Enhanced CPD DO C RestorativeDentistry

Bryan Daniel Murchie

Gagging – Bringing Up an Old

Problem Part 1: Aetiology and
Diagnosis
Abstract: Gagging is a problem which has plagued dentists and other members of the dental team, including non-dental colleagues,
during the course of their careers. Gagging not only has the potential to slow down the progression of the patient’s treatment, but it can
often lead to the development of dental fear, anxiety and future avoidance of their scheduled appointments; much to the frustration of
both parties. Subsequently, dentists may consider what went wrong with their initial approach and whether anything could have been
done differently. However, the gag reflex, particularly when severe, is normally beyond the scope of simple reflective exercises, as this
response may just be the tip of a very large psychological iceberg and, as deceptive as it seems, the dentist possibly never stood a fighting
chance on his/her own. The first part of this two-part series aims to explore the aetiology and diagnosing the severity of the condition. The
second part of the series will focus on the various management approaches which can be taken to overcome this physiological response
successfully.
CPD/Clinical Relevance: Gagging patients are a common occurrence within both general practice and hospital settings. It is important
that clinicians are able to identify and categorize patients suffering from this condition correctly at an early stage, before clinical
examination, or they will risk exacerbating dental fear and anxiety.
Dent Update 2018; 45: 609–616

Gagging, also widely known as retching severe variation of gagging is present; appointment. Patients’ dental anxiety,
and nausea, is a protective physiological under these circumstances, even the combined with the need for a complex
response to foreign bodies, or agents, simplest forms of treatment can prove restorative rehabilitation approach, often
entering the trachea, larynx and/or pharynx. extremely challenging or may be impossible results in radical treatment plans involving
Where an exaggerated form of the gag to execute. numerous extractions, leading to removable
reflex exists, it is a well-known hindrance Providing care for patients appliances (that patients will be unable
to dental procedures and a potential with a severe gag response can be a very to wear), which in turn heightens patient
barrier to optimal patient care. Mild stressful experience for both the clinician anxiety, with a loss of faith in a clinician’s
gagging problems are a relatively common and the patient. Furthermore, unsuccessful abilities and further missed appointments,
occurrence in dentistry where, in most treatment experiences will serve as a until they next return with further pain −
instances, various techniques and additional negative reinforcement of any pre-existing the term ‘gagging cycle’ seems appropriate
chairside time will allow the clinician to dental phobias. Consequently, patients’ (Figure 1).
navigate around the issue successfully and anticipation of the inevitable distress will Therefore, it is clear that
arrive at a satisfactory outcome. However, (understandably) affect their enthusiasm the clinician must understand how to
when the affected patient is unable to for routine dental care provision; it is identify correctly, diagnose and manage a
overcome the gagging sensation, a more estimated that gagging related issues hyperactive gag reflex. Ideally, this should
are responsible for approximately 20% of take place during the first consultation
overall avoidance cases.1 Therefore, those appointment, where the dentist should
Bryan Daniel Murchie, BDS, MJDF affected by a longstanding history of adopt a holistic approach, aimed at both
RCPS, PGCert(Implant), MSc(Rest Dent), gagging issues will have an increased risk of the psychological and somatic needs of the
Restorative Dentistry Department, poor dental health and extensive treatment patient.
Newcastle School of Dental Sciences. requirements. The unsuspecting dentist is
Newcastle University, Framlington Place, eventually greeted by the anxious patient Gag reflex physiology
Newcastle Upon Tyne, NE2 4BW, UK. who attends with pain at an emergency In order to understand the
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Figure 1. The ‘gagging cycle’.

