Medical knowledge | Dentistry » Mark-Camilla-Barry - The use of relative analgesia in the prosthetic treatment of the gagging patient

2EMOVABLE0ROSTHODONTICS -ARK % 0ACKER #AMILLA *OARDER "ARRY ! ,ALL 4HE 5SE OF 2ELATIVE !NALGESIA IN THE 0ROSTHETIC 4REATMENT OF THE @AGGING 0ATIENT !BSTRACT /BTAINING A STABLE AND RETENTIVE DENTURE BASE IS A MAJOR FACTOR IN ACHIEVING A SUCCESSFUL OUTCOME WHEN PROVIDING COMPLETE OR PARTIAL REMOVABLE DENTURES 4HE BEST RESULTS ARE OBTAINED WHEN THE DENTURE BASES ARE WELL EXTENDED ESPECIALLY IN THE UPPER ARCH 4HIS IS COMPLICATED WHEN THE PATIENT EXPERIENCES DIFFICULTY WITH THE IMPRESSION PHASE OF TREATMENT DUE TO A HYPERSENSITIVE GAG REFLEX 2ELATIVE !NALGESIA 2! ALSO TERMED INHALATIONAL SEDATION MAY BE EMPLOYED TO FACILITATE THE TAKING OF DENTAL IMPRESSIONS IN PATIENTS WITH A HYPERSENSITIVE GAG REFLEX 4HREE PATIENTS WHO HAD PREVIOUS FAILED ATTEMPTS TO PRODUCE A SATISFACTORY DENTAL IMPRESSION HAVE BEEN USED TO ILLUSTRATE THE TECHNIQUE AND OUTCOME )T MUST BE NOTED THAT THE CONCENTRATION OF NITROUS OXIDE REQUIRED TO PRODUCE SUPPRESSION OF THE GAG REFLEX WILL VARY FROM PATIENT

TO PATIENT 4HIS MAY BE IRRESPECTIVE OF SIZE AND WEIGHT THEREFORE EACH SUBJECT SHOULD BE INDIVIDUALLY MONITORED #LINICAL 2ELEVANCE 2ELATIVE ANALGESIA INHALATIONAL SEDATION MAY BE EMPLOYED TO FACILITATE THE TAKING OF DENTAL IMPRESSIONS IN PATIENTS WITH A HYPERSENSITIVE GAG REFLEX $ENT 5PDATE     /BTAINING A STABLE AND RETENTIVE DENTURE BASE IS A MAJOR FACTOR IN ACHIEVING A SUCCESSFUL OUTCOME WHEN PROVIDING COMPLETE OR PARTIAL REMOVABLE DENTURES 4HE BEST RESULTS ARE OBTAINED WHEN THE DENTURE BASES ARE WELL EXTENDED ESPECIALLY IN THE UPPER ARCH 4HIS IS COMPLICATED WHEN THE PATIENT EXPERIENCES DIFFICULTY WITH THE IMPRESSION PHASE OF TREATMENT "ARRY ! ,ALL "$3 --ED3CI 3ENIOR $ENTAL /FFICER #AMILLA *OARDER "$3 ,$3 2#3%NG 3ENIOR $ENTAL /FFICER #OMMUNITY $ENTAL $EPARTMENT &OLKESTONE (EALTH #ENTRE   $OVER 2OAD &OLKESTONE #4 *9 AND -ARK % 0ACKER "$3 -0HIL &$3 2#3%NG 3ENIOR ,ECTURER IN 0ROSTHETIC $ENTISTRY $EPARTMENT OF 0ROSTHETIC

$ENTISTRY UYS +INGS AND 3T 4HOMAS $ENTAL )NSTITUTE +INGS #OLLEGE ,ONDON #ALDECOT 2OAD ,ONDON 3% 27 5+  $ENTAL5PDATE 4HE RELATIONSHIP BETWEEN THE GAG REFLEX AND DENTURE INTOLERANCE IS WELL KNOWN BUT THE CAUSATIVE FACTORS MAY BE COMPLEX   )N MANY INDIVIDUALS IT IS RELATED TO THE POSTERIOR BORDER EXTENSION OF THE REMOVABLE PROSTHESIS (OWEVER A REDUCTION IN THE AMOUNT OF PALATAL COVERAGE HAS A DETRIMENTAL EFFECT ON DENTURE RETENTION 2EMOVABLE @TRAINING BASES MAY BE USED TO FACILITATE AND PREPARE THE PATIENT FOR THE PRESENCE OF A DENTURE BASE AND LATER ARTIFICIAL TEETH )T IS ESSENTIAL THAT THE @TRAINING BASES COVER THE MAXIMUM AREA OF THE DENTURE FOUNDATION IN THE FIRST INSTANCE &IGURE   -ODIFICATIONS CAN THEN BE MADE TO THE BASE SHAPE AS THE PATIENTS CAPACITY TO TOLERATE PALATAL COVERAGE IS ASSESSED 4HE OLD MAXIM @IT IS BETTER TO TAKE AWAY THAN TO ATTEMPT TO ADD IS VERY IMPORTANT IN THIS SITUATION AS THE BASES NEED TO BE WELL MADE AND A GOOD FIT 4HEY SHOULD

