Association of orthodontic treatment and aspiration pneumonia

INTRODUCTION

Orthodontic treatments are a common occurrence in dental practice and are a key reason patients seek dental care. However, complications during routine dental procedures, such as swallowing or aspiration of foreign bodies, can occur. Although both children and adults tend to aspirate foreign bodies, aspiration in dentistry is reported to be higher in the adult population. Accidental ingestion of orthodontic products occurs between 3.6% and 27.7% of the time; of those, 2% to 3.7% require immediate medical attention because foreign bodies clog the digestive or respiratory tract and cause consequences that could be fatal.¹ Most of the aspirated material passes through the gastrointestinal tract without any problems, while 10-20% require endoscopic removal and 1% require surgical removal.^2-4

In older adults, most pneumonia cases are caused by aspiration, which is termed "aspiration pneumonia," which is a function-based category of pneumonia. In the older population, aspiration pneumonia is a significant source of morbidity and mortality. Moreover, 30% of those who die of pneumonia are diagnosed with aspiration pneumonia. Many case reports have emphasized the incidence of foreign bodies during dental treatment and its fatal complications, such as pneumonia and other respiratory complications. The type of appliance aspirated or ingested depends on the stage of the orthodontic treatment. The most commonly reported aspirated orthodontic materials are orthodontic brackets, wire fragments, transplant arches, molar bands, activation keys, frayed twin blocks, removable retention appliances, and lingual retainers.^5-9 However, the incidence of broken orthodontic appliances or components constitutes the vast majority.⁸

Even if the orthodontic treatment enhances the quality of life, it may harm oral hygiene since orthodontic appliances frequently collect food particles and plaque and are difficult to clean.¹⁰ Maintaining good oral health requires adherence to oral hygiene routines, especially during orthodontic treatment. Poor oral hygiene can lead to permanent damage to dental tissues, ranging from white spot lesions to dental caries and periodontitis. These elements contribute to aspiration pneumonia in older people.¹¹

DISCUSSION

Accidental aspiration of foreign bodies in orthodontic dentistry

Iatrogenic accidents during routine clinical procedures are unpredictable and can occur sometimes regardless of all the possible precautions taken, although they can occur after the completion of dental treatment. Foreign body aspiration is a well-recognized complication of routine dental care such as orthodontic treatment and endodontic procedures. A wide variety of aspirated foreign bodies have been reported in dentistry from teeth, fixed orthodontic materials, restorative materials, and instruments. Patient groups that are at increased risk of aspiration include the elderly, complete denture wearers, sedated patients, patients with organic brain diseases such as Parkinson's, and those with neurological disabilities.¹² These patients may have a decreased gag reflex, functional swallowing impairment, or other abnormalities of the protective airway mechanism. Karmani et al reported that patients who are more prone to the ingestion of orthodontic appliances are those suffering from intellectual disability, epileptic seizures, hyperkinetic disorder, an intense vomit reflex, and panic attacks.⁹ Furthermore, a patient lying in the supine position increases the risk of aspiration during dental treatment.¹³ In a 10-year institutional review study, Tiwana et al observed that among all dental specialties, fixed prosthodontic treatment had the highest frequency of negative outcomes, followed by orthodontic treatment.¹⁴ A systematic review of 113 case studies by Sonwane et al revealed that 80% of accidentally ingested orthodontic appliances passed eventually through the gastrointestinal system.¹ The reported aspirated orthodontic appliances are the expansion key, archwire and archwire segments, fixed orthodontic brackets, removable appliances, retainer, twin block, orthodontic band material and molar bands and mini screws.^4-21 Some accidents happen in the dental clinic due to the operator's carelessness, while others happen outside the clinic. In a systematic review, 617 cases reported by 45 articles showed that aspirated and ingested dental material cases were more common in older patients.²² Male patients suffered more than female patients. And the cases were more frequently seen in this fine, time-consuming, and cumbersome procedure. Compared to endodontic materials, aspiration or ingestion of orthodontic appliances is less common and depends on the kind of appliance. However, regardless of shape, size, or even length, any foreign object can be aspirated or ingested.²² Orthodontic appliances are usually small and difficult to use, especially when covered with saliva. The risk of objects falling back into the oropharynx and being ingested or aspirated is higher when the patient is in the supine position, and it gets worse if you break the appliance.²³

