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Hyperactive Gag Reflex and Diving

This page is written and maintained by
Ernest S Campbell, MD

Hyperactive gag reflex is an extreme oropharyngeal response to stimulation resulting in pharyngeal and velar contractions - resulting in 'gagging'.

Opinions as to the proper management of the gag reflex in divers. 

Questions come up fairly frequently concerning an overactive gag reflex and vomiting underwater.

Some have had some success with hyperactive gag reflex by using mirror biofeedback. Start with the snorkel, breathe in count of 4 and out at count of 6, relax as you exhale. See the face relax. If you see the face, jaw, eyes, neck shoulders relax, then you are doing it right. Then we try tongue blades and then the mouthpiece itself. Haven't had that many patients but several did work out ok.
Murray Grossan, M.D.  http://www.ent-consult.com 




A diving dentist writes the following:

"Looking toward the causes of the hyperactive gag reflex is interesting.  It may be that the mouthpiece simply needs to be trimmed.  Removal of some of the silicone that extends back on the back teeth and trimming the extent which hits the roof of the mouth and the tongue may help.  But doing this still negates the benefit of being able to use your buddy's regulator.  Stimulus desentization worked for our diver. We just had him suck on that regulator mouthpiece all day long while we were working on gear configuration and filling tanks.

There are many factors which can lead to this problem.  Some are obvious and can be eliminated. Use of alcohol or medication can heighten the gag reflex.  Obesity, smoking, or tobacco use are also factors that can be eliminated.  Dental problems, systemic illness, and psychological factors including fear can be contributors.  In my opinion, as an open water instructor of ten years, a trimix cave diver, and a dentist, I would not recommend diving until such time that this reflex is under control.  It could be catastrophic.  This is dangerous for the diver and an unfair burden on his buddies.  Another option would be to put this fellow in the pool with a snorkel and have him swim laps forever until the gag reflex goes away.

If he only feels it with scuba and not with a snorkel (having a vitally identical mouthpiece) I would suggest that the gagging is anxiety related, and not anatomical or physiological  in nature."

 Dr. Tom O'Connor,


Dr. Pat Haley, of Orange Beach, Alabama states:

'I agree with Dr. O'Connor  regarding the trimming of the mouthpiece, especially in the soft palate area. We sometimes sprinkle sugar or salt on the tongue or palate before impressions to inhibit the gag reflex. A topical anesthetic works well especially Dyclone which is longer acting. For barfing I suggest  a return to the surface !!'


Dr. Kimberly Loos, DDS has the following advice:

"I cannot recommend a drug to relieve a hypersensitive gag reflex.  If the regulator mouthpiece is truly the cause of the gagging, I would suggest using an orthodontically correct regulator mouthpiece.  There are over-the-counter mouthpieces that can be made by softening them in hot water.  However, the best way to get an orthodontically correct mouthpiece is to have the dentist design one based on an impression of the diver's teeth.  Unfortunately, there are not many dentists that make custom regulator mouthpieces.

 My other
suggestion is that the diver use a full face mask.  Caveat: these masks cost between 1- 3 thousand dollars each! (One consultant feels this cost estimate to be way too high!)  If the salt water causes the gag reflex, perhaps the diver should dive only in fresh water.  If water seeping into the mouth between the mouthpiece and the lips causes the gag reflex, perhaps the diver should try a new mouthpiece with a different silicon seal."

==========================================================================

For What It's Worth - Hyperactive Gag Reflex Remedy

Here is a letter that we thought we'd pass on for those of you suffering from a hyperactive gag reflex. There must be a lot of you because we get numerous hits on our web page about this at http://www.scuba-doc.com/Gagrflx.htm .

"FYI in case it may help others:

I came across your web site a month ago while researching about the severe gag reflex problem that has prevented me from snorkelling for the past several years. I discovered only a week ago that my problem completely disappears if I wear a wristwatch while snorkelling! I'd stopped wearing watches in the water years ago because I'm rough on them and they unpredictably develop leaks.

