Use of Acupuncture in Controlling Gag Reflex in Completely Edentulous Patients: A Systematic Review

Aravind Kalambettu¹, Nagaraj E², Abby Abraham³, Dhanraj M Ganapathy⁴, Rony T Kondody⁵

¹Department of Prosthodontics, SRM Dental College and Hospitals, Chennai.

²Department of Prosthodontics, PMNM Dental College and Hospitals, Bagalkot.

³Department of Prosthodontics, Saveetha Dental College and Hospitals, Chennai.

⁴Department of Prosthodontics, Saveetha Dental College and Hospitals, Chennai.

⁵Department of Orthodontics at Sri Rajiv Gandhi College of Dental Sciences, Bangalore.

*Corresponding Author E-mail: aravindbhat29@gmail.com, dr_nagaraj_e@yahoo.co.in, drabbyabraham@gmail.com, dhanrajmganapathy@yahoo.co.in, ronykondody55@gmail.com

ABSTRACT:

A systematic search on the use of acupuncture in controlling gag reflex in completely edentulous patients was done on the PubMed databases.  A hand search was also performed in the Journal of Acupuncture and Meridian Studies, American Journal of Acupuncture from Jan 1965 to August 2019. The articles acquired from the above-mentioned databases were manually analyzed according to the pre-set inclusion and exclusion criteria independently. From the search results, four studies fulfilled the inclusion/exclusion criteria and were included in this review. There was a significant risk of bias and factual errors in the included studies. There was significant heterogeneity among the included studies and so a meta-analysis could not be done. Although the results showed a Cochrane review on gag reflex for patients undergoing dental treatment, it included very few completely edentulous patients. From the analysis of the articles included in this review, it was noted that there is insufficient evidence to recommend the use of acupuncture to control the gag reflex in completely edentulous patients. From the study, it could be concluded that completely edentulous geriatric patients, invariably present co-morbidity factors which would influence any medical or dental intervention. Considerable variation was observed in the protocols of the studies included in this review and the outcome measures. Further research is required to determine the effectiveness of acupuncture in controlling gag reflex in completely edentulous patients.

KEYWORDS: Acupuncture, Completely edentulous, Gag reflex, Systematic review.

INTRODUCTION: 

An exaggerated gag reflex is a hindrance to dental procedures. In such cases, any therapeutic procedure will be clinically challenging, both for the dentist who is unable to perform quality work and for the patient who is unable to overcome the sensation, thus rendering the procedure difficult or sometimes even impossible. Dental procedures such as obtaining maxillary and mandibular impressions, recording the posterior vibrating line for complete dentures, intra-oral tracing, and bite registration procedures in these patients would be a challenge even for the experienced dentist.

Gagging in patients with an exaggerated gag reflex could be triggered even during routine dental examinations such as the dentist’s fingers or instruments contacting the oral mucosa¹.

Gag reflex, which is an inborn reflex, is believed to progressively regress during the child’s first four years of life². With the appearance of the first dentition, the trigger for this reflex shifts more posterior, usually located at the tonsillar pillars³.

Management of patients with gag reflex:

The initial step in the management of these patients involves reducing their anxiety and helping them unlearn the behaviour that leads to gag reflex. Strategies to overcome gag reflex in treatment have focussed on behavioural management using systemic desensitization and distraction methods⁴. However, some patients would have severe retching when these methods do not work. In such patients, management through the use of pharmaceutical drugs has proved successful⁵.

During a gag reflex, neural impulses from receptors at the soft palate and posterior part of the tongue are transferred to the central nervous system in the medulla oblongata by afferent nerves. They are then transferred to the muscles involved in gagging by the vagus nerve and lead to muscular contractions⁶. Various reasons have been proposed as the aetiology for the severe gag reflex. In a review article, Bassi⁷ classified the causes of gag reflex into iatrogenic factors, systemic disorders, and psychological disorders.

