Managing Gag Reflex during Removable Partial Denture
Treatment: A Review and a Clinical Report
Spyridon Stefos, DDS, MS,1 Panagiotis Zoidis, DDS, MS, PhD,2 & Arthur Nimmo, DDS, FACP2
1
Private practice, Ioannina, Greece
2
Department of Restorative Dental Sciences, Division of Prosthodontics, University of Florida College of Dentistry, Gainesville, FL
Keywords Abstract
Final impression; gag reflex; removable partial
dentures; table salt.
A gag reflex is a common occurrence during dental procedures. A hypersensitive
gag reflex is less frequently encountered and may prevent the dental provider from
Correspondence
successfully completing critical clinical stages, resulting in poor treatment outcomes.
Panagiotis Zoidis, DDS, MS, PhD, Once patients suffer an unpleasant gag reflex experience in a dental office, they may
Department of Restorative Dental Sciences, become phobic, delaying or postponing their dental treatment. The purpose of this
University of Florida College of Dentistry, PO article is to review available treatment options and present a report of a partially
Box 100415, Gainesville, FL 32610-0415. edentulous patient with an exaggerated gag reflex, focusing on clinical management
E-mail: pzoidis@dental.ufl.edu using a simple yet effective table salt technique and proper prosthesis design.
Presented in part at the European
Prosthodontic Association (EPA) 41st Annual
Conference in Bucharest, Romania,
September 28st - 30th 2017.
The authors deny any conflicts of interest.
Accepted May 22, 2018
doi: 10.1111/jopr.12957
A gag reflex is a physiologic, involuntary defense mechanism Anatomical factors related to gag reflex are an atonic soft
to protect the pharynx and throat (soft palate, pharynx and palate, undue sensitivity of the soft palate, uvula, fauces, poste-
pharyngeal part of the tongue) from foreign objects.1-3 The rior pharyngeal wall, and the tongue.6 Medical factors are nasal
gag reflex is stimulated and controlled by nerve endings sit- obstruction, postnasal drip, sinusitis, nasal polyps, and conges-
uated in the soft palate, pharynx, and pharyngeal part of the tion of the oral, nasal, and pharyngeal mucosa. Iatrogenic and
tongue.2,4,5 Five intraoral areas known to be “trigger zones” dental factors that can cause gag reflex are inadequate posterior
are the palatoglossal and palatopharyngeal folds, base of the palatal seal, restricted tongue space in dentures, and overex-
tongue (posterior third), palate, uvula, and posterior pharyngeal tended borders.3,5,11,15
wall.6 Dental procedures such as obtaining impressions of max-
Gagging is a common problem during dental treatment, and illary and mandibular arches,2,7-9,11 mapping the posterior vi-
can make therapeutic procedures (e.g., tooth preparation, im- brating line for complete dentures,7 tooth preparations in pos-
pressions, mapping posterior vibrating line) distressing, diffi- terior teeth,7,8 third molar extraction,7 endodontic treatment of
cult, or even impossible to perform, with a higher incidence in posterior teeth,7 the taking of radiographs,2,5,8 and in some in-
female patients.7-11 Exaggerated gag reflex may lead to prob- dividuals, the insertion of a finger for examination purposes8
lems during clinical stages of fabrication and during wearing may cause an exaggerated gag reflex, which poses difficulty in
of removable complete and partial prostheses.12 An unusually performing the procedures successfully.7 Psychological factors
active gag reflex upsets the patient and consequently may lead include stress, phobia, alcoholism, fear, and visual and olfactory
to avoidance of routine dental treatment, poor oral hygiene, and stimuli. For many patients, the precise differentiation between
tooth loss.1,3,8,11,13,14 somatogenic and psychogenic gag reflex is not possible.11
Gag reflex management depends on treating the cause and not Many ways and techniques can be easily mastered by clin-
merely the symptoms. Thorough examination, medical history icians and may help both dentist and patient to deal with gag
review, and conversation with the patient help the dentist to reflex.1-3,5,7,8,10,15-17 The pharmacological technique incorpo-
identify the cause.15 rates pharmacological agents to manage gagging, can either act
Journal of Prosthodontics 00 (2018) 1–5
C 2018 by the American College of Prosthodontists 1
Managing Gag Reflex during RPD Treatment Stefos et al
peripherally or centrally, and can be local or general anesthetics, This clinical report describes the successful management of
herbal remedies, anti-nausea medicines, and sedatives.3,5,17 a partially edentulous patient with an exaggerated gag reflex,
A glossopharyngeal nerve block is a relatively safe, simple, emphasizing impression technique and final prosthesis design.
