clinical caSE - Dental and Medical Problems

clinical CASE
Dent. Med. Probl. 2013, 50, 3, 369–372
ISSN 1644-387X
© Copyright by Wroclaw Medical University
and Polish Dental Society
Marek Łuciuk1, 2, A–D, Dariusz Łuciuk3, B–D, Józef Andrzej Komorski1, A–C, E, F
Tooth in the Tongue – Case Report
Ząb w języku – opis przypadku
Department of Maxillo-Facial Surgery, Wroclaw Medical University, Wrocław, Poland
Department of Otolaryngology, Head and Neck Surgery, Wroclaw Medical University, Wrocław, Poland
3
Department of Cardiology, Wroclaw Medical University, Wrocław, Poland
1
2
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 common 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 przyjętego 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.
There are many reasons explaining why foreign bodies can be found penetrating into the tissues 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 injuries associated with losing consciousness or injuries sustained under the influence of alcohol or
drugs [1–3].
In another group there are injuries associated with practicing different sports. These damag-
370
es are mainly connected to the jaw and/or mandible, injuries of anterior teeth with punctured fragments 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 consciousness or as a result of epilepsy. In all of these cases there is always the possibility of penetration of
different foreign bodies or dense tissues of the human body – like bone or tooth – deep into the surrounding soft tissues. We can find most fragments
of the broken tooth in the lower and upper lip tissues [5–9] or in the tongue tissues [10]. This article 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 foreign material, such as fishbone, [11] part of the incisor 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 dislocated 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 situation can be quite difficult or even impossible to
achieve because of the extent of damage, drug intoxication 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 tomography and magnetic resonance is very helpful [1].
When dealing with metal substances or dense tissues, such as bones or teeth (with the X-ray contrast), the method of choice is an X-ray in various projections. The best method of diagnosing
foreign bodies in the soft tissues is an ultrasound
study or X-ray. Non-healing wounds, chronic infections or local abscesses are typical complications and first symptoms of an undiagnosed foreign body in the soft tissues. The main causes why
foreign bodies might be overlooked in the soft tissues 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 patient [2]. Therefore, besides carefully treating the
surgical wounds after face and neck traumas, it is
obligatory to make a precise anamnesis of the circumstances of the injury, assess the structure of
M. Łuciuk, D. Łuciuk, J. Komorski
the foreign material, select the appropriate laboratory tests and do an accurate physical examination of the patient.
A Case Report
A 66-year-old man was admitted to the hospital 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 Emergency 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 appeared “strange” symptoms on the tongue – tenderness, swelling without the typical features of
local inflammation. The patient reported to the
Clinic of Maxillofacial Surgery. A careful anamnesis 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
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Tooth in the Tongue – a Case Report
sis sutured. Antibiotic prophylaxis for five days was
recommended according to the guidelines. After
10 days the patient reported to the Clinic for routine control. The wound was healing properly and
the stitches were removed. The patient was scheduled for further control visits in the 1st, 3rd and
6th month. Surgical treatment was completed.
Discussion
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
Most dental traumas occur in the first decades
of life, mainly at the age of 2–3 and 8–12 [18]. Factors such as age, sex, direction and force of impact,
periodontal status of the patient are equally important 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 primarily by the patient or the family doctor [10, 11].
This article describes a different situation
where a permanent tooth in an adult male was totally dislocated and was lodged in the deep tissues
of the tongue. There are many types of complications resulting from this kind of injury, including infection, vessels and nerves damages, foreign
body aspiration into the bronchial tree, etc. [11].
Proper procedure in this case should include accurate anamnesis, physical examination, execution of additional 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 antibiotic treatment as there were no signs of infection.
However, antibiotics were prescribed as recommended [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 patient. A potentially harmless superficial wound of
the tongue was hiding a tooth in its deep structures. A foreign body could be diagnosed only as
a result of a detailed anamnesis, careful physical
examination of the patient and implemented diagnostic imaging. To get the best final results, it is
also recommended to treat wounds in accordance
with the guidelines for the initial treatment of facial 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 number of teeth and any differences in them before
and after the injury. Examination of the patient,
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M. Łuciuk, D. Łuciuk, J. Komorski
who suffered injury in the facial skeleton in unclear circumstances, requires an interdisciplinary
approach [5, 6, 10]. According to the literature, the
opinions about the using of antibiotics after surgery 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 intervention [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 susceptible 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 reattachment 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 malignancy. 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: [email protected]
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.
Zaakceptowano do druku: 27.09.2013 r.