Appropriate management of severe gag reflex is of considerable importance for the successful dental treatment outcome⁸. Although numerous studies have been carried out on controlling severe gag reflex during dental procedures, there has been no study on the problem of gagging in treating completely edentulous patients. Since completely edentulous patients are predominantly geriatric patients are different from other dentate patients. Several of these geriatric patients additionally have systemic disorders such as diabetes and hypertension and their associated side effects such as peripheral neuropathy⁹. Treatment of geriatric edentulous patients can also be complicated in the case of arthritis involving TMJ. These patients would respond differently to the various gag management techniques that have been demonstrated to provide positive results in another group of dental patients. It has also been reported that the gag reflex could be reduced in elderly patients¹⁰.

Etiology of gaging:

Gagging may be induced by either physical stimuli or psychological stimuli. The four factors that are believed to be important in the etiology of gagging include local and systemic disorders, anatomic factors, psychological factors (classical and operant conditioning), and iatrogenic factors⁷.

Locally, the gag reflex is triggered by mainly five types of stimuli. 1. Acoustic stimuli; 2. Olfactory/taste stimuli; 3. Visual stimuli; 4. Mechanical stimuli; 5. Psychic stimuli¹¹.

Gagging Severity index: 

Based on the severity a Gagging Severity Index (GSI) was proposed¹².

· Grade I (Normal gagging reflex)

· Grade II (Mild gagging)

· Grade III (Moderate gagging)   

· Grade IV (Severe gagging)

· Grade V (Very severe gagging)

The gagging severity may be assessed by using either the Gagging Problem Assessment Questionnaire¹³ or the visual analog scale using the swab insertion method¹⁴.

In patients with a severe gag reflex, it is recommended to first reduce the patient’s psychological stimuli to the maximum extent possible. Since the gag reflex is governed by the parasympathetic nervous system, drugs that selectively depress the parasympathetic have also been successfully tried. The other techniques that have been tried include acupressure and sedatives^4,5,15.

Different techniques advocated for the control of exaggerated gag reflex:

The management strategies to prevent gagging include pharmacological and non-pharmacological techniques. Prashanthi et al¹¹ have dealt in detail with all the interventions for controlling gag reflex. They are mentioned here for the sake of completeness.

The pharmacological interventions include topical and local anaesthetics which act either on the peripheral or central nervous system^16-19,5. The non-pharmacological interventions include behavioural modification, acupressure, acupuncture, transcutaneous electric nerve stimulation (TENS), application of salt on the tip of the tongue, prosthetic devices, and earplug technique^{7, 20, 21}.

Acupuncture:

Acupuncture is a branch of Chinese medicine that, in addition to controlling pain and gag reflex, is used to treat many diseases. Acupuncture at P6 point particularly is effective for anti-emesis^22,23.

Aim and Objectives:

Aim of the review:

There is a wide range of methods described for the management of a gagging patient in dental practice. A systematic review of the use of acupuncture in controlling gag reflex in completely edentulous patients is necessary to highlight the evidence of its effects in the successful management of such patients in the clinic.

Primary Objective:

To determine the effectiveness of acupuncture in controlling gag reflex in completely edentulous patients

Secondary Objective:

To compare the effectiveness of acupuncture technique over various other techniques reported in the literature to control gag reflex in completely edentulous patients.

Structured Question:

Is there a difference in the efficiency of controlling gag reflex in completely edentulous patients between the different techniques and methods?

Methods:

The PICO for the review was framed and appropriate search terms were shortlisted. The search terms were used in the PUBMED search engine to obtain relevant results. The literature search was performed by two researchers working independently using the selection criteria and their results were compared. The titles that were agreed upon by both the researchers as being relevant to the study alone were included and the rest discarded.

PICO:

Population: Edentulous patients

Intervention: Acupuncture

Comparison: Placebo, pharmacological agents, and behavioural management

Outcome: Gag reflex, Visual Analogue scale, hypersensitivity, increase in severity, decrease in severity

Inclusion and exclusion criteria:

Inclusion criteria:

1. People above the age of four.

2. Completely edentulous patients.

3. Patients with an exaggerated gag reflex.

4. The dental treatment of the patient is hampered because of the gag reflex.

Exclusion criteria:

1.   People who have undergone an intervention that can change the anatomy permanently (e.g. surgery).

2.   People using any systemic medications that might interfere with the interventional drug or affect the gag reflex.

3.   People with any type of central or peripheral nervous system disorder.

Types of interventions:

· Any intervention versus placebo or no treatment.

