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| CASE REPORT |
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Year : 2012? |? Volume : 1? |? Issue : 2? |? Page : 119-125 |
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Unusual habit ending as a foreign body lodgment: A report of case series
NB Nagaveni1, KV Umashankara2
1?Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India
2?Department of Oral and Maxillofacial Surgery, Bapuji Dental College, Davangere, Karnataka, India
| Date of Submission |
03-Jul-2012 |
| Date of Acceptance |
16-Sep-2012 |
| Date of Web Publication |
8-Jan-2013 |
Correspondence Address:
N B Nagaveni
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka
India
DOI: 10.4103/2278-9588.105703
Discovery of a foreign object embedded in a tooth is an uncommon finding. Many children with a habit of placing various objects in the oral cavity eventually end up with foreign body lodgment into the pulp chamber or root canal leading to pain and infection. This is more likely to occur in a tooth with a wide pulp chamber opened during root canal treatment for drainage of pus. Such a procedure can provoke the patient to fill the open tooth with any foreign body or may place the child at risk of foreign body lodgment in the chamber or canal. As a foreign object can act as a source of pain and cause difficulty in the elimination of infection from the root canal, prompt, but cautious attempts, must be made to retrieve it from the pulp chamber, thereby preventing pushing into the canals, and root canal treatment should be completed as early as possible. The present article describes few such cases and also briefly reviews the different techniques used for removing the foreign body from the pulp chamber and root canal.
Keywords:?Foreign object lodgment, primary molar, pulp chamber, retrieval, root canal
How to cite this article:
Nagaveni N B, Umashankara K V. Unusual habit ending as a foreign body lodgment: A report of case series. J Cranio Max Dis 2012;1:119-25 |
How to cite this URL:
Nagaveni N B, Umashankara K V. Unusual habit ending as a foreign body lodgment: A report of case series. J Cranio Max Dis [serial online] 2012 [cited?2013 Apr 16];1:119-25. Available from:?https://craniomaxillary.com/text.asp?2012/1/2/119/105703 |
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??Introduction |
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A pediatric dentist encounters children with different oral habits. The habit of chewing and placing various foreign objects in the oral cavity is an unusual finding. Fortunately this habit usually occurs without any consequences. However, sometimes this habit can cause both hard and soft tissue injuries in the oral cavity. [1] Occasionally, these objects can get lodged inside the pulp chamber or root canal of a tooth. [1] This is more likely to occur in case of large open carious lesions or in a tooth with an open pulp chamber caused by trauma and during root canal treatments, in which the pulp chamber and canals are kept open for drainage. This can provoke the patient to fill the open tooth with any foreign body or may place the patient at risk of foreign body lodgment in the chamber or canal, and this incident is seen most commonly in children as compared to adults. Such foreign objects may become a source of persistent pain and infection causing the patient to report to the dentist. Appropriate radiographic examination is required, to ascertain the size, shape, position, as well as composition of the object. Retrieval of such foreign objects in children is challenging to a pediatric dentist and requires both skill and patience.
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??Case Reports |
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Case 1
A six-year-old boy reported complaining of pain in the lower right back tooth since six days. On intraoral examination a large occlusal cavity was found in the primary mandibular right second molar [Figure 1]a. His past dental history revealed that he had pain in relation to the same tooth approximately four months back, and he had visited a general dental practitioner for treatment. According to the history collected from his mother, it was found that the tooth was opened for root canal treatment and after two visits they did not contact the dentist as pain was absent. An intraoral periapical radiograph was taken, which showed a radiopaque foreign body in the pulp chamber of the mandibular primary second molar [Figure 1]b. After questioning both the parent and patient, it was revealed that he had a habit of chewing metallic objects. The patient was not aware of the presence of foreign object in his tooth. While chewing the object accidentally it had gone into the open pulp chamber gradually blocking the root canal leading to pain and infection. As one-third root of the primary mandibular right second molar was resorbed with grade II mobility, extraction of the same tooth was carried out under local anesthesia. For our curiosity after extraction, the tooth was cut and the foreign object was found to be a stapler pin [Figure 1]c.
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Figure 1: (a) Clinical photograph showing primary right second molar with open pulp chamber, (b) Periapical radiograph illustrating radiopaque foreign body in pulp chamber of 85, (c) Photograph of retrieved stapler pin
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Case 2
A 12-year-old girl reported complaining of pain in the right lower back tooth since 15 days. On intraoral examination, a decayed permanent mandibular right first molar with open pulp chamber was noticed. The patient's past history revealed that she had visited a dentist for treatment of the same tooth as she had pain and swelling in relation to the same tooth. Her dentist had opened the tooth for root canal treatment. After two or three visits, the patient missed further appointments thinking that pain has gone. On inspection of the pulp chamber we detected a shiny glass bead-like foreign body within the pulp chamber that was tightly bound to it [Figure 2]a. After enquiring with the patient it was found that she has a habit of chewing various objects. So unknowingly the object was lodged inside the open pulp chamber leading to pain. On radiographic examination, a round, fairly radiopaque foreign object was detected in the pulp chamber [Figure 2]b. To promote better visualization of the foreign object, the internal tooth structure of the pulp chamber was removed to widen the pulp chamber using a thin tapering diamond bur. Then taking adequate grasp, the object was successfully retrieved using a tweezer [Figure 2]c. The retrieved object was confirmed to be a glass bead. The patient felt that it could be of her dress. Root canal treatment was completed and the access cavity was properly restored with amalgam followed by a semi-permanent stainless steel crown placement.
