An Unusual Incidental Radiographic Finding–A Stapler Pin: a Case

CASE REPORT / PRIKAZ SLUČAJA Serbian Dental Journal, vol. 61, No 1, 2014 45

UDC: 616.314.9-003.6-053.2 DOI: 10.2298/SGS1401045K An Unusual Incidental Radiographic Finding – A Stapler Pin: A Case Report

Smita Kamtane1, Monali Ghodke2 1Department of Oral Medicine and Radiology, Dr. D. Y. Patil Dental School, Pune, India; 2Department of Oral and Maxillofacial Surgery, Sinhgad Dental College and Hospital, Pune, India

SUMMARY Accidental discovery of a foreign object embedded in a tooth is not common. Children often have a habit of inserting objects into their mouth. Some of these objects can be accidentally ingested or even aspirated which can be a very frightening and a stressful experience. Herein, we report a case of a 7-year-old boy who presented with a stapler pin lodged in the root canal space of maxillary left deciduous central incisor. Keywords: foreign bodies; stapler pins; deciduous teeth

INTRODUCTION central incisor (Figure 2). To localize this foreign object additional parallax views were taken. On further question- Accidental ingestion or aspiration of a variety of foreign ing it was found that the child was playing with the stap- objects is a common pediatric emergency. The discovery ler pin a week before, when it got stuck in his tooth. The of foreign objects in teeth is a special situation, which child’s attempts to remove the foreign object were futile. is often diagnosed accidentally. Detailed case history, The incident was concealed from his parents as he was clinical and radiographic examinations are necessary to afraid of punishment. The timing of presentation enabled come to a conclusion about the nature, size and location us to solve the problem by extraction of the affected tooth of the foreign body as well as difficulties involved in its (after obtaining the written consent from the parents) as retrieval. Sometimes foreign objects get stuck in the root the permanent incisor was erupting. Subsequently, the canals and children do not reveal to their parents because maxillary left deciduous central incisor was extracted they are afraid of punishment. This situation is common (Figure 3). This timely diagnosis and management of in children. Majority of cases of accidental ingestion or foreign object embedded in the tooth avoided further aspiration of foreign objects in children occur between complications such as pain, bleeding and infection. the ages of 6 months to 3 years and include a variety of objects like coins, marbles, pins, keys, rings and toys [1]. Also, an injury of hard and soft tissues may occur as a DISCUSSION consequence of children’s habit to put foreign objects in mouth. These foreign objects may act as a potential source Various foreign objects have been reported lodged in the of infection and may later lead to a painful condition. In root canals and pulp chamber, which ranged from pencil the present case, we report a stapler pin found incident- leads [2], darning needles [3], metal screws [4], to beads ally on a radiograph of carious maxillary left deciduous [5] and stapler pins [6]. In our case, a stapler pin was central incisor. lodged into the root canal of the left maxillary decidu- ous central incisor. Grossman and Heaton [7] reported retrieval of indelible ink pencil tips, brads, tooth picks, ad- CASE REPORT sorbent points and even a tomato seed from the root can- als of anterior teeth left open for drainage. A radiograph A 7-year-old boy reported to the Department of Oral can be of diagnostic significance especially if the foreign Medicine and Radiology, with a chief complaint of a pain object is radioopaque. McAuliffe et al. [5] summarized in upper left back region that started 8 days ago. Pain was various radiographic methods useful to localize radio- moderate, intermittent, throbbing, non-radiating, non- opaque foreign objects as Parallax views, Triangulation referred and relieved by medications (Figure 1). An x- techniques, Stereo Radiography and Tomography. Special- ray was advised for the upper left deciduous first molar. ized radiographic techniques such as radiovisiography, 3D Occlusal caries was seen on the tooth 64 along with a CAT scans can play a pivotal role in localization of foreign radioopaque object resembling a stapler pin in root canal objects inside the root canal. space of deciduous maxillary left central incisor which For retrieval of foreign objects from the pulp chamber was superimposed with unerupted upper left permanent or canal, ultrasonic instruments [8], the Masserann kit

Address for correspondence: Monali GHODKE, Maharashtra Housing Board, M-45/2603, Yerwada, Pune-411006, Maharashtra, India; [email protected] 46 Kamtane S. et Ghodke M. An Unusual Incidental Radiographic Finding – A Stapler Pin: A Case Report

Figure 1. Clinical view of deciduous left maxillary central incisor Slika 1. Klinički izgled mlečnog gornjeg levog centralnog sekutića

Figure 3. Extracted deciduous left maxillary central incisor with present foreign object, stapler pin, in the root canal Slika 3. Izvađen mlečni gornji levi centralni sekutić sa stanim telom, municijom za heftalicu, u kanalu korena

This incident highlights the fact that parents should be advised to keep small objects out of reach of children. Although the presence of foreign objects retrieved from the root canals and pulp chambers of the permanent teeth have been reported, the presence of foreign objects found in the deciduous teeth is an uncommon situation.

