What is the follow-up protocol if a dental burr breaks during a dental exam and the patient (pt.) likely swallowed it?

Management of a Swallowed Dental Burr During Dental Examination

If a dental burr breaks during a dental examination and is likely swallowed by the patient, immediate radiographic confirmation and appropriate follow-up is required to prevent potential complications such as bowel perforation. 1, 2

Initial Assessment and Management

1. Immediate Actions:

   • Remain calm and stop the procedure
   • Position the patient upright and assess for respiratory distress
   • Determine if the object was likely swallowed (ingestion) or aspirated (entered airway)
   • Signs of aspiration include coughing, choking, wheezing, or respiratory distress
   • If aspiration is suspected (respiratory symptoms), immediate emergency medical attention is required

2. Documentation:

   • Document the incident thoroughly, including:
     • Size and type of dental burr
     • Time of incident
     • Patient's symptoms
     • Actions taken

Diagnostic Approach

For Suspected Ingestion (Most Common):

1. Immediate Imaging:

   • Obtain plain abdominal radiographs to confirm location of the dental burr 1, 3
   • Most dental burrs are radiopaque and will be visible on X-ray
   • Include chest radiograph to rule out aspiration

2. Patient Education:

   • Inform the patient about the incident and explain the follow-up plan
   • Provide written instructions regarding warning signs requiring immediate attention

Follow-up Protocol

For Confirmed Ingestion:

1. Serial Radiographic Monitoring:

   • Follow the daily descent of the dental burr with plain abdominal radiographs 1, 4
   • First follow-up radiograph within 24-48 hours
   • Continue monitoring until object passage is confirmed

2. Observation Period:

   • Most small, smooth objects (including many dental burrs) will pass through the digestive system without intervention within 7 days 2
   • Instruct patient to check stool for passage of the object

3. Indications for Intervention:

   • Endoscopic removal is indicated if:
     • The burr is large (>2 cm), sharp, or irregularly shaped 3, 2
     • The object becomes lodged (fails to progress on serial imaging)
     • Patient develops symptoms (abdominal pain, vomiting, signs of obstruction or perforation)
   • Surgical intervention is required if:
     • Signs of perforation, obstruction, or peritonitis develop
     • The object fails to progress after 7 days 2
     • Endoscopic removal is unsuccessful

Warning Signs Requiring Immediate Attention

Instruct patients to seek immediate medical attention if they experience:

• Severe or persistent abdominal pain
• Vomiting
• Fever
• Signs of gastrointestinal bleeding (melena, hematochezia)
• Inability to pass stool or gas

Prevention Strategies for Future Procedures

1. Use of Protective Barriers:

   • Implement throat packs or rubber dams during dental procedures 1
   • Use gauze barriers to isolate the oropharynx from the oral cavity

2. Equipment Safety Measures:

   • Regularly check integrity of dental instruments
   • Confirm secure connection of burrs to handpieces before use 1
   • Consider attaching floss to small instruments when working in posterior regions

Key Considerations

• Most ingested dental objects pass through the digestive tract without complications
• The most serious potential complication is bowel perforation, particularly with sharp objects
• Conservative management with serial imaging is appropriate for most cases, but close monitoring is essential
• Prompt referral for endoscopic removal is necessary for objects that are large, sharp, or cause symptoms

By following this protocol, dental practitioners can effectively manage the rare but serious event of dental burr ingestion while minimizing potential complications and ensuring patient safety.