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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 29-33

Ingestion and management of posterior esthetic restorative crown in pediatric dental setup


1 Postgraduate Student, Department of Pedodontics and Preventive Dentistry, D. Y Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India
2 Professor, Department of Pedodontics and Preventive Dentistry, D. Y Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India

Date of Web Publication30-Jan-2019

Correspondence Address:
Dr. Rupinder Bhatia
Professor, D. Y Patil School of Dentistry, Department of Pedodontics and Preventive Dentistry, D. Y Patil University, School of Dentistry, Nerul, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INPC.INPC_1_18

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  Abstract 


Aim: Pediatric foreign body ingestion is a worldwide problem. Dental appliances, instruments, teeth ingestions is the second most reported phenomena.
Case Description: This is a case report of a 4 year old female pediatric dental patient with ingestion of posterior aesthetic zirconia crown. Report includes its management and treatment. Also signs and symptoms of foreign body ingestion, their management and preventive protocols have been briefly discussed.
Conclusion: Early recognition of swallowed foreign bodies and knowledge regarding the signs and symptoms associated related to pediatric dental patients is the key to avoid unforeseen events.
Clinical Significance: Preventive protocol application and knowledge regarding foreign body aspiration and ingestion helps in providing better dental care and to avoid any negative consequences in this litigious era.

Keywords: Crowns, foriegn body ingestion, uneventful retrieval, zirconia


How to cite this article:
Shah UL, Bhatia R. Ingestion and management of posterior esthetic restorative crown in pediatric dental setup. Int J Prev Clin Dent Res 2018;5:29-33

How to cite this URL:
Shah UL, Bhatia R. Ingestion and management of posterior esthetic restorative crown in pediatric dental setup. Int J Prev Clin Dent Res [serial online] 2018 [cited 2019 Jun 20];5:29-33. Available from: http://www.ijpcdr.org/text.asp?2018/5/3/29/251046




  Introduction Top


Among the infinite emergencies that could arise in the pediatric dental setup, there are a few unforeseen incidents that occur sporadically despite being entirely preventable. Ingestion or aspiration of dental materials, appliances, or instruments constitutes this category. Foreign body aspiration or ingestion can be a potential risk or a life-threatening emergency situation. Foreign body ingestion is more likely to occur in pediatric patients due to behavior problems as well as the instability of children. Pediatric dental patients are more prone to sudden jerky and unforeseen movements which may lead to such an incidence. However, such cases may also be seen in adults, mentally and physically special children. These items can include teeth, teeth pieces, restorations, restorative materials, crowns, instruments small parts, files, rubber dam clamps, gauze packs, and impression materials which can be of various sizes and shapes, ranging from small, large, elongated, round, sharp, blunt, and can get wedged anywhere either in the gastrointestinal (GI) or the respiratory tract.[1] Foreign body ingestion of different types has been reported in various fields of dentistry. Webb et al.[2] reported that 92.5% of the swallowed foreign bodies enter the GI tract and 7.5% of these instances in the tracheobronchial tree. Various studies have stated that in all cases reported, only 10%–20% of cases necessitate nonsurgical intervention, and 1% or less requires surgical retrieval.[3] This report describes a case of a 4-year-old patient with ingestion of esthetic posterior zirconia crown while placing on a pulpectomized teeth. The retrieval, management, and preventive protocols also have been discussed.


  Case Report Top


A 4-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry with excruciating pain in the lower left back teeth region. Clinical examination revealed deep dental caries in lower left second deciduous molar. After radiographic evaluation, pulpectomy treatment was planned for the tooth. During the child's first dental visit, full-mouth scaling, fluoride varnish application, and behavior management technique using tell-show-do were performed on the dental chair to access cooperation, and the child was categorized under Frankel positive behavior. During the subsequent visit, local anesthesia was administered, a rubber dam was placed followed by access opening, pulp extirpation, and working length determination followed by biomechanical preparation. Pulpectomy treatment was completed by obturation with metapex material followed by restoration using glass-ionomer cement. The patient was scheduled for next appointment for final restoration by stainless steel crown. Crown preparation for stainless steel crown was performed, and the trial was taken; however, the patients' parents were not satisfied by the esthetics of the crown, and hence, it was decided to proceed with an esthetic posterior zirconia crown (Kinderkrowns Co). Following the preparation for zirconia crown was done. While taking trial with the crown for the fit, the patient jerked and with excess salivation around, the crown slipped out of the hand and was swallowed by the patient. The patient did not show any signs of discomfort. The operator tried unsuccessfully to retrieve the crown by making the patient spit and by patting the child on the back. The patient was immediately rushed to casualty of the DY Patil Medical College and hospital, where a posteroanterior (PA) abdomen, neck radiograph was taken. Since the patient did not show any signs such as coughing, dyspnea, wheezing, or choking, aspiration in the present case was ruled out. On radiograph, the crown was located at the L4–L5 level in the abdomen [Figure 1]. A pediatric surgeon was consulted regarding the same. Considering the location of the crown and the patient being asymptomatic, he decided to keep the patient under observation. The patient was advised to consume a fiber-rich diet including maximum of bananas to facilitate excretion of the crown. The patient's stool was constantly examined for the excretion of the crown; however, at 26 h, as the crown was not excreted a repeat PA abdomen was done to confirm its location.
Figure 1: Posteroanterior abdomen showing the zirconia crown (foreign body) at the L4–L5 level

