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The Gag Reflex: A Hurdle in Dentistry- Literature Review

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Gagging reflex poses a hurdle in numerous dental procedures. It causes discomfort for the patient, extended procedure time for the clinician, compromised quality of treatment and along with a lot of physiological discomfort for both. The normal gag reflex is protective in nature, but few individuals elicit extreme response, leading to problems during the treatment procedures. It is extremely important for the clinician to identify the cause and severity of the condition so that it can be decided whether the patient can handle standard treatment techniques or whether alternative methods must be considered. There is no universal solution for successfully managing the gagging patient. Various modalities can be used according to the doctor's assessment and patient's conditions in order to control the gag reflex so that the patient can be comfortable and cope with the dental treatment. A wide range of management solutions are available, and many cases need a Review Article Meenakshi et al.; JPRI, 33(46B): 224-237, 2021; Article no.JPRI.75193 225 combination of therapeutic procedures. The main aim of the present article is to comprehensively report the clinical significance, etiology, symptoms and various management approaches used during prosthodontic treatments.
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*Corresponding author: E-mail: dr.meenakshis@jssuni.edu.in;
Journal of Pharmaceutical Research International
33(46B): 224-237, 2021; Article no.JPRI.75193
ISSN: 2456-9119
(Past name: British Journal of Pharmaceutical Research, Past ISSN: 2231-2919,
NLM ID: 101631759)
The Gag Reflex: A Hurdle in Dentistry
Literature Review
S. Meenakshi1*, Shyla Dureja1, G. C. Kavitha2, M. Pallavi3,
K. N. Raghavendra Swamy1, Aishwarya Kottur1 and Ramith Ramu4
1Department of Prosthodontics, JSS Dental College and Hospital, JSS Academy of Higher Education
and Research, Mysuru-570015, Karnataka, India.
2Department of Studies in Biotechnology, Davangere University, Shivagangotri, Davangere-577007,
Karnataka, India.
3Department of Studies and Research in Biotechnology, Molecular Biomedicine Laboratory Sahyadri
Science College, Kuvempu University, Shimoga-577203, Karnataka, India.
4Department of Biotechnology and Bioinformatics, School of Life Sciences, JSS Academy of Higher
Education and Research, SS Nagar, Mysuru-570015, Karnataka, India.
Authors’ contributions
This work was carried out in collaboration among all authors. All authors read and approved the final
manuscript.
Article Information
DOI: 10.9734/JPRI/2021/v33i46B32937
Editor(s):
(1) Dr. S. Prabhu, Venkateswara College of Engineering, India.
Reviewers:
(1) Zenati Latifa, Algeria.
(2) Karla Mayra Rezende, University of Sao Paulo, Brazil.
Complete Peer review History: https://www.sdiarticle4.com/review-history/75193
Received 06 August 2021
Accepted 13 October 2021
Published 21 October 2021
ABSTRACT
Gagging reflex poses a hurdle in numerous dental procedures. It causes discomfort for the patient,
extended procedure time for the clinician, compromised quality of treatment and along with a lot of
physiological discomfort for both. The normal gag reflex is protective in nature, but few individuals
elicit extreme response, leading to problems during the treatment procedures. It is extremely
important for the clinician to identify the cause and severity of the condition so that it can be
decided whether the patient can handle standard treatment techniques or whether alternative
methods must be considered. There is no universal solution for successfully managing the gagging
patient. Various modalities can be used according to the doctor’s assessment and patient’s
conditions in order to control the gag reflex so that the patient can be comfortable and cope with the
dental treatment. A wide range of management solutions are available, and many cases need a
Review Article
Meenakshi et al.; JPRI, 33(46B): 224-237, 2021; Article no.JPRI.75193
225
combination of therapeutic procedures. The main aim of the present article is to comprehensively
report the clinical significance, etiology, symptoms and various management approaches used
during prosthodontic treatments.
Keywords: Gag reflex; prosthodontic gagging; etiology of gagging; neurophysiology of gag reflex.
1. INTRODUCTION
Gag reflex, clinically known as pharyngeal reflex,
is an involuntaryphysiological phenomenon in
human that is complex in nature [1,2,3]. This
response causes perplexity and frustration in a
variety of dental treatments, resulting
incompromised treatment [2]. 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 [4]. It can be managed by
properly educating the patients through the
procedure and providing a calm environment [5].
