Gag Reflex Isdh 2009 No Patient Idppt1374

8/13/2019 Gag Reflex Isdh 2009 No Patient Idppt1374

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The Assessment

and Management ofPatients with Pronounced

Gag Reflexes

Chris Dickinson

Department of Sedation & Special Care Dentistry

KCL Dental Institute

Floor 26. Guy‟s Hospital 1



“Had a bad day at the orifice, dear?”

2



Gagging - A normal protective reflex designed to protect

the airway and prevent material entering the oropharynx

and the upper gastro-intestinal tract

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

Gagging or Retching ?

3

Picture of patient



Prevalence of Gagging

• No data available on the prevalence or

distribution of pronounced gag reflexes inthe general population

• 26 % of young adults and 43 % of olderadults had a total absence of the gag

reflexDavies et al. 1995. The Lancet.

4



Classification by Aetiology

Somatic:

Induced by touching a „trigger‟ area

Psychogenic:

Induced without direct contact

Krol 1963

5



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‟

7



Medical

• Chronic nasal congestion

and obstruction

• Post nasal drip• Gastric disorders

• Motor neurone disease

• Dysphagia

• Obesity

• Other medical conditions

8

Picture of patient



Psychological ?

• Eating disorders• Fear

• Stress

• Neuroticism

• Learned responses

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Picture of patient



Iatrogenic – General

• Water & suction tubes

• Instruments

• Local anaesthesia

• Radiography

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Pictures of patient



Iatrogenic – Prosthetic

• Inadequate posterior palatalseal

• Restricted tongue space

• Loss of normal palatalcontour

• Poor retention• Incorrect occlusal plane

• Decreased freeway space

• Excess freeway space

• Incorrect tooth position

11



Implications for the Patient

Emotional

• Fear, anger &embarrassment

• Avoidance behaviour

Physical

• Acceptance of dental care

• Oral hygiene practices

• Ability to wear prostheses

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Picture of patient



Implications for the Dentist

Emotional

• Fear, anger & embarrassment

• Avoidance behaviour

Physical

• Compromises ability toexamine, diagnose and treat

• Influences treatment decisions

13



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 withsimple control techniques & reassurance

III Moderate: Limits treatment options

IV Severe: Some treatments impossibleV Very severe: Effects patient‟s behaviour and

dental attendance. All treatment impossible

Dickinson & Fiske. 2000 15



Methods of Control

• Relaxation & C.A.F

• Dental „techniques‟

• Distraction and

desensitisation

• Psychological andbehavioural techniques

• Local anaesthetic

techniques• Sedation techniques

• General anaesthesia

• Complementary therapies

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Picture of patient



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) 18



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

Rubber Dam Local Analgesia ??

• Palatine block• Inferior alveolar block

• LA incorporated into

impression material

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Distraction Techniques

• Sensory deprivation (Landa)

• Leg raising (Krol)

• Breathing exercises

• Talking(Faigenblum)

• Salt on tongue

• Sick stick (Robb)

• Temporal tap (Robb)

Concentration on a task, place, object or event to temporarily

divert the patient‟s attention away from the gagging

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Desensitisation Techniques

Homework and Rehearsal (Sewerin)

• Tongue/palate stimulation

• Marbles/discs (Singer)

• Progressive appliancewear & training bases

• Dentures with acrylicbeads & mat surfaces (Singer)

• Orthodontic plates andblow-down splints

• Soft swallowing (Wilks)

Aims to progressively reduce the gagging threshold

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Sedation & General Anaesthesia

• Inhalation

• Intravenous

• Oral

• Intranasal

• Combinations

• Large quantity ofrestorative or oral

surgical treatment

• Gag reflex not controlledby other methods

• GA - Last resort

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Picture of patient



Complementary Therapies

Hypnosis (Barsby)

• Reframing• Ego-enhancement

• Auto-hypnosis

• Contra-indicated

in psychologicalconditions?

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Picture of patient



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. Theonly 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

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Pictures of patient



Combination Techniques

• Pre-treatment

desensitisation

• Inhalation sedation• Acupuncture

• Acupressure

• Rubber dam• Visualisation

• Distraction

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Picture of patient



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 diagnosticprocedures difficult

V No Control – No treatment possible

Dickinson & Fiske, 2000

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Summary

• Fully assess the nature of thegag reflex

• Match the level of treatmentneed with the managementtechniques at your disposal

• Set small objectives for eachtreatment visit

• Don‟t continue until patientgags. Stop at a positive point if

possible• Use a variety of managementstrategies for different items oftreatment – be flexible

37

Pictures of patient



Thank You

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Gag Reflex Isdh 2009 No Patient Idppt1374

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