A NEW

APPROACH

TO THE

GAGGING

PROBLEM

ARTHUR J. KROL, D.D.S., B.S.

Loyola Uniuersity, School of Dentistry, Chicago, Ill.

NE of the more perplexing problems encountered by the dentist is the management and treatment of the patient when gagging persists or develops after the insertion of new dentures. After various attempts fail to alleviate the gagging the patients condition is usually considered to be psychogenic and he is dismissed from the dental office. Some of these patients go to other dentists seeking help, others to psychiatrists, and others, considering themselves beyond help, simply remove the denture or dentures and seek no further treatment. Over the past 8 years a study has been made of more than 100 patients who have had serious difficulty wearing dentures because of gagging ; as a direct result of this study, denture patients accused of being neurotic can now be successfully treated. Consideration was given to patients who, for several weeks or months, persistently tried to wear complete dentures but could never retain them in the n:outh for more than a few hours (or even a few minutes) without violent gagging. All of these patients complained that the dentures extended too far back into the throat; most of them pointed to the palatal border of the upper denture, complaining that it was too long. The palatal extension of the denture was carefully examined and, in most patients, was found to be correctly determined. When, upon the insistence of the patient, the palate of the denture was shortened, gagging persisted; then, the palate was further shortened until most of the palatal area was removed. When relief was still not obtained, the mandibular denture was shortened posteriorly with no lasting improvement. Tongue space was increased by grinding the lingual surfaces of the masillary and mandibular teeth, and, at times, teeth were repositioned to allow more tongue room. The patients were asked to chew gum, mints, or anesthetic troches, but to no avail. The dentures which had become quite loose as the result of the number of adjustments were relined or rebased in the hope that the snug feeling of the dentures in the mouth might help to minimize the gagging. On the contrary, gagging becameworse. The dental literature was re-examined in an effort to find further suggestions, but the paucity of material indicated the limited knowledge on this subject. The tendency in the literature has been, first, to attribute gagging to physical or mechanical stimulation that arises from overextended dentures, thickened dentures, especially in the posterior palatal area, confined tongue space, loose dentures, and pclstnasal drip with accompanying inflammation of the nasopharynx. \\:hen these are not responsible, gagging is then attributed to psychogenic causes
*Associate Professor and Chairman, Department 611 of Prosthetic Dentistry.

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Den. 1963

arising from emotional problems, menopausal disorders, excessive strain at work or at home, or even general physical disorders producing mental depression. All of these factors were considered in treating the patients, with little or no success. At this time, attention was turned from the mechanical approach of altering the individual dentures to a very careful analysis and re-evaluation of the biologic factors that might be involved. A meticulous examination of the jaw relations was made with particular attention given to a consideration of the facial height, that is, the facial vertical dimension, since this is the most difficult jaw relation to establish accurately.
IMPORTANCE OF FACIAL VERTICAL DIMENSION

The facial vertical dimension refers to the measurement of the facial height between two arbitrarily fixed points, one on the chin and the other on the tip of the nose. When speaking of facial vertical dimension, one may refer to a measurement between these two points when the teeth are in occlusion. This is called the occlusal facial height. Or one may refer to the measurement between these two points when the patients mandible is in its rest position. This latter measurement is called the rest facial height. should differ, In a patient with natural dentition, these two measurements the occlusal vertical dimension always being 2 to 4 mm. less than the rest vertical dimension. This is caused by the fact that when the mandibular musculature is resting, the mandible drops slightly, and a space of 2 to 4 mm. is established between the maxillary and mandibular teeth. This space is referred to as the interocclusal clearance or free-way space. The amount of interocclusal clearance was checked in these patients and found to be inadequate. It was decided to increase the interocclusal clearance by either mounting the dentures on an articulator and simply grinding the teeth, or remaking the dentures to a newly determined occlusal vertical dimension. The results were astounding. Some patients were relieved immediately of gagging ; others were relieved after a few hours, and others, within a day or two. Those who continued gagging after a few days were re-examined, and the occlusal vertical dimension was reduced further. A few patients required several reductions, but, eventually, all of the patients were freed from gagging.
CAUSES OF GAGGING

There can be no doubt that gagging is one of the symptoms when the occlusal facial height is too great. Why does gagging occur? At present, one can only conjecture that when the occlusal vertical dimension exceeds the rest vertical dimension, the elevator muscles can no longer relax normally. They probably enter into a spasm which, in turn, affects all of the other muscles involved in the kinetic chain of swallowing. Most likely, a spasm of the tensor palati muscle is responsible for the sensation that the maxillary denture seems to extend too far backward, because, in contracting, the tensor palati muscle slightly depresses the soft palate, pressing it against the posterior border of the denture. This dis-

