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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)
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
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.
• These patients tends not to seek a dental treatment or may request 
treatment under general anaesthesia. 
• Commonly results in exodontia. 
• Final outcome- Edentulousness....
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.
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.
Gagging is accompanied by excessive 
salivation,lacrimation,sweating,fainting or a panic attack.
Stimulation occurs intraorally 
afferent fibers of vagus, glossopharyngeal , trigeminal pass to medulla 
oblongata. 
efferent impulses give rise to spasmodic and uncoordinated muscle 
movement.
Five intraoral areas known to be “Trigger Zones”: 
1. Palatoglossal and palatopharyngeal folds 
2. Base of tongue
3. Uvula 
4. Palate 
5. Posterior pharyngeal wall
• 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.
Classification by Aetiology 
Somatic: 
Induced by touching a ‘trigger’ area 
Psychogenic: 
Induced without direct contact
CONTRIBUTORY FACTORS OF 
GAGGING 
1. Local and Systemic Factors 
2. Anatomic Factors 
3. Psychological Factors 
4. Iatrogenic factors
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.
Anatomic Factors 
Anatomic abnormalities and oropharyngeal abnormalities. 
Palate anatomy 
Long uvula 
Tongue shape 
Tongue position 
Other ‘irregularities
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
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.
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.
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
• Restricted tongue space 
• Loss of normal palatal contour 
• Poor retention 
• Incorrect occlusal plane
Implications for the Patient 
Emotional 
Fear, anger & embarrassment 
Avoidance behaviour 
Physical 
Acceptance of dental care 
Oral hygiene practices 
Ability to wear prostheses
Implications for the Dentist 
Emotional 
Fear, anger & embarrassment 
Avoidance behaviour 
Physical 
Compromises ability to examine, diagnose and treat 
Influences treatment decisions
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.
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?
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.
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)
“Traffic-light” Control Signals 
Green 
Amber 
Red
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
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...
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
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.
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.
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.
3.General anaesthesia 
Patients who do not respond to any of the treatment modalities have to 
be given general anaesthesia as the last resort.
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.
-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.
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. 
.
-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.
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.
-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.
Occlusal considerations. 
A bilateral balanced occlusion is achieved with a modified anatomic or 
cuspless tooth form.
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.
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.
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.
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.
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.
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
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.
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.
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

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The etiology and management of gagging

  • 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)
  • 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.
  • 43.
  • 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.
  • 45.
  • 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