NOT BE OVER BULKED ESPECIALLY AT THE PALATAL BORDER 0OORLY FITTING TRAINING BASES THAT DO NOT EXTEND TO THE FULL SULCUS WIDTH &IGURE  !N UPPER TRAINING BASE FOR AN EDENTULOUS PATIENT AND DEPTH WILL DEVELOP LITTLE OR NO BORDER SEAL 4HE CRUCIAL COMPONENT OF THIS IS TO OBTAIN HIGH QUALITY PRIMARY AND SECONDARY INTRA ORAL DENTAL IMPRESSIONS (OWEVER A HYPERSENSITIVE GAG REFLEX WILL RENDER IT IMPOSSIBLE TO ACHIEVE THIS GOAL PREDICTABLY .OVEMBER  2EMOVABLE0ROSTHODONTICS )NDICATIONS  $ENTALLY ANXIOUS  -ARKED GAG REFLEX #ONTRA INDICATIONS  "LOCKED NASAL AIRWAY  4ONSILAR AND ADENOIDAL ENLARGEMENT  3IGNIFICANT PULMONARY DISEASE EG BRONCHIECTASIS EMPHYSEMA  0ATIENTS UNDERGOING TREATMENT FOR PSYCHIATRIC DISORDERS  .EUROMUSCULAR DISEASES EG -ULTIPLE SCLEROSIS   -YASTHENIA GRAVIS  &IRST TRIMESTER OF PREGNANCY -ANAGEMENT OF THESE PATIENTS WOULD REQUIRE LIAISON WITH PHYSICIANS AND ANAESTHESIOLOGISTS ,IAISON WITH THE PSYCHIATRISTS AND PHYSICIANS

RESPONSIBLE FOR THE CARE OF THESE PATIENTS WOULD BE ESSENTIAL BEFORE CONSIDERING TREATMENT 4ABLE  )NDICATIONS AND CONTRA INDICATIONS FOR RELATIVE ANALGESIA IN THE GENERAL PRACTICE SETTING AFTER 2OBERTS   "EFORE TREATMENT  /N THE DAY OF THE APPOINTMENT EAT A LIGHT NON FATTY MEAL n HOURS BEFORE THE APPOINTMENT  4AKE ROUTINE MEDICATION AT THE USUAL TIME  )T IS ADVISABLE NOT TO DRIVE OR OPERATE MACHINERY IMMEDIATELY AFTER THIS SEDATION PROCEDURE )T IS RECOMMENDED THAT IF YOU PLAN TO DO SO YOU SHOULD LIAISE WITH YOUR INSURANCE COMPANY AND WORKPLACE REGARDING THEIR POLICY IN RELATION TO INHALATIONAL SEDATION PROCEDURES  7EAR LOOSE COMFORTABLE CLOTHING  ,ET US KNOW IF YOU HAVE DEVELOPED A COLD OR ARE UNABLE TO BREATHE THOUGH YOUR NOSE !FTER THE APPOINTMENT  4HE EFFECTS OF THE SEDATION GAS NORMALLY WEAR OFF VERY QUICKLY 9OU WILL BE FIT TO TRAVEL HOME SOON AFTER THE TREATMENT IS FINISHED  !LTHOUGH RECOVERY IS RAPID IT IS NOT RECOMMENDED TO DRIVE A CAR OR

OPERATE MACHINERY IMMEDIATELY FOLLOWING THIS SEDATION PROCEDURE  9OU MUST BE ACCOMPANIED BY A RESPONSIBLE ADULT  !LCOHOL SHOULD NOT BE CONSUMED FOR THE REST OF THE DAY FOLLOWING THE SEDATION PROCEDURE 4ABLE  )NSTRUCTIONS FOR PATIENTS RECEIVING INHALATION SEDATION )N THESE INDIVIDUALS THE PRESENCE OF A LARGE OBJECT IN THE MOUTH SUCH AS AN IMPRESSION TRAY ANDOR STIMULATION OF THE SOFT PALATE OR THE POSTERIOR THIRD OF THE TONGUE APPEARS TO STIMULATE AN @IDIOPATHIC SYMPTOMATIC HYPERVENTILATION PROVOKING ANXIETY AND A @GAGGING REACTION 4ECHNIQUES USED TO MANAGE THIS SITUATION AIM TO ENCOURAGE RELAXATION   CONTROL ANXIETY AND PREVENT PANIC ATTACKS AND THEREBY REDUCE THE SEVERITY OF THE GAG REFLEX SUCH THAT THE PATIENT IS ABLE TO TOLERATE THE PROCEDURE AND THE CLINICIAN CAN TAKE IMPRESSIONS OF ACCEPTABLE QUALITY .OVEMBER  !LTERNATIVELY THE STIMULUS CAN BE OVERRIDDEN BY TECHNIQUES SUCH AS DISTRACTION AND ACUPUNCTURE  TO ENABLE THE PERFORMANCE OF DENTAL PROCEDURES

ON PATIENTS WITH A HYPERSENSITIVE GAG REFLEX )NTRAVENOUS SEDATION TECHNIQUES HAVE LESSENED GAGGING AND CHOKING SENSATIONS IN ENDOSCOPY  AND DENTAL PROCEDURES BUT THIS TECHNIQUE CAN CAUSE RESPIRATORY DEPRESSION 4HE MONITORING EQUIPMENT REQUIRED EG PULSE OXIMETRY MATERIALS FACILITIES RECOVERY AREA AND EXPERTISE MAY NOT BE READILY AVAILABLE 2! OR INHALATIONAL SEDATION IS RECOGNIZED AS A SAFE NON INVASIVE TECHNIQUE   WHOSE DENTAL INDICATIONS INCLUDE ANXIETY PRONOUNCED GAGGING AND NEEDLE PHOBIA #ONTRA INDICATIONS PRINCIPALLY FOCUS ON THE ABILITY TO MAINTAIN BOTH A NASAL AIRWAY AND LUNG FUNCTION 4ABLE   2OBERTS INDICATED A THEORETICAL POSSIBILITY THAT PATIENTS WITH MULTIPLE SCLEROSIS AND MYASTHENIA GRAVIS MAY HAVE THEIR MUSCULAR ACTIVITY REDUCED BELOW A CRITICAL LEVEL )T SHOULD ALSO BE BORNE IN MIND THAT NITROUS OXIDE SEDATION AS WITH ALL SEDATION TECHNIQUES MAY HAVE UNEXPECTED EFFECTS ON PATIENTS WITH PSYCHIATRIC DISORDERS 4HEREFORE IN THESE CIRCUMSTANCES CLOSE

