Title: The Assessment and Management of Patients with Pronounced Gag Reflexes
1The Assessment and Management of Patients with
PronouncedGag Reflexes
Chris Dickinson Department of Sedation Special
Care Dentistry KCL Dental Institute Floor 26.
Guys Hospital
2Had a bad day at the orifice, dear?
3Retching - 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
4Prevalence 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.
5Classification by Aetiology
- Somatic
- Induced by touching a trigger area
Psychogenic Induced without direct contact
Krol 1963
6Contributory Factors
- Evidence is poor
- Anatomical
- Medical
- Emotional/Psychological
- Iatrogenic
7Anatomical
- Palate anatomy
- Long uvula
- Tongue shape
- Tongue position
- Other irregularities
8Medical
- Chronic nasal congestion and obstruction
- Post nasal drip
- Gastric disorders
- Motor neurone disease
- Dysphagia
- Obesity
- Other medical conditions
Picture of patient
9Psychological ?
- Eating disorders
- Fear
- Stress
- Neuroticism
- Learned responses
Picture of patient
10Iatrogenic General
- Water suction tubes
- Instruments
- Local anaesthesia
- Radiography
Pictures of patient
11Iatrogenic 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
12Implications for the Patient
- Emotional
- Fear, anger embarrassment
- Avoidance behaviour
- Physical
- Acceptance of dental care
- Oral hygiene practices
- Ability to wear prostheses
Picture of patient
13Implications for the Dentist
- Emotional
- Fear, anger embarrassment
- Avoidance behaviour
- Physical
- Compromises ability to examine, diagnose and
treat - Influences treatment decisions
14Assessment
- Precipitating factors
- Nature severity
- Relievers promoters
- Successful failed dental treatments
- Treatment required
- Treatment requested
- Somatic mapping
15Gagging 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
16Methods 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
17Psychological Techniques
- In - House
- Confidence building
- Ego enhancement
- Tell show - do
- Referral
- Cognitive Behavioural Therapies
- Psycho therapeutic analysis and treatment
18Relaxation 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)
19Relaxation 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
20Traffic-light Control Signals
Green
Amber
Red
21Dental Techniques
- Local Analgesia ??
- Palatine block
- Inferior alveolar block
- LA incorporated into impression material
22Distraction 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)
23Desensitisation 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)
24Sedation 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
25Complementary Therapies
- Hypnosis (Barsby)
- Reframing
- Ego-enhancement
- Auto-hypnosis
- Contra-indicated
- in psychological conditions?
Picture of patient
26How 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
28Acupuncture
- Technique
- Simple Quick
- Inexpensive
- Easily learned
- Effective
- Few contra-indications
29Chengjiang (CV24)
30Hegu (LI4)
31Ear Acupuncture
32Other Acupuncture Points
33Ear Acupuncture - Uses
- Diagnostic - Assessment
- Episodic - Treatment
- Desensitisation ??
34Ear Acupuncture - Before After
Pictures of patient
35Combination Techniques
- Pre-treatment desensitisation
- Inhalation sedation
- Acupuncture
- Acupressure
- Rubber dam
- Visualisation
- Distraction
Picture of patient
36Recording 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
37Summary
- 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
38Thank You