clinical caSE
Marek Łuciuk
1, 2, a–D, Dariusz Łuciuk
3, B–D, Józef andrzej Komorski
1, a–c, E, FTooth in the Tongue – Case Report
Ząb w języku – opis przypadku
1 Department of Maxillo-Facial Surgery, Wroclaw Medical University, Wrocław, Poland
2 Department of Otolaryngology, Head and neck Surgery, Wroclaw Medical University, Wrocław, Poland 3 Department of cardiology, Wroclaw Medical University, Wrocław, Poland
A – concept, B – data collection, C – statistics, D – data interpretation, E – writing/editing the text, F – compiling the bibliography
Abstract
a foreign body in the tongue is a very rare situation, especially when it is the patient’s own tooth. The most com-mon reason why a foreign body would get lodged in the tongue is as a result of external trauma (accident at work, other accidents). The aim of this study is to describe the case of a 66-year-old man admitted to the hospital because of swelling, tenderness tongue. in the anamnesis a few days ago as a result of loss of consciousness, the patient suffered a superficial injury of the tongue. immediately after the injury, the patient was treated in the emergency department. a detailed analysis of the circumstances of the injury, thorough physical examination of the patient and extra-imaging studies allowed us to locate a “foreign body” in the patient’s tongue and applied successful surgical intervention. in conclusion, a precise anamnesis along with the knowledge about the mechanism of the injury, a physical examination of the patient immediately after the injury with an accurate review of the wound is necessary in order to make a correct diagnosis, treatment and avoid complications (Dent. Med. Probl. 2013, 50,
3, 369–372).
Key words: tongue, foreign body, tooth, treatment.
Streszczenie
ciało obce w języku jest sytuacją bardzo rzadką, a gdy jest nim własny, całkowicie zwichnięty ząb pacjenta – wręcz niespotykaną. najczęściej ciało obce wnika do wnętrza języka drogą zewnętrzną na skutek urazu (wypadek w czasie pracy, wypadki komunikacyjne, urazy sportowe). W artykule opisano przypadek 66-letniego mężczyzny przyjęte-go do Kliniki Szczękowo-Twarzowej z powodu obrzęku oraz tkliwości języka. Z wywiadu wynikało, że z powodu utraty przytomności pacjent doznał urazu języka. na SOR został wstępnie zaopatrzony i wypisany do domu tego samego dnia. Szczegółowa analiza okoliczności urazu, dokładne badanie podmiotowe i przedmiotowe pacjenta oraz dodatkowe badania obrazowe pozwoliły na zlokalizowanie „ciała obcego” tkwiącego w języku pacjenta oraz wdrożenie skutecznej interwencji chirurgicznej. Podsumowując, szczegółowa anamneza wraz z informacjami na temat okoliczności powstania oraz mechanizmu urazu, badanie przedmiotowe bezpośrednio po obrażeniu oraz rewizja rany są niezbędne w celu postawienia prawidłowego rozpoznania, wdrożenia właściwego postępowania leczniczego oraz uniknięcia powikłań (Dent. Med. Probl. 2013, 50, 3, 369–372).
Słowa kluczowe: język, ciało obce, ząb, postępowanie lecznicze.
Dent. Med. Probl. 2013, 50, 3, 369–372
iSSn 1644-387X © copyright by Wroclaw Medical University and Polish Dental Society
There are many reasons explaining why for-eign bodies can be found penetrating into the tis-sues as a result of head and neck injuries. First of all, there are accidents at work – especially using mechanical equipment – traffic accidents, bullets from firearms, injuries associated with falls from
heights, damages done by various objects and juries associated with losing consciousness or in-juries sustained under the influence of alcohol or drugs [1–3].
in another group there are injuries associat-ed with practicing different sports. These
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es are mainly connected to the jaw and/or mandi-ble, injuries of anterior teeth with punctured frag-ments in the surrounding soft tissue, dislocation of teeth, alveolar injury, soft tissue wounds of the face and oral cavity (lip, tongue). according to the literature up to 13–39% of all dental injuries are related to sports training [4, 5]. On the other hand, 11–18% of all sports-related injuries belonged to the maxillofacial traumas [6]. another group of facial injuries is associated with losing conscious-ness or as a result of epilepsy. in all of these cas-es there is always the possibility of penetration of different foreign bodies or dense tissues of the hu-man body – like bone or tooth – deep into the sur-rounding soft tissues. We can find most fragments of the broken tooth in the lower and upper lip tis-sues [5–9] or in the tongue tistis-sues [10]. This arti-cle presents a case of a completely dislocated tooth penetrating into the tongue tissues.
