Effects of Accidental Swallowing of Orthodontic Appliance on Gastrointestinal Tract and Airway: An Evidence-Based Review of Case Reports

Abstract

Background:

Contemporarily, the use of innovative orthodontic appliances or their components has increased for safer, quicker results, and more comfort of the patient. But, researchers rarely highlight the potential demerits of accidental ingestion of these appliances. Thus, the present study aimed to investigate the evidence-based literature on the accidental swallowing of these appliances and their effect on the gastrointestinal tract (GIT) and airway.

Method:

An electronic search was performed on PubMed, Medline, Scopus, The Cochrane Library, and EMBASE until April 11, 2021. Methodological quality and synthesis of case series and case report tool (MQCC) was applied to determine the quality of these case reports and series. The outcome variable was to assess its effect on airway and GIT, and methods of removal of these foreign bodies. Meta-analysis was not performed as the study included case reports and case series in which no control groups were present.

Results:

Out of 113 case reports and series, 29 articles were included in this systematic review. Only 31% of articles have satisfied the MQCC scale and maintained as high-quality case reports, 43% of articles were medium to high quality, and 26% designated as low quality.

Conclusions:

Eighty percent of the accidental ingested orthodontic appliances that pass uneventfully through the gastrointestinal system require a fiber-rich diet and laxatives. A total of 10% to 20% lacerates oral, pharyngeal, and gastrointestinal mucosa result in pain, bleeding requires laryngoscope, endoscopically and laparoscopy with use of Magill’s forceps. Only 1% of cases have presented with a high morbidity and mortality alarming for surgical removal of ingested component. Thus, the precautions to be taken to overcome such incidences are tying silk thread to activation key, use of recent bonding method, use of contrast colors of removable appliances as the color merges with mucosal color, and operator position should be 7 O′ clock.

Keywords

Accidental swallow orthodontic appliances archwire mini-screw

Introduction

Accidental ingestion of foreign body is more often seen in children and around 1,500 people die each year due to this.¹ Incidence of foreign body aspiration occurs in children (80%), elderly, mentally impaired, or alcoholic individuals and sometimes it may occur deliberately in prisoners or psychiatric patients.^2-4

Commonly aspirated foreign objects are coins, meat boli, and button batteries; sewing needles, tooth picks, straightened paper clips, and razor blades; and dental objects. In most of the situations, these objects pass through the gastrointestinal tract (GIT) uneventfully, but 10% to 20% required endoscopic removal and 1% alarm for surgical removal.^4-6

Kurkciyan et al (1996)⁷, Pavlidis et al (2008)⁸, and Dhandapani et al (2009)⁹ have reported that the accidental swallowing of dental materials and other armamentarium or materials their product used in various dental procedures.^7-9,10-14 The most often accidentally swallowed dental objects are the broken fragments of burs, posts, root pieces, teeth, impression materials, implant components, and restorations. Overall incidence of dental foreign body aspiration is 3.6% to 227.7% and higher in adult than in children.^15-19 In prosthodontics, single crowns and loose dentures are more prone to swallowing in endodontics broaches and files, and also fragments of implants and other dental restorative materials are frequently swallowed.

Rohida and Bhad et al, Umesan et al, and Naragond et al have reported that during routine orthodontic treatment, chance of accidental aspiration of various orthodontic materials like bracket, wire fragment, activation key and fractured twin block, removable retention appliances and lingual retainers. However, these incidents are being managed successfully without medical emergency.^18-23

The major manufacturing limitations of dental and orthodontic materials are their shape and size, smaller and made up of radiolucent materials, which make them easy to swallow and difficult to detect with radiographs. Hence, it alarms to use bronchoscopy/endoscopy or computed tomography for its localization.^{1-17,23,25-27} Although only 2% to 3.7% require emergency treatment as these foreign bodies obstruct GIT or respiratory tract, and the rest of the material pass GIT without complications.²⁸

This systematic review aimed to investigate the most frequent ingesting of the foreign body during orthodontic treatment, associated complications, and management from available evidence like case reports and case series.

The objective of this systematic review is to collect, compile, and review the data available on accidental ingestion of orthodontic materials during treatment from various published case reports and case series.

