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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 63-66

Use of training denture base and palateless dentures: Two different strategies in the management of severe gag reflex in edentulous patients


Private Practitioner, Bhopal, Madhya Pradesh, India

Date of Submission17-Mar-2020
Date of Decision30-Apr-2020
Date of Acceptance08-May-2020
Date of Web Publication28-Jul-2020

Correspondence Address:
Dr. Medha Vivek Bhuskute
D1, 105, Coral Woods, Hoshangabad Road, Near Toyota, Showroom, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sidj.sidj_9_20

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  Abstract 

Gagging is a common problem encountered in clinical prosthodontic practice. In many cases gagging is of psychologic nature and should be treated before denture procedures are completed, so that the patient will be comfortable with well-constructed prostheses. Effective management of gag reflex includes a wide array of techniques ranging from use of common salt on the tip of tongue, acupressure, distraction, relaxation, pharmacotherapy and desensitization. This case report discusses how a holistic approach for gagging prevention and use of training denture base can facilitate denture wearing for a known potential gagger and also highlights how palateless denture helped overcome gagging in a patient with thick ropy saliva in another case.

Keywords: Desensitization, gagging, palateless denture, thick ropy saliva, training denture base


How to cite this article:
Bhuskute MV. Use of training denture base and palateless dentures: Two different strategies in the management of severe gag reflex in edentulous patients. Saint Int Dent J 2020;4:63-6

How to cite this URL:
Bhuskute MV. Use of training denture base and palateless dentures: Two different strategies in the management of severe gag reflex in edentulous patients. Saint Int Dent J [serial online] 2020 [cited 2020 Aug 5];4:63-6. Available from: http://www.sidj.org/text.asp?2020/4/1/63/291034


  Introduction Top


Overt gagging can be agonizing for the clinician and the patient as well. The mere sight of the dentist or dental equipment may provoke some patients to gag. Pondering over what might be the next step in the treatment, could be potent enough to stimulate gagging in some patients.[1]

Gagging or gag reflex or pharyngeal reflex is a protective reflex, mainly triggered by the stimulation of posterior pharyngeal wall, tonsillar area, and base of the tongue by glossopharyngeal (IX) and vagus (X) nerve just like retching, cough, and sneeze, which in edentulous patients can make clinical steps such as impression making and recording jaw relations disruptive and also may be a hindrance to optimum patient care and the wearing of prostheses.[1]

Although a multidisciplinary approach is helpful in gagging, prevention strategies should be tailored to suit the needs of individual patients. This case report discusses how effectively relaxation, distraction, premedication, and training denture base were used holistically in the management of gagging in one of the two cases of a completely edentulous patient.[2],[3] Gag reflex can be triggered by some anxiety, prior bad dental experience, excessive mouth opening, saliva accumulation, etc.

Based on the Dickinson and Fiske Gagging Severity Index,[4],[5] patients could be categorized as having Grade IV in the first case and Grade III in the second case.

Gagging severity index:[4]

  1. Grade I: Very mild; occasional and controlled by the patient
  2. Grade II: Mild; control is required by the patient with reassurance from the dental team
  3. Grade III: Moderate; consistent and limits treatment options
  4. Grade IV: Severe and treatment is impossible
  5. Grade V: Very severe; affecting patient behavior and dental attendance and making treatment impossible.



  Case Reports Top


Case report 1

A 58-year-old female patient reported to our dental clinic for replacement of missing teeth. Her past experience during dental treatment was very unpleasant and was revealed during history taking. The patient was informed of what the intraoral examination involved, and the inspection proceeded with her consent. During the intraoral examination, it was revealed that the sight of dental instruments, gloved fingers, and contact of the same with oral mucosa elicited gag reflex. Gagging was accompanied by excessive salivation, lacrimation, and retching with a vomiting sensation. Due to the small size of the jaw, a palateless denture was excluded during treatment planning [case report 1: [Figure 1], [Figure 2], [Figure 3].
Figure 1: Training denture base

