GOOD MORNING!

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GAGGING- A PROBLEM IN
DENTISTRY
C R MEANS, I E FLENNIKEN
JPD 1970;23(5):614-620

CLINICAL EVALUATION OF
THE GAGGING DENTURE
PATIENT
J J KOVATS
JPD 1971;25(6):613-619

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 PRESENTED BY

DR. MEGHA VARSHA

DEPARTMENT OF
PROSTHODONTICS AND
CROWN & BRIDGE
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DEFINITION
 GAGGING- AN INVOLUNTARY CONTRACTION OF
THE MUSCLES OF THE SOFT PALATE OR
PHARYNX THAT RESULTS IN RETCHING
GPT-8
 TO RETCH WITHOUT ACTUALLY VOMITING

 RETCHING- INVOLUNTARY SPASMODIC BUT

INEFFECTUAL ATTEMPT TO VOMIT

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INTRODUCTION
• THE GAG REFLEX IS A NORMAL DEFENSE
MECHANISM THAT PREVENTS FOREIGN BODIES
ENTERING THE TRACHEA, PHARYNX OR LARYNX.

• RANGES FROM SIMPLE CONTRACTION CIRCUMORAL

MUSCLES TO SPASM OF PHARYNGEAL STRUCTURES,
ACCOMPANIED BY VOMITING.

• UNWANTED, IRRITATING, OR TOXIC MATERIAL

IS EJECTED FROM THE UPPER RESPIRATORY
TRACT BY THE CONTRACTION OF THE
OROPHARYNGEAL MUSCLES

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• MAXILLARY DENTURE WHICH CAUSES GAGGING
MAY HAVE
• A POSTERIOR PALATAL MARGIN THAT IS SO
CONCAVE THAT IT TERMINATES ALMOST ON
THE HARD PALATE, OR OVEREXTENDED
• OR IT MAY HAVE A PALATE WHICH HAS A
MARKED DOWNWARD SLOPE AWAY FROM THE
SOFT PALATE.
• IN EITHER CASE, THE DENTURE CAN EXERT
ONLY MINIMAL PRESSURE AGAINST THE SOFT
PALATE

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FOR EXAMPLE
 EXPERIMENT CAN BE PERFORMED BY TOUCHING
THE BACK OF ONE'S HAND WITH THE LIGHTEST
POSSIBLE PRESSURE; THIS WILL USUALLY CAUSE A
TICKLING SENSATION.

 HOWEVER, IF THE PRESSURE ON THE SAME AREA

IS FIRM, NO TICKLING IS FELT

 AND SO, TOO, WITH THE MAXILLARY DENTURE: IT

IS MUCH MORE APT TO CAUSE A TICKLING
SENSATION IF IT EXERTS TOO LITTLE PRESSURE
AGAINST THE SOFT PALATE THAN IF IT EXERTS
TOO MUCH
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MUSCLES OF SOFT PALATE
 TENSOR PALATI
TIGHTENS THE SOFT PALATE, BROADENS IT
 LEVATOR PALATI
ELEVATES THE SOFT PALATE, PULLS IT POSTERIORLY
 MUSCULUS UVULAE
PULLS THE UVULA LATERALLY, ELEVATES UVULA
 PALATOGLOSSUS
PULLS THE ROOT OF TONGUE AND CLOSES THE
OROPHARYNGEAL ISTHUMUS, ELEVATES TONGUE
 PALATOPHARYNGEUS
ELEVATES PHARYNX AND LARYNX- HELP TO CLOSE
NASOPHARYNX

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Musculus
uvula

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10
TRIGGER ZONES
 PALATOGLOSSAL AND
PALATOPHARYNGEAL
FOLDS
 BASE OF TONGUE
 PALATE
 UVULA
 POSTERIOR PHARYNGEAL WALL

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PATHWAYS OF GAGGING
 AFFERENT FIBERS OF THE TRIGEMINAL, GLOSSOPHARYNGEAL, AND
VAGUS NERVES PASS TO THE MEDULLA OBLONGATA.

 NERVE FIBERS FROM THE MEDULLARY CENTER TO THE CEREBRAL

CORTEX ENABLE THE REFLEX TO BE MODIFIED BY CORTICAL OR
CONSCIOUS CONTROL

 MOTOR IMPULSES ARE TRANSMITTED THROUGH CRANIAL NERVES V,

IX, X, XI AND XII.

