Theetiologyandmanagementofgagging:Areviewoftheliterature - PDF document

Theetiologyandmanagementofgagging:Areviewoftheliterature G.S.Bassi,BDS,MDentSci,G.M.Humphris,PhD,MClinPsycholCPsychol, L.P.Longman,BSc,BDS,PhD LeedsDentalInstitute,Leeds,England;SchoolofPsychiatryandBehaviouralSciences,Universityof Manchester,Manchester,England;andLiverpoolUniversityDentalHospital,Liverpool,England Gaggingindentalpatientscanbedisruptivetodentaltreatmentandmaybeabarriertopatientcare, preventingtheprovisionoftreatmentandthewearingofprostheses.Thisarticlereviewstheliteratureon thegaggingproblemfromEnglish-languagepeer-reviewedarticlesfromtheyears1940to2002foundby conductinganelectronicsearchofPubMed,coupledwithadditionalreferencesfromcitationswithinthe articles.Dentallyrelevantarticleshavebeencitedwhereverevidenceexists,andabalancedviewgivenin situationswherethereiscontroversy.TheÞrstsectionconsidersthenormalgagreßexandfactorsthat disorders,andpsychologicalconditions.Areviewofthemanagementofpatientswithanexaggeratedgag reßexfollowsandincludesstrategiestoassistclinicians.(JProsthetDent2004;91:459-67.)aggingcommonlyoccursduringdentalproce-dures,suchasmakingamaxillaryimpression.ClinicianssuccessfullytreatmanypatientswithmildgaggingproblemsusingonlyminorproceduralmodiÞcations.Forsomepatients,however,severegaggingcanbeeli-citedbythedentistÕsÞngersorinstrumentscontactingtheoralmucosaorevenbynontactilestimuli,forexample,patientsseeingthedentistorrememberingapreviousdentalexperience.Providingdentaltreat-mentforthischallenginggroupcanbeastressful ConsultantinRestorativeDentistry,DivisionofRestorativeDen-tistry,LeedsDentalInstitute.ProfessorofHealthPsychology,ButeMedicalSchool,UniversityofSt.Andrews,St.Andrews,Scotland.ConsultantinRestorativeDentistry,DepartmentofRestorativeDentistry,LiverpoolUniversityDentalHospital.MAY2004THEJOURNALOFPROSTHETICDENTISTRY459 andposteriorpharyngealwall.Interestingly,thepassageoffoodacrosstheseareasdoesnotusuallyinciteretching.Gaggingmayalsobeelicitedbynontactilesensationssuchasvisual,auditory,orolfactorystim-Thesightofthedentistordentalequipmentmayprovokesomepatientstogag.Thesoundofthedentalhandpieceorapersonretchingmayinitiatethegagreßexinotherpatients.Landadescribedahusbandandwifewhobothsufferedfromseveregagging.ThesoundofthewiferetchingwassufÞcienttocausethehusbandtogag.Certainsmells,suchasdentalsubstances,cigarettesmoke,orperfume,mayalsoinducethegagreßex.Thisstronglysuggeststhatneutralstimulibecomecloselyassociatedtothegagreßex,providingevidencethatconditioninghasoccurred.Certainthoughtsmayalsobepotentenoughtostimulategagginginsomepatients.CONDITIONSASSOCIATEDWITHGaggingisoftenconsideredtohaveamultifactorialetiology,andavarietyofprecipitatingormodifyingfactorshavebeenproposed.TheliteratureidentiÞes2maincategoriesofretchingpatients.Thesom-atogenicgroup,inwhichgaggingisinducedbyphysicalstimuli,andthepsychogenicgroup,inwhichpsycho-logicalstimuliarethoughttoinitiategagging.Itmaynotbeeasytodistinguishbetweenthe2groupsbecausephysicalstimulimaystillprovokegaggingofpsycho-genicorigin;therefore,suchadistinctionisnotalwayshelpfulinpatientmanagement.The4factorsthatarebelievedtobeimportantintheetiologyofgagginginclude:localandsystemicdisorders,anatomicfactors,psychologicalfactors,andiatrogenicfactors.LocalandsystemicdisordersNasalobstruction,postnasaldrip,catarrh,sinusitis,nasalpolyps,mucosalcongestionoftheupperre-spiratorytract,adrymouth,andmedicationsthatcausenauseaasasideeffectarethoughttopredisposetoorcausegagging.Evidencethatcertainmedicalconditionsaremoreprevalentingaggersisequivocal.Chronicgastrointestinaldisease,notablychronicgastri-tis,pepticulceration,andcarcinomaofthestomach,canlowertheintraoralthresholdforexcitationandcontrib-utetogagging.Hiatusherniaanduncontrolleddiabeteshavealsobeensuggestedaspredisposingfactors.Gagginghasbeennotedasbeingworseinthemorningforsomepatients,owingtoanincreasedexcitabilityofthevomitingcentercausedbymetabolicdisturbancessuchascarbohydratestarvationandde-hydrationwithketosis.AnatomicfactorsPhysicalfactorssuchasanatomicabnormalitiesandoropharyngealsensitivitieshavebeensuggestedaspredisposingfactorstogagging.Inastudyofdenturewearersthatcomparedtheradiologicanatomyofgaggersandnongaggers,noanatomicabnormalitieswereobserved.Therewere,however,feweradaptivechangesinthepostureofthetongue,hyoidbone,andsoftpalateinthegagginggroup.Wrightsuggestedthatthedistributionoftheafferentneuralpathway,particularlythevagusnerve,maybemoreextensiveingaggingpatientscomparedwithnongaggingpatients.Enlargedareasofsensoryinnervationcannot,however,explainwhypatientsgagwithauditory,olfactory,orvisualstimuli.PsychologicalfactorsSystemicconditionscanhaveafunctional(psycho-somatic)componentthatmaycontributetotheetiologyandthemaintenanceofadiseasestate.Examplesoforofacialconditionsthatmayhaveastrongpsychogeniccomponentaretemporomandibularpaindysfunctionsyndrome,atypicalfacialpain,dentureintolerance,burningmouthsyndrome,andthegagreßex.Thepersonalityofpatientswithamarkedgagreßexhasbeeninvestigated,andnodifferenceswerefoundbetweengaggersandnongaggersforneuroticism,extroversion,orpsychoticism.Thefunctionalcomponentofaconditionmaybestronglyinßuencedbyanin-dividualÕsreactiontostressfulevents.ThisissometimesreferredtoasÔÔlearninghistory.ÕÕThereare2majormechanismsoflearningknownasclassicalandoperantconditioning.ClassicalconditioningClassicalconditioningoccurswhenanoriginallyneutralstimulusispairedwithaspeciÞcbehavioralresponse.Inoffensivestimuli,suchasthesightofanimpressiontray,thesmellofthedentalsurgery,orthesoundofadentalhandpiece,maybecomeassociatedwithanunpleasantgagresponse.Gaggingmayoccurinitiallyasaresultofanoverloadedimpressiontrayortheaccumulationoflargequantitiesofwaterfromthehandpiece.Thepatientlearnstobroadlyassociatethestimuliasthecauseofthegagging,andhenceaconditionedgagresponsetothesestimulimaydevelop.OperantconditioningOperantconditioningisatrainingprocesswherebytheconsequenceofaresponsechangesthelikelihoodthattheindividualwillproducethatresponseagain.Inoperantconditioning,somebehaviorpatternsmaybereinforcedbecausetheysecureattentionandsympathy(positivereinforcement),avoidastressfulsituation(negativereinforcement),orachievesomeotherdesir-ableresult.Anexampleisapatientwhogagsinadvertentlyandlearnstoassociatethiswithatempo-rarysuspensionoftreatment.TheoutcomeisbeneÞcial,THEJOURNALOFPROSTHETICDENTISTRYBASSI,HUMPHRIS,ANDLONGMAN460VOLUME91NUMBER5 