underlying aetiology of the gagging salivatory and vestibular centres; this stimuli, and the psychogenic group, which
response, we must first look at how it explains why gagging may be associated is induced by psychological stimuli. Patients
is initiated. This is an inborn defence with hypersalivation, hyperventilation, are allocated to the relevant group, based
mechanism which is controlled by lacrimation, fainting and/or panic attacks. on the stimulus thought to be the initiating
the parasympathetic division of the Subsequently, efferent impulses are relayed factor responsible for the reflex.2,3 However,
autonomic system. It is more prominent to the tongue, oropharynx and upper it should be recognized that the distinction
during the early stages of life, thereafter it gastrointestinal tract. This gives rise to between the two groups can be difficult to
progressively regresses after the fourth year unco-ordinated and spasmodic muscular diagnose accurately and, in the majority of
of life, as the oral functions such as nasal movements, which is characteristic of cases, there will inevitably be an underlying
breathing and swallowing begin to mature. gagging, and vomiting may then occur. A element of both stimuli involved in the
Eventually, under normal circumstances, clinical description of gagging has been reflex.
the gag reflex locates to the region of the outlined in Table 1 and demonstrated in Gagging is considered to
tonsillar pillars following eruption of the Figure 2. Interestingly, neural pathways have a multifactorial aetiology. There are
first dentition. from the cerebral cortex to the medulla four factors which are believed to play a
Gagging occurs in order to oblongata (Figure 3) allow the higher crucial role with regards to the aetiology of
eject unwanted and toxic material from the centres to influence or even initiate the gagging, including:
upper respiratory tract by contraction of gagging response. 1. Local and systemic factors;
the oropharyngeal muscles. Afferent fibres 2. Anatomic factors;
from the trigeminal, glossopharyngeal 3. Psychological factors;
and vagus nerves transmit tactile sensory Aetiological factors 4. Iatrogenic factors.
impulses to the vomiting centre, which Two main categories of gagging
is located in the medulla oblongata. The patients have been identified in the Local and systemic factors
centre of the medulla oblongata is in close literature: namely, the somatogenic group, There is a vast array of
proximity to the vasomotor, respiratory, where gagging is induced by physical underlying local and systemic factors which
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Puckering of the lips or attempting to close the jaws dehydration with ketosis.6 This may be a
useful consideration for the clinician when

←
scheduling treatment sessions for patients
Elevating or furrowing of the tongue, with rotation from back to front and with the with a hypersensitive gag reflex.
hyoid bone at the centre

← ← ←
Anatomic factors
Elevation of soft palate and hyoid bone Gagging may occur in response
to tactile stimulation of specific areas within
Fixation of the hyoid bone the oral cavity. The ability of each patient to
tolerate this varies widely and can normally
only be accurately predicted via knowledge
Closing of the nasopharynx by an approximation of the posterior pillars of the fauces of the patient’s past dental history. There
that elevate the soft palate are five intra-oral regions (Figures 3 and 4)
←

which have been identified as ‘trigger zones’

Contraction of the anterior and posterior pillars of the fauces, causing the tonsils to for stimulating the gagging response:
1. Base of tongue;
rotate in an anteriomedial direction
2. Fauces (palatoglossal and
←

palatopharyngeal arches);
Elevation, contraction and retraction of the larynx and closure of the glottis − the 3. Palate;
passage of air over the closed glottis gives rise to the well-known retching sound 4. Uvula;
5. Posterior pharyngeal wall.
← ←

Unco-ordinated respiratory muscle spasm These anatomical landmarks

should be given special consideration
during all stages of the dental examination
Vomiting − this does not occur in all cases (hopefully) and treatment. It cannot be stressed
enough how important it is to apply this
Table 1. A clinical description of gagging. knowledge equally to all patients, including
non-gaggers, as iatrogenic stimuli can
induce maladaptive thought processes
and exaggerated gagging issues could
develop. In particular, clinicians can tactfully
obstruction, catarrh, sinusitis, postnasal apply their knowledge of these high risk
drip, nasal polyps, dry mouth and anatomical trigger sites to build patients’
mucosal congestion of the upper trust and confidence during the clinical
respiratory tract.4 appointment. Suggested approaches and
considerations during the first examination
and/or treatment appointment:
Systemic factors  Complete avoidance of high risk sites −
Systemic factors include this is recommended where severe gagging
medications which predispose or anxiety is apparent.
to nausea/vomiting as a side-  Always begin with stimulation of low
effect, carcinoma of the stomach, risk sites − this will allow the clinician to
chronic gastrointestinal disease, gauge the patient’s response and assess for
Figure 2. Representation of gagging. Note peptic ulceration, hiatus hernia and the presence, including the severity, of an
elevation soft palate, furrowing of tongue, uncontrolled diabetes. Interestingly, exaggerated reflex.
contraction of fauces and rotation of tonsils
patients with a habitual alcohol intake  Forewarn the patient prior to stimulation
(compare this with Figure 4). Interestingly, this
and those who smoke on a regular basis of high risk areas − this should be carefully
reflex was solely psychogenic.
will be predisposed to a hypersensitive communicated in such a manner that the
pharynx.5 patient does not predetermine a gagging
The time of the day has also response prior to the procedure taking
are responsible for lowering the threshold been closely linked with an increased place. The aim here is not to concern the
required for excitation of the vomiting gagging response. Individuals in the patient, but rather to avoid panic if the
centre. morning have an increased excitability reflex did occur. This also has the added
of the vomiting centre as a result of benefit that the clinician always appears to
Local factors associated metabolic disturbances, be in control of the situation.
Local factors include nasal including carbohydrate starvation and There have been numerous

