Gagging1/ dental implant courses by Indian dental academy

The gagging problem in prosthodontic treatment. Description and causes.

Conny DJ, Tedesco LA. JPD 1983:49:5:601-605.

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Contents: Description and identification.

The nature of gagging.

Neural involvement in gagging.

Reflex characteristics of gagging.

Causes of gagging.

Management of gagging

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GAG REFLEX ď Ž

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

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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. www.indiandentalacademy.com

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. www.indiandentalacademy.com

RANGE 

Mild choking

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Violent uncontrolled retching may or may not be associated with vomiting

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Mechanism of gagging

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

AFFERENT PATHWAY 

Area supplied

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CN 5 [trigeminal]

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9 [glossopharyngeal]

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

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10 [vagus]

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Epiglottis,pharynx,larynx above vocal cords

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EFFERENT PATHWAY  

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Cn 5[trigeminal]

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Area supplied

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

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

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Larynx

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tongue

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ABNORMALY GAG REFLEX

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CAUSES Systemic Psychologic Physiologic Iatrogenic

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SYSTEMIC RESPIRATORY G.I TRACT ALCOHOLICS AND SMOKERS

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RESPIRATORY DEVIATED NASAL SEPTUM NASAL POLYPS SINUSITIS &PHARYNGITIS

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

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PSYCHOLOGIC ACTIVE

PASSIVE

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PHYSIOLOGIC INTRA-ORAL

EXTRA-ORAL

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EXTRA-ORAL Visual Auditory Olfactory stimuli

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

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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 

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Iatrogenic factor ď Ž

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

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Management

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Psycho logic intervention Pharmacological intervention Surgical correction Dental acupressure Clinical chair side management www.indiandentalacademy.com

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

Relaxtaion Distraction Hypnosis

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Relaxation ď Ž

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

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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 

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

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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.

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Centrally acting drugs – antihistaminic , sedatives , tranquillizers, parasympatholytics and CNS depressants Nitrous oxide www.indiandentalacademy.com

Surgical correction ď Ž

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

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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 www.indiandentalacademy.com

ď Ž

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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) www.indiandentalacademy.com

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 www.indiandentalacademy.com

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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 www.indiandentalacademy.com

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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 www.indiandentalacademy.com

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