Gagging
can become a conditioned response that makes dental treatment difficult
or impossible for both the individual and the dentist. The aim of this
study is to report a 50 year old female and two children (15 and 11
years old) with exaggerated gag reflex referred to Faculty of Dentistry
of Selçuk University.
Methods
During
obtaining records, taking impression procedure was elicited the
patients’ hypersensitive gagging reflex. Therefore, it was decided to
administer intranasal midazolam to facilitate the taking of accurate
dental impressions. After given verbal information about the procedure,
2.5 mg intranasal midazolam (Demizolam, Dem Medikal, Istanbul) were
applied incrementally in both nostrils.
Results
Five
minutes later; patients had no gagging reflex and allowed the clinician
to take satisfying impressions. No serious adverse effects were observed
and the patients remained cooperative during the entire procedure which
was completed to the full satisfaction of all involved. The short
absorption time and the fast relief process of anaesthetics transferred
to the systemic circulatory system are important advantages of nasal
application.
Conclusions
Intranasal
midazolam may be very useful for the treatment of gag reflex probably
effecting on the depression of upper airway reflex sensitivity.
The gag reflex is a physiological response
which safeguards the airway from foreign bodies. The aetiology of
gagging is complex and not fully understood. Gagging can become a
conditioned response that makes dental treatment difficult or impossible
for both the individual and the dentist. It can result in the avoidance
of dental care [1].
Clinicians successfully treat many patients
with mild gagging problems using only minor procedural modifications or
behaviour techniques. Generally, the ultimate goal for patients is to
make routine dental care possible by helping them ‘unlearn’ the
behaviour that leads to gagging [2]. Therefore, strategies to overcome
the gag reflex in treatment have focused on behaviour modification using
systemic desensitization and distraction methods [3]. Some patients
suffered from such severe gagging that behaviour techniques did not
sufficiently reduce gagging in dentistry. In these patients
pharmacological management (sedatives [propofol, midazolam, nitrous
oxide e.g.], antihistamine, or parasympathetic depressants) was thought
to be the last alternative to eliminate the reflex [4-6].
We present three cases which describe the
rehabilitation of a female and two paediatric patients who have
exaggerated gag reflex requiring prosthetic and orthodontic procedures
with the help of intranasal midazolam. This effect may focuses on the
inhibitory effect on gagging reflex.
CASE DESCRIPTION AND RESULTS
Case 1
A 50 year old, 65 kg female patient was
referred to the Prosthetic Department of Selçuk University for
rehabilitation of their oral function and aesthetic. She had malformed
anterior teeth in the maxilla and left first molar present in the
mandible. She had deeply resorbed alveolar ridges. The treatment was
planned as providing partial removable dentures retained with fixed
partial dentures. She had hypersensitive gag reflex during taking
impression. Intranasal midazolam 2.5 mg (Demizolam, Dem Medikal,
Istanbul) was employed to facilitate the taking of accurate dental
impressions without gagging during the whole procedure by the
anaesthesiologist. The patient was given verbal information about the
procedure at an assessment visit prior to the impression appointment.
The patient had no gag reflex and allowed the dentist to apply the
impression tray accurately in the mouth.
The duration of procedure was 3 minutes. The
patient was controlled after sedation for 45 minutes before she was
discharged. In addition, planning for “horse-shoe” palatal connector
reduced palatal coverage area, thereby, providing less interference for
tongue and reduced gag reflex (Figure 1 and 2).
Initial intraoral photograph of patient 1.
Metal framework try-in procedure of patient 1.
Case 2
A 15 year old, 56 kg child patient was
referred to the Prosthetic Department of Selçuk University. Patient was
suffering from chewing dysfunction resulting from maxillary tooth
agenesis and deficiency. The definitive treatment plan included
fabrication of a partial maxillary removable denture. He did not allow
the dentist to put the tray into his mouth and this encouraged us to
administer midazolam intranasally for its inhibitory effect on gagging.
