ORIGINALARTICLE  
TO DETERMINE THE ASSOCIATION OF GAG REFLEX WITH TYPES OF SOFT PALATE  
A CASE-CONTROL STUDY  
Sha Ullah Khan1  
How to cite this article  
ABSTRACT  
OBJECTIVES  
Khan SU. To Determine the  
This study aimed to assess the association between the gag reex and soft  
palate types.  
Association of Gag Reex with Types  
of Soft Palate – A Case-Control Study.  
J Gandhara Med Dent Sci.  
2026;13(2):92-97  
https://doi.org/10.37762/jgmds.13-2.857  
METHODOLOGY  
This case-control study was conducted in Khyber College of Dentistry,  
Peshawar. The study included 120 participants divided equally into gag  
reex (case=60) and non-gag reex (control=60) groups. Gag reex was  
categorized according to Dickinson and Fiske's Gagging Severity Index.  
Grade 1 was considered normal and allotted to the control group. Grade 2  
was considered mild gagging; Grade 3, moderate; and Grades 4 & 5, severe.  
The soft palate was categorized according to the House classication into  
Class I, Class II, and Class III. Sodium Alginate impressions were recorded  
for patients; those who experienced gagging during impression-taking were  
included in the case group, while those who did not were included in the  
control group.  
Date of Submission: 22-02-2026  
Date Revised:  
Date Acceptance:  
12-03-2026  
15-03-2026  
Correspondence  
1Sha Ullah Khan, Assistant Professor,  
Department of Prosthodontics, Khyber  
College of Dentistry, Peshawar  
RESULTS  
Of 120 patients, 39.2% were male, and 60.8% were female. Compared to the  
control group, gag was signicantly associated with Soft Palate type II (Odds  
Ratio: 4.97; 95% CI: 2.24 to 11) and Soft Palate type III (Odds Ratio: 5.88;  
95% CI: 1.0 to 33.36). Also, a signicant association of the gag reex was  
observed with motion sickness (p=0.001), Gastro-esophageal Reux Disease  
(p<0.001), and Mouth breathing (p=0.005). Age, gender, and education were  
not associated with the gag reex.  
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CONCLUSION  
There is a signicant association between the gag reex and soft palate type,  
motion sickness, and GERD.  
KEYWORDS: Gag Reex, Soft Palate, Impression Recording, Prosthodontic  
Treatment.  
INTRODUCTION  
contact, while the higher brain centre inuences  
psychogenic gagging.6 In somatic gagging, touching a  
One of the most common issues encountered during  
impression recording is an exaggerated gag reex. The  
gag reex is an involuntary contraction of the soft  
palate or pharynx that triggers retching.2 A normal gag  
reex serves as a protective mechanism, regulated by  
the primary parasympathetic division of the autonomic  
nervous system, to prevent foreign objects and harmful  
substances from entering the pharynx, larynx, or  
trachea.3 Abnormal or exaggerated gag reex can be a  
troublesome issue that aects all facets of dentistry,  
from diagnostic procedures to active treatment, and can  
cause distress for everyone involved, particularly  
specific trigger area prompts the reex. Although  
trigger areas vary among individuals, common sites  
include the lateral border of the tongue and certain  
regions of the palate. Somatogenic gagging can also  
arise from inadequate retention of the prosthesis, thick  
posterior borders of the denture, insucient posterior  
seal, tongue space encroachment, and malocclusion.7  
Psychogenic gagging can occur without any direct  
contact. The mere sight, sound, smell, or thought of  
dental treatment can provoke the reex.8 A clear  
division between the somatic and psychogenic reexes  
is not feasible. Somatogenic and psychogenic gagging  
may occur separately or a combination of both types  
may be present.9Several factors can trigger and initiate  
gagging in patients, which are classied as anatomical,  
during  
prosthodontic  
procedures.4  
Clinical  
manifestations of the gag reex include additional signs  
and symptoms such as sweating, weakness, altered  
breathing, increased heart rate, and increased  
salivation.5 The gag reex is classied into  
somatogenic and psychogenic types. Somatic gagging  
medical,  
psychological  
and  
dental/iatrogenic  
factors.10Local anatomical factors include nasal  
obstruction, post nasal drips, nasal polyps, congestion  
is triggered by sensory nerve stimulation from direct of the oral, nasal and pharyngeal mucosa, chronic  
April - June 2026  
J Gandhara Med Dent Sci  
92  
To Determine the Association of Gag Reex  
determine the association between the gag reex and  
diseases of gastrointestinal tract, dentures,  
and  
soft palate types.20 Therefore, this case-control study  
was conducted to assess the association between types  
of soft palate and gag reex among a sample of dental  
patients in our society.  
