Effects of Gagging.pptx

Effects of Gagging
PRESENTER:-
BAISHALIGHOSH
1ST YEARPGT
DEPARTMENTOFPROSTHODONTICS,CROWN&BRIDGE
UNDER THE ABLE GUIDANCE OF:-
DR.(PROF)JAYANTA BHATTACHARYA
[HOD&PRINCIPAL]
DR.(PROF)SAMIRANDAS
DR.(PROF)SOUMITRAGHOSH
DR.(PROF)PREETIGOEL
DR.(PROF)SAYANMAJUMDAR
DR.SHUBHABRATAROY

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Agenda
INTRODUCTION
GAG REFLEX
RECEPTORS
CLINICAL FACTORS
ETIOLOGY
MANAGEMENT
SUMMARY
CONCLUSION
REFERENCE
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Introduction
Gagging has been defined as an
ejectory constriction of the
muscles of the pharyngeal
sphincter. It is a normal protective
reflex designed to protect the
airway and remove irritant
materials from the posterior
oropharynx and upper G.I.T.
3

PHYSIOLOGY
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GAG REFLEX
The gag reflex, also known as the pharyngeal reflex, is an involuntary
reflex involving bilateral pharyngeal muscle contraction and elevation of
the soft palate. This reflex may be evoked by stimulation of the posterior
pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is
believed to be an evolutionary reflex that developed as a method to
prevent swallowing foreign objects and prevent choking
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TYPES OF GAG REFLEX
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GAG REFLEX
SOMATOGENIC
A somatogenic gag reflex
follows direct physical
contact with a trigger area.
PSYCHOGENIC
A psychogenic gag reflex
presents following a mental
trigger, typically without
direct physical contact.
NAFIS AHMAD ET AL. ETIOLOGY AND MANAGEMENT OF GAG REFLEX IN THE PROSTHODONTIC CLINIC: A REVIEW INTERNATIONAL JOURNAL OF ORAL HEA LTH DENTISTRY,
JAN-MARCH, 2015;1(1):25-28

TRIGGER ZONE
5 TRIGGER
ZONES
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BASE OF THE
TONGUE
PALATOGLOSSAL &
PALATOPHARYNGEAL
ARCH
UVULA
POSTERIOR
PHARYNGEAL WALL
PALATE
Gagging is more
common in high
palatal or V shaped
palatal vault form.
A focus of hyperirritability in tissue which when palpated is locally tender and
gives rise to heterotopic pain.
FIS AHMAD ET AL. ETIOLOGY AND MANAGEMENT OF GAG REFLEX IN THE PROST HODONTIC CLINIC: A REVIEW INTERNATIONAL JOURNAL OF ORAL HEALTH D ENTISTRY, JAN-
MARCH, 2015;1(1):25-28

CRANIAL NERVES CONTROLLING GAG
REFLEX
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GLOSSOPHARYNGEAL
(CN IX)
VAGUS (CN X)
Afferent(Sensory) limbs of
the reflex arc.
Efferent(Motor) limbs of
the reflex arc.
The nerve roots of cranial nerves IX and X exit the
medulla through the jugular foramen and descend on
either side of the pharynx to innervate the posterior
pharynx, posterior one-third of the tongue, soft palate, and
the stylopharyngeus muscle.
JAN-MARCH, 2015;1(1):25-28

PATHWAY OF GAG REFLEX
9
Soft palate
stimulus
Pharyngeal
constriction
Jaw opening
Tongue thrust
Sensory Loop
Motor Loop
Spinal Trigeminal nucleus or
nucleus tractus solitarius
Nucleus Ambigus
Motor Trigeminal
nucleus.
Hypoglossal nucleus.
CN IX
CN X
CN V
CN XII
Ipsilateral to the
side of the stimulus.
Contralateral to the
side of the stimulus.
DIRECT GAG
REFLEX
CONSENSUAL
GAG REFLEX