Focused question: What are the effects of accidentally swallowing an orthodontic appliance or part of a fixed orthodontic appliance to the airway and gastrointestinal tract?

Materials and Methods

This systematic review was conducted in agreement with the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The study has not been registered.

Eligibility Criteria

The inclusion and exclusion criteria were established according to the (population, intervention, control, and outcomes) PICO question reported above.

The included studies were case series and case reports published in English and regarding the accidental swallowing of orthodontic materials, associated complications, and their management. Also searched articles published in medical journals entitling on accidental swallow of dental or orthodontic materials.

Exclusion criteria: case reports, case series, and studies with orthodontic treatment in autism, Pica syndrome, geophagia, and subject with mouthing habit.

Information Sources

An electronic investigation was performed using PubMed, Medline, Scopus, PsycINFO, SciSearch, The Cochrane Library, EMBASE, HINARI, and EBSCO. The search was conducted until April 11, 2021. No restrictions were applied in time or language.

Search Strategy

The search was performed using recent developed protocol for systematic reviews of case reports and case studies for the year 2021 on the advanced PubMed search tool with a combination of the following keywords, MeSH (Medical Subject Heading), nonindexed terms and the corresponding Boolean operators: (((((((((growing) OR adolescent) OR adult)) OR (((growing[MeSH Terms]) OR adolescent[MeSH Terms]) OR adult[MeSH Terms])) OR (((growing[Text Word]) OR adolescent[Text Word]) OR adult[Text Word]))) OR ((("accidental swallow") OR "incidental engulf") OR "unintentional aspiration"))) OR (((((((((("orthodontic appliance")[MeSH Terms] OR "orthodontic expender")[MeSH Terms] OR "orthodontic expansion key")[MeSH Terms] OR "orthodontic archwire")[MeSH Terms] OR "orthodontic fixed bracket")[MeSH Terms] OR "orthodontic archwire segment")[MeSH Terms] OR "molar bands")[MeSH Terms] OR "orthodontic removable retainer")[MeSH Terms] OR "orthodontic fixed retainers"[MeSH Terms])). In each database, an advanced search was performed with similar permutation and combination of keywords. The search was then implemented on the references of the selected articles to complete missing link in initial search. Corresponding authors were contacted through e-mails for missing information (Tables 1 and 2).

Table 1.

Primary and Secondary Keywords.

Primary Keywords	Secondary Keywords
Accidental swallowing of orthodontic material	Sudden swallowing of dental materials
Aspiration of archwire	Swallowing of restorative materials
Unintentional swallowing of expansion key	Swallowing of implants or its parts
Aspiration of functional appliances
Accidental ingestion of orthodontic brackets

Table 2.

Electronic Search Approach for Each Database.

S. No.	Keywords	No. of Articles Searched	No. of Articles Selected	Reason for Exclusions
1	Accidental swallowing of orthodontic material	06	3	Swallowed metal splints
2	Aspiration of archwire	09	07	Not meeting inclusion criteria
3	Unintentional swallowing of expansion key	9	4	Not meeting inclusion criteria
4	Aspiration of functional appliances	11	01	Not specific about what appliance
5	Accidental ingestion of orthodontic brackets	19	03	Not meeting inclusion criteria
6	Accidental swallow of ligature wire	23	01	Not meeting inclusion criteria
7	Accidental swallow of expanders	05	03	Not meeting inclusion criteria
8	Accidental ingestion of removable appliances	08	02	Cast partial and treatment partial appliances
9	Accidental aspiration retention plate	03	01	Not meeting inclusion criteria
10	Sudden swallowing of dental materials	33	00	Case reports are not mentioned orthodontic material
11	Swallowing of restorative materials	07	02	Articles were on endodontic materials
12	Swallowing of implants or its parts	34	02	Articles were on restorative implants

Study Selection

The titles and abstracts of the searched articles were based on the PICO criteria. Two authors (SS and SR) simultaneously and independently conducted the search process according to the criteria of the PRISMA Protocol in a two-stage. In the first stage, the primary researcher (SS) analyzed the articles on titles and abstracts that were potentially eligible studies and full texts were being downloaded from the electronic search. In the second stage, researchers have conducted a selection process on downloaded articles according to the PRISMA Protocol to establish inclusion and exclusion criteria; duplicate publications were being removed. In case of any disagreement, a third reviewer has consulted, and unsuitable articles were being removed. The reason for the eliminated articles is being mentioned in Table 2. The distribution of the journals in which selected articles were published is illustrated in Table 3.

