GAGGING AND ITS PROSTHODONTIC MANAGEMENT.pptx

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1. Good Morning

2. GAGGING AND ITS PROSTHODONTIC MANAGEMENT PRESENTED BY : R.PRIYA DARSHINI 1 ST YEAR MDS

3. CONTENTS Introduction Definition Gagging mechanism Etiology Somatogenic group Psychogenic group Clinical phases of gagging Acute phase Chronic phase Management of patient with gagging Behovioural management Pharmacological management Conclusion References

4. INTRODUCTION The gag reflex is a normal defense mechanism that prevents foreign bodies from entering the trachea, pharynx , or larynx which ejects the unwanted, irritating , or toxic material from the upper respiratory tract by the contraction of the oropharyngeal muscles . In retching, peristalsis becomes spasmodic, uncoordinated and direction is reversed. Air is forced over the closed glottis producing a characteristic retching sound

5. GAG REFLEX Accompanied by Excessive salivation Lacrimation Sweating Fainting Panic attack

6. Definition Gagging – An involuntary contraction of the muscles of the soft palate or pharynx that results in retching (GPT-8)

7. Clinical Description Of Gagging Behaviour According To Khan: Puckering of lips or attempting to close the jaws Elevating and furrowing the tongue, with rotation from back to front and with hyoid bone at the centre Elevation of soft palate and hyoid bone Fixation of the hyoid bone Closing of the nasopharynx by an approximation of posterior pillars of fauces that elevate the soft palate. Contraction of anterior and posterior pillars of the fauces , causing the tonsils to rotate in an anteromedial direction Elevation, contraction and retraction of the larynx and closure of the glottis Retching or simultaneous and uncoordinated respiratory muscle spam. vomiting

8. GAGGING MECHANISM Intraoral stimulation on soft palate and posterior third of tongue. Afferent fibers – trigeminal, glossopharyngeal , vagus to Medulla oblangata Efferent impulses – trigeminal, facial, vagus , hypoglossus Spasmodic, uncoordinated muscle movement Gagging

9. Glossopharyngeal nerve is peculiar in that its afferent fiber includes fibers that both elicit and inhibit reflex. Clinically, important since there is less likelihood of gagging if a region innervated by glossopharyngeal nerve is stimulated than if a region supplied by one of the other cranial nerve stimulated.

10. TRIGGER ZONES Gagging is a natural reaction to tactile sensation. Wide variation in sensitivity of oral cavity and the ability of patients to withstand intraoral stimuli. 5 intraoral areas known as trigger areas are - Palatoglossal and palatopharyngeal fold Base of tongue Palate Uvula Posterior pharyngeal wall

11. ETIOLOGY Multifactorial etiology 2 categories of retching patients: 1) Somatogenic group: gagging due to physical stimuli Local stimuli – foreign objects in mouth overextended dentures dentures with increased vertical height Systemic stimuli – use of various drugs or excessive consumption of alcohol

12. 2) Psychogenic group: psychological stimuli due to excessive fear, apprehension or anxiety. Gagging occurs during examination, impression making, registration of jaw relation, insertion of dentures and even site of an instrument stimulates gag.

13. According to KRAMER & BRAHAM – fear is almost always the underlying factor influencing psychological gagger. This fear may be generalized and vague and some patients gag due to the fear of swallowing a foreign object. Before any treatment procedure to be started type of gagging should be recognised .

14. Factors that are important in etiology of gagging : 1) Local and systemic factors 2) Anatomic factors 3) Pchychological factors 4) Physiological factors 5) Iatrogenic factors

15. LOCAL AND SYSTEMIC FACTORS Nasal obstruction Post nasal drip Catarrh Sinusitis Nasal polyp Mucosal congestion of upper respiratory tract Dry mouth Medications that cause nausea as side effect

16. Chronic gastrointestinal disease, lowers intraoral notably chronic gastritis, peptic threshhold for ulcer & carcinoma of stomach excitation thus contributes to gagging Gagging has been noted as being worse in the morning for some patients, owing to an increased excitability of the vomiting center caused by metabolic disturbances such as carbohydrate starvation and dehydration with ketosis

17. ANATOMIC FACTORS Anatomic abnormalities and oropharyngeal sensitivities – predisposing factors to gagging. According to WRIGHT - No anatomic abnormalities between gaggers and non-gaggers, but only few adaptive changes in posture of tongue, hyoid bone and soft palate in gaggers. The distribution of afferent neural pathway, particularly the vagus nerve, may be more extensive in gagging patients.

