Association between dental anxiety, hypersensitive gag reflex, and sedative drug requirements during intravenous dental sedation

Abstract

Background

Dental anxiety and hypersensitive gag reflex are common clinical challenges in dentistry and frequently lead to referral for intravenous sedation. Although both conditions may interfere with dental procedures, their potential association with sedative drug requirements remains unclear. This study aimed to evaluate the relationship between dental anxiety, hypersensitive gag reflex, and sedative drug requirements during intravenous dental sedation.

Methods

In this prospective comparative study, 52 adult patients referred for intravenous sedation were categorized according to the primary indication for sedation as dental anxiety (Group 1, n = 26) or hypersensitive gag reflex (Group 2, n = 26). Dental anxiety and gag reflex severity were assessed using the Modified Dental Anxiety Scale (MDAS) and the Gagging Problem Assessment Questionnaire (GPAQ), respectively. Sedation depth was evaluated using the Ramsay Sedation Scale (RSS). Demographic characteristics, procedure duration, and sedative drug doses were recorded. Group comparisons and correlation analyses were performed.

Results

Patients in the dental anxiety group were significantly younger than those in the hypersensitive gag reflex group (p = 0.005). MDAS scores were significantly higher in Group 1, while moderate-to-severe gag reflex responses were more frequent in Group 2 (p < 0.001). No significant differences were observed between groups regarding sedative drug doses or procedure duration. Correlation analysis demonstrated a significant positive association between dental anxiety scores and propofol dose, whereas gag reflex severity was not significantly associated with sedative drug requirements.

Conclusions

Dental anxiety was associated with increased propofol requirements during intravenous sedation, whereas hypersensitive gag reflex severity was not associated with sedative dose. These findings suggest that anxiety-related factors may influence sedative requirements, while management of hypersensitive gag reflex may require additional or adjunctive strategies beyond pharmacological sedation.

Introduction

Dental anxiety is a common problem in the field of dentistry.This problem limits the treatment options of the dentist and at the same time poses significant difficulties for the patient [1]. It is mostly seen in women and young adults [2]. The prevalence ranges from 4.2% to 50% in the literature [3, 4].

Gagging is another common problem experienced by patients during dental treatment [5, 6]. The gag reflex is an involuntary muscle contraction in the back of the throat that prevents objects in the oral cavity from entering the throat outside of normal swallowing and helps prevent choking [7]. In some individuals, this reflex may become hypersensitive and result in clinically significant gagging. Patients with mild gagging can often be managed with non-pharmacological approaches, whereas severe cases may require pharmacological interventions, including intravenous sedative agents such as benzodiazepines or propofol, or in selected cases, general anesthesia [8–10].

Dental anxiety and gag reflex are two common problems in dentistry. Previous studies have emphasized that increased gag reflex may be associated with fear and anxiety about dental procedures and that patients with excessive gag reflex may have high dental anxiety [3, 7]. However, previous evidence suggests that dental anxiety primarily involves psychological and emotional factors, whereas hypersensitive gag reflex is largely mediated by neurophysiological reflex mechanisms [7, 11]. Therefore, although these two problems are often confused clinically, they should be evaluated separately. For this reason, the authors designed this paper on the evaluation and management of dental anxiety and gag reflex.

We hypothesized that dental anxiety and hypersensitive gag reflex represent distinct clinical entities, and that higher dental anxiety levels would be associated with increased sedative drug requirements during intravenous sedation, whereas gag reflex severity would not demonstrate a significant association with sedative dose.

Materials and methods

The study was approved by the Non-Interventional Scientific Research Ethics Committee of Ankara University Faculty of Dentistry (Meeting No: 13, Decision Date: 08.09.2025). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants were informed about the study and provided written informed consent prior to enrollment.

Study population

Patients referred to our department for intravenous sedation were screened for eligibility.

Inclusion criteria

• Adult patients (≥ 18 years of age).

• Patients referred for intravenous sedation due to either dental anxiety or hypersensitive gag reflex.

• Patients classified as suitable for sedation according to the American Society of Anesthesiologists (ASA) physical status classification.

• Patients who provided written informed consent.

Exclusion criteria

• Patients under 18 years of age.

• Patients with contraindications to intravenous sedation.

• Patients with a history of adverse reactions to anesthesia.

