|Year : 2007 | Volume
| Issue : 3 | Page : 126-131
Role of prosthodontist with regard to impacted esophageal dentures from an ENT perspective
Abhishek Jaswal, Avik K Jana, Atish Haldar, Biswajit Sikder, Utpal Jana, Tapan K Nandi
Department of Otolaryngology, Head and Neck Surgery, Calcutta National Medical College, Kolkatta, West Bengal, India
|Date of Web Publication||25-Dec-2007|
C/O Mr. Asoke Kumar Jana, Model Town, Garia, Balia, Kolkatta - 700 089, West Bengal
Source of Support: None, Conflict of Interest: None
Aims: The study tries to elucidate the contributing factors responsible for cases of denture impaction with regard to the events preceding the impaction, types of denture responsible for impaction, duration of the use of denture, age and sex distribution, presenting signs, symptoms, diagnosis and complications with an idea of providing an ENT perspective of the problem, thereby underlining the need for preventive measures and doctor/patient education. Based on the results, a few suggestions are made to serve these purposes. Settings: A tertiary hospital of a developing country. Study Design: A retrospective chart review. Materials and Methods: A retrospective analysis of 106 cases of denture impaction presenting to the Otorhinolaryngology Department over a period of 5 years (September 2000 to September 2005). Statistical Analysis Used: The statistical package for social sciences (SPSS) 10.0 windows compatible program. Results and Conclusion: Denture impaction was most prevalent in elderly persons (>50 years) using dentures for more than 5 years. The upper single tooth and double teeth nonhooked acrylic dentures were the most common types of denture responsible for impaction. The most common preceding event was the wrong manner of drinking water. The most common location of impaction was in lower one-third of the esophagus with rigid esophagoscopy being a fairly safe technique for management. The rate of complications was directly proportional to the duration of presentation. The current modalities of the localization of impacted denture were largely ineffective or high costs were involved for the routine use of radio-opaque materials and the alternative coloring of the denture. Hence, education of the doctor and patient regarding the availability of such materials and proper use of dentures should be given paramount importance.
Keywords: Esophageal, impacted dentures, prevention
|How to cite this article:|
Jaswal A, Jana AK, Haldar A, Sikder B, Jana U, Nandi TK. Role of prosthodontist with regard to impacted esophageal dentures from an ENT perspective. J Indian Prosthodont Soc 2007;7:126-31
|How to cite this URL:|
Jaswal A, Jana AK, Haldar A, Sikder B, Jana U, Nandi TK. Role of prosthodontist with regard to impacted esophageal dentures from an ENT perspective. J Indian Prosthodont Soc [serial online] 2007 [cited 2020 Jan 24];7:126-31. Available from: http://www.j-ips.org/text.asp?2007/7/3/126/37656
|Table 1: Number of cases of denture impaction between September 2000 and September 2005|
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|Table 1: Number of cases of denture impaction between September 2000 and September 2005|
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| Introduction|| |
With an increasing incidence of tooth loss due to caries and periodontal diseases, there is an increase in the number of people wearing dentures, thereby resulting in the proportionate increase in the incidence of impacted dentures in the upper gastrointestinal tract.  The condition is further aggravated by the ignorance on the part of the patient and non adherence to the instructions regarding the mechanics of use, life span, maintenance of dentures and to honor the recall visits to the dentists in order to assess the requirement for the change of dentures. The treating physician is often a culprit who contributes to the situation because a clear prescription regarding the material to be used for the preparation of denture and precautions to be followed subsequently is often lacking. This study attempts to explain these issues and to provide an ENT perspective to the problem of denture impaction based on the retrospective analysis of 106 cases of denture impaction during a period of 5 years. The aim is to reduce the discrepancies between the allied practices of dentistry and ENT by providing a much needed feedback with regard to the issues of denture impaction, which was lacking from previous studies.
| Materials and Methods|| |
The study was conducted in a tertiary referral hospital in eastern India. It comprises the retrospective analysis of 106 cases of denture impaction presenting to the Department of Otorhinolaryngology over a period of 5 years (Sept. 2000 to Sept. 2005).
Data collection entailed the sorting out of all the cases of denture impaction from the operating theater register. The case files were retrieved and information regarding age, sex, presenting complaints, preceding event and duration of denture use was noted. Further, the types of denture (upper/lower/hooked/unhooked), modes of removal of denture and subsequent complications were noted.
