Gag reflex

A GAG REFLEX PPT. BRIEF INFORMATION FOR PRESENTATION. FOR STUDENTS BUT CAN BE USEFUL TO ALL.

1. •
GAG REFLEXGAG REFLEX
prepared by:prepared by:
FINAL YEARFINAL YEAR
K.M.S. DENTAL K.M.S. DENTAL

2. Contents:Contents:
Introduction
Etiology of gagging
Conditions associated with gagging
Factors in gagging
Management

3. •The gag reflex is a normal, healthy defense mechanism. its function is to The gag reflex is a normal, healthy defense mechanism. its function is to
prevent foreign bodies from entering the trachea.prevent foreign bodies from entering the trachea.
stimuli-sightstimuli-sight
smell smell
taste taste
noise noise
other physiological factors other physiological factors
gagging can also result from the other systemic conditions likegagging can also result from the other systemic conditions like
git disorders git disorders
adenoids adenoids
tumors in upper respiratory tract tumors in upper respiratory tract
alcoholism alcoholism
severe smoking severe smoking

4. Gagging has been noted as worse in the morning Gagging has been noted as worse in the morning
for some patients owing to an increased excitability for some patients owing to an increased excitability
of the vomiting centre caused by the metabolic of the vomiting centre caused by the metabolic
disturbances such as carbohydrate starvation and disturbances such as carbohydrate starvation and
dehydration with ketosis.dehydration with ketosis.

5. FACTORS INVOLVED IN THE ETIOLOGY OF FACTORS INVOLVED IN THE ETIOLOGY OF
GAGGINGGAGGING
1. local and systemic disorders 1. local and systemic disorders
2. anatomic factors2. anatomic factors
3. psychological factors3. psychological factors
4. iatrogenic factors4. iatrogenic factors

6. LOCAL AND SYSTEMIC FACTORSLOCAL AND SYSTEMIC FACTORS
PREDISPOSING FACTORSPREDISPOSING FACTORS
1.nasal obstruction1.nasal obstruction
2.postnasal drip2.postnasal drip
3.catarrah3.catarrah
4.sinusitis4.sinusitis
5.nasal polyp5.nasal polyp
6.mucosal congestion of upper 6.mucosal congestion of upper
respiratory tract.respiratory tract.
7.dry mouth 7.dry mouth
8.medications8.medications
9.hiatus hernia9.hiatus hernia
10.uncontrolled diabetes10.uncontrolled diabetes
11.chronic gastritis11.chronic gastritis
12.peptic ulceration12.peptic ulceration
13.carcinoma of stomach13.carcinoma of stomach

7. ANATOMIC FACTORSANATOMIC FACTORS
PREDISPOSING FACTORSPREDISPOSING FACTORS
1. Anatomic abnormalities 1. Anatomic abnormalities
2. Oropharyngeal sensitivities2. Oropharyngeal sensitivities
There are no anatomic abnormalities but a fewer adaptive changes in the There are no anatomic abnormalities but a fewer adaptive changes in the
postures of tongue , hyoid bone and soft palate in gaggers.postures of tongue , hyoid bone and soft palate in gaggers.
The distribution of the afferent neural pathway particularly the vagus nerve The distribution of the afferent neural pathway particularly the vagus nerve
may be more extensive in gagging patients.may be more extensive in gagging patients.
Enlarged areas of sensory innervations cannot however explain why patients Enlarged areas of sensory innervations cannot however explain why patients
gag with auditory, olfactory or visual stimuli.gag with auditory, olfactory or visual stimuli.

8. PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
PREDISPOSING FACTORS PREDISPOSING FACTORS
1.temporomandibular pain 1.temporomandibular pain
dysfunction syndromedysfunction syndrome
2.atypical facial pain2.atypical facial pain
3.denture intolerance3.denture intolerance
4.burning mouth syndrome4.burning mouth syndrome
The functional component of a condition may be strongly influenced by The functional component of a condition may be strongly influenced by
an individual’s reaction to stressful events referred to as the ‘learning an individual’s reaction to stressful events referred to as the ‘learning
history’.history’.
There are 2 major mechanisms of learning history –There are 2 major mechanisms of learning history –
1. classical conditioning 1. classical conditioning
2. operant conditioning 2. operant conditioning

9. Classical conditioning occurs when an originally neutral stimulus is Classical conditioning occurs when an originally neutral stimulus is
paired with a specific behavioral response. in offensive stimuli such aspaired with a specific behavioral response. in offensive stimuli such as
sight of an impression tray sight of an impression tray
the smell of dental surgery the smell of dental surgery
the sound of a dental hand piece the sound of a dental hand piece
may become associated with an unpleasant gag response.may become associated with an unpleasant gag response.
CLASSICAL CLASSICAL CONDITIONINGCONDITIONING

10. OPERANT CONDITIONINGOPERANT CONDITIONING
It is a training process whereby the consequence of a response It is a training process whereby the consequence of a response
changes the likelihood that the individual will produce that changes the likelihood that the individual will produce that
response again.response again.
Some behavior patterns may be reinforced because they sequre Some behavior patterns may be reinforced because they sequre
attention and sympathy , avoid a stressful situation or achieve attention and sympathy , avoid a stressful situation or achieve
some other desirable result.some other desirable result.

11. IATROGENIC FACTORSIATROGENIC FACTORS
Poor clinical technique such as an overloaded Poor clinical technique such as an overloaded
impression tray or an unstable or poorly retained impression tray or an unstable or poorly retained
prosthesis , overextended borders of the prosthesis , overextended borders of the
prosthesis can impinge on the trigger zones and prosthesis can impinge on the trigger zones and
produce gaggingproduce gagging
A smooth, highly polished surface which in coated A smooth, highly polished surface which in coated
with saliva may produce a slimy sensation which is with saliva may produce a slimy sensation which is
sufficient to cause gagging in some patients.sufficient to cause gagging in some patients.

12. ASSESSMENTASSESSMENT
The management of the gagging is influenced by the severity and The management of the gagging is influenced by the severity and
etiology of the problem. It is important that the clinician obtains a etiology of the problem. It is important that the clinician obtains a
detailed history in an unhurried sympathetic manner and the detailed history in an unhurried sympathetic manner and the
environment should be calm and reassuring.environment should be calm and reassuring.
The patient should be informed of what the intraoral examination The patient should be informed of what the intraoral examination
involves and the inspection should only proceed when the consent has involves and the inspection should only proceed when the consent has
been given.been given.
The role of the dental team is to be sympathetic to the patient’s The role of the dental team is to be sympathetic to the patient’s
difficulties , to begin to establish a dialogue and to generate interest difficulties , to begin to establish a dialogue and to generate interest
which can be time consuming.which can be time consuming.

13. INTERVENTIONSINTERVENTIONS
The aim of the treatment is to allow the patient to receive the dental The aim of the treatment is to allow the patient to receive the dental
care with a minimum of anxiety and stress. many diverse strategies have care with a minimum of anxiety and stress. many diverse strategies have
been described in the literature and the rationale and the practicalities of been described in the literature and the rationale and the practicalities of
some techniques are questionable.some techniques are questionable.
when gagging is thought to be due to a poorly designed or ill fitting when gagging is thought to be due to a poorly designed or ill fitting
prosthesis, the faults should be rectified , which may necessitate the prosthesis, the faults should be rectified , which may necessitate the
remaking of the prosthesis.remaking of the prosthesis.

15. MANAGEMENT TECHNIQUESMANAGEMENT TECHNIQUES
1. 1. BEHAVIOURAL TECHNIQUESBEHAVIOURAL TECHNIQUES
Behavior modificationBehavior modification
It has been recommended that all disruptive gagging should be viewed and It has been recommended that all disruptive gagging should be viewed and
presented to the patient as a behavioral response and, therefore amendable to presented to the patient as a behavioral response and, therefore amendable to
behavior modification. an exaggerated or extended period of gagging in the behavior modification. an exaggerated or extended period of gagging in the
absence of the normal stimulus is a learned response.absence of the normal stimulus is a learned response.
Behavior modification of the most successful long term method of managing the Behavior modification of the most successful long term method of managing the
gagging patient.gagging patient.
Generally the objectives are to reduce the anxiety and to unlearn the behaviors Generally the objectives are to reduce the anxiety and to unlearn the behaviors
that provoke gagging.that provoke gagging.

