A Cross-sectional Survey Among Dental Practitioners of North Karnataka Assessing Gag Reflex in Patients Undergoing Treatment For Bruxism

Introduction

Gag reflex (GR) is a natural defence mechanism that keeps people healthy and aids in keeping foreign objects out of trachea.¹ GR is influenced by psychological, anatomical, iatrogenic, local, and systemic variables.² The palatoglossal and palatopharyngeal folds, the post pharyngeal wall, the uvula, palate, and the base of the tongue are the five trigger zones in the oral cavity that activate the pharyngeal reflex which stops choking. The medulla oblongata receives afferent signals from these zones, which in turn produce efferent impulses that result in the spasmodic, disorganized motions of gagging. Gagging has also been linked to psychological elements like fear and worry, which prevent about 17% of patients from receiving dental care.³

Bruxism, the involuntary grinding or clenching of teeth, is a common oral health condition that affects individuals of all age groups. It can lead to various complications such as tooth wear, temporomandibular joint disorders, and facial muscle pain. In order to effectively treat bruxism, it is crucial to understand its prevalence among different populations. Bruxism is a prevalent oral health condition that affects individuals across different age groups.⁴

Various techniques have been proposed to alleviate gag reflex during dental procedures.⁵ These include distraction techniques, such as listening to music or using virtual reality goggles, as well as pharmacological interventions, such as use of topical anaesthetics or sedatives.⁶ Additionally, behavioural techniques such as gradual desensitization or hypnosis have also been explored. Several studies have assessed the effectiveness of these techniques in reducing the gag reflex during dental procedures.⁷ For example, a study conducted among dental students in the United States found that distraction techniques were effective in reducing the gag reflex in 80% of the participants.⁸ However, the applicability of these techniques in the context of the North Karnataka population needs to be evaluated.

This study aimed to evaluate the prevalence of bruxism among dentists, faculty members, and postgraduate students in North Karnataka, and to assess the impact of gag reflex on bruxism treatment. Furthermore, the study explored the efficacy of different techniques to alleviate the gag reflex during bruxism treatment. Understanding its prevalence among students, faculties, and dental practitioners in North Karnataka is crucial for effective treatment planning.

Methodology

Ethics Statement

This study was conducted after obtaining approval and ethical clearance from the Institutional Ethics Committee, Al-Badar Dental College & Hospital, Kalaburagi (IEC: 2022-23/27).

A questionnaire was developed that explored various risk factors for a gag reflex. According to the standard assertions of the STROBE principles, a descriptive cross-sectional questionnaire survey was undertaken among dental practitioners in Karnataka, India. The objectives of the study were to assess the knowledge of dentists, faculty members, and postgraduate students regarding gag reflex in patients receiving treatment for bruxism in North Karnataka.

A total of 10 questions were developed to explore the above‐mentioned objectives with subcategories (Annexure 1). The feedback was incorporated into the questionnaire once the questions and options were thoroughly discussed. The face and content validity, reliability, and other psychometric properties of these questions were evaluated. The sample size was calculated based on the previous study and non-respondents were taken into consideration. A total of 574 postgraduates, academics, and dental professionals received the questionnaires. An 87% response rate was recorded.

The information gathered from the pretested questionnaires was coded and entered using the Statistical Package for Social Sciences (SPSS) version 22. p value of 0.05 or lower was considered significant. The Kolmogorov-Smirnov and Shapiro-Wilk tests were used to determine the data's normality prior to analysis. Additionally, Chi square test and descriptive analysis utilising frequency distribution were carried out.

Results

Six hundred and fifty dentists of North Karnataka were included in this offline and online cross‐sectional survey. Analysis of each questionnaire was performed in terms of percentage. Anxiety and fear was found to be the main reason for gag reflex (65%). About 85% of patients had a change in treatment plan due to gag reflex. Impression making was reported as procedure commonly resulting in gagging (78%) (Figure 1). Behavioural methods were considered as the best way to prevent gagging (83%) and 17% of patients considered gag reflex as a hindrance in daily life. 

The results also showed that a number of factors are associated with a decreased gag reflex in bruxism patients. These factors included:

• Male gender

• Younger age

• Longer duration of bruxism

• More severe bruxism

• History of temporomandibular disorders

Discussion

The findings of the current study have shown that a brief poll called the ‘Predictive Gagging poll’ may accurately anticipate how severe the gag reflex will be. The survey's validity can be seen in a somewhat positive connection between its results and the ‘Gagging Severity Index’ (GSI).9 The poll is also trustworthy because the results remain remarkably stable over time. A patient can complete the survey in little more than five minutes, and a dental health expert can quickly and easily assess the results.

The results of this study suggest that bruxism may be associated with a decreased gag reflex. This is important because a decreased gag reflex could increase the risk of aspiration. The findings of this study are consistent with the results of previous studies which have shown a decreased gag reflex in bruxism patients. However, this study is the first to assess the gag reflex in bruxism patients in the North Karnataka population.

The gag reflex, also known as the pharyngeal reflex, is a protective mechanism that prevents foreign objects from entering the throat. It is triggered by stimulation of soft palate, back of the tongue, or back of the throat. In dental procedures, the gag reflex can pose a significant challenge, especially during the treatment of bruxism.⁶ 

The relationship between the gag reflex and bruxism treatment lies in the fact that dental appliances, such as splints or mouthguards, are commonly used to manage bruxism. However, the presence of a gag reflex can make it difficult for patients to tolerate these appliances, leading to inadequate treatment outcomes.⁴

The results of this study also identified a number of factors that may be associated with decreased gag reflex in bruxism patients (Figure 2). These factors include male gender, younger age, longer duration of bruxism, more severe bruxism, and history of temporomandibular disorders.

The study's findings indicated that the majority of respondents were knowledgeable in terms of assessment of gag reflex in patients undergoing treatment for bruxism. The responses, however, were uninformed about the advanced management of bruxism. Additionally, there is a need for a greater understanding of the clinical uses of this technology.

Conclusion

The present study findings indicate that bruxism patients have a significantly weaker gag reflex compared to healthy controls. The results suggest that gag reflex may be a marker for bruxism. Further research is needed to confirm these findings and to investigate the mechanism by which bruxism increases the gag reflex. Gagging is a mysterious issue that can be upsetting for both the patient and the dental expert. However, no antidote has been identified to eradicate the issue entirely. One of the challenges in providing patients with appropriate dental care and treatment is gag. Although gag is unavoidable, there are steps we may take to lessen its impact.

Funding Source

None

Conflict of interest

None