Al-Wahadni A, Al-Hamad KQ, Al-Tarawneh A. Foreign body ingestion and aspiration in dentistry: a review of the literature and reports of three cases. Dent Update. 2006; 33:561-570
Nwaorgu OG, Onakoya PA, Sogebi OA Esophageal impacted dentures. J Nat Med Assoc. 2004; 96:1350-1353
Okoye BCC, Erefah AZT. Oesophageal foreign bodies in Port Harcourt, Nigeria. J Med Investig Pract. 2001; 2:62-64
Ashoor AA, Al Momen A. Foreign bodies of the oesophagus: a two-year prospective study. Ann Saudi Med. 2000; 20:173-175
Abdullah BJ, Teong LK, Mahadevan J Dental prosthesis ingested and impacted in the esophagus and orolaryngopharynx. J Otolaryngol. 1998; 27:190-194
Jones NS, Lannigana FJ, Salamaa NY. Foreign bodies in the throat: a prospective study of 388 cases. J Laryngol Otol. 1991; 105:104-108
Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg. 1978; 65:5-9
Matheson I. Foreign bodies in the oesophagus: a review of six hundred and two cases. J Laryngol Otol. 1949; 63:435-445
Asif M, Shah SA, Khan F Analysis of tracheobronchial foreign bodies with respect to sex, age, type and presentation. J Ayub Med Coll Abbottabad. 2007; 19:13-15
Fitri F, Fitria H. Removal of foreign body (denture) in esophagus with rigid esophagoscope. Jurnal Kesehatan Andalas. 2012; 1:92-97
Bandyopadhyay S, Dhua D, Maity PK The adventure of two dentures. J Assoc Phys India. 2012; 60
Patel PH, Slesser AAP, Idaikkadar P Delayed presentation of a small bowel perforation secondary to an ingested denture. J Roy Soc Med Short Reports. 2012; 3
Gallas M, Blanco M, Martinez-Ares D Unnoticed swallowing of a unilateral removable partial denture. Gerodontology. 2012; 29:e1198-e1200
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Khan MAI, Miah MT, Mahbub MS Unusual precordial pain by impacted denture. J Med. 2011; 12:58-60
Tihan D, Trabulu D, Altunkaya A Esophageal perforation due to inadvertent swallowing of a dental prosthesis. Turk J Gastroent. 2011; 22:529-533
Odigie VI, Yusufu LMD, Abur P Broncho-oesophageal fistula (BOF) secondary to missing partial denture in an alcoholic in a low resource country. Oman Med J. 2011; 26:50-52
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Loose or fractured dentures may be displaced towards the back of the mouth into the pharynx and become ingested or inhaled. The consequences of denture impaction on a patient's health can be severe, both short-term and long-term. Diagnosis and treatment can be challenging, therefore an understanding of the incidence, risk factors, symptoms and management of risk factors is important to reduce the occurrence of denture impaction in the aero-digestive system. This article includes an overview of the related literature and highlights the importance of managing risks and the importance of good denture design and appropriate maintenance.
Clinical Relevance: Dentists need to be aware of risk factors and harmful effects associated with inhaled and swallowed dentures to help minimize the incidence.
Article
Cases where various types of dental objects, including dental bridges and an orthodontic band, have been swallowed have been described by Al-Wahadni et al.1 Loose or fractured dentures may also be displaced towards the back of the oral cavity into the pharynx and become ingested or inhaled. Denture impaction in the gastrointestinal or respiratory tract is uncommon, however, the consequences of denture impaction on a patient's health can be severe both short-term and long-term.
This article describes the incidence, harmful effects and risk factors associated with denture impaction in the aero-digestive system. Preventive measures that should help to reduce the risk of inhalation and ingestion are also discussed.
In order to obtain information on incidence and harmful effects, an electronic search was performed on Google Scholar and PubMed databases using the search terms ‘swallowed denture’ and ‘inhaled denture’. The search yielded 184 relevant articles. References from the articles were not used to extend the search. Of the 184 articles, 16 were case series, 160 were case reports, 3 were review articles and 5 were biomaterials research related to radio-opaque denture base materials.
Of the 16 case series articles found in the search, 15 related to all types of foreign body impaction and one described only denture impaction. One of the case series articles related to inhaled foreign bodies and 15 described swallowed foreign bodies.