Figure 2. X ray of deciduous left maxillary central incisor with pres- ent unerupted permanent left maxillary central incisor REFERENCES Slika 2. Rendgenski snimak mlečnog gornjeg levog centralnog se- kutića sa neizniklim stalnim gornjim levim centralnim sekutićem 1. Van As AB, du Toit N, Wallis L, Stool D, Chen X, Rode H. The South African experience with ingestion injury in children. Int J Pediatr Oto- rhinolaryngol. 2003; 67:175-8. [9], modified Castroveijo needle holders [10] and other 2. Hall JB. Endodontics – patient performed. J Dent Child. 1969; 36:213-6. systems have been used. Ethylenediaminetetraacetic acid 3. Nernst H. Foreign body in the root canal. Quintessenz. 1972; 23:26. has been suggested as a useful aid in lubricating the canal 4. Prabhakar AR, Basappa N, Raju OS. Foreign body in a mandibular when attempting to remove foreign object. The Steglitz permanent molar: a case report. J Indian Soc Pedod Prev Dent. 1998; 16:120-1. forceps have also been described useful in silver points re- 5. Subba Reddy VV, Mehta DS. Beads. Oral Surg Oral Med Oral Pathol. moval from the root canal. McCullock [11] suggested that 1990; 69:769-70. access to the foreign object is improved if small amount 6. McAuliffe N, Drage NA, Hunter B. Staple diet: a foreign body in a of tooth structure is removed. According to Walvekar et tooth. Int J Paediatr Dent. 2005; 15:468-71. al. [12], if the foreign object is snugly bound in the canal, 7. Grossman JL, Heaton JF. Endodontic case reports. Dent Clin North Am. 1974; 18:509-27. the object may have to be loosened first; it should be re- 8. Meidinger DL, Kabes BJ. Foreign object removal utilizing the caviendo moved with minimal damage to internal tooth structure ultrasonic instrument. J Endod. 1985; 11:301-4. to prevent perforation of the root. Complications can 9. Williams VD, Bjourndal AM. The Masserann technique for the re- occur if these impacted foci of infection are not elimin- moval of fractured posts in endodontically treated teeth. J Prosthet ated on time. Actinomycosis following placement of the Dent. 1983; 49:46-8. 10. Fros UG, Berg JO. A method for the removal of broken endodontic piece of jewelry chain into a maxillary central incisor has instruments from the root canals. J Endod. 1983; 9:156-9. been reported by Goldstein et al. [13]. Chronic maxillary 11. McCullock AJ. The removal of restorations and foreign objects from sinusitis of dental origin developed due to foreign objects root canals. Quintessence Int. 1993; 24:245-9. pushed into maxillary sinus through the root canals was 12. Walvekar SV, Al- Duwari Y, Al-Kandri AM, Al-Quoud OA. Unusual reported by Costa et al. [14]. Serious complications like foreign objects in the root canal. J Endod. 1995; 2:526-7. 13. Goldstein BH, Scuibba JJ, Laskin DM. Actinomycosis of the maxilla: rupture of the common carotid artery, aortic pseudo- a review of literature and a report case. J Oral Surg. 1972; 30:362-6. aneurysms, esophageal tears and fistula, pericarditis 14. Costa F, Robiomy M, Toro C, Sembronio S, Politi M. Endoscopically and cardiac tamponade have also been reported [5, 6]. assisted procedure for the removal of a foreign body from the maxil- Attempts for removal of the object by the child or par- lary sinus and contemporary endodontic surgical treatment of the ent may result in accidental aspiration or ingestion with tooth. Head Face Med. 2006; 8:37. serious complications. In the present case, the child did not reveal the incident till the stapler pin was seen on the periapical radiograph. Received: 18/11/2013 • Accepted:30/01/2014 Stomatološki glasnik Srbije. 2014;61(1):45-48 47

