JRSM >
Volume 97, Number 2 >
Pp. 72-75
Department of Otolaryngology, James Paget Hospital, Lowestoft Road, Gorleston,
Great Yarmouth NR31 6LA
1 Department of Prosthodontics, GKT Dental Institute, London, UK
Correspondence to: Mr S M Hashmi E-mail: s.hashmi1{at}ntlworld.com
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| INTRODUCTION |
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| CASE HISTORIES |
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Case 2
A man aged 60, attending casualty after taking a drug overdose, complained
of sore throat with mild discomfort on swallowing. There was no clear history
of foreign body ingestion and he was able to drink. The lateral soft tissue
neck X-ray and chest X-ray were unremarkable. An initial fibreoptic
laryngopharyngoscopy was normal, but on later review the patient indicated
that he might have swallowed his denture. Fibreoptic nasendoscopy again showed
a normal hypopharynx with no pooling of saliva. The scope was passed into the
oesophagus where the denture was found to be lying transversely. The patient
then underwent a rigid oesophagoscopy with removal of the denture
(Figure 1) and recovered
without incident.
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Case 3
A man of 57 was referred for an opinion in relation to a legal claim
against his dentist. He had been fitted with an acrylic immediate replacement
lower partial denture carrying three incisor teeth that had soon become very
loose and uncomfortable, particularly when the patient was eating. He was
advised by the dentist to persist in eating with the denture since he would
become accustomed to it and it would 'tighten up' with use. A
specific reassurance was also given that the denture was too large to swallow
(it was 4 cm wide with a maximum depth of 3 cm). However, the denture did
lodge in the patient's throat while he was swallowing a drink and by the
time he reached casualty it had entered the oesophagus. As the prosthesis did
not show on a radiograph and could not be retrieved with the aid of an
oesophagoscope, laparotomy and gastrotomy had to be undertaken before the it
could be retrieved (Figure
2).
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At the time of case 3, telephone enquiries to dental advisers at UK protection societies suggested that any medicolegal consequences of swallowed dentures were infrequent. In relation to other categories of claim, this may well be so. However, one adviser subsequently reviewed his society's database to find that, in the period 1977–2003, a total of 26 claims were made against dental practitioners in respect of swallowed dentures (Phillips MW, personal communication). Although the database was not always specific as to whether the denture was partial or complete, the published work suggests that most would have been partial. In addition to the swallowed dentures, 3 complaints relating to inhaled dentures had also been received. It was of particular note that 47% of the swallowed-denture complaints specifically cited failure in diagnosis. Of the 13 cases that were now closed, 6 had resulted in payment to the claimant.
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Early diagnosis and treatment will avoid the oedematous reaction and mucosal infection and necrosis that heighten the risk of rigid oesophagoscopy.10 Reported late complications of the undiagnosed swallowed denture include extraluminal migration from the oesophagus causing either a diverticulum11 or perforation12 (once a perforation has occurred, further severe sequelae may be anticipated, e.g. tracheo-oesophageal fistula13), the need to resect 18 cm of ileum,14 enterocolonic fistula15 and sigmoid colon perforation16,17.
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Although a plain X-ray may well not identify a swallowed denture, the investigation has been recommended to exclude pneumomediastinum or gas within the soft tissues.18 A soft-tissue exposure is more likely to suggest the presence of a plastic denture than a standard exposure but, as with our experience in case 2, cannot be relied upon. Similarly a barium contrast medium before radiography is seldom helpful since it will coat all sides of a radiolucent object. Also, barium swallows can make subsequent endoscopy more difficult.19
Despite the many calls for use of radio-opaque denture base materials20–27 no such product seems available in the UK. The abridged published version of the report prepared by Brauer for the American Dental Association28 is an excellent source of information on the subject. At the time it was written, 1981, no plastic radio-opaque material was commercially available with physical properties, appearance and ease of handling to match those in radiolucent products. The amount of heavy metal salts and glass fillers that needed to be incorporated was sufficient to weaken the material, thereby increasing the possibility of fracture and the risk of swallowing a denture fragment. These inclusions also affected the appearance of the material.
Tsoa et al.29 conducted a clinical evaluation which, they claimed, validated the acceptability of a radioopaque acrylic that was available at the time. Their favourable conclusion was based on the finding of continuing radio-opacity of dentures after 5 years and that those patients who responded to the recall found their dentures 'reasonably satisfying'. However, only 22 of the original 102 patients attended for the recall, so we know nothing about the fate of the remaining eighty sets of dentures. Later work29,30 investigated the use of 40% poly(2,3-dibromopropylmethacrylate), introduced into the poly(methylmethacrylate) to render the denture base plastic radio-opaque. Because bromine was incorporated into the polymeric structure rather than present as a filler, the strength of the material was less affected. The material does not seem to have been marketed, possibly because of concerns that the halide might have cancer-inducing potential.
All metal partial dentures are readily detected on standard radiographs, but this fact did not prevent one epileptic patient from carrying such a prosthesis in the pyriform sinus for eleven months while a series of doctors tried to resolve his complaints of choking, dyspnoea and dysphagia.3 Metal components in a plastic denture, such as wire retainers or clasps, will also aid location on a radiograph. Clasps should render a partial denture less likely to dislodge but require regular review and maintenance for continuing efficiency. If swallowed, such components are likely to damage the gut lining.6,12
Denture labelling, to prevent the prosthesis entering the wrong mouth, is of value especially in a care home.31 Although this is a separate issue from the radiological location of swallowed dentures, both purposes could be served by the use of an embedded metal foil identity tag system in plastic denture bases.32 However, more than one tag may be required to counter the possibility that the denture may fracture in use and only one part be swallowed.
Acrylic dentures are more likely to be discernible by CT, since the process is more sensitive to small changes in X-ray attenuation, than by plain radiography.33,34 They can also be shown by MRI, the difficulty being access to MRI equipment in an emergency.
Direct visualization of a swallowed denture with a flexible or rigid endoscope is possible while the prosthesis remains in the hypopharynx or oesophagus. Examination with a fibre-optic instrument is more readily undertaken but, as our experience shows, not totally reliable. Although early oesophagoscopy has been recommended, the procedure is still not without the risk of perforation.10,35. Oesophagoscopy may miss the denture and Youngs et al.36 described a case in which rigid oesophagoscopy failed to identify a prosthesis that had passed into an extraluminal position.
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The hazard of the small 'side plate' has long been recognized.37 Alternatives include conventional bridgework, resin-bonded bridgework (where it is desirable to restrict the preparation of abutment teeth) and implant-borne bridges.38 There remains the possibility that such fixed prostheses will become detached and swallowed39 but, because they are smaller, have metal components and lack features liable to engage and traumatize the gut wall, such an event is less likely to cause the complications of a swallowed denture.
Where a removable denture has to be provided, it should be designed in such a manner as to render it retentive and stable. This consideration is of particular importance in treatment planning for the epileptic patient and those with learning difficulties. The minimal complete lower denture base reduces both the size and the stability of the denture. For the partial denture, the principles of retention (direct and indirect) and cross-arch bracing are particularly important. Checking over the dentures and undertaking necessary maintenance should be part of the regular dental recall/review process for the patient. Apart from the denture swallowing risk (and for reasons of overall dental health), patients should be advised not to wear dentures at night.
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The patient should be advised on the wearing and care of their dentures and the need to return regularly for maintenance.
Care workers need to know that certain individuals will be unable to perceive or report the disappearance of a denture; they should be alert to the possibility of swallowing or inhalation.
Medical personnel, especially those called upon to manage emergencies, should likewise be aware of the multiple hazards.
| Acknowledgments |
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