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
Gag reflex · Earplug · Trigeminal ·
Glossopharyngeus · Oral
Summary
Background: The gag reflex is a frequent problem oc-
curring during dental treatment procedures, especially
while making impressions of the maxillary teeth. The
present study aims to evaluate the efficacy of a simple
earplug as an external auditory canal stimulator to sup-
ress the profound gag reflex and as a second step, to
map areas of the oropharynx suppressed by this tech-
nique. Methods: In the first step of the study, 90 patients
who had a gag reflex during the impression procedure
were allocated to a study group, a sham group, and a
control group for evaluating the efficacy of the earplug
technique. Second, 20 new patients with a gag reflex
were included in order to map the oropharnygeal areas
suppressed by this technique. Results: The severity of
the gag reflex was reduced in the earplug group (but not
in the sham or the control group). The affected area in-
cluded the hard palate, uvula, and the tongue but not
the posterior wall of oropharynx. Conclusion: An ear-
plug technique can be a useful, practical, and effective
tool to overcome the gag reflex during oral procedures,
such as impression procedures of maxillary teeth.
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Schlüsselwörter
Würgereflex · Ohrstöpsel · Trigeminal ·
Glossopharyngeus · Oral
Zusammenfassung
Hintergrund: Der Würgereflex stellt ein häufiges Prob-
lem bei Zahnbehandlungen dar, insbesondere bei
Abdrücken der Zahnreihe des Oberkiefers. Die vorlie-
gende Studie erfasst daher die Wirksamkeit von her-
kömmlichen Ohrstöpseln zur Stimulierung des äuße-
ren Gehörgangs, um den Würgereflex zu unterdrücken.
Zudem werden Bereiche des Mundrachens erfasst, die
bei dieser Technik lahmgelegt werden. Methodik: Im
ersten Schritt der Studie wurden 90 Patienten mit
Würgereiz während der Zahnabdruck-Prozedur einer
Untersuchungsgruppe, einer Placebogruppe und einer
Kontrollgruppe zugeordnet. In einem zweiten Schritt
wurden 20 weitere Patienten mit Würgereiz einge-
schlossen, bei denen die Bereiche des Mundrachens
erfasst wurden, die beim Einsatz von Ohrstöpseln
lahmgelegt werden. Ergebnisse: Die Intensität des
Würgereflexes war in der Untersuchungsgruppe nied-
riger im Vergleich zur Placebo- und Kontrollgruppe.
Die betroffenen Bereiche umfassten den Gaumen, das
Gaumenzäpfchen sowie die Zunge, jedoch nicht die
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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Assoc. Prof. Yusuf Ozgur Cakmak, MD, PhD
Anatomy Department Z38
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Rumelifeneri Campus Sariyer
School of Medicine, Koç University
34450 Istanbul, Turkey
cozgur@yahoo.com
 Introduction
The gag reflex (GR) can be a frequent problem in dental
procedures and occuring especially during impression proce-
dures of the maxillary teeth. Although it is a normal reflex to
protect the airway, including the posterior oropharynx and the
upper gastrointestinal tract, in some individuals it may be ex-
aggerated. The origin of gagging has been categorized as either
a somatic type, initiated by sensory nerve stimulation from di-
rect contact, such as touching trigger areas (tongue, certain
parts of the palate) that can induce a reflex, or as a psycho-
genic type, originating in the higher centers of the brain that
can be influenced by sight, sound, smell, or thought without
direct contact [1, 2].
Several different strategies have been used to overcome the
GR, including auricular acupuncture, palm pressing devices, or
nerve block anesthesia [3–5]. However, current clinical appli-
cations of these methods are often not practical. An anesthetic
block of the glossopharyngeal nerve (the afferent arch of the
GR) can be considered as an invasive technique that requires
additional anesthetic injection and can only be used by experi-
enced dentists. The palm pressure technique seems to be a
noninvasive technique, but it requires specific pressure devices
and in some individuals it may be hard to find the correct point
without using a specific device. Although auricular acupunc-
ture is an effective method to overcome the GR, it may not be
accepted by all patients and cannot be used by every dentist.
Because of the indicated limitations of those different tech-
niques, the GR is still one of the most significant problems for
dentists while making impressions of the maxillary teeth.