• Syndromic patients or those with cognitive impairment affecting questionnaire reliability.

• Patients with incomplete clinical or questionnaire data.

The number of patients to be included in the study was determined as a result of power analysis.

Patients who were consulted to us and who did not have any contraindication to anesthesia after the examination and examination were divided into two groups according to the reasons for referral to us. Patients to be anesthetized due to dental anxiety were categorized as Group 1 and patients to be anesthetized due to gag reflex were categorized as Group 2. Demographic characteristics of the patients included in the study such as age, gender, weight and educational level were recorded. In addition to these demographic characteristics, information about comorbidities, medication use, previous dental procedures and previous dental procedures, if any, were recorded separately for each patient. Although patients were categorized according to the primary referral indication, both dental anxiety (MDAS) and gag reflex severity (GPAQ) were assessed in all participants, allowing evaluation of their associations with sedative drug requirements beyond referral-based grouping.

The Modified Dental Anxiety Scale (MDAS) was used to assess the dental anxiety level of the patients [11]. This questionnaire consists of 5 questions and evaluates the level of anxiety for each question with Likert-type responses ranging from very low to very high, with a total score ranging from 5 to 25.The Gagging Problem Assessment Questionnaire (GPAQ) was used to assess gag reflex status [12]. This is a self-report questionnaire that allows to measure the sensitivity of the patient’s gag reflex in dental practices. In this questionnaire, the situations that cause gagging in the past, the frequency and severity of the reflex and the difficulties experienced by the patient during dental treatment are evaluated.

The Ramsay Sedation Scale (RSS), which evaluates the doses of drugs administered to the patients during the procedure, the duration of the procedure and the level of sedation of the patient, was recorded for each patient [13]. RSS is a clinical scale that evaluates the level of sedation of patients in 6 grades. This scale allows to quickly reveal the sleep-wake state of the patient under sedation.

All patients were sedated in a standardized manner.Patients were evaluated according to the American Society of Anesthesiologists (ASA) physical status classification before the procedure.When it was time for the procedure, an intravenous line was opened and SpO2, heart rate and blood pressure were monitored continuously throughout the procedure.A combination of midazolam, fentanyl and propofol was used in all patients for sedation.The drugs were used gradually during the procedure according to the clinical response and depth of sedation.The depth of sedation was evaluated using RSS as previously mentioned.

The data mentioned above and recorded separately for each patient were recorded by the corresponding author and used for statistical analysis.

This study was designed, conducted, and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.

Statistical analysis

Data analysis was performed with SPSS 27.0 program and 95% confidence level was used. Frequency and percentage (n(%)) statistics for categorical (qualitative) variables, mean, standard deviation (mean ± ss), 25% and 75% percentile and median (M) statistics for numerical (quantitative) variables were given. Independent groups t/Mann Whitney test was used to compare the measurements determined in the study according to the groups, Chi-square test was used in the relationships between grouped variables, and Pearson/Spearman correlation test was used in the relationships between measurements. Statistical significance was set at p < 0.05 for all analyses.

Results

A total of 52 patients met the inclusion criteria, with 26 in Group 1 (dental anxiety) and 26 in Group 2 (hypersensitive gag reflex). The demographic and baseline clinical characteristics of the study population are presented in Table 1.

Table 1.

Demographic and baseline clinical characteristics of the study groups

Variable	Group 1 (Dental Anxiety) (n = 26)	Group 2 (Gag Reflex) (n = 26)	p-value
Age (years), mean ± SD	26.54 ± 10.17	33.15 ± 10.22	0.005*
Age < 30 years, n (%)	20 (76.9%)	9 (34.6%)	0.005*
Gender (Male), n (%)	11 (42.3%)	16 (61.5%)	0.267
Gender (Female), n (%)	15 (57.7%)	10 (38.5%)

There were no significant differences between the groups regarding comorbidities or medication use (p = 0.668 for all comparisons). Educational level (high school and below vs. above high school) did not differ significantly between the groups (p = 0.367). Previous chairside dental procedures were reported by 23 patients in Group 1 and 25 in Group 2, with no significant difference between groups (p = 0.610). Patient weight also showed no significant between-group differences (p = 0.778).