Table 3.

Propagation of the Journals in Which the Articles Are Published.

S. No.	Name of the Journal	No. of Articles
01	APOS Trends Orthodont	01
02	Turkish J Orthodont	01
03	J Orthodont	03
04	Dentistry J	01
05	Case Rep Dental	02
06	Int J Orthod Milwaukee	01
07	Am J Orthod Dentofac Orthop	11
08	J Dent Update	01
09	J Clin Orthod	01
10	Otolaryngol Head Neck Surg	01
11	SADJ	01
12	Br Dent J	02
13	J Dentomaxillofac Orthod	01
14	Aust Orthod	01
15	ASDC J Dent Child	01

Data Collection Process

Evidence obtained from the selected articles were retrieved and exported to Excel sheet (Microsoft window 2010) organized according to methodological quality and synthesis of case series and case reports tool (MQCC) under following 4 domains:

Subjects

Ascertainment

Causality

Reporting

Quality Assessment

Independent quality assessment of selected case reports and case series were conducted according to checklist provided by MQCC²⁸ under 4 domains by 2 reviewers (SS and SR). Any disagreement between the 2 authors was discussed and resolved by consensus or arbitration by the third reviewer (RR).

In this review, methodological quality and MQCC of Murad et al²⁸ was the modified tool of Bradford Hills and Newcastle Ottawa scale. In this Newcastle Ottawa scale’s, 8 items have converted into 4 domains: selection, ascertainment, causality, and reporting. Thus, the quality assessment of the case reports and series were evaluated assigning “stars” (Newcastle Ottawa scale). One “star” for an incomplete detail, two “star” for an acceptable, and three “star” for complete and alternate ways of accidental swallow.

Result

Selection of Case Reports and Case Series

The electronic search conducted to identify case reports and case series depends on the title admissible in the systematic review. However, a sum of 113 case reports and case series retrieved from various dental and orthodontic, and medical emergency journals. A thorough screening was performed and 70 nonorthodontic dental case reports were removed; 43 case reports were being shortlisted to determine their compliance with the eligibility, and 14 case reports were excluded. Finally, 29 articles fulfilled the selection criteria and were included for qualitative analysis of the systematic review.

This comprised 58.7% of the total articles retrieved from the data search. The present study was conducted and reported following the PRISMA, the outline of which is illustrated in Figure 1.

Figure 1.

PRISMA flow chart

Characteristics of Included Studies

The characteristics of included studies are summarized in Tables 4a 5 to 4c. The number of case reports and case series that have been published on subjects varies ranging from 2 to 34 with a mean age group ranging from 12 to 18 years. The data source for the publication of these case reports was from various hospitals and institutions.

Table 4a.

Study Characteristics and Case Report and Case Series Summary.

		Object	Place	Immediate Symptoms	Location	Complications	Basic Treatment	Final Outcome
Nazif and Ready²	9 yr/f	Activation of expansion key	Home	Vomiting	Stomach	No signs of bleedings	Fiber-rich diet	Child’s excrement
Hinkle³	18/f	Retention plate	Home	Vomiting	Esophagus	Nil	Not seen	Laparoscopy
Parkhhouse⁴	15/m	Removable plate	Home	Breathing	Esophagus	Medical emergency	Life support	Surgical removed
Lee⁵	15/m	Retention wire	Fast	Stomach pain	Pylorus	Bleeding in excreta	Soft diet	Gastroscope
Absi and Buckley⁶	25/m	Wire of Transpalatal bar	Home	Pain and vomiting	Upper part of iliac fosse	Pain	Methylcellulose, stomach filler	Proctoscopy
Dibiase et al⁸	9/f	Digit sucking appliance (habit braking appliance)	Home	Pain, palatal laceration ,	Esophagus	Due to laceration during removal	Soft diet, antibiotics, and analgesics	Without surgical intervention
Milton et al⁹	14/f	Fixed bracket	Home	Pain, bleeding excreta	Abdominal region	Antibiotics and analgesics	Fiber-rich diet	came out in large bowels
Quick and Harris¹⁰	26/m	Coil spring	Dental office	Vomiting	Stomach	Pain and blood spot in excreta	Fiber-rich diet and antibiotics	Gastroscope
Klein and Schoem¹¹	15/m	Retainer	Home	Plural chest pain	Chest left side	Decreased count of WBC and cough	Broad-spectrum antibiotics	Rigid bronchoscopy and removed

