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1. Good Morning

2. GAGGING AND ITS
PROSTHODONTIC MANAGEMENT
PRESENTED BY :
R.PRIYA DARSHINI
1ST
YEAR MDS

3. CONTENTS
• Introduction
• Definition
• Gagging mechanism
• Etiology
 Somatogenic group
 Psychogenic group
• Clinical phases of gagging
 Acute phase
 Chronic phase
• Management of patient with gagging
 Behovioural management
 Pharmacological management
• Conclusion
• References

4. INTRODUCTION
The gag reflex is a normal defense mechanism that
prevents foreign bodies from entering the
trachea, pharynx, or larynx which ejects the
unwanted, irritating, or toxic material from the
upper respiratory tract by the contraction of the
oropharyngeal muscles.
In retching, peristalsis becomes spasmodic,
uncoordinated and direction is reversed. Air is
forced over the closed glottis producing a
characteristic retching sound

5. GAG REFLEX
• Accompanied by
Excessive salivation
Lacrimation
Sweating
Fainting
Panic attack

6. Definition
• Gagging – An involuntary contraction of the
muscles of the soft palate or pharynx that results
in retching (GPT-8)

7. Clinical Description Of Gagging Behaviour
According To Khan:
• Puckering of lips or attempting to close the jaws
• Elevating and furrowing the tongue, with rotation from back to front
and with hyoid bone at the centre
• Elevation of soft palate and hyoid bone
• Fixation of the hyoid bone
• Closing of the nasopharynx by an approximation of posterior pillars
of fauces that elevate the soft palate.
• Contraction of anterior and posterior pillars of the fauces, causing
the tonsils to rotate in an anteromedial direction
• Elevation, contraction and retraction of the larynx and closure of the
glottis
• Retching or simultaneous and uncoordinated respiratory muscle
spam.
• vomiting

8. GAGGING MECHANISM
Intraoral stimulation on soft palate and posterior third of
tongue.
Afferent fibers – trigeminal, glossopharyngeal, vagus to
Medulla oblangata
Efferent impulses – trigeminal, facial, vagus, hypoglossus
Spasmodic, uncoordinated muscle movement
Gagging

9. • Glossopharyngeal nerve is peculiar in that its
afferent fiber includes fibers that both elicit and
inhibit reflex.
Clinically, important since there is less likelihood of
gagging if a region innervated by
glossopharyngeal nerve is stimulated than if a
region supplied by one of the other cranial nerve
stimulated.

10. TRIGGER ZONES
Gagging is a natural reaction to tactile sensation. Wide variation in
sensitivity of oral cavity and the ability of patients to withstand
intraoral stimuli.
5 intraoral areas known as trigger areas are -
• Palatoglossal and palatopharyngeal fold
• Base of tongue
• Palate
• Uvula
• Posterior pharyngeal wall

11. ETIOLOGY
• Multifactorial etiology
• 2 categories of retching patients:
1) Somatogenic group:
gagging due to physical stimuli
Local stimuli – foreign objects in mouth
overextended dentures
dentures with increased vertical
height
Systemic stimuli – use of various drugs or
excessive consumption of alcohol

12. 2) Psychogenic group:
psychological stimuli due to excessive fear,
apprehension or anxiety.
Gagging occurs during examination, impression
making, registration of jaw relation, insertion of
dentures and even site of an instrument
stimulates gag.

13. • According to KRAMER & BRAHAM – fear is
almost always the underlying factor influencing
psychological gagger.
This fear may be generalized and vague
and some patients gag due to the fear of
swallowing a foreign object.
 Before any treatment procedure to be started
type of gagging should be recognised.

14. • Factors that are important in etiology of gagging:
1) Local and systemic factors
2) Anatomic factors
3) Pchychological factors
4) Physiological factors
5) Iatrogenic factors

15. LOCAL AND SYSTEMIC
FACTORS
• Nasal obstruction
• Post nasal drip
• Catarrh
• Sinusitis
• Nasal polyp
• Mucosal congestion of upper respiratory tract
• Dry mouth
• Medications that cause nausea as side effect

16. Chronic gastrointestinal disease, lowers intraoral
notably chronic gastritis, peptic threshhold for
ulcer & carcinoma of stomach excitation
thus contributes to gagging
• Gagging has been noted as being worse in the
morning for some patients, owing to an increased
excitability of the vomiting center caused by metabolic
disturbances such as carbohydrate starvation and
dehydration with ketosis

17. ANATOMIC FACTORS
• Anatomic abnormalities and oropharyngeal
sensitivities – predisposing factors to gagging.
• According to WRIGHT-
No anatomic abnormalities between
gaggers and non-gaggers, but only few adaptive
changes in posture of tongue, hyoid bone and
soft palate in gaggers.
The distribution of afferent neural
pathway, particularly the vagus nerve, may be
more extensive in gagging patients.