GPAQ scores differed significantly between the groups. The “no reflex” response was more frequent in Group 1 (p < 0.001), whereas moderate and severe reflex responses were more common in Group 2 (p < 0.001). MDAS scores also differed significantly, with higher anxiety levels in Group 1 and higher “no anxiety” responses in Group 2 (p = 0.001).

The mean procedure time was 68.65 ± 19.26 min in Group 1 and 71.73 ± 19.90 min in Group 2, with no significant difference between the groups (p = 0.574). Sedative drug doses and dose ratios are presented in Table 2.

Table 2.

Distribution of the duration of the procedure and the doses and dose ratios of sedative drugs used in both groups

Parameters	Group 1(n = 26)	Group 2 (n = 26)	p Value
Midazolam(mg)	1,88 ± 0,33	1,92 ± 0,27	0,641
Fentanyl(µg)	56,73 ± 16,67	57,69 ± 18,40	0,953
Propofol(mg)	227,31 ± 129,66	221,15 ± 124,94	0,862
Midazolam(mg) / Patient Weight(kg)	0,027 ± 0,007	0,027 ± 0,005	0,694
Fentanyl(mg) / Patient Weight(kg)	0,80 ± 0,19	0,81 ± 0,19	0,800
Propofol(mg) / Patient Weight(kg)	3,22 ± 1,97	2,98 ± 1,33	0,608
Midazolam(mg) / Procedure Time(minutes)	0,03 ± 0,01	0,03 ± 0,01	0,400
Fentanyl(mg) / Procedure Time(minutes)	0,86 ± 0,37	0,90 ± 0,34	0,519
Propofol(mg) / Procedure Time(minutes)	3,18 ± 1,88	3,22 ± 1,64	0,937
Midazolam(mg) / Patient Weight(kg) / Procedure Time(minutes)	0,041 ± 0,017	0,044 ± 0,019	0,602
Fentanyl(mg) / Patient Weight(kg) / Procedure Time(minutes)	0,012 ± 0,005	0,013 ± 0,005	0,687
Propofol(mg) / Patient Weight(kg) / Procedure Time(minutes)	0,045 ± 0,026	0,044 ± 0,018	0,877

*p < 0.05 significant difference, Chi-square (group) test, t/Mann Whitney tests (measurement)

RSS scores were 2.96 ± 0.72 in Group 1 and 3.00 ± 0.57 in Group 2, with no significant group difference (p = 0.831).

In both groups, GPAQ and MDAS scores did not differ according to gender, age, or educational level (p > 0.05 for all). Correlation analyses between GPAQ, MDAS, RSS, demographic variables, procedure duration, and drug doses are presented in Table 3. In Group 1, MDAS scores demonstrated a significant positive correlation with propofol dose (r = 0.469, p = 0.016). MDAS scores were also significantly associated with weight-adjusted propofol dose (r = 0.439, p = 0.025) and propofol dose per procedure time (r = 0.486, p = 0.012). In Group 2, no significant association was observed between GPAQ scores and sedative drug doses. The significant correlations are summarized in Table 3.

Table 3.

Significant correlations between clinical variables and sedative drug parameters

Group	Variable	Correlated Parameter	r	p-value
Group 1	MDAS	Propofol (mg)	0.469	0.016
	MDAS	Propofol (mg/kg)	0.439	0.025
	MDAS	Propofol (mg/min)	0.486	0.012
	MDAS	Propofol (mg/kg/min)	0.487	0.012
	RSS	Propofol (mg)	0.676	< 0.001
	RSS	Propofol (mg/kg)	0.568	0.002
	RSS	Propofol (mg/min)	0.653	< 0.001
	RSS	Propofol (mg/kg/min)	0.575	0.002
Group 2	RSS	Propofol (mg)	0.543	0.004
	RSS	Propofol (mg/kg)	0.455	0.019
	RSS	Propofol (mg/min)	0.474	0.014
	Weight	RSS	0.490	0.011
	MDAS	Midazolam (mg)	0.464	0.017
	RSS	Fentanyl (µg)	0.577	0.002

Discussion

This study evaluated the relationship between dental anxiety, hypersensitive gag reflex, and sedative drug requirements, showing that dental anxiety was more common in younger patients and was positively associated with propofol dose, whereas gag reflex severity was not.

