Management of gagging for adult dental patients: a systematic review and network meta-analysis

This study aims to evaluate the effectiveness of pharmacological and nonpharmacological interventions for gag management during dental procedures. The PubMed, MEDLINE, Embase, Web of Science Core Collection, Scopus, CENTRAL, ClinicalTrials.gov, and WHO ICTRP databases were searched in December, 2025. The study included English-language randomized controlled trials (RCT) involving adults who received pharmacological or nonpharmacological interventions to manage gagging. Effect sizes were synthesized using meta-analyses of mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs) and a frequentist network meta-analysis to integrate direct and indirect comparisons. Eleven RCTs involving 991 unique participants were included. Based on low-to-very-low certainty evidence, earplugs showed the most favourable point estimate for reducing the gagging prevention index (GPI) in a single trial, followed by 2% lidocaine, 2% tannic acid, 2% zinc acetate, and ear acupuncture. Remimazolam plus remifentanil reduced GPI more than propofol (MD -1.70, 95% CI -1.89 to -1.52), while ear acupuncture showed the strongest improvement in GPI level 1 versus placebo (OR 8.50, 95% CI 1.77 to 40.72). For secondary outcomes, low-level laser therapy at CV24 and Pericardium 6 reduced the subjective severity of the gag reflex by 3.50 (95% CI -4.12 to -2.88) and vomiting events by 3.20 (95% CI -3.79 to -2.61).As certainty was not formally assessed for secondary outcomes, these findings should be considered exploratory. Based on low-to-very-low certainty evidence within a sparse network comprising several single-study comparisons, earplugs and topical desensitizing agents emerged as comparatively promising interventions for managing the gag reflex during dental procedures. These hypothesis-generating findings may help inform the selection of interventions for evaluation in future adequately powered RCTs, rather than support any change to current clinical practice. Other interventions demonstrated variable efficacy. While systemic pharmacological regimens may attenuate the gag reflex to a greater degree, their comparative safety could not be formally evaluated due to inconsistent adverse event reporting based on the current evidence. PROSPERO number: CRD420251276644.