ESOPHAGEAL FOOD BOLUS IMPACTION IN PARTIALLY EDENTULOUS PATIENTS. A CROSS-SECTIONAL STUDY OVER THE IMPACT OF KENNEDY'S CLASSIFICATION SYSTEM

Abstract

[...]edentulous patients are frequently exposed to the inability to properly masticate and swallow food. [...]esophageal food bolus impaction is a frequent and potentially serious condition affecting such patients. [...]the need for dental restorative care should be properly assessed. [...]34.6% of the patients with an edentulous mandible and 26.9% of those with an edentulous maxilla have experienced disphagia, needing endoscopic therapy (P = .042). Associating Kennedy's Class of edentulous space with mastication impairment and food bolus impaction is important to the overall patient referral rates for restorative dental management. [...]edentulous patients presenting with disphagia should be always evaluated for food bolus impaction, and assessment of chewing ability should be performed uniformly.

Headnote

Abstract

Background. Tooth loss and edentulous arcades are health issues emergent all around the world, as absence of teeth characterizes both a poor oral hygiene in developing countries and the old age in the Western world. It has a tremendous impact on mastication and nutrition. Therefore, edentulous patients are frequently exposed to the inability to properly masticate and swallow food. Thus, esophageal food bolus impaction is a frequent and potentially serious condition affecting such patients. The aim of our study is to evaluate the impact of various Kennedy classes of edentulous arcades on esophageal food bolus impaction, leading to disphagia. Materials and methods. 52 partially edentulous patients presenting with acute disphagia secondary to food bolus impaction were included in a cross-sectional study performed in two regional emergency hospitals of Romania between May 2017 and June 2019. Each patient was managed by either oto-rhino-laringology or digestive endoscopy department and tooth loss was established by Kennedy classification. Results and discussion. Patients aged 61 or older were significantly prone to food bolus impaction secondary to partial edentulousness, and Kennedy class 3 of edentulous ridges was significantly more frequently associated to food impaction and disphagia. The need for therapeutic endoscopy performed in emergency settings could help identifying orally disabled patients, as edentulous persons are easily diagnosed by both gastroenterologists and otorhino-laringologists performing flexible endoscopy. Hence, the need for dental restorative care should be properly assessed. Conclusions. Edentulous patients presenting with acute disphagia should generally be suspected for esophageal food bolus impaction. On the other hand, besides endoscopic therapy, patients should be referred for restorative dental care.

Keywords: disphagia, mastication, tooth loss, digestive endoscopy.

1.INTRODUCTION

Teeth are among the most important components not only of the oral cavity but also of the digestive tract. They are vital for a proper mastication and deglutition. Tooth loss and edentulous ridges lead to impaired mastication, food deprivation, malnutrition and in some cases to improper swallowing of partially processed food and esophageal food bolus impaction [1]. It seems that edentulous patients are to be found all around the world, as tooth loss is a multifactorial condition. It can be triggered by various causes, including poor oral hygiene, periodontal disease, dietary habits or old age [2,3], thus being a frequent health issue transregionally. Tooth loss and oral decline are causes for severe nutritional disparities, mainly because impaired mastication and inability to thrive [4]. Subsequently, when compared to normal mastication, also significant food bolus deterioration was observed, being associated with oral injuries and food bolus impaction [5].