Most of the accidentally aspirated foreign orthodontic particles entering the oropharynx will pass through the alimentary canal uneventfully. While the presence of a foreign body in the airway can be life-threatening in some cases and necessitates immediate intervention (< 4%).¹ A complete obstruction caused by a foreign body in the larynx may necessitate life-saving first aid and the Heimlich maneuver. According to a previous study, inhaled dental instruments and dental items required statistically more frequent hospitalization than ingested items.²⁴ Patients are susceptible to this complication, mainly due to the manufacturing limitations of orthodontic materials such as their shape and size, which are smaller and made up of radiolucent materials, which make them easy to swallow and difficult to detect with radiographs. The presence of saliva, difficulty in approaching posterior teeth due to positioning, difficulty with direct vision, and the patient's age can all worsen the risk for aspiration or swallowing.

Despite rare occurrences, endodontic instruments could be ingested or inhaled during the procedure and cause some dangerous secondary complications. Some dental materials are sharp, and therefore, there is a high risk of perforation.⁸ With the increasing risk of morbidity, the expenses of specialty care, and the potential liability for negligence and malpractice, which are too high to be ignored, early recognition and diagnosis are the keys to preventing serious consequences. Any delay in the proper management or timely intervention of such accidents may cause severe sequelae and can be lethal. The symptoms of aspirating a foreign body after dental treatment vary depending on where the object becomes impacted. If it gets stuck above the vocal cords, it could cause acute respiratory discomfort. while dental material of small size typically passes through the cords.²⁵ Dyspnea, coughing, and stridor are the earliest problems of laryngotracheal foreign bodies; coughing, limited air entry, dyspnea, and wheezing are the initial complications of bronchial foreign bodies.²⁶ Depending on whether the obstruction is partial or full, hoarseness will accompany obstruction of the larynx or trachea, either with or without cyanosis.²⁷ Small foreign bodies may not have any immediate impact and go unnoticed until later when secondary symptoms like pneumonia appear.²⁸ Long-term retention of a foreign body in the lung can result in pneumonia, pneumothorax, paralysis of the vocal cords, and even death.¹² Prior case reports produced evidence of recurrent pneumonia due to aspirated dental restorative material, implants, and prostheses.^13,29,30 When a patient has a history of asthma or when the history of inhalation is unclear, aspiration symptoms may also be disregarded. On the other hand, less commonly encountered chronic diseases such as COPD, asthma, pneumonia, and even tumors might mimic the signs of incorrectly identified foreign bodies when the initial event goes unnoticed, especially in elderly patients or patients with altered mental status.^31-34

