Prosthesis Complications in Elderly Patients: A Case of a Swallowed Overdenture

Total edentulism, a condition defined as the loss of all dentition, is a worldwide phenomenon. According to the World Health Organization criteria, edentulous patients are considered physically impaired, disabled, and handicapped because of their inability to masticate and speak properly.¹ Tooth replacement is conducted to improve masticatory efficiency and esthetics, reduce overeruption and drifting of unopposed teeth, and restore phonetics.²

According to the literature, around 20% of the population wears dentures.² The consequence of a growing number of people wearing dentures is a proportionate increase in the incidence of their dislodgement from the gums.³ Serious systemic complications may result if dentures are swallowed or aspirated, as this can lead to airway obstruction, esophageal perforation, and bowel obstruction or perforation; also, long-standing denture impaction can result in serious problems such as trachea-esophageal fistula and neck abscess.⁴

Ingested sharp foreign bodies can be potentially problematic when lodged in the esophagus, and in such cases, patients will often require emergency endoscopy. Usually, if the sharp object is within reach of the endoscopy, it can be removed before it progresses further.⁵ Such ingestions are a multidisciplinary problem that may involve such disciplines as surgery, dentistry, endoscopy, otolaryngology, anesthesiology, psychiatry, neurology, thoracic surgery, and emergency medicine.⁶ From a dentist's standpoint, possible complications of prosthetic rehabilitation in edentulous patients include episodes of inhalation or ingestion of a denture.^2,4,6

The following case report describes the swallowing of an overdenture by an elderly patient, who would undergo endoscopic removal of the foreign body.

The patient was a 95-year-old man, with a remote medical history of chronic obstructive pulmonary disease (COPD) treated in low-flow domiciliary oxygen therapy, hypertension, peripheral artery disease, diabetes, and edentulism. The patient was admitted to the emergency ward after dislocation and non-intentional ingestion of his maxillary full-arch dental prosthesis. On admission the patient presented with respiratory distress, inspiratory stridor, hoarseness, sialorrhea, and dysphagia. He appeared disoriented but was cooperative (Glasgow Coma Scale = 14), with no anxiety or psycho-motorial agitation. Vital parameters were: blood pressure 125/70 mmHg, heart rate 65 beats per minute, body temperature 36.4°C (97.5°F), and oxygen saturation sustained around 93% in oxygen therapy 3 liters per minute.

On physical examination there was no evidence of neck emphysema or any evidence of foreign bodies, and there were no bleeding signs in the oral cavity. Inspection of the edentulous jaw confirmed the absence of fixed implantation and the maxillary dental prosthesis dislocation.

The initial approach involved the use of a rigid laryngoscope, which revealed the foreign body impacted in hypopharyngeal lumen. Frontal and lateral radiographs of the neck identified the complete denture positioning anteriorly to the projection of vertebral bodies C3 through C5 (Figure 1 and Figure 2). The distal arch of the prosthesis was in correspondence with cricoid cartilage.

Because of progressive respiratory failure, with oxygen saturation at 89%, and considering the age of the patient, an esophagogastroduodenoscopy, or EGD, was performed in an emergency setting. The procedure was carried out with anesthesiologic support, under deep sedation provided intravenously. The patient was positioned in the left lateral decubitus position, and an endoscopic attempt was performed with a standard flexible instrument.

At first endoscopic sight, the dental prosthesis was noted to be embedded in the hypopharynx, over vocal cords, and its mobilization appeared very complicated. The first three dental units were visible, occupying the entire hypopharynx-upper esophageal lumen (Figure 3).

The dislodging of the prosthesis was carried out with a diathermic loop. The button-hole was positioned taking advantage of the sulcus between the first and second dental units, tucked up, and locked around the first unit of the dental arch. Gentle retraction was performed under endoscopic vision, with a good sliding of the full-arch prosthesis.

At the end of the procedure, the endoscopic check was negative for lesions of the mucosa (Figure 4). All 14 dental units on the prosthesis were present and accounted for.

A gastrographic swallow study on postoperative day 1 confirmed a regular transit and no signs of perforation; the patient was allowed a semisolid diet. A repeat endoscopy at 1 month follow-up showed a regular esophageal mucosa.

