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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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ORIGINAL ARTICLE
Year : 2016  |  Volume : 34  |  Issue : 3  |  Page : 238-243
 

Awareness and prevention of patient gag reflex among pedodontists in India: A web-based survey


Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India

Date of Web Publication25-Jul-2016

Correspondence Address:
Soumik Roy
Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur - 482 005, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.186742

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   Abstract 

Aim: The aim of this study is to devise a reliable and valid web-based survey to predict the awareness level and prevention of patient's gag reflex among Indian pedodontists. Materials and Methods: An 11-question predictive gagging survey was created, refined, and tested on 377 pedodontists. The questions focused on age group, common procedure associated with gag reflex and the most common technique adapted by dentists in their clinics to prevent gag. Results: There was no statistically significant difference in gagging reflex among age groups with 53.5% of patients reported anxiety and fear as a main cause of gag; behavioral modification technique was considered as the most reliable method for gagging prevention in 68.5% of patients and there was no statistically significant difference in gagging severity index among patients irrespective of age, causes, and methods used to prevent it. Conclusion: The web-based gagging survey established that level of awareness regarding management of patient's gag is significantly low among pedodontists in India and hence is a major hindrance in the clinical practice.


Keywords: Anxiety, fear, gag, gagging severity index, pedodontist


How to cite this article:
Roy S, Bhayya DP, Gupta S, Upadhyay K, Tiwari S, Rao A. Awareness and prevention of patient gag reflex among pedodontists in India: A web-based survey. J Indian Soc Pedod Prev Dent 2016;34:238-43

How to cite this URL:
Roy S, Bhayya DP, Gupta S, Upadhyay K, Tiwari S, Rao A. Awareness and prevention of patient gag reflex among pedodontists in India: A web-based survey. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2021 Jan 23];34:238-43. Available from: https://www.jisppd.com/text.asp?2016/34/3/238/186742



   Introduction Top


Gagging is a normal healthy defense mechanism or reflex, which attempts to eject unwanted irritating or toxic materials from the upper gastrointestinal tract or from entering the trachea. Gagging is most frequently experienced during impression making but is also reported while taking of radiographs, in the placement of restorations in posterior teeth and in some individuals, even with the insertion of a finger for examination purposes.[1],[2] Most patients can be successfully treated if the cause can be determined which can either be a psychogenic or somatogenic in origin.[2] Active gag reflex upsets the patient, compromises the quality of treatment, and frustrates the dentist. By thorough examination, taking of adequate medical history and conversation with the patient, the dentists need to determine the patient's problem which can be related to iatrogenic factors, organic disturbances, anatomic, or psychological factors. It is important to recognize whether single or multiple factors are causing the problem.[1] Occasionally, patients feel they are beyond help and discontinue their dental treatment which is more harmful.[2]

The literature identifies two main categories of gagging patients. The somatoform group, in which gagging is induced by physical stimuli and psychogenic group, in which psychological stimuli are thought to initiate gagging.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11]

The management of the patient with a mild to moderate gagging problem may be performed in general dental practice. However, a patient with a severe gagging problem may initially require referral to a clinician who has an interest in the management of such patients. Often the dentist is in an excellent position to reinforce and apply the management techniques to which the patient has been exposed. The management of the gagging patient may be influenced by the severity and etiology of the problem. It is important that the clinician obtains a detailed history in an unhurried, sympathetic manner and the environment should be calm and reassuring. The attitude of the clinician toward the patient may influence the treatment outcome. If the dentist attempts to identify the situations that trigger disruptive gagging, this may optimize patient care and operative success.[1],[5],[6],[8],[9] Thus, this web-based cross-sectional survey was done to assess the awareness level and prevention of patient gag reflex among pedodontists in India as gagging is more common in children and is challenging to manage.


   Materials and Methods Top


The web-based survey was conducted on 450 Indian pedodontists via mail, out of which only 377 completely responded; thus, response rate was 83.78%. A list of 11 questionnaires was developed that explores the above-mentioned objectives with subcategories. Questions and options were thoroughly discussed and feedback was incorporated into the questionnaire which included:

  1. How many years of clinical experience you have?

    1. 8804;5 years
    2. 6–10 years
    3. >10 years


  2. What is the age group of patients in which you face maximum gag reflex?

    1. 2–5 years
    2. 6–10 years
    3. 11–16 years
    4. Irrespective of age


  3. How many patients do you treat in a month with mild to severe gag reflex?

    1. Very occasional
    2. 1–5
    3. 5–10
    4. >10


  4. What do you consider the main reason for gag or gag reflex in your patients?

    1. Anxiety and fear
    2. Any medical condition
    3. Both of the above


  5. Do you think during gag or gag reflex there is a change in Heart Rate of the patient?

    1. Yes
    2. No
    3. Do you consider gagging severity index (GSI)/gag prevention index (GPI) before treating a patient with gag reflex?

