Management of the Retching Patient

Question 1

What is retching?

Answer 1

• physiological mechanism causing involuntary contraction of the muscles of the soft palate and pharynx
• modified by higher centres in the medulla oblongata
  
  • potentially a psychological component
• varies greatly between patients

Question 2

What are the two different types of retching?

Answer 2

• psychogenic
  
  • retching may occur by sight, smell or sound of a dental surgery or thought of a treatment
• somatic
  
  • touching trigger zones
    
    • palatoglossal and palatopharyngeal folds
    • base of tongue
    • palate
    • uvula
    • posterior pharyngeal wall
• usually coexist and anxiety make it worse

Question 3

What difficulties are posed by a retching patient in prosthodontics?

Answer 3

• impression material
• jaw registration
• toleration of dentures
• denture retention
  • palate often reduce to increase tolerance

Question 4

How can the retching patient be managed in prosthodontics?

Answer 4

• identification of problems
• identification of trigger zones
• anxiety reduction
• patience and empathy

Question 5

How can relaxation be used to help a retching patient?

Answer 5

• passive relaxation
  
  • dim lighting
  • music
  • avoid sight of dental instruments
    
    • identify triggers
• active relaxation
  
  • controlled rhythmic or relaxed abdominal breathing

Question 6

How can distraction be used to manage a retching patient?

Answer 6

• talking to patient
• get patient to concentrate on something
  
  • keeping legs raised
  • wiggling toes
  • tap temple
• salt on tongue
  
  • anecdotal evidence
  • focus on taste rather than procedure
• close eyes of focus on fixed point
• rinse mouth with very cold water
  
  • altered conditions in mouth

Question 7

When are distraction techniques useful for a retching patient and which is most effective?

Answer 7

• useful especially during impressions and jaw registration
• different techniques work for each patient
  • trial and error

Question 8

How can desensitisation be used to manage a retching patient?

Answer 8

• repeated brushing or stroking anterior palate or tongue
  
  • finger or toothbrush
  • pre-treatment ‘homework’
    
    • do not take impressions at first appointment
• swallowing with mouth open
• complementary treatment
  
  • hypnosis
  • acupressure
  • CBT

Question 9

How can impression taking be altered for the retching patient?

Answer 9

• modify stock trays
  
  • acrylic bur
• lower stock trays for upper arch
  
  • horseshoe CoCr does not require entire palate
• modified special trays
  
  • palatal reduction
  • sectional trays
• rapid setting impression materials
  
  • dental compound
  • alginate mixed with warmer water
    
    • reduced exposure time
    • must work quickly

Question 10

How can denture design be altered for a retching patient?

Answer 10

• consider shortened dental arch
  
  • especially for lower arch
  • 5-5
  • 4-4 or 3-3
    
    • use of bridges or implants
• horseshoe palatal connector
• buccal bar connector
  
  • rarely used
• Co/Cr rather than acrylic
• Essix retainer denture
  
  • short term
• training plate
• multiple post dams
  
  • application of pressure to palatal tissues
    
    • reduces retching
• denture well adapted to tissues
• reduced palatal thickness
• rounded cusps of posterior teeth
  
  • to not stimulate dorsal of tongue
• no second molars
  
  • not necessary on dentures

Question 11

What is a training plate and how can it help a retching patient?

Answer 11

• used for patient adapting to complete dentures
• acrylic plate with a small number of teeth
  
  • usually anterior teeth initially
  • teeth added
• several post dams
  
  • provide pressure on palatal tissue
    
    • reduced retching
  • can be cut back
    
    • retention not lost as quickly