HYPNOSIS AND DENTISTRY
A solution to fear, anxiety and pain
The use of hypnosis in dentistry is mostly unknown to specialists, especially in Italy. Nevertheless, experimental evidence demonstrates its efficacy and usefulness for both the dentist and his patients.
The dentist’s room is often associated to unpleasant experiences. The worst of them is maybe pain, but we also have to consider, among the others, the sensation of being at the mercy of somebody1, the sensation of uneasiness that comes from the contact with the tools and the gag reflex that they can cause. Epidemiological studies show that about 75% of dental patients feel scared, 10-15% feel anxious and 20% of them even report physical symptoms that are connected with feelings of discomfort2-5. The above listed characteristics put patients at the risk of skipping appointments, procrastinating routine examinations, or, in the best of hypotheses, to consider dental care with intense stress that, along with complicating the intervention, may reinforce avoiding behaviors6. Hypnosis, by acting on anxiety, pain and stress management skills, makes patients more collaborative and allows the specialist to work in a better context.
A research conducted during oral and maxillofacial interventions7 reports how patients treated with hypnosis before visits showed – compared to a control group – stress reductions. This is clear both from the behavioural and sympathetic nervous system activation standpoints; researchers, in fact, reported a better state of relaxation and a greater sensation of wellness associated to dental care, which remains stable in time. These results support what was previously observed in previous research: applying hypnotic techniques in dental environment to improve the perception of the room and of the dentist himself, lowers anxiety levels and favour attendance to visits.
In other words, hypnosis, while facilitating the dentist’s work, can improve patients’ psychological experience, promoting their dental health. This effect can be reinforced by controlling procedure-related pain of patients through hypnosis. A recent research9 was conducted on a group of patients affected by dentin hypersensitivity, a condition that characterizes individuals who feel intense pain when their teeth are exposed to different kinds of stimuli: thermic, osmotic, chemical or tactile10. By comparing group of subjects who were under different kind of desensitizing therapy, researchers found in hypnosis an effective alternative to currently used protocols – such as fluoridation or desensitizing substances based treatment – obtaining, since the first week after the beginning of treatment, a reduction of perceived pain that also lasted longer compared to other techniques. Furthermore the efficacy was not related to patients’ stress levels and it was associated to higher scores of treatment satisfaction.
Such effect can also be used to favour post-operatory recovery. An example of this application can be found in a group of patients to whom hypnosis was proposed as a way to deal with pain caused by molar extractions11: compared to a group that was treated with standard procedures, subjects exposed to hypnosis, reported, along with a remarkable decrease of anxiety during the intervention, a great reduction in the use of analgesics after the operation.
There is also evidence suggesting that hypnosis may be useful to reduce bleeding, frequency of infection12,13, recovery time14 and, therefore, the time spent in hospital in case of complex interventions15,16.
As the evidence presented suggest, along with other experimental results, we can infer that hypnosis can be useful to dentists especially when treating “sensitive” subjects, such as patients who have an intense gag reflex17-19, patients with dental phobia20-22, previously traumatized23, or with children.
Recent research seem to have focused on paediatric patients and, along with confirming results about the reduction of anxiety levels in adult patients, it is clear that hypnosis can be useful during specific phases of interventions that children experience as stressful. In a research conducted in 201124, researchers from the university of Rennes used hypnosis to help children overcoming the fear of the needles used for anaesthesia. In 19% of children (and 10% of adults) this becomes a true phobia. In extreme cases general anaesthesia can be used, even if it doesn’t always solve the problem, it often requires medical supervision and, along with being quite expensive, it is difficult to integrate it in dental care routines25-27. Results of the study, that compared a group of children who were exposed to hypnosis with a control group, show that hypnosis heightened pain threshold, reducing thus pain intensity and increasing the number of patients who didn’t feel anything. Such effects are stable and can be accompanied by reduction of weeping, of interfering behaviours, and by an overall reduction of physiologic arousal28.