Table 4b.

Study Characteristics and Case Report and Case Series Summary.

Author	Age/Sex	Object	Place	Immediate Symptoms	Location	Complications	Basic Treatment	Final Outcome
Sfondrini¹²	23/f	Broken transpalatal bar	Fast food	Bleed during speech	Upper part of GI tract	Pain
Abdel-Kader¹³	26/m	Fixed bracket	Home	Nil	Stomach	Pain initiated after 13 day	Soft diet, antibiotics, and analgesics	Gastroscope
Al-Wahadni et al¹⁴	15/f	10 mm NITI 17×25 wire	Dental office	Nil	Piriform recess	Pain during food intake	Postoperative pyrexia	Endoscopic retrieval
Allwork et al¹⁵	13/m	Quad helix	Dental office	Bleeding , vomiting	Lower esophagus.	Visceral perforation	Postoperative pyrexia	Mini-laparotomy
Fiho et al¹⁶	17/f	During orthognathic surgery	Operation theater	Nil	Piriform recess	Soft diet, antibiotics, and analgesics	Removed with Magill forceps	MacIntosh laryngoscope
Sheridan¹⁷	16/f	Bracket	Dental office	Nil	Lower esophagus.	Nil	Soft diet, antibiotics, and analgesics	Gastroscope
Nicolas et al¹⁸	17/m	17x25 Santilone	Dental office	Nasal bleeding	Floor at junction	Nasal spray Otrivin	Antibiotics and analgesics	Nasal endoscopy
Rohida and Bhad¹⁹	12/m	Broken twin block	Home at sleep	Pain TMJ	Upper part esophagus.	Nil	Soft diet, antibiotics, and analgesics	Endoscopy
Tripathi et al²⁰	17/m	Hyrax activation key	Home	Otorhinolaryngology emergency	hypopharynx	Otorhinolaryngology emergency	Magill’s forceps	Fiber-optic nasopharyngoscope

Table 4c.

Study Characteristics and Case Report and Case Series Summary.

		Object	Place	Immediate Symptoms	Location	Complications	Basic Treatment	Final Outcome
Monini Ada et al²¹	9/m	Expansion key	Home	Nil	Abdominal	Nil	Fiber food and drinks	Excreted after 4 days
Umesan et al²²	12/f	Arch wire 17x25 NITI	Dental office	Sharp pain in throat region	Laryngeal region	Nil	Fiber food and drinks	Endoscope
Naragond et al²³	16/m	Molar band	Home	Nil	Left lower chest	Nil	Laxative and fiber food	Endoscope with grasper
Park et al²⁴	19/m	Arch wire 19x25 NITI	Dental office	Momentary pain	Piriform recess	Nil	Routine food	MacIntosh laryngoscope
Hoseini²⁵	29/m	Premolar bracket	Home	Gastric irritations	Lower stomach.	Pancreatitis	Metronidazole, ceftriaxone, and Pantoprazole	Under sedation with midazolam
Tiller et al²⁶	37/f	Khubyoshki wire	Home	Calcification in pancreatic	Head of papillae of pancreas	Pancreatitis	Metronidazole, ceftriaxone, Pantoprazole	Endoscope
Wilmott et al²⁷	19/f	Bracket	Home	A scratch at the side of throat	Lower left posterior teeth	Pain unable to chew food	Five-day course of Amoxicillin	Oral and maxillofacial surgeon removed
Nikhilesh et al²⁹	11/m	Mini-screw	Dental office	Nil	Not located	Nil	Observation	Observation
Mahto³⁰	15/m	Molar band	Home	Nil	Neck Region of esophagus	Nil	Observation	Endoscopy

Quality Assessment

Only 31% of the articles have satisfied the MQCC scale and maintained as high-quality case reports, 43% of articles were medium to high quality, and 26% designated as low quality. Thus, MQCC scale was used to analyze the quality of published case reports. Methodological evaluations of the quality of all case reports were assessed using the MQCC scale. The detailed quality assessment of all the studies is tabulated in Tables 5a and 5b.

