If you've had a patient gag so much on you that you make them ill, it's something you'll never forget! But how can you avoid this in the first place.... here are my tips!
So firstly what's the difference between retching and gagging?
Retching - this is ejecting something that is already in the mouth/oropharynx
Gagging - a protective reflex to stop stuff from getting in
Aetiology of Hypersensitive Gag Reflexes
There are many causes of sensitive gag reflexes, when you see patients who present like this, you need to ascertain what the cause is because it can affect your management.
- Anatomy e.g. unusual palatal anatomy, long uvula, tongue shape and position (like guarding the roof of the mouth), other irregularities like occlusal instabilities
- Medical e.g. chronic nasal congestion/obstruction, post nasal drips, GORD, motor neuron disease, dysphagia, obesity - therefore if there is a sudden onset of gagging, refer for medical investigation
- Psychological e.g. eating disorders, fear, stress, PTSD
- Iatrogenic e.g. dental causes such as inappropraite use of suction, LA, prostheses which cause restricted tongue space, a decreased freeway space, or incorrect tooth position, or simply a lack of border seal that causes the prostheses to drop
When establishing a history of a patient's gag reflex, AVOID somatic mapping and making them gag... they will then assume coming to the dentist with gagging!
Gagging can be measured in severity according to the Gagging Severity Index (GSI), which is similar to Ellis grading. Shown below:
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| Gagging Severity Index |
Top Tips in Managing Patients' Gags
- Relaxation - if the cause of their gag is anxiety or fear, find ways to help them relax as much as possible. This could be by listening to music, breathing exercises, progressive muscle relaxation and of course by being caring and kind!
- Distraction - asking patients to raise their legs alternatively, squeeze someone's hand/stress ball, wiggle toes can all work very well. Some people use salt on the tip of tongues or asking the patient to give themselves a temporal tap
- Desensitisation - give patients things to try at home such as bitewing tabs, impression trays, suction tubes. disposable mirror or even custom made appliances such as training plates or soft splints
- Local anaesthesia - in the form of a spray at the back of the throat can work for some patients
- Use of rubber dam - I remember one patient whose gag was anxiety triggered and she was much calmer doing all her dentistry under rubber dam, which of course isn't always possible but it can help
Other Options
When all of these fail, this is when patients usually end up with me in special care because we have additional skills to offer patients with hypersensitive gags, such as:
- Sedation - in any form such as intravenous or inhalation can be very helpful to relax patients as well as dampen down that gag. Sometimes using advanced techniques such as propofol can be more useful as you can control the length of the procedure much more because it is given as a continuous infusion
- General anaesthetic - a last resort for some patients but can be useful if there is a lot of dentistry to get done
- Alternative therapies - hypnosis, acupuncture (note do not perform this in pregnancy)
- Psychological therapies - such as Cognitive Behavioural Therapy (CBT)
And of course with all these options its not just thinking about each option in isolation, but often a combination works very well e.g. inhalation sedation, acupuncture and distraction techniques.
How have you managed patients with pronounced gag reflexes? Let me know in the comments below.
