Systematic Reviews/Meta-Analysis

Effects of Accidental Swallowing of Orthodontic Journal of Indian Orthodontic Society

56(1) 13­–22, 2022
Appliance on Gastrointestinal Tract and Airway: © The Author(s) 2022
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https://doi.org/10.1177/03015742221075863
DOI: 10.1177/03015742221075863
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Siddharth Sonwane1 and Shweta R. Kamble2

Abstract
Background: Contemporarily, the use of innovative orthodontic appliances or their components has increased for safer,
quicker results, and more comfort of the patient. But, researchers rarely highlight the potential demerits of accidental
ingestion of these appliances. Thus, the present study aimed to investigate the evidence-based literature on the accidental
swallowing of these appliances and their effect on the gastrointestinal tract (GIT) and airway.
Method: An electronic search was performed on PubMed, Medline, Scopus, The Cochrane Library, and EMBASE until April
11, 2021. Methodological quality and synthesis of case series and case report tool (MQCC) was applied to determine the
quality of these case reports and series. The outcome variable was to assess its effect on airway and GIT, and methods of
removal of these foreign bodies. Meta-analysis was not performed as the study included case reports and case series in which
no control groups were present.
Results: Out of 113 case reports and series, 29 articles were included in this systematic review. Only 31% of articles have
satisfied the MQCC scale and maintained as high-quality case reports, 43% of articles were medium to high quality, and 26%
designated as low quality.
Conclusions: Eighty percent of the accidental ingested orthodontic appliances that pass uneventfully through the
gastrointestinal system require a fiber-rich diet and laxatives. A total of 10% to 20% lacerates oral, pharyngeal, and
gastrointestinal mucosa result in pain, bleeding requires laryngoscope, endoscopically and laparoscopy with use of Magill’s
forceps. Only 1% of cases have presented with a high morbidity and mortality alarming for surgical removal of ingested
component. Thus, the precautions to be taken to overcome such incidences are tying silk thread to activation key, use
of recent bonding method, use of contrast colors of removable appliances as the color merges with mucosal color, and
operator position should be 7 O′ clock.

Keywords
Accidental swallow, orthodontic appliances, archwire, mini-screw

Received: 28 May 2021; Revised: 30 December 2021; Accepted: 06 January 2022

Introduction Kurkciyan et al (1996)7, Pavlidis et al (2008)8, and

Accidental ingestion of foreign body is more often seen in
children and around 1,500 people die each year due to this.1
Incidence of foreign body aspiration occurs in children
(80%), elderly, mentally impaired, or alcoholic individuals
and sometimes it may occur deliberately in prisoners or
psychiatric patients.2-4
Commonly aspirated foreign objects are coins, meat boli,
Dhandapani et al (2009)9 have reported that the accidental
swallowing of dental materials and other armamentarium or
materials their product used in various dental proce­
dures.7-9,10-14 The most often accidentally swallowed dental
1 Department of Orthodontics, People’s College of Dental Sciences and
Hospital, Bhopal Madhya Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Government Dental

and button batteries; sewing needles, tooth picks, straightened College, Nagpur, Maharashtra, India
paper clips, and razor blades; and dental objects. In most of
Corresponding author:
the situations, these objects pass through the gastrointestinal Siddharth Sonwane, 38A, Galli no 1, Fulmathi Layout, Beltarodi Road,
tract (GIT) uneventfully, but 10% to 20% required endoscopic Nagpur, Maharashtra, India.
removal and 1% alarm for surgical removal.4-6 E-mail: Siddharth5678@gmail.com

