The patient has a big mouth

One of our readers wrote me the following e-mail. Since this month’s issue deals with orthodontic materials, I thought his question would be germane.

If a patient swallows some part of his braces or appliance at home, what is my responsibility? If it happened in my office, I would send the patient over for a chest x-ray and pay for it out of my pocket. But, if it happens at home, and mom calls or comes into the office all worried, what should I do? My instinct is to make sure that the patient is not in any respiratory distress, and, if not, I would assume that it wasn’t aspirated. I would then tell the mom that they are welcome to get a chest x-ray on their own if they want to confirm that it was merely swallowed. I would try to assure them that whatever it was that was swallowed usually passes without incident, normally within a few days. However, I still would probably sleep better if I sent the patient for the x-ray and paid for it myself just to make sure. I know this doesn’t happen too often, but I just wanted to get a legal take on the situation. Thanks, Dr S

Anyone who has been in practice for a while knows that it is not uncommon for foreign objects, including orthodontic appliances, to be ingested. Although usually not a problem, every now and then it can become serious. Aspiration, on the other hand, though much rarer, often has much more deleterious consequences. Once something passes the tongue, the odds are 12:1 that it will be swallowed vs inhaled. Bilder et al noted that “Objects that are ingested enter and traverse the alimentary canal and . . . the majority of them pass through the body without incident. . . . [A]spiration is more serious as . . . obstruction of the larynx or the trachea causes obstruction of the bronchial tree, which may result in pulmonary atelectasis, emphysema, or even death. An impacted foreign body in the gastrointestinal tract may lead to long-term complications such as esophageal erosion or perforation of the gut.”

Usually, we are spared the risk of aspiration because of the gag reflex; however, that can fail, and 3700 people die per year—equating to 1.2 deaths per 100,000—due to ingestion or inhalation of foreign objects or food. The objects most commonly reported are coins, meat, buttons, and batteries, followed by dental objects. Whereas most objects pass without incident, 10% to 20% require endoscopic removal, and 1% require surgical intervention. The position of the patient during treatment, sitting vs supine, is irrelevant; the literature is mixed on this issue. It goes without question that aspiration, but not so much ingestion, carries a higher risk of the potential for malpractice litigation.

In orthodontics, aspiration or ingestion of appliance parts most often occurs during “active procedures” such as banding or bonding, cutting the distal ends off archwires, and debonding. An incident can also occur “passively,” when patients are out of the office, during mastication because of fracturing of fixed appliance parts, usually during eating, sports, or fisticuffs; during appliance adjustment such as rapid maxillary expansion activation when the key is swallowed; and from removable appliance usage or breakage. Bilder et al noted that only 15% of incidents of ingestion or aspiration of dental materials occurred in the doctor’s office; the remaining 85% happened in various nonoffice locations. They also noted that, although most foreign objects can be located via endoscopy or radiologically, pink acrylic has a tendency to look like mucosal and cartilaginous tissues, and ceramic brackets pose identification issues because of their radiolucency.

Physiologically, the body’s responses to ingestion vs aspiration are vastly different. Often, patients don’t even know that they have swallowed something. If they do, there might be a slight initial cough reflex, but that is about it. Aspiration, on the other hand, might include a sign such as a wet or gurgly voice, increasing congestion, noisy breathing, a runny nose or watery eyes, or facial skin color changes around the eyes or mouth. In cases of partial aspiration, when a portion of the foreign object can still be seen, the utmost care should be taken when attempting to remove it, because there is a good chance that it will be displaced farther into the throat.

When an object is ingested, nothing more than palliative care is required. The patient or the parent should be told that, although the object can be followed radiographically to ensure that it passes through the body, doing so might be overkill, since the object will likely pass within a few days. The standard instruction is to tell the patient to check the stool for visual verification of passage. Aspiration, on the other hand, requires that the patient be immediately transported to the nearest emergency care center or hospital emergency room for evaluation of location and the best method of removal.

This is obviously an orthodontic risk that, if nothing else, needs to be placed in the practitioner’s informed consent document, thus providing notice to the patient as one would do with all material risks.

Commentary

So, many moons ago, in a program when I was the program director, one of our patients swallowed a bracket during a bonding procedure. Stuff happens. Well, as Murphy’s law would dictate, I was not present that day. The junior faculty member who was overseeing the patient immediately instructed the patient to go to the nearest hospital emergency room. A resident in gastroenterology was called, and he told the patient’s mom that the object could get caught in the gastrointestinal tract, and, if that happened, it would necessitate surgery to remove it. The long and short was that an endoscopic procedure was performed, the bracket was removed from the stomach, the patient’s medical insurance took care of the bill, and I was the only person who was really upset . . . when I found out what happened. Not that the incident had occurred, mind you, but that it became so overblown because my faculty member and the gastro guy just went a wee bit too far and subjected the patient to an invasive procedure that was not at all called for. Had a negative sequela occurred secondary to the endoscopy, there would have been hell to pay; it just wasn’t necessary.

Over the course of my career, foreign object ingestion has happened maybe half a dozen times—several times in the office and the rest outside—just like the stats predict. In a few cases, my helicopter moms would sift through the stools, most of the time finding what they were looking for. I had only 2 parents who wanted to follow the progress of the offending object radiographically. C’mon, a lot of ’em don’t even want you to take x-rays when you need to. All in all, to paraphrase the Bard of Avon, t’was much to do about nothing.

Our reader asked all the right questions, and he also had all the right answers. His instincts were sound, as it seems was his training. If the incident happened in the office and mom opted to follow the object’s trek through the gastrointestinal wilderness, I would offer, and have offered, to pay for the radiograph. It’s a nice touch but not necessary. If it happened out of the office, I would not feel inclined to make the same offer. The difference is that, in the office, the law supposes that you are under full control of the instrumentalities you use. Therefore, if such an event occurs in your office and the patient did not cause it, you have a good chance of being found negligent because you should have been in control of whatever instrument you were using. In addition, you did nothing to prevent the event from occurring.

Whoa, hold on now, what do you mean—prevent it from happening? What, should we all be using rubber dams when we treat patients? Of course not; it is not the standard of care. Sure, people have tried it and written about it, but it just doesn’t work for orthodontics. However, a sharp plaintiff’s attorney will ask “Hey doc, you ever hear of a 2 × 2 gauze square?” One of the first things we learned in operative dentistry and oral surgery was how to place a pharyngeal shield. Now wait, Larry, no one I know does this; therefore, it is not the standard of care.

One of the most famous cases taught in law school is Helling v Carey . The patient, a young woman in her early 20s, saw her ophthalmologist over an extended period of time, complaining of vision problems. It took quite some time, but she was ultimately diagnosed with glaucoma. In short, she suffered irreversible ocular damage. All of the experts, on both sides, agreed that the standard of care was not to perform glaucoma tests on patients under the age of 40; therefore, there was no negligence. The court, however, was irate. It held that it would not allow doctors to set their own standards of care so low that they could escape liability. Essentially, they stated that a glaucoma test was easy to perform, noninvasive, and inexpensive, and look at what could be prevented by doing it. They raised the standard of care for an entire specialty. Nothin’ for nothin’, but a 2 × 2 gauze square placed in the back of the mouth is easy to do, noninvasive, and inexpensive, and look at what could be prevented by it. Think about it.

Our reader wanted to sleep better at night. Okay, here is my recommendation. Slowly ingest a glass of single-malt scotch before retiring and call me in the morning.

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Apr 8, 2017 | Posted by in Orthodontics | Comments Off on The patient has a big mouth
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