Numerous authors have discussed various
aetiologies, 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 [6,7].
The gag reflex is a typical, healthy defence
system that works to keep foreign bodies out of
the trachea, pharynx, and larynx. It's a defensive
response that's meant to keep the airway clear
and irritants out of the posterior oropharynx and
upper gastrointestinal system [8]. Some people
have a weak or non-existent reaction, whilst
others have a strong one. Gagging reflexes
might jeopardize all elements of dental
operations, from diagnostics to radiography and
active treatment. Significant gag reflexes are
most typically found during prosthodontic
procedures, such as impression making, which
may jeopardize the process or cause discomfort
to patients and dentists [4].
This article describes in detail about the gag
reflex, its clinical significance, aetiology,
assessment, symptoms and a holistic
management approach to control the gag reflex
and provide a successful and comfortable
treatment outcome for both the patient and
clinician.It focuses on the various modifications
that could be made by the Prosthodontist during
rendering treatment to the patient and also
during the fabrication of the prosthesis, to
minimise the gag reflex in geriatric patients.
2. MATERIALS AND METHODS
This review article compiles the various aspects
of neurophysiology, etiology, classification,
assessment of the gag reflex and the various
methods available in literature for controlling it.
This comprehensive review was executed after a
thorough literature search performed in the year
March-April 2021. Research articles from reputed
national and international databases were
searched and ended with a large number of
studies published on the management of gag
reflexes. These studies were researched using
key words such as etiology of gagging,
physiological development of gag reflexes,
medicinal interventions for gagging, management
of gagging with an emphasis on prosthodontic
gagging. The selection criteria were set to
include research articles, short communications,
book chapters and review articles. The literature
search arrived at over 400 articles some of which
were repeated findings or reporting less
significant results. After eliminating such reports,
56 articles were retained and used for writing the
present review.
3. RESULTS
3.1 Neurophysiology of Gag Reflex
The gagging reflex can be caused either due to a
somatic or psychogenic response of the body.
The somatic gagging is caused by the activation
of the sensory nerve as a result ofdirect
stimulation of the trigger area. Even though the
trigger regions differ between individuals, some
of the commonareasaround the palate and lateral
margins of the tongue frequently triggerthis
reflex. On the other hand, psychogenic gagging
is generated without physical touch by higher
brain areas. A part of the population experience
such reflexes by the smell, sound, sight, or even
the mere concept of the dental treatment
procedure.These receptors are found on the
region of soft palate or the posterior part of the
tongue and are then transmitted to the gag
centre in the medulla oblongata by sensory
neurons through afferent (toward the brain)
nerves. Then, from this centre, motor neurons
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are transferred to the muscles in the throat that
are involved in gagging through efferent (away
from the brain) nerve fibres [3].
Gagging can be combined with lacrimation,
excessive salivation, perspiration, fainting and
sometimes a panic attack. When the
trigeminal,vagus and glossopharyngeal nerves
are stimulated intraorally, afferent fibres go
directly to the medulla oblongata in the brain.
The efferent impulses induce spasmodic and
uncoordinated muscular movement that is typical
of gagging. The gagging centre present in the
medulla oblongata is adjacent to the vomiting,
cardiac and salivating centres, which also may
be activated during gagging [5,6,7]. This reflex is
a normal response due to the stimulation of
specific intra-oral tissues by touch. There are five
intraoral “trigger zones”: the palatoglossal and
palatopharyngeal folds, the base of the tongue,
the palate, the uvula, and also the posterior
pharyngeal wall. In addition, non-tactile
sensations like visual, auditory, or olfactory
stimulation can also induce a gag reflex [5,8,9].
When the respiratory muscles contract
spasmodically while retching, the air is driven
past the glottis that is closed, generating a
distinctive retching sound. Furthermore, the
muscles in the chest are fixed, whereas the
thoracic inlet muscles contract. This obstructs the
venous return, leading to dilation of the veins of
the head and neck region and causing flushing
and also congestion of the face [10].
