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Original Article · Originalarbeit

Forsch Komplementmed 2014;21:94–98 Published online: March 28, 2014


DOI: 10.1159/000362140

An Earplug Technique to Reduce the Gag Reflex during


Dental Procedures
Yusuf Ozgur Cakmaka Ömer Ozdogmusb Yumusan Günayc Bahadır Gürbüzerd
Emre Tezulaşe Elif Ciğdem Kasparf Hüsniye Hacıoglug
a
Department of Anatomy, Rumelifeneri Campus, School of Medicine, Koç University,
b
Department of Anatomy, School of Medicine, Marmara University,
c
Section of Prosthodontics,
d
Section of Oral and Maxillofacial Surgery, Department of Dentistry, Haydarpasa Training Hospital, Gülhane Military Medical Academy,
e
Dental Academy, Private Practice, Kadikoy,
f
Department of Biostatistics, School of Medicine, Yeditepe University, Kayısdagi,
g
Department of Anatomy and Institute of the Neurological Sciences, School of Medicine, Marmara University, Istanbul, Turkey

Keywords Schlüsselwörter
Gag reflex · Earplug · Trigeminal · Würgereflex · Ohrstöpsel · Trigeminal ·
Glossopharyngeus · Oral Glossopharyngeus · Oral

Summary Zusammenfassung
Background: The gag reflex is a frequent problem oc- Hintergrund: Der Würgereflex stellt ein häufiges Prob-
curring during dental treatment procedures, especially lem bei Zahnbehandlungen dar, insbesondere bei
while making impressions of the maxillary teeth. The Abdrücken der Zahnreihe des Oberkiefers. Die vorlie-
present study aims to evaluate the efficacy of a simple gende Studie erfasst daher die Wirksamkeit von her-
earplug as an external auditory canal stimulator to sup- kömmlichen Ohrstöpseln zur Stimulierung des äuße-
ress the profound gag reflex and as a second step, to ren Gehörgangs, um den Würgereflex zu unterdrücken.
map areas of the oropharynx suppressed by this tech- Zudem werden Bereiche des Mundrachens erfasst, die
nique. Methods: In the first step of the study, 90 patients bei dieser Technik lahmgelegt werden. Methodik: Im
who had a gag reflex during the impression procedure ersten Schritt der Studie wurden 90 Patienten mit
were allocated to a study group, a sham group, and a Würgereiz während der Zahnabdruck-Prozedur einer
control group for evaluating the efficacy of the earplug Untersuchungsgruppe, einer Placebogruppe und einer
technique. Second, 20 new patients with a gag reflex Kontrollgruppe zugeordnet. In einem zweiten Schritt
were included in order to map the oropharnygeal areas wurden 20 weitere Patienten mit Würgereiz einge-
suppressed by this technique. Results: The severity of schlossen, bei denen die Bereiche des Mundrachens
the gag reflex was reduced in the earplug group (but not erfasst wurden, die beim Einsatz von Ohrstöpseln
in the sham or the control group). The affected area in- lahmgelegt werden. Ergebnisse: Die Intensität des
cluded the hard palate, uvula, and the tongue but not Würgereflexes war in der Untersuchungsgruppe nied-
the posterior wall of oropharynx. Conclusion: An ear- riger im Vergleich zur Placebo- und Kontrollgruppe.
plug technique can be a useful, practical, and effective Die betroffenen Bereiche umfassten den Gaumen, das
tool to overcome the gag reflex during oral procedures, Gaumenzäpfchen sowie die Zunge, jedoch nicht die
such as impression procedures of maxillary teeth. Hinterwand des Mundrachenraums. Schlussfolgerung:
Die Verwendung von Ohrstöpseln kann eine nützliche,
praktische, und wirksame Maßnahme sein, um den
Würgereflex, der bei zahnärztlichen Eingriffen, insbe-
sondere bei Abdrücken der Zahnreihe des Oberkiefers
ausgelöst wird, zu unterbinden.
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Introduction though the face, neck, thorax, and limbs are represented by
distinct areas in the somatosensory cortex, this is not the case
The gag reflex (GR) can be a frequent problem in dental for the somatosensory representation of the ear. Nihashi et al.
procedures and occuring especially during impression proce- [13] demonstrated that the skin of the ear is represented by
dures of the maxillary teeth. Although it is a normal reflex to distinct areas distributed over areas of the somatosensory cor-
protect the airway, including the posterior oropharynx and the tex that represent the head and neck. Such a unique represen-
upper gastrointestinal tract, in some individuals it may be ex- tation of the ear may account for the referred sensations that
aggerated. The origin of gagging has been categorized as either relate the oropharyngeal areas to the ear.
a somatic type, initiated by sensory nerve stimulation from di- In addition to these documented anatomical paths relating
rect contact, such as touching trigger areas (tongue, certain to referred pain from oropharyngeal areas (including the la-
parts of the palate) that can induce a reflex, or as a psycho- ryngeal inlet) to the skin of the EAC and the pinna, reciprocal
genic type, originating in the higher centers of the brain that interactions have also be reported in literature. Cerumen (ear
