According to findings in the Dental Professional Liability Claim Report: 3^rd Edition (3^rd Edition Report)[1], swallowed/aspirated object injuries represent a growing concern in dentistry. Ideally, such “never events” should be extremely rare occurrences. However, swallowed/aspirated object cases now represent 7.5 percent of closed claims with indemnity payments of $10,000 or more.

Furthermore, the average total incurred (indemnity plus claim-related expenses) increased 24.1 percent to $89,358 since the previous claim report.[2]
 
Swallowed or aspirated object incidents may immediately result in a life-threatening medical emergency. Or, patients may initially experience mild and short-lived symptoms. Patients may even be asymptomatic after swallowing or aspirating an object, followed by severe complications weeks or months after the incident. Individual cases can and do lead to severe losses and liability. While foreign body aspirations are less common than ingestions, the potential consequences and medical care required are often considerably more serious.
 

Claim Study

Practitioner: General dentist practitioner (GP)
Claimant: Male patient, aged 78 years with a history of compromised pulmonary function (smoking X 50+ years, chronic obstructive pulmonary disease [COPD], emphysema and hypertension)
Risk management topics: Inadequate precautions to prevent injury; swallowed/aspirated object prevention; post‑event management; documentation and communication; team emergency readiness
 

Facts

The GP delivered a maxillary full‑arch all‑on‑four prosthesis about a year before the incident. The patient presented with an acrylic fracture of the prosthesis in the right posterior segment, necessitating an open‑tray impression in preparation for prosthesis repair. During placement of the impression coping screw in the #9 region, the screw slipped from the GP’s fingers and fell toward the oropharynx.
 
The patient was immediately brought to an upright sitting position, and he coughed for approximately five minutes, initially reporting that he could feel the object in his throat. The sensation then resolved and he tolerated sips of water. After recovering, the patient returned to the dental chair and the appointment proceeded to completion.
 
The dentist then advised that the object may have been swallowed or aspirated. The GP strongly recommended imaging to determine the object’s location and whether medical intervention would be necessary. The office offered to transport the patient or to call a family member, but the patient elected to drive himself to the imaging center.
 
Subsequent medical care confirmed aspiration of the screw. After two failed bronchoscopy attempts, the patient required surgical removal of the foreign body, accomplished by resection of the lower portion of a lung lobe. Recovery included approximately two weeks in the hospital intensive care unit followed by a period of rehabilitation after discharge.
 

Analysis

The patient did not file suit but did seek legal counsel to assist with presenting a demand for damages due to significant out-of-pocket medical expenses. An initial standard of care review concluded that adequate precautions were not employed to prevent aspiration during screw placement. In particular, the dentist reviewer highlighted the absence of a pharyngeal gauze throat drape (throat pack) and failure to maintain a more upright chair position during the procedure as overlooked safe practice opportunities. The dental patient healthcare record did not describe use of any other preventive measures, such as the presence of continuous high‑velocity evacuation (HVE) with dental assistant support and/or use of dental floss or other means to tether the object.
 
The insured GP strongly disagreed that the standard of care required a throat pack and/or other measures. In fact, the GP stated that he never used a throat pack for this procedure. As a result, defense sought expert opinions from a periodontist and an oral surgeon with significant implant experience. The periodontist indicated that, given the known risk of swallowing or aspirating small components, the patient’s throat and airway should always be protected by means of a throat pack or dental dam, depending on the procedure. Additional or alternate preventive measures may be needed for patients who are restless, have a strong gag reflex, etc.
 
The oral surgeon agreed that throat packs are widely considered to represent the standard of care. However, using a more upright chair position and employing other preventive measures also may meet the standard of care. He stated that dropping a screw is a known risk and not a standard of care breach. He further opined that the dentist took appropriate action after the incident and that continuing and finishing the procedure was reasonable under the circumstances. However, since the patient did aspirate the screw and the GP did not document any preventive measures, defending the case would be challenging or impossible if the patient filed a lawsuit.

Although the patient considered filing a lawsuit and demanding the $1,000,000 policy limit in damages, he did not do so. The patient stated that he liked and respected the GP and understood that accidents can happen to anyone. As a result, the patient, through his attorney, requested a settlement of $650,000 by a specified date. He felt this was sufficient to cover out-of-pocket medical expenses and compensation for his mental anguish, pain, and suffering.
 

Outcome

The medical treatment and recovery required initial imaging, emergency room care, hospital admission with two unsuccessful bronchoscopies, followed by surgical foreign‑body removal with partial lung resection. The patient spent approximately two weeks in the ICU, followed by post‑acute rehabilitation. Given the facts and standard of care opinions, the defense team recommended to settle the case by the patient’s deadline, and the GP agreed to do so.
 

Risk Management Considerations and Takeaways

1. Plan isolation for small-component procedures. Use a dental dam when possible. Use a pharyngeal gauze throat drape (modified for gaggers as needed); maintain assistant‑held HVE; consider floss ligatures on small parts and drivers when practical; and employ upright or modified head positioning to enhance safety.
2. If an object is lost toward the oropharynx assume aspiration until ruled out. Stop treatment, assess the airway, and facilitate prompt imaging/medical evaluation. Arrange accompanied or EMS transport based on symptoms rather than allowing an unaccompanied patient to drive.
3. Document comprehensively. Record the who/what/when/where/how, patient statements/symptoms, object description (type, size, manufacturer if known), recommendations, referrals, follow‑up contacts, and final resolution. Use informed refusal documentation if a patient declines recommendations.
4. Train and drill. Maintain team competence in basic life support, including Heimlich maneuver and airway emergency response. Rehearse an office protocol for swallowed/aspirated objects along with other emergency scenarios.
5. Balance feasibility with necessity. While bite props and other aids may improve access and stability, they do not replace a throat pack or dental dam when small, detachable components are manipulated. Tailoring isolation to the patient’s tolerance may be necessary but document your risk‑benefit rationale, along with extra precautions taken for individual patients.

Swallowed or aspirated object incidents continue to be a source of both frequent and costly claims that may lead to severe patient outcomes. The injuries alleged by patients have included but are not limited to mental anguish, subsequent surgical procedures/trauma, infection, and death.
 
Some risks are inherent to providing dental care. However, remaining focused on prevention and safe practices will help to minimize the occurrence of adverse events in your practice, and bolster your defense should one occur.
 
Article by: Ronald Zentz, RPh, DDS, FAGD, CPHRM
CNA Dental Risk Control
 
Disclaimer:
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