Incidence
The case series study that focused exclusively on impacted dentures revealed that the incidence of swallowed dentures was greater in males (72.7%) than females (27.3%).2
The relative incidence of denture impaction of dentures compared with other objects was described in 7 of the case series articles. Further information about these case series is given in Table 1. The incidence of swallowed dentures in comparison with other types of object ranged from 0% to 11.5%, although in most studies the incidence was below 5%. The incidence of inhaled dentures compared with other types of foreign body in the study of Asif et al was 1.2%.9
There were 137 case reports relating to swallowed dentures published between 1909–2012 and 22 case reports relating to inhaled denture published between 1973–2011. In the last 5 years, 21 case reports have been published describing swallowed dentures and 5 describing inhaled dentures.
Tables 2 and 3 give details of the case reports of swallowed dentures and inhaled dentures, respectively, published within the last five years.
The relative number of both case series and case reports supports the view that swallowing dentures is more common than inhaling them. The studies also show that the oesophagus is the most common site of impaction. Females are less likely to swallow or inhale a denture than males. Middle-aged males are particularly at risk. Partial dentures were more frequently inhaled and ingested than complete dentures and maxillary prostheses slightly more likely to be impacted than mandibular dentures. The case reports note that radiography could only detect and locate the dentures with metal components.
Harmful effects
The harmful effects that arise from an impacted denture can be described as immediate effects, medium-term effects and long-term effects.
Immediate effects
An immediate effect of a denture impacted in the trachea is airway obstruction. As the oesophagus lies directly in front of the trachea, impaction in the oesophagus can also compromise the airway. This can lead to asphyxiation if the impacted fragment is not removed in sufficient time. Furthermore, attempted retrieval of the denture fragment can cause further impaction and airway obstruction. The fragment can prevent ventilation equipment passing down the airway, thus complicating emergency treatment.
Medium-term effects
Medium-term effects of denture impaction include pain, dysphagia and bleeding from the digestive or airway tract mucosa. This can signify ulceration, damage to blood vessels and even perforation of the body cavity wall. These symptoms can occur within hours or days after denture impaction. When these symptoms occur, it is important to diagnose and treat the patient quickly as patients can deteriorate rapidly. Perforation of the oesophagus by a foreign body is associated with a mortality rate as high as 30%.27
Long-term effects
Long-term complications arise when diagnosis and treatment are delayed. The oral bacteria present on the denture can cause serious infections leading to tissue necrosis, spreading infection and septicaemia. Perforation through the digestive or airway tract wall can create a fistula19 Severe long-term complications may necessitate the need to remove the part of the body cavity that has been damaged surgically.29
Symptoms, diagnosis and treatment
Symptoms
Symptoms of an impacted denture vary depending on whether it is in the digestive tract or the airway. Initial common symptoms of an inhaled denture include localized pain, coughing, wheezing, shortness of breath, haemoptysis and pyrexia. Some patients can become cyanotic. If a denture has been ingested, common symptoms include localized pain, dysphagia, odynophagia, sialorrhoea, food regurgitation and haematemesis.
In most cases patients are aware of either swallowing or inhaling a denture fragment. However, owing to reduced mental capacity, or level of consciousness (ie sleep or unconsciousness) at time of impaction, it is possible for some patients to be unaware of denture impaction. Generally, the symptoms of denture impaction occur immediately; however, there have been reports of symptoms appearing years after unrecognized denture impaction.28
Diagnosis
Diagnosis should be made as early as possible to reduce serious complications, therefore if impaction is suspected patients should seek immediate help from their general practitioner or an accident and emergency department.
Investigations such as radiography and endoscopy are used to help locate the denture fragment; however, both methods of investigation have significant disadvantages.
Radiographs only detect tissues and objects that are radio-opaque (Figure 1). Poly(methylmethacrylate) (acrylic resin) is a radiolucent material. As most dentures contain significant portions of acrylic resin or are made entirely of acrylic resin, the detection of impacted dentures on x-ray films is difficult. This can significantly delay diagnosis and treatment. One study showed 33% of impacted dentures were detectable by radiographic investigation. This was, however, because each of the dentures contained a metal component.5
Figure 1. Radiograph of a partial metal/acrylic denture impacted in the oesophagus.