asthepatientderivesgainfromtheaction,whichisconsistentwithoperantconditioning.Treatmentin-volvesdiscontinuationofthereinforcingactionsandteachingalternativesocialskills,becausegaggingmaybethoughttobeamoresociallyacceptablereasonfornothavingdentaltreatmentthanadmittingtobeingdentallyanxious.IatrogenicfactorsPoorclinicaltechniquemayelicitthegagreßexinpatientsnotnormallysusceptibletogagging.Forexample,anoverloadedimpressiontrayoranunstableorpoorlyretainedprosthesismayinducegagging.Overextendedbordersofaprosthesis,particularlytheposterioraspectofthemaxillarydentureandtheposteriorlingualregionofthemandibularprosthesis,canimpingeontheÔÔtriggerzonesÕÕandproduceAnincreasedverticaldimensionofocclusionhasalsobeensuggestedasprecipitatinggagging.smooth,highlypolishedsurfacewhichiscoatedwithsalivamayproduceaÔÔslimyÕÕsensationwhichissufÞcienttocausegagginginsomepatients;amatteÞnishhasbeenadvocatedasmoreacceptableinthissituation.Themanagementofthepatientwithamildtomoderategaggingproblemmaybeperformedingeneraldentalpractice.However,apatientwithaseveregaggingproblemmayinitiallyrequirereferraltoaclinicianwhohasaninterestinthemanagementofsuchpatients.Thisdoesnotimplythatthegeneralpractitionerhasnofurtherroletoplay.Often,thepatientÕsdentistisinanexcellentpositiontoreinforceandapplythemanagementtechniquestowhichthepatienthasbeenexposed.Themanagementofthegaggingpatientmaybeinßuencedbytheseverityandetiologyoftheproblem.Itisimportantthattheclinicianobtainsadetailedhistoryinanunhurried,sympatheticmanner,andtheenviron-mentshouldbecalmandreassuring.Theattitudeofthecliniciantowardsthepatientmayinßuencetheoutcomeoftreatment.Ifthedentistattemptstoidentifythesituationsthattriggerdisruptivegagging,thismayoptimizepatientcareandoperativesuccess.Itishelpfulifthecliniciancanascertainiftherewasaprecipitatingeventresponsibleforinitiatinggagging,althoughthismaynotalwaysbepossible.Figure1outlinestheassessmentprocedure.Thepatientshouldbeinformedofwhattheintraoralexaminationinvolves,andtheinspectionshouldonlyproceedwhenconsenthasbeengiven.Thedentistshouldtrytoavoidstimulatingthegagreßexanddistressingthepatient;therefore,onlyalimitedexam-inationmaybepossible.TheroleofthedentalteamistobesympathetictothepatientÕsdifÞculties,tobegintoestablishadialogue,andtogeneratetrust,whichcanbetimeconsuming.Theaimoftreatmentistoallowthepatienttoreceivedentalcare,suchasrestorativetreatmentorthewearingofdentalprostheseswithaminimumofanxietyandstress.Manydiversemanagementstrategieshavebeendescribedintheliterature,andtherationaleandpracticalitiesofsometechniquesarequestionable.Ingeneral,whichevertechniqueisemployed,dentaltreatmentisperformedoveranumberofvisitswithreinforcementofthepreferredtechniqueateachappointment.Themanagementtechniquesshouldbecompletelyexplainedtothepatienttoallayasmanyfearsaspossibleandtoobtainvalidconsent.TablesIandIIoutlinesomeofthetreatmentstrategies.Whengaggingisthoughttobeduetoapoorlydesignedorill-Þttingprosthesis,thefaultsshouldberectiÞed,whichmaynecessitatetheremakingoftheprosthesis.BEHAVIORALTECHNIQUESBehaviormodiÞcationIthasbeenrecommendedthatalldisruptivegaggingshouldbeviewedandpresentedtothepatientasabehavioralresponseand,therefore,amenabletobehaviormodiÞcation.Anexaggeratedorextendedperiodofgaggingintheabsenceofanormalstimulusisusuallyalearnedresponse.Theoretically,thisresponsecanbeunlearnedorextinguished.BehavioralmodiÞca-tionisthemostsuccessfullong-termmethodofmanagingthegaggingpatient.Generally,theob-jectivesaretoreduceanxietyandÔÔunlearnÕÕthebehaviorsthatprovokegagging.Relaxation,distraction,suggestion,andsystematicdesensitizationareallmet-hodsthatcanbeemployed,singlyorincombina-Cognitivebehavioraltherapyandsensoryßoodingareadditionaltechniquesthatareavailable.Thegagreßexmaybeamanifestationofananxietystate.Relaxationtechniquesmaybehelpfulinreducingorabolishingthegagreßex.Relaxationcanhelpameliorateoroverrideunhelpfulthoughtprocesses.Anexampleofthisistoaskthepatienttotenseandrelaxcertainmusclegroups,startingwiththelegsandworkingupwards,whilecontinuallyprovidingreassur-anceinacalmatmosphere.DistractiontechniquescanbeusefultotemporarilydivertapatientÕsattentionandmayallowashortdentalTHEJOURNALOFPROSTHETICDENTISTRYBASSI,HUMPHRIS,ANDLONGMANMAY2004461 