Gagging

It describes the gagging problems in prosthodontics and the management for the successful treatment.

1. GAGGING PRESENTED BY : Dr Sabnoor Aujla M.D.S First Year MMCDSR, Mullana

2. INTRODUCTION Gag reflex  (laryngeal spasm) is a  reflex  contraction of the back of the throat, evoked by touching the roof of the  mouth , the back of the tongue, the area around the  tonsils  and the back of the  throat . It prevents something from entering the throat except part of the normal  swallowing  and helps prevent  choking . Gagging reaction range from MILD CHOCKING when the palate is inadventely touched with the mouth mirror to UNCONTROLLED RETCHING during the impression making along with the varied sympt-oms differentiating mild from the severe experiencing nausea to the complete in-acceptance to the treatment which is termed as ‘Severe Gaggers’. Gagging stimuli may be physical, auditory, visual, olfactory or psychologically mediated and the muscular contractions provoked may result in vomiting.

3. CONTENTS This seminars describes and identifies the gag reflex and its causes and various approaches for the management of the gagging patients : The contents : Physiology of gagging Various triggering areas The signs and symptoms Grading evaluation Etiology of gagging Management of gagging Conclusion

4. PHYSIOLOGY Stimulation occurs intraorally A fferent fibers of vagus, glossopharyngeal , trigeminal pass to reflex centre in medulla oblongata. E fferent impulses give rise to spasmodic and uncoordinated muscle movement. (to palate, pharynx, tongue, diaphragm, abdomen, neck etc ) The reflex center in medulla is very close to vomiting, salivating, and cardiac center, that’s why gagging is almost always accompanied by additional reflex activity (salivation, tearing etc)

5. TRIGGERING AREAS Non-Tactile and Tactile stimulation of the certain intraoral structures. Trigger zone means: ‘A focus of hyperirritability in tissue, which when palpated, is locally tender and gives rise to heterotrophic pain ’.    

6. CLINICAL SYMPTOMS Puckering the lips and attempting to close the jaws, Elevating and furrowing of the tongue. Elevation of soft palate and hyoid bone, Retching or simultaneous and uncoordinated respiratory muscle spasm, and Vomiting.   Extra oral gag behaviors : excessive salivation, lacrimation, coughing, sweating . At times patient shows full body response i.e. extension of head, arms, neck, and back in an attempt to completely withdraw from the stimuli. Intra oral symptoms-   T he patient who gags may present with a range of disruptive reaction; from simple contraction of Palatal or Circumoral musculature to spasm of the pharyngeal structures, accompanied by Vomiting.  

7. GAGGING SEVERITY INDEX GSI Grade I Very mild: Controlled by patient II Mild : Control regained by patient/dentist with simple control techniques & reassurance III Moderate : Limits treatment options IV Severe : Some treatments impossible V Very severe: Effects patient’s behaviour&dental attendance. All treatment impossible Dickinson & Fiske. 2000

8. AETIOLOGICAL FACTORS SYSTEMIC CAUSE PSYCHOLOGICAL FACTORS a) active reaction b) passive reaction PHYSIOLOGICAL FACTORS a) extraoral stimuli b) intraoral stimuli IATROGENIC FACTORS

9. SYSTEMIC CAUSE

10. PSHYCOLOGICAL CAUSE

11. PHYSIOLOGIC FACTORS– Extra Oral Stimuli

12. PHYSIOLOGIC FACTORS-Intra Oral Stimuli DENTAL PROSTHESIS ANATOMICAL REASONS DENTAL PROCEDU-RES

13. IATROGENIC FACTORS Procedural factor: Water spray on the palate while working on the maxillary posterior teeth. Stimulation of disto lingual area of the mandible by the suction tip.

14. 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. MANAGEMENT The management is done on the basis of the causes which lead to the gagging ; which are as follows :

15. PSHYCOLOGIC INTERVENTION IN SOME PATIENTS DIFFICUILTY IN GAGGING MAY BE THE RESULT OF PSYCHOLOGIC STIMULI

16. DEPENDING UPON CLASSES CORRECTION DEPENDING UPON CLASSES CORRECTION PSYCHOLOGICAL FACTORS HYPNOSIS Results are also quite successful ,but the time involved with the multiple sessions is an important limiting factor for its routine use in dental BEHAVIOURAL THERAPY (Generally the objective is to reduce anxiety & unlearn the behaviour that provokes gagging) Praise patient Building a confident atmosphere Acting positively and avoiding the term “gagging”. Reassurance to the patient and explaining him the fact that gagging is natural which is sometimes more active in some individuals DISTRACTION -ENAGAING IN CONVERSATION Making the patient count breathe audibly (Kovats) Raise leg and to hold for fatigue Apnea (prolong respiratory effort than inspiration)

17. Depending upon Classes Corrections systemic desensitization ( the incremental exposure of the patient to the feared stimulus ) 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 patient is given an object to place in the mouth 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 increases until the patient is able to tolerate the dental procedures.

