BRITISH DENTAL JOURNAL VOLUME 190. NO.11 JUNE 9 2001 - PDF document

BRITISH DENTAL JOURNAL VOLUME 190. NO.11 JUNE 9 2001 palate. Psychogenic gagging is induced without direct contact andthe thought of the stimulus, such as a dental intervention, is suffi-cient to induce the reflex. A single aetiological factor is too simplistican explanation. For example, somatic gagging induced by a dental investigate any placebo effect.agging has been defined as an ejectory contraction of the mus-cles of the pharyngeal sphincter. It is a normal protective reflexdesigned to protect the airway and remove irritant material from theposterior oropharynx and the upper gastrointestinal tract. In someindividuals this protective reflex is exaggerated causing difficultiesin the provision and acceptance of routine dental treatment. *Senior Lecturer and Honorary Consultant in Special Care Dentistry, Assistant, Department of Sedation and Special Care Dentistry Floor 26, Guy'sTower, London SE1 9RT*Correspondence to: J Fiskeemail:janice.fiske@kcl.ac.uk REFEREEDPAPERReceived 29.09.00; Accepted 21.03.01British Dental Journal BRITISH DENTAL JOURNAL VOLUME 190. NO.11 JUNE 9 2001 be employed in an effort to control gagging.Ear acupuncture was selected for the following reasons:¥There is a specific, recognised anti-gagging point on the ear (Fig. 1)¥The needles are not disturbed during access to the mouth fordental treatment¥The needles are out of the patientÕs line of vision Ð a bonus foranyone with a dislike of needlesThe technique involves the insertion of one, fine, single-use dispos-able needle of 7 mm length into the anti-gagging point of each ear toa depth of 3 mm. The needles are manipulated for 30 seconds priorto carrying out dental treatment. The needles remain throughout treatment and are removed before the patient isdischarged. The patient does not require an escort and is not incon-venienced in any way following treatment.Ten people, with an exaggerated gag reflex, who had been referredto a specialist sedation unit because their gag reflex prevented con-ventional dental treatment agreed to try ear acupuncture to controlthe reflex. The technique was explained and informed consentobtained in all cases. The magnitude of the gag reflex was assessedusing the Gagging Severity Index (GSI)prior to acupuncture(Table 1). The acupuncture needles were inserted, as describedabove, and dental treatment commenced. The Gagging PreventionIndex (GPI)was used to assess the effectiveness of the earacupuncture in controlling the reflex and allowing dental treatmentto take place (Table 2). On the completion of treatment, the needleswere removed. All acupuncture treatments were carried out by onedentist trained in dental acupuncture.ResultsEight men and two women had ear acupuncture in an effort to con-trol their gag reflex so that they could accept dental treatment. Theirages ranged from 40Ð65 years.Using the GSI, four people rated IV with a severe reflex that madetreatment impossible and six people rated V with a very severe reflexwhich made treatment impossible and affected their dental atten-dance (Fig. 2). Prior to referral, two people had avoided treatment,six people were only able to receive treatment with intravenoussedation and two people had not been able to receive treatment at allbecause of their exaggerated gag reflexes.Using ear acupuncture, these ten people underwent a total of 25dental treatment episodes. Procedures carried out included scaling,root planing, impressions, fillings, extractions, adhesive bridgeplacement, a molar endodontic treatment and a biopsy of the lateralborder of the tongue.The cost of materials for ear acupuncture was £0.2 or 0.3 Eurosper person per treatment episode. After the initial explanation, theadditional time per visit was in the order of 2Ð3 minutes. There wereno adverse reactions to the technique and, on all occasions, patientswere fit to leave the surgery and travel home unaccompanied.Using the GPI to assess the effectiveness in controlling the groupsÕgag reflexes, for eight people and 23 episodes of treatment the scorewas I with the reflex obtunded and dental procedures carried outsuccessfully (Fig. 3). For two people and two episodes of treatmentthe score was II with the reflex partially controlled and