gagging and its managemment

1. GAGGING AND ITS
MANAGEMENT IN
PROSTHODONTICS
Presented By : Dr. Monika kumari
PGT 1st year

2. CONTENTS

3. INTRODUCTION

4. PHYSIOLOGY

5. TRIGGERING
AREAS
• • Non-Tactile and Tactile stimulation of the certain
intraoral structures.
• Trigger zone means: ‘A focus of hyperirritability in tissue,
which when palpated,
• 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 patient 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

8. GAG REFLEX
CLASSIFIED AS:

9. AETIOLOGIC
AL FACTORS
• SYSTEMIC CAUSE
• PSYCHOLOGICAL FACTORS
a) active reaction
b) passive reaction
• PHYSIOLOGICAL FACTORS
a) extraoral stimuli
b) intraoral stimuli
• IATROGENIC FACTORS

10. SYSTEMIC CAUSE
• Systemic disorders:
 Chronic problems of nasorespiratory tract
 Congestion of upper respiratory tract
 Problems of GIT
 Inflammation of pharynx(hypersensitivity gag reflex)
 Medication
 Diaphramatic hernia
 Hiatus hernia and uncontrolled diabetes

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

12. PHYSIOLOGIC
FACTORS-
EXTRA ORAL
STIMULI
• Factors like
• fear,
• alcoholism,
• stress,
• phobia,
• sight and
• sound of clinical dentistry,
• apprehension,
• hyperventilation

13. PHYSIOLOGIC FACTORS-
INTRA ORAL STIMULI
• Factors include-:
• Denture designs faults-
• Weak posterior palatal seal,
• Overextension,
• Abnormal thickness of the posterior palatal border

14. IATROGENI
C FACTORS
• Poor execution intraoral procedures
• Rough or careless technique
• Temperature extreme of instruments
Procedural factors:
• Water spray on the palate while
working on the maxillary posterior
teeth
• Stimulation of disto lingual area of
the mandible by the suction tip

15. MANAGEMENT
• 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.
It include -
• PHARMACOLOGICAL MANAGEMENT
• NON-PHARMACOLOGICAL MANAGEMENT

16. PHARMACOLOGICAL
MANAGEMENT
• Application of local anesthesia(spray, gel, injection) on
mucosa and palate.
• Use of oral sedatives such as benzodiazepines, or use of
nitrous oxide sedation
• General anesthesia in patients who do not respond to
any form of sedation or behavioral therapy and dental
treatment

17. NON-PHARMACOLOGICAL
MANAGEMENT
• RELAXATION
 The gag reflex may be a manifestation of an anxiety state.
 Relaxation techniques may be helpful in reducing or abolishing
the gag reflex.
 An example of this is to ask the patient to tense and relax certain
muscle groups, starting with the legs and working upwards, while
continually providing reassurance in a calm atmosphere.

18. • DISTRACTION
 Distraction techniques can be useful to temporarily divert a patient's
attention and may allow a short dental procedure to be performed
while the mind is dissociated from a potentially distressing situation.
 For example, inhaling through the nose and exhaling through the
mouth.
 Distraction technique can be used in combination with relaxation
procedure

19. • 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 systemic desensitization.
It work by asking patient to introduce some substances to his
sensitive intraoral parts and keep them for a period of time.
Such materials as toothbrush, radiograph, impression tray, or
denture.

20. MARBLE TECHNIQUE
 "Singer" devised the marble technique in which the patients gag reflex can be
exhausted and this gradual exhaustion of the reflex allows for a gradual
exposure to the dental treatment or prosthesis.
 First visit- patient is advised to keep 5 round glass marbles (approximately ½
inch diameter) in the mouth continuously for 7 days except eating or drinking.
 Second visit- patient was motivated and his ability to wear dentures was
evaluated.
 Third visit- preliminary impression was made, refined and completed without
a wash.

21.  Fourth visit- base tray for lower denture was inserted
 Fifth visit- upper denture base was inserted and the use of
marbles was discontinued.
 Sixth visit- jaw relation is made and occlusion rims marked.
The patient should continue to wear the upper and lower
base plates while the dentures are being acrylized.
 Seventh visit- complete denture was inserted.

22. SALT TECHNIQUE
•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. PROSTHODONTIC MANAGEMENT
• Thick, ropy saliva is a factor in causing patients to gag while impressions are made
and after the new dentures are installed.
• Problem of gag may actually be related to the denture themselves, or there may be
a psychologic component , or both.
• The problem often may relate to the posterior border of the upper denture.
• The border may be improperly extended, or the posterior border seal may be
inadequate.
• The gagging seems to be caused most often from a making and breaking of the
posterior palatal seal as the tissue posterior to the vibrating line moves upward and
downward during function.

