Don’t give up on gaggers

by Cathy Hester Seckman, RDH

Oct 1st, 2009
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by Cathy Hester Seckman, RDH

As a hygienist, you get used to hearing these dire pronouncements. “I’m a bad gagger, just so you know.” “X-rays always make my son throw up; I thought I’d better warn you.”

Some people almost seem to take pride in making them, as though they’re really saying: “Here’s the toughest patient you’ll ever come across.”

The first three thousand times I heard those statements, they made me feel inadequate. I questioned my training, skills, even the ability to do my job. “Unable to get X-rays,” “unable to use ultrasonic,” and “unable to apply fluoride” were frequent notations in my charts. But I’ve learned to cope. A big part of hygiene practice is the ability to tailor treatment to each individual patient. In the case of gaggers, a little creative tailoring goes a long way toward getting those X-rays, using that ultrasonic unit, and completing fluoride treatment.

According to Wikipedia, the pharyngeal or gag reflex is “a reflex contraction of the back of the throat, evoked by touching the soft palate.” I’ve discovered other things that can trigger a gag reflex:

  • Getting a finger or instrument within a few millimeters of the soft palate
  • Touching the outside of the throat
  • Placing a saliva ejector too close to the tonsils
  • Using a strongly scented or flavored prophy paste
  • Letting too much water/saliva accumulate in the back of the mouth
  • Having the patient open too wide
  • Passing a mirror or other instrument through the lips

What kinds of people are likely to be gaggers? Small children, of course. The track from mouth to the stomach in a small child is likely to be a short, straight shot. Just about anything, it seems, can make them gag or vomit. As a child grows, the esophagus lengthens and develops more of a right-angle bend, which reduces the need to gag. Pregnant women and people who are ill or undergoing chemotherapy/radiation can be temporary gaggers.

Very overweight people can be gaggers because they’re unable to breathe through their noses. If their only available airway (the mouth) is blocked, they panic and gag. Allergy and cold sufferers who are coping with drainage and stuffy noses can be gaggers as well.

And some people are just natural gaggers; science has agreed. A 2008 study in the Netherlands concluded, “Gagging appeared to be a specific problem that cannot be interpreted as some form of dental anxiety.”

With experience, you can predict when a gagging episode will start, especially in children. It’s when the patient stops breathing. Sometimes it’s possible to short-circuit the gag reflex by reminding the patient to breathe, and keep breathing.

“Take a big breath in through your nose, Gavin. There, that’s it … now breathe out. Breathe in again … real loud, Gavin, so Mommy can hear you. OK, breathe out. Good boy.”

Other ways to prevent gagging in the first place include having the patient tip his or her head to the side, so water/saliva doesn’t accumulate on the soft palate; telling a patient to sit tall, raise the chin, and keep his/her lips separated to aid breathing while biting on a film holder; and putting wax dams on the backs of impression trays to keep material from overflowing onto the soft palate.

But if gagging happens in spite of preventive measures like those above, here are some tried and true strategies I’ve either discovered or collected from other hygienists.

— Humming. It produces positive air flow; in other words, it keeps the patient breathing. Next time you need to take an impression on a gagger, ask the patient to hum “Twinkle, Twinkle, Little Star” all the way through.

— Muscle control. I’ve heard two theories. The first, which has never worked for me, is to ask the patient to raise his/her knees and place the feet flat on the chair. That’s supposed to keep the stomach muscles relaxed so he/she won’t gag.

I’ve had more success with the other theory: Ask the patient to raise one or both legs a few inches off the chair. That will tighten the stomach muscles so he/she won’t gag. I believe keeping a leg raised also takes concentration, so patients aren’t so focused on whether or not they’ll gag.

— Salt. The first time I saw this work was when my boss was on medical leave and he hired a skinny little squirt fresh out of dental school to cover his patients. I had a 10-year-old gagger in my chair, and couldn’t take X-rays. The squirt arrived for the exam and said, “Hey, I know what’ll work.” He ducked into the lounge and came back with a salt shaker. “I’ll put some of this on your tongue,” he told the 10-year-old, “and it’ll stop you from gagging.”

It worked like a charm.

— Topical anesthetic. Applied to the soft palate with a Q-tip, topical anesthetic can numb the area enough to temporarily suppress the gag reflex. Spray Chloraseptic works the same way.

— Ice or ice water. Having a patient suck on ice chips or swirl ice water in the mouth will have an effect similar to a topical anesthetic, temporarily numbing the soft palate.