MOTOR NEURON LESION
UPPER MOTOR
NEURON LESION
LOWER MOTOR
NEURON LESION
Abnormality in ipsilateral side.
Abnormality in contralateral side.
Jaw deviation to the ipsilateral side of
the lesion.
Jaw deviation to the contralateral side of the
lesion.
Failure to elevate palate on the
ipsilateral side of the lesion.
Failure to elevate palate on the contralateral
side of the lesion.
Deviation of the tongue towards the
ipsilateral side of the lesion.
Deviation of the tongue towards the
contralateral side of the lesion.
ag reflex absent in contralateral side. Gag reflex absent in ipsilateral
side.
EXAMINATION OF
GAG REFLEX
To test the gag reflex, we gently touch one and then the
other palatal arch with a cotton swab or tongue blade,
waiting each time for gagging.

RECEPTORS OF GAG REFLEX
The sensory stimuli capable of
initiating the gag reflex are
detected by three types of
receptors :-
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OROFACIAL
RECEPTOR
S
BLOOD
FLOW
RECEPTOR
S

OROFACIAL RECEPTORS
13
LOCATION:- These nociceptive receptors that are present in the posterior pharynx , tonsillar pillars as
well as in the tongue papillae can trigger the gag reflex..
AFFERENTS
ASSOCIATED
WITH THESE
RECEPTORS:-
LABYRINTH
RECEPTORS
Cochlear branch of the vestibulocochlear nerve VIII
OCCULAR
RECEPTORS
Optic nerve II
ORAL CAVITY Trigemminal nerve, V2 & V3 branch
JAN-MARCH, 2015;1(1):25-28

BLOOD FLOW RECEPTORS
In triggering the gag reflex, the blood flow and lymph carry the chemical
mediators responsible for the changes in the chemoreceptor area situated in the
postrema area, in the wall of the fourth ventricle, rich in dopaminergic receptors.
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PATHWAYS OF MOTOR IMPULSE
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Vagus nerve
Glossopharyngeal nerve
Trigeminal nerve
It generates hypersalivation & lifting of the palatine veil.
Intercostal nerves
Iliohypogastric nerves
Ilioinguinal nerves
Innervate the muscles of the abdominal wall and the
intercostal muscles, which causes cramping of abdomen.
Phrenic nerve Innervates the diaphragm.

Sequential events of Gagging
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1. Puckering of the
lips or attempting to
close the jaws.
2. Elevating
or furrowing
the tongue.
3. Elevation of
soft palate and
hyoid bone.
4. Closing of the
nasopharynx by an
approximation of the
posterior pillars of the
fauces that elevate the
soft palate.
5. Contraction of the
anterior and posterior
pillars of the fauces,
causing the tonsils to
rotate in an
anteriomedial direction.
6. Elevation,
contraction and
retraction of the
larynx and closure of
the glottis.
7. Retching or
simultaneous and
uncoordinated
respiratory muscle
spasm, and
8. Vomiting.

CLINICAL FEATURES
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EXTRA ORAL INTRA ORAL
LACRIMATION
COUGHING
SWEATING
RETCHING NOISES
FAINTING
PANIC ATTACKS
Puckering the lips & attempting
to close the jaws.
Elevating & furrowing of the
tongue.
Excessive salivation or drooling.
HATTAB FN, OMARI M, DUWAYRI A. MANAGEMENT OF A P ATIENT’S GAG REFLEX IN MAKING AN IRREV ERSIB LE HYDROCOLLOID IMP RESSION. J P ROSTHET DENT. 1 9 9 9 ; 8 1 : 3 6 9 -7 2

AETIOLOGICAL
FACTOR
ANATOMIC FACTORS
SYSTEMIC DISORDERS
PSYCHOLOGICAL FACTORS
• Active reaction
• Passive reaction
PHYSIOLOGICAL FACTORS
• Extraoral stimuli
• Intraoral stimuli
IATROGENIC FACTORS
18
GAGGING : AETIOLOGY AND MANAGEMENT SMITA MUSANI, ET AL. INDIAN JOURNAL OF DENTAL ADVANCEMENTS, 2(4), OCTOBER -DECEMBER, 2010, (23-31)

