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Orthodontics

How do I manage a patient who swallowed or aspirated parts of an orthodontic appliance?

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This Dental Urgent Care Scenario (USC) is adapted and presented by the JCDAOASIS team in collaboration with Dr. James Noble of Orthodontics at Don Mills in Toronto

You can find the full USC on JCDAOasis Mobile

Context

Patients receiving orthodontic treatment are at a very high risk of having appliances swallowed into the oropharynx during treatment due to the small size of brackets and clipped wires. Orthodontic appliances that can be swallowed include wires, brackets, transpalatal arches, temporary skeletal anchorage devices, and keys for expanders and removable appliances among others.

Foreign bodies entering the alimentary canal rarely represent a serious medical issue as they pass through the GI tract uneventfully. In some instances, a foreign body may result in impaction or perforation of the gut wall. Foreign bodies entering the airway pose much more serious consequences.

Signs & Symptoms

  • Loose appliance: The patient’s orthodontist must be notified immediately for recementation or replacement.
  • Aspired appliance:
    • Excessive coughing, difficulty breathing, and increased congestion or noisy breathing
    • Patient choking or gagging, runny nose or watery eyes
    • Dusky bluish or red changes in the face, on or under the eyes or around the mouth
  • Large object swallowed into the alimentary canal:
    • Difficulty, inability. or pain when swallowing
    • Muscle incoordination
    • Haematemesis and/or vomiting

Investigation

  • Perform a complete intraoral exam.
  • Look for an ulcer that may develop on the mucosa and may have the potential to cause an infection.
  • Look for an irritation of the mucosa of the inner cheek.
  • Look for the orthodontic bracket, wire, or appliance that may be dislodged.
  • Ask the patient if they swallowed it similar to how they swallow food or if they coughed or choked when they swallowed it.

Diagnosis

Based on the intraoral examination, it is determined that a long wire may be irritating the mucosa or a broken bracket may be detached.

Treatment

  • If aspiration is suspected, referral to the ER or an orotolaryngologist is indicated.
  • Rule out obstruction of the larynx or the trachea.
  • If a large foreign body is trapped above the vocal cords, respiratory distress can occur and urgent care is needed, involving back blows and the Heimlich maneuver.
  • Ask the patient to keep calm, turn their head down and attempt to cough excessively. Stridor is also a common sign.
  • If the object passes through the airway without obstruction, refer the patient to a hospital for immediate medical attention.
  • If the object is still trapped, the dentist or a team member should call 911:
    • Maintain positive airway pressure with CPR until the paramedics arrive.
    • Explain the situation to the paramedics.

Recommendations to mitigate the risk of foreign objects ingestion or inhalation

  • Attach floss to appliances and objects when appliances are being cemented and placed intra-orally.
  • Use a barrier, such as gauze, when adjusting orthodontic appliances or placing brackets.
  • Use radio-opaque acrylic, if possible, to radiographically visualize appliances that are swallowed or aspirated.
  • Tether bands with an adequate length of floss through the molar tubes during banding procedures, especially for second molars.
  • Cinch the archwire whenever possible.
  • Reinforce removable quad-helices and transpalatal arches at the point of attachment by using elastomeric ligatures or, preferably, stainless steel ligatures.
  • Micro-implants must be adequately attached by steel ligatures to the main appliance.
  • Advise patients not to try to reseat damaged, ill-fitting, or broken fragments of any appliance. Instead, they should return to the orthodontist to have the appliance checked.

Follow-up: What further information would you like on this topic? Email us at jcdaoasis@cda-adc.ca

Readers are invited to comment on this initial response and provide further insights by posting in the comment box which you will find by clicking on “Post a reply” below. You are welcome to remain anonymous and your email address will not be posted.

 

5 Comments

  1. Brian Schow March 6, 2013

    There was a serious case in Calgary last year involving a wire appliance attached by ortho bands. The appliance was cut free at the band solder joint and before being removed was swallowed by the 13 year old young man. He had to go to emergency where it was removed by fishing it back up thru the esophagus. In so doing the esophagus was torn requiring the patient to be hospitalized and tube fed for one month while the wound healed.

    Reply
  2. Martin Cloutier March 7, 2013

    Very good review Dr Noble. Aspiration or inhalation of a foreign body in dentistry is unfortunately fairly common. If I may add, a chest radiograph should be ordered if any doubt. Ingested foreign bodies don’t not always require removal but an asymptomatic aspiration could led to disastrous consequences.

    Reply
  3. Randy Crowell March 13, 2013

    I am only commenting on the airway issue from an in office aspiration. Small bits of Ag and Comp as well as tooth pieces and debris are swallowed everyday in Dentistry and simply “pass”. If the client however feels that their airway is in anyway continually compromised then this becomes a medical issue. Complete obstruction takes a large object but laryngospasm can occur with small items that lay on the vocal cords. This is almost always self limiting and cleared by the pt’s own reflexes. If not, this spasm will lead to continued stridor and duskiness needing ER transport and O2. Complete spasm/blockage will lead to unconsciousness and the resulting 911 call. Should this rare event happen then use a pocket mask or bagger to ventilate past the spasm/blockage if possible. Please note, if air is passing past the object do not interfere with the object but rather let the pt deal with clearing it with coughing etc and transport.

    Reply
  4. Ian McConnachie March 18, 2013

    Dr. Noble’s review is excellent. To the comment about cutting off a soldered appliance, I always use a locking hemostat on the portion to be cut off. Alternately, waxed dental floss of sufficient length to reach outside of the mouth is very helpful in many clinical situations, particularly when working in posterior sextants

    Reply
  5. Manjitsingh Bhalla November 21, 2014

    Orthodontic appliances being swallowed would ever need to be removed immediately, true; signs and symptoms need to be urgently recognized; tips provided on it are broadly appreciated; preventive steps, very crucial to be taken leaving the patients safe from such careless practice – investigation, diagnosis and thereby appropriate treatments; good one!

    Reply

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