The eureka moment for me came when a friend told me she'd worn "Sea-Band" on her wrists and experienced no sea-sickness on a recent cruise even though she's prone to nausea. Those bands are worn where one would place a wrist watch! Because of the neighbour's "Sea Band" experience, I bought a new water-tight watch which I now wear while snorkelling and much to my delight the gag problem has completely disappeared! "

My response: A study of many divers would be needed to show a significance.

I'll pass this on as a possibility.

scubadoc

=======================================================================

Dr. Larry Stein, our diving dental consultant, has the following note about the gag reflex:
"
I saw the article on your site about the gag reflex. A number of compounding pharmacies make and "electrolyte tablet" that is supposed to suppress the gag reflex. It is supposed to be useful for giving anesthetic, taking impressions. swallowing tablets, performing oral hygiene.

This suppresses the reflex rather than eliminating it. I don't want to imagine the outcome of a diver with a suppressed reflex suddenly wearing off under water.

Here is a copy of some of the text from a pharmacy website and a journal reference:

Suppressing the Gag Reflex

The gag reflex can cause a patient considerable discomfort as well as interfere with dental procedures. An electrolyte tablet administered and retained intraorally a few minutes before the start of a procedure can suppress the gag reflex, allowing a mandibular block to be given with much greater ease, which further reduces the gagging reflex.

Tablets can be prescribed for home use for patients who can not properly perform oral hygiene procedures due to the gagging problem. Severe gaggers may need to repeat a dose in 15 to 20 minutes. (Dent Today. 1991 Dec;10(9):68-71)

Some patients and dentists prefer to use electrolyte lollipops.



Citations from Medline

1: Bassi GS, Humphris GM, Longman LP.
The etiology and management of gagging: a review of the literature.
J Prosthet Dent. 2004 May;91(5):459-67.
2: Conny DJ, Tedesco LA.
The gagging problem in prosthodontic treatment. Part II: Patient management.
J Prosthet Dent. 1983 Jun;49(6):757-61. Review.
3: Fiske J, Dickinson C.
The role of acupuncture in controlling the gagging reflex using a review of ten cases.
Br Dent J. 2001 Jun 9;190(11):611-3.
4: Saunders RM, Cameron J.
Psychogenic gagging: identification and treatment recommendations.
Compend Contin Educ Dent. 1997 May;18(5):430-3, 436, 438 passim.
5: Broersma-van der Meulen MJ.
[The extreme gag reflex in dental situations: a review of the literature]
Ned Tijdschr Tandheelkd. 1986 Jun;93(6):217-20 concl. Review. Dutch. No abstract available.



Vomiting while at depth

I was unable to locate any studies regarding vomiting during scuba diving.
The Divers Alert Network (DAN) acknowledges that divers do occasionally vomit while underwater but they do not have a protocol for this event.  They also do not advise vomiting during a dive because of the risk of choking.  Choking may cause a diver to rush to the surface for air.  We are well aware of the dangers associated with this scenario.

If a diver must suddenly vomit during a dive, a common-sense approach might be to:
1) remove the regulator from the mouth and hold it in the hand;
2) vomit;
3) clear the regulator using the purge valve;
4) place the regulator back into the mouth;
5) contact the dive buddy and signal to
abort the dive; and
6) if safe, begin an immediate, controlled ascent to the surface.

*Another point of view is that it's better to go ahead and vomit through the regulator. It is felt that anything would be better than the diver removing the regulator, vomiting and then reflexively gasping a lungful of salt water. The regulator can then be purged and cleared of any stomach content that might be lodged in the valves. A compromise between leaving it in and taking it out would be to leave one side of the regulator in the corner of the mouth, vomiting out the other side and immediately replacing the regulator
for the next breath. This presupposes an aware, highly competent and experienced diver, however.

Recreational scuba diving is supposed to be a fun sport.  If this diver is gagging and vomiting, I doubt he is having fun!  If the gag reflex persists, the diver should discontinue scuba diving.  For additional information, I suggest contacting:

United States Dental Diving Association (USDDA)
http://www.empg.com/usdda
phone: 617-969-6904
fax: 617-224-1908
email: RXGB37A@prodigy.com


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 Ernest Campbell, MD, FACS All Rights Reserved.



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