ANATOMIC FACTORS
Atypical anatomy and oropharyngeal sensitivity influences patient to gag.
A comparatively long soft palate and a larger angle between the hard and soft palates are
associated with the gagging problem.
Gagging also has been seen in hypersensitivity of the soft palate, uvula, fauces, posterior
pharyngeal wall, and the tongue.
Wright examined a number of anatomical features cited as possible influences on retching.
• • Posterior point of the soft palate.
• Angle of the soft palate.
• Posterior point of the tongue.
• Palatopharyngeal airway.
• Anterior position of the hyoid.
• Nasopharyngeal isthmus.
Innate hypersensitivity has been postulated along with variations of the intra- and extra-oral
areas innervated by the 5th, 9th, and 10th cranial nerves. 19

SYSTEMIC DISORDERS
CHRONIC
CONDITIONS OF
OF NOSE
• deviated septum
• nasal polyps
• sinusitis
• blocked nasal passages increase the likelihood of the gag
the gag reflex.
CHRONIC
CONDITIONS OF
OF GIT
• Chronic gastritis
• carcinoma of stomach
• peptic ulcer
• cholecystitis
OTHER
CONDITIONS
• Inflammation of Pharynx
• This condition is common in persons who drink and smoke
and smoke excessively
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PSYCHOLOGICAL FACTORS
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ACTIVE
REACTION
PASSIVE
REACTION
It is due to factors that currently have some
functional purpose in the patient's life
situation.
It is due to factors that are no longer
functionally important.
For various psychologic reasons, patients
may gag to gain attention from the
dentist, to avoid treatment, and or to
avoid the outcome of treatment.
It is associated with past events in
patient’s life.

PHYSIOLOGICAL FACTORS
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EXTRAO
RAL
STIMULI
SIGHT
SMELL
SOUND
OTHER
FACTORS
The mere sight of a mouth mirror or
impression tray is stimulus enough to
cause some patients to gag.
Smell of various dental substances, cigarette
smoke etc have been reported to cause gag
reflex.
It has been reported that the sound of gagging
in a fellow patient was sufficient to precipitate
an attack of gagging in the concerned patient.
Factors like stress, fear, apprehension and
several other factors can also stimulate gag.
INTRAOR
AL
STIMULI
Tactile stimulation of the oral tissues inevitably
occurs when executing various dental procedures.
TACTILE SENSATIONS IN PALATE
The palate is roughly divided into two response
regions for tactile irritation hyposensitive and
hypersensitive. A line drawn through the fovea
palatine demarcates the relatively hyposensitive
anterior portion from the hypersensitive posterior
portion.
TACTILE SENSATIONS IN TONGUE
It has been stated that the upper surface of the
posterior 1/ 3 of the tongue is the most sensitive
region in the entire oral cavity.

IATROGENIC FACTORS
23
Inadequate post dam
Disharmonious occlusion
Poor retention
Surface finish of acrylic resin
Inadequate free way space.
Over extended posterior borders
Under extended posterior borders
Inadequately extended borders results in poor retention producing an
unstable prosthesis & their movements may stimulate tickling sensation
and elicit a gag
When a post dam is too shallow, the tight pressure that results, can
produce a tickling sensation which elicits a gag.
Krol stated that inadequate free way space may cause gagging related to
complete dentures and his explanation suggested that the elevator muscles
do not relax normally if the occlusal vertical dimension exceeds the
vertical dimension at rest. This may cause a spasm that sets in action a
chain of swallowing muscle responses

GAGGING SEVERITY INDEX (GSI) -
Dickinson and Fiske
• Patients himself controlled the gagging.
1. Very mild:
• Gagging can be controlled by patient/dentist by applying simple
measures.
2. Mild:
• Some treatment options are not accepted by the patients.
3. Moderate:
• Some treatments are impossible.
4. Severe:
• All the procedures are impossible and effects patient’s behavior.
5. Very severe:
24