can be influenced by sight, sound, smell, or thought without wax), located in the EAC, can trigger chronic cough because
direct contact [1, 2]. the referred irritation represents the larygeal inlet; thus,
Several different strategies have been used to overcome the chronic cough relief can be achieved by the removal of the
GR, including auricular acupuncture, palm pressing devices, or cerumen [14].
nerve block anesthesia [3–5]. However, current clinical appli- Moreover, it has been shown that auricular acupuncture
cations of these methods are often not practical. An anesthetic points become ineffective in a denervated ear; therefore it can
block of the glossopharyngeal nerve (the afferent arch of the be concluded that the effect of stimulating auricular points oc-
GR) can be considered as an invasive technique that requires curs through auricular nerves which also innervate EAC [15].
additional anesthetic injection and can only be used by experi- On the basis of the available evidence, it can be theorized
enced dentists. The palm pressure technique seems to be a that stimulation via EAC triggered by an earplug may influ-
noninvasive technique, but it requires specific pressure devices ence or block sensory pathways of the GR within the somato-
and in some individuals it may be hard to find the correct point sensorial cortex, and/or at the brainstem and/or as an antidro-
without using a specific device. Although auricular acupunc- mic stimulation of the neuronal pathways of the oral referred
ture is an effective method to overcome the GR, it may not be pain (otalgia) over the EAC skin.
accepted by all patients and cannot be used by every dentist. In a first step, this study evaluated the use of a simple ear-
Because of the indicated limitations of those different tech- plug (which can be obtained and easily used by any dentist)
niques, the GR is still one of the most significant problems for stimulating the external ear and supressing the profound GR
dentists while making impressions of the maxillary teeth. that was generated by making impression of the maxillary
Although the glossopharyngeal nerve is considered to be teeth. As a second step, the study mapped the oropharnygeal
the main afferent pathway for GR, which contributes to areas from which the GR could be suppressed.
oropharyngeal mucosa sensation, tactile stimulation from ar-
eas innervated by the trigeminal nerve, such as the anterior
faucial pillars, the base of the tongue and the soft palate may Methods
also elicit the GR [4–9]. It is worth noting that the trigeminal
The study was performed at the clinics of Gülhane Military Medical
nerve allows for paradoxical preservation of the GR after a
Academy, Haydarpasa Training Hospital, Department of Dentistry, Sec-
glossopharyngeus lesion [10]. The oropharyngeal areas inner- tion of Prosthetic Dentistry in Istanbul, Turkey. The trial protocol has
vated by the trigeminal nerve also overlap the external ear; been approved by an ethical committee and meets the standards of the
sensation from the external auditory canal (EAC) and adja- Declaration of Helsinki in its revised version of 1975 and its amendments
cent structures travels along 4 cranial nerves (V, VII, IX, and of 1983, 1989, and 1996.
X) as well as the upper cervical plexus. All of these signals ter- Subjects
minate in the nucleus of the spinal tract of the trigeminal nerve Patients, who on previous occasions had demonstrated difficulties in
in the brainstem [7, 8, 11, 12]. accepting the procedure of making impressions of maxillary teeth due to
According to current literature, the messages from oropha- a severe GR, were invited to participate in our study. The patient inclu-
sion criteria involved the following 4 statements: 1–3, as in the acupunc-
ryngeal areas and the skin of the ear may merge at the different
ture study on GR by Rosted et al [1] and the fourth added for standardi-
anatomical levels including the cortex and brainstem: It has zation of the present study.
been reported that oral, pharyngeal, and laryngeal inlet cancers 1. Inability to accept dental treatment on a previous occasion due to a
can produce referred pain over the skin of the EAC [6]. Dis- severe GR.
eases of the mouth and face are the most frequent sources of 2. Current dental treatment requires a maxillary irreversible hydrocol-
loid impression to be taken.
referred otalgia, and the trigeminal nerve with its spinal tract
3. The individual is able to give informed consent.
nucleus is the most frequent pathway for referred otalgia. 4. Patients with GR severity were assigned to a gagging severity index
It is worth stressing that the representation of the ear in the (GSI) III–IV (for standardization of the baseline severity in between
somatosensory cortex is unique among the body parts. Al- groups of step 1).
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Table 1. Gagging severity index (GSI)
The gagging reflex is