Although the glossopharyngeal nerve is considered to be
the main afferent pathway for GR, which contributes to
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
also elicit the GR [4–9]. It is worth noting that the trigeminal
nerve allows for paradoxical preservation of the GR after a
glossopharyngeus lesion [10]. The oropharyngeal areas inner-
vated by the trigeminal nerve also overlap the external ear;
sensation from the external auditory canal (EAC) and adja-
cent structures travels along 4 cranial nerves (V, VII, IX, and
X) as well as the upper cervical plexus. All of these signals ter-
minate in the nucleus of the spinal tract of the trigeminal nerve
in the brainstem [7, 8, 11, 12].
According to current literature, the messages from oropha-
ryngeal areas and the skin of the ear may merge at the different
anatomical levels including the cortex and brainstem: It has
been reported that oral, pharyngeal, and laryngeal inlet cancers
can produce referred pain over the skin of the EAC [6]. Dis-
eases of the mouth and face are the most frequent sources of
referred otalgia, and the trigeminal nerve with its spinal tract
nucleus is the most frequent pathway for referred otalgia.
It is worth stressing that the representation of the ear in the
somatosensory cortex is unique among the body parts. Al-
Earplug Technique to Reduce Gag Reflex
though the face, neck, thorax, and limbs are represented by
distinct areas in the somatosensory cortex, this is not the case
for the somatosensory representation of the ear. Nihashi et al.
[13] demonstrated that the skin of the ear is represented by
distinct areas distributed over areas of the somatosensory cor-
tex that represent the head and neck. Such a unique represen-
tation of the ear may account for the referred sensations that
relate the oropharyngeal areas to the ear.
In addition to these documented anatomical paths relating
to referred pain from oropharyngeal areas (including the la-
ryngeal inlet) to the skin of the EAC and the pinna, reciprocal
interactions have also be reported in literature. Cerumen (ear
wax), located in the EAC, can trigger chronic cough because
the referred irritation represents the larygeal inlet; thus,
chronic cough relief can be achieved by the removal of the
cerumen [14].
Moreover, it has been shown that auricular acupuncture
points become ineffective in a denervated ear; therefore it can
be concluded that the effect of stimulating auricular points oc-
curs through auricular nerves which also innervate EAC [15].
On the basis of the available evidence, it can be theorized
that stimulation via EAC triggered by an earplug may influ-
ence or block sensory pathways of the GR within the somato-
sensorial cortex, and/or at the brainstem and/or as an antidro-
mic stimulation of the neuronal pathways of the oral referred
pain (otalgia) over the EAC skin.
In a first step, this study evaluated the use of a simple ear-
plug (which can be obtained and easily used by any dentist)
stimulating the external ear and supressing the profound GR
that was generated by making impression of the maxillary
teeth. As a second step, the study mapped the oropharnygeal
areas from which the GR could be suppressed.
Methods
The study was performed at the clinics of Gülhane Military Medical
Academy, Haydarpasa Training Hospital, Department of Dentistry, Sec-
tion of Prosthetic Dentistry in Istanbul, Turkey. The trial protocol has
been approved by an ethical committee and meets the standards of the
Declaration of Helsinki in its revised version of 1975 and its amendments
of 1983, 1989, and 1996.
Subjects
Patients, who on previous occasions had demonstrated difficulties in
accepting the procedure of making impressions of maxillary teeth due to
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-
ture study on GR by Rosted et al [1] and the fourth added for standardi-
zation of the present study.
1. Inability to accept dental treatment on a previous occasion due to a
severe GR.
2. Current dental treatment requires a maxillary irreversible hydrocol-
loid impression to be taken.
3. The individual is able to give informed consent.
4. Patients with GR severity were assigned to a gagging severity index
(GSI) III–IV (for standardization of the baseline severity in between
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).
Assessment of Gagging Severity
The GR evaluation was performed by the same dentist for all the pa-
tients. The GR assessment was undertaken prior to the insertion of the
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
of the treatment, as decribed by Dickinson and Fiske [16].
Procedure
Each group was evaluated for GR severity by using GSI. The statisti-
cian and the patients were blind to the method. Allocation was performed
in order; when one group finalized, the other initiated.
