Gagging etiology and management in relation to prosthodontics

Gag reflex definition :

is a normal healthy defense mechanism designed to prevent foreign bodies from entering the trachea.
Trigger zone in intraoral area:
1- palatoglossal and palatopharyngeal folds
2- base of tongue
3- palate
4- uvula
5-posterior pharyngeal wall
gaging may also elicited by non tactile sensation : visual, auditory, olfactory stimulation.
factors that are believed to be important in the etiology of gagging include:
1- local and systemic disorders.
2- anatomic factors.
3- psychological factors.
4- and iatrogenic factors.
-------------------------------1- local systemic disorder:
Nasal obstruction, postnasal drip, catarrh, sinusitis, nasal polyps, mucosal congestion of the upper respiratory tract, a dry
mouth, and medications that cause nausea as a side effect are thought to predispose to or cause gagging.
Hiatus hernia and uncontrolled diabetes have also been suggested as predisposing factors.
Gagging has been noted as being worse in the morning for some patients.
2- Anatomic factors:
anatomic abnormalities and oropharyngeal sensitivities like: tongue posture, hyoid bone, soft palate.
-distribution of the afferent neural pathway (vagus nerve)
3- Psychological condition:
a- classical conditioning.
b- Operant conditioning.
4- Iatrogenic factors:
Poor clinical technique may elicit the gag reflex in patients not normally susceptible to gagging.
Example:
a- overloaded impression tray.
b- improper denture contour.
i- thick rough or unevenly finished posterior border of maxillary denture.
ii- underxtension of the distal aspect of maxillary denture.
iii- overextension denture border particularly the posterior aspect of the maxillary denture and the posterior lingual region
of the mandibular prosthesis.
c- inadequate maxillary retention:
d- inadequate free way space.
e- restricted tongue space.
f- disharmonious occlusion. (increased vertical dimension of occlusion)
g- A smooth, highly polished surface which is coated with saliva may produce a slimy sensation which is
sufficient to cause gagging in some patients ( a matte finish has been advocated as more acceptable in this situation).
Alaa Otaibi

6. Oct. 2012

Gagging etiology and management in relation to prosthodontics

Management:
A- Mild to moderate gagging problem may be performed in general dental practice.
B- Severe gagging problem may initially require referral to a specialist who has an interest in the management of such
patients.
Management technique:
A- BEHAIVORAL
B- PHARMACHOLOGICAL
C- PROSTHETIC
D- ACUPRESSURE TECHNIQUE
* but whichever the technique going to used the clinician have to follow the same criteria to control the gagging during
impression making:
1- reassure the anexious pt to encourage both physical and mental relaxation.
2- speak loudly and clearly so the pt will listen to you.
3- never mention the word GAG to the pt. ( the word itself is often enough to set up the reflex.
4- assure the pt that little difficulty will be experienced if instructions are followed and the discomfort will be minimized as
much as possible.
5- seat the pt in an upright position with the occlusal plane parallel with the floor.
6- ask the pt to keep a deep breat and hod the breath while dentist quickly checks the size and fit of tray.
7- ask the pt to rinse with astringent mouth rinse followed by a rinse with cold water before impression is made.
8- explain to the pt that as soon as the impression seated, the head may be brought well forward over the lap and the bowel will
be provided to old under the chin to catch any saliva that may run out the mouth this will reduce fear of being choked.
9- must of the pt tolerate the lower impression better than the upper one so if the lower imp. Made first the success of the
procedure is likely to reassure the pt.
10- select a suitable impression material ( smell, taste, ,consistency , setting time).
for predictable results,
11- a local anesthesia solution may be incorporated into alginate material for reducing the gag reflex.
inform the pt that this
The advantage of this tech are:
alginate is specially prepared
a- controls the flow of anesthetic agent to vomiting and gagging sensitive areas.
to eliminate gagging.
b- minimize the risk of hazard and toxicity.
c- Allays apprehension by not including items to the pt's mouth, except the impression material.
d- dampens the sesitivity of entire arch during the impression making
e- the tech is simple and does not need special lab work.
12- Bead the posterior border of the maxillary tray with utility wax to confine the materialand prevent it from running down the
throat.
13- mix the impression material out of the pt's sight, and place minimum amount in the tray which is just enough to record the
relevant structures.
14- just before seating the tray shake some table salt on the tip of the tongue (distraction modality)
15- seat the impression as quickly as possibl, seating the posterior part and then rotating the tray into position.
16- remove excess impression material that may rolling down the palate with cotton applicators or gauze.
17- Employ some of the following mind distraction ways by loudly and forcefully instruction the pt to:
a- keep the eyes open during the impression procedure.
b- keep the eyes foucesed on some small object.
c- breath through the nose.
Alaa Otaibi

