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A clinical survey of gagging patientsW. M. Murphy, M.D.S., F.D.S.*Dental Schoo l, Cardiff, W ales

T e management of dental patients who gag canbe a frustrating experience for the dentist and anembarrassing and distressing experience for thepatient. The term gagging refers to a defense reflexwhich attempts to eject unwanted, irritating, or toxicmaterials from the upper gastrointestinal tract. Agreat deal has been written about this subject in thedental literature.*-6 Although many papers containindividual reports of patients, there is little back-ground information available on a large sample ofgagging patients or of the long-term efficacy oftreatment.The object of this article is to describe someof therelevant features associated with the gagging reflexin a sample of 74 patients and to report on theoutcome of treatment over a 5-year period.DETAiLS OF SAMPLE

The patients in this survey were referred by dentalpractitioners in the hospital service because of amarked gagging reflex which prevented the carryingout of satisfactory dental treatment. The age and sexdistribution of the sample can be seen n Table I.There were slightly more men than women in thesample, and the mean age of the women was greaterthan that of the men. Forty patients were totallyedentulous, 20 partially edentulous, and 14 edentu-lous in the maxillae and dentulous in the mandi-ble.Twenty-seven patients (36%) gave a history ofgastrointestinal disorders described in various wayssuch as nervous stomach or occasional indigestion.There was definite evidence of a duodenal ulcer inonly two patients. There was no pattern to thepatients taking tranquilizers or other drugs. Twopatients gave histories of severe nightmares orphobias, and 10 patients (14%) stated that membersof their own family had the same problem.*Senior Lecturer and Consultant, Department of Restorative

Dentistry.

0022s3913/79/080145 + 04$00.40/00 1979 The C. V. Mosby Co.

The Eysenck Personality Inventory was adminis-tered to a sample of 27 patients (Table II). Thisinventory is designed to measure two major dimen-sions of personality, extraversion and neuroticism.The gagging population yielded a significantly highscore (p < .02) for the neuroticism scale, and whenmen and women were looked at separately, the scoreof the women for neuroticism was significantly high($ < .Ol). As the mean age of the normal populationquoted by Eysenck was 27 years, compared with 54years for the gagging patients, a separate controlgroup matched for age and sex with the gaggingpopulation was analyzed. It was found that therewas no statistically significant difference between thematched control group and the gagging populationfor either extraversion or neuroticism.CAUSES OF GAGGING

The dental causesof gagging are summed up inTable III. The main complaint in 58 of the 74patients (78%) involved either the complete orpartial maxillary denture. Five patients were able towear the complete upper or lower denture but notboth together. Most patients with dentures haddifficulty when impressions were made, but eightpatients were specifically referred becauseof a failureto tolerate the impression procedure. Three patientswere unable to have a satisfactory examination orroutine dental treatment. Fifteen patients com-plained that toothbrushing caused or had causedgagging when they had their own natural teeth.Thirty-one patients stated that gagging was stim-ulated by feel, touch, taste, sight, or thought ofcertain nondental factors. As regards feel, touch, ortaste, patients quoted a number of stimuli such as ealeaves, a hair, a piece of eggsheil, a piece of bone, athermometer, a clothes peg, and an uncrushed tabletor pill. A number of patients said that the sound ofother people gagging or the sight of blood wouldmake them gag. A few patients said that certainodors would upset them such as the smell of cabbage,

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Table I. Age and sex distribution of patients TREATMENT

No.Mean age (years)Age range (years)

Male Female Total39 35 7451 56 54

34-70 20-81 20-81

Table II. Eysenck Personality Inventory meanscores

E NWormal population (n = 2000) 12.07 9.07Gagging population (n = 27) 11.15 11.26 (p C .02)

Male (n = 14) 10.50 10.07Female (n = 13) 11.85 12.54 (p C .OI)

Note: E = Extraversion; N = Neuroticism.

On the patients fir st vis it a history was taken, andthis was considered to be of considerable importancein the overall treatment. After a thorough discussionof the complaint, the physiology of gagging wasexplained in simple language, and great emphasiswas placed on reassuring the patient that he or shedid not suf fer from a disease enti ty, but rather awell-developed normal ref lex. The word normal wasemphasized as part of the reassurance. During theearly part of the survey, lateral skull radiographswere made, but these were discontinued after 15patients because the tracings did not appear to becontributing to the study. It had been hoped that themorphology of the tongue, sof t palate, or pharynxwould give some useful information.

