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Roentgenographic service for the gagging patient
American
Academy of Oral Roentgenology
Arthur H. Wuehrmmn,
.
.
.
.
.
Editor
.
.
ROENTGENOGRAPHIC
.
.
.
.
SERVICE
.
.
.
.
.
.
.
FOR THE GAGGING
.
.
.
.
.
.
PATIENT
the acccntuatcd g ag rcflcs is ;I result. of psychologic or physiologic cauxcs, the patient. who gags poses ;I Will problem it1 So far as roentgcnographic service is conctbrncd. Although the patient who has an accentuated gag reflex is in the minorit.y, he is c~stremely uncomfortable and generally desires to be eooprrativc. There arc certain techniques or principles which can be used to help the: patient who gags. These will be &ken up here, beginning with the simplest proccdurcs and progressing to thn more complicated ones.
W
(;AISISG
HETHEK
THE
I’ATIENT
!S COSVIDRSCF:
The f&t fact which should bo kept in mind is thnt the patient who has an accent.uatcd gag reflex probably has had previous unpleasant c!sperienccs with respect. to roentgenographic service. The patient’s stat.e of mind can influence the success of the service rendered, Lozierl lists the following psychologic factors which may induce t.he gag wfles : fctu* oE the unknown, cstrcme fear of sal’focation, fear of the film coming into contact with it sensitive area of the mouth, failure of the patient to comprchcntl the operator’s instructions, and lack 01 confidence in the operator. our first contact with the patient should bc a pleasant, one, and WC s1Io~ld make ovcry effort to give the patient. confidence in our ability to perform t,hc ser&e which w\‘carc about to l*cnd~~r. 13~ discussing t.hc patient’s problem with ]liln and explaining tlW proccdurcs which WC?ill’r about. lo perform, we can often alleviate t.lic patient ‘8 nervousness. By gaining the patient’s confidence, *Assistant IW.hgenology.
Professor,
Ikpurtrnc!nt
of Oral
Diagnosis. G2
Member,
Amerirxn
Academy
of Oral
By placing the filni. firi~ly and positively in thib area desired, the gag IT~CS nlay hc reduced. Xany timcts the gag reflex is broughC on by the small movement. or vibration of the soft tissues when placing the film in position. molar iWlXS. kftcl This is especially true! in the maxillary ant1 ~llillldibUlar the film has bccbn posibioncd correctly, the patient sl~oulcl be instructed to USC firm, positive prcssm*c in retaining the film; the gag refles is reduced by &tlillilting an)- slight movcmcnt of the film resulting from light prcssurc~. Gagging also may be reduced if the patient is instructed to concentrate on hrcatliing rapidly and shallowly. This will help to take his mind off the proccdnre in progress. To some patients, this form of hrea.thing is best described Ennis and Bcrry3 FCCO~I~C’~~ having the patitqll ilS ” ljanting Iiktr a dog.” h0ltl bi~rnt hc through the nose, and Richards rccommcnds having t Iw piltit!nt Tlic c;uwcss ol the various Iwratliing the t)rwth while t.hc film is being placid. instructions c1qw11ds to a ~~~1~~i~l~~i~l~l~rsicwt upon the pnticnt ‘H tc?mpwsnwnt and his willingness lo c*oopr~ratr.
Thcrc arc scvc~xl mechanical aids which may bc used for Clm positioning and film retention. The first of these aids is the cotton roll. When the cotton roll is placed bctwccn the soft tissues and t.he film, there is less surface contact with t.hc soft tissues; thus less area is provided for t.he movement of the tissues and there is less gag reflex. The cotton roll can 1~ used in all areas of the mouth and will also prevent some f&n. bending as a result. of the pressure applied by the patient-. The second mechanical aid is the plastic film holcler (Fig. 1)) which providos a method of holding the film and a biting rurfacc for the patient to IY:-
64
Bl~.
