Background Many patients avoid dental appointments because of severe gagging when they have work performed, such as taking impressions. There are several methods known to alleviate gagging, and some studies have suggested that acupuncture may be effective in reducing gag reflex. The aim of the present study therefore was to evaluate whether acupuncture can produce a reduction of the gag reflex.
Methods A total of 20 patients, aged between 19 and 80 years, with history of gag reflex on taking dental impressions, were recruited. All patients fulfilling the inclusion criteria had an upper and lower dental alginate impression taken without acupuncture, and a second upper and lower alginate impression taken immediately after acupuncture based on traditional Chinese medicine. After each impression, the patients recorded their emetic sensation using a visual analogue scale (VAS).
Results The results showed a significant (p<0.05) reduction in the gag reflex scores after acupuncture. For upper impressions, they fell from 6.8 (1.1) to 1.1 (1.1); and for lower impressions, from 5.45 (1.0) to 0.4 (0.7) (mean (SD)).
Conclusions The findings from our study suggest that acupuncture may be useful for preventing and treating gag reflex, and justifies further study.
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The gag reflex is a normal protective, physiological mechanism that prevents foreign objects or noxious material from entering the pharynx and larynx. It can be activated by stimulating certain trigger areas in the oral cavity, or by psychogenic mechanisms, involving higher brain centres. Some people have a reduced or absent reflex, while others have a pronounced one.
In everyday dental practice, dentists encounter patients who either believe they will gag, or subsequently do gag. Gagging is most frequently experienced during taking impressions, but is also reported during taking radiographs, restoration work in posterior teeth and, in some individuals, inserting a finger for examination purposes.1 A significant number of patients attend for dental treatments that require impressions, and for those with gagging problems this can be a horrendous experience. Therefore, reducing the ordeal is better for all involved.2 ,3 The control of this reflex is very important in order to improve the well-being of the patient, who is often subjected to manoeuvres that are not comfortable that can evoke the reflex.3 ,4
Many techniques have been described that attempt to overcome this problem, and having a variety of management strategies is necessary to aid the delivery of dental care. Acupuncture is one of the several methods thought to relieve gagging.
Acupuncture is over 2000 years old and achieves neuromodulation (traditionally described as re-establishing a balance flow of energy, termed Yin and Yang) throughout the body through 12 meridians and over 300 acupuncture points. The acupuncture needles in traditional Chinese medicine (TCM) are described as releasing blocked energy or qi, and recipients of acupuncture have described the sensation as similar to being ‘pricked with a toothpick’.5–7
Acupuncture has been used to decrease the emetic reflex induced by taking dental impression and to improve the state of anxiety and stress response induced by dental examination.8 A previous case series found improvements in the gag reflex after the use of acupuncture.9 Stimulation of an acupuncture point prior to undergoing treatment has been used to help control the gag reflex, allowing dentists to perform a variety of procedures without compromising the patient's safety and comfort.
The aim of this study was to evaluate the effectiveness of acupuncture for the treatment of gag reflex.2
A non-randomised clinical crossover study was carried out among patients from the Section of Orthodontics, Department of Surgical, Oncology and Stomatologic Sciences, University of Palermo, Italy. The group included 20 participants (6 men and 14 women) with an age range of 19–80 years. All patients were evaluated for inclusion when the history and examination were being taken. The inclusion criteria for acupuncture were: (1) a positive history of nausea in taking dental impression, with visual analogue scale (VAS) score of >5; (2) good general health; (3) no use of drugs that affect the gag reflex in the month before and during our trial; (4) the exclusion of other conditions that can cause gag reflex and; (5) for women, not being pregnant or lactating.
The study was carried out in accordance with the ethical standards of the Helsinki Declaration of 1975. This investigation was approved by the Ethics Committee of the Faculty of Medicine, Department of Surgery and Oncology of the University of Palermo. All participants received oral and written information regarding the study purpose and experimental protocols and provided written informed consent before being enrolled in the study. All participants scored the gag reflex sensation using a VAS from 0–10, with 0 indicating absence of gag reflex and 10 maximum sensation.
The crossover study was conducted in two phases: first, upper and lower alginate impressions were taken, without acupuncture, as a baseline. Second, after 1 month, upper and lower impressions were taken immediately after acupuncture. The mean VAS scores taken at the end of each individual impression (upper and lower) without and with acupuncture were then compared.
