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Cover page of the Journal of Health Sciences


 
 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 3  |  Page : 324-327

Tooth aspiration following maxillofacial trauma: Report of a rare case


Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India

Date of Web Publication21-Dec-2016

Correspondence Address:
Dr. Sanjay S Rao
Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, KLE University, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.196336

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  Abstract 

Maxillofacial trauma is often associated with avulsion of teeth. Occasionally, there may be tooth aspiration either spontaneously or following intubation. We report a case of tooth aspiration in a patient of head injury and maxillofacial soft tissue injury following motor vehicle accident and have discussed regarding its incidence, sequelae, and management.

Keywords: Bronchoscopy, maxillofacial trauma, tooth aspiration


How to cite this article:
Rao SS, Baliga SD. Tooth aspiration following maxillofacial trauma: Report of a rare case. Indian J Health Sci Biomed Res 2016;9:324-7

How to cite this URL:
Rao SS, Baliga SD. Tooth aspiration following maxillofacial trauma: Report of a rare case. Indian J Health Sci Biomed Res [serial online] 2016 [cited 2019 Dec 5];9:324-7. Available from: http://www.ijournalhs.org/text.asp?2016/9/3/324/196336

Introduction

Many casualties from road traffic accidents demand emergency intubation due to airway compromise from either head injury or maxillofacial injury. Such an intubation may act as a life-saving procedure. Trauma to the face is often associated with dentoalveolar fractures or avulsed teeth.[1],[2] Occasionally, this avulsed tooth or prosthesis may be aspirated spontaneously or during an emergency intubation. We present one such rare case of avulsed tooth aspiration following maxillofacial trauma in a patient with diffuse axonal injury in the brain and soft tissue injury of the face.


  Case Report Top


A 34-year-old male patient reported to casualty following road traffic accident wherein the motorcycle he was driving, collided into a truck. Patient immediately lost consciousness. When he arrived at casualty, he was semiconscious, irritable, disoriented and had severe dyspnea. Patient underwent emergency intubation at the emergency set up and was placed on oropharyngeal airway as an aid to maintain oxygen saturation.

On examination, he had multiple contused lacerated wounds on his face extending from the hairline on the right side involving the nose and up to the right commissure of the mouth, measuring approximately 12 cm. He was advised computed tomography scan of brain which revealed no findings thereby indicating underlying diffuse axonal injury. Maxillofacial X-rays showed no evidence of fractures in this region. Chest X-ray revealed a suspicious radiopacity in right principal bronchus. Patient's oral cavity could not be examined as he was intubated and on an airway. He was neurologically unstable and hence could not be taken up for immediate primary suturing. He was kept under observation for 48 h. Patient was started on antibiotics, anticonvulsants, mannitol, analgesics, and an antacid. Once the neurological fitness was obtained, patient was taken up for suturing under general anesthesia [Figure 1]. Here, when a definitive examination was carried out, it was observed that there were multiple missing teeth namely 11, 12, 43, 44, 45. Following this; the chest X-ray was reviewed critically to reveal a radiopaque foreign body (FB) akin to a tooth in the right principal bronchus [Figure 2]. When still under general anaesthetic, rigid bronchoscopy with the aid of a C-arm was carried out. When three repeated attempts to remove the tooth failed leading to further displacement into the lower lobe of right lung, a decision was made to stop intervention. Patient was maintained on ventilator postoperative owing to the surgical trauma to the lung. He was weaned off the ventilator by 2nd postoperative day. Patient recovered uneventfully. Healing of sutured wounds was satisfactory. He has been on regular follow-up for 6 months till date with no evidence of any complication.
Figure 1: Clinical photograph of the patient following maxillofacial trauma involving the nose and oral cavity

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Figure 2: Chest radiograph demonstrates tooth (arrows) aspirated in the lungs

