GAGGING IN DENTAL OFFICE !!- WHAT TO DO ? –  

SUMIT DUBEY MDS Reseach Associate

It’s a protection turning in to a problem for a dental surgeon and the condition becomes worsen if it occurs at the time of impression making. There are many treatment option to over come gagging. This can be very upsetting when you want to have dental treatment.

 Gagging can be due to psychological factors, or physiological factors, or both. Psychological factors can include fear of loss of control and past traumatic experiences. A bad gag reflex is so common that all dentists will have encountered this and should have developed ways of helping you cope.

So here I am writing for all.

What text, articles and reviews say for gagging?

“When a food bolus is transported towards the back of thet ongue, presence usually elicits an automatic series of muscle contractions designed to propel the bolus further onwards through the pharynx and oesophagus all of which comprise the swallow. The stimulus eliciting this process is primarily a mechanical one.

If a mechanical stimulus is applied to the back part of the tongue or to the soft palata and the resultant motor response is unsuccessful in moving the food bolus or is unsuccessful in dislodging the source of the stimulus, then a gag response is elicited. Efforts at removal first increase, and then the movements are converted to those of expulsion. The soft palate is elevated (closing off the nasal airway), the jaw lowered, and the back of the tongue lifted followed by a forward sweep of the lifted part. If there is a continued failure to remove the source of the stimulus, retching and finally vomiting can be triggered.
Gagging is a term that tends to be used somewhat differently by neurologists and by dentists. Neurologists are interested in the competence of the reflex for diagnostic purposes; they may use the term to mean simply that a mechanical stimulus to the back of the mouth elicits one element of the complex pattern described above: reflex elevation of the soft palate; this confirms the integrity of the reflex pathway, via cranial nerves and the brain stem. Dentists tend to use the term to refer to the response of those individuals in whom the threshold for the whole complex pattern is so very low that even a simple dental examination can provoke violent rejection movements followed rapidly by retching and vomiting.”

Gag reflex is a normal reflex in human, that prevents the passage of anything from throat, except during normal swallowing. It is also named as pharyngeal reflex. Touching the soft palate results in a very strong gag reflex in most healthy people. The gag reflex can also be used to make someone vomit. - Wikipedia

Hyperactive gag reflex is an extreme oropharyngeal response to stimulation resulting in pharyngeal and velar contractions - resulting in 'gagging'.

Tips to over come Gagging-

·   "Concentrate on breathing through your nose and if you feel the gag reflex lift both your legs. By doing that your tummy muscles tighten and it helps with the gagging."

·   "Always have the patient breathe through their nose!"

·   "Breathe. Breathe. Breathe. I say it 3 times because sometimes it is hard for me to breathe through my nose. I have to consciously force myself to take deep breaths and try not to get overwhelmed."

·   "To help with the gag reflex, I find that using a nasal decongestant before my appointment is very helpful in keeping the nasal passageways open to promote breathing through the nose."

·   A throat spray with numbing action, such as over-the-counter Vicks Ultra Chloraseptic Throat Spray, can relieve the gag reflex in gaggers or people with a cough or asthma. Dosage: 2 or 3 sprays right before treatment should last about an hour. This works really well for lots of people, so give it a try!

·   "One pretty bomb proof tip for handling gaggers is the use of table salt on the tip of the tongue..get the patient to dip their moist finger into a dampen dish of salt and get them to dab it onto the tip of their tongue. Works 95% of the time."

·   "Yes, the salt trick works great for a lot of gaggers. It's definitely got some physiological basis because I've used it on a girl with severe brain damage and it worked, so not just a placebo effect. Sprinkle a little paper packet of it on the back of the tongue. The wee ones you get in canteens are about right, say 1-2g, dosage isn't critical. If possible having the patient rinse round for a few minutes with some Normasol (0.9% saline) is even better."

·   "Gagging can be caused by fear, address your fear with your doctor and staff members in order to overcome it."

·   "I apparently picked up the notion that gagging is a very effective way to get the dentist to stop work when I started to feel uncomfortable. I didn't really know how to communicate with him without talking, so I just gagged."

·   "Talking with the dentist. This was probably the biggest thing that helped me. Establishing communication and letting him know my fears was a big step. For example, my dentist now places tools in my mouth at different angles than he did in the past. He lets his assistant know not to rest the sucking thing against my cheek. He also does not put so many things in my mouth at one time."

