PEDIATRIC DENTISTRY V 30 NO 1 )AN FEB 08

Stainless Steel Crown Aspiration During Sedation in Pediatric DentistryA. Adewumi, BDS, MPaedDent' • David W, Kays, MD'

Abstract: Foreign body aspiration (FBA) causes death in more than 300 chiidren every year in the United States. Morbidity and mortality are increased inchildren due to narrow airways and immature protective mechanisms. Factors to consider in pediatric dentistry are: (I) the patient's age and behavior: (2)presence and extent of disability: (3) tocat anesthesia: (4) body positioning: and (5) loose teeth. FBA requires prompt recognition and early treatment tominimize potentially serious and sometimes fatal consequences. The purpose of this case report was to describe the aspiration of a stainiess steel crownin a 5-year-otd boy during conscious sedation, it also discusses how a prompt and accurate diagnosis, eariy referral, and immediate treatment helpedprevent serious complications. (Pediatr Dent 2008:30:59-62) Received March 9.2006 / Last Revision June i. 2007 I Revision Accepted June 10.2007.

KEYWORDS: ASPIRATION. PEDIATRIC DENTISTRY. STAINLESS STEEL CROWN

Foreign body aspiration (FBA) is the cause of death for morethan 300 children each year in the United States with ahigher incidence in boys.' Morbidity and mortality tend tobe increased in children because they have narrow airwaysand immature protective mechanisms." A study by Black etal found that 78% of those who die after FBA were between2 months and 4 years of age.̂ Additionally, Sersar et al statedthat FBA was one of the most common and serious problemsamong children, accounting for 7% of lethal accidents in 1 to3-year-old children.^

The most frequently aspirated objects in children arefoods, especially peanuts, followed by nonorganic materialslike metals, plastics, or toys.' Aspirated foreign bodies tendto become lodged in the right main bronchus,* possibly dueto the nature of the anatomy of the tracheobronchial tree.Dislodgements in the left bronchus have also been reported.'

The common triad of presenting symptoms in an aspira-tion is coughing, choking and wheezing. Other signs includeacute dyspnea and diminished breath sounds.'^ Sersar etal* suggested that, of all these signs and symptoms, themost predictive is a witnessed aspiration associated with achoking episode—this is referred to as "penetration syndrome."Aspiration of teeth and restorations is a recognized yet infre-quent happening reported in the dental literature. Aspiration

'Dr, Adewumi is an Assistant Professor. Department of Pediatric Dentistry. College

of Dentistry, and '•^Dr. Kays is a Pediatric Surgeon. Division of Pediatric Surgery.

Department of Surgery, both at the Universityof Rorida. Gainesville. Ra.

Correspond with DrAdewumLat aadewumi@dental. ufl. edu

of foreign objects during restorative procedures, especially undersedation, remains a real threat dtie to the challenges involvedwith treating young children and the difficulty in airwaymanagement.

The purpose of this case report was to describe the aspirationof a stainless steel crown (SSC) in a young child undergoingconscious sedation for restorative dental treatment. It alsodisctisses how an accurate diagnosis prompted early referral fortreatment, resulting in a safe outcome for the patient.

Case reportA healthy 5-year-old boy attended the Department of PediatricDentistry of the University of Florida, Gainesville, Fla, forroutine restorative dental treatment. The child exhibitedextreme anxiety at the initial visit and screening. Followingdiscussion with the child's mother, it was decided that the besttreatment option for the patient was the provision of dentaltreatment using sedation. The patient was in the primarydentition phase, his medical history was unremarkable, airwayassessment was normal, and he was considered ASA class I.For treatment to be completed, 4 sedation sessions werescheduled.

The failure of oral niidazolam alone to adequately sedatethe patient at the first restorative appointment necessitatedthe use of a combination of midazolam and hydroxyzine** forsubsequent sedation appointments to increase patient coopera-tion and gain working time. This combination proved to besuccessful with this patient, and the sedations were relativelyuneventful.

The final appointment involved the placement of an SSCon the primary maxillary left first and second molars.

