Cynthia R. Biron, RDH
Treating patients who are in a supine position may prevent syncope, but the chance of the supine patient swallowing an object is greater. Many of the small objects used in dentistry can easily be dropped into the patient`s oropharynx. The following cases (in which all names have been changed) actually occurred in U.S. dental offices.
Angela, the dental hygienist in Dr. Green`s office, was polishing the teeth of her patient, Katie, an 86-year-old lady who was a habitual tea-drinker. The tea stains on the facial surfaces of the mandibular teeth were quite heavy. Angela was having to press and flare the rubber cup - attached to the end of the disposable angle - quite a bit to get the stain removed from Katie`s teeth. Suddenly, Angela noticed that the rubber cup separated from its screw-like attachment and flew back into Katie`s oropharynx.
Angela`s immediate response was to place her left hand (her nondominant hand) across the occlusal surfaces of the mandibular teeth so Katie couldn`t swallow. Within seconds, the saliva filled the oropharynx and up floated the rubber cup over the back of the tongue. Angela simultaneously put down the handpiece, grabbed the cotton pliers off the bracket-table tray, and retrieved the rubber cup, without showing any signs of fright.
Katie never knew the rubber cup was floating in her oropharynx. Angela never told Katie a problem occurred as she went about her business of replacing the disposable angle and prophy cup with a new one, so the polishing could be completed.
Lucille, the dental hygienist at Dr. Gibbon`s office, was scaling the teeth of her patient, Harry. He was a very big man with a large mouth that practically would accommodate Lucille`s whole hand. He had moderate periodontitis and significant pocket depths on the abutting teeth of a three-unit bridge between teeth numbers two and four.
As Lucille was thoroughly scaling the deep area at the mesial of number two, the bridge suddenly came off and plunged into Harry`s huge oropharynx. He jumped up in a startled reaction, practically knocking Lucille off her stool. In the process, he actually swallowed a three-unit bridge!
Lucille was flabbergasted when she attempted to look for the bridge in Harry`s mouth and Harry told her he knew he had swallowed it. Lucille called in Dr. Gibbons. He told Harry that he needed to go to the hospital for X-rays to locate the bridge. Chest X-rays were taken first to determine if the bridge had been aspirated into the lungs.
Fortunately, that was not the case. X-rays of the gastrointestinal tract showed the bridge was in the patient`s stomach. Harry was instructed to return for still more X-rays the next day. These X-rays showed the bridge to be in the large intestine. Harry was instructed to watch for the bridge in case it was excreted from his body. The next day, Harry called Dr. Gibbons office to report that the bridge had been excreted.
In the first case, Angela`s presence of mind prevented her patient from swallowing the rubber cup. When an object is fairly lightweight, it will float on the top of the saliva and can be retrieved easily with cotton pliers or a suction tip. Heavier objects may go down the throat before either the patient or the operator knows what happened, which was what happened in the second case.
In most situations, a swallowed object will go down the esophagus and into the gastrointestinal tract. On rare occasions, the object is aspirated and goes into the trachea and becomes lodged in either bronchus of the lungs. An object is more likely to get caught in the esophagus than anywhere else in the gastrointestinal tract. An object that enters the trachea usually requires surgical removal. Objects entering the gastrointestinal tract will most likely be excreted during bowel movements.
If objects get caught in the intestines, surgery is necessary. Objects lodged in the intestines could perforate the intestinal wall and cause peritonitis, which is usually fatal. So in every case, a patient who has swallowed an object must get immediate medical care and X-rays to try and locate the foreign object. Never assume that a swallowed object will be excreted without complications. Always get such patients to a hospital as soon as possible.
How to prevent problems
Dentists can prevent their patients from swallowing objects by using rubber dams for as many procedures as possible. There also is an advantage in having a chairside assistant, who can readily use high-volume suction to retrieve objects that fall into the oropharynx.
A medium-to-large gauze square, tied to a long section of dental floss, may be placed across the back of the oral cavity. This acts as a net for catching amalgam debris or small objects. The floss is a safety mechanism for pulling out the gauze, should it begin to enter the oropharynx.
However, dental hygienists usually are unassisted and must take every precaution to prevent their patients from swallowing objects. Rubber cups frequently spin off when the slow handpiece is mistakenly left in reverse. Make sure that the handpiece is in the forward position, before placing it in the patient`s mouth. Instrument tips, especially oversharpened, thin scalers, easily can break off and fly into the oropharynx during supragingival scaling. During subgingival scaling, a broken instrument tip may be lodged in an interdental area or in the bottom of a deep pocket. It is best to discard thin, worn scalers and replace them with new instruments that are strong and properly contoured.
Bargain-priced instruments are not such a bargain, if they break easily under pressure. Inexpensive explorers have been known to break off at the working end, when they are used for caries detection of occlusal pits. If a Sheppard`s hook flies off and lands in the oropharynx, a pierced tongue or throat could be the result.
Cotton pliers always should be a part of every tray set-up, so that they are readily available to retrieve objects that stray towards the oropharynx.
The dentist should have a pair of Magill intubation forceps on his/her emergency cart and readily available in each operatory. Magill`s forceps only should be used to retrieve objects from the oropharynx that are visible. They should never be used to blindly grab into the pharynx in hope of retrieving objects which are not clearly visible.
