The Assessment  and Management of  Patients with Pronounced Gag Reflexes   Chris Dickinson  Department of Sedation & Speci...
“ Had a bad day at the orifice, dear?”
<ul><li>Gagging  - A normal protective reflex designed to protect the airway and prevent material entering the oropharynx ...
Prevalence of Gagging <ul><li>No data available on the prevalence or distribution of pronounced gag reflexes in the genera...
Classification by Aetiology <ul><li>Somatic:   </li></ul><ul><li>Induced by touching a ‘trigger’ area </li></ul>Psychogeni...
Contributory Factors <ul><li>Evidence is poor </li></ul><ul><li>Anatomical </li></ul><ul><li>Medical </li></ul><ul><li>Emo...
Anatomical <ul><li>Palate anatomy  </li></ul><ul><li>Long uvula </li></ul><ul><li>Tongue shape </li></ul><ul><li>Tongue po...
Medical <ul><ul><li>Chronic nasal congestion and obstruction </li></ul></ul><ul><ul><li>Post nasal drip </li></ul></ul><ul...
Psychological ? <ul><li>Eating disorders </li></ul><ul><li>Fear </li></ul><ul><li>Stress </li></ul><ul><li>Neuroticism </l...
Iatrogenic – General  <ul><li>Water & suction tubes </li></ul><ul><li>Instruments </li></ul><ul><li>Local anaesthesia </li...
Iatrogenic – Prosthetic <ul><li>Inadequate posterior palatal seal </li></ul><ul><li>Restricted tongue space </li></ul><ul>...
Implications for the Patient <ul><li>Emotional   </li></ul><ul><li>Fear, anger & embarrassment  </li></ul><ul><li>Avoidanc...
Implications for the Dentist <ul><li>Emotional </li></ul><ul><li>Fear, anger & embarrassment </li></ul><ul><li>Avoidance b...
Assessment <ul><li>Precipitating factors </li></ul><ul><li>Nature & severity </li></ul><ul><li>Relievers & promoters </li>...
Gagging Severity Index GSI Grade I Very mild:  Controlled by patient II Mild:  Control regained by patient/dentist with  s...
Methods of Control <ul><li>Relaxation & C.A.F </li></ul><ul><li>Dental ‘techniques’ </li></ul><ul><li>Distraction and dese...
Psychological Techniques <ul><li>In - House </li></ul><ul><ul><ul><li>Confidence  building </li></ul></ul></ul><ul><ul><ul...
Relaxation Techniques <ul><li>Passive Relaxation   </li></ul><ul><ul><li>Calming environment </li></ul></ul><ul><ul><li>Mu...
Relaxation & C.A.F <ul><li>Caring Attitude Factor  (Shipmon) </li></ul><ul><ul><li>Empathetic but firm </li></ul></ul><ul>...
“ Traffic-light” Control Signals Green Amber Red
Dental Techniques <ul><li>Rubber Dam </li></ul><ul><li>  Local Analgesia ?? </li></ul><ul><ul><li>Palatine block </li></ul...
Distraction Techniques <ul><li>Sensory deprivation  (Landa)   </li></ul><ul><li>Leg raising  (Krol) </li></ul><ul><li>Brea...
Desensitisation Techniques <ul><li>Homework and Rehearsal   (Sewerin) </li></ul><ul><ul><li>Tongue/palate stimulation </li...
Sedation & General Anaesthesia <ul><li>Inhalation </li></ul><ul><li>Intravenous </li></ul><ul><li>Oral </li></ul><ul><li>I...
Complementary Therapies <ul><li>Hypnosis   (Barsby) </li></ul><ul><ul><li>Reframing </li></ul></ul><ul><ul><li>Ego-enhance...
How does it work?
“  That a needle stuck into the skin of the foot should help a case of migraine is obviously incredible, it makes no sense...
Acupuncture <ul><li>Technique </li></ul><ul><li>Simple & Quick </li></ul><ul><li>Inexpensive </li></ul><ul><li>Easily lear...
Chengjiang (CV24)
Hegu  (LI4)
Ear Acupuncture
Other Acupuncture Points <ul><li>Face </li></ul><ul><li>Head </li></ul><ul><li>Back </li></ul><ul><li>Hand </li></ul>
Ear Acupuncture - Uses <ul><li>Diagnostic - Assessment </li></ul><ul><li>Episodic - Treatment </li></ul><ul><li>Desensitis...
Ear Acupuncture - Before & After Pictures of patient
Combination Techniques <ul><li>Pre-treatment desensitisation </li></ul><ul><li>Inhalation sedation </li></ul><ul><li>Acupu...
Recording Success <ul><li>Gagging Prevention Index </li></ul><ul><li>GPI Grade </li></ul><ul><li>I   Fully Controlled   – ...
Summary <ul><li>Fully assess the nature of the gag reflex </li></ul><ul><li>Match the level of treatment need with the man...
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gag reflex ISDH 2009 no patient ID.ppt

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