Gagging Problem Assessment: a re‐evaluation

The Gagging Problem Assessment (GPA) is an instrument to evaluate dental gagging. Although the GPA seemed to be reliable and valid in a pilot study, a replication study with more subjects was needed. Based on the pilot study, the number of items was reduced, resulting in the revised version of the GPA (GPA‐R). The aims of this study were to replicate the reliability of the GPA‐R and to investigate the correlation between dental gagging and general anxiety. Dental gagging patients (n = 59) were compared with a control group (n = 17) at t0 and 3 weeks later. The ‘gagging group’ also filled in the SCL‐90 anxiety scale. Gagging‐specific homogenous domains and internal consistency were determined. Stability and distinguishing capacity of the GPA‐R were assessed. SCL‐90‐Anxiety scores were compared with standard values in a non‐clinical population. The GPA‐R patient part was able to reliably discriminate between the absence or the presence of dental gagging. However, the reliability of the GPA‐R‐dentist part was insufficient. The GPA‐R seems to be sensitive to subtle differences in acts of the dentists. To overcome these problems, more detailed and explicit instructions on how to use the GPA‐R should be formulated and more specific gagging stimuli should be included. The ‘gagging group’ reported ‘fear of choking’ significantly more often than the control group (P = 0·008). This finding might be important for the treatment of dental gagging. Considering the outcome of our study, development of a new diagnostic gagging tool needs another approach that focuses on gagging severity.     

Self‐reported gagging in dentistry: prevalence,psycho‐social correlates and oral health

Although gagging has a profound effect on the delivery of dental care, it is a relatively under‐investigated phenomenon. This study aimed to derive a prevalence estimate of gagging during dental treatment based on patient‐reported information, to determine some socio‐demographic and psychological correlates and to assess the relationship of gagging with self‐reported oral health and avoidance of dental care. Data were collected with a survey among Dutch twin families (n = 11 771). Estimated overall prevalence of gagging during dental treatment was 8·2% (95% CI 7·7–8·7). Patients' self‐report of gagging was found to be significantly associated with female sex, a lower level of education and higher levels of dental trait anxiety, gagging‐related fears (e.g. fear of objects in the mouth), anxious depression and neuroticism. Gagging also appeared to be significantly associated with untreated cavities, gingival bleeding and wearing full dentures, but not with avoidance of dental care. It can be concluded that individuals who report to gag during dental treatment are moderately dentally anxious, fear‐specific situations that can trigger a gagging response and, albeit visiting the dentist equally frequently, report to have a poorer oral health compared to those who do not gag.     

Gagging

Gagging is a protective reflex to stop unwanted entry into the mouth and oropharynx. Some people have a reduced or absent reflex, while others have a pronounced one. Pronounced gag reflexes can compromise all aspects of dentistry, from the diagnostic procedures of examination and radiography to any form of active treatment. In some patients with marked gagging reflexes, it can lead to avoidance of treatment. Many techniques have been described that attempt to overcome this problem, and a variety of management strategies is necessary to aid the delivery of dental care. This is a review of the etiology of gagging problems, clinical assessment, and their classification and categorization prior to clinical treatment. It discusses as well methods for managing patients with gag reflexes during dental treatment.     

Relationship between gagging severity and its management in dentistry

The purpose of this study was to investigate how grading according to our new gagging reflex index correlated with patient background and subsequent management. After obtaining institutional approval and informed consent, 110 patients with a gagging problem were enrolled. The patients completed the State–Trait Anxiety Inventory (STAI), the Dental Anxiety Scale (DAS), and a health questionnaire at initial consultation. On the second visit, an intra‐oral examination was carried out and the severity of gag reflex determined according to our new, 5‐level Classification of Gagging Problem (CGP) index: normal gagging but not desensitised (G1 = score 1); mild gagging (G2 = score 2); moderate gagging (G3 = score 3); severe gagging (G4 = score 4); and very severe gagging (G5 = score 5). No difference was found in grade based on age or STAI or DAS scores. The CGP score in male patients was significantly higher than that in female. The management classification method and degree of desensitisation were investigated retrospectively in each patient at 3 months and 1 year after initial consultation. The higher the CGP grade, the more often intravenous sedation or general anaesthesia was required due to difficultly in desensitisation. The present results suggest that determining whether it is possible to examine the molar area without inducing the gag reflex offers the key to deciding the treatment strategy.     

