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\begin{document}

\title{Accidental ingestion of a dental bur in an 84 year-old-male}



\author[1]{Francesk Mulita}%
\author[1]{Georgios-Ioannis Verras}%
\author[1]{Elias Liolis}%
\author[1]{Levan Tchabashvili}%
\author[1]{Ioannis Panagiotopoulos}%
\author[1]{Charalampos Kaplanis}%
\author[1]{Ioannis Perdikaris}%
\author[1]{Konstantinos Bouchagier}%
\affil[1]{University General Hospital of Patras Holy Mary the Help}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
This report describes the case of an 84-year-old male who was brought to
the emergency room because a dental bur was swallowed accidentally
during a dental procedure. The foreign body was successfully removed by
gastroenterologists endoscopically 8 days after the ingestion and was
identified as a 2-cm-long dental bur.%
\end{abstract}%



\sloppy


CASE REPORT

\section*{Accidental ingestion of a dental bur in an 84
year-old-male}

{\label{accidental-ingestion-of-a-dental-bur-in-an-84-year-old-male}}

\textbf{Francesk Mulita\textsuperscript{1}, Georgios-Ioannis
Verras\textsuperscript{1}, Elias Liolis\textsuperscript{2}, Levan
Tchabashvili\textsuperscript{1}, Ioannis
Panagiotopoulos\textsuperscript{3}, Charalampos
Kaplanis\textsuperscript{1}, Ioannis Perdikaris\textsuperscript{1},
Konstantinos Bouchagier\textsuperscript{1}}

\textsuperscript{1}Department of General Surgery, General University
Hospital of Patras, Greece

\textsuperscript{2}Department of Internal Medicine, General University
Hospital of Patras, Greece

\textsuperscript{3}Department of Cardiothoracic Surgery, General
University Hospital of Patras, Greece

Correspondence: Francesk Mulita MD, MSc, PhD(c), Resident Surgeon at the
Department of Surgery, General University Hospital of Patras, Achaia,
Greece, Tel.: +30 6982785142; E-mail:\emph{oknarfmulita@hotmail.com};
ORCID Id:\emph{https://orcid.org/0000-0001-7198-2628}

\textbf{Abstract}

This report describes the case of an 84-year-old male who was brought to
the emergency room because a dental bur was swallowed accidentally
during a dental procedure. The foreign body was successfully removed by
gastroenterologists endoscopically 8 days after the ingestion and was
identified as a 2-cm-long dental bur.

\textbf{Key words:} Foreign body, endoscopy, x-rays

\textbf{Key Clinical Message}

Although the majority of ingested foreign bodies pass through the
gastrointestinal tract, endoscopic intervention is necessary in 10-20\%
of these cases.

\section*{Introduction}

{\label{introduction}}

\section*{}

{\label{section}}

Ingestion of foreign bodies is very common. Especially, more than
120.000 cases were recorded in the USA in only one year, while
approximately 1500 deaths per year are attributed to ingestion of
foreign bodies {[}1-2{]}. Various complications can be occurred during
daily clinical practice by accidental ingestion of dental objects such
as burs, impression materials, dental inlays or crowns, endodontic
posts, fixed or removable prosthetic restorations {[}3{]}. These
life-threatening complications like peritonitis, sepsis, fistulas and
duodenocolic fissures, abscess formation and injury to the digestive
tract are related to obstruction or perforation caused by the ingested
foreign body {[}1, 3{]}. Ingested foreign bodies usually pass through
the anus without any complication. In 10-20\% of patients endoscopic
removal is required, while in 1\% of patients surgery is necessary
{[}3{]}. We herein report a case of an accidental ingestion of a dental
bur in an 84 year- old-male.

\section*{Case Report}

{\label{case-report}}

An 84-year-old male with atrial fibrillation, hypertension and type 2
diabetes mellitus was brought to the emergency room of our hospital by a
private dental practitioner. The dentist disclosed that a 2-cm dental
bur was swallowed accidentally by his patient 2 hours ago during the
dental procedure. On examination, the patient's temperature was 36.5,
heart rate was 71 beats per minute, blood pressure was 151/87 and
respiratory rate was 17 breaths per minute. His abdomen was soft,
without distension and with no evidence of palpable mass. His routine
blood tests including haemogram, C-reactive protein level, liver and
renal function test, serum amylase and lipase were normal. Chest
radiography showed no evidence of free air and no other abnormalities.
X-ray of the abdomen revealed a hyperdense, foreign body in the left
lower quadrant (Fig. 1A). Upper endoscopy was not performed as the
foreign body was shown distal to stomach -- not accessible to endoscopy.

Patient was kept under close observation in the department of surgery.
He was kept under high fibrous diet and 20ml of oral gastrografin was
prescribed every 8 hours for allowing the rapid transport of the foreign
object within the gastrointestinal (GI) tract. Serial radiographic
examinations were performed to monitor the migration of the ingested
foreign body. A repeated x-ray of the abdomen was taken 24 hours after
the ingestion of the object. This radiograph suggested the presence of
the foreign body in the right lower quadrant of the abdomen (Fig. 1B).
As the patient did not agree to make any endoscopic or surgical
intervention, abdominal radiographies were performed 48 hours (Fig.1 C),
72 hours (Fig.1 D), 5 days (Fig.1 E) and 7 days (Fig.1 F) after the
foreign body ingestion, but the object remained in the same position.

An attempt was made by gastroenterologists to remove the foreign body
endoscopically. Eventually, anterograde colon preparation and
colonoscopy was performed. The foreign body was detected in terminal
ileum, was grasped with an endoscopic loop, pulled through the valve and
removed per anus. The length of the dental bur was about 2 cm. The
patient did not have any complication and he was mobilized 2 hours after
the foreign body removal. He was started on oral diet 12 hours
afterwards and was discharged home in a very good condition 24 hours
after the endoscopy.

