Republic of Iraq

Ministry Of Higher Education

And Scientific Research
University Of Baghdad
College Of Dentistry

Gag Reflex, Treatment Options

and Procedures

A project submitted to
the Prosthodontic Department/College of Dentistry,
University of Baghdad
in partial fulfillment of the requirement for a B.D.S.
degree

By:
Maram Dheyaa Fadhil

Supervised by:
Assist. Lect. Zinah Salah Mawlood
B.D.S., M.Sc. Prosthodontics

2023 A.D. 1444 A.H.

‫من سورة يوسف‪ /‬جزء من االية (‪)٧٦‬‬
 Declaration

I certify that this project entitled " Gag reflex, Treatment Options and

Procedures " was prepared by the fifth-year student Maram Dheyaa Fadhil

under my supervision at the College of Dentistry/University of Baghdad in

partial fulfilment of the graduation requirements for the bachelor’s degree

in Dentistry.

Assist. Lec. Dr. Zinah Salah Mawlood

I
 Dedication
All thanks to Allah for giving me the strength to do the best I can and to
be in place.
They said, "The women who were prevented from running will give birth
to women with wings."
To whom gave me wings from the depths of grief
To whom suffered, endured, and waited till the end
To my mother
To whom God made a supporting spirit for me, encouraged and always
told me, "You can."
To Abeer
To everyone who wished me the best.

Maram Dheyaa

II
 Acknowledgment
First of all, I thank God Almighty, who blessed me with wisdom,
patience, and willpower to reach this level in my life.
I would like to thank Professor Dr. Raghad Al Hashimi, the dean of the
College of Dentistry, University of Baghdad for providing me the
opportunity to complete my work.
Also, I express my thanks to Prof. Dr. Ali H. AlBustani, Assistant Dean
for Scientific Affairs and students of the College of
Dentistry-University of Baghdad for his continuing support to complete
this work.
I would like to thank Asst. Prof. Dr. Abdulbasit Ahmed, the chairman of
the prosthodontic department for his support.
My sincere appreciation is to my supervisor Dr.Zinah Salah, for his
thoughtful guidance, suggestion, invaluable help and advice planning and
conducting this research.

III
 List of Content
Subject Page No.
Declaration I
Dedication II
Acknowledgment III
List of Content IV
List of Figure VII
List of Tables VIII
List of Abbreviation IX
Introduction 1
Aims of the study 3
Chapter One: Literature Review
1.1 The Nature of the gag reflex 4
1.2 The Development of the gag reflex 4
1.3 The Mechanism of the gag reflex 5
1.4 Method for examining the susceptibility of gagging 7
1.4.1 Equipment used in the examination of gagging 7
1.4.2 Technique used in the examination of gagging 7
1.4.3 Alternatives in the examination of gagging 7
1.4.4 Contraindications in the examination of gagging 8
1.5 Classification of the gag reflex 8
1.6 Etiology of Gagging 10
1.6.1 Local factors 10
1.6.2 Systemic Factors 10
1.6.3 Psychological factors 10
1.6.4 Prosthetic factors 10
1.6.5 Iatrogenic factors 10

IV
1.7 Extraoral stimulation of gag reflex 11
1.8 Intraoral Stimulation of gag reflex 11
1.9 Clinical features of gag reflex 12
1.10 Methods for the Management of Gag Reflex 12
1.10.1 Psychological Intervention 13
1.10.1.1 Relaxation 13
1.10.1.2 Distraction 13
1.10.1.3 Systematic desensitization 15
1.10.1.4 Cognitive Behavioral Therapy (CBT) 16
1.10.2 Prosthodontic Management 16
1.10.2.1 The selection of trays 16
1.10.2.2 Patient position 16
1.10.2.3 Material selection 16
1.10.2.4 Posterior palatal seal area 17
1.10.2.5 Modification of maxillary custom tray 17
1.10.2.6 Recording jaw relations 17
1.10.2.7 Final Prosthesis Fabrication 17
1.10.2.8 Use of Training Bases 18
1.10.2.9 Making implant-retained prostheses 18
1.10.2.10 Roofless dentures 18
1.10.2.11 Matte finished dentures 19
1.10.2.12 Post insertion denture issues 19
1.10.3 Pharmacological Methods 19
1.10.4 Surgical Correction 21
1.10.5 Acupuncture and Acupressure Therapy 22
1.10.6 Laser Stimulation 25
1.10.7 Intraoral scanning systems 25
Chapter Two: Conclusion

V
2. Conclusion 27
References 28

VI
 List of Figure

Figure Page No.

Figure 1: The mechanism of gag reflex 6
Figure 2: Earplug and temporal tap method 14
Figure 3: Ear anti-gagging point 22
Figure 4: The Pressure points 24
Figure 5: A. The acupuncture point conception vessel 24 25
(CV 24)
B. View of a red-light soft magnetic field laser
stimulation on CV 24

VII
 List of Tables

Tables Page No.

Table 1: Centrally acting agents. 20
Table 2: Provides details of the various pressure points 23
that have been employed for relieving gagging reflex.

