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.     

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.     

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 and its associations with dental care–related fear,fear of pain and beliefs about treatment

BackgroundGagging is a behavioral response that interferes with oral health care and may be related to dental care–related fear. Little is known, however, about the epidemiology of gagging during dental treatment.MethodsTo explore this phenomenon, the authors recruited participants from the waiting area of an oral diagnosis clinic. Participants completed a gagging behavior questionnaire, the Dental Fear Survey, the Fear of Pain Questionnaire—9, the Revised Dental Beliefs Survey and a demographics questionnaire.ResultsAlmost one-half of the 478 participants reported gagging on at least one occasion during dental visits, and 7.5 percent of participants reported almost always or always gagging. With higher frequency of problems with gagging, patients were more likely to have greater levels of dental care–related fear, fear of pain and more negative beliefs about dental professionals and dental treatment. Furthermore, participants who gagged more readily had greater dental care–related fear than did participants who had less of a propensity to gag.ConclusionsGagging in the dental office is a prevalent problem, and dental care–related fear and fear of pain are associated with more frequent gagging.Practical ImplicationsGiven the prevalence of patients reporting problems with gagging, it may be helpful for providers to assess patients' propensity for gagging, which can be a barrier to treatment. By targeting dental care–related fear, fear of pain and negative beliefs about dental care in patients who often gag when receiving dental care, clinicians may be able to help reduce gagging in frequency or intensity, potentially making treatment more comfortable for patients and easier for dental care providers.     

The impact of stress and anxiety on the pressure pain threshold of myofascial pain patients

Summary  The purpose of this study was to evaluate the influence of stress and anxiety on the pressure pain threshold (PPT) of masticatory muscles and on the subjective pain report. Forty-five women, students, with mean age of 19·75 years, were divided into two groups: group 1:29 presenting with masticatory myofascial pain (MFP), according to the Research Diagnostic Criteria for Temporomandibular Disorders and group 2: 16 asymptomatic controls. An electronic algometer registered the pain thresholds on four different occasions throughout the academic year. To measure levels of stress, anxiety and pain, the Beck Anxiety Inventory, Lipp Stress Symptoms Inventory and Visual Analog Scale (VAS) were used. Three-way anova and Tukey's tests were used to verify differences in PPT between groups, times and sites. Levels of anxiety and VAS were compared using Mann–Whitney test, while Friedman's test was used for the within-groups comparison at different times (T1 to T4). The chi-squared and Cochran tests were performed to compare groups for the proportion of subjects with stress (α = 0·05). Differences in PPT recordings between time ( P  = 0·001) and sites ( P  < 0·001) were detected. Higher levels of anxiety and lower PPT figures were detected at T2 (academic examination) ( P  = 0·001). There was no difference between groups for anxiety and stress at any time ( P  > 0·05). The MFP group also has shown significant increase of VAS at the time of academic examination ( P  < 0·001). External stressors such as academic examinations have a potential impact on masticatory muscle tenderness, regardless of the presence of a previous condition such as masticatory myofascial pain.     

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.     

The relationship between bone age, chronological age and dental age in children with isolated growth hormone deficiency

Aim . To relate dental age and bone age to chronological age in a group of children with isolated growth hormone deficiency (GHD).
Design . A group of 25 children between the ages of 6 and 18 years, diagnosed as having GHD were studied. Of these, 16 were male and nine were female, undergoing replacement therapy with growth hormone (GH) over 2·5 years. Dental age (DA) was estimated from orthopantograms (Haavicko Methods) and compared to bone age (BA) by Greulich and Pyle Standards, and chronological age (CA).
Results . CA versus BA – there was a statistically significant difference of 1·52 years between the average chronological age and bone age ( t  = 5·61, P < 0·001). CA versus DA – there was a statistically significant difference of 0·92 years between the average chronological age and dental age ( t  = 3·93, P < 0·001). BA versus DA – statistically nonsignificant differences were found between the average bone age and dental age ( t  = –0·60, P  = 0·10).
Conclusion . After 2·5 years of therapy with growth hormone both DA and BA showed a significant delay compared to CA. Despite the fact that some catch-up occurs in speed of growth there is no evidence from the children in our study that might support the occurrence of a similar speed-up in dental age.     

