Patients often view x-ray procedures with disdain. They may have had previous bad experiences and children are sometimes overwhelmed by the technology. Confidence and compassion on the part of the operator can do wonders for patient compliance.
The key to controlling gagging is breathing through the nose, or holding the breath. No one gags while they are eating, even though food fills the entire oral cavity. The reason is that one does not breath through the mouth while it is filled with food. The position of the tongue in the mouth is all-important because as long as the throat is blocked by the posterior portion of the tongue, gagging does not take place. In order to properly position the tongue, ask the patient to open the mouth as wide as possible and then hum through the nose. If any noise comes out of the mouth (you can usually tell by listening) ask the patient to block the throat with the back of the tongue and try again. Once the patient is clearly humming through the nose with the mouth wide open, tell them to be sure to inhale with the tongue in the same position forcing the breath to enter through the nose. With the breathing controlled in this manner, patients are less likely to have gagging problems. It sometimes helps to lighten the mood by having the patient hum a tune for a few moments while you congratulate him or her on a fine singing voice. As long as the patient remembers to continue to breath through the nose and open very wide while you are inserting the film, the gag reflex is fairly easy to control.
Gagging has a very large psychological component even though it is a physical reaction. While the order of film exposure is of little consequence with most patients, it takes on more significance with gaggers. It is generally best to start the series with anterior or premolar shots which, being placed further forward in the mouth are less likely to stimulate gagging. This shows the patient they can be successful in spite of their fears. It also helps to establish you as the authority. Don’t leave the film or sensor in the patient’s mouth for any longer than absolutely necessary. Set up the machine and do everything else necessary before putting the film in the patient’s mouth. Always instruct the patient to breathe through his or her nose while placing the apparatus. Set the film or sensor in place with confidence and don’t move it around. If the patient gags anyway, try to reassure them that it is a common survival instinct and that you know just what to do to help them control it.
There are mouth washes and throat lozenges available to anesthetize the mouth. Some practitioners swear by salt on the tongue. Others instruct the patient to concentrate on an object or picture in the room. Probably the best thing to concentrate on is breathing through the nose. The common thread running through these techniques is that the operator insists that this technique has worked for many other patients. Since the reflex is triggered by psychological factors, any way that occupies the concentration skills of the patient is helpful. Try different techniques when the opportunity presents itself.
Patients will sometimes refuse x-rays for a variety of reasons. Many will say they do not want to be exposed to the radiation. Explain to the patient that the doses of radiation are small in comparison to the benefit of the diagnostic importance of the x-ray. “The doctor cannot give you a full examination without these.” Also explain to the patient that every effort is made to expose them to the least amount of radiation possible to gain a good x-ray. If the patient has recently had x-rays for medical purposes, they may not want to be exposed again. Each case will be different, depending on the reason for the oral x-ray (routine or because of a problem). If the patient still refuses the x-rays, have the dentist speak to the patient. Every effort should be made on your part to explain the situation to the patient to establish your credibility.
The safety issue is often best resolved by explaining to the patient that the amount of radiation received from dental x-rays is so small that it would take 20 full series surveys (360 films in all) to equal the amount of radiation the patient normally receives from normal environmental background sources over the course of one year. It may be helpful to maintain a printed handout containing some of the information from The practical aspects of radiation safety section in this study course.
The one exception is in the case of a pregnant patient. In an emergency, it is probably best to consult with the patient’s physician before any x-rays are taken, especially in the first trimester. If the patient has a suspicion that they may be pregnant, it is wise to postpone routine x-rays until she is sure she is not pregnant. The lead apron should protect the reproductive area if the x-rays must be taken, but if the patient’s physician recommends against it, postpone any x-rays until after the baby is born.
Informed Consent/Informed Refusals
The patient should give documented informed consent. The patient should have a full explanation of the benefits and the risks of exposure to radiation and they must specifically express his or her permission to have them taken. A written, signed consent form is the easiest way to document the patient’s approval.