Reliability and validity of the Turkish version of the shorter form of the gagging problem assessment questionnaire

Summary  The aim of this study was to evaluate the reliability and validity of the Turkish version of the shorter form of the gagging problem assessment questionnaire. Forty-three patients with gagging problems and 89 patients who showed no signs of gagging during dental examination were included in the study. The patients completed the patient portion of the gagging problem assessment questionnaire, as well as the modified dental anxiety scale, dental fear scale and Spielberger trait anxiety scale for comparison. Two experienced dentists subsequently completed the dentist portion of the gagging problem assessment questionnaire by performing clinical examinations with a dental mirror. The results indicate that patients with gagging problems had significantly higher mean scores than the control group ( P  <   0·001). The internal consistency of the questionnaire was found to be adequate, and good intra- and inter-observer reliability was present. Patients with a gagging reflex had significantly higher anxiety scores, indicating the validity of the questionnaire. The Turkish translation of the shorter form of the gagging problem assessment questionnaire was found to be reliable and valid for distinguishing among patients with and without a gagging reflex.     

A modified edentulous maxillary custom tray to help prevent gagging

The gag reflex can be a normal, healthy defense mechanism to prevent foreign objects from entering the trachea. During certain dental procedures, however, gagging can greatly complicate the final result, especially during the maxillary complete denture final impression. A modification can be made to the maxillary custom acrylic resin tray to aid in securing a clinically acceptable elastomeric final impression. This modification involves forming a vacuum chamber at the posterior extent of the custom tray to which a saliva ejector tip is embedded. When the saliva ejector is connected to the low-volume evacuation hose, the chamber will trap any excess impression material that might extrude from the posterior border of the loaded tray. This results in a reduced chance of eliciting the patient's gag reflex.     

A review of gagging problems in dentistry: I. Aetiology and classification

Some people have a pronounced gag reflex that can be a severe limitation to their ability to accept dental care and the clinician's ability to provide it. It can compromise all aspects of dentistry, from diagnostic procedures to active treatment and can be distressing for all concerned. Many techniques have been described that attempt to overcome the problem. Dentists will undoubtedly see patients with gagging problems and knowledge of a variety of management strategies is necessary to aid the delivery of dental care. This first paper looks at the background to gagging problems and their classification and categorization prior to clinical treatment. The second article will look at the clinical assessment of the patient presenting for dental treatment with a history of gagging problems. It will also review methods used to manage patients with gagging reflexes during dental treatment.     

A review of gagging problems in dentistry: aetiology and classification.

Some people have a pronounced gag reflex that can be a severe limitation to their ability to accept dental care and the clinician's ability to provide it. It can compromise all aspects of dentistry, from diagnostic procedures to active treatment and can be distressing for all concerned. Many techniques have been described that attempt to overcome the problem. Dentists will undoubtedly see patients with gagging problems and knowledge of a variety of management strategies is necessary to aid the delivery of dental care. This first paper looks at the background to gagging problems and their classification and categorization prior to clinical treatment. The second article will look at the clinical assessment of the patient presenting for dental treatment with a history of gagging problems. It will also review methods used to manage patients with gagging reflexes during dental treatment.     

The correlation of gagging threshold with intra-oral tactile and psychometric profiles in healthy subjects: A pilot study

Excessive gag reflex could be problematic for adequate dental care. Although various factors may increase the susceptibility to gagging, its contributing factors have not been fully determined. This study aimed to determine whether gag reflex was associated with tactile sensitivity and psychological characteristics. Fifteen volunteers of healthy males and females each were recruited for this study. After completing a questionnaire describing the self-perceived gag reflex activity, a disposable saliva ejector was inserted along the palate into the mouth until gagging was evoked. The ratio of the insertion depth to the palatal length was used as an index for the gagging threshold. The two-point discrimination (TPD) and Semmes-Weinstein monofilament (SWM) tests were performed to assess the tactile sensitivity of the palatal regions (hard palate, anterior and posterior soft palate). The Symptom Checklist-90-Revised was used to investigate the relationship between the gagging threshold and the psychological status. Our findings showed that the gagging threshold had a significant positive correlation with the TPD and SWM thresholds on the hard palate. The psychological profiles of psychoticism and hostility score were also significantly correlated with the gagging threshold. However, there were no significant differences in the tactile and gagging thresholds, as well as the psychological profiles, between males and females. Our results suggested that the tactile sensitivity of the anterior palate is a determining factor for the gagging threshold and implied that the initial response of the oral entry site to stimulation may lead to the development of gag reflex.     

