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Continuing Dental Education

D E N TA L M AT E R I A L S

Ensuring Patient Comfort

and Clinical Accuracy
During Impression Taking
Shannon Pace Brinker, CDA, CDD

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DENTAL MATERIALS
Ensuring Patient Comfort and Clinical
Accuracy During Impression Taking
Shannon Pac e Br inker, CDA , CD D

E
ABSTRACT nsuring patient comfort during dental pro-
Patient discomfort during dental procedures cedures is an essential aspect of oral health
can be psychological as well as physical. Physi- care, not only during treatments such as
cal discomfort may include gagging during restorative procedures and more complex dental
dental treatments and diagnostic procedures, reconstructions, but also during simple diagnos-
while psychological discomfort may range from tic procedures such as imaging and impression
mild apprehension to intense anxiety. Both taking. Providing comfort to the patient can in-
physical and psychological discomfort con- volve addressing psychological as well as phys-
tribute toward avoidance of dental treatments, ical issues, as dental anxiety (ie, the stress or
which can have serious consequences for the dread experienced before, during, or after dental
oral health and overall general health of the treatment) is a common source of patient discom-
patient. This article examines dental anxiety and fort. Because it often leads to avoidance of den-
gagging that occur during impression-taking pro- tal treatment, dental anxiety may also indirectly
cedures, and discusses simple interventions contribute to increased oral and general health
that can be undertaken during the office visit to problems.1 Patient discomfort may additionally
ensure patient comfort during these procedures. result from unpleasant physical sensations during
The advantages and disadvantages of common dental procedures, such as gagging reflexes that
impression materials, particularly with regard to may occur when bitewing radiographs are taken
ensuring patient comfort during impression or with impression taking, which may, in turn,
taking, are also described. result in psychological distress during the dental
visit.2 In the case of impression taking, gagging
LEARNING OBJECTIVES may also severely limit the ability of the den-
• Describe the phenomenon of dental anxiety tal practitioner to perform the procedure, which
and its occurrence during the impression- can compromise the accuracy and fit of the final
taking procedure restorations and, ultimately, the quality of care.3
Impression taking is one of the most essen-
• Describe the gag reflex and its etiology tial procedures involved in the fabrication of res-
• Discuss simple techniques that can be torations. Although the exact prevalence is un-
employed to reduce gagging and dental known,4 unfortunately many patients experience
anxiety during impression taking, and explain gagging during impression taking, while anxiety
the role of dental impression materials in and other forms of discomfort during the proce-
mitigating gagging and ensuring patient dure are common.5 Dental healthcare profession-
comfort als should therefore employ various management

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In one study … pressure applied to a

specific point on the palm consistently altered
the severity of the gag reflex

strategies to address the gag reflex and anxi- for their anxiety.7 Impression-taking procedures
ety that patients can experience during dental can potentially induce these feelings in some
procedures. Practitioners should consider ways patients. Left unaddressed, dental anxiety can
of mitigating aspects of impression taking that lead to avoidance of dental treatment, which
may contribute to these problems, such as the can harm oral and general health.1
duration of the procedure. This article exam-
ines strategies and techniques to reduce dental THE GAG REFLEX AND ITS ETIOLOGY
anxiety and gagging during impression taking. Gagging is an involuntary and unpleasant con-
It discusses ways to maximize patient comfort, traction of the soft palate or pharynx muscles
such as by performing the procedure more ef- that results in retching.8 As such, the gag re-
ficiently and, when possible, with dental im- flex is the body’s natural way to prevent po-
pression materials that minimize gagging and tentially dangerous objects in the mouth from
promote efficiency, thus creating a more com- entering the throat and blocking the airway and
fortable experience for the patient. thus helps prevent choking when the situation
does not involve normal swallowing. Accord-
DENTAL ANXIETY ing to a study published in The Lancet, about
Many patients may feel uncomfortable, anx- 37% of healthy adults do not have a gag re-
ious, or fearful before, during, and even after flex.9 Conversely, 10% to 15% of people have a
dental procedures. This phenomenon, known hypersensitive gag response in which even the
as dental anxiety, is highly prevalent worldwide slightest sensation can trigger an involuntary
(approximately 25% of the population).1,6 How- throat contraction.10 The remainder typically
ever, while it is often assumed that perceptions respond to non-swallowing sensations in the
or anticipation of pain cause dental anxiety, for pharynx. Therefore, when taking dental im-
some patients there are additional causes for pressions, dental healthcare professionals must
their anxiety about dental treatments, which consider the trigger that the impression mate-
may be experienced even during “pain-free” rial will cause during insertion.
procedures.6 It has been postulated that the Five areas of the oral cavity are trigger
origin of dental anxiety is multidimensional zones for gagging: the palate, uvula, base of
and includes both endogenous and exogenous the tongue, the fauces (leading to the pharynx),
causes; several psychological disorders (such and the posterior pharyngeal wall.2,10 When any
as low self-esteem, general anxiety disorder, of these areas is stimulated by touch, afferent
and alcohol dependence) have been reported fibers from the trigeminal, glossopharyngeal,
in patients with dental anxiety.6 Many patients and vagus nerves pass to the medulla oblongata
who have never had negative dental experiences in the brain stem. This then signals the muscles
have reported feelings of vulnerability and of in the back of the mouth to contract or push up,
“not being in control” as well as the perceived resulting in gagging.2 Also, neural pathways
“unpredictability” of the procedures as reasons from the center of the medulla oblongata or the