I Very mild, occasional and controlled by the patient


II Mild, and control is required by the patient with reassurance from the dental team
III Moderate, consistent and limits treatment options
IV severe and treatment is impossible
V very severe; affecting patient behaviour and dental attendance and making treatment
impossible

Table 2. Gagging prevention index (GPI)


Treatment management method employed

I Obtunded gag reflex; treatment successful


II Partially controlled gag reflex; all treatment possible
III Partially controlled gag reflex but frequent gagging; simple treatment possible
IV Inadequately controlled gag reflex; simple treatment unable to be completed
V Gag reflex severe; no treatment possible

The prospective observational, non-randomized, clinical trial study


was planned in 2 steps:
In the first step of the study, 90 patients who had a GR during the
maxillary irreversible hydrocolloid impression procedure (Kromopan,
Firenze, Italy) were allocated to a study group (n = 30, 9 female, 21 male,
mean: 35.2 ± 16.18) a sham group (n = 30, 14 female, 16 male, mean: 31.13
± 10.94), and a control group (n = 30, 12 female, 18 male, mean: 30.6 ±
14.72). Irreversible hydrocolloid impression material was mixed in ac-
cordance with the instructions of the manufacturer, and impressions were
taken by the same dentist.
As a second step, the oral areas affected by the earplug were mapped
in only those patients who had a GR of grade GSI III (moderate, consis-
tent and limited treatment options) during maxillary irreversible hydrocol-
loid impression procedure (n = 20, 9 female, 11 male, mean: 46.3 ± 14.52). Fig. 1. a Earplugs; b mapped areas: maxillary area (MX), glossopharyn-
geus area (GLO), mandibular division of trigeminal nerve area (MN),
Assessment of Gagging Severity maxillary and glossopharyngeal nerve overlap area (MX-GLO); c stick-
The GR evaluation was performed by the same dentist for all the pa- on metal sphere and its sticking area on forehead indicated by white
tients. The GR assessment was undertaken prior to the insertion of the arrows.
earplug using GSI (table 1), which assesses the magnitude of the GR, and
again after inserting the earplug and the dental impression, by using the
gagging prevention index (GPI) (table 2), which assesses the effectiveness Step 2: Four different areas [17] representing the distribution of the
of the treatment, as decribed by Dickinson and Fiske [16]. maxillary nerve (MX), mandibular nerve (MN), area of intersection of
the glossopharyngeal and maxillary nerves (MX-GLO), and glossopha-
Procedure ryngeal nerve only (GLO) were touched to check the positive GR (GSI
Each group was evaluated for GR severity by using GSI. The statisti- III grade) response. 20 patients with a positive GR reflex in 1 or more of
cian and the patients were blind to the method. Allocation was performed the evaluated areas were included in the second step of the study. Pa-
in order; when one group finalized, the other initiated. tients who had different GSI grades in different areas were excluded.
Step 1: After the GSI evaluation, the earplugs (Moos Cosmetics Ltd., Areas with a positive GR (GSI grade III) were considered as ‘1’ and
Istanbul, Turkey; fig. 1a) were inserted bilaterally into the EAC of the areas with a negative GR were considered as ‘0’ for statistical analysis of
study group patients who were asked to wait with the earplugs in their mapping (fig. 1b). After mapping the positive GR areas, the earplugs
ears in the patients’ room for 10 min. In the sham group, stick-on metal were inserted bilaterally similar to the study group in step 1, and the pa-
spherical pellets, which are designed for compressive stimulation over tients were asked to wait in the patients’ room for 10 min. At the end of
acupuncture points (fig. 1c), were stuck bilaterally onto the forehead of this period, the patients were reevaluated for GR positivity (GPI grade
the patients (over the impression of the temporal line of the frontal II–V considered as ‘1’) or negativity (GPI grade I considered as ‘0’) by
bone, 1 cm above the eyebrows; fig. 1c) as a forehead skin stimulation touching the same areas in order to evaluate the absolute effectivity of
for 10 min. After the GSI evaluation, the patients in the control group the earplug technique for each area.
were also asked to wait in the patients’ room for 10 min, without apply-
ing the earplug or stick-on metal sphere pellets on the forehead. After Statistical Analysis
10 min, patients of all of groups (earplug, sham, and control) were taken The results of the first step of the study were statistically evaluated by
to the treatment room for making the maxillary irreversible hydrocol- using the Wilcoxon signed-rank test. The results of the second step of the
loid impression; their GR was reevaluated by GPI (table 2) . The ear- study were statistically evaluated by using the McNemar tests with SPSS
plugs and stick-on metal sphere pellets were not taken out during the version 19.0 (SPSS Inc., Chicago, Ill, USA) and GraphPad software Prism
reevaluation. 5.0 (San Diego, CA, USA).
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Results