VIII
 List of Abbreviations
CN IX Cranial nerve 9
CN X Cranial nerve 10
CN V Cranial nerve 5
CN 12 Cranial nerve 12
GSI Gagging Severity Index
PPS Posterior Palatal Seal
CBT Cognitive Behavioral Therapy
VD The Vertical Dimension
GNB Glossopharyngeal Nerve Block
CNS Central Nervous System
5-HT3 5-hydroxytryptamine
IV Intravenous
nm nanometer
cm centimeter
HZ Hertz
mW milliwatts
mm millimeters
ml milliliter
3D Three dimensional
CV-24 Conception vessel-24

IX
Introduction
The gag reflex also called gagging is a normal, defensive,
physiological mechanism that happens to forestall foreign bodies or toxic
materials from getting entry to pharynx, larynx or trachea (Kaira et al.,
2014).
In 1959, Schote found a relation between gag reflex and vomiting
reflex and revealed that gagging center and vomiting center lies in dorsal
portion of lateral reticular formation of medulla oblongata and may include
tractus solitarius (Schole, 1959).
In 1970, Means and Flennien stated that mechanisms of swallowing
and gagging are also physiologically related to each other as both
mechanisms share similar afferent neural pathways, brain centers and
efferent neural pathways (Means and Flennien, 1970).
A prosthodontist commonly encounters patients with gagging while
providing prosthodontic treatment (Van Houtem et al., 2015).
Various stimulating or triggering factors of gag reflex in prosthodontic
patients but broadly the gag reflex has been classified as either somatogenic
or psychogenic (Dickenson and Fiske, 2005; Ahmad et al., 2015).
Somatogenic gagging starts from insufficient retention of the
prosthesis, thick posterior borders of the denture, inadequate posterior seal,
lack of tongue space and malocclusion. Psychogenic gagging is triggered
by anxiety, taste, fear and apprehension (ALI et al., 2018).
Some factors contribute and initiate gagging in patients, these are
categorized as anatomical, medical, psychological and dental/iatrogenic
factors (Bassi, 2004; Goyal, 2014).
There are different levels of severity of this problem in different
patients. Faigenblum categorized such patients by severity of the problem.
The prosthodontic patient’s gagging problems were divided into mild and
severe in this study (Eachempati et al., 2019).
1
 Identifying the severity of this condition enables the physician to
determine if the patient can handle standard treatment techniques or an
alternative method must be considered (Dickinson and Fiske, 2006).
Numerous authors have discussed various etiologies, methods of
assessment and symptoms of gagging. Many treatment modalities
including psychological intervention, prosthodontic management,
systemic desensitization, pharmacological methods, surgical correction,
acupressure and acupuncture have been tried to curb the gag Reflex (patil
et al., 2020; patil et al., 2021).

2
Aims of the study
To review the mechanism, etiology, clinical features of gag reflex,
and the role of different methods to treat gagging in the
prosthodontic clinic.

3
Chapter One: Literature Review
Chapter One Literature Review

1.1 The Nature of the gag reflex

The gag reflex is a normal protective and healthy defense mechanism
of the human body. This reflex prevents entry of foreign objects into
trachea and lower airway. Initially, there is puckering of the lips aiming to
close jaws. The tongue is then elevated with rotation postero-anteriorly and
with the hyoid bone at the center. Then, soft palate and hyoid bone gets
elevated followed by fixation of the hyoid bone. It is followed by
contraction of anterior and posterior faucial pillars, rotation of tonsils in an
anteromedial direction and elevation, contraction and retraction of the
larynx with closure of the glottis. Simultaneous, uncoordinated spasm of
respiratory muscles may occur followed by vomiting. On stimulation of
trigger zones, afferent impulses are transmitted to gag reflex center in the
medulla oblongata. From this gag reflex center, efferent impulses are
transmitted to effector cells located in the same initial region that can carry
out the appropriate response. This results in uncoordinated spasmodic
movements of pharyngeal muscles causing gagging. The gagging center
lies near the vomiting, salivating and cardiac centers in medulla oblongata.
This explains why gagging is frequently associated with these additional
reflexes like increased salivation, increased lacrimation, increased
heartbeat, etc (Sarwono, 2022).
1.2 The Development of the gag reflex
The gag reflex is mediated by the glossopharyngeal nerve (CN IX) and
the vagus nerve (CN X). Embryologically, the glossopharyngeal nerve is
associated with the derivatives of the third pharyngeal arch, while the
vagus nerve is associated with the derivatives of the fourth and sixth
pharyngeal arches (Frisdal and Trainor, 2014).
In the first few months of life, the gag reflex is triggered by any food
that the nucleus tractus solitarius deems too large or solid for a baby to

