Review Article
Accidental Intake of Foreign Bodies in
Aditi Gaur1, Sanjeev
Kumar Verma2,
Sandhya
Maheshwari 3,
Fehmi Mian4
1,2.3,4
Department of
Orthodontics and
Dentofacial Orthopedics,
Dr. Z.A. Dental College,
Aligarh Muslim University,
Aligarh, India.
Correspondence to:
Dr. Aditi Gaur,
Department of
Orthodontics and Dental
Anatomy, Dr. Z.A. Dental
College, Aligarh Muslim
University, Aligarh, India.
E-mail Id:
aditigaur2289@gmail.
com
How to cite this article:
Gaur A, Verma SK,
Maheshwari S et al.
Accidental Intake of
Foreign Bodies in
Orthodontic Patients: A
Management Protocol. J
Adv Res Dent Oral Health
2016; 1(2): 2-7.
ISSN: 2456-141X
© ADR Journals 2016. All Rights Reserved.
Orthodontic Patients: A Management
Protocol
Abstract
One of the common emergencies during dental treatment is accidental intake of dental
materials. Dental patients being treated in supine position increases the risk of
accidental ingestion during various dental procedures. Orthodontic patients are prone
to such incidences because of the small size of materials used such as brackets, molar
bands, tubes and archwire clips. Ingestion of a number of orthodontic materials such as
retainers, sectional wires, hooks, bands, brackets, or expansion appliance keys have
been reported. These materials may be ingested or aspirated and become lodged in the
oropharyngeal or gastrointestinal tract. The response to such conditions may vary from
no symptoms, mild irritation, to severe consequences such as choking or asphyxiation.
A protocol must be available to avoid such untoward episodes and to ensure effective
management in case of an occurrence. This article presents a literature review of
accidental ingestion or aspiration of orthodontic materials and elucidates an effective
management protocol for such emergencies.
Keywords: Accidental, Foreign body, Ingestion, Aspiration, Orthodontics.
Introduction
Accidental foreign body ingestion or aspiration is a common complication in dental
practice mostly due to the supine position of the patients undergoing dental
treatment.1 Patients receiving orthodontic treatment are at a high risk of having
appliances swallowed into the oropharynx during treatment due to the small size of
brackets and clipped wires. Aspiration of the orthodontic appliance components into
the nasopharyngeal airway may also occur in some cases. Orthodontic appliances that
can be ingested/ aspirated include wires, brackets, transpalatal arches, and keys for
expanders and removable appliances.2-5 There are many strategies to avoid such
accidents during dental procedures - use of rubber dam, use of gauze throat, tying small
objects with floss, directly observing the entire procedure, using the most upright
patient position possible and providing detailed instructions to patients. Most cases can
be managed if the clinician is aware of the measures that can be undertaken when
encountering such emergency situations.
Incidence
Tamura et al. reported that the range of accidental ingestion/ aspiration of dental
appliances was between 3.6% and 27.7% of all foreign bodies, with a considerably
higher incidence in adults than children.6 The greatest incidence of accidental intake of
foreign bodies in dentistry has been found in prosthodontic and orthodontic patients.7
It has been observed that the chances of ingestion is higher than aspiration.8 Eighty-five
percent of such adverse events have been found outside the orthodontist’s office, on
the other hand occurrences in the clinic during appliance manipulation were found to
be 15% of the cases.9 Dentures and small orthodontic appliances (73%) account for the
majority of accidental sharp objects ingestion in normal adults.10 Orthodontic
components are mostly small, handling can be difficult and any object that is placed
into or removed from the oral cavity can be aspirated or ingested.
J. Adv. Res. Dent. Oral Health 2016; 1(2)
After ingestion, 75% of the foreign bodies may pass
through the gastrointestinal passage, but in some cases
might result in perforations.11 Once a foreign body has
reached the stomach it has an 80-90% chance of passing
along the gut without major complications.12 Less than
1% of foreign bodies have caused a perforation.13 After
leaving the stomach, the most common subsequent site
of perforation or obstruction is the ileocaecal valve and
the sigmoid colon.14
Type of Orthodontic Components
One of the first cases of accidental ingestion of an
orthodontic material was reported by Hinkle et al.
(1987) who reported a case with accidental swallowing
of an acrylic retainer and its retrieval.15 Klein et al.
reported a case of aspiration of dental retainer by an
orthodontic patient.16 Kharbanda et al. (1995) reported
a case of a pediatric patient in which a cast gold crown
became loose and was ingested by the patient,
following the placement of a brass separator for band
insertion.17 Quick et al. (2002) presented a case of an
orthodontic patient who accidentally ingested a section
of orthodontic wire and coil spring from a fixed
expansion device placed in the maxillary dental arch.3
Hoseini et al. (2014) reported a case of out-of-office
displacement of an orthodontic archwire, in which there
was an accidental ingestion of an archwire by the
patient during eating.18 Nicolas et al. reported an
unusual case in which an archwire loosened from the
brackets during manipulation got misplaced and was
detected in the nasal cavity on radiographic
examination.19 Another case report was discussed by
Lee, of an orthodontic patient who had swallowed a
fractured piece of an archwire from orthodontic
appliance during eating.20 Umesan et al. (2002) reported
a patient who accidentally swallowed an archwire which
became embedded in the larynx.21 Sfondrini et al.
reported a case of an accidental swallowing of a rapid
palatal expander by a female patient after the
expansion appliance broke off from the bands after
sutural opening.22 Wilmott et al. presented a case of an
orthodontic bracket which dislodged from the appliance
and got embedded on the medial pterygoid surface of