Step 1: After the GSI evaluation, the earplugs (Moos Cosmetics Ltd.,
Istanbul, Turkey; fig. 1a) were inserted bilaterally into the EAC of the
study group patients who were asked to wait with the earplugs in their
ears in the patients’ room for 10 min. In the sham group, stick-on metal
spherical pellets, which are designed for compressive stimulation over
acupuncture points (fig. 1c), were stuck bilaterally onto the forehead of
the patients (over the impression of the temporal line of the frontal
bone, 1 cm above the eyebrows; fig. 1c) as a forehead skin stimulation
for 10 min. After the GSI evaluation, the patients in the control group
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
10 min, patients of all of groups (earplug, sham, and control) were taken
to the treatment room for making the maxillary irreversible hydrocol-
loid impression; their GR was reevaluated by GPI (table 2) . The ear-
plugs and stick-on metal sphere pellets were not taken out during the
reevaluation.
Fig. 1. a Earplugs; b mapped areas: maxillary area (MX), glossopharyn-
geus area (GLO), mandibular division of trigeminal nerve area (MN),
maxillary and glossopharyngeal nerve overlap area (MX-GLO); c stick-
on metal sphere and its sticking area on forehead indicated by white
arrows.
Step 2: Four different areas [17] representing the distribution of the
maxillary nerve (MX), mandibular nerve (MN), area of intersection of
the glossopharyngeal and maxillary nerves (MX-GLO), and glossopha-
ryngeal nerve only (GLO) were touched to check the positive GR (GSI
III grade) response. 20 patients with a positive GR reflex in 1 or more of
the evaluated areas were included in the second step of the study. Pa-
tients who had different GSI grades in different areas were excluded.
Areas with a positive GR (GSI grade III) were considered as ‘1’ and
areas with a negative GR were considered as ‘0’ for statistical analysis of
mapping (fig. 1b). After mapping the positive GR areas, the earplugs
were inserted bilaterally similar to the study group in step 1, and the pa-
tients were asked to wait in the patients’ room for 10 min. At the end of
this period, the patients were reevaluated for GR positivity (GPI grade
II–V considered as ‘1’) or negativity (GPI grade I considered as ‘0’) by
touching the same areas in order to evaluate the absolute effectivity of
the earplug technique for each area.
Statistical Analysis
The results of the first step of the study were statistically evaluated by
using the Wilcoxon signed-rank test. The results of the second step of the
study were statistically evaluated by using the McNemar tests with SPSS
version 19.0 (SPSS Inc., Chicago, Ill, USA) and GraphPad software Prism
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
an increase) of 30 patients of the control group. However, the
GSI and GPI scores were exactly equal in 26 of 30 patients of
the control group in step 1 of the study. The analysis of step 1
results is shown in figure 2.
Step 2: Mapping the Effective Areas
In the second step of the study, areas were mapped in which
earplug application altered the GR, and the statistical signifi-
cance of the results was evaluated. The positive GR responses
in the MX area dissappeared with the earplug application and
the results were statistically significant (p = 0.000). The posi-
tive GR response in the MX-GLO area, which includes the
uvula, were also altered by the earplug technique; the results
were also statistically significant (p = 0.008). The GRs trig-
gered in the MN area, which contributes the lingual branch of
mandibular division of the trigeminal nerve, were also altered
clinically by the earplug application, and the effect was statisti-
cally significant (p = 0.000). On the other hand, for the GLO
area (the posterior oropharyngeal wall) there was no signifi-
cant difference between pre and post earplug application
(p = 0.125). The analysis of step 2 is shown in figure 2.
Discussion
Our results show that using earplugs is an effective tech-
nique to reduce GR triggered in the hard palate (MX area),
uvula (MX-GLO area) and tongue (MN area), but not in pos-
terior oropharyngeal wall (GLO). In addition, GR could not
be reduced in either the sham or the control group.
The maxillary irreversible hydrocolloid impression proce-
dure mainly triggers GR through contact with trigeminal
nerve areas (MX, MN, and MX-GLO), which are sufficiently
blocked by the earplug, thus GR can be overcome in patients
undergoing maxillary teeth impression procedures. The pre
and post evaluations of the first step demonstrated clearly the
effectiveness of the earplug technique when making impres-
sions of the maxillary teeth.
