HYPNOSIS IN DENTISTRY

H. B. GIBSON & M. HEAP

HYPNOSIS IN THERAPY: LAWRENCE ERLBAUM: ASSOCIATES: HILLSDALE USA: 1991

INTRODUCTION: Hypnosis in dentistry has been used since very early in the scientific era. It was the dentists rather than the medical profession who paid what now seems to us a proper attention to the problem of pain in treatment, and the early introduction of anaesthesia by nitrous oxide and by ether was a dental innovation and only later introduced to general surgery (see Gibson, 1982, chapter 2). At the Assembly of the French Royal Academy of Medicine in 1837 a case was presented by Cloquet in which several dental extractions had been performed painlessly under “magnetic anaesthesia” by Oudet (1837). The Assembly would not accept the fact that painless extractions could be performed thus, and maintained that Cloquet must have been “tricked”.

It is worth nothing that an interest in hypnotism among dentists was generated in the Second World War because battle casualties often produced injuries to the mouth that had to be repaired at the front, where the normal dental facilities and range of chemical analgesics were not always readily available. Obtaining analgesia by means of hypnotic suggestion was therefore a very useful technique. A paper by Sampimon and Woodruff (1946) describes such usage.

It may well be asked why we should now bother about producing analgesia in dentistry by hypnotic techniques as we have so many effective chemical anaesthetics in this modem age. But hypnosis is not used primarily in dentistry as a means of abolishing pain. Its major use is, as Moss (1963) points out, “to ‘normalize’ the patient so that we can manage him as we do other patients”. Hypnotism has its place (159) in modem dentistry, therefore, especially in the treatment of a minority of patients who have special problems in relation to treatment, problems that also exist to some degree in all medical practice but which are specially acute in relation to dentistry and deserve special study.

THE PATIENT FRIGHTENED OF DENTAL TREATMENT: For various reasons people are specially afraid of interference with the oral cavity which has a very special significance in our protective reactions. Janis (1958) found that patients’ fear of treatment of dental operations was generally more acute than their fear of minor or even major surgery. Various studies have shown that what can be termed an actual dental phobia exists in from 6% to 16% of the general population (Gale & Ayer, 1969; Kegeles, 1963; Kleinknecht, Klepac, & Alexander, 1973; Marks, 1969). According to Gerschman, Burrows, and Reade (1979), about 16% of the population are avoiding having dental treatment because of general fears of treatment. We shall therefore first examine what can be termed general dental phobia and then more specific problems, and discuss how hypnotic techniques can assist in overcoming these problems. As noted above, the object of such techniques is to “normalize” the patient.

Fairfull Smith (1985) studied 20 patients with dental phobia referred to the Glasgow Dental Hospital and treated with a combination of behaviour therapy and hypnotic techniques. They were given half-hour sessions at weekly intervals, and received from two to eight sessions at weekly intervals, and were all taught a technique of self-hypnosis and instructed to practise it at home daily at least once, but preferably three times, employing sessions of from five to ten minutes. It was therefore a fairly intensive course of treatment. About 85% of the patients overcame their phobia to a degree that permitted normal dental treatment, and after two years they were symptom- free and attending for dental treatment regularly. Fairfull Smith remarked that the

general mental health of these patients improved in that “other neuroses also disappeared”. Whether this was entirely the case does not matter, but at least this accords with the general finding that if one phobic condition is eradicated or improved, the general status of the patient is improved. The idea originally proposed by such psychoanalytically oriented therapists as Bookbinder (1962) that there would be “symptom substitution” has received no support in practice. It is not clear from Fairfull Smith’s paper what staff at the Glasgow Dental Hospital carried out the psychological therapy, for he himself was qualified as a dentist only.

Gall (1985) has classified dental patients into four categories:

(1) those who accept whatever dental treatment is necessary without qualms. Many patients in this category do not require any local anaesthetic for drilling or filling procedures;

(2) those who experience some anxiety about dental treatment but nevertheless overcome their fears and accept the treatment;

(3) those who have a very acute fear of (160) dental procedures, but are willing to attend although their anxieties create special problems during treatment;

(4) those who are generally unable to attend for treatment, and when they do come it is only because of the severe pain of the neglected teeth drives them to overcome their fear. The patients in category (4) have often suffered a very traumatic experience at a dental surgery in the past, and even though the treatment they have now forced themselves to undergo on a special occasion has been painless and not involved any special trauma, they still retain their phobic attitude to dentistry.