proceduretobeperformedwhilethemindisdissociatedfromapotentiallydistressingsituation.Conversationcanbeuseful,orthepatientmaybeinstructedtoconcentrateonbreathing,forexample,inhalingthroughthenoseandexhalingthroughthemouth.Itisoftenhelpfultoaskthepatient,priortocommencingtreatment,tothinkofandvisualizeasafe,comfortable,relaxingplaceandthentodescribeitbrießytothedentist.Theclinicianmaythenhelpreinforcethisimagebyverballydescribingobviousfeaturesofthissceneaccompaniedbyfeelingsofwell-being.ThisistermedÔÔdistractionimagery.ÕÕTheroleofdistractioncanbefurtheremphasisedbyaskingapatienttoparticipateinactivitiesthatcausemusclefatigue,suchasaskingapatienttoraisealegoffthedentalchairandholdtheposition.AsthepatientÕsmusclesbecomeincreasinglyfatigued,moreconsciouseffortisrequiredtoholdtheleginanelevatedposition,thusdivertingattentionawayfromanyintraoralprocedures.Distractiontechniquescanbeusedincombinationwithrelaxationprocedures.ForexampleifpatientsÞnditdifÞculttodissociatefromgaggingduringrelaxationtechniques,theuseofamantrathatisrepeatedsilentlythroughouttheproceduremaybehelpful.Distraction Fig.1.Assessmentofgaggingpatient.THEJOURNALOFPROSTHETICDENTISTRYBASSI,HUMPHRIS,ANDLONGMAN462VOLUME91NUMBER5 techniquescanbevaluableforpatientswithmildgaggingtoallowshortdentalprocedurestobeper-formedsuchasimpressionsorintraoralradiographs.Thesetechniquesmaybeinadequate,whenusedalone,inpatientswithaseveredisruptivegagreßex.Distractiontechniqueshavealsobeenadvocatedfortheinsertionofnewdentures.Amethodofdeeprhythmicbreathing,asadvocatedbytheNationalChildbirthTrustoftheUK,hasbeenusedwithsomesuccessindenturewearers.suggestshavingthepatientcountrapidlyto50thenreadoutloud.Kovatsreportedatechniqueinwhichthepatientbreathesthroughthenoseandatthesametimerhythmicallytapstherightfootontheßoor.DistractiontechniquescanbereÞnedbyincorporat-inganelementofsuggestion.Patientscanbein-formedthatretchingwillnotoccurduringthedistractingactivity.Visualimagerymaybeusedtoenhancesuggestion.Hypnosismayhelptorelaxapatientandsotemporarilyremoveoramelioratethegagreßextoallowdentaltreatmenttobeperformed.Therearefewcontraindicationstohypnosis,butitshouldonlybeusedaftertheclinicianhasreceivedappropriatetrain-Anexperiencedhypnotherapistmayuseasophisticatedsuggestionapproachtohelpabolishthegagreßex. TableI.SummaryofmanagementofgaggingpatientIndividualassessmentAssesspatient’sattitudeandmotivationtotreatmentWillingnessto:-trytreatmentandinvesttimeintreatment-committo‘‘homework’’-acceptthattreatmentmaybePatient’sultimategoalfortreatment?Doespatientbelieveitisachievable?TechniquescommontoallpatientsSympatheticapproachPositiveattitudeThoroughhistoryReassurepatientGaggingisanormalresponseManypatientshaveverysensitivegagreexThemajorityofpatientscanlearntocontrolgagging,butittakestimeGaggingisnothingtobeembarrassedaboutBuildpatient’sself-condenceExplainanddemonstratestopsignal(forexample,raisinghand)AllowpatienttofeelsomecontrolCarefulintraoralexaminationObtainpatientfeedbackandcontinuallyre-negotiateconsentAvoidtriggerzonesPraisepatientSpeciÞctreatmentmodalitiesBehavioralRelaxationtechniquesDistractionSuggestion/hypnosisSystematicdesensitizationCognitivebehavioraltherapyPharmacologicalOralIntravenousCombinedSeveraltechniquesmaybeusedtogetherorinsuccessionSimplemeasuresforallpatients(reduceiatrogenicDonotoverloadimpressiontrayUsequick-settingimpressionEnsureefcientaspirationMiscellaneousAkinosiclosed-mouthtechniqueforlocalanalgesiaofinferiordentalnerveTreatpatientinanuprightpositionFrequentcessationoftreatment TableII.SuggestedtreatmentstrategiesforpatientwithdisruptivegagreexTreatmentproblemManagementoptionsProsthodonticUnabletotolerateimpressionsDistractiontechniquesSystemicdesensitizationUnabletoweardenture(s)Satisfactorydenturesavailable–‘errorless’learningNosatisfactorydentures–systematicdesensitization,forexample,trainingbaseand’errorless’learning.AcrylicdiscsmaybehelpfulpriortoprovisionoftrainingUnabletotolerateinstrumentation,forexample,examination,scaling,toothpreparationNoshort-termtreatment-hypnosis-systematicdesensitizationfororalhygienemeasure,scaling,polishing-encourageregularInurgentneedoftreatment:-hypnosisTHEJOURNALOFPROSTHETICDENTISTRYBASSI,HUMPHRIS,ANDLONGMANMAY2004463 SystematicdesensitizationThemaladaptivethoughtsandexpectationsofpatientscanbealteredbypositiveexperienceandthisformsthebasisofre-educationtechniquessuchassystematicdesensitization.Behaviorthathasbeenlearnedbyclassicalconditioningcanbeunlearnedbyessentiallyreversingtheconditioningprocess.Thetechniqueconsistsofincrementalexposureofthepatienttothefearedstimulus.Thepatient,underconditionsofrelaxationandreassurance,isexposedtoamildlyaversivestimulusandlearnstocopewiththis.Thepatientisthengraduallyexposedtoincreasinglyaversivestimuli.Inotherwords,theintensity,duration,andfrequencyofthenoxiousstimuliisslowlyincreased,therebyallowingthepatienttogentlyhabituatebydevelopingcopingstrategiestodealwiththefeelingsofdiscomfortorpanicexperienced.Thismayofteninvolvebehavioraltechniquessuchasdeepbreathingandmusclerelaxation.Itisimportanttouseacontrolledstep-wiseapproachtopreventorminimizethepatientÕsgagging.Theuseofreassuranceandpraiseisstronglyrecommended.Manyre-educationtechniqueshavebeendescribedinwhichthepatientisgivenanobjecttoplaceinthemouthforaperiodoftime.11,23,35Thesizeoftheobjectandthelengthoftimeforwhichitisheldinthemouthgraduallyincreasesuntilthepatientisabletotoleratedentalprocedures.Atoothbrush,radio-graph,impressiontray,marbles,acrylicdiscs,buttons,dentures,andtrainingdeviceshaveallbeenusedtohelppatientsovercomethegaggingproblem.23,26,35Forexample,thehardpalateisgentlybrushedwithatoothbrushwithoutinducingthegagreßex.Thepatientmarksthepositionofthemaxillaryincisorsonthetoothbrushhandle.Theaimistomovethebrushmoreposteriorlyandthepatientisencouragedasthemarkonthetoothbrushmovesprogressivelydownthehandle.Singerdescribedatechniquewhereordi-naryglassmarbleswereusedtore-educatethepatientpriortodenturefabrication.Essentially,for1weekmarblesaresuckedinthepatientÕsmouthforin-creasingperiodsoftimewhileawake.Oncethesearetolerated,maxillaryandmandibulardenturerecordbasesaremade,andlaterconvertedtoconventionaldentures.Alternatively,acrylicballsordiscsmaybeused.Relaxationtechniquesareoftenemployedatthesametimeasundertakingtheintraoralexercise.Homeworkisanessentialcomponentofasystematicdesensitizationprogram.Suchproceduresshouldbeundertakenregularly,preferablydaily,andalogbookofeventskept.TrainingbasesThisisafurtherdesensitizationtechnique,wherebyapatientisprogressivelysuppliedwithaseriesofsmalltofull-sizeddenturebases.Itisusefulforpatientswhoaretobecomedenturewearers.Athinacrylicdenturebase,withoutteeth(Fig.2),isfabricatedandthepatientis