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IMAGE 2010-11 ISSN: 2229-5658 Vol No: 11 ISSUE No: 4 29 Abstract MANAGEMENT OF GAG IN DENTAL PRACTICE - A REVIEW Dr. Sandeep garg, MDS, professor, Dr. Sushant garg, MDS, Professor & head, Dr. Kusum yadav, Post graduate student - M.M. College of Dental Sciences & Research, Mullana, Ambala (Haryana), India The gag reflex is a normal defense mechanism to prevent foreign objects from entering the trachea. In some individuals this reflex is active to the point that can be overridden by the desire to eject any object in the mouth. Gagging has been generally classified either somatogenic (induced by touching a trigger area) or psychogenic (stimulation appears to be psychic in origin). A number of techniques for reduction of gagging have been suggested, including distraction of patient's attention from the dental procedure, relaxation, hypnosis, acupressure and drugs .This article reviews the management of patients with an exaggerated gag reflex and includes strategies to assist clinicians. Key Words : Gag Reflex, Retching, Acupressure. Introduction Most difficult and common problem, which is descried and analyzed by many dentists, is gagging or retching, which has been found extremely difficult to treat. The gag reflex is a normal defense mechanism that prevents foreign bodies from entering the trachea, pharynx, or larynx. The patient who gags may present with a range of disruptive reactions; from simple contraction of palatal or circumoral musculature to spasm of the pharyngeal structures, accompanied by vomiting. 1 Gagging may be accompanied by excessive salivation, lacrimation, sweating, fainting, or, in a minority of patients, a panic attack. 2 Pronounced gag reflexes can be a severe limitation to the patientís ability to accept dental care and it can compromise all aspects of dentistry, from the diagnostic procedures of examination to any form of active treatment. Gagging has been generally classified either somatogenic (induced by touching a trigger area) or psychogenic (stimulation appears to be psychic in origin). Five intraoral areas are known to be ëëtrigger zonesíí: palatoglossal and palatopharyngeal folds, base of tongue, palate, uvula, and posterior pharyngeal wall. 3 Interestingly, the passage of food across these areas does not usually incite retching. factors that are believed to be responsible for gagging are usually divided into anatomic factors ( eg. A long soft palate, a sudden drop at the junction of hard and soft ORAL MEDICINE AND SURGERY palate), psychological factors ( eg. Fear, stress), physiologic factors ( non tactile sensations such as visual, auditory, or olfactory stimuli 4,5 ) , iatrogenic factors ( eg. inadequate posterior palatal seal, unstable and poorly retained prosthesis, overloaded impression trays) and local and systemic disorders ( eg. nasal obstruction, postnasal drip, chronic GI diseases). Management Effective management of gagging depends on treating the cause and not merely the symptoms. Through examination, adequate medical history, and conversation with patient are important for correct diagnosis of the cause of the gagging. The different approaches for management of gagging fall into following categories : Psychological management. Prosthodontic management. Pharmacological measures. Alternative measures. Psychologic management: These techniques are mainly based on diverting the attention of the patient from gagging stimuli e.g. Talking to the patient on some topic of interest, have the patient count from 1 to 20 , by asking the patient to raise his leg and to hold Visit: http://image.idakunnamkulam.com/ The International Journal of Indian Dental Association, Kunnamkulam Branch. Indexed in Journals Master List of IC TM
IMAGE 2010-11 ISSN: 2229-5658 Vol No: 11 ISSUE No: 4 30 it in air. Faigenblum 6 suggested that patient can be instructed to prolong the expiratory effort at the expense of inspiration . This will produce a state of mild apnea, and gagging will be discouraged, as vomiting is impossible during apnea. He also suggested that well rested , relaxed and empty stomach patient is less likely to gag. Prosthodontic management: Impression technique-Daniel W. Borkin 7 described an impression technique in which he used a material that will give the dentist full control of the setting time and which can be easily corrected. A preliminary impression of the edentulous area is made using an appropriate stock tray and red modeling compound, this impression can be removed from the mouth at will, warmed, and reseated between paroxysms of gagging until a fairly accurate impression is obtained. A cast of stone or plaster is poured and a tray is made of acrylic resin or shellac base plate, but it must be made with rolled borders which are slightly short of the reflections. The tray is tried in the mouth and a low-fusing wax is added to this accurately fitted tray. Particular attention is paid to adding wax to the borders of the tray. When the tray is completely covered with warm wax, it is carried quickly to the mouth and inserted, using as much force as is necessary to properly seat the tray. Muscle trimming is done to the patient tolerance. This procedure is repeated as many times as is necessary to make an acceptable impression. Since low-fusing wax will not set hard at mouth temperature. When the impression is acceptable, the low-fusing wax must be hardened in the mouth by squirting ice water from a bulb syringe along the borders of the completed impression and over as much of the impression surface as possible. The ice water will retard the paroxysms of gagging by its cooling effect so this chilling can be done with a minimum of difficulty. Once set, remove it and pour. Faiez N. Hattab 8 suggested management of gag while making an irreversible hydrocolloid impression. He dispensed 1 capsule of local anesthetic solution (1.8 mL of 2% lidocaine with 1 part in 100,000 epinephrine) to the plastic measuring cylinder and then added water to the correct volume. Then he mixed the water/anesthetic mixture to the alginate powder and impression were made. Results proved to be satisfactory. Callision 9 proposed a maxillary custom tray in which a saliva ejector tip is embedded in order to suck excess impression material into vacuum chamber at the posterior extent of the tray. Ansari 10 recommended the use of a highviscosity elastomer for making a primary impression of a maxillary partial edentulous patient, in an attempt to minimize the distal flow of the material to sensitive areas. Marble technique- Singers 11 marble technique is a method by which the gag reflex can be exhausted. At the first office visit five rounded, glass marbles approximately inch in diameter were placed on a tray in front of the patient and was asked to put the marbles in his mouth, one at a time, until all marbles were in his mouth. The patient was assured that if he swallows the marble, it could not harm him. He was urged to keep five marbles in his mouth continuously for one week, except when eating and sleeping. On 2 nd visit, the patient was given assurance, which further bolstered his own motivation. On 3 rd visit, before impression making; the hard palate, soft palate, cheeks, lips and tongue were swabbed with 2% pentocaine solution in order to produce topical anesthesia. Preliminary impression is made and Base plate of matte finish is prepared. On 4 th visit the lower base plate is inserted, and the patient was told to continue to keep three marbles in his mouth, in addition to base plate. A training bead (a small bead of colored acrylic resin) was placed on the lingual aspect of the lower base plate at the normal position of the lower central incisors. On 5 th visit the upper base plate was inserted, he was asked to keep both of them in his mouth continuously, except when eating. The use of marbles was discontinued. On 6 th visit jaw relations were established and patient was instructed to continue with the upper and lower base plate. On 7 th visit the completed lower denture was inserted first and used in conjunction with the upper base plate. The training bead was placed in the lower denture as a guide to tongue position. The patient should be instructed to keep the tip of the tongue always touching the bead, which would prevent the Visit: http://image.idakunnamkulam.com/ The International Journal of Indian Dental Association, Kunnamkulam Branch. Indexed in Journals Master List of IC TM
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