Embedded toothbrush foreign body in cheek--report of an unusual case.
BACKGROUND: Toothbrush injuries are common in children, and those
of impalement and embedded injuries are the more serious. CASE REPORT: A
five-year-old girl presented with a complaint of a swelling affecting
the left side of her face and with difficulty in opening her mouth for
the previous 15 days. She gave a history of a fall while brushing her
teeth. A foreign body (head of a toothbrush) located adjacent to the
mandibular ramus was identified with the help of a CT scan. TREATMENT:
The foreign body was located by surgical exploration and retrieved. An
extra-oral sinus that was present was excised and the resulting defect
was reconstructed using a Limberg flap. FOLLOW-UP: Healing was
uneventful during the follow-up period. After 18 months the child's
mouth had completely healed although some extra-oral scarring was
present. CONCLUSION: When dealing with children reporting for evaluation
following trauma while tooth brushing, a thorough evaluation is
essential for embedded foreign bodies.
Key words: child, toothbrush, embedded injury, Limberg flap
|Article Type:||Case study|
Foreign bodies (Medical care)
Foreign bodies (Medical care) (Diagnosis)
Toothbrushes (Health aspects)
Tooth diseases (Risk factors)
Tooth diseases (Diagnosis)
Tooth diseases (Care and treatment)
Tooth diseases (Patient outcomes)
Tooth diseases (Case studies)
|Publication:||Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300|
|Issue:||Date: Oct, 2011 Source Volume: 12 Source Issue: 5|
|Product:||Product Code: 3991321 Toothbrushes NAICS Code: 339994 Broom, Brush, and Mop Manufacturing SIC Code: 3991 Brooms and brushes|
|Geographic:||Geographic Scope: India Geographic Code: 9INDI India|
Traumatic injuries arising from the use of a toothbrush in the oral cavity are common in young children. They are often ignored because of trivial clinical features that usually only involve the gingiva. Generally, these injuries occur from rigorous movement of the toothbrush by a child. In children, these injuries are more common when compared with the adult population because their manual dexterity is less developed and they brush vigorously. Traumatic injuries involving toothbrush damage in the oral cavity [Ebenezer et al., 2007] and oropharyngeal wall [Sasaki et al., 2006] have been reported in children. The spectrum of possible injuries ranges from minor blunt abrasions or injuries as a result of embedding broken pieces of toothbrush. A case is presented herein in which the head of a toothbrush was embedded in the cheek of a five-year-old girl.
Trauma history A five-year-old girl reported to the outpatients' department of Sri Siddhartha Dental College, (Tumkur, India) with a complaint of a swelling involving the left side of her face and with difficulty in opening her mouth. The history indicated this had lasted for the previous 15 days. She complained that the facial swelling had progressively increased in size and extra-oral drainage of clear fluid had started from a sinus for the past five days. A full history revealed that she had fallen down while brushing her teeth in the courtyard of her family's house after which she had bleeding from her mouth. She was treated at a primary care centre where the intra-oral bleeding was arrested by local application of pressure.
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She was prescribed analgesics by the primary care worker and was referred to a general dentist. However, her parents, considering the condition to be a minor problem, arising simply as the result of a fall, had neglected the situation and delayed visiting a dentist for follow-up care. As days progressed their child's condition worsened. As a result the parents and child eventually sought further dental care at our centre.
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Medical history This recorded a normal healthy 5-year-old child with no past medical problems. Growth and development were assessed as normal.
Extra-oral examination An extra-oral clinical examination revealed a diffuse extra-oral swelling on the left lower third of her face of approximate size 8 x 5 cms. There was also an extraoral draining sinus of diameter 6-7 mm, located approximately 3 cms distal to the corner of her mouth (Figure 1) giving an impression of sub-massetric and submandibular space infection. The area around the sinus was indurated. Her mouth opening was severely restricted (4 mm).
Intra-oral examination This showed a full set of primary teeth. Intra-orally there was a wound of approximate size 1 x 1.5 cms, with sloughing. Palpation of the affected area indicated the presence of a hard mass in the left buccal mucosa. A foreign body in the buccal mucosa being suspected the child was referred for a CT scan.