When the diagnosis is not established immediately, retained foreign bodies may lead to recurrent pneumonia and other lung complications such as bronchiectasis, recurrent hemoptysis, pneumothorax, lung abscesses, and pneumomediastinum. A large systematic review of the adult population reported non-resolving pneumonia (30.6%) as the most observed radiological finding in patients with a history of foreign body inhalation, which includes patients who aspirated dental appliances, dental prostheses, dental crowns, etc.³² Case reports have been published indicating that an unidentified dental treatment foreign body is one of the suspected causes of persistent obstructive pneumonia.^13,35,36 Case reports or epidemiological studies of aspiration pneumonia caused by the inhalation of orthodontic material are not well reported. Even though the probability of misdiagnosis or delayed diagnosis and the development of secondary symptoms due to orthodontic material cannot be omitted due to the possibility of a false positive diagnosis, recurrent pneumonia cases that do not respond to antimicrobial medication should prompt a bronchoscopic test to rule out an obstruction from a foreign body or tumor. Studies have shown that bronchoscopy is superior to radiographs when there is a suspicion that foreign material has been aspirated.³⁷ Late diagnosis of foreign material aspiration due to the aspiration of orthodontic appliances is rarely encountered in the literatur.¹ Even though, based on the case reports and narrative reviews of other dental materials, early detection of aspirated materials is critical for avoiding complications, Unnoticed or unestablished aspiration of dental material is noticed primarily in geriatric patients. In elderly patients, there is a decrease in psychological and neurological function, which puts them in a greater risk group in this regard. The extraction of aspirated foreign bodies should be undertaken as soon as possible to alleviate acute symptoms and prevent long-term complications. Acute obstruction can be life-threatening, and delaying the removal of foreign objects may make a bronchoscopy technically more difficult. When treating patients who are at high risk of aspiration or swallowing, extreme caution should be exercised. In our opinion, orthodontic material inhalation occurs not only during but also after dental treatment. A patient's failure to properly care for an orthodontic appliance can also cause it to become loose, so it's crucial to teach them how to do so and to promptly notify their doctor if anything goes wrong.³⁸

Poor oral hygiene in orthodontic patients and incidence of aspiration pneumonia

It was hypothesized that poor oral hygiene increases the rate of colonization of dental plaque and oral mucosa to cause aspiration pneumonia because aspiration of oropharyngeal flora into the lung is the main pathogenesis of aspiration pneumonia.³⁹ The colonization of dental plaque and oral mucosa represents a reservoir of potential pathogens that can reach the lung.⁴⁰ Even if orthodontic treatment has various recognized benefits like enhancing esthetics, function, and quality of life, orthodontic appliances can cause unwanted complications like enamel demineralization, tooth decay, and gingivitis because of poor oral hygiene. Inadequate pre-treatment oral hygiene and poor oral hygiene during orthodontic treatment led to plaque retention, which can lead to increased development of hyperplastic gingivitis and periodontal breakdown.^41,42 Hence, it is a challenging task to maintain acceptable oral hygiene in patients undergoing fixed orthodontics to prevent dental caries and gingival inflammation. Geriatric people are more at risk for aspiration pneumonia because of poor dental hygiene. It is the second most prevalent infection in nursing facilities, where it is highly lethal, accounting for 86.7% of cases of aspiration pneumonia in the older population.⁴³ Further, it has been noted that 71% of elderly patients with pneumonia experience silent aspiration while sleeping, and oral bacteria-induced quiet aspiration is likely to be the primary cause of aspiration pneumonia in older individuals.⁴⁴ Poor oral hygiene can lead to the aspiration of food particles, fluids, and saliva that are infected with bacteria, which can result in potentially fatal complications like pneumonia. As dental health deteriorates, oral activity's bacterial load rises, and bacteria-filled oropharyngeal material inhaled into the lungs raises the risk of aspiration pneumonia.⁴⁵

Academic disciplines have recognized the importance of oral care in preventing aspiration pneumonia. A cohort study from Korea showed that the risk of pneumonia was higher in groups with a higher number of dental caries and missing teeth.⁴⁶ In contrast, the risk of pneumonia was lower in the frequent tooth brushing group and the regular professional dental cleaning group. Which indicated that improved oral health may reduce the risk of pneumonia.