Age, gender, education and socio-economic status have been associated with dental anxiety. It has been shown that female gender, low socio-economic status and young age may be associated with dental anxiety [14, 15]. Kumal et al. evaluated 276 adult patients in their study and showed that age is a parameter associated with dental anxiety [16]. They showed that the level of dental anxiety was higher in younger patients. Different studies in the literature have similarly revealed that dental anxiety can be seen more frequently at lower ages [17, 18]. Locker et al. explained the reason for these age-related changes with their study.As a result of this study, it was stated that the reason for the decrease in dental anxiety may be due to age-related changes in the brain, the gradual decrease in fear responses with age and exposure to more medical treatment over time [19]. Unlike these studies in the literature, Uzel et al. showed a negative relationship between age and dental anxiety in this age group in a study conducted in the pediatric population [20]. Amyot et al., on the other hand, showed that there was no relationship between age and dental anxiety scores [21]. We found that patients younger than 30 years were significantly more prevalent in the dental anxiety group compared to the hypersensitive gag reflex group (p = 0.005). This observation is consistent with previous studies reporting higher levels of dental anxiety among younger individuals.

Intravenous sedation can be successfully used in dental treatment with low mortality and morbidity rates [22]. Pharmacologic sedation can also be successfully used to manage hypersensitive gag reflex as well as dental anxiety [23]. Increasing the patient’s level of fear and anxiety limits patient tolerance and cooperation and increases the likelihood of complications [24]. Apart from these, an increase in the need for sedation and analgesia may also occur [24]. Meço et al. in their study evaluating colonoscopy patients, which is another procedure performed with sedation; revealed that there was no relationship between anxiety level and total drug dose [25]. Chung et al. also evaluated the relationship between anxiety level and sedation requirement before colonoscopy and reported that there was no significant relationship between anxiety levels and drug doses. However, unlike this study, it has been shown that high anxiety level before the procedure may increase the need for sedation and anesthesia during general anesthesia [26–28]. There are limited data in the literature clearly demonstrating the relationship between anxiety level before dental procedures and drug dosages. In the present study, we showed that the need for propofol increased in patients with high dental anxiety level, but there was no relationship between reflex level and drug dosages in patients who were sedated due to hypersensitive gag reflex.

As in every study, there are some limitations in this study. First of all, the study was conducted in a single center with a relatively limited sample size, and the generalizability of the results to larger populations is limited. Patient selection based on voluntary participation increases the possibility of selection bias. The assessment of dental anxiety and gag reflex levels using self-report questionnaires carries the risk of measurement error due to subjective responses of patients. In addition, patient grouping was based on the primary referral indication, which may not have fully eliminated potential overlap between dental anxiety and gag reflex severity. Although both variables were measured in all participants, residual overlap between these clinical entities may have influenced group-based comparisons.Although the sedation protocol was standardized for all patients, drug titration was based on clinical response, which may have created practitioner dependency. Furthermore, the types, durations, and procedural characteristics of dental procedures are not fully standardized, which may have a potential impact on sedative requirements and reflex response. Finally, long-term outcomes or postoperative anxiety/gag reflex changes have not been evaluated.

Conclusions

There was a significant positive correlation between dental anxiety level and propofol dose, indicating an increased sedative requirement in patients with higher anxiety. In contrast, no significant correlation was found between the severity of hypersensitive gag reflex and sedative drug doses. These findings suggest that sedation is effective in managing dental anxiety but may be insufficient for suppressing a hypersensitive gag reflex, for which additional behavioral or local management strategies may be necessary. Furthermore, dental anxiety was observed more frequently in younger patients.

Authors’ contributions

Yasemin Akçaalan contributed to study conception and design, data acquisition, data analysis and interpretation, and drafting and critical revision of the manuscript. Ayşegül Mine Tuzuner contributed to methodological planning, data interpretation, and critical revision of the manuscript. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets generated and/or analyzed during the current study contain identifiable clinical information and are not publicly available due to ethical and confidentiality restrictions. De-identified data may be made available from the corresponding author upon reasonable request and with appropriate institutional approvals.

Declarations

Ethics approval and consent to participate

The study was approved by the Non-Interventional Scientific Research Ethics Committee of Ankara University Faculty of Dentistry (Meeting No: 13, Decision Date: 08.09.2025). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants were informed about the study and provided written informed consent prior to enrollment.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.