Marc R. Leffler, DDS, Esq.
Dental Risk Solutions Lead, MedPro Group
Head, Dental Advisory Board, MedPro Group
One of the more frequent and growing areas of claimed dental malpractice involves the swallowing or aspiration of just about anything that a dentist places into or works on inside of a patient’s mouth. Objects swallowed or aspirated, include burs thrown from handpieces, endodontic files, rubber dam clamps, implants, implant instruments, pieces of teeth/restorations, and many others.
As a refresher, an object is swallowed if it makes its way to and into the GI tract (esophagus, stomach, and beyond), whereas an object is aspirated if it enters the respiratory tree (trachea, bronchi, lungs). Swallowed objects are sometimes allowed to (hopefully) pass in stool, but many are retrieved by way of endoscopy; some situations involve the object lodging in the intestines or even appendix, thereby requiring abdominal surgery for removal. Aspirated objects cannot be left in place in that dead-end organ system, but must be removed by bronchoscopy or, rarely, by open chest surgery.
Prevention is the risk management key here: if appropriate mechanisms are established by the dentist such that nothing can pass into, behind and below the oropharynx, swallowing and aspiration events are stopped before they happen. How is that done? By employing any of multiple ways: use of rubber dam whenever possible (as objectionable as that might sound, both to dentist and patient); tying dental floss through holes in instruments or around others, with the free end of the floss remaining under the dentist’s control always; commercially available “gripping” instruments; positioning patients so that gravity helps objects fall to the floor of the mouth rather than to the throat; active and attentive suctioning; maintaining extra vigilance when sedation or general anesthesia is involved (because some physiological protective reflexes are muted or eliminated); and placing oropharyngeal drapes.
If those precautions are taken, then even unforeseen events like earthquakes or construction debris flying through a dentist’s window (yes, those things have happened) will not lead to a swallowing or aspiration episode.
If a dentist loses sight of any object which ought to be accounted for, then it should be assumed that the missing object was swallowed or aspirated, until proven otherwise. At that point, time is of the essence in getting the patient into the care of medical colleagues who can locate and treat (or refer for treatment), before an object travels too deeply into the GI tract or wedges itself into lung tissue, complicating what might otherwise be a fairly straightforward procedure. The time saved by temporizing a restoration in progress, as compared with finishing it before referral, is often the difference between simple and complex treatment.
Patients do not expect to have an endoscopy, bronchoscopy or chest/abdominal surgery due to having dentistry performed. Because it is almost always preventable.