Ask a Dentist: "I have a terrible gag reflex. Is there anything to make visits easier?"

A strong involuntary gag reflex and dentistry aren’t typically good bedfellows.  For patients with this condition, nearly everything about dentistry is more difficult.  From taking x-rays, to restorative work like fillings and crowns, to having their teeth cleaned, a strong gag reflex can present a significant obstacle to both patient and dentist in the office.  Even the normally straightforward task of brushing their teeth at home can be difficult.  Because of all these difficulties, patients with strong gag reflexes often require both larger and comparatively more dental work than their non-gagging counterparts.  This is especially true with molars and other posterior teeth.  Perhaps this scenario sounds familiar to some of you?...well have faith!  Over the course of this article, I will guide you to a better understanding of the condition as well as share some of my most effective techniques that have allowed completion of great dental work on heavy gaggers over my career.  These techniques create a much more tolerable, if not enjoyable, experience for the patient...and the dentist!

The pharyngeal reflex or gag reflex (also known as a laryngeal spasm) is a reflex contraction often evoked by touching the roof of the mouth, the back of the tongue, the area around the tonsils, or the back of the throat.  It is intended to prevent something from entering the throat except as part of normal swallowing and therefore helps prevent choking.  A gag reflex is a good safety mechanism for those with “average” reflexes, but what about people on the extreme ends?  Did you know that slightly over one third of healthy adults don’t even have a gag reflex?  These people typically have no problem with dental work so let’s focus on the other extreme, those with a severe gag reflex.  There are MANY different techniques that both the dentist and the patient can utilize to combat a severe gag reflex.  We’ll cover some of my favorites in this article.  Remember, not every technique yields the same results for each patient, so it’s important to try as many as possible and see which works best.  Let’s begin...

OK, here you go...I’ve decided to start the discussion with my best gold nugget technique that has far and away helped me render comfortable treatment on severe gaggers throughout my career.  Ready...?  Numb the soft palate (and everything else in the back of the mouth/throat area while you’re there)!  When an object touches the soft palate (i.e. your throat), it can easily trigger the gag reflex.  Think swab throat culture taken by the nurse at your MD’s office when you suspect Strep throat.  Not fun for most, and nearly impossible for some.  Unlike the throat culture, dental work is not typically completed in a few seconds and rarely involves the soft palate.  The long duration of many dental procedures, combined with lying on your back, combined with a dental provider placing instruments near the soft palate, is more than enough to cause repeated gagging in many patients.  This is why I numb not only the soft palate but surrounding tissue as well.  This can be accomplished by using either a topical gel or topical spray, typically composed of 20% Benzocaine.  While both can be effective, I vastly prefer the spray because it covers more area with less product.  Simply spray the entire rear of the mouth, have the patient hold it for a few moments, and then swallow.  Duration of numbness varies from patient to patient but easily lasts 15-30 minutes with the spray that I use.  Repeat as needed throughout the appointment and before you know it, the procedure is finished with everyone smiling!

Another technique is to have the patient relax.  Easier said than done...it IS a dental appointment right!  The gag reflex cannot only be triggered by physiology, but psychology as well, and for some patients the latter plays the dominant role!  The psychological dissection of a dental appointment is incredibly complex and beyond the focus of this article, but we’ll cover the highpoints.  Since dental anxiety can heighten the gag reflex, it needs to be controlled.  Perhaps the patient had a traumatic dental experience in the past or perhaps they have an unspoken fear of losing control.  These are both quite common sources of dental anxiety and the first step to reversing them is open and honest communication between dentists and patient.  It is extremely important to me to have the patient in control of the appointment.  For those of you who I’ve worked on, perhaps you remember me mentioning at the appointment to “raise your left hand if you need something. “  It doesn’t matter to me why a patient raises their left hand because all reasons are valid!  From needing a bathroom break to an overabundance of water in their mouth to sensing a cough or sneeze coming on, each of these pauses in the action helps me provide a more pleasant dental appointment.  I strongly rely on patient feedback to inform me about how to deliver better care.  Additional anti-anxiety methods are also quite effective.  Nitrous oxide (laughing gas), working with the room lights off, dark sunglasses, an IPod with soothing music, and even hypnosis are all good techniques that calm a patient and thereby diminish the likelihood of a gag reflex during the appointment. 