Fig.2.Trainingdenturewithoutteeth. Fig.4.Trainingdenturewithposteriorteeth. Fig.3.Trainingdenturewithanteriorteethonly.Improvedestheticsmaybemotivatingfactor.THEJOURNALOFPROSTHETICDENTISTRYBASSI,HUMPHRIS,ANDLONGMAN464VOLUME91NUMBER5 askedtowearitathome,graduallyincreasingthelengthoftimethetrainingbaseisworn.Asuitableregimemaybe5minutesonceeachday,thentwiceeachdayandsoon.After1weekthepatientisaskedtoincreasethisto10minutes3timeseachday,then15minutes,30minutes,and1hour.Eventuallythepatientisabletotoleratethetrainingbaseformostoftheday.Thetimingandrateofprogresswillvarybetweenpatients,de-pendinguponindividualneedsandexpectations.Ifproblemsareencountereditmaybenecessarytoreducetheextensionoftheposteriorborderofthedenture.Theplacementof2posteriorpalatalsealsduringfabricationishelpfulasthisallowsthepostpalatalsealtobemaintainedeveniftheextensionoftheposterioraspectofthetrainingbaseissubsequentlyreduced.Itcanbeadvantageoustousedistractiontechniqueswiththisapproach.Thepatientisaskedtoinitiallywearthetrainingbasewhenbusyorconcentratingonanon-stressfultasksuchaswatchingafavoritetelevisionprogram.Relaxationtechniquescanalsobecombinedwiththeinitialwearingofthetrainingbase.Anteriorteethareaddedtotheoriginaloranextendedtrainingbase(Fig.3)and,whenthepatientisabletotoleratethis,posteriorteethareadded(Fig.4).Compromisingthestandardsofdentureproductioniscounterproduc-tive,andretentionandstabilityoftheprosthesisshouldbeoptimized.PalatelessdentureshavebeenshowntobeeffectiveinsomepatientsandlossofretentionisnotalwayssigniÞcantlyaffected.Someauthors,how-ever,wouldstillonlyrecommendthisoptionasalastErrorlesslearningThisdesensitizationtechniqueisaneffectivesimplemethodthatcanbeusedbyallclinicians,andishelpfulforpatientswhohavedenturesbutdonotwearthembecausethedenturesevokegagging.Thedisadvan-tageisthatitcanbeaveryslowtechnique.However,onceamotivatedpatientunderstandstheprocedureandrationale,theintervalbetweenclinicappointmentscanbeextendedwhilethepatientcontinuestopracticetheThepatientisinstructedtosetasidetimetopositionthedentureclosereachdayandeventuallyintothemouthinÔÔsuccessiveapproximations.ÕÕThatis,thedentureisplacedperhapsmillimetersatatimeclosertotheÞnalposition.Insituationswhereretchingisinducedsimplybylookingatthedenture,thenthepatientismerelyrequestedtolookatorholdthedentureandtostopbeforesymptomsofretchingdevelop.Theprocessisrepeated,withasmallincreaseintimespentundertakingthistask,untileventuallythepatientcanwearthedenture.Itisimperative(andgivesthetechniqueitsname)thatgaggingisnotinducedandthereisnoreinforcementoftheassociationbetweenretchinganddenturewearing.Theobjectiveistounlearntheconditionedresponse.Itisalaborioustaskonthepartofthepatientandtheprogressmadeshouldbestronglyencouragedbythedentist.CognitivebehavioraltherapyThismethodfocusesonchangingirrationalthoughtprocesses.Alterationoreliminationofunhelpfulcogni-tionsmayleadtoachangeofbehavior.Cognitivebehavioraltherapy(CBT)invitespatientstochallengestronglyheldbeliefsabouttheconsequencesofgaggingbyaskingthepatienttoconfrontthesebeliefswithevidencecollectedfromlifeexperience.ApatientwhocatastrophizesthepossibleoutcomeofdentaltreatmentmaybesuitableforCBT.Forexample,somepatientsretchwhenwaterfromthehigh-speedhandpieceisfelt.Whenquestioned,itisnotunusualforanindividualtoadmittoafearofchoking,believingthatbreathingwillstop,resultingindeath.Somepatientsmaybelievethatthefearofdentistrywillcauseafatalheartattack.Acognitivebehavioralpsychotherapistwillattempttorationalizethesethoughtpatternsinpatientswithpersistentpsychogenicgagging.Agooddescriptionofapplyingcognitiveprinciplestogaggingismadebywhoconsiderspatientswithagaggingproblemsusceptibletopanicattacks.SensoryßoodingAtechniqueknownassensoryßoodinghasbeenadvocatedbysometobeeffective.Itreliesonarapidextinctionofthelinkbetweenthestimulus(forexampleadenture)andgagging.Itisaccomplishedbyencour-agingthepatienttoretainthedentureinthemouthforaslongaspossiblewiththereassurancethattheaversivereactionsencounteredwilldiminish.Thebasisofthismethodistoinformthepatientthatthephysiologicalsystemcannotmaintainthestrengthoftheinitialresponseandthathabituationwilloccurwithin30minutesorso.Thismethodwouldnotbeappropriatewithseveregaggingproblems,andcompliancewouldbeunlikely.Somesupportforsingle-sessionexposuretechniquessuchasthishasbeenreportedwithotheranxiety-relatedconditionssuchasclaustrophobiaandbloodphobia.Ifthisapproachisattempted,fullcooperationmustbeelicitedfromthepatientandtherationaleexplained.Thisapproachisindirectopposi-tiontotheerrorlesslearningapproach.TeachingpatientstoswallowwiththeirmouthopenIthasbeensuggestedthatallpatientswhogagcharacteristicallyswallowwiththeirteethclenched,usingtheteeth,lipsandcheeksasabuttressforthetonguetopushagainst.Teachingthepatienttoswallowwiththeteethapart,thetipofthetongueplacedanteriorlyonthehardpalate,andtheorbicularisorismusclesrelaxed,hasbeenadvocated.THEJOURNALOFPROSTHETICDENTISTRYBASSI,HUMPHRIS,ANDLONGMANMAY2004465 PHARMACOLOGICALTECHNIQUESLocalanesthesiaTheuseoflocalanesthesiaforgagginghasbeencriticizedbysomeauthors,16,23,24,42butproponentssuggestthatifthemucosalsurfacesaredesensitized,thepatientislesslikelytogag.Theagentsmaybeappliedintheformofsprays,gels,lozenges,mouthrinses,orinjection.Whiletopicalanestheticsmayworkforsomepatients,inothersitmayincreasenauseaandvomitingandmayfailtosuppressthegagreßex.depositionoflocalanestheticaroundtheposteriorpalatineforamenhasbeenusedforpatientswhogagwhentheposteriorpalateistouched.However,theadministrationofalocalinjectionmaynotbepossibleandmayinitselfprovokegagging.Furthermore,injectionoflocalanestheticsolutionmaydistendthesofttissuesresultinginaninaccurateimpression,whichmaycompromiseretentionoftheprosthesis.abehavioralviewpoint,theuseofanestheticsservestofocusthepatientÕsthoughtsontheimpendingstimu-orpossiblyactasadirectantecedentwithoutrequiringaninterveningconsciousthoughtprocess.ConscioussedationWhenadisruptivegagreßexisthoughttobeamanifestationofanxiety,removaloftheanxietymaypreventgagging.Theuseofconscioussedationwithinhalational,oral,orintravenousagentsmaytemporar-ilyeliminategaggingduringdentaltreatmentwhilemaintainingreßexesthatprotectthepatientÕsairway.Psychologicalapproachessuchasdistractionorre-laxationtechniquesmaybeenhancedwhenusedinconjunctionwithsedation.Cliniciansshouldconsiderthisincreasedsuggestibilitywhentreatingtheretchingpatient.AreportbyRosenprovidesadetailedexampleofhowpositivesuggestioncanbeusedwithnitrousoxidesedation.Often,theuseofsedationdoesnotobviatetheneedforothertreatmentmodalities.Sedationmaybeusedinitiallytoallowurgentdentaltreatmenttobecompletedafterwhichabehavioralapproachisusedtoaffectalong-termsolution.Asmallnumberofpatientswillbecomedependentonsedationfordentaltreatmenttobesuccessfullycom-pleted.However,whilesedationmayallowadequatetreatmenttobeperformed,itwillnothelpthepatientovercomeretchingif,forexample,aprosthesismustbeworn.Nitrousoxidealterstheperceptionofexternalstimulianditissuggestedthatthisalteredperceptiondepressesthegagreßex.ThepatientÕstolerancetotheplacementofintraoralobjectsisincreasedandtheanxiolyticpropertiesofnitrousoxidecanreduceorabolishthenegativecognitionsassociatedwithgag-ging.Inaddition,theeffectivenessofsemihypnoticsuggestionisenhancedbytheadministrationofin-halationsedation.Theuseoforalsedativesmaybeunpredictableandisusuallyonlyusefulinthemildgaggingpatientwithanunderlyinganxietystate.Intravenoussedationisoftenmuchmorepredictablethanoralsedation,andcanbeofuseinpatientswhereinhalationsedationisineffective.GeneralanesthesiaAminorityofpatientsdonotrespondtoanyformofsedationorbehavioraltherapyanddentaltreatmentundergeneralanesthesiamaybeappropriateasalastresort.ItistheauthorsÕopinionthatthelimitedresourcesavailablefortheprovisionofrestorativedentistryundergeneralanesthesiaandtheinherentrisksassociatedwithageneralanestheticmiligateagainsttheroutineprovisionofdentaltreatmentusinggeneralanesthesiainpatientswithadisruptivegagreßex.Overtgaggingcanbedistressingforboththepatientandclinician.Thereappearstobenouniversalremedyforthesuccessfulmanagementofthegaggingpatient.Awidevarietyofmanagementstrategieshavebeendescribedandtheseshouldbetailoredtosuittheneedsofindividualpatients.Thiscanonlybeascertainedbytakingadetailedhistory.Inmanysituationsacombina-tionoftreatmenttechniquesisrequiredbut,unfor-tunately,inasmallminorityofpatients,successfulmanagementmaynotalwaysbepossible.Studies,includingcaseseriesandrandomizedcontrolledtrialswithsingletreatmentmodalitiesandmixedinterventionapproaches,areencouragedtoimprovetheevidencebase.TheauthorsthankMrR.A.HowellforhiscommentsduringthepreparationofthemanuscriptandMrsB.Learmanfortypingit.REFERENCES1.WrightSM.Medicalhistory,socialhabits,andindividualexperiencesofpatientswhogagwithdentures.JProsthetDent1981;45:474-8.2.ConnyDJ,TedescoLA.Thegaggingprobleminprosthodontictreatment-PartI:descriptionandcauses.JProsthetDent1983;49:601-6.3.MeekerHG,MagaleeR.Theconservativemanagementofthegagreexinfulldenturepatients.NYStateDentJ1986;52:11-4.4.LogemannJA.Swallowingphysiologyandpathophysiology.OtolaryngolClinNorthAm1988;21:613-23.5.WrightSM.Anexaminationoffactorsassociatedwithretchingindentalpatients.JDent1979;7:194-207.6.AndrewsP,WiddicombeJ.Pathophysiologyofthegutandairways.London:PortlandPress;1993.p.100-2.7.DavenportHW.Physiologyofthedigestivetract.5thed.Chicago:YearBookMedicalPublishers;1982.p.99–100.8.LeslieSW.Anewoperationtoovercomegaggingasanaidtodentureconstruction.JCanDentAssoc1940;6:291-4.9.LandaJS.Practicalfulldentureprostheses.London:Kimpton;1954.p.10.MurphyWM.Aclinicalsurveyofgaggingpatients.JProsthetDent11.WilksCG,MarksIM.Reducinghypersensitivegagging.BrDentJTHEJOURNALOFPROSTHETICDENTISTRYBASSI,HUMPHRIS,ANDLONGMAN466VOLUME91NUMBER5 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