It describes the gagging problems in prosthodontics and the management for the successful treatment.

1. PRESENTED BY :
Dr Sabnoor Aujla
M.D.S First Year
MMCDSR, Mullana

2. INTRODUCTION
• Gag reflex (laryngeal spasm) is a reflex contraction of the back of the
throat, evoked by touching the roof of the mouth, the back of the
tongue, the area around the tonsils and the back of the throat.
• It prevents something from entering the throat except part of the
normal swallowing and helps prevent choking.
• Gagging reaction range from MILD CHOCKING when the palate is
inadventely touched with the mouth mirror to UNCONTROLLED
RETCHING during the impression making along with the varied sympt-
oms differentiating mild from the severe experiencing nausea to the
complete in-acceptance to the treatment which is termed as ‘Severe
Gaggers’.
• Gagging stimuli may be physical, auditory, visual, olfactory or psycholo
gically mediated and the muscular contractions provoked may result
in vomiting.

3. CONTENTS
• This seminars describes and identifies the gag reflex and its
causes and various approaches for the management of the
gagging patients :
• The contents :
 Physiology of gagging
 Various triggering areas
 The signs and symptoms
 Grading evaluation
 Etiology of gagging
 Management of gagging
 Conclusion

4. PHYSIOLOGY
Stimulation occurs intraorally
Afferent fibers of vagus, glossopharyngeal , trigeminalpass to reflexcentre in medulla oblongata.
Efferent impulses give rise to spasmodic and uncoordinated muscle movement.
(to palate, pharynx,tongue, diaphragm, abdomen, necketc )

5. TRIGGERING AREAS
• Non-Tactile and Tactile stimulation of the certain intraoral structures.
Trigger zone means: ‘A focus of hyperirritability in tissue, which when palpa
ted, is locally tender and gives rise to heterotrophic pain’.

6. CLINICAL SYMPTOMS
• Puckering the lips and attempting to close the jaws,
• Elevating and furrowing of the tongue.
• Elevation of soft palate and hyoid bone,
• Retching or simultaneous and uncoordinated respiratory muscle spasm, and
• Vomiting.
• Extra oral gag behaviors : excessive salivation, lacrimation, coughing, sweating. At times pati
ent shows full body response i.e. extension of head, arms, neck, and back in an attempt to completely
withdraw from the stimuli.
• Intra oral symptoms-
The patient who gags may present with a range of disruptive reaction; from simple contraction of
Palatal or Circumoral musculature to spasm of the pharyngeal structures, accompanied by
Vomiting.

7. 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&dental attendance
. All treatment impossible
Dickinson & Fiske. 2000

8. AETIOLOGICAL FACTORS
• SYSTEMIC CAUSE
• PSYCHOLOGICAL FACTORS
a) active reaction
b) passive reaction
• PHYSIOLOGICAL FACTORS
a) extraoral stimuli
b) intraoral stimuli
• IATROGENIC FACTORS

9. SYSTEMIC CAUSE
SYSTEMIC
DISORDERS
CHRONIC
PRBLEMS OF
NASO -
RESPIRATORY
TRACT
CONGESTION OF
UPPER
RESPIRATORY
TRACT
PROBLEMS OF
GIT
IMFLAMMATION
OF PHARYNX
(hypersensitivity
gag reflex)
MEDICATION
DIAPHRAMATI
C
HERNIA
Hiatus
hernia and
uncontrolled
diabetes

10. PSHYCOLOGICAL CAUSE
• Factors which have the functional
purpose in patients existing life
• For various reasons patients gag
a) to gain attention b) avoid
dental treatment
ACTIVE
REACTION
• Factors which have no functional
reason
• It is associated with past events
in patients life
PASSIVE
REACTION

11. PHYSIOLOGIC FACTORS– Extra Oral
Stimuli

12. PHYSIOLOGIC FACTORS-Intra Oral
Stimuli
Over extended
posterior borders
DISHARMINIOUS
OCCLUSION
POOR RETENTION
SUFACE FINISH OF
ACRYLIC RESIN
INADEQUATE
FREEWAY SPACE
PALATE
TONGUE
• Hyposensitive area
• Hypersensitive
area
• Hyposensitive area
• Hypersensitive
area
DENTAL
PROSTHESIS
ANATOMICAL
REASONS
DENTAL
PROCEDU-
RES

13. IATROGENIC FACTORS
POOR
EXECUTION
INTR-ORAL
PROCEDURES
ROUGH OR
CARELESS
TECHNQUES
TEMPERATURE
EXTREME OF
INSTRUEMENTS
Procedural factor:
•Water spray on the palate while working on the maxillary posterior teeth.
•Stimulation of disto lingual area of the mandible by the suction tip.