All the patients who were managed electively were subjected to common battery of tests, including the routine blood tests, soft tissue X-ray in the anterior-posterior neck regions and lateral view, chest X-ray and chest X-ray with light barium swallow; very few patients required computerized tomography (CT) scan for localization.
Cases were divided into two broad groups on the basis of impaction with hooked ( i.e., those with metallic hooks and pointed wire components) and nonhooked dentures ( i.e, acrylic dentures without any metallic components). The dentures responsible for impaction were further divided on the basis of number of teeth present. The dentures implicated in impactions were further categorized on the basis of site of use, i.e, upper vs lower denture.
Moreover, the age and sex distributions, duration of use of the denture and contributing factors responsible for the condition of denture impaction with regard to the events preceding the impaction were noted. Further assessment was done with regard to the signs and symptoms presented and the resulting diagnosis and complications.
The statistical package for social sciences (SPSS) 10.0 windows compatible program was used for statistical analysis. During the evaluation of the data from the study, bivariate analysis was performed and odds ratio for the respective preoperative and preoperative variables along with its 95% confidence interval was calculated. The results were evaluated with respect to the 95% confidence level and significance levels of P<0.05.
| Results|| |
This study comprises 106 cases of dentures managed in the Otolaryngology Department of a developing country. The non hooked dentures outnumbered the hooked dentures with a ratio of 1.7:1 (hooked = 39, non hooked = 67) [Table - 1].
The mean age of the patients was 56.2 years. The age group most prone to denture impaction was those between 50 and 60 years. Patients with more than 50 years of age constituted 81.13% of the cases. None of the cases were below 30 years of age [Table - 1]. Male patients outnumbered the female patients with a ratio of 2.7:1.
The common symptoms at the time of presentation were odynophagia (100%) and foreign body sensation (65.09%) with a rare presentation of stridor (2.83%). One of the common signs observed was the pooling of saliva (81.13%) [Figure - 1].
When the dentures responsible for impaction were further divided on the basis of number of teeth present, those with single tooth and double teeth outnumbered the larger dentures (29.24% and 41.50% respectively) with the acrylic non hooked dentures outnumbering the hooked dentures in both the categories [Table - 2]. Larger dentures were more commonly found with metallic hooks in comparison to smaller dentures, which were generally made of acrylic.
The upper dentures outnumbered the lower dentures by a ratio of 2.15:1. The z test for a single sample with continuing correction came out to be 3.78 with the resulting P value to be less than 0.01, thereby making this observation highly significant [Table - 3].
The duration of the use of dentures revealed that most of the patients wore the dentures for more than 5 years (46.22%). Those patients wearing the dentures for less than 1 year were the next group (21.69%). The chi-square test for checking the trends was carried for checking the chances of denture impaction with the duration of use. Subsequently, the calculated P value was 0.000…(1.92 × 10 -8 ), which was highly significant [Table - 4].
The events preceding the impaction revealed that the most common event preceding the impaction was wrong manner of drinking water or taking medicines (78.30%) [Figure - 2].
Most of the patient presented within the first 24 h of denture impaction (58.49%). This was closely followed by those presented after 48 h (28.30%). In 2.83% cases presented after the first week of impaction, the most common site of impaction of denture was in lower one-third of the esophagus (34.90%) followed closely by the next common site that is the middle one-third of the esophagus (32.07%) [Figure - 3],[Figure - 4].
Investigations for the removal of dentures were performed via commonly rigid esophagoscopy (58.49%) and hypopharyngoscopy (27.35%). Spontaneous expulsion of denture through bowel was noted in 11.32% cases whereas 2.83% cases required thoracotomy for the removal of denture for which they were referred to the department of cardiothoracic surgery [Figure - 5].
The complications of interventions for denture removal were mediastinitis (3.77%), pneumothorax (0.94%) and neck abscess (0.94%). Other complications including recurrent laryngeal nerve palsy were noted in 2.83% cases.
| Discussion|| |
Replacing the missing teeth not only improves the facial esthetics but also makes eating a more pleasant experience and enhances the clarity of speech. It also prevents malocclusion and tilting of the adjacent teeth and collection of food in the edentulous spaces.  With the coincident increase in the number of people wearing dentures in the past 25 years, an increase was also observed in the incidence of impacted dentures in the esophagus. The incidence of impacted dentures ranges between 3.6-27.7% of all the foreign bodies impaction - the number being considerably higher in adults than in children.  The occurrence of denture impaction among all upper digestive tract foreign body, in our study was 4.78% per year.