 GAGGING CENTRE IS CLOSE TO VOMITING, SALIVATING AND CARDIAC

CENTRES

 ACCOMPANIED BY EXCESSIVE SALIVATION, LACRIMATION, SWEATING,

FAINTING, OR, IN A MINORITY OF PATIENTS, A PANIC ATTACK.

 RESPIRATORY CENTRE IS INHIBITED.

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 THE SOFT PALATE IS PULLED
POSTERIORLY AND
SUPERIORLY TO CLOSE THE
OPENING OF NASOPHARYNX

 FIXATION OF HYOID BONE

 CONTRACTION OF FAUCIAL
PILLARS

 ELEVATION, CONTRACTION
AND RETRACTION OF THE
LARYNX

 CLOSURE OF GLOTTIS

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14
 PSYCOGENIC

GAGGING SOMATOGENIC

IMMEDIATE

DELAYED

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PSYCHOGENIC GAGGING
 PSYCHOGENIC GAGGING CAN BE INDUCED BY ANXIETY, FEAR, AND
APPREHENSION

 VISUAL, ACOUSTIC, OLFACTORY, AND IMAGINARY STIMULI

 ODORS FROM DENTIST’S HANDS

 SMELL OF IMPRESSION MATERIALS

 DEEP SEATED PERSONALITY DISORDERS

 PATIENTS FEELING MAXILLARY DENTURE TOO LONG

 SHORTENING OF THE PALATAL MARGIN REDUCES THE SENSATION

OF LENGTH, BUT USUALLY DOES NOT RELIEVE THE GAGGING.

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PSYCHOGENIC GAGGING
 TMJ DYSFUNCTION SYNDROME

 ATYPICAL FACIAL PAIN

 DENTURE INTOLERANCE

 BURNING MOUTH SYNDROME

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SOMATOGENIC GAGGING
 SOMATOGENIC GAGGING IS DUE TO LOCAL,
PHYSICAL, OR SYSTEMIC STIMULI

 EXAMINATION PROCEDURES

 RADIOGRAPHS

 MAKE IMPRESSIONS

 INFLAMMATION OF ORAL, NASAL, PHARYNGEAL

MUCOSA

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 PROLONGED LOCAL IRRITATION (OVER EXTENDED
DENTURES)

 DRUG INDUCED (PARASYMPATHOMIMETICS)

 SEVERE PAIN OR STRONG EMOTIONAL STIMULI

 CHRONIC GASTROINTESTINAL DISEASE, CARCINOMA
OF STOMACH
 HIATUS HERNIA, UNCONTROLLED DIABETES
 CARBOHYDRATE STARVATION, DIABETIC KETOSIS

 EXCESSIVE CONSUMPTION OF ALCOHOL

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IMMEDIATE TYPE
 OVEREXTENSION OR TOO MUCH THICKNESS
IN THE POSTERIOR BORDER OF THE
MAXILLARY DENTURE

 A BULGY DISTOLINGUAL FLANGE IN THE

MANDIBULAR DENTURE.

 A VERY LIGHT PRESSURE IS APLLIED

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 DELAYED TYPE
 2 WEEKS OR 2 MONTHS LATER

 INCOMPLETE BORDER SEAL

 MALOCCLUSION

 THE DENTURES TO BECOME LOOSE, PERMITS SALIVA TO ENTER BELOW

THE INTAGLIO AND MIGHT CAUSE A GAG REFLEX

 LACK OF SPACE

 FORCES THE TONGUE INTO THE PHARYNX, THE DORSAL SURFACE OF

THE TONGUE TOUCHES THE UPPER DENTURE PREMATURELY CAUSING
CHOKING AND GAGGING.

 INCREASED VERTICAL DIMENSION

 PREVENTS TENSOR VELI PALATINI OF SOFT PALATE RELAX NORMALLY

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DELAYED TYPE
 RESEMBLES CONDITIONED REFLEX

 ONCE GAGGING HAS BEEN CAUSED BY A DENTURE,

 MERE SIGHT OR ANY PERSON, PROCEDURE,

OR ENVIRONMENT ASSOCIATED WITH IT

 CAN TRIGGER GAGGING

 A STRONG CORRELATION IS FORMED WITH

DENTURE AND GAGGING

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MANAGEMENT OF GAGGING

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CONTROL LOCAL STIMULI
 AVOID A FATIGUED PATIENT

 EXPLAIN THE PATIENT

 SIT IN UPRIGHT POSITION AND HEAD BENT FORWARDS,

DOWNWARDS

 RINSE THE MOUTH WITH COLD-WATER

 FINGER MASSAGE OF THE SOFT PALATE OR BY WEARING AN

OVEREXTENDED BASEPLATE

 AS LITTLE IMPRESSION MATERIAL AS FEASIBLE SHOULD BE

USED
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CONTROL LOCAL STIMULI
 PROPER EXTENSION OF DENTURE

 MAXILLARY- IN POSTERIOR PALATAL SEAL AREA

 MANDIBULAR – IN DISTOLINGUAL AREA

 PROPER VERTICAL DIMENSION

 SUFFICIENT PRESSURE BY THE DENTURE IN

POSTERIOR PALATAL SEAL AREA

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BEHAVIORAL MANAGEMENT
 TO ABOLISH THE STRONG CORRELATION BETWEEN DENTURE
AND GAGGING