Table 5a.

Methodological Quality and Synthesis of Case Series and Case Report Tool.

	Authors	Domains
	Authors	Selection	Ascertainment	Causality	Reporting
1	Nazif and Ready²	*	**	*	*
2	Nafiz et al (1987)	*	*	*	*
3	Parkhhouse⁴	*	**	*	*
4	Lee⁵	*	**	*	*
5	Absi and Buckley⁶	*	*	*	*
6	Dibiase et al⁸	**	**	**	**
7	Milton et al⁹	*	**	*	*
8	Quick et al¹⁰	**	*	**	*
9	Klein and Schoem¹¹	*	**	*	*
10	Sfondrini¹²	**	*	**	**
11	Abdel-Kader¹³	*	*	*	**
12	Al-Wahadni et al¹⁴	*	*	*	*
13	Allwork et al¹⁵	**	**	**	**

Note: *Incomplete detail; **acceptable.

Table 5b.

Methodological Quality and Synthesis of Case Series and Case Report Tool.

	Authors	Domains
	Authors	Selection	Ascertainment	Causality	Reporting
1	Fiho et al¹⁶	*	*	**	*
2	Sheridan¹⁷	*	*	*	*
3	Nicolas et al¹⁸	*	*	*	*
4	Rohida and Bhad¹⁹	**	**	**	**
5	Tripathi et al²⁰	*	*	*	*
6	Monini et al²¹	*	*	*	**
7	Umesan et al²²	**	**	**	**
8	Naragond et al²³	*	*	*	*
9	Park et al²⁴	*	**	*	**
10	Hoseini²⁵	*	*	*	**
11	Tiller et al²⁶	*	*	*	*
12	Wilmott et al²⁷	*	*	*	*
13	Nikhilesh et al²⁹	**	**	**	**
14	Mahto et al³⁰	**	**	**	**

Note: *Incomplete detail; **acceptable.

Risk of Bias Assessment

Methodological quality and synthesis of MQCC scale was applied to determine the quality of these case reports and series and is illustrated in Tables 5a and 5b.

Nineteen out of 29 were case reports and 10 case series, in which 74% of case reports have satisfactorily addressed the method of MQCC and its applicability to be the general population.

Synthesis of Results

Twenty-nine articles have published the unexpected swallow of orthodontic materials (archwire, segment of archwire, removable appliance, retainer, expanders, expansion key, and mini-screw). Nine out of 29 articles have been notified on incidental assimilate of the archwire, segment of archwire, and ligature wires; and 7 on expanders, and expansion key’s rest of the articles documented twin block, mini-screw, and removable appliances.

Discussion

Synthesis of Evidence

Case reports and case series are communicative studies that are prearranged for demonstrating novel, unusual, or atypical features recognized in subjects of medical, dental, and orthodontic practice, and they hypothetically create new research questions.^{26, 27} Most of the case reports and case series define and scrutinize the diagnosis and management of 1 or more than 3 patients; also from the base of the evidence-based pyramid.²⁸

Accidental Swallow of Expansion Key

Nafiz and Ready MA in 1983 have published two case reports on accidental aspiration of expansion key. This incident took place in the dental office while the operating subject turned head and slipped from the operator’s hand; as the patient’s position was the supine key was swallowed a fiber-rich diet was advised and after 4th week seen in excreta.²

Tripathi et al¹⁹ published a similar case report of the 17-year-old male (cleft lip and palate) patient; the incident occurred in a dental office as the patient turned up his head and the expansion key slipped from the operator’s hand.¹⁹ This case was managed as a medical emergency, and the key was removed using “Magril force” with fiber-optic nasopharyngoscope. An exact case report was published by Monini Ada et al.²⁰