·   "I feel like most gagging occurs from airway problems or anxiety in the dental office. When needing films, it seems that when the patient holds the film, they gag less - strange!)

·   "For many people, there is a sense of loss of control in a dental chair during treatment and the tendency to gag is one representation of this. If you have this sense at all, then your dentist must reassure you that he or she will stop immediately if you want them to, whether it be to rinse, or just to catch your breath. If you have a trusting relationship, then your sense of control should increase. You may want to practice diaphragmatic breathing exercises through your nose to relax you in the chair. This info is readily available in any relaxation book."

·   "I do gaggers. They are so appreciative if you can just go for it. Just whatever dont show ANY sign of frustration. Just treat it like it's nothing special and that will help the psychological factors. Nitrous, antianxiety meds, ceticaine spray the area before you get near it, small handpiece, and now breath rights spray. That should do it."

·   "I find the most important factor in dealing with gagging problems is a calm manner - if you get stressed by not being able to take an impression, your patient is only going to gag more. Acknowledge the problem and show that you are not phased by it."

·   "Desensitization methods can also work well. Give patients various dental tools such as a mouth mirror and small impression trays. They can then take these home and introduce these instruments into their mouths themselves. They should keep a diary of how long they feel comfortable by timing it. Doing this a few times in a row twice a day, you will become less sensitive to the gag reflex. As a dentist, you can ask the person to practice until, for example, they feel comfortable sitting with the tray in place for 5 minutes."

·   Let your dentist know what procedures or situations have triggered gagging in the past and see if alternative ones can be used.

·   "Lift one foot up in the air to have them concentrate on that."

·   "Have the patient hum while the film is in their mouth - they can't gag and hum at the same time. I tried it on a patient who hadn't had x-rays for 2 years because she would gag on the bitewings. Worked great - we were both pleasantly surprised!"

·   "For my patients that are gaggers, I put a little topical lidocaine on a cotton tip applicator and put it on the palate and the back of the tongue and it works great, and patients like the taste, I use watermelon. This works really well for x-rays, so it should also help for impressions etc."

·   "When placing films (bitewings), you could place some topical anaesthetic on the film to try and prevent the gagging. I have tried this and it works."

·   "Try to find a good time of day for you. The mornings are when I gag the most when brushing my teeth. Now I try to schedule appointments for the afternoon."

·   "I have a lot of success when the patient takes a sip of very cold water prior to placing the x-ray film." (probably not the best idea if you have sensitive teeth)

·   "Listening to music - I am too busy trying not to gag that I simply do not have the mental energy to 'imagine myself someplace else' or 'think positive thoughts'. I bring in my own headphones with my own music and simply try to focus on that."

·   Sitting up rather than lying down can also help with the gag reflex. "In some situations, unconventional measures may be required. I once had to take an impression with the patient standing up to help defeat the gag reflex." Using super-fast setting impression material and letting the patient walk around while the mold is setting also help.

·   If you cannot tolerate intra-oral x-rays a panoramic x-ray which keeps the film outside the mouth can be used (provided your dentist has this equipment). However, it is usually necessary to take bitewing x-rays as well. The child-sized ones are often easier to tolerate.

·   Providing treatment in short increments can also help.

·   Hypnosis can also help with the gag reflex. Make sure you choose a  Qualified hypnotherapist.

·   Nitrous oxide (laughing gas) is very effective in reducing the gag reflex. IV sedation is even more effective and almost always eliminates the gagging.

·   Physiological causes which can predispose or cause a person to gag include not being able to breathe through your nose properly, catarrh, sinusitis, nasal polyps, mucus in the upper respiratory tract, a dry mouth, and medications that cause nausea as a side effect. Certain medical conditions (gastrointestinal diseases) can also contribute to gagging.

·   Gagging can be worse in the morning for some people. If this is the case for you, try and schedule appointments for the afternoon.

A severe gag reflex can be big obstacle for some people who need dentures. Here are some tips:

·   the gag reflex can be triggered by a denture that extends too far into the palate - oftentimes it's possible to trim it enough to make it comfortable

·   sheer wanting will can help

·   hypnosis can also help

·   desensitization can work for some people - a bleaching shim with the palate included is worn as much as possible to see if you can be desensitized

·   if finances allow, implant-retained dentures or implants may be an option