Accidental swallowing of an endodontic file

To report the management of an iatrogenic incident in which an endodontic file was swallowed accidentally and passed into the gastrointestinal tract.

A 51-year-old male swallowed a 21 mm, size 30 endodontic file during root canal treatment without rubber dam. In the absence of clinical complications, the patient was reviewed with serial chest and abdominal radiographs, and stool tests for occult blood until the instrument was discharged at 3 days. This report discusses early differential diagnosis for locating foreign bodies and underlines the importance of serial radiographic evaluation for signs of foreign body migration.

The use of rubber dam is mandatory for patient safety during root canal treatment. Early location of an inhaled or ingested foreign body facilitates appropriate and timely treatment management and referral. When a foreign body passes into the gastrointestinal tract, clinical symptoms and signs should be monitored closely until it is excreted or removed. An endodontic file can pass through the gastrointestinal tract asymptomatically and apparently atraumatically within 3 days.