Gagging has certain characteristic features such
as lip puckering, attempt to close the jaws, vomit
sensation, excessive salivation, lacrimation,
coughing, sweating. Furthermore, the tongue is
elevated and rotated from back to the front with
hyoid bone in the centre that appears
elevated.This appears such due to the
convergence of posterior pillars of fauces that
raises the soft palate and closes the
nasopharynx resulting in the rotation of tonsils
anteromedially due to contraction of anterior &
posterior fauces pillars. These lead to the
laryngeal elevation, contraction, and retraction,
as well as glottic closure, retching, concurrent
and uncoordinated respiratory muscle spasm
[1,4,11].
3.2 Etiology of Gagging
Gagging phenomenon is triggered but various
factors that are classified as follows:
LocalFactorsinclude deviated nasal septum,
nasal polyps, nasal obstruction, sinusitis,
postnasal drip and psychological factorsinclude
fear, stress, learned responses and neuroticism
[12]. Systemic Factors such as 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
[4,5].
Furthermore, several physiological factors also
play an important role in causing gagging
reflexes. Extraoral stimulation such as stimuli
that are visual, auditory, or due to the objector
and intraoral stimulation. For example, the mere
sight of the impression trays, mouth mirror, and
the smell or taste of various dental materials.
Intraoral Stimulation, here 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 posterior one-third of
the tongue is the most sensitive region of the oral
cavity [1,2].
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), [1]
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 or excessive
surface finish of the acrylic dentures and an
inadequate freeway space also cause gagging
reflexe. [4]. Patients reported that the issue was
particularly severe in the morning hours during
dental hygiene procedures and denture insertion
process [13]. 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 [14].
Iatrogenic factors namely, suction and water
tubes, instrumentation, radiography, poor clinical
technique and overloaded impression tray also
contribute to gagging.Finally, the psychosomatic
factors classified under classical conditioning
process and operant conditioning process also
adds to the factors responsible for gagging [15].
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The classical conditioning process occur under
the following circumstances.When a previously
neutral stimulus is linked with a specific type
ofbehavioural response, classical conditioning
develops. Normal sensations, such as the sight
of an impression tray, the scent of dental
materials, or even the sound of a dental
handpiece, may become problematic. The gag
reflex may startdue 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 [16,17].
Similarly, the operant conditioning processis a
training strategy in which the outcomes of a
response influence the chance that the subject
will repeat that response. Some behaviour
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 whogags unintentionally
learns to identify it with the temporary
cessation of therapy. This outcome is favourable
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
[11,14].
3.3 Classification of Gagging
(a) Based On Origin: According to Krol et al
in 1963 as Psychogenic or Somatic
(b) Based On Severity: According to
Faigenblum et alin 1968 as Mild or Severe
[4]
3.4 Assessment of Gag Reflex
Gagging severity is generally assessed based on
the following description as given in Table 1.
Table 1. Gagging Severity Index by Dickinson and Fiske et al. [4]
Grades of
Gagging
Severity of
Gagging
Description
Grade I
Normal
gagging reflex
Gagging reflex develops on rare instances during high-risk
dental procedures such as making maxillary impressions or
restoring the distal, palatal, or lingual surfaces of molar teeth.
Under intense treatment conditions, this is essentially a 'normal'
gag reflex. It is controlled primarily by the patient.
Grade II
Mild gagging
reflex
Sometimes, gagging develops during basic dental procedures
like fillings, scaling, and impressions. The patient can generally
retake control, but may require support and reassurance from
members of the dental team, and treatment should be resumed.
In most cases, no additional steps are necessary to ease normal
therapy, although more complex procedures may require them.
Grade III
Moderate
gagging reflex
Gagging reflex is common during routine dental treatments.
Mere physical examination of high-risk regions, including the
lingual side of lower molars, may induce the reflex. Control is
difficult to regain after the operation has been initiated.
Temporary suspension may be challenging required. Generally,
gag prevention measures are needed. The gag may have an
influence on treatment strategy and limit therapy possibilities.
Grade IV
Severe gagging
reflex
Gagging occurs with all aspects of dental treatment including
basic visual examination. Routine treatment is impossible without
a specific measure to try to regulate the gag reflex. Treatment
options could be restricted, and the gagging issue will play a
significant role in treatment decisions.
Grade V
Very severe
gagging reflex
Gagging is a common reflex that does not always require
physical intervention to activate. The gagging problem may
influence the patient's behaviour and dental participation, and it
will be a major consideration while planning therapy. The
treatment choices available may be extremely restricted. Dental
treatment will be impossible to perform without particular,
specialized therapy for gagging.
