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BMJ Case Rep. 2010; 2010: bcr10.2009.2401.
Published online Jan 13, 2010. doi:  10.1136/bcr.10.2009.2401
PMCID: PMC3028143
Unusual presentation of more common disease/injury
Delayed presentation of a swallowed partial denture
Kevin N Kulendra,1 Christopher J Skilbeck,1 John Blythe,2 and Dennis I Choa1
1Royal National Throat Nose and Ear Hospital, Grays Inn Road, London WC1X 8DA, UK
2Southampton General Hospital, Oral and Maxillofacial Surgery, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
Kevin N Kulendra, knk79/at/blueyonder.co.uk
Abstract
We report a unique case of a young patient who accidentally swallowed his partial denture and alarmingly only presented to our ear, nose and throat (ENT) department 4 weeks later despite several previous presentations to primary and secondary care. The partial denture was successfully removed under general anaesthetic using direct laryngoscopy following admission. He was discharged on a normal diet 6 days later after oesophageal perforation was excluded using a contrast swallow.
Accidental swallowing and aspiration of dental prostheses is increasingly being reported in medical and dental literature. This is of particular concern given the morbidity and mortality linked with the sequelae of trauma to and perforation of the upper aerodigestive tract. The authors report an extraordinary case that highlights the problem of assessment and diagnosis and reviews the appropriate management of a swallowed denture. The location of such a prosthesis may be demonstrated radiographically, but is hindered by radiolucent acrylic resins used for dental prostheses. Therefore there is a growing body of evidence supporting the inclusion of a radio-opaque marker in acrylic based dentures.
This case demonstrates the importance of the history given by patients presenting to primary or secondary care and the importance of a thorough ear, nose and throat (ENT) examination in patients presenting with dysphagia and related symptoms before discharge. Finally, this report introduces the concept of appropriate doctor led dental referrals for patients found to be “at risk” of swallowing a denture.
A 29-year-old Irish man living in sheltered accommodation was referred to our ENT department by a radiologist following a lateral cervical spine radiograph. On presentation to primary and secondary care several times he was complaining of dysphagia and having suspected swallowing his upper partial denture 4 weeks previously. He had been using this denture for the previous 4 years. He was initially discharged from primary care several times and subsequently self discharged from the emergency department. When he later returned to primary care complaining of weight loss, lateral cervical spine (fig 1) and chest radiographs were requested. He was still complaining of dysphagia when seen by our ENT department. Apart from his reported symptoms he suffered with no other physical or mental health disorders.
Figure 1
Figure 1
Lateral cervical spine x-ray demonstrating soft tissue swelling anterior to C5–C7.
On examination there were no signs of respiratory distress, but he was noted to be underweight. Flexible nasolaryngoscopy revealed a foreign body in the post-cricoid region with pooling of saliva. He was admitted to hospital and given intravenous co-amoxiclav (amoxicillin–clavulanic acid), dexamethasone, pantoprazole and fluids, and was kept nil by mouth.
Investigations
The initial lateral cervical spine radiograph demonstrated a prominent soft tissue swelling anterior to C5 to C7 (fig 1). Postoperative chest and lateral cervical spine radiographs were performed to check the nasogastric (NGT) position and exclude any surgical emphysema. The NGT position was confirmed and air was noted in the prevertebral soft tissue on the cervical spine radiograph. However, there was improvement when compared with the cervical spine radiograph on admission. A gastrograffin swallow was arranged 3 days postoperatively, which excluded any oesophageal leak.
Differential diagnosis
Given the history and examination findings, the evidence pointed to only one diagnosis.
The patient was taken to theatre the day following admission for direct laryngoscopy and oesophagoscopy in order to remove the foreign body. This confirmed that the patient had swallowed his partial denture (figs 27), with the incisors embedded in the soft tissue of the post-cricoid region and the right posterior molar extending past the cricopharyngeus. There was a scarred, stenotic area at the site of impaction, which was not biopsied due to the risk of perforation. A fine bore feeding NGT was inserted. during the postoperative period, the patient was monitored closely for evidence of an oesophageal leak. Feeding via the NGT was commenced following confirmation of the correct position. Following this the patient was commenced on sterile water and a soft diet the following day.
Figure 2
Figure 2
Anterior view of partial denture.
Figure 7
Figure 7
Superior view of partial denture.
Figure 3
Figure 3
Inferior view of partial denture.