LIAISON WITH PHYSICIANS AND PSYCHIATRISTS IS ESSENTIAL PRIOR TO THE USE OF ANY SUCH TECHNIQUES FOR THESE PARTICULAR PATIENT GROUPS 4HE SUCCESS OF 2! DEPENDS NOT ONLY ON THE INHALATION OF NITROUS OXIDE IN OXYGEN BUT ALSO ON THE CORRECT BEHAVIOURAL MANAGEMENT OF THE PATIENT  4HE LATTER REFERS TO THE ACCOMPANIMENT OF A STEADY FLOW OF ENCOURAGING TALK AND REASSURANCE TO THE PATIENT RESULTING IN A KIND OF SEMI HYPNOTIC SUGGESTION 4HE PATIENT REMAINS CONSCIOUS CO OPERATIVE AND IS IN FULL CONTROL OF HISHER AIRWAY .ITROUS OXIDE IS QUICKLY CLEARED FROM THE PATIENTS BODY BY OXYGEN ADMINISTRATION WITH LITTLE RESIDUAL EFFECT AND WITH NO NEED TO ADMINISTER AN ANTAGONIST AGENT 0ATIENT SAFETY IS NOT COMPROMISED BECAUSE ALTHOUGH THERE IS A REDUCTION IN GAG REFLEX THE LARYNGEAL REFLEX WORKS NORMALLY  0ATIENT SAFETY IS ALSO ASSURED BY THE USE OF REGULARLY SERVICED AND MAINTAINED EQUIPMENT 4HE APPARATUS SHOULD NOT BE ABLE TO ADMINISTER LESS THAN  OXYGEN MODERN MACHINES ARE

UNABLE TO DELIVER LESS THAN  OXYGEN AND MUST HAVE A DEVICE THAT CUTS OFF THE NITROUS OXIDE IF THE OXYGEN SUPPLY RUNS OUT )T IS VITAL THAT THE WASTE GASES ARE EFFECTIVELY SCAVENGED TO REDUCE THE EXPOSURE OF STAFF TO NITROUS OXIDE   )T MAY BE NECESSARY TO ROTATE STAFF THAT ARE FREQUENTLY INVOLVED WITH ITS USE OWING TO ITS CUMULATIVE EFFECT .ITROUS OXIDE INHALATION SEDATION CAN SIGNIFICANTLY REDUCE THE GAGGINGRETCHING REACTION IMPRESSIONS CAN THEREFORE BE TAKEN IN PATIENTS WHO NORMALLY CANNOT TOLERATE THIS PROCEDURE WITHOUT GAGGING 4HE GAG REFLEX SEEMS TO BE MOVED TO THE POSTERIOR BORDER OF THE TONGUE 2OSEN REPORTED A CASE STUDY WHERE POSITIVE SUGGESTIONS AND NITROUS $ENTAL5PDATE  2EMOVABLE0ROSTHODONTICS EXPLAIN HOW THE PROCEDURE IS PERFORMED DESCRIBE THE SENSATIONS THAT MAY BE FELT BY THE PATIENT 4ABLE  AND ANSWER ANY CONCERNS THE PATIENT MAY HAVE PRIOR TO THE TREATMENT VISIT 4HE ACCURACY OF THE PATIENTS MEDICAL HISTORY MUST BE VERIFIED AND IT IS

ESSENTIAL THAT THE PATIENT IS ABLE TO BREATHE THROUGH HISHER NOSE 4ABLES  AND   )T SHOULD BE REMEMBERED THAT INDIVIDUALS REACT DIFFERENTLY TO 2! THEREFORE IT SHOULD BE EMPHASIZED THAT THE PATIENT MAY FEEL SOME ALL OR NONE OF THE VARYING TYPES OF SENSATIONS DESCRIBED 4ABLE   ,ACK OF SENSATIONS DOES NOT INDICATE THAT THE PROCEDURE HAS NOT BEEN EFFECTIVE #ONSEQUENTLY IT IS ESSENTIAL TO MONITOR THE REACTION OF EACH PATIENT TO THE LEVEL OF NITROUS OXIDE EMPLOYED SO THAT THIS IS SUFFICIENT MERELY TO PRODUCE SUPPRESSION OF THE GAG REFLEX /NE MUST NOT ASSUME THAT THE SAME PERCENTAGE OF NITROUS OXIDE WILL HAVE A UNIVERSAL EFFECT AS ILLUSTRATED IN THE FOLLOWING INDIVIDUAL CASES &IGURE  0ATIENT UNDERGOING RELATIVE ANALGESIA 4HE PROCEDURE &IGURE  2ECORDING THE DENTAL IMPRESSION OXIDE SEDATION WERE USED TO CONSTRUCT DENTURES FOR A PATIENT WITH A SENSITIVE GAG REFLEX +AUFMAN ET AL HAVE SINCE CARRIED OUT A STUDY THAT SHOWED THAT NITROUS OXIDE HAS A DEFINITIVE EFFECT

ON THE INCIDENCE OF EXPERIMENTALLY INDUCED GAGGING (OWEVER THE SUBJECTS WERE ALL NON GAGGERS IN THIS PARTICULAR STUDY 4HE FOLLOWING CASES ILLUSTRATE HOW A SIMPLE AND SAFE TECHNIQUE CAN BE EMPLOYED TO FACILITATE THE CLINICIAN  $ENTAL5PDATE IN OBTAINING ACCURATE IMPRESSIONS WITH MINIMAL DISTRESS TO THE PATIENT !DMINISTRATION OF RELATIVE ANALGESIA FOR PROSTHODONTIC PROCEDURES 4HE PREPARATORY APPOINTMENT 0RE OPERATIVE INSTRUCTIONS 4ABLE  ARE PROVIDED AT AN APPOINTMENT PRIOR TO THE 2! SESSION 4HIS ENABLES THE DENTIST TO )T IS IMPORTANT PRIOR TO THE COMMENCEMENT OF THE 2! PROCEDURE THAT THE PRE OPERATIVE INSTRUCTIONS HAVE BEEN COMPLIED WITH 4HE MEDICAL HISTORY SHOULD BE RE CHECKED AND THE ABILITY OF THE PATIENT TO BREATH THROUGH HISHER NOSE CONFIRMED )T IS IMPORTANT TO REAFFIRM THE PROCEDURE INCLUDING OUTLINING THE SENSATIONS THAT MAY BE EXPERIENCED DURING 2! )T MUST BE EMPHASIZED THAT IF AT ANY STAGE THE PATIENT DOES NOT FEEL COMFORTABLE WITH ANY OF THE SENSATIONS