According to a recent study, patients with pneumonia who have poor dental hygiene have more obligatory anaerobes in their lungs.⁴⁷ Due to an older adult’s weakened immune system, when oral bacteria in the saliva enter the bronchi and lungs, it is more likely to result in pneumonia. Moreover, periodontal pathogenic bacteria can enter the lung through aspiration in high-risk patients, resulting in pneumonia. Several observational studies found a link between poor periodontal health and an increased risk of nosocomial pneumonia and respiratory disease.^48,49 Terpenning et al found evidence that the presence of periodontal bacteria is an important risk factor for aspiration pneumonia.⁵⁰ Also, studies have proven that an increased number of teeth with active periodontal infections increases the risk of complications from aspiration pneumonia as well as being an independent predictor of mortality due to pneumonia.⁵¹ The risk of aspiration pneumonia is increased when periodontal disease, dental caries, and poor oral hygiene are compounded by swallowing disease, feeding problems, and poor functional status, mostly in geriatric patients.⁵²

The oral cavities of patients who contract aspiration pneumonia have characteristics such as mucous membranes, soft tissue, teeth, and oral function, which involves retaining moisture in the oral cavity and cleaning the lingual surfaces and palate.⁵³ By mechanically cleaning the oral cavity, aspiration pneumonia risk can be diminished.⁵³ The possibility of aspirating orthodontic dental material during treatment is rare, as this research has discussed, and a delayed diagnosis can result in recurring pneumonia and other severe complications. The general public, especially the elderly, may be at risk for micro aspiration pneumonia as a result of conventional orthodontic treatment and concomitantly poor oral hygiene.

