The Assessment and Management of Patients with Pronounced Gag Reflexes

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The Assessment and Management of Patients with
PronouncedGag Reflexes
Chris Dickinson Department of Sedation Special
Care Dentistry KCL Dental Institute Floor 26.
Guys Hospital
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Had a bad day at the orifice, dear?
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Retching - An ejectory contraction of the muscles
of the gastro-intestinal tract and oropharynx
Gagging or Retching ?
Picture of patient

• 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

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

Picture of patient
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Psychological ?

• Eating disorders
• Fear
• Stress
• Neuroticism
• Learned responses

Picture of patient
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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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Implications for the Patient

• Emotional
• Fear, anger embarrassment
• Avoidance behaviour
• Physical
• Acceptance of dental care
• Oral hygiene practices
• Ability to wear prostheses

Picture of patient
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Implications for the Dentist

• Emotional
• Fear, anger embarrassment
• Avoidance behaviour
• Physical
• Compromises ability to examine, 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 with
simple control techniques reassurance III
Moderate Limits treatment options IV
Severe Some treatments impossible V Very
severe Effects patients behaviour and dental
attendance. All treatment impossible Dickin
son Fiske. 2000
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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

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)

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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

• Local Analgesia ??
• Palatine block
• Inferior alveolar block
• LA incorporated into impression material

• Rubber Dam

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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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Sedation General Anaesthesia

• Inhalation
• Intravenous
• Oral
• Intranasal
• Combinations
• Large quantity of restorative or oral
• surgical treatment
• Gag reflex not controlled by other methods
• GA - Last resort

Picture of patient
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Complementary Therapies

• Hypnosis (Barsby)
• Reframing
• Ego-enhancement
• Auto-hypnosis
• Contra-indicated
• in psychological conditions?

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. The only
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
Pictures of patient
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Combination Techniques

• Pre-treatment desensitisation
• Inhalation sedation
• Acupuncture
• Acupressure
• Rubber dam
• Visualisation
• Distraction

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 diagnostic
  procedures difficult
• V 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

Pictures of patient
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Thank You