Crowning achievement: a case of dental aspiration.

Aspiration of foreign bodies during dental procedures is a rare but potentially serious complication. We present a case of a 75-year-old man who aspirated a dental crown requiring flexible bronchoscopic retrieval. We discuss the risk factors for aspiration, the radiographic features of diagnosis, and the techniques for management and retrieval.

Case report

A 75-year-old man aspirated a gold dental crown when he hiccupped during a dental procedure. He was evaluated in the emergency department immediately afterward, and focal right-sided wheezing was auscultated. A chest radiograph demonstrated a radio-opaque mass near the inferior right hilum (Fig. 1A and B). Flexible bronchoscopy was performed within hours revealing a gold crown lodged in the bronchus intermedius (Fig. 1C), which was retrieved using a basket net retrieval device (Fig. 1D and E). The patient was discharged with a temporary crown, which was ultimately replaced by the recovered gold crown.

Fig. 1

Following a dental procedure, a radio-opaque foreign body was seen on both posterior-anterior (A) and lateral (B) chest radiographs (arrows). Bronchoscopy confirmed the presence of a foreign body (C) in the bronchus intermedius (arrow), which was successfully retrieved using a basket net retrieval device (D). This recovered dental crown (E) was later re-implanted

Discussion

Aspiration of foreign bodies during dental procedures is a rare complication, occurring much less often than accidental ingestion of dental foreign bodies [1], [2]. The largest review of dental aspirations, a retrospective analysis of insurance records of 24,651 French dentists over 11 years, identified only 44 cases of foreign body aspiration after a dental procedure [1]. Aspiration occurs more frequently in patients with neurocognitive disability and in those at the extremes of age. The most frequently aspirated dental objects include teeth, fillings, crowns, bridges, and dental tools [2]. Prosthesis manipulation confers a higher aspiration risk, possibly because objects become slippery after cement glue application [1]. Outside the dental office, dental aspiration can also occur in the context of seizures, trauma or, rarely, after endotracheal intubation [3].

There are several preventative strategies to minimize dental aspiration including the routine use of a rubber dam during dental work and the tying of suture or floss to the prosthesis or tools during placement to facilitate recovery. Despite this, the rate of adherence to these guidelines is reported to be less than 20% [4], [5]. If aspiration does occur, patients can be instructed to cough forcefully to expel the object; however, the vast majority of dental aspirations require medical evaluation and intervention [4], [6].

Detection of dental aspiration may be prompt, as in this case; however, significant delays in diagnosis have been reported and may be associated with greater morbidity [7]. It is prudent to assume that any object lost during dental manipulation has been aspirated and for the dentist to accompany the patient to a medical facility for prompt radiographic evaluation. Even asymptomatic patients should be evaluated as an aspirated object may shift causing airway obstruction.

Radiographic findings include direct visualization of a radio-opaque foreign body or identifying its effects such as atelectasis, lobar collapse, or distal hyperinflation. The most common site of tracheobronchial foreign body aspiration in adults is the bronchus intermedius because of its larger diameter and straighter course, although other airways may be affected depending on body position at the time of aspiration [8]. Computed tomography is often unnecessary, as many aspirated dental objects are radio-opaque and can be identified on a standard chest radiograph. Importantly, however, the absence of a foreign body on radiograph does not reliably exclude aspiration and further work-up may be necessary [9].

Pulmonary consultation should be sought as bronchoscopy can confirm aspiration, and prompt retrieval may prevent complications such as atelectasis, postobstructive pneumonia, and hemoptysis [10]. Other uncommon complications of dental aspiration include airway obstruction potentially leading to hypoxemia and perforation leading to potentially fatal infectious (eg, mediastinitis) or bleeding complications.

Flexible bronchoscopy can be performed rapidly and safely under local analgesia or moderate sedation and is typically the first intervention. Several bronchoscopic techniques exist for retrieval via flexible bronchoscopy, including forceps, baskets, cages, and Fogarty balloons. In the case of occult aspiration with long latency before detection, granulation tissue can complicate object removal and potentially lead to persistent obstruction. If flexible bronchoscopy is unsuccessful, rigid bronchoscopy under general anesthesia may be required. Although the vast majority of aspirated foreign bodies can be retrieved bronchoscopically [11], occasionally a surgical approach may be necessary.

The prognosis for dental aspiration is typically excellent, as it was in this case. Morbidity, although infrequent, is attributed primarily to delays in diagnosis or to rare complications such as bleeding or perforation [7]. Occasionally, unrecognized dental aspiration may be misdiagnosed as asthma, pneumonia, bronchitis, or even cancer [7], [12], [13].

Dental aspiration, especially occurring during dental procedures, is a rare but important event requiring prompt recognition, diagnosis, and treatment. Recognition of the aspirated object on chest imaging and removal of the foreign body via bronchoscopy is essential to prevent long-term sequelae.