Chris Dickinson Department of Sedation & Special Care Dentistry KCL Dental Institute
Gagging or Retching ?
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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
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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
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Classification by Aetiology
Somatic: Induced by touching a trigger area
Contributory Factors
Evidence is poor
Anatomical Medical Emotional/Psychological Iatrogenic
Anatomical
Palate anatomy Long uvula Tongue shape Tongue position Other irregularities
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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Iatrogenic General
Water & suction tubes Instruments Local anaesthesia Radiography Pictures of patient
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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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Assessment
Precipitating factors Nature & severity Relievers & promoters Successful & failed dental treatments Treatment required Treatment requested Somatic mapping
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III
IV V
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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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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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Communication and signalling Positioning/Neck extension Breathing control Careful instrument handling
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Green
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
Concentration on a task, place, object or event to temporarily divert the patients attention away from the gagging Sensory deprivation (Landa) Leg raising (Krol) Breathing exercises Talking (Faigenblum) Salt on tongue Sick stick (Robb) Temporal tap (Robb)
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Desensitisation Techniques
Aims to progressively reduce the gagging threshold 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)
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Complementary Therapies
Hypnosis
(Barsby)
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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
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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Combination Techniques
Pre-treatment desensitisation Inhalation sedation Acupuncture Acupressure Rubber dam Visualisation Distraction
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Recording Success
Gagging Prevention Index
GPI Grade I II III IV V Fully Controlled Treatment successful Partially controlled Treatment possible Partially controlled Some simple treatments possible with frequent gagging Inadequately controlled Even diagnostic procedures difficult 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 Dont 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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