16. RELAXATIONRELAXATION
It may be helpful in reducing or abolishing the gag reflex. it can help It may be helpful in reducing or abolishing the gag reflex. it can help
ameliorate or override unhelpful thought processes.ameliorate or override unhelpful thought processes.
An example of this is to ask the patient to tense or relax certain group An example of this is to ask the patient to tense or relax certain group
of muscles starting with the legs and working upwards , while continuing of muscles starting with the legs and working upwards , while continuing
providing reassurance in a calm atmosphere.providing reassurance in a calm atmosphere.

18. 2. SYSTEMATIC DESENSITIZATION2. SYSTEMATIC DESENSITIZATION
This technique consists of the incremental exposure of the patient to This technique consists of the incremental exposure of the patient to
the feared stimulus .the patient is then gradually exposed to increasingly the feared stimulus .the patient is then gradually exposed to increasingly
aversive stimuli thereby allowing the patient to gently habituate by aversive stimuli thereby allowing the patient to gently habituate by
developing coping strategies to deal with the feeling of discomfort or developing coping strategies to deal with the feeling of discomfort or
panic experienced.panic experienced.
It is important to use a step wise approach to prevent or minimize the It is important to use a step wise approach to prevent or minimize the
patient’s gagging.patient’s gagging.

19. Many re education techniques have also been described in Many re education techniques have also been described in
which the patient is given an object to place in the mouth which the patient is given an object to place in the mouth
for a longer period of time. The size of the object and the for a longer period of time. The size of the object and the
length of the time for which it is held in the mouth gradually length of the time for which it is held in the mouth gradually
increases until the patient is able to tolerate the dental increases until the patient is able to tolerate the dental
procedures.procedures.

20. a tooth brush, radiograph, impression tray,
marbles, acrylic discs, buttons, dentures and the
training devices have all been used to help the
patients overcome the gagging problem. for ex-
the hard palate is gently brushed without inducing
die gag reflex.

21. The patient marks the position of the max.
Incisors on the toothbrush handle. The aim
is to move the brush more posterior and
the patient is encouraged as the mark on
the toothbrush moves progressively down
the handle.

22. Singer described a technique where ordinary glass marbles Singer described a technique where ordinary glass marbles
were used to re educate the patient prior to the denture were used to re educate the patient prior to the denture
fabrication. Essentially for 1 week, marbles are sucked in the fabrication. Essentially for 1 week, marbles are sucked in the
patient’s mouth for increasing periods of time while awake. patient’s mouth for increasing periods of time while awake.
Once these are tolerated, maxillary and mandible denture Once these are tolerated, maxillary and mandible denture
record bases are made and later converted to the record bases are made and later converted to the
conventional dentures. Alternatively acrylic balls or discs conventional dentures. Alternatively acrylic balls or discs
may be used.may be used.

23. TRAINING BASESTRAINING BASES
This is a further desensitization technique, whereby a This is a further desensitization technique, whereby a
patient is progressively supplied with a series of small to full patient is progressively supplied with a series of small to full
sized denture bases. it is useful to the patients who are to sized denture bases. it is useful to the patients who are to
become denture bearers. A thin acrylic denture base, become denture bearers. A thin acrylic denture base,
without teeth is fabricated and the patient is asked to wear without teeth is fabricated and the patient is asked to wear
it at home.it at home.