4
Chapter One Literature Review

digest. Starting around six or seven months of age, the gag reflex
diminishes, allowing infants to swallow more solid foods (Stevenson and
Allaire, 1991).
1.3 The Mechanism of the gag reflex
The gag reflex can be classified as either somatogenic or psychogenic.
A somatogenic gag reflex follows direct physical contact with a trigger
area, which may include the base of the tongue, posterior pharyngeal wall,
or tonsillar area. A psychogenic gag reflex presents a mental trigger,
typically without direct physical contact. In cases of psychogenic gag
reflexes, even the thought of touching a sensitive trigger area, such as
occurs when going to the dentist, can induce gagging (Saunders and
Cameron, 1997).
The gag reflex is controlled by both the glossopharyngeal (CN IX) and
vagus (CN X) nerves, which serve as the afferent (sensory) and the efferent
(motor) limbs for the reflex arc, respectively. The nerve roots of cranial
nerves IX and X exit the medulla through the jugular foramen and descend
on either side of the pharynx to innervate the posterior pharynx, posterior
one-third of the tongue, soft palate, and the stylopharyngeus muscle
(Klimaj et al., 2020).
The stimulus is provided by sensation to the posterior pharyngeal wall,
the tonsillar pillars, or the base of the tongue. These sensations are carried
by CN IX, which acts as the afferent limb of the reflex to the ipsilateral
nucleus solitarius (also referred to as the gustatory nucleus) after synapsing
at the superior ganglion located in the jugular foramen. In turn, these nuclei
send fibers to the nucleus ambiguus, a motor nucleus in the rostral medulla.
Efferent nerve fibers to the pharyngeal musculature traverse from the
nucleus ambiguus through CN X, as shown in (figure:1), resulting in the
bilateral contraction of the posterior pharyngeal muscles. Contraction of
the pharyngeal musculature ipsilateral to the side of the stimulus is known
5
Chapter One Literature Review

as the direct gag reflex, and contraction of the musculature on the

contralateral side is known as the consensual gag reflex. Stimulation of the
soft palate can also elicit the gag reflex; in this case, the sensory limb is the
trigeminal nerve (CN V). Here, sensory stimulation of the soft palate
travels through the nucleus of the spinal tract of the trigeminal nerve
(Sivakumar and Prabhu, 2022).

Figure 1: the mechanism of gag reflex.

(Fisch, 2012;Sivakumar and Prabhu, 2022)

6
Chapter One Literature Review

1.4Method for examining the susceptibility of gagging

1.4.1 Equipment used in the examination of gagging

The gag reflex can be elicited using a tongue blade or soft cotton
applicator. However, a suction device may be most convenient for testing
in an intubated patient (Sivakumar and Prabhu, 2022).

1.4.2 Technique used in the examination of gagging

The examiner stimulates the posterior pharynx using a tongue blade or

cotton applicator. After doing so, the patient will produce a gagging
reaction, which may lead to vomiting in some individuals. Additionally,
the elevation of the bilateral posterior pharyngeal muscles requires
examination. In a study among 104 medical students assessing the gag
reflex, researchers noticed that stimulation of the posterior pharynx was
more likely to elicit a gag reflex when compared to stimulation of the
posterior tongue (Abe et al., 2014).

An asymmetric response or absence of response when stimulating one

side indicates the presence of pathology and warrants further assessment
(Sivakumar and Prabhu, 2022).

1.4.3 Alternatives in the examination of gagging

Soft palatal reflex can help to assess the function of CN IX and CN X,

as this reflex may be intact in the absence of the gag reflex. The voice is
evaluated by looking for hoarseness and dysphonia to determine CN X
pathology. Research has also found that the cough reflex was better
reproduced in intubated patients than the gag reflex to test for brainstem
function (Polverino et al., 2012).

7
Chapter One Literature Review

1.4.4 Contraindications in the examination of gagging

The gag reflex should not be performed during airway assessment for
intubation in an obtunded patient due to the risk of vomiting and
subsequent aspiration (Mackway-Jones and Moulton, 1999).

Assessing the oral cavity in patients with a hypersensitive gag reflex

may be difficult. These patients may benefit from intravenous sedation
during prosthodontic treatment (Yoshida et al., 2007).

1.5 Classification of gag reflex

Faigenblum classified gag reflex as mild form to severe retching.
Patients showing mild retching may feel nauseated because of the
reaction to the stimulus and they can control and manage the reaction
on their own. There is no need for any clinician intervention. Most of
the patients lie in this category. Severe forms of retching can also
occur easily and may require physical intervention. Patients may get
choking sensation (Faigenblum, 1968).
Morstad also classified gagging based on time duration, whether
gagging occurred immediately after delivering of prosthesis or after
certain delayed period (Hajira et al., 2020) :
1. Immediate gagging – Overextension at post palatal
region in maxillary denture or bulky distolingual flange in mandibular
denture can cause this type of gagging. It occurs immediately on insertion
of the prosthesis in patient’s mouth.
2. Delayed – This type of gagging occurs in a period of two weeks to two
months after denture insertion. Incomplete and improper border seal
allows flow of saliva under the denture and stimulates the gag reflex.

