Aaron A. Moss D.D.S., F.S.C.E.H.
As was mentioned in an earlier chapter, the hypnosis movement faded into oblivion for the third time as a result of Freud's abandonment of it. Two generations later, it was again “rediscovered,” thus giving rise to the resurgence, which is the fourth turn in the hypnosis cycle. At this time the United States is the world's center of activity in hypnosis. The impetus for the current resurgence is due to a few dentists, of whom the author is one, who banded together to teach the “gospel” of hypnosis at the end of World War II. Initially, only dentists were interested; later on, physicians and psychologists “joined the movement.” This second wave now outnumbers the dental contingent. However, credit is due the dentists for initiating the current widespread interest in hypnosis.
The author coined the term hypnodontics in 1948, to signify the use of hypnosis in dentistry. This was to overcome the irrational prejudices of the lay public as well as in the dental and allied professions. The role dentists played in bringing hypnosis to the fore is as much a tribute to American dentistry as what they did in introducing general anesthesia one hundred years earlier, when Drs. Morton and Wells, both dentists, gave the first clinical demonstrations in general anesthesia. The latter, oddly enough, was introduced to nitrous oxide, or “laughing gas,” during an exhibition of hypnosis in 1844 by G. Q. Colton, an itinerant chemist and hypnotist. Colton's claim to fame is that he was undoubtedly the world's first professional anesthetist. A little-known letter set forth clearly how hypnosis led to the development of anesthesia:
Dr. I. C. Green
Colton Dental Association
19 Cooper Institute
New York, Feb. 2, 1891
Dear Sir:
The only claim I have to the discovery of anesthesia is that I was the accessory of the discovery; and that I administered the nitrous oxide gas to Dr. Horace Wells of Hartford, Conn. on the 11th of December, 1844 for the first tooth that was ever extracted without pain. This was honor enough for me. The discovery was made at my exhibition (to facilitate hypnosis) of the gas the evening previous.
Yours very truly, G. Q. Colton
DENTAL APPLICATIONS OF HYPNOSIS
What are the uses of hypnosis in dentistry? Although hypnosis can be a very dramatic way of producing anesthesia, that is not its primary or most prevalent use. If there were no other application, hypnodontics would be nothing more than a spectacular phenomenon, quite impractical for general dental application, since only a small percentage of people are susceptible to complete hypnoanesthesia. Actually, there are several other areas in dentistry in which hypnosis can be applied. Space limitations permit the presentation of only a few of these applications. The uses of hypnodontics fall into two categories: therapeutic and operative.
The therapeutic uses of hypnodontics include:
1. Patient relaxation;
2. Elimination of the patient's tensions and anxieties, and his fears of pain and discomfort;
3. Removal of objections to necessary orthodontic or prosthetic appliances after the patient had agreed to accept them;
4. Maintenance of the patient's comfort during long, arduous periods of dental work;
5. Accustoming the patient to orthodontic or prosthetic appliances;
6. Modification of noxious dental habits.
The operative uses of hypnodontics include:
1. Reduction of anesthesia or analgesia;
2. Amnesia for unpleasant work;
3. Substitution for, or in combination with, premedication in general anesthesia;
4. Prevention of gagging and nausea;
5. Control of salivary flow;
6. Control of bleeding;
7. Postoperative anesthesia;
8. Reduction of postoperative shock.
TYPES OF SUGGESTION
Hypnodontics is that branch of dental science which deals with the application of controlled suggestion and/or hypnosis to the practice of dentistry.24 Hypnodontics does not necessarily eliminate analgesia or anesthesia; rather, it is used as an adjunct to chemoanesthesia. Thus there is no danger of overemphasizing the use of hypnoanesthesia in hypnodontics.
Although the term hypnosis has been defined, the meaning of controlled suggestion needs some elaboration. The deliberate and careful feeding of a suggestion into the brain in order to accomplish a given effect is known as controlled suggestion. If the desired effect is accomplished, the suggestion is said to be realized. When a suggestion is realized, it effects the following changes:13
1. Sensory change: the hand (or any other part of the body) may feel colder or warmer, or have a tingling sensation;
2. Motor change: the arm may rise or float into the air; the leg may become rigid;
3. Emotional change: feelings of guilt, fear, or anger may be aroused;
4. Change in ideas or beliefs: confidence may be lost or enhanced (in the latter case, the patient develops a good rapport with his dentist).
Suggestion can be divided arbitrarily into two types: direct and indirect. A direct suggestion is one received during full awareness. It is used in the process of hypnotic induction. An indirect suggestion is one which bypasses awareness and, as a result, affects the perceptual processes subliminally; the subject is seldom aware of being exposed to the suggestion. Therefore, his responses are generally spontaneous. Since he is not aware of its origin, his defenses and resistance are not mobilized.
Tests
Tests for hypnotic susceptibility, such as the falling back test or the handclasp test, are good examples of direct suggestion. The contagious effect of yawning after one has observed someone else doing it is an example of indirect suggestion. The individual concerned may be completely oblivious of his behavioral response to the suggestion.