Neobičan slučajan radiografski nalaz – municija za heftalicu: prikaz slučaja

Smita Kamtane1, Monali Godke2 1Katedra za oralnu medicinu i radiologiju, Stomatološki fakultet „Dr D. J. Patil“, Pune, Indija; 2Katedra za oralnu i maksilofacijalnu hirurgiju, Stomatološki fakultet i bolnica „Sinhgad“, Pune, Indija

KRATAK SADRŽAJ Na­laz stra­nog te­la u zu­bu ni­je čest. De­ca ima­ju obi­čaj da uno­se stra­ne pred­me­te u usta. Ne­ki od ovih pred­me­ta mo­gu se slu­čaj­no pro­ gu­ta­ti ili čak udah­nu­ti u di­saj­ne pu­te­ve, što mo­že bi­ti ve­o­ma za­stra­šu­ju­će i stre­sno is­ku­stvo. Ovo je pri­kaz sed­mo­go­di­šnjeg de­ča­ka ko­ji je do­šao na pre­gled i kod ko­ga je pro­na­đe­na mu­ni­ci­ja za hef­ta­li­cu u ka­na­lu ko­re­na mleč­nog mak­si­lar­nog le­vog cen­tral­nog se­ku­ti­ća. Ključ­ne re­či: stra­na te­la; hef­ta­li­ca; mleč­ni zu­bi