3.. -Wooden
bite-block
film
holder.
mends this pretucdication for patients who gap front prosthet.ics procedures, it is applicable to the roentgeaograghic service as well. I,ozicY advocates prrmedicaCon with a.tropiw sulfate, !/r (,(, gt’.? thirty minutes lwforc the roentgcnoyraphic ],roct!tlure. :Itropittc~ sulfate acts as a:~ anodinc a ttd a ttt ispasmodic. Precautions should tw taken to haw someone awo~ttpany the patient when he leaves the dfkc~
ikftrlr
taking
1 Ilrse
lllrdicilt-ions.
m,wi
iltl(l IVillti” ac’l\oc:~tc: i)“.ivittg l.hc pafitbttt tt clt%tk of iw \~atcsr (it wo~11d tw to ltitv(! the .I);ktictli hold it pica of ice itt the mouth) prior to filtti pli~wti~.~~t~f.;i h: kc! witt.c~t- or iw dulls the: s~ttsot~y ttwvc cwdings to tltch cxtcnt that tliv ~oc~tit~otio~t~apltic scwiw Pill1 lw pcr~ortttotl. :I
variation
A liquid topical anesthetic, such as NeoTopanol (Cook-Waite), may be applied with a cotton swab, or the patient may rinse the cndire mout.11 with it. type of txtpicul ancstliotic, such as Orailnnt S]>l’ily (XZZY), is CSThe Spay tt*t:tlldy Itwl’ttl since it illSO ctln Iw used itt spwific: :ttwts (Fig. 4). ThC dfht8 8t’P vc?l*y dmsc for shwt I)cbriotls 01: l.itttc!--;tl)prosit~l~t~(~l~ twcttty tttiimtw. 111 I~lOSl topitrr-11 iltlc!St lidks 01: illc liqtii(l tititl spray lylw the actiw ttncsbhet.ic~ iIgWlt. is l)mxoctt.itti~, wtticatt ~~tw~lttws ii tttittitttuttt deggrtw 01: 1111 f’ilVOtXl)l~ tissue rCit(4 iott. 1lie tlmitist cau decide whirh iopical auestlicticb Through sottie c~l)rl~itttctttatiott, products tlto best results in his particular circumstance.
GENER.AL ANRSTHETIW The general anesthetic sholAl probably be used as a last. Ivsort for PStremcly difficult. patients. There are III~I~>- drawbacks to the use ot’ a gcncral anesthetic as an aid to dental rocntpc~noal,aI)hic stvviccb. In addition 1-o1~1~inc*onvenicncc to 1)ot.h the doctor ant1 the patient, thcrc is also the matter of cost for this servic(l. The pr01)1(~111ol’ al’t:;lngillg FOYthen potlclxl aiic~stlictic ilnd fw the use of a portable x-ra>- niachioe at the hospital also caxists. Jkeeptions to these objections might hc -I’ou~icl in thcb cwc of :i patient who is Iiospitalixcd 01’ ill tllla wsc Of th sc!v~JY?l~~ already for some other disvasv 01~ COlll~)hiilt physically handicapped or nl(~ntilll\- Il:~tldi~a1)I)(‘(l patichlll ~110 ~WIIIO~. POO~WM c ‘I‘h inhf3wit risk I)(’ iuiy poticl*al itnWttletic in the roctntgenographic ptvccdnrc. must. he kept in mind. O(X:I,lTSAL OR EXTRAOKAI. BW,JTTR(‘H NIQUES lTpdegravei describes a technique! l’or llsin, w occlusal film in the maxillary The technique involves placing t.hc and mandibular antrrior and postwior areas. occlnsal film parallel with the ocr~lusal plaw iItl(l having the patient, bite the film. The angle formed by the long axis oi’ the? teeth in the region and the plane of thv film is bisected, and the central ~1-1~or hcam is directed pcrpendiculnr to the bisection line through the apex of t.hc tooth or tctrth in question. Tn cases in which t.his technique is not. applicable, extraoral rocnt.genograms may be taken with either the occlusal films OP 5 1)~ 17 or 8 by 10 inch cstraoral films. ‘\Vit.h the extraoral films, either cardboard film holders or cassettes arc required.
Hypnosis, perhaps more t.han any ot,ller method, holds a bright promise for t.hc futurr. Past succcsscs in mcdicinc and in other dental procedures indicate that it most. certainly would bc useful in the making of a roent,gcnographic survey. As more people beconw trained in the use of hypnosis, this l-echniqne The main drawback is not thtr i.cchniquc: will probably become more popular. itself but the lack of trained personnel. MOSSYreports good results and describes a method for using what is tcrmcd thca “waking hypnotit~ suggestion. ” WICII this method is used, the pat.icnt does not enter il, trance st;ltc. Since il t IWW~ is not necessary, very little time is rcquircd for induction of the suggestion or idea.