HYPNODONTIC INDICATIONS AND APPLICATIONS
Does the hypnodontist apply his technics to every patient? Yes and no. This answer is contradictory and requires further explanation. For instance, hypnotic states are induced rarely and only when all other methods of dealing with the patient's problems have failed. They are used when drugs have failed to produce the desired anesthesia necessary for patient control and cooperation.3,5,16,25,29,31,34
Normally, the routine patient that comes to a hypnodontist's office is handled in only a slightly different manner from the one who goes into some other dentist's office. This slight difference consists in the routine application of hypnotic technics. The four levels or areas in which hypnodontics may be applied are controlled suggestion and light, deep, and waking hypnotic suggestion.
Controlled Suggestion
In the dentist's office, controlled suggestion is applied constantly in both direct and indirect forms. In attempting to win a patient's confidence, the office personnel's choice of words is of the utmost importance. Mannerisms and the general office atmosphere constitute suggestions of prime significance.
The dentist's personality and appearance are also of tremendous importance in establishing the patient's confidence. For instance, the patient would doubt the dentist's ability to remove the decay from a tooth or the infection from a socket if he had dirty fingernails or soiled gown. Negative conditioning on the part of the dentist initiate powerful negative suggestions in the patient, making him mistrust the dentist. More often than not, the patient is not even aware of the fact that such indirect suggestions are affecting him. Thus he may reject the dentist's recommendations by rationalizing that the fees are too high.
Other less obvious but equally negative suggestions are not washing one's hands after answering the telephone; handling a soiled handkerchief, coughing into it or picking an object off the floor; being late for appointments; not properly organizing office routine; fumbling for instruments, charts, etc.
The application of hypnodontics to an office routine implies the administration of as many positive indirect suggestions as possible, such as instruction in proper toothbrushing technics and giving the patient a mirror to verify that all the decay has been removed from his tooth. These steps indicate to the patient that the dentist is interested in and concerned about his welfare.
Thus, by carefully controlled, positive indirect suggestion, confidence can be established and good rapport developed between dentist and patient. Persons interested in practice management and business administration can learn much from this phase of hypnodontics.
Light Hypnosis
Another application of hypnodontics is the use of direct suggestion in producing light hypnosis to facilitate relaxation. In this state, the patient is amenable to suggestions directed to the lessening of tensions and the building of confidence. It takes only 5 or 10 minutes to achieve relaxation by means of direct suggestion. Since this type of hypnosis is not intended to produce anesthesia, conventional analgesic drugs may be used if necessary. This phase of hypnosis is used the most frequently.
There are several advantages to hypnorelaxation: it consumes relatively little time, it is successful in over 80 per cent of the cases, and the patient retains full awareness. Controlled relaxation, attained by the application of hypnotic technics, effectively influences the frightened dental patient whose pain threshold has been lowered as the result of negative emotions.
Deep Hypnosis
Deep hypnosis is used when medication is contraindicated or when drugs alone or drugs in combination with light hypnosis are ineffectual. Generally the time element involved in producing a deep hypnotic state and the fact that less than 20 per cent of patients are susceptible make it impractical for use as a routine procedure. However, once somnambulism has been induced, it takes but a few minutes to reestablish it at the next appointment. Most dentists have the misconception that those who use hypnosis apply the deep state to every patient that comes to their offices.
Hypnotic or direct suggestion is used by some dentists to correct certain objectionable dental habits such as nail-biting, thumb-sucking, and bruxism (grinding of teeth). This involves psychotherapy and should therefore be practiced only in conjunction with a psychotherapist or a physician. Hypnodontics may also be used to condition patients to wear dentures that fit well but which cause gagging for psychological reasons. These cases are not very common, yet there are instances in which a light state is generally effective.
CONTRAINDICATIONS FOR HYPNODONTICS
The author would like to sound a strong warning to dentists using hypnosis: Hypnodontics should not be abused by the dental profession. The dentist using hypnosis has the means at his disposal of probing into the emotional problems of an individual. Even with limited experience, he can produce such characteristic phenomena of hypnosis as age regression, revivification, negative and positive sensory hallucinations, catalepsy, and automatic writing. These phenomena lie in the highly specialized fields of either psychotherapy or experimental psychology, and the training, the experience, and the background of a dentist do not qualify him for this work! This does not mean that the dentist should hesitate to use hypnosis in his work. Hypnosis can be a very valuable instrument in his hands as can a lancet, but having the legal and moral right to use it does not entitle him to remove an appendix with it. The dentist, as well as the physician, has an ethical and moral obligation to his patients to borrow knowledge from all fields of science to alleviate pain, suffering and discomfort, and to improve the general welfare of mankind. Because of this, the dentist should avail himself of hypnosis and apply it to his dental practice. Therefore, he should make judicious use of the lancet and the hypnotic technic, which, like anesthesia and drugs, are instruments that belong to the dentist's as well as to the physician's armamentarium.