14. Effective management of gagging depends on treating the cause and not
merely the symptoms. Through examination, adequate medical history, and
conversation with patient are important for correct diagnosis of the cause of the
gagging.
The management is done on the basis of the causes which
lead to the gagging ; which are as follows :

15. IN SOME PATIENTS DIFFICUILTY IN GAGGING MAY BE THE RESULT OF
PSYCHOLOGIC STIMULI

16. DEPENDING UP
ON
CLASSES CORRECTION
DEPENDING
UPON
CLASSES CORRECTION
PSYCHOLOGICAL
FACTORS
HYPNOSIS Results are also quite successful ,bu
t the time involved with the multipl
e sessions is an important limiting
factor for its routine use in dental
BEHAVIOURAL
THERAPY
(Generally the obje
ctive is to reduce
anxiety & unlearn
the behaviour that
provokes gagging)
• Praise patient
• Building a confident atmosphere
• Acting positively and avoiding th
e term “gagging”.
• Reassurance to the patient and e
xplaining him the fact that gagging
is natural which is sometimes more
active in some individuals
DISTRACTION -ENAGAING IN CONVERSATION
-Making the patient count
- breathe audibly (Kovats)
- Raise leg and to hold for fatigue
- Apnea (prolong respiratory effort
than inspiration)

17. Depending
upon
Classes Corrections
systemic desensitization
(the incremental exposur
e of the patient to the
feared stimulus )
a tooth brush, radiograph, impressi
on tray, marbles, acrylic discs,
buttons, dentures and the training
devices have all been used to help
the patients overcome
the patient is given an object to place in the mouth for a longer
period of time. The size of the object and the length of the time for
which it is held in the mouth gradually increases until the patient is
able to tolerate the dental procedures.

18. TECHNICAL MODIFICATIONS TO RENDER THE PROSTHESIS MORE
ACCEPTABLE TO THE PATIENT .

19. Depending
upon
classes correction
PROSHODONTIC
MANAGEMENT
correction of
prosthesis  Matte finish denture
 Over extended borders
are corrected.
 Adequate free way space
 Training basses
 Palatless Dentures
Changes in mate
rial (low viscosity
and increase sett
ing time)
 Primary impression : Impr
ession compound
 Other materials : silicon
elastomer putty

20. No oral examination. Five rounded, multicolored, glass
marbles approximately ½ inch in diameter
ONE WEEK
Assurance
Before impression : topical anesthesia
Preliminary impression: Impression Compound
Base Plate of Matte Finish was prepared
Lower Base Plate was inserted.
The patient was told to continue to keep three
marbles in his mouth, in addition to base plate
TRAINING BEAD
First Visit
Second Visit
Third Visit
Forth Visit

21. Establish Jaw Relations
The patient should continue to wear the upper and lower base
plates while the dentures are being acrylized
The completed lower denture was inserted
first and used in conjunction with the upper
base plate.
Next the upper denture was inserted
Upper Base Plate was
inserted
The use of marbles
was discontinued.
Fifth Visit
Sixth Visit
Seventh Visit

22. Maxillary impressions or posterior radiographs can
be difficult and uncomfortable for patient with
extreme gag reflex.
Friedman and Weintraub described a simple method
where the patient is instructed to extend his or her
tongue, and the Tip of the tongue is briefly salted
(for approx. 5 sec) with ordinary table salt. The
impression or radiograph can usually be taken with
no difficulty. The gag reflex is extinguished by a
superimposed simultaneous stimulation of the
chorda tympani branches to the taste buds in the
anterior two-thirds of the tongue.

23. This is a further desensitization technique, whereby a patient is progressively
supplied with a series of small to full sized denture bases. it is useful to the
patients who are to become denture bearers. A thin acrylic denture base,
without teeth is fabricated and the patient is asked to wear it at home.
Patient is supplied with a series of small to full sized denture bases. A thin acrylic denture
base without teeth is fabricated and the patient is asked to wear it at home, gradually
increasing the length of the time the training base is worn. Initially 5 min once each day,
then twice each day and so on. After 1 week; 10mins; thrice a day, then 15 mins, 30
min & 1 hour. Anterior teeth are added and when the patient is able to tolerate it, posterior
teeth are added.

24. - 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 sense of taste positively, and reduces or eliminate gagging tendency.
IT COULD BE :
IMPLANT
SUPPORTED
ATTACHMENT
SUPPORTED
MAGNETIC RETAINED

25. • When clinical and prosthodontic procedures are
ineffective, pharmacological measures are used.
• Efficacy is not universally accepted

26. DEPENDING
UPON
CLASSES CORRECTIONS
DRUGS Centrally active
drugs
• Antihistamines,
• Sedatives,
• Tranquilizers,
• Parasympatholytics
• CNS depressants
Periphery acting
drug
• Topical and local anesthetic
agents
• Sprays, gels or lozenges or
injections.

28. • Conny DJ, Tedesco LA. The gagging problem in prosthodontic treatment. Part I: Description
and causes. J Prosthet Dent 1983;49:601-6.
• Conny DJ, Tedesco LA. The gagging problem in prosthodontic treatment. Part II:
Patient management. J Prosthet Dent 1983;49:757-761
•Singer L. The marble technique. J Prosthet Dent 1973;29:146-50.
• Krol AJ. A new approach to the gagging problem. J Prosthet Dent
1963;13:611-6.
• Kovats JJ. Clinical evaluation of the gagging patient. J Prosthet Dent 1971;25:613-9.
• Bassi GS, Humphris GM, Longman LP. The etiology and management of gagging: a
review of the literature. J Prosthet Dent 2004;91:459-67.
• Farmer JB, Connelly ME. Palatless dentures: help for the gagging patients.
J Prosthet Dent 1984;52:691-693