A normal gag reflex is designed to protect the airway and prevent choking and foreign objects entering the airway. Around one third of people do not have a gag reflex. This is in general a very useful reflex but in patients with a severe or exaggerated gag reflex dental treatments can be a nightmare. Simple tasks such as tooth brushing, taking radiographs or even a basic examination using a mirror becomes a challenge. This group of patients will need careful management in order to accept dental treatment and to avoid their condition leading to irregular or non-attendance. The dental team can also become stressed in dealing with such patients however successful management can be very rewarding professionally and the practice will have a satisfied patient for life.
Gag reflexes can be psychogenic or result from touch or trigger zones. Other causative factors can be due to anatomical variation, smoking related or in the presence of gastric disorders. It is always important to inquire at the outset if patients suffer from a gag reflex as this will influence their management and appointments will need to be tailored to their needs. Actually, it is very likely that patients will warn the dental team of their problem on first contact.
The management of patients with severe gag reflexes can take several visits and should always begin with simple techniques. This may involve relaxation using music, colour or yoga. Breathing exercises can be extremely effective and patients can be encouraged to breathe in deeply through their nose as this often focuses the mind further. In cases of blocked noses then a simple decongestant is very useful. Patients can be distracted via a variety of techniques such as focusing on a picture on the wall or simply by encouraging them to imagine being in a favourite place such as their garden or a memorable holiday location. A very useful distraction technique which I often use with my patients is to ask them to raise one of their legs during impression techniques and if fatigue sets in I ask them to switch legs. One of my colleagues often puts a pinch of salt on the patient’s tongue and this seems to override the gag reflex in many sufferers. Tapping on the patient’s temple area is also a well-described distraction technique. Local anaesthesia may also help some cases.
Desensitisation is another management tool for patients with severe gag reflexes. Patients can be given mouth mirrors or impression trays to try at home and gradually acclimatise to the feeling of alien objects in their mouths. Holding a marble or button in the mouth can have a similar effect. If patients manage early stages of treatment a trial plate may be worth trying and teeth can be gradually added.
Complementary therapies such as acupressure, acupuncture, trans electrical nerve stimulation (TENS) and hypnosis can all play a role and may be suitable for more challenging cases. More difficult situations may need sedation or even general anaesthesia if all other methods have failed.
As patients with severe gag reflexes are not uncommon it is very important for dental team members to adapt and allow these patients to access dental treatment with confidence.