increased OVD.11Various studies have employed  
dierent indices to quantify the severity of gag reex,  
such as the gag severity index (GSI), the gag prevention  
index (GPI), the gag problem assessment(GPA), the  
visual analogous scale and measuring the depth of swap  
penetration into the soft palate.12 GSI was introduced by  
Fiske and Dickinson, which classies the gag reex  
into ve grades primarily based on level of diculty  
experienced during dental procedures, such as  
recording impressions and performing restorations.13  
METHODOLOGY  
This case-control study was conducted at the  
Prosthodontics Department of Khyber College of  
Dentistry, Peshawar, Pakistan, from 21st August 2025 to  
Numerous techniques have been documented in the 23rd January 2026. The STROBE checklist was used to  
literature to mitigate the gag reex during impression  
recording.14 Some research has demonstrated the  
efciency of acupuncture and behavior modication.15  
Pharmacologic agents that act either peripherally or  
centrally, e.g., topical and local anesthetics, as well as  
general anesthesia, also help control the gag reex by  
blocking aerent impulses from sensitive oral tissues.16  
There are two classications of the soft palate: the  
Angle classication and the You et al. classication. 17  
Angle classication, proposed by MM House, describes  
the extent of soft palate that the posterior palatal seal  
will cover. According to House, there are three types of  
soft palates. Class I: More than 5 mm of movable  
tissues available for post-damming. Class II: 1-5mm of  
movable tissues available for post-damming, where  
good retention is typically achievable. Class III: Less  
than 1 mm of movable tissue available for post-  
damming, where retention is generally poor, often  
observed in conjunction with a high V-shaped palatal  
vault.18 You et al classied the soft palate into six  
report the study's main ndings. The study was  
conducted in full accordance with the World Medical  
Association Declaration of Helsinki. Ethical approval  
was obtained from the Institutional Research Review  
Board (70/RRB/KCD dated 11-August 2025). Non-  
probability, consecutive sampling technique was used.  
The null hypothesis was that there was no association  
between the type of soft palate and gag reex. The  
sample size was calculated using Open Epi sample size  
calculator, considering 35.7% gag reex in healthy  
compared to 13.4% gag reex in medically  
compromised patients, having Odds ratio of 0.29, with  
95% condence interval, alpha ≤ 0.05, with power 80%  
and unexposed/exposed ratio =1.22 The sample size  
calculated was 120 (with 60 cases and 60 controls).  
Inclusion criteria included patients aged 20 to 60 years  
who came for treatment with any prosthesis (removable  
partial denture, xed partial denture, complete denture,  
and/or stabilizing splint) for which impression  
recording was necessary. Exclusion criteria included  
psychological ailment, patients with cleft/lip palate, any  
muscle dystrophy, having any systemic disease,  
palatopharyngeal incompetency, any oral pathology,  
any dental tissue trauma, and /or nasal obstruction. The  
patients for this study were selected based on the  
inclusion and exclusion criteria. The patients were  
briefed about the research. Verbal informed consent to  
participate in this study was obtained. Each patient was  
seated in a dental chair in an upright position, with his  
head against the headrest, facing the dentist, and his  
legs straight. The patients were examined using a  
mouth mirror by gently moving it from the anterior  
palatal region to the junction of the hard and soft  
palates to trigger the gag reflex. After that, a proper-  
sized tray was selected. The Alginate impression  
material was mixed according to the manufacturer's  
instructions. The mixed material was loaded in the  
selected tray. Impressions of the upper arch were  
recorded to assess the gag reflex and to obtain a cast for  
measurement to determine the type of soft palate  
according to House classication.23 Based on angular  
relationship formed by soft palate with hard palate, soft  
palate is classied as "type I": broad and normal with a  
morphological  
types  
based  
on  
digital  
lateral  
cephalogram(Type 1: leaf-shaped; Type 2: rat tail; Type  
3: butt-like; Type 4:straight line; Type 5: S-shaped, and  
Type 6: crook-shaped.19 According to a study by  
Halboub E. et al., the prevalence of class I, class II, and  
