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The Assessment and Management of Patients with Pronounced Gag Reflexes

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Gagging - A normal protective reflex designed to protect the airway and ... Dysphagia. Obesity. Other medical conditions. 8. Picture of patient. Psychological ? ... – PowerPoint PPT presentation

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Title: The Assessment and Management of Patients with Pronounced Gag Reflexes


1
The Assessment and Management of Patients with
PronouncedGag Reflexes
Chris Dickinson Department of Sedation Special
Care Dentistry KCL Dental Institute Floor 26.
Guys Hospital
2
Had a bad day at the orifice, dear?
3
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

4
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.

5
Classification by Aetiology
  • Somatic
  • Induced by touching a trigger area

Psychogenic Induced without direct contact
Krol 1963
6
Contributory Factors
  • Evidence is poor
  • Anatomical
  • Medical
  • Emotional/Psychological
  • Iatrogenic

7
Anatomical
  • Palate anatomy
  • Long uvula
  • Tongue shape
  • Tongue position
  • Other irregularities

8
Medical
  • Chronic nasal congestion and obstruction
  • Post nasal drip
  • Gastric disorders
  • Motor neurone disease
  • Dysphagia
  • Obesity
  • Other medical conditions

Picture of patient
9
Psychological ?
  • Eating disorders
  • Fear
  • Stress
  • Neuroticism
  • Learned responses

Picture of patient
10
Iatrogenic General
  • Water suction tubes
  • Instruments
  • Local anaesthesia
  • Radiography

Pictures of patient
11
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

12
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
13
Implications for the Dentist
  • Emotional
  • Fear, anger embarrassment
  • Avoidance behaviour
  • Physical
  • Compromises ability to examine, diagnose and
    treat
  • Influences treatment decisions

14
Assessment
  • Precipitating factors
  • Nature severity
  • Relievers promoters
  • Successful failed dental treatments
  • Treatment required
  • Treatment requested
  • Somatic mapping

15
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
16
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
17
Psychological Techniques
  • In - House
  • Confidence building
  • Ego enhancement
  • Tell show - do
  • Referral
  • Cognitive Behavioural Therapies
  • Psycho therapeutic analysis and treatment

18
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)

19
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

20
Traffic-light Control Signals
Green
Amber
Red
21
Dental Techniques
  • Local Analgesia ??
  • Palatine block
  • Inferior alveolar block
  • LA incorporated into impression material
  • Rubber Dam

22
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)

23
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)

24
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
25
Complementary Therapies
  • Hypnosis (Barsby)
  • Reframing
  • Ego-enhancement
  • Auto-hypnosis
  • Contra-indicated
  • in psychological conditions?

Picture of patient
26
How does it work?
27
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
28
Acupuncture
  • Technique
  • Simple Quick
  • Inexpensive
  • Easily learned
  • Effective
  • Few contra-indications

29
Chengjiang (CV24)
30
Hegu (LI4)
31
Ear Acupuncture
32
Other Acupuncture Points
  • Face
  • Head
  • Back
  • Hand

33
Ear Acupuncture - Uses
  • Diagnostic - Assessment
  • Episodic - Treatment
  • Desensitisation ??

34
Ear Acupuncture - Before After
Pictures of patient
35
Combination Techniques
  • Pre-treatment desensitisation
  • Inhalation sedation
  • Acupuncture
  • Acupressure
  • Rubber dam
  • Visualisation
  • Distraction

Picture of patient
36
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

37
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
38
Thank You
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