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A6784 - Aspiration of Dental Molding in a Patient with Extensive Lung Disease: A Need for Intervention
Author Block: J. Centeno1, A. Iftikhar2, A. Adial3, R. Thomas1, R. Levy1; 1New York Presbyterian Queens, Flushing, NY, United States, 2New York Presbyterian Queens, Roslyn, NY, United States, 3New York Presbyterian Queens, Fairview, NJ, United States.
Introduction:   The nature of aspirated foreign bodies are highly variable, but common amongst children. However, it can occur in the adult population especially in the elderly, mentally impaired, and substance abuse. Aspiration of foreign contents in dentistry occurs rarely, but radiographic studies are typically helpful to visualize where contents are lodged. In addition, foreign body aspiration can be subtle and may present as respiratory failure. We present a case of an elderly male who presented with hypoxic respiratory failure, later found to have a right mainstem foreign body after bronchoscopy was performed because of multiple failed spontaneous breathing trials.  
Case:  88 year old male with past medical history of COPD, bronchiectasis, history of mycobacterium avium complex infection (MAC), right upper lobectomy, presented after the family noted patient to be in respiratory distress and unresponsive. On presentation to the ED patient was emergently intubated. CT scan of lung showed a left lower lobe nodule measuring 1.4cm with a region of cystic bronchiectasis and surrounding inflammation.  He was started on vancomycin, cefepime, flagyl for pneumonia, but had repetitive failure of weaning trials. He underwent bronchoscopy which a foreign body was successfully removed using a claw grasper. Retrospectively family reported he was being fitted for dentures two days prior to the event.  Afterwards, there was a significant decrease in secretions, and he was successfully extubated.
Discussion: The most commonly aspirated objects are food items, the second predominant group of aspirated objects consists of dental equipment or prostheses. Foreign body aspiration is common in children with acute or recurrent pulmonary symptoms, but is rarely considered in adults with subacute or chronic respiratory symptoms, unless there was a clear history of an aspiration event.  Our patient had a significant past medical history of COPD, MAC, bronchiectasis, previous lobectomy, and pulmonary fibrosis. A foreign body did not appear in the radiographic studies, but the persistent secretions and failed spontaneous breathing trials led to a bronchoscopy procedure and removal of the denture molding. This foreign body was causing significant distress due to underlying pathology in the left lung which had multiple areas of atelectasis, scarring, and fibrosis. Incidence of all foreign bodies in dentistry is 3.6-27.7%, with a considerably higher incidence in adults than children. Adults may aspirate any foreign body usually as a result of careless rapid eating, and diagnosis may be delayed from 24 hours to one month in 47% patients, and even up to a year in some cases. This case highlights the importance of having a broad differential in order to address any possible cause for respiratory decompensation and to have a low threshold for intervention once conservative strategies are refractory.