Background - In previous issues of Malpractice Minute, information about malpractice cases resulting from a dentist's cognitive or judgmental error, failures within the dental care delivery process, and other unusual circumstances have been presented. Although much can be learned from those cases, the focus of this issue is a source of patient injury occurring with increasing frequency: injuries resulting from the swallowing or aspiration of foreign material. 

Case Discussion - Dr. J, a recent graduate from a general practice residency, landed her first position in a large, multilocation practice in her home city. On the date in question, she saw a patient scheduled for four uncomplicated restorations. After she obtained and reviewed the patient’s history and physical information and received appropriate informed consent to treat, she started the procedure. Shortly after entering the patient's oral cavity, the burr dislodged from the handpiece, struck the back of the patient's mouth, and the patient aspirated it.  

The patient was having some respiratory distress, so the office contacted emergency medical services (EMS). An ambulance transported the patient to a local hospital. An X-ray indicated the burr was in the base of the lung. An otolaryngologist was unsuccessful in reaching the burr endoscopically; ultimately, a thoracic surgeon removed it.

A malpractice action was brought against Dr. J and the practice alleging negligent equipment maintenance. Because the case was determined to be indefensible, it was settled with a midrange payment on behalf of both defendants. As required by law, the payment was reported to the National Practitioner Data Bank and the state Board of Dentistry in Dr. J's name.

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Risk Management Considerations
Mario Catalano, DDS, MAGD
Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM

The swallowing or aspiration of foreign material can potentially result in significant injury. In some instances, the foreign material can be a piece of tooth, a small piece of orthodontic wire, or a whole crown. Often, little can be done to prevent the adverse outcome. In this case, the adverse outcome — the separation of a burr (or part of a burr) from the handpiece — could largely be prevented.  

Generally, when a separation occurs, one or two causative factors can be identified.  First, the handpiece or burr can be defective in some way (or they do not interface properly), so when the handpiece is operated, the burr separates from it. Second, in some cases the burr remains attached to the handpiece, but a portion of the burr breaks loose. These cases occur most often when single-use burrs are reused.

When a separation occurs, the burr can only land in one of four places: (1) outside the oral cavity (which can cause its own problems, but is not common); (2) in the soft tissue of the oral cavity where the burr can imbed (a dentist may be able to retrieve it, but if unsuccessful, an oral and maxillofacial surgeon or an otolaryngologist may need to do so); (3) in the digestive tract (after swallowing); and (4) in the lungs (after aspirating). 

If the burr is swallowed, it must be evaluated whether the burr is likely to pass through the entire digestive tract and cause any damage, such as imbedding in or tearing any portion thereof. If there is not reasonable confidence that it will pass, it is necessary to try to remove it endoscopically as soon as possible. If the burr travels to the small bowel, it can no longer be scopically retrieved, and surgical removal will be necessary if it does not pass.

However, if the burr is aspirated, it cannot be expected to pass, and therefore it must be retrieved. If it is lodged in the upper portion of the lung, it can often be retrieved endoscopically; however, if it travels deeper into the lung, surgery is usually the only option.

If a separation does occur, the dental procedure should be immediately aborted. If the separated piece cannot be immediately located, the patient must be carefully evaluated.  If the patient is suffering any respiratory distress, assume an aspiration has occurred and contact EMS to transport the patient to the hospital. 

If no respiratory distress is evident, verify the location of the piece. The patient can proceed to an emergency department or urgent care center for a chest X-ray because ambulance transport is likely unnecessary. Unless the cause of the separation is clearly identified, the handpiece should not be used until a technician can evaluate it and clear it for further use.   

Dentists can take these steps to minimize separation: 

• Ensure that the burrs and handpieces are compatible. 
• Follow the manufacturer’s recommendations exactly.
• Do not reuse single-use burrs. 
• Verify that the burr is securely seated before entering the oral cavity with the prepared handpiece. Be sure to operate the handpiece for a few moments to ensure that it is secure. 
• Use high velocity suction. 
• Use a dental dam if possible (potential for swallowing or aspiration is significantly reduced).

Conclusion - Dentistry will never be risk free, but anticipating the potential for patient injury and taking reasonable steps to minimize it will help dentists practice with confidence and the satisfaction that patient safety is their priority.    

Question - What other potentials for patient injury exist from using dental equipment, and what steps can be taken to minimize the risk of injury?