class III soft palates was 53%, 33%, and 14%,  
respectively, and they found an association between  
soft palate type and the gag reex.20 According to one  
study by Kainat Alamgir, the prevalence of the gag  
reex was found to be 55.14%.13 Nagham H Kassab  
reported a prevalence of 17.70% of gag reex.21  
According to another study by Meshni AA, 49.1%  
patients had a gag reex. This study further evaluated  
gag reexes according to patients' general health status  
and found that healthy patients (35.7%) had a higher  
rate of gag reexes than medically compromised  
patients (13.4%).22 As most oral and dental treatments  
can trigger the gag reex, it is very important to know  
about the gag reex and its associated or causative  
factors. To our knowledge, no case-control study has  
examined the relationship between soft palatal types  
and the gag reex; however, only a single cross-  
sectional study has been conducted in Saudi Arabia to  
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To Determine the Association of Gag Reex  
band of 5-12 mm resilient tissue posterior to the line the frequency of soft palate type I was 66.7% (n=40),  
between tuberosities which is almost horizontal or turns  
down from the hard palate gently at angle <10°; "type  
II": about 3-5 mm resilient tissue posterior to the line  
between tuberosities which turns down from the hard  
palate at angle 10-45°; and "type III": about 2-3 mm  
resilient tissue anterior to the line between tuberosities  
which turns down sharply from the hard palate at angle  
>45°. The severity of the gag reex was assessed  
through the Dickinson and Fiske gagging severity  
index.24 Grade 1 was considered to have no abnormal  
gag reex. Grade 2 was considered mild, Grade 3  
moderate, and Grades 4 & 5 as severe gag reex.  
Patients who experienced gagging during impression  
recording and during mirror movement in the palatal  
region were considered cases, and those who did not  
were selected as controls. Demographic and general  
information were recorded in a structured proforma.  
Based on education, patients were divided into 5  
groups: group 1 with no education; group 2 with up to  
type II was 30% (n=18) and type III was 3.30 % (n=2)  
while among the cases (n=60), soft palate type I was  
28.3% (n=17), type II was 63.3% (n=38) and type III  
was 8.3% (n=5) (table 3). Among cases, according to  
the Gag Reex Severity Index, grade II (mild) was  
86.66% (n=52), grade III (Moderate) was 7 (11.6%),  
and grade IV (Severe) was 1 (1.66%), respectively  
(Table 2). Chi-square analysis shows a signicant  
association between soft palate type and gag reex  
(Chi=<0.05; table 3). Compared to the control, the odds  
of being palatal type II are 4.97 (95% C.I., 2.24-11)  
times greater than in gag reex patients, and also,  
compared to the control, the odds of being palatal type  
III are 5.88 (95% C.I., 1-33.36) times greater than in  
gag reex patients. Binary logistic regression analysis  
was applied, using the gag reex as the dependent  
variable and age, gender, education, motion sickness,  
GERD, mouth breathing, and palatal type form as  
independent variables. The model was suitable, and the  
Hosmer-Lemeshow test was adequate (Table 4).  
primary education; group  
3
with up to middle  
education; group 4 with up to SSC; and group 5 with  
HSSC or above. Concerning age, the patients were  
divided into four age groups, i.e., Group I = 20-30  
years, Group II=31-40 years, Group III = 41-50 years,  
and Group IV = 51-60 years. The data was analyzed  
using SPSS version 23. Independent variables were age,  
gender, education, soft palate type, motion sickness,  
mouth breathing, and Gastro-Esophageal Reux  
Disease (GERD). The dependent variable was the gag  
reex. The mean and standard deviation were  
determined for a scale variable, such as age. Frequency  
and percentages were calculated for categorical  
variables, including age groups, gender, types of soft  
palate, mouth breathing, motion sickness, GERD, and  
severity of gag. Odds ratio with 95% condence  
interval was used to assess the association between the  
gag reex and types of soft palate. The chi-square test  
was used to assess the association between gender, age  
group, motion sickness, mouth breathing, and GERD  
and the gag reex. A binary logistic regression model  
was also applied to identify the study variables that  
were predictive of the gag reex.  