Foreign body impaction in the esophagus causing disphagia is one of the most common causes for admission in the emergency departments. While foreign body ingestion occurs more frequently in pediatric population, food bolus impaction in the esophagus is typical for elderly patients [6,7]. Over 80% of the foreign bodies pass spontaneously, however, the rest of the cases need endoscopic or surgical foreign body removal [8]. The need for endoscopic therapy is evaluated after the assessment of patient's history and physical examination. Radiographic evaluation of food bolus impaction is characterized by a higher rate of false-negative results [9,10], therefore a computed-tomography scan is performed only when perforative or hemorrhagic complications are suspected [8]. Management of non-complicated food bolus impaction is performed either by an ear, nose and throat (ENT) specialist, when impaction is detected at the upper esophageal sphincter or above, or by a digestive endoscopist for food impaction, when it occurs below the upper esophageal sphincter. ENT management includes either direct or endoscopic extraction [11]. Digestive endoscopy management usually involves the push technique, that allows gentle advancement of food bolus towards the stomach in the vast majority of cases, with minimal complications [10]. Such technique should be used when subsequent esophageal strictures are excluded. In case of large food boluses, endoscopic accessory fragmentation prior to pushing is recommended, nevertheless, if resistance is encountered, pushing is counterindicated because of the high probability of an underlying esophageal stenosis and subsequent risk for perforation [8]. When the impacted food bolus cannot be managed by the pushing technique, extraction is mandatory, especially in cases of sharp impacted bony boluses. Under such circumstances, en bloc or piecemeal retrieval using various types of grasping forceps, snares, nets, or baskets should be performed [8,9].

2.MATERIALS AND METHODS

Patients

In order to evaluate the impact of Kennedy's class of partial edentulousness over food bolus impaction in adults, 52 partially edentulous patients presenting with acute disphagia secondary to food bolus impaction were included in a cross-sectional study performed in the Institute of Gastroenterology and Hepatology within the St. Spiridon Emergency Hospital of Iaşi, in two regional emergency hospitals in Romania and in the Floreasca Clinical Emergency Hospital of Bucharest, Romania, between May 2017 and June 2019. Inclusion criteria consisted in adult age, emergency admission, presence of acute disphagia, presence of at least an edentulous ridge, and the need for either ENT or digestive endoscopy intervention. Exclusion criteria comprised the presence or suspicion of perforative, infectious and hemorrhagic complications, the need for surgery, the presence or suspicion of an underlying esophageal stricture or neurological disease causing disphagia and detection of foreign body ingestion other than food. As shown by Tables 1 and 2, gender distribution of cases favored male patients and there was a non-homogenous distribution of subjects over age with the majority of patients between 61 and 74 years.

Intervention

All patients were primarily assessed in the emergency departments and the need for either digestive endoscopy or ENT management has been decided after proper physical examination. History evaluation and exclusion of complications were performed. Patients with upper disphagia were primarily assessed by an ENT specialist, while the others were primarily referred for digestive endoscopy. Generally, patients with food impaction at the upper esophageal sphincter were managed within the ENT department, while the rest were managed endoscopically. Endoscopic therapy, performed in all patients within the emergency setting, consisted in either extraction with retrieval graspers, grasping forceps, baskets and snares (Olympus Europe, Hamburg, Germany) or, when feasible, by gently pushing the impacted food into the stomach, if no visible sharp bone impaction had been observed. Before the intervention, clinical oral examination has been performed and detection of edentulousness has been established according to Kennedy's classification of edentulous space [12], as: (i) Class 1: Bilateral edentulous ridges located posterior to the remaining teeth; (ii) Class 2: Unilateral edentulous arch located posterior to the remaining teeth; (iii) Class 3: One unilateral edentulous area with remnant teeth both anterior and posterior to it; (iv) Class 4: Single but bilateral edentulous ridge located anterior to the remaining teeth; (v) Absence of an edentulous space was qualified by Class 0 for statistical analysis. Class combinations were recorded accordingly. In order to preserve the dynamics of case examination and inclusion, patients were not separately stratified according to Kennedy's Class modifications.

Statistical analysis

The impact of Kennedy's class of edentulous ridges over the rate of food bolus impaction via this cross-sectional study was assessed by Pearson Square-Chi testing, while the heterogeneity of patients within the group was has been assessed by Student t test. Correlations were regarded as statistically significant when P < .05. Statistical data analysis has been performed with a SPSS 24.0 software.

