gagging a svere poblem fr doctors!!!

1. THE ETIOLOGY AND
MANAGEMENT OF
GAGGING:A REVIEW
OF THE LITERATURE
J Pros Dent.-G.S Bassi,G.M. Humphris,L.P. Longman(May
2004)

2. Gagging or Retching ?
Retching - An ejectory contraction of the muscles of the gastro-intestinal tract and oropharynx
Gagging - A normal protective reflex designed to protect the airway and prevent material entering the
oropharynx and the upper gastro-intestinal tract

3. INTRODUCTION
• Gagging commonly occurs during dental procedures,such as making a
maxillary impression.
• Severe gagging can be elicited by the dentist’s fingers or instruments
contacting the oral mucosa or even by nontactile stimuli.

4. • These patients tends not to seek a dental treatment or may request
treatment under general anaesthesia.
• Commonly results in exodontia.
• Final outcome- Edentulousness....

5. THE GAG REFLEX
It is a normal defense mechanism that prevents foreign
bodies from entering the trachea,pharynx,or larynx.
Unwanted ,irritating, or toxic material is ejected from the
upper respiratory tract by the contraction of
oropharyngeal muscles.

6. Retching :peristalsis becomes spasmodic, uncoordinated and the direction
is reversed.
 Air is forced over the closed glottis producing a characteristic
retching sound.
Reactions by patient: simple contraction of palatal or circumoral
musculature to spasm of pharyngeal structures, accompanied by
vomiting.

7. Gagging is accompanied by excessive
salivation,lacrimation,sweating,fainting or a panic attack.

8. Stimulation occurs intraorally
afferent fibers of vagus, glossopharyngeal , trigeminal pass to medulla
oblongata.
efferent impulses give rise to spasmodic and uncoordinated muscle
movement.

9. Five intraoral areas known to be “Trigger Zones”:
1. Palatoglossal and palatopharyngeal folds
2. Base of tongue

10. 3. Uvula
4. Palate
5. Posterior pharyngeal wall

11. • It may also be elicited by non-tactile sensations such as
visual,auditory,or olfactory stimuli.
• Sight of dentist or dental equipment.
• Sound of dental handpiece or person retching.
• Certain smells like cigarette smoke, or perfume.
• Certain thoughts.

12. Classification by Aetiology
Somatic:
Induced by touching a ‘trigger’ area
Psychogenic:
Induced without direct contact

13. CONTRIBUTORY FACTORS OF
GAGGING
1. Local and Systemic Factors
2. Anatomic Factors
3. Psychological Factors
4. Iatrogenic factors

14. Local factors
 Nasal obstruction,postnasal drip,catarrh,sinusitis,nasal polyps,mucosal
congestion of the upper respiratory tract,a dry mouth, and
medications.
 Chronic gastrointestinal disease,notably chronic gastritis,peptic
ulceration,and carcinoma of the stomach .
 Hiatus hernia and uncontrolled diabetes.

15. Anatomic Factors
Anatomic abnormalities and oropharyngeal abnormalities.
Palate anatomy
Long uvula
Tongue shape
Tongue position
Other ‘irregularities

16. Psychological Factors
 Systemic conditions like:TMJ dysfunction syndrome, atypical facial
pain, denture intolerance, burning mouth syndrome, the gag reflex.
 There are two mechanisms of learning known as:
1. Classical conditioning
2. Operant conditioning

17. Classical conditioning
-It occurs when an originally neural stimuli is paired with a specific
behavioral response.
-Inoffensive stimuli such as sight of an impression tray,smell of dental
surgery,sound of dental handpiece.
-Overloaded impression tray or the accumulation of large quantities of
water from the handpiece.

18. Operant conditioning
-It is a training process whereby the consequence of a response changes
the likelihood that the individual will produce that response again.
-some behaviour pattern are reinforced because they secure attention and
sympathy(positive reinforcement), avoid a stressful situation (negative
reinforcement) , or achieve some other desirable result.

19. Iatrogenic factors
 Poor cliical technique.
 Overextended borders of a prosthesis.
 Increased vertical dimension of
occlusion.
 A smooth,highly polished surface which
is coated with saliva may produce a
slimy sensation,therefore, a matte finish
is advocated.
 Inadequate posterior palatal seal

20. • Restricted tongue space
• Loss of normal palatal contour
• Poor retention
• Incorrect occlusal plane

21. Implications for the Patient
Emotional
Fear, anger & embarrassment
Avoidance behaviour
Physical
Acceptance of dental care
Oral hygiene practices
Ability to wear prostheses

22. Implications for the Dentist
Emotional
Fear, anger & embarrassment
Avoidance behaviour
Physical
Compromises ability to examine, diagnose and treat
Influences treatment decisions

23. MANAGEMENT
1.ASSESSMENT OF THE PATIENT
Identify
initiating
event
• Choking associated with swallowing of impression material.
• Panic attack by difficulty in removing new prosthesis.
• Non dental events such as suffocation.
• Sexual abuse involving oro genital penetration.
Ascertain triggers
• Tactile(examination,radiographs,impressions,wearing dentures.
• Gustatory for eg:smell of impression material.
• Olfactory for eg:smell of surgery.
• Visual for eg:white coats,dental chairs.
• Auditory for eg:sound of handpiece.
• Cognitions for eg:memories of past events.