\‘ol,rrnc 1; VlHnllcr 1
ROENTGENOGRAPHIC
SERVICE
FOR
GAGGrNG
PATlENT
67
RUN ivIARY
The patient who has an accentuated gag reflex, for whatever reason, can t)ose a severe problem in t.he dental office when rocntgcnographic service is necessarg. There is no substitute for experience and ingenuit.y in dealing with problems which the patient may present. However, several procedures have been presented, varying from the simple to the more elaborate, which alone or in combination, may help overcome the gag rrflos. Sincca in many casts the pationt.‘s problem is psychologic rather than physical, that ultiulate method of treatment may bc through hypnosis. RRFEXICSCES 1. f.ozicr, 2. 3. 4. 5. 6. 7. 8.
Matthew : Etiology and Control of the Gagging Refles in tkc Practice of Intraoral Roentgenography, ORAL SURG., ORAL MED. & ORAL PATH. 2: 766-769, 1949. and Psychological Approach to the Problem of Stepkens, Douglas W. : Physiological Gagging, D. Survey 26: 1795-179i, 1949. Rnnis, I,. M., and Berry, H. M., Jr.: Dental Roentgenology. ed. 5, Philadelphia, 1959, Lea & Febiger, p. 104. Ki(*hards, .41bert G. : The Control of Gagging in Dental Radiograpky, J. Michigan State D. Sot. 31: 110-111, 1949. Dresen, 0. MY.: Control of the Gagging Patient, Texas 1). J. 65: 332-333, 1947. Clinical Dental Roentgcnology, ed. 4, Pldladelphia, 1957, McCall, J. O., and Wald, 5. 8.: \V. R. Haunders Cdmpany, p. 24. Updrgrave, W. J. : Radiodontrc Technique for the Child hti(~llt, J. NW Jcrscy D. Hoe. 22: 11-14, 1951. Moss, Aaron A.: The Confident Dentist Can Eliminate Gagging by Waking Hypnotic Sug gestion, D. Survey 26: 198-399, 1956.
Academy of Oral Roentgenology
Arthur H. Wuehrmmn,
.
.
.
.
.
Editor
.
.
ROENTGENOGRAPHIC
.
.
.
.
SERVICE
.
.
.
.
.
.
.
FOR THE GAGGING
.
.
.
.
.
.
PATIENT
the acccntuatcd g ag rcflcs is ;I result. of psychologic or physiologic cauxcs, the patient. who gags poses ;I Will problem it1 So far as roentgcnographic service is conctbrncd. Although the patient who has an accentuated gag reflex is in the minorit.y, he is c~stremely uncomfortable and generally desires to be eooprrativc. There arc certain techniques or principles which can be used to help the: patient who gags. These will be &ken up here, beginning with the simplest proccdurcs and progressing to thn more complicated ones.
W
(;AISISG
HETHEK
THE
I’ATIENT
!S COSVIDRSCF:
The f&t fact which should bo kept in mind is thnt the patient who has an accent.uatcd gag reflex probably has had previous unpleasant c!sperienccs with respect. to roentgenographic service. The patient’s stat.e of mind can influence the success of the service rendered, Lozierl lists the following psychologic factors which may induce t.he gag wfles : fctu* oE the unknown, cstrcme fear of sal’focation, fear of the film coming into contact with it sensitive area of the mouth, failure of the patient to comprchcntl the operator’s instructions, and lack 01 confidence in the operator. our first contact with the patient should bc a pleasant, one, and WC s1Io~ld make ovcry effort to give the patient. confidence in our ability to perform t,hc ser&e which w\‘carc about to l*cnd~~r. 13~ discussing t.hc patient’s problem with ]liln and explaining tlW proccdurcs which WC?ill’r about. lo perform, we can often alleviate t.lic patient ‘8 nervousness. By gaining the patient’s confidence, *Assistant IW.hgenology.
