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The Assessment
and Management ofPatients with Pronounced
Gag Reflexes
Chris Dickinson
Department of Sedation & Special Care Dentistry
KCL Dental Institute
Floor 26. Guy‟s Hospital 1
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“Had a bad day at the orifice, dear?”
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Gagging - A normal protective reflex designed to protect
the airway and prevent material entering the oropharynx
and the upper gastro-intestinal tract
Retching - An ejectory contraction of the muscles of thegastro-intestinal tract and oropharynx
Gagging or Retching ?
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Picture of patient
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Prevalence of Gagging
• No data available on the prevalence or
distribution of pronounced gag reflexes inthe general population
• 26 % of young adults and 43 % of olderadults had a total absence of the gag
reflexDavies et al. 1995. The Lancet.
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Classification by Aetiology
Somatic:
Induced by touching a „trigger‟ area
Psychogenic:
Induced without direct contact
Krol 1963
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Contributory Factors
Evidence is poor
• Anatomical
• Medical
• Emotional/Psychological
• Iatrogenic
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Anatomical
• Palate anatomy
• Long uvula
• Tongue shape
• Tongue position
• Other „irregularities‟
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Medical
• Chronic nasal congestion
and obstruction
• Post nasal drip• Gastric disorders
• Motor neurone disease
• Dysphagia
• Obesity
• Other medical conditions
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Picture of patient
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Psychological ?
• Eating disorders• Fear
• Stress
• Neuroticism
• Learned responses
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Picture of patient
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Iatrogenic – General
• Water & suction tubes
• Instruments
• Local anaesthesia
• Radiography
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Pictures of patient
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Iatrogenic – Prosthetic
• Inadequate posterior palatalseal
• Restricted tongue space
• Loss of normal palatalcontour
• Poor retention• Incorrect occlusal plane
• Decreased freeway space
• Excess freeway space
• Incorrect tooth position
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Implications for the Patient
Emotional
• Fear, anger &embarrassment
• Avoidance behaviour
Physical
• Acceptance of dental care
• Oral hygiene practices
• Ability to wear prostheses
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Picture of patient
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Implications for the Dentist
Emotional
• Fear, anger & embarrassment
• Avoidance behaviour
Physical
• Compromises ability toexamine, diagnose and treat
• Influences treatment decisions
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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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Gagging Severity Index
GSI Grade
I Very mild: Controlled by patient
II Mild: Control regained by patient/dentist withsimple control techniques & reassurance
III Moderate: Limits treatment options
IV Severe: Some treatments impossibleV Very severe: Effects patient‟s behaviour and
dental attendance. All treatment impossible
Dickinson & Fiske. 2000 15
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Methods of Control
• Relaxation & C.A.F
• Dental „techniques‟
• Distraction and
desensitisation
• Psychological andbehavioural techniques
• Local anaesthetic
techniques• Sedation techniques
• General anaesthesia
• Complementary therapies
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Picture of patient
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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) 18
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Relaxation & C.A.F
• Caring Attitude Factor (Shipmon)
• Empathetic but firm
• Calm, confident, in control• Rapport
• Communication and signalling
• Positioning/Neck extension
• Breathing control
• Careful instrument handling
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“Traffic-light” Control Signals 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
• Sensory deprivation (Landa)
• Leg raising (Krol)
• Breathing exercises
• Talking(Faigenblum)
• Salt on tongue
• Sick stick (Robb)
• Temporal tap (Robb)
Concentration on a task, place, object or event to temporarily
divert the patient‟s attention away from the gagging
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Desensitisation Techniques
Homework and Rehearsal (Sewerin)
• Tongue/palate stimulation
• Marbles/discs (Singer)
• Progressive appliancewear & training bases
• Dentures with acrylicbeads & mat surfaces (Singer)
• Orthodontic plates andblow-down splints
• Soft swallowing (Wilks)
Aims to progressively reduce the gagging threshold
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Sedation & General Anaesthesia
• Inhalation
• Intravenous
• Oral
• Intranasal
• Combinations
• Large quantity ofrestorative or oral
surgical treatment
• Gag reflex not controlledby other methods
• GA - Last resort
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Picture of patient
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Complementary Therapies
Hypnosis (Barsby)
• Reframing• Ego-enhancement
• Auto-hypnosis
• Contra-indicated
in psychologicalconditions?
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Picture of patient
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How does it work?
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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. Theonly trouble with this argument is that
as a matter of empirical fact, it does
happen.”
Aldous Huxley
Evidence of effect is emerging in several areas
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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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Other Acupuncture Points
• Face
• Head
• Back• Hand
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Ear Acupuncture - Uses
• Diagnostic - Assessment• Episodic - Treatment
• Desensitisation ??
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Ear Acupuncture - Before & After
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Pictures of patient
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Combination Techniques
• Pre-treatment
desensitisation
• Inhalation sedation• Acupuncture
• Acupressure
• Rubber dam• Visualisation
• Distraction
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Picture of patient
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Recording Success
Gagging Prevention Index
GPI Grade
I Fully Controlled – Treatment successful
II Partially controlled – Treatment possible
III Partially controlled – Some simple treatments
possible with frequent gagging
IV Inadequately controlled – Even diagnosticprocedures difficult
V No Control – No treatment possible
Dickinson & Fiske, 2000
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Summary
• Fully assess the nature of thegag reflex
• Match the level of treatmentneed with the managementtechniques at your disposal
• Set small objectives for eachtreatment visit
• Don‟t continue until patientgags. Stop at a positive point if
possible• Use a variety of managementstrategies for different items oftreatment – be flexible
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Pictures of patient
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Thank You
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