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as a consequence of gagging, then he/

she will be more inclined to repeat this
behaviour in the future; this is termed
negative reinforcement.
Interestingly, neural pathways
from the medulla oblongata to the cerebral
cortex allow the reflex to be modified by
higher centres of the brain.9
The conditioned behaviour,
which occurred as a result of fear and
anxiety, links previously neutral stimuli
to the gag reflex, including olfactory,
Figure 5. Overloaded maxillary impression tray gustatory, olfactory, visual and auditory
will stimulate high risk anatomical sites. stimuli. A clinician who has an appreciation
for the underlying psychological
components of gagging will have the
foresight to create opportunities which
nerve, may be more extensive in gagging will facilitate changes of the conditioned
Figure 3. Relevant anatomy. (a) Medulla patients.8 Unfortunately, nerve innervation behaviours.
oblongata. (b) Cerebral cortex − outer covering of
alone does not explain patients who have
grey matter over the hemispheres, 2−3 mm thick.
psychogenic triggers for gagging. Therefore,
(c) Larynx. (d) Trachea. (e) Base of the tongue. Iatrogenic factors
at the present time, there have been no
Tactile sensation of the oral
clear links established in the literature
tissues is an inevitable outcome when
between anatomical abnormalities and
executing any form of dental treatment. If
neural pathways with the gag reflex.
this is performed utilizing a poor clinical
technique and with a lack of anatomical
Psychological factors awareness, then the reflex may be elicited
There are two main mechanisms in patients who are naturally more resistant
of learning, these are known as classical and to gagging, and it will reinforce previously
operant conditioning.9 This is particularly learned behaviours in patients who are
relevant to severe forms of gagging, which already suffering from prominent gagging
are usually related to a learned behaviour. issues. For example, a distolingually
over-extended lower denture which also
encroaches upon the tongue space.
Classical conditioning
In situations where stimulation
Classical conditioning occurs
of the gag reflex is necessary for optimal
when a previously neutral stimulus is
treatment outcomes, such as a correctly
paired with an unconditioned stimulus.
extended complete upper denture, gagging
For instance, if an overloaded impression
information booklets and interventions
tray is placed in the mouth which triggers
should be instigated before starting the
Figure 4. Anatomy of the oral cavity (at rest). (a) the patient’s gag response (Figure 5). As
treatment and this should also factor into
Palatoglossal arch. (b) Palatopharyngeal arch. (c) a consequence, the patient may learn to
the consent process.
Uvula. (d) Posterior pharyngeal wall. (e) Palate. associate the stimulus with the unpleasant
gagging sensation; therefore, a conditioned
gag reflex has been established in relation Assessment of gagging
to this procedure.
A detailed patient history must
investigations undertaken to explore a be recorded at the initial appointment. The
potential association between anatomical Operant conditioning clinician should approach the patient with
abnormalities and oropharyngeal Operant conditioning occurs a caring and understanding attitude, which
sensitivities with an increased gagging when an association is formed between will build rapport, whilst developing trust.
response.6,7 A controlled study, which the behaviour and the consequence of that A useful guide to assess gagging patients
investigated the radiographic anatomy of behaviour. Therefore, depending on the has been outlined in Table 2. The ‘red flag’
gaggers with non-gaggers, demonstrated outcome, the patient will be more or less warnings should become very apparent
no anatomical differences. Wright likely to repeat the response again in the during the early stages of the consultation,
postulated that the afferent nerve future. For example, if the patient learns when the right questions are asked.
distribution, particularly involving the vagus that he/she can avoid having a restoration The clinical examination will
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Grade II − Mild gagging

Identify the Initiating Event Gagging occurs occasionally
Begin with an open question, such as ‘describe your problems with gagging when you during routine dental procedures such
are in the dental chair’, with complementary follow-up questions. as fillings and impressions. Importantly,
the patient is able to maintain control
In the author’s experience, patients are often unable to recall when this event was
over the gag reflex. No special
originally triggered, the usual response is ‘it has been there as long as I can remember’. treatment considerations are usually
required. Behavioural interventions
Triggers may be necessary during high risk
Identify the underlying somatic and/or psychogenic factors. procedures.
Pre-examination estimation of the extent of gagging and consideration of the relevant
Grade III − Moderate gagging
severity grade.
Gagging occurs routinely
during normal dental procedures,
Clinical Features
such as examination of high risk sites.
What happens to the patient once the gag reflex has been stimulated, this may include: The patient is unable to maintain
palpitations, sweating, fainting, vomiting, panic attacks, etc. control over the gag reflex once it
has been stimulated and cessation of
Dental History the treatment is necessary. This form
What attempts have been made to resolve this issue and were they successful? of gagging may limit the potential
treatment options and preventive
Has the patient ever visited non-dental medical colleagues for management of their
gagging measures are normally
gagging? employed successfully.
What dental treatments have been successfully managed previously?
Grade IV − Severe gagging
Relevant Patient Factors Gagging occurs with all
Are there contributory medical factors? forms of dental treatment including
simple examination. Therefore,
What are their expectations of the dental treatment?
treatment is not possible without
Are the patient’s expectations realistic? utilizing interventions (see next paper
What types of treatment are they willing to consider? in the series).