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Figure 2: (a) Mirror view of 46, showing glass bead-like foreign body (arrow) in pulp chamber (b) Periapical radiograph showing a round, fairly radiopaque object in the pulp chamber (arrow), (c) Retrieved glass bead
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Case 3
A nine-year-old boy reported complaining of pain in the upper left posterior tooth. On inspection, a large open pulp chamber was noticed in relation to the primary maxillary left first molar. Radiographic examination of the same tooth showed a radiopaque foreign body within the pulp chamber [Figure 3]. Further enquiring with the parents and patient revealed that the tooth had been opened for root canal treatment long back. Patient reported that as he was facing frequent food impaction within this tooth he used to use metallic objects to remove the same, as he had noticed the doctor inserting some pins into the tooth while taking treatment in the past. One day while doing the same, the object got stuck in the tooth. He did not inform his parents about this incident. As the tooth was deciduous and resorbed, the tooth was extracted under local anesthesia. After extraction, the foreign body found was a stapler pin.
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Figure 3: Radiopaque foreign object in the pulp chamber of 64
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An embedded wooden stick in the root canal [Figure 4] and stapler pin in the pulp chamber [Figure 5] were also found in other two patients. [Table 1] elaborates different foreign objects discovered in our cases.
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Table 1: Description of various foreign bodies encountered in children
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Figure 4: (a) A wooden stick found in the root canal of 21 (arrow), (b) The wooden stick retrieved (in pieces) from the canal
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Figure 5: (a) Metal-like foreign object detected in the pulp chamber of 36 (arrow), (b) Radiograph of the same tooth showing radiopaque foreign object, (c) Retrieved stapler pin
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??Discussion |
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Young children have a strange habit of experimenting with toys, pins, marbles, buttons, pencils, and the like, and they test them orally. Such objects may be ingested, aspirated, or may cause injury to the oral tissues. The practice of keeping various objects within childrens' reach may result in inadvertent insertion of foreign bodies within the pulp chamber or root canals. A comprehensive review of literature has shown cases of various foreign objects being embedded in the open pulp chamber or root canal. These cases was seen in these teeth, when their pulp chamber was wide open caused by large carious lesion, trauma or in a tooth undergoing endodontic treatment. The objects that have been found in the root canals or pulp chamber can range from pencil leads, [2] sewing needles, [3] and beads, [4] to metal screws, [5] stapler pins, [6] and paper clips. [7] Harris [8] reported the placement of various objects within the root canals of maxillary anterior teeth. These included pins, needles, a wooden toothpick, a pencil tip, plastic objects, toothbrush bristles, and crayons. Grossman [9] reported placement of indelible ink pencil tips, brads (small nails), a toothpick, absorbent points, and even a tomato seed in the root canals of anterior teeth that had been left open for drainage. Gelfman and colleagues [10] reported a case wherein a three-year-old child had inserted two straws into the root canal of a primary central incisor. In all these cases, the patients had inserted the objects in the root canals to remove food plugs from the teeth. Thus, parents and patients should be informed about the possibility of lodgment of objects inside the pulp chamber or root canals of teeth undergoing endodontic treatment, in order to avoid such a sequel.
Reports of lodgment of stapler pins and glass beads are very few in the literature. Moreover, they have been reported in the anterior teeth. [4],[6],[11] The present cases show the embedding of stapler pins and glass bead in the molars, which has been rarely reported.
Various reports on foreign objects detected within an exposed pulp chamber and root canal, question the safety of open drainage during root canal treatment. A common procedure employed during emergency root canal treatment involves leaving the pulp chamber open where pus continues to discharge through the canal and cannot be dried within a reasonable period of time. Such a procedure may place the patient at risk of foreign body lodgment in the pulp chamber. [12] To overcome this problem Weine [13] suggested that the patient remains in the office with a draining tooth for an hour or even more and finally ends the appointment by getting the access cavity sealed. With the access cavity closed, foreign body lodgment within the pulp chamber can be avoided. However, dentists should always consider the benefits and risks associated with leaving the pulp chamber open for prolonged periods of time. If a dentist decides to leave the pulp chamber open following access cavity preparation, the patient and parents should be warned about the risks of any foreign object being lodged in the open pulp chamber. The other method that can be followed is, placing a small cotton pellet inside the pulp chamber and sealing the cavity with a thin layer of cement and making a small hole in the center for drainage of pus.