the oropharynx.4 De queiroz et al. (2013) reported a
case of a submandibular-space abscess associated with
a molar tube that detached during orthognathic surgery
and became embedded in the soft tissues and resulted
in infection of the site.23 Filho et al. reported a case of
bond failure of an orthodontic second-molar bracket
during orthognathic surgery and slipping into the
second molar tube during orthognathic surgery.24
Naragond et al. (2012) showed a case in which a molar
band was swallowed by the orthodontic patient.25
Macey et al. (1992) gave an unusual report of an
3 ISSN: 2456-141X
Gaur A et al.
orthodontic bracket dislodged into a sagittal split site
corresponding to the mandibular premolar-canine
region.26 Abdel-Kader et al. (2003) presented a case
report of a broken transpalatal archwire which stuck to
the throat of the patient.5 Rohida et al. (2011) reported
a case of an orthodontic patient who accidentally
swallowed a fractured twin-block appliance.27 Tripathi
et al. (2011) presented with a case of a patient who
swallowed a key for turning fixed-expansion appliances,
which became lodged in the patient’s pharynx but
subsequently passed through the gastrointestinal tract.6
Monini et al. (2011) reported a similar case with a
patient who swallowed a key which was used to activate
a rapid maxillary expansion appliance.28 Allwork et al.
(2007) reported a case in which a Down’s syndrome
patient ingested a quadhelix appliance.29
Symptoms
An ingested foreign body may result in difficulty or
inability to swallow, pain on swallowing, muscle in-
coordination and hematemesis or vomiting.30 Aspirated
foreign body may result in otalgia, pharyngitis and
trismus without fever, dysphagia or dyspnea. Excessive
coughing, difficulty in breathing, choking, congestion,
runny nose or watery eyes, dusky-bluish or red changes
in the face, on or under the eyes or around the mouth
lead to a more morbid condition such as asphyxiation.31
Management
The management of foreign body inhalation or ingestion
depends upon the nature and type of the foreign body,
symptoms in the patient and the duration of accidental
intake. The basic steps for management have been
enlisted in Fig. 2.
Immediate Removal
As soon as any foreign body is displaced, the first line of
action involves the Heimlich maneuver (Fig. 1),
abdominal or chest thrusts in pregnant or obese
patients, and finger sweeps when the object is located
in the oral cavity in unconscious adults.32 An object
which drops into the mouth of a supine patient during
dental procedures, the head may be turned to one side
to encourage the object to fall into the cheek rather
than the oropharynx. The object should be removed
using forceps and high-volume suction. Most commonly,
the object gets entrapped into the supra-tonsillar recess
followed by the epiglottic vallecula and the piriform
recess.33 Absence of localization of the object in these
areas confirms that the patient has either swallowed or
aspirated the object. The nature of the component and
the symptoms can prove to be useful regarding the
lodgment site and the need for immediate intervention.
Gaur A et al.
Figure 1.Heimlich’s Maneuver for Immediate Retrieval of Foreign Body
Localization of the Foreign Body
In case of inability to retrieve the foreign body from the
oral cavity, the patient must be referred for medical
attention. The localization of the ingested or aspirated
component can be made using a plain chest and
abdominal radiographs.34 Endoscopic examinations are
required in some conditions. Metallic components such
as brackets and bands are easier to locate than the
radioluscent ceramic brackets, elastics and acrylic
appliances. For radiolucent objects, ingestion of cotton
wool pellets mixed with small amounts of barium
sulfate suspension has been reported to form a radio-
opaque bolus around the object, which allows it to be
tracked through the gut radiographically. Barium
swallows are sometimes used to detect non-radio-
opaque items but they must be avoided in case there
are chances of gastric perforation. In such
circumstances, gastrografin is used as a contrast
agent.35,36 CT and CBCT scans are preferable in such
cases and can prove to be highly useful in locating the
radioluscent foreign bodies.37
Wait and Watch
When objects reach the stomach, the majority will pass
the gastrointestinal tract without complications, as a
result of peristaltic movement. Periodic radiographs are
required for evaluating the position of the object; in
case of no change in position, removal should be
considered. The patients who have been asymptomatic
for around 24 hours can be considered for observation
ISSN: 2456-141X
J. Adv. Res. Dent. Oral Health 2016; 1(2)
in case the object that has been ingested is of non-
threatening nature.38
Invasive Procedures
All foreign objects in the respiratory tract need to be
removed as soon as possible because the localization
and removal of the object will be more difficult if
edema, excessive secretions, and formation of
granulation tissue occur. Bronchoscopes are usually
used for retrieval of objects in respiratory system. For
objects larger than 6 cm in children and longer than 10
cm in adults, surgical intervention is necessary.39 For
objects smaller than 6.5 cm, in adults, endoscopy and/
or observation will result in a success rate of
approximately 50%. Definite indications for endoscopy
are objects that are sharp, non-radio-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 and are prone to
enlodgement/ perforation.40 Urgent endoscopy is
mandatory in cases where there is airway obstruction or
evidence of other severe complications. Foreign bodies
lodged in the esophagus should be removed
endoscopically, but some small, blunt objects may be
pulled out using a Foley catheter or pushed into the
stomach using bougienage.41 Endoscopic or surgical
intervention is indicated if significant symptoms develop
or if the object fails to progress through the
gastrointestinal tract.
4
J. Adv. Res. Dent. Oral Health 2016; 1(2) Gaur A et al.