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3.5 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 behaviour and the treatment
approach [5].
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
instil trust in the patient [2]. Management of this
reflex action should be subjective to individual
patients. Several management methods are
available and listed below.
1. Psychological Intervention
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 to
alleviate or eliminate 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 [2,5].
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 [11].
Landaet al in 1946 proposed that the dentist start
a conversation with the patient about a topic of
special interest to engage the patient [18,19].
Krol et al in 1963 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 [20].
According to Faigenblum et al in 1968, vomiting
was impossible during apnea. So, to control this
gagging reflexthe patient was urged to increase
his expiratory effort at the expense of his
inspiration. This process will result in apnea and
thus discourage gagging[13]. Kovats et al in
1971 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. [21,22]
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 [23]. Further, asquoted by Boitelet al,
temple tap method deals with the digital
stimulation of the temporoparietal suture in
conjunction with suggestionsthat prospectively
regulate the gag reflex [24]. Herein, the authors
also recommend closing their eyes and washing
their mouths with icy water, and also distracting
the patient's mind by asking the patient to count
the numerical numbers [25].
Systematic desensitization
Desensitization is done systematically. Classical
conditioning-learned behaviour may be
unlearned by reversing the conditioning process
[5]. This approach involves gradually exposing
the patient to a 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. Singer's 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-coloured 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.
Singer's 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 maintain the five marbles in his
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mouth at all times, 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 anaesthetics on the
third and fourth visits. Three marbles were
instructed to be kept in the patient's mouth
thereafter [3,26]. Wilks and Marks et al in 1983
advocated teaching the patient the procedure to
swallow with their teeth apart, allowing the tip of
their tongue to be more anteriorly placed on the
palate causing the muscles to relax, thus
minimizing gagging from occurring [27].
Another technique was to brush the hard palate
softly with a toothbrush without causing the gag
reflex. 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 [28].
Cognitive Behavioural Therapy (CBT)
This strategy tries to modify patients' irrational
behaviour 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
[29,30]. A psychotherapist, for example, can use
CBT to rationalize a patient who cannot handle
the water in his/her mouth, fearing that the
excess volume of water will choke him/her [5,31].
2. Prosthodontic Management
The selection of traysduring the prosthodontic
procedures plays a very important role as an
oversized tray can lead to gagging. The other
parameters that should be considered are:
Patient position: During a dental impression, the
patient's head must be bent down and he should
always be in a seated and resting position [25].
Material selection:The utilization of afast-setting
material is preferred. Impression material should
not be used when its consistency is thin. The
impression 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 andfast setting materials
(like impression compound).
Posterior palatal seal area: It should be recorded
appropriately and should never be underdamed
or overdamed. Manynumbers of post dams are
provided on the final maxillary denture base to
allow customization according to the patient's
preference [32,33].
Modification of maxillary custom tray: It can be
used to prevent thegag reflex. 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 [34].
Major connector with a ‘horseshoe' design
minimizes palatal coverage, resulting in less
interference for the tongue.
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 [35,36,34].
Final Prosthesis Fabrication: A well-filling denture
must be provided to reduce the most common
aetiologies 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
[37,38].
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 of time that
is gradually increased. A reasonable regimen
maybefor 5 minutes once a day, then twice a day
progressing forward. [38,39,40]. One week later,
the patient is instructed to raise this time to 10
minutes for 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 [41,42,43].
If issues arise, the extension of the denture's
posterior border may need to be reduced.
Anterior teeth are introduced into the original
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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 [30,37].
Making implant-retained prostheses: This
process allows a decrease in prosthetic size and
extension thus reducing the overallcoverageand
lowering gagging reflex.
Roofless dentures: Gagging is reduced or
eliminated when palatal coverage is reduced.
Maxillary dentures could be shortened and made
into a U-shaped boundary which is around ten
millimetres from the dental arch [44].
Matte-finished dentures: Jordan et al proposed
this in 1954. 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.
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)
[39].
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 dentureor malocclusion that
causesthe denture to loosen both of which allows
saliva to seep under the denture to induce
gagging [45,46].
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:
Peripherally acting agents Local and topical
anaesthetics
The rationale behind using such medications is
that if the afferent signals from more sensitive
oral tissues are blocked, the gag response is
prevented. Watt and MacGregor et al
recommend infiltrating the palatine nerves with
local analgesia for maxillary impression taking.