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14 Journal of Indian Orthodontic Society 56(1)
objects are the broken fragments of burs, posts, root pieces,
teeth, impression materials, implant components, and
restorations. Overall incidence of dental foreign body
aspiration is 3.6% to 227.7% and higher in adult than in
children.15-19 In prosthodontics, single crowns and loose
dentures are more prone to swallowing in endodontics
broaches and files, and also fragments of implants and other
dental restorative materials are frequently swallowed.
Rohida and Bhad et al, Umesan et al, and Naragond et al
have reported that during routine orthodontic treatment,
chance of accidental aspiration of various orthodontic
materials like bracket, wire fragment, activation key and
fractured twin block, removable retention appliances and
lingual retainers. However, these incidents are being managed
successfully without medical emergency.18-23
The major manufacturing limitations of dental and
orthodontic materials are their shape and size, smaller and
made up of radiolucent materials, which make them easy to
swallow and difficult to detect with radiographs. Hence, it
alarms to use bronchoscopy/endoscopy or computed
tomography for its localization.1-17,23,25-27 Although only
2% to 3.7% require emergency treatment as these foreign
bodies obstruct GIT or respiratory tract, and the rest of the
material pass GIT without complications.28
This systematic review aimed to investigate the most
frequent ingesting of the foreign body during orthodontic
treatment, associated complications, and management from
available evidence like case reports and case series.
The objective of this systematic review is to collect,
compile, and review the data available on accidental ingestion
of orthodontic materials during treatment from various
published case reports and case series.
Focused question: What are the effects of accidentally
swallowing an orthodontic appliance or part of a fixed
orthodontic appliance to the airway and gastrointestinal tract?
Materials and Methods
This systematic review was conducted in agreement with the
statement of Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA). The study has not
been registered.
Eligibility Criteria
The inclusion and exclusion criteria were established
according to the (population, intervention, control, and
outcomes) PICO question reported above.
The included studies were case series and case reports
published in English and regarding the accidental swallowing
of orthodontic materials, associated complications, and their
management. Also searched articles published in medical
journals entitling on accidental swallow of dental or
orthodontic materials.
Exclusion criteria: case reports, case series, and studies
with orthodontic treatment in autism, Pica syndrome,
geophagia, and subject with mouthing habit.
Information Sources
An electronic investigation was performed using PubMed,
Medline, Scopus, PsycINFO, SciSearch, The Cochrane
Library, EMBASE, HINARI, and EBSCO. The search was
conducted until April 11, 2021. No restrictions were applied
in time or language.
Search Strategy
The search was performed using recent developed protocol
for systematic reviews of case reports and case studies for the
year 2021 on the advanced PubMed search tool with a
combination of the following keywords, MeSH (Medical
Subject Heading), nonindexed terms and the corresponding
Boolean operators: (((((((((growing) OR adolescent) OR
adult)) OR (((growing[MeSH Terms]) OR adolescent[MeSH
Terms]) OR adult[MeSH Terms])) OR (((growing[Text
Word]) OR adolescent[Text Word]) OR adult[Text Word])))
OR ((("accidental swallow") OR "incidental engulf") OR
"unintentional aspiration"))) OR (((((((((("orthodontic
appliance")[MeSH Terms] OR "orthodontic expender")
[MeSH Terms] OR "orthodontic expansion key")[MeSH
Terms] OR "orthodontic archwire")[MeSH Terms] OR
"orthodontic fixed bracket")[MeSH Terms] OR "orthodontic
archwire segment")[MeSH Terms] OR "molar bands")[MeSH
Terms] OR "orthodontic removable retainer")[MeSH Terms]
OR "orthodontic fixed retainers"[MeSH Terms])). In each
database, an advanced search was performed with similar
permutation and combination of keywords. The search was
then implemented on the references of the selected articles to
complete missing link in initial search. Corresponding authors
were contacted through e-mails for missing information
(Tables 1 and 2).
Table 1. Primary and Secondary Keywords.
Primary Keywords Secondary Keywords
Accidental swallowing of Sudden swallowing of dental
orthodontic material materials
Aspiration of archwire Swallowing of restorative
materials
Unintentional swallowing Swallowing of implants or
of expansion key its parts
Aspiration of functional
appliances
Accidental ingestion of
orthodontic brackets
Sonwane and Kamble 15

Table 2. Electronic Search Approach for Each Database.

No. of Articles No. of Articles
S. No. Keywords Searched Selected Reason for Exclusions
1 Accidental swallowing of 06 3 Swallowed metal splints
orthodontic material
2 Aspiration of archwire 09 07 Not meeting inclusion
criteria
3 Unintentional swallow- 9 4 Not meeting inclusion
ing of expansion key criteria
4 Aspiration of functional 11 01 Not specific about what
appliances appliance
5 Accidental ingestion of 19 03 Not meeting inclusion
orthodontic brackets criteria
6 Accidental swallow of 23 01 Not meeting inclusion
ligature wire criteria
7 Accidental swallow of 05 03 Not meeting inclusion
expanders criteria
8 Accidental ingestion of 08 02 Cast partial and treatment
removable appliances partial appliances
9 Accidental aspiration 03 01 Not meeting inclusion
retention plate criteria
10 Sudden swallowing of 33 00 Case reports are not
dental materials mentioned orthodontic
material
11 Swallowing of restor- 07 02 Articles were on end-
ative materials odontic materials
12 Swallowing of implants 34 02 Articles were on restor-
or its parts ative implants