6. Oct. 2012

Gagging etiology and management in relation to prosthodontics

Management techniques:
A- BEHIVORAL MANEGMENT:
1 -behavioral modification
asking the patient to participate in the impression making.
Advantage:
1- Distraction of the patients attention from the stimuli is the base of the method.
2- The technique is simple
3-With the personal participation of the patient, the impression making process was smooth and effortless since it has given
him the confidence and control over the situation.
4- permits self-assurance that a disaster could be avoided.

2-distraction technique
a- Conversation
b- pt instructed to concentrate on breathing
c- asking a patient to participate in activities that cause muscle fatigue.
3-Relaxation:
ask the pt to tense and relax certain muscle gp, starting with legs and
working upwards, while continually providing reassurance
4- Systemic Desensitization:
a- Training Bases
b-Errorless learning:
Illustration 1: trainig base
Illustration 2: trainig base
The patient is instructed to set aside time to position the denture
closer each day and eventually into the mouth in successive approximations. That is, the denture is placed perhaps
millimeters at a time closer to the final position. In situations where retching is induced simply by looking at the denture,
then the patient is merely requested to look at or hold the denture and to stop before symptoms of retching develop. The
process is repeated, with a small increase in time spent undertaking this task, until eventually the patient can wear the
denture.
c- cognitive behavioral therapy
d- sensory flooding:
It is accomplished by encouraging the patient to retain the denture in the mouth for as long as possible with the reassurance that the aversive
reactions encountered will diminish. The basis of this method is to inform the patient that the physiological system cannot maintain the
strength of the initial response and that habituation will occur within 30 minutes or so.

e- Teaching pt to swallow with their mouth open

f- Hypnosis.

B-PHARMACOLOGICAL MANEGMENT:
1- local anaesthesia (sprays, gels or lozenges, and injections )
May actually increase nausea and vomiting. This is due to the sense of numbness produced in the sensitive palate and pharyngeal areas that may be subject
to the vomiting reflex.

2- conscious sedation
3- general anaesthesia
4- other ( antihistamines, sedatives, tranquilizers, and CNS depressants)
Alaa Otaibi

6. Oct. 2012

Gagging etiology and management in relation to prosthodontics

offer only a short term solution, especially for some severe cases.

C-PROSTHETIC
1- impression tech (that mentioned in page 2)
2- modification of maxillary custom tray to prevent gagging
3- plateless dentures (metal): aluminum or chrome nickel alloy is recommended.
4- marble technique.

proposed by Singer.

Tech: 5 round multicolored, glass marbles, approximately inch in diameter. Pt was told to put the marbles in his mouth,
one at time until all 5 were in his mouth. He was urged to keep the 5 marbles in his mouth continuously for one week, except
when eating and sleeping.

It appears that his approach presents definite medico-legal risks in the event of aspirating some of the marbles by
the patient.
required patient motivation.

D-ACUPRESSURE MANEGMENT:
1- According to Chegjiang: (REN-24) :
- is an effective acupressure point for controlling the gag reflex during impression procedures.
- is situated in the horizontal mentolabial groove, approximately midway between chinand the lower lip.
Tech:
-with index finger, a light pressure is applied, progressively increasing the finger pressure until the pt feel discomfert.
- should start at least 5 min before impression making.
- continue through impression procedures and be stopped only after impression has been removed from the
pt's mouth.
2-according to Xianyun:
tech: light pressure is applied and increased to heavy pressure until the pt feels discomfort
to both R+L concave are at medial aspect by the forearm (Neiguan) and concave area between first and 2 nd
metacarpal bone (hegus cave) with the thumb for 5 to 20 mins.

References:
1- F. M. Fahmi, A simple Technique to control gagging during impression making, The Saudi dental journal,1990
2- Rajashkar, Rao B, Gagging and its management in relation to prosthodontics, SRM University Journal of dental sciences, 2011
3- G. S. Bassi, G. M. Humphris, The etiology and management of gagging, The Journal Of Prosthetic Dentistry, 2004
4- Mostafa Hasaballa, Clinical Complete Denture Prosthodontics, chapter7, 2004

Alaa Otaibi

6. Oct. 2012