It has been noted that edentulous patients are unable to masticate properly and coupled with the absent sensation of the teeth, they are more prone to ingest a foreign body. This problem is amplified by aging as evident by the age profile of the patients in this study, in which 81.13% cases were above 50 years of age [Table - 1] with a mean age of presentation of 56.2 years. This is opposed to the pervious studies where no significant association was observed between aging and the incidence of denture impaction. ,, Male patients outnumbered the female patients by a ratio of 3:1, which is similar to the earlier reported ratio of 2.7:1, , possibly indicating that females take more care of their denture appliances in comparison to males.
Symptoms at the time of presentation varied from the usual symptoms of odynophagia (100%) and foreign body sensation (65.09%) to unusual symptoms of hoarseness of voice (13.20%) and respiratory distress (2.83%). The latter can be explained on the basis of the large denture occluding the hypopharynx and laryngeal opening and denture impacting in postcricoid region with compression and the edema of the respiratory tract. About 8.49% cases of late presentation also presented with fever. The signs at the time of presentation included pooling of saliva (81.13%) and neck tenderness (43.39%) [Figure - 1].
Prolonged use of dentures, which in most cases is made of acrylic material, are not as retentive and rugged as those with metallic framework and hence the dentures cannot readily withstand forces generated during daily use. These dentures become loose on regular use over a duration of 4-5 years and require replacement. , In this study, the acrylic partial denture outnumbered the traditional metallic hooked dentures by a ratio of 1.7:1 [Table - 2].
The events preceding the impaction of denture revealed that most common event was the manner of drinking water, particularly while taking medicines (78.3%). Drinking water directly from the glass that is in contact with lips did not cause the damage, but it was the indirect method of drinking water in which the water was poured from an elevated position without keeping the glass in contact with the lips [Figure - 2]. As expected, it was the rates of impaction of upper dentures that outnumbered the rates of the lower denture impaction (2.15:1). The difference between the rates of impaction and dislodgement of upper dentures were found to be significant in comparison to those of the lower dentures ( P<0.01) on carrying out a single sample analysis [Table - 3]. This method of drinking water is quite prevalent in the Indian subcontinent.
The problem of a misfit denture is further amplified by the fact that after loss of teeth, the alveolus and residual ridges continue to resorb as the person ages, resulting in the further loosening of denture that requires adjustment. The fact is strengthened by the results of this study in which most of the patients (46.22%) were using the dentures for more than 5 years. Another subset of patient that formed major portion of cases of denture impaction were the new users with the duration of use less than 1 year (21.69%), possibly because they are not accustomed to the proper use of dentures. When the chi-square test for checking the trend was carried for the chances of denture impaction with the duration of use, the results obtained were highly significant ( P=0.000….) indicating that significant association exists between the chances of impaction and duration of use of denture that increases drastically if the dentures are used for more than 5 years [Table - 4]
The level of impaction and ease of extraction of the denture depends upon the size and configuration of the denture and presence or absence of wire hooks. Dentures with single or double tooth are easy to extract but are lodged in lower esophagus in opposition to the larger dentures with three or more teeth. Considering the wire clasps and collets (sharp edges) of a denture, which enhance its arrest when ingested, it is not surprising that impactions in the lower esophagus are rare. , The majority of the cases in our study were smaller dentures (70.75%) whereas there were only 29.24% cases for larger dentures. As expected, the common level of impaction was in the lower two-third of the esophagus (66.98%). The next common site of impaction was the hypopharynx and postcricoid region (27.35%); this is in agreement with the proportion of large dentures (29.24%), which are more prone to impaction in upper part of digestive tract [Figure - 4].
Most of the cases of impaction were managed by rigid esophagoscopy (58.49%) whereas 27.35% cases were managed by hypopharyngoscopy. This is in agreement with the common location of impaction and types of denture impacted. , Very few cases of large hooked impacted dentures required thoracotomy (2.83%). Extraction with rigid esophagoscopy was hampered in two cases that required thoracotomy due to late presentation where excessive edema around the denture precluded safe extraction. Spontaneous expulsion via bowel was noted in as many as 11.32% cases. In six of these cases, due to difficulty in extracting the denture proximally, the dentures were pushed into the stomach, which lead to spontaneous expulsion over a period of 36 h to 5 days [Figure - 5]
The chances for complications following the extraction of denture depend upon the size, rigidity, sharp edges of the dentures and presence of hooks. In addition to these, the degree of inflammation at the site of impaction also increases the risk of complications. Complications are more likely if the presentation or intervention is delayed with the rate of complications rising from 3.2% after 24 h to 23.5% after 48 h [Figure - 3]. , In this study, the rate of complication was 7.54% with serious complications such as mediastinitis secondary to perforation observed in only 3.77% cases, which is in agreement with the major series. All the cases of mediastinitis could be managed by conservative therapy with antibiotics and steroids could be used in few cases and none of the cases required thoracotomy for such a complication.
