PMY Tang, RYT Chan

Abstract

Accidental foreign body ingestion is common in children. With the widespread use of removable dental appliance in children at an increasingly young age, we would expect more accidental ingestion of such foreign body. We report a case of an accidental ingestion of a sizeable removable dental appliance in a young girl in Hong Kong. The appropriate management algorithm, potential preventive measures and review of literature are discussed.

Introduction

Foreign body ingestion in children is common. Coin, toys and fish bone are among the common objects accidentally swallowed in the paediatric population. The need for endoscopic intervention largely depends on the clinical presentation and the nature of the swallowed foreign body. A comprehensive management protocol for selective upper endoscopy for foreign body ingestion in children had been reported by Wong et al.¹ However, data on the management of swallowed orthodontic appliance in children is lacking. We reported a case of an accidental ingestion of a removable orthodontic appliance in an 11-year-old girl, and the management algorithm was discussed.

Case Report

An 11-year-old girl (body weight 35 kg) with good past health had started orthodontic treatment with a private orthodontist since August 2024. A pair of removable orthodontic appliances (twin block) was prescribed. In December 2024, she accidentally swallowed the lower orthodontic appliance while drinking clear water. No immediate airway compromise was noted and she was able to speak in complete sentence. However, in view of the persistent foreign body sensation in the throat, she attended the Accidental & Emergency Department on the same day.

On clinical examination, she was haemodynamically stable and was not in respiratory distress. Chest X-ray showed radio-opaque object in the T3 level (Figure 1). There was no localised neck tenderness or surgical emphysema. Emergency flexible oesophageal-duodenoscopy (OGD) under general anaesthesia was arranged in view of suspected foreign body in oesophagus.

Figure 1 Chest X-ray showing the radio-opaque swallowed dental device.

After the child was endotracheal intubated (with cuff) by the anaesthestist, standard flexible 9.2 mm upper endoscopy was performed within 6 hours of hospital admission, showing the swallowed orthodontic appliance to be intact, and had already spontaneously passed to the stomach (Figure 2). As the dental appliance was deemed too hard and rigid to be fractured by the endoscopic forceps, and it was beyond the size of the endoscopic lumen and endoscopic overtube (Figure 3), it was removed under direct vision with the foreign body retrieval basket, with the sharp metal hooks facing inwards. Mild mucosal injury at the upper oesophagus was sustained during the retrieval, immediate re-check endoscopic inspection confirmed no significant oesophageal erosion or bleeding (Figure 4). And the retrieved dental appliance remained intact (Figure 5). Oral diet was tolerated and oral proton pump inhibitor was given for one week.

Figure 2 Endoscopic photo showing the intact dental device in stomach.

Figure 3 Showing the overtube available.

Figure 4 (a) Endoscopic photo showing mild upper oesophageal mucosal tear sustained during retrieval of the dental device. (b) Endoscopic photo showing mild upper oesophageal mucosal injury.

Figure 5 The pair of removable dental device prescribed to the girl. She has accidentally swallowed the device shown on top.

Discussions

When a foreign body has been lodged onto the oesophagus, prompt endoscopic retrieval is often indicated. Firstly, the natural passage and progression of the foreign body to the stomach is less likely due to the weak peristalsis of the oesophagus. Secondly, the soft tissue swelling secondary to the foreign body induced inflammation could potentially compress and comprise the adjacent airway. Thirdly, the potential risk of sudden oesophageal perforation and sepsis or fistula. In our case, although the swallowed device had spontaneously passed to the stomach while the emergency OGD was being arranged, endoscopic retrieval was decided in view of the large size of the foreign body, and the doubtful possibility of the foreign body to pass the pylorus spontaneously.

A recent study reviewing 90 cases of oesophageal foreign bodies in adults suggested that when the dental prostheses were larger than 5.8 cm, endoscopic extraction was likely to fail, while when the dental prostheses were smaller than 1.6 cm, endoscopic extraction was likely to be successful.² While accidental ingestions of dentures are frequently seen in the elderly population, it is relatively uncommon for children to swallow a removable dental appliance of such size. Our case highlighted that endoscopic retrieval of the swallowed dental appliance is not without risks, including failure of endoscopic retrieval and oesophageal injury. Parents and children should be counselled of the associated risks, appropriate education and precautions should be taken when such removable dental appliance is used. The dental professionals should also be mindful of the risk of accidental swallowing when such device is used in young children, and a contingency plan should be discussed, especially when airway aspiration could also be a potential risk.

In the past, most orthodontic appliances are bonded to teeth, and even when they fall off and are accidentally ingested, the metal brackets or rubber bands are usually small and could easily pass through the gastrointestinal tract uneventfully, without requiring endoscopic retrieval. However, recently, there is increasing popularity of removable dental appliance used in children for orthodontic intervention, and at increasingly young age. Thus, we expect to see an increasing incidence of the accidental ingestion of such device.

Conclusions

In order to minimise the risk of accidental ingestion of removable dental appliance in children, we recommended that:

1. More retentive features should be added to the removable dental appliance for children
2. Children should take out the removable dental appliance when eating and drinking
3. Parents and children should be counselled on the potential risk of accidental ingestion and aspiration

Conflict of Interest

None

References

1. Wong KK, Fang CX, Tam PK. Selective upper endoscopy for foreign body ingestion in children: an evaluation of management protocol after 282 cases. J Pediatr Surg 2006;41:2016-8.

2. Tatsuya M, Naoko H, Norio K, et al. Management of esophageal foreign bodies: experience of 90 cases. Esophagus 2009;6:155-9.