When it happens anyway
If your patient already is in a supine position and you are unassisted when an object is dropped into the oral cavity, an instrument tip breaks, or rubber cup flies off the angle, do not show any expression of fear. Do not allow the patient to sit up. Place the four fingers of your nondominant hand flatly over the tongue and occlusal surfaces of the mandibular teeth, while positioning the patient trendelenburg (head lower than feet). Gravity then will cause the object to fall towards the nasopharynx, where it can be seen.
While keeping your nondominant hand positioned over the mandibular occlusals to prevent swallowing, use your dominant hand to retrieve the object with cotton pliers. This technique should be an automatic reaction that is performed swiftly and calmly.
If the object does not become visible, keep the patient in a trendelenburg position, but placed on the stable side, and ask him/her to cough. A cough is very effective in discharging objects from the oropharynx, and a trendelenburg position provides the additional assistance of gravity for bringing objects back to the oral cavity.
Hopefully, you will have retrieved the object during the initial steps of management, when the patient is unaware that an object has entered the oropharynx. This typically is the case with rubber cups and tiny objects, such as instrument tips. Once a patient becomes aware that an object has entered his/her throat, it is difficult to keep that individual in a supine or trendelenburg position, as the patient`s usual reaction to the situation is to try to sit upright to cough and allow the diaphragm to breathe easier.
This is why management of this kind of an emergency can be so difficult. A feeling of "air hunger" causes panic. Keeping the patient calm and explaining the need for a trendelenburg position - while the patient is in such distress - takes a great deal of competence and presence of mind.
Dealing with airway obstructions
The two types of airway obstructions are complete and partial. Because the objects in dentistry that may be swallowed usually are so small, it is unlikely that they would totally obstruct the airway.
A complete airway obstruction is evidenced by the patient`s inability to speak and an absence of air exchange, with the distressed patient displaying a frantic expression on his/her face. The grasping of the throat is the universal "choking sign." All dental personnel should recognize this sign and respond by asking the patient if he/she can speak. If the patient is unable to speak, the Heimlich Maneuver should be performed.
All health professionals should be CPR-certified. They should be capable of performing the Heimlich Maneuver and providing basic life support until EMS arrives.
A partial obstruction of the airway could occur, and, if so, there still is an air exchange. The patient who has a good air exchange should cough forcefully, since such a cough can expel the object from the throat. A patient with a poor air exchange will be unable to cough effectively and, as he inhales, a stridor (crowing noise) will indicate that the air exchange is indeed quite poor. The patient with this problem cannot speak and can make only incoherent sounds.
A patient with a partial airway obstruction and a poor air exchange must be treated like a patient with a complete airway obstruction. If the object is expelled within four minutes, the patient will return to normal very quickly. If five or more minutes has passed before the object is expelled, the patient will deteriorate quite rapidly into a state of shock, with no pulse or blood pressure, and then go into cardiac arrest. The Heimlich Maneuver (abdominal thrusts), alternating with cardiopulmonary resuscitation, must be performed until the arrival of the EMS.
If the dentist or a member of the dental team is registered in Advanced Cardiac Life Support (ACLS), he or she may be experienced in the use of an endotracheal laryngoscope, where the vocal-chord area is made visible and Magill`s forceps are used to retrieve the object. Invasive airway procedures, such as a cricothyrotomy, should be performed only by well-trained and experienced professionals.
Every dental-office team should have a stopwatch in its emergency kit and every staff member should be practiced in starting the stopwatch at the time of an emergency. Then and only then can members of your staff be absolutely sure of the amount of time a patient has not been breathing.
In an emergency, two minutes can easily seem like four to five minutes, when you are witnessing a patient who is cyanotic (blue) from lack of oxygen and you are overly anxious from an adrenaline surge. Anxious health-care providers, who rarely deal with emergencies, have been known to perform CPR on patients who have not arrested and advanced airway procedures on patients who have had an obstruction for only two minutes. All of these procedures are of lifesaving value when the time is right to resort to them, but if a less traumatic procedure reverses the situation, there is no need to rush into procedures which cause other injuries, such as fractured ribs and/or sternum, or which cause laryngospasms and permanent scarring.
Develop an Action Plan
Most offices are not within five minutes of EMS personnel. Therefore, it is essential that the dental team have a competent, well-defined plan of action for airway-obstruction management, as the first six minutes are the most important. Supplemental oxygen must be a part of that plan. A demand-valve resuscitator can force oxygen beyond a partial obstruction and keep the patient alive until EMS gets there. Low-flow delivery of oxygen for breathing patients is a must. Assisting ventilation of patients in respiratory distress with a bag-valve mask (AMBU bag) can make the difference between whether a patient lives or dies.
The use of supplemental oxygen is not a part of CPR training for health professionals - one reason why so many health professionals do not think of it as an integral part of airway management. However, EMS-trained professionals do. If the members of your dental team are not trained in oxygen safety and delivery, find a continuing education course that provides "hands-on" training, or call your local EMS or fire department and ask if they can provide in-service training in oxygen delivery for your office staff.
Most emergency-care professionals appreciate the opportunity to help health-care professionals with emergency preparedness.
Cynthia R. Biron, RDH, is chair of the dental health program at the Tallahassee Community College. She is also a certified emergency medical technician.