Dental Foreign Body Aspiration: How a Missing Tooth Root Led to a Lung Lobectomy
A 53 year old woman underwent extraction of her remaining 20 teeth in preparation for dentures. The procedure was performed with local anesthesia and nitrous oxide. Nothing immediately appeared catastrophic. She experienced more pain than expected and had episodes of coughing and a choking sensation, but those symptoms did not seem unusual enough at the time to suggest that something had entered the airway.
A few weeks later, she went to the hospital with a persistent cough. A chest radiograph revealed a tooth root lodged in the left lower lobe bronchus with distal atelectasis. CT confirmed the finding. Bronchoscopy was attempted but failed to remove the root. After evaluation by a cardiothoracic surgeon, the patient underwent a left lower lobectomy.
It is the kind of case that invites hindsight. A dental procedure ended with the loss of part of a lung, so negligence can feel obvious. But a catastrophic outcome does not prove that the standard of care was breached. Aspiration is a recognized complication of dental treatment, even when precautions are taken, and the malpractice case itself was never decided on the clinical merits. The first lawsuit relied on a dentist without oral and maxillofacial surgery training as the expert witness and was dismissed. The case was refiled with an OMS expert, but by then the statute of limitations had expired. The judge strongly criticized the plaintiff’s attorney. That criticism concerned the lawyer’s handling of the case, not the oral surgeon’s treatment.
For practicing dentists, the more useful question is what this case teaches about recognizing a rare event before it becomes a catastrophic one.
Dental aspiration is uncommon. In a 10 year institutional review, 36 incidents involved objects disappearing toward the pharynx. Twenty five were ingested and only one was confirmed to have been aspirated. A seven year dental hospital study found 39 aspiration or ingestion events across more than 2.6 million patient visits, with only two actual aspirations. The base rate matters. Dramatic cases are memorable, but they are not typical.
Still, aspiration can be serious. Teeth, crowns, prostheses, implant components, burs, endodontic instruments, and other objects can enter the lower airway. In a multicenter study of 138 adults treated for airway foreign bodies, teeth were the single most common object, accounting for 37.7 percent of cases, and dental clinics were the reported setting in 21 percent. Those numbers do not mean dental treatment commonly causes aspiration. They describe patients who already had an airway foreign body. What they do show is that dentistry contributes a meaningful share of serious adult aspiration cases.
The clinical trap is that aspiration may not look dramatic. In that same multicenter study, cough was the most common symptom, but only 43.5 percent of patients had a definite history of choking or aspiration. A patient can aspirate a tooth or restoration, remain stable, leave the office, and present later with cough, pneumonia, atelectasis, or another nonspecific pulmonary problem.
That is why the critical question in the operatory is often not whether the patient coughed. Patients cough and gag for many reasons. The more consequential question is whether anything is missing.
If a tooth, root, crown, bur, implant component, file, screw, or other object disappears and cannot be accounted for, swallowing should not simply be assumed. Aspiration remains possible even when the patient is breathing comfortably. Stop, determine what is missing, document what happened, and arrange prompt localization and medical evaluation when aspiration cannot be excluded.
A 2007 oral surgery case shows the value of recognition. During removal of an impacted mandibular third molar under local anesthesia, the patient gagged and the tooth disappeared from the operative field. The clinicians immediately suspected aspiration, obtained imaging, found the tooth in the right bronchial tree, and had it removed with rigid bronchoscopy. The event remained a retrieval problem rather than progressing to secondary lung injury.
Bronchoscopy is highly effective in adults. A systematic review found flexible bronchoscopy successful in about 90 percent of attempted removals. A multicenter study reported 91.3 percent success. In another series of 94 adults, flexible bronchoscopy succeeded in 90 percent. Most of the failures were then managed with rigid bronchoscopy, and only one patient ultimately required lobectomy.
Those numbers do not prove that the woman in the lobectomy case could have avoided surgery if the root had been recognized immediately. We do not know the exact position of the root, the condition of the bronchus, the extent of inflammation, what retrieval methods were attempted, or why the cardiothoracic surgeon concluded that lobectomy was necessary.
What the evidence does support is simpler. Earlier recognition preserves options. A newly aspirated object is mainly something to retrieve. A retained object can become surrounded by inflammation and granulation tissue, obstruct airflow, produce atelectasis or pneumonia, and eventually damage the lung enough that removal becomes more difficult and surgery more likely.
Prevention still matters. Rubber dams remain among the best barriers when the procedure allows them. Small components can often be secured with floss ligatures. Gauze throat screens may help in selected procedures. Burs and detachable components should be checked before entering the mouth. Extra caution is appropriate in older patients and in those with impaired swallowing, neurologic disease, cognitive impairment, reduced protective reflexes, or sedation.
Documentation matters too. In a complicated case, the chart becomes the memory of the procedure. Recording what was planned, what was removed, what symptoms occurred, and what actions were taken can be clinically valuable long before it becomes legally important. Poor documentation does not prove poor care, but it can make sound clinical judgment difficult to reconstruct later.
The larger lesson is one of calibration. Dental aspiration is rare. Most misplaced dental objects are swallowed, not inhaled. Most adult airway foreign bodies that require intervention can be removed bronchoscopically. Lung resection is unusual.
Yet the event is serious enough that a missing object deserves immediate attention. A calm patient is not proof that nothing entered the airway. A brief cough is not proof that something did. The most useful question is concrete.
When something disappears during treatment, how certain are you that you know where it went?
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