Effect of aromatherapy with peppermint essential oil on the gag reflex: a randomized, placebo-controlled, single-blind, crossover study.

BACKGROUND: Sensitive gag reflexes prevent dental patients from receiving appropriate treatment. Aromatherapy helps patients relax during dental procedures. However, the effect of aromatherapy on the gag reflex caused by the stimulation of the oral cavity is unknown. This study aimed to evaluate whether aromatherapy reduces gag reflexes during oral stimulation. METHODS: In this randomized, placebo-controlled, single-blind, crossover study, the gag reflexes of 24 healthy individuals (12 females and 12 males; mean age: 34.3 ± 9.5 years) were quantified. A standard saliva ejector was slowly guided down the participant's throat to determine the maximum tolerance of the gag reflex, and the insertion distance was measured to quantify the gag reflex. All individuals participated in an aromatherapy session with peppermint essential oil and a placebo session with distilled water. The gag reflex was quantified before (baseline) and after each session. Another measurement was performed using nitrous oxide/oxygen inhalation as a positive control. RESULTS: Gag reflex values significantly increased after aromatherapy with both peppermint essential oil and placebo compared to baseline values (paired t-test, P < 0.001 and P = 0.014, respectively). The gag reflex value also increased significantly during nitrous oxide/oxygen inhalation (paired t-test, P < 0.001). There was no significant difference in the increase rate of gag reflex values between the positive control and aromatherapy interventions, but it was significantly lower after the placebo intervention (repeated measures analysis of variance, P = 0.003; post-hoc test, P = 0.83 and P = 0.02). CONCLUSION: Aromatherapy with peppermint essential oil has the potential for reducing gag reflex during dental procedures. TRIAL REGISTRATION: The study was registered in the University hospital Medical Information Network Clinical Trials Registry under the code UMIN000050616 (approved 17/03/2023).

Comparative evaluation of effect of microcurrent electrical stimulation on acupoints to control gag reflex in patients receiving prosthodontic treatment: An in vivo study.

Aims: The aim of this study is to see if microcurrent electrical stimulation on two acupoints, auricular and Hegus, can help patients prevent their gag reflex. Settings and Design: This was an in vivo cross-sectional study. Materials and Methods: Thirty patients were randomly assigned to three groups: A, B, or C, of ten patients present in each group. Group A and Group B undergone electroacupuncture (microcurrent electrical stimulation) using electroacupuncture device on auricular point and Hegus point (Li 4), respectively, for 1 min and Group C formed the placebo group, point Shou San Li (Li 10). The gag severity index and the gag prevention index were used to measure the gag reflex, which was done in two steps. Statistical Analysis Used: SPSS (SPSS Inc., Chicago IL, USA) version 24 software was used for statistical analysis. Paired t-test, one-way analysis of variance test, post hoc Bonferroni test was used to analyse and compare the data. Results: It was found that Point A and Point B were significantly effective in reducing the severity of gag reflex. Point C demonstrated insignificant results. In addition, Point B (Hegus [Li4]) is more effective than Point A (auricular) in controlling the gag reflex in patients within the set age group of 20-70 years of age. Conclusions: Microcurrent electrical stimulation is a useful adjuvant in the treatment of unfavorable gag reflexes during routine dental procedures. Point Hegus and point auricular acupuncture are both useful in decreasing the severity of gag reflex, with point Hegus being more effective than point auricular.

One- or two-operator techniques for oesophago-gastro-duodenoscopy in unsedated patients: A comparative prospective randomized study.