18. PSYCHOLOGICAL FACTORS According to BARTLETT psychosomatic reaction may be Active – due to factors that have some functional purpose in patient’s life situation Patients gag - to gain attention from dentist - to avoid treatment - to avoid the outcome of treatment

19. Passive – due to conditioned reflexes established earlier in life for various reasons, the causes of which are no longer functionally important. 1/3 rd of the gagging patients have reported the problem as being most acute in morning during oral hygiene and insertion of dentures. This might occur from lack of habituation to stimulation from denture, since it is not worn at night

20. PHYSIOLOGICAL FACTORS Extraoral stimuli – Visual – the sight of an unpleasant stimulus such as the sight of another patient retching or gagging. Site of a mouthmirror or an impression tray. Auditory – sound of another patient retching may initiate gag reflex to another patient Olfactory – a smell of certain chemicals or other substances such as smell of cigarette on a dentists fingers or a perfume may also initiate gag.

21. Intraoral stimuli – Mainly due to tactile stimulation of hypersensitive areas, such as soft palate back of throat, and distal part of tongue. Biomechanical aspects of gagging- Poor clinical procedures Over loaded tray Inadequate post dam Unstable or poorly retained prosthesis Overextended borders Increased vertical dimension of occlusion Highly polished surface – slimy sensation Inadequate free way space

22. Poor clinical procedures Over loaded tray Overextended borders Overextended flanges Thick denture base

23. IATROGENIC FACTORS Exaggerated gag reflex can be due to – Procedural factors Factors related to dental practitioners Procedural factors : Water spray on the palate while working on maxillary posterior teeth. Stimulation of disto lingual area of the mandible by suction tip.

24. Factors relating to dental practitioners : Poor execution of intra oral procedures Rough or careless handling Temperature extremities of the instruments

25. CLINICAL PHASES OF GAGGING 2 distinct clinical phases of gagging Acute and chronic Acute phase – characterized by initial gagging episode and repeated unsuccessful attempts to wear a denture In this phase, only denture induces gagging. Chronic phase – characterized by an increase in intensity of gagging as well as an increase in objects, situations, or procedures which may induce the reflex.

26. MANAGEMENT Behavioural management Pharmacological management

27. BEHAVIORAL MODIFICATION TECHNIQUES Relaxation Distraction & Suggestion Systemic desensitization Training bases Teaching to swallow with their mouth open

28. RELAXATION Gag reflex is a manifestation of an anxiety state. Ask the patient to tense & relax certain muscle groups starting with the legs & working upwards, providing reassurance in a calm atmosphere

29. DISTRACTION Conversation with patient Breathing – inhaling through the nose and exhaling through mouth Distraction imagery Distraction , relaxation combination Mantra – repeated silently throughout the procedures KOVATS – patients breath through nose and at the same time rhythmically tap the right foot on the floor LANDA -Count rapidly to 50 then read out loudly Hypnosis a state that resembles sleep but that is induced by suggestion

30. Systemic desensitization Exposed to a mild aversive stimulus Gradually increasing aversive stimulus Slowly increase Intensity, duration and frequency of noxious stimuli Gently habituate by developing coping strategies to deal with the feeling of discomfort or panic experience This may often involve behavioral techniques such as deep breathing and relaxation Reassurance and praising

31. Tooth brush Radiographic film Impression tray Marbles Acrylic discs & balls Buttons Dentures Training devices Daily home work with log book According to FRIEDMAN , placing salt on then tip of the tongue can also reduce gag reflex.

32. Ideal thickness of denture flanges Acrylic disks Training the patient themselves Marbles

33. Training bases Training bases – A series of small to full-sized denture bases with out teeth are given to patients to train him for the future dentures. Initially the patient is adviced to wear denture bases when busy or when concentrating on non-stressful task and also relaxation techniques are also combined. G. S. Bassi J Prosthet Dent 2004;91:459-67.

