A missing denture's misadventure!

The long lost denture: a rare case of an acquired, non-malignant tracheo-oesophageal fistula

BACKGROUND

Ingested dental prosthesis are susceptible to impaction in the gastrointestinal tract due to their sharp edges, size and contour. Delays in presentation arise from the lack of clear history of ingestion and misdiagnosis occurs due to the radiolucency of denture material on plain radiography. An acquired, non-malignant tracheo-oesophageal fistula (TOF) may develop from a chronically impacted denture. Surgical management of a TOF secondary to denture is a challenging clinical problem that is rarely reported in the literature and no previous case reports have described the two-staged reconstruction approach that we present here.

CASE PRESENTATION

We report a case of a male in his early 60s who presented to an acute general hospital with symptoms ongoing for over one year of dysphagia, recurrent chest infections and weight loss. Barium swallow and computed tomography identified an ingested dental prosthesis (denture) that had caused a TOF. He was transferred to our specialist thoracic surgery unit where an attempt to remove the foreign body endoscopically was abandoned due to firm impaction and risk of further injury. The subsequent multi-disciplinary management of this complex case required a two-staged reconstruction approach. The first procedure involved extracting the foreign body, repairing the underlying defects with tracheal resection and anastomosis, and creating an oesophageal diversion with cervical oesophagostomy. The second procedure achieved continuity of the gastrointestinal tract with gastric pull-up and pharyngo-gastric anastomosis. Following rehabilitation, the patient was discharged on oral intake alongside percutaneous jejunostomy feeding.

CONCLUSIONS

Early recognition and removal of impacted dental prosthesis is essential to prevent morbidity and mortality. Delayed diagnosis can lead to acquired TOF with associated consequences such as recurrent pulmonary infection, mediastinitis and nutritional deficit. Challenges we encountered, such as failed attempts at endoscopic retrieval and the difficult dissection of fibrotic tissue, were directly due to the delayed identification of the denture. We highlight the importance of holding a high index of clinical suspicion of foreign body ingestion in dental prosthesis wearers who present with recurrent chest infections and ongoing dysphagia. We also promote the need for a collaborative multi-disciplinary approach in the surgical management of complex cases.

Designing for Safety: Implications of a Fifteen Year Review of Swallowed and Aspirated Dentures

Objectives

Dentures are worn by around 20% of the population, yet if they become displaced they may enter the gastrointestinal or respiratory system, sometimes with grave consequences. The aim of this study was to review recent published literature in order to identify the epidemiology of patients and characteristics of swallowed and aspirated dental prostheses, and propose strategies to minimise these risks.

Material and Methods

A fifteen year retrospective of published case series and case reports was carried out. Photographs, radiographs and descriptions of the dental prostheses were gathered, as well as the patient’s presenting complaint, the anatomical site where the denture was caught and the procedure required to remove the denture.

Results

Ninety one separate events of swallowed or aspirated dentures were identified from 83 case reports and series from 28 countries. Average age was 55 years, and these were 74% male. Photographs were retrieved for 49 of these dentures. Clasps were present in 25 of the dentures. There was no significant difference between clasped and unclasped dentures for perforation rates, need for open surgery and spontaneously passed dentures.

Conclusions

We discuss the implications of this study regarding denture designs, specifically the importance of using a radiopaque acrylic, using clasps when required even if there is a risk of aspiration, advising patients to return if a denture is loose or damaged, and finally that all patients who wear a denture are at risk of aspiration and swallowing events, and associated morbidity and mortality.

Adult Bronchoesophageal Fistula Diagnosed on Computed Tomography

Tracheoesophageal and bronchoesophageal fistulas are usually diagnosed early in life after an infant presents with difficulty feeding or recurrent pneumonias. These conditions rarely presents in adulthood. We report a case of a 59-year-old woman who presented with cough and recurrent pneumonias. The workup revealed a bronchoesophageal fistula that was diagnosed on CT and confirmed with a barium esophagogram.

Accident in implant dentistry: involuntary screwdriver ingestion during surgical procedure. A clinical report

Although unusual, foreign body ingestion occurs in dentistry and may result in serious complications, such as intestinal perforation. The presence of the foreign body should be confirmed with the use of radiographs. The exam will allow the correct diagnosis and the treatment to be conducted according to the specific situation of the object in the gastrointestinal (GI) tract. The orientation of the patient as well as the awareness of the patient's medical history are key factors in preventing serious complications. Generally, instruments that enter the GI tract pass asymptomatically and atraumatically within 4 days to 2 weeks. Sometimes, a surgical approach is necessary to remove the instrument when there is bleeding, obstruction, or impaction in the GI tract. Thus, a correct diagnosis is vital to avoid unnecessary surgical interventions. The aim of this article is to report an accidental ingestion of a screwdriver by a patient who had previously undergone a hemi-mandibulectomy and its medical resolution.

