Oral Maxillofac Surg (2010) 14:43–47
DOI 10.1007/s10006-009-0178-0
CASE REPORT
Bronchial impaction of an implant screwdriver
after accidental aspiration: report of a case and revision
of the literature
Lorena Pingarrón Martín & María José Morán Soto &
Rocío Sánchez Burgos & Miguel Burgueño García
Published online: 16 October 2009
# Springer-Verlag 2009
Abstract
Background Adverse outcomes resulting from aspiration or
ingestion of instruments and materials can occur in any
dental procedure. Clinical manifestation depends on the
location, the obstructive potential of the foreign body, and
the temporal factor since the accidental incident. Accidental
inhalation of dental appliances can be an even more serious
event than ingestion and must always be treated as an
emergency situation.
Case report A 62-year-old woman was admitted to our
hospital with the suspicion of ingestion of a screwdriver
implants. In spite of the clinically asymptomatic presenta-
tion, chest radiography in posteroanterior and lateral
projections showed a radiopaque dental instrument impact-
ed on the right main inferior bronchus. Rigid bronchoscope
was successful to remove the dental instrument under
general anesthesia, and the patient was discharged 24 h
later.
Conclusion Aspiration and ingestion of dental foreign
objects are infrequent, but they can occur at large
multidisciplinary dental procedures. These episodes have
the potential to result in acute medical and life-threatening
emergencies since the beginning of the event or at a late
stage in proceeding in the underdiagnosed patient. Preven-
tion of such incidents is, therefore, the best approach via the
mandatory use of precautions during all dental procedures,
and in case of suspicion with no retrievable material, patient
must always be submitted to a radiographic study.
L. Pingarrón Martín (*) : M. J. Morán Soto :
R. Sánchez Burgos : M. Burgueño García
Department of Oral and Maxillofacial Surgery,
La Paz University Hospital,
Madrid, Spain
e-mail: lorenapingarron@yahoo.es
Keywords Implant screwdriver . Aspiration .
Bronchoscopy . Bronchial impaction
Background
The aspiration or ingestion of instruments or materials used
in treatment at every field of the dental profession is a
potentially avoidable risk with the use of adequate
precautions during all procedures.
Foreign bodies vary in size and shape and range from
endodontic instruments, burs, posts, root copings, teeth,
orthodontic brackets, and impression materials to tempo-
raries, implant components, and restorations [1]. Some
objects are made of materials that lack radiopacity, which
makes it impossible to identify their position; diagnostic
bronchoscopy or computed tomography for localization is
then required.
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. However, there are situations
in which the use of a rubber dam may not be feasible. 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 [2, 3].
Patient-related factors which make them more prone to
swallow foreign bodies form select groups including
prisoners, psychotic individuals, alcoholics, the senile,
mentally retarded individuals, patients who are nervous or
restless, patients with an excessive gag reflex, patients with
difficult access sites secondary to anatomical restrictions
(e.g., small oral cavity, short palate, macroglossia, large
neck) and patients with increased intra-abdominal pressure,
as in overweight patients and pregnant women, dysphagy
44 Oral Maxillofac Surg (2010) 14:43–47

may also be present, especially in a reclined position, being
at greater risk of ingesting or inhaling foreign bodies.
Clinical manifestation depends on the location, the
obstructive potential of the foreign body, and the temporal
factor since the accidental incident.
Aspiration or ingestion is an infrequent occurrence, the
latter happening more often as a direct result of the strong
coughing that occurs when there is a foreign object in the
patient’s airway, which makes it more difficult for aspira-
tion to occur.
Accidental inhalation of dental appliances can be an
even more serious event than ingestion and must always
be treated as an emergency situation. Early complica-
tions of foreign body aspiration include acute dyspnea,
asphyxia, cardiac arrest, and laryngeal edema. Thin,
pointed instruments increase the risk of perforation and
pneumothorax.
Chronic complications such as esophageal erosion and
pneumonia resulting from unrecognized aspiration or
ingestion are serious medical issues that require further
care and hospitalization.
These complications not only have associated economic
cost but also carry the risk of malpractice litigation against
the clinical practitioner [4].
Bronchoscopy is the treatment of choice for removal of
the foreign body. If the foreign body cannot be removed by
flexible bronchoscopy [5], rigid bronchoscopy can be used
as an appropriate alternative treatment option, but this
requires the administration of general anesthesia. The
advantages of rigid bronchoscopy include a larger working
channel and better visualization of the central bronchial
tree, but foreign bodies located more distally are out of
reach [6].
Chest radiography in posteroanterior and lateral projec-
tions showed right main inferior bronchus with impaction
of a radiopaque dental instrument (Figs. 1 and 2).
Following a fiber-optic intubation, a thoracic surgeon
introduced a rigid bronchoscope. The approach revealed an
endobronchial foreign body (1×1.5 cm cylindrical, titanium
screwdriver implant) obstructing the right main bronchus,
which was successfully removed at that time.
The patient was discharged 24 h later with no compli-
cations and complete resolution of the episode.
Discussion
Adverse outcomes resulting from aspiration or ingestion of
instruments and material can occur in any dental procedure
[7].
The incidence grows when the advisable preventive
methods are not used. These steps include using a rubber
dam whenever possible, tethering any small instrument
with a ligature, and placing a gauze screen across the
oropharynx of the conscious or sedated patient to minimize
risk by using gauze throat screens and rubber dams.
Depending on the size, shape, and flexibility of the object,
some occurrences present minimal danger, while others
have the potential to be lethal [8].
A patient who aspirates or ingests dental foreign objects
is one patient too many; these incidents are preventable if
the correct precautions are taken.