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“gagging center” to the cerebral cortex allow while encouraging them to share their anxieties
the reflex to be modified by higher centers, helps reinforce their trust and confidence.12
allowing thoughts about stimulation to initi- When a dental impression material has been
ate the gagging in some instances.2 Therefore, selected that minimizes the likelihood of gag-
in some patients, simply thinking about dental ging, as in the case of vinyl polysiloxane (VPS)
impressions (or other procedural stimuli) may (as discussed later in this article), the practi-
stimulate this reflex. tioner should explain the benefits of the dental
impression material and how the material will
TECHNIQUES TO REDUCE GAGGING AND improve the patient’s comfort during the pro-
DENTAL ANXIETY DURING IMPRESSION cedure; positive encouragement should always
TAKING set the tone for every dental procedure, and by
Depending on the patient’s gag reflex severity, helping patients understand and know what to
techniques to reduce gagging can be introduced expect, their anxiety will be reduced.
and incorporated into the dental visit. While
there are many evidence-based approaches to Relaxation Techniques
reduce gagging before the office visit in a pa- Relaxation techniques that the patient can per-
tient with a history of a gag reflex, including form during the office visit include breathing
anti-nausea medicine, sedatives, local and gen- exercises, which can both alleviate anxiety and
eral anesthetics, behavioral therapies, and acu- reduce gagging.8 To begin rhythmic breathing,
puncture,2 these interventions are beyond the the dental practitioner should ask patients to
scope of this section, which focuses on simple, breathe through their noses. The practitioner
nonpharmaceutical strategies, many of which should ask the patient to sit up straight in the
can be adopted during the office visit. Like- chair and relax their shoulders. Next, the pa-
wise, several management strategies exist to tient should be instructed to uncross their legs
address dental anxiety, including pharmaco- and tip their toes towards the practitioner. Be-
logic and psychotherapeutic interventions, that cause anxiety such as that caused by impression
are beyond the scope of this article.1 In this ar- taking may trigger faster breathing, patients
ticle, we will explore simple strategies that can should be told to continue breathing through
be undertaken during or immediately before their nose and to take deep breaths, as this will
impression taking when anxiety is identified help increase how much oxygen is taken in.
during the office visit. This may help slow breathing, reduce the heart
rate, and alleviate the patient’s anxiety.12 The
Inspire Trust and Provide Reassurance author recommends asking patients to practice
Experiencing occasional anxiety is a normal first by closing their lips and inhaling slow-
part of life. However, people with anxiety dis- ly through the nose, letting the chest rise and
orders frequently have intense, excessive, persis- fill with air; the practitioner can demonstrate
tent worries and fears about everyday situations. this by practicing the exercise with the patient.
Having an initial conversation with patients Breathing deeply through the nose should be
about their anxieties before taking impressions continued throughout the minutes required to
helps inspire trust and conveys sensitivity and take a good impression.
understanding.11 Explaining the impression
taking procedure to patients, including the esti- Keep a Tissue Handy
mated time for placement and setting, can reas- Always have a tissue handy in case the patient
sure patients and help them feel safe and in con- feels they are drooling. Provide a tissue to the
trol. Additionally, answering patients’ questions patient so that they can allow saliva to drain