Table 1: Characteristics of Patients Who Participated  
Parameters  
Age groups  
20-30 years  
31-40 years  
41-50 years  
51-60 years  
Gender  
Frequency (%)  
36 (30%)  
24 (20%)  
21(17.5%)  
39 (32.5%)  
Male  
47 (39.2%)  
73 (60.8%)  
Female  
Education  
No education  
Primary  
61 (50.8%)  
07 (5.8%)  
09 (7.5%)  
11 (9.2%)  
14 (11.7 %)  
18 (15 %)  
Middle  
Matric  
FSc  
Bachelor's or higher  
Motion sickness  
No  
92 (76.7%)  
28 (23.3%)  
Yes  
GERD  
No  
Yes  
91 (75.8%)  
29 (24.2%)  
Breathing during sleep  
Through Nose  
Through Mouth  
Palatal types  
Type I  
86 (71.7%)  
34 (28.3%)  
RESULTS  
57 (47.5%)  
56 (46.7%)  
07 (5.8%)  
A total of 120 patients were enrolled in this study,  
divided into two groups: 60 cases and 60 controls. The  
patients' ages ranged from 20 to 60 years, with a mean  
of 41.9 (± 14). The mean age of patients in the case and  
control groups was 41.8 (±13.5) and 42 (±14.7),  
respectively. Of 120 patients, 39.2% were male, and  
60.8% were female (Table 1). The numbers of males  
and females were almost the same in the case group as  
in the control group (Table 3). Among controls (n=60),  
Type II  
Type III  
Table 2: Frequency Distribution of Gag Reflex Severity in the  
Case Group  
Gag severity  
Mild gag  
Moderate gag  
Severe gag  
Frequency  
%age  
52  
07  
01  
86.66 %  
11.66 %  
1.66 %  
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To Determine the Association of Gag Reex  
Table 4: Binary Logistic Regression Analysis Showing Odds  
Table 3: Cross-Tabulation of Gag Reex with Age, Gender,  
Education, Motion Sickness, Gerd, Breathing, and Palatal Type.  
Ratios and Condence Intervals of Gag about Age, Gender,  
Education, Motion,Gerd, Breathing Pattern, and Palatal Type  
Parameters  
Case or Control  
P value  
Variables  
Crude Odds Adjusted Odds  
p-  
(chi-square)  
Control  
Case  
Ratio  
Ratio  
value  
Age groups  
20-30 years  
31-40 years  
41-50 years  
51-60 years  
Gender  
(95% CI)  
(95% CI)  
REF Value 1.0  
1.51  
0.379  
19  
12  
07  
22  
17  
12  
14  
17  
Age  
groups  
Group 1  
Group 2  
1.12  
0.547  
0.090  
0.258  
( 0.39-3.14) (0.396-5.76)  
Group 3  
Group 4  
2.24  
3.88  
(0.81-18.6)  
2.17  
(0.73-6.84)  
0.864  
0.575  
0.179  
Male  
25  
35  
22  
38  
Female  
(0.35-2.15)  
(0.566-8.32)  
REF Value 1.0  
3.6  
Education  
No education  
Primary  
Gender  
Male  
Female  
37  
02  
05  
03  
06  
24  
05  
04  
08  
08  
11  
1.23  
(0.59-2.57)  
0.036  
(1.1-11.75)  
REF Value 1.0  
Middle  
Education No  
education  
Matric  
HSSC  
Primary  
Middle  
Matric  
HSSC  
3.9  
7.5  
0.067  
0.773  
0.041  
0.333  
0.352  
Bachelor's or higher 07  
Motion sickness  
(0.69-21.49) (0.869-65.3)  
1.23  
1.323  
0.001  
0.000  
0.005  
0.000  
No  
54  
06  
38  
22  
(0.30-5.1)  
4.11  
(0.197-8.87)  
7.48  
Yes  
GERD  
(0.99-17.1)  
2.1  
(1.09-51.22)  
2.089  
No  
55  
05  
36  
24  
Yes  
(0.63-6.7)  
(0.471-9.27)  
2.112  
Breathing during sleep  
Through Nose  
Through Mouth  
Palatal types  
Type I  
Bachelor's 2.4  
50  
10  
36  
24  
or above  
No  
Yes  
(0.82-7.12)  
(0.438-10.193)  
REF Value 1.0  
4.96  
Motion  
sickness  
5.21  
0.007  
0.006  
0.091  
40  
18  
02  
17  
38  
05  
(1.91-14.07) (1.54-15.99)  
REF Value 1.0  
Type II  
GERD  
No  
Yes  
Type III  
7.33  
5.55  
(2.56-20.98) (1.63-18.91)  
REF Value 1.0  
Breathing Nose  
Mouth  
3.33  
(1.42-7.82)  
2.57  
(0.86-7.69)  
REF Value 1.0  
2.97  
Palate  
Type  
Type I  
Type II  
4.97  
0.041  
0.05  