His parent was also given verbal information about the procedure.
Intranasal midazolam 2.5 mg (Demizolam, Dem Medikal, Istanbul) were
applied incrementally in both nostrils. Patient’s behaviour was
excellent during the impression phase. Patient was able to overcome his
gagging reflex and completed the treatment by the help of midazolam.
Case 3
An 11 year old, 45 kg child patient was
referred to the Orthodontic Department of Selçuk University. It was
learnt from the medical history of the patient that he used regular
medication for hyperactivity. In extraoral clinical examination, it was
observed that the patient had a skeletal Class III malocclusion and
concave profile. In the intraoral and radiographic examination, it was
detected that the patient was in mixed dentition stage and Angle class
II molar relationship on both sides. According to the facial midline,
the maxillary midline was 1 mm on the left and the mandibular midline
was 1 mm on the right. Overjet was 2 mm and overbite was 2.5 mm. The
orthodontic treatment plan included non-extraction treatment after using
face mask.
During obtaining initial records, taking
impression procedure was elicited patient’s hypersensitive gagging
reflex. Therefore, it was decided to administer intranasal midazolam in
advantage to take precise dental impressions without gagging during the
whole procedure. After patient’s parents were given verbal information
about the procedure, 2.5 mg intranasal midazolam (Demizolam, Dem
Medikal, Istanbul) were applied incrementally in both nostrils. Five
minutes later, the patient felt himself relaxed and the level of
sedation was sufficient to take dental impression. We experienced the
benefit of intranasal midazolam to facilitate taking precise dental
impressions in problematic gagging patients intolerable to dental
therapy. All patients suffered moderate burning in the nostril after
delivery of intranasal midazolam (Figure 3 and 4).
Initial extraoral and intraoral photographs of patient 3.
Intraoral photographs of patient 3 after bracket bonding.
DISCUSSION
Retentive denture prosthesis is a major
factor in achieving a successful result when providing partial removable
dentures. The best results are obtained when the prosthesis bases
contain all anatomic landmarks in the upper and lower arches. This is
really complicated when the patients’ anamnesis tells us the difficulty
with the impression phase of treatment due to a hypersensitive gag
reflex. Intranasal midazolam may be safely used to facilitate the taking
of dental impressions in these patients.
In the aetiology of gagging, the factors
involved in its development are divided into psychological and
somatogenic [7,8]. Anatomical abnormalities or neural hypersensitivity
in the oropharynx have been identified as somatogenic factors in the
development of the gag reflex [7]. In a previous study by Saıta et al.
[9], it was reported that psychological factors were identified in all
patients with strong anxiety indicated as the probable cause of the gag
reflex. However same authors were stated that the gag reflex was caused
by touching the oral mucosa in most of patients with some difference in
degree of severity. In our patients, a pre-treatment oral examination
was not performed to determine gagging severity but a hypersensitive gag
reflex was developed during taking impression in all patients. However
it may not be easy to distinguish between two aetiological factors
because physical stimuli may still provoke gagging of psychogenic origin
[7].
A number of techniques for reduction of
gagging have been suggested, including distraction of patient’s
attention from the dental procedure, relaxation, hypnosis, acupuncture,
drugs and general anaesthesia (GA). GA is also conducted in a patient
with extremely problematic gagging who is intolerable to dental therapy
under intravenous sedation. The advantage of GA is complete elimination
of the reflex, but costs should be considered in comparison to the
benefit of dental care [10]. Previous case reports also showed the
adjustment to dental care [3,11]. As another alternative, inhalation
sedation using nitrous oxide is the most common method of delivery of
conscious sedation in dentistry. Nitrous oxide inhalation sedation was
shown to be useful for control of the gagging reflex [11]. Nitrous oxide
is a commonly used pharmacologic agent but has the main disadvantage in
especially children of being a nasal inhalation agent [12]. One of the
popular medications available to the dentist for use in children is
midazolam. Midazolam is a short-acting benzodiazepine with a short
half-life, in children, of two hours compared to 18 hours for diazepam.
