| Abstract|| |
Gagging is a frequent impediment to the performance of dental procedures. This stimulation of the gagging reflex, or more accurately, the vomiting reflex, is a special problem in prosthodontic service. A hypersensitive gagging reflex often prevents the dentist from carrying out critical procedures or causes them to performat a less than satisfactory level. In addition, once having suffered an unpleasant gagging experience in a dentist's office, the patients develop a fear of further visits to dentists. The purpose of this paper is to describe methods of managing the gagging patient that has a sound rationale based on modified treatment approaches starting from impression making to design of the prosthesis aided by training dentures to help the patient to tolerate prosthesis in mouth before fabrication of definite prosthesis.
Keywords: Customized metal mesh, gagging, horseshoe-shaped maxillary denture, trigger zones
|How to cite this article:|
Yadav S, Sheorain AK, Puneet, Shetty V. Use of training dentures in management of gagging. Indian J Dent Res 2011;22:600-2
An unusually active gag reflex may upset the patient, and consequently, the severely affected patient tends not to seek routine dental treatment. Such patients generally have poor oral hygiene leading towards early edentulousness. Management of gagging depends on treating the cause and not merely the symptoms. Through examination, taking adequate medical history and conversation with the patient helps the dental professional to determine the cause. 
|How to cite this URL:|
Yadav S, Sheorain AK, Puneet, Shetty V. Use of training dentures in management of gagging. Indian J Dent Res [serial online] 2011 [cited 2019 Sep 18];22:600-2. Available from: http://www.ijdr.in/text.asp?2011/22/4/600/90311
Gagging can be defined as a "stimulated, protective reflex response to prevent material from entering the mouth or oropharynx, the stimuli may be physical, auditory, visual, olfactory, or psychologically mediated and muscular contractions resulting in vomiting."
| Etiology|| |
Five intraoral areas known to be ''trigger zones'' are palatoglossal and palatopharyngeal folds, base of tongue, palate, uvula, and posterior pharyngeal wall.  Sensitivity to these areas are known to cause gag reflex. Various other factors are as follows.
- Anatomic factors: Atonic and relaxed soft palate, undue sensitivity of the soft palate, uvula, fauces, posterior pharyngeal wall and the tongue.
- Medical factors: Nasal obstruction, postnasal drip, sinusitis, nasal polyps, congestion of the oral nasal and pharyngeal mucosa.
- Psychological factors: Stress, phobia, alcoholism, fear, visual, and olfactory stimuli.
- Dental factors: Inadequate posterior palatal seal, restricted tongue space in dentures and overextended borders. 
| Management of Gagging|| |
Individual assessment of the patient is done and the dentist attempts to identify the situations that trigger gagging. History is taken which should be empathic, specific, open questioning about previous dental treatment. Clinical examination should then be carried out with a ball burnisher to find out trigger areas. Treatment approaches can be modified with various gagging reduction therapies such as behavioral techniques (relaxation, distraction, and desensitization), complementary therapies, psychological approach and pharmacological agents. Distraction techniques include talking to patient (Faigenblumraising) watching one of the legs (Krol), putting table salt on tip of tongue, etc. Desensitization techniques such as marble technique (Lee-Singers), training denturessoft blow down splints, slow swallowing technique (wills) are the most accepted ones. ,
Modification of impression procedures can be done by use of non-perforated trays, post-damming with wax or silicone putty, use of sectional impression trays and avoiding overflow of impression materials.
| Case Report|| |
A 40-year-old female patient reported with chief complaint of difficulty in chewing and wanted replacement of missing teeth [Figure 1]. Intraoral examination revealed that teeth 13, 16, 17, 26, and 27 were missing in maxillary arch and mandibular arch was edentulous. The patient during conversation disclosed that she had experienced severe nausea and vomiting sensation during past dental treatment, and therefore, discontinued the treatment. With this background various treatment options considered for the patient were as follows.