Archwire and Archwire Segments

Absi and Buckley⁶ reported that a 25-year-old female had an accidental swallow of transpalatal bar made up of crescent-shaped piece of rigid stainless steel wire of 0.9 mm diameter and approximately 2.5 cm length, with a U-loop at both the ends. An abdominal radiograph located that wire was in the upper-right iliac fossa. She was given methylcellulose as bulk filler, and then it was located passing from small bowel to a large intestine, then the patient was discharged. Later, the patient complained of abdominal pain, now the wire was located at rectal region and removed with proctoscopy. Nicolas et al¹⁷ published a case report of a 17-year-old male who came with the chief complaints of nasal bleeding and pain; nasal endoscopy was used to remove the wire fragment. Umesan et al²¹ reported a 12-year-old girl’s case report of accidental ingestion of archwire (17X25 NITI) segment of 20-mm length in dental office during the routine visit. This incident occurred while cutting a posterior excess archwire with distal end cutter; wire was located at laryngeal region and was successfully removed using endoscopy.

Fixed Orthodontic Bracket

Milton et al⁹ published a case report of a 19-year-old woman who visited with pain, cough, and scratchy throat. On clinical examination, premolar bracket was missing, and on the X-ray of the chest and stomach, location of an ingested foreign body was unidentified. The patient was encouraged with fiber food, more drinks, and amoxicillin tablets. Later, an orthopantomograph revealed that dislodge premolar bracket seen in a posterior second molar area was removed. Fiho et al¹⁵ and Sheridan¹⁶ reported that a 17-year-old girl, 32-year-old boy, and 29-year-old women respectively were the orthognathic patients post-surgery that found the missing second molar tube and brackets.

On X-ray, missing appliances were located at the piriform recess of the larynx, with the help of Macintosh laryngoscope, and removed using Magill forceps.

Removable Appliance, Retainer, and Twin Block

Park et al²³ published a case report of a 15-year-old boy who was given a tongue crib and was accidentally ingested during fast food eating. He later complained of stomach pain and bleeding spots in stools, and it was located at the pylorus region; managed with gastroscopy. Dibiase et al⁸ reported an 18-year-old male with an accidental swallow of the removable plate. The immediate complaint was difficulty in breathing, and the appliance was at the esophagus region. This case was alarmed for a medical emergency and surgical removal. Rohida and Bhad¹⁸ circulated a case report of 12-year-old male with accidental swallow of fracture twin block. The author reveals that the patient was using repaired piece of broken twin block, located at the esophagus and removed using endoscopy.

Orthodontic Band Material and Molar Bands

Naragond et al²² reported through a case report of a 16-year-old male who accidentally engulfed a molar band during eating fast food. It was located at the lower-left region of the chest. No immediate or delayed symptoms were found and by using endoscopy with grasper, the foreign body was removed. Mahto et al²⁹ reported a similar incident that occurred in a 16-year-old cleft lip boy and was removed using endoscopy with a grasper.

Mini-Screw

Nikhilesh et al³⁰ published a case report of 11-year-old male patient who was getting treated with mini-screw-supported distalizing appliance. During the routine visit, one of the mini-screws was loose, and the operator wanted it to remove and reposition it. While removing, a patient turned his head, gave a push, and a mini-screw fell in the pharyngeal region. However, it was not located in the X-ray. The author concluded that the mini-screw might have expelled.

Management Protocol

The development of signs and symptoms depends upon the age of the subject (child or an adult), 75% of the case reports have revealed that the foreign body gets entrapped at the upper esophageal sphincter, and 30% at a lower level.^1-5 The accidental ingested foreign body follows 4 levels with the specific sign and symptoms at each level such as, at oropharyngeal level drooling of saliva, inability to swallow; at an esophageal level in adults complaining of discomfort at the center of the chest or epigastric region, dysphagia and children clinically presents retching, neck, or throat pain, gagging, vomiting later may develop fever, recurrent aspiration pneumonitis/pneumonia.^{10,16,18,22,27,30} Similarly, if the foreign body entrapped at a suboesophageal level can present passing rectal blood and melena and few cases develop subacute intestinal obstruction, and if the appliance is sharp trapped in a GIT may present gastrointestinal perforation signs and symptoms as acute mediastinitis, chest pain, dyspnea, and signs of pneumonitis/pleural effusion.^{11, 12, 13, 25} In this situation, the patient should be calmed and careful examination should be performed; the location of foreign objects at each level is mandatory. Thus, abdominal and chest X-rays, endoscopy, and computed tomography scans of the thorax and abdomen are advised.^{12,14,16,20,21,26,29-31}