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  Discussion Top


Maxillofacial trauma is often associated with fracture or avulsion of teeth.[1] Occasionally, this avulsed tooth or prosthesis may be aspirated spontaneously or during an emergency intubation.[2],[3],[4] Dental damage contributes to 11% of the litigation related to airway complications of anesthesia.[5],[6] Upper incisors contribute to 85% of injured teeth.[6] Aspiration of FBs has been described extensively in literature. However, incidence of tooth aspiration is rare.[7],[8] The earliest case of tooth aspiration was reported in a mummy dating back to 950 AD.[9] Aspiration of primary tooth following avulsion in the pedodontic age group has been reported.[10] In dental practice, aspiration of teeth, dental materials, and prosthesis have been described.[11],[12] Rarely, the aspirated tooth may be discovered secondarily at the time of reintubation or even after death.[7],[13]

A complete dental examination on arrival of the patient at the trauma center by the anesthesiologist and the surgeon prior to intubation is important, given the constraints of a low conscious state and urgency. Number of avulsed teeth on arrival must be noted. In the aforementioned case, the patient arrived in a semiconscious, irritable state, and a nasoendotracheal tube as well as oropharyngeal airway was secured immediately thereby making intraoral examination difficult. The various possible events following avulsion are expulsion of the avulsed tooth, its ingestion or aspiration.[11] Aspirated FBs can be diagnosed on radiographs and with bronchoscopy, the latter being the diagnostic aid of choice in case of nonradiopaque objects.[14] Diagnosis of tooth aspiration has been missed repeatedly even in the presence of ideal radiographs, emphasizing the importance of suspicious assessment by the avid clinician.[7],[9],[15] FB aspiration must be suspected in unresponsive patients with unexplained pulmonary findings.[15],[16] An aspirated tracheobronchial FB must be diagnosed, assessed, and managed early.[14] Delay in treatment may be dangerous and fatal.[7],[9]

Management of an aspirated FB would be in early diagnosis and removal of the same. However, the position of the FB in the tracheobronchial tree and clinical condition of the patient is important parameters in the choice of treatment and timing of procedure. FBs lying along the trachea and upper bronchus may be spontaneously coughed out or expelled by the Heimlich maneuver.[17] A patient with primary respiratory compromise tending toward distress must be considered for removal of the object. This may be accomplished by rigid or flexible bronchoscopy, though this is a difficult proposition owing to the slippery nature of the tooth.[4],[6],[7] Death following bronchial perforation as a complication of an attempted flexible bronchoscopy has been reported.[7] In this case, the decision of dropping the bronchoscopic retrieval after three failed attempts can thus be justified. Recently techniques such as attachment of an endoscopic hood attachment and use of tracheal backflow air in difficult or failed cases of traditional bronchoscopic retrieval have been described.[14],[18]

When a FB is situated such that it does not cause functional impairment to the patient, one might choose to observe the patient without any active intervention to remove the same.[19] Among the described sequelae of an aspirated tooth retained in the lung are early complications such as respiratory distress, emphysema,[1] and death [7] and late complications such as pneumonia, atelectasis, bronchiectasis, empyema, endobronchial actinomycosis, and lung abscess.[17],[19],[20] In the described case, the patient recovered his respiratory efficiency gradually after he was weaned off the ventilator following a course of antibiotics to prevent respiratory infection. He received active chest physiotherapy and has on regular follow-up. No further complications observed in 6 months.


  Conclusion Top


Avulsion of teeth or dental prosthesis can be expected in cases of maxillofacial trauma. The same may be expelled from the oral cavity or may be aspirated or ingested either spontaneously or as a result of intubation or manipulation of the jaws. Aspiration may result in acute respiratory obstruction and risk for death. When associated with other head injury or systemic injury, primary management is directed toward saving the patient. Once patient is stabilized, a detailed examination with due suspicion in cases with avulsed teeth and unexplained respiratory symptoms aid in diagnosis of an aspirated tooth. Attempt must be made toward removal of the tooth from the accessible areas of the lung using bronchoscopy or other described methods. However, a deep seated FB or failed attempts at removal justifies leaving the same in situ. Periodic follow-up with special attention to respiratory symptoms and secondary management is advocated.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hefny AF, El-Ashaal Y, Ali YB, Abu-Zidan FM. Medical image. Aspiration of an incisor tooth in a poly-trauma patient. N Z Med J 2009;122:73-4.  Back to cited text no. 1
    