8
Chapter One Literature Review

Fiske and Dickinson gave Gagging Severity Index (GSI) and classified
gagging into five grades (Fiske and Dickinson, 2001) :

1. Grade I (Normal/Obtunded gag reflex): This type of gagging is a very

mild form and can be controlled and managed by the patient. It is
present during dental treatment procedures like making maxillary
impressions or restorative procedure of palatal, distal or lingual surfaces
of molars.
2. Grade II (Mild/Partially controlled gag reflex): This is also a mild type
of gagging. It can occur during dental treatment procedures such as
scaling, restorations and impression making but does not limit dental
procedure. Patients need assurance from the dentist to control gag
reflexes.
3. Grade III (Moderate/Partially controlled gag reflex but frequent): This
is a moderate type of gagging which sometimes restricts treatment
procedure. It may occur during simple dental procedures such as
clinical examination of regions such as lingual aspect of lower molars.
4. Grade IV (Severe/Inadequately controlled gag reflex): This represents
a severe form of gagging and dental treatment becomes difficult without
clinician interventions. This type of gag can occur with even simple
visual examination.
5. Grade V (Very severe gagging): This form of gagging is very severe
and can affect patient’s behavior on dental chair. It occurs very easily,
frequently and does not require any physical intervention to trigger the
gag reflex. Dental treatment is highly impossible without proper
management of gag reflex.

9
Chapter One Literature Review

1.6 Etiology of Gagging

1.6.1 Local factors
These factors Include: Nasal obstruction, Deviated septum, Postnasal
drip, sinusitis, Nasal polyps and congestion of the oral, nasal and
pharyngeal mucosa (Bassi et al., 2004).
1.6.2 Systemic Factors
These factors Include: alcoholism, smoking, chronic gastritis, carcinoma
of the stomach, partial gastrectomy, peptic ulceration, cholecystitis,
carcinoma of the pancreas, diaphragmatic hernia, uncontrolled diabetes
and medication produces nausea as a side effect (Dickinson et al., 2006;
Rubina, 2018).
1.6.3 Psychological factors
These factors Include: Eating disorders, fear, stress, Neuroticism and
learned responses (Meenakshi et al., 2021).
1.6.4 Prosthetic factors
Prosthetic factors such as overextended denture borders (posterior
portion of maxillary denture and distolingual region of mandibular denture
may trigger regions resulting in a gag), inharmonious occlusions, poor
retention of dentures, inadequate PPS, inadequate or excessive surface
finish of the acrylic dentures and an inadequate freeway space also cause
gagging reflex (Dickinson and Fiske, 2006).
Patients reported that the issue was particularly severe in the morning
hours during dental hygiene procedures and denture insertion process. The
reason for this could be that the patients were not habituated to the
stimulation that is caused by the dentures, as they were not worn at night
for many hours (Meenakshi et al., 2021).
1.6.5 Iatrogenic factors
These factors Include: suction and water tubes, instrumentation,
radiography, poor clinical technique, and overloaded impression tray also
10
Chapter One Literature Review

contribute to gagging. Finally, the psychosomatic factors classified under

classical conditioning process and operant conditioning process also add to
the factors responsible for gagging. The gag reflex may start due to an
overflowing impression tray or if a significant quantity of water is collected
in the mouth from the handpiece. Whenever the patient learns to strongly
identify the stimuli as a trigger for gagging, a conditioned gag reflex to
such stimuli may develop (Patil et al., 2020).
Similarly, the operant conditioning process is a training strategy in
which the outcomes of a response influence the chance that the subject will
repeat that response. Some behavior patterns may be rewarded in operant
conditioning because they gain attention and compassion, avoid a stressful
circumstance, or accomplish another desirable result. One example is that
a patient who gags unintentionally learns to identify it with the temporary
cessation of therapy. This outcome is favorable for him since the patient
gains from the action, that is the treatment comes to a halt, this is consistent
with the operant conditioning process (Bartlett, 1971; Ansuia et al.,
2012).
1.7 Extraoral stimulation of gag reflex
Extraoral stimulation of gag reflex such as visual and auditory stimuli.
For example, the mere sight of impression trays, mouth mirror, and the
smell or taste of various dental materials (Kaira et al., 2014).
1.8 Intraoral Stimulation of gag reflex
The palate is divided into two regions that show different responses
namely, the hyposensitive and hypersensitive ones.
The hyposensitive anterior section is separated from the hypersensitive
posterior section by a line imagined through the fovea palatine. In addition,
the tongue is also divided into two different response regions: a hypo-
sensitive anterior third and a hyper-sensitive posterior third. In that, the

11
Chapter One Literature Review

posterior one-third of the tongue is the most sensitive region of the oral
cavity (Goyal, 2014; Kaira et al., 2014).
Apart from these, the prosthetic factors such as inadequate post dam
indentures (causes gagging due to insufficient pressure exerted onto the
palatal tissue and a shallow post dam causing tight pressure might give a
tickling sensation that induces a gag reflex) (Kaira et al., 2014).
1.9 Clinical features of gag reflex
Feintuch described clinical features of a gagging patient. “As the body
trembles and footrest is stamped, large tears roll down from the eyes. The
face of the victim takes on the hue of apoplectic purple and the patient
gasps for breath, at the same time attempting to eject the introduce from
his mouth and his insides with them”. When uncontrolled spasmodic
contraction of muscles of respiration occurs during retching, air is
forcefully passed through the closed glottis, which produces a
characteristic retching sound. Additionally, thoracic muscles undergo
contraction which causes decreased venous return, dilating veins of facial
region, leading to congestion and flushing of the face. Some extra- oral
reflexes and symptoms can be seen during gagging. These include
excessive drooling of saliva, lacrimation, sweating and coughing.
Sometimes, the whole body shows a reaction in response to gagging. If the
stimulus is still present, continuing, or repeated, extremely apprehensive or
excited patient may collapse requiring urgent medical assistance (Kaira et
al., 2014).
1.10 Methods for the Management of Gag Reflex
The treatment of a patient who shows mild to moderate gagging can be
treated in routine dental practice. A patient who shows severe gagging, on
the other hand, needs a change in both the dentist's behavior and the
treatment approach (Rubina, 2018).