Hypnosis can also be used to favour compliance of children in long-term therapeutical projects, such as those that include the use of orthodontic appliances that are far better tolerated by children who benefited from a hypnotic treatment.
In conclusion, ultra-rapid techniques can also be used in dental settings, in order to promote well being and a balanced, daily dental care routine.
Bibliography
1. Eitner, S., et al., Changes in neurophysiologic parameters in a patient with dental anxiety by hypnosis during surgical treatment. J Oral Rehabil, 2006. 33(7): p. 496-500.
2. Gatchel, R.J., The prevalence of dental fear and avoidance: expanded adult and recent adolescent surveys. J Am Dent Assoc, 1989. 118(5): p. 591-3.
3. Hakeberg, M., U. Berggren, and S.G. Carlsson, Prevalence of dental anxiety in an adult population in a major urban area in Sweden. Community Dent Oral Epidemiol, 1992. 20(2): p. 97-101.
4. Locker, D., D. Shapiro, and A. Liddell, Who is dentally anxious? Concordance between measures of dental anxiety. Community Dent Oral Epidemiol, 1996. 24(5): p. 346-50.
5. Moore, R., et al., Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol, 1993. 21(5): p. 292-6.
6. Peltier, B., Psychological treatment of fearful and phobic special needs patients. Spec Care Dentist, 2009. 29(1): p. 51-7.
7. Eitner, S., et al., Neurophysiologic and long-term effects of clinical hypnosis in oral and maxillofacial treatment--a comparative interdisciplinary clinical study. Int J Clin Exp Hypn, 2006. 54(4): p. 457-79.
8. Moore, R., I. Brodsgaard, and R. Abrahamsen, A 3-year comparison of dental anxiety treatment outcomes: hypnosis, group therapy and individual desensitization vs. no specialist treatment. Eur J Oral Sci, 2002. 110(4): p. 287-95.
9. Eitner, S., et al., Comparison of conventional therapies for dentin hypersensitivity versus medical hypnosis. Int J Clin Exp Hypn, 2010. 58(4): p. 457-75.
10. Addy, M. and N. Pearce, Aetiological, predisposing and environmental factors in dentine hypersensitivity. Arch Oral Biol, 1994. 39 Suppl: p. 33S-38S.
11. Enqvist, B. and K. Fischer, Preoperative hypnotic techniques reduce consumption of analgesics after surgical removal of third mandibular molars: a brief communication. Int J Clin Exp Hypn, 1997. 45(2): p. 102-8.
12. Lucas, O.M., Dental extraction in hemophiliac: Control over emotional factors by hypnosis. American Journal of clinical hypnosis, 1962. 14: p. 126-127.
13 Newman, M., Hypnotic handling of the chronic bleeder in extraction: a case report. Am J Clin Hypn, 1971. 14(2): p. 126-7.
14. George, J.M., et al., The effects of psychological factors and physical trauma on recovery from oral surgery. J Behav Med, 1980. 3(3): p. 291-310.
15. Enqvist, B., L. von Konow, and H. Bystedt, Pre- and perioperative suggestion in maxillofacial surgery: effects on blood loss and recovery. Int J Clin Exp Hypn, 1995. 43(3): p. 284-94.
16. Enqvist, B., L. von Konow, and H. Bystedt, Stress reduction, preoperative suggersion in maxillofacial surgery. Stress medicine, 1995. 11: p. 229-233.
17. Barsby, M.J., The use of hypnosis in the management of gagging and intolerance to dentures. British dental journal, 1994. 176: p. 97-102.
18. Eitner, S., M. Wichmann, and S. Holst, "Hypnopuncture"--a dental-emergency treatment concept for patients with a distinctive gag reflex. Int J Clin Exp Hypn, 2005. 53(1): p. 60-73.
19. Eitner, S., M. Wichmann, and S. Holst, A long-term therapeutic treatment for patients with a severe gag reflex. Int J Clin Exp Hypn, 2005. 53(1): p. 74-86.