PREDICTIVE GAGGING SURVEY -
Herring
1. Do you have a gag reflex? YES/NO
2. How strong would you say your gag reflex is? Please circle the corresponding number on the following scale.
1 2 3 4 5 6 7
3. Have you ever had a negative incident with gagging? YES/NO
4. Have you ever gagged at a dentist/orthodontist office before? YES/NO
5. Please circle any of the following experiences that have caused you to gag: Routing teeth-cleaning Root canal Cavity filling Dental impression
Dental x-ray Other orthodontic work Other dental work
6. When you are going to the dentist, how much stress (if any) do you experience that is related to your gag reflex? Please circle the
corresponding number on the following scale. 1 2 3 4 5 6 7 none -----------somewhat-------------much------------a great deal
7. Have daily activities, like brushing or flossing your teeth, ever made you gag? YES/NO How often are these occurrences? 1 2 3 4 5 6 7 never
-------------seldom------------sometimes------------often
8. Do you ever worry that daily activities other than brushing or flossing your teeth will cause you to gag? YES/NO
9. Does coughing ever cause you to gag? YES/NO
10. Have you ever gagged while trying to swallow pills? YES/NO
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ASSESSMENT OF GAGGING PATIENT
Identify
initiating
event.
Ascertain
triggers to
gagging.
Detailed dental
history and
expectation.
Associated
clinical feature.
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 Choking associated with swallowing of
impression material.
 Panic attack provoked by difficulty removing
new prosthesis.
 TACTILE= Examination, wearing dentures.
 GUSTATORY= Taste of impression material.
 OLFACTORY= Smell of gloves or impression
materials.
 VISUAL= Sight of white coat.
 COGNITION= Memories of past experience.

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PHARMACOLOGICAL INTERVENTION
PHARMACOLOGIC
AL INTERVENTION
PERIPHERALLY
ACTING
AGENTS
ANAESTHETICS
TOPICAL
Benzocaine
Tetracaine
LOCAL
CENTRALLY
ACTING
AGENTS
Trimethobenzamide.
5-HT3 antagonists:
Granisetron
Tropisetron.
Conscious sedation using nitrous oxide
sedation, propofol or intravenous propofol-
remifentanil.
General anaesthesia: a minority of patients do not respond to any form
of sedation or behavioural therapy, are likely to have their dental
treatment done under general anaesthesia as a last resort (Bassi 2004).
ALI ET AL GAGGING AND ITS MANAGEMENT IN PROSTHODONTIC
PATIENTS – A REVIEW OF LITERATURE. BIOMEDICA VOL. 34, ISSUE
3, JUL. – SEP., 2018
29

ACUPRESSURE / ACUPUNCTURE
Acupuncture is a system of medicine in which a fine needle is inserted
through the skin to a depth of a few millimeters, left in place for a time,
sometimes manipulated and then withdrawn, whereas acupuncture is
application of pressure on certain points for 5- 7 minutes or until patient
feels discomfort.
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ACUPRESSURE/ ACUPUNCTURE
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TECHNIQUE:-
It involves the insertion of a fine,
single-use disposable needle of 7
mm length into the anti-gagging
point to a depth of 3 mm. The
needle is manipulated for 30
seconds prior to carrying out
dental treatment. The needles
remain in situ throughout the
treatment.
Initially a light pressure
followed by a heavy pressure is
applied to the anti gagging
points until the patient feels
discomfort and the area is sore.
Dental treatment should be
carried out during this time as an
assistant continues to apply
pressure
ACUPUNCTURE
ACUPRESSURE
ALI ET AL GAGGING AND ITS MANAGEMENT IN PROSTHODONTIC PATIENTS – A REVIEW OF LITERATURE. BIOMEDICA VOL. 34, ISSUE 3, JUL. – SEP., 2018