Fear of dentistry is often acquired in childhood, and this is most unfortunate as it may lead to a neglect of oral hygiene in later years. As children are particularly susceptible to hypnosis there is a good case to be made for introducing dental techniques to them using some degree of hypnosis to allay any possible fears, even if this necessitates no actual dental treatment on the child’s first visit. Writers such as Carpenter (1941), Harland (1960), and Morgan (1940) have studied the onset of children’s fear of dentistry, and proposed measures for its avoidance.

The techniques of the late Fairfull Smith for inducing hypnosis in children in the dental chair and preventing the development of anxiety in the situation are becoming well known, and one such session with a little girl was filmed and presented on BBC television in September 1982. The following is an account, given by Hilgard and LeBaron (1984, pp. 179-180), of some of the late Fairfull Smith’s methods with children: “Dr G. W. Fairfull Smith … makes wide use of laughter in his practice with children. He explains his successful method for keeping child patients happy and pain-free while they are undergoing various dental procedures … The method employs liberal doses of laughter, magic games, and sometimes hypnosis. “1 always try to create a ‘laughter-happy’ mind-set before starting to work.” Dr Smith, who possesses a very hearty laugh, says that the more he laughs, the more the child laughs, because laughter is infectious. He inquires of the child, “Can you laugh with me?” After both laugh, he continues, “Come on, you can do better.” So both laugh again more enthusiastically. And again if need be. If the procedure is a tooth extraction, the magic game begins with this question: “Do you know any magic words? .. I’ve got one … Abracadabra … I’m going to rub your gums with my magic finger and we will both say it.” Dr Smith rubs the gum with 2 percent Xylotox while he and the child repeat together “Abracadabra”. Just before he injects Xylocaine, he announces, “I’m going to touch your teeth with my magic wand and we’ll both say the magic word.” They do, the child is intrigued, and he injects. The actual extraction is next. “Now you’ll notice that your lip feels cotton wooly and your tooth has gone to sleep … Sleep!”

It may be noted that Fairfull Smith is employing the ancient method of inducing hypnosis pioneered by the Abbe de Faria (1819/1906), that of establishing proper rapport with the patient and then giving (161) the suggestion to “Sleep!” Further details of Fairfull Smith’s methods are given by Hilgard and LeBaron (1984, pp. 180-181): “Describing how he goes about filling a tooth in a school-age child using hypnosis as the sole anaesthetic, Dr Smith told us about his patient Jane, who had a deeply decayed tooth to be drilled and filled. In front of Jane is a long cord belt … that rolls around and around on small pulleys to activate the drill. After he has established a lighthearted mood, Dr Smith places two bits of white cotton on the belt as it moves in its course, and then introduces an imaginative story: “Watch the two bunnies going round and round. Do you see them?” Jane’s eyes fixate on the rabbits. “Pretty soon you will see a naughty fox chasing them (this is entirely hallucinated, with no cotton as a prop) … When you see a naughty fox chasing them, your hand and arm will get very light like a feather and your mouth will open.” After a few complete runs afthe belt, the hand and the arm rise, the mouth opens. “Now I’m going to use the vacuum on the tooth. It’s a tickly machine. I’m going to tickle your tooth … It will make yournose very itchy and you’ll laugh.” By this time, Dr Smith is drilling and he says the children never notice, even though a nerve has been touched. Once the tooth was sufficiently drilled, the hole in the tooth was incorporated in the story as the hiding place for the bunnies after they had escaped from the fox-a hiding place whose entrance Dr Smith then closed with the filling. The procedure ended, Jane hopped out ofthe chair still smiling.

Some readers, familiar to some extent with the formal inductions of hypnosis that are described in many books, may not recognize the above description as being hypnotism, although of a kind that would only be effective with a child at an age when the borderline between fantasy and reality is not very firmly established. Because of this possible misunderstanding, Hilgard and LeBaron (1984, pp. 181) comment on Fairfull Smith’s account very insightfully:

The hypnotic procedures are introduced so subtly and informally that the reader may miss the extent to which some of the familiar features of hypnosis have been used. First, a compatible relationship with the hypnotist was established as a shared jovial mood. The attentive focus on bits of cotton moving with the belt serves to accomplish eye fixation which is followed by suggestions of arm levitation and mouth opening. The bunnies are hallucinated by using cotton as a prop, and the fox is hallucinated without props. Jane’s eyes fixated but never closed, a familiar feature of hypnosis in young children. With mood always pleasant and attention focused outward, any pain Jane might have felt was dissociated or converted by suggestion to tickling in the tooth or itching in the nose.