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At 26 h, PA abdomen depicted the crown below the sacral level very close to the anal region [Figure 2]. The same afternoon, the crown was excreted with the patients' stool [Figure 3]. After 2 weeks, an appointment was scheduled, and the final restoration using the zirconia crown (Kinderkrowns Co) was done with safety measure of placing gauze piece, cotton posteriorly, and the chair being upright at 90° angle.
Figure 2: Posteroanterior abdomen showing crown below sacral level

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Figure 3: Ingested crown retrieved after its excretion from stool

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  Discussion Top


Pediatric foreign body ingestion is a worldwide problem. Ingestion of various foreign bodies, such as coins, toy parts, batteries, magnet, and safety pins, have been reported.[4] Foreign body ingestion and aspiration are potentially life-threatening emergencies that may happen in any field of dentistry.[5],[6] Aspiration or ingestion of foreign objects, including instruments, materials, or even tooth, is reported to be the second most common reason for foreign body aspiration in the lung.[7] In a clinical dental setting, the patient's risk of aspirating a foreign body is increased by myriad factors such as sedation, local anesthesia, supine and reclined positioning of the patient, jerky or unexpected movement, excessive salivation and in cases of pediatric dental patients uncooperative behavior also plays a major role. There is no agreement in the literature regarding the position of the patient to minimize the risk of foreign bodies' aspiration.

Neuhauser[8] suggested that patients in a supine position are more or less prevented from swallowing foreign objects. Barkmeier et al.[9] stated that supine position increases the risk of swallowing. Tiwana et al.[7] examined these adverse outcomes by specialty. There were eight such cases in prosthodontics, three in orthodontic/pediatric dentistry, five in restorative dentistry, five in oral and maxillofacial surgery, and one in endodontics. According to a recent review by Hou et al., aspiration happened more during implantation, prosthodontics, and restorative dentistry. Ingestion happened more during prosthodontic procedures.[10] Susini et al.[11] reported that the incidences of aspiration and ingestion in root canal treatment were 0.001 per 100,000 and 0.12 per 100,000, respectively. In pediatric dentistry, three cases have been reported in the literature on ingestion of protaper hand file in children, of which one was removed through esophagogastroscopy by Bhatnagar et al.,[12] another passed through stools after 41 h by Bondarde et al.,[13] and other one by Dandekar et al.[4] in which file passed through stools after 26 h. In cases of foreign body ingestion, children may present with a variety of symptoms, including choking, drooling, and poor feeding in younger patients; dysphagia, odynophagia, and chest pain in older patients; or respiratory symptoms, especially in younger patients, due to tracheal compression or esophageal erosion.[14] In our case, aspiration was ruled out due to the absence of symptoms of aspiration. In case of foreign body in airway, it is an acute emergency and presents with the respiratory arrest, stridor, and classic triad of wheezing, coughing, and dyspnea.[1] Moreover, some inadvertently aspirated small foreign objects can pass through the vocal cords without obstructing the upper airway and remain asymptomatic for several months.[15] Their long-term retention can result in late complications such as vocal cord paralysis, postobstructive pneumonia, atelectasis, bronchiectasis, pneumothorax, hemorrhage or lung abscess, and death.[16] In case of foreign body at the oropharyngeal level, the patients usually have a clear sensation of something being trapped, discomfort, drooling of saliva, inability to swallow, airway compromise1, and also infection and perforation can also occur, about 60% of the foreign bodies become trapped at this level.[11] As stated earlier, most of the objects enter GI and pass out uneventfully without needing any intervention. In ingestion cases, the site of involvement is probably related to the time after the accident. If the checking time is short after the ingestion, the object may be in the stomach; as seen in our case, otherwise, it will be in the intestine.[10] However, at times in cases of ingestion at potential sites of impaction along the GI tract, the symptoms vary between abdominal pain, fever, nausea, vomiting, and abdominal distension that may complicate diagnosis.[17] Objects with sharp edges increase the chances of perforation and damage by 15%–35%.[18] However, as the zirconia crown ingested was blunt object with no sharp or pointed edges, this complication was counteracted. In case of a swallowed or aspirated dental radio-opaque object, then abdominal X-ray, PA chest X-ray, and lateral chest X-ray should be carried out to confirm the location of the object and prepare for the further treatment planning. Endoscopy of upper GI tract should be carried out when the ingested object is not radio-opaque, X-ray investigations are unlikely to help. Urgent endoscopy is mandatory in cases where there is airway obstruction or evidence of other severe complications. Endoscopy is definitely indicated when ingested objects are sharp, nonradio-opaque, elongated, or where there are multiple swallowed objects or a high-risk of esophageal injury. Endoscopy is also indicated for gastric or proximal duodenal foreign bodies that have a diameter of 2 cm, length of 5-7 cm or are eccentrically-shaped, and prone to lodgment and perforation.[19] Of the foreign bodies that come to medical attention, 80%–90% pass spontaneously, 10%–20% require endoscopic removal, and <1% require surgical intervention.[20] As in our case the crown being a blunt small object seen in the stomach, we decided to keep patient on a high fibrous, banana and moistened diet which would accentuate and help in easy and quick excretion of crown though stools. Which is supported by Pavlidis et al. stating that if the object is smaller in size, then observation and waiting for the duration of 2 weeks is advisable because of high chances of the object passing out through stools without any complications[21] and Parolia et al. stating that patients with stomach or small-intestine foreign bodies of width <2 cm or length <6 cm can be discharged home with instructions on symptoms that should prompt their re-attendance and diet instructions about a diet high in roughage and frequent ingestion of soft food items, such as banana or moistened bread, may aid in the passage of swallowed foreign object.[19] Following the protocols, in our case, the crown was uneventfully excreted post 26 h.

