Gagging problem in prosthodontics /certified fixed orthodontic courses by Indian dental academy

The gagging problem in prosthodontic
treatment. Description and causes.
Conny DJ, Tedesco LA.
JPD 1983:49:5:601-605.

www.indiandentalacademy.com

INDIAN DENTAL ACADEMY
Leader in continuing dental education



Contents:
Description and identification.
The nature of gagging.
Neural involvement in gagging.
Reflex characteristics of gagging.
Causes of gagging.
Management of gagging


GAG REFLEX


A beautiful protective mechanism
provided by nature to prevent
unwanted entry of any foreign
body to respiratory passage which
will lead to choking.


GAGGING
Constriction of the constrictor
muscles of the pharynx elicited by
the stimulation of the sensory
receptors on the soft palate,by the
psychic stimuli,or systemically by
the drugs.

OR
AN EJECTORY CONSTRICTION OF THE
MUSCLES OF THE PHARYNGEAL
SPHINCTER. IT IS A NORMAL
PROTECTIVE REFLEX DESIGNED TO
PROTECT THE AIRWAY AND
REMOVAL OF THE IRRITANT
MATERIAL FROM THE POSTERIOR
OROPHARYNX.

RANGE


Mild choking




Violent uncontrolled retching
may or may not be associated with vomiting


Mechanism of gagging


Stimulation on the soft palate or posterior part
of the tongue

afferent impulses

medulla oblongata

efferent impulses
 Spasmodic and uncontrolled movements of
gagging

AFFERENT PATHWAY




9 [glossopharyngeal]



10 [vagus]

Area supplied





CN
5 [trigeminal]



Lips,buccal surface of
cheeks,anterior 2/3 of
tongue,soft
palate,sublingual region
Posterior 1/3 of the
tongue,posterior pharynx





Epiglottis,pharynx,larynx
above vocal cords


EFFERENT PATHWAY









Cn
5[trigeminal]



Area supplied



7[facial]
9,10,11[pharyngeal
plexus]
10[vagus]
12[hypoglosal]




Muscles of
mastication,mylohyoid,
tensor timpani
Muscles of the lips
Fauces , palate,pharynx



Larynx



tongue


ABNORMALY GAG REFLEX


CAUSES
Systemic
Psychologic
Physiologic
Iatrogenic


SYSTEMIC
RESPIRATORY
G.I TRACT
ALCOHOLICS AND SMOKERS


RESPIRATORY
DEVIATED NASAL SEPTUM
NASAL POLYPS
SINUSITIS &PHARYNGITIS


G.I TRACT
CHRONIC GASTRITIS
CARCINOMA OF STOMACH
PEPTIC ULCER
CHOLECYSTITIS
DIAPHRAGMATIC HERNIA


PSYCHOLOGIC
ACTIVE

PASSIVE


PHYSIOLOGIC
INTRA-ORAL

EXTRA-ORAL


EXTRA-ORAL
Visual
Auditory
Olfactory stimuli


Intra oral- trigger zones
Posterior part of palate
 Posterior 1/3 of tongue
( most effective trigger zones)



Intra oral--- dental causes
Impression making
 Over/under extended prosthesis like Complete
Dentures
 Aerosols
 Routine Intra oral examination and
instrumentation
 X- Rays
(tactile stimulation of oral tissues inevitably occurs



Iatrogenic factor


In the otherwise non gagging patient’s,
poor execution of intra oral procedures
may elicit gag reflex. Sensitive tissues may
be stimulated as a result of rough or
careless techniques and temperature
extremes of instruments


Management








Psycho logic intervention
Pharmacological intervention
Surgical correction
Dental acupressure
Clinical chair side management

Psychologic intervention
(runs from gental manner to psychotherapy)




Relaxtaion
Distraction
Hypnosis


Relaxation


Try tensing muscles and then relax them
one muscle group at a time


Distraction
Lift one leg in the air and keep it there
( as the patient muscles become incredibly fatigued more and
more conscious effort is required to hold the leg up)
 Ask patient to breath audibly through the nose and at the
same time rhythmically tap the right foot on the floor
 Apnoea – prolong the expiratory effort at the expense of
inspiration. This will produce a state of apnoea and
discourage gagging.
 Reverse counting



Pharmacological (offer only short term solution
especially for severe and chronic problems)



Peripherally acting drugs –topical &
local anesthetics

( will numb the mouth and throat)—rational for the use of these drug is
that if the afferent impulses from sensitive oral tissues are eliminated
the reflex of gagging will not take place.





Centrally acting drugs – antihistaminic ,
sedatives , tranquillizers, parasympatholytics
and CNS depressants
Nitrous oxide

Surgical correction


For the patients unable to tolerate complete
dentures.basis for this techenique stems from the
observation that persistant gagging results from
an atonic and relaxed soft palate found in nervous
patients.to correct this situation,an operation

to shorten and tighten the soft palate


Dental accupressures
Ear acupressure selected because there is
specific,recognized anti gagging points on ear
and needles are not disturbed during access to the
mouth.needles are out of patients line of vision.
Technique involves the insertion of fine single use
disposable needles of 7mm and inserting into an
anti gagging point on each ear to a depth of
3mm.the needle is manipulated 3omin prior to
carrying out the treatment





It is thought that this form of acupressure
might work by causing the release of
chemicals that influence the functioning of
the vagus nerve that controls swallowing
and gagging.
(has been used successfully to stop nausea
and vomiting in the chemotherapy patients
and pregnant women)

Dental chairside management







Audible breathing
Flex forehead downwards
Swallow saliva
Rubber dam(a barrier that blocks fluids and
other particles from entering the mouth)
Use of super fast setting impression
material








Cutting of the over extended borders of
prosthesis and orthodontic appliances
Avoid patient visits after meals
Make patient accustomed to
instrumentation
Use a few drops of lemon juice before
insertion of dentures







Apply lower dentures first for habituation
Use minimum amount of impression material
Mesial bend and direction of retentive tags in
ortho appliances to prevent over extension ofn the
palate
A panaromic x-ray which keeps the film outside
the mouth can be used for those who cannot
tolerate intraoral films

Thank you
Leader in continuing dental education


Gagging problem in prosthodontics /certified fixed orthodontic courses by Indian dental academy

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