PHYSICALLY OR PSYCHOLOGICALLY THEN THEY MUST INDICATE TO THE OPERATOR AT ONCE AS THE PROCEDURE IS VERY EASILY AND QUICKLY REVERSED 4HE PATIENT IS MADE COMFORTABLE AND THE NASAL MASK GENTLY POSITIONED SO THAT THERE IS NO LEAKAGE &IGURE  AND A  OXYGEN  FLOW IS COMMENCED )T IS VERY IMPORTANT THROUGHOUT THE PROCEDURE FOR THE OPERATOR TO PROVIDE A CONTINUOUS FLOW OF ENCOURAGEMENT AND EXPLANATIONS FOR THE VARIOUS SENSATIONS ! QUIET GENTLE MONOTONOUS VOICE IS USED THROUGHOUT !LLEN SUGGESTED THAT 2! IS FUNDAMENTALLY A SEMI HYPNOTIC TECHNIQUE AND THAT SUGGESTION IS RATHER MORE IMPORTANT THAN THE NITROUS OXIDE "ARBER ET AL PROPOSED THAT NITROUS OXIDE INHALATION PRODUCES AN ALTERED STATE OF CONSCIOUSNESS INCREASING THE PATIENTS .OVEMBER  2EMOVABLE0ROSTHODONTICS  4INGLING IN PARTS OR WHOLE OF BODY EG FINGERS TOES LIPS TONGUE   ENERAL FEELING OF RELAXATION  ,ETHARGY OR MILD INTOXICATION  7ARMTH  3ENSE OF DETACHMENT n FLOATING OR DRIFTING

SENSATION  2EDUCED AWARENESS OF PAIN 4ABLE  3UBJECTIVE SENSATIONS EXPERIENCED DURING RELATIVE ANALGESIA RESPONSE TO SUGGESTION 4HE OPERATOR MAY GENTLY TOUCH THE BACK OF THE HAND WHEN DESCRIBING THE TINGLING SENSATIONS THAT MAY BE EXPERIENCED EG THE PATIENT IS ASKED TO KEEP HISHER EYES OPEN THROUGHOUT THE PROCEDURE AND TO INFORM THE OPERATOR IF AT ANY TIME HESHE FEELS SLEEPY OR UNCOMFORTABLE 4HE PATIENT IS ENCOURAGED TO RELAX WITH DROPPED SHOULDERS UNCROSSED LEGS AND TO LET THE HANDS REST GENTLY ON THE LAP /NE HUNDRED PERCENT OXYGEN IS MAINTAINED TO ESTABLISH A FLOW RATE FOR TWO TO THREE MINUTES TO ALLOW RELAXATION AND FAMILIARIZATION WITH THE EQUIPMENT 4HE PERCENTAGE OF NITROUS OXIDE IS THEN GRADUALLY INCREASED AT FIVE PERCENT INTERVALS WITH AN AUTOMATIC AND CORRESPONDING REDUCTION OF OXYGEN #OMMUNICATION WITH THE PATIENT SHOULD BE CONTINUOUS THROUGHOUT THE PATIENT IS INTERMITTENTLY ASKED WHAT THEY ARE FEELING AGAIN WITH SOME EXPLANATION AND ENCOURAGEMENT /NCE THE

DESIRED LEVEL OF ANALGESIA HAS BEEN ACHIEVED THE CLINICAL PROCEDURE IS CARRIED OUT &IGURE  ENSURING THAT THE PATIENT CONTINUES TO BREATHE IN THROUGH HIS HER NOSE WHILE THE MOUTH IS OPEN 4HE LEVEL OF SEDATION SHOULD NOT HINDER THE PATIENT RESPONDING TO THE OPERATORS COMMANDS 4HIS IS ESSENTIAL TO BE ABLE TO BORDER MOULD THE DENTAL IMPRESSION CORRECTLY EG SUCKING IN THE CHEEKS OPENING CLOSING AND LATERAL MOVEMENTS OF THE MANDIBLE  #AREFUL POSITIONING OF THE MASK IS ESSENTIAL TO ENABLE UNHINDERED ACCESS TO THE LABIAL SULCUS )F AT ANY TIME THE PATIENT SHOWS EVIDENCE OF BECOMING @TOO DEEP THE NITROUS OXIDE SHOULD BE REDUCED TO REVERSE THE PROCESS 4HE LEVEL SHOULD BE DECREASED BY n AND THE PATIENT RE MONITORED 4HESE SIGNS MAY INCLUDE THE EYES OR MOUTH CLOSING AND FAILING TO OPEN ON DIRECTION )T SHOULD BE REMEMBERED THAT THERE IS A POSSIBILITY THAT SOME PATIENTS MAY LOSE  $ENTAL5PDATE CONSCIOUSNESS WITH LEVELS AS LOW AS  NITROUS OXIDE AND  OXYGEN !T THE END

OF THE PROCEDURE THE NITROUS OXIDE IS GRADUALLY REDUCED UNTIL  OXYGEN IS BREATHED FOR n MINUTES 4HE MASK IS REMOVED AND THE PATIENT IS ASKED TO REMAIN IN THE CHAIR BREATHING AMBIENT AIR FOR  MINUTES 4HE PATIENT IS ENCOURAGED TO DESCRIBE HOW HESHE FELT DURING THE PROCEDURE AND ADVISED THAT HESHE MAY FEEL QUITE RELAXED AND RESTED FOR SOMETIME AFTER .ITROUS OXIDE IS RAPIDLY CLEARED FROM THE BODY AND THE PATIENT CAN AFTER AN APPROXIMATELY  MINUTE REST THEORETICALLY BE ABLE TO DRIVE OR RETURN TO WORK AFTER THE PROCEDURE 4HE PATIENT SHOULD HOWEVER BE WARNED TO CHECK WHETHER HISHER CAR INSURANCE COMPANIES OR WORKPLACE HAVE ANY CLAUSES THAT WILL PREVENT DRIVING OR OPERATING MACHINERY FOR A LONGER PERIOD OF TIME 4HE PATIENT SHOULD BE REISSUED WITH THE INSTRUCTION SHEET AFTER THE PROCEDURE TO ENSURE HESHE IS FULLY INFORMED 4ABLE   )LLUSTRATIVE CASE STUDIES 4HE FOLLOWING CASES ILLUSTRATE THE TECHNIQUE AND OUTCOME FOR THREE CASES WHO HAD PREVIOUS FAILED ATTEMPTS TO PRODUCE A

