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The gag reflex is a normal response for patients, designed to protect the airway and remove irritants from the posterior oropharynx and the upper gastro-intestinal tract. However, some patients have an increased gag reflex which presents many challenges for both dentist and patient. Empathy and patience is needed, in addition to an appropriate treatment plan and clinical technique. This paper describes the gag reflex, its clinical significance and a range of management and treatment strategies in order to produce a successful treatment outcome.