The presence of foreign bodies in the tongue tissues is not a common situation. The literature describes individual cases of the presence of for-eign material, such as fishbone, [11] part of the in-cisor or other teeth, part of a pipe [12], a dental drill [13], a part of an umbrella [14] in the tissues of the lips and tongue [15–17]. a completely dislo-cated tooth found in the deep tissues of the tongue is a casuistry situation. The most important aspect for diagnosis is to locate and identify the type of foreign body and apply the appropriate treatment is carried out very accurate anamnesis as to the circumstances of the event. Sometimes this situ-ation can be quite difficult or even impossible to achieve because of the extent of damage, drug in-toxication or loss of consciousness with retrograde amnesia [1]. in the case of diagnosing non-metalic bodies (without the X-ray contrast – like glass or wood, etc.) an ultrasound study, computer tomog-raphy and magnetic resonance is very helpful [1]. When dealing with metal substances or dense tis-sues, such as bones or teeth (with the X-ray con-trast), the method of choice is an X-ray in vari-ous projections. The best method of diagnosing foreign bodies in the soft tissues is an ultrasound study or X-ray. non-healing wounds, chronic in-fections or local abscesses are typical complica-tions and first symptoms of an undiagnosed for-eign body in the soft tissues. The main causes why foreign bodies might be overlooked in the soft tis-sues during the first physical examination could result from problems in accessing image studies, the type of foreign body, inexperienced medical staff or inaccurate physical examination of the pa-tient [2]. Therefore, besides carefully treating the surgical wounds after face and neck traumas, it is obligatory to make a precise anamnesis of the cir-cumstances of the injury, assess the structure of
the foreign material, select the appropriate labo-ratory tests and do an accurate physical examina-tion of the patient.
A Case Report
a 66-year-old man was admitted to the hospi-tal with a suspision of a foreign body in the tongue. From the interview a few days earlier, we learned that as a result of losing consciousness, he fell and suffered facial trauma. He reported to the Emer-gency Department, where he consulted specialists (including a maxillo-facial surgeon). The surgeon sutured the deep wounds of the tongue, fixed the superficial abrasions of the skin and discharged the patient home. The wounds healed completely and the patient felt good. a few days later there ap-peared “strange” symptoms on the tongue – ten-derness, swelling without the typical features of local inflammation. The patient reported to the clinic of Maxillofacial Surgery. a careful anam-nesis and physical examination were performed (Fig. 1). With a diagnosis of a foreign body in the soft tissues of the tongue, the patient was given a pantomographic X-ray of the jaw and asked to bite on the plate X-ray. The radiogram showed the unusual presence of a foreign body – a tooth – in the structures of the tongue (Fig. 2). The patient was qualified to surgical removal of the foreign body and was admitted to the ward.
Under local anesthesia with 2% lignocaine with adrenaline the mucosa incision was made on the left side, dorsal part of the tongue. access to the foreign body was obtained (Fig. 3). The tooth was completely removed (Fig. 4). The cavity left after the extracted tooth was carefully explored, cleaned, rinsed with H2O2, and ensuring
hemosta-Fig. 1. The clinical examination before surgery Ryc. 1. Stan kliniczny przed zabiegiem chirurgicznym
Tooth in the Tongue – a case Report
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sis sutured. antibiotic prophylaxis for five days was recommended according to the guidelines. after 10 days the patient reported to the clinic for rou-tine control. The wound was healing properly and the stitches were removed. The patient was sched-uled for further control visits in the 1st, 3rd and 6th month. Surgical treatment was completed.
Discussion
Most dental traumas occur in the first decades of life, mainly at the age of 2–3 and 8–12 [18]. Fac-tors such as age, sex, direction and force of impact, periodontal status of the patient are equally im-portant in the diagnosis. crowns of the deciduous teeth are more prone to injuries than permanent teeth [19, 20]. Generally, foreign bodies damage the superficial part of the tongue and are removed pri-marily by the patient or the family doctor [10, 11].
This article describes a different situation where a permanent tooth in an adult male was to-tally dislocated and was lodged in the deep tissues of the tongue. There are many types of complica-tions resulting from this kind of injury, includ-ing infection, vessels and nerves damages, foreign body aspiration into the bronchial tree, etc. [11]. Proper procedure in this case should include ac-curate anamnesis, physical examination, execu-tion of addiexecu-tional imaging tests – especially when diagnosing foreign bodies in the soft tissues – and applying appropriate treatment. according to the literature, about 22% of children’s injury cases are related to soft tissues.
in this case, there was no need for antibiot-ic treatment as there were no signs of infection. However, antibiotics were prescribed as recom-mended [4, 5].
This case showed situations where a dislocated tooth lodged into the deep structures of the tongue was overlooked both by the physician and the pa-tient. a potentially harmless superficial wound of the tongue was hiding a tooth in its deep struc-tures. a foreign body could be diagnosed only as a result of a detailed anamnesis, careful physical examination of the patient and implemented di-agnostic imaging. To get the best final results, it is also recommended to treat wounds in accordance with the guidelines for the initial treatment of fa-cial injuries.