ACUPRESSURE POINTS
32
REN-24 point is
situated in the
horizontal
mentolabial groove at
its centre just below
the lower lip.
CHENGJIANG
(REN-24)
HEGU (LI-4)
These points are left and
right concave area
between first and second
metacarpal bones.
NEIGUAIN (PC-6)
A point located three-finger
breadths below the wrist on
the inner forearm in between
the two tendons
DAITH POINT
The daith point is at
the smallest fold of
cartilage in the ear,
just above the
opening to the ear
toward the front.
ALI ET AL GAGGING AND ITS MANAGEMENT IN PROSTHODONTIC PATIENTS – A REVIEW OF LITERATURE. BIOMEDICA VOL. 34, ISSUE 3, JUL. – SEP., 2018

BEHAVIOR MODIFICATION
TERM & OBJECTIVE
• It has been recommended that all
disruptive gagging should be viewed
and presented to the patient as a
behavioral response and, therefore,
amenable to behavior modification.
• OBJECTIVE=
to reduce anxiety and ‘‘unlearn’’ the
behaviors that provoke gagging.
METHODS OF BEHAVIOR
MODIFICATION
RELAXATION DISTRACTION
SUGGESTION
SYSTEMATIC
DESENSITIZATION
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BASSI ET AL ,THE ETIOLOGY AND MANAGEMENT OF GAGGING: A REVIEW OF THE LITERATURE THE JOURNAL OF PROSTHETIC DENTISTRY MAY 2004VOLUME 91 NUMBER 5
(234-238) 33

RELAXATION
34
Hoad-
Reddick(1986)
CONTROLLED
RHYTHMIC
BREATHING
When two impulses pass through along a final common
pathway they become antagonistic, the more powerful reflex is
evoked and weaker is inhibited. Here, respiration is stronger and
can overcome retching.
Barsby(1994)
RELAXED
ABDOMINAL
BREATHING
It is a simple biofeedback mechanism where the patient places
their hand(s) on their abdomen to monitor their abdominal
breathing movements.
(234-238)

DISTRACTION
Krol
(1963)
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Leg lift
technique
Krol asked patients to raise one of their legs during
impression making and to concentrate on keeping it there for
the duration of the procedure.
Robb
(1996)
Sick Stick
A piece of broom handle, approximately 18 inches long and an inch thick, is
engraved with a mark somewhere in the middle . The stick is held by the patient ,
at arms length during the impression procedure. Patients are asked to stare at the
mark on the stick and are strongly informed to remain focused on the mark, then
they are suggested they will not gag.
Temporal
Tap
The clinician gently taps the
Temporal area as a trigger to
verbal suggestion regarding
gagging prevention, before dental
procedures.
Friedman
(1983)
Salt
Technique
It is a temporary elimination of gag
reflex using common salt. Tip of
tongue is salted for 5 s with table salt.
Gag is extinguished by superimposed
simultaneous stimulation of chorda
tympani branches to taste buds in
anterior 2/3 of tongue.

SUGGESTION
Distraction techniques can be refined by incorporating an element
of suggestion
It relies on a rapid extinction of the link between the
stimulus (for example a denture) and gagging.
It is accomplished by encouraging the patient to retain the denture
in the mouth for as long as possible with the reassurance that the
aversive reactions encountered will diminish.
The basis of this method is to inform the patient that the
physiological system cannot maintain the strength of the initial
response and that habituation will occur within 30 minutes or so.
Patients can be informed that retching will not occur during the
distracting activity.
• Visual imagery may be used to
enhance suggestion
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SENSORY FLOODING

SYSTEMIC DESENSITIZATION
The maladaptive thoughts and expectations of patients can be altered by
positive experience and this forms the basis of re-education techniques
such as systematic desensitization.
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The patient, under conditions of relaxation and reassurance, is exposed to a mild
aversive stimulus and learns to cope with this.
The patient is then gradually exposed to increasingly aversive stimuli i.e the
intensity, duration, and frequency of the noxious stimuli is slowly increased,
thereby allowing the patient to gently habituate by developing coping strategies
to deal with discomfort or panic experienced
This may often involve behavioral techniques such as deep breathing. It is
important to use a controlled step-wise approach to prevent or minimize the
patient’s gagging.