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1 2

3 4
Fig 1. Applying pressure to the center of the palm can help suppress the gag reflex. The thumb of the opposite hand can be used to apply the
pressure. Fig 2. In the author’s experience, applying pressure to the Hegu point, or the concave point between the thumb and index finger, is
effective in helping suppress the gag reflex. Fig 3. Impression made from alginate. Fig 4. Preoperative mandibular impression made from VPS.

out of the mouth. This may sometimes reduce reflex (Figure 1).14 In the author’s experience,
the gag reflex.13 anecdotal evidence also suggests that if a per-
son closes their left hand over their left thumb
Acupressure and applies gentle pressure, it may stop them
Although acupuncture has been shown to be from gagging. Another technique for suppress-
successful in reducing gag reflex,8 this pro- ing the gag reflex that has been effective in the
cedure can be performed only by a licensed author’s experience involves applying pressure
therapist. Acupressure is very similar to acu- to the concave point between the thumb and in-
puncture, utilizing the same pressure points, dex finger (Figure 2).
but it can be performed by anyone and without
the use of needles. Because acupressure uses Simple Distractions
gentle-to-firm finger pressure alone to stimu- Distraction techniques have been reported to
late pressure points on the body, it is ideal for reduce anxiety and gagging.8 The dental prac-
self-treatment wherever and whenever neces- titioner should provide the patient with some-
sary. Evidence supports its use for reducing thing to hold. Stress balls can reduce stress,
the gag reflex; in one study, researchers found enhance mood, and induce relaxation. A stress
that pressure applied to a specific point on the ball diverts the patient’s attention from negative
palm consistently altered the severity of the gag thoughts towards those that are more pleasant

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and promotes relaxation. Talking to the patient particularly in term of ensuring efficiency and
or even singing (for example, singing along decreased procedural time during impression
with the radio in the operatory) can provide taking. It produces great detail reproduction,
simple distractions that will help take the pa- has stability over time, and high tear strength
tient’s mind off the procedure.8 and elastic recovery.18 However, because VPS
is a hydrophobic substance, proper moisture
Selection of Impression Materials control must be maintained to achieve accuracy
The choice of impression materials is also es- and a high-quality impression.18
sential in providing a more comfortable experi- These anatomical impressions made from
ence and reducing gagging for patients during VPS reproduce the dental and mucosal struc-
impression taking.15 Alginate is an irreversible ture of the patient’s oral cavity (Figure 4 and
elastic hydrocolloid (Figure 3) that has various Figure 5) and are used to create orthodontic
applications in dentistry. The applications of models, opposing models, temporaries, night
alginates include making impressions of eden- guards/splints, and custom bleaching trays
tulous and partially edentulous arches, dupli- (Figure 6). An impression made from VPS can
cation of casts, and study models. Alginates withstand numerous pours; this allows the im-
possess numerous vital properties such as pression to be used to make multiple models
hydrophilicity, the ability to record finer de- for the patient, if necessary. With an alginate
tails, and elastic recovery, and because it is impression, only one model can be made, and
inexpensive, this material is widely used in duplicates will need to made with a unique ma-
dentistry. Unfortunately, alginate impression terial. Repeating the impression taking clear-
materials historically have demonstrated a ly adds to the overall procedural time, which
low tear strength and inconsistent setting and increases the likelihood of discomfort for pa-
working times.16 Because of their delicate na- tients with a history of dental anxiety or gag-
ture, impressions made from alginate materi- ging. VPS also creates less mess and reduces
als have not been used for multiple pours; al- the likelihood of seepage of the material toward
ginate impressions typically must be poured the back of their throat.
immediately to avoid losing accuracy due to The efficiency of the impression-taking pro-
dehydration.17 cedure can be largely driven by the dental im-
Although VPS impression material is slight- pression material. With VPS impression materi-
ly more expensive, it has several advantages, al, impressions can be poured immediately—or

5 6
Fig 5. Quality quad detailed impression made from VPS. Fig 6. Stone model poured from VPS impression material.