In endodontics, it is possible to minimize the risk of inhalation or ingestion of root canal instruments by using a rubber dam on a routine basis. For implant treatment, the main precaution is to tether any screwdriver that has a small hole in its handle, for this purpose; however, such tethering is not possible with other components.
The cases that have been published so far show embedding of foreign objects in anterior teeth. Lodgment of objects in posterior teeth like molars is very rare. This may be explained by the fact that the posterior teeth are less accessible compared to anterior teeth. Very few cases have been reported so far. In those reportrs, one report cited placement of a pencil lead in the distal root of a primary left first molar. [1] Furthermore, another report showed placement of a metallic screw in the permanent mandibular first molar. [5] The case reported by Nadkarni et al. [14] showed a sewing needle in the palatal root of a maxillary molar. The present three cases can be added to this list of rare entities.
Consequences of foreign bodies
The ingestion or aspiration of instruments or materials used in treatment can occur in every field of the dental profession. Foreign bodies vary in size and shape and range from endodontic instruments, burs, posts, root copings, teeth, orthodontic brackets, and impression materials, to temporaries, implant components, and restorations. Foreign objects may become a potent source of pain and focus of infection for the patient. Actinomycosis infection has been reported in a patient lodging a piece of jewellary chain into a maxillary central incisor. [15] Foreign objects pushed through a root canal into the maxillary sinus is one of the causes of chronic maxillary sinusitis of dental origin. [16] Other complications associated with foreign body impaction in the pulp chamber is that they may act as obstructions for the smooth passage of endodontic instruments. If the object is found within the pulp chamber, it does not cause much complications except pain and re-infection of the canals as it blocks the drainage of pus. However, when an object enters the root canals and periapical area, it leads to bizarre situations that require both skill and perseverance for its retrieval. Thus, it is very important that an attempt should be made to remove the object from the pulp chamber whenever it is found, and root canal treatment should be completed as early as possible to avoid lodgment of foreign object.
Foreign body aspiration (FBA) is a more common, serious, and potentially life-threatening occurrence in young children than ingestion. Therefore, children found chewing a foreign object should always be monitored or educated about the consequences. Early complications of foreign body aspiration include acute dyspnea, asphyxia, cardiac arrest, and laryngeal edema, sometimes leading to death. Thin, pointed instruments can increase the risk of perforation and pneumothorax. Chronic retention of non-removed foreign bodies may lead to formation of granulation tissue and inflammatory polyps around the foreign body, which may obstruct the bronchus. [17],[18],[19]
Radiographic examination can be more helpful especially if the foreign object is radiopaque. Varieties of radiographic methods like parallax views, vertex occlusal views, and triangulation techniques can be used to localize a metallic foreign body. [6] Specialized radiographic techniques such as radiovisiography, stereo radiography, and 3D CAT (computed axial tomography) scans can play a pivotal role in the localization of the exact position of these foreign objects. Some objects are made of materials that lack radiopacity, which makes it impossible to identify their position. In such cases diagnostic fiberoptic bronchoscopy or computed tomography for localization is very helpful. [17],[18],[19]
Different types of instruments have been described in the literature for retrieval of foreign objects lying in the pulp chamber or canal. These include ultrasonic instruments, [18] the Masserann kit [19] and modified Castroviejo needle holders. [20] Several authors [18],[19],[20],[21] have proposed techniques for the retrieval of foreign objects from the teeth. McCullock, [21] Fors, and Berg [20] have described a method that involvs removal of a considerable amount of internal tooth structure prior to removal of foreign objects from the root canal or pulp chamber in order to improve the access to the foreign object. The same technique has been employed in case 2, for removal of the object. According to Walvekar et al. [22] if the foreign object is snugly bound in the pulp chamber or canal, the object may have to be loosened first and then be removed, with minimal damage to the internal tooth structure, to prevent perforation of the pulp chamber or root canal. Roig and Greene [23] have demonstrated a simple device, comprising of a disposable 25 gauge dental needle, a thin segment of steel wire, and a small mosquito forceps, to remove broken silver cones. Steglitz forceps have also been described for use in the removal of silver points from the root canal. [24]
For removing objects lying in the pulp chamber, other than a tweezer and a tissue holding forceps, a small mosquito forceps can be used. [25],[26] When removing the foreign object from the pulp chamber, care should be taken not to push an object into the root canal or cause perforation of the pulpal floor, and subsequent impaction of the foreign body in the inter-radicular soft tissue. For retrieval of objects from the periapical area, a surgical approach (apicectomy) is required, which is a highly complicated procedure in molars. Bronchoscopy either flexible or rigid is the treatment of choice for removal of the aspirated foreign body. [17],[18],[19]
This article highlights the dangerous potential of foreign objects in the presence of young children. Based on the present cases, it can be recommended that large carious lesions be managed promptly, prolonged open drainage be avoided in children, and parents also be warned about foreign body lodgment during endodontic treatment, in order to avoid the risks of foreign body impaction.
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? [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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