24. • When the vibrating line has been properly located, it is not necessary and usually
not desirable to extend the posterior border of the upper denture more than 2 mm
past this point.
• If the posterior palatal seal is inadequate, modeling compound can be added to
reshape this part of the upper denture and determine if this will help alleviate the
situation.
• Then the modelling compound can be replaced with acrylic resin.
• Occlusion can also be a factor, since shifting of the denture bases may cause the
making and breaking of the posterior palatal seal and result in gagging.

25. • Patient is asked to rinse the mouth with astringent mouthwash and then hold cold
water in the mouth, provided the teeth are not sensitive.
• A fast setting alginate or slightly warmer than normal(approximately 24⁰C{75⁰F})
water is used to hasten the set of the alginate.
• The “leg lift”procedure is used before and during the making of the impression.

26. GAGGING IN PARTIAL DENTURES
• Gagging in the wearer of a maxillary partial denture is caused most frequently by
failure of the maxillary major connector, either metal or acrylic resin, to be adapted
closely enough to the hard palate.
• Failure to modify the impression tray to reduce the space between the tray and the
palate results in the impression material slumping before the final set occurs.
• This produces an inaccurate cast and results in a major connector that will have a
space between the tissue surface of the metal and the soft tissue of the palate.
• Saliva will accumulate in this space and in some patients, produce a gagging
sensation.

27. • The remedy for this problem, if the major connector is constructed of acrylic resin, is
to reline the major connector and obliterate the space.
• However, if the major connector is cast metal, a remake of the prosthesis may be
necessary
• (This inaccuracy of the palatal fit should have been recognized at the framework try
in appointment or at the time of delivery if corrected procedures were followed)
• If the presence of a space cannot be shown for a maxillary partial denture, posterior
overextension of the major connector may be causing the gagging.

28. • With the partial denture out of the mouth, an indelible pencil mark should be made
along the posterior border of the partial denture

29. • The prosthesis is seated in the oral cavity

30. • The position of the removable partial denture’s posterior border is transferred to the
palatal tissues, and placement of the posterior border is evaluated.

31. • An overextended major connector may be shortened using a heatless stone in a
low-speed hand-piece or dental laboratory engine.

32. • The bead line that prevents food from collecting between the major connector and
the palatal tissues has been lost as a result of adjustment. This may necessitate
remaking the removable partial denture.

33. • In mandibular partial dentures gagging, may be caused by an alteration of the
occlusal vertical dimension.
• Decrease in the proper occlusal vertical dimension would stimulate gagging-caused
primarily by crowding of the tongue and adjacent soft tissues.
• An increase in the occlusal vertical dimension with concomitant elimination of
freeway space also is capable of producing a prolonged gagging reaction(an
investigation by Krol)- probably caused by spasm of the levator and tensor muscles
of the velum palatinum- correction of this difficulty requires reestablishment of the
proper occlusal vertical dimension.

34. • Another potential cause of gagging is the overextension, both in length and bulk, of
the denture base flanges of a mandibular class I removable partial denture.
• Reduces the available tongue space and produces involuntary retching or nausea.
• To correct this problem, the posterior lingual borders should be thinned and
shortened.

35. PROSTHODONTIC TECHNIQUES
• The choice of impression material is important for the patients who gag.
• "Ansari" concluded that a high viscosity elastomer material must be used for
recording the initial impression of a maxillary partially edentulous patient.
• Use of high viscosity material will hamper the flow of the impression material to
the gag reflex producing areas.
• Stock trays can be modified, the distal or back end of stock trays may be built up
with wax to stop the flow of impression material towards the throat.
• In clinical situations where full arch impressions are not needed, sectional trays
may be used in such patients.

36. TRAINING BASES
• 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.

38. PALATLESS DENTURES
• 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

39. CONCLUSION

40. REFRENCES
• BASSI, G. (2004). The etiology and management of gagging: A review of
the literature. The Journal of Prosthetic Dentistry, 91(5), 459–
467. doi:10.1016/s0022-3913(04)00093-9
• ALI S.,(2018). GAGGING AND ITS MANAGEMENT IN PROSTHODONTIC
PATIENTS-A REVIEW OF LITERATURE.BIOMEDICA VOL. 34, ISSUE 3
• BOUCHER'S PROSTHODONTIC TREATMENT FOR EDENTULOUS
PATIENTS(EIGHTH EDITION)
• STEWART CLINICAL REMOVABLE PARTIAL PROSTHODONTICS(FOURTH
EDITION)