— Shortened film. If you need to take bitewings for IP caries detection on a gagger, use a Snap-A-Ray and a folded film. Fold one narrow end of the film in, about an eighth of an inch. Insert the folded end into the jaws of the Snap-A-Ray and take your picture. Because the Snap-A-Ray has a thicker biting plane, and because the film is shorter, the patient will have less tendency to gag.

Surprisingly, even with a size 0 film, you can still get a good picture that includes the distal of the second primary molar through the distal of the primary cuspid.

— Sea Bands. Originally marketed to people suffering from seasickness, Sea Bands are now used for any kind of motion sickness. They also suppress nausea during pregnancy, chemotherapy, and radiation, and they’re the best-kept secret in dentistry for short-circuiting the gag reflex. They work through acupressure, an important component of traditional Chinese medicine.

Sea Bands — also sold under the names Acu-Straps, Travel-Eze, and Preggy Bands — are terrycloth wrist bands with a hard plastic button inside. To use them, place a band on each wrist, position the buttons squarely on top of the P6 or Nei-Kuan acupressure points, and wait five minutes. You’ll be able to take those X-rays or impressions, use that ultrasonic unit, or place that fluoride tray with little or no gagging. They’re drug-and latex-free, and are effective in children age 2 and older. Sea Bands can be found in major drugstores alongside motion sickness products, or on the Internet. In my personal experience, Sea Bands work about 70% of the time.

Acupressure is a technique of traditional Chinese medicine that revolves around the balance of chi (qi), or life energy. Chi, it is believed, circulates through the body along meridians. Some 2,000 acupoints are located on the meridians, and stimulating these points can free the flow of chi, if it is blocked, and restore it to harmony.

Western medicine has tried to explain chi and acupressure. Some scientists speculate about a “gate control theory.” Nerves carrying messages of acupressure appear to reach the brain faster than pain or nausea messages. The brain can only receive so many messages at once, so a “gate” is closed by the time a message of pain or nausea arrives. Pressure messages to the brain can also stimulate endorphins, it is believed.

Each acupoint is linked to a particular illness, organ, or condition. The Nei-Kuan acupoint on the underside of the wrist is associated with nausea. Instructions for finding it are on every package of Sea Bands. Simply place your middle three fingers on the palm side of the opposite wrist, with the edge of the ring finger next to the crease nearest the wrist. The Nei-Kuan point is under the edge of the index finger, between the tendons.

An interesting study done at the University of Rochester and published this year attempted to determine whether patients’ expectations of success affected the efficacy of acupressure bands. Radiation patients at two cancer centers were divided into three groups. The first group was a control, and received standard care for nausea. The second group was given acupressure bands and neutral instructions for their use. The third group was given acupressure bands with positive information regarding the bands’ efficacy.

Results showed that the patients in the second and third groups reported a 19% greater reduction in average nausea than patients in the control group. There was no statistical difference between nausea reports in the second and third groups, leading researchers to conclude that acupressure bands “are an effective, low-cost, nonintrusive, well-accepted, and safe adjunct to standard antiemetic medication.”

A 2008 study, conducted specifically to test gag reflexes in dentistry, found that acupressure on a palm acupoint would “consistently alter the gag reflex trigger.” Researchers called for a more detailed, systematic approach to studying the gag reflex.

Coincidentally, a team at the University Medical Center in Groningen, Netherlands, has developed a Gagging Problem Assessment (GPA) tool to measure dental gagging. A 2008 pilot study of the tool is to be followed by a confirmation study.

Whether or not you believe in the usefulness of traditional Chinese medicine, Western science has now proven that Sea Bands can help control the gag reflex. Still, as with all the other tips, using them might or might not work, depending on the patient’s state of mind and state of health that day. That’s why it’s best to keep the entire arsenal in mind, and do your best to tailor treatment to each individual patient.

References

  • Roscoe JA, et al. Acupressure bands are effective in reducing radiation therapy-related nausea. Journal of Pain Symptom Management, Mar. 27, 2009.
  • Scarborough D, Bailey-Van Kuren M, Hughes M. Altering the gag reflex via a palm pressure point. Journal of the American Dental Association, Oct. 2008; 139(10):1365-72.
  • Van Linden van den Heuvell GF, Ter Pelkwijk BJ, Stegenga B. Development of the gagging problem assessment: a pilot study. Journal of Oral Rehabilitation, Mar. 2008; 35(3):196-202.
  • http://med.stanford.edu/personal/pointfinder/
  • http://www.sea-band.com

About the Author

Cathy Hester Seckman, RDH, is a frequent contributor based in Calcutta, Ohio. Besides working in a pediatric dental practice, Seckman is a prolific freelance writer, a book indexer, and a speaker on dental and writing/indexing topics. She can be reached at cathy@cathyseckman.com.

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