An unusual case of tracheoesophageal fistulae

Acquired tracheoesophageal fistulae (TEF) are commonly due to malignancy (M. F. Reed and D. J. Mathisen, 2003). We present the case of a patient with a deceptive history for TEF and report an approach that provides adequate oxygenation, ventilation, surgical exposure, and postoperative analgesia with excellent outcome.

Broncho-Oesophageal Fistula (BOF) Secondary to Missing Partial Denture in an Alcoholic in a Low Resource Country

The clinical course of a missing partial denture with secondary BOF in an alcoholic is presented. In the index case we report an exceptional clinical course of a patient who did not ascribe his symptoms to his ''missing'' dentures for several years, the odontologist who replaced an unrecovered denture, and the generalist who administered the barium swallow in an unsuspected BOF. Preoperative optimization of the patient was by blenderized local feeds through a feeding tube gastrostomy and by chest physiotherapy. Extraction of the denture and closure of fistula were done through a right thoracotomy. The importance of a high index of clinical suspicion of BOF in a low resource setting to avoid the morbidity and mortality associated with missing dentures is discussed. Odontologists, caregivers and clinicians must educate patients on the hazards of missing dentures and cases of missing / lost dentures should be adequately investigated / explored in the patient's history and clinical assessment before they are replaced.

Accidental ingestion of BiTine ring and a note on inefficient ring separation forceps

Background:

Accidental ingestion of medium-to-large instruments is relatively uncommon during dental treatment but can be potentially dangerous. A case of BiTine ring ingestion is presented with a note on inefficient ring separation forceps.

Case description:

A 28-year-old male patient accidentally ingested the BiTine ring (2 cm diameter, 0.5 cm outward projections) while it was being applied to a distoproximal cavity in tooth # 19. The ring placement forceps were excessively flexible; bending of the beaks towards the ring combined with a poor no-slippage mechanism led to sudden disengagement of the ring and accelerated movement towards the pharynx. We followed the patient with bulk forming agents and radiographs. Fortunately the ring passed out without any complications.

Clinical implications:

Checking equipment and methods is as important as taking precautions against any preventable medical emergency. It is the responsibility of the clinician to check, verify and then use any instrument/equipment.

Swallowed dental bridge causing ileal perforation: a case report

We report the case of a 53 year old gentleman who had accidentally swallowed his dental bridge. One week following this he experienced a sudden onset of generalised abdominal pain and underwent laparotomy. At operation he was found to have a distal ileal perforation and an ileocaecal resection was performed. Although most swallowed foreign bodies pass through the gastrointestinal tract without problem, serious complications including intestinal perforation can occur.

Accidental swallowing of an endodontic file

AIM

To report the management of an iatrogenic incident in which an endodontic file was swallowed accidentally and passed into the gastrointestinal tract.

SUMMARY

A 51-year-old male swallowed a 21 mm, size 30 endodontic file during root canal treatment without rubber dam. In the absence of clinical complications, the patient was reviewed with serial chest and abdominal radiographs, and stool tests for occult blood until the instrument was discharged at 3 days. This report discusses early differential diagnosis for locating foreign bodies and underlines the importance of serial radiographic evaluation for signs of foreign body migration.

KEY LEARNING POINTS

The use of rubber dam is mandatory for patient safety during root canal treatment. Early location of an inhaled or ingested foreign body facilitates appropriate and timely treatment management and referral. When a foreign body passes into the gastrointestinal tract, clinical symptoms and signs should be monitored closely until it is excreted or removed. An endodontic file can pass through the gastrointestinal tract asymptomatically and apparently atraumatically within 3 days.

Recurrent laryngeal nerve palsy due to impacted dental plate in the thoracic oesophagus: case report

Background

Retained oesophageal foreign bodies must be urgently removed to prevent potentially serious complications. Recurrent laryngeal nerve palsy is rare and has not been reported in association with a foreign body in the thoracic oesophagus.

Case presentation

We present a case of a dental plate in the thoracic oesophagus that caused high dysphagia. Delayed diagnosis led to a recurrent laryngeal nerve palsy, which persisted despite successful surgical removal of the foreign body.

Conclusion

Oesophagoscopy is essential to fully assess patients with persistent symptoms after foreign body ingestion, irrespective of the level of dysphagia. Recurrent laryngeal nerve palsy may indicate impending perforation and should prompt urgent evaluation and treatment.