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Behavioral approaches to reduce hypersensitive gag response
Behavioral approaches to reduce hypersensitive gag response Joseph K. Neumann, PhD,a and Gird A. McCarty, DDS, MSb James H. Quillen VA Medical Center, Johnson City, Tenn.
Gagging may preclude obtaining maxillary impressions. Past efforts to manage gagging have included hypnosis, anesthesia, acupressure, and transelectrical nerve stimulation.1-4 Evidence-based research studies have not been performed in this area, so it is not clear which procedures are the most helpful for patients or subsets of patients. The following behavioral techniques have been found to be helpful with dental patients whose gagging either prevented making maxillary impressions or made the use of existing dentures impossible. None of the patients treated had unusual psychological trauma related to the mouth, although several had psychiatric diagnoses (for example, dysthymia and posttraumatic stress disorder).
TECHNIQUES 1. Discuss fears related to dental procedures with the patient, and advise him/her to practice relaxation several times a week. Give audiotapes of relaxation procedures, which include imagery, progressive muscle relaxation, and self-suggestion components, to the patient with instructions that constant practice might reduce his/her arousal level sufficiently to decrease or eliminate the gagging response. 2. Advise the patient to stimulate his/her maxillary alveolar ridges and palatal vault with a toothbrush, spoon, mouthwash, or other stimuli. Patients need to receive a treatment rationale similar to that used in behavioral tinnitus treatment.5 The regular stimulation of the maxillary alveolar ridge and palatal vault may increase stimulation to the brain, thus making discrimination of the impression/denture stimuli more difficult (by increasing the noise in the signal-to-noise ratio). 3. If dentures/occlusion rims cannot be tolerated, instruct the patient to practice using his/her prosthesis at home at least 3 times a day, 5 days a week. Encourage the patient to increase time slowly (by 30-second intervals) until reaching a comfortable level (3 periods with no gagging). Instruct the
Supported by resources at the James H. Quillen VA Medical Center. aClinical Psychologist Department of Psychology, VAMC; and Clinical Associate Professor, Department of Psychiatry and Internal Medicine, James H. Quillen College of Medicine. bStaff Prosthodontist VAMC; and Clinical Associate Professor, Department of Prosthodontics, University of Tennessee, Knoxville, Tenn. J Prosthet Dent 2001;85:305. MARCH 2001
patient to eat soft foods such as applesauce until he/she feels comfortable enough to eat desired dense food. In sessions, verbally reinforce hope and the sense that the patient has control over gagging, and encourage the patient to experiment with different foods and routines. 4. If dentures/rims are not tolerated after initial treatment, a topical anesthetic containing benzocaine (14%), butyl aminobenzoate (2%), and tetracaine hydrochloride (2%) can be sprayed on a gauze pad and placed on the back of the upper arch until the area is obtunded. After applying this anesthetic, instruct the patient to try the dental prosthesis again. Encourage longer insertion times and express approval of the patient’s efforts. Instruct the patient to: (a) swallow regularly to decrease any buildup of saliva that might trigger gagging, and (b) try periodically pressing the upper prosthesis with a thumb to increase suction and patient self-control. 5. When the occlusion rim or denture is in place, mechanical adjustments (for example, beveling the rear edge or reducing the post dam extent) can be made to further reduce gagging problems and increase comfort. REFERENCES 1. Barsby MJ. The use of hypnosis in the management of ‘gagging’ and intolerance to dentures. Br Dent J 1994;176:97-102. 2. Hattab FN, Al-Omari MA, Al-Duwayri ZN. Management of a patient’s gag reflex in making an irreversible hydrocolloid impression. J Prosthet Dent 1999;81:369. 3. Ren X. Making an impression of a maxillary edentulous patient with gag reflex by pressing caves. J Prosthet Dent 1997;78:533. 4. Morrish RB Jr. Suppression and prevention of the gag reflex with a TENS device during dental procedures. Gen Dent 1997;45:498-501. 5. Jastreboff PJ, Hazell JW, Graham RL. Neurophysiological model of tinnitus: dependence of the minimal masking level on treatment outcome. Hear Res 1994;80:216-32. Reprint requests to: DR JOSEPH K. NEUMANN PSYCHOLOGY SERVICE (116B2) JAMES H. QUILLEN VA MEDICAL CENTER PO BOX 4000 MOUNTAIN HOME, TN 37684 FAX: (423)232-6976 E-MAIL: [email protected] 10/4/114273
doi:10.1067/mpr.2001.114273
THE JOURNAL OF PROSTHETIC DENTISTRY 305
Gagging may preclude obtaining maxillary impressions. Past efforts to manage gagging have included hypnosis, anesthesia, acupressure, and transelectrical nerve stimulation.1-4 Evidence-based research studies have not been performed in this area, so it is not clear which procedures are the most helpful for patients or subsets of patients. The following behavioral techniques have been found to be helpful with dental patients whose gagging either prevented making maxillary impressions or made the use of existing dentures impossible. None of the patients treated had unusual psychological trauma related to the mouth, although several had psychiatric diagnoses (for example, dysthymia and posttraumatic stress disorder).
