Hypnosis for dental anxiety

Anxiety

A fundamental skill that a dental surgeon has to offer to a patient is surely the anatomical knowledge and the ability to place local anaesthetic where it will remove pain sensation and enable treatment to be carried out. So why, from a patient's perspective, might this not be entirely satisfactory when local anaesthetic is almost 100% effective? There is the problem of anxiety. Even the most dentally experienced patients, dental surgeons included, admit to a degree of apprehension, but most of the time this is accepted and passed over. Consider the dentist who has a practice in a leafy suburb. The patients are well educated, well behaved, intelligent and sufficiently wealthy to provide this clinician with a comfortable income. Neither this dentist nor the patients are particularly concerned by anxiety that may interfere with the provision of treatment but it is possible that he or she has acquired all the attributes that mitigate anxiety: confidence, trust, respect, prestige, pleasant demeanour and empathy. Some of these, respect for example, need to be mutually felt by both clinician and patient. However, the anxiety scale has a vast range, from fear of needles to extreme dental phobia.

Most dentists will never see extreme phobics – their ‘coping strategy’ is to avoid contact with anything dental, even to the extent of avoiding walking or driving down the road where there may be a dental surgery. If they suffer pain or infection, they will go to their doctor, receive antibiotics and eventually may have to be admitted for a general anaesthetic. They are so fearful of their own mouths that they use them simply as a portal for food and drink and will not use a toothbrush, in case it should reveal something ghastly that needs attention. If these people are eliminated from the equation, there still remain an unknown number who wish for dental care but are wholly dependent on what a dentist is prepared to do about their anxiety. Our example dentist can choose his or her patients to fit into a narrow ‘comfort zone’ and would defend this position as self-knowledge of limitations, reinforcing the view that, in this regard, the dental profession is privileged. The anxiety problem can be left to the NHS community dental service or secondary care! Clearly, a lone practitioner cannot provide all aspects of dental care and referral to specialists is acceptable, but anxiety is such an all-pervasive feature of dentistry that, with the possible exception of intravenous sedation, it should not be regarded as a specialist subject. The far-reaching effects of dental anxiety on daily living have been well researched by Cohen et al.1

Hypnosis

The nature of hypnosis has been debated for more than two centuries and still seems elusive, but the American Psychological Association (APA) has stated that ‘one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought or behaviour’. A study comparing the effects on the electroencephalogram (EEG) of hypnosis and nitrous oxide sedation2 showed a distinctive pattern, apparently identical, that could be used to detect the hypnotic state (Figure 1).

This pattern of a dominant alpha rhythm and suppression of the lower frequencies can be seen in other states of altered consciousness, such as meditation and in sports ‘getting in the zone’. It is possible to train oneself to generate an alpha rhythm and there are binaural sound recordings that entrain brain waves into such rhythms (available on the internet). However, the crucial point is that an independent hypnotist is needed to provide the post-hypnotic suggestions that are the cornerstone of hypnotherapy and relevant to the specific problems. These are suggestions or ideas that are given to the patient while in the hypnotic state that afterwards influence the patient's behaviour, emotions, perceptions or beliefs in a beneficial, but usually unconscious way.

The anecdotal evidence of success of hypnotherapy for dental anxiety is irrefutable. However, there have been two systematic reviews3^,4 of 32 hypnotherapy trials for chronic pain with highly favourable outcomes, although the authors emphasize that hypnosis is seriously underused. If hypnosis is so effective then why is this so? The answer may be that susceptibility to hypnotic suggestion is very variable in the population, unlike local or general anaesthesia. The existence of so many scales of susceptibility seems to imply that, if the subject does not do well, then hypnosis should not be attempted. It is the author's view that, if hypnotherapy is needed, then it should be started, because to abandon therapy on the grounds of failure of a doubtful susceptibility test is ethically unfair. Agreed, some patients are slow to respond, but persistence will pay off, ultimately. Once the patient has experienced deep relaxation, an ‘Aha! Effect’ takes place. Practitioners using nitrous oxide sedation undoubtedly employ hypnotic suggestions to ensure its success: this could be used to ‘kick-start’ relaxation in the slow responder.