Having dealt with the general question of the use of hypnosis in the treatment of generalised anxieties and fear of dental treatment and how the development of such fear may be avoided in the early dental experiences of children, we shall proceed to examine some common conditions that present to dentists, and which are often monosymptomatic, and how hypnosis can usefully be employed in their treatment. (162)

WHO GIVES WHAT TREATMENT? We generally take it for granted that all dental problems should be treated by professionals who are dentally qualified, just as medical problems should be diagnosed and treated by those who are medically qualified. There is, however, a certain “grey area” concerned with those problems that are predominantly psychological rather than somatic. All good dentists and GPs have to be good “psychologists” in the ordinary sense of the word, and the above description of Fairfull Smith’s methods show him to have had a profound psychological insight into the problems of children coming to the dental surgery for their early experiences of dentistry and the place that hypnotism could have in dental practice. Dentists are

not mere technicians. Professor Caws on of Guy’s Dental Hospital in London criticized the training of dental undergraduates in that it did not lay sufficient stress on the skills of patient management. He considered that, “the first essential of the young graduate when he starts practice is to be an expert in patient management and that advanced technical skills are of secondary importance” (Cawson, 1969). Yet in all professional work the competent practitioner has to recognise just when the patient should be referred for additional treatment to a colleague in another professional discipline. Many GPs now recognize cases in which a patient is best referred to a psychiatrist or a clinical psychologist for the treatment of emotional problems that often present at the surgery in a psychosomatic form. Within the area of what is sometimes termed “psychological medicine” there has been over the past 30 years and longer considerable changes as psychiatrists and clinical psychologists have worked out between them just who treats what. Generally, a happy compromise has been reached, and patients get the best treatment under the care of multidisciplinary teams.

Now dentists have learned to make a wider use of hypnotism in their practice there has been a tendency for some practitioners who have dental qualifications only to set up in a practice as “hypnotherapists”, treating all manner of psychological problems by hypnotism with less than adequate knowledge ofthe complexity of the work they are trying to do. Some dentists who have been practising “hypnotherapy” with cases quite unrelated to dentistry have applied to the prestigious British Society of Experimental and Clinical Hypnosis but have been refused membership on the grounds that they were acting outside their proper professional competence. Bernard Oliver, deals with the matter in general terms in an Editorial (Oliver, pp. 2-3,1977) in which he quotes the advice given in the 1977 Annual Report of the Medical Defence Union: “A dental surgeon reported that he and a number of colleagues, skilled in the practice of hypnosis, were finding that their skills were sought, not only in the course of dental practice, but also in the course of psychotherapy. He asked whether his membership of the Union covered him for such practice and whether the Union had views on the subject, it being known that members had been warned in the past about the possibility of ‘abnormal and unusual results (including unfounded allegations of improper (163) behavior by the dental surgeon when no chaperon is present)’. The member was advised that Section 33 (I) of the Dentists’ Act 1957, which defines the practice of dentistry, does not include using hypnosis for non-dental problems. Accordingly, the cover given by the Union to a dental surgeon can only extend to his use of hypnosis in the course of dental treatment.

It should be noted that the case of Fairfull Smith’s treatment of children with hypnosis described above was entirely proper and within his professional competence because he was preventing the development of any sort of dental phobia or antipathy to treatment. Once such phobias have developed, however, the matter is more complex and may, in some cases, be so bound up with the patient’s general psychopathology that it calls for treatment on a broader basis by professional colleagues skilled in the general area of psychopathology rather than in dentistry. The matter is discussed by David Rowley (Rowley, 1986, p.121) who writes: “It is a mistake to think that a dental phobia is actually a dental problem; it is a psychological problem in which the phobic object is the dentist, the drill, etc. Although the chances of harming the patient are remote, professional cthics should demand that the treatment of psychological problems should be left to the right professional

agency.”

This is not just a matter of interdisciplinary rivalry between professions. Two eminent members of the staff at the School of Dentistry in Tel Aviv (Kleinhauz & Eli, 1986) examine the

question very thoroughly, citing four case reports of dental patients who had distressing psychological side-effects after dental hypnosis and requiring treatment from non-dental specialists. They make a strong case urging that “The professional using hypnosis should not stray from his area of expertise”. In the treatment offered at a famous school of dentistry there is the advantage of immediate referral to appropriate professionals if necessary, but dentists working on their own are less favored in the matter of interdisciplinary support with little delay. It is a matter for their careful consideration.

