The normal physiological gag reflex holds an important place in dentistry because it prevents potential life-threatening obstructions of the gastro-intestinal tract by foreign objects and alerts the dentist that undesired material has slipped into the pharynx area. However, a phenomenon termed the excessive or exaggerated gag reflex, a hypersensitive response to most foreign oral stimulation, may be found in some patients. Exaggerated gagging can successfully prevent the dentist from examining or operating on the patient. The tendency to lurch forward while retching poses a danger to the patient and liability to the dentist if sharp dental instruments are positioned within the oral cavity. Other than being a dental nuisance, however, the exaggerated gag reflex rarely poses any other threat to the patient. Most patients who claim to be unable to place foreign appliances into their mouth, or even to perform routine dental procedures, such as tooth brushing, find no difficulty in managing solid foods.
One of the following three factors probably contributes to an exaggerated gag reflex in a patient. First is the belief on the part of the patient that for efficient breathing, the oral cavity must be entirely unobstructed. Since dental instruments obstruct the cavity, a sense of suffocation overcomes the patient, and a gag reflex manifests itself. Secondly, situational factors inducing previous gagging may lead the patient to believe that s/he is 'prone to gagging.' Finally, clinicians who label the patient as a 'chronic gagger' reinforce the patient's self-image as a gagger.
There are several effective approaches used for the patient with the hyperactive gag response. First show the patient that it is possible to breathe through the mouth while the mouth is open. Ask the patient to close the mouth and gently and calmly inhale and exhale through the nose. After a few moments of nasal breathing, ask the patient to continue to breathe through the nose, and open the mouth. Finally, ask for permission to demonstrate nose breathing with an open and full mouth, and once granted, gently spray water into the mouth with the air/water syringe. Let the patient experience their ability to comfortably breathe through the nose as the water pools in the mouth.
An elegant approach to help the patient who has a hyperactive gag reflex which prevents them from wearing a dental prosthesis, having intraoral radiographs taken or having an impression made, is based on Dr Harold Golan's classic script (Golan, 1990a). The script has been modified here, and a similar one may be pre-recorded by the practitioner. The patient may listen to the tape in the office or clinic or be offered a copy to listen to at home.
The body is the person's most prized possession ... and deserves the respect of good health. With the new teeth (dentures) the face looks well. See how people respond warmly to the new smile. The new teeth make it possible to eat well, to be able to swallow naturally, to aid in digestion. Remember that properly chewed and digested food is necessary for life itself.
Notice how good it feels right now, how the breathing rate has slowed. Every muscle from the tip of the toes to the top of the head is relaxing, comfortably and easily. [Name the muscle systems.] It's pleasant and reassuring to practice calm breathing at least six times a day until it becomes second nature ... Do this after a while with eyes closed or open, because it's necessary to eat with eyes open.
Carry out this magnificent skill ... whenever the need arises. It's pleasing to be in control of the body. Smile, realizing an immense feeling of confidence and pride ... Smile at the tissues of the mouth and throat, using this new control ... This relaxation is the most complete a body can experience. Now make a tight fist. Make the arm rigid, strong, tight. Stronger, tighter. Feel the tension. Now relax [ relaxes the arm and hand.] This is what happens during gagging ... tightening of the throat muscles and forgetting to relax the muscles. Now tighten and then relax the other fist, the other arm. Knowing how to tense and relax is a wonderful skill. Every portion of the mouth and throat can be tightened and relaxed. Let the mouth relax. Relax the palate, throat, floor of the mouth, the cheeks. Continue to sense the relaxation, let the eyes open, let the mouth open and with a clean finger touch the various parts of the mouth and become aware of the comfort. Experience a sense of great confidence to be able to touch any area of the mouth.
Now, feeling rested and refreshed, as though waking up from a very pleasant nap, let the eyes open in a few moments ... Let that inner smile grow...
HYPNOSIS IN DENTISTRY
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Hypnosis has been defined as a state of heightened suggestibility in which the subject is able to uncritically accept ideas for self-improvement and act on them appropriately. When a hypnotist hypnotizes his subject, it is known as hetero-hypnosis. When an individual puts himself into a state of hypnosis, it is known as self-hypnosis.