Each patient received acupuncture at fixed points. The needles were manipulated for 25–35 s prior to dental treatment and remained in place until the patient was discharged.10
The acupuncture technique employed in the study was based on TCM methods. Sterile, disposable, needles with stainless steel bodies and copper handles were applied through a guide tube (Hwato, Suzhou, China). The needles were 0.25 mm in diameter and 13 mm in length11 ,12; the depth of insertion varied in relation to the anatomic area.
The acupuncture points stimulated were: PC6 (Neiguan), EX 1 (localised in the skin projection of the forehead/nasal suture) and CV24 (Chengiang). The needles were inserted 0.3–0.5 mm and rotated clockwise and anticlockwise. De qi was elicited accompanied by redness and feeling of numbness around the needles. The operator (GB) had experience in the clinical application of acupuncture in the field of dentistry. Then, the impression tray was inserted in the patient’s mouth and the dentist continued the procedure. The needles were left in situ throughout the procedure and removed on its completion. All patients were treated by the same operator (GB), and no adverse reactions were reported.
The Student t test was used to compare mean VAS scores, without and with acupuncture. The significance level was set at p<0.05.
The patients included 14 women and 6 men, with mean ages of 45 and 46 years, respectively. All patients fulfilling the inclusion criteria completed the study. Table 1 states the individual VAS scores.
The VAS scores for gag reflex were significantly lower with than without acupuncture for upper and lower impressions (p<0.05 for both).
There was no significant difference between the responses in male and female participants.
In our study of 20 patients with a history of gag reflex for taking impressions, we found a significant reduction of gag reflex symptoms when assessed after acupuncture for upper and lower alginate impressions.
Table 1 indicates the severity of symptoms without acupuncture: 25% of participants had a gag reflex score of eight or nine, 35% a score of seven and 30% a score of seven. Figure 1 illustrates the size of the reduction in gagging scores on upper impression after acupuncture. It is evident that every patient responded to acupuncture, showing a clinically significant reduction of the scores for the gag reflex. This result was seen in men and women.
Limitations of our design include that the improvement in symptoms may have been due at least in part to other factors, such as familiarity with taking repeated impressions. Also, we cannot determine the role of the needles themselves without using a sham control group.
A recent Cochrane review showed that 31% of adults are fearful of dental treatment. A patient who is phobic may develop reluctance or avoidance towards dental treatment and deprive themselves from receiving proper dental care.13 A patient who is anxious during dental procedures may also hinder the operator from executing proper treatment.14
Fiske et al have shown that patients with gag reflex do not appeal to dentists. Many studies by this group have compared techniques to combat gag reflex; among these, acupuncture appears the most valid. The studies of Rosted et al have shown that gag reflex improved after acupuncture and the patients better accepted dental treatment. Our results were consistent with these other studies.
The overall benefits of an approach using acupuncture include reduction of emetic reflex,13 ,15 greater patient comfort during dental practice,16 good patient compliance,17 acute and chronic pain treatment,18 ,19 immune system strengthening20 and reduced patient/operator stress.16
The technique of acupuncture is potentially useful because is relatively non-invasive, is cheap and requires little additional time. Also, it can be applied even in the presence of other diseases.21 ,22 All the patients tolerated the acupuncture extremely well and were able to travel home without assistance.
In this study, gag reflex induced by taking upper or lower dental alginate impressions was significantly reduced after giving acupuncture. If parallel arm studies confirm this to be an effect of acupuncture, then acupuncture could be a useful option for controlling gag reflex in odontostomatology, also relaxing the patients and thus facilitating dental surgery and saving time.23
Acupuncture has the advantages that it can be used in patients with systemic health problems by avoiding the use of drugs,24 and uses cheap instruments.
The results suggest it is justified to undertake more rigorous prospective and randomised studies to provide a better understanding of this phenomenon.
A total of 20 patients with a history of nausea during dental work were included.
Dental impressions were taken first without, then with acupuncture.
Gagging scores were reduced significantly after acupuncture.
Contributors GB drafted the manuscript, and was involved in the conception and design of the study. GB and AF wrote the statistical analysis plan. The authors had access to all data sources, contributed to the interpretation of results, commented on the report and approved the final version for publication. GB is the guarantor.
Competing interests None.
Patient consent Obtained.
Ethics approval This investigation was approved by the Ethics Committee of the Faculty of Medicine, Department of Discipline Surgery and Oncology and of the University of Palermo.
Provenance and peer review Commissioned; externally peer reviewed.
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