Study Selection Table 3. Propagation of the Journals in Which the Articles Are
Published.
The titles and abstracts of the searched articles were based on
No. of
the PICO criteria. Two authors (SS and SR) simultaneously
S. No. Name of the Journal Articles
and independently conducted the search process according to
01 APOS Trends Orthodont 01
the criteria of the PRISMA Protocol in a two-stage. In the
first stage, the primary researcher (SS) analyzed the articles 02 Turkish J Orthodont 01
on titles and abstracts that were potentially eligible studies 03 J Orthodont 03
and full texts were being downloaded from the electronic 04 Dentistry J 01
search. In the second stage, researchers have conducted a 05 Case Rep Dental 02
selection process on downloaded articles according to the
06 Int J Orthod Milwaukee 01
PRISMA Protocol to establish inclusion and exclusion
criteria; duplicate publications were being removed. In case 07 Am J Orthod Dentofac Orthop 11
of any disagreement, a third reviewer has consulted, and 08 J Dent Update 01
unsuitable articles were being removed. The reason for the 09 J Clin Orthod 01
eliminated articles is being mentioned in Table 2. The
10 Otolaryngol Head Neck Surg 01
distribution of the journals in which selected articles were
published is illustrated in Table 3. 11 SADJ 01
12 Br Dent J 02
13 J Dentomaxillofac Orthod 01
Data Collection Process
14 Aust Orthod 01
Evidence obtained from the selected articles were retrieved
15 ASDC J Dent Child 01
and exported to Excel sheet (Microsoft window 2010)
16 Journal of Indian Orthodontic Society 56(1)

organized according to methodological quality and synthesis

of case series and case reports tool (MQCC) under following
4 domains:
1. Subjects
2. Ascertainment
3. Causality
4. Reporting

Quality Assessment
Independent quality assessment of selected case reports
and case series were conducted according to checklist
provided by MQCC28 under 4 domains by 2 reviewers (SS
and SR). Any disagreement between the 2 authors was
discussed and resolved by consensus or arbitration by the
third reviewer (RR).
In this review, methodological quality and MQCC of
Murad et al28 was the modified tool of Bradford Hills and
Newcastle Ottawa scale. In this Newcastle Ottawa scale’s, 8
items have converted into 4 domains: selection, ascertainment,
causality, and reporting. Thus, the quality assessment of the
case reports and series were evaluated assigning “stars”
(Newcastle Ottawa scale). One “star” for an incomplete
detail, two “star” for an acceptable, and three “star” for
complete and alternate ways of accidental swallow. Figure 1. PRISMA flow chart

Result Quality Assessment

Selection of Case Reports and Case Series
The electronic search conducted to identify case reports and
case series depends on the title admissible in the systematic
review. However, a sum of 113 case reports and case series
retrieved from various dental and orthodontic, and medical
emergency journals. A thorough screening was performed and
70 nonorthodontic dental case reports were removed; 43 case
reports were being shortlisted to determine their compliance
with the eligibility, and 14 case reports were excluded. Finally,
29 articles fulfilled the selection criteria and were included for
qualitative analysis of the systematic review.
This comprised 58.7% of the total articles retrieved from
the data search. The present study was conducted and reported
following the PRISMA, the outline of which is illustrated in
Figure 1.
Characteristics of Included Studies
The characteristics of included studies are summarized in
Tables 4a5 to 4c. The number of case reports and case series
that have been published on subjects varies ranging from 2 to
34 with a mean age group ranging from 12 to 18 years. The
data source for the publication of these case reports was from
various hospitals and institutions.
Only 31% of the articles have satisfied the MQCC scale and
maintained as high-quality case reports, 43% of articles were
medium to high quality, and 26% designated as low quality.
Thus, MQCC scale was used to analyze the quality of
published case reports. Methodological evaluations of the
quality of all case reports were assessed using the MQCC
scale. The detailed quality assessment of all the studies is
tabulated in Tables 5a and 5b.
Risk of Bias Assessment
Methodological quality and synthesis of MQCC scale was
applied to determine the quality of these case reports and
series and is illustrated in Tables 5a and 5b.
Nineteen out of 29 were case reports and 10 case series, in
which 74% of case reports have satisfactorily addressed the
method of MQCC and its applicability to be the general
population.
Synthesis of Results
Twenty-nine articles have published the unexpected swallow
of orthodontic materials (archwire, segment of archwire,
Sonwane and Kamble 17