      1. Yes
      2. No


    4. Does gag or gag reflex ever change your treatment plan or modality in your patient?

      1. Yes
      2. No
      3. Sometimes


    5. In which procedure you encounter maximum gag reflex in your patient?

      1. Diagnostic procedure
      2. Impression procedure
      3. Operative procedure


    6. What do you consider the best way to prevent gag or gag reflex in your patients?

      1. Behavioral methods
      2. Pharmacological methods
      3. Other methods
      4. Combination of methods


    7. Have you ever changed or modified your impression technique or impression material in a patient with gag reflex?

      1. Yes
      2. No
      3. Sometimes


    8. Do you consider gag reflex to be a severe hindrance in your clinical dental practice?

      Yes
    9. No.


Statistical analysis

The sample size was calculated using OpenEpi, version 3 software (CDC, Atlanta, GA, USA approved).


   Results Top


Three hundred and seventy-seven Indian pedodontists were included in the web-based cross-sectional survey. Analysis of each questionnaire was performed in percentage. Distribution of study population according to clinical experience revealed that 56.2% of pedodontists have >10 years of clinical experience [Graph 1 [Additional file 1]], there was maximum (47.2%) irrespective age group of patients with gag reflex [Graph 2 [Additional file 2]], there were 1–5 maximum patients treated in a month for gag reflex constituting 72.1% [Graph 3 [Additional file 3]], anxiety and fear was found to be the main reason for gag reflex (56.5%) [Graph 4 [Additional file 4]], 84.6% of patients reported a change in heart rate during gag reflex [Graph 5 [Additional file 5]], 90.2% of patients did not respond to GSI and GPI [Graph 6 [Additional file 6]], 45.1% of patients had a change in treatment plan due to gag reflex [Graph 7 [Additional file 7]], impression procedures constituted maximum to gagging (91.8%) [Graph 8 [Additional file 8]], behavioral methods were considered as the best way to prevent gagging (56%) [Graph 9 [Additional file 9]], 65.5% of patients responded positively to change or modification in impression technique or impression material [Graph 10 [Additional file 10]] and 67.4% of patients considered gag reflex as a hindrance in clinical dental practice [Graph 11 [Additional file 11]]. There was no statistically significant difference (P = 0.088) obtained in age group; however, the majority of the patients needed a change in treatment [Table 1]. Of 377 patients, 319 reported a change in heart rate on gagging with anxiety and fear being the main reason (53.3%) which was statistically significant with P = 0.003 [Table 2]. Two hundred and thirteen participants reported anxiety and fear as main cause of gagging with 68.5% suggested behavioral modification as the best way to prevent it. Participants with gagging due to medical conditions (66.7%) reported combined behavioral and pharmacological methods as the best which was highly, statistically significant (P = 0.000) [Table 3]. There was no statistically significant difference obtained with GSI with a number of patients treated in a month (P = 0.060) [Table 4]. Among 170 participants, who considered a change in treatment plan, 122 considered gag reflex as a hindrance in clinical practice, and among 141 participants, who sometimes require a change in treatment plan, 97 considered gagging as a hindrance in clinics which was statistically significant (P = 0.020) [Table 5].
Table 1: Association between age group of patients with

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Table 2: Association between main reason for gag or gag reflex in patients and change in heart rate

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Table 3: Association between the best way to prevent gag or gag reflex in patients and main reason for gag or gag reflex in patients

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Table 4: Association between a number of patients treated in a month and gagging severity index/gag prevention index

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Table 5: Association between change in treatment plan and gag reflex is hindrance in clinical practice

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   Discussion Top


Gagging is a prevalent, intrusive concern in dental care. There are no observed effects of sex, age, or level of education on problems with gagging, which suggest it is generalized across socioeconomic and other demographic strata.[12] The four factors that are believed to be important in the etiology of gagging include – local, systemic disorders such as nasal obstruction, postnasal drip, catarrh, sinusitis, nasal polyps, upper respiratory tract mucosal congestion, and dry mouth, medications induced nausea, chronic gastritis, peptic ulceration, stomach carcinoma, hiatus hernia, and uncontrolled diabetes, anatomic and psychological factors and iatrogenic factors like poor clinical techniques such as overloaded impression tray, unstable or poorly retained prosthesis, overextended borders of prosthesis, increased vertical dimension of occlusion, and smooth highly polished surface coated with saliva which produce slimy sensation.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10]

The main of the treatment is to allow the patient to receive dental care with a minimum of anxiety and stress. Many diverse management strategies have been described in the literature which includes behavioral modification techniques such as relaxation, distraction, systemic desensitization, training bases, cognitive behavioral therapy, and sensory flooding, pharmacological techniques such as local anesthesia, conscious sedation, and general anesthesia, and complimentary therapies such as acupressure, acupuncture,[1],[2],[3],[4],[5],[6],[8],[9] transcutaneous electrical nerve stimulation, hypnosis, and modification of impression technique and material.[1],[2],[3],[5],[6],[8],[9]