Table III. Dental causes of gagging of sampleCause No.

ProsthesesComplete upper denture 40Complete lower denture 6Complete upper and lower denture 5Partial Upper denture 18Partial lower denture 5

OtherImpressions 8Toothbrush 15Routine dental procedures 3

At the second vis it, the reassurance was reinforcedand any additional aspects of the problem discussed.Impressions were made using a technique designedto gain the confidence of the patient by progressingin gradual stages toward an accurate impression,using first of all an empty stock impression tray andthen either impression compound or alginate (irre-versible hydrocolloid) or both. Successfu l impres-sions tiere made in all instances by adopting a firm,confident manner and by constant reassurance.

Table IV. ResultsNo. of patients

Wear prostheses all/most of the time 33Wear prostheses some of the time 5Wear prostheses none of the time 4Under treatment 7Patient discontinue d attendance 24Treatment changed 1

Total 74

celery, coffee, grilled bacon, or fish. Only one patientstated that anxiety caused the reflex to commence.He was an entertainer, and before a performance hewould gag with great vigor, but once on stage thereflex would disappear. A number of patients saidthat the thought of wearing their dentures or thethought of dental t reatment would initiate the reflex.A few patients were unable to wear a scar f or tie, andtwo patients were unable to shave in the morningsbecause touching their face would make them gag.

A clear acrylic resin base, fu lly extended to thevibrating line, was constructed for each patient, whowas advised how to wear it. During the treatment,many d ifferent methods were tried to help thepatient tolerate the base, including breathing andrelaxation exercises, distraction and target tech-niques, and chewing either candy or acrylic resinmarbles.* It was emphasized that regardless ofprogress the patient should continue to attend fortreatment. This point was made because it soonbecame evident that patients tended to becomediscouraged very quick ly. If no progress was made,the posterior palatal extension was reduced, and ifthere was still no progress, the patient was referred toa clinical psychologist whose approach was basedmainly upon relaxation and heterohypnotic tech-niques. The patient was provided with cassetterecordings of hypnotic induction, and these wereplayed in the patients home with the object ofteaching autohypnosis.RESULTS

The results can be seen in Table IV. Of the 74patients, 24 discontinued attendance. It is dif ficu lt toknow why so many were unwilling or unable toattend for further treatment. It may be that they

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CLINICAL SURVEY OF GAGGING PATIE NTS

believed that no progress was being made and werediscouraged to such an extent that they fel t there wasno point in continuing. As far as it could be madeout, there were no characteristic features of thepatients who failed to attend, with the exception thatall patients who had problems wearing their lowerdentures did not continue treatment.

For the patients who were able to tolerate thedenture base, appropriate permanent prostheseswere constructed using the shape of their diagnosticbase as a guide. In 80% of the successful patients, themaxillary denture base had a reduced posteriorpalatal extension.

A number of patients who were able to wear theirprostheses satisfactorily returned on subsequentvis its and stated that the original problem hadrecurred. Following further treatment, several ofthese patients were able to wear their dentures again.It became evident that the problem was a fluctuat-ing one where relapses were not uncommon, and itwas impossible to state that a complete cure hadoccurred at any time. In four patients (two men andtwo women), no progress was made. One of thesepatients refused to cooperate; the other three hadpsychotherapy that helped for a while, but theysuffered complete relapses. In one patient a remov-able partial denture was discarded but a fixed partialdenture was successfu lly tolerated.DISCUSSION

Since the patients were not selected on a randombasis, it is difficu lt to attach significance to either themean age of the sample or the fac t that there weremore men than women. However, a similar-observa-tion that men suf fer more than women has beenmade by others., T fi It is interesting to note that whenpedodontic and orthodontic colleagues were ques-tioned on this matter, they could not recall everfailing to fi t a removable appliance in a childbecause of gagging. They did agree, however, thatmaking impressions and routine dental proceduresoften stimulated the gag reflex in some children.

The number of patients who gave a history ofgastrointestinal disorders (36%) is similar to thatpreviously reported. 2 However, most patients in thisinvestigation were beyond middle age, and somesystemic disease would be expected. In a nongaggingpopulation of elderly denture wearers, 20% werefound to be suffering from some form of gastrointes-tinal complaint.