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when convenient, so provisional fabrication can be in provisionals for several months, during
begin as soon as the impression is removed which time the temporaries may need to be re-
from the patient’s mouth. Other impression ma- placed. If alginate impressions were taken, the
terials can require 20 minutes of waiting before patient would require another impression pro-
pouring. The use of VPS impression material cedure. With VPS, the initial impression can
thus results in a shorter and more convenient be used and a new provisional easily created,
appointment for patients. Shorter procedural without the need for a repeated impression-
durations reduce the opportunities for anxiety taking procedure.
to develop, and patients will be less anxious
about future impression-taking procedures, as CONCLUSION
they will remember their last experience in a Dental anxiety is a multidimensional phenom-
positive light. enon, and dental healthcare professionals may
Finally, the accuracy of the dental impression sometimes be limited in their ability to fully
is a crucial aspect of ensuring patient comfort, address this problem in certain patients. Never-
as the final successful outcome of the restora- theless, much can be done to ensure that pa-
tion promotes confidence in the patient and tients are as comfortable as possible during
allays anxiety about requiring further dental dental treatments and procedures, and dental
treatment for the restored tooth. Also, when anxiety can be ameliorated in most cases by
dental impressions are found to be inaccurate, employing some simple techniques during the
unstable, or deformed, dental impressions will office visit. Likewise, gagging, which is by
need to be retaken. As already mentioned, when definition an involuntary reflex, can be pre-
proper moisture control is ensured, the use of vented and reduced at the time of or immedi-
VPS impression material provides fine detail ately before the procedure through interven-
and accuracy in impressions.18 Furthermore, tions such as acupressure, breathing exercises,
VPS material demonstrates low dimensional and distraction techniques. Selection of im-
changes and retains its shape upon setting for pression materials, such as vinyl polysiloxane
months without needing special storage.19 The (VPS), can also help reduce gagging and anx-
material also can be disinfected without con- iety during impression taking. Advancements
cerns about affecting dimensional stability. As in material science and the handling charac-
a result, impressions can be used again in the teristics, accuracy, stability, and setting times
future, avoiding the need for repeating the im- of VPS have helped provide efficient, short-
pression taking. Patients’ future needs and con- duration procedures and accurate and high-
cerns can thus be addressed quickly and effi- quality impressions, which are crucial for suc-
ciently, even in emergencies. Providing patients cessful outcomes and avoid the need for re-
with the assurance that impression taking will taking impressions. By following these simple
not need to be repeated creates a positive ex- strategies, dental practitioners can ensure pa-
perience for the patient, which in turn helps tient comfort both during impression taking
reduce future dental anxiety. and beyond, by creating a positive experience
With impressions made from VPS, a provi- that will carry over to future dental visits.
sional restoration that needs adjustment or be-
comes dislodged can be remade using the ini- REFERENCES
tial impression. Even after final restorations 1. Hoffman B, Erwood K, Ncomanzi S, Fischer V,
are delivered, temporary crowns may again O’Brien D, Lee A. Management strategies for adult pa-
be needed.18 For example, patients who under- tients with dental anxiety in the dental clinic: a system-
go gingival surgery or implant placement may atic review. Aust Dent J. 2022;67(Suppl 1):S3-S13.

