Control patient gagging

Oct. 18, 2013
Many times when we are about to take an impression, we are stopped when a patient goes through an episode of hyperactive gagging.

Part One

By Joseph J. Massad, DDS

Welcome back. This month I am going to give you some tips to control patient gagging. Many times when we are about to take an impression, we are stopped when a patient goes through an episode of hyperactive gagging. Virtually all dentists will experience this phenomenon sometime in their careers. Patients who appeared during the examination to be able to tolerate dental procedures with ease were not always so easy to work on. When least expected during a routine impression, a patient will become extremely hyperactive and begin to gag. This generally ends up in aborting the appointment. My mentor taught me an easy way to determine who these patients are. His method was to place a slightly oversized metal tray into the patient's mouth at the examination and move the tray back toward the palate while applying pressure. The patient who would be able to tolerate impressions would have little to no response. Other patients would begin to increase their breathing rhythm and begin to hyperactively gag. This simple test allows us to know our patients' needs better and to treat them accordingly.

Here are some methods that I have utilized to reduce gagging reactions during dental procedures. The gag reflex is generally thought to be controlled by the hypothalamus of the brain. We also know that other reactions are controllable by the hypothalamus. Place a Q-tip with salt on the tip of the patient's tongue. We are now stimulating taste sensors. This taste will also be reflected in the same part of the brain as the reflex, so we are giving the hypothalamus a second signal. The next plan of action is to give the patient a lollipop made with tetracaine 1%. This is the same medical topical anesthetic utilized after tonsillectomies or for sore throats. We suggest a 1% concentration and have the patient suck the lollipop until it begins to coat both the hard and soft palates. The third method of defense would be to use extreme cold in the form of a chemical ice. We have the patient massage their hands with a chemical ice bag. We also know that extreme cold sensations are also signaled in the hypothalamus. These are three different methods to send additional signals to the hypothalamus to decrease the gag reflex due to getting bogged down, like being caught in a traffic jam.

The next suggestion is to ask the patient to move their ankle and calf of the leg slightly off of the chair and hold it, not allowing it to touch the chair. Flexing muscles will also distract the patient by sending additional signals to the brain, thereby creating a traffic jam. We have used the following tactics to reduce patient anxiety. A patient who is listening to music while watching TV will be distracted and more relaxed, which diminishes the reflex. Dental chairs are now available with heat and vibrating modes. The patient controls the dental chair with their own remote control that provides pleasing vibration during the procedure. It is impossible and impractical to put every patient to sleep. We need the patient's cooperation to get a good functional impression. Nitrous oxide is a good way to calm the patient and their reactions to sensations during dental procedures. The last line of defense would be to utilize an antianxiety elixir. Generally, the patient will be asked to come in with a driver and not eat breakfast. Morning appointments are very effective especially for the anxious patient, and – combined with giving the patient an appropriate amount of antianxiety elixir – will decrease the patient's anxiety and improve the dental experience.

I'm hoping that these tricks will assist you as they have assisted me. If you would like references, please do not hesitate to email me and I would be happy to send you references for the distraction techniques and antianxiety methods to decrease patient gagging. I hope my pleasure in dentistry will also be yours. Until next month, be safe.

Joseph Massad

Dr. Joe Massad may be reached by phone at (918) 749-5600 or by e-mail at [email protected].

To see Dr. Massad's video tips, visit

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