Management of self-inflicted dental injuries with various nonsurgical techniques: Case series

Ganesh Ranganath Jadhav; Priya Mittal; Dipali Shah; Umesh Dharmani

doi:10.4103/1658-5984.189354

CASE REPORT

Year : 2016 | Volume : 6 | Issue : 3 | Page : 148-152

Management of self-inflicted dental injuries with various nonsurgical techniques: Case series

Ganesh Ranganath Jadhav¹, Priya Mittal², Dipali Shah¹, Umesh Dharmani³
¹ Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
² Department of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
³ Department of Conservative Dentistry and Endodontics, Dental College, RIMS, Imphal, Manipur, India

Date of Web Publication

29-Aug-2016

Correspondence Address:
Ganesh Ranganath Jadhav
Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/1658-5984.189354

Abstract

Children have a common habit of exploring carious or traumatically exposed teeth using various foreign objects such as metal screws, staple pins, darning needles, pencil leads, beads, paper clip, and toothpicks, which may sometimes break inside the pulp chamber or root canal. Majority of such cases are asymptomatic and hence diagnosed accidentally on routine radiographic examination. However, embedded foreign objects may sometimes act as a potential source of infection and are convoyed with pain or recurrent swelling. Dentists must be aware of the self-inflicted dental injury, its consequences, and selection of the all-inclusive treatment strategies giving due consideration to cost-benefit ratio of the different treatment options. This case series highlights the possible dental consequences of placing foreign objects in the mouth and various management strategies. Four cases of self-inflicted dental injuries involving patients aged 10–20 years are presented and investigated from the endodontic, pedodontic, and psychiatric viewpoints. In all cases, the cause has been easily identified by clinical appearance corroborated with a good history. This paper discusses a nonsurgical technique to retrieve these objects from the root canal with minimal damage to internal tooth structure.

Keywords: Foreign objects, self-inflicted injuries, sewing needle, toothpick

How to cite this article:
Jadhav GR, Mittal P, Shah D, Dharmani U. Management of self-inflicted dental injuries with various nonsurgical techniques: Case series. Saudi Endod J 2016;6:148-52

How to cite this URL:
Jadhav GR, Mittal P, Shah D, Dharmani U. Management of self-inflicted dental injuries with various nonsurgical techniques: Case series. Saudi Endod J [serial online] 2016 [cited 2023 Mar 22];6:148-52. Available from: https://www.saudiendodj.com/text.asp?2016/6/3/148/189354

Introduction

In dental setup, self-inflicted hard and soft tissue injuries are commonly seen in children as a consequence of child's habit of placing foreign objects into the mouth. Foreign objects such as metal screws,^[1] staple pins,^[2] darning needles, gates glidden drill,^[3] pencil leads,^[4] beads,^[5] paper clip, and toothpicks may get embedded in carious or traumatically exposed teeth. These injuries can be premeditated, accidental, or result of an uncommon habit and can be seen in patient with special needs or patient with normal intelligence. Foreign body lodged in the tooth is diagnosed accidentally on routine radiographic examination; however, it may convoy with infection, pain or recurrent swelling. Thorough clinical and radiographic examination is deemed necessary to confirm the presence, size, location, and type of foreign objects. This case series describes the retrieval of foreign objects lodged in teeth as sequelae of self-inflicted injury in four patients.