While Krolet al recommended numbing the soft
palate, Kramer et al employed local anaesthetic
sprays and Lee-Singer et al utilized swabs for
topically application ofa local anaesthetic to the
palate before impressions [20,21,47]. Similarly,
Hattab et al added local anaesthetic into the
alginate impression material [30].
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 [48]. The GNB procedure
was carried out with the operator standing
contralaterally 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 [48].
Centrally acting agents
Further, several marketed drugs act on the
nervous system and classified under centrally
acting agents as represented in.
4. Surgical Correction
Leslie et al 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 also
tighten the soft palate to remedy thisissue [1,21].
5. Acupunctureand Acupressure Therapy
Acupuncture therapy is a medical method in
where a small needle is put into the skin to a few
millimetres, kept in place for a while, occasionally
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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 [1].
Acupuncture, according to Rosted et al, 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 [1,53]. The
mechanism of action of this treatment might be
explained by the fact that one of the few primary
nerves that isinvolved in the swallowing
mechanism, the vagus nerve, also stimulatesa
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, andpalate. As a result, activating these
anti-gagging points triggers systems that inhibit
the gagging reflex [4,54].
Table 2. Centrally acting agents
Class of drug
Name
Reference
Conscious
sedation
Nitrous oxide
[5,49]
Antihistamines
Benadryl
Diphenhydramine
hydrochloride
[2,21]
CNS depressants
Intranasal
midazolam
[50]
Serotonin
antagonists
Ondansetron
Granisetron
[51]
Dopamine
antagonists
Metoclopramide
Domperidone
[21]
Anticholinergics
Hyoscine
Dicyclomine
[51]
Sedative
IV Propfol
[21,21,52]
The last option that a dentist will resort to is general anaesthesia [25]
Fig. 1. Acupuncture at anti-gagging point (Hashim)
Meenakshi et al.; JPRI, 33(46B): 224-237, 2021; Article no.JPRI.75193
232
Table 3. Provides details of the various pressure points that have been employed for relieving
gagging reflex
Pressure point
Location
Procedure
Reference
The REN-24/ CV-24
point (Fig. 2a)
Horizontal
mentolabial
groove, roughly
halfway between
the lower lip and
the chin
With the index finger, Use gentle finger
pressure. Gradually increase finger
pressure until the patient feels
discomfort/pain and distension.
[55,56]
Nei Guan (P6 or PC6)
point (Fig. 2b)
Inner forearm
between the two
tendons
Three finger breadths underneath the
wrist on the forearm is pressed. It is
widely used to treat nausea, motion
sickness, carpal tunnel syndrome,
stomach upsets and also headaches.
[55,56]
He Gu (LI4) (Fig. 2c)
Between the thumb
and the fore finger
When the thumb and index fingers are
pulled together this point is positioned
on the highest point of the muscle.
[21]
Yintang (Fig. 2d)
Midway between
the medial ends of
the eyebrows
With the index finger, Use gentle finger
pressure. Virtually used to treat
insomnia and anxiety.
[57,58]
Fig. 2. a)REN-24/ CV-24 point b) Nei Guan point c) He Gu (L14) point and d) Yintang (M-HN-3)
point
Meenakshi et al.; JPRI, 33(46B): 224-237, 2021; Article no.JPRI.75193
233
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. [Fig.
1]. 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 [54].
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 [1,11].
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. The red-light soft laser
triggers the organism's bioenergetic regulatory
mechanisms at the cellular level. At a distance of
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 [56].
4. DISCUSSION
Dentists see a large number of patients in their
practice who have an oral cavity that is extremely
sensitive, thus these patients cannot tolerate any
foreign material in it. Gag reflexes can be
triggered by any kind of dental procedure both
before and after treatment for various reasons.
Furthermore, it can be stated that the dentist's
competence and patience are the prerequisites
to controlling gag reflex and providing
comfortable treatment outcomes. This article is a
narrative review which comprises of a
compilation of data on the gag reflex and the
various methodologies documented in literature
for controlling it. It comprehensively covers the
various aspects of gagging from a geriatric
standpoint. It includes the various modifications
that could be made by the p rosthodontist during
treatment procedures as well as during the
fabrication of the prosthesis, to minimise the gag
reflex in patients. Although there is no universal
solution for successfully managing the gagging
patient, various modalities can be used under the
discretion of the dentist in order to control the
gag reflex leading to smooth implementation of
dental treatment.