3.RESULTS AND DISCUSSION

The majority of patients included in the study required digestive endoscopy management, over 75% of them being successfully treated within the gastroenterology department, as shown in Table 3. In patients with upper disphagia, as well, flexible endoscopy seems to be the elective management method, despite the higher impacted boluses, being well tolerated, costeffective and characterized by lower complication rates and higher success rates [11,13,14]. Flexible digestive endoscopy can be safely performed under local anesthesia with or without mild sedation, as the method of choice especially in disabled patients, with higher risks for anesthesia [14]. As proven in one of our previous works, digestive endoscopy techniques can be reliably used, too, for the detection and management of oro-pharyngeal conditions, [15] stressing once more the reliability and reproducible character of such procedures.

Patients were generally non-homogenously distributed according to age and gender, with Student t Test values of 1.901 (P = .063), as shown in Table 4. Such result was to be expected, as edentulousness occurs especially in older ages, but, interestingly, most of the patients were aged 61-74 years (over 48%), as opposed to the younger 55-60 year-old patients or the 75-89 year-old ones. Such result is perhaps associated with the dietary habits of these patients, not used to mastication impairment and therefore tending to eat less processed food, thus having a higher chance of food impaction.

Statistically significant correlations have been found regarding Kennedy's Class and food bolus impaction. As shown in Table 5, edentulous patients with Kennedy's Class 3 ridges of both maxilla and mandible have experienced significantly more frequent food bolus impaction in the esophagus, as compared to the other classes. Thus, 34.6% of the patients with an edentulous mandible and 26.9% of those with an edentulous maxilla have experienced disphagia, needing endoscopic therapy (P = .042). Furthermore, it is to be noticed that the combination of Kennedy's class 1 of maxilla and class 3 of the mandible has been more frequently associated with food bolus impaction (5.8% of patients) than other Kennedy's class mixed cases.

Indeed, Kennedy's Class 3 has been described by the literature as the most frequent form of edentuloulism [16,17]; nevertheless, research papers exploring its connection with impaired mastication and food bolus impaction are scarce. Traditionally, it has been acknowledged that, independently on the class of partial edentulism, patients experience impaired mastication and subsequent nutritional disparity [18]. Associated dental and oral conditions, such as periodontal disease, loose teeth, dental caries and toothache have also been associated with chewing difficulties [19]. Not the least, impaired mastication may be associated with various systemic conditions like dementia, neurologically impaired deglutition, poor-fitting dentures or poor food preparation - especially in elderly patients [20], each of the contributing factors playing an important role in the clinical setting of patients. In what age is concerned, it has been showed that older adults with reduced posterior occlusion were significantly more frequently associated to poor mastication, which leads to the impairment of daily performance [21]. Such results are consistent with our findings, proving the important impact of both Kennedy's Class 1 and 3 on mastication impairment.

Regarding the need for either ENT or endoscopic therapy, as shown in Tables 6 and 7, there were no statistically significant correlations between the type of therapy applied and Kennedy's Class of edentulous space. The preferred management course is clearly dictated by the site of food bolus impaction and also by the local expertise of teams. In this respect, randomized data should be analyzed.

4.CONCLUSIONS

Both ENT surgeons and digestive endoscopists are frequently exposed to food bolus impaction in partially edentulous patients. Despite the lack of individualized emergent management of such patients, mastication impairment and subsequent nutritional disparity should be assessed. Associating Kennedy's Class of edentulous space with mastication impairment and food bolus impaction is important to the overall patient referral rates for restorative dental management. Moreover, edentulous patients presenting with disphagia should be always evaluated for food bolus impaction, and assessment of chewing ability should be performed uniformly.

References

References

1. Gaewkhiew P, Sabbah W, Bernabé E. Does tooth loss affect dietary intake and nutritional status? A systematic review of longitudinal studies. J Dent. 2017;67:1-8.

2. Tonsekar PP, Jiang SS, Yue G. Periodontal disease, tooth loss and dementia: is there a link? A systematic review. Gerodontology. 2017;34(2):151-63.