Table 2. Assessment of the gagging patient.

Grade V − Very severe gagging
This form of gagging
does not require tactile sensation to
vary greatly between different patients; the dental surgery. When performing trigger the reflex. As with grade IV, it
for those with a more severe form of treatment, it is advisable first to establish demonstrates a conditioned behaviour
gagging, or extremely anxious patients, it a good level of communication, such and the ability of the cerebral cortex to
may only be possible to perform a simple as hand signalling, and begin with only influence the gagging centre. Treatment
examination at the first visit in order to simple procedures in order to build-up is not possible without utilizing
avoid pushing the patient beyond his/her the patient’s confidence. interventions (see next paper in the
limitations. series).
When the gagging is mainly The grade IV and V severe
Grading the severity of the
somatogenic in nature, it is good practice forms of gagging will (rather obviously)
gag reflex
to ‘map out’ the areas associated with have a substantial impact on affected
gagging using the ball end of a burnisher The Gagging Severity Index10 patients’ overall behaviour and their
instrument and document detailed will help the clinician to identify the attendance of dental appointments.
findings in the patient’s records. severity of the gagging condition and it These types of patients are categorized
At the second visit, the will assist with the patient’s treatment under the psychogenic category,
clinician should use the collated patient plan. as there will be a strong underlying
data to help facilitate treatment, taking Grade I − Normal psychological element responsible for
into account any psychogenic factors that Very occasional gag reflex their exaggerated reflex.
were previously mentioned. For example, which can be controlled by the patient. Once this definitive
ensure that the patient is taken promptly The patient has a normal gag reflex diagnosis has been confirmed, it is
into the surgery if waiting enhances their which is stimulated as a result of difficult important to consider whether the
anxiety, or mask any ‘trigger’ smells in treatment procedures. reflex could be successfully managed
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within the dental setting, or should the own limitations. Where it is felt that Dental Research, The United Dental
clinician consider enlisting the support the gagging severity is beyond the Hospital of Sydney Discussion Group).
of another medical colleague in order capability of general practice, then it Dent J Aust 1949; 21: 108−204.
to avoid worsening the condition is important to refer the patient for a 6. Bassi GS, Humphris GM, Longman P. The
(discussed in the next paper in the specialist opinion at an early stage. etiology and management of gagging:
series). a review of the literature.
References J Prosthet Dent 2004; 91: 459−467.
7. Wright SM. Medical history, social
Conclusion 1. Saita N, Fukuda K, Koukita Y,
habits, and individual experiences of
Ichinohe T, Kaneko Y. Classification
It is clear that, with an patients who gag with dentures.
of factors formed dental phobia.
additional understanding of the gag J Prosthet Dent 1981; 45: 474−478.
J Jpn Dent Soc Anesthesiol 2010; 38:
reflex, the clinician can accurately 8. Wright SM. The radiologic anatomy of
596−597.
assess and diagnose the patient, which patients who gag with dentures.
2. Bartlett KA. Gagging. A case report.
should always take place prior to the J Prosthet Dent 1981; 45: 127−133.
Am J Clin Hypnosis 1971; 14: 54−56.
clinical examination. Unfortunately, it is 9. Prashanti E, Sumanth KN, Renjith
3. Saunders RM, Cameron J.
very easy for the clinician to reinforce George P, Karanth L, Soe HHK.
Psychogenic gagging: identification
negatively learned behaviours; this is Management of gag reflex for patients
and treatment recommendations.
particularly relevant to those who are undergoing dental treatment (Review).
Compend Contin Dent Educ Dent
severely affected by the condition. Cochrane Database Syst Rev 2015; 10:
1997; 18: 430−438.
The clinician should therefore adopt
4. Wright SM. An examination of CD011116.
a systematic approach for patients
factors associated with retching 10. Dickinson CM, Fiske J. The role of
suffering from a severe gagging
in dental patients. J Dent 1979; 7: acupuncture in controlling the gagging
response. It is important for each
194−207. reflex using a review of ten cases.
clinician to be mindful of his/her
5. Lawes FAE. Gagging (Institute of Br Dent J 2001; 190: 611−613.

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616 DentalUpdate July/August 2018