LIMITATIONS OF HYPNODONTICS
The hypnodontist should understand enough basic psychology or psychiatry to realize the fact that he is dealing with a complex tool. He must avoid exceeding his competence in using hypnosis for medical or nondental purposes. For instance, he should not attempt to cure the smoking habit, which may be a manifestation of tension and serve as an outlet for the release of nervous energy. He must know that smoking, like thumbsucking, constipation, headache, or inferiority feelings, is often the result of many hidden, powerful emotional forces. The removal of a habit, even by the trained psychotherapist, without “trading down” to a less noxious symptom, may throw the entire psyche of a deeply disturbed person into confusion and imbalance.
The untrained therapist may be satisfied with the dramatic and forceful removal of a symptom, but the sophisticated one knows that a permissive approach, preferably by autohypnosis, will prevent the appearance of other symptoms which sometimes can constitute a powerful threat to the entire personality structure. Symptom removal by such measures does not have a traumatic effect and is in sharp contradistinction to the authoritative “bull in a china shop” hypnotic approach.
Psychodental therapy, however, is strictly within the province of dentistry. The elimination of fear and anxiety associated with drilling and surgery has been a constant problem for dentists. When necessary, the dentist has resorted to drugs such as sedatives, and to premedication. Hypnosis is an extremely useful substitute for these.
The elimination of fear and apprehension is difficult, owing to the deeply ingrained conviction that these are the concomitants of dental work. It is hard to convince a person that he will not have pain when all his life's experience tells him otherwise. Because the oral cavity is a very important erotogenic zone and all parts of it have great psychic importance, it may be that exposing these areas to the manipulation of another individual could have a highly disturbing emotional significance to many individuals. It is from these roots that fear and anxiety may spring. The extraction of teeth, for instance, may be associated with punishment, masochism, or even castration. The patient is not aware of this; however, the hypnodontist should be.
Because of these facts, one cannot possibly remove or even reduce fear in all patients, but it is possible to remove all fear in some people, and some fear in most people. More than one session may be required to accomplish this. Before dental work is started, perhaps two or three sessions should be devoted to hypnosis for the removal of fear. Severely emotionally disturbed individuals, particularly, require extra time and effort. As to the time factor, once fear and anxiety have been eliminated via hypnosis, or hypnoanesthesia has been produced, a hypnotic state can be induced almost instantaneously in all subsequent sessions.
HYPNODONTIC PROCEDURES
For didactic purposes, the hypnodontic procedure is divided into seven steps:
1. Mind-set (indoctrination);
2. Testing;
3. Induction;
4. Deepening;
5. Utilization (operation);
6. Posthypnotic suggestions;
7. Dehypnotization (termination).
1. Mind-set. Mind-set is the procedure used to accomplish a state of receptivity or cooperation on the part of the patient. This is done in several ways, as described in Chapter 11, but primarily via a preliminary conversation before the use of any hypnotic procedures. The object of this step is to correct the subject's previous misconceptions or inaccurate ideas about the hypnotic state. Only in this way can good cooperation and proper motivation be obtained.
2. Testing. Certain tests, already described in detail, are utilized to determine the patient's susceptibility to hypnosis. Frequently, these may constitute the first stage of induction into hypnosis. There are many who consider it unwise to make tests for susceptibility in actual clinical practice. It is the author's opinion that all patients should be considered susceptible unless actual experience proves otherwise.
3. Induction. There are many procedures used to induce hypnosis. Hypnotic mechanical aids may be employed, although, as a rule, verbal suggestions can accomplish the same results. Certain rotating spirals on a dental engine can be used as a hypnotic aid. The brain wave synchronizer is another aid. For a dentist, the ordinary pen light on the dental unit is as effective an aid as any, when used in conjunction with the eye fixation technic. Induction may be direct or indirect. The direct method is used when the subject is aware that hypnosis is being employed. The indirect method implies the use of subterfuge; that is, the subject is prevented from becoming aware that hypnosis is being used. It is also known as a hidden approach in contrast with the open approach, in which direct hypnosis is used with the subject's awareness.
4. Deepening. Although it may take only a few minutes to induce a light hypnotic state, it may require several sessions to deepen it to the level at which it is compatible with the purpose for which hypnosis is being used. One of the commonest reasons for lack of success is failure to deepen the hypnotic state to one consistent with the requirements for Step 5. Step 4 requires training, patience, perseverance, and experienced judgment.
5. Utilization. The purposes for which hypnosis is to be used may vary widely. For example, the purpose for which the obstetrician uses it may be entirely different from that of the psychotherapist.
6. Posthypnotic Suggestions. Posthypnotic suggestions, in addition to making it easier and quicker to induce hypnosis at subsequent sittings, are used also for therapeutic dental purposes, as previously mentioned. At the final hypnotic session, the operator always gives the posthypnotic suggestion to the patient that in the future no one but a physician, a dentist, or a qualified psychologist will be able to place him in a hypnotic state. This procedure, called locking the “unconscious,” is a precaution against the patient's being exploited by a parlor or stage hypnotist for entertainment. The author is aware that some feel that this is not successful for the purpose intended; he takes issue with this view.
7. Dehypnotization. It is important that no patient be permitted to leave the office unless he is completely and fully coordinated. More about this will be said later in this chapter.
HYPNODONTIC TECHNICS
The following technic lends itself very adequately to producing relaxation prior to a dental operation. It is not dependent on somnambulism and, therefore, it has a wide range of success. It may be presented to the patient in such a manner that the words hypnosis, trance, and sleep are never mentioned.
