Case Report 1, Issue 11.3

Management of a Hyperactive Gag Reflex for Oral Appliance Therapy: A Case Report

http://dx.doi.org/10.15331/jdsm.7346

Andrew S. Ryser, CPT, DDS, 1 Kyung Kim, COL, DMD, 2 Steven Handel, LTC, DMD, 2 Jennifer Sabol, COL, DDS, 3 Maddie E. Ryser, DNP, FNP-BC, 4

1 Prosthodontic Resident, Department of Prosthodontics, Army Postgraduate Dental School, Postgraduate Dental College, Uniformed Services University, Fort Eisenhower, GA, USA ; 2 Assistant Program Director, Department of Prosthodontics, Army Postgraduate Dental School, Postgraduate Dental College, Uniformed Services University, Fort Eisenhower, GA, USA ; 3 Program Director, Department of Prosthodontics, Army Postgraduate Dental School, Postgraduate Dental College, Uniformed Services University, Fort Eisenhower, GA, USA ; 4 Private Practice, Augusta, GA

Background:

A patient sought treatment at a prosthodontics practice for obstructive sleep apnea with a mandibular advancement device.

Case Information:

Because of a hyperactive gag reflex, a patient required implementation of a unique protocol to overcome gagging whenever the mandibular advancement device was placed in the mouth.

Conclusion:

The protocol described in this case report allowed the patient to overcome a hyperactive gag reflex and successfully use a mandibular advancement device to treat obstructive sleep apnea.

Keywords:

Gag reflex; MAD; OSA; OAT

Citation:

Ryser AS, Kim K, Handel S, Sabol J, Ryser ME. Management of a hyperactive gag reflex for OAT: A case report. J Dent Sleep Med. 2024;11(3)

INTRODUCTION 

Impression taking and other dental procedures such as wearing a maxillary complete denture can be stressful for some patients and dentists because of the presence of a gag reflex. Sivakumar and Prabhu1 defined the gag reflex as an involuntary reflex involving bilateral pharyngeal muscle contraction and elevation of the soft palate. It is thought that the gag reflex arose as humans evolved to prevent swallowing foreign objects and choking.1 Physical exami­nation of reflexes such as the gag reflex and response to pain often are used to determine brain activity levels or if brain death has occurred.2 The gag reflex is controlled by cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve) and is derived from the third, fourth, and sixth phar­yngeal arches during development.1 In newborns, the gag reflex is activated whenever the brainstem deems food to be too large or solid for an infant to digest. At approxi­mately 6 months of age, the gag reflex becomes less pro­nounced, and the infant can start consuming more solid foods.3

The gag reflex can be classified as either somatogenic or psychogenic in nature. A somatogenic gag reflex occurs when there is direct physical contact with the base of tongue, the tonsillar pillar area, or the posterior pharyngeal wall with a physical object such as a piece of food, dental hand mirror, or oral appliance. A psychogenic gag reflex occurs from a mental trigger, often without a physical con­tact. A psychogenic factor could be the simple thought of going to a dental appointment, which can induce the gag reflex. 4

A direct gag reflex is defined as the contraction of the pharyngeal musculature ipsilateral to the side of the stimu­lus. A consensual gag reflex is when the musculature of the pharynx contracts on the contralateral side of the stimulus.1 Gagging can also occur when the soft palate is stimulated by activating the trigeminal nerve (CN V). According to a 1995 study by Davies et al, 5  approximately 37% of people do not have a gag reflex; in addition, it was concluded that there is an increase in the absence of a gag reflex in those who smoke or use tobacco.5 An absent gag reflex can be a cause for concern, however, because it might indicate cra­nial nerve damage or brain death.5 Neumann and McCarty in 2001 found that 10% to 15% of people have a hypersen­sitive gag reflex and they will often gag when eating sticky or thick foods.6

There are many etiologic factors that stimulate the gag reflex:

  1. Local factors: nasal obstruction, deviated septum, postnasal drip, sinusitis, congestion.
  2. Systemic conditions: chronic gastritis, Patterson dysplasia, cancer of the stomach and pancreas, uncontrolled diabetes, and peptic ulcers.
  3. Social factors: smoking, coughing, chronic alco­holism.
  4. Psychologic factors: eating disorders, stress, neu­roticism
  5. Iatrogenic factors: medical/ dental instruments, local anesthesia, small tongue space.
  6. Prosthetic factors: poor retention of prostheses, overextended or under extended dentures, inade­quate posterior palatal seal.7-9

The Dickinson and Fiske gagging severity index can be used to classify the gag reflex severity as follows:10

  • Grade I: Very mild: patient is able to control gagging
  • Grade II: Mild: gagging is able to be con­trolled by patient/ dentist using simple measures
  • Grade III: Moderate: some treatment is not accepted by patient without gagging
  • Grade IV: Severe: some treatment is not pos­sible
  • Grade V: Very severe: any procedure in the oral cavity is impossible and affects patient behavior.