CONCLUSION

The association between the aspiration of orthodontic material and aspiration pneumonia is not well established. Aspiration pneumonia is a secondary symptom of misdiagnosis or delayed diagnosis of dental material aspiration. It may increase the risk of recurrent pneumonia. Hence, general dentists and orthodontists must provide precautionary measures to prevent foreign body aspiration to avoid complications. Additionally, poor oral hygiene can also increase the risk of aspiration pneumonia in elderly patients since poor oral hygiene during orthodontic treatment leads to plaque retention, which can lead to increased development of hyperplastic gingivitis and periodontal breakdown, an established risk factor for aspiration pneumonia.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Sonwane ds, Kamble S. Effects of Accidental Swallowing of Orthodontic Appliance on Gastrointestinal Tract and Airway: An Evidence-Based Review of Case Reports. J Ind Orthodontic Society. 2022;56:13-22.
2. 2. Parkhouse RC. Medical Complications in Orthodontics. Brit J Orthodontics. 1991;18(1):51-7.
3. 3. Lee BW. Case report-swallowed piece of archwire. Australian Orthodontic J. 1992;12(3):169-70.
4. 4. Absi EG, Buckley JG. The location and tracking of swallowed dental appliances: the role of radiology. Dento Maxillo Facial Radiol. 1995;24(2):139-42.
5. 5. Rohida NS, Bhad WA. Accidental ingestion of a fractured Twin-block appliance. Am J Orthodontics Dentofacial Orthopedics. 2011;139(1):123-5.
6. 6. Monini Ada C, Maia LG, Jacob HB, Gandini LG, Jr. Accidental swallowing of orthodontic expansion appliance key. Am J Orthodontics Dentofacial Orthoped. 2011;140(2):266-8.
7. 7. Umesan UK, Ahmad W, Balakrishnan P. Laryngeal impaction of an archwire segment after accidental ingestion during orthodontic adjustment. Am J Orthodontics Dentofacial Orthopedics. 2012;142(2):264-8.
8. 8. Naragond A, Kenganal S, Rajasigamani K, Kumar NS. Accidental ingestion of molar band and its management: maintenance is better than management. Case Rep Dentistr. 2013;2013:891304.
9. 9. Karamani, II, Makrygiannakis MA, Bitsanis I, Tsolakis AI. Ingestion of orthodontic appliances: A literature review. J Orthodontic Sci. 2022;11:20.
10. 10. Arici S, Alkan A, Arici N. Comparison of different toothbrushing protocols in poor-toothbrushing orthodontic patients. Europ J Orthodont. 2007;29(5):488-92.
11. 11. Zaghrisson BU, Zachrisson S. Caries incidence and oral hygiene during orthodontic treatment. Europ J Oral Sci. 1971;79(4):394-401.
12. 12. Zitzmann NU, Elsasser S, Fried R, Marinello CP. Foreign body ingestion and aspiration. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 1999;88(6):657-60.
13. 13. Mann R, Srinivasan B, Baker A. Managing aspiration. Brit Dental J. 2012;212(10):464-465.
14. 14. Tiwana KK MT, Tiwana PS. Aspiration and ingestion in dental practice: A 10-year institutional review. J Am Dental Asso. 2004:135(139):1287-91.
15. 15. Nazif MM, Ready MA. Accidental swallowing of orthodontic expansion appliance keys: report of two cases. ASDC J Dentistry Children. 1983;50(2):126-7.
16. 16. Tripathi T, Rai P, Singh H. Foreign body ingestion of orthodontic origin. Am J Orthodontics Dentofacial Orthoped. 2011;139(2):279-83.
17. 17. Nicolas R, Eggers G, Komposch G. Orthodontic archwire in the nasal cavity. A case report. J Orofacial Orthoped. 2009;70(1):92-7.
18. 18. Sheridan A. Orthodontic bracket lost in airway. Am J Orthodontics Dentofacial Orthoped. 2009;135(1):5.
19. 19. Park JH, Owtad P, Milde B. Incident management guidelines for an ingested orthodontic object. Int J Orthodontics (Milwaukee, Wis). 2013;24(3):45-9.
20. 20. Mahto RK, Rana SS, Kharbanda OP. Accidental Swallowing of a Molar Band. Turk J Orthodontics. 2019;32(2):115-8.
21. 21. V. NVPSM. Oops! There goes my minis-crew! APOS Trends Orthod. 2016;6:277-80.
22. 22. Hou R, Zhou H, Hu K. Thorough documentation of the accidental aspiration and ingestion of foreign objects during dental procedure is necessary: review and analysis of 617 cases. Head Face Med. 2016;12(1):23.
23. 23. Hoseini M, Mostafavi SM, Rezaei N, Boluri EJ. Orthodontic Wire Ingestion during Treatment: Reporting a Case and Review the Management of Foreign Body Ingestion or Aspiration (Emergencies). Case Rep Dentistr. 2013;2013:426591.
24. 24. Susini G, Pommel L, Camps J. Accidental ingestion and aspiration of root canal instruments and other dental foreign bodies in a French population. Int Endodontic J. 2007;40(8):585-9.