· Head-to-head comparisons and comparisons of different doses of the same drug.

· All routes of drug administration or modes of application.

Search Strategy:

The search strategy included searching the PubMed database from January 1965 to August 2019. The studies included in the review were randomized controlled trials, which were either single-blinded or double-blinded studies, case reports, and case series. All other studies were excluded from the study. A hand search was also performed in the Journal of Acupuncture and Meridian Studies, American Journal of Acupuncture, and British Dental Journal. This research was supplemented by cross-checking the reference lists of the selected studies and review articles to locate additional papers that could meet the eligibility criteria fixed for this study. The database was searched using the following terms:

Search Results:

Table 1. Results of some articles obtained through systematic search using relevant queries in PUBMED

Search	Query	Items found
#69	Search (Edentulous patient) OR edentulous patients) OR denture) OR dentures) OR old patients) OR old patient) OR denture wearer) OR denture wearers) OR impression) OR impressions) OR complete denture impression) OR complete denture impressions)) AND (accupuncture) OR acupuncture) OR acupressure) OR electro acupuncture) OR electroacupuncture) OR pressure points)) AND (placebo) OR pharmacological agents) OR pharmacological agent) OR local anesthetic) OR local anesthetics) OR local anaesthetic) OR local anaesthetics) OR lignocaine) OR LOX) OR amides) OR esters) OR behavioural modification) OR antihistamines) OR sedatives) OR tranquilizers) OR parasympatholytics) OR CNS depressants) OR general anesthesia) OR laser stimulation) OR prosthetic management) OR palateless dentures) OR reducing extension of dentures) OR custom bar overdenture) OR training devices)) AND ((((((((((((((gag reflex) OR Visual Analouge scale) OR visual analogue scale) OR Improvement in gagging severity) OR reduction in gagging) OR Increased gag reflex) OR decreased gag reflex) OR adverse drug reaction) OR allergy) OR adverse reaction) OR hypersensitivity) OR sensitization) OR sensitivity) OR immune reaction)) AND (clinical trials) OR randomised controlled trials) OR blinded study) OR single blinded study) OR double blinded study) OR case report) OR case series)	17

Selection of studies:

The review process consists of two phases. In the first phase, titles and abstracts of the search were initially screened for relevance and the full text of relevant abstracts was obtained and accessed. The hand search of the selected studies, as well as the search of references in the selected studies, was also done. The articles that were obtained after the first step of the review process using the inclusion and exclusion criteria were screened in the second phase and relevant and suitable articles were isolated for further processing and data extraction.

Data Extraction:

The data from the finally included studies were tabulated and the following information was extracted:

· Study Design applied.

· The type of technique used.

· The total number of techniques compared with.

· Methods of evaluating the efficacy/efficiency of the treatment technique.

· The statistical test is done.

      The data were synthesized and summarized by two reviewers independently. They were then compared and analyzed after which the extracted data were included for the review.

Flow Chart For Search Strategy

Figure 1: Flow chart describing the search strategy for the related articles

RESULTS:

Table 2 shows the details about the selected articles having variables of interest. The following information was extracted and tabulated; the name of the author, study design, Treatment method used, statistical analysis done.

S. No	Author	Journal/ Year of Publication	Study Design	Gag Reflex control method	Sample size	Procedure done	Statistical Data
1	Fiske and Dickinson	2001/British Dental Journal	Case series	Acupuncture	10	Ear Acupuncture – Dental treatment	Mean
2	Zotelli VLR, Grillo	2014/Journal of Acupuncture	Case control study	Acupuncture	33	Acupuncture at PC6. Outcome evaluated using VAS and GSI/GPI	Spearman Correlation
3	Rosted et al	2005/British Dental Journal	Audit study	Acupuncture	37	Acupuncture at CV 24.  Outcome evaluated using GSI/GPI	Wilcoxon signed rank test
4	Sari and Sari	2010/British Dental Journal	Outcomes Research	Laser stimulation and Acupuncture	45	GSI and GPI	Wilcoxon signed rank test and Spearman rank Correlation