BACKGROUND: The standard oesophago-gastro-duodenoscopy procedure is performed with a single endoscopist (SE). Nurse-assisted (NA) oesophago-gastro-duodenoscopies have not yet been studied. We aimed to evaluate the efficacy of an NA endoscopy compared to an SE endoscopy. METHODS: A prospective, single-center, randomized trial, in which 500 adult patients were divided into two groups. In the first group, patients underwent an endoscopy with an SE. In the second group, the endoscopy was performed with an NA. The ease of the procedure (scores 1-4; 1 difficult, 2 satisfactory, 3 easy, 4 veryeasy), evaluation of patient satisfaction (scores 1-4; 1 uncomfortable, 2 satisfactory, 3 comfortable, 4 verycomfortable), total time of the procedure and vocal cord observation were determined as quality indicators. RESULTS: Mean patient satisfaction scores in groups 1 and 2 were 2.98±0.79 and 3.11±0.78, respectively (p=0.043), with uncomfortable ratings in 5.2% vs 4%, satisfactory in 16.8% vs 13.2%, comfortable in 53.2% vs 50.4%, and very comfortable in 24.8% vs 32.4% of patients in groups 1 and 2, respectively. Retching rates during the procedure were 54.4% and 45.2% (p=0.040) in groups 1 and 2, respectively. No differences were seen in vocal cord observation (54.4% vs 56.0%), total procedure time (2.35±1.56 vs 2.41±1.48min) and easy score (3.26±0.603 vs 3.25±0.64) in groups 1 and 2 for the procedures. Very easy, easy, satisfactory, and difficult ratings were given by 33.6% vs 34.8%, 60.4% vs 56.4%, 4.8% vs 7.6% and 1.2% vs 1.2% of groups 1 and 2, respectively. CONCLUSIONS: Compared with the conventional method, the assisted endoscopic technique provides more comfort and less gag reflex without increasing the processing time or difficulty of performing the procedure.

Reliability, validity, and sex differences in a quantitative gag reflex measurement method.

A reliable assessment method is required to manage the gag reflex. We tested the inter- and intra-examiner reliability and validity of a quantitative measurement method and evaluated the differences between sexes. This study included 21 healthy adults (10 women, 11 men; mean age, 27.1 ± 9.9 years). An examiner inserted a standard saliva ejector slowly down the participant's throat to determine the maximum tolerance of the gag reflex; the insertion depth was used as an index of gag reflex. The reflex was measured by one examiner during two sessions (S1 and S3) and by a second examiner during one session (S2) under the same conditions. The galvanic skin response (GSR) and heart rate (HR) were recorded during each session to test the method validity. Data were analysed using the intraclass correlation coefficient (ICC), paired t test, and two-way repeated-measures analysis of variance. The ICC of the gag reflex measurements was 0.91 between S1 and S2, and 0.93 between S1 and S3. The GSR and HR increased significantly after the maximum tolerance of the reflex in S1, S2, and S3 (GSR: P < 0.001, P = 0.004, P = 0.001, respectively; HR: all, P < 0.001). Differences in the measurements according to sex and session were not significant. Our method exhibited excellent inter- and intra-examiner reliability and was unaffected by the participants' sex. Measurement revealed significant autonomic reactivity, which is common for this reflex. Consequently, this method may be used in clinical and laboratory-based applications.

[A study to determine possible success variables in the treatment of gag reflex patients]. / Onderzoek naar mogelijke succesvariabelen bij de behandeling van kokhalspatiënten.

A disproportionately sensitive gag reflex can hamper adequate dental treatment. Because an evidence-based treatment for this condition is lacking at this moment, a study of patients and success variables for the treatment was carried out. The study was based on the clinical records of and interviews with 40 people who had been treated in a Centre for Special Dental Care (CBT) because of extreme gag problems two years earlier. It was found that the gag complaints of half of the respondents had disappeared or become manageable, while those of the other half had not changed. It did not matter which intervention had been adopted. In order to determine how patients can best be treated and which patients can best be treated, research among larger patient samples is needed.

Accuracy of a Laryngopharyngeal Endoscopic Esthesiometer (LPEER) for Evaluating Laryngopharyngeal Mechanosensitivity: A Validation Study in a Prospectively Recruited Cohort of Patients.