SATISFACTORY DENTAL IMPRESSION 4HE SAME TWO OPERATORS MANAGED THE CASES ONE CARRIED OUT ALL THE CLINICAL PROCEDURES WHILST THE SECOND SUPERVISED THE 2! &IGURES  AND   )T MUST BE EMPHASIZED THAT TWO DENTAL SURGEONS ARE NOT REQUIRED TO UNDERTAKE THE PROCEDURE !N OPERATOR SEDATIONIST WITH AN APPROPRIATELY TRAINED ASSISTANT EG A QUALIFIED DENTAL NURSE MEETS THE CURRENT GUIDELINES  )N ADDITION THE NASAL MASK CAN BE SECURELY ATTACHED SO THAT IT DOES NOT REQUIRE MANUAL SUPPORT )N THE CASES REPORTED HERE A SEDATIONIST PROVIDED THE 2! AS THE PROSTHODONTIST HAD NOT UNDERTAKEN AN APPROPRIATE TRAINING PROGRAMME IN CONSCIOUS SEDATION !LL THREE CASES HAD EXHIBITED VERY STRONG GAG REFLEXES PREVENTING THE TAKING OF IMPRESSIONS NECESSARY FOR THE REQUIRED PROSTHODONTIC WORK 0ATIENT ! 0ATIENT ! WAS A  YEAR OLD GENTLEMAN WITH A VERY STRONG AND SENSITIVE GAG REFLEX (E WAS EXTREMELY ANXIOUS OF DENTAL TREATMENT AND SUFFERED WITH ANGINA )T WAS CONSIDERED 2! WOULD HELP TO CONTROL

HIS ANXIETY   THUS REDUCE THE CHANCE OF A RELATED ANGINA ATTACK AND MINIMIZE OR ELIMINATE THE GAGGING RESPONSE (E REQUIRED A REPLACEMENT UPPER COMPLETE DENTURE AS THE PREVIOUS ONE WAS VERY LOOSE 4HIS WAS OWING TO ITS UNDER EXTENSION AS THE GAG REFLEX HAD ALWAYS PREVENTED ADEQUATE IMPRESSIONS BEING TAKEN IN THE PAST 0RIOR TO THE 2! SESSION A SPECIAL TRAY HAD BEEN CONSTRUCTED ON A MOULD TAKEN FROM THE FITTING SURFACE OF HIS EXISTING UPPER DENTURE 0ATIENT ! WAS FOUND TO GAG VERY VOCALLY AND DRAMATICALLY AS SOON AS AN EMPTY TRAY ENTERED HIS MOUTH (E SHOWED SIGNS OF ANXIETY AND EMBARRASSMENT ABOUT HIS OBVIOUS AND LOUD GAGGING AND SO WAS OFFERED THE OPPORTUNITY OF HAVING THE PROCEDURE PERFORMED UNDER 2! 4HE 2! WAS COMMENCED AT THE NEXT VISIT HE FELT VERY RELAXED AT A TITRATION OF  NITROUS OXIDE  OXYGEN ALTHOUGH HE DID NOT DESCRIBE THE SENSATIONS FELT IN HIS LIMBS AS A @TINGLING HE DID SAY THEY @FELT DIFFERENT (E SHOWED SIGNS OF VISIBLY RELAXING COMPARED WITH HIS INITIAL

QUITE RIGID AND ANXIOUS APPEARANCE .O GAGGING OCCURRED ON EXAMINATION OF HIS MOUTH EVEN WHEN A FINGER WAS EXTENDED ON TO THE SOFT PALATE 4HE SPECIAL TRAY WAS MODIFIED AND AN UPPER WORKING IMPRESSION USING A POLYETHER IMPRESSION MATERIAL @)MPREGUM %30% 3EEFELD ERMANY WAS THEN COMPLETED !FTER n SECONDS THE PATIENT STARTED TO GAG ALTHOUGH NOT AS MARKEDLY AS WITHOUT 2! (E WAS ENCOURAGED TO CONCENTRATE ON BREATHING DEEPLY AND SLOWLY IN THROUGH HIS NOSE AND OUT THROUGH HIS MOUTH RELAX AND DROP HIS SHOULDERS WITH A GENTLE HAND ON HIS SHOULDER TO REINFORCE THIS !FTER A FEW SECONDS HE VISIBLY RELAXED AND OVERCAME HIS GAGGING SUFFICIENTLY FOR THE UPPER IMPRESSION TO BE COMPLETED 0OLYETHER IMPRESSION MATERIALS HAVE A SOMEWHAT EXTENDED SETTING TIME .OVEMBER  2EMOVABLE0ROSTHODONTICS SO ARE NOT NECESSARILY AN IDEAL CHOICE FOR A PATIENT WITH A HYPERSENSITIVE GAG REFLEX (OWEVER THEIR EXCELLENT FLOW CHARACTERISTICS MAKE THEM IDEAL IMPRESSION MATERIALS FOR THE MAXILLARY EDENTULOUS