Case Reports

Case 1

A 10-year-old boy reported to the Department of Conservative Dentistry and Endodontics with chief complaint of severe pain in left mandibular area. Past dental history revealed that patient had visited a private dental clinic 2–3 months ago during which root canal treatment was initiated but not completed in the left mandibular first molar (#36). Intraoral clinical examination revealed a large occlusal cavity, a furcal perforation, and a metallic object embedded in the tooth [Figure 1]a. An intraoral periapical radiograph revealed the presence of a long radiopaque object in the coronal third of mesial canal and large periradicular radiolucency in relation to mesial root [Figure 1]b. Patient's mother was unaware of patients' habit of insertion of foreign objects in the tooth. However, in response to detailed questioning, the patient admitted that he used to place a sewing needle in the tooth to relieve the discomfort associated with the involved tooth. When needle fractured inside the root canal, the patient did not disclose the incidence to the parents. Patient's parents were explained about the presence of perforation and embedded sewing needle in the tooth #36 and written informed consent was signed. Under rubber dam isolation (Hygienic, Coltène/Whaledent, Inc., USA), sewing needle was removed using cotton pliers [Figure 1]c and [Figure 1]d and chemomechanical preparation was completed [Figure 1]f. Furcal perforation was sealed using mineral trioxide aggregate (MTA) (DENTSPLY, Tulsa Dental)^[6],[7] [Figure 1]e and moistened cotton was placed in the pulp chamber. Patient was recalled after 48 h. Cotton was removed from the pulp chamber, and intracanal medicament of calcium hydroxide (Prime Dental Products Pvt. Ltd., Mumbai, India) was applied for 2 weeks. Obturation was completed using Gutta-percha cones and epoxy resin-based root canal sealer (AH plus sealer, Dentsply/Maillefer, Tulsa, OK, USA) [Figure 1]g.

Figure 1: Clinical (a) and radiographic (b) examination of tooth #36 showing a furcal perforation and embedded sewing needle. Sewing needle was retrieved (c and d), perforation was sealed with mineral trioxide aggregate (e and f), and obturation was completed (g)

Click here to view

Case 2

An 18-year-old healthy male reported to the department complaining from discolored upper anterior tooth. The patient had a history of trauma 10–12 years ago when the maxillary right central incisor (#11) fractured. Past history revealed that the patient had a habit of placing foreign objects in his mouth during childhood. However, the patient did not recall about any incidence when a foreign body got fractured in the tooth. Intraoral clinical examination revealed a discolored maxillary right central incisor with an embedded round radiopaque object in the pulp chamber [Figure 2]a.

Figure 2: Clinical (a) and radiographic (b) examination of tooth #11 revealed an embedded pearl in the pulp chamber. Pearl (c) was removed using ultrasonics and copious irrigation (d), and obturation was completed (e)

Click here to view

Intraoral periapical radiograph of tooth #11 revealed a round radiopaque object in the pulp chamber [Figure 2]b. Embedded pearl [Figure 2]c was removed using ultrasonics and copious irrigation [Figure 2]d. Chemomechanical preparation was completed, and the canal was premeditated with nonsetting calcium hydroxide (Prime Dental Products Pvt. Ltd., Mumbai, India). Patient was recalled after 2 weeks. Obturation was completed using Gutta-percha cones and AH plus sealer [Figure 2]e.

Case 3

A 20-year-old healthy male reported to the Department of Conservative Dentistry and Endodontics complaining from embedded metallic wire in the upper anterior tooth. The patient had severe pain in the maxillary right lateral incisor (#12) 10 days ago when he attempted to push a metallic object through the tooth to reduce the pain. The metallic pin pierced the attired tooth, and patient got instant pain relief. However, pin was broken inside the tooth. Intraoral clinical and radiographic examination revealed the presence of a metallic pin in the pulp chamber of tooth #12 [Figure 3]a and [Figure 3]b. Patient was administered local anesthetic solution with adrenaline (2% lidocaine with 1:1,00,000 epinephrine, LOX 2%, Neon Lab, India). Ultrasonics along with copious irrigation was used to remove the embedded metallic pin [Figure 3]c,[Figure 3]d,[Figure 3]e. In the same appointment, chemomechanical preparation and obturation was completed using Gutta-percha cones and AH plus sealer [Figure 3]f.