The question of dentists using hypnosis in therapy that lies outside the professional realm of dentistry has been debated elsewhere (Gibson, 1988; Nicolaou, 1988).

SPECIAL DENTAL PROBLEMS:

Gagging: Gagging is an automatic reflex to the threat of some foreign body obstructing the airway. Normally it is no problem because dental procedures do not pose any threat to the breathing, and the patient trusts the dentist not to do anything that would constitute such a threat. However, in a small number of patients there is an abnormal degree of gagging, which may become so severe that ordinary dental treatment becomes impossible and the sufferer allows oral hygiene to deteriorate over a long period through fear of going to the dentist.

The abnormal gagging response may occur not only in the dental chair but even in such a matter as wearing and retaining necessary dentures, and people who suffer from this abnormal gagging response are not necessarily neurotic in any general sense. Wright (1980) investigated the matter with 53 people prone to abnormal gagging and could find no evidence of any personality abnormality in them. Other writers such as Levine (1960) and Savage and McGregor (1970) tend to see the problem in terms of more deep-seated personality disorders. Possibly, there are two main types of gagger as suggested by Eli and Kleinhauz (1985). The first are people who have had some severe and traumatic experience at some time when they were in a specially vulnerable state and this has produced an abnormal conditioned reaction, as it would with many of us. The second type are people who have suffered no specially severe experience but their general unstable personality has led to the build up of this particular phobic reaction. Therapists of a generally psychodynamic orientation tend to look for symbolic and complex causation of the abnormal gagging response in the latter type of person. In either case hypnosis combined with the ordinary principles of behaviour therapy is an ideal vehicle for treating the disorder, for as noted in Chapter 3 of this book, those with a special disposition to phobic responses often make excellent hypnotic subjects and respond very readily. The following is a case study of a man who had reacted badly to a previous dental procedure.

Case Study. A 32-year-old male exhibiting an extreme gagging reflex was referred to the Clinic. The reflex not only prevented dental treatment, but was sometimes provoked by the ingestion of food. The gagging had begun four years previously during an impression procedure, which produced a “horrible feeling of choking”, although the patient insisted that fear of pain was “not a problem”. Assuming that this experience had acted as a conditioning stimulus, the treatment of choice was hypnorelaxation combined with in vivo desensitization. Eli and Kleinhauz (1985, p.102) go on to say:

At the first session the patient achieved a good state or relaxation during which oral hygiene, scaling, and simple root extraction were compacted. At the next session examination revealed extremc destruction or [he lower first molar, caused by repeated postponement of treatment, making surgery unavoidable. Extraction was performed under good hypnorelaxation levcl in conjunction with local anaesthesia. There wert’ no gagging problems. Additional dental treatment was carried out in other session under hypnorelaxation with good co-operation.

Although the need for hypnorelaxation during dental treatment remains, the patient is now able to ondergo routine treatment. (165)

Eli and Kleinhauz also cite more complex cases in which there is some evidence of a generalised neurotic disposition, which is manifested in the presenting symptom of the abnormal gagging response. In such cases it is more doubtful whether dentists should attempt the treatment themselves as it is not a simple dental problem. This is well recognized by many dentists, who prefer to refer such cases in the first place to therapists such as clinical psychologists and psychiatrists who are specially trained to deal with generalised emotional problems. This point is noted by Rowley

(1986, p.121) who writes: “There are a number of potential problems in the use of hypnosis by dentists. One is that the patient may have some psychological problem which being hypnotized gives them the freedom to reveal. Since they are not qualified to deal with this, and it is really not possible effectively to screen patients for this, dentists must be aware that this is a possibility, albeit remote, and know what course of action to take. Such action would generally be advising the patient to seek help from another professional.”

