Keywords
dentistry - orthopaedic treatment - adentia - dentophobic reactions
Introduction
The relevance of improving dental care in Russia is determined by the significant
prevalence of dental pathology, reaching 70 to 100% in various regions.[1]
[2]
[3] Various types of adentia occupy oral diseases, and in this regard, the focus of
scientific medical research is aimed at improving the provision of medical care for
this category of patients.[3]
[4]
[5]
[6] Modern dentistry pays much attention to gender and gerontology.[7]
[8] Additionally, such factors as the vomiting reflex in dental patients often remain
outside the attention of researchers, and only rare publications are devoted to this
problem.[7]
[9]
[10]
Nevertheless, dentists often face the necessity to provide orthopaedic dental care
to patients of various age groups with adentia and exaggerated vomiting reflex.[4]
[7]
[11]
[12] It is known that the exaggerated vomiting reflex can be one of the factors causing
deterioration of dental health by provoking dentophobic reactions in patients. Discomfort
while visiting a dentist and experiencing oral sanitation can result in the patient’s
rejection of dental interventions and, as a consequence, in the progression of dental
pathology with the subsequent development of adentia, as well as it can negatively
affect the psychological health of patients.[13]
[14]
[15]
In cases when patients with adentia and exaggerated vomiting reflexes seek dental
care, it is essential to determine the optimal treatment strategy.[12]
[16]
[17] Currently, a two-stage intraosseous dental implantation using intraoral scanning
to simplify the individual stages of denture manufacturing is the most widespread
modern method for the orthopaedic treatment of secondary adentia.[18]
[19]
[20]
[21]
However, without a special modification of the dental examination procedure and orthopaedic
treatment aimed at preventing vomiting reflex activation, it is often difficult to
perform dental procedures for patients with exaggerated vomiting reflexes. For this
purpose, various methods are applied: from introducing elements of psychotherapy in
dental practice to employing digital impressions.[7]
[8]
[17]
[22]
[23]
The above-mentioned method makes us pay more attention to the specific aspects of
the impact of exaggerated vomiting reflexes on dental interventions and predetermines
the search for ways to prevent and mitigate the adverse consequences of exaggerated
vomiting reflexes in dental patients. The purpose of the research is to establish
the peculiarities of the exaggerated vomiting reflex impact while conducting dental
examination and getting dental impressions for patients with complete secondary adentia
seeking orthopaedic dental treatment.
Materials and Methods
This was a clinical, prospective single-center randomized controlled trial. The study
was conducted at the Department of Orthopaedic Dentistry at the I.M. Sechenov First
Moscow State University, based on the Maxillofacial Surgery Clinic of the I.M. Sechenov
First Moscow State University (Moscow, Russia). Two hundred patients with complete
secondary adentia requiring dental orthopaedic treatment were examined and treated.
All patients would have a jaw impression during medical procedures. There were 108
(54%) women and 92 (46%) men. Both sexes were represented in the sample in relatively
equal proportions (p > 0.05). The age of the patients ranged from 41 to 68 years; the average age of the
patient was 53.72 ± 2.06 years.
The study consisted of two stages. At the first stage, the patients were examined
to find out the severity of the vomiting reflex and the peculiarities of psychological
experiences due to the vomiting reflex. At the second stage of the study, the patients
were treated with various tactics of stopping the vomiting reflex during the procedure
of dental examination and imprinting procedure. The patients were divided into two
groups according to the purpose of the research.
The first group was the experimental group (EG) that included 98 patients with the
exaggerated vomiting reflex and complete secondary adentia, who needed orthopaedic
treatment. This group was divided into three subgroups depending on the prophylactic
management strategies that were applied and aimed at reducing the severity of vomiting
reflex manifestation during dental procedures. The EG-1.1 subgroup included 33 patients
for whom topical spray anesthesia with 10% lidocaine solution was prescribed before
taking the dental impression. The EG-1.2 subgroup included 32 patients who received
0.1% Galazolin nasal solution 1 to 3 minutes before the dental impression was taken.
The EG-1.3 subgroup consisted of 33 patients who were subjected to an “optical impression”
using the 3Shape Trios intraoral scanner to reduce vomiting reflex manifestations
instead of classical imprinting.
The second group was the control group (CG) and included 102 patients with complete
secondary adentia seeking orthopaedic treatment. No exaggerated vomiting reflex was
noted in these patients, and, therefore, standard dental examination and impression
taking strategies were applied. There were no statistically significant gender or
age differences between the experimental and the CG (p > 0.05).
The research methods included dental history, clinical history, and stomatoscopic
impression taking methods. Diagnostic measures were aimed at eliminating factors that
impede rational prosthetics, such as the presence of congenital or acquired pathological,
morphological and functional conditions of the bone-maxillary apparatus, diseases
and pathological changes in the tissue of the oral cavity, exostoses, tumor-like diseases,
and the establishment of the actual dental status. The impressions were taken by transfer
copying using the open or closed tray technique, depending on the available conditions,
and by means of the 3Shape Trios intraoral scanning.
