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A sharp intake of breath

05 June 2020

With our patients generally supine, there is always the risk of dental instruments and materials being swallowed or even inhaled. When this happens, there may be an immediate danger to the airway. Subsequently, the patient may face an unpleasant procedure to remove the item if it gets lodged in the airway or does not pass through the digestive tract.

The use of a rubber dam is a well-recognised strategy not only to maximise the quality and predictability of outcomes during dental treatment, but also as a means of controlling the risk of inhaling or ingesting any of the instruments and materials used in the mouth.

Although a rubber dam is routinely advised for endodontic procedures, it is not routinely used for other dental procedures such as restorative dentistry, prosthodontics, orthodontics or implant dentistry. All these procedures result in small items being placed in the mouth with an associated element of risk. Although the risk is small, if something goes wrong the event can be very distressing for the patient and the dental team. Should the offending item become lodged deep in the lungs, subsequent retrieval can involve major surgery.

Included in the list of surprising bits and pieces that have recently been found in patients’ guts or airways are:

  • Cast post and core
  • Crowns
  • Veneers
  • Inlays
  • Implant healing caps
  • Orthodontic wire, bands and brackets
  • Copper rings
  • Dental burs
  • A denture clasp
  • Ultrasonic scaler tip
  • The ‘screwdriver’ for an intra-oral screw post system 

Case study

During the removal of decay from an upper second molar, a bur became dislodged from the slow handpiece. There followed the seemingly slow-motion drop of the bur onto the posterior tongue, where it settled momentarily before disappearing down the oropharynx.

The patient was immediately sat up and assessed. They thought they had swallowed something but were not sure. They were not breathless and when asked to cough, there was no indication that the bur was in the airway. However, after some discussion, apology and explanation, the patient was persuaded that it would be sensible to seek medical opinion at the local hospital.

The dentist was careful in managing the somewhat shocked patient and, in order to assist the medical team in assessing the situation, rang ahead and informed the hospital of the incident and the patient’s imminent arrival. They also sent a member of the team with the patient, who took with them an identical bur to help the hospital see what had been ingested.

To be safe, the medical team suggested taking a chest radiograph and, despite the lack of symptoms, the results unfortunately showed the bur had lodged in the middle lobe of the right lung. With fiberoptic bronchoscopy, the bur was successfully removed and postoperative recovery was uneventful; however, the patient obviously had a very unpleasant and unexpected experience.

Given the adverse outcome, the dentist was naturally concerned that the patient may sue or complain to the dental regulator. Thankfully, neither happened, which was directly linked to how the member and Dental Protection acted to resolve the matter.

When the incident occurred, our member focused upon the patient and the subsequent care, providing support and empathy, with a team member accompanying the patient to the hospital. Having spoken to Dental Protection, the member was assured of the correct steps to take and we also advised that they should assure the patient that any hospital costs and out of pocket expenses would be reimbursed. With Dental Protection’s approval of this approach, the member was informed that they would then be reimbursed of these costs. Our knowledge and expertise enables Dental Protection to assist with members resolving matters at the earliest stage and not having to wait for a formal claim to arrive before financial help can be provided.

While the patient and their family were naturally very concerned, they were grateful that the member stayed in contact with the patient throughout the journey and, having been invited to a meeting at the practice to discuss the matter, they accepted an apology and reimbursement of all medical bills and expenses as a resolution.

As we are healthcare workers, such events can weigh heavily upon us and it can take time to recover and regain confidence. Members often comment that talking the event through and taking advice from a dental colleague in Dental Protection can be very helpful and we always invite members to contact us as we are here to help.

Nobody gets up in the morning with the intent to harm a patient. Adverse outcomes can and will happen. Be honest with the patient, be seen to facilitate whatever remediation is required and, of course, contact Dental Protection – we are here to help support and protect you through these events.

Learning points

Be seen to act and don’t abandon patients – if this patient had not been so well cared for (eg just told that they might want to go to hospital and not contacted again) then a claim or regulatory complaint would be much more likely to occur.

Adverse incidents occur – how we manage them will influence the outcome. If possible, follow up with a meeting to ensure all the patient’s concerns are addressed and the patient is reassured.

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These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits Dental Protection members enjoy as part of their subscription. 
For more detailed advice on any issues, contact us

© 2019 The Medical Protection Society Limited

DPL Australia Pty Ltd (“DPLA”) is registered in Australia with ABN 24 092 695 933. Dental Protection Limited (“DPL”) is registered in England (No. 2374160) and along with DPLA is part of the Medical Protection Society Limited (“MPS”) group of companies. MPS is registered in England (No. 00036142). Both DPL and MPS have their registered office at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG. DPL serves and supports the dental members of MPS. All the benefits of MPS membership are discretionary, as set out in MPS’s Memorandum and Articles of Association. “Dental Protection member” in Australia means a non-indemnity dental member of MPS. Dental Protection members may hold membership independently or in conjunction with membership of the Australian Dental Association (W.A. Branch) Inc. (“ADA WA”).

Dental Protection members who hold membership independently need to apply for, and where applicable maintain, an individual Dental Indemnity Policy underwritten by MDA National Insurance Pty Ltd (“MDA”), ABN 56 058 271 417, AFS Licence No. 238073. DPLA is a Corporate Authorised Representative of MDA with CAR No. 326134. For such Dental Protection members, by agreement with MDA, DPLA provides point-of-contact member services, case management and colleague-to-colleague support.

Dental Protection members who are also ADA WA members need to apply for, and where applicable maintain, an individual Dental Indemnity Policy underwritten by MDA, which is available in accordance with the provisions of ADA WA membership.

None of ADA WA, DPL, DPLA and MPS are insurance companies. Dental Protection® is a registered trademark of MPS.