34. RADIOGRAPHIC MANAGEMENT Richards – Fast speed film Preset the timer Moisten the film pack Cool water mouth rinse Extraoral radiographs Cool water rinsing

35. ACUPuncture pressure caves PRESSURE ON NEIGUAN Apply light pressure and increase to a heavy pressure until the patient feels soreness and distension ( Suan Zhang) to both the left and right concave area at medial aspect of the forearm ( Neiguan ) and concave area between first and second metacarpal bones ( Hegus cave) with the thumb for 5 to 20 minutes. The patient should feel soreness and distention ( Suan Zhang) immediately. The impression tray can be inserted into the mouth without gagging at this time. Ren Xianyun , J Prosthet Dent 1997;78:533.

36. ACUPRESSURE PRESSURE ON HEGU Ren Xianyun , J Prosthet Dent 1997;78:533.

37. EAR ACUPUNCTURE British Dental Journal Volume 190. No.11 June 9 2001

38. PHARMACOLOGICAL TECHNIQUES Local Anesthesia Conscious Sedation General Anesthesia Medications Surgical Managements

39. LOCAL ANESTHESIA Spray Injection Gel Lozenges Mouth rinse

40. conscious sedation Inhalation, oral, IV- temporarily eliminates gagging – maintains reflexes that protect the patients airway. Psychological approach – relaxation, distraction may be enhanced when used in conjuction with sedation. Nitrous oxide alters perception of external stimuli – decreases the gag reflex. General anesthesia

41. APPLEBY & DAY – reported that common salt can minimize the reflex. Placed on the tongue or on the palatal region of the dentures, salt may help gagging patients tolerate complete dentures.

42. Surgical management Persistent gagging results from an atonic and relaxed soft palate, which is found in nervous patients. LESLIE – surgery to shorten and tighten the soft palate. Removal of uvula.

43. MEDICATIONS Antihistamines Sedatives Tranquilizers Parasympatholytics CNS depressant Anti-gagging drug Trimethobenzamide

44. CONCLUSION Gagging – compromised treatment The aetiology of gagging is complex and not fully understood. Whether its aetiology is somatic, psychogenic or a combination of the two, the outcome is to make the acceptance of dental treatment Though many techniques are available, Combined techniques will be effective. Behavioral approach will always be the first option .

45. References Wright SM. Medical history, social habits, and individual experiences of patients who gag with dentures . J Prosthet Dent 1981;45:474-8. 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;49:757-61. Murphy WM. A clinical survey of gagging patients. J Prosthet Dent 1979;42:145-8. Kovats JJ. Clinical evaluation of the gagging denture patient. J Prosthet Dent 1971;25:613-9.

46. Wright SM. The radiologic anatomy of patients who gag with dentures. J Prosthet Dent 1981;45:127-33. Neumann JK, McCarty GA. Behavioral approaches to reduce hypersensitive gag response . J Prosthet Dent 2001;85:305. Singer IL. The marble technique: a method for treating the ‘‘hopeless gagger’’ for complete dentures. J Prosthet Dent 1973;29:146-50. Farmer JB, Connelly ME. Palateless dentures: help for the gagging patient. J Prosthet Dent 1984;52:691-4. Schole ML. Management of the gagging patient . J Prosthet Dent 1959;9:578-83. G. S. Bassi , G. M. Humphris ,. The etiology and management of gagging: A review of the literature . J Prosthet Dent 2004;91:459-67.

47. Krol AJ. A new approach to the gagging problem. J Prosthet Dent 1963;13:611-6. Ren Xianyun . Making an impression of a maxillary edentulous patient with gag reflex by pressing caves . J Prosthet Dent 1997;78:533. Comvander Henry A. Collett . Some psychologic aspects of denture stimulated gagging. J Prosthet Dent 1953;3:665-671. Faiez N. Hattab . Management of a patient’s gag reflex in making an irreversible hydrocolloid impression. J Prosthet Dent 1999;81:369. Cruig R. Means. Gagging – a problem in prosthetic dentistry. J Prosthet Dent 1970;23;614-620. J. Fiske, and C. Dickinson. The role of acupuncture in controlling the gagging reflex using a review of ten cases. British Dental Journal 2001; 190: 611–613