Figure 3: Clinical and radiographic examination of tooth #12 revealed a fractured metallic pin in the pulp chamber and coronal third of root (a and b). It was removed using ultrasonic (c-e). Obturation was completed in the same appointment (f)

Click here to view

Case 4

A 12-year-old boy reported to the Department of Conservative Dentistry and Endodontics complaining from continuous pain in upper anterior teeth for the past 2 weeks. The patient had Down syndrome with low intelligent quotient of 50. Intraoral clinical examination revealed discolored maxillary right central incisor (#11) and lateral (#12) with cavitations in tooth #11 [Figure 4]a and [Figure 4]e. Patient had a habit of using sharp objects to clean the cavitated tooth. An intraoral periapical radiograph revealed the presence of two radiopaque objects in the root canal of tooth #11 and large periapical radiolucency related to teeth #11 and #12 [Figure 4]b. Root canal treatment was started in both #11 and #12. File braiding technique using H-files was used to retrieve the metallic wire from the root canal [Figure 4]f. After two dressings of calcium hydroxide, obturation of #11 was completed by sectional filling of MTA and backfilling with thermoplasticized Gutta-percha cones [Figure 4]c and [Figure 4]d. Porcelain fused to metal bridge was given to replace the missing #21 [Figure 4]g.

Figure 4: Intraoral periapical radiograph showing two radiopaque objects in the root canal of tooth #11 and large periapical pathologies in relation to both #11 and #12 (a and e). Metallic pin (mp) was retrieved (b and f). Obturation in #11 was completed by sectional filling with mineral trioxide aggregate and backfilling with thermoplasticized Gutta-percha (c). Tooth #12 was obturated by a conventional technique (d). Teeth were restored using porcelain fused to metal bridge (g)

Click here to view

Discussion

Self-inflicted dental injuries can be seen in children with either normal intelligence or with psychological outlook. In children with normal intelligence playing while eating, imitation of colleagues or older siblings, attempts to relieve chronic irritation, fear of dentistry, etc., are responsible for placing foreign objects in the mouth. However, patients with mental retardation show higher prevalence of such behavior.^[8] In the presented case series, only one patient showed mental retardation due to Down syndrome. Such patients show premeditated destruction of oral soft and hard tissues without conscious intention.^[9] Thorough understanding of various factors that precipitate the episodes of self-inflicted dental injuries may help in the prospective determination of children that are at greater risk. This may aid in early intervention and prevention of any future complications of the injury.

Self-inflicted dental injuries are categorized based on etiology as Type A – injuries superimposed on a preexisting lesion or irritation; Type B – injuries secondary to another established habit; Type C – injuries of unknown or complex etiology.^[10] Here, case one and case three were categorized under Type A, case two and case three under Type B. The foreign objects embedded in root canal can be metallic such as screws, staple pins, darning needles or nonmetallic such as pencil leads, beads, and toothpicks. The metallic objects can be readily identified on routine radiographs because of their radiopacity. On the other hand, nonmetallic objects can be identified clinically upon encountering resistance in the canal. A conventional practice of keeping pulp chamber open during emergency root canal treatment to drain out the pus should be discontinued. The patient should remain in office till the weeping canal becomes dry. This prevents the foreign body lodgment and the introduction of new microbial strains in the root canal.

Various factors such as root canal related–root canal anatomy, radicular dentin thickness; foreign body related – location, size, shape, inertness of object, and operator-related availability of equipment, experience, clinical skill determine the clinical outcome.^[11] Inert objects such as steel, glass may not cause significant inflammation if lodged in a noninfected tooth. However, these foreign objects prevent thorough cleaning and shaping of the root canal system. Hence, removal of all foreign bodies embedded in the tooth is mandatory to prevent any future secondary infection. Numerous methods such as operating microscope along with ultrasonic instruments,^[12] Masserann kit,^[13] stieglitz forceps,^[14] modified Castroviejo needle holders,^[15] an assembly of a disposable injection needle and thin steel wire loop formed by passing the wire through the needle along with a mosquito hemostat,^[16] and braided multiple H-files technique ^[17] can be used for the retrieval of foreign objects lodged in the tooth. In rare instances, when nonsurgical approach fails, periapical surgery, or intentional reimplantation can be employed.^[18] However, the ultimate success in the management of self-inflicted dental injury can be achieved if the different motivation sources of injury are recognized and behavioral therapy is employed to modify patterns of behavior that have a negative impact on a person's quality of life.