Table 4a. Study Characteristics and Case Report and Case Series Summary.
Immediate Complica- Basic Final
Object Place Symptoms Location tions Treatment Outcome
Nazif and 9 yr/f Activation of Home Vomiting Stomach No signs of Fiber-rich Child’s
Ready2 expansion key bleedings diet excrement
Hinkle3 18/f Retention plate Home Vomiting Esophagus Nil Not seen Laparoscopy
Parkhhouse4 15/m Removable plate Home Breathing Esophagus Medical Life support Surgical
emergency removed
Lee5 15/m Retention wire Fast Stomach Pylorus Bleeding in Soft diet Gastroscope
pain excreta
Absi and 25/m Wire of Home Pain and Upper part Pain Methylcel- Proctoscopy
Buckley6 Transpalatal bar vomiting of iliac fosse lulose, stom-
ach filler
Dibiase et al8 9/f Digit sucking Home Pain, palatal Esophagus Due to Soft diet, an- Without surgi-
appliance laceration , laceration tibiotics, and cal intervention
(habit braking during removal analgesics
appliance)
Milton et al9 14/f Fixed bracket Home Pain, bleed- Abdominal Antibiotics and Fiber-rich came out in
ing excreta region analgesics diet large bowels
Quick and 26/m Coil spring Dental Vomiting Stomach Pain and blood Fiber-rich Gastroscope
Harris10 office spot in excreta diet and
antibiotics
Klein and 15/m Retainer Home Plural chest Chest left Decreased Broad- Rigid bron-
Schoem11 pain side count of WBC spectrum choscopy and
and cough antibiotics removed

Table 4b. Study Characteristics and Case Report and Case Series Summary.
Immediate Complica- Basic Final
Author Age/Sex Object Place Symptoms Location tions Treatment Outcome
Sfondrini12 23/f Broken Fast food Bleed during Upper part Pain
transpalatal speech of GI tract
bar
Abdel-Kader13 26/m Fixed Home Nil Stomach Pain initiated Soft diet, an- Gastroscope
bracket after 13 day tibiotics, and
analgesics
Al-Wahadni 15/f 10 mm NITI Dental office Nil Piriform Pain during Postopera- Endoscopic
et al14 17×25 wire recess food intake tive pyrexia retrieval
Allwork et al15 13/m Quad helix Dental office Bleeding , Lower Visceral Postopera- Mini-laparot-
vomiting esophagus. perforation tive pyrexia omy
Fiho et al16 17/f During Operation Nil Piriform Soft diet, an- Removed MacIntosh
orthognathic theater recess tibiotics, and with Magill laryngoscope
surgery analgesics forceps
Sheridan17 16/f Bracket Dental office Nil Lower Nil Soft diet, an- Gastroscope
esophagus. tibiotics, and
analgesics
Nicolas et al18 17/m 17x25 Santi- Dental office Nasal bleed- Floor at Nasal spray Antibiotics Nasal endos-
lone ing junction Otrivin and analge- copy
sics
Rohida and 12/m Broken twin Home at Pain TMJ Upper part Nil Soft diet, an- Endoscopy
Bhad19 block sleep esophagus. tibiotics, and
analgesics
Tripathi et al20 17/m Hyrax acti- Home Otorhino- hypophar- Otorhino- Magill’s Fiber-optic
vation key laryngology ynx laryngology forceps nasopharyn-
emergency emergency goscope
18 Journal of Indian Orthodontic Society 56(1)