dental treat-GaggingThe aetiology of gagging is complex and not fully understood.Whether its aetiology is somatic, psychogenic or a combination ofthe two, the outcome is to make the acceptance of dental treatmentimpossible for some people. Participants in the current review hadÔtried everythingÕ to control their gag reflexes in the dental situation.Some had resorted to treatment with intravenous sedation which isan invasive technique using a sedative drug (commonly, Midazolamwhich has an elimination half-life of two hours). Intravenoussedation requires the person to have an escort and affects their abil-ity to carry out certain activities, eg driving, work, etc. The manu-facturers of Midazolam recommend that these activities are avoidedfor eight hours post-administration of the drug.avoided dental treatment completely and worried how they wouldcope if they had a dental emergency. On the occasions when they did try to cope with dental treatment the inability to control theirgagging resulted in embarrassment and Ôfeeling like a childÕ. Fig. 1 Anti-gagging point on ear anti-gagging pointexternal auditory meatus Table 1 Gagging severity index (GSI)IVery mild, occasional and controlled by the patientII.Mild, and control is required by the patient with reassurance fromIII.Moderate, consistent and limits treatment optionsIV.Severe and treatment is impossibleV.Very severe; affecting patient behaviour and dental attendance and making treatment impossible.Source: Dickinson, 2000 Table 2 Gagging prevention index (GPI)Treatment management method employed:I.Obtunded gag reflex; treatment successfulII.Partially controlled gag reflex; all treatment possibleIII.Partially controlled gag reflex but frequent gagging; simple treat-IV.Inadequately controlled gag reflex; simple treatment unable to be V.Gag reflex severe; no treatment possible. Fig. 2 Patient gagging prior to ear acupuncture  BRITISH DENTAL JOURNAL VOLUME 190. NO.11 JUNE 9 2001 Review of the techniqueEar acupuncture helped all ten people to accept dental treatmentcomfortably. However, no account has been taken of any placeboeffect. The authors have been unable to find any reference in thedental literature to the previous use of this technique for controllingthe gag reflex. A systematic review of the evidence related to thetreatment of nausea and vomiting (due to surgery, chemotherapyand pregnancy) concludes that acupuncture is an effective tech-nique in reducing both nausea and vomiting.In 27 of the 29 trialsreviewed, acupuncture was significantly superior to the placebo.No reference could be found to the use of acupuncture as a long-term preventive treatment for nausea.The technique of ear acupuncture is relatively non-invasive. Itcauses little discomfort, is cheap and requires little additional clini-cal time. The patient is unaffected by the technique, does not requirean escort and can return to normal daily activities after treatment.However, it is important that informed consent is gained prior totreatment. The increased public awareness of therapies comple-mentary to medicine meant that all the participants had some priorknowledge of the technique. Although a number of people in thisreview expressed doubt that the technique would be helpful, theywere all agreeable to trying the method. Their readiness to try thetechnique may have been a reflection of their desperation for a cure.Rosteddescribes acupuncture as a very safe technique providedbasic anatomy and aseptic procedures are applied by an appropri-ately trained practitioner. In this instance the acupuncture was car-ried out by a dentist with a diploma in dental acupuncture.Information on training can be obtained from the British DentalAcupuncture Society (see Useful Address).Possible mechanisms of actionThe neurophysiology of acupuncture analgesia is well explainedwhile that of ear acupuncture in controlling the gag reflex is not.Indeed, the traditional explanation of ear acupuncture is at oddswith any scientific basis. It depicts different points on the ear, whichrepresent various body parts equivalent to those of a foetus mappedon the external helix and lobe of the ear. Interestingly, the anti-gag-ging point on the ear does not correspond to the anatomical repre-sentation of the head on the lobe of the