24. Detailed dental history
and expectations
• How has previous treatment been performed?
• Has preventive treatment been employed?
• Is patient willing or suitable for restoration?
• What are patient’s motivation?
• Is attitude to treatment helpful?
• Are expectations realistic?
Associated clinical
features
• Are panic attacks,fainting,mood changes or other features associated with gagging?

25. BEHAVIORAL TECHNIQUES
1.BEHAVIOR MODIFICATION
• It has been recommendedthat all disruptive gagging should be
viewed and presented to the patient as a behavioral response and
, therefore, amenable to behavioral modification.
• An exaggerated or extended period of gagging in the absence of a
normal stimulus is usually a learned response.
• GENERALLY THE OBJECTIVES ARE TO REDUCE THE ANXIETY AND
TO UNLEARN THE BEHAVIOURS THAT PROVOKE GAGGING.

26. 2.RELAXATION
Passive Relaxation
• Calming environment
• Music
Active Relaxation
• Controlled rhythmic breathing (Hoad-Reddick)
• Relaxed abdominal breathing (Barsby)
• Visualisation/visual aids
• Biofeedback
• Progressive muscle relaxation (NCT)

27. “Traffic-light” Control Signals
Green
Amber
Red

28. 3. Distraction Techniques
Concentration on a task, place, object or event to temporarily
divert the patient’s attention away from the gagging
a. Short dental procedure
b. Leg raising (Krol)
c. Breathing exercises
d. Talking (Faigenblum)
e. Salt on tongue
f. Describing the procedure

29. 4.Systemic desensitization
Aims to progressively reduce the gagging threshold
• Tongue/palate stimulation
• Marbles/discs (Singer)
• Progressive appliance wear & training bases
• Dentures with acrylic beads & mat surfaces
Hard palate is gently brushed with a toothbrush without inducing gag reflex.
5.Training bases
5mins-once a day
5mins-twice a day
10mins 3times a day
15mins till 1hr...

30. 6.Errorless learning
For patients who have dentures but do not wear them because dentures
evoke gagging.
Patients are advised to look at the dentures or hold it till the symptoms of
retching develops.
7.Cognitive behavioral therapy
8.Sensory flooding

31. Teaching patients to swallow with their mouth open
Gaggers swallow with their teeth clenched,using the teeth,lips and cheeks
as buttress for tongue to push against.
Teach the patient to swallow with teeth apart,tip of tongue placed
anteriorly on hard palate, orbicularis muscle relaxed.

32. PHARMACOLOGICAL TECHNIQUES
1.Local anaesthesia
Mucosal surface is desensitized ,the patient is less likely to gag.
Sprays ,gels,lozenges are used.
Topical anaesthetics are used in few but in others it may induce nausea
and vomiting.
Deposition in posterior palatal foramen in few in those patients who gag
when it is touched.
But it is criticized by many authors.

33. 2.Conscious sedation
Nitrous oxide alters the perception of external stimuli and it is suggested
that this altered perception depresses the gag reflex.
Patients tolerance to keep intraoral objects is increased.

34. 3.General anaesthesia
Patients who do not respond to any of the treatment modalities have to
be given general anaesthesia as the last resort.

35. PALATELESS DENTURES
:help for gagging patients
TECHNIQUE
Impression procedures
-Preliminary impression of edentulous maxillary arch is made in a stock Rim-Lock edentulous tray and
modeling compound.
-Impression tray can be removed and modeling compound refined by repeatedly warming or by placing
additional modeling compound until the desired preliminary border molding and impression are
completed.

36. -The tray is readily removed between gagging episodes.
-An acrylic custom tray is fabricated on the resultant cast.
-The tray is constructed 2mm short of the reflections and adjusted intraorally.
-Border molding with modeling compound is accomplished to obtain a physiological
seal.
-The border molding encompasses the entire maxillary region as well as the labial and
buccal vestibules.

37. Cast Preparation
-the labial and buccal extensions for border seal is established in final impression.
-the lingual palatal border is established by placing a bead line prepared with a No.4
round bur and refined with a spoon excavator.
-the bead line should be approximately 0.5 to 1mm in depth and width.
.

38. -The palatal borders should be located at the junction of horizontal and vertical
slopes of the palate and be as symmetric as possible.
-Anteriorly,the beaded border should cross the mid palatal suture line at right
angles and placed in rugae valleys when possible.
-Posteriorly ,the bead line extends to and blends with the pterygomaxillary
notches bilaterally.