Table 4c. Study Characteristics and Case Report and Case Series Summary.
Immediate Complica- Basic Treat-
Object Place Symptoms Location tions ment Final Outcome
Monini Ada et 9/m Expansion Home Nil Abdominal Nil Fiber food and Excreted after
al21 key drinks 4 days
Umesan et al22 12/f Arch wire Dental Sharp pain Laryngeal Nil Fiber food and Endoscope
17x25 NITI office in throat region drinks
region
Naragond et 16/m Molar band Home Nil Left lower Nil Laxative and Endoscope
al23 chest fiber food with grasper
Park et al24 19/m Arch wire Dental Momentary Piriform Nil Routine food MacIntosh
19x25 NITI office pain recess laryngoscope
Hoseini25 29/m Premolar Home Gastric Lower Pancreatitis Metronidazole, Under sedation
bracket irritations stomach. ceftriaxone, and with midazolam
Pantoprazole
Tiller et al26 37/f Khubyoshki Home Calcification Head of Pancreatitis Metronidazole, Endoscope
wire in pancreatic papillae of ceftriaxone,
pancreas Pantoprazole
Wilmott et al27 19/f Bracket Home A scratch at Lower left Pain unable Five-day course Oral and maxil-
the side of posterior to chew of Amoxicillin lofacial surgeon
throat teeth food removed
Nikhilesh et al29 11/m Mini-screw Dental Nil Not located Nil Observation Observation
office
Mahto30 15/m Molar band Home Nil Neck Region Nil Observation Endoscopy
of esophagus

Table 5a. Methodological Quality and Synthesis of Case Series and Case Report Tool.
Domains
Authors Selection Ascertainment Causality Reporting
1 Nazif and Ready2 * ** * *
2 Nafiz et al (1987) * * * *
3 Parkhhouse4 * ** * *
4 Lee5 * ** * *
5 Absi and Buckley6 * * * *
6 Dibiase et al8 ** ** ** **
7 Milton et al9 * ** * *
8 Quick et al10 ** * ** *
9 Klein and Schoem11 * ** * *
10 Sfondrini12 ** * ** **
11 Abdel-Kader13 * * * **
12 Al-Wahadni et al14 * * * *
13 Allwork et al15 ** ** ** **

Note: *Incomplete detail; **acceptable.

Sonwane and Kamble 19

Table 5b. Methodological Quality and Synthesis of Case Series and Case Report Tool.
Domains
Authors Selection Ascertainment Causality Reporting
1 Fiho et al16 * * ** *
2 Sheridan17 * * * *
3 Nicolas et al18 * * * *
4 Rohida and Bhad19 ** ** ** **
5 Tripathi et al20 * * * *
6 Monini et al21 * * * **
7 Umesan et al22 ** ** ** **
8 Naragond et al23 * * * *
9 Park et al24 * ** * **
10 Hoseini25 * * * **
11 Tiller et al26 * * * *
12 Wilmott et al27 * * * *
13 Nikhilesh et al29 ** ** ** **
14 Mahto et al30 ** ** ** **
Note: *Incomplete detail; **acceptable.