12
Chapter One Literature Review

Prior briefing about the intraoral examination should be followed by

the patient’s consent and then the dental procedure. It is the job of the
dental team to be empathic towards the patient's concerns, to begin a
discussion with him, and to instill trust in the patient, Management of this
reflex action should be subjective to individual patients (Goyal, 2014).
1.10.1 Psychological Intervention
1.10.1.1 Relaxation
Relaxation techniques can assist to alleviate the memory of treatments
performed. If the gag reflex is caused by anxiety, relaxation techniques
may be beneficial. Relaxation can assist in alleviating or eliminating
unhelpful thought processes. The patient is instructed to tense and release
some muscle groups, beginning with the legs and moving up, while
offering constant encouragement in a calm environment (Goyal, 2014;
Rubina, 2018).
1.10.1.2 Distraction
The distraction technique could be useful for momentarily diverting the
patient's focus and may enable short dental operations to be conducted
while the patient's mind is detached from potentially uncomfortable
conditions (Gupa et al., 2012).
Landa proposed that the dentist start a conversation with the patient
about a topic of special interest to engage the patient (landa et al., 1946;
Kovats, 1971).
Krol suggested a strategy to distract attention in which the patient is
advised to lift and hold his leg in the air. During this, the patient's muscle
fatigues because to keep the leg up, more and more conscious effort is
required, this distracts the patient and reduces gagging (Krol et al, 1963).
According to Faigenblum, vomiting was impossible during apnea. So,
to control this gagging reflex the patient was urged to increase his

13
Chapter One Literature Review

expiratory effort at the expense of his inspiration. This process will result
in apnea and thus discourage gagging (Faigenblum et al., 1968).
Kovats described a method where the patient breathes audibly through
his nose while repeatedly tapping the right foot on the floor. When
concentrating on these tasks the patient’s focus is shifted away from the
gagging sensation. In addition to these methods, authors proposed that
common salt be used to temporarily eliminate the gag reflex. On tip of the
tongue, table salt is placed for a span of five seconds. The gag is suppressed
by stimulation of the branches of chorda tympani at the taste buds in the
anterior 2/3 of the tongue (Chidiac et al., 2001; Jain, 2018).
Yet another method of managing gagging reflex is by the earplug
method wherein the earplug functions as the stimulator of the external
auditory canal thus controlling the overactive gag reflex, as shown in
(figure:2, A) (Cakmak et al., 2014).
Further, as quoted by Boitel temporal tap method deals with the digital
stimulation of the temporoparietal suture in conjunction with suggestions
that prospectively regulate the gag reflex as shown in (figure:2, B) (Boitel,
1984).
Herein, the authors also recommend closing their eyes and washing
their mouths with icy water and distracting the patient's mind by asking the
patient to count the numerical numbers (Claire and Ian, 2016).

Figure 2: Earplug and temporal tap method (Samaleti and

Jawdekar, 2020)
14
Chapter One Literature Review

1.10.1.3 Systematic desensitization

Desensitization is done systematically. Classical conditioning-learned
behavior may be unlearned by reversing the conditioning process (Rubina
,2018).
This approach involves gradually exposing the patient to feared stimuli
in such a manner that when the frequency, intensity, and duration of the
unpleasant stimuli increases, it leads to the patient being gradually
habituated to the treatment to be performed. The Marble Method is a
successful desensitization method for the treatment of hopeless gaggers.
During the initial appointment visit, no oral assessment of any type was
performed using this approach. The patient was instructed to insert five,
round glass, multi-colored marbles, roughly 0.5 inch in diameter, in his
mouth one by one till all five marbles had been put in his mouth. The
patient was then reassured that ingesting a marble would not endanger him,
as the anxiety of ingesting a foreign item might cause gagging. Marble
Technique is a successful desensitization method for treating terrible
gaggers. Alongside this technique, at each weekly session, the patient was
assured that he would be able to wear and use dentures. The patient was
instructed to always maintain the five marbles in his mouth, except while
eating and sleeping, for a duration of one week. The patient was able to
tolerate the five marbles on the second appointment and was reassured
again that he would eventually be able to wear dentures, this added to his
determination. Before making impressions, the hard palate and soft palate,
along with the cheeks, tongue and lips were swabbed with topical
anesthetics on the third and fourth visits. Three marbles were instructed to
be kept in the patient's mouth thereafter (singer, 1973; Pisulkar et al.,
2018).
Wilks and Marks in 1983 advocated teaching the patient the procedure
to swallow with their teeth apart, allowing the tip of their tongue to be more

