Year : 2007 | Volume
: 25 | Issue : 4 | Page : 200--202
An unusual injury from a toothbrush: A case report
J Ebenezer1, DD Adhikari2, GC Mathew1, RK Chacko1,
1 Department of Dental and Oral Surgery, Christian Medical College, Vellore - 632 004, India
2 Department of Child Health, Christian Medical College, Vellore - 632 004, India
Department of Dental and Oral Surgery, Christian Medical College and Hospital, Vellore, Tamilnadu 632 004
The use of toothbrushes has significantly improved oral hygiene. However, if brushing of the teeth is not done judiciously, it could result in severe trauma to the soft tissues of the oral cavity. This is particularly true in the young age group, since children tend to be very playful while brushing their teeth. This article describes the case report of a child who sustained a penetrating injury while brushing his teeth. A detailed plan for the management of such injuries is also presented.
|How to cite this article:|
Ebenezer J, Adhikari D D, Mathew G C, Chacko R K. An unusual injury from a toothbrush: A case report.J Indian Soc Pedod Prev Dent 2007;25:200-202
|How to cite this URL:|
Ebenezer J, Adhikari D D, Mathew G C, Chacko R K. An unusual injury from a toothbrush: A case report. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2021 Sep 16 ];25:200-202
Available from: https://www.jisppd.com/text.asp?2007/25/4/200/37019
Ever since its invention, the toothbrush has played a vital role in the maintenance of oral health and dental hygiene. Dentists throughout the world advocate the regular use of the toothbrush. While the use of toothbrushes has significantly reduced the incidence of dental caries and periodontitis, there has also been a relative increase in the risk of injury to dental tissues, primarily due to improper brushing techniques, and also due to trauma to the soft tissues during the act of brushing.
This paper presents a case report where a toothbrush traumatized the buccal soft tissues so severely that the brush got embedded inside the buccal mucosa and required surgical intervention for its removal.
A young boy slipped and fell in his house while brushing his teeth. The boy reported that he was playing with his sister while brushing. He fell with the tooth brush in his mouth, causing the bristle portion of the brush to be embedded in the buccal mucosa on the left side. The child reported to the emergency medical department and after an initial evaluation by the casualty medical officer, was referred to our department with the tooth brush still in his mouth.
In out-patient department, the patient was sitting quietly without any obvious distress, with the handle of the tooth brush projecting horizontally forward from his mouth [Figure 1]. The child was in good health and was cooperative. The vital signs were normal. There was a small amount of saliva drooling from his mouth but no active bleeding was present. Extraorally a tender bulge was present on the posterior aspect of his left cheek [Figure 2]. Intraorally, the bristle portion, up to the neck of the toothbrush, could not be seen, indicating a deep impaction [Figure 3]. The brush had penetrated the left buccal mucosa at the lower left first molar level and was lying superficial to the masseter muscle. The extraoral bulge on the left cheek was caused by the toothbrush, which was lying just underneath the skin and fascia. Initially, gentle force was used to remove the toothbrush. However, the patient had severe pain and so, after administering a local anesthetic, an incision was placed at the site of the impaction. After gaining access to the embedded bristle portion, the toothbrush was removed by using an elevator and gently dissecting the bristles from the soft tissues [Figure 4]. The wound was copiously irrigated with sterile saline solution and sutures were placed. The patient was discharged and oral antibiotics were prescribed. One week later, the wound had healed well and there were no further complaints.
Even though the toothbrush is indispensable for oral hygiene, its use in children carries the risk of trauma to the oral tissues. Injuries caused by toothbrushes to the soft tissues of the oral cavity appear to occur in children who have slipped and fallen down with the toothbrush inside their mouth.  In such cases, the brush can cause penetrating injuries in the buccal soft tissues or in the pharynx. Some of these injuries can cause serious complications, such as abscess or mediastinitis. 
The literature contains case reports where pharyngeal injuries (caused by objects held in the mouth) have resulted in thrombosis, hematomas, and death due to trauma to the internal carotid artery.  Law et al.  described two cases of children falling with the toothbrush in their mouths, causing injuries to the soft palate and the anterior faucial pillar; the soft palatal injury progressed to mediastinitis, while the faucial pillar injury progressed to a retropharyngeal abscess. Both these patients were less than 3 years of age and had to be put on mechanically assisted ventilation for at least a week. 
Moran  reported a case of a toothbrush injury sustained by a 2-year-old boy when the child fell down with the toothbrush in his mouth, resulting in the brush being embedded in the buccal mucosa. Another case report  is also documented in which the broken head of the toothbrush was implanted medial to the ramus at the region of the pterygomandibular space. In this case, the child had sustained an injury over his cheek with a cricket ball while brushing his teeth outside the house.
The penetrating injuries can result in serious complications, all patients who present with such injuries should be examined immediately for:
Signs of airway obstructionBleeding from mucosal tears/lacerationNeurological changes, such as alterations in mental status and nausea/vomitingSigns of an acute infection, such as swellings of the soft tissue or pyrexia
Patients with any of these symptoms may be admitted and treated accordingly. 
If these symptoms are not apparent and the toothbrush is embedded in the buccal soft tissues, it can be removed under local anesthesia on the dental chair, provided the patient is cooperative. The brush should not be removed with a single jerk but the embedded bristles should be carefully dissected off the surrounding soft tissues. Otherwise there is a risk of tearing the adjacent blood vessels.
When the toothbrush has penetrated the pharyngeal tissues, it can be removed via a wide incision to access the toothbrush. This procedure is preferably done under general anesthesia. If trauma to the internal carotid artery is suspected, it is necessary to refer the patient to the appropriate specialists. 
After removal of the toothbrush hemostasis should always be evaluated. Failure to do so could lead to the formation of a hematoma or bleeding into the deeper tissue spaces, which could be fatal. Suturing of the wound should be done taking into consideration the size of the laceration and the length of the incision made to release the toothbrush. Antibiotics must also be administered along with a dose of tetanus toxoid injection. After discharge, the patient should be reviewed closely for several days as complications could take upto 72 hours to manifest. 
In concluding, we would like to emphasize the following points:
Children should always be supervised when brushing their teeth and should not be allowed to walk or run with any object in their mouth.Penetrating injuries to the soft tissues of the oral cavity should be considered as potentially serious and the object should be removed from the wound only in a controlled environment.Post-trauma monitoring is essential even if the initial injury appears to be minor, as complications may not manifest immediately. 
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