Clinicians can test for a gag reflex by using a tongue blade or cotton tip applicator. Using one of the two instru­ments, the clinician stimulates each side of the posterior pharynx, waiting each time for gagging.1 In patients with severe gagging, placing dental instruments such as impres­sion trays, a gloved finger, or even intraoral mirrors could be enough to stimulate the gag reflex. Management tech­niques to control gagging include behavior modification, desensitization, conditioning prostheses, pharmacologic therapy, acupuncture/ acupressure, modification of pros­theses, hypnosis, and holistic remedies.11 This article dis­cusses a new and novel technique used on a patient with a Dickinson and Fiske grade IV gag reflex to successfully treat the patient’s obstructive sleep apnea (OSA) using a mandibular advancement device.

NARRATIVE

A 60-year-old patient presented to a prosthodontics practice for treatment of OSA and bruxism. The patient was 64 inches tall and weighed 155 lb with a body mass index of 26.8. The patient's medical history was significant for hypertension, hyperlipidemia, Parkinson disease, im­paired fasting glucose, melanoma, allergic rhinitis, soma­toform disorder, and OSA. Full-night polysomnography (PSG) at Fort Eisenhower sleep clinic was completed, and the PSG results revealed an apnea-hypopnea index of 12.9 with moderate to loud snoring. The total sleep time during the PSG was 362 minutes, with 11% of total sleep in stage N1, 44.1% in stage N2, 32.6% in stage N3, and 12.3% in rapid eye movement sleep. Sleep latency was 9.5 minutes and rapid eye movement latency was 119 minutes. The pa­tient spent 48.5 minutes sleeping in the supine position. Baseline oxygen saturation was 94.9% and the lowest rec­orded oxygen saturation was 87.9%.  Increased periodic limb movements were observed.

 The patient completed an in-home autotitration study that demonstrated effective treatment of OSA, but it also demonstrated inappropriate compliance using continuous positive airway pressure. The patient followed up with the sleep clinic, stating she did want to use a continuous posi­tive airway pressure device and wanted to try oral appli­ance therapy. The patient’s intraoral examination revealed a history of dental restorations, attrition of the dentition, mild crowding, barely visible tonsils, a normal uvula size, and a class 3 Mallampati score. The patient's Epworth Sleepiness Scale score was 15 and she complained of snor­ing, daytime drowsiness, bruxism, drooling while sleeping, and restlessness.

The patient had a hyperactive gag reflex that pre­sented any time the intraoral mirror would touch the tongue or go past the anterior dentition. Intraoral scans with a Primescan (Dentsply Sirona, Charlotte, North Carolina, USA) were obtained by placing salt on the tongue as de­scribed by Friedman.14 A protrusive bite registration using a George Gauge with 3-mm-thick bite fork (Great Lakes Sleep Technologies, Tonawanda, New York, USA) at 60% maximum protrusion was made. The scans and bite regis­tration were sent to the laboratory and an EVO appliance (Prosomnus Sleep Technologies, USA) was fabricated. During the delivery appointment, the patient was unable to tolerate the maxillary and mandibular EVO appliance with­out gagging. A desensitization protocol was developed and implemented to aid the patient in being able to use the MAD to treat the OSA. The protocol was as follows:

  • Days 1 through 7:  The patient would wear the maxillary MAD for an increasing amount of time through­out the day, as much as the patient could tolerate.
  • Days 8 through 14:  The patient would use both maxillary and mandibular trays simultaneously for an in­creasing amount of time throughout the day.
  • Day 15:  The patient would use the MAD at bed­time and go to sleep while using it for as long as tolerable.
  • Day 16:  The patient stated she was able to lie in bed and go to sleep with the MAD but after a brief period she would start gagging intermittently. The patient also stated she could sit up without any gagging occurring. The protocol was modified, and the patient was instructed to go to sleep with three pillows propping up her head/upper body.
  • Day 18:  The patient was instructed to remove one pillow.
  • Day 20:  The patient was instructed to remove the second pillow. 
The patient was able to successfully lie in bed using the MAD without gagging and without any po­sitional modification to elevate the head/upper body.