Radiographic assessment The child's CT scan revealed the presence of rows of circular radio-opaque foreign bodies adjacent to the mandibular ramus on the lateral aspect (Figure 2). This was suggestive of a head of a toothbrush embedded in the tissues.
Diagnosis Any odontogenic focus of infection was ruled out. A diagnosis of probable injury involving an embedded foreign body was made and that this was likely to be part of a toothbrush.
Under general anaesthesia blunt dissection was carried out through the entry wound. The broken end of the toothbrush was exposed and retrieved completely (Figure 3a). The intra-oral wound was debrided and closed with 4-0 vicryl sutures. Extra-orally the sinus opening was excised and the defect was closed using a Limberg flap [Chasmar, 2007], as shown in (Figure 3b).
Wound healed was uneventfully. On recall initially after two weeks the child's jaw function was found to have been restored to normal. At a further follow-up, after 18 months full speech, eating and swallowing was normal however extra-oral scarring was present (Figure 4) and the patient was discharged back to her regular general dentist for continuing dental care.
Cases of traumatic injury [Ebenezer et al., 2007], accidental swallowing of a toothbrush [Chao and Chao, 2008; Lu et al., 2008], toothbrush as a foreign body causing oropharyngeal trauma [Sasaki et al., 2006; Kumar et al., 2008] have been reported. Implantation of a head of a toothbrush with bristles in the soft tissue medial to the ramus [Oza et al., 2002] has also been reported.
Kumar and co-workers,  have proposed a classification of oral injuries caused by toothbrush damage, as noted by orthopantomograms (OPT). A suggested classification of such injuries is:
* Blunt injury: where there is no mucosal break or perforation,
* Penetrating injury: where there is deep laceration/deep perforation of the soft tissues but the toothbrush has been already removed from the wound,
* Impalement injuries: toothbrush is impacted within the tissues because of the fish hooking of bristles,
* Embedded injuries: head of the toothbrush breaks and is retained deep within the tissues.
In the case reported here the embedded type of injury was noted with a toothbrush head being located lateral to the ramus and complicated by the development of an extra-oral sinus. The main treatment aim was, therefore, to remove the impacted foreign body, to restore the mouth opening to normal and achieve full oral functions. In addition, excision of the sinus tract with the aesthetic reconstruction of the residual defect was a further requirement.
A Limberg flap (LF) [Chasmar, 2007] was used for the closure of the defect. LF that is also called a rhomboid flap, is a transposition flap with good vascularity. It has been used for coverage of various defects throughout the body, and can be used on the face with good results. Cases have been reported of using LF on the face for closure of small defects resulting from surgical treatment of basal cell carcinoma, cystic acne, and kerato acanthoma [Chasmar, 2007]. In the case herein the LF was for the closure of the sinus defect after excision of the extra-oral sinus, with encouraging results, thus making LF a reliable option for reconstruction of small facial defects.
When presented with a child with oro-facial trauma it is imperative to take a thorough case history and to check meticulously for retained pieces of toothbrush as well as tooth fragments or other foreign bodies. In cases reporting with a history of trauma from a possible toothbrush injury early diagnosis is needed to avoid complications arising from these retained foreign bodies.
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Chasmar LR. The versatile rhomboid (Limberg) flap. Can J Plast Surg 2007;15:67-71.
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Kumar S, Gupta R, Arora R, Saxena S. Severe oropharyngeal trauma caused by toothbrush--case report and review of 13 cases. Br Dent J. 2008;205:443-447.
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Sasaki T, Toriumi S, Asakage T et al. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatr. 2006;118:e1284-1286.
R. Sathish *, S. Suhas *, G. Gayathri **, G. Ravikumar *, L. Chandrashekar *, T. L. Omprakash *
* Oral and Maxillofacial Surgery, ** Oral Medicine and Radiology Sri Siddhartha Dental College, Tumkur, India.
Postal address: Dr. R. Sathish . Department of Oral and Maxillofacial Surgery, Sri Siddhartha Dental College , BH Road, Agalkote, Tumkur 572107, Karnataka, India.
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