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Clinical evaluation of the gagging denture patient

J. J. Kovats, D.D.S., M.D.


Burbank, Calif.

0 ne of the most bewildering clinical problems encountered in complete prostho-


dontics is that presented by the patient referred to as a “gagger.”
As presently defined, gagging is an involuntary retching reflex that may be
stimulated by something touching the posterior palatal region1 The retching may
lead to actual vomiting, and is accompanied by lacrimation, salivation, and flush-
ing. These symptoms are usually triggered by tactile stimulation of the soft palate
by the maxillary denture, but may also be caused by virtually any intraoral pro-
cedure.

CLINICAL FEATURES
The history of the gagging patient is usually related to a maxillary denture which
causes a tickling or gagging sensation, and which is felt to be “too long.” Shortening
of the palatal margin reduces the sensation of length, but usually does not relieve
the gagging. This cycle of gagging, followed by shortening and more gagging, con-
tinues until the patient despairs, and abandons all efforts to wear the denture.
Although the gagging appears most commonly at the time of the initial placing of
the maxillary denture, it can appear at any time during the clinical course as a
result of conditions to be discussed later.
The maxillary denture of the gagging patient usually has either of two character-
istic contours. It may have a posterior palatal margin that is so concave that it
t.erminates almost on the hard palate, or it may have a paIate which has a marked
downward slope away from the soft palate. In either case, the denture can exert
only minimal pressure against the soft palate.
Perhaps the most paradoxical feature found in almost every gagging patient is
the specificity of the stimulus that triggers the reflex. Characteristically, although
the soft palate is extremely sensitive to the contact of the denture or any instrument,
the patient seldom gags on the foods and liquids of his diet which contact this same
area during swallowing.
Also interesting is the fact that despite the patient’s extreme apprehension and
gagging at even the slightest contact of the soft palate during even simple oral
--
Read before the Southern California Academy of Genera1 Dentistry, Los Angeles, Calif.

613
614 Kovats J. Prosth. Dent.
June, 1971

examination, this sensitivity markedly decreases, or even disappears, if at the time


of such examination, the patient’s attention is completely diverted. Both of these
features, the specificity of the stimulus, and the essential role played by the patient’s
attention to the stimulation, lead one to the thought that perhaps gagging in the
so-called “gagger” involves more than simple contact of the soft palate by a foreign
object.
In long-standing cases, the picture is typical: the patient makes no attempt to
wear his denture, continues to consume a relatively normal diet including meat,
and simply resigns himself to his edentulous condition. Attempts to obtain a new
denture are uniformly futile, and the gagging intensifies and comes to be triggered
by an ever-widening group of stimuli. Ultimately, the gagging can be induced not
only by the denture or any intraoral procedure, but by even the thought of such
procedure.

CLINICAL PHASES OF GAGGING


It can thus be seen that the picture presented by the average gagger can be
separated into two rather distinct clinical phases-the acute and the chronic. The
acute phase is characterized by the initial gagging episode and the repeated unsuc-
cessful attempts to wear the denture. During this phase, it is usually only the denture
that induces gagging. The chronic phase is characterized by an increase in the
intensity of the gagging, as well as by an increase in the number of objects, situa-
tions, or procedures which may induce the reflex.

Acute phase
A consistent feature of the history is a maxillary denture which feels “too long”
and causes gagging which is not relieved by palate shortening. In light of this fact
that shortening of the palate does not decrease the tendency to gag, but may actually
increase it, it may very well be that the palatal margin in these dentures is already
too short, or that the posterior palatal seal is too shallow. This is suggested by the
fact that, even in a nongagger, light touch or pressure against the soft palate can
cause a tickling sensation, whereas firm pressure is much less apt to do so. A similar
experiment can be performed by touching the back of one’s hand with the lightest
possible pressure; this will usually cause a tickling sensation. However, if the pres-
sure on the same area is firm, no tickling is felt. And so, too, with the maxillary
denture: it is much more apt to cause a tickling sensation if it exerts too little pres-
sure against the soft palate than if it exerts too much. Indeed, experience indicates
that if excessive palatal margin pressure is really present, the sensation caused is not
tickling, but pain.
Consistent with this concept-that relatively firm pressure against the soft palate
actually helps to avoid gagging rather than causes it-is the often heard comment
from the patient that the tendency to gag is reduced if he clenches his teeth
together and breathes through his nose. What obviously happens at such time is
that the clenching forces the denture firmly upward against the soft palate, while
breathing through the nose forces the soft palate downward against the denture.
Both these actions increase the pressure between denture and soft palate, thereby
decreasing the tickling sensation.
E2E ‘6” Clinical evaluation of gagging denture patient 615

As might be expected, therefore, gagging may be induced by any factor which


leads to an inadequate posterior palatal seal, be it something inherent in the contour
of the denture, as discussed above, or some other factor which causes the posterior
palatal seal to decrease at any time later in the clinical course. For example, both
distal settling of a mandibular distal extension partial denture and posterior dis-
lodging of a maxillary denture have in common the one factor which may contribute
to gagging : they are both associated with a decrease in the posterior palatal seal
of denture base against soft tissue.