The accidental presence of foreign bodies in the aerodigestive tract is not all that uncommon. In adults and the elderly population, foreign body ingestion occurs especially in individuals who have a psychiatric disorder, are alcoholic, have mental retardation, or are a denture wearer.^6,7 The most commonly swallowed foreign bodies among adults are fish bones (9% to 45%), bones other than fish bones (8% to 40%), and dentures (4% to 18%).⁸ Artificial dentures are the most common objects ingested by elderly patients. Moreover, accidental ingestion of foreign bodies has reportedly been increasing in recent years because of an aging society, and accidental ingestion of dentures has risen by about twofold.⁸

Studies have shown that the major complaints among almost a third of edentulous patients wearing dentures involved their stability and retention.³ A recent report revealed that eating, maxillofacial trauma, and dental treatment procedures are the main reasons for an aspirated tooth or denture, and although ethanol intoxication, dementia, stroke, and epilepsy are predisposing factors, most cases occur in patients with no known risks.⁹

Factors predisposing to denture dislodgement from the gums and impaction into the esophagus include inappropriate denture fabrication, prolonged usage, and failure of patients in keeping appointments for dental clinic follow-up evaluations, especially when the denture becomes unstable.⁸ Male gender is generally more predisposed to this problem than the female gender, with 71.4% prevalence in males. This may indicate that females are more conscious of their health and tend to take care of their dentures better than males through regular medical and dental check-ups. Smoking, with its associated nicotine-induced poor mucosal sensations, is also more prevalent among males.³

Most reported cases of accidental swallowing of dentures are related to food ingestion.¹⁰ The anatomical sites of obstruction, in descending order, are the upper esophageal sphincter (cricopharyngeal area), aortic arch, lower esophageal sphincter (diaphragmatic hiatus), pylorus, and ileocecal valve.^7,8 The most common anatomical sites for a denture to be lodged are the esophagus, hypopharynx, or larynx.^2,6 Denture impaction in the small bowel is a rare phenomenon.⁶ The passage through the duodenum depends on the diameter and length of the ingested foreign body. Foreign bodies longer than 6 cm and with a diameter of more than 2.5 cm pass the duodenum with difficulty.⁸

Swallowed and aspirated dentures are responsible for significant morbidity and occasional mortality.² Gastrointestinal tract perforation is the most common cause of generalized peritonitis and pneumoperitoneum.⁷ Dentures impacted in different parts of the gastrointestinal tract lead to various complications that may require surgery, including perforation, bleeding, and obstruction.⁸ Esophageal perforation is a potentially life-threatening condition with high morbidity and mortality (>20% of cases), and foreign body ingestion is a common cause of perforation (3% to 35% of cases).^11-13

Endoscopic removal of foreign bodies in the aerodigestive tract using rigid scopes under general anesthesia is considered the gold standard for treatment; however, there have been reports of patients requiring tracheotomy for removal.⁹ If an object remains motionless for 3 days in the intestine or 1 week in the stomach, surgery will likely be required.⁸ The mean time of occurrence of perforation after ingestion of a sharp foreign object is 10.4 days.⁷

Dentures are a unique type of foreign body that require the awareness of different medical specialists. In addition to removable dentures, fixed dentures are also at high risk of aspiration and ingestion, especially if they are unstable. Early diagnosis and treatment are vital in the management of swallowed or aspirated dentures. Patients with loose removable or fixed dentures should be recommended to visit their dentists immediately and have them checked. Adequate follow-up after the insertion of dentures or prostheses is essential, especially with elderly patients, in order to avoid accidental dislodgement and potential dangerous consequences.

Luigi Tagliatesta, DDS
Specialist in Oral Surgery, Department of Biomedical, Surgical and Dental Sciences, Head of Pediatric Oral Surgery Unit, Santi Paolo and Carlo Hospital, University of Milan, Milan, Italy

Matteo Arcari, DDS
Resident in Oral Surgery, Department of Biomedical, Surgical and Dental Sciences, Unit of Oral Surgery, Santi Paolo and Carlo Hospital, University of Milan, Milan, Italy

Laura Porcheddu
Dentistry Student, Department of Biomedical, Surgical and Dental Sciences, Unit ofPediatric Oral Surgery, Santi Paolo and Carlo Hospital, University of Milan, Milan, Italy

Marco Lorenzoni, DDS
Resident in Oral Surgery, Department of Biomedical, Surgical and Dental Sciences, Unit of Oral Surgery, Santi Paolo and Carlo Hospital, University of Milan, Milan, Italy

Stefano Siboni, MD
Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, Division of General and Foregut Surgery, University of Milan, San Donato Milanese (MI), Italy