18. PHYSIOLOGICAL FACTOR : PROSTHODONTIC MANAGEMENT TECHNICAL MODIFICATIONS TO RENDER THE PROSTHESIS MORE ACCEPTABLE TO THE PATIENT .

19. Depending upon classes correction PROSHODONTIC MANAGEMENT correction of prosthesis Matte finish denture Over extended borders are corrected. Adequate free way space Training basses Palatless Dentures Changes in material (low viscosity and increase setting time) Primary impression : Impression compound Other materials : silicon elastomer putty

20. No oral examination. Five rounded, multicolored, glass marbles approximately ½ inch in diameter ONE WEEK Assurance Before impression : topical anesthesia Preliminary impression: Impression Compound Base Plate of Matte Finish was prepared Lower Base Plate was inserted. The patient was told to continue to keep three marbles in his mouth, in addition to base plate TRAINING BEAD MARBLE TECHNIQUE First Visit Second Visit Third Visit Forth Visit

21. Establish Jaw Relations The patient should continue to wear the upper and lower base plates while the dentures are being acrylized The completed lower denture was inserted first and used in conjunction with the upper base plate. Next the upper denture was inserted Upper Base Plate was inserted The use of marbles was discontinue d. Fifth Visit Sixth Visit Seventh Visit

22. Maxillary impressions or posterior radiographs can be difficult and uncomfortable for patient with extreme gag reflex. Friedman and Weintraub described a simple method where the patient is instructed to extend his or her tongue, and the Tip of the tongue is briefly salted (for approx. 5 sec) with ordinary table salt. The impression or radiograph can usually be taken with no difficulty. The gag reflex is extinguished by a superimposed simultaneous stimulation of the chorda tympani branches to the taste buds in the anterior two-thirds of the tongue. SALT TECHNIQUE

23. This is a further desensitization technique, whereby a patient is progressively supplied with a series of small to full sized denture bases. it is useful to the patients who are to become denture bearers. A thin acrylic denture base, without teeth is fabricated and the patient is asked to wear it at home. TRAINING BASES Patient is supplied with a series of small to full sized denture bases. A thin acrylic denture base without teeth is fabricated and the patient is asked to wear it at home, gradually increasing the length of the time the training base is worn. Initially 5 min once each day , then twice each day and so on . After 1 week; 10mins; thrice a day, then 15 mins , 30 min & 1 hour. Anterior teeth are added and when the patient is able to tolerate it, posterior teeth are added.

24. PALATLESS DENTURES - maxillary denture can be reduced to a U-shaped border situated approximately 10mm from the dental arch. Denture wearers with the above type of dentures reported that reduction of the palatal coverage influences their sense of taste positively, and reduces or eliminate gagging tendency. IT COULD BE : IMPLANT SUPPORTED ATTACHMENT SUPPORTED MAGNETIC RETAINED

25. PHARMACOLOGICAL MEASURES When clinical and prosthodontic procedures are ineffective, pharmacological measures are used. Efficacy is not universally accepted

26. DEPENDING UPON CLASSES CORRECTIONS DRUGS Centrally active drugs Antihistamines, Sedatives, Tranquilizers, Parasympatholytics CNS depressants Periphery acting drug Topical and local anesthetic agents Sprays, gels or lozenges or injections.

27. CONCLUSION :))

28. Conny DJ, Tedesco LA. The gagging problem in prosthodontic treatment. Part I: Description and causes. J Prosthet Dent 1983;49:601-6 . Conny DJ, Tedesco LA. The gagging problem in prosthodontic treatment. Part II: Patient management. J Prosthet Dent 1983;49:757-761 Singer L. The marble technique. J Prosthet Dent 1973;29:146-50. Krol AJ. A new approach to the gagging problem. J Prosthet Dent 1963;13:611-6. K ovats JJ. Clinical evaluation of the gagging patient. J Prosthet Dent 1971;25:613-9. Bassi GS, Humphris GM, Longman LP. The etiology and management of gagging: a review of the literature. J Prosthet Dent 2004;91:459-67 . Farmer JB, Connelly ME. Palatless dentures: help for the gagging patients. J Prosthet Dent 1984;52:691-693 REFRENCES