Table 3 Describes the reasons for excluded articles, in this name of the author, the study design and reasons for excluded articles were specified

S. No	Name of the author/year	Study design	Reasons for exclusion
1.	Mata J, et al (2015)	Clinical Trial	Title and abstract not pertaining to the selected topic
2.	Rodríguez C et al (2015)	Case report	Title and abstract not pertaining to the selected topic
3.	Handa T, Fukuda K, Ichinohe T.	Case report	Describes a technique to control pain
4.	Ding et al (2013)	Clinical Trial	Used acupuncture in Cholesystectomy patients
5.	Lee S et al (2013)	Randomized controlled pilot trial	Used electroacupuncture to treat diabetic neuropathy
6.	Que et al (2013)	Randomized controlled trial	Used acupuncture to treat neck pain
7.	Sultan SJ, Sameem F. (2012)	Case report	Title and abstract not pertaining to the selected topic
8.	Saito et al (2012)	Randomized controlled trial)	Title and abstract not pertaining to the selected topic
9.	Penza et al (2011)	Clinical Trial	Study on use of electroacupuncture in chronic neuropathies
10.	Panagopoulou et al (2011)	Prospective, randomized, double-blinded study. Clinical Trial	Study done for cholecystectomy patients
11.	Su et al (2002)	Case report	Title and abstract not pertaining to the selected topic
12.	Karst et al (2001)	Randomized, Placebo controlled trial	Acupuncture was used to treat tension type Headache
13.	Souche et al (1991)	Clinical Trial	Study on anti-depressants to treat resistant depression
14.	Andrien P, Lemberg L. (1986)	Case report	Title and abstract not related to selected topic
15.	Martelete M, Fiori AM (1985)	Clinical Trial	Compared the analgesic effect of transcutaneous nerve stimulation (TNS); electroacupuncture (EA) and meperidine in the treatment of postoperative pain

Table 4 Shows the CEBM evidence level of selected articles.

S. No.	Author Name	Year of Publication/Journal	Study Design	Level of Evidence
1.	J. Fiske, and C. Dickinson	2001/British Dental Journal	Case series	4
2.	Zotelli VLR, Grillo	2014/Journal of Acupuncture	Case control study	3b
3.	Rosted et al	2005/British Dental Journal	Audit study	2c
4.	Sari and Sari	2010/British Dental Journal	Outcomes Research	2c

Synthesis of Results:

Fiske and Dickinson²⁴ used acupuncture in the ear to control gag reflexes It was considered to be a safe, quick, inexpensive and relatively noninvasive technique. A controlled clinical trial is required to investigate any placebo effect while Sari and Sari²⁵ used Laser stimulation of acupuncture sites CV24 and PC6. The average improvement between the Gagging Severity Index (GSI) and Gagging Prevention Index (GPI) scores was 58.9% before and after the laser stimulation in Group B 37.9% in Group A and 11.2% in Group C. Both acupuncture points CV 24 and PC 6 were found to be effective in controlling Gag Reflex (GR) in orthodontic patients. The study of Rosted et al²⁶ was an audit study and included case reports from 21 dentists, who had submitted 64 case reports and out of which 37 were included in the study. The results of the study indicated that acupuncture of point CV-24 is an effective method of controlling severe GR (Gag Reflex) during dental treatment including impression taking. However, the results of this audit need to be tested in a randomised controlled study to substantiate the effectiveness of this method. Zotelli et al²⁷ used acupuncture on PC 6 point and evaluated both the control group as well as a study group.  This study showed no correlation existed between the expected and the actual reductions in nausea. The results indicated that acupoint PC6 was effective for controlling nausea during the maxillary impression-taking procedure. While Fiske and Dickinson evaluated the effectiveness of acupuncture in the prevention of gaging by evaluating the ease of carrying out dental treatment, the other investigators used upper alginate impression as the trigger for a gag reflex and assessed the severity of the gagging.