The use of relative analgesia in the prosthetic treatment of the 'gagging' patient

Obtaining a stable and retentive denture base is a major factor in achieving a successful outcome when providing complete or partial removable dentures.The best results are obtained when the denture bases are well extended, especially in the upper arch.This is complicated when the patient experiences difficulty with the impression phase of treatment due to a hypersensitive gag reflex. Relative Analgesia (RA), also termed inhalational sedation, may be employed to facilitate the taking of dental impressions in patients with a hypersensitive gag reflex.Three patients, who had previous failed attempts to produce a satisfactory dental impression, have been used to illustrate the technique and outcome. It must be noted that the concentration of nitrous oxide required to produce suppression of the gag reflex will vary from patient to patient.This may be irrespective of size and weight; therefore each subject should be individually monitored. CLINICAL RELEVANCE: Relative analgesia (inhalational sedation) may be employed to facilitate the taking of dental impressions in patients with a hypersensitive gag reflex.     

The role of acupuncture in controlling the gagging reflex using a review of ten cases.

The gagging reflex is a physiological reaction which safeguards the airway from foreign bodies. In some people this response is exaggerated to the extent that the acceptance/provision of dental treatment is not possible. The aim of this paper is to review the role of acupuncture in controlling gagging as a safe, cheap, quick and relatively non-invasive technique. METHOD: Ten people agreed to try ear acupuncture to control gagging during dental treatment. Prior to treatment the severity of gagging was assessed. Acupuncture needles were inserted into a specific anti-gagging point on each ear, manipulated briefly and left in situ. Dental treatment was then carried out and the effectiveness of the acupuncture in preventing gagging was assessed. After treatment, the needles were removed and the patient discharged. All acupuncture was carried out by a dentist trained in its use. RESULTS: Four people had a severe gag reflex which made treatment impossible and six had a very severe reflex which made treatment impossible and affected their dental attendance. Ear acupuncture completely controlled the gag reflex in eight cases (23 treatment episodes) and partially controlled the reflex in two cases (two treatment episodes). Dental treatment could be carried out in all cases and at all visits. The cost of materials was 0.2 pounds per person per visit. Additional clinical time was in the order of 2-3 minutes. There were no adverse reactions to the technique and, on all occasions, patients were fit to leave the surgery and travel home unaccompanied. CONCLUSIONS: Ear acupuncture was successful in controlling the gag reflex. It is a safe, quick, inexpensive and relatively noninvasive technique. A controlled clinical trial is required to investigate any placebo effect.     

The etiology and management of gagging: a review of the literature

Gagging in dental patients can be disruptive to dental treatment and may be a barrier to patient care, preventing the provision of treatment and the wearing of prostheses. This article reviews the literature on the gagging problem from English-language peer-reviewed articles from the years 1940 to 2002 found by conducting an electronic search of PubMed, coupled with additional references from citations within the articles. Dentally relevant articles have been cited wherever evidence exists, and a balanced view given in situations where there is controversy. The first section considers the normal gag reflex and factors that may be associated with the etiology of gagging, including anatomical and iatrogenic factors, systemic disorders, and psychological conditions. A review of the management of patients with an exaggerated gag reflex follows and includes strategies to assist clinicians.     

Comparison between digital and conventional impression techniques in children on preference,time and comfort: A crossover randomized controlled trial

Objective

To compare the conventional alginate impression and the digital impression taken with an intraoral scanner of both dental arches in children, using a randomized crossover design.

Trial Design

This is a monocentric, controlled, superiority, randomized, crossover, open study.

Methods

Twenty-four orthodontic patients between 6 and 11 years of age underwent intraoral scanning (TRIOS 3; 3Shape) and alginate impression of both dental arches with an interval of 1 week between the two procedures. Participants were recruited from September 2021 to March 2022 and the study was completed in April 2022. Impression time for the two procedures was compared. Patients were asked which one of the two impression procedures they preferred. A questionnaire including Visual Analogue Scale (VAS) for comfort, pain, gag reflex and difficulty in breathing, was administered to the patients.