\section*{Discussion}

{\label{discussion}}

\section*{}

{\label{section-1}}

Ingestion of foreign body is commonly encountered in radiological
practice and its significance should not be underestimated {[}1{]}.
Whenever a dentist loses a dental material or any other foreign object
inside oral cavity, a radiologist must be consulted even if the patient
has no symptoms {[}4{]}. Usually, the foreign bodies pass through the GI
tract and are evacuated in 2 to 5 days without symptoms {[}3{]}. The two
most common locations of an ingested foreign object at the initial
presentation is in the stomach (58.1\%) and small intestine (32.7\%)
{[}5{]}. Endodontic files have been reported to pass through GI tract
within 3 days, while 10-20\% require endoscopic intervention and only in
1\% surgery is necessary {[}6{]}.

Radiographic examination with chest and abdominal x-ray is necessary for
determining the location, size and nature of the ingested foreign object
{[}7{]}. The computed tomography (CT) scan can also be used to localize
foreign objects, but it is usually performed to define the exact extent
of injury to the involved organs and the damage to the surrounding
tissues {[}1{]}. In our case, the foreign body was radio opaque and the
size assessment was noted. We did not perform a CT scan as the foreign
body was identified in radiography and the patient had normal blood
tests and no symptoms.

Size, sharpness and shape of the ingested foreign body are some
characteristics that should be taken into consideration when a medical
professional has to deal with this condition. The risk of injury
increases when the size of the object is more than 5cm or has a pointed
shape {[}8{]}.

According to the literature, the removal of a foreign object that has
entered the gastrointestinal tract is determined on the basis of
patients' age, size shape and location of the object, and time since the
ingestion. The risk of complications such as obstruction or perforation
determines the timing of endoscopy {[}9{]}. The overall rate of
perforation caused by ingested foreign bodies is in the range of 1-7 \%.
However, the incidence is increased to 15-35\%, when pointed or sharp
foreign bodies are considered {[}10{]}. According to Bondarde P et al.,
the management of sharp bodies such as endodontic file, when lodged in
GI tract, is endoscopic retrieval or the careful monitoring with
periodic radiographs. If the foreign body does not succeed to progress
after 72 hours or complications such as perforation, obstruction or
bleeding are noticed, surgery should be preferred immediately {[}4{]}.
In our case, periodic abdominal radiographies were performed for 7 days,
because the patient did not agree to make any endoscopic or surgical
intervention the first 7 days. Oral gastrografin was prescribed for
allowing the rapid transport of the foreign body within the GI tract.
The barium sulfate was not preferred to be used because of its
side-effects such as constipation and mechanical obstruction of bowel,
which can make it difficult to perform endoscopy {[}11{]}. In addition,
laxative treatment should be given to patients after barium studies to
reduce the incidence of colonic retention of barium sulfate {[}12{]}.
Fortunately, the foreign body which was identified as a 2-cm-long dental
bur was successfully removed by gastroenterologists endoscopically 8
days after the ingestion.

\subsection*{Conclusion}

{\label{conclusion}}

Iatrogenic accidents during routine dental procedures are common and
unpredictable. Early recognition and diagnosis of this condition is the
key to prevent serious complications. In 10-20\% of these cases
endoscopic intervention is necessary and less than 1\% of patients
require surgical retrieval. In our case the foreign body was removed by
gastroenterologists endoscopically.

\textbf{Ethical approval and consent to participate}

A written informed consent was obtained from the patient for publication
of this case report.

\textbf{Conflict of interest}

There are no conflicts of interest to declare.

\textbf{Financial support and sponsorship}

None

\textbf{Author contribution}

FM, G-IV, EL, LT, IP, IP and CK: contributed to the clinical data
collection and prepared the case report. FM and KB: contributed to the
design of the case report presentation and performed the final revision
of the manuscript.

\textbf{Data availability}

Data available on request from the authors

\textbf{Acknowledgments}

This paper was accepted and presented as an e-poster in the
32\textsuperscript{th} Hellenic Congress of Surgery 2021 and appears
online in part.

\subsection*{References}

{\label{references}}

\subsection*{}

{\label{section-2}}

\begin{enumerate}
\tightlist
\item
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\item
  Amarlal D, Jeevarathan J, Muthu MS, Venkatachalapathy A, Rathna Prabhu
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\item
  Dionysopoulos D. Accidental ingestion and aspiration of foreign
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\item
  Bondarde P, Naik A, Patil S, Shah PH. Accidental Ingestion and
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\item
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\item
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\item
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\item
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\item
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\item
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\item
  Khartade HK, Meshram VP, Tumram NK, Parchake MB, Pathak HM. Fatal
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\item
  Pathan S, Benzar T, Master S, Peddi P. Iatrogenic constipation from
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\end{enumerate}

\subsection*{}

{\label{section-3}}

\subsection*{}

{\label{section-4}}

\subsection*{}

{\label{section-5}}

\subsection*{}

{\label{section-6}}

\subsection*{}

{\label{section-7}}

\subsection*{}

{\label{section-8}}

\subsection*{}

{\label{section-9}}

\subsection*{}

{\label{section-10}}

\subsection*{}

{\label{section-11}}

\subsection*{}

{\label{section-12}}

\subsection*{}

{\label{section-13}}

\subsection*{Figures}

{\label{figures}}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Fig. 1.} Abdominal radiography: Showed a hyperdense, foreign
body in the left lower quadrant 2 hours after ingestion (A). Movement of
foreign body in the right lower quadrant 24 hours after ingestion
(B).The foreign body remains in the same position 48 hours (C), 72 hours
(D), 5 days (E) and 7 days (F) after ingestion.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}

\selectlanguage{english}
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