Doctors are urging patients to remove dentures before undergoing general anesthesia after a 72-year-old man suffered from pain, bleeding, and swallowing difficulties when his false teeth became lodged in his throat during surgery. The dentures had been stuck in the man’s larynx for a total of eight days, according to a study now published in BMJ Case Reports.

The elderly man had undergone surgery to remove a harmless lump in his abdominal wall. For six days following the procedure, he experienced a variety of symptoms, including bleeding in his throat, shortness of breath, and difficulty swallowing that prohibited him from eating solid food. Subsequent test results at the hospital indicated he was healthy, and doctors diagnosed him with a respiratory infection and pain from having a test tube down his throat during the operation. He was given mouthwash, steroids, and antibiotics and was sent home.

Two days later, the man returned with worse symptoms – he couldn’t swallow the medicine he was given and he reported worsening pain. Doctors admitted him with what they thought was aspiration pneumonia, a chest infection caused by inhaling food or stomach acid into the lungs. A chest exam revealed a semi-circular object lying across his vocal cords in the upper aerodigestive tract (UADT) that had caused blistering and swelling. It was then the patient revealed he had not seen his dentures – a metal plate with three false teeth – since his surgery.

Doctors conducted an emergency surgery and were able to remove the dentures using a laryngoscope and forceps and discharged the man six days following the surgery. But it doesn’t stop there. Several weeks and three hospital visits later, medical tests showed that the man was also suffering from internal tissue damage around the site of the blister. Doctors had to cauterize it to stop the bleeding and conduct a blood transfusion because he had lost so much blood. He was discharged two days later but returned yet again with more bleeding due to a torn artery in his wound.

Following the last surgery, it took a total of six weeks for his blood count to return to normal.

It’s not the first time dentures have been swallowed during anesthesia. A 15-year review of more than 80 denture-swallowing cases found that 14 percent were found in the larynx and 7 percent were aspirated during general anesthesia. Other objects have been swallowed during both dentistry and surgery requiring anesthesia, including a tooth and a latex glove. The authors say these incidents speak to the importance of establishing set national guidelines on managing dentures and other objects during anesthesia to ensure they don’t get lost, particularly as about one-in-five people between 18 and 74 use dentures.

“This case is important as it highlights a number of key learning points for anesthetists, theatre staff, emergency physicians and ear, nose and throat (ENT) surgeons alike,” wrote the authors.

The authors also note the importance of listening to your patient and their symptoms in order to think outside of the box and work around distractions, such as positive test results and other cognitive biases.