DISCUSSION:

Making upper alginate impressions in patients with a gagging reflex is a challenging situation. Various investigators have proposed different techniques to manage the gag reflex^24-28. Some of the techniques include making the secondary impression with injection type polyvinyl siloxane in a custom tray²⁵, and extending the tongue to reduce the gag reflex by moving the point of stimulus to the tongue tip²⁹ Amongst the different techniques advocated, acupressure and acupuncture are today widely recognized as rapid, simple, and very reliable methods of controlling the gag reflex with no morbidity.

Fiske and Dickenson²⁴ used ear acupuncture on 10 patients and reported to have obtained good control of the gag reflex which enabled the completion of dental procedures. Rosted²⁶ and Lu et al²¹ showed that acupuncture at point CV 24 and arm points (PC 6) have been also been effective in controlling gag reflex.

In children, laser acupuncture has been shown to control the gag reflex²⁵. Schlager et al³⁰ reported that laser stimulation (670 nm) of acupuncture point PC 6 reduced the incidence of vomiting. Several other studies have corroborated that CV 24 and PC 6 were effective acupuncture points to control gagging reflex. It must be noted that in comparison with needle acupuncture, acupressure, and laser acupuncture allow for lesser painful stimulation.

Despite the advances in science, the mode of action of acupuncture in controlling gag reflex through acupuncture is yet to be fully understood. The gag reflex is assumed to be controlled by the vomiting center in the brain. In the majority of gaging patients encountered during dental treatment, the most likely cause of the gag reflex is the activation of trigger zones in the posterior region of the oral cavity, which is innervated by the glossopharyngeal nerve (IX).

It is believed that, through the stimulation of acupuncture points CV 24 and PC 6, the impulses ascend to centers in the mid-brain. The serotonin (5-HT) that is secreted in the brain due to this stimulation³¹ is then metabolized to, β-endorphins, which are thought to exert an anti-emetic action.

The overall benefits of an approach using acupuncture include reduction of emetic reflex^31-33 greater patient comfort during dental practice³⁴, good patient compliance, acute and chronic pain treatment³⁵, immune system strengthening³⁶, and reduced patient/operator stress³⁷. The technique of acupuncture is potentially useful because it is relatively non-invasive, is cheap, and requires little additional time. Also, it can be applied even in the presence of other diseases³⁸.

The systematic review was not able to find any study that compared the efficiency of different gag-reflex controlling techniques in completely edentulous patients. In the authors’ opinion, the management of gag-reflex in completely edentulous patients must be more based on behaviour management and other non-pharmacologic interventions such as acupuncture and acupressure. Pharmacologic interventions may be resorted to after exhausting all non-pharmacologic options.

Over the years various studies have been done related to the effectiveness of acupuncture in various fields like Labour pain³⁹, lower back pain⁴⁰ etc. Whereas in the field of dentistry, its use was limited and inconclusive. Further studies should be done to understand its effectiveness in various aspects of dentistry like reduction of pain^41,42, discomfort during impression for venners⁴³, and complete denture⁴⁴. The knowledge and awareness regarding various treatment options in dentistry needed to be updated to minimise errors and make treatment more effective^45-48.

Risk of Bias in the included studies:

The sample size in the included studies was small and few were case reports. They also give evidence of different acupuncture sites or techniques as being effective in controlling gag reflex. Hence, a more extensive Randomized Clinical Trial is essential to further investigate the use of acupuncture for controlling gag reflex.

LIMITATION OF THE STUDY:

This study is based upon only the PubMed database and hand-searched articles. There are other databases such as EMBASE and OVID which can also be searched for more extensive literature.

CONCLUSION:

Though acupuncture has obvious advantages over pharmacological methods in controlling gag reflex in the elderly and edentulous population, presently there is insufficient evidence to recommend the use of anyone technique over the other. Considerable variation was observed in the protocols of the studies included in this review and the outcome measures. Further research is required to determine the effectiveness of acupuncture in controlling exaggerated gag reflex in completely edentulous patients.

DISCLOSURE STATEMENT:

The authors declare that there are no conflicts of interest and no financial interests related to the material of this manuscript.

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Received on 04.11.2021            Modified on 13.06.2022

Accepted on 03.10.2022           © RJPT All right reserved

Research J. Pharm. and Tech 2023; 16(4):2044-2050.

DOI: 10.52711/0974-360X.2023.00336