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Risk Management

Preventing Aspiration or Accidental Ingestion

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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 thoroughly.

 

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 include:

 

  1. 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.

 

  1. 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.

 

  1. 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 situations.

 

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 instrument.