2.
Sakellaridis T, Koulaxouzidis G, Panagiotou I, Kigka C, Papamichalis G, Antypas G. Aspiration of fixed dental prosthesis following maxillofacial trauma. Emerg Med J 2008;25:143.  Back to cited text no. 2
    
3.
Delap TG, Dowling PA, McGilligan T, Vijaya-Sekaran S. Bilateral pulmonary aspiration of intact teeth following maxillofacial trauma. Endod Dent Traumatol 1999;15:190-2.  Back to cited text no. 3
    
4.
Xiao WL, Zhang DZ, Wang YH. Aspiration of two permanent teeth during maxillofacial injuries. J Craniofac Surg 2009;20:558-60.  Back to cited text no. 4
    
5.
Cook TM, Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: An analysis of claims against the NHS in England 1995-2007. Anaesthesia 2010;65:556-63.  Back to cited text no. 5
    
6.
Alabidi A. Aspiration of an incisor tooth after adenotonsillectomy in a 10-year-old Saudi boy. East Mediterr Health J 2008;14:228-30.  Back to cited text no. 6
    
7.
Nadjem H, Pollak S, Windisch W, Perdekamp MG, Thierauf A. Tooth aspiration: Its relevance in medicolegal autopsies. Forensic Sci Int 2010;200:e25-9.  Back to cited text no. 7
    
8.
Lu A, Aronowitz P. Better if left under pillow. J Gen Intern Med 2010;25:873.  Back to cited text no. 8
    
9.
Allison MJ, Pezzia A, Gerszten E, Giffler RF, Mendoza D. Aspiration pneumonia due to teeth-950 AD and 1973 AD. South Med J 1974;67:479-83.  Back to cited text no. 9
    
10.
Leith R, Fleming P, Redahan S, Doherty P. Aspiration of an avulsed primary incisor: A case report. Dent Traumatol 2008;24:e24-6.  Back to cited text no. 10
    
11.
Tiwana KK, Morton T, Tiwana PS. Aspiration and ingestion in dental practice: A 10-year institutional review. J Am Dent Assoc 2004;135:1287-91.  Back to cited text no. 11
    
12.
Salerno T, Cutrera R, Bottero S, Malena S, Bush A. 'Iatrogenic' tooth inhalation. Pediatr Pulmonol 2008;43:726.  Back to cited text no. 12
    
13.
Stone RR, Alexander B, Adams RR, Carter MD. Tooth Aspiration Discovered on Reintubation. Available from: http://www.rcjournal.com/abstracts/2000/?id = A00000380. [Last accessed on 2016 Jun 20].  Back to cited text no. 13
    
14.
Bunno M, Kawaguchi M, Yamahara K, Kanda C. Removal of a foreign body (artificial tooth) from the bronchial tree: A new method. Intern Med 2008;47:1695-8.  Back to cited text no. 14
    
15.
Ostrinsky Y, Cohen Z. Images in clinical medicine. Tooth aspiration. N Engl J Med 2006;354:e25.  Back to cited text no. 15
    
16.
Broom T, Okereke CD. “All that wheezes is not asthma”. Emerg Med J 2008;25:311.  Back to cited text no. 16
    
17.
Kant S, Verma SK, MahajanV. Spontaneous expulsion of aspirated teeth in left lung following maxillofacial trauma: Case report. Internet J Pulm Med 2007;8:22-4.  Back to cited text no. 17
    
18.
Fung ST, Poon YY, Chong ZK, Jawan B, Lee JH. Removal of an aspirated prosthetic tooth by tracheal backflow air. Anesth Analg 2000;90:993-4.  Back to cited text no. 18
    
19.
Omland SH, Lindegaard P, Omland O. Aspiration of dental foreign body during dental visit. Ugeskr Laeger 2009;171:1194.  Back to cited text no. 19
    
20.
Bergthorsdottir R, Benediktsdottir KR, Thorsteinsson SB, Baldursson O. Endobronchial actinomycosis secondary to a tooth aspiration. Scand J Infect Dis 2004;36:384-6.  Back to cited text no. 20
    


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  [Figure 1], [Figure 2]



 

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