- Implant treatment (patient not willing).
- Cast partial denture for maxillary arch.
- Reinforced complete denture for mandibular arch.
| Treatment Planning|| |
Identification of trigger zones
During first appointment a detailed history was taken, trigger points were identified with the help of ball burnisher [Figure 2] by moving it slowly barely touching the mucosa all over the oral cavity. Immediate gag reflex was provoked once the area of soft palate adjoining hard palate was palpated. This area was identified as trigger zone.
Impression making and anesthetizing soft palate
For impression making soft palate was anesthetized (trigger zone) with topical anesthesia.
Impressions were made with appropriate sized stock tray whose extensions were checked carefully and perforations were sealed with polyethene sheet loosely adapted to contour of the tray leaving a space of 5 mm between tray and the sheet. Thick mix of alginate (fast set) was used 11 and excess material was prevented from coming out by sealing the tray with polyethene sheet to minimize the gag reflex.
Single crown prosthesis was decided for 14 and 15 because of severe sensitivity to the patient. Tooth preparation was done in relation to 14 and 15 along with mouth preparation to receive rest seats for cast partial denture in relation to 24 and 25. Mandibular border moulding was carried out with single step putty technique and final impression was made with light-bodied impression paste.
Insertion of training dentures and designing cast partial denture
In the same appointment, training denture without teeth with open palate design was given to train the patient to be worn 4-5 hr per day for 1 week so as to teach the patient to keep prosthesis in oral cavity [Figure 3] and [Figure 4]. Cast partial denture with modified horseshoe was designed for the patient to reduce contact of tongue with denture, and hence, reduce gag sensation [Figure 5].
Training dentures with teeth
After a week training dentures with teeth were given to the patient. Cast partial denture framework was tried and jaw relations were recorded. Face bow transfer was done and casts were mounted on articulator. A custom-made metal mesh was also fabricated for lower mandibular denture to reinforce it against maxillary denture.
Try in appointment
Verification of jaw relations was done. Occlusal relations and extensions were verified. Training dentures were evaluated.
Final dentures were delivered [Figure 6] and recall was done after 24 h. The patient was advised to wear only maxillary denture initially for 1 week. After regular counseling, the patient started wearing both the dentures and had no difficulty in phonetics and mastication.
| Discussion|| |
Impressions with proper sized non-perforated trays can solve the problem initially while making diagnostic impressions. Identifying trigger zones and managing them appropriately will not only increases patient comfort, but also helps during various steps of treatment. In this case, anesthetizing trigger zones while making impressions increased patient compliance. Training dentures helped the patient to learn to keep prosthesis in mouth gradually over a period of time. Planning for horse-shoe-shaped major connector reduced palatal coverage area, thereby, providing less interference for tongue and reduced gag reflex.
| Summary and Conclusion|| |
If organic disturbances, anatomic anomalies, or biomechanical inadequacies of existing prostheses are not key causes, the services of trained specialists are needed to help with behavioral management of the problem. Modification of treatment approaches can enhance patient acceptance and also result in successful treatment outcome.
| References|| |
|1.||Means CR, Flenniken IE. Gagging - A problem in prosthetic dentistry. J Prosthet Dent 1970;23:614-20. |
|2.||Meeker HG, Magalee R. The conservative management of the gag reflex in full denture patients. N Y State Dent J 1986;52:11-4. |
|3.||Bassi GS, Humphris GM, Longman LP. The etiology and management of gagging: A review of the literature. J Prosthet Dent 2004;91:459-67. |
|4.||Conny DJ, Tedesco LA. The gagging problem in prosthodontic treatment. Part I: Description and causes. J Prosthet Dent 1983;49:601-6. |
|5.||Conny DJ, Tedesco LA. The gagging problem in prosthodontic treatment. Part II: Patient Management. J Prosthet Dent 1983;49:757-61. |
Sharad Pawar Dental College and Hospital, Sawangi(M) Wardha
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]