If you’ve been practicing dentistry for any length of time, you’ve encountered your fair share of gaggers. It's a familiar situation: There you are working, and suddenly you see the patient’s tongue lift. Before you can say “pharyngeal reflex,” the patient is sputtering and choking nearly to the point of tears.
For clinicians, a patient’s 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, isn’t 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.
The biopsychology of gagging
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. VanArsdall notes that the correlation between dental anxiety and gagging in the 2014 JADA study warrants further investigation. “I’ve read that study, and it’s interesting because it’s a chicken-and-egg problem. The study authors mention in the article that they don’t know whether the fear causes the gagging or the other way around. A patient who didn’t previously have a gagging problem might have developed one after a bad dental experience—maybe the impression tray was overfilled and they felt like they couldn’t breathe. Or perhaps they had a predisposition toward gagging that had nothing to do with the dentist or hygienist.”
Dr. VanArsdall says that a patient’s 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 101
Mindfulness meditation is a specific type of meditation that emphasizes paying attention to one’s 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 one’s sense of self from one’s 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 it’s reasonable to hypothesize that mindfulness meditation may have an effect on gagging during dental appointments.
While there’s 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 haven’t 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.”
Mindfulness can be learned
Teaching mindfulness techniques in your practice doesn’t 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 aren’t amenable to sedation or whose insurance doesn’t 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.”
A simple starter exercise: Diaphragmatic breathing
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.”
There’s an app for that!
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 experience—which is something that every dental clinician can get behind.
- Bassi GS et al. The etiology and management of gagging: A review of the literature. J of Prosthet Dent. 2004;91(5):459-467.
- Randall CL et al. Gagging and its associations with dental care-related fear, fear of pain and beliefs about treatment. Journal Am Dent Assoc. 2014:145(5):452-458.
- Taren AA et al. Mindfulness meditation training alters stress-related amygdala resting state functional connectivity: A randomized clinical trial. Soc Cogn Affect Neur. 2015;10(12):1758-1768.
- Jon Kabat Zinn Me Me Me. You Tube website. https://www.youtube.com/watch?v=ULJSacYFzzQ&feature=emb_logo. Published May 28, 2015.
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.