Reviews of the problem of gagging in dentistry and the various methods used to treat it have been published by Conny and Tedesco (1983a,b). Traditionally the problem has been dealt with by various sorts of pre-medication as described by Kramer and Braham (1977) and by Rothschild (1959), but although pre-medication may enable treatment to be carried out on a specific occasion, patients do not overcome the difficulty for the future and may still tend to avoid dental treatment because of their fear. The long -term object should be to enable patients to overcome the habit, and this is the purpose of hypnotherapy. Weyandt (1972) cites the case of a man who was unable to tolerate dental treatment without an anaesthetic because of his extreme gagging, but found that he could permit X-rays to be taken when hyponotised, and in later years he was able to undergo various dental treatments quite comfortably when in hypnosis and hence lost his fear of going to the dentist. In this context hypnotism would seem to be the ideal solution to a problem that prevents some people making visits to the dentist on a regular basis.

Excessive Bleeding:

Excessive bleeding after tooth extraction or other such work on the gums is of course a special problem for patients suffering from haemophilia and demands very special measures for control. There are other patients, however, who are not haemophiliacs yet suffer from excessive bleeding from the gums after dental operations, and hypnotism offers a means by which such bleeding may be controlled. Hilgard and

Hilgard (1983, p.158) comment: How the control of bleeding is achieved as a consequence of suggestion is by no means clear. It may be a secondary consequence of the general relaxation achieved under hypnosis; or it may be related to the specific control of vasomotor responses that can be developed through hypnosis and biofeedback, as in the selective control of hand temperature.” (166)

Newman (1971) cites the case of a woman who had bled for eight hours after the extraction of a tooth. On a later occasion she was hypnotized and after a tooth was removed she was given strong suggestions that she would not bleed and that her mouth would feel perfectly comfortable. The bleeding stopped after about one minute, and she felt so normal that she returned to work. This entire procedure involving hypnotism and extraction of a tooth took about 15 minutes only.

Hypnosis has also been used in the case of hemophiliacs despite the very special physiological problem they present. The following case study is reported by Dubin and Shapiro (1974) as summarized by Bowers (1983, p.145):

A patient suffering a particularly severe form of hemophilia needed a left upper molar removed. There was particular concern about postoperative hemorrhaging, and, as a consequence, a decision was made to employ hypnosis as a way of minimizing the patient’s blood loss. Training and preparation before surgery included repeated hypnotizing of the patient, suggestions for pain anaesthesia, and suggestions that he would not hemorrhage before or after surgery. The patient was told to accomplish this last suggestion by visualizing blood as water coming from a faucet that he could turn off, willfully constricting the blood vessels, or mentally suturing the sides of his wounds. According to the authors, ‘the extractions was accomplished without incident and with minimal bleeding’ (p.82). The ‘patient was discharged on the eighth postoperative day, having required no blood or plasma replacement’ (p.82).

It may be surprising that so physiological a condition as hemophilia, depending as it does on an abnormal constitution of the blood, should be modifiable as to its manifestations by hypnotic suggestion, but there is good evidence that this is the case.

Bruxism and Myofascial Pain: Bruxism is the forceful grinding or clenching of the teeth when food is not being chewed. There are two main varieties, diurnal, which generally consists of a mere clenching of the teeth in periods of stress and is largely involuntary, and nocturnal, which is often a grinding motion that is frequently audible. This habit may result in the development of flat areas on the teeth, with facets, excessive wear and even fractures. The teeth are not the only site of injury in some cases. The powerful exercise of the related muscles may cause breakdown of the bone supporting the teeth and peridontal disease may result, with a loosening and loss of teeth (see Glaros & Rao, 1977).

A further result of bruxism may be that the masticatory muscles and those around the temporomandibulary joints are injured by the excessive strain, giving rise to the myofascial pain-dysfunction syndrome, a chronically painful condition of the face (Cannistraci, 1977). This pain is often one-sided, and once established it is very difficult to treat successfully. (167)

The causes of bruxism have not been clearly established. It seems reasonable to suppose that the diurnal variety arises in people who are subject to a good deal of anxiety, and indeed to suppressed rage in which they “grind” or “gnash” their teeth. Lewis (1961) suggests that it is an expression of repressed oral aggression. The nocturnal variety does not appear to be associated with any special abnormality of personality; Hartman et al. (1987) made a quite detailed study of 16 people who suffered from nocturnal bruxism, but could find nothing unusual about their personality or way of life. It is likely that nocturnal bruxism is one of these habits characterized by Broughton (1968) as disorders of arousal, that is, an unusual and occasional result of the depth of sleep lightening and causing spasms of muscular movement.