Volume Number

13 4

NEW

APPROACH

TO GAGGING

PROBLEM

613

turbance of the normal behavior of these muscles seems to provide the logical stimulus for the gag reflex. In addition to the study of gagging in patients who already have had dentures constructed and have had difficulty wearing them, a further study was made of gagging that occurs during various procedures such as intraoral examinations, recording of intraoral roentgenograms, impressions, etc. Such gagging, which is for the most part psychogenic, does at times present serious problems. Difficulty in performing intraoral procedures may result in a strained dentist-patient relationship, as well as faiure to accot~~plish adequate treatment.
AWARENESS OF THE STIMULUS

In treating psychogenic gagging, one must recognize the fact that the gagging occurs only when the patient is azure of the stimulus. In other words, the stimulus, real or imaginary, must pass through the cortex of the brain where this awareness or consciousness takes place. In this sense, it would not be a pure reflex action. The gagging can be reduced in direct proportion to the reduction of awareness of the stimulus. Therefore, if a patient can be forced to direct his attention away from the stimulus, gagging may be controlled. One means of accomplishing this would be as follows: ask the patient to hold his foot raised from the base of the chair. He will soon tire and will require more and more conscious effort to keep the foot raised. As the patient becomes more exhausted, more conscious effort is required. Before long, the patient would have some difficulty carrying on a conversation, since nearly all of his conscious effort would be directed to his foot. At this time, but no sooner, the intraoral proc:edure should be attempted. The more deeply engrained the spontaneous gagging, the more difficult it is to control. Once successis obtained with such a technique, however, one will find the patient more and more cooperative at subsequent appointments. The use of topical anesthetics to control gagging is not as effective as one would expect. For, although the mucosa is anesthetized, the patient is very much WXZYB of the stimulus. In some casesof severe psychogenic gagging, the topical anesthetic may even initiate the action becauseof the feeling of swelling of the tongue and palate that is produced.
CLASSIFICATION OF THE CAUSES OF GAGGING

The causes of gagging can be classified into psychogenic and somatogenic. Among the psychogenic causes, one finds the presence of psychic stimuli resulting from excessive fear, apprehension, anxiety, etc., whereas in somatogenic gagging one finds the presence of physical stimuli that may be either local or systemic. Local stimuli include those arising from foreign objects in the mouth or throat that excite gagging. Local stimuli either arise from overextended dentures which directly stimulate gagging, or from dentures constructed to too great an occlusal facial height which indirectly stimulate gagging by interfering with muscular behavior. Systemic stimuli are those arising from the use of various drugs or from excessive consumption of alcohol which stimulates the gag reflex. The recogni-

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J. Pros. July-August,

Den. 1963

tion of the type of gagging is most important before any attempt is made to treat the patient. Psychogenic gagging occurs during the various mouth procedures such as examination, impression making, registration of jaw relations, insertion of dentures, etc. In some instances, simply bringing the mouth mirror in contact with the patients lip excites the gagging action. In addition to these tactile stimuli, real or imaginary, visual, acoustic, and olfactory stimuli further stimulate gagging. If, upon insertion of a new set of dentures, gagging occurs, one may assume this to be psychogenic. But, if gagging persists for more than a few days, then one must think in terms of a somatic disturbance. Gagging that develops after complete or partial dentures have been worn successfully for several months, or even as long as a year, falls into the same category. The patient may or may not have gagged during the various mouth procedures. A prolonged somatic disturbance will produce psychological consequences ; hence, prolonged gagging of somatic origin will, in time, also involve psychogenic gagging. For example, a patient may be wearing dentures successfully for months when suddenly he begins gagging. This gagging is purely reflexive since he does not recognize or understand the stimulus. When he realizes that by removing the dentures the gagging ceases, he becomes aware of them as the source of the stimulus. It is this association of the denture with gagging that becomes deeply engrained psychologically, so that in the construction of new dentures psychogenic gagging may occur during the intraoral procedures and after insertion of the new dentures. If the somatic stimulus has been eliminated, the psychogenic factor will take care of itself since the patient would have to initiate gagging purely through imaginary stimuli which no longer exists in reality. If such a patient continues to gag a few days after receiving the new dentures, then the somatic factor or stimulus has not been eliminated.
TREATMENT OF THE GAGGING PATIENT

In the treatment of a gagging patient whose dentures are constructed to too great an occlusal vertical dimension, the correction may involve more than at first seems apparent. An error of 1 to 3 mm. may, at times, be corrected simply by occlusal grinding. A greater error may require remaking one or both dentures. Even surgical intervention may be necessary to provide adequate clearance between the maxillary and mandibular ridges, especially in the maxillary tuberosity and mandibular retromolar region. If difficulty is experienced in determining the correct occlusal vertical dimension for a patient, one may construct acrylic resin occlusion rims which are adjusted to an arbitrary facial height and worn by the patient for a few days. Subsequent reduction of the height of the rims is made until the gagging ceases. A record of this occlusal vertical dimension, which is now acceptable to the patient, is used as a guide in the construction of new dentures. A technique for handling the patient whose gagging is psychogenic has been shown. This technique of directing the patients attention away from what is being done in the mouth will demand full patient cooperation if it is to be effective. Furthermore, the dentist must appear positive and confident in his attitude. If a

