The Assessment and Management of

Patients with PronouncedGag Reflexes

Chris Dickinson

Department of Sedation & Special Care Dentistry

KCL Dental Institute

Floor 26. Guy’s Hospital1

“Had a bad day at the orifice, dear?”

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Gagging - A normal protective reflex designed to protect the airway and prevent material entering the oropharynx and the upper gastro-intestinal tract

Retching - An ejectory contraction of the muscles of the gastro-intestinal tract and oropharynx

Gagging or Retching ?

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Picture of patient

Prevalence of Gagging

• No data available on the prevalence or distribution of pronounced gag reflexes in the general population

• 26 % of young adults and 43 % of older adults had a total absence of the gag reflex

Davies et al. 1995. The Lancet.4

Classification by Aetiology

Somatic:

Induced by touching a ‘trigger’ area

Psychogenic:

Induced without direct contact

Krol 1963

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Contributory Factors

Evidence is poor

• Anatomical• Medical• Emotional/Psychological• Iatrogenic

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Anatomical

• Palate anatomy • Long uvula

• Tongue shape• Tongue position• Other ‘irregularities’

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Medical

• Chronic nasal congestion and obstruction

• Post nasal drip• Gastric disorders• Motor neurone disease

• Dysphagia

• Obesity• Other medical conditions

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Psychological ?

• Eating disorders• Fear• Stress• Neuroticism• Learned responses

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Picture of patient

Iatrogenic – General

• Water & suction tubes• Instruments• Local anaesthesia• Radiography

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Pictures of patient

Iatrogenic – Prosthetic

• Inadequate posterior palatal seal

• Restricted tongue space• Loss of normal palatal

contour• Poor retention• Incorrect occlusal plane• Decreased freeway space• Excess freeway space• Incorrect tooth position

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Implications for the Patient

Emotional

• Fear, anger & embarrassment

• Avoidance behaviour

Physical

• Acceptance of dental care • Oral hygiene practices• Ability to wear prostheses

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Picture of patient

Implications for the Dentist

Emotional

• Fear, anger & embarrassment• Avoidance behaviour

Physical

• Compromises ability to examine, diagnose and treat

• Influences treatment decisions

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Assessment

• Precipitating factors• Nature & severity• Relievers & promoters• Successful & failed

dental treatments

• Treatment required• Treatment requested• Somatic ‘mapping’

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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 and dental attendance. All treatment impossible

Dickinson & Fiske. 2000 15

Methods of Control

• Relaxation & C.A.F• Dental ‘techniques’• Distraction and

desensitisation• Psychological and

behavioural techniques• Local anaesthetic

techniques• Sedation techniques• General anaesthesia• Complementary therapies

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Picture of patient

Psychological Techniques

In - House• Confidence building• Ego enhancement

• Tell – show - do

Referral• Cognitive Behavioural Therapies

• Psycho – therapeutic analysis and treatment

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Relaxation Techniques

Passive Relaxation

• Calming environment• Music

Active Relaxation

• Controlled rhythmic breathing (Hoad-Reddick)

• Relaxed abdominal breathing (Barsby)

• Visualisation/visual aids• Biofeedback• Progressive muscle relaxation (NCT)

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Relaxation & C.A.F

• Caring Attitude Factor (Shipmon)

• Empathetic but firm• Calm, confident, in control• Rapport

• Communication and signalling • Positioning/Neck extension• Breathing control

• Careful instrument handling

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“Traffic-light” Control SignalsGreen

Amber

Red

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Dental Techniques

Rubber Dam Local Analgesia ??

• Palatine block

• Inferior alveolar block• LA incorporated into impression material

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Distraction Techniques

• Sensory deprivation (Landa) • Leg raising (Krol)

• Breathing exercises• Talking (Faigenblum)

• Salt on tongue• Sick stick (Robb)

• Temporal tap (Robb)

Concentration on a task, place, object or event to temporarily divert the patient’s attention away from the gagging

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Desensitisation Techniques

Homework and Rehearsal (Sewerin)

• Tongue/palate stimulation• Marbles/discs (Singer)

• Progressive appliance wear & training bases

• Dentures with acrylic beads & mat surfaces (Singer)

• Orthodontic plates and blow-down splints

• Soft swallowing (Wilks)

Aims to progressively reduce the gagging threshold

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Sedation & General Anaesthesia

• Inhalation• Intravenous• Oral• Intranasal• Combinations• Large quantity of

restorative or oral surgical treatment

• Gag reflex not controlled by other methods

• GA - Last resort

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Complementary Therapies

Hypnosis (Barsby)

• Reframing• Ego-enhancement• Auto-hypnosis• Contra-indicated

in psychological conditions?

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Picture of patient

How does it work?

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“ That a needle stuck into the skin of the foot should help a case of migraine is obviously incredible, it makes no sense. Within our system of explanation there is no reason why the needle prick should be followed by an improvement, therefore we say it cannot happen. The only trouble with this argument is that as a matter of empirical fact, it does happen.”

Aldous Huxley

Evidence of effect is emerging in several areas

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Acupuncture

Technique

• Simple & Quick• Inexpensive• Easily learned

• Effective• Few contra-indications

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Chengjiang (CV24)

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Hegu (LI4)

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Ear Acupuncture

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Other Acupuncture Points

• Face• Head• Back

• Hand

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Ear Acupuncture - Uses

• Diagnostic - Assessment• Episodic - Treatment• Desensitisation ??

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Ear Acupuncture - Before & After

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Pictures of patient

Combination Techniques

• Pre-treatment desensitisation

• Inhalation sedation• Acupuncture• Acupressure• Rubber dam

• Visualisation• Distraction

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Picture of patient

Recording Success

Gagging Prevention Index

GPI Grade

I Fully Controlled – Treatment successful II Partially controlled – Treatment possible III Partially controlled – Some simple treatments possible with frequent gaggingIV Inadequately controlled – Even diagnostic

procedures difficultV No Control – No treatment possible

Dickinson & Fiske, 2000

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Summary

• Fully assess the nature of the gag reflex

• Match the level of treatment need with the management techniques at your disposal

• Set small objectives for each treatment visit

• Don’t continue until patient gags. Stop at a positive point if possible

• Use a variety of management strategies for different items of treatment – be flexible

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Thank You

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