easy to master technique for treating a patient with exagger-
ated gag reflex, especially when performing dental procedures Clinical report
in the posterior part of the mouth.7 The use of topical anes-
thetics to anesthetize the soft palate,1,3,5,7,14,17 injecting the soft A 61-year-old man presented for replacement of his posterior
palate,1 or injecting a few drops of local anesthetic into the missing teeth, in a “dental fear” state. The patient’s chief com-
posterior palatine foramen,5 or use of various drugs such as plaint was impairment his chewing efficiency due to lack of
barbiturates to depress the central nervous system, sedatives, posterior teeth. He also reported discomfort when large items,
antihistamines to reduce the feeling of sickness, parasympa- such as a toothbrush or dental mirror were in his mouth because
thetic depressants to reduce salivation, and antinausenants,1,14 of his gag reflex. As a result, the patient rarely made visits to
have been suggested to reduce gag reflex. These anesthetics and the dentist and received only conservative periodontal treatment
premedications have drawbacks and side effects and may make and extractions as emergency treatment. He finally decided to
the patient apprehensive.1 address his esthetic and functional needs.
The potential of intravenous (IV) sedation as a way to over- His medical history was free of any disease, and he had no
come the gag reflex has not been sufficiently explored in den- current medications. Clinical examination revealed lack of pos-
tistry, probably due to the long recovery time and the occa- terior support due to multiple missing teeth in both arches, poor
sional need for hospital admission.3,13,17 Nonpharmacological oral hygiene, and a high caries rate. Several nonrestorable roots
techniques include behavioral modification, prosthetic manage- were present in both arches. The patient was diagnosed with
ment, use of table salt, acupressure, and acupuncture.3,5,16,17 generalized moderate periodontitis by the referring periodon-
Individual patient assessment is prioritized as the dentist at- tist. The nonrestorable teeth were extracted. Initial periodontal
tempts to identify situations that trigger gagging. Treatment therapy and CAMBRA (caries management by risk assessment)
history is recorded and should be specific and open questioning protocol were used.29
about previous dental treatment. Clinical examination should Following initial therapy, the remaining teeth were the max-
be conducted with a ball burnisher to identify trigger zones. illary canines, mandibular premolars, and canine on the left
The treatment approach can be modified, incorporating vari- side, and the first premolar and canine on the right (Fig 1). No
ous gagging reduction therapies such as behavioral techniques temporobandibular disorder signs or symptoms were observed
(relaxation, distraction, desensitization), complementary ther- during clinical examination.
apies, psychological approaches, and certain pharmacological Two removable partial dentures (RPD) were treatment
agents.4,5,14,15 planned to restore posterior occlusion and support. The patient
Distraction techniques include conversation,18 raising one of was highly anxious about treatment due to previous experience
the legs,19 or putting table salt on tip of tongue.2,3,14,15 Table salt, with another dentist who could not complete treatment and
for 5 seconds on the tip of the tongue, eliminates the gag reflex dismissed the patient from the practice.
acting on chorda tympani branches in two-thirds of the tongue’s At the start of definitive prosthodontic treatment, a detailed
taste buds.2,3,14,15 Desensitization techniques such as the marble medical and dental history was recorded, and trigger zones were
technique,20 training dentures,21,22 soft vacuuform splints, and identified with the help of a ball burnisher. An immediate gag
slow swallowing technique23 are the most commonly used.15 reflex was provoked as the burnisher reached the junction of
Of primary importance is to gain the patient’s confidence,1 hard and soft palate and as the mirror or fingers touched the
and to make routine dental care possible by reducing anxiety tongue.
and helping them “unlearn” previous behavior that leads to The use of table salt as an immediate behavioral management
gagging.5,13,17 These may occur at any stage of treatment, in- technique was advocated to improve patient’s tolerance during
cluding impression-taking, maxillomandibular registration, the appointments and impression taking. The patient was instructed
complete denture wax try-in, on complete denture delivery, and to extend his tongue, and apply salt to the tip of his tongue for
during the recall stage.24-26 approximately 5 seconds (Fig 2).
Most articles describe impression making as the most fear- Impression trays were carefully and gently inserted, and con-
ful and stressful dental procedure for patients with severe gag tact with trigger zones avoided. Preliminary diagnostic impres-
reflex.2,3,5,9-12,14,15,24 Some techniques have been used to re- sions were performed using stock trays and fast-set irreversible
duce gag reflex during impression procedures.3,8 Tray extension hydrocolloid impression material (Kromopan; Kromopan USA
and adaptation,8,15,24 or even the use of alternative impression Inc., Morton Grove, IL) in a thick mix to reduce time and pos-
materials,8,15 altered consistency to avoid overflow,15 breathing terior flow. The resulting diagnostic casts were fabricated using
techniques,8,15 acupressure,8,16 acupuncture27 or hand pressure type III dental stone and were surveyed and tripoded to design
point,13,16,28 as well as nitrous oxide inhalation14 are some of the RPDs.
these techniques. It has been suggested that nitrous-oxide in- Mouth preparation including tooth re-contouring, guide
halation reduces the negative perception and the conditions planes, and occlusal rest preparations were performed. Custom
associated with gagging, and thereby increases patient toler- trays were fabricated using light-polymerized resin material
ance to the placement of intraoral objects.13 Clinicians may (Triad Trutray; Dentsply Sirona, York, PA). Border molding
have to try several of these, perhaps in conjunction, to assist was performed using impression compound (Green Stick; Kerr
their patients.8,15 Corp., Orange, CA) and poly(vinyl siloxane) (PVS) impression
2 Journal of Prosthodontics 00 (2018) 1–5
C 2018 by the American College of Prosthodontists
Stefos et al Managing Gag Reflex during RPD Treatment
Figure 4 Mandibular RPD framework.
