ANNALS OF IBADAN POSTGRADUATE MEDICINE
A.A. Adeyemo1,2 and S.A. Ogunkeyede2,3
Background: Denture restores aesthesis and function of missing teeth. Accidentally swallowed denture is an otorhinolaryngology emergency. The types of denture base and oesophageal anatomy infuluence the site of impaction.
Objective: To review site of denture impaction and factors associated with site of impaction. To correlate site and duration of denture impaction before removal with associated sequelae.
Method: A retrospective study of 27 patients managed in Otorhinolaryngology Department of University College Hospital Ibadan, Nigeria for oesophageal partial denture impaction, between August 2006 and September 2016. The demographic and clinical data of the patients were extracted from the hospital records, and statistical tables were used to illustrate the data.
Results: A total of 27 patients; 14(51.9%) males and 13(48.1%) females, (M: F, 1.1:1) were studied. The age ranged from 24 to 77 years (mean age 49.0 ± 14.2years). Dentures were worn for 3 to 30 years (mean 3.8 ± 2.3years) without follow-up visit to dentist and 85.2% were upper dentures. All patients had history of accidental ingestion of denture, and the mean site of impaction was 18.2 ± 3.2cm from upper incisor, typically at upper cervical oesophagus in elderly patients and in lower oesophagus in females. There was no association between site of denture impaction, duration of denture impaction and operative findings.
Conclusion: Advanced age and female gender are associated with site of denture impaction. Late hospital presentation significantly promotes sequelae associated with management of impacted dentures. It is recommended that fundamental changes in denture designs, education on regular follow-ups and avoidance of ill-fitting dentures would reduce the prevalence of denture impaction.
Keywords: Denture impaction, Health education, Oesophagus, Oesophagoscopy and Nigeria
Dr. S.A Ogunkeyede
Dept. of Otorhinolaryngology,
College of Medicine,
University of Ibadan,
Missing teeth can compromise pronunciation, chewing with associated poor quality of life.1 The desire to restore function and aesthetic has resulted in wearing of dentures.2 Etruscans was the first to make partial dentures.3 Acrylic dentures are removable teeth- replacement options which are made from a radiolucent polymethylmethacrylate material.4
Denture impaction in the oesophagus is a common otolaryngology emergency with management challenges. Patients usually present with dysphagia, throat pain, odynophagia and pooling of saliva in pyriform sinus.5 Factors responsible for dislodgment of dentures from the alveolar ridge and subsequent impaction in the esophagus are: poor fit of the denture at insertion, prolonged usage, and failure of dental clinic follow-up evaluations especially when the denture becomes loose.6
In addition the insulating nature of acrylic dentures reduces sensitivity of the oral cavity.7 The large surface area of the dentures and their pointed edges encourages impaction in the aerodigestive tract. Impacted dentures are typically found at anatomically narrow areas of the oesophagus; the cricopharyngeal sphincter8, the level of the aortic arch, left bronchus, left atrium and at the lower esophageal sphincter.9
Oesophageal denture impaction ranges between 1.3% - 38.6% in clinical practice,10,11 and the management outcome depends on: site of impaction, shape and size of the denture, duration of impaction, premorbid medical conditions of the patient, the surgeon’s expertise and availability of appropriate instruments, especially in resource limited countries.
Historically impacted oesophageal foreign bodies are removed through rigid esophagoscope12, currently both flexible and rigid esophagoscopy are used for removal of oesophageal foreign bodies, with varying degree of success and mortality rates.13,14 Other methods includes; cervical oesophagotomy, the use of Foley’s catheter under fluoroscopic guidance15 and the use of flexible esophagoscopy with polypectomy snare.16 Delay in removal of the impacted denture in oesophagus increases the risk of complications such as oesophageal obstruction, pressure necrosis, oesophageal perforation, pulmonary aspiration, sepsis and mediastinitis.17
Evaluating the local pattern of denture impaction and related sequelae will provide relevant data to boost patient-doctor communication, health promotion and public health education on the risks associated with denture and failure of routine denture evaluation at clinics.
This study evaluated site of denture impaction and likely factors responsible for impaction at those sites, it also correlated the sites of denture impaction and associated sequelae.
MATERIALS AND METHODS
A retrospective review of all patients managed for oesophageal denture impaction, in the Department of Otorhinolaryngology, University College Hospital, Ibadan, between August 2006 and September 2016. The hospital records of the patients were retrieved, socio-demographic and clinical data were extracted. The clinical information included duration of denture impaction before presentation, the radiographic findings, surgical operation findings, status of the oesophageal mucosa after denture extraction, duration of hospital stay after surgical intervention, and the management outcome. The socio-economic status was determined by using the patient’s occupation, and the pensioners were classified based on their last job before retirement.18 The data was analysed using IBM-SPSS 20 and results were presented in descriptive forms using tables. Statistical significance was set at p < 0.05
There were 27 patients with denture impaction, 14(51.9%) males and 13(48.1%) females, with M: F ratio of 1.1:1. The age of the patients ranged from 24-77years (mean age 49.72 years ±14.2) and 16(59.3%) of them were from low-socioeconomic class as shown in table I. The majority 15(55.5%) of the patients presented within 48hours of denture ingestion, and a patient presented after 6 weeks of denture impaction. The dentures had been worn for a period of 3 to 30 years (mean 3.8 ± 2.3years) without follow-up visit to dentist (Table 1). All the patients had history of accidental ingestion of the partial dentures, throat pain, and dysphagia at presentation. Plain soft tissue radiograph of the neck showed air entrapment and increased pre-vertebral soft tissue shadow in 19 (70.4%) of the patients, while the dentures were confirmed at surgery in 8 (29.6%) cases. The impacted dentures were at 16-32 cm from upper incisor. Most of the dentures 11(40.7%) were impacted at 20 cm from upper incisor which is around the left bronchus, while 3(11.1%) were at the cricopharyngeal sphincter, as shown in Table 1. The findings at surgery included, pooling of saliva, hyperemic oesophageal mucosa, and oedema of oesophageal mucosal as shown in Table 2. The dentures were removed by rigid oesophagoscopy, with the aid of foreign body grasping forceps, except in two patients that had oesophagotomy and denture extraction due to failed oesophagoscopy. The number of teeth on the denture varied between 1-4 teeth, and upper denture constituted 85.2 % of the impacted dentures. The female gender was associated with distal impaction of the denture in the oesophagus (p = 0.03) after excluding age as a confounding factor. There was no association between the level of oesophageal denture impaction and numbers of teeth on the denture (p = 0.10). There was no association between the duration of hospitalisation, the type of denture (p = 0.07), and number of teeth on denture (p = 0.10), but those with cervical oesophageal denture impaction had short hospital stay (p = 0.02). The period of hospital admission ranged from 2 days to 33days (mean of 8.2 days ± 7.8), the prolonged period of admission of 33 days in a patient was due to other medical conditions. Those in the 6th decade of life and above had short hospital stay post denture extraction (p = 0.04) and the denture impaction in this category of people were at the upper oesophagus (Table 3). Complications observed were mucosa lacerations 3(11.1%) and excessive primary hemorrhages in 2(7.4%) cases and oesophageal perforations in 1(3.7%). All the patients had good clinical outcome, except 1 patient that died from thromboembolism.