15
Chapter One Literature Review

anteriorly placed on the palate causing the muscles to relax, thus

minimizing gagging from occurring (Thessaloniki, 2021).
Another technique was to brush the hard palate softly with a toothbrush
without causing gag reflexes. On the toothbrush handle, the patient marks
the location of the maxillary incisors. The goal was to move the brush
further posteriorly, and the patient was motivated as the marking on the
toothbrush moved down the handle progressively (Robb and Crothers,
1996).
1.10.1.4 Cognitive Behavioral Therapy (CBT)
This strategy tries to modify patients' irrational behavior patterns
regarding dental procedures that may enhance the sensitivity of the gag
reflex. Patients are challenged by CBT to dispute firmly established views
about gagging catastrophes based on personal experience (Barsby, 1997;
Bassi et al., 2004).
A psychotherapist, for example, can use CBT to rationalize a patient
who cannot handle the water in their mouth, fearing that the excess volume
of water will choke them (Rubina, 2018; Meenakshi et al., 2021).
1.10.2 Prosthodontic Management
1.10.2.1 The selection of trays
The selection of trays during the prosthodontic procedures plays a
very important role as an oversized tray can lead to gagging (Meenakshi
et al., 2021)
1.10.2.2 Patient position
The patient's head must be bent down and he should always be in a
seated and resting position during a dental impression (Forbes-Haley
and Blewitt, 2016; Meenakshi et al., 2021)
1.10.2.3 Material selection
The utilization of a fast-setting material is preferred. Impression
material should not be used when its consistency is thin. The impression
16
Chapter One Literature Review

tray should never be overloaded with impression material, only an

adequate amount of material is to be used to treat the patient with a shorter
exposure time, use a rigid mix of impression materials and fast setting
materials (like impression compound) (turner et al., 2012).
1.10.2.4 Posterior palatal seal area
It should be recorded appropriately and should never be underdamped
or overdamped. Many numbers of post dams are provided on the final
maxillary denture base to allow customization according to the patient's
preference (Hoad-Reddick, 1986; Singh et al., 2013).
1.10.2.5 Modification of maxillary custom tray
Modification of maxillary custom tray can be used to prevent gag
reflexes. It is preferable to utilize these trays using disposable saliva
ejectors at their distal end, allowing surplus impression material to pass
through these regions without activating the soft palate (Witter et al.,
1999).
A major connector with a ‘horseshoe' design minimizes palatal
coverage, resulting in less interference for the tongue (Meenakshi et al.,
2021).
1.10.2.6 Recording jaw relations
The vertical Dimension (VD) at occlusion must be recorded correctly
because as VD decreases, room for the tongue diminishes, causing the
tongue to sink back and produce a gag reflex (Witter et al., 1998; jain et
al., 2013).
1.10.2.7 Final Prosthesis Fabrication
A well-fitting denture must be provided to reduce the most common
etiologies of gag reflex, i.e., Denture looseness, thick palatal coverage,
thickened denture posterior border, narrow arch bringing cusps of posterior
teeth near the tongue’s dorsal surface (Akeel et al., 2000; Yadav et al.,
2011).

17
Chapter One Literature Review

1.10.2.8 Use of Training Bases

This is another desensitization strategy in which the patient is gradually
given a series of small to full-sized denture bases. This procedure is
beneficial to people that are about to start wearing dentures for the first
time. A thin denture base made of acrylic, without teeth is made, and the
patient is advised to use it at home for a period that gradually increased. A
reasonable regimen maybe for 5 minutes once a day, then twice a day
progressing forward (Fløsystrand et al., 1986; Akeel et al., 2000).
One week later, the patient is instructed to raise this time to 10 minutes
three times each day, and then for 15, 30 and 60 minutes each day. Finally,
the patient can endure these training bases for most time of the day.
According to the patient's requirements and expectations, the time-frame
and the rate of improvement will differ ( Pushpa et al., 2021; Pati et al.,
2022).
If issues arise, the extension of the denture's posterior border may need
to be reduced. Anterior teeth are introduced into the original training base,
and posterior teeth are introduced when the patient can bear it.
Compromises in denture fabrication standards are unproductive. The
retention and denture stability should be improved. Palate-less denture use
has been demonstrated to be beneficial for certain patients, and retention
failure in such cases is not usually significant (Bassi et al., 2004; Yadav
et al., 2011).
1.10.2.9 Making implant-retained prostheses
This process allows a decrease in prosthetic size and extension thus
reducing the overall coverage and lowering gagging reflex (Forbes-
Haley et al., 2016).
1.10.2.10 Roofless dentures
Gagging is reduced or eliminated when palatal coverage is reduced.
Maxillary dentures could be shortened and made into a U-shaped
18
Chapter One Literature Review

