If you have been in dentistry for any time at all, you know that one of the challenges we deal with when it comes to patient management is the gagging patient. They are the patient whose gag reflex goes crazy if you simply place a mirror in their mouth or if they lay back too far in the chair. And, since almost everything we do is related to invading this area that sets off the gag reflex, you have to figure out ways to manage those patients and help them maintain their oral health in a way that works for everyone involved.
So, what is the gag reflex and why do some people have it worse than others? The gag reflex, also known as the pharyngeal reflex, is a protective mechanism to help prevent something from occluding the throat/pharynx/larynx/trachea area and expelling it out of the way to help protect the airway.
Why do some people have worse gag reflexes than others? There is no clear evidence of what exactly causes the gag reflex to be worse on some patients than others, but it can be a mix of anatomical and/or constricted airways, hypersensitive gag reflexes, and directly or indirectly related anxiety/psychological issues.
Until we know otherwise or have a “cure” for hypersensitive gag reflexes, we can only manage the issue using a variety of methods that may or may not work. Therefore, the more tricks you have in your bag to manage these patients, the better off you and your patient will be.
Using my own personal experiences as well as anecdotes from fellow clinicians, I created a list of methods to help manage that gagging patient the next time they walk in your door.
- One of the most common ways to manage the gagging patient is with the use of topical or local anesthetics to numb either the tongue, roof of the mouth/soft palate area, or all of the above. This can be achieved using topical gels and sprays or doing nerve blocks to numb the tongue. Outside of dentistry, the Glossopharyngeal Nerve Block Technique has been used by anesthesiologists and otolaryngologists. The technique was recently published1 for helping the severe gagging patient who has endodontic treatment needs, thus requiring the use of rubber dams. This is, of course, something that can be obtrusive to one’s ability to swallow.
- There is another method that is difficult to understand but seems to work: using salt. Salt? Yes, simple table salt rubbed or placed on the sides of the tongue helps diminish the gag reflex. I have personally used this method several times for patients; for some, it works wonders.
- A third method puts the impetus on the patient. Have the patient practice focusing on taking nice, even breaths in and out through their nose. Diaphragmatic breathing has long been a proven method to help the body relax and reduce stimulation of the sympathetic nervous system (the flight-or-fight part of the nervous system).
- This leads us to another important part of the gag reflex: anxiety and fear. Patients may feel these emotions in regards to their dentist visit or even just at the thought of gagging. In this case, the use of nitrous oxide by itself or in addition to anti-anxiety medications or sedation can help calm the patient as well as their overactive gag reflex.
- Another patient-led method is having them desensitize the affected area by slowly stimulating the area over time. They will essentially get the hypersensitive areas more accustomed to being stimulated, but in a way that doesn’t cause themselves to gag.
- Finally, distractions during the event that causes the gagging may also work well for the patient and has no real side effects. For example, allowing the patient to listen to music as distraction throughout the procedure can help them forget about gagging at all.
The next time you have a patient who has a hyperactive gag reflex, try some of these tips and hopefully you and your patient will have a better visit.
(Click here for more articles by Dr. Jeff Lineberry.)
Jeff Lineberry, DDS, FAGD, FICOI Visiting Faculty and Contributing Author, Spear Education www.cccdds.com