Case report

A previously healthy, 62-year-old woman was admitted to

our hospital with the suspicion of ingestion of a screwdriver
implant. She was accompanied by her odontologist who
was treating her with dental implants rehabilitation.
During the anamnesis, the patient related that an object
dropped into the oropharynx and that she swallowed it
without any difficulty. She was encouraged to cough
vigorously, but in the examination of mouth and local area,
the screwdriver was not found. She started a completely
asymptomatic period.
Her vital signs upon admission were as follows: T,
37.1°C; B.P., 130/85 mm Hg; H.R., 92 bpm; and R.R., 21
breaths/minute.
On physical examination, the findings were: absence of
inspiratory stridor, not labored breathing, and preservation Fig. 1 Posteroanterior chest radiograph showing implant screwdriver
of breath rounds with 99% of O2 saturation. located in right main bronchus
Oral Maxillofac Surg (2010) 14:43–47 45

stridor are indicators of laryngeal obstruction, and attempts

must be made instantly to avoid respiratory arrest. If
coughing fails to relieve the obstruction, the Heimlich
maneuver should be performed [9, 10]. If this is not
successful, the patient should be transferred immediately to
the nearest emergency room meanwhile cardiopulmonary
resuscitation maneuver is carried out including cricothyr-
oidotomy if necessary [11]. If the patient is asymptomatic,
he or she should be reassured and informed about the
necessity of immediate medical examination. Frontal and
lateral chest and abdominal roentgenograms should reveal
whether the object has been swallowed or inhaled [12, 13].
Even though it is not common, occlusion of the larynx with
an aspirated large object can cause an acute and dramatic
presentation, and a brief period of choking and gagging may
be associated with hoarseness, aphonia, and cyanosis. In the
presence of long-standing aspirated foreign bodies, recurrent

SUSPICION OF FOREIGN BODY ASPIRATION OR INGESTION

Fig. 2 Lateral chest radiograph showing implant screwdriver located
in the bronchial system

Symptoms and signs of airway obstruction

While these events occur infrequently, the potential YES NO

morbidity associated with a single incident is too high to
ignore. HEIMLICH MANOEUVRE Examination
of mouth and local area:
Preparation for such incidents will prevent many of object retrieved?
them, and this makes important to emphasize the need to
check all dental instruments before their use, as a safeguard
Efective No expulsion of the foreign body YES NO
against possible failure [4].
Current policy for infection control maintains strict RESOLUTION
guidelines for asepsis. With the increasing use of steam
autoclaving and cleansing products, an increased rate of Expulsion of the foreign body AIRWAY PROTECTION
failure may be seen in some instruments.
Manufacturers should be contacted for instrument care
and sterilization recommendations, as well as projected RESOLUTION
longevity of the instrument, if their sterilization procedures Total airway compromise Asymptomatic patient
are followed. The economic implications of replacing CPR HOSPITAL
instruments because of the protocol for maintaining asepsis CRICOTHYROIDOTOMY
will undoubtedly contribute to the rising cost of care.
Prevention has been the goal of dentistry for decades and Chest & abdominal roentgenogram
dental emergencies are not excluded. Preparation for such
incidents will prevent many incidents and allow for proper
patient management should they occur [4]. Location AIRWAY Location TRACT DIGESTIVE