ear. However, it doescorrespond with the area of skin of the external auditory meatusinnervated by the auricular branch of the vagus nerve, and is adja-cent to an area innervated by the auriculo-temporal branch of themandibular division of the trigeminal nerve. The vagus nerve isrelated to swallowing and gagging. Between them, the vagus and thetrigeminal nerves are responsible for much of the sensory innerva-tion of the laryngeal, pharyngeal, palatal and oral musosa, and themotor innervation of the musculature of the larynx, pharynx andpalate. In nine of the ten cases in this review, once the acupuncture needleswere in place, it was possible to trail a dental mirror across the hardand soft palates. Although the individuals could feel and locate themirror, no gagging occurred. One can only speculate that in someway, as yet not understood, stimulation of the antigagging points acti-vates mechanisms that inhibit the muscle activity of the gag reflex. Placebo effectThe placebo or suggestive effect of treatment can be very powerful.A recent systematic review has confirmed that the placebo effect ismediated via endogenous opioids.Also, the therapeutic responsedepends on the complicated interaction of patient factors andexpectations, operator factors and expectations, and treatment fac-tors.The current report is based on clinical cases and not aplanned clinical trial, thus no attempt was made to control for theeffect of suggestion. The people involved were desperately seeking asolution, and had done so, unsuccessfully, over many years. As oneperson said when challenged by a friend that she, Ôjust wanted it toworkÕ, ÔI have wanted something to work for the last twenty yearsÕ.However, there is a need to investigate the placebo effect. A con-trolled clinical trial is planned in order to do this.There is also scope to investigate if acupuncture can be helpful as along-term preventive therapy that would remove the individualÕsdependency on its use to facilitate dental treatment.Ear acupuncture was 100% successful in controlling the gag reflex inthe ten cases reviewed and it was not necessary to compromise den-tal treatment. The technique is safe, quick, inexpensive and rela-tively non-invasive. There is a need to investigate the placebo effect.Useful AddressBritish Dental Acupuncture Society (BDAS), Dr Tom Thayer,Trafalgar House, 14 Barker Street, Nantwich, Cheshire CW5 5SY.1Savage R D, McGregor A R. Behaviour therapy in prosthodontics. J ProsthetDent 2Saunders R M, Cameron J. Psychogenic gagging: identification andtreatment recommendations. Compendium of Continuing Education inDentistry3Mack A O. Complete dentures. Br Dent J4Wright SM. Medical history, social habits and individual experiences ofpatients who gag with dentures. J Prosthet Dent5Barsby MJ. The control of hyperventilation in the management of gagging.Br Dent J6Wright S M. An examination of the personality of dental patients whocomplain of retching with dentures. Br Dent J7Faigenblum MJ. Retching, its causes and management in prostheticpractice. Br Dent J8Levine M. Gagging, A problem in prosthondontics. J Can Dent Assoc9Ramsay D S, Weinstein P, Milgrom P, Getz M S. Problematic gagging.Principles of treatment. J Am Dent Assoc10Dickinson C. Gagging Problems in Dental Patients: Literature Review forthe Diploma in Dental Sedation. 2000: GKT Dental Institute of KingÕsCollege London.11Filshie J, Cummings M. Western medical acupuncture . In: Acupuncture aScientific Appraisal.Ernst E & White A (Eds). 1999; Butterworth-Heinemann: Oxford. 35-59.12Association of British Pharmaceutical Industries. Hpnovel. Compendium ofData Sheets and Summaries of Product Characteristics Datapharm Publications Ltd: London. 1132-1133. 13Meechan J G, Robb N D, Seymour R A. Pain and Anxiety Control for theConscious Dental Patient. 1998; Oxford: University Press. 321-32214Vickers A J. Can acupuncture have specific effects on health? A systematicreview of acupuncture antiemesis trials. J R Soc Med15Rosted P. Introduction to acupuncture in dentistry. Br Dent J16White A. Neurophysiology of acupuncture analgesia. In: Acupuncture aScientific Appraisal.Ernst E & White A (Eds). 1999; Butterworth-Heinemann: Oxford. 60-92.Fig. 3 Patient with acupuncture needles in the ears, receiving dental earing)