Recent studies have shown an association between alterations in laryngopharyngeal mechanosensitivity (LPMS) and dysphagia, obstructive sleep apnea, and chronic cough hypersensitivity syndrome. A previous reliability study of a new laryngopharyngeal endoscopic esthesiometer and rangefinder (LPEER) showed high intra- and inter-rater reliability; however, its accuracy has not been tested. We performed an accuracy study of the LPEER in a prospectively and consecutively recruited cohort of 118 patients at two tertiary care university hospitals. Most of the patients were suffering from dysphagia, and all of them underwent a standard clinical evaluation and fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) using a new sensory testing protocol. The sensory test included determinations of the laryngeal adductor reflex threshold (LART), the cough reflex threshold (CRT) and the gag reflex threshold (GRT). Abnormalities on these reflex thresholds were evaluated for associations with major alterations in swallowing safety (pharyngeal residues, penetration, and aspiration). We evaluated the discriminative capacity of the LPMS test using ROC curves and the area under the curve (AUC-ROC) and its relationship with the eight-point penetration-aspiration scale (PAS) using the Spearman's ρ correlation coefficient (SCC). We found a positive correlation between the PAS and LART (SCC 0.47; P < 0.001), CRT (SCC 0.46; P < 0.001) and GRT (SCC 0.34; P = 0.002). The AUC-ROC values for detecting a PAS ≥7 were as follows: LART, 0.83 (P < 0.0001); CRT, 0.79 (P < 0.0001); GRT, 0.72 (P < 0.0001). In this study, the LPEER showed good accuracy for evaluating LPMS. These results justify further validation studies in independent populations.

[Multidisciplinary treatment approach in a patient with a severe gag reflex]. / Multidisciplinaire aanpak bij een patiënt met een verhoogde kokhalsneiging.

A patient was referred to a centre for special care dentistry due to problems with a severe gag reflex and dental care-related anxiety. A regular treatment was started with gradual exposure in vivo in combination with breathing exercises, which involved the patient doing exercises at home. In addition, she was referred to an (external) speech therapist. During the treatment the patient suffered from pain in [molar] tooth 27 and a short-term solution was necessary. Regular treatment was not (yet) possible due to the existing severe gag reflex. Treatment with nitrous oxide was chosen to address the pain, in combination with the treatment that had already been started, so that the nitrous oxide could eventually be reduced again. Due in part to the patient's motivation and a multidisciplinary approach a good and stable result has been achieved.

Pharyngeal stimulus-induced reflexes are impaired in infants with perinatal asphyxia: Does maturation modify?

BACKGROUND: Development of pharyngo-esophageal protective reflexes among infants with hypoxic ischemic encephalopathy (HIE) is unclear. Our aim was to distinguish these reflexes from controls and examine the maturational changes in HIE infants. METHODS: We evaluated 14 HIE infants (seven males) at 41.4±0.6 (HIE Time-1) and 46.5±0.6 (HIE Time-2) weeks postmenstrual age (PMA). Seven controls (three males) were evaluated at 43.5±1.3 weeks PMA. Graded pharyngeal stimulation with liquids (0.1, 0.3, 0.5 mL in triplicate) concurrent with high-resolution manometry was used to analyze sensory-motor components of pharyngeal reflexive swallowing (PRS), upper esophageal sphincter (UES), contractile reflex (PUCR), and esophageal body characteristics. Linear mixed and generalized estimating equation models were used for comparison among groups. KEY RESULTS: Compared to controls, HIE infants (Time-1 and Time-2) exhibited decreased number of pharyngeal peaks and latency to terminal swallow. HIE Time-1 infants showed increased UES resting tone and distal latency, compared to controls and HIE Time-2. Contractile vigor was increasingly abnormal during maturation, compared to healthy controls. Threshold volumes and frequency distribution of primary responses (PRS: PUCR: None) were not significant among all groups. CONCLUSIONS & INFERENCES: Compared to controls, HIE infants display significant hypertonicity of skeletal muscle components, impairment of pharyngeal provocation-induced reflexes and smooth muscle contractile vigor, reflecting poor propagation with maturation. These mechanisms may be responsible for inadequate clearance of secretions, ascending refluxate, and oropharyngeal bolus in HIE infants.

Reliability of a laryngo-pharyngeal esthesiometer and a method for measuring laryngo-pharyngeal mechano-sensitivity in a prospectively recruited cohort of patients.

