Management of implant screwdriver ingestion: reflection and guidance for the GDP placing implants

Background

A 91-year-old lady was diagnosed with T4N0M0 squamous cell carcinoma (SCC) of the left buccal mucosa with mandibular involvement. This was treated surgically in October 2018 with a left segmental mandibulectomy, neck dissection and fibula free flap. She was then referred to the restorative dentistry team for oral rehabilitation to improve her quality of life in relation to nutrition and digestive problems.

The initial plan was to provide upper and lower dentures; however, despite several attempts, it was not possible to construct a satisfactory lower denture owing to extensive mandibular atrophy/surgical resection.⁴ A joint decision was then made between the patient, family, restorative and maxillofacial teams to make an implant-supported shortened dental arch bridge.

Once the implants had been placed osseo-integration achieved, the implants were uncovered (Figures 1–4). During removal of the LL4 region healing abutment, the patient made a brisk movement of her head and the implant screwdriver slipped and fell behind a protective gauze. The procedure was immediately aborted, and the patient was leaned forward and encouraged to cough. She felt she had ingested the driver and there were no signs of aspiration/airway compromise. The patient was urgently referred to radiology for chest and abdominal radiographs (Figures 5–7).

A DATIX report was made to register the clinical incident. Furthermore, the gastroenterology (GI) team was contacted and we were advised that a series of abdominal radiographs should be taken to track the implant driver. Regular follow-ups were undertaken, and the patient was asked to look out for signs of obstruction, including constipation, bleeding or pain. The GI team advised that a a non-invasive monitoring approach be undertaken with a view to avoiding surgical intervention. Two weeks later another abdominal radiograph was taken when it was demonstrated that the driver had been excreted uneventfully (Figure 7).

Reflection and guidance

A review and analysis of 617 cases published in Head and Face Medicine reported that the number of ingestion/inhalation incidents has increased greatly since the new millennium. This is in line with an increasing demand for higher risk procedures such as prosthodontics, endodontics, implantology and orthodontics. Furthermore, the over 60-year-old population, who has the greatest demand for complex procedures, is known to be at significantly greater risk of aspiration when compared to other age groups.⁵

Case selection can be important to mitigate risks. Some patient groups known to be at greater risk include the very young, older people, those who are overweight, or have learning disabilities or dementia, and medically compromised patients. Environmental factors can also play a role, and use of sedation, inadequate high-volume suction, inadequate lighting and a supine position can be considerations.⁶

In light of the experience in our department, we developed a new protocol to help prevent accidental aspiration or swallowing of instruments during implant procedures (Table 1).

The role of human error in surgical incidents is often multifactorial and includes both organizational issues and human factors. Contributing factors can include stress, fatigue, emotional state, hunger, and situational awareness. New digital technologies, such as intra-oral scanners, can be used to simplify workflows and potentially reduce human error. ^7,8,9,10 From an organizational point of view, efforts should be undertaken to streamline processes and reduce risk of error.¹¹ The Swiss cheese model (Figure 8) illustrates how several adverse events can culminate in patient harm.¹²

Timely referral to appropriate medical specialties can greatly improve outcomes (Figure 9). Early complications can include acute airway obstruction, pneumonia, mucosal abrasions, bleeding, gastric outlet obstruction, and perforation. Chronic complications can include mediastinitis, peritonitis, abscess or fistula formation.¹

If a foreign body is ingested, certain predisposing conditions can increase the risk of obstruction, perforation, haemorrhage or fistual formation (Table 2). Once referred appropriately, the hospital surgical teams may organize radiographic imaging to identify, locate and determine the size and shape of ingested foreign bodies. Most objects pass uneventfully in 4–6 days, but some may take up to 4 weeks and should be monitored with regular weekly radiographs. In cases where removal is indicated, this is usually completed within 24 hours to decrease the risk of perforation. This can be achieved via endoscopic removal (with forceps or retrieval net) or surgery.¹³Table 3 outlines the general timings for endoscopy. Consideration must also be given to patient factors such as age, complexity, comorbidities, and performance status.

Conclusion

The literature shows that the incidence of foreign-body aspiration/ingestion in the dental environment is increasing. Good case selection and a streamlined working environment can help to mitigate these risks. The lessons that have been learned from this incident and reflected upon are the importance of engaging the nursing staff in complex treatments, treating patients in an upright seating position, using floss to ligate implant drivers, counting screws/drivers before and after the procedures, high volume/surgical suction should always be available, same-day escalation/reporting, and the importance of prompt referral to the correct emergency and long-term team. Timely management can improve outcomes and decrease severity of potential complications.