Professor,
Ikpurtrnc!nt
of Oral
Diagnosis. G2
Member,
Amerirxn
Academy
of Oral
By placing the filni. firi~ly and positively in thib area desired, the gag IT~CS nlay hc reduced. Xany timcts the gag reflex is broughC on by the small movement. or vibration of the soft tissues when placing the film in position. molar iWlXS. kftcl This is especially true! in the maxillary ant1 ~llillldibUlar the film has bccbn posibioncd correctly, the patient sl~oulcl be instructed to USC firm, positive prcssm*c in retaining the film; the gag refles is reduced by &tlillilting an)- slight movcmcnt of the film resulting from light prcssurc~. Gagging also may be reduced if the patient is instructed to concentrate on hrcatliing rapidly and shallowly. This will help to take his mind off the proccdnre in progress. To some patients, this form of hrea.thing is best described Ennis and Bcrry3 FCCO~I~C’~~ having the patitqll ilS ” ljanting Iiktr a dog.” h0ltl bi~rnt hc through the nose, and Richards rccommcnds having t Iw piltit!nt Tlic c;uwcss ol the various Iwratliing the t)rwth while t.hc film is being placid. instructions c1qw11ds to a ~~~1~~i~l~~i~l~l~rsicwt upon the pnticnt ‘H tc?mpwsnwnt and his willingness lo c*oopr~ratr.
Thcrc arc scvc~xl mechanical aids which may bc used for Clm positioning and film retention. The first of these aids is the cotton roll. When the cotton roll is placed bctwccn the soft tissues and t.he film, there is less surface contact with t.hc soft tissues; thus less area is provided for t.he movement of the tissues and there is less gag reflex. The cotton roll can 1~ used in all areas of the mouth and will also prevent some f&n. bending as a result. of the pressure applied by the patient-. The second mechanical aid is the plastic film holcler (Fig. 1)) which providos a method of holding the film and a biting rurfacc for the patient to IY:-
64
Bl~.
3.. -Wooden
bite-block
film
holder.
mends this pretucdication for patients who gap front prosthet.ics procedures, it is applicable to the roentgeaograghic service as well. I,ozicY advocates prrmedicaCon with a.tropiw sulfate, !/r (,(, gt’.? thirty minutes lwforc the roentgcnoyraphic ],roct!tlure. :Itropittc~ sulfate acts as a:~ anodinc a ttd a ttt ispasmodic. Precautions should tw taken to haw someone awo~ttpany the patient when he leaves the dfkc~
ikftrlr
taking
1 Ilrse
lllrdicilt-ions.
m,wi
iltl(l IVillti” ac’l\oc:~tc: i)“.ivittg l.hc pafitbttt tt clt%tk of iw \~atcsr (it wo~11d tw to ltitv(! the .I);ktictli hold it pica of ice itt the mouth) prior to filtti pli~wti~.~~t~f.;i h: kc! witt.c~t- or iw dulls the: s~ttsot~y ttwvc cwdings to tltch cxtcnt that tliv ~oc~tit~otio~t~apltic scwiw Pill1 lw pcr~ortttotl. :I
variation
A liquid topical anesthetic, such as NeoTopanol (Cook-Waite), may be applied with a cotton swab, or the patient may rinse the cndire mout.11 with it. type of txtpicul ancstliotic, such as Orailnnt S]>l’ily (XZZY), is CSThe Spay tt*t:tlldy Itwl’ttl since it illSO ctln Iw used itt spwific: :ttwts (Fig. 4). ThC dfht8 8t’P vc?l*y dmsc for shwt I)cbriotls 01: l.itttc!--;tl)prosit~l~t~(~l~ twcttty tttiimtw. 111 I~lOSl topitrr-11 iltlc!St lidks 01: illc liqtii(l tititl spray lylw the actiw ttncsbhet.ic~ iIgWlt. is l)mxoctt.itti~, wtticatt ~~tw~lttws ii tttittitttuttt deggrtw 01: 1111 f’ilVOtXl)l~ tissue rCit(4 iott. 1lie tlmitist cau decide whirh iopical auestlicticb Through sottie c~l)rl~itttctttatiott, products tlto best results in his particular circumstance.