(2.23-11.03) (1.048-8.432)  
Type III  
5.88  
8.004  
(1.04-33.35) (0.984-65.122)  
DISCUSSION  
soft palate type was highly signicant (p<0.001) (Table  
3). These observations are consistent with Halboub et  
al. and Qamar K., who reported a signicant correlation  
between soft palate type and gagging.20, 25 In this study,  
no association between gender and the gag reex was  
found, which is consistent with Muhammad Kamran  
and Hiroyuki Karibe. However, in contrast to the  
studies of Alamgir, Halboub E, and Qamar K, where  
they found an association of gender with gag reex and  
according to them a higher proportion of females  
experienced gag compared to males, In the present  
study, the association between age groups and the gag  
reex was found to be insignicant (p=0.379). 13, 20, 25  
Similar ndings were reported by Halboub E and  
Qamar K, who found no signicant association between  
age groups and gagging.20,25 There was a signicant  
association between motion sickness, GERD, mouth  
breathing, and the gag reex. The binary logistic  
regression analysis suggests that, for every unit increase  
Gag reex is often a problem for dentists during  
dental procedures, hindering or even preventing them  
from being performed. This study aimed to investigate  
the association between soft palate type and the gag  
reex in patients during impression recording with  
Sodium alginate. In the present study, among the case  
group, a mild gag reex was most common (86.7%),  
followed by moderate (11.6%), while severe (1.7%)  
was least common. These ndings align with those of  
Halboub E and Qamar K.20,25 Regarding soft palate  
morphology, among controls, type I was 66.7%,  
followed by type II (30%) and type III (3.3%). Similar  
findings were also observed by Qamar K et al., who  
found soft palate type I=60%, type II=31.6%, and type  
III=3.3%.25 However, among cases (gag group), soft  
palate type I was 28.3%, type II was 63.7%, and type  
III was 8.3%, which contrasts with the study by Khan  
SU.26 The association between gag reex severity and in soft palate type II and type III, the odds of increased  
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J Gandhara Med Dent Sci  
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To Determine the Association of Gag Reex  
5. Kanlieva T, Georgiev K, Abadjiev M. Dierent methods for the  
gag reex were 3 and 8 times, respectively (Table 4).  
There are various methods for managing the gag reex.  
Gag reex can be managed either by pharmacological  
or non-pharmacological means.27 Local anesthetics,  
general anesthesia, sedatives, and herbal medications  
are examples of pharmacological approaches. As a  
preventive measure, Rabemac-DSR (rabeprazole 20 mg  
and domperidone 30 mg sustained release) can be  
prescribed orally 1 h prior to the nal impression  
making for eective prevention of nausea and  
vomiting.28 Non-pharmacological techniques such as  
behavioral therapy, hypnosis, acupuncture, distraction  
and laser therapy are also mentioned.29 Digital  
impression or the intra-oral scanning might be the best  
option in this matter.30 In certain instances, a lack of a  
gag reex may be a symptom of a more severe medical  
condition, such as cranial nerve damage or brain  
death.31 A larger sample with more participants with a  
severe gag reex would enable a stronger association of  
the gag reex with other covariates.  
management of the gag reex during prosthetic treatment. Int  
Bull Otorhinolaryngol. 2022;4:13-17.  
