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Foreign body aspiration during dental treatment

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Foreign body aspiration is the act of inhaling or breathing foreign bodies into the respiratory tract.
The term is particularly relevant in emergency medicine, but also in the area of anesthesiology.
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Symptoms and signs of aspiration

The aspiration of dental instruments and materials represents a critical situation that must always be classified as an emergency.

Acute symptoms
  • Frequent touching of the throat by the distressed patient
  • Facial paleness followed by cyanosis
  • Coughing
  • Choking, vomiting
Early complications
  • Acute respiratory distress (dyspnea)
  • Respiratory depression or arrest due to airway obstruction (asphyxia)
  • Laryngeal edema
  • Cardiac arrest is possible
  • Risk of pleural perforation and pneumothorax
The risk of pleural perforation and pneumothorax is especially high after aspiration of thin, sharp instruments.

All efforts should be made to remove the foreign body immediately!

Delaying the diagnosis of foreign body aspiration increases the incidence of complications such as bronchial stricture, local bronchiectasis, pulmonary abscess, and pneumonia.
The efficacy of bronchoscopy may be considerably impaired if the time to extraction of the object exceeds 24 hours (Zitzmann et al. 2000).


Immediately after a foreign body disappears in the throat of a patient:
  1. Prop up the patient’s upper body at a 20 to 30-degree angle with the head reclined

  2. Administer oxygen (6 L/min) via a nasal tube
    The air that can still be inhaled should be well oxygenated.

  3. Ask the patient to cough; aspirated foreign objects can often be ejected in this manner, especially if they have not passed the level of the glottis (Zitzmann et al. 2000)
    If coughing leads to choking, respiratory difficulties or inspiratory stridor, the foreign body is already caudal to the larynx and can no longer be coughed up.

  4. Heimlich maneuver
    The Heimlich maneuver is performed only in cases where there is total obstruction of the airways and the patient is at risk of choking to death. A foreign body can often be ejected from the throat by forcefully thrusting the abdomen in the direction of the diaphragm to raise the pressure in the tracheobronchial system.

    Heimlich maneuver in a sitting patient
        Stand behind the patient and wrap the arms around the patient’s chest; place the hands in the upper abdominal area just below the costal arch.
    Grasp one hand in the other.
    Forcefully thrust into the patient’s abdomen by quickly and sharply pulling the arms back.
    Repeatedly thrust the chest and particularly the upper abdominal region to increase the pressure in the chest in order to eject the foreign body from the trachea.
    It is best to have a second person inspect the patient’s throat in order to remove the ejected foreign body either by hand or with a pair of Magill’s forceps.

    The majority of foreign bodies (75%) are detected in the steep and more distal right primary bronchus or right lower lobe bronchus.

  5. Send the patient to a hospital able to remove the foreign body by bronchoscopy once its position has been identified radiographically

    Whenever an object disappears in the oropharynx, X-rays must be taken to assess the possibility of aspiration regardless of whether [one believes it was] swallowed or aspirated.

    To send the patient home under these conditions believing the object was swallowed and is on the natural course to the intestinal tract constitutes negligence and can have life-threatening consequences.

  6. If the patient falls unconscious
    • Tilt the head back and open the mouth by pulling the chin downward and forward.
    • Remove all visible obstructions.
    • Assess the breathing by the “seeing-listening-feeling” method.
    • Administer two breaths of effective artificial respiration.
    • While performing these measures, have someone call an emergency medical service.

  7. If it is not possible to perform effective artificial respiration:
    • Start cardiac massage immediately to dislodge the foreign body.
      Start without first assessing the circulatory status.
    • After depressing the chest 15 times, examine the mouth for foreign bodies, then try to administer artificial respiration again.
    • Once it becomes possible to administer artificial respiration, assess the patient’s circulatory status.

Legal basis

(Herdach and Große-Sende (2002))

Failure of a dentist to carry out the safety measures deemed necessary by dental science when using a small instrument constitutes negligence (German Supreme Court ruling of 1952). Swallowing, tongue and defensive movements of the patient are to be expected; the dentist cannot depend on his or her skill and experience and treat patients with unsecured root canal instruments (Nuremberg Higher Regional Court ruling of 1953). The dentist is obligated to limit the extent of damages; therefore, whenever an incident occurs, the dentist must immediately initiate all necessary measures to avert further damages; otherwise, the dentist can be charged with negligence.

Patients with increased risk

The following patients have an increased risk of swallowing or aspirating foreign objects (Prakash and Cortese 1994):
  • Prisoners
  • Patients with psychiatric disorders
  • Alcoholics
  • Senile, debilitated, nervous and/or hyperactive individuals
  • Patients with an extreme gag reflex (Prakash and Cortese 1994)
  • Patients with hiatus hernias and symptoms of reflux oesophagitis (impaired swallowing reflex)
  • Patients with increased intra-abdominal pressure (e.g., obese or pregnant individuals) may suffer from dysphagia (difficulty swallowing), especially when the upper body is reclining
  • Difficult or limited access to the patient’s head-and-neck region or oral cavity due to anatomic peculiarities, such as barrel chest, microstomia or macroglossia.
  • Patients with depressed or impaired central nervous system function (e.g., due to the use of sedatives, tranquilizers or opiates)
  • Patients wearing full dentures (reduced tactile perception capacity in the region of the palatinal mucosa) (Maleki and Evans 1970)).

Preventive measures

  • Use of a rubber dam
  • Use of a dental floss ligature to secure small instruments or root pins
  • Use of gauze to cover the oropharynx of intubated patients during treatment
  • Patients with impaired coordination of swallowing and coughing reflexes should always be treated in a sitting or only slightly reclining position.
  • Removal of broken prostheses
    Polymethyl methacrylate (PMMA) is only slightly radiopaque; therefore, swallowed or aspirated pieces of prostheses made of this material are very difficult to identify in X-rays due to shadowing from radiodense structures, among other things.
    Incorporation of a steel wire in prostheses helps to stabilize broken prostheses and makes it easier to identify them in X-rays. (Herdach and Große-Sende 2002).


  • Herdach F, Große-Sende S (2002)   Verschlucken und Aspiration von Fremdkörpern während der zahnärztlichen Behandlung   Int Poster J Dent Oral Med 2002, Vol 4 No 2, Poster 118
  • Maleki M, Evans WE (1970)   Foreign-body perforation of the intestinal tract. Report of 12 cases and review of the literature   Arch Surg 101:475-7
  • Prakash UBS, Cortese DA (1994)   Tracheobronchial foreign bodies   Chapter 18, In: Prakash UBS (Ed.). Bronchoscopy. 2. Aufl. Raven Press, New York, 253–277
  • Zitzmann NU, Fried R, Elsasser S, Marinello CP (2000)   The aspiration and swallowing of foreign bodies. The management of the aspiration or swallowing of foreign bodies during dental treatment   Schweiz Monatsschr Za