TECHNIQUES 1. Discuss fears related to dental procedures with the patient, and advise him/her to practice relaxation several times a week. Give audiotapes of relaxation procedures, which include imagery, progressive muscle relaxation, and self-suggestion components, to the patient with instructions that constant practice might reduce his/her arousal level sufficiently to decrease or eliminate the gagging response. 2. Advise the patient to stimulate his/her maxillary alveolar ridges and palatal vault with a toothbrush, spoon, mouthwash, or other stimuli. Patients need to receive a treatment rationale similar to that used in behavioral tinnitus treatment.5 The regular stimulation of the maxillary alveolar ridge and palatal vault may increase stimulation to the brain, thus making discrimination of the impression/denture stimuli more difficult (by increasing the noise in the signal-to-noise ratio). 3. If dentures/occlusion rims cannot be tolerated, instruct the patient to practice using his/her prosthesis at home at least 3 times a day, 5 days a week. Encourage the patient to increase time slowly (by 30-second intervals) until reaching a comfortable level (3 periods with no gagging). Instruct the
Supported by resources at the James H. Quillen VA Medical Center. aClinical Psychologist Department of Psychology, VAMC; and Clinical Associate Professor, Department of Psychiatry and Internal Medicine, James H. Quillen College of Medicine. bStaff Prosthodontist VAMC; and Clinical Associate Professor, Department of Prosthodontics, University of Tennessee, Knoxville, Tenn. J Prosthet Dent 2001;85:305. MARCH 2001
patient to eat soft foods such as applesauce until he/she feels comfortable enough to eat desired dense food. In sessions, verbally reinforce hope and the sense that the patient has control over gagging, and encourage the patient to experiment with different foods and routines. 4. If dentures/rims are not tolerated after initial treatment, a topical anesthetic containing benzocaine (14%), butyl aminobenzoate (2%), and tetracaine hydrochloride (2%) can be sprayed on a gauze pad and placed on the back of the upper arch until the area is obtunded. After applying this anesthetic, instruct the patient to try the dental prosthesis again. Encourage longer insertion times and express approval of the patient’s efforts. Instruct the patient to: (a) swallow regularly to decrease any buildup of saliva that might trigger gagging, and (b) try periodically pressing the upper prosthesis with a thumb to increase suction and patient self-control. 5. When the occlusion rim or denture is in place, mechanical adjustments (for example, beveling the rear edge or reducing the post dam extent) can be made to further reduce gagging problems and increase comfort. REFERENCES 1. Barsby MJ. The use of hypnosis in the management of ‘gagging’ and intolerance to dentures. Br Dent J 1994;176:97-102. 2. Hattab FN, Al-Omari MA, Al-Duwayri ZN. Management of a patient’s gag reflex in making an irreversible hydrocolloid impression. J Prosthet Dent 1999;81:369. 3. Ren X. Making an impression of a maxillary edentulous patient with gag reflex by pressing caves. J Prosthet Dent 1997;78:533. 4. Morrish RB Jr. Suppression and prevention of the gag reflex with a TENS device during dental procedures. Gen Dent 1997;45:498-501. 5. Jastreboff PJ, Hazell JW, Graham RL. Neurophysiological model of tinnitus: dependence of the minimal masking level on treatment outcome. Hear Res 1994;80:216-32. Reprint requests to: DR JOSEPH K. NEUMANN PSYCHOLOGY SERVICE (116B2) JAMES H. QUILLEN VA MEDICAL CENTER PO BOX 4000 MOUNTAIN HOME, TN 37684 FAX: (423)232-6976 E-MAIL: [email protected] 10/4/114273
doi:10.1067/mpr.2001.114273
THE JOURNAL OF PROSTHETIC DENTISTRY 305