The patient is seated comfortably, with eyes fixed on a given spot slightly forward and upward. There should be no strain on any part of the body; the hands are unclasped, resting comfortably in the lap. Instruct the patient to close his eyes when he feels like it and to keep them closed. The exact verbalization for patient relaxation via hypnotic induction is as follows (Step 1 and Step 2 are omitted):
I will teach you to relax. You will relax not only your body, but your mind as well.… When I pick up your right (or left) hand, let it fall limp. (Pick up one hand.) No, you've helped. Let your hand fall limp as though it were without any power or life, like the hand of a rag doll. Do not help or anticipate. (Try again and again until the hand and the arm are completely relaxed. This may take from 3 to 5 minutes, but it is absolutely necessary to accomplish complete relaxation before proceeding. Be patient and persevering. Then continue.) Breathe in deeply and relax your diaphragm.… Again. (This must be done five or six times in unison with the patient's breathing. Hyperventilation of the lungs will tend to relax mind and body.) Now, relax your feet and legs the same way as you did your hands. Make them very, very heavy. You'll probably find a very pleasant, tingling, relaxed feeling in your toes. It will travel through the soles of your feet, up your legs, to your abdomen and chest. (Pause.) Take another deep breath and relax your diaphragm still more.… Again.… Now relax your lower jaw … more … relax your cheeks. (By this time, the eyes are usually closed. If they are not, continue as follows.) Now your eyes are very tired and heavy. They are closing, closing, closing. (The eyes will then close.) Remove the wrinkles from your forehead and relax more. Let only my voice reach you. Drift pleasantly into a pleasing state of relaxation as you hear my voice. (Now give three suggestions, repeating each several times.)
1. You will remain relaxed as you are with eyes closed for 2 minutes. I'll inform you when the time is up.
2. When you open your eyes, you will be fully alert but completely relaxed and full of confidence for your dental appointment.
3. Each time, when you come back for your dental appointment, you will relax quickly and deeply with this method.
(After about 1½ minutes, dehypnotize the patient, using the following words:) When I count 3, you will open your eyes and be completely relaxed, feeling fine: 1 … 2 … 3. (If the patient does not open his eyes immediately, do not become alarmed, but repeat the above suggestions about 3 minutes later. Never show alarm or anxiety at slow dehypnotization.)
The above technic may be used routinely on all tense patients, provided, of course, that they will cooperate. It has some degree of success in over 80 per cent of cases. The technic is not spectacular, yet one will hear the following comment from the patient: “I feel very relaxed, but I was not hypnotized.” The answer should be: “It was not the intent to hypnotize you but only to relax you.” This should always be done prior to the operation, and the patient should be completely out of hypnosis before any dental work is attempted, the technic being intended for use as a substitution for or in conjunction with premedication.
Hypnodontics in Adaptation to Prosthetic Devices
Another use of dental hypnotherapy is in the conditioning of a patient to wear a prosthetic or orthodontic appliance. This is accomplished by giving him, while in hypnosis, positive, firm, posthypnotic suggestions that he will have no difficulty in becoming accustomed to the appliance. In this connection, there are times when it may be necessary to question the patient under hypnosis to get at the root of the problem. This is not recommended for the dentist, as he should realize that certain dental symptoms may ramify into the field of psychotherapy, and he should evaluate the advisability of using hypnosis accordingly. If direct suggestions are applied in several sessions, good results can frequently be obtained. But if the patient stubbornly persists in retaining his symptom, the case should be referred to a qualified psychotherapist.
Hypnodontics for Bruxism
Most patients with chronic bruxism are under marked tension and loaded with inhibited rage and aggression. These areas must be alleviated by a psychologically trained individual. The symptom itself can be controlled by teaching the patient selfhypnosis. Each time he finds himself clenching his teeth during the night, he is to pair the clenching with a relaxing scene. The latter, with repetition and reinforcement, will eventually countercondition the bruxism. A case of bruxism has been reported that was reversed when she was regressed to a bus crash which precipitated her teeth-grinding.14
Control of Bleeding
Dentists claim that bleeding can be controlled. However, the reports, though impressive, are anecdotal and poorly designed studies.11,14,19,27 Crasilneck and Fogelman showed that there were not differences in the clotting time in hypnotized and nonhypnotized dental patients.8 However, they admit that their experimental design did not measure the small capillaries. Hypnosis has been suggested as an ancillary measure in hemophilia—an approach that is certainly worth trying. Lucas and co-workers, and Lucas and Tocantins combined protective splints and packing of the sockets in 114 extractions in 24 hemophiliacs without the need for transfusions.20,21 La Baw has used hypnosis in hemophilia.18 He notes the adverse effect of anxiety on blood coagulation and fibrinolytic activity. Bleeders are chronically anxious. Hypnosis reduces the anxiety and, as a result, the morbidity. Less blood was needed than in a control series. Fredericks reported two cases in which hypnosis was helpful.12
Tongue Thrust and Swallowing
Tongue thrust and swallowing often are refractory to all kinds of therapy; hypnosis has been recommended for control of these habit patterns.9 Other investigators discuss swallowing difficulties and other psychophysiologic manifestations.10 Many tongue thrusters are unable to be quiet while eating. Most have malocclusion. Barrett and von Dedenroth reported on 25 cases treated successfully with hypnosis in one to four sessions.2
Hypnodontics in Anesthesia
The use of hypnosis in conjunction with, or as a substitute for, premedication prior to general anesthesia is quite a common practice today among medical anesthesiologists. Raginsky mentions that fear of anesthesia may be due to fear of loss of consciousness, or mutilation, of loss of life, or of the unknown.28 He states that it results in change in blood pressure, heart rate, capillary permeability, urinary output, coronary flow, rate and depth of respiration, and carbon dioxide content of the blood. He writes:
He [the anesthesiologist] must learn the structure or normal personality, and see how and to what degree the patient to be anesthetized deviates from that of the normal. With this knowledge [hypnosis] he can quiet the patient more effectively, use much less of the anesthetic agent and have a smoother induction.