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2. Eachempati P, Kumbargere Nagraj S, Kiran Kumar 11. Hashim MJ. MD patient-centered communication:
Krishanappa S, George RP, Soe HHK, Karanth L. Man- basic skills. Am Fam Physician. 2017;95(1):29-34.
agement of gag reflex for patients undergoing dental 12. Yang X-J, Jiang H-M, Hou X-H, Song J. Anxiety
treatment. Cochrane Database Syst Rev. 2019;2019(11): and depression in patients with gastroesophageal reflux
CD011116. disease and their effect on quality of life. World J Gastro-
3. Dickinson CM, Fiske J. A review of gagging problems enterol. 2015;21(14):4302-4309.
in dentistry: 2. Clinical assessment and management. 13. Alhajj M, Babos M. Physiology, Salivation. In: Stat-
SADJ. 2006;61(6):258-262, 266. Pearls [Internet]. Treasure Island, FL: StatPearls Publish-
4. Mangano A, Beretta M, Luongo G, Mangano C, Man- ing; 2021. Available from: https://www.ncbi.nlm.nih.gov/
gano F. Conventional vs digital impressions: acceptabil- books/NBK542251/. Accessed February 4, 2022.
ity, treatment comfort and stress among young orthodon- 14. Scarborough D, Bailey-Van Kuren M, Hughes M.
tic patients. Open Dent J. 2018;12:118-124. Altering the gag reflex via a palm pressure point. J Am
5. Yilmaz H, Konca FA, Aydin MN. An updated com- Dent Assoc. 2008;139(10):1365-1372.
parison of current impression techniques regarding time, 15. Farrier S, Pretty IA, Lynch CD, Addy LD. Gagging
comfort, anxiety, and preference: a randomized crossover during impression making: techniques for reduction. Dent
trial. Turk J Orthod. 2021;34(4):227-233. Update. 2011;38(3):171-172, 174-176.
6. Facco E, Zanette G. The odyssey of dental anxiety: 16. Massad J, Lobel W, Garcia L, Monarres A, Hammes-
from prehistory to the present. a narrative review. Front fahr PD. Building the edentulous impression–a layering
Psychol. 2017;8:1155. technique. Compend Contin Educ Dent. 2006;27(8):
7. Armfield JM. Towards a better understanding of dental 446-451.
anxiety and fear: cognitions vs. experiences. Eur J Oral 17. Kurtzman G. Creating great dental impressions.
Sci. 2010;118(3):259-264. Inside Dental Assisting. 2012;8(1):42-45.
8. Forbes-Haley C, Blewitt I, Puryer J. Dental manage- 18. Heboyan AG, Muradyan RG. Impression material se-
ment of the ‘gagging’ patient - an update. Int J Dental lection and soft tissue management in contemporary fixed
Health Sciences. 2015;3(2):424-431. prosthodontics. Int Acad Journal Web of Scholar. 2019;
9. Davies AE, Stone SP, Kidd D, MacMahon J. Pharyn- 5(35). doi: 10.31435/4sglobal_wos/31052019/6499
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DENTAL MATERIALS
Ensuring Patient Comfort and Clinical Accuracy
During Impression Taking
Shannon Pace Brinker, CDA, CDD

1. What is the prevalence of gagging during impression 6. Which of the following should be done when having an
taking? initial conversation with patients about their anxieties
A. 25% before taking impressions, to help inspire trust and convey
B. 57% sensitivity and understanding?
C. 82% A. Explain the impression-taking procedure
D. The exact prevalence is unknown B. Explain the estimated time for placement and setting
C. Answering patients’ questions while encouraging them to
2. Dental anxiety is how prevalent worldwide? share their anxieties
A. Not highly prevalent (approximately 1%) D. All of the above
B. Highly prevalent (approximately 25%)
C. Extremely highly prevalent (approximately 80%) 7. Because acupressure uses gentle-to-firm finger pressure
D. 97% alone to stimulate pressure points on the body, it is:
A. ideal for self-treatment wherever and whenever necessary.
3. Which of the following patients have reported feelings B. useful for addressing anxiety, but not the gag reflex.
of vulnerability and “of not being in control” as well as the C. performed only by a licensed therapist.
perceived “unpredictability” of the procedures as reasons D. All of the above
for their [dental] anxiety?
A. Only patients who have experienced pain during prior dental 8. Alginate impression materials historically have
visits demonstrated which of the following?
B. Only patients who have had negative dental experiences A. Low tear strength C. High expense
C. Many patients who have never had negative dental B. Hydrophobicity D. None of the above
experiences
D. None of the above 9. Which of the following are advantages of vinyl
polysiloxane ((VPS) material?
4. What percentage of people have a hypersensitive gag A. It produces great detail reproduction
response in which even the slightest sensation can trigger B. It has stability over time
an involuntary throat contraction? C. It has high tear strength
A. 1% C. 37% D. All of the above
B. 10% to 15% D. 67%
10. An impression made from VPS can withstand:
5. Which areas of the oral cavity are trigger zones for gagging? A. numerous pours.
A. The lips, palate, uvula, and the tongue B. lack of proper moisture control without affecting its ability to
B. The palate, uvula, tip of the tongue, and posterior pharyngeal achieve fine details and accuracy.
wall C. only one pour, after which duplicates will need to be made
C. The palate, uvula, base of the tongue, the fauces (leading to with a unique material.
the pharynx), and the posterior pharyngeal wall D. B and C
D. The uvula, base of the tongue, buccal mucosa, and posterior
pharyngeal wall

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