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Figure 2: Training denture base in the patient's mouth

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Figure 3: Transformation of the patient from potential gagger to a regular denture wearer

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Case report 2

A 65-year-old edentulous patient reported to our dental clinic for replacement of her missing teeth. Intraoral examination revealed that patient had thick ropy saliva, accumulation of which underneath maxillary denture could have compromised retention of the prosthesis. Also, the posterior region of hard palate was found to be extremely sensitive to touch. So as to make denture wearing a pleasant experience, a maxillary palateless denture was planned for the aforementioned patient. This prosthodontic treatment modality is found to prevent the contact of the prosthesis with the severe sensitive region of hard palate.[6],[7] (Case report 2 images: [Figure 4] and [Figure 5]). In this case, a palateless denture was used to facilitate wearing of the prosthesis in a patient with thick ropy saliva. Thick ropy saliva when gets accumulated under the conventional maxillary denture results in dislodgement of the prosthesis, severe gagging and discomfort in patient.[8],[9]
Figure 4: Palateless maxillary and conventional mandibular denture

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Figure 5: Palateless denture in the patient's mouth

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Holistic approach

  1. Relaxation:[1] The gag reflex may be a manifestation of an anxiety state. Relaxation techniques may be helpful in reducing or abrogating the gag reflex. In the present case, the patient was asked to tense and relax certain muscle groups, starting with the legs and working upward, while continually providing reassurance in a calm environment.
  2. Distraction:[1] Distraction techniques can be useful to temporarily divert a patient's attention. The patient was instructed to concentrate on breathing, inhaling through the nose and exhaling through the mouth. The patient was asked to think of and visualize a safe, comfortable, relaxing place, which allowed a short dental procedure of making primary impression with impression compound without major discomfort to the patient.
  3. Training base:[1],[7] On the primary cast, a thin acrylic denture base, without teeth, was fabricated, and the patient was asked to wear it at home [Figure 1] and [Figure 2].


  4. This is a desensitization technique and is useful for patients who are to become denture wearers. A suitable regimen maybe 5 min once each day, then twice each day, and so on. After 1 week, the patient is asked to increase this to 10 min thrice a day, then 15 min, 30 min, and 1 h. Eventually, the patient was able to tolerate the training base for most of the day. Relaxation techniques can also be coupled with the initial wearing of the training base. Some authors recommend this option as a last resort.[8] However, it was found extremely beneficial in this particular patient.

  5. Premedication: As a preventive measure, Rabemac-DSR (rabeprazole 20 mg and domperidone 30 mg sustained release) was prescribed orally 1 h prior to the final impression making for effective prevention of nausea and vomiting. With tolerance developed with training base and premedication, final impressions were made, jaw relation was recorded, and trial insertion and denture delivery were done in an uneventful manner [Figure 3]. Using premedication (rabeprazole 20 mg and domperidone 30 mg sustained release) an hour prior to appointments, preliminary and final impressions were recorded conventionally. During jaw relation recording, accumulation of thick ropy saliva under the trial denture base made the procedure cumbersome. Hence, for hassle-free jaw relation recording, the palateless trial denture base was redesigned. This helped in positive reinforcement for the patient that she will be able to tolerate the prosthesis. After an event, free try-in appointment palateless complete denture was fabricated and was well tolerated by the patient [Figure 4] and [Figure 5]. A 65-year-old edentulous patient reported to our dental clinic for replacement of her missing teeth. Intraoral examination revealed that the patient had thick ropy saliva, accumulation of which underneath the maxillary denture could have compromised the retention of the prosthesis. Furthermore, the posterior region of the hard palate was found to be extremely sensitive to touch. Hence, to make denture wearing a pleasant experience, a maxillary palateless denture was planned for the aforementioned patient.



