Purpose <p>Excessive gagging in children can hinder the successful completion of intraoral radiographs, adversely impacting diagnosis and treatment. The literature on the use of active distraction during intraoral radiographic techniques in children is limited. The study examined the relationship between the gag reflex and dental anxiety in paediatric patients as well as effectiveness of using an acrylic thumb light in reducing gag severity during intraoral periapical radiography.</p> Methods <p>This in vivo comparative crossover study included 25 children aged 6–13&#xa0;years with moderate to very severe gag reflex (classification of the gagging problem index). Each participant underwent intraoral periapical radiography twice: control (without distraction) and interventional (with play-based distraction using an acrylic thumb light), the order of which was randomised. Gag severity was assessed via the gagging severity (GS) criteria, and dental anxiety was measured via the Modified Child Dental Anxiety Scale–Faces version (MCDASf). The data were analysed via McNemar’s test and the Chi-square test.</p> Results <p>A significant reduction in severe/worst gagging was observed in the intervention group compared with the control group (<i>p</i> = 0.001). Mild/moderate gag responses were noted in 84% of the children in the intervention group versus 40% in the control group. A significant association was found between higher MCDASf scores and increased gag severity in both the control (<i>p</i> &lt; 0.001) and intervention (<i>p</i> = 0.019) conditions.</p> Conclusion <p>Play-based distraction using an acrylic thumb light significantly reduced gag reflex severity during intraoral periapical radiography, with dental anxiety influencing gag response.</p>