Dental treatment of bruxism may take several forms, such as endeavoring to obtain optimal occlusion by selective grinding or restoration of the teeth. In addition, acrylic shields may be made to protect the teeth and thus to cure the habit (Greenwald, 1968). If the habit is cured by such appliances which are normally worn at night, it is probably due to an interruption of the feedback mechanism, as suggested by Scandrett and Ervin (1973). Several types of psychological treatment have also been used in the treatment of bruxism, including psychoanalysis (Goldberg, 1973), massed practice (Ayer & Levin, 1975), biofeedback (Piccione, Contes, George, Rosenthal, & Kargmark, 1982), and hypnotism (Graham, 1974). Naturally the latter type of treatment will appeal to the many dentists who now use hypnotism for various purposes in their surgeries.

Hypnotism has been shown to be useful in the treatment of other nocturnal disorders of arousal such as enuresis, and it is appropriate to use it in the present context, although very little has been published concerning its effectiveness. When bruxism has led to the myofascial paindysfunction syndrome, hypnosis can also be effective, as reported by Golan (1971).

Dentists may feel fairly confident in the treatment of bruxism with hypnotism by themselves and have no need in most cases to refer patients to a professional colleague. In complex cases of myofascial pain, however, there may be additional complications involving the psychopathology of patients which is really outside the dental sphere. This matter has been discussed above with reference to the problem of gagging and the observation of Rowley (1986) on the matter. In severe cases of myofascial pain it may be necessary to supplement whatever dental work is necessary by referring patients to a pain clinic where they will get the benefit of therapy from an interdisciplinary team.

HYPNOSIS IN THE RELIEF OF OPERATIVE PAIN: We began this chapter with a reference to Oudet who extracted a tooth in 1837 with hypnosis as the sole analgesic and aroused much scepticism among his professional colleagues. We then went on to point out that, as there are now many suitable painkilling drugs, relying on hypnosis as the sole means of analgesia is most unusual today and that hypnosis is used in the treatment of many problems in dentistry other (168)

than in the direct relief of pain. It is of interest, however, to note that hypnosis may be of used in pain-killing by enabling the anxious or phobic patient to accept the injection of a drug, and also in the mitigation of post-operative pain. Just occasionally, in rather special circumstances, hypnosis is used as the sole analgesic, and it is instructive to look at some of the cases.

Hypnosis as the Sole Analgesic: Crasilneck, McCranie, and Jenkins (1956) report the case of a woman who had a special allergy and who had reacted to the injection of procaine with nausea and various other unpleasant symptoms, and so she later neglected to seek further dental treatment until her teeth were in a very bad state and needing various complex and lengthy dental procedures. Because of her allergy and her past unhappy experience, she was persuaded to try such treatment with hypnosis as the sole analgesic. She reacted to hypnotism very favourably and achieved a satisfactory trance state, and with the aid of hypnosis she was able to dispense with analgesic drugs throughout five lengthy sessions of dental treatment.

Another recognized although uncommon use of hypnosis as the sole analgesic is with people who have a special attitude to health that involves the total rejection of the use of drugs. Such a case is reported by Weyandt (1972), concerning a man who needed to have seven upper maxillary teeth extracted in order that he could be fitted with an upper denture, but was not prepared to accept the use of the drug injections that would normally be deemed necessary. He was willing to attend the surgery on a number of occasions on which the whole question of hypnotism was explained to him and there were practice sessions of hypnotic induction of a conventional kind. Preliminary non-painful procedures such as the taking of impressions for dentures were initiated in these early sessions and his capacity to produce analgesia in hypnosis was assessed. Fortunately he proved to be a very susceptible subject and the seven teeth were eventually extracted painlessly. Hypnosis also helped in the post-operative work of removing sutures, and in inducing tolerance of the newly fitted dentures. Such a long-continued series of sessions was quite time-consuming, but it did enable the patient to have the necessary work done without infringing what was for him an important matter of principle.

Another unusual case is reported by Radin (1972) who treated a man who suffered from a rheumatic heart and various associated symptoms that made a general anaesthetic inadvisable.

The poor condition of his teeth was such that he needed a long course of treatment, and this he underwent over several months with the aid of hypnosis and without any chemical anaesthesia.

In the three cases just cited the patients were excellent hypnotic subjects, and it was only because they had such a good aptitude for hypnosis that drug-free treatment proceeded so successfully.