18. PSYCHOLOGICAL FACTORS
According to BARTLETT psychosomatic reaction
may be
Active – due to factors that have some functional
purpose in patient’s life situation
Patients gag - to gain attention from dentist
- to avoid treatment
- to avoid the outcome of
treatment

19. Passive – due to conditioned reflexes established
earlier in life for various reasons, the causes of
which are no longer functionally important.
• 1/3rd
of the gagging patients have reported the
problem as being most acute in morning during
oral hygiene and insertion of dentures. This might
occur from lack of habituation to stimulation from
denture, since it is not worn at night

20. PHYSIOLOGICAL FACTORS
Extraoral stimuli –
• Visual – the sight of an unpleasant stimulus such
as the sight of another patient retching or
gagging. Site of a mouthmirror or an impression
tray.
• Auditory – sound of another patient retching may
initiate gag reflex to another patient
• Olfactory – a smell of certain chemicals or other
substances such as smell of cigarette on a
dentists fingers or a perfume may also initiate
gag.

21. Intraoral stimuli –
• Mainly due to tactile stimulation of hypersensitive
areas, such as soft palate back of throat, and
distal part of tongue.
• Biomechanical aspects of gagging-
1. Poor clinical procedures
2. Over loaded tray
3. Inadequate post dam
4. Unstable or poorly retained prosthesis
5. Overextended borders
6. Increased vertical dimension of occlusion
7. Highly polished surface – slimy sensation
8. Inadequate free way space

22. Poor clinical procedures
Over loaded tray
Overextended borders
Overextended flanges Thick denture base

23. IATROGENIC FACTORS
Exaggerated gag reflex can be due to –
• Procedural factors
• Factors related to dental practitioners
Procedural factors :
• Water spray on the palate while working on
maxillary posterior teeth.
• Stimulation of disto lingual area of the mandible
by suction tip.

24. Factors relating to dental practitioners :
• Poor execution of intra oral procedures
• Rough or careless handling
• Temperature extremities of the instruments

25. CLINICAL PHASES OF
GAGGING
• 2 distinct clinical phases of gagging
Acute and chronic
• Acute phase – characterized by initial gagging
episode and repeated unsuccessful attempts to
wear a denture In this phase, only denture
induces gagging.
• Chronic phase – characterized by an increase in
intensity of gagging as well as an increase in
objects, situations, or procedures which may
induce the reflex.

26. MANAGEMENT
• Behavioural management
• Pharmacological management

27. BEHAVIORAL MODIFICATION
TECHNIQUES
• Relaxation
• Distraction & Suggestion
• Systemic desensitization
• Training bases
• Teaching to swallow with their mouth open

28. RELAXATION
• Gag reflex is a manifestation of an anxiety state.
• Ask the patient to tense & relax certain muscle
groups starting with the legs & working upwards,
providing reassurance in a calm atmosphere

29. DISTRACTION
• Conversation with patient
• Breathing – inhaling through the nose and exhaling through mouth
• Distraction imagery
• Distraction, relaxation combination
• Mantra – repeated silently throughout the procedures
• KOVATS – patients breath through nose and at the same time rhythmically tap the
right foot on the floor
• LANDA -Count rapidly to 50 then read out loudly
• Hypnosis a state that resembles sleep but that is induced by suggestion

30. Systemic desensitization
• Exposed to a mild aversive stimulus
• Gradually increasing aversive stimulus
• Slowly increase Intensity, duration and frequency
of noxious stimuli
• Gently habituate by developing coping strategies
to deal with the feeling of discomfort or panic
experience
• This may often involve behavioral techniques
such as deep breathing and relaxation
• Reassurance and praising

31. • Tooth brush
• Radiographic film
• Impression tray
• Marbles
• Acrylic discs & balls
• Buttons
• Dentures
• Training devices
• Daily home work with log book
• According to FRIEDMAN, placing salt on then tip of the
tongue can also reduce gag reflex.

32. Ideal thickness of denture flanges
Acrylic disks
Training the patient themselves
Marbles

33. Training bases
• Training bases – A series of small to full-
sized denture bases with out teeth are
given to patients to train him for the
future dentures. Initially the patient is
adviced to wear denture bases when
busy or when concentrating on non-
stressful task and also relaxation
techniques are also combined.
G. S. Bassi J Prosthet Dent 2004;91:459-67.