24. SUMMARY OF MANAGEMENT OF GAGGING PATIENTSUMMARY OF MANAGEMENT OF GAGGING PATIENT
INDIVIDUAL ASSESSMENTINDIVIDUAL ASSESSMENT
ASSESS PATIENT’S ATTITUDE WILLINGNESS TOASSESS PATIENT’S ATTITUDE WILLINGNESS TO
AND MOTIVATION TO IT. -TRY IT. AND INVEST TIME IN IT.AND MOTIVATION TO IT. -TRY IT. AND INVEST TIME IN IT.
-COMMIT TO HOMEWORK -COMMIT TO HOMEWORK
-ACCEPT THAT MAY BE PROLONGED -ACCEPT THAT MAY BE PROLONGED
TECHNIQUES COMMON TO ALL PATIENTSTECHNIQUES COMMON TO ALL PATIENTS
1. SYMPATHETIC APPROACH1. SYMPATHETIC APPROACH
2. POSITIVE ATTITUDE2. POSITIVE ATTITUDE
3. THOROUGH HISTORY3. THOROUGH HISTORY
4. REASSURE PATIENT GAGGING IS A NORMAL RESPONSE.MANY 4. REASSURE PATIENT GAGGING IS A NORMAL RESPONSE.MANY
PATIENTS HV VERY SENSITIVE GAG REFLEX. PATIENTS HV VERY SENSITIVE GAG REFLEX.
THE MAJORITY OF PATIENTS CAN LEARN TO THE MAJORITY OF PATIENTS CAN LEARN TO
CONTROL GAGGING BUT IT TAKES TIME. CONTROL GAGGING BUT IT TAKES TIME.
GAGGING IS NOTHING TO BE EMBARRESSED GAGGING IS NOTHING TO BE EMBARRESSED
ABOUT.BUILD PATIENT’S SELF CONFIDENCE. ABOUT.BUILD PATIENT’S SELF CONFIDENCE.
EXPLAIN AND DEMONSTRATE EXPLAIN AND DEMONSTRATE
STOP SIGNAL [FOR EX-RAISING ALLOW THE PATIENT TO FEEL SOME CONTROLSTOP SIGNAL [FOR EX-RAISING ALLOW THE PATIENT TO FEEL SOME CONTROL
HAND ] HAND ]
CAREFUL INTRAORAL EXAMINATION OBTAIN PATIENT’S FEEDBACK AND CAREFUL INTRAORAL EXAMINATION OBTAIN PATIENT’S FEEDBACK AND
CONTINUALLY RE NEGOTIATE CONSENT. CONTINUALLY RE NEGOTIATE CONSENT.
AVOID TRIGGER ZONES AVOID TRIGGER ZONES
PRAISE PATIENT. PRAISE PATIENT.

25. SPECIFIC TREATMENT MODALITIESSPECIFIC TREATMENT MODALITIES
BEHAVIORAL RELAXATION TECHNIQUESBEHAVIORAL RELAXATION TECHNIQUES
DISTRACTION DISTRACTION
SUGGESTION/ HYPNOSIS SUGGESTION/ HYPNOSIS
SYSTEMATIC DESENSITIZATION SYSTEMATIC DESENSITIZATION
COGNITIVE BEHAVIOURAL THERAPY COGNITIVE BEHAVIOURAL THERAPY
PHARMACOLOGICAL ORALPHARMACOLOGICAL ORAL
INHALATION INHALATION
INTRAVENOUS INTRAVENOUS
COMBINED SEVERAL TECHNIQUES MAY BE USED TOGETHER OR COMBINED SEVERAL TECHNIQUES MAY BE USED TOGETHER OR
IN IN
SUCCESSSION SUCCESSSION
SIMPLE MEASURES FOR ALL DON’T OVERLOAD IMP. TRAYSIMPLE MEASURES FOR ALL DON’T OVERLOAD IMP. TRAY
PATIENTS USE QUICK SETTING IMPRESSION MATERIALSPATIENTS USE QUICK SETTING IMPRESSION MATERIALS
ENSURE EFFICIENT ASPIRATION ENSURE EFFICIENT ASPIRATION
MISCELLANEOUS AKINOSI CLOSED MOUTH TECHNIQUE FORMISCELLANEOUS AKINOSI CLOSED MOUTH TECHNIQUE FOR
LOCAL ANALGESIA OF INFERIOR DENTAL NERVE. LOCAL ANALGESIA OF INFERIOR DENTAL NERVE.
TREAT PATIENT IN AN UPRIGHT PSITION TREAT PATIENT IN AN UPRIGHT PSITION
FREQUENT CESSATION OF THE TREATMENT. FREQUENT CESSATION OF THE TREATMENT.

26. THANKTHANK YOUYOU