boundary which is around ten millimeters from the dental arch

(Thangarajan et al., 2017).
1.10.2.11 Matte finished dentures
Avery smooth, highly polished denture surface that is coated with
saliva might induce a slimy sensation in some patients, causing gagging;
in this situation, a matte surface has been proposed as more acceptable
(Meenakshi et al., 2021).
1.10.2.12 Post insertion denture issues
Immediately after denture insertion, gagging is likely to occur owing
to the two factors namely, maxillary dentures (an overextension of
maxillary denture as well as an extensively thick posterior border) and
mandibular dentures (distolingual flange of the denture maybe extensively
thick) (Fløsystrand et al., 1986).
Some of the patients complain of delayed gagging which is 2 weeks to
2 months after insertion for reasons such as: An incomplete border seal in
the denture or malocclusion that causes the denture to loosen both of which
allows saliva to seep under the denture to induce gagging (Meeker and
Magalee, 1986; Ali et al., 2018).
1.10.3 Pharmacological Methods
When clinical and prosthodontic therapy fails to reduce gagging,
pharmaceutical approaches are considered. The drugs used to treat gagging
are classified under the following sections (Krol, 1963; Kramer and
Braham, 1977; Jain, 2018) :
1. Peripherally acting agents –Local and topical anesthetics
The rationale behind using such medications is that if the afferent
signals from more sensitive oral tissues are blocked, the gag response is
prevented. Som authors recommend infiltrating the palatine nerves with
local analgesia for maxillary impression taking. While others
recommended numbing the soft palate, employed local anesthetic sprays

19
Chapter One Literature Review

and utilized swabs for topically application of a local anesthetic to the

palate before impressions.
Similarly, added local anesthetic into the alginate impression material
(Bassi, 2004).
It is well known that the glossopharyngeal nerve block (GNB) is a
generally safe, uncomplicated, and easy-to-learn technique for treating
patients with excessive gag reflexes. GNB can be utilized in dental
treatments in individuals who have an overactive gag reflex or while doing
operations at the back of the mouth (Murthy et al., 2011).
The GNB procedure was carried out with the operator standing contra
laterally to the side to be blocked and the patient's mouth wide open. The
palatopharyngeal fold (posterior tonsillar pillar) was identified, and a
tongue blade (held in the non-dominant hand) was used to move the tongue
medially (towards the contralateral side), establishing a gutter between the
tongue and the teeth. A syringe with a 25-gauge needle was inserted into
the membrane near the base of the anterior tonsillar pillar and inserted
about 0.25 to 0.5 cm, then after careful aspiration, 3 ml of 2% lignocaine
solution with 1:200000 epinephrine was slowly injected, and the injection
was performed on the opposite side (Murthy et al., 2011).
2.Centrally acting agents
Several marketed drugs act on the nervous system and classified under
centrally acting agents as represented in the table1.
Table 1: Centrally acting agents
Class of drug Name Mode of action
Conscious Nitrous oxide Alters the perception of external stimuli and thus
sedation this depresses the gag reflex
(Yagiela, 2001; Rubina et al., 2018).
Serotonin Ondansetron 5-HT3 receptors in the chemoreceptor trigger
antagonists Granisetron zone and gastrointestinal tract are blocked
(Athavale et al., 2020).

20
Chapter One Literature Review

Class of drug Name Mode of action

CNS depressants Intranasal Short-acting benzodiazepine central nervous
midazolam system (CNS) depressant. Nasal anesthesia has
several benefits, including a quick absorption
period and a rapid release process of anesthetics
transmitted to the systemic circulatory system
(Malkoc et al., 2013).
Antihistamines Benadryl Histamine binding to cellular receptors on nerve
Diphenhydraie terminals, smooth muscles, and glandular cells is
hydrochloride competitively antagonized, thus depressing the
gag reflex (Goyal, 2014; Jain, 2018).
Dopamine Metoclopramie Block dopamine type 2 (D2) receptors both
antagonists Domperidone centrally and peripherally in the chemoreceptor
trigger zone in the gastrointestinal tract
respectively (Jain, 2018).

Anticholinergics Hyoscine Muscarinic receptors in the vestibular nucleus,

Dicyclomine vomiting center, and higher brain centers are
blocked (Athavale et al., 2020).

Sedative IV Propfol Antagonist at the 5HT3 receptor, as well as by

regulation of subcortical pathways
(Jain, 2018; Kampo et al., 2019).

The last option that a dentist will resort to is general anesthesia (Forbes-Haley et al.,
2016).
1.10.4 Surgical Correction
Described a surgical procedure for relieving gagging in patients who
could not tolerate complete dentures. The theory behind this approach is
based on the fact that recurrent gagging is caused by a relaxed soft palate,
which is common in anxious patients. This procedure was mainly
recommended to shorten and tighten the soft palate to remedy this issue
(Kaira et al., 2014; Jain, 2018).

