Swallowed partial denture in severe intellectual disability patient

Abstract

Swallowed partial dentures in elderly patients is an emergency situation that requires a swift response. Here, we report a case involving a patient with severe intellectual disability who swallowed his denture, which lodged at the oesophagus inlet. After failure of endoscopic removal, denture with clasp was removed using long forceps through intraoral approach under intravenous sedation. At the pharynx and oesophagus inlet level, removal of foreign body via intraoral approach should be preferentially considered over open surgery for faster patient recovery.

Background

Edentulous elderly patients are often fitted with dentures, which is a relatively cost-friendly option. Because tooth loss leads to alveolar bone resorption and gingival recession, dentures become loose after ≥1 year of use, and prolonged use can cause motor and sensory nerves to become desensitised.¹ Sleeping with dentures can cause damage to the gingival tissue and accelerate bone resorption because the tissue is not given time to relax.² Loosening of denture is also seen when the abutting teeth anchoring the clasp become loose or extracted.³ This can then lead to accidental denture ingestion, which is an emergency situation that requires a swift response. The authors report a case involving a patient with intellectual disability who swallowed his denture, which lodged at the oesophagus inlet and was removed using forceps under intravenous sedation, after a failed attempt at endoscopic removal.

Case presentation

A 62-year-old man with intellectual disability and no significant medical history, who had been bedridden in a nursing facility for several years, presented to the emergency room with dysphagia. The patient had been using an upper partial denture for 10 years, wearing it during the day and while sleeping. The caregiver checked the patient’s condition at 06:00 on the day of the hospital visit and found that his denture was missing. Because it was not found around the bed area and the patient was drooling, with his mouth open and groaning while grabbing his neck as if in pain, the caregiver assumed that the patient swallowed it and brought him to the hospital.

Investigations

Chest X-ray revealed the presence of the denture at the oesophagus inlet (figure 1); accordingly, an emergency call was made to a gastroenterologist to attempt endoscopic removal. The denture was lodged at the oesophagus inlet and attempts to remove it were made using a grasp and snare technique (figure 2); however, the denture clasp was so tightly fixed to the mucosal wall that it could not be removed. The otolaryngology department was consulted to plan for surgical removal.

Figure 1.

The skiagram of the neck (lateral view). Radiological appearance of the impacted foreign body.

Figure 2.

Endoscopic examination showed a denture with clasp. Endoscopic removal was tried with graspin and snare forceps, but it was failed.

Treatment

The patient was transferred to the operating room 4 hours after admission to the emergency room. Because the foreign body was partially obstructing the vocal cord, surgery was performed after sodium thiopental sedation without intubation. The patient weighed 63 kg and thiopental sodium was administered as an initial bolus dose of 3 mg/kg. A McIvor retractor was applied in Rose position to expose the pyriform sinus and oesophagus inlet. Because the denture clasp was firmly embedded in the pyriform sinus wall, the clasp was grasped using a long Kelly forceps to remove it from the wall, and the full denture was then pulled out using a twisting motion. Once the patient was confirmed to be stable after intubation, minimal bleeding in the pharyngeal wall was controlled and the surgery was completed (figure 3).

Figure 3.

Extraction of denture via intraoral approach.

Outcome and follow-up

After surgery, the patient exhibited stable vital signs and no longer complained of pain. A soft diet was attempted 24 hours later and was tolerable; as such, the patient was discharged and moved to the previous nursing facility. One week later, he made an outpatient visit for fibrescopic examination, which revealed that the surgical site was well-healed, and the caregiver reported no significant complaints by the patient. The caregiver was instructed that the extracted denture should be assessed by the prosthodontist to assess the integrity and to certify fitness for re-use by the patient in future.

Discussion

Oesophageal foreign body is more common in children than in adults. Infants most commonly swallow coins by accident while playing, and adults often experience fishbones caught in their throat while eating.⁴ Adults with mental illness/disability, however, can accidentally ingest various foreign bodies such as spoons and toothbrushes.⁵ Denture ingestion by older individuals with impaired mastication has also been reported.⁶

The oesophagus has three regions of physiological constriction: at the top of the oesophagus, where the oesophagus and laryngopharynx join behind the cartilage; where the oesophagus crosses in front of the aortic arch and the left main bronchus; and the oesophageal hiatus, where it passes through the diaphragm. Foreign bodies mostly become lodged in one of these three locations.⁷ The most common site of denture impaction is the oesophagus.⁶ Oesophageal foreign bodies can cause dysphagia and sometimes dyspnoea if the foreign body presses on the tracheal wall. If not removed early, it can even damage the oesophageal wall, causing mediastinitis or abscess.⁸ In particular, the sharp denture clasp can cause mucosal erosion, oesophageal perforation and severe complications; as such, a swift response is necessary.⁹

In healthy adults, the larynx functions, to a certain extent, as a protective sphincter to prevent foreign body aspiration. In patients who experience cerebrovascular accident or those with severe intellectual disability, various bodily reflexes, such as the gag reflex, are impaired and, thus, accidental denture swallowing often occurs.¹⁰ These patients are often diagnosed late and experience complications because they are not able to communicate their thoughts accurately. Small dentures can easily be removed via endoscopic techniques; however, in the case of larger-size dentures or clasp embedded in the oesophagus, surgical treatment, such as oesophagotomy, is required.¹¹

In the present case, the size of the denture was not small and the caregiver quickly suspected denture swallowing. The patient had a radiopaque clasp in the denture; hence, the diagnosis was made easily based on plain film radiographs; therefore, surgical treatment was not delayed. Clinician may face difficulties with dentures made of radiolucent materials that are not clearly visible on radiographs.

Blood tests revealed no sign of infection and the patient was able to recover from surgery without problems. When approaching a lodged denture endoscopically, the use of instruments is limited, and it may be difficult to grasp the denture properly and exert pressure. At the pharynx and oesophagus inlet level, the foreign body can be approached through the oral cavity; thus, removal using various forceps should be preferentially considered over open surgery for faster patient recovery. In the case of mentally disabled elderly individuals who use dentures due to various underlying diseases, education about accidental swallowing must be administered regularly. In particular, elderly patients with a swallowing disorder are at a higher risk for denture swallowing and may require more care. Moreover, caregivers should always consider the possibility of accidental foreign body swallowing and devote close attention to evaluate patient condition accurately. If symptoms such as dysphagia and odynophagia persist, accidental swallowing should be suspected and prompt treatment is required.

Learning points.

• In patients who experience cerebrovascular accident or those with severe intellectual disability, the gag reflex is impaired and, thus, accidental denture swallowing often occurs.

• In the case of mentally disabled elderly individuals who use dentures, education about accidental swallowing must be administered regularly.

• At the pharynx and oesophagus inlet level, the foreign body can be approached through intraoral approach; thus, removal using various forceps should be preferentially considered over open surgery for faster patient recovery.