Sir, the paper The use of acupuncture in controlling the gag reflex... (BDJ 2006; 201: 721–725) raises some interesting ideas but fundamentally misses some obvious points.

The gag reflex is not a stand alone reflex, it is dependent on whether the patient's swallowing reflex can adapt to the stressors to which it is subjected. If it can, there is no gagging, eg sword swallowing. If it cannot adapt, there is gagging.

In more severe cases interference with breathing reflexes initiated by obstructing the oral airway causes coughing and then gagging (we all know the importance of nose breathing when taking a full upper impression).

All the contributory factors to gagging the authors' list — and there are many others — affect swallowing. However, to try and distinguish between somatic and psychogenic gagging further blurs the simplicity of swallowing conditioning which leads to gagging problems. Pavlov's simple experiment would affect his dogs' swallowing!

Each patient has their own individual swallowing pattern which has variable adaption to a greater or lesser degree. Skilful less intrusive dentists encourage patients to have control over their swallowing.

I am surprised that there were no observations of the patient's swallowing movements. In my experience,1-3 all gaggers exhibit subconscious habitual clenched swallowing, which subsides on successful completion of treatment.

I note the authors state that in their technique, the needle is left in situ during impression taking, but in the results, they state that the impression was taken after acupuncture! If so, why was not the needle removed? Did any of the patients have impressions for a full upper denture? If so could they wear the full upper denture?

While a successful technique in the hands of dental acupuncturists, it is difficult to see how to set up a randomised controlled study taking into account all the variables.

The author of the paper, Consultant Acupuncturist Palle Rosted, responds: Thank you for the comments on my paper. We agree that gagging is a complex problem, where the patient's reaction pattern and the dentist's approach to the problem are of importance. In the majority of cases, the dentist and the patient together manage to solve the problem. However, there remains a small group of patients who despite all efforts are unable to solve the problem. It is this group of patients this study concerns.

In this study, all patients had unsuccessfully received the dentist's standard treatment to control the gagging reflex, and the acupuncture was a supplement to this. Dr Wilks mentions a number of important factors for controlling the gag reflex, but as this treatment is a supplementary treatment, one must assume that most of these factors have been tried by the dentist in the past.

Regarding the description of the technique 'the needle is left in situ during impression taking and the impression was taken after acupuncture', the correct wording should have been: 'after stimulation the needle was left in situ during the impression and removed after the impression was taken'.

We have investigated the problem for various procedures, eg for a full upper denture and a bite-wing x-ray. However, to make the test group as homogeneous as possible, we decided only to include this group of patients.

We agree it would be difficult to carry out a proper randomised controlled study in this case; however, it needs to be done to establish, ultimately, if acupuncture is useful to treat this condition.