ARCH THEY ARE SUFFICIENTLY VISCOUS TO SUPPORT THEMSELVES BEYOND THE BORDERS OF THE IMPRESSION TRAY YET ARE READILY MOULDED DURING BORDER MOULDING MOVEMENTS OF THE SOFT TISSUES 4HIS IS ESSENTIAL WHEN ATTEMPTING TO ACHIEVE A GOOD BORDER SEAL FOR A COMPLETE DENTURE BASE 4HE 2! WAS THEN GRADUALLY REVERSED TO  OXYGEN AND AFTER FIVE MINUTES OF AMBIENT AIR THE PATIENT WAS ENCOURAGED TO DESCRIBE HOW HE HAD FELT (E WAS STILL SLIGHTLY EMBARRASSED ABOUT HIS GAGGING BUT SAID HE HAD FELT @VERY RELAXED AND WAS SURPRISED BY THE SUCCESSFUL RESULT 4HE WHOLE 2! PROCEDURE WAS COMPLETED IN APPROXIMATELY  MINUTES 0ATIENT " 0ATIENT " WAS A  YEAR OLD GENTLEMAN WHO REQUIRED AN UPPER PARTIAL DENTURE BUT GAGGED AS SOON AS AN EMPTY IMPRESSION TRAY WAS POSITIONED IN HIS MOUTH $URING THE 2! PROCEDURE HE REPORTED FEELING WARM AND EXPERIENCED A @TINGLING SENSATION IN HIS HANDS AND FINGERS AT A CONCENTRATION OF ONLY  NITROUS OXIDE  OXYGEN  4HE LOWER IMPRESSION WAS COMPLETED

WITHOUT ELICITING A GAG RESPONSE (E COPED WELL WITH THE PLACEMENT OF THE UPPER TRAY BUT GAVE THE APPEARANCE OF STARTING TO GAG WHEN THE ALGINATE IMPRESSION MATERIAL AND TRAY WERE INSERTED (E WAS ENCOURAGED TO RELAX AND BREATHE SLOWLY AND DEEPLY RESPONDING WELL WITHIN A FEW SECONDS WITH NO SUBSEQUENT GAGGING 4HIS ALLOWED A SUCCESSFUL UPPER IMPRESSION TO BE TAKEN THE WHOLE PROCEDURE WAS COMPLETED IN  MINUTES !T THE END OF THE SESSION THE PATIENT STATED THAT HE HAD FELT VERY COMFORTABLE WHILE @BREATHING THE GASES AND ENJOYED THE RELAXED FEELING (E WAS PLEASED AND EXPRESSED SURPRISE THAT THE GAGGING WAS VIRTUALLY ELIMINATED DURING THE PROCEDURE 0ATIENT " RETURNED A FEW WEEKS LATER FOR ANOTHER APPOINTMENT TO COMPLETE THE WORKING IMPRESSIONS (E WAS REMINDED OF THE PROCEDURE AND THE POSSIBLE SENSATIONS HE MIGHT EXPERIENCE THE IDEAL .OVEMBER  LEVEL WAS AGAIN FOUND TO BE  NITROUS OXIDE  OXYGEN  4HE UPPER WORKING IMPRESSION WAS TAKEN WITH AN ADDITIONAL CURED

SILICONE MATERIAL 0RESIDENT 2EGULAR #OLTENE -AHWAH .EW *ERSEY  $ESPITE THE LONGER SETTING TIME NO GAGGING OCCURRED 4HE PATIENT AGAIN EXPERIENCED TINGLING AND WARM SENSATIONS AS BEFORE ALTHOUGH THESE WERE NOT AS STRONG 4HE DURATION OF THE PROCEDURE WAS  MINUTES 0ATIENT # 0ATIENT # WAS A  YEAR OLD LADY WHO REQUIRED A LOWER PARTIAL DENTURE 3HE REPORTED THAT THE EXTENT OF HER GAGGING VARIED ON A DAY TO DAY BASIS BUT SHE WAS UNABLE TO TOLERATE IMPRESSIONS 3HE HAD A SMALL MOUTH SUFFERED FROM 3JÚGRENS SYNDROME AND ASSOCIATED XEROSTOMIA WHICH COMPOUNDED THE DIFFICULTIES IN IMPRESSION TAKING 3OON AFTER COMMENCEMENT OF THE 2! THE PATIENT EXPRESSED CONCERN THAT SHE FELT NO DIFFERENT ON BREATHING THE GASES 3HE WAS REASSURED AND THE PREVIOUSLY MENTIONED ENCOURAGEMENT AND SUGGESTION TECHNIQUES WERE USED !T  NITROUS OXIDE  OXYGEN THE PATIENT FELT MORE RELAXED BUT @NOTHING ELSE !S THE NITROUS OXIDE CONCENTRATION WAS INCREASED TO  NITROUS OXIDE  OXYGEN SHE BEGAN TO

@FEEL WARMER AND EXPERIENCED @HEAVINESS IN HER ARMS AND LEGS %XAMINATION OF HER HARD PALATE PRODUCED NO RESPONSE BUT CONTACT WITH THE SOFT PALATE ELICITED A SLIGHT GAGGING RESPONSE 2AISING THE CONCENTRATION TO  NITROUS OXIDE  OXYGEN ELIMINATED THE GAG REFLEX 4HE LOWER IMPRESSION TRAY WAS MODIFIED WITH SILICONE PUTTY TO RECORD THE FREE END SADDLE REGION ACCURATELY 0RESIDENT 0UTTY #OLTENE -AHWAH .EW *ERSEY  4HIS TOOK A FEW MINUTES TO SET DURING WHICH TIME THE PATIENT COPED WELL ! VERY SLIGHT GAGGING WAS NOTED TOWARDS THE END OF THE PROCEDURE AT WHICH TIME SHE ALSO EXPERIENCED A SLIGHT HEADACHE 4HE PATIENT WAS REASSURED AND AFTER REMOVAL OF THE SUCCESSFUL PUTTY IMPRESSION SHE WAS ASKED ABOUT HER FEELINGS 4HE HEADACHE HAD DISAPPEARED WITHIN A MINUTE AND THE PATIENT REPORTED AN INCREASE IN ANXIETY DURING THE GAGGING AND FELT THIS TO BE THE CAUSE OF THE HEADACHE )T WAS DECIDED TO CONTINUE AT THIS CONCENTRATION AS THE HEADACHE WAS MILD SHORT LASTING AND THE PATIENT WAS KEEN