When this was written in 1948, the thought of offering hypnosis as part of the training and background of the anesthesiologist was far-fetched and remote. Today, this training has become routine for many anesthesiologists. If possible, the dentist, like the anesthesiologist, should see his patient several days before the scheduled operative procedure and begin the initial induction so that, by the time the patient reaches the office on the day of the operation, he may receive the full benefits of previous hypnotic conditioning. This brings about lessening of fear and anxiety, which results in less and easier anesthetic induction if it should be necessary. The element of safety is thus an outstanding feature in the use of hypnosis in conjunction with general anesthesia.
ELIMINATION OF GAG REFLEX
An important application of hypnosis is in eliminating the gag reflex which is so frequently a nuisance to the dentist. It is not necessary to place the patient under hypnosis for this purpose, because the elimination of gagging can be accomplished exceptionally well by waking hypnotic suggestion. The author and other dentists to whom he has taught this technic have had most gratifying results. The following technic is used for eliminating gagging reflex via waking hypnotic suggestion, for taking x-rays or impressions:
Stand in front of the patient and direct him to keep his gaze fixed continuously on your eyes during the entire procedure. Should his gaze wander, call this to his attention and start again from the beginning. Fix your own gaze on the bridge of the subject's nose. Do not stare into his eyes. Say:
1. “I am going to eliminate your gag reflex by instructing you in breathing exercises. You must keep your gaze fixed on my eyes at all times.”
2. “Take a deep breath and hold it while I count to 5. 1, 2, 3, 4, 5. Now relax.”
3. Repeat Step 2, never allowing the patient's gaze to wander.
4. “Now I have eliminated your gag reflex.” Say firmly, with conviction, “You will not be able to gag. You may try as hard as you can but you will not be able to gag.” The patient's gaze must not be allowed to wander until the entire suggestion in Step 4 is completed.
5. “You may now relax, and you will not gag while I take your impressions (x-rays).”
6. The previous 5 steps should be repeated, after saying, “To make sure that you will not gag, I shall repeat the entire procedure once more.” Continue Steps 1 through 5 and proceed to take the impressions (x-rays).
The success of this procedure is largely dependent on the strength of the operator's conviction. If it is weak and without firmness, the incidence of success diminishes.
This technic will be found quite adequate for taking roentgenograms or impressions; it will not be effective in eliminating gagging or nausea due to the wearing of dentures. The latter requires a more intensive approach. First and foremost, it must be ascertained that the dentures are well constructed and properly fitted. After this is ascertained, posthypnotic suggestions should be given which are aimed at helping the patient to use the dentures for twice the period that he was able to use them heretofore before gagging or nausea took place. For example, if the patient reported in his original interview that he could wear the denture for only 10 minutes, then the posthypnotic instruction should be, “You will find that upon coming out of hypnosis you will have no difficulty in keeping your denture comfortably in position for 20 minutes. You will repeat this on the hour daily, and report to me in 3 days.” After the patient returns and is again hypnotized, the time is increased to 30 minutes, or perhaps 35. He is to repeat this every hour and a half. It will be found that, with this technic, at least 50 per cent of all denture gaggers either can be entirely improved or at least helped. It is important to take a very thorough history before using hypnosis.
It is inadvisable for the dentist who made the denture to treat the gagger. It is better to refer him to another “neutral” or disinterested dentist. When it is known that the patient is a gagger, dentures should not be constructed or even impressions made until after several therapeutic hypnotic sessions. These can save considerable time and trouble. In preventive hypnosis, however, it is acceptable for the dentist doing the prosthetic work also to perform the hypnosis. When failure to eliminate gagging via hypnosis occurs, it is advisable to refer the patient to a psychotherapist for further treatment. The symptom may be related to a deep-seated neurosis.
If the dentist uses hypnosis in this fashion for the treatment of gagging or of any other noxious habit, he is well within the limits of his field. Dangers are insignificant if the dentist does not resort to probing of the “unconscious.” A clinical follow-up of failures referred to a psychotherapist has shown that half of the cases have successful outcomes. In other words, it may safely be said that with proper management, three out of every four patients can be safely cured of denture gagging or nausea (50 percent by the dentist and 25 percent by the psychotherapist).
