Foreign Bodies in Soft and Hard Tissues of Oral Cavity: A Report of three Cases

Introduction

Encountering instances of foreign body lodgment in oral cavity is a rare and uncommon event.^1,2,3 Periodically reported literature shows that pediatric group is more prone for such incidents compared to adults.^2-5 Most commonly involved foreign bodies reported are pins, screws, fish bones, wood pieces, pencil tips, surgical instruments, dental instruments and materials etc.^1,2,6 These are either inserted, deposited or ingested in orofacial region accidently.¹ The foreign bodies deposited may serve as a source of infection and pain. Radiographs play a vital role in determining the size, shape, composition and location of these foreign bodies.^1,3,5 Retrieval of these depends on the site of deposition and accessibility. They can be effortlessly removed if present in an easily accessible area and can become complicated if lodged in inaccessible areas like apical soft tissues or in hard tissues.⁶ Here we report three unusual cases of metallic foreign bodies lodged in both hard and soft tissue structures in adult patients.

Case Report

Case 1

A 68-year-old male patient reported to the Department of Oral medicine and Radiology with a chief complaint of pain in left upper front tooth region. His past dental history revealed traumatic surgical removal of impacted left maxillary canine. Intraoral examination did not reveal any significant findings; thus radiographic investigation was advised. Panoramic radiograph showed a radiopaque foreign body in the region and maxillary right canine was also found to be impacted (Figure 1). With these findings, possibility of a broken bur or instrument tip embedded in the area was considered, which might have been accidently deposited within bone during previous surgical procedure. Surgical removal of this foreign entity and also the impacted canine was undertaken (arrows pointed in figure 1). A piece of broken bur was retrieved from the area (Figure 1). Healing was uneventful after its removal.

Case 2

A 38-year-old male patient reported to the Department of Oral Medicine and Radiology with a complaint of pain in the lower right back teeth region. Patient gave a history of food lodgment in the same region and use of pin, wooden tooth pick etc., to remove the lodged food. Recently, he attempted to remove the food with a stapler pin which got accidentally embedded in the area and the patient was unable to retrieve it by himself. Intraoral examination revealed the presence of stapler pin in the interdental region between mandibular right first and second molars. Intraoral periapical radiograph was advised which revealed a radiopaque structure (Figure 2). Alveolar bone loss was noted between the involved teeth which could be the reason for using the pin. Both the teeth presented with proximal carious lesions. Retrieval of stapler pin was done using tweezers and small mosquito forceps (Figure 2). Anti-inflammatory drugs were prescribed for three days and healing was uneventful.

Case 3

A 16-year-old female patient reported to the department with a complaint of a wire stuck in her front tooth. Her past dental history revealed incomplete root canal treatment of left maxillary central incisor, where only access opening was prepared and patient did not continue with the treatment. As food lodgment was apparent, patient developed a habit of occasionally using certain foreign objects such as toothpick, wire to remove the food, resulting in a wire stuck in the tooth. On intraoral examination, an open root canal was observed in the left maxillary central incisor. Intra oral periapical radiograph which was already available with the patient revealed a long linear radiopaque object in the root canal, along with another thick pointed radiopaque structure with its sharp pointed end in the apical region (Figure 3). A diagnosis of embedded metallic foreign object in root canal was made and its retrieval was advised. However, the patient did not report back for the treatment.

Discussion

People have eccentric habits of inserting alien objects into their oral cavity. Self-inflicted oral injuries can occur due to these strange habits either accidentally or they could be premeditated.⁶ Most often these strange habits are observed in children, but cases have also been reported occasionally in adults. Foreign bodies in the orofacial region are frequently deposited either iatrogenically or traumatically.¹ Iatrogenic deposition includes pins, screws, stapler pins, pencil tips, needles, amalgam, dental instruments, dental materials, wooden pieces etc. Traumatic foreign body deposition can occur due to motor vehicle accidents, bullet balls, assault with objects, glass material injuries etc.^1,2,3

Majority of cases are seen in children due to their habit of placing foreign bodies in the mouth, especially in easily accessible open areas such as root canals or open cavities.^3,5,7 All the cases reported in this series are of adults among which two cases involved habitual insertion of foreign objects in to the mouth, while one case reported involved iatrogenically embedded foreign object during a dental procedure. Cases of foreign bodies such as stapler pins, wooden pieces in root canals, pulp chambers, tooth brush injuries, impression material and glass lodgment etc in oral tissues have been reported earlier.^1,2,3,4,8 Nagaveni NB and Umashankara KV reported cases of lodgment of foreign bodies such as stapler pins, glass beads and wooden sticks in children.³ Sumanth et al., reported a case of glass piece lodged in lower labial mucosa for a period of 20 years.⁶ Another case of broken needle and stapler pin was reported by Mishra I et al. ¹ Anterior region is more vulnerable compared to posteriors due to easy accessibility.³ In our present article, all the three foreign bodies were metals. Site and type of foreign bodies reported in our cases such as broken bur piece in maxillary bone, stapler pin in the interdental region of mandibular molars and wire in maxillary incisor have been rarely reported.

Foreign bodies embedded in orofacial region may be asymptomatic or can produce a variety of tissue reactions such as pain, inflammation, abscess, granuloma and fistula formation. Steel and glass produce less significant reactions but organic foreign bodies may produce greater reaction such as abscess and fistula.^1,8,,9 In our report, all the patients presented with symptom of pain and no significant swelling was observed.

Radiographic examination plays a vital role in the detection of these non-native materials. Three-dimensional computed axial tomography has an important role in determining their exact position. Visibility of these foreign bodies on radiograph depends on their ability to attenuate the X-rays. Metallic objects are radiopaque while objects like plastic, wood, fish bone are not opaque. Non-leaded glass is also faintly visible on the radiographs.^1,3,8 Radiolucent foreign bodies of considerable thickness or density may be identified on the radiographs.¹⁰ In the cases reported here, radiographs significantly contributed to the diagnosis as all the foreign objects involved were metallic.

Retrieval of these alien bodies is mandatory as they serve as a source of infection. Different types of instruments described in the literature such as ultrasonic instruments, masserann kit, Castroviejo needle holder, tweezers, small mosquito forceps etc., have been used to retrieve the foreign objects. Care should be taken not to push these foreign bodies more into inaccessible areas such as apical region.³ In our case, stapler pin in the interdental region was removed using tweezers and small mosquito forceps. The piece of bur was surgically removed and case with steel wire in open root canal could not be retrieved due to non-compliance of patient.

This article highlights the importance of detailed case history, history of any abnormal habits, thorough inspection of oral cavity, radiographic evaluation and proper investigations that can lead to correct diagnosis and treatment. This article also emphasizes the risk of leaving open root canal for longer time that can lead to potential danger of lodgment of foreign objects and its associated complications.

Sources of support:

Nil

Conflict of Interest:

Nil

Declaration of patient consent: the authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.