Results

Eighteen out of 24 patients preferred digital impression (75%, 95% confidence interval [CI]: 55% to 88%; P = .014). Scanning time was significantly shorter than alginate impression time (difference −118 seconds; 95% CI: −138 to −99; P < .001). Comfort was significantly higher for digital impression (difference 1.7; 95% CI: 0.5 to 2.8; P = .007). There was no difference in pain (difference −0.2; 95% CI: −1.5 to 1.0; P = .686) while gag reflex and breathing difficulties were smaller for digital impression (gag reflex difference −2.5; 95% CI: −4.0 to −0.9; P = .004 and breathing difficulties difference −1.5; 95% CI: −2.5 to −0.5; P = −.004).

Conclusions

Digital impression is preferred by children aged 6–11 years and it is significantly faster in acquisition time than conventional alginate impression.

Registration

The study was registered on ClinicalTrials.gov with registration number NCT04220957 on January 7th, 2020 ( https://clinicaltrials.gov/ct2/show/NCT04220957 ).     

Development of the Gagging Problem Assessment: a pilot study

Summary  An accepted management strategy for gagging problems appears not to exist. A reliable and valid instrument is needed to develop an evidence based treatment for this clinical problem. The aim of this pilot study was to evaluate the reliability and validity of a newly developed measurement tool for dental gagging: the Gagging Problem Assessment (GPA). An experimental group ( n  =   13) comprising individuals with gagging problems, and a control group ( n  =   12) that had received dental care without gagging, completed a questionnaire focused on general health aspects and dental anxiety and the patient part of the GPA. The dentist part consisted of tests with increasing intrusiveness. This part was completed by two dentists. Statistical analyses concerned inter-rater reliability (Cohen's κ ) , reliability of the questionnaire (Cronbach's α , Pearson correlation coefficient) and the statistical difference between the GPA and two dental anxiety questionnaires (Mann–Whitney U- test, α  = 0·05). Within the limits of this study, the findings suggested that dental gagging warranted the development of a diagnostic and evaluative instrument. Gagging appeared to be a specific problem that cannot be interpreted as some form of dental anxiety. The GPA proved to be a reliable questionnaire to assess the presence of gagging problems, with a satisfying inter-rater reliability ( κ  = 0·64; s.d. = 0·16). Significant differences were noted between the experimental group and the control group. This pilot study will be followed by a confirmation study with a larger sample size, evaluated according to recently formulated quality criteria for measurement properties of health status questionnaires.     

Managing Endodontic Patients with Severe Gag Reflex by Glossopharyngeal Nerve Block Technique

Introduction

Gagging is a protective reflex, but when the gag reflex becomes abnormally active, it poses a difficulty for the dentist because it hinders all aspects of dental procedures including diagnosis, radiography, and any form of active procedure.

Methods

In this case report, to overcome this difficulty the authors used a glossopharyngeal nerve block technique that is used by anesthetists and otolaryngologists, but its endodontic use has gone previously unreported.

Results

Response to gag reflex decreases after successful glossopharyngeal nerve block.

Conclusions

The glossopharyngeal nerve block technique is a relatively safe, simple, and easy to master technique as compared with general anesthesia for treating a patient with an exaggerated gag reflex. The glossopharyngeal nerve block technique may be used in dental procedures in patients with an exaggerated gag reflex or when performing procedures in the posterior aspect of the mouth. Due caution should be exercised to prevent inadvertent intravascular administration of local anesthetic when using this procedure.     

Comparison of direct and indirect occlusal contact examinations with different clenching intensities