in summary, soft tissue injuries of the facial skeleton require an accurate anamnesis, as to the time, location and circumstances of the injury, physical examination and radiological diagnosis, including a radiological comparison of the num-ber of teeth and any differences in them before and after the injury. Examination of the patient,
Fig. 2. X-ray, visible shadow of a foreign body. in the
tissues of the tongue
Ryc. 2. RTG zgryzowe na płytkę, widoczny cień ciała
obcego w tkankach języka
Fig. 3. During the procedure, the removal of a foreign
body in the tissues of the tongue
Ryc. 3. Zabieg usuwania ciała obcego
Fig. 4. a foreign body (tooth) removed from the tongue Ryc. 4. ciało obce (ząb) usunięte z tkanek języka
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who suffered injury in the facial skeleton in un-clear circumstances, requires an interdisciplinary approach [5, 6, 10]. according to the literature, the opinions about the using of antibiotics after sur-gery are unclear. Some experts say that there is no need for antibiotic prevention after surgery when there are no signs of infection at the time of the in-tervention [8], while others recommend their strict
adherence to prevent infection and to facilitate wound healing. according to Zadik et al., wounds of the lips, including the tongue, are more suscep-tible to infections than other wounds because of the presence of saliva. Moreover, in cases where these wounds are caused by the teeth, antibiotic prophylaxis helps to prevent infections caused by microorganisms in plaque.
References
[1] Osmola K.: ciała obce w obrębie twarzy, jamy ustnej i szyi. nowiny lek. 1996, 65, 3, 299–304.
[2] Wnukiewicz J., Łuczak K., Komorski a.: The diagnostic problems in localization of foreign bodies followin maxillo-cacial traumas. Wrocł. Stomatol. 1990, 77–85 [in Polish].
[3] nienartowicz j., Kołosowski W., Wnukiewicz J.: a foreign body penetrating a cheek to the oral cavity – case report czas. Stomatol. 2006, 59, 649–652 [in Polish].
[4] Zadik Y.: antibiotic coverage for lip wound. Dental Traumatology 2006, 22, 56.
[5] cubukcu c.E., aydin U., Ozbek S., Kahveci R.: Delayed removal of a primary incisor embedded in the upper lip after dental trauma: a case report about the importance of soft tissue examination. Dent. Traumatol. 2011, 27, 314–317.
[6] altundasar E., Demiralp B.: The importance of soft tissue examination in post-traumatic decision-making: a case report. aust Endod. J. 2013, 39, 35–38.
[7] Pasini S., Bardellini E., Keller E., conti G., Flocchini P., Majorana a.: Surgical removal and immediate re-attachment of coronal fragment embedded in lip. Dent. Traumatol. 2006, 22, 165–168.
[8] Munerato M.c., Silveira da cunha F., Tolotti a., losekann Paiva R.: Tooth fragment lodged in the upper lip after traumatic dental injury: an unusual case report. Dent. Traumatol. 2008, 24, 487–489.
[9] Busuttil naudi a., Fung D.E.: Tooth fragment reattachment after retrieval from the lower lip – a case report. Dent. Traumatol. 2007, 23, 177–180.
[10] de Santana Santos T., Melo a.R., Tiago R., Pinheiro a., azoubel antunes a., Wathson R., de carvalho F., Dourado E.: Tooth embedded in tongue following firearm trauma: report of two. Dent. Traumatol. 2011, 27, 309–313.
[11] lin c.J., Su W.F., Wang c.H.: a foreign body embedded in the mobile tongue masquerading as a neoplasm. Eur. arch. Otorhinolaryngol. 2003, 260, 277–279.
[12] Shugar M.a., Kelly J.H., Glinski E.J., Strome M.: an unusual foreign body of the tongue masquerading as ma-lignancy. laryngoscope 1980, 90, 673–675.
[13] Yamaoka M., Furusawa K.: The location of a disposable broken bur in the tongue. Br. Dent. J. 1993, 175, 55–58. [14] da Silva E.J., Deng Y., Tumushime-Buturo c.G.: an unusual foreign body in the tongue. Br. J. Oral Maxillofac.
Surg. 2000, 38, 241–242.
[15] Hill F.J., Picton J.F.: Fractured incisor fragment in the tongue: a case report. Pediatr. Dent. 1981, 3, 337–338 [16] McDonnell D.G., McKiernan E.X.: Broken tooth fragments embedded in the tongue: a case report. Br. J. Oral
Maxillofac. Surg. 1986, 24, 464–466.
[17] da Silva Schwengber G.F., cardoso M., De Souza Vieira R.: Bonding of fractured permanent central incisor crown following radiographic localization of the tooth fragment in the lower lip:a case report. Dental. Traumatol. 2010, 26, 342–345.
[18] Forsberg c.M., Tedestam G.: Etiological and predisposing factors related to traumatic injuries to permanent teeth. Swed. Dent. J. 1993, 17, 183–190.
[19] andreasen J.O.: Etiology and pathogenesis of traumatic dental injuries. a clinical study of 1,298 cases. Scand. J. Dent. Res. 1970, 78, 329–342.
[20] abbasoglu Z., Ozbay G., Gocmen G., Kargul B.: Fragment zuba u gornjoj usni nakon dentalne traume: opis neobičnoga kliničkog slučaja. acta Stomatol. croat. 2011, 45, 280–286.
Address for correspondence:
Marek Łuciuk
Department of Maxillo-Facial Surgery Wroclaw Medical University
Borowska 213 50-556 Wrocław Poland E-mail: marekl.00@wp.pl Received: 21.06.2013 Revised: 24.09.2013 accepted: 27.09.2013
Praca wpłynęła do Redakcji: 21.06.2013 r. Po recenzji: 24.09.2013 r.
