Aspirated Tooth in a Child Following Traditional (Non-Clinical) Extraction: A Rare Complication with Delayed Referral in the Right Bronchus — A Case Report

Background

Aspiration of a foreign body into the trachea and bronchi is more common in children, particularly boys under the age of three, although it can also occur in adults.¹ Early diagnosis and treatment are crucial to avoid complications such as pneumonia, bronchial obstruction, and long-term lung damage.² Choking remains a leading cause of death in children under 14 years of age.³

The most common aspirated items are organic in origin, such as nuts, seeds, berries, and grains, although inhalation of dental instruments and natural teeth has also been reported.^4–6 Foreign bodies can be broadly divided into organic and inorganic types: organic FBs (eg, bones, meat, fruits, vegetables, and seeds) are the most frequent and often cause more complications due to swelling and inflammatory reactions, while inorganic FBs (eg, coins, pins, screws, and plastic objects) are less reactive but may still result in airway obstruction or trauma.⁷

Auscultatory findings in foreign body aspiration typically include localized wheeze, diminished breath sounds, or stridor on the affected side.⁸ Radiopaque foreign bodies are visible on plain radiographs, allowing direct detection and localization, whereas radiolucent foreign bodies are not directly seen and are instead diagnosed through indirect signs such as air-trapping, atelectasis, or soft tissue changes.⁹

We present a rare case in which a 9-year-old child aspirated a tooth during a traditional, non-instrumental extraction. The case is further notable for the delayed referral from Kismayo to Mogadishu, where the tooth was ultimately retrieved from the right main bronchus at MSTH.

Case Presentation

A 9-year-old girl was referred to MSTH for a persistent cough and progressive shortness of breath. These symptoms occurred after a tooth was extracted in the family’s home using traditional hand-based techniques. No suction, airway protection, or appropriate tools were in use.

During the procedure, the child coughed suddenly and had respiratory distress. The family suspected that the tooth had been aspirated. She was brought to the closest hospital in Kismayo, where no effort at extraction was made because of a shortage of tools and skilled staff. After that, she was sent to Shafi Hospital in Somalia’s capital, Mogadishu, where she received supportive care. After an unsuccessful attempt to remove the aspirated tooth, she was moved to MSTH, our tertiary hospital.

A radiopaque substance in the right main bronchus was discovered by a thorax CT scan at Shafi Hospital, which was compatible with an aspirated tooth. An attempt to get rid of it failed. After that, the patient was referred to our hospital, MSTH.

Upon arrival, the child was stable but had decreased air entry in the right lung. We did a confirmatory chest X-ray Figure 1. Under general anesthesia, a rigid bronchoscopy was performed to successfully remove the aspirated tooth from the right main bronchus. Figure 2. The procedure was smooth and we repeated the chest x-ray, which was normal. Figure 3.

Figure 1 Posteroanterior chest radiograph demonstrating a radiopaque foreign body (blue arrow) lodged in the right main bronchus, consistent with an aspirated tooth.

Figure 2 Gross image of the extracted foreign body — a human tooth retrieved from the right main bronchus during flexible bronchoscopy.

Figure 3 Post-bronchoscopy chest radiograph demonstrating complete resolution of the previously noted right bronchial foreign body, with normalization of lung aeration and mediastinal alignment. No residual radiopaque object, atelectasis, or air-trapping is observed.

The child had a smooth post-operative course and was discharged in good condition on postoperative day 2.

Discussion

Our case involves a 9-year-old female, which contradicts previous studies showing that foreign body aspiration is more common in children, particularly males under the age of three.¹ Tooth aspiration is a rare and extremely dangerous situation. If it is not identified and treated promptly, it can result in significant morbidity and mortality in children. The situation in our case was made worse by the delayed referral from Kismayo to Mogadishu (approximately 410–480 km), due to lack of resources and trained personnel.