3. Peyron MA, Woda A, Bourdiol P, Hennequin M. Age-related changes in mastication. J Oral Rehabil. 2017;44(4):299-312.

4. Zelig R, Touger-Decker R, Chung M, Byham-Gray L. Associations between tooth loss, with or without dental prostheses, and malnutrition risk in older adults. Top Clin Nutr. 2016;31(3):232-47.

5. Peyron MA, Santé-Lhoutellier V, François O, Hennequin M. Oral declines and mastication deficiencies cause alteration of food bolus properties. Food funct. 2018;9(2):1112-22.

6. Sugawa C, Ono J, Taleb M et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: A review. World J Gastrointest Endosc. 2014; 6(10):475-81.

7. Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus on rehabilitation strategies. Aging Clin Exp Res. 2016;28(4):607-17.

8. Birk M, Bauerfeind P, Deprez PH, Häfner M, Hartmann D, Hassan C, Hucl T, Lesur G, Aabakken L, Meining A. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-96.

9. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Decker GA, Fanelli RD, Fisher LR, Fukami N, Harrison ME, Jain R, Khan KM, Krinsky ML, Maple JT, Sharaf R, Strohmeyer L, Dominitz JA. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011;73(6):1085-91.

10. Ko HH, Enns R. Review of food bolus management. Can J Gastroenterol; 2008; 22(10):805-8.

11. Tseng CC, Hsiao TY, Hsu WC. Comparison of rigid and flexible endoscopy for removing esophageal foreign bodies in an emergency. J Formos Med Assoc. 2016;115(8):639-44.

12. Al Johany SS, Andres C. ICK classification system for partially edentulous arches. J Prosthodont. 2008;17(6):502-7.

13. Gmeiner D, Von Rahden BH, Meco C, Hutter J, Oberascher G, Stein HJ. Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus. Surg endosc. 2007;21(11):2026-9.

14. Ferrari D, Aiolfi A, Bonitta G, Riva CG, Rausa E, Siboni S, Toti F, Bonavina L. Flexible versus rigid endoscopy in the management of esophageal foreign body impaction: systematic review and metaanalysis. World J Emerg Surg. 2018;13(1). DOI: 10.1186/ s13017-018-0203-4

15. Balan GG, Sandru V, Petcu A, Constantinescu G. Incidental discovery of oro-pharyngeal cancer during routine upper gastrointestinal tract endoscopy. Is it that obvious? International Journal of Medical Dentistry. 2018;22(3):307-13.

16. Patel JY, Vohra MY, Hussain JM. Assessment of Partially edentulous patients based on Kennedy's classification and its relation with Gender Predilection. International Journal of Scientific Study. 2014;2(6):32-6.

17. Burlui V, Vasiliu M, Tomita D, Girbea C, Apintilesei A, Costin G, Cigu AT, Cucoveica O. Morphofunctional rehabilitation of edentulous patients-an interdisciplinary approach. International Journal of Medical Dentistry. 2019;23(1):79-93

18. Bharathi M, Babu KR, Reddy G, Gupta N, Misuriya A, Vinod V. Partial Edentulism based on Kennedy's classifcation: an epidemiological study. J Contemp Dent Pract. 2014;15(2):229-31.

19. Peek CW, Gilbert GH, Duncan RP. Predictors of chewing difficulty onset among dentate adults: 24month incidence. J Public Health Dent. 2002;62(4):21421.

20. Triadafilopoulos G, Roorda A, Akiyama J. Update on foreign bodies in the esophagus: diagnosis and management. Current gastroenterology reports. 2013;15(4):317.

21. Kida IA, Åstrøm AN, Strand GV, Masalu JR, Tsakos G. Psychometric properties and the prevalence, intensity and causes of oral impacts on daily performance (OIDP) in a population of older Tanzanians. Health Qual Life Outcomes. 2006;4(1):56.