20. Finkelstein, S., Hypnotically assisted preparation of the anxious patient for medical and dental treatment. Am J Clin Hypn, 1991. 33(3): p. 187-91.
21. Forgione, A.G., Hypnosis in the treatment of dental fear and phobia. Dent Clin North Am, 1988. 32(4): p. 745-61.
22. Hammarstrand, G., U. Berggren, and M. Hakeberg, Psychophysiological therapy vs. hypnotherapy in the treatment of patients with dental phobia. Eur J Oral Sci, 1995. 103(6): p. 399-404.
23. Boundy, M., Dental distress. A possible relief. Aust Endod J, 2001. 27(3): p. 123-5.
24. Huet, A., et al., Hypnosis and dental anesthesia in children: a prospective controlled study. Int J Clin Exp Hypn, 2011. 59(4): p. 424-40.
25. Dworkin, S.F., et al., Analgesic effects of nitrous oxide with controlled painful stimuli. J Am Dent Assoc, 1983. 107(4): p. 581-5.
26. Faytrouny, M., Z. Okte, and Z. Kucukyavuz, Comparison of two different dosages of hydroxyzine for sedation in the paediatric dental patient. Int J Paediatr Dent, 2007. 17(5): p. 378-82.
27. Zanette, G., E. Facco, and G. Manani, The use of intranasal midazolam in the treatment of paediatric dental patients. Anaesthesia, 2008. 63(8): p. 887.
28. Gokli, M.A., et al., Hypnosis as an adjunct to the administration of local anesthetic in pediatric patients. ASDC J Dent Child, 1994. 61(4): p. 272-5.
29. Trakyali, G., et al., Conscious hypnosis as a method for patient motivation in cervical headgear wear--a pilot study. Eur J Orthod, 2008. 30(2): p. 147-52.
30. Finkelstein, S., Rapid hypnotic inductions and therapeutic suggestions in the dental setting. Int J Clin Exp Hypn, 2003. 51(1): p. 77-85.
The dentist’s room is often associated to unpleasant experiences. The worst of them is maybe pain, but we also have to consider, among the others, the sensation of being at the mercy of somebody1, the sensation of uneasiness that comes from the contact with the tools and the gag reflex that they can cause. Epidemiological studies show that about 75% of dental patients feel scared, 10-15% feel anxious and 20% of them even report physical symptoms that are connected with feelings of discomfort2-5. The above listed characteristics put patients at the risk of skipping appointments, procrastinating routine examinations, or, in the best of hypotheses, to consider dental care with intense stress that, along with complicating the intervention, may reinforce avoiding behaviors6. Hypnosis, by acting on anxiety, pain and stress management skills, makes patients more collaborative and allows the specialist to work in a better context.
A research conducted during oral and maxillofacial interventions7 reports how patients treated with hypnosis before visits showed – compared to a control group – stress reductions. This is clear both from the behavioural and sympathetic nervous system activation standpoints; researchers, in fact, reported a better state of relaxation and a greater sensation of wellness associated to dental care, which remains stable in time. These results support what was previously observed in previous research: applying hypnotic techniques in dental environment to improve the perception of the room and of the dentist himself, lowers anxiety levels and favour attendance to visits.
In other words, hypnosis, while facilitating the dentist’s work, can improve patients’ psychological experience, promoting their dental health. This effect can be reinforced by controlling procedure-related pain of patients through hypnosis. A recent research9 was conducted on a group of patients affected by dentin hypersensitivity, a condition that characterizes individuals who feel intense pain when their teeth are exposed to different kinds of stimuli: thermic, osmotic, chemical or tactile10. By comparing group of subjects who were under different kind of desensitizing therapy, researchers found in hypnosis an effective alternative to currently used protocols – such as fluoridation or desensitizing substances based treatment – obtaining, since the first week after the beginning of treatment, a reduction of perceived pain that also lasted longer compared to other techniques. Furthermore the efficacy was not related to patients’ stress levels and it was associated to higher scores of treatment satisfaction.