Chronic phase
The chronic phase of a gagger’s history resembles a simple Pavlovian conditioned
r’cflex, in that the oft-repeated gagging becomes so intimately associated with the
denture that ultimately any procedure involving that denture, or the oral cavity, can
set off the reflex.
The medical laboratory counterpart of this has long been established. For
instance, in the dog, administration of morphine normally causes vomiting. After
a. series of these injections, the mere sight of the syringe, or even the approach of
t’he attendant who previously administered the drug, is enough to cause vomiting
previously caused only by the drug. 2 The prosthodontic parallel is obvious: once
gagging has been caused enough times by a denture, a conditioned reflex is estab-
lished; as a result of this reflex, the mere sight of the denture, or any person,
procedure, or environment associated with it, can trigger the reflex.
In order to more clearly understand chronic gagging as a conditioned reflex, it
is necessary to recall the classical experiment of Pavlov” which served as a model
for much of his work in this field. He found that acid injected into a dog’s mouth
normally causes a profuse secretion of saliva. If, during a series of such injections,
a. bell is rung at the same time that the acid is injected, the ringing of the bell alone
soon becomes sufficient to cause secretion of the saliva. In this way, the dog is said
to be conditioned to the ringing of the bell, and the bell is called the conditioned
stimulus.
Pavlov made two additional observations which bear on the problem of the
gagger. He noted that the reflex secretion of the saliva in response to the bell would
gradually disappear if the acid was not occasionally reintroduced in conjunction
with the bell-ringing; he called this reinforcement of the reflex. He also noted that
this reflex could be weakened or abolished if, at the time of the ringing of the bell,
a new stimulus, such as a strange sound or a painful sensation, were introduced; he
called this external inhibition of the reflex. Most interesting of all, he found that
the only requisite this inhibiting stimulus had to have, in order to be effective, was
enough strength to divert all of the animal’s attention from the bell.
These observations of Pavlov go far to explain what happens in the chronic
phase of the gagger’s history. It can easily be seen that if a denture initially causes
gagging for whatever mechanical or physical reasons, and the patient experiences
enough such episodes, that denture can become so intimately associated with gagging
that virtually any contact with it, or even the thought of such contact, may cause
gagging.
It can also be seen that the concept of external inhibition explains the mecha-
616 Kouats J. Prosth. Dent.
June, 1971

Fig. 1. A maxillary denture which caused gagging. Note the markedly concave posterior
margin commonly associated with this problem.

nism by which, as mentioned by Kovats” and Krol,4 the gag reflex can be markedly
diminished if the patient’s complete attention is diverted by having him maintain
a leg in an elevated position. The same end may be achieved by having the patient
execute any other action which occupies all his attention.
Therefore, keeping in mind the fact that even an established conditioned reflex
will disappear if not periodically reinforced, and remembering that a conditioned
reflex may be abolished temporarily by any new and stronger stimulus, the means
by which a chronic gagger can be helped will become apparent: if a new maxillary
denture, with an adequate posterior palatal seal, can be placed with the aid of an
external inhibiting stimulus to divert the patient’s attention, that patient will gag
only minimally, if at all. After that, every passing minute and hour that the denture
is in place will be just so long that the reflex is not being reinforced. Thus, after
a while, the tendency to gag, not having been reinforced because of the adequacy
of the posterior seal, will gradually disappear.

TREATMENT OF A GAGGING PATIENT


A 74-year-old man presented for prosthodontic treatment with the complaint
of severe gagging caused by his complete maxillary denture. Complete maxillary
and mandibular dentures had been placed immediately after the extraction of his
natural teeth four years previously; they had never been worn for more than a few
minutes at a time because of gagging. Examination of the maxillary denture re-
vealed a markedly concave posterior palatal margin (Fig, 1). Except for the lack
of retention of the maxillary denture, no factor other than the extremely short
palate was apparent as an explanation of the gagging.

*Kovats, J. E.: Personal communication, 1945.


