A Longstanding Foreign Body In The Oral Cavity: An Unusual Presentation

Introduction

A wide range of materials can get entrapped into the oral cavity and thereby act as a foreign body. Foreign body entrapment may occur as a result of a traumatic event or even iatrogenically. The foreign body impaction may be diagnosed only if the patient becomes symptomatic or during a chance radiographic examination for some unrelated symptom. Many times patients are unaware as well as asymptomatic and hence such cases are not diagnosed. Plain radiographs are routinely used to aid in the diagnosis of any pathology about the jaws but being two-dimensional, it is inadequate to locate the foreign body. Thus, it could give a misleading presentation of its bony location. Cone Beam Computed Tomography can overcome this problem. In a situation of financial constraints, a thorough history and clinical examination can help in locating a foreign body. We reported a case of a longstanding iatrogenic foreign body in the oral cavity with an intriguing radiographic presentation. The study indicated the importance of taking a thorough history and clinical examination as well as checking for the integrity of surgical instruments post usage.

Case Report

A 53-year-old man was referred to the department of oral and maxillofacial surgery for the removal of a foreign body from the left maxillary second molar region of the jaw. The patient had visited them for artificial tooth fabrication in the same region. Before planning of fixed prosthesis, an intraoral periapical radiograph was taken which revealed a root tip-shaped radio-opacity. This was interpreted as a broken implant component/ foreign body (Fig. 1) and thereby referred to us for retrieval.

The patient had a history of difficult extraction 10 years back in the same region. The socket wound had healed uneventfully and the patient had remained asymptomatic since then. Clinical examination of the missing tooth region revealed a well-rounded alveolar ridge and a healthy overlying mucosa (Figure 2). On palpation of the maxillary vestibule of that region, an irregularly raised ridge with step deformity was felt with no tenderness or mobility. It was in stark contrast to the same region on the contra-lateral side, the palpation of which revealed a smooth raised ridge of the zygomatic process of the maxilla. The unusual palpatory findings raised our suspicion that a foreign body might be impacted in that region, given that the patient had no history of trauma.

Under local anesthesia, following standard aseptic protocol a three-cornered flap was raised, revealing a metallic piece (Fig.3). The piece was retrieved with ease using a Molts no. 9 periosteal elevator. The retrieved metallic object seemed to be a broken tip of the beak of the root extraction forceps/ elevator (Fig. 4). The flap was re-approximated and sutured back in position. The wound healed uneventfully and the patient is planning for a fixed prosthesis.

Discussion

Studies of a foreign body impacted in the oral cavity are few owing to the patients being asymptomatic. Although, it is more commonly reported in children [1]. Foreign bodies that have been found impacted either traumatically or iatrogenically have been reported in the literature [2]. Diagnosis of the exact site of the foreign body with plain radiographs can be challenging as it gives only a two-dimensional view which is inadequate to locate any object. The inherent radiodensity of the foreign body also influences its detectability on a plain radiograph [3]. In literature, foreign body impactions have been radiographically misdiagnosed as some pathology [4]. This highlights the inadequacy of plain radiographs in diagnosing the location as well as the type of entity. Notably, in our case, the referral we got was for the removal of a foreign body from the left maxillary second molar region. The radiographic presentation was peculiar and intriguing as the foreign body had a similar shape to that of the root tip but was more radio-opaque than the usual root presentation (Fig. 1). The shape was also unusual for a radiographic presentation of an odontoma. The patient did not have any history of implant placement as well. A thorough clinical examination helped in diagnosing the site of the foreign body, facilitating its retrieval with ease, and hence its importance shouldn’t be overlooked. Cone Beam Computed Tomography is an excellent diagnostic tool for identifying the location of the metallic foreign body [4,5]. Financial restraints and the socioeconomic background of patients precludes its use [4].

Defective instruments when used in exodontia may lead to its breakage which rarely goes unidentified [5]. However, in our case, the patient was unaware as well as asymptomatic and the instrument tip was retrieved a decade later. In a similar case report, a dental elevator tip was retrieved from the mandibular third molar socket area which was found to be covered with a layer of granulation tissue [5]. But in our case, no such observation was reported. Moreover in our case, the instrument tip was laying just below the mucosa over the buccal bone.

The importance of a thorough clinical examination cannot be overemphasized in identifying the probable location of a foreign body lying superficially. As a plain radiograph is rendered inadequate, Cone Beam Computed Tomogram is recommended for accurate location of foreign body in the oral cavity. Care should be taken by the dentist to inspect the instruments post-operatively to avoid missing instrument breakage in situ.

Conflict of Interest

None