Volume Number

13 4

NEW

APPROACH

T O GAGGING

PROBLEM

615

drug is used to relax the patient, a tranquilizer with an antiemetic action may prove effective. In a limited study, chloropromazine (Thorazine), used after the insertion of new dentures, appeared to be helpful in the control of gagging. To illustrate more clearly the findings described above, two case histories of gagging patients are presented here, the first of typical psychogenic gagging, and the second, typical somatogenic gagging.
PliYCIIOGENIC GAGGING

ti 45year-old man, apparently in good health, requested the addition of an artificial tooth on a removable partial denture. The patient had recently had an abutment tooth extracted under general anesthesia and wished to have the tooth replaced. Told that several roentgenograms were necessary, as well as maxillary and mandibular impressions, the patient immediately balked, stating that his last experience with roentgenograms and impressions was one he would have difficulty forgetting since he always had been a severe gagger and suffered great11 in these procedures. This was readily confirmed in the oral examination. At his first appointment, the patient was asked to elevate his foot off of the footrest and hold it in that position. He was assured that if he cooperated the procedures could be accomplished. After about three minutes, the patient stated he was having real difficulty keeping his foot suspended. This effort became very apparent in his facial expression and the tension in his body, but the roentgenograms were obtained with only slight difficulty. The patient was dismissed and asked to return the following week for the impressions. During his next appointment, the same technique of holding his foot off the footrest was employed and impressions were obtained without difficulty. One week after insertion of the partial denture, the patients wife came to the office to express her appreciation not only for the work that was done, but also for the effect on her husband. She stated that, for years, every time he brushed his teeth he gagged so terribly she herself became nauseated. Since his visits to the office, however, she noticed that the gagging had stopped. At first she believed he had discontinued brushing his teeth, but, upon observing him one day, she noticed him brushing his teeth with one foot raised off of the floor.
SOMATOGENIC GAGGING

A 52-year-old woman sought help regarding her problem of gagging. Esamination revealed the edentulous maxillae and a full complement of mandibular teleth. The patient had had several maxillar:- dentures constructed and the problem was the same with all of them. She could not keep anv of them in her mouth for more than a half hour before she began to gag; she could eat no meals with the denture in place for the same reason. Examination of the various dentures in the patients mouth revealed a common error. Each was constructed to too great an occlusal vertical dimension. With the denture removed and the mandible at rest, the patient had approximately 1 mm. of clearance between the mandibular incisors and the maxillary anterior ridge. The incisal edges of the mandibular anterior

616 teeth were badly worn and further reduction to obtain more clearance seemed questionable. A new maxillary denture was constructed with a reduced occlusal vertical dimension, and the patient returned 24 hours after insertion with the same complaint of gagging, stating that she believed the denture extended too far back. She said this was the same problem she had had with the other dentures, even though all were reduced short of the vibrating line at th& junction of the hard and soft palates, and the palate of one denture had been entirely removed. The denture was remounted ; the vertical dimension was reduced slightly by occlusal grinding; and the denture was returned to the patient. The next day her complaint remained the same and the denture was remounted again. After the fourth remounting and occlusal reduction, the patient responded by stating that the correction in length of the palate had finally solved the problem, even though the palate length was never altered. The patient could now wear the denture throughout the day and eat without gagging. Because the anterior part of the maxillary denture had been so reduced, the denture soon fractured. A new denture with a metal palate was constructed and the patient has worn this denture successfully for 2 years.
SUMMARY

Causes of gagging may be classified into psychogenic and somatogenic. Gagging that occurs during various procedures such as intraoral examination, etc., is for the most part psychogenic. Such gagging is a result of excessive fear, apprehension, anxiety, etc., and occurs only when the patient is aware of the stimulus. This gagging can be reduced in direct proportion to the reduction of the awareness of the stimulus. If the patients attention can be sufficiently diverted (e.g., by the effort involved in keeping the foot elevated from the footrest), intraoral procedures can be accomplished successfully. Gagging that persists after the insertion of new dentures, or develops after dentures have been worn successfully for many weeks or months, must be considered as somatogenic. A careful study of such patients showed that an exaggerated increase of the occlusal vertical dimension was the cause of gagging. When the occlusal facial height was too great, the elevator muscles no longer relaxed normally. This disturbance, in turn, most likely affected all the musculature involved in swallowing and provided the stimulus for the gag reflex. When the occlusal facial height was reduced, gagging was eliminated.
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12,

HARRISON ILL.

ST.