A word of advice – dentures out before anaesthetic


In one notable case, a simple operation turned into quite a saga. Amelia Nichele reports.


Dentures out when the anaesthetist arrives.

Ittipol Nampochai / EyeEm, via Getty Images

Here’s a tip for all denture wearers – remove them before you go into surgery.

Writing in the journal BMJ, a British doctor describes the case of a 72-year old-man who didn’t heed this advice.

He ended up with his dentures stuck in his throat for eight days, requiring additional hospital visits, blood transfusions and eventually more emergency surgery.

While it might sound like an unlikely event, the doctor notes that this isn’t the first documented case of dentures being inhaled while a patient is under anaesthetic.

In this case, the man had successful abdominal surgery to remove a harmless lump but later returned to the hospital complaining of blood in his mouth, pain and difficulties swallowing.

Test didn’t indicate anything other than a respiratory infection and the side effects of having had a tube down his throat. As a result, he was sent home with mouthwash, antibiotics and steroids.

Only two days later he returned with worsening symptoms. He was admitted to the hospital with suspected aspiration pneumonia.

During his stay, a diagnostic procedure to look at his throat and voice box revealed a semi-circular object lying across his vocal cords.

It was then the patient revealed that his dentures, comprising a metal roof plate and three false teeth, had been lost during his previous visit. The dentures were then removed during an emergency surgery.

However, the story doesn’t end there.

The man returned to the hospital on two more occasions with blood in his mouth. Tests were run again, and he was sent home as the bleeding stopped.

He returned again – his sixth visit – and it was found that he had an internal wound tissue around the internal blistering, requiring a blood transfusion.

Then, on a seventh visit it was found that a torn artery in the wound was the source of the bleed. The man underwent emergency surgery and was then discharged.

The story does, however, end well. Six weeks later his blood count was back to normal, and check-ups found the tissue was healing well.

In her report, the doctor notes that the “presence of any dental prosthetics should be clearly documented before and after any procedure, and all members of the theatre team should be aware of the perioperative plan for them”.

She also highlights the importance of doctors listening to patients.

“In addition to reminding us of the risks of leaving dentures in during induction of anaesthesia when the Swiss cheese model of errors aligns, this case also highlights a number of important learning points,” she writes. “The first is to always listen to your patient.”

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  1. http://casereports.bmj.com/lookup/doi/10.1136/bcr-2019-230055
  2. https://longreads.com/2015/04/02/understanding-the-swiss-cheese-model-of-error/
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