UVOD ni­cao (Sli­ka 3). Bla­go­vre­me­no po­sta­vlje­na di­jag­no­za i br­zo le­ če­nje spre­či­li su na­sta­nak da­ljih kom­pli­ka­ci­ja, kao što su bol, Gu­ta­nje ili aspi­ra­ci­ja raz­li­či­tih stra­nih te­la je čest hit­ni slu­čaj u kr­va­re­nje i in­fek­ci­ja. pe­di­ja­tri­ji. Ot­kri­će stra­nih te­la u zu­bi­ma je po­seb­na si­tu­a­ci­ja, ko­ja se če­sto di­jag­no­sti­ku­je slu­čaj­no. Neo­p­hod­no je sa­zna­ti de­ talj­nu isto­ri­ju slu­ča­ja i oba­vi­ti de­talj­ne kli­nič­ke i ra­di­o­graf­ske DISKUSIJA pre­gle­de, da bi se za­klju­či­lo o pri­ro­di, ve­li­či­ni i lo­ka­ci­ji stra­nog te­la, te mo­gu­ćim te­ško­ća­ma u nje­go­vom pro­na­la­že­nju. Po­ne­kad U li­te­ra­tu­ri se mo­že pro­na­ći mno­štvo po­da­ta­ka o raz­li­či­tim su stra­na te­la za­gla­vlje­na u ka­na­lu ko­re­na zu­ba, a de­ca če­sto iz stra­nim te­li­ma ko­ja su prona­ ­la­že­na u komo­ ­ri pul­pe i ka­na­lu stra­ha pre­ću­te to svo­jim ro­di­te­lji­ma. Zbog to­ga je ova­kva si­tu­ ko­re­na, kao što su: mi­ne za olov­ke [2], igle za ši­ve­nje [3], me­ a­ci­ja kod de­ce če­šća. Naj­ve­ći broj slu­ča­je­va slu­čaj­nog gu­ta­nja ili tal­ni šra­fo­vi [4], per­le [5] i mu­ni­ci­ja za hef­ta­li­cu [6]. U na­šem aspi­ra­ci­je stra­nih te­la de­ša­va se kod de­ce uz­ra­sta od šest me­se­ci pri­ka­zu slu­ča­ja mu­ni­ci­ja za hef­ta­li­cu je pro­na­đe­na u ka­na­lu do tri go­di­ne i ob­u­hva­ta raz­li­či­te pred­me­te, kao što su nov­či­ći, ko­re­na mleč­nog mak­si­lar­nog le­vog cen­tral­nog se­ku­ti­ća. Gro­ kli­ke­ri, igle, klju­če­vi, pr­ste­nje i igrač­ki­ce [1]. Ta­ko­đe, kao po­sle­ sman (Gros­sman) i Hi­ton (He­a­ton) [7] su na­ve­li i po­na­la­že­nje di­ca na­vi­ke de­ce da sta­vlja­ju stra­ne pred­me­te u usta mo­že do­ći i vr­ha he­mij­ske olov­ke, či­o­de, čač­ka­li­ce, ad­sor­bu­ju­ćih po­e­na i do po­vre­de tvr­dih i me­kih tki­va u usti­ma. Ova stra­na te­la mo­gu se­me­nki pa­ra­daj­za u ka­na­lu ko­re­na pred­njih zu­ba ko­ji su bi­li de­lo­va­ti kao po­ten­ci­jal­ni iz­vor in­fek­ci­je i po­ne­kad mo­gu u ka­ osta­vlje­ni otvo­re­ni zbog dre­na­že. Ra­di­o­gra­fi­ja je od po­seb­nog sni­jem sta­di­ju­mu do­ve­sti do bol­nih sta­nja. Sle­di pri­kaz de­ča­ka di­jag­no­stič­kog zna­ča­ja, na­ro­či­to ako je stra­no te­lo ra­di­o­o­pak­ kod ko­jeg je slu­čaj­no pro­na­đe­na mu­ni­ci­ja za hef­ta­li­cu na snim­ no. Ma­ko­lif (McA­u­lif­fe) i sa­rad­ni­ci [5] su pri­ka­za­li raz­li­či­te ku ka­ri­je­snog mlečnog­ mak­si­lar­nog le­vog cen­tral­nog se­ku­ti­ća. ra­di­o­graf­ske me­to­de koje­ mo­gu bi­ti ko­ri­sne u lo­ka­li­zo­va­nju ra­di­o­o­pak­nog stra­nog te­la. To su pa­ra­lel­ne me­to­de, teh­ni­ka tri­an­gu­la­ci­je, ste­reo ra­di­o­gra­fi­ja i to­mo­gra­fi­ja. Spe­ci­ja­li­zo­va­ne PRIKAZ SLUČAJA ra­di­o­graf­ske teh­ni­ke, kao što su ra­di­o­vizi­ ­o­gra­fi­ja i tro­di­menzi­ ­ o­nal­no CAT ske­ni­ra­nje, mo­gu ima­ti ključ­nu ulo­gu u lo­ka­li­za­ci­ji Sed­mo­go­di­šnji de­čak je pri­mljen na Ode­lje­nje za oral­nu me­di­ stra­nih te­la unu­tar ka­na­la ko­re­na. ci­nu i ra­di­o­lo­gi­ju sa glav­nim te­go­ba­ma u vi­du bo­la u gor­njem Za ukla­nja­nje stra­nih te­la iz ko­mo­re pul­pe ili ka­na­la mo­gu le­vom boč­nom re­gi­o­nu ko­ji je tra­jao du­že od osam da­na. Bol je se ko­ri­sti­ti ul­tra­zvuč­ni in­stru­men­ti [8], kom­plet Mas­se­rann bio ume­ren, po­vre­men, po­tmuo, ni­je ira­di­rao u dru­ge de­lo­ve i [9] i mo­di­fi­ko­va­ni Ka­stro­ve­i­hovi (Ca­stro­ve­i­jo) no­sa­či igle [10]. ni­je pre­sta­jao na­kon uzi­ma­nja analge­ ­ti­ka (Sli­ka 1). Na­či­njen je Eti­len­di­a­min­te­tra­sir­ćet­na ki­se­li­na je ta­ko­đe ko­ri­sna za pod­ sni­mak gor­njeg le­vog mleč­nog pr­vog mo­la­ra. Na rend­gen­skom ma­zi­va­nje ka­na­la pri­li­kom ukla­nja­nja stra­nog te­la. Šte­gli­co­va snim­ku uočen je oklu­zal­ni ka­ri­jes na zu­bu 64. Ta­ko­đe, ra­di­o­ (Ste­glitz) kle­šta su ta­ko­đe dobra za ukla­nja­nje sre­br­nih ko­či­ća o­pak­ni obje­kat na­lik mu­ni­ci­ji za hef­ta­li­cu uočen je u ka­na­lu iz ka­na­la ko­re­na. Ma­ka­lok (McCul­lock) [11] pred­la­že ukla­nja­ ko­re­na mleč­nog mak­si­lar­nog le­vog cen­tral­nog se­ku­ti­ća. On je nje ma­le ko­li­či­ne struk­tu­re zu­ba da bi se pri­stu­pi­lo stra­nom bio su­per­po­ni­ran sa još ne­iz­ni­klim gor­njim stal­nim le­vim cen­ te­lu. Val­ve­kar (Wal­ve­kar) i sa­rad­ni­ci [12] sma­tra­ju da, ako je tral­nim se­ku­ti­ćem (Sli­ka 2). Da bi­smo lo­ka­li­zo­va­li ovaj pred­met, stra­no te­lo čvr­sto za­gla­vlje­no u ka­na­lu, ono se pr­vo mo­ra ola­ na­či­njeno­ je još ne­ko­li­ko sni­ma­ka s po­me­re­nim uglom. Po­tom ba­vi­ti pa on­da tek uklo­ni­ti mi­ni­mal­nim ošte­će­njem unu­tra­šnje je is­pi­ti­va­njem utvr­đe­no da se de­te igra­lo hef­ta­li­com ne­de­lju struk­tu­re zu­ba, ka­ko ne bi do­šlo do per­fo­ra­ci­je ko­re­na. Ako se da­na ra­ni­je, ka­da se mu­ni­ci­ja hef­ta­li­ce za­gla­vi­la u nje­go­vom stra­na tela­ ne uklo­ne na vre­me, mo­že do­ći do da­ljih kom­pli­ka­ zu­bu. De­te je bez­u­spe­šno poku­ ­ša­va­lo da uklo­ni stra­no te­lo iz ci­ja. Gold­štajn (Gold­stein) i sa­rad­ni­ci [13] su opi­sa­li na­sta­nak zu­ba. De­te ovaj in­ci­dent ni­je pri­ja­vi­lo ro­di­te­lji­ma jer se bo­ja­lo ak­ti­no­mi­ko­ze na­kon što je ko­mad na­ki­ta do­speo u mak­si­lar­ ka­zne. Na sre­ću, vre­me ka­da se on de­sio (vre­me ni­ca­nja stal­nog ni cen­tral­ni se­ku­tić. S dru­ge stra­ne, Ko­sta (Co­sta) i sa­rad­ni­ci zu­ba) omo­gu­ćilo je da se pro­blem re­ši va­đe­njem zu­ba (na­kon [14] opi­sa­li su hro­nič­ni mak­si­lar­ni si­nu­zi­tis zub­nog po­re­kla do­bi­ja­nja pi­sa­ne sa­gla­sno­sti ro­di­te­lja). Mleč­ni mak­si­lar­ni le­ ko­ji je na­stao zbog pro­la­ska stra­nih te­la kroz ka­nal ko­re­na u vi cen­tral­ni se­ku­tić je iz­va­đen, a stal­ni cen­tral­ni se­ku­tić je već mak­si­lar­ni si­nus. Te­ške kom­pli­ka­ci­je, po­put pu­ca­nja za­jed­nič­ke 48 Kamtane S. et Ghodke M. An Unusual Incidental Radiographic Finding – A Stapler Pin: A Case Report