5. CONCLUSION
A gag reflex in a healthy is meant to protect us
but can cause hurdles for some individuals
leading to interference with their everyday life
and normal function. In dentistry procedures,
gagging may upset the patient and the physician
leading to apprehensions towards dental visits.
There is no universal solution for successfully
managing this reflex, but subject to individual
patient, various modalities can be used
according to the doctor’s assessment and
patient’s conditions. With appropriate patient
education and motivation as well as a careful
approach and meticulous work by the dentist, a
comfortable and productive treatment may be
obtained. A wide range of management solutions
have been elaborated, and many cases need a
combination of therapeutic procedures. The
present review article provides an overview of
various treatment modalities documented in
literature to control the gag reflex thus providing
a successful and comfortable treatment outcome
for both the patient and clinician.
ACKNOWLEDGEMENTS
The authors acknowledge the contribution of the
Department of Prosthodontics of the JSS Dental
College and Hospital, JSSAHER, Mysuru for all
the support.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
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Gagging is an involuntary protective reflex. Some patients have an extremely low threshold for the gag reflex. A severe gag reflex can be a big obstacle in certain dental procedures especially during the making of a maxillary impression. Many dental patients avoid going to the dentist because of an abnormally severe gag reflex. Treating such group of patients can be stressful and a time-consuming experience, both for the dentist and for the patient. The main aim of this article is to understand the etiology and effective management of such patients for a stress-free and fruitful clinical practice.
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Objective: We aim to provide a critical review focused on the various pharmacological activities of Azadirachta indica A. Juss related to diabetes management. We also emphasise on phytochemistry and toxicology of A. indica, which could provide a comprehensive approach for plant-based drug development in future. Key findings: From 2784 identified studies, only 83 were considered after double screening based on the inclusion criteria. Further, 63 pharmacological investigations were considered for review. Resultant studies deliberated on using different extracts and phytochemicals of A. indica on blood glucose level, lipid profile, oxidative stress, carbohydrate digestion enzymes, diabetic complications, glucose tolerance, and uptake of glucose. Summary: In the end, one can know the efficacy of A. indica as a potent antidiabetic herbal medicine. However, based on gaps in research, recommendations have been provided to evaluate A. indica. in a systematic manner to develop plant-based drugs, nutraceuticals, and to evaluate their clinical efficiency and safety against diabetes mellitus.
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Background Azadirachta indica A. Juss. is an Indian medicinal plant with innumerable pharmacological properties. Studies have proven that the phytochemicals from neem possess remarkable contraceptive abilities with limited knowledge on its mechanism of action. Purpose The present review aims to summarize the efficiency of A. indica treatment as a contraceptive. Methods The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used. Published scientific articles on antifertility, antispermatogenic, antiovulation, hormone altering, contraceptive, and abortifacient activities of A. indica were collected from reputed Journals from 1980 to 2020 using electronic databases. Specific keywords search was completed to collect numerous articles with unique experiment design and significant results. This was followed by the selection of the requisite articles based on the criteria designed by the authors. Data extraction was based on the common research elements included in the articles. Results A total of 27 studies were considered for reviewing, which included key pharmacological investigations. In the beginning, authors evaluated a number of publications on the contraceptive properties of A. indica, in which it was revealed that most of the publications were made between 1995 and 1999. All the collected articles were categorised and reviewed as antifertility, antispermatogenic, antiovulation, hormone altering, contraceptive, and abortifacient. Authors also assessed studies based on the plant parts used for pharmacological evaluations including leaves, seeds, stem-bark, and flowers. The article was primarily divided into different sections based on the previous works of authors on phytochemistry and pharmacological review articles. Conclusion Although A. indica is not reported with the complete alleviation of reproductive system in both male and female animal models, studies have proven its efficacy as a contraceptive. Extracts and phytochemicals from neem neither reduced the libido nor retarded the growth of secondary sexual characters, thus indicating only a temporary and reversible contraceptive activity. However, there is a dearth for clinical studies to prove the efficacy of A. indica as a herbal contraceptive.
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