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

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


Soumik Roy, Deepak P Bhayya, Shilpi Gupta, Kanchi Upadhyay, Sonia Tiwari, Ashish Rao 
 Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India

Correspondence Address:
Soumik Roy
Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur - 482 005, Madhya Pradesh
India

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.



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;34:238-243


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 2022 May 17 ];34:238-243
Available from: https://www.jisppd.com/text.asp?2016/34/3/238/186742


Full Text

 Introduction



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



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:

How many years of clinical experience you have?

8804;5 years6–10 years>10 years

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

2–5 years6–10 years11–16 yearsIrrespective of age

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

Very occasional1–55–10>10

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

Anxiety and fearAny medical conditionBoth of the above

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

YesNoDo you consider gagging severity index (GSI)/gag prevention index (GPI) before treating a patient with gag reflex?

YesNo

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

YesNoSometimes

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

Diagnostic procedureImpression procedureOperative procedure

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

Behavioral methodsPharmacological methodsOther methodsCombination of methods

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

YesNoSometimes

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

YesNo.

Statistical analysis

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

 Results



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 [SUPPORTING:1]], there was maximum (47.2%) irrespective age group of patients with gag reflex [Graph 2 [SUPPORTING:2]], there were 1–5 maximum patients treated in a month for gag reflex constituting 72.1% [Graph 3 [SUPPORTING:3]], anxiety and fear was found to be the main reason for gag reflex (56.5%) [Graph 4 [SUPPORTING:4]], 84.6% of patients reported a change in heart rate during gag reflex [Graph 5 [SUPPORTING:5]], 90.2% of patients did not respond to GSI and GPI [Graph 6 [SUPPORTING:6]], 45.1% of patients had a change in treatment plan due to gag reflex [Graph 7 [SUPPORTING:7]], impression procedures constituted maximum to gagging (91.8%) [Graph 8 [SUPPORTING:8]], behavioral methods were considered as the best way to prevent gagging (56%) [Graph 9 [SUPPORTING:9]], 65.5% of patients responded positively to change or modification in impression technique or impression material [Graph 10 [SUPPORTING:10]] and 67.4% of patients considered gag reflex as a hindrance in clinical dental practice [Graph 11 [SUPPORTING: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}{Table 2}{Table 3}{Table 4}{Table 5}

 Discussion



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}

 Conclusion



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.

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