Disadvantages of hypnosis

Hypnosis may be a benign approach with very little likelihood of causing negative side-effects, according to Jensen and Patterson.3 However, there are some caveats. It would be considered wise to avoid patients with mental health problems, personality disorders or neurodegenerative diseases. The risks of undesirable side-effects are low, but there is a greater risk of failure, since the patient's mental activity may inhibit hypnosis. One should restrict one's field of hypnosis activity to conditions directly relevant to dentistry and not be tempted to delve into the patient's psyche (such as regression to a traumatic event in the past). This can be obviated by making all suggestions positive and forward-looking, with ego-strengthening and coping as a major feature.

There may be a hefty time commitment for the therapist and patient in the case of low susceptibility. The question of fitting this into the business plan of a dental practice is difficult but could be regarded as an investment, not only for the patient, but also as an enhancement of the reputation of the practice. Some practitioners would argue that it should be left to the salaried sector, where time does not translate directly into money.

Rapport

Almost anyone can be a hypnotist, including performers on stage. These characters can pick their subjects by simple tests of susceptibility (gullibility?) and entertain onlookers by inducing phenomena that can be cruel, stupid and dangerous. There is no element of therapy. In contrast, the clinician wishing to do ethical hypnotherapy cannot choose his or her patients and must establish a rapport or harmonious relationship, called by Freeman a ‘treatment alliance’.5 Success of hypnotherapy depends heavily on the patient's motivation and interest in his/her dentition, but this could be improved by the therapy itself. The qualities of the therapist sought by the patient are those mentioned above: confidence, trust, respect, prestige, pleasant demeanour, empathy and a reputation for success. A surprising finding of the work by Ambady et al6 was that 40 seconds of surgeons’ speech distinguished between surgeons who had been sued for malpractice and those who had not, revealing the power of the information communicated by the tone of the voice. I believe that shaking hands also contributes significantly – it is as if the patient suddenly becomes aware of one's presence as a person. Often, as a reflex, they will say ‘Nice to meet you’ before announcing their hatred of dentists, but exclude you from this generality, although continuing to address their remarks to the nurse.

Suggested hypnosis procedure

Apart from comprehensive history-taking, the well validated Modified Corah Dental Anxiety Scale7 will provide a good indication of the base anxiety level and may also point to specific problems. It can be used to monitor progress and to encourage the patient.

There are as many methods of inducing hypnosis as there are hypnotists. The internet hypnosis forums may give the impression that the only successful hypnotists are conceited, highly opinionated and able to induce a trance in 30 seconds. This is hard to believe. It pays to adhere to a simple technique, responding to the subject's progress with patience. The room should be quiet and of pleasant ambience created with warmth, low lighting, an aromatic oil vaporizer and background music or sounds. It is helpful to make a recording of the session for the patient to use at home. The following stages are suggested:

Induction by eye-fixation and progressive relaxation. See a typical script in the Appendix.

Deepening by breathing exercises, suggestions of arm lightness/heaviness and fractionation, ie taking the patient in and out of hypnosis several times in rapid succession with suggestions of progressive depth.

Guided visual imagery prolonged as long as 45 minutes.

Scripts could be used to aid the therapist's memory of ego-strengthening and visual imagery routines, also for specific problems like needle phobia. This will help to avoid omission of important points. The subject may not remember all that has been said but, it is to be hoped, retain everything subconsciously. There are many free scripts available online, for example http://www.choosehypnosis.com/hartland_egostrengthening.htm

Suggested therapeutic aims

Advice to practitioners who wish to learn hypnotic techniques

Much is to be considered before starting a course of hypnosis for a patient, not covered in this article and best learned from clinicians who use hypnosis regularly. Selection of patients is important, especially with regard to those covered in the ‘Disadvantages’ paragraph above.

Hypnosis is achieved by consent and anything untoward would probably result in the patient leaving the surgery. Nevertheless, it could be said that the patient is in a state involving imagery and fantasy that may be open to misinterpretation, so it is wise to have a chaperone.

There is, however, considerable benefit from learning about hypnosis on courses that are regularly available. The knowledge and understanding gained can be used to develop a ‘hypnoidal’ approach to the whole practice. This engenders a calming effect on patients, nurses and receptionists and redounds credit to the dentist. At the end of a day's work, everyone feels fresh and has more energy for home life and socializing.

Conclusion

The role of hypnosis in the management of dental anxiety is highly dependent on the commitment and interest of the individual clinician and, unlike local anaesthetic, hypnosis is not necessarily universally applicable or effective, yet can be extremely satisfying for patient and practitioner.

Competing interests: M Griffiths is a consultant for Alpha-Active Ltd.