The aims of this study were to examine the change of occlusal contact area following the increment of clenching intensity using silicone materials and electromyography (EMG) in normal subjects and to compare direct intra‐oral examination with indirect examination using dental casts mounted by means of two impression methods. Participants were 7 men and 5 women with no more than one missing tooth per quadrant and no pain in the head and neck region. During the task, intercuspal position was maintained with minimal force, 20% maximum voluntary contraction (MVC) and 40% MVC using electromyography visual feedback. Three types of occlusal contact examinations were performed with the aid of blue silicone material in randomised order: (i) intra‐oral direct occlusal contact examination (DE), (ii) indirect occlusal contact examination with dental casts using conventional impression method (IEC) and (iii) using occlusal impression method (IEO). Total occlusal contact area during DE and IEO significantly increased from baseline to 20% MVC and from baseline to 40% MVC, but not during IEC. Total occlusal contact area during DE in all tooth clenching conditions was significantly larger compared to IEO and IEC (P < 0·05). At 40% MVC, total occlusal contact area during IEO was significantly larger than during IEC (P < 0·05). These findings suggest that indirect occlusal contact examinations may not accurately reflect the intra‐oral occlusal condition. If the intra‐oral condition is reproduced using dental casts, these findings also suggest the occlusal impression method was more accurate compared to the conventional method (240 words).     

Managing Gag Reflex during Removable Partial Denture Treatment: A Review and a Clinical Report

A gag reflex is a common occurrence during dental procedures. A hypersensitive gag reflex is less frequently encountered and may prevent the dental provider from successfully completing critical clinical stages, resulting in poor treatment outcomes. Once patients suffer an unpleasant gag reflex experience in a dental office, they may become phobic, delaying or postponing their dental treatment. The purpose of this article is to review available treatment options and present a report of a partially edentulous patient with an exaggerated gag reflex, focusing on clinical management using a simple yet effective table salt technique and proper prosthesis design.     

Self‐reported Bruxism ‐ associations with perceived stress,motivation for control,dental anxiety and gagging*

Summary To examine possible associations between self‐reported bruxism, stress, desirability of control, dental anxiety and gagging. Five questionnaires were distributed among a general adult population (402 respondents): the Perceived Stress Scale (PSS), Desirability of Control Scale (DC), Dental Anxiety Scale (DAS), Gagging Assessment Scale (GAS), and Bruxism Assessment Questionnaire. A high positive correlation between DAS and GAS (R = 0·604, P < 0·001) was found. PSS was negatively correlated with DC (R = ?0·292, P < 0·001), and was positively correlated with GAS (R = 0·217, P < 0·001) and DAS (R = 0·214, P < 0·001). Respondents who reported bruxing while awake or asleep showed higher levels of GAS, DAS and PSS than those who did not. There were no differences between the bruxers and the non‐bruxers (sleep and aware) with regard to the DC scores. The best predictors of awake bruxism were sleep bruxism (OR = 4·98, CI 95% 2·54–9·74) and GAS (OR = 1·10, CI 95% 1·04–1·17). The best predictors of sleep bruxism were awake bruxism (OR = 5·0, CI 95% 2·56–9·78) and GAS (OR = 1·19; CI 95% 1·11–1·27). Self‐reported sleep bruxism significantly increases the odds for awake bruxism and vice versa. Tendency for gagging during dental care slightly increases the odds of both types of self‐reported bruxism, but desirability of control is not associated with these phenomena.     

Expectations and final evaluation of complete dentures by patients,dentist and dental technician

Summary There is a poor association between the dentist’s evaluation of denture quality and patients’ satisfaction with their dentures. Possible differences between dental professionals and patients’ expectations might help explain differences in outcome evaluations. This study compared scores given by a dentist, a dental technician and patients for their expectations before and their final evaluation after complete dentures treatment. Twenty completely edentulous patients, a prosthodontist and a dental technician provided scores for the expected aesthetic and functional results of their dentures based on a visual analogue scale at baseline. Post‐treatment completion ratings were given after adjustments, by dentist and patients. The dental technician provided post‐treatment completion ratings after completing the dentures. The patients had higher expectations than the dental technician and the dentist perceived for both aesthetic and function (P < 0·001). The patients also presented higher post‐treatment completion ratings than the dental professionals perceived for final aesthetics (P = 0·016, Kendall’s W = 0·207) and function (P = 0·002, Kendall’s W = 0·303). Only the dentist presented a statistically significant difference between expectations (lower) and final (higher) outcomes for aesthetics (P = 0·017) and function (P = 0·003). There was no correlation between expectations and post‐treatment completion ratings according to the patients’ age. There was also no correlation between the patients’ gender and expectation scores. Patients presented higher expectations regarding their dentures than dental professionals. The dentist believed that dentures would bring fewer benefits than patients did, but his perception of denture benefits post‐treatment was significantly higher than his expectations.