25. 25. Israel HA, Leban SG. Aspiration of an endodontic instrument. J Endodontics. 1984;10(9):452-4.
26. 26. Blazer S, Naveh Y, Friedman A. Foreign body in the airway. A review of 200 cases. Am J Dis Children (1960). 1980;134(1):68-71.
27. 27. Von Haacke NP, Wilson JA. Missing denture as a cause of recurrent laryngeal nerve palsy. Brit Med J. 1986;292(6521):664.
28. 28. Umesan UK, Chua KL, Balakrishnan P. Prevention and management of accidental foreign body ingestion and aspiration in orthodontic practice. Therapeutics Clin Risk Management. 2012;8:245-52.
29. 29. Lakadamyalı H, Yağbasan BD, Kıvanç T. Interactive case report: Recurrent Pneumonia Caused by The Aspiration of a Quad Dental Prosthesis, Late Diagnosed and Treated with Rigid Bronchoscopy. Respiratory Case Rep. 2016;5(1):22-4.
30. 30. Welcker K, Nakashima M, Branscheid D. Aspiration of dental implant-reasons, management and prevention. Pneumologie (Stuttgart, Germany). 2005;59(3):174-7.
31. 31. Yurdakul AS, Kanbay A, Kurul C, Yorgancılar D, Demircan S, Ekim N. An occult foreign body aspiration with bronchial anomaly mimicking asthma and pneumonia. Dental Traumatol. 2007;23(6):368-70.
32. 32. Sehgal IS, Dhooria S, Ram B. Foreign Body Inhalation in the Adult Population: Experience of 25,998 Bronchoscopies and Systematic Review of the Literature. Respiratory Care. 2015;60(10):1438-48.
33. 33. Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest. 1999;115(5):1357-62.
34. 34. Lin L, Lv L, Wang Y, Zha X, Tang F, Liu X. The clinical features of foreign body aspiration into the lower airway in geriatric patients. Clin Interventions Aging. 2014;9:1613-8.
35. 35. Kshatriya RM, Khara NV, Paliwal RP, Patel SN. Role of virtual and flexible bronchoscopy in the management of a case of unnoticed foreign body aspiration presented as nonresolving pneumonia in an adult female. Lung India. 2016;33(4):420-3.
36. 36. Welcker K, Nakashima M, Branscheid D. [Aspiration of dental implant-reasons, management and prevention]. Pneumologie (Stuttgart, Germany). 2005;59(3):174-7.
37. 37. Hewlett JC, Rickman OB, Lentz RJ, Prakash UB, Maldonado F. Foreign body aspiration in adult airways: therapeutic approach. J Thoracic Dis. 2017;9(9):3398-409.
38. 38. Naragond A, Kenganal S, Rajasigamani K, Kumar NS. Accidental Ingestion of Molar Band and Its Management: Maintenance Is Better than Management. Case Rep Dentistr. 2013;2013:891304.
39. 39. Verghese A, Berk SL. Bacterial pneumonia in the elderly. Medicine. 1983;62(5):271-85.
40. 40. Scannapieco FA, Mylotte JM. Relationships between periodontal disease and bacterial pneumonia. J Periodontol. 1996;67(10):1114-22.
41. 41. Lundström F, Krasse B. Caries incidence in orthodontic patients with high levels of Streptococcus mutans. Europ J Orthodontics. 1987;9(2):117-21.
42. 42. Zachrisson BU, Zachrisson S. Caries incidence and oral hygiene during orthodontic treatment. Scand J Dental Res. 1971;79(6):394-401.
43. 43. Uno I, Kubo T. Risk Factors for Aspiration Pneumonia among Elderly Patients in a Community-Based Integrated Care Unit: A Retrospective Cohort Study. Geriatrics (Basel, Switzerland). 2021;6(4).
44. 44. Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respiratory Crit Care Med. 1994;150(1):251-3.
45. 45. Pusins JM. Oral Health and Aspiration Pneumonia. Today's Geriatric Med. 2015;11(6):16.
46. 46. Son M, Jo S, Lee JS, Lee DH. Association between oral health and incidence of pneumonia: a population-based cohort study from Korea. Scientific Rep. 2020;10(1):9576.
47. 47. Hata R, Noguchi S, Kawanami T. Poor oral hygiene is associated with the detection of obligate anaerobes in pneumonia. J Periodontol. 2020;91(1):65-73.
48. 48. El Attar MM, Zaghloup MZ, Elmenoufr HS. Role of periodontitis in hospital-acquired pneumonia. Eastern Mediterranean Heal J. 2010;16(5):563-9.
49. 49. Sharma N, Shamsuddin H. Association between respiratory disease in hospitalized patients and periodontal disease: a cross-sectional study. J Periodontol. 2011;82(8):1155-60.
50. 50. Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominguez BL, Loesche WJ. Aspiration Pneumonia: Dental and Oral Risk Factors in an Older Veteran Population. J Am Geriatr Soc. 2001;49(5):557-63.
51. 51. Awano S, Ansai T, Takata Y. Oral health and mortality risk from pneumonia in the elderly. J Dental Res. 2008;87(4):334-9.
52. 52. Terpenning M. Geriatric oral health and pneumonia risk. Clin Infect Dis. 2005;40(12):1807-10.
53. 53. U Koichiro. Preventing aspiration pneumonia by oral health care. JMAJ. 2011;54(1):39-43.