removable appliance, retainer, expanders, expansion key, and
mini-screw). Nine out of 29 articles have been notified on
incidental assimilate of the archwire, segment of archwire,
and ligature wires; and 7 on expanders, and expansion key’s
rest of the articles documented twin block, mini-screw, and
removable appliances.
Discussion
Synthesis of Evidence
Case reports and case series are communicative studies that
are prearranged for demonstrating novel, unusual, or atypical
features recognized in subjects of medical, dental, and
orthodontic practice, and they hypothetically create new
research questions.26,27 Most of the case reports and case
series define and scrutinize the diagnosis and management of
1 or more than 3 patients; also from the base of the evidence-
based pyramid.28
Accidental Swallow of Expansion Key
Nafiz and Ready MA in 1983 have published two case reports
on accidental aspiration of expansion key. This incident took
place in the dental office while the operating subject turned
head and slipped from the operator’s hand; as the patient’s
position was the supine key was swallowed a fiber-rich diet
was advised and after 4th week seen in excreta.2
Tripathi et al19 published a similar case report of the
17-year-old male (cleft lip and palate) patient; the incident
occurred in a dental office as the patient turned up his head
and the expansion key slipped from the operator’s hand.19
This case was managed as a medical emergency, and the key
was removed using “Magril force” with fiber-optic
nasopharyngoscope. An exact case report was published by
Monini Ada et al.20
Archwire and Archwire Segments
Absi and Buckley6 reported that a 25-year-old female had an
accidental swallow of transpalatal bar made up of crescent-
shaped piece of rigid stainless steel wire of 0.9 mm diameter
and approximately 2.5 cm length, with a U-loop at both the
ends. An abdominal radiograph located that wire was in the
upper-right iliac fossa. She was given methylcellulose as bulk
filler, and then it was located passing from small bowel to a
large intestine, then the patient was discharged. Later, the
patient complained of abdominal pain, now the wire was
located at rectal region and removed with proctoscopy.
Nicolas et al17 published a case report of a 17-year-old male
who came with the chief complaints of nasal bleeding and
pain; nasal endoscopy was used to remove the wire fragment.
Umesan et al21 reported a 12-year-old girl’s case report of
accidental ingestion of archwire (17X25 NITI) segment of
20-mm length in dental office during the routine visit. This
incident occurred while cutting a posterior excess archwire
with distal end cutter; wire was located at laryngeal region
and was successfully removed using endoscopy.
Fixed Orthodontic Bracket
Milton et al9 published a case report of a 19-year-old woman
who visited with pain, cough, and scratchy throat. On clinical
examination, premolar bracket was missing, and on the X-ray
20 Journal of Indian Orthodontic Society 56(1)
of the chest and stomach, location of an ingested foreign body
was unidentified. The patient was encouraged with fiber food,
more drinks, and amoxicillin tablets. Later, an
orthopantomograph revealed that dislodge premolar bracket
seen in a posterior second molar area was removed. Fiho et
al15 and Sheridan16 reported that a 17-year-old girl, 32-year-
old boy, and 29-year-old women respectively were the
orthognathic patients post-surgery that found the missing
second molar tube and brackets.
On X-ray, missing appliances were located at the piriform
recess of the larynx, with the help of Macintosh laryngoscope,
and removed using Magill forceps.
Removable Appliance, Retainer, and Twin Block
Park et al23 published a case report of a 15-year-old boy who
was given a tongue crib and was accidentally ingested during
fast food eating. He later complained of stomach pain and
bleeding spots in stools, and it was located at the pylorus
region; managed with gastroscopy. Dibiase et al8 reported an
18-year-old male with an accidental swallow of the removable
plate. The immediate complaint was difficulty in breathing,
and the appliance was at the esophagus region. This case was
alarmed for a medical emergency and surgical removal.
Rohida and Bhad18 circulated a case report of 12-year-old
male with accidental swallow of fracture twin block. The
author reveals that the patient was using repaired piece of
broken twin block, located at the esophagus and removed
using endoscopy.
Orthodontic Band Material and Molar Bands
Naragond et al22 reported through a case report of a 16-year-
old male who accidentally engulfed a molar band during
eating fast food. It was located at the lower-left region of the
chest. No immediate or delayed symptoms were found and by
using endoscopy with grasper, the foreign body was removed.
Mahto et al29 reported a similar incident that occurred in a
16-year-old cleft lip boy and was removed using endoscopy
with a grasper.
Mini-Screw
Nikhilesh et al30 published a case report of 11-year-old male
patient who was getting treated with mini-screw-supported
distalizing appliance. During the routine visit, one of the
mini-screws was loose, and the operator wanted it to remove
and reposition it. While removing, a patient turned his head,
gave a push, and a mini-screw fell in the pharyngeal region.
However, it was not located in the X-ray. The author
concluded that the mini-screw might have expelled.
Management Protocol
The development of signs and symptoms depends upon the