6. Karibe H, Okamoto A, Kato Y, Shimazu K, Goddard G.  
Reliability, validity, and sex dierences in a quantitative gag  
reex measurement method. J Oral Rehabil. 2018;45:798-804.  
https://doi.org/10.1111/joor.12667 PMID: 30004169.  
7. Fiske J, Dickinson C. The role of acupuncture in controlling the  
gagging reex: a review of ten cases. Br Dent J. 2001;190:611-  
613. https://doi.org/10.1038/sj.bdj.4801043 PMID: 11453176.  
8. Dickinson CM, Fiske J. A review of gagging problems in  
dentistry: aetiology and classication. Dent Update.  
2005;32(1):26-32.  
9. Ali S, George B, Kirmani U, Al-Saiari AKA, Almasabi FRA,  
Iqbal Z. Gagging and its management in prosthodontic patients:  
a review of literature. Biomedica. 2018;34(3):178-183.  
10. Bassi GS, Humphris GM, Longman LP. The aetiology and  
management of gagging: a review of the literature. J Prosthet  
Dent.  
2004;91(5):459-467.  
PMID:  
https://doi.org/10.1016/j.prosdent.2004.02.003  
15153851.  
11. Ahmad N, Yunus N, Jafri Z. Etiology and management of gag  
reex in the prosthodontic clinic: a review. Int J Oral Health  
Dent. 2015;1(1):25-28.  
12. Mehdizadeh M, Mohammadbeigi A, Sharinejad A. An  
overview of new methods in management of gag reex during  
dental treatment:  
a
systematic review.  
J
Dent (Shiraz).  
LIMITATIONS  
2023;24(4):372-381.  
https://doi.org/10.30476/dentjods.2023.98274.1960  
38119877 PMCID: PMC10735476.  
PMID:  
The limitation was the small sample size, which may  
have undermined the study's power to detect  
dierences/associations and limited the generalizability  
of the results. Secondly, with the above study  
procedure, we were able to trigger a somatogenic type  
of gag reex; hence, the Psychogenic type of gag reex  
was out of scope for this study.  
13. Alamgir K, Saleem T. Prevalence and severity of gag reex in  
patients presenting at the department of prosthodontics. Prof  
Med  
J.  
2024;31(9):1301-1306.  
https://doi.org/10.29309/TPMJ/2024.31.09.7850.  
14. Rosted P, Bundgaard M, Fiske J, Pedersen AML. The use of  
acupuncture in controlling the gag reex in patients requiring an  
upper alginate impression: an audit. Br Dent J. 2006;201:721-  
725. https://doi.org/10.1038/sj.bdj.4814259 PMID: 17128222.  
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hypersensitive gag response. J Prosthet Dent. 2001;85(3):305-  
CONCLUSIONS  
309.  
https://doi.org/10.1067/mpr.2001.113848  
PMID:  
11268352.  
According to this study, soft palate type is signicantly  
associated with the gag reex. The gag reex is also  
more common in patients with motion sickness, GERD,  
and mouth breathing.  
16. Kaira LS, Dabral E, Kukreja HS. Gagging: a review. Nitte Univ  
J Health Sci. 2014;4:149-155.  
17. Mariyam A, Verma AK, Saurabh C, Naeem A, Anuj S.  
Posterior palatal seal (PPS): a brief review. J Sci Innov Res.  
2014;3(6):602-605.  
18. Bindhoo YA, Thirumurthy VR, Jacob SJ, Anjanakurien, Limson  
KS. Posterior palatal seal: a literature review. Int J Prosthodont  
Restor Dent. 2011;1(2):108-114.  
CONFLICT OF INTEREST: None  
FUNDING SOURCES: None  
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AUTHORS CONTRIBUTION  
Shafi Ullah Khan - Concept & Design; Data Acquisition; Data  
outbreak.  
J
Dent  
Sci.  
2021;16:791-792.  
Analysis/Interpretation;  
Drafting  
Manuscript;  
Critical  
https://doi.org/10.1016/j.jds.2020.12.002 PMID: 33614837  
PMCID: PMC7892874.  
Revision; Supervision; Final Approval  
28. Bhuskute MV. Use of training denture bases and palateless  
dentures: two strategies for managing severe gag reex in  
edentulous patients. Saint Int Dent J. 2020;4:63-66.  
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