PRESENTED BY :

Dr Sabnoor Aujla
M.D.S First Year
MMCDSR, Mullana
 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 psycholo

gically mediated and the muscular contractions provoked may result
in vomiting.
 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
 PHYSIOLOGY
Stimulation occurs
intraorally

Afferent fibers of vagus, glossopharyngeal , trigeminal pass to reflex centre in medulla

oblongata.

Efferent impulses give rise to spasmodic and uncoordinated muscle

movement. (to palate, pharynx, tongue, diaphragm, abdomen, neck etc )
 TRIGGERING AREAS
• Non-Tactile and Tactile stimulation of the certain intraoral structures.

Trigger zone means: ‘A focus of hyperirritability in tissue, which when

palpa ted, is locally tender and gives rise to heterotrophic pain’.
 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
pati ent 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-

The 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.
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
 AETIOLOGICAL FACTORS
• SYSTEMIC CAUSE

• PSYCHOLOGICAL FACTORS
a) active reaction
b) passive reaction

• PHYSIOLOGICAL FACTORS
a) extraoral
stimuli
b) intraoral
stimuli
SYSTEMIC CAUSE
CHRONIC
PRBLEMS OF
NASO -
RESPIRATO
Hiatus RY TRACT
CONGESTION OF
hernia and UPPER
uncontroll RESPIRATORY
TRACT
ed
diabetes

SYSTEMIC
DISORDE
DIAPHRAMA
RS PROBLEMS OF
TI C
GIT
HERNIA

IMFLAMMATIO
N OF
MEDICATION PHARYNX

(hypersensitiv
ity gag
PSHYCOLOGICAL CAUSE
• Factors which have the functional
purpose in patients existing life
ACTIVE
• For various reasons patients gag
REACTIO a)to gain attention b) avoid
dental treatment

• Factors which have no functional

reason
PASSIVE
• It is associated with past events
REACTIO in patients life

N
PHYSIOLOGIC FACTORS– Extra Oral
Stimuli
PHYSIOLOGIC FACTORS-Intra Oral
Stimuli
Over extended DISHARMINIOUS SUFACE FINISH OF
POOR RETENTION
posterior borders OCCLUSION ACRYLIC RESIN

DENTAL
PROSTHESIS
INADEQUATE
FREEWAY SPACE
ANATOMICAL
REASONS

• Hyposensitive

PALA area
• Hypersensiti
DENTAL
PROCED TE ve area
U- RES • Hyposensitive
area
TONGU • Hypersensiti
ve area
 IATROGENIC FACTORS

TEMPERATURE
EXTREME OF
INSTRUEMENT
ROUGH OR
S
CARELESS
TECHNQUE
S
POOR
EXECUTION
INTR-ORAL
PROCEDURE
S

Procedural factor:
•Water spray on the palate
while working on the maxillary
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 management is done on the basis of the causes which

lead to the gagging ; which are as follows :
IN SOME PATIENTS DIFFICUILTY IN GAGGING MAY BE THE
RESULT
OF PSYCHOLOGIC STIMULI
DEPENDING CLASSES CORRECTION
UPON
PSYCHOLOGI HYPNOSIS Results are also quite successful ,bu
CAL FACTORS
DEPE DING UP t the COR
time ECTIO
involved with the
N CLASSES multipl eRsessionsN is an important
ON limiting
factor for its routine use in dental
BEHAVIOU • Praise patient
RAL • Building a confident atmosphere
THERAPY • Acting positively and avoiding th
(Generally the obje e term “gagging”.
ctive is to reduce • Reassurance to the patient and e
anxiety & unlearn xplaining him the fact that gagging
the behaviour that is natural which is sometimes more
DISTRACTION
provokes -ENAGAING
gagging) active in some INindividuals
CONVERSATION
-Making the patient count
- breathe audibly (Kovats)
- Raise leg and to hold for fatigue
- Apnea (prolong respiratory effort
than inspiration)
Depending Classes Corrections
upon
systemic desensitization a tooth brush, radiograph, impressi
(the incremental exposur on tray, marbles, acrylic discs,
e of the patient to the buttons, dentures and the training
feared stimulus ) 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.
TECHNICAL MODIFICATIONS TO RENDER THE PROSTHESIS MORE
ACCEPTABLE TO THE PATIENT .
Depending classes correction
upon
PROSHODON correction of
TIC prosthesis  Matte finish denture
MANAGEMENT
 Over extended borders
are corrected.

 Adequate free way

space

 Training basses

 Palatless Dentures
Changes in mate  Primary impression : Impr
rial (low ession compound
viscosity and  Other materials : silicon
increase sett ing elastomer putty
time)
 No oral examination. Five rounded, multicolored, glass
First marbles approximately ½ inch in diameter
Visit ONE WEEK

Second Assurance
Visit

Before impression : topical anesthesia

Third Preliminary impression: Impression Compound
Visit Base Plate of Matte Finish was prepared

Lower Base Plate was inserted.

The patient was told to continue to keep three
Forth marbles in his mouth, in addition to base plate
Visit TRAINING BEAD
 Upper Base Plate
Fifth was
Visit inserted
The use of
marbles was
discontinued.

Establish Jaw Relations

Sixth The patient should continue to wear the upper and lower base
Visit plates while the dentures are being acrylized

The completed lower denture was inserted

first and used in conjunction with the upper
Seventh base plate.
Visit
Next the upper denture was inserted
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.
 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.

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.
- 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 ATTACHMEN MAGNETIC

SUPPORT T RETAINED
ED SUPPORTED
•When clinical and prosthodontic procedures are
ineffective, pharmacological measures are used.

• Efficacy is not universally accepted

DEPENDIN CLASSES CORRECTIONS
G UPON

DRUGS Centrally active • Antihistamines,

drugs • Sedatives,
• Tranquilizers,
• Parasympatholytics
• CNS depressants

Periphery acting • Topical and local anesthetic

drug agents
• Sprays, gels or lozenges or
injections.
•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. JProsthet 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.

• Kovats 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