39. Denture base construction
-A cast metal denture base of aluminium or chrome nickel alloy is
recommended.
-The primary advantage is the achievement of intimate contact between the
denture base and the underlying tissue,which markedly increases the
retention of the prosthesis.
-The metal base also provides rigidity to resist breakage and arpage,uniform
thickness material,a beaded metal finish line on the palatal surface,and a
stable substructure for recording jaw relations.

40. -The metal base extends from the palatal bead line to cover the crest of the ridge.
-No 14 retention beads are placed for attachment of the acrylic resin to the metal base.
-The labial and buccal borders of the denture are processed in acrylic resin.
-An external palatal finish line is placed on the anterior lingual and palatal slopes to
within 5mm of the denture border to provide for acrylic resin palatal contours and
avoid a resin-metal junction that might interfere with speech or irritate the tongue.

41. Occlusal considerations.
A bilateral balanced occlusion is achieved with a modified anatomic or
cuspless tooth form.

42. MAKING AN IMPRESSION OF A
MAXILLARY EDENTULOUS
BY PRESSING CAVES PATIENT
-The gag reflex is stimulated and controlled by nerve endings situated in soft
palate,pharynx,and pharyngeal part of the tongue.
Some suggested to anaesthetize the soft palate or injecting local anaesthetic into
posterior palatal foramen.
-Ansari advocated a secondary impression with injection type polyvinyl siloxane in a
custom tray.
-Friedman suggested to extend their tongue and place salt on the tip of the tongue.
-Ren Xianyun suggested to press two chinese caves,or accupuncture caves.

44. PROCEDURE
1.Apply light pressure and increase to a heavy pressure until the patient feels soreness
and distension to both the left and right concave area at medial aspect by the
forearm and concave area between the first and second metacarpal bones with the
tumb for 5to 20 minutes.
-The patient should feel the soreness and distension immediately.
-The impression tray should be inserted into the mouth witout gagging at thistime.
2.Pressure can be applied by the patient,dental assistant or dentist.

46. MANAGEMENT OF GAG REFLEX IN
PATIENTS
MAKING AN IRREVERSIBLE HYDROCOLLOID IMPRESSION
-A local anaesthetic was incorporated into irreversible hydrocolloid
material for reducing the gag reflex.
-ADVANTAGES:- 1.Controls the flow of anaesthetic agent to sensitize gag
and vomit-reflex areas.
2.Minimizes the risk of hazard and toxicity.
3.It allays apprehension by not introducing secondary items to the
patient’s mouth.
4.It dampens the sensitivity of the entire arch during the impression
making.
5.Technique is simple.

47. Procedure
1.Prepare the patient by stimulating positive attitude towards dental care,allaying
anxiety,and instilling confidence.inform the patient that this hydrocolloid is
specially prepared to eleminate gagging.
2.Instruct the patient in basic breathing and muscle relaxation exercises.
3.Dispense 1 capsule of local anaesthetic solution(1.8ml of 2% lidocaine with 1 part in
1,00,000 epinephrine)to the plastic measuring cylinder and then add water to the
correct volume.
4.Pour the water/anaesthetic mixture into the bowl,then add the measured powder
and mix thoroughly.insert the loaded tray gently in the patient’s mouth and press
until set.

48. SUMMARY OF MANAGEMENT OF
GAGGING PATIENT
Individual assessment
Assess patient’s attitude willingness to
And motivation to tt. -Try tt. And invest time in tt.
-Commit to homework
-accept that the tt. May be prolonged
techniques common to all patients
1. Sympathetic approach
2. Positive attitude
3. Thorough history
4. Reassure patient gagging is a normal response.Many
patients hv very sensitive gag reflex.
The majority of patients can learn to
control gagging but it takes time.
Gagging is nothing to be embarressed
about.Build patient’s self confidence.

49. Explain and demonstrate
stop signal [for ex-raising allow the patient to feel
Hand ] some control
Careful intraoral examination obtain patient’s feedback and
continually re negotiate consent.
Avoid trigger zones
praise patient.
Specific treatment modalities
behavioral relaxation techniques
distraction
suggestion/ hypnosis
systematic desensitization
cognitive behavioural therapy

50. Pharmacological oral
inhalation
intravenous
Combined several techniques may be used together or
in successsion
Simple measures for all don’t overload imp. Tray
patients use quick setting impression materials
ensure efficient aspiration
Miscellaneous akinosi closed mouth technique for
local analgesia of inferior dental nerve.
Treat patient in an upright psition
frequent cessation of the treatment.

51. Prosthodontic
Unable to tolerate impressions distraction technique
relaxation
systemic desensitization
hypnosis
sedation
Unable to wear denture satisfactory dentures
available-’errorless learning’
no satisfactory dentures-systemic
desensitization ,for
eg,training basis and errorless
learning.
acrylic discs may be helpful prior
to provision of training bases.

52. Restorative
Unable to tolrate no short term treatment requirements:
instrumentation,For eg, -hypnosis
examination,scaling, -systemic desensitization for oral
tooth preparation hygiene measure,scaling ,polishing
-encourage regular reviews
-sedation
in urgent need of treatment:
-hypnosis
-sedation