TO CARRY ON 4HE LOWER IMPRESSION WAS THEN COMPLETED WITH THE ADDITION OF AN ALGINATE WASH !LGINATE 0LUS (ENRY 3CHEIN -ELVILLE .9 AND THE UPPER IMPRESSION COMPLETED IN ALGINATE /N BOTH OCCASIONS NO GAGGING WAS ELICITED 4HE DURATION OF THE PROCEDURE WAS  MINUTES &OLLOWING COMPLETION OF THE PROCEDURE THE PATIENT SAID THAT SHE HAD FELT RELAXED AND THAT THIS HAD MADE A TREMENDOUS DIFFERENCE TO HER GAGGING 3HE ALSO ADMITTED TO HAVING HAD DOUBTS THAT THE TECHNIQUE WOULD WORK )NTERESTINGLY THIS PATIENT DID NOT EXPERIENCE ANY @TINGLING SENSATIONS AND REQUIRED A HIGHER CONCENTRATION OF NITROUS OXIDE BEFORE REPORTING ANY NOTICEABLE PHYSICAL EFFECTS AS COMPARED WITH THE PREVIOUS TWO PATIENTS 4HE OTHER PATIENTS WERE MALE AND CONSIDERABLY LARGER THAN THE SLIGHTLY BUILT FEMALE PATIENT THEREFORE IT MUST NOT BE ASSUMED THAT MEN REQUIRE HIGHER LEVELS OF NITROUS OXIDE THAN WOMEN OR THAT A HEAVIER PERSON WILL REQUIRE A HIGHER LEVEL %ACH PATIENT MUST BE INDIVIDUALLY MANAGED 4HESE CASES

ILLUSTRATE HOW A SIMPLE AND SAFE TECHNIQUE CAN BE EMPLOYED TO FACILITATE THE CLINICIAN IN OBTAINING A HIGH QUALITY WORKING IMPRESSION TO OBTAIN THE BEST POSSIBLE MASTER CAST 4HIS DOES NOT GUARANTEE THAT SUBSEQUENT STAGES MAY BE PROBLEM FREE (OWEVER IT IS OFTEN THE IMPRESSION PHASE THAT CAUSES THE PATIENTS THE MOST DISTRESS !S SUGGESTED EARLIER THIS WILL FACILITATE THE PRODUCTION OF @TRAINING BASES IF THE PATIENTS EXPERIENCE DIFFICULTY AT SUBSEQUENT VISITS )T IS RECOMMENDED THAT THE MASTER CAST IS DUPLICATED AND RETAINED FOR THE CONSTRUCTION OF THE DEFINITIVE APPLIANCE WHILST THE DUPLICATE CAST IS USED TO FABRICATE THE @TRAINING BASE 2ELATIVE ANALGESIA IS AN EXTREMELY SAFE PROCEDURE AS THE PATIENTS RECEIVE A CONSTANT SUPPLY OF OXYGEN HOWEVER CLOSE MONITORING OF THE PATIENT IS ESSENTIAL )T IS RECOMMENDED THAT ALL PERSONNEL INVOLVED ARE ACQUAINTED WITH AND ADHERE TO THE RECOMMENDED GUIDELINES  #ONCLUSION 2ELATIVE ANALGESIA INHALATIONAL SEDATION MAY BE EMPLOYED TO

FACILITATE THE TAKING OF DENTAL IMPRESSIONS IN PATIENTS $ENTAL5PDATE  2EMOVABLE0ROSTHODONTICS WITH A HYPERSENSITIVE GAG REFLEX 4HE CONCENTRATION OF NITROUS OXIDE REQUIRED TO PRODUCE SUPPRESSION OF THE GAG REFLEX WILL VARY FROM PATIENT TO PATIENT 4HIS MAY BE IRRESPECTIVE OF SIZE AND WEIGHT THEREFORE EACH SUBJECT SHOULD BE INDIVIDUALLY MONITORED   2EFERENCES         7RIGHT 3- !N EXAMINATION OF FACTORS ASSOCIATED WITH RETCHING IN DENTAL PATIENTS * $ENT   n 7RIGHT 3- !N EXAMINATION OF THE PERSONALITY OF DENTAL PATIENTS WHO COMPLAIN OF RETCHING WITH DENTURES "R $ENT *   n 7RIGHT 3- -EDICAL HISTORY SOCIAL HABITS AND INDIVIDUAL EXPERIENCES OF PATIENTS WHO GAG WITH DENTURES * 0ROSTHET $ENT   n #HIDIAC * #HAMSEDDINE , "ELLOS  AGGING PREVENTION USING NITROUS OXIDE OR TABLE SALT A COMPARATIVE PILOT STUDY )NT * 0ROSTHODONT   n 3PEIRS 2, "ARSBY -* (YPERVENTILATION IN THE

DENTAL CHAIR $ENT 5PDATE   n 2OBB .$ #ROTHERS !* 3EDATION IN DENTISTRY 0ART  -ANAGEMENT OF THE GAGGING PATIENT $ENT 5PDATE   n "ARSBY -* 4HE CONTROL OF HYPERVENTILATION IN THE MANAGEMENT OF @GAGGING;#OMMENT= "R $ENT *   n "ARSBY -* 4HE USE OF HYPNOSIS IN THE MANAGEMENT OF @GAGGING AND INTOLERANCE TO DENTURES "R $ENT *           n &ISKE * $ICKINSON # 4HE ROLE OF ACUPUNCTURE IN CONTROLLING THE GAGGING REFLEX USING A REVIEW OF TEN CASES "R $ENT *   n ,U $0 ,U 0 2EED *& RD !CUPUNCTURE ACUPRESSURE TO TREAT GAGGING DENTAL PATIENTS A CLINICAL STUDY OF ANTI GAGGING EFFECTS EN $ENT   n "ELL $ 2EVIEW ARTICLE PREMEDICATION AND INTRAVENOUS SEDATION FOR UPPER GASTROINTESTINAL ENDOSCOPY !LIMENT 0HARMACOL 4HER   n 4OMIOKA 3 5CHIDA $ %GUCHI 3 .AKAJO  %LIMINATION OF HYPERSENSITIVE GAGGING REACTION TO