Hypnotic Analgesia in Normal Practice: Wadden and Anderton (1982) report a large number of studies by various therapists who used hypnosis in the alleviation of pain, and they make the point that the success of the analgesic suggestions is largely related to the degree of susceptibility to hypnosis of the individual patient. Their list of studies includes one by Gottfredson (1973) with dental patients in which the effectiveness of a chemical analgesic is compared with that of hypnotic suggestion. The relative degrees of susceptibility to hypnosis were formally assessed and it was found that patients who were highly susceptible to hypnosis were about twice as successful in benefitting from hypnotic analgesia as those who were assessed as being poorly susceptible.

There are also in this list of studies two dental studies by Joseph Barber (Note 1, 1977) which are very surprising in that they appear to go against the general trend of all the other studies reporting the use of hypnosis in the alleviation of pain. In the first of these there was no relationship between measured hypnotic susceptibility and the alleviation of pain. In the second study, although hypnotic susceptibility was not measured, it is reported that “99% completed the dental treatment without chemical anesthetic” (Wadden & Anderton, 1982, p. 232). The reasons for this surprising anomaly and astonishingly high rate of claimed success would seem to lie partly in the particular procedure used by Barber, and in the nature of the “hypnotic induction”. Barber called this “Rapid Induction Analgesia” (RIA), but the form of words in it seems designed to calm and reassure patients rather than to produce any actual alterations in their perception of pain such as is usual in hypnotic

suggestions for analgesia.

The nature of pain is discussed in detail in Chapter 8. Pain is a complex experience made up partly of an emotional-motivational component that is affected very much by the degree of anxiety that the patient is experiencing, and partly of a sensory component which is a matter of the perception of aversive stimuli that can be greatly modified by hypnotic suggestion. As already pointed out, the form of words of the RIA would appear designed to calm the emotional-motivational factor, but not to address the sensory factor at all.

Gillett and Coe (Note 9) tried to replicate Barber’s study using 60 dental patients and, using Barber’s criteria, they claimed a 52% success rate, but they add significantly: “It is one thing to claim 52% success overall, it is another to recognize that most of the success was shown on dental procedures that may not require chemical anaesthesia in the first place” (emphasis added). It seems likely that in Barber’s study, as long as the patients were kept calm and reassured, they could endure dental procedures that were not particularly painful without demanding the chemical analgesics that were to hand if required. Barber’s study and the “spiel” known as the RIA has come in for a good deal of comment and criticism. Van Gorp and Meyer (Note 17) found that the RIA was no more effective in reducing pain than a no-treatment control procedure. The latter study was experimental, and in the clinical study of Crowley (1980), using the RIA with podiatric surgery, it was found (170)

that only a “small percentage” of patients responded successfully in terms of real analgesia. Similarly, in a clinical study by Snow (1979) the success rate was rather low . Important criticisms of the RIA have also been made by Gibson (1985), Hilgard (1978), andOme (1980b).

Finally it should be noted that although the RIA by its title is alleged to be “Rapid”, it takes all of 23 minutes to administer.

CONCLUSION: A good deal of space has been devoted to discussing and criticising the study of Barber (1977) with its astonishing claim of “99% success”, and the RIA, because there is always the danger that this or that method of hypnotism can become oversold and the continuing scepticism that all hypnotism is something of a marginally respectable “con trick” will be reinforced. It is safe to say that while dental procedures that are not particularly painful anyway are tolerated much better when patients are calm and reassured, one has to obtain a considerable degree of hypnotic responsiveness before analgesia can be induced in really painful operations, and this is only possible when patients have a good aptitude for hypnosis.

It is useful for dentists who practise hypnotism to have an adequate knowledge of the wide possibilities and limitations of hypnotic procedures in the induction of analgesia and their applications to other dental problems. Above we quoted three examples of the use of hypnosis as the sole analgesic measure in some quite severe dental operations; these are unusual cases but they are illustrative in their own right. Hilgard and Hilgard (1983, p. 150) present a table reporting nine separate published studies in which, for one reason or another, hypnotic suggestion was the sole means of securing analgesia in quite major operations, and it is clear that this is a possibility when drugs are contra-indicated. As most people tolerate drugs well, hypnotism must be regarded as a useful adjuctive technique, first, for calming anxiety, and, second, for producing in most people a degree of relative analgesia, which enhances the traditional drug-based methods that are already in use, and facilitates their application in some difficult cases. This chapter has endeavoured to give an overview of the relevant evidence and to make a case for the expanding use of hypnotism in dentistry. (171)