Other practitioners have employed hypnosis to reduce the gag reflex with some modicum of success.1,4,6,30,33 Often direct suggestions without hypnosis may be helpful. Ament used desensitization, reciprocal inhibition, operant conditioning, and time distortion on groups of patients with gagging due to dentures.1
CONTROL OF SALIVATION
Control of the flow of saliva can be achieved by hypnotic means,17 since the autonomic nervous system is subject to volitional control. It is possible, in the experimental laboratory, to bring about (through hypnotic suggestion) vasoconstriction or vasodilation of peripheral blood vessels and to produce blushing or even blanching of a hand or a face. It is therefore not surprising that the flow of saliva can be affected in the same way. The advantages for the dentist are obvious. Fortunately, a patient need not be in very deep hypnosis to obtain this control. The salivary flow not only can be influenced during hypnosis but for a reasonable time thereafter by means of posthypnotic suggestion.
PREINDUCTION PROCEDURES
Because of the existing prejudices among the public, the method of suggesting hypnosis to the patient is of paramount importance. If the nature of the hypnotic phenomenon is not properly presented, the patient may refuse to undergo induction. Sometimes prejudices are so deeply rooted that, even with the proper approach, consent to hypnosis cannot be obtained. There are two ways of handling such resistance: the direct technic and the indirect (disguised) technic.
Direct Technic
With the direct technic, the patient is told, either by the dentist himself or by his assistant, of the many advantages of hypnodontics. It may be helpful for him to observe another patient being operated on while in a hypnotic state. The role of the dental assistant is of great importance and, in many instances, by a careful approach, she can induce the patient to request hypnosis even without the dentist's having suggested it. Pamphlets or brochures on hypnosis may be placed carefully in the reception room. A patient should never be forced to accept hypnosis. Jacoby has used taped instructions on over 300 patients.15
Indirect Technic
In the disguised approach, nothing is told to the patient which would make him aware that he is about to be hypnotized. He is told simply that he is being taught to relax and that he should make himself comfortable and let his arms and legs become loose and heavy. It is explained that in a relaxed state the threshold of pain is markedly raised, and also that fear and apprehension can be lessened if he remains completely relaxed physically and mentally. Through these means, using the technic previously described for waking relaxation, he is gradually brought into hypnosis. The patient is then unaware that he has been hypnotized. While such a method is usually successful, it must be understood that a patient might realize what is transpiring and become resentful. This can result in a bad relationship.
AUDIO-ANALGESIA TECHNIC
In discussing the disguised or indirect technic of hypnosis induction, it behooves the author to include two additional “nonhypnotic” technics of producing anesthesia and relaxation in dentistry. Reference has already been made to the first, namely, the use of nitrous oxide. The other technic, known as audio-analgesia, was in vogue some years ago. Although most advocates of the latter technic may be unaware of the underlying principle, namely, the state of hypnosis or suggestion, as the reason for its success, it is the opinion of the author that both these technics lean heavily on the disguised technic of hypnosis. This is not written with the intent of denying the strong analgesic or anesthetic action of the nitrous oxide gas. Rather, it is intended to point out that in many instances the anesthesia which might be attributed to the gas is due partly or solely to the effect of hypnosis or suggestion.
At a meeting of the American Analgesic Society in New York City, attended by about 100 dentists, the author, who was the clinician for the evening, asked for a show of hands of all those who had, at one time or another, obtained all the effects of nitrous oxide analgesia without actually administering the gas, either because of an oversight or deliberately. At least a third of those present raised their hands, indicating that they had obtained positive analgesic effects when the patient thought he was getting the nitrous oxide, while in reality he was inhaling only atmospheric air. The conclusions are quite obvious. The author has no doubt that the sounds coming through to the patient by means of the audio-analgesia set-up have the same psychological effects in producing anesthesia and relaxation in dental patients.
There is no question as to the efficaciousness of both nitrous oxide and audio-analgesia as hypnotic agents. In an article written by Cherry and Pollin in 1948,7 a technic is described in which music is fed to the patient while nitrous oxide is being administered. The authors describe an elaborate set-up of earphones, connected to a phonograph with a microphone tie-in, and attached to the patient's ears, allowing the anesthetist to speak directly to the patient. Selected music, such as Clair de Lune, Moonlight Sonata, and Evening Star, was used. The authors conclude that “… in this method designed to reduce reflex irritability without resorting to depressing premedication, the nitrous oxide oxygen mixtures were maintained with a minimum of 24 per cent oxygen. Nausea, retching, excitement, jactitation, soft tissue obstruction, aspiration and swallowing have been conspicuously absent.”
Handling Resistant Patients
Even though these technics are presented by the author as hypnotic aids or placebos, there are instances in which they are indicated in preference to outright hypnosis. For example, one encounters patients whose prejudices compel them to reject hypnosis. There are still other patients whose deep seated resistance to hypnosis makes them refractory to its use. But with the aid of nitrous oxide or audio-analgesia, the resistances, both conscious and unconscious, are not mobilized. Thus the patient can “let go” without having his self-esteem threatened.