When a foreign body drops into the oropharynx, first of

all, the patient should be positioned in reverse Trendelen-
burg position (in which the upper part of the body is raised BRONCHOSCOPY

20° to 30°) and asked to cough trying to regurgitate the Impactation and/or complications

inhaled object.
The appropriate behavior will depend on the airway
ENDOSCOPY/COLONOSCOPY LAPAROTOMY
management (Fig. 3).
Symptoms such as choking, labored breathing, and using Fig. 3 Behavior algorithm for airway management in case of
the accessory musculature to aid respiration and inspiratory suspicion foreign body aspiration or ingestion
46
hemoptysis, and symptoms consistent with recurrent bronchi-
tis, pneumonia, and bronchiectasis, such as chronic produc-
tive/unproductive cough, and wheezing, may exist [7, 14].
On physical examination, the most common findings of
foreign body aspiration cases of long evolution include
tachypnea, stridor, unilateral or bilateral decreased breath
sounds, localized wheezing and/or crackles, and sometimes
fever. Unusual presentations consist of pneumomediasti-
num, subcutaneous emphysema, and/or pneumothorax [6].
In adults, the right bronchial system is more likely to be
obstructed by aspirated foreign bodies.
However, the preponderant right-sided location of the
foreign body is not found in children because the left
mainstem bronchus is closer in size to the right mainstem
one; in addition, the left mainstem bronchus does not
branch at the same acute angle as in adults [12]. Two thirds
of aspirated objects lodge in the main stem bronchi rather
than in the distal bronchi [6].
Although most of the foreign bodies corresponding to
dental instruments and materials used in oral surgery are
radiolucent, a standard radiological workup, including a
posteroanterior and a lateral chest film, and a lateral soft
tissue neck radiograph should be performed in cases of
suspected foreign body aspiration.
One should remember that chest radiographs may be
normal in the first 24 h, and initial radiological findings
which show unilateral or segmental hyperaeration can
become visibly better on either expiratory radiographs or
fluoroscopic examination of the lungs [3].
In case of location in the digestive tract, the patient must
be aware of the situation, and advice should be given
regarding examination of stools.
Use of a high-bulk diet may be helpful; however, there is
no scientific evidence on the benefit of any special diet to
support such objects passage. Purgatives should be avoided
because they increase the effect of a peristaltic contraction
and thus make intestinal perforation more likely [15]. If an
object becomes impacted within the mucosal folds of the
intestinal tract, rectoscopy, colonoscopy, or a surgical
intervention may be necessary, depending on the object
location, such as areas of physiologic or pathologic
narrowing (pylorus, ligament of Treitz, ileocecal valve,
rectosigmoid junction, and anus) which are potential sites
of impaction [13, 16].
Depending on the location in the digestive tract, the
clinical spectrum is different [17]: the majority of foreign
bodies that cause obstruction lodge in the upper esophagus
[15]. This can lead to esophageal perforation with second-
ary mediastinitis and esophageal obstruction with the risk
of aspiration. Thus, swallowed foreign bodies retained in
the esophagus should be urgently removed using fiber-optic
endoscopy. Once a foreign body has reached the stomach,
however, there is a greater than 90% chance of the object
Oral Maxillofac Surg (2010) 14:43–47
being passed from the gastrointestinal tract without prob-
lems, usually over a 7–10-day period [18].
The risk of a foreign body causing perforation or
obstruction is related to the shape and size of the object.
Sharp, pointed objects are associated with a higher risk
of perforation. Objects longer than 5 cm are unlikely to pass
the duodenum. In both cases, early endoscopic removal
should be undertaken [19].
Once an object has left the stomach, in most cases, it will
pass through the small bowel. The most common subse-
quent site of perforation or obstruction is the ileocecal
valve. Removal can be attempted colonoscopically. In the
case of swallowed foreign bodies, the complications of
intestinal obstruction, perforation with subsequent abscess
formation, hemorrhage, or fistula and failure of objects to
progress may occur [13].
The patient should be evaluated for symptoms of
intestinal perforation or obstruction, such as pain or
vomiting, and serial radiographs can be used to monitor
onward progress and confirm passage of the foreign body.
If the patient’s airway is not compromised, this situation