BACKGROUND: There are not reliable methods for measuring laryngo-pharyngeal mechano-sensitivity (LPMS). We aimed to determine the reliability of a new method for measuring LPMS using a new laryngo-pharyngeal esthesiometer (LPEER) in a prospective cohort of dysphagic stroke and non-dysphagic patients. The patients underwent clinical and endoscopic evaluations of swallowing (FESSST). The LPMS assessments consisted of measurements by an expert and a novel rater of the laryngeal-adductor reflex threshold (LART), cough reflex threshold (CRT) and gag reflex threshold (GRT) using the LPEER. We assessed the Bland-Altman limits of agreement, the intraclass correlation coefficients (ICCs) and Spearman correlation coefficients (SCCs). For the inter-rater comparisons, we contrasted the expert and novel raters. A total of 1608 measurements were obtained from 34 dysphagic stroke patients and 33 non-dysphagic patients. The intra-rater ICCs for all reflex thresholds were >0.90. The inter-rater ICCs were 0.87 for the LART, 0.79 for the CRT and 0.70 for the GRT. The intra-rater SCCs for all reflex thresholds were above 0.88 (P < 0.0001). The inter-rater SCC were 0.80 for the LART, 0.79 for the CRT and 0.70 for the GRT (all P < 0.0001). The Bland-Altman plots revealed good agreement for the LART and CRT and moderate agreement for the GRT. The median normal value was 0.14 mN for the LART, 4.4 mN for the CRT and 11.9 mN for the GRT. The median thresholds values in patients with aspiration were LART: 1.31 mN; CRT: 32.9 mN and GRT: 32.9 mN (all P < 0.006 vs normal thresholds). The LPEER exhibited substantial to excellent intra- and inter-rater reliability.

Extubation Failure in Brain-injured Patients: Risk Factors and Development of a Prediction Score in a Preliminary Prospective Cohort Study.

BACKGROUND: The decision to extubate brain-injured patients with residual impaired consciousness holds a high degree of uncertainty of success. The authors developed a pragmatic clinical score predictive of extubation failure in brain-injured patients. METHODS: One hundred and forty brain-injured patients were prospectively included after the first spontaneous breathing trial success. Assessment of multiparametric hemodynamic, respiratory, and neurologic functions was performed just before extubation. Extubation failure was defined as the need for ventilatory support during intensive care unit stay. Extubation failure within 48 h was also analyzed. Neurologic outcomes were recorded at 6 months. RESULTS: Extubation failure occurred in 43 (31%) patients with 31 (24%) within 48 h. Predictors of extubation failure consisted of upper-airway functions (cough, gag reflex, and deglutition) and neurologic status (Coma Recovery Scale-Revised visual subscale). From the odds ratios, a four-item predictive score was developed (area under the curve, 0.85; 95% CI, 0.77 to 0.92) and internally validated by bootstrap. Cutoff was determined with sensitivity of 92%, specificity of 50%, positive predictive value of 82%, and negative predictive value of 70% for extubation failure. Failure before and beyond 48 h shared similar risk factors. Low consciousness level patients were extubated with 85% probability of success providing the presence of at least two operating airway functions. CONCLUSIONS: A simplified clinical pragmatic score assessing cough, deglutition, gag reflex, and neurologic status was developed in a preliminary prospective cohort of brain-injured patients and was internally validated (bootstrapping). Extubation appears possible, providing functioning upper airways and irrespective of neurologic status. Clinical practice generalizability urgently needs external validation.

The Effect of Various Concentrations of Nitrous Oxide and Oxygen on the Hypersensitive Gag Reflex.

The purpose of this study was to compare the effectiveness of various concentrations of N2O/O2 on obtunding a hypersensitive gag reflex. We hypothesized that the administration of nitrous oxide and oxygen would obtund a hypersensitive gag reflex enough to allow a patient to tolerate the placement and holding of a digital x-ray sensor long enough to obtain a dental radiograph. Volunteers claiming to have a hypersensitive gag reflex were first screened to validate their claim and then tested by placing a size 2 digital x-ray sensor in the position for a periapical radiograph of the right mandibular molar area and holding it in place for 10 seconds. Subjects were first tested using room air only, then 30%, 50%, or 70% nitrous oxide until they were able to tolerate the sensor without gagging or discomfort. A visual analog scale was used for subjective responses, and other statistical tests were used to analyze the results. We found that for some subjects, 30% nitrous oxide was sufficient; for others, 50% was needed; and for the remainder of the subjects, 70% was sufficient to tolerate the test. Using a combination of 70% nitrous oxide and 30% oxygen allowed all patients claiming to have a hypersensitive gag reflex to tolerate the placement and holding of a digital x-ray sensor long enough to take a periapical radiograph.