age of the subject (child or an adult), 75% of the case reports
have revealed that the foreign body gets entrapped at the
upper esophageal sphincter, and 30% at a lower level.1-5 The
accidental ingested foreign body follows 4 levels with the
specific sign and symptoms at each level such as, at
oropharyngeal level drooling of saliva, inability to swallow;
at an esophageal level in adults complaining of discomfort at
the center of the chest or epigastric region, dysphagia and
children clinically presents retching, neck, or throat pain,
gagging, vomiting later may develop fever, recurrent
aspiration pneumonitis/pneumonia.10,16,18,22,27,30 Similarly, if
the foreign body entrapped at a suboesophageal level can
present passing rectal blood and melena and few cases
develop subacute intestinal obstruction, and if the appliance
is sharp trapped in a GIT may present gastrointestinal
perforation signs and symptoms as acute mediastinitis, chest
pain, dyspnea, and signs of pneumonitis/pleural
effusion.11,12,13,25 In this situation, the patient should be
calmed and careful examination should be performed; the
location of foreign objects at each level is mandatory. Thus,
abdominal and chest X‑rays, endoscopy, and computed
tomography scans of the thorax and abdomen are advi
sed.12,14,16,20,21,26,29-31
Act quickly, keep the patient’s head low, and instruct to
cough or if a foreign body is visible, remove it with small
forceps or use the Heimlich maneuver method. Based on the
location of the ingested foreign body-appropriate devices
such as MacIntosh laryngoscope with Magill forceps, fiber-
optic nasopharyngoscope is used to remove it.1,3,5,7,21,30
Wasundhara Bhad et al advised that the use of removable
appliances should have contrast color of gastrointestinal (GI)
tract that helps in locating the swallowed part of functional
appliance.18
Recommendations
Most of the accidental aspirated orthodontic foreign particles
entering the oropharynx will pass through the alimentary
canal uneventfully. Only 1% of the large and sharp object
causes complication as they have impact in GI
tract.1-6,9,10,17,20,22,27,30
1. Orthodontic wire segment, if impact at the level of 4th
cervical vertebra and laryngeal impaction present
with dysphagia and odynophagia can be managed
with endoscopic retrieval. The use of a distal end
cutter avoids the accidental swallow.3,10,17,21,25
2. Removable orthodontic appliance accidentally
ingested and is located at esophageal area may
present chest pain, drooling of saliva, and vomiting
and if the appliance fragment lodged at ileocecal
junction or at the sigmoid colon area, it presents with
muscle incoordination, incessant twitching, and
hematemesis causes.3,10,17,21,25,26,30 Later, patient
presents with abdominal pain, fever, nausea,
vomiting, and abdominal distension because of
perforation of the ileocecal junction and the sigmoid
colon. The use of Fiber-optic nasopharyngoscope to
Sonwane and Kamble 21
locate and remove the aspirated fragment or
appliance.12,16,19,22 Use silk thread and tie a knot to
labial bow or Adam’s clasp for immediate retrieval
from the esophagus; use a contrast-colored appliance
to identify at the time of removal.9,24,11,23,29-31
Strength of the Study
In the era of clinical trial and evidence-based practice, this
systematic review withstands to describe hidden or undetected
scientific observations for clinical trials. This also generates a
hypothesis that provides an evidence-based orthodontic
practice. This systematic review enlightens patient-centered
clinical awareness of an individualized nature of contemporary
patient care and can be used for teaching, review, and research
purposes.
Weakness of the Study
This systematic review comprised of scanty evidence,
deceptive, and no control group to compare outcomes, and
has no statistical validity.
Conclusion
We conducted this systematic review to answer the question:
“What are the effects of accidentally swallowing an
orthodontic appliance or part of a fixed orthodontic appliance
to the airway and gastrointestinal tract?”
Based on the meticulous search, 29 case reports and case
series have published the accidental swallow of different
orthodontic materials. To answer the research question, we
have clubbed the case report and series reporting similar
items of accidental swallow, and we have got the following
conclusions.
1. Nine individual case reports were on accidental
swallowing of wire segments in resident and subjects
reported with abdominal pain; nasal bleeding and
airway compromised.
2. Seven case reports were reported on expanders and
expansion keys, and patients reported with discomfort,
drooling of saliva, and inability to swallow.
3. One article reported a functional appliance swallow
with a chief complaint of breathless with a severe
cough.
4. Most of the case reports could not satisfy the
methodological evaluating domains.
5. Clinician must warn the subject and parents before
beginning with any orthodontic treatment.
6. Activation key tied to silk thread and 7 O′ clock
position of the operator can prevent its accidental
ingestion
Acknowledgments
The authors would like to thank Dr. Wasundara Bhad and Dr Santosh
Chavan for their moral support to complete this study.
Author Contributions
Dr Siddharth Sonwane: writing, design, compile, data collection,
and analysis; Dr.Shweta.Kamble (sonwane): concept, supervision,
and grammar.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Siddharth Sonwane https://orcid.org/0000-0003-4766-7876
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