gag reflex ISDH 2009 no patient ID.ppt

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  • 1. The Assessment and Management of Patients with Pronounced Gag Reflexes Chris Dickinson Department of Sedation & Special Care Dentistry KCL Dental Institute Floor 26. Guy’s Hospital
  • 2. “ Had a bad day at the orifice, dear?”
  • 3.
    • Gagging - A normal protective reflex designed to protect the airway and prevent material entering the oropharynx and the upper gastro-intestinal tract
    Retching - An ejectory contraction of the muscles of the gastro-intestinal tract and oropharynx Gagging or Retching ? Picture of patient
  • 4. Prevalence of Gagging
    • No data available on the prevalence or distribution of pronounced gag reflexes in the general population
    • 26 % of young adults and 43 % of older adults had a total absence of the gag reflex
    • Davies et al. 1995. The Lancet .
  • 5. Classification by Aetiology
    • Somatic:
    • Induced by touching a ‘trigger’ area
    Psychogenic: Induced without direct contact Krol 1963
  • 6. Contributory Factors
    • Evidence is poor
    • Anatomical
    • Medical
    • Emotional/Psychological
    • Iatrogenic
  • 7. Anatomical
    • Palate anatomy
    • Long uvula
    • Tongue shape
    • Tongue position
    • Other ‘irregularities’
  • 8. Medical
      • Chronic nasal congestion and obstruction
      • Post nasal drip
      • Gastric disorders
      • Motor neurone disease
      • Dysphagia
      • Obesity
      • Other medical conditions
    Picture of patient
  • 9. Psychological ?
    • Eating disorders
    • Fear
    • Stress
    • Neuroticism
    • Learned responses
    Picture of patient
  • 10. Iatrogenic – General
    • Water & suction tubes
    • Instruments
    • Local anaesthesia
    • Radiography
    Pictures of patient
  • 11. Iatrogenic – Prosthetic
    • Inadequate posterior palatal seal
    • Restricted tongue space
    • Loss of normal palatal contour
    • Poor retention
    • Incorrect occlusal plane
    • Decreased freeway space
    • Excess freeway space
    • Incorrect tooth position
  • 12. Implications for the Patient
    • Emotional
    • Fear, anger & embarrassment
    • Avoidance behaviour
    • Physical
    • Acceptance of dental care
    • Oral hygiene practices
    • Ability to wear prostheses
    Picture of patient
  • 13. Implications for the Dentist
    • Emotional
    • Fear, anger & embarrassment
    • Avoidance behaviour
    • Physical
    • Compromises ability to examine, diagnose and treat
    • Influences treatment decisions
  • 14. Assessment
    • Precipitating factors
    • Nature & severity
    • Relievers & promoters
    • Successful & failed dental treatments
    • Treatment required
    • Treatment requested
    • Somatic ‘mapping’
  • 15. Gagging Severity Index GSI Grade I Very mild: Controlled by patient II Mild: Control regained by patient/dentist with simple control techniques & reassurance III Moderate: Limits treatment options IV Severe: Some treatments impossible V Very severe: Effects patient’s behaviour and dental attendance. All treatment impossible Dickinson & Fiske. 2000
  • 16. Methods of Control
    • Relaxation & C.A.F
    • Dental ‘techniques’
    • Distraction and desensitisation
    • Psychological and behavioural techniques
    • Local anaesthetic techniques
    • Sedation techniques
    • General anaesthesia
    • Complementary therapies
    Picture of patient
  • 17. Psychological Techniques
    • In - House
        • Confidence building
        • Ego enhancement
        • Tell – show - do
    • Referral
        • Cognitive Behavioural Therapies
        • Psycho – therapeutic analysis and treatment
  • 18. Relaxation Techniques
    • Passive Relaxation
      • Calming environment
      • Music
    • Active Relaxation
      • Controlled rhythmic breathing (Hoad-Reddick)
      • Relaxed abdominal breathing (Barsby)
      • Visualisation/visual aids
      • Biofeedback
      • Progressive muscle relaxation (NCT)
  • 19. Relaxation & C.A.F
    • Caring Attitude Factor (Shipmon)
      • Empathetic but firm
      • Calm, confident, in control
      • Rapport
    • Communication and signalling
    • Positioning/Neck extension
    • Breathing control
    • Careful instrument handling
  • 20. “ Traffic-light” Control Signals Green Amber Red
  • 21. Dental Techniques
    • Rubber Dam
    • Local Analgesia ??
      • Palatine block
      • Inferior alveolar block
      • LA incorporated into impression material
  • 22. Distraction Techniques
    • Sensory deprivation (Landa)
    • Leg raising (Krol)
    • Breathing exercises
    • Talking (Faigenblum)
    • Salt on tongue
    • Sick stick (Robb)
    • Temporal tap (Robb)
    Concentration on a task, place, object or event to temporarily divert the patient’s attention away from the gagging
  • 23. Desensitisation Techniques
    • Homework and Rehearsal (Sewerin)
      • Tongue/palate stimulation
      • Marbles/discs (Singer)
      • Progressive appliance wear & training bases
      • Dentures with acrylic beads & mat surfaces (Singer)
      • Orthodontic plates and blow-down splints
      • Soft swallowing (Wilks)
    Aims to progressively reduce the gagging threshold
  • 24. Sedation & General Anaesthesia
    • Inhalation
    • Intravenous
    • Oral
    • Intranasal
    • Combinations
    • Large quantity of restorative or oral
    • surgical treatment
    • Gag reflex not controlled by other methods
    • GA - Last resort
    Picture of patient
  • 25. Complementary Therapies
    • Hypnosis (Barsby)
      • Reframing
      • Ego-enhancement
      • Auto-hypnosis
      • Contra-indicated
      • in psychological conditions?
    Picture of patient
  • 26. How does it work?
  • 27. “ That a needle stuck into the skin of the foot should help a case of migraine is obviously incredible, it makes no sense. Within our system of explanation there is no reason why the needle prick should be followed by an improvement, therefore we say it cannot happen. The only trouble with this argument is that as a matter of empirical fact, it does happen.” Aldous Huxley Evidence of effect is emerging in several areas
  • 28. Acupuncture
    • Technique
    • Simple & Quick
    • Inexpensive
    • Easily learned
    • Effective
    • Few contra-indications
  • 29. Chengjiang (CV24)
  • 30. Hegu (LI4)
  • 31. Ear Acupuncture
  • 32. Other Acupuncture Points
    • Face
    • Head
    • Back
    • Hand
  • 33. Ear Acupuncture - Uses
    • Diagnostic - Assessment
    • Episodic - Treatment
    • Desensitisation ??
  • 34. Ear Acupuncture - Before & After Pictures of patient
  • 35. Combination Techniques
    • Pre-treatment desensitisation
    • Inhalation sedation
    • Acupuncture
    • Acupressure
    • Rubber dam
    • Visualisation
    • Distraction
    Picture of patient
  • 36. Recording Success
    • Gagging Prevention Index
    • GPI Grade
    • I Fully Controlled – Treatment successful
    • II Partially controlled – Treatment possible
    • III Partially controlled – Some simple treatments
    • possible with frequent gagging
    • IV Inadequately controlled – Even diagnostic procedures difficult
    • V No Control – No treatment possible
    • Dickinson & Fiske, 2000
  • 37. Summary
    • Fully assess the nature of the gag reflex
    • Match the level of treatment need with the management techniques at your disposal
    • Set small objectives for each treatment visit
    • Don’t continue until patient gags. Stop at a positive point if possible
    • Use a variety of management strategies for different items of treatment – be flexible
    Pictures of patient
  • 38. Thank You