“SEALING” THE PATIENT AGAINST HYPNOSIS
The hypnodontist should give the patient posthypnotic suggestions which will serve as a protection against the experimenting amateur or stage hypnotist. The wording of these suggestions might be: “In the future, no one will be able to hypnotize you except a dentist, a physician, or some other qualified person such as a psychologist. Unless you expressly desire to be hypnotized, no one can hypnotize you.” It is important not to close out all future susceptibility, as the patient might later be a subject for therapeutic purposes.
DEHYPNOTIZATION
Before dismissing any patient who has been in a hypnotic state, it is imperative to observe two rules:
1. Remove any hypnotic suggestion that might continue to operate in the posthypnotic period.
2. Make certain that the patient is alert.
Any suggestions which might have been given, perhaps as tests, such as “paralysis” of a limb, should be removed. If a counter-suggestion is not made, there is a remote possibility that such a “paralysis” may continue to operate in the posthypnotic period. It is important to set a time limit to any analgesia or anesthesia in the posthypnotic period. If a negative or a positive sensory hallucination has been produced during hypnosis, it is important to remove it before dehypnotization. These are important considerations, whether the operator is a dentist, a psychologist, a psychiatrist, or an amateur hypnotist.
The hypnodontist, as well as the psychotherapist, is legally and morally responsible for a patient's condition and welfare at the time he leaves the office and after he has been in hypnosis. This is just as true for hypnosis as it is for general anesthesia. If a patient should meet with an automobile accident because of a partially depressed state owing to incomplete dehypnotization, the practitioner might be involved in legal complications. This is also the case with an ambulatory patient after the administration of a general anesthetic. It is wise to observe every patient for a short time and to converse with him before dismissing him to ascertain his complete recovery from the hypnotic state. This precaution is necessary only when a patient has been in a very deep state.
OPERATIVE HYPNODONTICS
The management of the operative dental technics after a patient is in a hypnotic state is known as operative hypnodontics. Through trial, error, and experimentation, a method of managing the patient has been established.
The following is the procedure which the author has developed and applied to hundreds of cases over the past several years:
Maintenance of Hypnotic Level.
After inducting the patient and testing for depth, always end by assuring him that he will not awaken from the hypnotic state until you dehypnotize him. This will require several strong hypnotic suggestions such as, “You will remain deeply relaxed until I ‘awaken’ you. Nothing, absolutely nothing, will awaken you until I do!” This is the first step before attempting any work in the mouth.
Approach to Treatment in the Mouth.
Sometimes, despite the above precaution, when the patient is asked to open his mouth, he may come out of hypnosis. Therefore, this second step is always applied with the following verbalization: “With eyes closed and without ‘awakening,’ open your mouth … wider!” Then massage the jaw muscles lightly on the outside of the face and continue, “Your jaw is becoming stiff, like a vise. It is now so stiff that you cannot close your mouth. You may try, but you will find it impossible. Stop trying! Deep, deep asleep. Your mouth will remain open until I tell you otherwise.”
This step, known as muscle catalepsy, is taken not only to ensure an open mouth throughout the entire operation, but also to act as a test in determining the depth of hypnosis, and, finally, to deepen the hypnotic state. Whenever a test in the technics of hypnotic induction is made successfully, the suggestion of deep, deep “asleep” tends to deepen the hypnosis.
Production of Anesthesia.
One should never assume that anesthesia is present, even though a patient may be in deep hypnosis. Always include this step to produce anesthesia first; then test before operating. The procedure is to take hold of the tooth to be treated between the index finger and the thumb, rocking it and at the same time depressing it in the socket, gently at first but gradually more firmly. While doing this, say: “As I press down on this tooth, you will find that it is getting numb and losing all its feeling. It is beginning to feel as though you've had an injection. You feel a tingling sensation … cold and numb.…” Then test for anesthesia.
Test for Anesthesia.
Take a sharp explorer and gently press into the gingival area around the tooth, saying, “I am pricking your gum with this point, but, you see, you feel absolutely no discomfort.” Stop, and say, “I shall do the same to the other side of your mouth, but you will feel a sharp pain there.” Then prick the gingival tissues on the normal side very lightly. Almost always, the patient will react with a sudden start. Now go back to the first side and indicate the difference to the patient. If there is any doubt in the operator's mind, either the hypnosis should be deepened and the above words repeated, or the patient should be given procaine and further tests should be made.
Operative Procedure.
The author always applies the following rules:
1. Never operate without an assistant.
2. Never attempt too much during the first visit.
3. Advise the patient to keep his eyes closed throughout the entire operation.
4. Keep the patient passive and do not disturb him by requesting that he spit or bend over. This can be avoided by the constant use of an aspirator by the assistant. The patient should be treated as though he were in a state of general anesthesia.
5. Never overheat the tooth. Work slowly and have a constant stream of water running on the tooth from any of the special watercooling attachments on the market.
6. Complete the entire operation, including restoration, while the patient is in hypnosis. This is important because, in this way, it is possible to produce complete amnesia for the operative procedure and to avoid focusing of the normal waking attention on the operation in the posthypnotic period. Thus, it is necessary to place the matrix band, the wedges, and the restoration, and to remove the excess and carve the restoration while the patient is still in a hypnotic state.