ASPIRATION OF A STAiNLESS STEEL CROWN 59

PEDIATRiC DENTISTRY V 30 NO 1 JAN . FEB 08

Figure 1. Lateral chest view with the stain-

less steel crown in place.

On the appointed day,the patient's weightwas 18.1 kg. Followinginformed consent by themother and verificationof no change in the me-dical history, a combi-nation of 10 mg (0.6mg/kg) of midazolamwith 50 mg (3 mg/kg)of hydroxyzine wasgiven orally. As withprevious visits, thepatient was placed ina supine position andmedically immobilizedusing a Papoose Board(Olympic Medical,Seattle, Wash) beforetreatment was initi-

ated.^ Local anesthesiawas administered in the form of maxillary buccal and palatalinfiltrations using 4% Septocaine with epinephrine 1:100,000(SeptodontUSA, New Casde, Del). A mouth prop was inserted,rubber dam isolation was used, and the primary molars wereprepared for SSCs.

To complete thedistal preparation ofthe primary maxillaryleft second molar,the rubber dam wasremoved. The appro-priate sizes of IonCrowns (3M ESE,St. Paul, Minn) were,respectively, selectedand fitted with a gauzethroat shield in placeto protect the airway.During the removalof the SSC on thefirst primary molarprior to cementation,the crown becamedislodged distally be-hind the throat packinto the patient's airway.Following a quick oral

exam and high vacuum suctioning, the mouth prop andthe Papoose Board were immediately removed. The patientwas placed in the prone position with several back slaps toattempt displacement of the crown from his airway. Theseattempts, followed by the Heimlich maneuvet, did not yieldthe crown.

Figure 2. Posterior-anterior view with the

stainless steel crown in place.

The initial assess-ment by the dentistshowed that the patientwas choking, coughing,and exhibiting mildexpiratory wheezingwith no obvious signsof respiratory distress.The operator made aprovisional diagnosisof FBA. Since thepatient showed goodair exchange and nofurther signs of distress,he was moved into arecovery area where hismother was informedof the incident. She was

extremely understand- ^ , -TL r i•' higure 3. 1 he stainless steei crown is

ing and agreed to our [oaged in the right main bronchus.attempts to retrieve thecrown. The dentist had a telephone consultation with thepediatric radiologist at Shands hospital at the University ofFlorida, informed him of her suspicion, and provided himwith a concise history of the preceding events followed by averbal request for a chest radiograph.

The patients respi-ratory status remainedstable, and he was takenin a wheelchair to thehospital's radiologydepartment—escortedby his mother and adental assistant who wastrained in cardiopul-monary resuscitation.

Upon return tothe Depar tment ofPediatric Dentistry andwhile awaiting theradiologist's results,the patients conditioncontinued to remainedstable. The dentistproceeded to cementnew SSCs on theprimary maxillary left

Figure 4. Photograph of the bronchus

following removal of the crown.

first and second molarsusing Fuji I glass ionomer luting cement (GC America, Inc,Alsip, III). The radiologist confirmed the diagnosis of FBAover the telephone and informed the dentist of the presenceof the SSC in the entrance to the right main stem bronchtis(Figures 1 and 2).

60 ASPIRATION OF A STAiNLESS STEEL CROWN

PEDiATRIC DENTISTRY V 30 NO 1 JAN FEB 08

The pediatric surgeon on call was immediately contacted,and a diagnostic laryngoscopy with rigid bronchoscopy wasperformed under genera! anesthesia to retrieve the foreign body(Figures 3 and 4). The surgery was uneventful, and the patientwas discharged home the same day.

DiscussionThis case illustrates the ease with which dental foreign bodiescan become dislodged in the airway of a child following routinedental treatment. Children are often referred for sedation be-cause they express extreme behavioral management challengesfor the dentist. Though age-appropriate, these behaviors—when coupled with extreme anxiety—make ordinary dentaltreatment difficult.