This survey suggests that although strongpsychogenic factors are clearly associated with the

condition, somatogenic factors could not bediscounted. Several patients could wear a fu llyextended base only during mealtimes or while chew-ing candy, and most successful bases had a reducedposterior palatal extension.

At a physiologic level, thresholds of oral sensationand perception may have played an important part.It would be interesting to record threshold levels in agagging population and compare them withcontrols. Sensory input may be greater in thesepatients because of low thresholds of sensory recep-tors. On the other hand, responses t.o the sensoryinput may be important factors which in turn maybe influenced by personality traits (although thelevel of neuroticism in the present investigation wasno different from that in normal personsj.

The psychosomat ic factors were more complicatedthan originally thought. At the beginning of theinvestigation a number of patients were found tohave more than one psychological problem, but asthe survey progressed these problems were notconsidered to be any different from those of nongag-ging denture wearers. However. further study isrequired to compare this group to normal andphobic groups from the point of view of motivat ion,needs, and anxiety levels.

It appears that the attitude of the clinician towardthe patient and his or her problem is an importantpart of the treatment. Constant reassurance that thepatient is not suffering from a physical disease andeffort s to reduce the patients embarrassment causedby the reflex undoubtedly reduce anxiety andtension. Many patients can be treated quite success-ful ly by building confidence in themselves and theirability to overcome the problem. However, there areothers where all conventional methods fail , and it isthis group which requires a great deal of furtherstudy to help alleviate this distressing condition.SUMMARY

A clinical investigation was carried out on 74dental patients who were suffering from a severegagging reflex. The most common stimulating factorwas the maxillary denture. Routine history andclinical examination were carried out for eachpatient, and lateral skull radiographs and anEysenck Personality Inventory were complered forsome of the patients. Treatment consisted of the useof an acryl ic resin training base combined withrelaxation therapy and heterohypnotic techniques.The results of this ongoing study were: (1) there wereno consistent features of the group which differen-

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tiated them from control groups; (2) a number ofpatients were insufficiently motivated and discontin-ued treatment; and (3) some patients who weredeclared completely cured suffered relapses.

REFERENCES1. Rrol, A. J.: A new approach to the gagging problem. J

PRO~THET DENT 13:611, 1963.2. Faigenblum, M. J.zRetching, its caus es and managem ent in

prosthetic practice. Br Dent J 125:485, 1968.

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Wright, S. M.: An examination of factors as sociated withretching in dental patients. J Dent (In press)Eysenck, H. J., and Eysenck S. B. G.: Manual of the EysenckPersonality Inventory. London, 1970, University of LondonPress Ltd.Singer, I. L.: The marble technique: A method for treatingthe hopeless gagger for complete dentures. J PROSTHE TDENT 29:146, 1973.Harrison, A.: Alveolar bone resorption in two edentulouspopulations. J Dent 1:77, 1972.

3. Savage, R. D., and MacGregor, A. R.: Behavior therapy in Reprint requests to:prosthodo ntics. J PROSTHE T DENT 24:126, 1970. .DR. W. M. MURPHY

4. Means, C. R., and Flenniken, I. E.: Gagging-A problem in DENTAL Smoorprosthetic dentistry. J PRO~THET DENT 23:614, 1970. HEATH PARK

5. Kramer, R. B., and Braham, R. L.: The management of the CARDIFF CF4 4XYchronic or hysterical gagger. J Dent Child 44:111, 1977. WALE S, U. K.

Journal adopts new policy for illustrations in colorThe Editorial Council and publisher of THE JOURNAL OF PROSTHETIC DENTISTRY have agreed to publish articles

that contain color illustrations at a reduced cost to authors. Authors will pay only $225 per color page, or partthereof, and can present f rom one to eight illustrations on each page.Two high-quality 35 mm color transparencies (an original and duplicate) must be submitted for each

illustration, and manuscript length cannot exceed 10 to 12 double-spaced typewritten pages. The Editor and hisreviewers have final authority to determine if color illustrations afford the most effe ctive presentation.Artic les containing color will appear in selected issues beginning in 1980. Authors are requested to include a

statement whenthey submit their manuscript agreeing to pay $225 for each page of color. Billing will come fromthe publisher after the author has approved color proofs and the article is scheduled for publication. Manuscriptsand illustrations will be accepted immediately for evaluation.

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