The effect of sociodemographic factors on dental anxiety in children seen in a suburban Nigerian hospital

Summary. Objective. This paper attempts to determine the sociodemographic factors that relate to dental anxiety in suburban African children. Methods. A short form of the Dental subscale of the Child Fear Survey schedule (DFSS_SF) was administered to 81 patients (first time attendees at the clinic) between the ages of eight and 13 years. The psychometric scale was used after determining its reliability and validity to ensure that it was culturally appropriate. Age, gender, sociodemographic status were also recorded. The dental anxiety score distribution, its threshold level as well as the relationship between the sociodemographic variables and patients’ anxiety were determined. Results. There was no statistically significant association between age (P = 0·856), gender (P = 0·124), socio‐economic status of the children (P= 0.12) and level of dental anxiety. However, a statistically significant relationship did exist between the type of school the child attended and the anxiety level (P = 0·009). Also, 18 (14·8%) of the children were found to have high anxiety levels. Conclusions. Further studies involving larger non‐clinic samples are needed to examine the issues raised by the findings of this study.     

Use of Patient Self-Report Oral Health Outcome Measures in Assessment of Dental Treatment Outcomes

Objective: To assess the sensitivity of a newly developed brief measure of oral health-related quality of life (OQOL). Methods: Self-assessed oral health and OQOL were measured in three groups of patients who had presented for either prophylaxis ( n =  32), endodontic care ( n =  15), or for a denture ( n =  16) in a dental school setting before and after treatment. Main outcome measures included the single-item self-report of oral health (OH-1) and the 6- and 12-item versions of a new OQOL instrument. General linear modeling was used to compute means of self-reported oral health by treatment group. Results: Of the 63 patients who completed the baseline questionnaire, 44 (70 percent) returned questionnaires after treatment. The sample averaged 43  ±  15 years, 48 percent male and 55 percent with some college education. Ethnic representation included 35 percent White, 33 percent Black, and 32 percent other – mostly Latino. The mean self-reported number of teeth was 20.6. In terms of sensitivity, significant differences were observed between the treatment groups on the items assessing being upset ( P <  0.05), feeling depressed ( P <  0.05), and uncomfortable about the appearance of teeth or dentures ( P <  0.05). However, magnitude of change, as measured by an effect size, was characterized as minimal to small in the recall and endodontic groups and borderline moderate in the denture group. Conclusion: The measure was sensitive to differences within groups, with a small to borderline magnitude of change.     

The Level of Exposure-Dental Experiences Questionnaire (LOE-DEQ): a measure of severity of exposure to distressing dental events

To understand the development of dental anxiety better and to identify those at increased risk of developing dental anxiety, the Level of Exposure-Dental Experiences Questionnaire (LOE-DEQ) was developed. The aim of the current study was to determine the psychometric properties (i.e. factor structure, reliability, and validity) of the LOE-DEQ and to determine its suitability as an additional screening instrument for dentally anxious patients. Five different samples were used: (i) highly dentally anxious patients ( n  = 119); (ii) general dental patients ( n  = 480); (iii) students ( n  = 186); (iv) psychiatric outpatients ( n  = 17); and (v) oral surgery patients ( n  = 34). Results of the factor analysis revealed a four-factor solution. The LOE-DEQ has sufficient internal consistency (Cronbach's alpha values ranging from 0.69 to 0.85) and satisfactory test–retest reliability (intraclass correlation coefficient = 0.78). The results further suggest that this instrument has adequate discriminant, concurrent, and predictive validity. It is concluded that the LOE-DEQ is a useful tool for assessing patients' background in terms of previous exposure to distressing dental events, which is considered a vulnerability factor in the development of dental anxiety.     

Dental avoidance behaviour in parent and child as risk indicators for caries in 5-year-old children

Aim.  The aim of this study was to explore associations between avoidance behaviour and dental anxiety in both parents and children and caries experience in 5-year-old children. It was hypothesised that parents' dental avoidance behaviour and dental anxiety were related to dental caries in 5-year-old children.
Design.  Data were collected from dental records and by clinical and radiographic examination of 523 children. The parents completed a questionnaire regarding education, national background, dental anxiety, dental attendance, and behaviour management problems. Bivariate and multivariate logistic regression was conducted.
Results.  Children having one or more missed dental appointments (OR = 4.7), child behaviour management problems (OR = 3.3), child dental anxiety (OR = 3.1), and parents avoiding dental care (OR = 2.1) were bivariately associated with caries experience at the age of 5 years. In multivariate logistic regression, having one or more missed dental appointments (OR = 4.0) and child behaviour management problems (OR = 2.4) were indicators for dental caries in 5-year-old children, when controlling for parents education and national origin.
Conclusion.  Parents that avoid bringing their child to scheduled dental appointments and previous experiences of behaviour management problems for the child indicated risk for dental caries in 5-year-old children.     