GENER.AL ANRSTHETIW The general anesthetic sholAl probably be used as a last. Ivsort for PStremcly difficult. patients. There are III~I~>- drawbacks to the use ot’ a gcncral anesthetic as an aid to dental rocntpc~noal,aI)hic stvviccb. In addition 1-o1~1~inc*onvenicncc to 1)ot.h the doctor ant1 the patient, thcrc is also the matter of cost for this servic(l. The pr01)1(~111ol’ al’t:;lngillg FOYthen potlclxl aiic~stlictic ilnd fw the use of a portable x-ra>- niachioe at the hospital also caxists. Jkeeptions to these objections might hc -I’ou~icl in thcb cwc of :i patient who is Iiospitalixcd 01’ ill tllla wsc Of th sc!v~JY?l~~ already for some other disvasv 01~ COlll~)hiilt physically handicapped or nl(~ntilll\- Il:~tldi~a1)I)(‘(l patichlll ~110 ~WIIIO~. POO~WM c ‘I‘h inhf3wit risk I)(’ iuiy poticl*al itnWttletic in the roctntgenographic ptvccdnrc. must. he kept in mind. O(X:I,lTSAL OR EXTRAOKAI. BW,JTTR(‘H NIQUES lTpdegravei describes a technique! l’or llsin, w occlusal film in the maxillary The technique involves placing t.hc and mandibular antrrior and postwior areas. occlnsal film parallel with the ocr~lusal plaw iItl(l having the patient, bite the film. The angle formed by the long axis oi’ the? teeth in the region and the plane of thv film is bisected, and the central ~1-1~or hcam is directed pcrpendiculnr to the bisection line through the apex of t.hc tooth or tctrth in question. Tn cases in which t.his technique is not. applicable, extraoral rocnt.genograms may be taken with either the occlusal films OP 5 1)~ 17 or 8 by 10 inch cstraoral films. ‘\Vit.h the extraoral films, either cardboard film holders or cassettes arc required.
Hypnosis, perhaps more t.han any ot,ller method, holds a bright promise for t.hc futurr. Past succcsscs in mcdicinc and in other dental procedures indicate that it most. certainly would bc useful in the making of a roent,gcnographic survey. As more people beconw trained in the use of hypnosis, this l-echniqne The main drawback is not thtr i.cchniquc: will probably become more popular. itself but the lack of trained personnel. MOSSYreports good results and describes a method for using what is tcrmcd thca “waking hypnotit~ suggestion. ” WICII this method is used, the pat.icnt does not enter il, trance st;ltc. Since il t IWW~ is not necessary, very little time is rcquircd for induction of the suggestion or idea.
\‘ol,rrnc 1; VlHnllcr 1
ROENTGENOGRAPHIC
SERVICE
FOR
GAGGrNG
PATlENT
67
RUN ivIARY
The patient who has an accentuated gag reflex, for whatever reason, can t)ose a severe problem in t.he dental office when rocntgcnographic service is necessarg. There is no substitute for experience and ingenuit.y in dealing with problems which the patient may present. However, several procedures have been presented, varying from the simple to the more elaborate, which alone or in combination, may help overcome the gag rrflos. Sincca in many casts the pationt.‘s problem is psychologic rather than physical, that ultiulate method of treatment may bc through hypnosis. RRFEXICSCES 1. f.ozicr, 2. 3. 4. 5. 6. 7. 8.
Matthew : Etiology and Control of the Gagging Refles in tkc Practice of Intraoral Roentgenography, ORAL SURG., ORAL MED. & ORAL PATH. 2: 766-769, 1949. and Psychological Approach to the Problem of Stepkens, Douglas W. : Physiological Gagging, D. Survey 26: 1795-179i, 1949. Rnnis, I,. M., and Berry, H. M., Jr.: Dental Roentgenology. ed. 5, Philadelphia, 1959, Lea & Febiger, p. 104. Ki(*hards, .41bert G. : The Control of Gagging in Dental Radiograpky, J. Michigan State D. Sot. 31: 110-111, 1949. Dresen, 0. MY.: Control of the Gagging Patient, Texas 1). J. 65: 332-333, 1947. Clinical Dental Roentgcnology, ed. 4, Pldladelphia, 1957, McCall, J. O., and Wald, 5. 8.: \V. R. Haunders Cdmpany, p. 24. Updrgrave, W. J. : Radiodontrc Technique for the Child hti(~llt, J. NW Jcrscy D. Hoe. 22: 11-14, 1951. Moss, Aaron A.: The Confident Dentist Can Eliminate Gagging by Waking Hypnotic Sug gestion, D. Survey 26: 198-399, 1956.