The low rate of complications in our study can be attributed to the early presentation as 86.79% cases presented within first 48 h of impaction in opposition to 13.20% cases that presented late.
The most important issue concerning the management of impacted dentures in upper digestive tract is the inability to localize the dentures preoperatively and during the time of intervention. The role of radiography in preoperative localization is controversial as most of dentures were radiolucent. , Alternative methods of identification and localization include computerized CT scanning and barium swallows for objects impacted in the esophagus; however, the high cost of CT scan and the almost universal symptom of odynophagia at presentation renders these modalities to be more of theoretical significance in our scenario.  In this study, the localization of impacted dentures was performed using conventional radiology, which was ineffective in most cases and more often this was conducted for the sake of medicolegal causes than for true localization. The signs such as air entrapment and increased prevertebral soft tissue thickness, whenever present, were helpful aids in diagnosis. In cases of radiolucent dentures (acrylic, non hooked), the chest X-ray taken using a light barium meal was a quite helpful investigation in cases where it was feasible. Only one case required CT scan to localize and asses the associated complications.
The use of a radio-opaque acrylic has been recommended extensively in the literature over a considerable period of time for use in dental appliances to aid the detection of acrylic fragments as they are usually radiolucent, which makes it difficult to locate them with plane radiography. Attempts have been made to produce radio-opaque acrylic for denture construction. These include incorporation of radio-opaque bodies (lead foil, amalgam), the salts of heavy metals (barium fluoride, barium sulfate, bismuth glass and barium acrylate) and the production of copolymers in which one of the copolymer contains a heavy atom. ,, Unfortunately, the incorporation of these materials into acrylic has adversely affected the properties of the acrylic from the esthetics to the finish that can be achieved. A material called opex and incorporation of a radio-opaque polymer of methyl methacrylate containing bromine into the denture base materials has been reported to yield good radio-opacity while retaining good mechanical properties.  Recently, glitter-containing acrylics have become available that renders the acrylic to become radio-opaque on plain radiograph. ,
Although recommendations for the use of radio-opaque acrylic in dentistry are present since 1981, the materials are still not used on regular basis mainly due to lack of interest and support from the prescribing physician and cost of newer materials. However, with regular prescription and interest, the costs are bound to decrease in the near future. 
The use of colored acrylics, rather than pink, for the construction of removable appliances is a viable alternative to assist the per-operative visualization of the dentures on esophagoscopy. Although the use of alternative colors, other than pink or clear, are expected to hamper the esthetic appearance of the dentures, the use of colors in selected part of dentures is all that is required. From our experience, we have observed that most of the dentures are located along the curvature of esophagus exposing their concave inner surface. The selective coloring of this concave inner surface maintaining the outer convex surface as pink will resolve most of the concerns regarding the esthetic value of the denture.
Other suggestion regarding the preparation of dentures can be attempts to make all the components of the removable appliances smooth and rounded as far as possible. All cribs and springs should not have sharp ends and finger springs and stops should be rounded.  Hooked or "C" clasps should be avoided if possible or alternative retentive components should be used. Patients should always be advised both verbally and with written instructions that they should not try to reinsert damaged, ill-fitting or broken fragments of any appliance. They should stop using them and contact the office or practice of an prosthodontist to have the appliance checked. , Further instructions should include the requirement to undergo regular follow-up for the checking of dentures and to replace the dentures if they become loose. Patient should be told to follow the right method of drinking water using visual aids and to seek immediate medical advice in cases the denture is dislodged and impacted.
| Conclusion|| |
Denture impaction was most prevalent in elderly persons (>50 years) who were using dentures for more than 5 years. Upper single and double teeth non hooked acrylic dentures were most commonly responsible. The most common preceding event was wrong manner of drinking water. The most common location of impaction was in lower one third of the esophagus with rigid esophagoscopy being a fairly safe technique for management. The rate of complications was directly proportional to the duration of presentation. The current modalities of localization of impacted denture were largely ineffective or involved high costs for the routine use of radio-opaque material and alternative coloring of the dentures. Hence, doctor and patient education regarding the availability of such material and proper use of denture should be given paramount importance.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]