34. RADIOGRAPHIC MANAGEMENT
Richards –
• Fast speed film
• Preset the timer
• Moisten the film pack
• Cool water mouth rinse
• Extraoral radiographs
Cool water rinsing

35. ACUPuncture pressure
caves
PRESSURE ON NEIGUAN
Apply light pressure and increase to a heavy
pressure until the patient feels soreness and
distension (Suan Zhang) to both the left and right
concave area at medial aspect of the forearm
(Neiguan) and concave area between first and
second metacarpal bones (Hegus cave) with the
thumb for 5 to 20 minutes.
The patient should feel soreness and distention
(Suan Zhang) immediately. The impression tray
can be inserted into the mouth without gagging at
this time.
Ren Xianyun, J Prosthet Dent 1997;78:533.

36. ACUPRESSURE
PRESSURE ON HEGU
Ren Xianyun, J Prosthet Dent 1997;78:533.

37. EAR ACUPUNCTURE
British Dental Journal Volume 190. No.11 June 9 2001

38. PHARMACOLOGICAL
TECHNIQUES
• Local Anesthesia
• Conscious Sedation
• General Anesthesia
• Medications
• Surgical Managements

39. LOCAL ANESTHESIA
• Spray
• Injection
• Gel
• Lozenges
• Mouth rinse

40. conscious sedation
• Inhalation, oral, IV- temporarily eliminates
gagging – maintains reflexes that protect the
patients airway.
• Psychological approach – relaxation, distraction
may be enhanced when used in conjuction with
sedation.
• Nitrous oxide alters perception of external stimuli
– decreases the gag reflex.
• General anesthesia

41. • APPLEBY & DAY – reported that common salt
can minimize the reflex.
• Placed on the tongue or on the palatal region of
the dentures, salt may help gagging patients
tolerate complete dentures.

42. Surgical management
• Persistent gagging results from an atonic and
relaxed soft palate, which is found in nervous
patients.
• LESLIE – surgery to shorten and tighten the soft
palate.
• Removal of uvula.

43. MEDICATIONS
• Antihistamines
• Sedatives
• Tranquilizers
• Parasympatholytics
• CNS depressant
• Anti-gagging drug
Trimethobenzamide

44. CONCLUSION
• Gagging – compromised treatment
• The aetiology of gagging is complex and not fully
understood. Whether its aetiology is somatic,
psychogenic or a combination of the two, the
outcome is to make the acceptance of dental
treatment
• Though many techniques are available,
Combined techniques will be effective.
• Behavioral approach will always be the first
option.

45. References
• Wright SM. Medical history, social habits, and individual
experiences of patients who gag with dentures. J Prosthet
Dent 1981;45:474-8.
• 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;49:757-61.
• Murphy WM. A clinical survey of gagging patients. J
Prosthet Dent 1979;42:145-8.
• Kovats JJ. Clinical evaluation of the gagging denture
patient. J Prosthet Dent 1971;25:613-9.

46. • Wright SM. The radiologic anatomy of patients who gag
with dentures. J Prosthet Dent 1981;45:127-33.
• Neumann JK, McCarty GA. Behavioral approaches to
reduce hypersensitive gag response. J Prosthet Dent
2001;85:305.
• Singer IL. The marble technique: a method for treating the
‘‘hopeless gagger’’ for complete dentures. J Prosthet Dent
1973;29:146-50.
• Farmer JB, Connelly ME. Palateless dentures: help for the
gagging patient. J Prosthet Dent 1984;52:691-4.
• Schole ML. Management of the gagging patient. J
Prosthet Dent 1959;9:578-83.
• G. S. Bassi, G. M. Humphris,. The etiology and
management of gagging: A review of the literature. J
Prosthet Dent 2004;91:459-67.

47. • Krol AJ. A new approach to the gagging problem. J
Prosthet Dent 1963;13:611-6.
• Ren Xianyun. Making an impression of a maxillary
edentulous patient with gag reflex by pressing caves. J
Prosthet Dent 1997;78:533.
• Comvander Henry A. Collett. Some psychologic aspects of
denture stimulated gagging. J Prosthet Dent
1953;3:665-671.
• Faiez N. Hattab. Management of a patient’s gag reflex in
making an irreversible hydrocolloid impression. J Prosthet
Dent 1999;81:369.
• Cruig R. Means. Gagging – a problem in prosthetic
dentistry. J Prosthet Dent 1970;23;614-620.
• J. Fiske, and C. Dickinson. The role of acupuncture in
controlling the gagging reflex using a review of ten cases.
British Dental Journal 2001; 190: 611–613