gag reflex isdh 2009 no patient id.ppt
TRANSCRIPT
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The Assessment and Management of
Patients with PronouncedGag Reflexes
Chris Dickinson
Department of Sedation & Special Care Dentistry
KCL Dental Institute
Floor 26. Guy’s Hospital1
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“Had a bad day at the orifice, dear?”
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Gagging - A normal protective reflex designed to protect the airway and prevent material entering the oropharynx and the upper gastro-intestinal tract
Retching - An ejectory contraction of the muscles of the gastro-intestinal tract and oropharynx
Gagging or Retching ?
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Prevalence of Gagging
• No data available on the prevalence or distribution of pronounced gag reflexes in the general population
• 26 % of young adults and 43 % of older adults had a total absence of the gag reflex
Davies et al. 1995. The Lancet.4
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Classification by Aetiology
Somatic:
Induced by touching a ‘trigger’ area
Psychogenic:
Induced without direct contact
Krol 1963
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Contributory Factors
Evidence is poor
• Anatomical• Medical• Emotional/Psychological• Iatrogenic
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Anatomical
• Palate anatomy • Long uvula
• Tongue shape• Tongue position• Other ‘irregularities’
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Medical
• Chronic nasal congestion and obstruction
• Post nasal drip• Gastric disorders• Motor neurone disease
• Dysphagia
• Obesity• Other medical conditions
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Psychological ?
• Eating disorders• Fear• Stress• Neuroticism• Learned responses
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Iatrogenic – General
• Water & suction tubes• Instruments• Local anaesthesia• Radiography
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Iatrogenic – Prosthetic
• Inadequate posterior palatal seal
• Restricted tongue space• Loss of normal palatal
contour• Poor retention• Incorrect occlusal plane• Decreased freeway space• Excess freeway space• Incorrect tooth position
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Implications for the Patient
Emotional
• Fear, anger & embarrassment
• Avoidance behaviour
Physical
• Acceptance of dental care • Oral hygiene practices• Ability to wear prostheses
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Implications for the Dentist
Emotional
• Fear, anger & embarrassment• Avoidance behaviour
Physical
• Compromises ability to examine, diagnose and treat
• Influences treatment decisions
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Assessment
• Precipitating factors• Nature & severity• Relievers & promoters• Successful & failed
dental treatments
• Treatment required• Treatment requested• Somatic ‘mapping’
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Gagging Severity Index
GSI Grade
I Very mild: Controlled by patient
II Mild: Control regained by patient/dentist with simple control techniques & reassurance
III Moderate: Limits treatment options
IV Severe: Some treatments impossible
V Very severe: Effects patient’s behaviour and dental attendance. All treatment impossible
Dickinson & Fiske. 2000 15
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Methods of Control
• Relaxation & C.A.F• Dental ‘techniques’• Distraction and
desensitisation• Psychological and
behavioural techniques• Local anaesthetic
techniques• Sedation techniques• General anaesthesia• Complementary therapies
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Psychological Techniques
In - House• Confidence building• Ego enhancement
• Tell – show - do
Referral• Cognitive Behavioural Therapies
• Psycho – therapeutic analysis and treatment
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Relaxation Techniques
Passive Relaxation
• Calming environment• Music
Active Relaxation
• Controlled rhythmic breathing (Hoad-Reddick)
• Relaxed abdominal breathing (Barsby)
• Visualisation/visual aids• Biofeedback• Progressive muscle relaxation (NCT)
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Relaxation & C.A.F
• Caring Attitude Factor (Shipmon)
• Empathetic but firm• Calm, confident, in control• Rapport
• Communication and signalling • Positioning/Neck extension• Breathing control
• Careful instrument handling
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“Traffic-light” Control SignalsGreen
Amber
Red
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Dental Techniques
Rubber Dam Local Analgesia ??
• Palatine block
• Inferior alveolar block• LA incorporated into impression material
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Distraction Techniques
• Sensory deprivation (Landa) • Leg raising (Krol)
• Breathing exercises• Talking (Faigenblum)
• Salt on tongue• Sick stick (Robb)
• Temporal tap (Robb)
Concentration on a task, place, object or event to temporarily divert the patient’s attention away from the gagging
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Desensitisation Techniques
Homework and Rehearsal (Sewerin)
• Tongue/palate stimulation• Marbles/discs (Singer)
• Progressive appliance wear & training bases
• Dentures with acrylic beads & mat surfaces (Singer)
• Orthodontic plates and blow-down splints
• Soft swallowing (Wilks)
Aims to progressively reduce the gagging threshold
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Sedation & General Anaesthesia
• Inhalation• Intravenous• Oral• Intranasal• Combinations• Large quantity of
restorative or oral surgical treatment
• Gag reflex not controlled by other methods
• GA - Last resort
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Complementary Therapies
Hypnosis (Barsby)
• Reframing• Ego-enhancement• Auto-hypnosis• Contra-indicated
in psychological conditions?
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How does it work?
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“ That a needle stuck into the skin of the foot should help a case of migraine is obviously incredible, it makes no sense. Within our system of explanation there is no reason why the needle prick should be followed by an improvement, therefore we say it cannot happen. The only trouble with this argument is that as a matter of empirical fact, it does happen.”
Aldous Huxley
Evidence of effect is emerging in several areas
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Acupuncture
Technique
• Simple & Quick• Inexpensive• Easily learned
• Effective• Few contra-indications
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Chengjiang (CV24)
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Hegu (LI4)
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Ear Acupuncture
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Other Acupuncture Points
• Face• Head• Back
• Hand
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Ear Acupuncture - Uses
• Diagnostic - Assessment• Episodic - Treatment• Desensitisation ??
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Ear Acupuncture - Before & After
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Combination Techniques
• Pre-treatment desensitisation
• Inhalation sedation• Acupuncture• Acupressure• Rubber dam
• Visualisation• Distraction
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Recording Success
Gagging Prevention Index
GPI Grade
I Fully Controlled – Treatment successful II Partially controlled – Treatment possible III Partially controlled – Some simple treatments possible with frequent gaggingIV Inadequately controlled – Even diagnostic
procedures difficultV No Control – No treatment possible
Dickinson & Fiske, 2000
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Summary
• Fully assess the nature of the gag reflex
• Match the level of treatment need with the management techniques at your disposal
• Set small objectives for each treatment visit
• Don’t continue until patient gags. Stop at a positive point if possible
• Use a variety of management strategies for different items of treatment – be flexible
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Thank You
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