Overlap between dental anxiety, gagging and Blood-Injection-Injury related fears - A spectrum of one multidimensional phenomenon.

BACKGROUND AND OBJECTIVES: Dental anxiety (DA) and gagging (GAG) are prevalent problems that severely impact social behavior and quality of life. Furthermore, because dental phobia is considered a Blood-Injection-Injury (B-I-I) phobia, the present study contrasted DA, GAG and control subjects regarding the severity of dental anxiety and investigated the comorbidity of GAG, DA and B-I-I fears. METHODS: Demographics, Verbal Pain Scale (VPS), Oral Health Impact Profile-14 (OHIP-14), Decay, Missing and Filled Teeth (DMFT), Dental Anxiety Scale (DAS) and response to phobic stimuli were collected from 53 GAG, 68 DA and 80 control subjects. RESULTS: GAGs exhibited results between DA and controls regarding the likelihood to have high-anxiety/phobia (DA group: OR=55.56; GAG group: OR=17.24), self-assessed dental anxiety (OR=29.14; OR=17.48), fear of dental injections (OR=8.51; OR=2.91) and dental drills (OR=12.02; OR=5.82). DA and GAG had similar results regarding: DAS score (p=0.13), fear of blood tests (OR=4.68; OR=4.09) and blood donations (OR=3.13; OR=3.10). Overlap between GAG, DA and a B-I-I fear was observed. GAG and DA patients and worse maximal VPS and OHIP-14 scores retained their significant positive association with the DAS score in the multivariate analysis. CONCLUSIONS: The co-occurrence of DA, GAG and B-I-I-related fears suggests these entities are linked. However, different anxiety levels, symptoms and triggers, reflect the broad spectrum of fear of medical/dental situations.

A Case of Mediastimal Emphysema Possibly Caused by the Insertion of a Laryngoscope.

Insertion of a laryngoscope to a patient with a strong pharyngeal reflex resulted in pharyngeal injury and subsequent development of mediastinal emphysema. An increase in airway pressure accompanying a strong pharyngeal reflex, as well as pharyngeal injury were thought to be factors associated with the development of mediastinal emphysema.

Autonomic nervous activity of patients with gagging problems during dental mirror insertion.

OBJECTIVE: To investigate autonomic nervous activities in patients with gagging problem. METHODS: Subjects were 12 and 12 individuals, graded as Group G2 (mild gagging problem) and Group G3 (middle gagging problem), respectively, according to the Classification of Gagging Problem index (CGP) and compared with 15 normal patients. Heart rate (HR), low-frequency/high-frequency ratio (L/H), the coefficient of component variation for high frequency (CCVHF), and the coefficient of variation of R-R intervals (CVRR) were assessed by heart rate variability on electrocardiogram. The measurement was recorded continuously for 1 min before and after dental mirror insertion. RESULTS: The insertion did not affect HR, L/H, CCVH, and CVRR in Group G2. HR did not change despite both increases in L/H and CCVHF after the insertion in Group G3. CONCLUSIONS: Patients with a gagging problem in G3, dental mirror insertion increased both parasympathetic and sympathetic nervous activities, despite no change in HR.

Effects of birth asphyxia on the modulation of pharyngeal provocation-induced adaptive reflexes.