Clinical evaluation of gagging denture patient 617

Fig. 2. The basal surfaces of the old and new dentures. (Left) The denture associated with
gagging, and (right) the denture which induced no gagging. Note the greater length of the
palate of the new denture which did not produce the gagging.

The patient was in good health, taking no medication, and seemingly well
motivated. Examination revealed both the maxillary and mandibular ridges to be
high, broad, firm, and covered by normal mucosa. Gagging could be elicited by
touching virtually any area of the palate.
Prior to tray preparation, the patient was instructed to breathe through his
nose slowly and audibly, and at the same time, to rhythmically tap his right foot
on the floor. All instructions were given in a warm and understanding, but very
firm, tone of voice. By having the patient concentrate on his breathing and foot-
tapping, his attention was diverted enough to allow the making of the mandibular
impression without incident.
During the preparation of the maxillary tray, the instructions were the same.
!fn addition, an anesthetic was sprayed onto the entire palate, Except for the neces-
sary repeating of the instructions, the procedure was uneventful, because whenever
it appeared during the making of impressions that the patient was about to gag, he
was firmly ordered to continue the breathin g and foot-tapping as described.
For the registration of centric relation, virtually the entire palate of the maxil-
1lar-y occlusion rim was removed in order to reduce to an absolute minimum the
area of contact between rim and palatal tissue. In addition, a thin film of adhesive
‘was sprinkled onto the rim for retention, and an anesthetic was sprayed onto the
palate. The patient followed instructions regarding the breathing and foot-tapping,
and except for occasional brief delays caused by a breakthrough of gagging, the
procedure was completed without incident.
Prior to the actual placing of the new dentures, the patient was prepared for a
temporary period of discomfort, but was assured that, although intensely uncom-
fortable, it would be short-lived.
The lower denture was placed without difficulty with the patient following
instructions. The maxillary denture was then placed and the patient was immedi-
ately requested to close into centric occhtsion in centric reIation. He began to gag at
once until he again resumed the deep, slow, and audible nose-breathing, and foot-
618 Kovats J. Prosth. Dent.
June, 1971

Fig. 3. A comparison of the lateral aspects of the denture which caused no gagging (above)
and the denture which induced gagging (below). Note markedly longer palate length of the
new denture.

tapping. Although initially very severe, the gagging subsided over a period of four
to five minutes. The patient experienced a recurrence of gagging several times daily
for the first four days, each episode being controlled by nose-breathing and clench-
ing his teeth together. By the end of this period, he was no longer gagging at all,
and has experienced no recurrence in the twelve months he has been wearing the
dentures.
It is interesting to note some differences between the denture which induced
gagging and the new one (Fig. 2). The length of the palate from palatine (incisive)
papilla to the middle of the palatal margin measures 26.9 mm. on the old denture
and 47.8 mm. on the new. Similarly, the new denture, measured from palatine
papilla to the hamular notch, is 5 to 6 mm. longer than the old denture on each
side. A lateral view shows how the palate lengths of the two dentures contrast
(Fig. 3). Of particular interest is the fact that the palate of the new denture slopes
downward only slightly, thereby assuring firm contact with the soft palate, so that,
although it is almost 21 mm. longer than the palate of the old denture, it does not
induce gagging.

CONCLUSION
This article has attempted to elaborate some aspects of the gagging denture
patient not usually considered. Perhaps the most important of these on a theoretical
level is that the so-called gagger is a patient who once had a normal gag reflex, but
who has become hypersensitized to oral prostheses and procedures which are
normally well tolerated. This sensitization is most likely due to the establishment
of a simple Pavlovian conditioned reflex in which the maxillary denture becomes
the conditioned stimulus which induces gagging.
Vobtme 25 Clinical evaluation of gagging denture patient 619
Number 6

On a clinical level, the most important fact to remember is that judicious


pal.atal coverage, per se, does not induce gagging if the denture is so designed as
to maintain an adequate posterior palatal seal during function and phonation.
Because of this, acceding to the patient’s request to shorten the palate immediately
upon placement of a new maxillary denture may actually predispose to gagging,
and is, therefore, contraindicated in the absence of objective mucosal signs.

References
1. Boucher, C. O., editor: Current Clinical Dental Terminology, St. Louis, 1963, The C. V.
Mosby Company.
2. Pavlov, I. P.: Conditioned Reflexes, ed. 1, London, 1927, Oxford University Press.
3. Ibid.
4. Krol, A. J.: A New Approach to the Gassing Problem, J. PROSTH. DENT. 13: 61 l-616,
1963.

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