Step 1: Efficacy
The statistical analyses for the first step of the study showed
that the GSI and GPI differences of the earplug group were
statistically significant (p  0.0001). The GSI and GPI scores of
27 of the 30 patients showed a suppression of the GR in the
earplug group. The GSI and GPI scores were equal in only 3 of
the patients in the earplug group.
In contrast, the GSI and GPI differences between control
(p = 0.424) and sham group (p = 0.586) were not statistically
significant.
The GSI and GPI scores differed in 9 of 30 patients (4 of
whom were increased) of the sham group.
The GSI and GPI scores differed in only 4 (1 of whom was Fig. 2. Graphical
representation of the
an increase) of 30 patients of the control group. However, the
results; ns = not
GSI and GPI scores were exactly equal in 26 of 30 patients of significant, * =  0.05,
the control group in step 1 of the study. The analysis of step 1 *** =  0.0005.
results is shown in figure 2.

Step 2: Mapping the Effective Areas The skin of the EAC, that is stimulated by the earplug, re-
In the second step of the study, areas were mapped in which ceives auricular branches (Arnold’s branch) of the vagus nerve
earplug application altered the GR, and the statistical signifi- which is the efferent pathway of the GR. Arnold’s branch of
cance of the results was evaluated. The positive GR responses the vagus arises from the superior (jugular) ganglion of the
in the MX area dissappeared with the earplug application and vagus and can receive fibers from the facial and glossopharyn-
the results were statistically significant (p = 0.000). The posi- geal nerves as well as the vagus nerve [18]. Moreover, Arnold’s
tive GR response in the MX-GLO area, which includes the branch receives input from all parts of the EAC but mostly
uvula, were also altered by the earplug technique; the results from the posteroinferior wall [19, 20]. It might be speculated
were also statistically significant (p = 0.008). The GRs trig- that supression of the GR with the earplug occurs by means of
gered in the MN area, which contributes the lingual branch of the contribution of Arnold’s branch to GLO; however the GR
mandibular division of the trigeminal nerve, were also altered that is triggered from the posterior wall of the oropharynx
clinically by the earplug application, and the effect was statisti- could not be blocked by the earplug technique. Therefore the
cally significant (p = 0.000). On the other hand, for the GLO GR supression with the earplug application cannot be attrib-
area (the posterior oropharyngeal wall) there was no signifi- uted to Arnold’s branch contribution to GLO. In addition, it
cant difference between pre and post earplug application has also been demonstrated that the stimulation of Arnold’s
(p = 0.125). The analysis of step 2 is shown in figure 2. branch represents the motor functions of the vagus nerve (Ar-
nold’s ear-cough reflex can be elicited by palpation of the EAC
skin [18]); this might suggest that the GR motor pathway of
Discussion the vagus nerve may be altered by earplug application. How-
ever, this effect may also be excluded on the basis of the intact
Our results show that using earplugs is an effective tech- GR from the posterior pharyngeal wall. On the other hand, it
nique to reduce GR triggered in the hard palate (MX area), is worth mentioning that the sensory input from Arnold’s
uvula (MX-GLO area) and tongue (MN area), but not in pos- branch to the skin of the EAC also terminates at the trigemi-
terior oropharyngeal wall (GLO). In addition, GR could not nal spinal nucleus although it travels with the vagus nerve and,
be reduced in either the sham or the control group. moreover, the mandibular division of the trigeminal nerve
The maxillary irreversible hydrocolloid impression proce- gives off the auriculotemporal nerve which receives sensory