The likelihood of aspiration was increased since the tooth extraction was performed by hand using traditional methods. In many regions of Somalia, where access to modern dental treatment is limited, traditional dentistry is still widely practiced. Such practices lack proper instruments, aseptic precautions, and airway protection, making children particularly vulnerable to complications.

Cases of dental (or other foreign body) aspiration reported in the literature show varied symptoms, including nonproductive cough, shortness of breath, wheezing, hemoptysis, cyanosis, or even complete absence of symptoms.² Auscultatory findings typically include unilateral wheeze, diminished breath sounds, or stridor, depending on the site and degree of obstruction.³ Failure to diagnose foreign body aspiration can result in recurrent atelectasis, chest infection, emphysema, or even misdiagnosis as asthma.¹⁰

Most reported cases of tooth aspiration occur during intraoral procedures such as dental extractions under anesthesia, adenotonsillectomy, and other oropharyngeal manipulations, where reduced protective airway reflexes increase the risk of aspiration.^6,11,12 Trauma may also result in tooth dislodgement and aspiration, especially in unconscious or semiconscious individuals.¹³

Foreign bodies can be organic or inorganic. Organic FBs (such as seeds, nuts, or meat) tend to swell and elicit marked inflammatory reactions in the airway, often causing severe obstruction and post-obstructive pneumonia. Inorganic FBs (such as coins, pins, or teeth) do not swell but can still cause airway blockage and mucosal trauma.⁷ Importantly, teeth are radiopaque, which usually facilitates diagnosis on plain radiographs or CT scans. In contrast, radiolucent FBs (such as food boluses or plastic) are harder to visualize and are often only suspected through indirect signs such as atelectasis or air-trapping.^9,14

Misdiagnosis or inappropriate management of patients with FBA prolongs symptoms, increases complication rates, and raises healthcare costs before the correct diagnosis is established.¹⁵

Late-stage diagnosis of foreign body aspiration—often resulting from vague symptoms, normal early radiographs, and delayed referral—greatly increases therapeutic challenges and may necessitate more invasive interventions. Such delays also heighten the risk of complications, prolong recovery, and significantly impact overall patient outcomes.¹⁶

In cases where foreign body aspiration is diagnosed at a late stage, therapeutic intervention becomes more complex, often requiring prolonged bronchoscopy, repeated procedures, or even surgical retrieval due to advanced airway inflammation and obstruction.^15,16

The right main bronchus is the most common site of foreign body aspiration in both children and adults due to its larger diameter and more vertical orientation.¹³ This was consistent with our case, where the tooth was impacted in the right bronchus. CT imaging helped localize the foreign body, but definitive management required rigid bronchoscopy. Rigid bronchoscopy remains the gold standard for foreign body removal, allowing direct visualization, airway control, and safe extraction even in pediatric patients.¹⁴

This case underscores the dual challenges of foreign body aspiration in low-resource settings: the persistence of traditional dental practices and the impact of delayed referral on outcomes. Public health education, stricter regulation of non-clinical tooth extraction, and improved access to trained personnel and bronchoscopy facilities are critical to reducing morbidity and mortality.

The case highlights the need for public health education and dental care regulation in avoiding serious complications from traditional nonmedical methods. It also serves as a reminder to physicians to consider foreign body aspiration in the differential diagnosis of acute respiratory symptoms in contexts where informal hand-based tooth extraction is still prevalent. It also underlines the significance of caution during tooth extractions in children, stronger referral networks, and improved equipment and training in rural and other areas that are in need.

Conclusion

Aspiration of a tooth during the traditional hand-based technique, which is unusual and extremely rare, illustrates an unusual setting for tooth aspiration, and tooth extraction was performed outside of a medical setting. This procedure is still popular in many low-resource or rural communities and can result in major consequences. This example highlights the importance of early detection, adequate imaging, and rigid bronchoscopy in such cases. Raising awareness and updating healthcare infrastructure are crucial to decreasing and improving outcomes in such events.