The common symptoms of foreign body aspiration arecoughing, wheezing, choking, and acute dyspnea.' * Thesesymptoms may spontaneously subside, even when the foreignbody remains. Radiographic features depend on the size,location, duration since aspiration, and the nature of theforeign body. Aspiration of foreign body may appear as atelec-tasis, consolidation, or bilateral over-aeration.^ Bronchoscopycan be performed for both definitive diagnosis and treatment,if aspiration is suspected. Despite the rarity of these adverseevents, aspirations or ingestions in dentistry have been knownto occur, typically during cementation of permanent crownsand adjunct procedures such as placement of cast post andcore, onlays, and implants.'' A study by Tiwana and Mortonshowed that, ofthe 36 cases of aspiration or ingestion of dentalinstruments or materials that occurred over a 10-year period,only one involved a true aspiration of a cast post and core.''Hodges et al published a case report of a swallowing incidentfollowing a fractured solder joint of a dental mirror in an18-year old developmentally disabled child.^

A search ofthe dental literature did not reveal any reportedcases of aspirations in pediatric dentistry. We felt, however, thatit was imperative to highlight this case to serve as a reminderthat adverse events, though largely preventable, can still occur.

Aspiration or swallowing incidents are more likely to occurwhen treating a population of young patients with physical,medical, and mental disabilities. These patients often lackcooperative or communicative skills or adequate protectiverefiexes required for routine dentistry. This often necessitatesthe use of restraints, sedation, or general anesthesia to achievea successful outcome of dental procedures. These factors inher-ently place the patient at more risk for aspiration or swallowingepisodes due to their altered state of consciousness. The useof sedation may also be complicated by drug interactions,decreased communication skills, and emesis. Other factorsto be considered in pediatric dentistry may include localanesthesia, body and head positioning, loose teeth, loose burs,or instrument fatigue." Aspiration accidents can be minimizedby the use of a physical barrier such as rubber dam or gauzethroat shields. Alexander and Delholm suggested using dentalfloss to secure the rubber dam clamp.^

Another suggestion is that local anesthesia, especially amandibular block or palatal anesthesia, can interfere with thesensory or motor control ofthe pharynx, tongue, and palate.'*This creates an altered sensation, allowing objects to enter theposterior aspect ofthe oral cavity, and precipitating an aspira-tion or swallowing incident. The use of topical anesthetics alsocontributes to this altered sensory nerve function.

Positioning of the patient is a controversial subject. Someindividuals believe the supine position decreases the risk ofaspiration or swallowing while others believe this positionpromotes these incidents."'' While position does play a role,it is often mediated by other associated factors. In the casedescribed, the patient underwent conscious sedation with acombination of midazolam and hydroxyzine. This pharma-cological combination has proven successful for producing amild to moderate sedation level in children.''

The combination of these sedatives with palatal anesthesia,the use of restraints, and a supine position, however, may haveincreased this patient's risk of aspiration in spite of placinga gauze throat shield in the posterior part of the oral cavity.Despite the fact that most aspirations are preventable, Hodgeset al described the surprise onset ofthe object being "lost"or "dropped" into the oral cavity. The use of four-handeddentistry, high-speed suction, ligation of a properly fittedrubber dam clamp, and a gauze throat shield remains themost effective means of preventing aspirations and swallowingmaterials and loose instruments in dentistry.''

Children with behavioral challenges such as attentiondisorders, severe autism, or extreme and aversive behavioralmanifestations—^where communication is difficult and restraintis required—also pose an increased risk for aspirations. Generalanesthesia may be a more viable option for these patients thanmultiple sedation appointments. Loose primary teeth shouldbe routinely checked, anticipated, and removed if necessaryprior to placement of mouth props. Repeated sterilizationtechniques can result in an increase in instrument wear, leadingto failure of soldered joints and disintegration of burs.^

Regardless of the reason for the adverse outcome, it isincumbent upon the dentist to be attentive to both early anddelayed signs and symptoms of an aspiration accident and actpromptly if and when it does occur. In this case, the ability ofthe dentist to recognize the signs and symptoms of aspirationfollowing failed attempts to retrieve the crown prompted therequest of a chest film. Hodges also recommended, in theabsence of signs or symptoms of distress by the patient, precisecommunication with the radiologist following an aspiration orswallowing event with a duplicate sample ofthe foreign body toaccompany the patient. This communication will aid recogni-tion by allowing the appropriate radiographic technique tobe selected/ Immediate medical and surgical intervention forthis patient resulted in the retrieval ofthe SSC within 2 hoursofthe incident and a safe discharge from the hospital on thesame day. Over the years, professionals in the field of dentistryhave worked hard to prevent and minimize adverse events

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PEDIATRiC DENTISTRY V 30 NO I jAN • FEB 08

in the work environment through edtication and trainingof dental personnel. Accidents still happen, however, and it isessential that clinicians and their staff remain calm to makeprompt decisions and take appropriate actions that will not onlyprevent potentially serious complications, but may ultimatelysave their patients' lives.