DENTISTRY BY PROPOFOL AT SUBHYPNOTIC DOSES /RAL $IS   n 2OSEN - 4HE CONTROL OF GAGGING BY SUGGESTION AND NITROUS OXIDE SEDATION n A CASE REPORT * $ENT !SS 3 !FR   n 2OBERTS * 4HE EFFICACY OF THE LARYNGEAL REFLEX DURING RELATIVE ANALGESIA OXYGENNITROUS OXIDE PSYCHO SEDATION  3!!$ $IGEST   n $UNCAN ( -OORE 0 .ITROUS OXIDE AND THE DENTAL PATIENT A REVIEW OF ADVERSE REACTIONS * !M $ENT !SSOC   n 2OBERTS * )NHALATION SEDATION RELATIVE ANALGESIA WITH OXYGENNITROUS OXIDE GAS MIXTURES  0RACTICAL TECHNIQUES $ENT 5PDATE   n !LLEN 7 2ELATIVE !NALGESIA $ENT 0RACTICE   n 2OBERTS * 2ELATIVE !NALGESIA n AN         INTRODUCTION $ENT 5PDATE   n #LEATON *ONES 0 4HE LARYNGEAL CLOSURE REFLEX AND NITROUS OXIDE OXYGEN ANALGESIA !NESTHESIOLOGY   n 2OBERTS * )NHALATION SEDATION RELATIVE ANALGESIA WITH OXYGENNITROUS OXIDE GAS MIXTURES 

0RINCIPLES $ENT 5PDATE   n !$! #OUNCIL ON 3CIENTIFIC !FFAIRS !$! #OUNCIL ON $ENTAL 0RACTICE .ITROUS OXIDE IN THE DENTAL OFFICE * !M $ENT !SSOC   n (ENDERSON +! -ATTHEWS )0 %NVIRONMENTAL MONITORING OF NITROUS OXIDE DURING DENTAL ANAESTHESIA "R $ENT *   n +AUFMAN % 7EINSTEIN 0 3OMMERS %% 3OLTERO $* !N EXPERIMENTAL STUDY OF THE CONTROL OF THE GAG REFLEX WITH NITROUS OXIDE !NESTH 0ROG   n "ARBER * $ONALDSON $ 2AMRAS 3 !LLEN $ 4HE RELATIONSHIP BETWEEN NITROUS OXIDE CONSCIOUS SEDATION AND THE HYPNOTIC STATE * !M $ENT !SSOC   n -AINTAINING STANDARDS 7HAT THE PROFESSION EXPECTS 0AIN AND ANXIETY CONTROL ENERAL $ENTAL #OUNCIL  REVISED  n WWWGDC UKORGPDFSMS?FULL?NOVPDF 3TANDING $ENTAL !DVISORY #OMMITTEE #ONSCIOUS SEDATION IN THE PROVISION OF DENTAL CARE 2EPORT OF AN EXPERT GROUP ON SEDATION IN DENTISTRY $EPARTMENT OF (EALTH  WWWDOHGOVUKSDAC OR

WWWDOHGOVUKDENTAL !BSTRACTS -!+% 352% 9/52 $%.4!, 523% 2%!$3 4()3
! CLEANING PROTOCOL FOR ROTARY NICKEL TITANIUM ENDODONTIC INSTRUMENTS 0 0ARASHOS 0 ,INSUWANONT AND (( -ESSER !USTRALIAN $ENTAL *OURNAL   n 4HE CLEANING OF ENDODONTIC FILES AS WITH ALL DENTAL INSTRUMENTS IS A PREREQUISITE PRIOR TO STERILIZATION 4HIS STUDY INVESTIGATED MORE THAN  METHODS OF CLEANING SIX DIFFERENT ENDODONTIC INSTRUMENTS LOOKING MACROSCOPICALLY AND MICROSCOPICALLY FOR STAINED DEBRIS ! RANGE OF CHAIRSIDE  $ENTAL5PDATE PROCEDURES CHEMICAL PROCESSES AND ULTRASONIC ACTION WERE COMPARED .EW UNUSED FILES WERE ALSO EXAMINED AS THESE ARE NOT USUALLY SUPPLIED IN A STERILE CONDITION !FTER THE VARIOUS PROCEDURES ALL THE NEW UN USED FILES APPEARED CLEAN TO THE NAKED EYE BUT MICROSCOPICALLY SHOWED EVIDENCE OF NON STAINED DEBRIS WITH SIX FILES INCLUDING ONE BRAND SUPPLIED @PRE STERILIZED SHOWING STAINED DEBRIS 4HE CLEANING SUCCESS OF THE USED FILES VARIED SIGNIFICANTLY WITH THE VARIOUS

PROTOCOLS BUT THE AUTHORS CONCLUDE THAT IT IS INDEED POSSIBLE TO RENDER ALL FILES MICROSCOPICALLY FREE OF DEBRIS 4HE RECOMMENDED PROTOCOL COMPRISED  VIGOROUS STROKES IN A SCOURING SPONGE SOAKED IN  CHLORHEXIDINE SOLUTION A  MINUTE PRE SOAK IN AN ENZYMATIC CLEANING SOLUTION  MINUTES OF ULTRASONICATION IN THE SAME SOLUTION A  SECOND RINSE IN RUNNING TAP WATER )N A BUSY PRIVATE PRACTICE IT WOULD BE EASY FOR INSTRUMENT CLEANING TO BE HURRIED )T IS SUGGESTED THAT THIS PROTOCOL SHOULD BE FOLLOWED ROUTINELY FOLLOWING FULL STAFF TRAINING 0ETER #ARROTTE LASGOW $ENTAL 3CHOOL .OVEMBER