Figure 4
Figure 4
Left lateral view of partial denture.
Figure 5
Figure 5
Posterior view of partial denture.
Figure 6
Figure 6
Right lateral view of partial denture.
Outcome and follow-up
The patient was discharged on postoperative day 6 with oral antibiotics. A dental follow-up to review his dentures and ENT follow-up appointments were arranged. At follow-up he was noted to be eating a normal diet and was asymptomatic, but he failed to attend his dental appointment.
There have been five reports of swallowed dentures15 including delayed presentation5 of up to 3 months in paediatric patients. Dental and ENT history and examinations are rarely taught at medical school. Patients with a suspected swallowed denture should have a focused dental history included in the global history, and initially be examined with indirect laryngoscopy using a laryngeal mirror if there is no equipment available for direct laryngoscopy. If an adequate view is not obtained, such patients should be referred to ENT for direct laryngoscopy using a flexible nasal endoscope.
This particular case was relatively uncomplicated, but serious complications including oesophageal or colonic perforation, mediastinitis, pneumothorax and pneumopericardium can occur.24 Elderly patients, particularly those who have been sedated, are at risk,1 as are paediatric and psychiatric patients or those with learning disabilities.4 The senior author has removed partial dentures from an elderly patient who simply swallowed the denture while drinking a cup of tea, a person with epilepsy following a fit, and a patient who was intoxicated following excessive alcohol consumption. The latter patient required a thoracotomy to remove the partial denture, when the clasp became embedded in the mucosa of the thoracic oesophagus.
As partial dentures are fairly easily swallowed beyond the cricopharyngeus, they are also the most dangerous to retrieve owing to various projections, which form part of their structure. The minimal morbidity encountered in this case report is in fact unusual, the reason being that the denture was only partially obstructing the oesophagus, so did not cause total dysphagia, secondary airway compromise or systemic symptoms. It is also the reason for delayed diagnosis, which is in part due to the patient’s impatience in the emergency department and his lack of credibility as far as his primary physician was concerned.
The initial lateral cervical spine radiograph (fig 1) demonstrates the diagnostic difficulty presented by radiolucent foreign bodies composed of polymethyl methacrylate,6 such as the denture in this case. In this particular case there was noticeable retropharyngeal soft tissue swelling (C5–C7), due to the delayed presentation. With the continued use of acrylic for dental prostheses,6 swallowed prostheses will continue to present radiological diagnostic difficulties. Using radio-opaque marker in the acrylic dentures may negate this problem.
Learning points
  • The authors recommend that such patients presenting to primary care or the emergency department doctors should have a focused dental history taken as part of the global history.
  • Patients should be referred to ENT for direct laryngoscopy using a flexible nasal endoscope if an adequate view is not obtained.
  • This article acknowledges a group of medical patients in which poor fitting removable dental prostheses are contraindicated. Often medical professionals are in a better position to identify this group of “at risk” patients than general dental practitioners. Appropriate referrals to dentists would minimise the inappropriate provision of dentures and provide suitable alternative treatments.
  • There is a growing body of evidence supporting the inclusion of a radiopaque marker in acrylic based dentures.
  • It would also appear that our patient received sub-optimal healthcare due to his poor socioeconomic situation. This should not arise as we all have a duty of care to all patients.7
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
1. Auluck A, Desai R. Accidental swallowing of a prosthesis. Dent Update 2008; 35: 577–9. [PubMed]
2. Chen CY, Lee SC, Chen CW, et al. Denture mis-swallowing in the sliding esophageal hiatal hernia mimics esophageal perforation. J Formos Med Assoc 2008; 107: 663–6. [PubMed]
3. Cottrell SG, Hanley JM. Swallowed partial denture: a case report. Gen Dent 2001; 49: 384–5. [PubMed]
4. De Ruiter MH, Van Damme PA, Drenth JP. Serious complications following (removal after) ingestion of a partial denture. Ned Tijdschr Tandheelkd 2008; 115: 267–70. [PubMed]
5. Tawari GJ, Kumar S, Hirmiz ZN, et al. Denture: an emergency department misadventure. Eur J Emerg Med 2008; 15: 176–8. [PubMed]
6. Bloodworth KE, Render PJ. Dental acrylic resin radiopacity: literature review and survey of practioners’ attitudes. J Prosthet Dent 1992; 67: 121–3. [PubMed]
7. General Medical Council Good Medical Practice 2006; 1: 6.
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