Preventing “A Bridge Too Far”: Promoting Earlier Identification of Dislodged Dental Appliances During the Perioperative Period

Abstract

The presence of fixed partial dentures presents a unique threat to the perioperative safety of patients that require orotracheal intubation or placement of instruments into the gastrointestinal (GI) tract. There are many chances for the displacement of a fixed partial denture: instrumentation of the airway for intubation, or introduction of temporary devices, such as gastroscopes or transesophageal echo probes. If dislodged, the fixed partial dentures can enter the hypopharynx, esophagus or lungs and cause perforations with their sharp tines. Oral or esophageal perforation can lead to potentially fatal mediastinitis. We describe a case of a patient with a fixed partial denture who underwent cardiac surgery with intubation and transesophageal echocardiography (TEE). His partial denture was intact after the procedure. After extubation, he reported that his teeth were missing. Multiple procedures were required to remove his dislodged partial dentures. In sign-out reports, verbal descriptions of the patient’s partial dentures were not adequate in this case. A picture of the patient’s denture and oral pharynx pre-operatively would have provided a more accurate template for the post-operative team to refer to when caring for the patient. This may have avoided the multiple potentially risky procedures the patient had to undergo. We describe a suggested protocol utilizing a pre-operative photo to reduce the incidence of unrecognized partial denture dislodgement in the perioperative period. Because the population is aging, this will become a more frequent issue confronting practitioners. This protocol could mitigate this complication.

Swallowed dentures: Two cases and a review

“…Moreover, most reported cases demonstrate ingestion of removable dentures. Fixed unstable dentures are also at high risk of aspiration and ingestion during eating as demonstrated in our second case, drinking [8] , anesthesia [12] . Materials commonly used in denture fabrication are acrylic resins, porcelain, gold, nickel-chrome alloy, cobalt-chrome alloy and zirconium.…”

“…The three physiologic constrictions of the esophagus, therefore, appear to be frequent location of impacted denture, the upper constriction being the narrowest portion of the esophagus and the commonest site of denture impaction (15 cm from upper incisors; where the esophagus commences at the cricopharyngeal sphincter). Most of reported cases demonstrate ingestion of removable dentures especially partial ones; however, fixed dentures also become a subject of ingestion in case of spontaneous or traumatic dislodgement what requires awareness of anesthesiologists who ask patients only about removable dentures before anesthesia [12] . Denture impaction in small bowel is rare; and in almost all reported cases the site of impaction appeared to be terminal ileum [13] , [14] .…”

“…Denny et al. proposed a new scheme of perioperative management including photo documentation and removal of unstable dentures, thus minimizing the risk of denture aspiration and ingestion during anesthesia [12] .…”