 EVEN AN ESTABLISHED CONDITIONED REFLEX WILL BE

ABOLISHED
 IFNOT REINFORCED PERIODICALLY
 ANY NEW STRONGER STIMULUS

 ACHIEVED BY DISTRACTION (STRONGER STIMULUS)

 EXAMPLE- ASK THE PATIENT TO RAISE THE LEG DURING THE

PROCEDURE
 ASK THE PATIENT TO BREATHE THROUGH THE NOSE
 AND GIVING A NEW DENTURE WITH AN ADEQUATE POSTERIOR
PALATAL SEAL
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THERAPEUTIC MANAGEMENT
 ATROPINE SERIES

 ANTI-HISTAMINICS
 BUT DONOT REDUCE GAGGING WHERE SALIVA IS NOT
THE ETIOLOGY
 CNS DEPRESSANTS
 BARBITURATES AND TRANQUILIZERS
 TOPICAL ANESTHETICS
 ACTUALLY THEY MAY INDUCE GAGGING
 PROTECTIVE COUGH IS ABOLOISHED
 INJECTION OF LOCAL ANESTHETICS
 TISSUE EXPANSION MAY OCCUR
 CAN BE MINIMIZED BY ADDING HYALURONIDASE(0.25CC-
1CC)
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TREATMENT OF A GAGGING
PATIENT
 A 74 YEAR OLD MAN PRESENTED FOR
TREATMENT WITH SEVERE GAGGING

 PATIENT IN GOOD HEALTH, TAKING NO

MEDICATION, WELL MOTIVATED

 PREVIOUS MAXILLARY DENTURE REVEALED AN

EXTREMELY CONCAVE BORDER

 EXCEPT FOR LACK OF RETENTION, AND

CONCAVE BORDER, NO OTHER FACTOR WAS
APPARENT FOR GAGGING
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PREVIOUS DENTURE

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 PRIOR TO TRAY PREPARATION, THE PATIENT WAS
INSTRUCTED TO BREATHE THROUGH HIS NOSE
SLOWLY,AT THE SAME TIME, TO RHYTHMICALLY
TAP HIS RIGHT FOOT

 WHENEVER THE PATIENT WAS ABOUT TO GAG, HE

WAS FIRMLY ORDERED TO CONTINUE THE
BREATHING AND FOOT-TAPPING

 PRIOR TO ACTUAL , THE PATIENT WAS PREPARED

FOR A TEMPORARY PERIOD OF DISCOMFORT, BUT
WAS ASSURED THAT, ALTHOUGH INTENSELY
UNCOMFORTABLE, IT WOULD BE SHORT-LIVED.
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 WHEN DENTURE WAS PLACED HE BEGAN TO
GAG AT ONCE UNTIL HE AGAIN RESUMED THE
DEEP, SLOW, AND AUDIBLE NOSE-BREATHING,
AND FOOT TAPPING

 GAGGING THOUGH INITIALLY SEVERE, SUBSIDED

OVER PERIOD OF 4-5 MINUTES

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 THE PATIENT EXPERIENCED A RECURRENCE OF
GAGGING SEVERAL TIMES DAILY FOR FIRST FOUR
DAYS, EACH EPISODE BEING CONTROLLED BY
NOSE-BREATHING AND CLENCHING HIS TEETH
TOGETHER.

