Journal of Investigative and Clinical Dentistry (2011), 2, 148150

CASE REPORT

Potential danger of toothbrushes for children

R.M. Lalitha, K. Ranganath, Kavitha Prasad, Khemraj Agrawal & Mahendra Perumal
Department of Oral and Maxillofacial Surgery, M.S. Ramaiah Dental College and Hospital, Bangalore, Karnataka, India

Keywords impaction, injury, safety, toothbrush. Correspondence Dr Khemraj Agrawal, Department of Oral and Maxillofacial Surgery, M.S. Ramaiah Dental College and Hospital, Bangalore, Karnataka 560054, India. Tel: +91-9008747560 Email: khemusonu@yahoo.co.in Received 23 October 2009; accepted 24 January 2010. doi: 10.1111/j.2041-1626.2010.00002.x

Abstract Toothbrush, the innocent cleaning aid, has been reported to cause life threatening oropharyngeal injuries in pediatric literature. A case of a 4-year-old child reporting to an emergency department with a toothbrush impaled in her mouth while her father was forcefully brushing her teeth is reported here. Hemostasis was achieved by digital pressure and the impaled toothbrush was removed surgically. Uneventful recovery was noted. Parental anxiety and a lack of patient cooperation was noted. Such impaled objects fractured and left behind have been reported to cause serious space infections and mediastinitus. Advising parents to be careful with their childrens toothbrush is important as prevention of injuries from such commonly used object could be easily achieved.

Introduction The toothbrush is an ubiquitous device. Because of its purpose and shape, there is a hazard associated with its use (or misuse) by children. There have been a number of documented cases in the pediatric literature of potentially lifethreatening penetrating oropharyngeal trauma associated with the toothbrush1 (and other similarly shaped common instruments, such as pens, pencils, and chopsticks). Toothbrush swallowing by bulimics attempting to induce vomiting, and the subsequent trauma associated with this, has also been reported.2,3 Literature contains case reports of children injuring themselves while playing with toothbrushes in their mouths.2 This paper presents a case report of a 4-year-old girl who was injured when a toothbrush became embedded to the buccal tissues. Materials and methods Case report A 4-year-old girl was brought to casualty at M.S. Ramaiah Medical and Teaching Hospital by her parents 2 h after the girl was injured with a toothbrush, which penetrated into her oral mucosa. Vital signs of the patient were within the normal range. Upon examination, a childs toothbrush was observed to be hanging out of the oral cavity of the patient and she was crying in pain
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Figure 1. Childs toothbrush hanging out of the oral cavity of the child.

(Figure 1). Intraoral irrigation and continuous suctioning were performed. The intraoral examination revealed a penetrating injury in the right buccal mucosa with a childs toothbrush. Two-thirds of the toothbrushs head was inside the buccal tissues, and the wound was actively bleeding (Figure 2). The patients father explained that he was brushing the childs teeth forcefully and the child suddenly moved. The parents tried to retrieve the
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Potential danger of toothbrushes for children

Figure 4. Superior surface of toothbrush. Figure 2. Two-thirds of the toothbrushs head penetrating into the buccal tissues.

toothbrush, but failed to do so because there was profuse bleeding. Management Thorough irrigation was performed with isotonic saline. Topical anesthesia was applied, and local inltration was given with 2% lignocaine containing adrenaline (1:200 000). Mucosal laceration was dissected bluntly to relieve the toothbrush from the surrounding tissues. The toothbrush retrieved successfully from the buccal tissues. The anteroposterior wound was extending from the occlusal surface of the maxillary rst molar up to the anterior border of ramus, and medially in severed muscle layers (Figure 3). Bleeding was controlled with digital pressure. The wound was irrigated with saline and closed

with sutures in layers with 4-0 Vicryl. Figure 4 shows the retrieved toothbrush head. The patient was discharged with a prescription of antibiotics, analgesics, and mouthwash, and was reviewed after 1 week. Intraoral healing was normal, and the patient did not have any trismus. Discussion There are many reports in literature which show a variety of penetrating injuries in buccal tissues both intraorally and extraorally.3,4 Penetrating injuries with bullets, metal pieces, windshields, and wood have been reported in the literature.2 Adhikari and Chacko reported a similar case of a penetrating toothbrush in buccal mucosa of a young boy.2 Sudip and Tapan reported a case of a foreign body in buccal tissues with buccal space infection.4 That foreign body was found to be a broken head of toothbrush in the buccal tissues. Kumar reported a case of a tooth brush in the rectum.5 Law et al. described two cases of toothbrush injuries in the soft palate and anterior faucial pillar, which resulted in mediastinitis and a retropharyngeal abscess, respectively.3 Grochowski and Hynes reported a case of a toothbrush being lodged in the oropharynxperipharyngeal tissues of an 18 month old who fell down while learning to brush his teeth.1 Goyal and Suhas presented a case of a 6-year-old boy with a history of soft tissue injury caused by a toothbrush, the snapped head of which lodged into the medial aspect of the right ramus of the mandible.6 Potentially serious sequelae following an injury of this nature are not rare. These include a deep neck abscess, wide spread emphysemas, internal carotid thrombosis, and stroke. These kinds of penetrating injuries should be examined carefully. Airways, breathing, and circulation should be
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Figure 3. Intraoral wound.

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R.M. Lalitha et al.

maintained. Bleeding should be arrested. The patient should be evaluated for neurological signs and symptoms. Antibiotics should be used judiciously for the management of infection. The opinion of an otolaryngologist and pediatrician should be taken as and when needed. Conclusion In the pediatric patient, parental anxiety and lack of patient cooperation are additional factors that the oral and maxillofacial surgeon must contend with. However, proper examination and debridement with appropriate

surgical care is necessary in managing a child patient, especially with an emergency condition like this. The parents of our case-study patient were advised not forcefully brush the teeth of the child so that accidental injuries could be prevented in future. The toothbrush should be treated as a potentially dangerous instrument, and very young children should be supervised while brushing their teeth. Children should not be allowed to play with any object in the oral cavity. The phrase Dont run with that in your mouth is often voiced too late after an object in a childs mouth suddenly gets jammed against something rm. As with many accidents, prevention and education are still important to this issue.

References
1 Grochowski J, Hynes B. A toddler with a pharyngeal foreign body. Can Fam Physician 2008; 54: 16956. 2 Adhikari DD, Ebenezer J, Chacko RK, Matthew GC. An unusual injury from a tooth brush: a case report.

J Indian Soc Pedod Prevent Dent 2007; 25: 2002. 3 Law RC, Fouque CA, Angus W, Eleri C. Lesson of the week: penetrating intra-oral trauma in children. BMJ 1997; 314: 50. 4 Sudip S, Tapan A. Unusual foreign body in buccal spacea case report.

J Maxillofac Oral Surg 2008; 7: 3945. 5 Kumar M. Dont forget your tooth brush. Br Dent J 2001; 191: 278. 6 Goyal S, Suhas S. Traumatic injury from a tooth brush: an unusual hazard of oral hygiene. J Oral Health Comm Dent 2009; 3: 189.

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