Endoscopic examination can cause further impaction of the denture, can itself cause perforation28 and, in some cases, can still not locate the position of the denture.14
Treatment
Treatment of an impacted denture can be complicated. In some cases, the denture can be hooked out of the oesophagus or trachea using endoscopy. The risk of this treatment option is further impaction or perforation. If removal is not successful or possible with endoscopy, open surgery is required. Surgery carries a risk of permanent scarring and organ damage. Both surgery and endoscopic retrieval require general anaesthesia, which itself caries a mortality risk. Some of the more serious cases have reported the need to remove significant portions of the oesophagus surgically due to complications.30
Risk factors
Patient risk factors
The study of foreign bodies in the oesophagus showed that older patients are at high risk of foreign body ingestion and that 50% of adult patients who swallowed foreign bodies have psychiatric histories.30 It has been suggested that, if a patient presents with symptoms of foreign body ingestion or inhalation and is missing natural teeth, denture impaction should be considered.31 Other associations or risk factors evident in the literature are loose dentures, wearing dentures whilst sleeping, alcohol and drug intoxication and loss of consciousness. Denture impaction is also a risk in traumatic accidents (such as road traffic accidents and sport injuries).
Denture risk factors
Size
The size of the denture is important. Smaller denture designs, such as unilateral removable partial dentures, single tooth removable dentures and small flexible partial dentures are more likely to be swallowed or inhaled.
Small unilateral dentures should not be provided if possible. The Dental Defence Union and Dental Protection organizations both advise that, if there is an adverse incident, practitioners must justify their treatment planning and decisions regarding the way that treatment is provided. The decision to provide a small unilateral partial denture in acrylic resin or any other plastic material might be difficult if not impossible to defend, whether before the General Dental Council in the UK or in a court of law.
Several case studies have described impactions of relatively large mandibular partial dentures32 and even mandibular complete denture can enter the oropharynx ‘end-on’ and rotate vertically down the oesophagus or trachea.
Clasps
Clasps provide better direct retention but can cause soft tissue damage if impaction occurs. As most clasps are metal, they can be detected on radiographs, which makes locating them easier. However, if a denture containing clasps becomes impacted, the damage to the internal soft tissues can be severe. Injuries from the sharp clasps include laceration, perforation and serious infection from the oral bacteria on the denture clasp.12
Thickness
The thickness of a denture base is important, as thicker bases are stronger. A significant proportion of impactions occur when dentures fracture and the smaller fragments are swallowed or inhaled.25 Although thick bases are difficult for patients to tolerate, an adequate base thickness should be ensured.
Radio-opaque material
Radio-opaque materials, as discussed above, are more likely to be located on radiographs, which hasten the time for diagnosis and treatment.
Prevention
Denture design
Although a denture does not have to be small to be swallowed or inhaled, it is important to minimize the risk as much as possible. A removable denture must be designed to offer maximum retention and stability to prevent displacement. This should include optimal retention (direct and indirect) and cross-arch bracing. Small unilateral designs should be avoided.
Radio-opaque acrylic denture materials were developed through the addition of radio-opaque glass powder to poly(methylmethacrylate). Unfortunately, these materials have not been successful due to poor handling properties, fracture resistance and surface finish.32 These products are not available for use in the UK.
Radio-opaque inserts in the form of metal foil embedded in the acrylic have been recommended to improve location on radiographs.33 It is suggested that more than one tag may be required in case the denture fractures and one fragment is swallowed.
Patient selection
It is important to consider whether a patient has a high risk of swallowing or inhaling dentures when providing dentures. However, it is impossible to avoid providing dentures to all patients in the high-risk groups. Appropriate treatment planning and possible treatment alternatives (eg bridges/implants) or no dentures may be preferred for these patients.
Advice on wearing dentures
All denture-wearing patients and carers should be warned of the risk of ingestion or inhalation. Patients should be encouraged to visit the dentist for regular check-ups to assess the condition of their dentures and allow for regular denture maintenance. If a patient's denture is fractured, it should be replaced/repaired as soon as possible and the patient must be advised not to wear it. Patients should be advised to take their dentures out at night, during contact sports or in high-risk situations, such as water sports.
Conclusions
Swallowing and inhaling dentures is not common but can be a serious adverse event. All denture-wearing patients and carers should be warned of the risk of ingestion or inhalation. Patient selection is important; however, making dentures for patients in the high risk groups is sometimes unavoidable. Advice to patients wearing dentures should include regular dental visits and removal of dentures at night and during physical activities such as contact sports. To reduce the risk of denture impaction still further, dentures should be designed in a manner that is robust, retentive and stable. Small dentures should be avoided whenever possible.