References1. deOliveira CF, Almeida JF,Troster EJ, Vas FA. Compli-

cations of trachoebronchial foreign body aspiration inchildren: Report of 5 cases and review of literature. RevHosp Clin Fac Med Sao Paulo 2002;57:108-11.

2. Sersar SI, Hamza UA, Abdel Hameed WA, et al. Inhaledforeign bodies: Management according to early and latepresentation. EurJ Cardiothorac Surg 2005;28:369-74.

3. Black RE, Johnson DG, Matlack ME. Bronchoscopicremoval of aspirated foreign bodies in children. J PediatrSurg 1994;29:682-4.

4. Shapira J, Kupietzky A, Kadari A, Fuks AB, Holan G.Comparison of oral midazolam with and without hydro-xyzine in the sedation of pediatric dental patients. PediatrDent 2004;26:492-6.

5. Frankel Rl. The papoose board and mothers' attitudesfollowing its use. Pediatr Dent 1991;l3:284-8.

6. Tiwana KK, MortonTTiwana PS. Aspiration and ingestionin dental practice: A 10-year institutional review. J Am DentAssoc 2004;133:1287-91.

7. Hodges ED, Durham TM, Stanley RT. Managementof aspiration and swallowing incidents: A review of theliterature and report of case. J Dent Child 1992;59:413-9.

8. Alexander RE, Delholm JJ. Rubber dam clamp ingestion—an operative risk: Repon of case. J Am Dent Assoc 1971;82:1387-9.

9. Cameron SM, Whidock WL, Tabor MS. Foreign bodyaspiration in dentistry: A review. J Am Dent Assoc 1996;127:1224-9.

Toothbrushing techniques in orthodontic patientsSince manuai toothbrushes with different head designs are stiil the focus of interest for both manufacturers and clinicians, the aim of this study was to de-termine whether curved-bristie toothbrushes (CBTs) aione wouid be more effective in piaque eiimination and promoting gingivai health than orthodontictoothbrushing protocois in poor-toothbrushing orthodontic patients. The labial surfaces of the maxillary canine-to-canine anterior teeth of 30 patients(12 maies and 18 females) were individually photographed following dentai plaque staining before and 4 weeks after each toothbrushing protocol, witha 1-month washout interval. The toothbrushes used were: (1) a CBT; (2) an orthodontic toothbrush (OT): ond (3) an OT in combination with interproximattoothbrush (OT + IT). OT + IT produced a statistically significant decrease in the mean plague percentage both for the total labial (7%) and interproximai(18%) tooth surfaces, when compared with the other toothbrushing protocois (P <.O5). No statisticaiiy significant differences were found between the CBTand OT for the amount of bacteriai piaque and Gl scores (P >.O5). Neither the CBT nor the OT alone was able to remove plaque under the archwires inpoor-toothbrushing patients. Therefore, the use of ITs should be mandatory for effective plaque removal in these patients.

Comments: When flossing is compromised due to orthodontic appiiances, the use of interproximai toothbrushes should be reinforced not only by ortho-dontists but also pediatric dentists during reguiar recalls. FMS

Address correspondence to: Dr Selim Arid, Ortodonti Anabiiim Daii, Di Hekimli I Fakultesi, Ondokuz Mayis University, 55139 Kurupeiit, Samsun, Turkey:e-mail: sarici&^omu.edu.tr.

AriciS, Alkan A, Arid N. Comparison of different toothbrushing protocols in poor-toothbrushing orthodontic patients. EurJ Orthod 2007:29:488-92.

21 references

62 ASPIRATION OF A STAiNLESS STEEL CROWN