Gagging – bringing up an old problem part 1: aetiology and diagnosis

Gagging, also widely known as retching and nausea, is a protective physiological response to foreign bodies, or agents, entering the trachea, larynx and/or pharynx. Where an exaggerated form of the gag reflex exists, it is a well-known hindrance to dental procedures and a potential barrier to optimal patient care. Mild gagging problems are a relatively common occurrence in dentistry where, in most instances, various techniques and additional chairside time will allow the clinician to navigate around the issue successfully and arrive at a satisfactory outcome. However, when the affected patient is unable to overcome the gagging sensation, a more severe variation of gagging is present; under these circumstances, even the simplest forms of treatment can prove extremely challenging or may be impossible to execute.

Providing care for patients with a severe gag response can be a very stressful experience for both the clinician and the patient. Furthermore, unsuccessful treatment experiences will serve as a negative reinforcement of any pre-existing dental phobias. Consequently, patients' anticipation of the inevitable distress will (understandably) affect their enthusiasm for routine dental care provision; it is estimated that gagging related issues are responsible for approximately 20% of overall avoidance cases.¹ Therefore, those affected by a longstanding history of gagging issues will have an increased risk of poor dental health and extensive treatment requirements. The unsuspecting dentist is eventually greeted by the anxious patient who attends with pain at an emergency appointment. Patients' dental anxiety, combined with the need for a complex restorative rehabilitation approach, often results in radical treatment plans involving numerous extractions, leading to removable appliances (that patients will be unable to wear), which in turn heightens patient anxiety, with a loss of faith in a clinician's abilities and further missed appointments, until they next return with further pain – the term ‘gagging cycle’ seems appropriate (Figure 1).