Perinatal asphyxia and aerodigestive symptoms are troublesome. We tested the hypothesis that pharyngeal provocation alters proximal and distal aerodigestive reflex coordination and kinetics in infants with hypoxic ischemic encephalopathy (HIE), compared with healthy controls. Specifically, we characterized the sensory-motor properties of pharyngeal provocation-induced effects on upper esophageal sphincter (UES) and lower esophageal sphincter (LES) reflexes. Ten orally fed controls (32.0 ± 1.5 wk gestation) and 25 infants with HIE (38.1 ± 0.4 wk gestation) were evaluated at 39.7 ± 0.9 and 41.9 ± 0.6 wk postmenstrual age respectively. Pharyngo-esophageal reflexes evoked upon graded water stimuli were tested using water-perfusion micromanometry methods. Analysis included sensory-motor characteristics of pharyngeal reflexive swallow (PRS), pharyngo-UES-contractile reflex (PUCR), esophageal body-waveform kinetics, and pharyngo-LES-relaxation reflex (PLESRR). For controls vs. infants with HIE, median appearance, pulse, grimace, activity, respiration (APGAR) scores were 6 vs. 1 at 1 min (P < 0.001) and 8 vs. 3 at 5 min (P < 0.001). Upon pharyngeal- stimulation, HIE infants (vs. controls) had frequent PUCR (P = 0.01); increased UES basal tone (P = 0.03); decreased LES basal tone (P = 0.002); increased pharyngeal-waveforms per stimulus (P = 0.03); decreased frequency of LES relaxation (P = 0.003); and decreased proximal esophageal contractile amplitude (P = 0.002), with prolonged proximal esophageal contractile duration (P = 0.008). Increased tonicity and reactivity of the UES and dysregulation of LES may provide the pathophysiological basis for pooling of secretions, improper bolus clearance, and aspiration risk. Deficits in function at the nuclear or supranuclear level involving glossopharyngeal and vagal neural networks and respiratory regulatory pathways involved with aerodigestive protection may be contributory.

Oral Health Related Quality of Life in Young Individuals with Dental Anxiety and Exaggerated Gag Reflex.

PURPOSE: To measure the oral health-related quality of life (OHRQoL) among young individuals presenting with dental anxiety and exaggerated gag reflex and to compare it to the OHRQoL among young individuals attending restorative dental treatment. MATERIALS AND METHODS: Patients with dental anxiety and/or exaggerated gag reflex who were referred to the Department of Oral Medicine were included. Clinical examinations included DMFT index (Decayed, Missing and Filled Teeth) according to the WHO criteria and oral hygiene was assessed with the plaque index (PI). The survey included the validated Hebrew version of the Oral Health Impact Profile (OHIP-14). RESULTS: Overall, 322 patients completed the study. The dental anxiety group consisted of 68 patients, the exaggerated gag reflex group of 54 patients and the control group of 200 patients. Control group patients presented with lower PI and DMFT values. Patients with dental anxiety and/or exaggerated gag exhibited worse OHIP-14 scores overall as well as on each separate subscale. PI and DMFT were found to be in strong relation to the OHIP-14. Multivariable logistic regression analysis of factors influencing the OHIP-14 scores revealed a significant influence of the DMFT score. CONCLUSIONS: Patients with dental anxiety and exaggerated gag reflex were shown to suffer considerably from impaired oral health-related quality of life. This impairment may be attributed to a higher prevalence of caries and avoidance of dental treatment. Those populations should be identified and monitored carefully as well as encouraged to seek the appropriate behavioural treatment in order to improve their dental heath and oral health related quality of life.

Self-reported gagging in dentistry: prevalence, psycho-social correlates and oral health.

Although gagging has a profound effect on the delivery of dental care, it is a relatively under-investigated phenomenon. This study aimed to derive a prevalence estimate of gagging during dental treatment based on patient-reported information, to determine some socio-demographic and psychological correlates and to assess the relationship of gagging with self-reported oral health and avoidance of dental care. Data were collected with a survey among Dutch twin families (n = 11 771). Estimated overall prevalence of gagging during dental treatment was 8·2% (95% CI 7·7-8·7). Patients' self-report of gagging was found to be significantly associated with female sex, a lower level of education and higher levels of dental trait anxiety, gagging-related fears (e.g. fear of objects in the mouth), anxious depression and neuroticism. Gagging also appeared to be significantly associated with untreated cavities, gingival bleeding and wearing full dentures, but not with avoidance of dental care. It can be concluded that individuals who report to gag during dental treatment are moderately dentally anxious, fear-specific situations that can trigger a gagging response and, albeit visiting the dentist equally frequently, report to have a poorer oral health compared to those who do not gag.