Our study showed that out of 377 patients, 319 reported a change in heart rate on gagging which was statistically significant. Our study was supported by Hosseini et al. and concluded that gagging increased heart velocity and had a differential effect on two branches of cardiac autonomic nerves.[13] In our study, 213 participants reported anxiety and fear as a main cause of gagging and was also supported by a study conducted by Randall et al. on 478 participants and almost one-half of them reported higher frequency of gagging with greater levels of dental care-related fear, fear of pain, and more negative beliefs about dental professionals and dental treatment.[12] Our study revealed that participants with gagging due to medical conditions reported combined behavioral and pharmacological methods as the best gagging preventive methods and among 170 participants considered a change in treatment plan. Our study was supported by Malkoc et al. who reported that 5 min after administration of 2.5 mg intranasal midazolam patients had no gagging reflex and allowed the clinician to take satisfying impressions.[14] A study conducted by Chidiac et al. also concluded on 15 healthy volunteers that nitrous oxide inhalation sedation significantly reduced gagging reaction.[15]

Our study revealed no statistically significant difference with GSI with a number of patients treated in a month which was contradicted by a valid survey conducted by Hearing et al. and revealed a moderate positive correlation between the predictive gagging survey and Fiske and Dickinson's GSI [Table 6], r = +0.64.[16]
Table 6: Gagging scores Dickinson and Fiske gagging severity index[7]

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   Conclusion Top


The study clearly pointed out that the level of awareness regarding management of patient's gag is significantly low among pedodontists in India and illuminated that patient gag is a major hindrance in the clinical practice. Thus, gagging is a mystifying problem encountered which can be distressing for both patient and dental professional. However not a single antidote has been diagnosed to completely solve the problem. Gag is thus considered as one of the obstacles in rendering patients proper dental care and treatment. Although we cannot avoid gag, we definitely can take preventive measures to make it less severe.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Musani S, Musani I, Dugal R, Kothavade M. Gagging: Aetiology and management. IJDA 2010;2:332-6.  Back to cited text no. 1
    
2.
Naik S, Behere SS, Preetham MP, Shreelok BS. Gagging: A prosthetic review. IJDRR 2012:32-4.  Back to cited text no. 2
    
3.
Jurel SK, Singh P, Singh M. Gagging: Aetiology and management. INJMS 2011;2:127-32.  Back to cited text no. 3
    
4.
Bassi GS, Humphris GM, Longman LP. The etiology and management of gagging: A review of the literature. J Prosthet Dent 2004;91:459-67.  Back to cited text no. 4
    
5.
Singh S, Ali FM, Nazirkar G, Dole VK, Gaikwad B. Gag-etiology and its skillfull management – A review. J Evol Med Dent Sci 2013;2:1509-16.  Back to cited text no. 5
    
6.
Shriprasad S, Shilpashree HS. Gag reflex: No more a gag to a d entist the behavioral techniques, pharmacological techniques, acupressure and acupuncture in controlling the gag reflex – A review. Bangladesh J Med Sci 2012;11:12-7.  Back to cited text no. 6
    
7.
Thomas A, Raju BS, Varma M, Peedikayil FC, Gopal D. Gagster: A new technique for maxillary impression without gagging. J Indian Orthod Soc 2014;48:69-71.  Back to cited text no. 7
  Medknow Journal  
8.
Ahmad N, Yunus N, Jafri Z. Etiology and management of gag reflex in the prosthodontic clinic: A review. Int J Oral Health Dent 2015;1:25-8.  Back to cited text no. 8
    
9.
Ramesh R, Manonmani P, Vidhyasankari. Gagging – A review of literature. JIDAT 2010;2:100-3.  Back to cited text no. 9
    
10.
Ardelean L, Bortun C, Motoc M. Gag reflex in dental practice – Etiological aspects. TMJ 2003;54:312-15.  Back to cited text no. 10
    
11.
Fahmi FM. A simple technique to control gagging during impression making. Saudi Dent J 1990;2:141-3.  Back to cited text no. 11
    
12.
Randall CL, Shulman GP, Crout RJ, McNeil DW. Gagging and its associations with dental care-related fear, fear of pain and beliefs about treatment. J Am Dent Assoc 2014;145:452-8.  Back to cited text no. 12
    
13.
Hosseini SM, Jamshir M, Maleki A. The effect of gag reflex on cardiac sympatovagal tone. Oman Med J 2012;27:249-50.  Back to cited text no. 13
    
14.
Malkoc MA, Demir N, Ileri Z, Erdur A, Apiliogullari S. Intranasal midazolam may prevent gagging reflex: A case report. J Oral Maxillofac Res 2013;4:e5.  Back to cited text no. 14
    
15.
Chidiac JJ, Chamseddine L, Bellos G. Gagging prevention using nitrous oxide or table salt: A comparative pilot study. Int J Prosthodont 2001;14:364-6.  Back to cited text no. 15
    
16.
Hearing CM, Bind RH, Tabacco MJ, Hallock RM. A reliable and valid survey to predict a patient's Gagging Intensity. J Oral Maxillofac Res 2014;5:e3.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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