Termination of Hypnosis.
When terminating the hypnosis, always give the following posthypnotic suggestions:
1. There will be no recollection of any pain or discomfort.
2. If the patient is in a somnambulistic state, complete amnesia for the entire period of hypnosis may be suggested successfully. There are some who feel that amnesia is not desirable. The author often finds it useful.
3. The patient will feel normal, cheerful, and happy when he is dehypnotized.
4. He will enter hypnosis quickly and deeply each time in the future that it is suggested to him, provided, of course, that it is in accord with his wishes to be induced.
5. He will have no fear or anxiety about dental treatment at subsequent visits. Any other therapeutic suggestions might be given at this time.
After dehypnotization of a patient, never question him about discomfort. Always assume that it was diminished. Do not press a patient to exceed his threshold of response. Inform him of what you have done as though he knows nothing about it. Assure him that the procedure was entirely successful, as planned, and that he will do even better next time.
The author would like to emphasize that the above is a sketchy outline of the technic used. Certain factors had to be omitted, such as the importance of the attitude of the dentist as a determinant of success or failure; the practice of running a continuous commentary throughout the operative procedure to maintain a constant hypnotic depth and to prevent the patient from coming out of it; and the occasional need to stop treatment to deepen the hypnosis if signs of spontaneous dehypnotization appear. These and many other details must be excluded because of the necessary brevity of this chapter, but they are discussed elsewhere in this book.
PEDIADONTICS
Hypnosis has been found to be a useful adjunct in pediadontics.32 It is particularly indicated in the control and the management of emotionally disturbed children who require dental work. The author, who specializes in dentistry for the emotionally disturbed and handicapped, has various means of coping with this class of patients. Among the technics in his armamentarium are all forms of drugs, such as local and general anesthetics, sedatives, tranquilizers, and analgesics. But hypnosis is always used as an attempt to eliminate or lessen the amounts used. In some instances, it is possible to avoid the use of general anesthesia in cases which had been scheduled for it.
DISADVANTAGES OF HYPNODONTICS
From the foregoing, it would appear that there is only good associated with the use of hypnosis in dentistry. Unfortunately, this is not the case. A disadvantage in using hypnosis is the time consumed in conditioning a patient. However, this can be obviated by group training (see Chap. 35). Busy dentists may find it impractical and undesirable to spend the required time on individual patients, in view of the uncertainty involved. Many practitioners also feel that the training and experience required for a high percentage of success is an obstacle. Insofar as time is concerned, it must be pointed out that reinduction of hypnosis is only a matter of a few seconds or a few minutes, when proper posthypnotic suggestions to this effect have been given. There are times when a psychologist trained in hypnosis or a hypnodontic specialist may be called upon to condition a patient, either at his own office or at that of the dentist. Rapport can be then be transferred to the dentist. There are more skilled psychologists capable of such work today than at any time in the past, owing to the growing use of and interest in hypnosis in fields other than dentistry.
ADVANTAGES OF HYPNODONTICS
Against the above disadvantages, there are a number of advantages which have been discussed throughout the text. Hypnosis is extremely useful in the relaxation of nervous and excitable patients, eliminating fear and tension, making long, arduous sittings more tolerable. The well-conditioned patient approaches the dental appointments with pleasant anticipation instead of dread and anxiety. There is a definite enhancement in the prestige of the hypnodontist because of his added interest, skill, and ability. It is the usual experience of hypnodontists that new patients seek appointments and request hypnosis when word-of-mouth information is spread by patients who have experienced hypnotic treatment. Many dentists, including the author, have found that with some patients it becomes unnecessary to continue the use of hypnosis after the initial sessions have overcome the fear and anxiety.
Although less than 20 years ago a dentist had to be a courageous pioneer in using hypnosis, this is not the case today. The company in which he travels, of those using hypnosis in disciplines other than dentistry, is both respected and substantial. The Boards in Hypnosis consist of three separate entities, of which the American Board of Dental Hypnosis is one. The others are in medicine and psychology. The fact that hypnosis is taught in at least a dozen dental colleges speaks for itself. It is hoped that those reading this chapter will view sympathetically the possibilities and the potentials of the use and the application of hypnodontics. Jacoby has provided practical suggestions for working with hypnodontics.16
CONCLUSIONS
1. The average dentist is capable of learning the technics of hypnodontics.
2. It is completely harmless in every way and from every point of view when used by a dentist for dental purposes.
3. There is no possibility of emotional or psychological trauma if no experimentation in psychiatric therapy is attempted. Stay within the limitations of dentistry. Do not attempt to practice psychiatry!
4. Susceptibility to hypnosis is not related to intelligence or to strong- or weak-mindedness.
5. It is a practice-builder, as it enhances the prestige of the dentist.
6. It is relatively widely accepted by the medical, dental, and psychological professions, as compared with only 10 or 15 years ago.
7. There is a deep personal satisfaction in being able to render such a useful service to the patient.
8. Failures cannot be avoided, but practical experience, together with adequate postgraduate instruction, will minimize the incidence of failures.
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