Midazolam has been used for preoperative sedation by the intramuscular,
rectal, oral and nasal routes [13]. The injections are painful and
injection procedure is the most common fear of the children. The
anaesthetics used orally and rectally start to relieve symptoms in a
longer time. The recovery is a slow process after oral medication.
Children are prone to vomit or spit out the anaesthetics given orally
[14,15]. This technique has advantages when compared with oral
administration as the bioavailability of intranasal administered
midazolam is approximately 55%, compared with 15% when administered
orally [16,17]. The rate of onset and recovery are more rapid, but
intranasal burning is the main disadvantage of the nasal application of
midazolam [18].
The nasal anaesthesia is popular as a useful
and safe way. The short absorption time and the fast relief process of
anaesthetics transferred to the systemic circulatory system are
important advantages of nasal anaesthesia. Our patients’ gagging
behaviours was modified with the use of intranasal midazolam. No serious
adverse effects were observed and the patients remained cooperated in
the impression phase as in the beginning of the treatment; they had no
gagging during the entire procedure which was completed to the full
satisfaction of all involved. These three cases showed that intranasal
midazolam could be very effective treatments in exaggerated gag reflex
in paediatric and adult patients.
For some patients, however, severe gagging
can be elicited by the dentist’s fingers or instruments contacting the
oral mucosa or even by nontactile stimuli, for example, patients seeing
the dentist or remembering a previous dental experience [7]. Taking
impression becomes a very challenging procedure for clinicians to
handle. Some clinicians swab the sensitive mucosal areas with topical
anaesthetics, whereas others suggest that impressions should be made
under general anaesthesia or hypnosis. Anaesthetic sprays are difficult
to control and their use may result in increased risk of toxicity [5].
Intranasal midazolam has been found to be effective in doses ranging
from 0.2 to 0.6 mg / kg (maximum 15 mg) when used for conscious sedation
and as a premedicant for children. In our clinic; 2.5 mg or 5 mg
intranasal midazolam is being used according to the anaesthesiologists’
preference in adults and 0.5 mg / kg (maximum 10 mg) in child. In this
clinical report; 2.5 mg intranasal midazolam was preferred for all
patients. The reason of this quantity of dose preference for the child
patients is their weights (56 and 45 kg) and no sedation effect is
required for them. The beneficial effects of midazolam include sedation,
anxiolysis, and reduction of postoperative vomiting [15,19,20].
A written consent should be obtained prior
to application midazolam. Our patients were given written consent before
orthodontic and prosthetic treatment and also verbal information about
the midazolam procedure at an assessment visit prior to the impression
appointment.
Premedication with oral midazolam has shown
to be more effective than parental presence or placebo in reducing
gagging anxiety and improving compliance at induction of anaesthesia
[19,20]. Intranasal drug administration is relatively quick, simple, and
may have benefits over transmucosal routes or rectal administration,
which requires more patient cooperation. And, intravenous way is not
needed.
The use of conscious sedation with
inhalational, oral, or intravenous agents may temporarily eliminate
gagging during dental treatment [21]. In dental procedures; midazolam is
accepted as one of the most effective agents to reduce gagging reflex
due to its sedative effects [21]. In a study by Murphy et al. [22] which
has investigated the effect of intravenously administered midazolam on
the sensitivity of upper airway reflexes in volunteers, the authors
concluded that midazolam produced significant depression of upper airway
reflex sensitivity. And this conclusion may also explain our clinical
results.
CONCLUSIONS
Besides the sedative effect of midazolam,
the intranasal midazolam was found to be very useful for taking
impressions probably effecting on the depression of upper airway reflex
sensitivity. Further investigations by using quantitative methods are
needed to be done to clearly prove this effect of midazolam in
dentistry.
ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS
The authors report no conflicts of interest related to this study.
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