Defying gravity

A CALL received with increasing frequency at MDDUS – albeit in more normal times – is the panicked dentist reporting that one of their patients has “swallowed” a dental instrument or restoration. Examples of such foreign objects can include a post crown, a Maryland bridge, an implant screwdriver, an implant healing cap, an endodontic file, a scaler tip, a diamond or steel bur, a denture, an extracted tooth or a Monoject syringe tip. The possibilities seem endless.

Dentists will often say: “they didn’t cough so I assume it wasn’t inhaled” – and in the majority of cases, the foreign object will have been ingested and can be expected to eventually pass through the gastrointestinal (GI) tract. However, there are a significant number in which, upon medical assessment, the foreign object is found to have been aspirated (inhaled), even without signs of coughing or choking at the time of the incident. The most important way to deal with ingested or inhaled instruments is to prevent such incidents happening in the first place by protecting the patient’s airway during dental treatment – and this will be considered later in this article. Here we consider more immediate measures.

KEEP CALM

A dental instrument or restoration dropped in a patient’s mouth should obviously be swiftly and effectively retrieved. Should the object be ingested or inhaled, it is imperative to stop treatment straight away. Calmly tell the patient what has happened (even though inside you might be panicking) and ask them to cough. If nothing appears and they are not choking (which would need immediate intervention), inform them that medical assessment will be necessary.

Send the patient immediately to the local accident and emergency department with a referral letter, clearly setting out was has happened. A sample or scaled photograph of the object can be attached to the letter so that the medics will know what they are looking for. A medic will decide whether a chest X-ray should be taken. Do not refer a patient directly for an X-ray as this is not something a dentist can determine is needed or report on.

Explain to the patient that in referring them to A&E you have their best interests at heart and want to rule out/avoid any possible complications. Inform them that an A&E visit may involve a significant wait but the patient should still be assessed as soon as possible. Any patient declining to attend A&E after being fully informed of the risks should be briefed on red flag symptoms, and a clinical note of their decision and your advice should be recorded. Follow-up is advised with such patients to further encourage them to attend A&E, and if they still decline, offer to liaise directly with their GP (with patient consent).

Once the patient has attended A&E, it can be helpful to request (with their consent) a copy of the hospital discharge sheet for your records in order to provide confirmation of the outcome. Being informed that an object was ingested, rather than inhaled, may offer some relief but the patient should still be monitored until it has passed through the GI tract. Concern that the foreign object has not been passed may necessitate further medical intervention.

Should the object be identified on a chest X-ray as having been inhaled, the patient will likely require bronchoscopy or, in the worst-case scenario, surgery. Again, in these circumstances, it is wise to keep in touch with the patient or family to check on progress.

SAYING SORRY

Incidents like this will be stressful for all concerned and saying sorry is important. An apology is not an admission of liability but expresses an understanding of how the patient might feel about having to spend several hours in A&E. Goodwill can go a long way.

Some patients may take the view that “accidents do happen”, but others might be rather more disgruntled. It may seem counterintuitive, but if a patient is expressing concerns, it is better to tell them about the practice in-house complaints procedure rather than risk them complaining directly to an external organisation.

Seek immediate advice and assistance from MDDUS when an incident occurs or if a complaint or legal claim is received. In cases where there is no clear evidence of the airway having been protected during treatment and with resulting harm (i.e. requiring bronchoscopy or surgery), a claim for compensation is likely to be successful. Consider completing a significant event analysis (SEA) in order to explore what happened, how it happened and how it might be prevented from happening again (see p. 8 of this issue). This will demonstrate insight and a proactive approach to future risk, both to the patient and in any possible escalation of the matter. It is important that the SEA is anonymous (i.e. not stating the patient’s name and only describing the incident) and that it is recorded in the practice incident file and not in the patient’s clinical records.

Aspiration or ingestion of a foreign body requiring medical intervention, such as a surgical procedure, will almost certainly be considered an “unexpected or unintended incident” involving harm to a patient and, as such, will trigger the statutory duty of candour procedure for the practice (details for each jurisdiction can be found here). In England, if there is a “retained foreign object post procedure” it will be classed as a ‘never event’, requiring CQC notification.

PREVENTION BETTER THAN CURE

Rather than having to deal with the fall-out of an ingested or inhaled object, it is obviously far better to avoid such incidents happening in the first place. We all know not to lie down when eating to avoid the risk of choking, and yet as dentists we usually treat our patients in the supine position, producing water and debris from drilling with our handpieces and precariously dangling dental materials, restorations, instruments and components over the black hole of every patient’s airway.

In these circumstances, high vacuum suction is obviously essential and rubber dam can thankfully provide the safety net we require, but on other occasions we should still consider how to protect patients and ourselves. For example, tying floss around fiddly implant instruments, using a throat gauze screen in addition to high-vacuum suction when cementing that slippery post crown, using a parachute chain or a throat sponge. It is important to record in the clinical notes what precautions have been taken, and it is essential to regularly service equipment such as handpieces and scalers to ensure that they are latching securely onto burs and tips.

Can we defy gravity? No. So we must take steps to protect every patient’s airway during dental treatment.

Sarah Harford is a dental adviser at MDDUS

CASE EXAMPLES

• Root canal treatment at LR4 with no rubber dam in situ. An endodontic file disappeared down the throat. The patient was asked to cough, nothing appeared, and they seemed well. The patient was advised to visit A&E and a chest X-ray revealed the endodontic file in the right lung. Rigid bronchoscopy was unsuccessful and the patient required open surgery to remove the foreign body from the lung. A legal claim was received.

• Implant screwdriver without floss attached, used to tighten component. The instrument was dropped and went down throat. There was no coughing or reaction from patient. The dentist referred the patient to A&E with a letter and sample of instrument. The chest X-ray revealed a foreign object in tracheobronchial tree. Bronchoscopy was planned, but the patient miraculously coughed up the foreign object prior to the procedure. A complaint from the patient was received highlighting the stress and anxiety caused.