The patient returned to the clinic for reevaluation ap­proximately 21 days after the desensitization period ended. The patient stated she was able to use the MAD on a regular basis and was able to sleep with it throughout the night. She reported getting better sleep and waking up in the morning feeling more energetic, and that she was feeling less tired during the day. The patient was referred to her primary care manager for a follow-up sleep study; however, the MAD efficacy PSG has not yet been completed because of urgent medical conditions the patient had experienced. The patient and primary care manager are planning PSG once the pa­tient’s medical condition has stabilized.

DISCUSSION

According to Bassi.7, gagging can be disruptive to dental treatment and can prevent the wearing of a prosthe­sis such as a complete denture or a mandibular advance­ment device. Gagging can be challenging for the patient and make dentistry difficult or sometimes even impossible to perform. As previously stated, many different tech­niques have been developed to prevent gagging, including medications, sedatives, holistic remedies such as herbs, ac­upressure and acupuncture, alteration of prosthetic devices, and general or local anesthesia.11 

Sometimes, simple behavior modification and distrac­tion such as providing reassurance and having the patient attempt to relax with music, television, or talking can stop the gag reflex.9 Pharmacologic options to reduce the gag reflex include local anesthesia, conscious sedation, and general anesthesia.12,13 Altering the size and shape of a prosthesis, such as reduction of the palate on a maxillary complete denture, could be enough to prevent gagging.15 Other prosthodontic management techniques for gagging include reducing thickness and extensions of prostheses, choosing impression material with a high viscosity, provid­ing patients with training prostheses prior to final prosthe­sis delivery, and making denture surfaces with a matte fin­ish instead of smooth and glossy.16 Friedman and Wein­traub14  discussed placing salt on the palatal region of a prosthesis or on the tongue to reduce gagging, a technique often used in dentistry to reduce gagging when obtaining radiographs or making impressions. In 2022, Mehdiza­deh et al. 17 performed a systematic review that provided an update on the management of the gag reflex and stated that nitrous oxide, low-level lasers, and distraction techniques were effective in reducing the occurrence of the gag reflex.

A common technique used in dentistry to control the gag reflex is desensitization. Desensitization consists of slowly exposing the patient to a stimulus that invokes the gag reflex. Frequency, duration, and intensity of the stim­ulus is gradually increased with the goal of habituating the procedure that is to be performed or the use of a prosthesis such as a complete denture or other removable prosthesis.9

Colvenkar et al. 15 described a step-by-step process to man­age gagging in a patient without teeth that included having the patient brush the palate as far posterior as possible with a toothbrush and placing four pieces of chocolates in his mouth one at a time until all four pieces would go in with­out gagging.15 In 1973, Singer18 published an article dis­cussing desensitization for treating patients with a severe gag reflex. The Singer marble technique called for placing marbles in the patient’s mouth to desensitize the patient in preparation for use of complete dentures, demonstrating an odd but novel way to treat patient successfully. In dentistry, clinicians often must come up with creative ways to desen­sitize or distract, as did Colvenkar and Singer,to perform procedures that might stimulate the gag reflex, calm fears, or decrease anxiety.

CONCLUSION

This case report discusses a novel technique used to help a patient acclimate to using a MAD without activation of the gag reflex. The described protocol works with the patient’s tolerances for wearing the appliance in small in­crements, allowing the patient to have complete control of the environment. The result allowed the patient to be able to use the MAD without the occurrence of gagging. This new and novel technique was successful for this patient, has the potential to help other patients overcome a hyper­active gag reflex, and can be personalized for each individ­ual patient.

DISCLAIMER 

The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy of the United States Government, the Department of De­fense, the Defense Health Agency, or Uniformed Services University.

REFERENCES

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  2. Park MJ, Byun JS, Jung JK, Choi JK. The correlation of gagging threshold with intra-oral tactile and psychometric profiles in healthy subjects: A pilot study. J Oral Rehabil. 2020;47:591-598.
  3. Stevenson RD, Allaire JH. The development of normal feeding and swallowing. Pediatr Clin North Am. 1991;38:1439-1453.
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  15. Colvenkar S, Reddy V, Thotapalli S, Deepa Rani K, Bharadwaj S. A simple step-by-step technique for the management of gagging in edentulous patient. Cureus. 2022;14:e24423.
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SUBMISSION & CORRESPONDENCE INFORMATION

Submitted for publication October 19, 2023
Submitted in final revised form February 9, 2024
Accepted for publication April 18, 2024

Address correspondence to: Dr. Andrew S. Ryser, CPT, DDS; Email: ryser.3@buckeyemail.osu.edu
 

DISCLOSURE STATEMENT

The authors have no conflicts of interest to report.


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