  Discussion Top


Clinicians might face difficulties during the recording of maxillary impressions if the patient gags. Some minor changes made in the technique can facilitate uneventful impression making, which can affect the treatment outcome significantly. No particular method can be quoted as a panacea for the successful management of the gagging patient. From the wide array of management strategies, a holistic approach was chosen in case of the first patient. In this case, the small jaw excluded the use of a palateless denture. Use of a training base helped the patient in desensitizing, and it gained the confidence necessary for successful denture wearing. In a small percentage of patients, successful management may not always be possible.

In case 2, thick ropy saliva was the major cause of concern. Recording posterior palatal seal aids in the retention of the maxillary denture, but in this particular case, other physical forces of retention were the mainstay for achieving good retention. Retention in complete dentures is based on physical factors such as adhesion, cohesion, interfacial surface tension, and atmospheric pressure. As the patient had well-rounded ridges, these factors were sufficient to hold the denture in place. Excessively thick and ropy saliva tends to accumulate beneath the denture base, which results in an easy displacement of the denture.

Wright has reported in his study that over 40% of the patients gagged only after wearing dentures.[10] His study also emphasized that a reduction in palatal length makes denture wearing comfortable in about 24.5% of patients. The less palatal coverage also has an added advantage of better taste and temperature perception, with acrylic denture base being a bad conductor of heat.[11] Over 80% of patients experienced that complete palatal coverage leads to a decrease in touching and stimulation of palate as this is enhanced in a palateless design. Palateless design improves the ability to tolerate dentures in a first-time denture wearer. Hence, a palateless design was well accepted in case 2.


  Conclusion Top


Fabrication of acrylic training base along with relaxation, distraction, and premedication was found to be effective in the management of gag reflex in an edentulous patient. A holistic approach ensured smooth transition of the patient from a potential gagger to a regular denture wearer. In another case, palateless denture proved to be an effective remedy in the management of gag reflex. Minor treatment modifications can enrich patient acceptance and result in successful treatment outcome in gag reflex patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bassi GS, Humphris GM, Longman LP. The etiology and management of gagging: A review of the literature. J Prosthet Dent 2004;91:459-67.  Back to cited text no. 1
    
2.
Kovats JJ. Clinical evaluation of the gagging denture patient. J Prosthet Dent 1971;25:613-9.  Back to cited text no. 2
    
3.
Zach GA. Gag control. Gen Dent 1989;37:508-9.  Back to cited text no. 3
    
4.
Dickinson CM, Fiske J. A review of gagging problems in dentistry: I. Aetiology and classification. Dent Update 2005;32:26-32.  Back to cited text no. 4
    
5.
Jacob SA, Gopalakrishnan A. Saliva in prosthodontic therapy – All you need to know! RRJDS 2013;1:13-25.  Back to cited text no. 5
    
6.
Jain A, Vijayalaxmi V, Bharathi RM, Patil V, Alur J. Management of severe gag reflex by an unique approach: Palateless dentures. J Clin Diagn Res 2013;7:2394-5.  Back to cited text no. 6
    
7.
Neumann JK, McCarty GA. Behavioral approaches to reduce hypersensitive gag response. J Prosthet Dent 2001;85:305.  Back to cited text no. 7
    
8.
Ramsay DS, Weinstein P, Milgrom P, Getz T. Problematic gagging: Principles of treatment. J Am Dent Assoc 1987;114:178-83.  Back to cited text no. 8
    
9.
Farmer JB, Connelly ME. Palateless dentures: Help for the gagging patient. J Prosthet Dent 1984;52:691-4.  Back to cited text no. 9
    
10.
Wright SM. Medical history, social habits, and individual experiences of patients who gag with dentures. J Prosthet Dent 1981;45:474-8.  Back to cited text no. 10
    
11.
Singh K, Gupta N. Palateless custom bar supported overdenture: A treatment modality to treat patient with severe gag reflex. Indian J Dent Res 2012;23:145-8.  Back to cited text no. 11
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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Abstract
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Case Reports
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