The novelty of this research is the use of minimally invasive intraoral scanner 3Shape
Trios to prevent not only the vomiting reflex but also dentophobic reactions in patients
with increased vomiting reflex during the scratching print procedure. Both methods,
such as the method of comparing minimally invasive scanner and pharmacological medications,
can reduce the vomiting reflex, but it was been investigated how they affect the psychological
well-being and dentophobic reactions in patients with then increased vomiting reflex.
Statistical analysis was performed using methods of mathematical statistics, including
the Pearson χ2 criterion and the statistical probability criterion (p).
Results
The degree of vomiting reflex manifestation among patients with the exaggerated vomiting
reflex shifted toward the moderately expressed exaggerated vomiting reflex (43 patients—43.88%).
Moderately expressed exaggerated vomiting reflexes were diagnosed in 32 (32.65%) EG
patients. The number of patients with strongly and very strongly expressed vomiting
reflexes did not exceed ⅓ of the number of patients in the EG group and amounted to
12 and 15 people (11.22 and 14.29%), respectively. In the CG, all patients were diagnosed
with a minimal degree of vomiting reflex manifestation ([Table 1]). Tongue root, distal portion of the hard palate, soft palate, and mandibular retromolar
areas served as anatomical landmarks of vomiting reflex trigger zones in the oral
cavity
Table 1
The degrees of gag reflex manifestation in patients with complete secondary adentia
|
Degree of gag reflex manifestation
|
Gag reflex characterization
|
Clinical trial groups
|
|
EG
(n = 98)
|
CG
(n = 102)
|
|
n
|
%
|
n
|
%
|
|
1
|
Normal vomiting reflex. Rare, patient-controlled attacks
|
–
|
–
|
102
|
100
|
|
2
|
Mild exaggerated vomiting reflex. It is necessary to control and prepare the patient
for dental intervention
|
32
|
32.65
|
–
|
–
|
|
3
|
Moderate exaggerated vomiting reflex. The vomiting reflex limits the duration of individual
procedures and complicates the use of various techniques in treatment
|
43
|
43.88
|
–
|
–
|
|
4
|
Strong vomiting reflex. It is impossible for the patient to visit a dentist without
special measures. The vomiting reflex can occur even during the oral cavity examination
|
11
|
11.22
|
–
|
–
|
|
5
|
Very strong vomiting reflex. Dental treatment is impossible without the use of means
to reduce the vomiting reflex
|
14
|
14.29
|
–
|
–
|
|
χ2
|
37.05
|
204.00
|
|
p-Value
|
<0.001
|
<0.001
|
In 97.96% of observations in the EG, the available exaggerated vomiting reflexes were
associated with dentophobic experiences and several dentophobic reactions, which significantly
differed from the CG results, where dentophobic experiences and the resulting dentophobic
reactions were observed in 36.27% of observations.
The nature of dentophobic experiences was diverse and included a wide range of contents—from
fear of pain and helplessness during medical procedures to fear of dental medical
instruments. In 73.47% of cases, dentophobic experiences were directly related to
exaggerated vomiting reflexes, and included phobias such as fear of vomiting during
dental procedures, choking on vomit due to the vomiting reflex activation during dental
procedures, contaminating clothes or floor with vomit, and jaw clenching due to the
vomiting reflex activation in the process of dental care provision followed by a bite
of dental instruments ([Table 2]).
Table 2
The nature of dentophobic experiences of patients with complete secondary adentia
and exaggerated gag reflex
|
Content of patients’ dentophobic experiences
|
Clinical trial groups
|
χ2
|
p-Value
|
|
EG
(n = 98)
|
CG
(n = 102)
|
|
n
|
%
|
n
|
%
|
|
Abbreviations: EG, experimental group; CG, control group.