Figure 1 Retained maxillary and mandibular teeth following initial
therapy.
Figure 2 Patient applying table salt to the tip of his tongue.
Figure 5 Definitive prostheses – occlusal views. A. Maxillary RPD.
B. Mandibular RPD.
Figure 3 Maxillary RPD framework.
material (Aquasil Ultra Monophase; Dentsply Caulk, Milford,
DE) was used for the final impression. Definitive casts were fab-
ricated in type IV dental stone (Silky Rock; Whip Mix Corp.,
Louisville, KY), and the RPDs were waxed, sprued, and cast in
a cobalt chromium alloy (Vitallium; Dentsply Sirona).
The maxillary RPD used a U-shaped palatal major connector,
wrought wire clasps as direct retainers, engaging in buccal un-
dercuts on the maxillary canines, and definitive occlusal rests on
the maxillary canines (Fig 3). The mandibular RPD consisted Figure 6 Definitive prostheses, frontal view.
Journal of Prosthodontics 00 (2018) 1–5
C 2018 by the American College of Prosthodontists 3
Managing Gag Reflex during RPD Treatment Stefos et al
of a lingual plate major connector, wrought wire clasps engag- The table salt technique alleviates gag reflex, extending
ing buccal undercuts of the left second premolar and right first working time and facilitating prosthodontic procedures in a
premolar, with mesial rests to minimize stress on these abut- comfortable manner. It is simple, does not require special or
ments (Fig 4). Metal frameworks were tried in, and physiologic expensive instrumentation or drug administration, and is ade-
adjustment was done on the guide plates to minimize stress quately effective for the treatment of RPD cases when compared
on the abutment teeth. An occlusal registration was performed to other available treatment methods.
using PVS material (Blu-Mousse; Parkell Inc, Edgewood, NY). The impression material was medium-consistency, fast-
Artificial tooth selection (Trubyte Bioblend; Dentsply setting, monophase PVS in order to minimize flow beyond the
Sirona) and denture tooth set-up were performed. Wax try-in tray and increase comfort during the procedure. The technique
was performed, and occlusion and esthetics were verified prior of using interim RPDs to introduce the patient to RPD treat-
to RPD processing. Heat-polymerizing acrylic resin (Lucitone ment modality and help reduce gag reflex over time was not
199; Dentsply Sirona) was used for RPD processing according used in this instance, since it would prolong treatment,12 and
to the manufacturer’s instructions. because acrylic resin is thicker than metal, therefore creating
The RPDs were fitted and inserted, and patient was instructed more gagging. Also, since the major connector was designed
in prosthesis placement and removal (Figs 5 and 6). The maxil- for reduced palatal coverage there was no need for use of train-
lary RPD design avoided proximity to trigger zones, resulting ing prostheses. Regular maintenance appointments should be
in comfort and easy treatment acceptance. A schedule of peri- scheduled for these patients, since ridge resorption and the per-
odic maintenance appointments was set to re-evaluate patient ception of space under denture bases and major connectors, as
compliance. well as instability, further triggers the gag reflex.4
Discussion Conclusion
Although gagging is a physiologic protective reflex, it can be- Using the table salt technique is a very simple, fast, and practi-
come very disturbing, causing anxiety and dental fear. The top cal method for a dentist to manage gagging without using more
priority of the provider should become to reduce the level of invasive and complicated methods. It also promotes patients’
stress and gain the patient’s confidence.14 Identifying trigger behavioral adjustment to dental care, allowing the provider
zones and managing them appropriately does not only increase to perform critical stages of treatment, leading to successful
patient comfort, but also helps during various steps of treatment. treatment outcomes. The design of the final restoration in-
Gender may influence the type of gag reflex. It has been re- creased patient comfort, resulting in compliance and treatment
ported that females showed a higher incidence of dental fear acceptance.
and gag reflex than males, who are reported to have more so-
matogenic gag reflex.11 This is explained because women have
relatively smaller jaws and may be psychologically more sen- Acknowledgment
sitive when compared to males.4 This article described a male
with an exaggerated gag reflex, less commonly reported in the In memory of the late Prof. Asterios Doukoudakis for the initial
current literature. and practical idea of using table salt.
There could also be an association with gag reflex and the
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