Such effect can also be used to favour post-operatory recovery. An example of this application can be found in a group of patients to whom hypnosis was proposed as a way to deal with pain caused by molar extractions11: compared to a group that was treated with standard procedures, subjects exposed to hypnosis, reported, along with a remarkable decrease of anxiety during the intervention, a great reduction in the use of analgesics after the operation.
There is also evidence suggesting that hypnosis may be useful to reduce bleeding, frequency of infection12,13, recovery time14 and, therefore, the time spent in hospital in case of complex interventions15,16.
As the evidence presented suggest, along with other experimental results, we can infer that hypnosis can be useful to dentists especially when treating “sensitive” subjects, such as patients who have an intense gag reflex17-19, patients with dental phobia20-22, previously traumatized23, or with children.
Recent research seem to have focused on paediatric patients and, along with confirming results about the reduction of anxiety levels in adult patients, it is clear that hypnosis can be useful during specific phases of interventions that children experience as stressful. In a research conducted in 201124, researchers from the university of Rennes used hypnosis to help children overcoming the fear of the needles used for anaesthesia. In 19% of children (and 10% of adults) this becomes a true phobia. In extreme cases general anaesthesia can be used, even if it doesn’t always solve the problem, it often requires medical supervision and, along with being quite expensive, it is difficult to integrate it in dental care routines25-27. Results of the study, that compared a group of children who were exposed to hypnosis with a control group, show that hypnosis heightened pain threshold, reducing thus pain intensity and increasing the number of patients who didn’t feel anything. Such effects are stable and can be accompanied by reduction of weeping, of interfering behaviours, and by an overall reduction of physiologic arousal28.
Hypnosis can also be used to favour compliance of children in long-term therapeutical projects, such as those that include the use of orthodontic appliances that are far better tolerated by children who benefited from a hypnotic treatment.
In conclusion, ultra-rapid techniques can also be used in dental settings, in order to promote well being and a balanced, daily dental care routine.
Bibliography
1. Eitner, S., et al., Changes in neurophysiologic parameters in a patient with dental anxiety by hypnosis during surgical treatment. J Oral Rehabil, 2006. 33(7): p. 496-500.
2. Gatchel, R.J., The prevalence of dental fear and avoidance: expanded adult and recent adolescent surveys. J Am Dent Assoc, 1989. 118(5): p. 591-3.
3. Hakeberg, M., U. Berggren, and S.G. Carlsson, Prevalence of dental anxiety in an adult population in a major urban area in Sweden. Community Dent Oral Epidemiol, 1992. 20(2): p. 97-101.
4. Locker, D., D. Shapiro, and A. Liddell, Who is dentally anxious? Concordance between measures of dental anxiety. Community Dent Oral Epidemiol, 1996. 24(5): p. 346-50.
5. Moore, R., et al., Prevalence and characteristics of dental anxiety in Danish adults. Community Dent Oral Epidemiol, 1993. 21(5): p. 292-6.
6. Peltier, B., Psychological treatment of fearful and phobic special needs patients. Spec Care Dentist, 2009. 29(1): p. 51-7.
7. Eitner, S., et al., Neurophysiologic and long-term effects of clinical hypnosis in oral and maxillofacial treatment--a comparative interdisciplinary clinical study. Int J Clin Exp Hypn, 2006. 54(4): p. 457-79.
8. Moore, R., I. Brodsgaard, and R. Abrahamsen, A 3-year comparison of dental anxiety treatment outcomes: hypnosis, group therapy and individual desensitization vs. no specialist treatment. Eur J Oral Sci, 2002. 110(4): p. 287-95.
9. Eitner, S., et al., Comparison of conventional therapies for dentin hypersensitivity versus medical hypnosis. Int J Clin Exp Hypn, 2010. 58(4): p. 457-75.
