Corresponding Author: Dr Simon Laidlaw, Department of Ageing and Health, Ninewells Hospital and Medical School, Dundee, DD1 9SY.
E-mail: simon.laidlaw@tpct.scot.nhs.uk
Abstract
Accidental ingestion of medicines and household goods can be a problem in people with cognitive impairment. There is significant associated morbidity and mortality. Here we present a case of an 87-year-old gentleman with vascular dementia who accidentally ingested two Steradent denture-cleaning tablets. He rapidly developed acute upper airway obstruction and extensive oesophageal ulceration. He required intubation and ventilation. This case reinforces the importance of minimising the risk of accidental ingestion.
Keywords: Steradent, accidental ingestion, oesophageal ulceration
Introduction
Over the counter medicinal products have the potential to cause harm if administered inappropriately. Accidental ingestion of medicines and other household goods is a well-recognised problem in young children. Perhaps less well recognised is the risk posed to older people, especially those with coexisting sensory and cognitive impairment. The following case describes a severe reaction to Steradent ingestion in an older patient with cognitive impairment, helping to illustrate the risk of such events.
Case Report
An 87 year old gentleman was admitted with worsening mobility, agitation and self-neglect. He had a past history of cerebrovascular disease and vascular dementia. He was mobile with a frame but required increasing assistance with his activities of daily living. His MSQ was 8 out of 10. On examination he had a left sided weakness resulting from a previous stroke. He wore dentures. Baseline investigations were unremarkable. It was felt his deterioration was due to a further cerebrovascular event. A CT scan of his brain confirmed a new left occipital lobe infarct.
On his second day in hospital he accidentally ingested two Steredent tablets brought to him by his wife. These had used these at home for cleaning his dentures and were stored on his bedside locker whilst in hospital. His condition deteriorated rapidly. He developed gross neck and tongue swelling and his breathing became stridorous. Intravenous steroid, antihistamine and nebulised adrenalin were administered. Concern grew about the patency of his upper airway and he was transferred to a tertiary centre under the care of ENT surgeons. He required urgent intubation. Laryngoscopy showed gross oedema and erythema of the floor of the mouth, uvula and supraglottis. The larynx was obscured. An endotracheal tube was passed with difficulty. Oesophagoscopy revealed mucosal oedema and ulceration down to 38 cm.
He was sedated, paralysed and ventilated and remained on intravenous steroid. The upper airway swelling gradually improved and after 4 days he was extubated. A water-soluble contrast swallow showed significant aspiration into both lungs but no evidence of oesophageal perforation or stricture formation. He required a protracted period of enteral feeding through a gastrostomy tube. His swallow gradual improved and his gastrostomy tube was removed 35 days after ingestion of his tablets. His recovery was complicated by two episodes of pneumonia. His function improved and by 47 days after ingestion he was discharged home with increased social support.
Discussion
Steradent is a widely used denture cleaner. Its active ingredients are caustic alkalis that sterilise and clean dentures. The manufacturer advises that dentures are rinsed after cleaning and warn against ingestion and skin contact. In people older than 70 years Steradent ingestion was the commonest reason for contacting the United Kingdom Poisons Information Bureau advice line [1]. Three case reports have previously linked Steradent ingestion with chemical burns in the upper airway and oesophagus. In one patient an oesophageal stricture developed [2-4]. In this case there was oesophageal ulceration and the gentleman’s swallow mechanism took some time to recover. In addition, this patient developed gross swelling and oedema of his upper airway as a result of direct chemical irritation, this is not described previously.
Following acute ingestion of caustic alkali the administration of milk or water may act to neutralise the alkali. The evidence is for this is, however, not clear and there is some concern that the heat generated from the reaction may worsen the damage [5]. Corticosteroid administration can reduce local inflammation and prevent stricture formation [6]. Antibiotics have been shown to reduce the risk of infection in animal models, as yet there is no convincing human data, but there use is advocated [7]. It is recommended endoscopy should be carried out within the first 12 to 24 hours of ingestion. This allows the extent of injury to be assessed, there after softening of scar tissue make endoscopy too risky [8]. Further supportive care is indicated as required.
Conclusion
In older patients with cognitive impairment it is important to be aware of the risk of accidental ingestion of medicines and common household goods. Even readily available products such as Steradent can have serious adverse effects if administered inappropriately. Following such accidents mortality is higher in older than younger patients [9]. It is thus important to minimise the risk of accidental ingestion occurring. It is now the policy of this hospital to store denture cleaners along with other medicines in a locked trolley
Key Points
People with cognitive impairment are at risk of accidental ingestion of medicines and other household goods.
Morbidity and mortality following accidental ingestion in older people is high.
Efforts should be made to minimise the risk of such events happening.
References
National Poisons Information Bureau (UK) Annual Reports. 1998-2000.
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