Conclusion

Nonsurgical retrieval of foreign objects lodged in the root canal is a treatment challenge. In patients with suspected “mouthing” of foreign objects, detailed case history taking, early radiological and clinical examinations are needed. It is crucial to follow a definite treatment algorithm depending upon the clinical situations for the management of such cases. Despite all rigorous efforts, if it becomes impractical to remove or bypass the object, a surgical procedure may be the only alternative to eliminate pain and infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Prabhakar AR, Basappa N, Raju OS. Foreign body in a mandibular permanent molar – A case report. J Indian Soc Pedod Prev Dent 1998;16:120-1. [PUBMED]
2.	Alrahabi M, Gabban H. Management of foreign object in the root canal of central incisor tooth. Saudi Endod J 2014;4:154-7.
3.	Al-Zahrani MS, Al-Nazhan S. Retrieval of separated instruments using a combined method with a modified vista dental tip. Saudi Endod J 2012;2:41-5.
4.	Hall JB. Endodontics – Patient performed. ASDC J Dent Child 1969;36:213-6. [PUBMED]
5.	Subbareddy VV, Mehta DS. Beads. Oral Surg Oral Med Oral Pathol 1990;69:769-70.
6.	Kaushik A, Talwar S, Yadav S, Chaudhary S, Nawal RR. Management of iatrogenic root perforation with pulp canal obliteration. Saudi Endod J 2014;4:141-4.
7.	Savitha A, Rekha AS, Ataide I, Hegde J. Retreatment and surgical repair of the apical third perforation and osseous defect using mineral trioxide aggregate. Saudi Endod J 2013;3:34-8.
8.	Lucavechi T, Barbería E, Maroto M, Arenas M. Self-injurious behavior in a patient with mental retardation: Review of the literature and a case report. Quintessence Int 2007;38:e393-8.
9.	Dilsiz A, Aydin T. Self-inflicted gingival injury due to habitual fingernail scratching: A case report with a 1-year follow up. Eur J Dent 2009;3:150-4.
10.	Stewart DJ, Kernohan DC. Self-inflicted gingival injuries. Gingivitis artefacta, factitial gingivitis. Dent Pract Dent Rec 1972;22:418-26. [PUBMED]
11.	Grover C, Thomas M, Pai AR. Foreign object lodgement in the root canal and its management: A case report and overview. J Contemp Dent 2012;2:47-52.
12.	Meidinger DL, Kabes BJ. Foreign object removal utilizing the Cavi-Endo ultrasonic instrument. J Endod 1985;11:301-4. [PUBMED]
13.	Williams VD, Bjorndal AM. The Masserann technique for the removal of fractured posts in endodontically treated teeth. J Prosthet Dent 1983;49:46-8. [PUBMED]
14.	Lumley PJ, Walmsley AD. Removal of foreign objects from root canals. Dent Update 1990;17:420-3.
15.	Fors UG, Berg JO. A method for the removal of broken endodontic instruments from root canals. J Endod 1983;9:156-9. [PUBMED]
16.	Roig-Greene JL. The retrieval of foreign objects from root canals: A simple aid. J Endod 1983;9:394-7. [PUBMED]
17.	Gutmann JL, Dumsha TC, Lovdahl PE. Problem solving challenges in the revision of previous root canal procedures. In: Problem Solving in Endodontics; Prevention, Identification and Management. 4^th ed. St. Louis: Mosby; 2006. p. 239-79.
18.	Srivastava N, Vineeta N. Foreign body in the periradicular area. J Endod 2001;27:593-4.