If youve been practicing dentistry for any length of time, youve encountered your fair share of gaggers. It's a familiar situation: There you are working, and suddenly you see the patients tongue lift. Before you can say pharyngeal reflex, the patient is sputtering and choking nearly to the point of tears.

For clinicians, a patients strong gag reflex means longer appointment times and more treatment challenges. But to the patient, gagging is a potential barrier to care. In fact, a 2004 literature review found that frequent gaggers are more likely to postpone dental care than nongaggers.1

Gagging, however, isnt just a physiological problem. There is also a psychological component. According to a 2014 research paper in the Journal of the American Dental Association, a survey of 478 dental patients found that 50% had gagged at least once during a dental visit.2 Moreover, 7.5% reported gagging during every or almost every appointment. The survey also found that frequent gaggers were more likely to report higher levels of dental anxiety than nongaggers.

Clinicians who want to create a better experiences for gaggers and eliminate barriers to care have several options at their disposal, ranging from sedation to desensitization. But one little-used strategy could also be the easiest to implement: mindfulness meditation. In fact, teaching patients just a few simple mindfulness exercises could be the difference between a dreaded appointment and effective treatment.

Pam VanArsdall, DMD, MPH, is a dentist by trade and a former academic dean at the University of Kentucky College of Dentistry. She is also a mindfulness instructor certified in Koru Mindfulness, an evidence-based mindfulness curriculum developed by psychiatrists at Duke University. Dr. VanArsdall says that while anatomical variability in the sizes and locations of the glossopharyngeal, vagus, and trigeminal nerves can contribute to a stronger gag reflex, not all instances of gagging have purely physiological causes.

Dr. Pam VanArsdallThere are two components [to gagging], she says. Anatomic variation and systemic physical disorders like sinusitis can play a role, but there are also psychological factors like anxiety.

Dr. VanArsdall notes that the correlation between dental anxiety and gagging in the 2014 JADA study warrants further investigation. Ive read that study, and its interesting because its a chicken-and-egg problem. The study authors mention in the article that they dont know whether the fear causes the gagging or the other way around. A patient who didnt previously have a gagging problem might have developed one after a bad dental experiencemaybe the impression tray was overfilled and they felt like they couldnt breathe. Or perhaps they had a predisposition toward gagging that had nothing to do with the dentist or hygienist.

Dr. VanArsdall says that a patients strong gag reflex can pose a variety of challenges. A patient with even a mild gagging problem may make it more difficult to take x-rays, for instance. Depending on the severity of the gag reflex, the appointment may run longer than scheduled...or need to be cancelled partway through. Some patients, she says, have such a severe gag reflex that they may vomit mid-appointment, which can compromise the sterile environment.

Mindfulness meditation is a specific type of meditation that emphasizes paying attention to ones current environment without attaching emotional meanings or passing judgments on the events that are happening. The goal of mindfulness meditation is to induce a change in brain activity that creates a sense of relaxed focus and separates ones sense of self from ones thoughts and emotions.

Jon Kabat-Zinn is the inventor of Mindfulness-Based Stress Reduction and a former Professor of Medicine at the University of Massachusetts Medical School. Kabat-Zinn defines mindfulness this way: Mindfulness is the awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally.4

Mindfulness meditation is also an effective means of reducing stress and changing the brain structures responsible for creating the feeling of anxiety. One 2015 randomized clinical trial found that a three-day mindfulness meditation training intervention caused a statistically significant reduction in the size of the right amygdala, the brain structure that coordinates the stress response.3 This change was also correlated with reduced levels of cortisol and cortisone in participants hair and a reduction in participants self-report scores for perceived stress. Control subjects who participated in a nonmindfulness stress-reduction program did not see similar changes.

For patients who are not amenable to sedation, mindfulness meditation could potentially be an effective tactic for combatting a strong gag reflex. If frequent gagging is correlated with higher levels of dental anxiety, and if mindfulness meditation reduces stress and anxiety as Taren et al. found, then its reasonable to hypothesize that mindfulness meditation may have an effect on gagging during dental appointments.

While theres currently no research on the books to either establish or refute a direct causal link between meditation and reduced gagging, Dr. VanArsdall says that some patients may be amenable to mindfulness meditation.

There havent really been any studies on whether mindfulness can reduce gagging. It would definitely be an interesting study to conduct. But we do know that different strategies work for different patients. A mindfulness exercise could be helpful for mild gagging during an x-ray, but it takes practice.

Teaching mindfulness techniques in your practice doesnt have to be time-consuming or challenging. Resources from organizations such as the University of Massachusetts Center for Mindfulness in Medicine, Health Care, and Society, or even tools like Headspace and Calm.com, can provide you with easy-to-teach mindfulness strategies that patients can start using immediately. While not all patients will benefit from mindfulness techniques, it could be an effective strategy for those who arent amenable to sedation or whose insurance doesnt cover sedation.

There are strategies (like mindfulness meditation) that could be helpful for patients, strategies that are less risky and less expensive than sedation, Dr. VanArsdall says. It goes back to whether the patient is open to trying new things.

Dr. VanArsdall says the easiest in-chair mindfulness exercise to start with is diaphragmatic breathing. Ask the patient to place one hand on the chest and one hand on the stomach, and then close the eyes and breathe into the stomach.

Once the patient has a handle on diaphragmatic breathing, they can slowly count silently to three or four on the inhale and exhale. This can be hard for some people. The key is to encourage patients not to be hard on themselves and to approach the breathing in a non-judgmental way.

A smartphone app is an easy way to introduce patients to mindfulness meditation. Insight Timer is a freemium app for Apple and Android devices that offers guided meditations ranging in length from three minutes to three hours. Offline listening is only available with the paid version, but your patients can listen to any one of 28,000 free meditations when their mobile devices are connected to your office WiFi network.

Much like teaching proper flossing technique, mindfulness exercises could be an effective part of patient education that could help patients to have a more positive experience during appointments. More research is needed to investigate whether mindfulness meditation could resolve the gag reflex, but the available data suggests that, at the very least, it can help anxious patients relax and create a calmer, more peaceful in-chair experiencewhich is something that every dental clinician can get behind.

References

Mike Straus is a freelance medical and dental writer based in western Canada. He holds a Toronto Star Award for journalism, and his work has been published in Nutritional Outlook, Canadian Chiropractor, Grow Opportunity, and Massage Therapy Canada.

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Resolving the gag reflex with...meditation? - Dentistry IQ