|
|
Fear of dental pain
|
96
|
97.96
|
37
|
36.27
|
85.37
|
<0.001
|
|
Fear of dentists
|
1
|
1.02
|
2
|
1.96
|
0.30
|
>0.05
|
|
Fear of the dental office
|
0
|
0.00
|
1
|
0.98
|
0.97
|
>0.05
|
|
Fear of dental medical instruments
|
42
|
42.86
|
22
|
21.57
|
10.41
|
0.002
|
|
Fear of dental procedures
|
70
|
71.43
|
35
|
34.31
|
27.61
|
<0.001
|
|
Fear of helplessness during medical procedures
|
59
|
60.20
|
3
|
2.94
|
76.62
|
<0.001
|
|
Fear of choking on saliva during dental procedures
|
72
|
73.47
|
8
|
7.84
|
89.69
|
<0.001
|
|
Fear of a foreign body aspiration during dental procedures
|
30
|
30.61
|
10
|
9.80
|
13.53
|
<0.001
|
|
Fear of vomiting during dental procedures
|
72
|
73.47
|
–
|
–
|
117.09
|
<0.001
|
|
Fear of choking on vomit due to gag reflex activation during dental procedures
|
72
|
73.47
|
–
|
–
|
117.09
|
<0.001
|
|
Fear of contaminating clothes or floor with vomit in case of gag reflex activation
during dental procedures
|
18
|
18.37
|
–
|
–
|
20.59
|
<0.001
|
|
Fear of jaw clenching due to gag reflex activation in the process of dental care provision
followed by a bite of dental instruments
|
36
|
36.73
|
–
|
–
|
45.69
|
<0.001
|
|
Total patients with dentophobic experiences
|
96
|
97.96
|
37
|
36.27
|
85.37
|
<0.001
|
Dentophobic reactions, in addition to the vegetative and emotional states, included
a verbal component, macro- and micromotor responses in the form of tilted body, head
turns, jaw clenching, increased swallowing movements, etc., which complicate dental
examination and obtaining a high-quality impression. Without taking preventive measures
aimed at reducing the vomiting reflex, dental procedures in all EG patients were difficult
or impossible to conduct.
To prevent the vomiting reflex development in the EG patients, one of the following
preventive strategies was implemented:
-
Using topical spray anesthesia with 10% lidocaine solution prior to impression taking;
-
Using 0.1% nasal solution of Galazolin 1 to 3 minutes prior to impression taking;
-
Using the 3Shape Trios intraoral scanner, which has a function of double scanning
to create a three-dimensional image of gingiva and prosthetic bed.
The EG patients were divided into three subgroups (EG-1.1, EG-1.2, EG-1.3), which
did not have significant differences among themselves, to study the effectiveness
of measures to prevent the vomiting reflex activation. One of the above preventive
tactics was applied to these patients; the results are given in [Table 3]. It was established that the topical application of 10% lidocaine solution spray
enabled to reduce vomiting reflexes; however, the use of this medication provoked
the development of unpleasant sensations in patients, such as throat irritation, hypersalivation,
swollen mucosa in distal portions of the hard palate, a feeling of slight suffocation
with restless behavior, and micromotions when the impression was taken. The indicated
adverse reactions during impression taking by this method—using 10% lidocaine solution
spray—led to inaccurate impressions, which subsequently caused insufficient adherence
of complete dentures and an increase in the denture adaptation time. Upon completion
of impression taking, until the effect of the medication was terminated, patients
complained of dysphagia, the excessive saliva accumulation in the mouth, the preserved
feeling of slight suffocation, and a fear of choking on saliva.
Table 3
Comparative characteristics of the effectiveness of prophylactic management strategies
for patients with complete secondary adentia and exaggerated gag reflex
|
Indicator
|
EG subgroups
|
χ2
|
p-Value
|
|
EG-1.1
(n = 33)
|
EG-1.2
(n = 32)
|
EG-1.3
(n = 33)
|
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Abbreviation: EG, experimental group.
|
|
Available subjective sensations:
|
|
|
–Throat irritation
|
17
|
51.52
|
5
|
15.63
|
2
|
6.06
|
20.45
|
<0.001
|
|
–Choking sensation
|
10
|
30.30
|
1
|
3.13
|
–
|
–
|
18.33
|
<0.001
|
|
–Dizziness
|
–
|
–
|
4
|
12.50
|
–
|
–
|
8.60
|
0.014
|
|
–Nausea, vomiturition
|
17
|
51.52
|
2
|
6.25
|
–
|
–
|
33.27
|
<0.001
|
|
–Hypersalivation
|
16
|
48.48
|
–
|
–
|
–
|
–
|
37.66
|
<0.001
|
|
–Xerostomia
|
–
|
–
|
4
|
12.50
|
–
|
–
|
8.60
|
0.014
|
|
–Discomfort in the oral cavity
|
18
|
54.55
|
12
|
37.50
|
4
|
12.12
|
13.27
|
0.002
|
|
Impression taking is impossible
|
2
|
6.06
|
–
|
–
|
–
|
–
|
4.02
|
0.134
|
|
Impression taking is complicated
|
10
|
30.30
|
7
|
21.88
|
–
|
–
|
11.25
|
0.004
|
|
Impression taking is without complications
|
11
|
33.33
|
25
|
78.13
|
33
|
100.00
|
36.56
|
<0.001
|
|
Impression quality:
|
|
|
–Unsatisfactory
|
5
|
15.15
|
2
|
6.25
|
–
|
–
|
5.77
|
0.056
|
|
–Satisfactory
|
26
|
78.79
|
30
|
93.75
|
33
|
100.00
|
9.39
|
0.010
|
The use of 0.1% Galazolin nasal solution to prevent vomiting reflex activation caused
less unpleasant sensations in patients during dental care provision. While the impression
mass was kept for the required time in the oral cavity, the researchers identified
a lack of excessive salivation vomiturition and restless behavior of patients, which
promoted the good quality of the impressions. However, upon completion of dental procedures
12.50% of patients complained of oral and nasal dysphagia and dizziness.