A prospective study of dental anxiety in a cohort of children followed from 5 to 9 years of age

Background.  The development of dental anxiety in children is poorly understood.
Aims.  The aims of this study were to measure changes in dental anxiety over time and to examine the relationship between anxiety, dental care, and other factors.
Design.  A prospective cohort study of children in the north-west of England followed from 5 to 9 years of age. The participants were clinically examined and their parents completed the same questionnaire at 5 and 9 years.
Results.  The majority (54.3% N  = 38) of participants who were anxious at 5 years were no longer anxious at 9 years, but a large proportion of children who were anxious at 5 remained anxious at 9 years of age (45.7% N  = 32). During the follow-up period, a larger proportion of children developed anxiety (11.7% N  = 85) than the proportion of children who were reported as being anxious at baseline (8.8% N  = 70). At 9 years of age, dental anxiety was significantly associated with girls; parental anxiety; a history of extraction; and irregular, asymptomatic dental visiting. These factors were also significantly associated with dental anxiety at 5 years old.
Conclusions.  Dental anxiety was cumulative in the study population over time, and its development influenced by multiple variables. Results suggest that adverse conditioning and vicarious learning are both important in the development of this condition.     

Treatment outcomes of dental injury diagnoses as related to blood flow measurements from teeth

Summary  The purpose of this study was to investigate whether dental injury diagnoses may predict adverse outcomes occurring 102 weeks after trauma, and to evaluate whether the severity of adverse outcome is related to laser Doppler flowmetry (LDF) measurements of blood flow from teeth. In 309 trauma patients, 404 permanent maxillary incisors and the respective contralateral homologous control teeth were investigated clinically and radiographically, and by LDF to assess local blood flow values. Dental displacement injuries were classified as grade I (subluxation), grade II (lateral or extrusive luxation), and grade III (avulsion or intrusive luxation). Dental fracture injuries were classified as uncomplicated crown fractures, complicated crown fractures, and root fracture. An adverse outcome was defined as the presence of 'periapical radiolucency and/or grey discolouration'. Significant increase in risk of an adverse outcome occurred with a grade II dental displacement injury (15·07 odds ratio; P  = 0·000), a grade III dental displacement injury (28·33 odds ratio; P  = 0·000), and a root fracture (106·25 odds ratio; P  = 0·000). Blood flow measurements that were significantly associated with more severe outcome were blood flow levels of ≤3 perfusion units (PU; 170·72 odds ratio; P  = 0·000), and those of >3 PU and ≤6 PU (76·71 odds ratio; P  = 0·000). Diagnoses of displaced and root fractured teeth predicted dental injury patients who went on to show adverse treatment outcomes of splinting. Blood flow measurements from teeth were related to the severity of adverse outcome.     

Caries and dental fluorosis in a 0·25 and a 2·5 ppm fluoride area in the Sudan

The purpose of this study was to assess the caries prevalence of children living in areas with either 0·25 or 2·5 ppm fluoride in the drinking water, and to relate caries experience to the severity of dental fluorosis. The children, aged 6–16 years (mean 11·3 years), were lifelong residents of their rural villages. The severity of dental fluorosis in the maxillary central incisors, assessed by Deans index, was 1·4 ± 0·9 ( n  = 59) and 2·3 ± 0·9 ( n  = 65) in the 0·25 and 2·5 ppm areas, respectively. There was no significant difference in DMFT between children from the two areas (2·6 ± 2·3 n  = 59 versus 2·1 ± 2·3, n  = 65). In the low-fluoride area 75% of the children had decayed permanent teeth compared to 66% in the high-fluoride area. In the primary teeth, however, both the caries prevalence and the dmft were significantly lower in the 2·5 ppm area than in the low-fluoride area. Stepwise, multiple, linear regression analyses, including all children, showed a significant effect of age on DMFT (30% of the variance explained), but no explanatory effect of fluoride in drinking water, severity of dental fluorosis, or gender. Regression analyses based on children in the 2·5 ppm area alone, showed significantly higher DMFT by increased severity of dental fluorosis. In children with a mixed dentition ( n  = 66), there was no association between caries in the primary and permanent teeth.     