10. Addy, M. and N. Pearce, Aetiological, predisposing and environmental factors in dentine hypersensitivity. Arch Oral Biol, 1994. 39 Suppl: p. 33S-38S.
11. Enqvist, B. and K. Fischer, Preoperative hypnotic techniques reduce consumption of analgesics after surgical removal of third mandibular molars: a brief communication. Int J Clin Exp Hypn, 1997. 45(2): p. 102-8.
12. Lucas, O.M., Dental extraction in hemophiliac: Control over emotional factors by hypnosis. American Journal of clinical hypnosis, 1962. 14: p. 126-127.
13 Newman, M., Hypnotic handling of the chronic bleeder in extraction: a case report. Am J Clin Hypn, 1971. 14(2): p. 126-7.
14. George, J.M., et al., The effects of psychological factors and physical trauma on recovery from oral surgery. J Behav Med, 1980. 3(3): p. 291-310.
15. Enqvist, B., L. von Konow, and H. Bystedt, Pre- and perioperative suggestion in maxillofacial surgery: effects on blood loss and recovery. Int J Clin Exp Hypn, 1995. 43(3): p. 284-94.
16. Enqvist, B., L. von Konow, and H. Bystedt, Stress reduction, preoperative suggersion in maxillofacial surgery. Stress medicine, 1995. 11: p. 229-233.
17. Barsby, M.J., The use of hypnosis in the management of gagging and intolerance to dentures. British dental journal, 1994. 176: p. 97-102.
18. Eitner, S., M. Wichmann, and S. Holst, "Hypnopuncture"--a dental-emergency treatment concept for patients with a distinctive gag reflex. Int J Clin Exp Hypn, 2005. 53(1): p. 60-73.
19. Eitner, S., M. Wichmann, and S. Holst, A long-term therapeutic treatment for patients with a severe gag reflex. Int J Clin Exp Hypn, 2005. 53(1): p. 74-86.
20. Finkelstein, S., Hypnotically assisted preparation of the anxious patient for medical and dental treatment. Am J Clin Hypn, 1991. 33(3): p. 187-91.
21. Forgione, A.G., Hypnosis in the treatment of dental fear and phobia. Dent Clin North Am, 1988. 32(4): p. 745-61.
22. Hammarstrand, G., U. Berggren, and M. Hakeberg, Psychophysiological therapy vs. hypnotherapy in the treatment of patients with dental phobia. Eur J Oral Sci, 1995. 103(6): p. 399-404.
23. Boundy, M., Dental distress. A possible relief. Aust Endod J, 2001. 27(3): p. 123-5.
24. Huet, A., et al., Hypnosis and dental anesthesia in children: a prospective controlled study. Int J Clin Exp Hypn, 2011. 59(4): p. 424-40.
25. Dworkin, S.F., et al., Analgesic effects of nitrous oxide with controlled painful stimuli. J Am Dent Assoc, 1983. 107(4): p. 581-5.
26. Faytrouny, M., Z. Okte, and Z. Kucukyavuz, Comparison of two different dosages of hydroxyzine for sedation in the paediatric dental patient. Int J Paediatr Dent, 2007. 17(5): p. 378-82.
27. Zanette, G., E. Facco, and G. Manani, The use of intranasal midazolam in the treatment of paediatric dental patients. Anaesthesia, 2008. 63(8): p. 887.
28. Gokli, M.A., et al., Hypnosis as an adjunct to the administration of local anesthetic in pediatric patients. ASDC J Dent Child, 1994. 61(4): p. 272-5.
29. Trakyali, G., et al., Conscious hypnosis as a method for patient motivation in cervical headgear wear--a pilot study. Eur J Orthod, 2008. 30(2): p. 147-52.
30. Finkelstein, S., Rapid hypnotic inductions and therapeutic suggestions in the dental setting. Int J Clin Exp Hypn, 2003. 51(1): p. 77-85.
