams may also lessen the spread of airborne coronavirus (SARS-CoV-2)[45] and systemic diseases such as AIDS, hepatitis, and tuberculosis. However, many dentists still abstain from the usage of rubber dam during endodontic treatment. A recent analysis inferred that only 44% of the general dental practitioner during root canal treatment used rubber dam.[46] In the present case, if the patient had been guarded under rubber dam isolation and meticulous attendance during root canal procedure such an accident could be circumvented.

Negligence, contravene, and litigation

Dental procedures demand manual dexterities and are always specifically exigent. Dentists deal with small instruments/prostheses, and negligence can occur at any phase. Negligence is contravened of the authorized duty or responsibility of professionals by his/her proficient principles and moral values.[47] Dentists should be conversant and proficient to diagnose and treat. He/she must follow a definite standard of responsibility and concern. A violation in it causes carelessness and litigation against the dentist. Ethical standard practice guidelines should be the focal element of the dental practice to lessen and evade the unreasonable difficult, perilous situation.[48] While discussing malpractice against procedural accidents, malpractice is the negligence occurring out of the doctor-patient rapport, whereas negligence is the act of inattentiveness or blunder by the operator that results in patient damage.[21] All specialty of dentistry is directed by country's National Code of Ethics, issuing guidelines for national standard of care. Standard of care is the rational concern and conscientiousness normally implemented by alike members of the profession in comparable cases in the same situation given due consideration for state of the art.[49],[50],[51] The standard is a waver between expert spectators, confirmation, advanced enhanced procedures, and technology. Conversely, the guiding principle for ordinary care is directed by any specialist, national specialty/organization as a model, not lawful authorizations. Finally, the court will decide and conclude about operator negligence.[52],[53] Numerous cases in which legal proceedings are encompasses-such as failure to make in time referral decision to a specialist, incapable of accurate diagnose, incapable to execute inclusive diagnostic tests, poor documentation, and record of conclusion and treatment, disappointment with prosthetics, treatment of the incorrect tooth, hypochlorite/other unconventional materials mishaps, root perforations, no well-versed consent acquired, patient not updated regarding instrument partings in the canal, failure to use a rubber dam, extraction blunders, implant failure, paresthesia subsequently endodontic or surgical practice, temporomandibular dysfunction, unacceptable crown, improper patient's medical history taken, inappropriate prescription, child mistreatment, sexual harassment, and improper use of intravenous sedation.[48],[54]

The dentist can surmount such alleges by:

  • sustaining good doctor–patient rapport
  • Appropriate communication of information and estimations with patients[49]
  • Prior treatment suitable conversant permission should be signed
  • Comprehensible elucidate designated procedure, its justification, advantages, outcome, and risk of the procedure
  • Documentation and record maintenance of all cases.[53]

  Conclusion Top

It is imperative to identify risky cataclysmic conditions, which predisposes the patient to aspiration/ingestion situations. Early supervision of such emergencies, all defensive measures, and ethical standard of care, management, and prevention protocol should be followed to avoid accidental mishaps and litigations.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

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