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References

Bassi GS, Humphris GM, Longman P. The etiology and management of gagging: a review of the literature. J Prosthet Dent. 2004; 91:459-467
Murthy V, Yuvraj V, Nair PP, Thomas S, Krishna A, Cyriac S. Management of exaggerated gagging in prosthodontic patients using glossopharyngeal nerve block. BMJ Case Reports. 2011;
Dickinson CM, Fiske J. A review of gagging problems in dentistry: 2. Clinical assessment and management. Dent Update. 2005; 32:74-80
Ren X. Making an impression of a maxillary edentulous patient with gag reflex by pressing caves. J Prosthet Dent. 1997; 78
Ramsay DS, Weinstein P, Milgrom P, Getz T. Problematic gagging: principles of treatment. J Am Dent Assoc. 1987; 114:178-183
Lu DP, Lu GP, Reed JF Acupuncture/acupressure to treat gagging dental patients: a clinical study of anti-gagging effects. Gen Dent. 2000; 48:446-452
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Tricks of the trade: the gagging patient – salt solution

From Volume 11, Issue 3, July 2018 | Pages 116-117

Authors

Mohammad S Ali

BDS, MFDS RCPS(Glasg)

Specialty Registrar in Orthodontics, Leeds Dental Institute, UK

Articles by Mohammad S Ali

Jonathan Sandler

BDS (Hons), MSc, PhD, MOrth RCS, FDS RCPS, BDS(Hons), MSc, PhD, FDSRCPS, MOrth RCS, Consultant Orthodontist, , DOrth RCS

Consultant Orthodontist, Chesterfield Royal Hospital, Chesterfield, UK

Articles by Jonathan Sandler

Email Jonathan Sandler

Article

Gagging/retching is a normal somatic response by the body, as it attempts to eliminate foreign bodies/objects from the oral cavity by way of muscular contraction of the pharyngeal wall and at the base of the tongue. Some patients, unfortunately, have an exaggerated gag reflex which can make dental treatment more difficult to tolerate and deliver. Gagging can be considered as multifactorial and patients can be categorized into two groups:

  • Somatic - nerve stimulation from direct/physical contact; or
  • Psychogenic – psychological stimulation.

    • Whether it be taking an upper alginate impression, receiving routine dental treatment or, as in this article, taking occlusal photographs, gagging can be induced and this is accompanied by excessive salivation, lacrimation and vomiting.1

    This experience can be quite traumatic, particularly for a younger patient, which may result in a loss of compliance, motivation, and subsequent avoidance of dental treatment, and the development of significant dental anxiety. From a clinical perspective, this may result in wasted time, stress or the inability to perform the desired procedure.

    Many different techniques have been tried by practitioners to reduce/eliminate the gag reflex to facilitate treatment with varying degrees of success over the years including:

  • Pharmacological interventions: topical/local anaesthesia, antihistamines, sedatives, tranquillizers and central nervous system depressants.2
  • Non-pharmacological interventions: acupuncture, relaxation/distraction techniques, transcutaneous electric nerve stimulation (TENS), hypnosis and various prosthetic devices.1, 3, 4, 5, 6

    • A Cochrane review in 2015 concluded that there was insufficient evidence to confirm any benefit of acupuncture in reducing gagging to allow successful completion of dental procedures. They also found that there was no evidence to support any other interventions for managing the gag reflex during treatment.

    Orthodontic photography is sufficient oral stimulus to induce the gag reflex in susceptible patients. The author was one of these individuals who participated in an orthodontic photography course recently. He was 100% certain he would gag and retch violently when the occlusal mirror was placed in his mouth as this was his experience on many previous occasions, and warned the photographer and the person retracting to be prepared for an extremely unfavourable response. It was therefore suggested that we try the ‘salt solution’(Figure 1). A few grains of salt were placed, by the subject, on the tip of his own tongue (Figure 2) and the series of orthodontic photographs were recorded without incident (Figure 3).

    Figure 1. A packet of table salt in preparation for application.
    Figure 2. Salt application to the tip of the tongue by the patient.
    Figure 3. Gag reflex eliminated allowing clinical photograph to be taken.

    Conclusion

    This gag response can be due to the physical contact to certain trigger areas by the mirrors, the action of opening wide or even just the thought of the procedure. For those patients where the physical contact is the trigger for the gag reflex, applying a few grains of salt to the tip of the patient's tongue will reduce/eliminate the gag reflex, thereby allowing completion of the necessary dental procedure.

    This technique works by stimulating the taste buds on the anterior portion of the tongue, resulting in activation of the chorda tympani nerve which leads to inactivation of the gag reflex.7 This simple, quick and extremely cheap solution may be just the trick you need to improve your patients' experience and overcome their sensitive gag reflex.