Act quickly, keep the patient’s head low, and instruct to cough or if a foreign body is visible, remove it with small forceps or use the Heimlich maneuver method. Based on the location of the ingested foreign body-appropriate devices such as MacIntosh laryngoscope with Magill forceps, fiber-optic nasopharyngoscope is used to remove it.^{1,3,5,7,21,30}

Wasundhara Bhad et al advised that the use of removable appliances should have contrast color of gastrointestinal (GI) tract that helps in locating the swallowed part of functional appliance.¹⁸

Recommendations

Most of the accidental aspirated orthodontic foreign particles entering the oropharynx will pass through the alimentary canal uneventfully. Only 1% of the large and sharp object causes complication as they have impact in GI tract.^{1-6,9,10,17,20,22,27,30}

Orthodontic wire segment, if impact at the level of 4th cervical vertebra and laryngeal impaction present with dysphagia and odynophagia can be managed with endoscopic retrieval. The use of a distal end cutter avoids the accidental swallow.^{3,10,17,21,25}

Removable orthodontic appliance accidentally ingested and is located at esophageal area may present chest pain, drooling of saliva, and vomiting and if the appliance fragment lodged at ileocecal junction or at the sigmoid colon area, it presents with muscle incoordination, incessant twitching, and hematemesis causes.^{3,10,17,21,25,26,30} Later, patient presents with abdominal pain, fever, nausea, vomiting, and abdominal distension because of perforation of the ileocecal junction and the sigmoid colon. The use of Fiber-optic nasopharyngoscope to locate and remove the aspirated fragment or appliance.^12,16,19,22 Use silk thread and tie a knot to labial bow or Adam’s clasp for immediate retrieval from the esophagus; use a contrast-colored appliance to identify at the time of removal.^{9,24,11,23,29-31}

Strength of the Study

In the era of clinical trial and evidence-based practice, this systematic review withstands to describe hidden or undetected scientific observations for clinical trials. This also generates a hypothesis that provides an evidence-based orthodontic practice. This systematic review enlightens patient-centered clinical awareness of an individualized nature of contemporary patient care and can be used for teaching, review, and research purposes.

Weakness of the Study

This systematic review comprised of scanty evidence, deceptive, and no control group to compare outcomes, and has no statistical validity.

Conclusion

We conducted this systematic review to answer the question: “What are the effects of accidentally swallowing an orthodontic appliance or part of a fixed orthodontic appliance to the airway and gastrointestinal tract?”

Based on the meticulous search, 29 case reports and case series have published the accidental swallow of different orthodontic materials. To answer the research question, we have clubbed the case report and series reporting similar items of accidental swallow, and we have got the following conclusions.

Nine individual case reports were on accidental swallowing of wire segments in resident and subjects reported with abdominal pain; nasal bleeding and airway compromised.

Seven case reports were reported on expanders and expansion keys, and patients reported with discomfort, drooling of saliva, and inability to swallow.

One article reported a functional appliance swallow with a chief complaint of breathless with a severe cough.

Most of the case reports could not satisfy the methodological evaluating domains.

Clinician must warn the subject and parents before beginning with any orthodontic treatment.

Activation key tied to silk thread and 7 O′ clock position of the operator can prevent its accidental ingestion

Footnotes

Acknowledgments

The authors would like to thank Dr. Wasundara Bhad and Dr Santosh Chavan for their moral support to complete this study.

Author Contributions

Dr Siddharth Sonwane: writing, design, compile, data collection, and analysis; Dr.Shweta.Kamble (sonwane): concept, supervision, and grammar.

Declaration of Conflicting Interests

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Siddharth Sonwane

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