should be maintained. The patient should be transferred to
hospital so that appropriate radiographic and clinical
examination can be carried out. This should consist of
chest and abdominal radiographs, which should enable the
attending physician to determine the location of the object.
In case of an aspirated foreign object, this can
constitute a true medical emergency. The development of
laryngospasm and respiratory embarrassment are poten-
tially life-threatening, and immediate measures, including
cricothyroidotomy, may be required to establish and
maintain a patent airway [11].
Even if the airway does not appear to be in immediate
jeopardy, possibly early complications of foreign body
aspiration may occur including acute dyspnea, laryngeal
edema, perforation, and pneumothorax.
Thus, once a foreign body has been localized in the
respiratory tract using appropriate radiography, retrieval
should be carried out as soon as possible with bronchos-
copy, the method of choice, [5, 14] before mucosal
inflammation and edema around the object may hinder
manipulation of the bronchoscopy. In such a case, surgical
approach by thoracoscopy becomes necessary [6, 20].
Conclusion
Aspiration and ingestion of dental foreign objects at large
multidisciplinary dental procedures These episodes can
result in acute medical and life-threatening emergencies.
Prevention of such incidents is, therefore, the best
approach, via the mandatory use of precautions during all
dental procedures, aimed at securing potentially loose
Oral Maxillofac Surg (2010) 14:43–47
dental objects. In case of development of an event,
assurance of the patient´s airway is crucial, followed by
location of the foreign body in the digestive tube or
respiratory tract with the aim to establish the proper
treatment.
References
1. Cameron SM, Whitlock WL, Tabor MS (1996) Foreign body
aspiration in dentistry: a review. J Am Dent Assoc 127:1224–1229
2. Tiwana KK, Morton T, Tiwana PS (2004) Aspiration and
ingestion in dental practice: a 10-year institutional review. J Am
Dent Assoc 135:1287–1291
3. Bergermann M, Donald PJ, Wengen DF (1992) Screwdriver
aspiration. A complication of dental implant placement. Int J Oral
Maxillofac Surg 21:339–341
4. Hodges ED, Durham TM, Stanley RT (1992) Management of
aspiration and swallowing incidents: a review of the literature and
report of case. ASDC J Dent Child 59(6):413–419
5. Donado JR, De Miguel E, Casado ME, Alfaro JJ (1998)
Tracheobronchial foreign body extraction with fiberoptic bron-
choscopy in adults. Arch Bronconeumol 34:76–81
6. Dikensoy O, Usalan C, Filiz A (2002) Foreign body aspiration:
clinical utility of flexible bronchoscopy. Postgrad Med J 78:399–403
7. McArthur DR, Taylor DF (1975) A determination of the minimum
radiopacification necessary for radiographic detection of an aspirated
or swallowed object. Oral Surg Oral Med Oral Pathol 39(2):329–338
8. Fields RT, Schows SR (1998) Aspiration and ingestion of foreign
bodies in oral and maxillofacial surgery; a review of the literature
47
and report of five cases. Am J Oral Maxillofacial Surg 56:1091–
1098
9. Heimlich HJ (1975) A life-saving maneuver to prevent food-
choking. J Am Med Assoc 234:398–401
10. Heimlich HJ (1977) The Heimlich maneuver: prevention of death
from choking on foreign bodies. J Occup Med 19:208–210
11. Dierks EJ (2008) Traqueotomy: elective and emergent. Oral
Maxillofac Surg Clin North Am 20(3):513–512
12. Zitzmann NU, Elsasser S, Fried R, Marinello CP (1999) Foreign
body ingestion and aspiration. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 88:657–660
13. Maleki M, Evans WE (1970) Foreign-body perforation of the
intestinal tract. Arch Surg 101:475–477
14. Martinot A, Closset M, Marquette CH et al (1997) Indications for
flexible versus rigid bronchoscopy in children with suspected foreign
body aspiration. Am J Respir Crit Care Med 155:1676–1679
15. Henderson CT, Engel J, Schlesinger P (1987) Foreign body
ingestion; review and suggested guidelines for management.
Endoscopy 19:68–71
16. Brady PG (1995) Management of esophageal and gastric foreign
bodies. Gastrointest Endosc 42:622–625
17. Milton TM, Hearing SD, Ireland AJ (2001) Ingested foreign
bodies associated with orthodontic treatment: report of three cases
and review of ingestion/aspiration incident Management. Br Dent
J 190:592–596
18. Webb WA (1988) Management of foreign bodies of the upper
gastrointestinal tract. Gastroenterol 94:204–216
19. Soergel KH, Hogan WJ (1983) Therapeutic endoscopy. Hosp
Pract 18:81–92
20. D’Ovidio C, Carnevale A, Pantaleone G (2008) A case of accidental
aspiration of a dental cutter into the bronchopulmonary tree:clinical
implications and legal considerations. Minerva Stomatol 57
(10):535–547