Did you know that a gag reflex can be un-learned?  If a patient with a severe gag reflex is able to gradually get their soft palate accustomed to being touched, their gag reflex can be minimized, or possibly eliminated.  This is the same method used by sword swallowers in the circus.  While it does require practice and effort over time, it is an actual long-term solution to the condition.  “Curing” oneself of a severe gag reflex will dramatically make your trips to the dental office easier as well as your daily oral hygiene routine!  The following is from a website that I feel summarized the desensitization technique quite well:

· Find out where your gag reflex starts.  This can be done by simply using your toothbrush to brush your tongue.  The point nearest the front of your tongue that makes you gag is where you want to concentrate.

· Brush your tongue right where your gag begins.  Yes, you'll gag, and it will be unpleasant—but not for long.  Spend about ten seconds brushing that area (and gagging), and then call it a night.

· Repeat the process over the next few nights in the exact same spot.  You'll notice you gag less each time you do it.

· Increase the brushing area.  Once you can touch your toothbrush on that spot without gagging, it's time to move the toothbrush further back.  Try brushing ¼ to ½ inch (6mm–12mm) behind where your gag used to begin.  This is your new starting point.  Repeat the process as you did in the first spot.

· Continue moving the brush farther back.  Each time you move the toothbrush back, your gag has been desensitized in the previous spot.  Keep moving it farther and farther back until you've reached the farthest visual point of your tongue.  Eventually, the toothbrush will come in contact with the soft palate, if it hasn't already.

Be persistent.  This whole process should take approximately a month to complete.  When the process is complete, you should be able to have a doctor swab the back of your throat without gagging.  You might have to redo the process from time to time, as your reflex may return if you don't.  A good way to keep yourself desensitized is to brush your tongue regularly.  Not only will it help quell the gag reflex, it will also give you fresher breath!

I’d like to mention three final techniques are simple, straightforward, and quite effective.  #1: “Breathe through your nose” is a great rule of thumb to abide by when in the dental chair.  With all the water spray, the instruments, and the hands of the provider(s), it makes sense not to complicate the situation by breathing through your mouth.  That is when gagging, and possibly choking, occurs.  Be sure your nasal passages are clear and take a decongestant beforehand if needed.  Taking a simple over-the-counter Sudafed or Claritin-D one hour prior to an appointment can make a world of difference!  #2: Schedule your appointment appropriately!  Some people report they gag easier in the morning or during the day.  If this is true, be sure to schedule in the afternoon or during one of my evening appointments.  #3: Do something with your body during the appointment to take your mind off gagging.  Holding a squishy stress ball in each hand and alternating squeezes during the appointment is a great technique!  Another great option is to squeeze your left (or right) thumb if you feel a gag coming on.  Some patients like lifting both their ankles slightly off the dental chair and holding them for awhile before relaxing.  While effective, I always mention a word of caution when I discuss the ankle technique: be sure to keep both your head AND the dental chair still.  Removing/minimizing the gag reflex is good but not at the expense of turning in to a moving target for your dental provider!  Keep your motions subtle and small.  For this reason, I prefer the squish ball or thumb squeeze techniques.

Having a strong gag reflex and being unprepared can be a nightmare at the dental office.  I hope that by utilizing the techniques and information from this article you can minimize, or possibly eliminate your severe reflex and have a much more enjoyable dental experience.  As always, if you have any questions, or would like to speak further about this topic, please do not hesitate to contact me.

Sincerely,

Dr. Jackson

dreric@oralhealthcareprofessionals.com

I  http://en.wikipedia.org/wiki/Pharyngeal reflex

II http://en.wikipedia.org/wiki/Pharyngeal reflex

III http://www.wikihow.com/Suppress-the-Gag-Reflex

IV http://www.dentalfearcentral.org/fears/gagging/