21
Chapter One Literature Review

1.10.5 Acupuncture and Acupressure Therapy

Acupuncture therapy is a medical method in where a small needle is
put into the skin to a few millimeters, kept in place for a while, occasionally
adjusted, and finally withdrawn. Ear acupuncture is considered a non-
invasive treatment method. This method produces very slight discomfort,
it is inexpensive, and takes minimal extra clinical time (Kaira et al., 2014).
Acupuncture is a highly safe practice if fundamental anatomy and
aseptic precautions are followed by a properly qualified practitioner. Ear
acupuncture was hundred percent effective for regulating the gag reflex,
according to some authors as shown in (figure:3) (Kaira et al., 2014;
Anand et al., 2015).
The mechanism of action of this treatment might be explained by the
fact that one of the few primary nerves that is involved in the swallowing
mechanism, the vagus nerve, also stimulates a portion of the ear which
houses the acupuncture point for anti-gagging. This site is also close to the
trigeminal nerve branch. Both the trigeminal and vagus nerves work
together to control many of the motor and sensory activities of the larynx,
throat, and palate. As a result, activating these anti-gagging points triggers
systems that inhibit the gagging reflex (Dickinson and Fiske,2005;
Hashim et al., 2017).

Figure 3: Ear anti-gagging point (Meenakshi et al., 2021).

22
Chapter One Literature Review

After disinfecting the skin with 70% alcohol at the location of the
needle penetration, one tiny, single-use disposable needle (0.35 mm 40
mm) was pierced to a depth of 3 mm directly above the tragus in each ear's
anti-gagging point. Before performing the dental treatment, the needles
were spun clockwise and then anticlockwise for a span of thirty seconds.
The needles were kept in place during the impression-taking procedure and
were withdrawn once the impression tray was withdrawn from the patient's
mouth (Hashim et al., 2017).
Acupressure works on the same principles as acupuncture, but the
former uses mild finger pressure to stimulate the points rather than small
needles, making it a less intrusive procedure. The acupressure procedure
should begin about 5 minutes before the impression procedure. It is
continued during the impression operations and is terminated only after the
impression has been completely removed from the patient's mouth. The
patient, dental assistant, or dentist can all apply pressure (Gupta et al.,
2012; Kaira et al., 2014).
Table 2: Provides details of the various pressure points that have been
employed for relieving gagging reflex.
Pressure point Location Procedure
CV-24 point Horizontal mentolabial With the index finger, Use gentle
(Fig. 4a) groove, roughly halfway finger pressure. Gradually increase
between the lower lip and finger pressure until the patient
the chin feels discomfort/pain and
distension (Vachiramon and
Wang, 2002; Sari and sari,
2010).
He Gu (Fig. 4b) Between the thumb and When the thumb and index fingers
the forefinger are pulled together this point is
positioned on the highest point of
the muscle (Jain, 2018).

23
Chapter One Literature Review

Pressure point Location Procedure

Nei Guan point Inner forearm between the Three finger breadths underneath
(Fig. 4c) two tendons the wrist on the forearm are
pressed. It is widely used to treat
nausea, motion sickness, carpal
tunnel syndrome,stomach upsets
and headaches (Vachiramon and
Wang, 2002; Sari and sari, 2010).
Yintang (Fig. 4d) Midway between the With the index finger, Use gentle
medial ends of the finger pressure. Virtually used to
eyebrows treat insomnia and anxiety
(Rowbotham, 2005;
Thangarajan et al., 2017).

Figure 4: The Pressure points (Meenakshi et al., 2021).

24
Chapter One Literature Review

1.10.6 Laser Stimulation

For 1 minute, a red-light soft laser with a power output of 0.5 mW and
a wavelength of 650 nm, a pulsating magnetic field of 9 Hz, and a
penetration depth of 30 cm was utilized to stimulate (CV 24) point as
shown in (figure:5).The red-light soft laser triggers the organism's
bioenergetic regulatory mechanisms at the cellular level. At 1 cm from the
laser probe, the laser was applied directly to the skin. Laser treatment on
acupuncture point CV 24 has been shown to be an effective treatment
option for orthodontic patients with gagging reflexes (Sari and sari, 2010).

Figure 5: A. The acupuncture point conception vessel 24 (CV 24)

B. View of a red-light soft magnetic field laser stimulation on CV 24
(Sari and Sari, 2010).

1.10.7 Intraoral scanning systems

The use of intraoral scanners for study models has increased
dramatically among dentists. Digital scanners can obtain high quality
impressions and reduce the gag reflex and several problems (Grünheid et
al., 2014).
Digital impressions can offer a variety of advantages such as reduced
patient discomfort, time-efficiency, simplified clinical procedures, and
ability of capturing and storing highly accurate information (the 3D virtual
models of patients) without pouring stone casts. The possibility of avoiding

25
Chapter One Literature Review

pouring stone casts can save space and time in the clinic. Further
advantages of the digital impressions and scanning systems are the
possibility to easily transfer digital data to the dental technician, via email,
avoiding impression shipping to the laboratory: this results in a better
communication with the laboratory (Grauer et al., 2011).

26
Chapter Two: Conclusion
Chapter Two Conclusion

2. Conclusion
The gag reflex is a common problem that can interfere with
daily activities and proper function. There is no single approach that
works for effectively controlling it, but a variety of modalities can be
used depending on the patient's conditions. A comfortable and
effective treatment can be achieved with the right patient education
and motivation, as well as a cautious approach and attentive work by
the dentist. This review provides an overview of the numerous
treatment techniques that have been scientifically supported in the
literature.

27
 References

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