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The Assessment and Management of Patients with Pronounced Gag Reflexes

Chris Dickinson Department of Sedation & Special Care Dentistry KCL Dental Institute

Floor 26. Guys Hospital 1

Had a bad day at the orifice, dear?

Gagging or Retching ?
Picture of patient

Retching - An ejectory contraction of the muscles of the gastro-intestinal tract and oropharynx

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

Contributory Factors
Evidence is poor
Anatomical Medical Emotional/Psychological Iatrogenic

Anatomical
Palate anatomy Long uvula Tongue shape Tongue position Other irregularities

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

Picture of patient

Psychological ?
Eating disorders Fear Stress Neuroticism Learned responses

Picture of patient

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

Picture of patient

Acceptance of dental care Oral hygiene practices Ability to wear prostheses


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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 II Very mild: Controlled by patient Mild: Control regained by patient/dentist with simple control techniques & reassurance

III
IV V

Moderate: Limits treatment options


Severe: Some treatments impossible Very severe: Effects patients behaviour and dental attendance. All treatment impossible
Dickinson & 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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Green

Traffic-light Control Signals

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
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 Picture of patient Oral Intranasal Combinations Large quantity of restorative or oral surgical treatment Gag reflex not controlled by other methods GA - Last resort
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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 II III IV V Fully Controlled Treatment successful Partially controlled Treatment possible Partially controlled Some simple treatments possible with frequent gagging Inadequately controlled Even diagnostic procedures difficult 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

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