The use of the 3Shape Trios scanner for impression taking caused less dentophobic
experiences in patients with exaggerated vomiting reflexes. The scanner enabled to
obtain a high-quality “optical impression” with the ability to interrupt scanning
for the patient to have a rest in the event of the vomiting reflex; there were no
adverse effects of the procedure, which allows us to consider this strategy as a preferred
one for impression taking in patients with exaggerated vomiting reflexes.
DISCUSSION
All researchers agree that patients with increased vomiting reflex need a correction
of therapy to avoid the unpleasant consequences of the reflex during dental procedures.
However, there is still a question which therapeutic tactics aimed at eliminating
the increased vomiting reflex is the most effective.[9]
[11]
[14]
[19]
[23]
In this study, the authors applied three prophylactic tactics to patients aimed at
reducing the severity of the vomiting reflex during dental procedures. Since previous
researchers point to the positive effect of short-term pharmacotherapy for eliminating
the increased vomiting reflex,9 two of the tactics we used were pharmacotherapy -
using local aerosol anesthesia with 10% lidocaine solution and 0.1% Galazolin nasal
solution, and the third tactic was instrumental - 3Shape Trios intraoral scanner.
We expected that the use of an intraoral scanner will help improve the condition of
patients with an increased emetic reflex since this tactic excludes the presence of
triggers for activating the vomit reflex.
Many researchers point out that psychotherapy is an effective tactic that helps to
cure increased vomiting reflex.9 The authors did not include psychotherapy in the
study since it is significantly time-consuming and involves involving not only a dentist
but also a psychotherapist in therapy.
Such a tactic for the treatment of increased vomiting reflex as acupuncture, which
is based on the studies by Fiske J. and Dickinson C. It eliminates or partially eliminates
the increased vomiting reflex,11 the authors excluded from the study since acupuncture
is not recognized in all countries by classical medicine.
This study demonstrated that, although all three tactics allowed for reducing the
severity of the gag reflex, the effectiveness of these tactics is different. Two of
the tactics used - the use of local aerosol anesthesia with 10% lidocaine solution
and 0.1% Galazoline nasal solution had side effects that made it difficult to obtain
a high-quality impression, such as nausea, vomiting, dizziness, hypersalivation, or
vice versa, dry mucous membranes. The authors believe that this is because the side
effects of these tactics are identical to those effects that accompany the increased
vomiting reflex and its consequences, and therefore provoke the appearance of the
same stomatophobic reactions in patients as with the activation of the vomiting reflex.
When using the 3Shape Trios intraoral scanner, several patients also reported side
effects in the form of an unpleasant sensation in the mouth or a sore throat, but
this did not lead to problems when taking an impression.
In addition, not all of these tactics made it possible to eliminate completely the
stomatophobic reactions associated with an increased emetic reflex, which also affected
the quality of the obtained impression. So, satisfactory quality of casts in all patients
could be obtained only with the use of the 3Shape Trios intraoral scanner; when applying
local aerosol anesthesia with a 10% solution of lidocaine or a 0.1% nasal solution
of Galazolin in 15.15% and 6.25%, the quality of the casts was unsatisfactory due
to the destructive behavior of patients due to stomatophobic reactions.
This study proved the effectiveness of using the 3Shape Trios intraoral scanner to
take a high-quality impression in patients requiring prosthetics and suffering from
an increased vomiting reflex. However, its effectiveness in other dental procedures
in patients with an increased gag reflex is debatable and requires additional research.
Conclusions
The role of the vomiting reflex in orthopaedic treatment of dental patients is reduced
to the following aspects:
-
The development of dentophobic experiences associated with the available exaggerated
vomiting reflex and dentophobic reactions in patients prior to and/or during dental
procedures;
-
The development of motor–behavioral reactions due to the vomiting reflex activation
during the provision of dental care;
-
The need to modify the dentist’s behavior before starting medical procedures toward
joining a time-consuming explanatory health counseling aimed at stopping the dentophobic
experiences conditioned by the exaggerated vomiting reflex.
In general, the available exaggerated vomiting reflexes in patients seeking orthopaedic
treatment lead to an increase in the time of dental examination, an expansion of the
range of dental procedures with the need to attract additional pharmacological preparations
or dental instruments; the above determined the need to update the problem of exaggerated
vomiting reflexes in dental practice and to develop preventive medical measures.
