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 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.     

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 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.     

A review of gagging problems in dentistry: 2. Clinical assessment and management

A pronounced gag reflex can be a severe limitation to a patient's ability to accept dental care and for a 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 'management' techniques have been described. This paper describes the different categories of treatment used to manage people with pronounced gag reflexes.     

A review of gagging problems in dentistry: 2. Clinical assessment and management.

A pronounced gag reflex can be a severe limitation to a patient's ability to accept dental care and for a 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 'management' techniques have been described. This paper describes the different categories of treatment used to manage people with pronounced gag reflexes.     

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 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.     

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.     

Altering the gag reflex via a palm pressure point

BACKGROUND: The gag reflex regularly interferes with dental procedures. The authors hypothesize that applying pressure to a specific point on the palm alters the gag reflex and that hypersensitive gag reflexes may be categorized according to oropharyngeal landmarks. METHODS: Thirty-six neurologically intact subjects underwent a series of gag reflex trials (baseline, sham and treatment). The authors developed a hand pressure device for subjects to wear, which provided a consistent force, and they described a gag trigger point index (GTPI) scale. On the basis of the GTPI, they divided subjects into a hypersensitive group and an expected-sensitivity (control) group. RESULTS: The trigger point of the gag reflex moved posteriorly in all subjects as a result of pressure to the palm point. Statistical results from repeated measures analysis of variance support the GTPI baseline data, and group assignments helped predict mean GTPI scores across conditions. The authors noted a significant treatment-group interaction effect, which indicated that the difference in mean GTPI responses between the hypersensitive and expected-sensitivity groups depended on the treatment being used. CONCLUSIONS: The authors introduce a treatment involving the stimulation of a pressure point that consistently altered the gag reflex trigger. The results of the study show the need for a more detailed, systematic approach to studying the hypersensitive gag reflex. CLINICAL IMPLICATIONS: The change in trigger point in the hypersensitive group represented a functional gain. Application of the pressure point during dental procedures would decrease the likelihood of triggering a gag reflex.     

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 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 management of blood phobia and a hypersensitive gag reflex by hypnotherapy: a case report

Coping with a hypersensitive gag reflex can be a cause for concern for both the patient and the operator. This report describes a case of blood phobia directed solely towards the oral cavity, linked with the inability to tolerate dentures due to a hypersensitive gag reflex. Management by hypnotherapy using a systematic desensitization technique allowed for extraction of teeth and permanent elimination of the gagging problem.     

Infantile reflexes and their effects on dental caries and oral hygiene in cerebral palsy individuals

The aim of this study was to evaluate the presence of pathological primitive reflexes and their effects on dental caries and oral hygiene in cerebral-palsied individuals. A group of 124 non-institutionalized patients (57 males) attending Lar Escola Sao Francisco Rehabilitation Center, who had a medical diagnosis of spastic CP (age range 3-17 years, mean+/-s.d.=8.6+/-4.3) were selected for dental clinical evaluation according to WHO (Oral health surveys: basic methods, WHO, Geneva, 1997) and oral hygiene using the oral hygiene index proposed by Greene and Vermillion (J Am Dent Assoc, 1964, 68, 7). The presence/absence of the pathological primitive oral reflexes of rooting, suckle-swallow, biting and gagging was evaluated by observing patients' reaction after a stimulus. Results were statistically analysed by Fisher's exact, Chi-square and Kruskal-Wallis tests. A significantly higher percentage of the biting reflex in patients with quadriplegia was observed, and also the absence of this reflex in patients with hemiplegia (P=0.006). Patients with hemiplegia presented significantly lower DMF index values. Kruskal-Wallis test showed no statistical difference (P=0.335; 0.677; 0.202) for OHI-S among the quadriplegia, diplegia and hemiplegia for all dentitions. Our data suggest that the more severe the neurological damage is, the more frequent is the presence of the biting reflex and consequently, the higher is the risk of oral diseases in this population due to the difficulty to perform an adequate oral hygiene.     

A clinical survey of gagging patients.

A clinical investigation was carried out on 74 dental patients who were suffering from a severe gagging reflex. The most common stimulating factor was the maxillary denture. Routine history and clinical examination were carried out for each patient, and lateral skull radiographs and an Eysenck Personality Inventory were completed for some of the patients. Treatment consisted of the use of an acrylic resin training base combined with relaxation therapy and heterohypnotic techniques. The results of this ongoing study were: (1) there were no consistent features of the group which differentiated them from control groups; (2) a number of patients were insufficiently motivated and discontinued treatment; and (3) some patients who were declared completely cured suffered relapses.     

Implant-retained overdentures: a review

Implant-retained overdentures represent a treatment option for many patients unable to tolerate conventional dentures. They may be specifically indicated in patients with altered anatomy, neuromuscular disorders, a pronounced gag reflex or severe residual ridge resorption. This article discusses the different ways in which implant overdentures can be retained, outlines some of the clinical stages involved in planning and providing these prostheses, and highlights long-term maintenance requirements associated with implant-retained overdentures. Clinical Relevance: Patients with implant-retained overdentures are likely to present in general dental practice. Practitioners should be aware of issues associated with the design, treatment planning and maintenance of these prostheses.