 BY THE END OF THIS PERIOD, HE WAS NO LONGER

GAGGING AT ALL, AND HAS EXPERIENCED NO
RECURRENCE

 NEW DENTURE HAD A LENGTH(INCISIVE PAPILLA

TO MIDDLE OF PALATAL MARGIN) OF 47.8MM IN
CONTRAST TO OLD LENGTH OF 26.9MM
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 ALSO THE NEW DENTURE, MEASURED FROM
INCISVE PAPILLA TO THE HAMULAR NOTCH, IS 5
TO 6 MM, LONGER THAN THE OLD DENTURE ON
EACH SIDE

 ALTHOUGH IT IS ALMOST 21 MM. LONGER THAN

THE PALATE OF THE OLD DENTURE, IT DOES
NOT INDUCE GAGGING

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PREVIOUS DENTURE NEW DENTURE

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35
NEWER TECHNIQUES

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GAGGING SEVERITY INDEX

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SIMPLE METHODS
 PLACE A PINCH OF SALT ON THE TIP OF THE
TONGUE

 SUCK ON A HARD CANDY

 THIS WORKS ONLY ON MILD GAGGERS

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BEHAVIORAL MODIFICATION
IT IS THE MOST SUCCESSFUL LONG TERM
METHOD OF ELIMINATING GAGGING

RELAXATION
•RELAXATION TECHNIQUE

•TENSE AND RELAX CERTAIN GROUP

OF MUSCLES

•STARTING WITH LEGS AND WORKING UPWARDS

•PROVIDING CALM ATMOSPHERE

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SUGGESTION
 HYPNOSIS

 CAN BE USED TO DISTRACT TEMPORARILY

 SHOULD BE TAKEN PRECAUTIOUSLY AS THERE

ARE CERTAIN CONTRA-INDICATIONS FOR
HYPNOSIS

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SYSTEMATIC DESENSITIZATION
 MILDLY AVERSIVE STIMULUS TO COPE UP

 INCREASINGLY SUBJECTED TO AVERSIVE STIMULI

 STEP WISE APPROACH TO GENTLY HABITUATE THE PATIENT

FOR DEFINITIVE TREATMENT

 TOOTHBRUSH, RADIOGRAPH, IMPRESSION TRAYS, MARBLES,

BUTTONS, TRAINING DENTURES

 PATIENT IS ENCOURAGED TO MOVE THE TOOTHBRUSH MORE

POSTERIORLY EVERYTIME

 MARBLES, ACRYLIC DISKS,ARE PLACED IN PATIENTS MOUTH

FOR INCREASING PERIODS
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TRAINING BASES
 A SERIES OF SMALL TO FULL SIZED DENTURES
ARE PLACED

 TO START WITH A THIN ACRYLIC BASE HARDLY

COVERING THE PALATE, WITHOUT TEETH IS
GIVEN

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 THEN DENTURE BASE WITH ANTERIOR
TEETH AND EXTENDED PALATAL COVERAGE
IS GIVEN

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 THEN TRAINING DENTURE WITH POSTERIOR
TEETH AND FULL PALATAL COVERAGE IS
GIVEN

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 A SUITABLE REGIME WILL BE
 5 MINUTES ONCE A DAY
 THEN TWICE A DAY
 1 WEEK THE PATIENT IS ASKED TO
INCREASE THIS TO 3 TIMES EACH DAY,
THEN 15 MINUTES, 30 AND 1 HOUR

 USUALLY PATIENT IS ASKED WEAR WHEN

BUSY OR DURING NON STRESSFUL TASKS

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ERRORLESS LEARNING
 IT’S A VERY SLOW TECHNIQUE

 HELPFUL FOR PATIENTS WHO HAVE DENTURES

BUT DO NOT WEAR THEM THE DENTURES
BECAUSE THEY EVOKE GAGGING.

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47
 PATIENT IS INSTRUCTED TO SET ASIDE TIME TO
POSITION THE DENTURE CLOSER EACH DAY AND
EVENTUALLY INTO THE MOUTH IN "SUCCESSIVE
APPROXIMATIONS."

 THAT IS, THE DENTURE IS PLACED PERHAPS

MILLIMETERS AT A TIME CLOSER TO FINAL
POSITION.

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COGNITIVE BEHAVIORAL
THERAPY
 COGNITIVE BEHAVIORAL THERAPY INVITES PATIENTS TO
CHALLENGE STRONGLY HELD BELIEFS ABOUT THE
CONSEQUENCES OF GAGGING

 FOR EXAMPLE, SOME PATIENTS RETCH WHEN WATER

FROM THE HIGH-SPEED HANDPIECE IS FELT.

