Acupuncture - An effective tool in the management of gag reflex.

Gagging is of great concern to the dentist as it is a serious impediment during the execution of various dental procedures. The etiology of gagging is multifactorial, and several suggestions have been offered to arrest this reflex, some of which are nonsustainable and does not show the immediate result. Acupuncture has been successfully employed as an adjunct to local anesthesia in dental extractions, pain management and also in the symptomatic management of temporomandibular joint disorders. The author highlights the application of acupuncture in the management of patients with gag reflex during dental procedures and its benefits are reported.

Gagging is a reflex act produced by the transmission of afferent impulses to the center and outflow as efferent impulses to the musculature of the oropharynx.[123] The afferent stimuli can be tactile, gustatory, visual, acoustic, and olfactory. It is believed that the center for gag reflex is situated in the medulla oblongata. The exact location of it is not yet clearly understood. Gagging is characterized by a feeling of nausea, accompanied with violent spasms of the musculature of the oropharynx and also a simultaneous contraction of the musculature of the abdomen.[4] Gag reflex may manifest during mouth examination, recording procedures, wearing of artificial dentures and several other clinical dental procedures. The stimuli responsible for gag reflex differ from patient to patient. Certain patients gag only when the tissues around the oropharynx is subjected to some form of irritation, while others may gag at the sight, taste, smell of certain objects without any form of physical stimuli being present.[56]

Etiology of Gagging

The causes of gag reflex can be either psychogenic or somatogenic.

Psychogenic causes

The stimuli which cause gagging have its origin in the mind. Psychic stimuli resulting from fear, anxiety and apprehension can predispose to gagging. Patient's emotional factors such as appreciable mental strain and depression also have an influence as one of the causes of gag reflex.[78910]

Somatogenic causes

It is due to the presence of definite physical stimuli which acts locally. The presence of irritating foreign objects in the mouth or oropharynx may excite gag reflex. Physical stimuli may have their action either directly or indirectly.

Effect of tactile, visual, acoustic, olfactory stimulation gag reflex.

Tactile irritation is one of the most common source of stimuli to initiate gag reflex. The slightest contact of either finger or instrument on the hypersensitive areas is sufficient to precipitate gagging. The palate can be divided into two areas. The boundary line between these two areas pass from one tuberosity to another along the fovea palatinae in the middle line.[11] The area anterior to this line is hyposensitive while the area posterior to it is very sensitive to any form of tactile irritation. Similarly the superior surface of the tongue is also be divided into two zones. The posterior one-third of the tongue is very sensitive to tactile irritation while the anterior two-third is relatively immune. It is observed that the posterior one-third of the dorsum of the tongue is the most sensitive area in the entire oral cavity.[1213] During dental procedures, precaution has to be taken to avoid contact of materials, instruments and other foreign bodies on the soft palate and posterior third of tongue in view of its hypersensitivity. The visual unpleasant sight of impression tray loaded with impression material in certain subjects is enough to cause gagging. Similarly, the sight of blood can also induce gagging.[141516] Gagging may also develop in persons who watch another gagging. Acoustic stimuli also effects gagging, and there are cases on record who have turned out to be gaggers who hear another gag.

Management of Gagging Patients

Use of medicaments

Tranquilizers are useful in patients who are under mental strain and tension. These drugs bring about a calm outlook by reducing mental tension and relieve anxiety. Topical application of surface anesthetics like xylocaine jelly when swabbed onto the sensitive areas, reduces the tendency for gagging. It should not be allowed come in contact with the surrounding pharynx where anesthesia is not desirable as it abolishes the physiological cough reflex.[17] In the absence of cough, there are a chances of impression materials to get aspirated into the pharynx, which may prove to be dangerous. Injection of anesthetic solution at the posterior palatine foramen also produces a similar effect. These anesthetics arrests gagging by their effect upon the impulses carried by the afferent fibers to the center but its effect is transient.

Psychological therapy

It involves disengaging patients mind by directing away from the stimulus. In this manner the patients consciousness is diverted. This is done by asking the patient to breathe through the nose, indulging in conversation, raising the foot uprightly away from the dental chair.

Acupuncture, as an alternative medicine originated in China 3,000 years ago. It is a technique done by inserting single disposable stainless steel needles at various acupuncture points in the body.[18] Acupuncture activates small myelinated nerve fibers in muscle, which send impulses to the spinal cord and then activate the midbrain and pituitary hypothalamus. It has been shown that enkephalin, beta-endorphin, serotonin and nor adrenaline are involved in this process.[1920] There are several methods of acupuncture practiced these are classical acupuncture, Su-Jok, electro-acupuncture, laser and ear acupuncture. A number of studies have shown, it is very effective in temporomandibular joint disorders dysfunction and facial pain. In view of its beneficial results, several publications on acupuncture have been made during the recent years. Acupuncture points are situated all over the body. There are totally 12 meridians of which two meridian points are for controlling gag reflex.

It is located on the anterior forearm, two thumb finger width horizontally proximal to the transverse crease, between the tendons of Palmaris longus and flexor carpi radialis [Figure 1]. Here perpendicular insertion of the needle is done up to a depth of 2 mm to 4 mm. Caution must be taken on over penetration since median nerve lies directly beneath this point.

Figure 1

Acupuncture meridian point pericardium meridian 6

It is located in the depression center of the mentolabial groove, inferior to the middle of lower lip [Figure 2]. Here oblique upward insertion of the needle is done up to a depth of 3 mm to 6 mm.

Figure 2

Acupuncture meridian point conception vessel 24

The needle site should be sterilized, then acupuncture needle is inserted subcutaneously 3 mm to 6 mm in conception vessel (CV) 24 mm and 2 mm to 4 mm in pericardium meridian (PC) 6 acupuncture points. Hand stimulation was performed on CV 24 point only clockwise and anticlockwise for 2 min. The needle is left in situ when the clinical procedures are performed. Acupressure with light to increased pressure using the index finger for 5 min on CV 24 will cause soreness and distension to a patient, during which also clinical procedures can be made.[21] If bleeding occurs on removal of the needle the area should be wiped with cotton and massage done.

Conclusion

Overall gagging can be stressful for both the patient and dentist during clinical procedures in dentistry. Acupuncture a very easy technique helps in the management of gag reflex in a short time. A short training course in acupuncture is enough for inserting needles in CV 24 and PC 6 acupuncture points.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.