SYSTEMIC
DESENSITIZATI
ON
BRUSHING THE HARD PALATE
The hard palate is
gently brushed with a
with a toothbrush
without inducing the
the gag reflex.
The patient marks the
the position of the
maxillary incisors on the
the toothbrush handle.
The aim is to move the brush more
more posteriorly and the patient is
patient is encouraged as the mark on
mark on the toothbrush moves
progressively down the handle
SINGER’S MARBLE
TECHNIQUE
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SINGER’S MARBLE TECHNIQUE
The processed
lower denture
was inserted and
used in
conjunction with
the upper base
plate.Once the
patient is
habituated the
upper denture is
inserted.
7TH VISIT:
The patient
will now be
able to tolerate
the presence of
both base
plates. The
patient should
carry on
wearing the
upper and
lower base
plates till the
dentures are
being
fabricated.
6TH VISIT:
Now upper
base plate was
also inserted,
which may be
little difficult
for the patient
to tolerate than
the lower one,
but he must be
encourage to
keep both of
them in his
mouth except
when eating.
5TH VISIT:
Lower denture’s
base plate was
inserted & the
patient was
asked to
continue to keep
three marbles in
his mouth. A
“training bead”
(cold cure
acrylic resin)
was placed on
the lingual
aspect of the
lower base plate
to keep the
proper tongue
position.
4TH VISIT:
Palate, cheeks,
lips & tongue
were swabbed
with topical
anesthesia
before the
primary
impression.
3RD VISIT:
The patient
was promised
that he would
be able to
wear denture,
which further
boost his own
motivation.
2ND VISIT:
Any oral
examination is
avoided. 5
glass marbles,
1.5 cm in
diameter were
shown to the
patient & was
asked to put
them in his
mouth, one by
one, at his
freedom.
1ST VISIT:
39
AHMAD ET AL, ETIOLOGY AND MANAGEMENT OF GAG REFLEX IN THE P ROSTH ODONTIC CLINIC: A JOURNAL OF ORAL HEALTH DENTISTRY, JAN -MARCH, 2 0 1 5 ;1(1):25 -2 8

TRAINING BASE
40
TRAINING DENTURE
WITHOUT TEETH
TRAINING DENTURE
WITH ANTERIOR TEETH
ONLY. Improved esthetics
may be a motivating
factor.
TRAINING DENTURE
WITH POSTERIOR
TEETH ONLY.
(234-238)

ERRORLESS LEARNING
This desensitization technique is an effective simple method that can be used by all clinicians, and is helpful for
patients who have dentures but do not wear them because the dentures evoke gagging but it can be a very slow
technique.
The patient is instructed to set aside time to position the denture closer each day and eventually into the mouth in
‘‘successive approximations.’’
That is, the denture is placed perhaps millimeters at a time closer to the final position. In situations where retching is
induced simply by looking at the denture, then the patient is merely requested to look at or hold the denture and to
stop before symptoms of retching develop.
The process is repeated, with a small increase in time spent undertaking this task, until eventually the patient can
wear the denture.
The objective is to unlearn the conditioned response. It is a laborious task on the part of the patient and the progress
made should be strongly encouraged by the dentist.
41
(234-238)

CONSIDERATIONS WHILE MAKING AN
IMPRESSION FOR GAGGING PATIENTS.
Explain to the patient the exact nature of the procedure and a feeling of confidence is
imparted to him.
An upright position with the head tilted slightly forward will allow saliva to escape
from the mouth preventing an accumulation which otherwise might stimulate
gagging.
The selected impression tray should fit accurately, and as little impression material as
feasible should be used.
Distract the patient by constantly talking to him or by having him lift his foot which
reduces the awareness of a stimulus.
Inform him not to swallow while the impression is being made. The patient should breathe
deeply to combat gagging.
MEANS, C. R., & FLENNIKEN , I. E. (1 9 7 0 ). GAGGING— A PROBLEM IN PROS THETIC DENTIS TRY. THE JOURNAL OF PROS TH ETIC DENTIS TRY, 2 3 (6 ), 6 1 4 – 62 0.
42