 WHEN QUESTIONED, IT IS NOT UNUSUAL FOR AN

INDIVIDUAL TO ADMIT TO A FEAR CHOKING, BELIEVING
THAT BREATHING WILL STOP, RESULTING IN DEATH

 A COGNITIVE BEHAVIORAL PSYCHOTHERAPIST WILL

ATTEMPT TO RATIONALIZE THESE THOUGHT PATTERN
IN PATIENTS WITH PERSISTENT PSYCHOGENIC GAGGING.
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SOFT SWALLOWING
 TEACHING THE PATIENT TO SWALLOW
WITH THE TEETH APART, THE TIP OF THE
TONGUE PLACED ANTERIORLY ON THE
HARD PALATE, AND THE ORBICULARIS ORIS
MUSCLES RELAXED, HAS BEEN ADVOCATED

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ACUPUNCTURE
 EAR ACUPUNCTURE

 THERE IS A SPECIFIC,
RECOGNISED ANTI-GAGGING POINT
ON THE EAR

 IT CORRESPONDS WITH THE AREA OF SKIN OF THE

EXTERNAL AUDITORY MEATUS INNERVATED BY THE
AURICULAR BRANCH OF THE VAGUS NERVE,

 THE NEEDLES ARE NOT DISTURBED DURING ACCESS TO THE

MOUTH FOR DENTAL TREATMENT

 THE NEEDLES ARE OUT OF THE PATIENT'S LINE OF VISION

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 THE TECHNIQUE INVOLVES THE INSERTION OF
ONE, FINE, SINGLE-USE DISPOSABLE NEEDLE OF
7 MM LENGTH INTO THE ANTI-GAGGING POINT
OF EACH EAR TO A DEPTH OF 3 MM.

 THE NEEDLES ARE MANIPULATED FOR 30

SECONDS PRIOR TO CARRYING OUT DENTAL
TREATMENT.

 THE NEEDLES REMAIN IN SITU THROUGHOUT

TREATMENT AND ARE REMOVED BEFORE THE
PATIENT IS DISCHARGED.
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53
CONSCIOUS SEDATION
 INHALATIONAL, ORAL OR INTRAVENOUS

 NITROUS OXIDE SEDATION

 HOWEVER, CONSCIOUS SEDATION MAY ALLOW

ADEQUATE TREATMENT TO BE PERFORMED,

 IT WILL NOT HELP THE PATIENT OVERCOME

THE RETCHING, FOR EXAMPLE, THE
PROSTHESIS MUST BE WORN

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GENERAL ANESTHESIA
 A MINORITY OF PATIENTS DO NOT RESPOND
TO ANY SEDATION OR BEHAVIORAL
THERAPY AND DENTAL TREATMENT UNDER
GENERAL ANESTHESIA MAY BE
APPROPRIATE AS A LAST RESORT

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GAGGING PREVENTION INDEX

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CONCLUSION
 THE MOST IMPORTANT FACT TO REMEMBER IS
THAT, JUDICIOUS PALATAL COVERAGE TO
MAINTAIN ADEQUATE PALATAL SEAL.

 ACCEDING TO PATIENTS REQUEST TO SHORTEN

THE PALATE IMMEDIATELY MAY ACTUALLY
PREDISPOSE TO GAGGING

 THEREFORE IS CONTRAINDICATED IN THE

ABSENCE OF OBJECTIVE MUCOSAL SIGNS

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REFERENCES
 GS BASSI, GM HUMPRIS, MCLIN PSYCHOL. THE ETIOLOGY
AND MANAGEMENT OF GAGGING,JPD 2004;91:459-67

 BARSBY MJ. THE USE OF HYPNOSIS IN MANAGEMENT OF

GAGGING AND INTOLERANCE TO DENTURE BDJ
1994;176:97-102

 SINGER IL. THE MARBLE TECHNIQUE FOR TREATING THE

HOPELESS GAGGER JPD 1973;29:146-50

 J FISKE, C DICKINSON THE ROLE OF ACUPUNCTURE IN

CONTROLLING THE GAGGING REFLEX USING A REVIEW
OF TEN CASES BDJ 2001;190:611 – 613

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REFERNCES
 DICKINSON C. GAGGING PROBLEMS IN DENTAL
PATIENTS: LITERATURE REVIEW FOR THE DIPLOMA
IN DENTAL SEDATION. 2000.GKT DENTAL
INSTITUTE OF KING'S COLLEGE LONDON.
 GAGGING PROBLEM IN PROSTHODONTIC
TREATMENT PART I DESCRIPTION & CAUSES PART
II PATIENT MANAGEMENT 1983;50:601-6
 NEIL SN, NETTER’S HEAD AND NECK ANATOMY
FOR DENTISTRY
 KHURANA, TEXTBOOK OF HUMAN PHYSIOLOGY
FOR DENTAL STUDENTS
 GUYTON, MEDICAL PHYSIOLOGY, 8TH EDITION
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THANK YOU

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