Earplug Technique to Reduce Gag Reflex
Fig. 2. Graphical
representation of the
results; ns = not
significant, * =  0.05,
*** =  0.0005.
The skin of the EAC, that is stimulated by the earplug, re-
ceives auricular branches (Arnold’s branch) of the vagus nerve
which is the efferent pathway of the GR. Arnold’s branch of
the vagus arises from the superior (jugular) ganglion of the
vagus and can receive fibers from the facial and glossopharyn-
geal nerves as well as the vagus nerve [18]. Moreover, Arnold’s
branch receives input from all parts of the EAC but mostly
from the posteroinferior wall [19, 20]. It might be speculated
that supression of the GR with the earplug occurs by means of
the contribution of Arnold’s branch to GLO; however the GR
that is triggered from the posterior wall of the oropharynx
could not be blocked by the earplug technique. Therefore the
GR supression with the earplug application cannot be attrib-
uted to Arnold’s branch contribution to GLO. In addition, it
has also been demonstrated that the stimulation of Arnold’s
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
the vagus nerve may be altered by earplug application. How-
ever, this effect may also be excluded on the basis of the intact
GR from the posterior pharyngeal wall. On the other hand, it
is worth mentioning that the sensory input from Arnold’s
branch to the skin of the EAC also terminates at the trigemi-
nal spinal nucleus although it travels with the vagus nerve and,
moreover, the mandibular division of the trigeminal nerve
gives off the auriculotemporal nerve which receives sensory
input from walls of the EAC [7, 11, 12, 19–22]. Therefore, it can
be speculated that earplug application may have a blocking
effect for the GR mediated by the trigeminal nerve through
auriculotemporal nerve and Arnold’s branch going to spinal
nucleus of the trigeminal nerve and acting by compression of
the walls of the EAC. The effect of the trigeminal contribution
may also explain the GR suppression in addition to the intact
GR from the posterior pharyngeal wall. The ophtalmic branch
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of the trigeminal nerve does not have any known correspond-
ing areas within the oral cavity. In addition, no possible inter-
actions in the brainstem to modulate the GR could be ob-
served, that might have occured in the sham group in which
the ophtalmic branch of the trigeminal nerve was stimulated
with the aid of the forehead compression with stick-on metal
spherical pellets.
We can conclude that the GR blocking effects of the ear-
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
details of the overlapping level could not be clarified in the
present study and it is still needed to be investigated within the
neuronal level with imaging techniques in humans. Further-
more, the earplug technique may also have a sedative effect in
addition to its trigeminal blocking effects. It has been demon-
strated that electrical stimulation of the ear skin areas inner-
vated by Arnold’s branch has mood-enhancing effects [23].
Although such an additional benefit has not been evaluated in
this study, we cannot exclude such a contribution as an add-on
effect of GR modulation, in addition to trigeminal nerve con-
tributions. Mood-enhancing effects of the earplug technique
are needed to be clarified in further studies. Finally, further
double blind and randomized studies are needed to replicate
our results.
The earplug technique may be effective not only in making
impression of the maxillary teeth but also in other dental pro-
cedures, such as making a periapical radiograph of the poste-
rior teeth or retraction of the tongue. The technique is simple
and noninvasive and may therefore also be helpful for pediat-
ric oral examinations.
However, the earplug technique may not be effective in
every patient, as shown in the 3 cases in the first step of the
study. Nevertheless, the earplug technique can be considered
as an effective noninvasive option to alleviate GR before inva-
sive techniques are applied.
Conclusion
Patients with GR are a challenge to the dentist and we be-
lieve that the earplug technique, which is an easily applicable
and noninvasive technique, can be accepted by all age groups
and will be a step forward to overcome GR. Further, the ef-
fects of the earplug technique need to be investigated for oth-
er possible medical applications. In this study, we have de-
scribed the earplug technique for the first time in literature
and demonstrated that it can reduce GR in areas innervated
from the trigeminal nerve during impression procedures of the
maxillary teeth.
Disclosure Statement
The authors of this manuscript declare that they have no conflict of
interests.

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