IMPRESSION MATERIAL- Considerations for a
gagging patient.
MEANS, C. R., & FLENNIKEN, I. E. (1970). GAGGING—A PROBLEM IN PROSTHETIC DENTISTRY. THE JOURNAL OF PROSTH ETIC DENTISTRY, 23(6), 614–620.
43
A fast-setting impression material is
desirable, and the impression should
be removed as soon as possible.
SET OF THE
IMPRESSION
MATERIAL
Fast setting alginate= 1-3 minutes
Addition silicon = 4-6.5 minutes
A material with minimal flow would certainly be advisable. When using a putty and
wash technique for crown and bridge, for example, using the minimal amount of
light bodied wash should be advocated to prevent any overflow posteriorly.
FLOW & QUANTITY
OF THE IMPRESSION
MATERIAL

. HATTAB FN, OMARI M, DUWAYRI A. MANAGEMENT OF A PATIENT’S GAG REFLEX IN MAKING AN IRREVERSIB LE HYDROCOLLOID IMPRESSION. J PROSTHET
DENT. 1999; 81: 369-72
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HATTAB et al
(1999)
Carpule of local anesthesia (1.8 ml of 2% lignocaine having 1:100,000 epinephrine) was added to the
measuring cylinder and after that water was added to the exact volume. This water/anesthesia mixture
was poured into bowl and powder was then added and mixed thoroughly.
INCORPORATION OF LOCAL ANAESTHESIA
INTO IRREVERSIBLE HYDROCOLLOID
IMPRESSION
(1) It controls the flow of anesthetic agent to sensitive gag and vomit–reflex areas
(2) It 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) The technique is simple and does not need special laboratory procedures
ADVANTAGE
ALTERATIONS IN
THE PROPERTIES
OF ALGINATE
(Qaisar 2019)
Insignificant decrease was observed in compressive and tear strength of irreversible hydrocolloid.
There was significant increase in setting time of irreversible hydrocolloid impression material.

IMPRESSION TRAY
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CUSTOM TRAY
STOCK TRAY
The distal or back end of
stock trays may be built up
with wax to stop the flow
of impression material
towards the throat.
Disposable saliva ejector
embedded in wax at approximate
midline of custom acrylic resin
tray.
CALLISON in 1989
In clinical situations where
full arch impressions are
not needed, sectional trays
may be used in such
patients.

GAGGING- A POST INSERTION DENTURE
PROBLEM
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CALSSIFICATION
BY
MORSTAD
Immediate type of
gagging.
Delayed type of
gagging.
It is caused by overextension or excess
thickness in the posterior border of the
maxillary denture or by a bulgy
distolingual flange in the mandibular
denture.
The delayed type of gagging can occur
from two weeks to two months after
insertion, and it may be due to an
incomplete border seal which allows
seepage of saliva under the denture.

CAUSE AND MANAGEMENT OF GAGGING IN DENTURE
WEARERS
PASTOREL
LO
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Extended extension of
denture beyond hamular
notch-tuberosity area.
Proper delineation of posterior border of denture.
KRO
L
Increased vertical
dimension of occlusion.
The spasm of the
tensor veli palatini
pressing the soft
palate against the
posterior border of
the maxillary
denture explains
the sensation of
overextended
dentures.
This provides the
stimuli for
gagging.
These muscles
enter into spastic
contractions which
ultimately involve
all the muscles
activated during
swallowing.
Increased vertical
dimension of
occlusion prevents
the elevator
muscles from
relaxing normally.
Increasing the interocclusal distance, either by grinding the
occlusal surfaces after remounting the dentures on an
articulator or by remaking the dentures with a newly
established vertical dimension of occlusion.