The varied preventive protocols that may be applied initially begins by obtaining a proper case history of patient keeping in considerations the physical, mental, and any special health considerations which may play a pivotal role in such cases. Age of the patient plays an important role as young children met by pediatric dentists are quite playful, more unstable, uncooperative at times, and their inability to follow instructions by dentist which increases chances of such incidences and additional care and attention must be provided to avoid the ingestion or aspiration consequences. In cases of conscious sedation or general anesthesia, a throat pack must be placed as the patient in these states has loss of protective reflexes; however, before removal of throat pack oral cavity must be thoroughly suctioned to avoid any complications.[22] Rubber dam application must be practiced in cases of endodontic treatment.[23],[24] It offers effective protection against aspiration or swallowing of endodontic instruments, broken burs, restorative materials, and pins. However, at times ingestion of rubber dam clamp is observed, to avoid this floss must be attached to the clamp.[25] In children, rubber dam application reduces their cooperative behavior, and hence in case of endodontic procedures, floss must be attached to all small files, broaches. As stated by Dandekar et al.,[4] in case of hand protaper files dental floss can be incorporated into the file handle with the help of suture needle. All instruments, such as mirrors, their attachments to handles must be checked before the usage. Orthodontic bands and wires must be attached to floss.[26] In procedures, where the use of rubber dam is precluded an alternative is to place a 4” × 4” gauze protective barrier in the oral cavity distal to the area where small items are being manipulated. Additional precautions include appropriate anesthesia and treatment selection, proper body and head positioning, upright position of the chair, adequate lighting, and four-handed dentistry with an attentive assistant, and high-speed evacuation. Furthermore, the patients must be instructed that if an object falls on the tongue, they should try to suppress the swallowing reflex and turn their heads to the side; however, this may be difficult in very young patients.


  Conclusion Top


Although such events are unforeseen, an old adage “prevention is better than cure” holds true in such situations. Preventive measures must be practiced religiously by the dentists to avoid such circumstances for the clinician as well as the patient. Early recognition of swallowed foreign bodies and knowledge regarding the signs and symptoms associated during various procedures related to pediatric dental patients is the key to avoid catastrophic effects. Appropriate patient selection after taking detailed history related, religious adherence to clinical procedures, periodic check for wear of instruments, and replacement if indicated appropriate use of high-volume suction, adequate assistance, adequate attachment of the floss to the instruments, rubber dam application, or gauze usage as per the procedure being performed as well as proper patient education are all pivotal factors in the prevention of any complications. In this litigious era, much attention must be paid to prevention as well as education regarding the management of such unavoidable emergencies.

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

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