Accidental ingestion/aspiration of foreign bodies

Asymptomatic Symptomatic

Wait and watch Immediate removal: Heimlich

maneuver, abdominal or chest
thrusts

Retrieval of foreign body

Positive Negative

Seek medical care

Radiologic, endoscopic
confirmation

Removal using bronchoscope,

endoscope.

Figure 2.Flowchart for Management of Accidental Ingestion/ Aspiration of a Foreign Body

Clinical Recommendations for Preventive
Measures
1. High-volume suction should be used during bonding
and banding procedures to prevent swallowing of
components.
2. The bonding must be done under a dry field to
achieve sufficient bond strength.
3. Bands must be contoured to fit tightly around the
teeth and must be cemented properly.
4. Rubber dams can be used while working in small
area in the oral cavity.
5. The archwire ends must be cinched to prevent
loosening of archwire.
6. Cotton gauze must be placed behind archwire ends
before cutting the distal ends.
7. While cutting the distal ends of the archwire,
patient’s head can be reclined to one side to catch
the cut end in the buccal pouch.
8. Appliances such as transpalatal arches, NiTi
expanders which need to be fitted into the lingual
sheaths must be tied with floss which can be
removed once the appliance has been secured (Fig.
3).
9. Components such as activation keys should be tied
with floss to prevent slippage while usage by the
patient. Keyes has devised a keyless RME appliance
which eliminates the risk of accidental ingestion of
the activation key.
10. Sharp components such as C-clasps should be
avoided in the fabrication of the removable
appliances.
11. Patients should be instructed to report on any
breakage or loosening of components during fixed
orthodontic treatment.

5 ISSN: 2456-141X
Gaur A et al.
Figure 3.Orthodontic Materials such as Palatal Expanders and Molar Bands Can Be Tied with Dental Floss before
Placing in the Patient’s Mouth
Conclusion
Dislodgement of orthodontic appliance components can
occur commonly in the patients. The orthodontist must
be vigilant during treatment procedures and the dental
office must be well-equipped to counter emergency
situations. Before initiating the orthodontic treatment,
both the patients and parents must be made aware of
the adverse effects that might be associated with the
treatment and the protocol to manage such conditions.
The clinician must take all the necessary precautions to
avoid such untoward occurrences, as prevention is
easier than management of these situations.
Conflict of Interest: Nil
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Date of Submission: 10th Jul. 2015
Date of Acceptance: 22nd Jan. 2016