PALATELESS DENTURE
• Maxillary denture can be
reduced to a U-shaped
border situated
approximately 10mm from
the dental arch.
• Denture wearers with the
above type of dentures
reported that reduction of the
palatal coverage influences
their senses of taste
positively and reduces or
eliminates gagging tendency.
48
PALATELESS
DENTURE
CONVENTIONAL
PALATELESS DENTURE
TOOTH RETAINED
PALATELESS OVERDENTUR
IMPLANT SUPPORTED
PALATELESS DENTURE

PALATELESS DENTURE DESIGN
MODIFICATIONS
FARMER, J. B., & CONNELLY, M. E. (1984). PALATELESS DENTURES: HELP FOR THE GAGGING PATIENT. THE JOURNAL OF PROSTHETIC
DENTISTRY, 52(5), 691–694. 49
PALATELESS DENTURE PALATELESS DENTURE with
reinforced palatal bar ( 5mm thick &
1 mm width)
PALATELESS METAL BASED
DENTURE (Metal base= 7mm wide
& 0.5 mm thick)
Palateless dentures deform
buccopalatally ( from buccal to
palatal side) & require rigid
metal palatal structure of 2
types:-
a) Palatal bar
b) Metal based denture

PALATELESS DENTURE
IMPRESSION
CAST
PREPARATION
DENTURE
BASE
CONSTRUCTI
ON
OCCLUSAL
CONSIDERATI
ON
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A preliminary impression of the edentulous maxillary arch is
made in a stock Rim-Lock edentulous tray and modeling
compound.
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 1 mm in depth and width.
The palatal borders should be located at the junction of the horizontal and
vertical slopes of the palate and be as symmetric as possible.
Anteriorly, the beaded border should cross the midpalatal suture line at right
angles and be placed in the rugae valleys when possible. Posteriorly, the bead
line extends to and blends with the pterygomaxillary (hamular) notches
bilaterally
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
Maxillomandibular records are obtained, teeth selected, and the
denture completed in usual manner.

SUMMARY OF THE
MANAGEMENT OF
GAGGING PATIENTS
TREATMENT PROBLEM MANAGEMENT OPTIONS
Unable to tolerate impressions Distraction techniques
Relaxation
Systemic desensitization
Sedation (extreme cases of intolerance)
Unable to wear denture(s) Errorless learning
Training base
Marble technique
Unable to tolerate instrumentation, for example,
examination, scaling, tooth preparation
Regular review
Relaxation.
Systemic desensitization.
Sedation (extreme cases of intolerance)
51

CONCLUSION
Overt gagging can be distressing for both the
patient & clinician.
The dentist frequently encounters patients with
unusual gagging in their practice.
The most serious issue of concern with such
patient is that there is a chance of treatment
compromise.
A wide variety of management strategies have
been tailored to suit the needs of individual patients.
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REFERENCE
• Nafis Ahmad et al. Etiology and Management of Gag Reflex in the Prosthodontic
Clinic: A Review International Journal of Oral Health Dentistry, Jan-March,
2015;1(1):25-28
• Farmer, J. B., & Connelly, M. E. (1984). Palateless dentures: Help for the gagging
patient. The Journal of Prosthetic Dentistry, 52(5), 691–694.
• Hattab FN, Omari M, Duwayri A. Management of a patient’s gag reflex in making
an irreversible hydrocolloid impression. J Prosthetic Dent. 1999; 81: 369-72
• AHMAD ET AL, Etiology and Management of Gag Reflex in the Prosthodontic
Clinic: A Journal of Oral Health Dentistry, Jan-March, 2015;1(1):25-28
• Bernard Levin, Impression for complete denture. Quintessence Publishing Co.,
Inc. 1984
• Gagging : Aetiology and Management Smita Musani, et al. Indian Journal OF
DENTALADVANCEMENTS, 2(4), October-December, 2010, (23-31)
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Thank you
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