ka­ro­tid­ne ar­te­ri­je, aort­ne pse­u­do­a­ne­u­ri­zme, ošte­će­nja slu­zo­ko­ in­ci­den­tu dok stra­no te­lo ni­je slu­čaj­no ot­kri­ve­no na pe­ri­a­pi­ že jed­nja­ka i na­sta­nak fi­stu­la, pe­ri­kar­di­tisa i tam­po­na­de sr­ca, kal­nom ra­di­o­gra­mu. ta­ko­đe su opisa­ ­ne u li­te­ra­tu­ri [5, 6]. Po­ku­šaj de­te­ta ili ro­di­te­lja Ovaj in­ci­dent uka­zu­je na či­nje­ni­cu da rodi­ ­te­lji mo­ra­ju dr­ža­ti da uklo­ne stra­no te­lo mo­že iza­zva­ti ne­na­mer­ne kom­pli­ka­ci­je sit­ne objek­te van do­ma­ša­ja de­ce. Iako po­sto­ja­nje stra­nih pred­ u vi­du aspi­ra­ci­je ili gu­ta­nja stra­nog te­la s te­škim po­sle­di­ca­ma. me­ta u ka­na­lu ko­re­na stal­nih zu­ba ni­je ret­ka po­ja­va, pri­su­stvo U pri­ka­za­nom slu­ča­ju de­te ni­je oba­ve­sti­lo ro­di­te­lje o ovom stra­nih pred­me­ta kod mleč­nih zu­ba je­ste.