The clinical assessment of TMJ sounds by means of auscultation, palpation or both

Anterior disc displacements are an important diagnostic subgroup (Group II) of TM disorders according to the Research Diagnostic Criteria (RDC; Dworkin & LeResche, 1992 ). Although the RDC yields clear-cut criteria for the diagnosis of a disc displacement, the interobserver reliability for the clinical recognition of joint sounds is highly variable. This high variance may be caused by the fact that the clinical assessment of joint sounds is difficult. In many previous studies, auscultation with a stethoscope was used. This technique is often claimed to be the most reliable one. However, it is unclear whether in these studies, auscultation was performed without simultaneous palpation of the contralateral joint. Therefore, the aim of the present study was to test the interobserver reliability of the clinical assessment of TMJ sounds by means of auscultation, palpation or both. A total of 220 undergraduate students (100 men; 120 women; mean age 21·9 ± 3·6 years) was examined independently by two calibrated dentists for the presence, probable presence or absence of sounds caused by anterior disc displacement, hypermobility, or another cause. The 79 students underwent auscultation only (i.e. without contralateral manual palpation); 87 students underwent bilateral palpation; the remainder (54 students) was subjected to both auscultation and palpation. The results show that the combination technique yields the highest reliability (Cohen's κ =0·53). For other techniques, κ -values of 0·46 (auscultation) and 0·48 (palpation) were found.
It was concluded that the combination of auscultation and palpation yields the highest interobserver reliability for the recognition of TMJ sounds, although the differences with other techniques were small . (Supported by the IOT)     

Children choosing between general anaesthesia or inhalation sedation for dental extractions: the effect on dental anxiety

Summary. Aim. To compare the levels of dental anxiety experienced by children having dental extractions using general anaesthesia (GA) with those having extractions using local anaesthesia and inhalation sedation (IHS) when offered a programmed choice between the two techniques prior to treatment.
Design . Structured interview with child at pre-treatment and at one week (approximately) follow up.
Setting . Community: primary health care centre.
Subjects . Children aged 9–15 years referred to a local NHS Trust dental clinic ( n  = 88).
Intervention . Child and parent provided with information about IHS and its benefits over GA for the assistance in tolerating extraction of teeth and provided with a choice of procedure.
Main outcome measure . An eight question modified child dental anxiety scale.
Results . Full information was received from 76 children giving an 86% response rate. Post-operative dental anxiety was lower in children who had chosen (with their parent) IHS in comparison to those who had chosen general anaesthesia ( P < 0·05). Dental anxiety remained unchanged in the group who chose to have their extractions under GA.
Conclusion . Children and their parents who select IHS as opposed to GA to assist in extractions demonstrate less psychological distress.     

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.     

The effect of hydrogen peroxide concentration on metal ion release from dental casting alloys

summary  There are concerns that tooth bleaching agents may adversely affect dental materials. The aim of this study was to test the hypothesis that increasing concentrations of hydrogen peroxide (HP) are more effective than water at increasing metal ion release from two typical dental casting alloys during bleaching. Discs ( n  =   28 for each alloy) were prepared by casting and heat treated to simulate a typical porcelain-firing cycle. Discs ( n  =   7) of each alloy were immersed in either 0%, 3%, 10% or 30% (w/v) HP solutions for 24 h at 37 °C. Samples were taken for metal ion release determination using inductively coupled plasma-mass spectrometry and the data analysed using a two-way anova followed by a one-way anova . The surface roughness of each disc was measured using a Talysurf contact profilometer before and after bleaching and the data analysed using a paired t -test. With the exception of gold, the differences in metal ion concentration after treatment with 0% (control) and each of 3%, 10% and 30% HP (w/v) were statistically significant ( P  <   0·05). Metal ion release from the two alloys increased with increasing HP concentrations (over 3000% increase in Ni and 1400% increase in Pd ions were recorded when HP concentration increased from 0% to 30%). Surface roughness values of the samples before and after bleaching were not significantly different ( P  > 0·05) Exposure of the two dental casting alloys to HP solutions increased metal ion release of all the elements except gold.