dure mainly triggers GR through contact with trigeminal input from walls of the EAC [7, 11, 12, 19–22]. Therefore, it can
nerve areas (MX, MN, and MX-GLO), which are sufficiently be speculated that earplug application may have a blocking
blocked by the earplug, thus GR can be overcome in patients effect for the GR mediated by the trigeminal nerve through
undergoing maxillary teeth impression procedures. The pre auriculotemporal nerve and Arnold’s branch going to spinal
and post evaluations of the first step demonstrated clearly the nucleus of the trigeminal nerve and acting by compression of
effectiveness of the earplug technique when making impres- the walls of the EAC. The effect of the trigeminal contribution
sions of the maxillary teeth. may also explain the GR suppression in addition to the intact
GR from the posterior pharyngeal wall. The ophtalmic branch
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Earplug Technique to Reduce Gag Reflex Forsch Komplementmed 2014;21:94–98 97


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of the trigeminal nerve does not have any known correspond- rior teeth or retraction of the tongue. The technique is simple
ing areas within the oral cavity. In addition, no possible inter- and noninvasive and may therefore also be helpful for pediat-
actions in the brainstem to modulate the GR could be ob- ric oral examinations.
served, that might have occured in the sham group in which However, the earplug technique may not be effective in
the ophtalmic branch of the trigeminal nerve was stimulated every patient, as shown in the 3 cases in the first step of the
with the aid of the forehead compression with stick-on metal study. Nevertheless, the earplug technique can be considered
spherical pellets. as an effective noninvasive option to alleviate GR before inva-
We can conclude that the GR blocking effects of the ear- sive techniques are applied.
plug application probably may have occurred due to the merg-
ing of the oropharyngeal trigeminal areas and EAC skin ter-
ritories innervated by the trigeminal nerve. However, the Conclusion
details of the overlapping level could not be clarified in the
present study and it is still needed to be investigated within the Patients with GR are a challenge to the dentist and we be-
neuronal level with imaging techniques in humans. Further- lieve that the earplug technique, which is an easily applicable
more, the earplug technique may also have a sedative effect in and noninvasive technique, can be accepted by all age groups
addition to its trigeminal blocking effects. It has been demon- and will be a step forward to overcome GR. Further, the ef-
strated that electrical stimulation of the ear skin areas inner- fects of the earplug technique need to be investigated for oth-
vated by Arnold’s branch has mood-enhancing effects [23]. er possible medical applications. In this study, we have de-
Although such an additional benefit has not been evaluated in scribed the earplug technique for the first time in literature
this study, we cannot exclude such a contribution as an add-on and demonstrated that it can reduce GR in areas innervated
effect of GR modulation, in addition to trigeminal nerve con- from the trigeminal nerve during impression procedures of the
tributions. Mood-enhancing effects of the earplug technique maxillary teeth.
are needed to be clarified in further studies. Finally, further
double blind and randomized studies are needed to replicate
our results. Disclosure Statement
The earplug technique may be effective not only in making
impression of the maxillary teeth but also in other dental pro- The authors of this manuscript declare that they have no conflict of
interests.
cedures, such as making a periapical radiograph of the poste-

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